Assessment of the Cost-Effectiveness of a Brief Video Intervention for Sexually Transmitted Disease Prevention.

BACKGROUND: Cost-effective, scalable interventions are needed to address high rates of sexually transmitted diseases (STDs) in the United States. Safe in the City, a 23-minute video intervention designed for STD clinic waiting rooms, effectively reduced new infections among STD clinic clients. A cost-effectiveness analysis of this type of intervention could inform whether it should be replicated. METHODS: The cost-effectiveness of a brief video intervention was calculated under a baseline scenario in which this type of intervention was expanded to a larger patient population. Alternative scenarios included expanding the intervention over a longer period or to more clinics, including HIV prevention benefits, and operating the intervention part time. Program costs, net costs per STD case averted, and the discounted net cost of the intervention were calculated from a health sector perspective across the scenarios. Monte Carlo simulations were used to calculate 95% confidence intervals surrounding the cost-effectiveness measures. RESULTS: The net cost per case averted was $75 in the baseline scenario. The net cost of the intervention was $108,015, and most of the alternative scenarios found that the intervention was cost saving compared with usual care. CONCLUSIONS: Single session, video-based interventions can be highly cost effective when implemented at scale. Updated video-based interventions that account for the changing STD landscape in the United States could play an important role in addressing the recent increases in infections.

Inward- and Outward-Directed Violence in the Lives of Urban Minority Adults Followed from Middle School into Their Thirties.

This study explores connections between inward-directed violence and outward-directed violence using data from the Reach for Health sample, which was originally recruited in the 1990s from three middle schools in economically distressed, predominantly African American neighborhoods of New York City. Now in their thirties, participants (N = 595) completed surveys assessing current suicidal thoughts and behaviors as well as other violence involvements, including intimate partner violence victimization and perpetration. About 10% of males and females reported any suicidal ideation or attempt in the past 12 months. In logistic regression analyses adjusting for sociodemographics, prior reports of feeling blue in middle school (OR: 1.12, CI: 1.02-4.39) and young adult suicidality (OR: 2.54, CI: 1.30-4.95) are significantly related to later suicidality. So are concurrent aggressive behaviors, including reports of physical fighting outside the home (OR: 2.70, CI: 1.29-5.67) and IPV perpetration (OR: 2.09, CI: 1.11-3.94). Neither IPV victimization nor witnessing neighborhood violence is correlated. Findings shed light on the persistence of suicidality in the lives of those who come of age, and often remain, in communities with high levels of poverty, and confirm linkages of suicidality with externally directed aggression. Life-stage interventions are needed to counter the interwoven causes and consequences of multiple forms of violence.

Sexual abstinence and other behaviours immediately following a new STI diagnosis among STI clinic patients: Findings from the Safe in the City trial.

BACKGROUND: Few studies have assessed patients' sexual behaviours during the period immediately following a new diagnosis of a curable sexually transmitted infection (STI). METHODS: Data were analysed from a behavioural study nested within the Safe in the City trial, which evaluated a video-based STI/HIV prevention intervention in three urban STI clinics. We studied 450 patients who reported having received a new STI diagnosis, or STI treatment, 3 months earlier. Participants reported on whether they seriously considered, attempted and succeeded in adopting seven sex-related behaviours in the interval following the diagnostic visit. We used multivariable logistic regression to identify, among men, correlates of two behaviours related to immediately reducing reinfection risk and preventing further STI transmission: sexual abstinence until participants were adequately treated and abstinence until their partners were tested for STIs. RESULTS: Most participants reported successfully abstaining from sex until they were adequately treated for their baseline infection (89%-90%) and from sex with potentially exposed partners until their partners were tested for HIV and other STIs (66%-70%). Among men who intended to be abstinent until they were adequately treated, those who did not discuss the risks with a partner who was possibly exposed were more likely not to be abstinent (OR, 3.7; 95% CI 1.5 to 9.0) than those who had this discussion. Similarly, among men who intended to abstain from sex with any potentially exposed partner until the partner was tested for HIV and other STIs, those who reported not discussing the risks of infecting each other with HIV/STIs were more likely to be sexually active during this period (OR, 3.5; 95% CI 1.6 to 8.1) than were those who reported this communication. CONCLUSIONS: Improved partner communication could facilitate an important role in the adoption of protective behaviours in the interval immediately after receiving a new STI diagnosis. TRIAL REGISTRATION NUMBER: NCT00137670.

Community reductions in youth smoking after raising the minimum tobacco sales age to 21.

OBJECTIVE: Raising the tobacco sales age to 21 has gained support as a promising strategy to reduce youth cigarette access, but there is little direct evidence of its impact on adolescent smoking. Using regional youth survey data, we compared youth smoking trends in Needham, Massachusetts--which raised the minimum purchase age in 2005--with those of 16 surrounding communities. METHODS: The MetroWest Adolescent Health Survey is a biennial census survey of high school youth in communities west of Boston; over 16,000 students participated at each of four time points from 2006 to 2012. Using these pooled cross-section data, we used generalised estimating equation models to compare trends in current cigarette smoking and cigarette purchases in Needham relative to 16 comparison communities without similar ordinances. To determine whether trends were specific to tobacco, we also examined trends in youth alcohol use over the same time period. RESULTS: From 2006 to 2010, the decrease in 30-day smoking in Needham (from 13% to 7%) was significantly greater than in the comparison communities (from 15% to 12%; p<.001). This larger decline was consistent for both genders, Caucasian and non-Caucasian youth, and grades 10, 11 and 12. Cigarette purchases among current smokers also declined significantly more in Needham than in the comparison communities during this time. In contrast, there were no comparable differences for current alcohol use. CONCLUSIONS: Our results suggest that raising the minimum sales age to 21 for tobacco contributes to a greater decline in youth smoking relative to communities that did not pass this ordinance. These findings support local community-level action to raise the tobacco sales age to 21.

Assessing Patient Exposure to a Video-Based Intervention in STD Clinic Waiting Rooms: Findings From the Safe in the City Trial.

Safe in the City, a video intervention for clinic waiting rooms, was previously shown to reduce sexually transmitted disease (STD) incidence. However, little is known about patients' recall of exposure to the intervention. Using data from a nested study of patients attending clinics during the trial, we assessed whether participants recalled Safe in the City, and, if so, how the intervention affected subsequent attitudes and behaviors. Analyses were restricted to responses to a 3-month follow-up questionnaire among participants who were exposed to the video (n = 708). Impact was measured as participants' reports of the video's effect on behaviors and attitudes. Associations were evaluated using multivariable logistic regression. Of participants who were exposed, 685 (97%) recalled viewing the video, and 68% recalled all three vignettes. After watching the video, participants felt more positive about condoms (69%) and comfortable acquiring condoms (56%), were reminded of important information about STDs and condoms (90%), and tried to apply what they learned to their lives (59%). Compared with those who recalled viewing one or two vignettes, participants who recalled viewing all three vignettes reported more positive attitudes toward condoms and peer/provider communication. These findings demonstrate that a low-resource video intervention for waiting rooms can provide sufficient exposure to positively influence STD-related attitudes/behaviors.

Adapting the VOICES HIV behavioral intervention for Latino men who have sex with men.

Latino men who have sex with men (MSM) are disproportionately impacted by HIV/AIDS, but few behavioral interventions address their prevention needs. Adaptation of evidence-based interventions is a pragmatic strategy that builds upon lessons learned and has the potential to fill gaps in prevention programming. Yet there are few reports of how transfers are executed and whether effectiveness is achieved. This research reports on the adaptation of VOICES/VOICES, a single-session intervention designed for heterosexual adults, into No Excuses/Sin buscar excuses for Latino MSM. To test the adapted intervention, 370 at-risk Latino MSM were enrolled in a randomized trial. At a three-month follow-up, there was a sharper decrease in unprotected intercourse in the intervention group compared to controls (59 % vs. 39 %, ANOVA p < 0.05, F = 4.10). Intervention participants also reported more condom use at last intercourse (AOR = 1.69; 95 % CI 1.02-2.81, p < 02). Findings support use of adapted models for meeting prevention needs of high-priority populations.

HIV testing among sexually active Hispanic/Latino MSM in Miami-Dade County and New York City: opportunities for increasing acceptance and frequency of testing.

HIV testing behavior is important in understanding the high rates of undiagnosed infection among Hispanic/Latino men who have sex with men (MSM). Correlates of repeat/recent testing (within the past year and ≥5 tests during lifetime) and test avoidance (never or >5 years earlier) were examined among 608 sexually active Hispanic/Latino MSM (Miami-Dade County and New York City). Those who reported repeat/recent testing were more likely to have incomes over $30,000, speak English predominately, and have visited and disclosed same-sex behavior to a health care provider (HCP) in the past year. Those who were classified as test avoiders were less likely to have incomes over $10,000 and to have seen an HCP in the past year. The main reason for not testing (in both groups) was fear of HIV positivity; however, twice as many test avoiders considered this their main reason, and more test avoiders had confidentiality concerns. Results suggest that messages to encourage testing among Hispanic/Latino MSM may be most effective if past testing patterns and reasons for not testing are considered. HCPs can play an important role by consistently offering HIV tests to MSM and tailoring messages based on prior testing histories.

Cyberbullying, school bullying, and psychological distress: a regional census of high school students.

OBJECTIVES: Using data from a regional census of high school students, we have documented the prevalence of cyberbullying and school bullying victimization and their associations with psychological distress. METHODS: In the fall of 2008, 20,406 ninth- through twelfth-grade students in MetroWest Massachusetts completed surveys assessing their bullying victimization and psychological distress, including depressive symptoms, self-injury, and suicidality. RESULTS: A total of 15.8% of students reported cyberbullying and 25.9% reported school bullying in the past 12 months. A majority (59.7%) of cyberbullying victims were also school bullying victims; 36.3% of school bullying victims were also cyberbullying victims. Victimization was higher among nonheterosexually identified youths. Victims report lower school performance and school attachment. Controlled analyses indicated that distress was highest among victims of both cyberbullying and school bullying (adjusted odds ratios [AORs] were from 4.38 for depressive symptoms to 5.35 for suicide attempts requiring medical treatment). Victims of either form of bullying alone also reported elevated levels of distress. CONCLUSIONS: Our findings confirm the need for prevention efforts that address both forms of bullying and their relation to school performance and mental health.

Effectiveness of the VOICES/VOCES sexually transmitted disease/human immunodeficiency virus prevention intervention when administered by health department staff: does it work in the "real world"?

BACKGROUND: Prevention providers wonder whether benefits achieved in the original, researcher-led, efficacy trials of interventions are replicated when the intervention is delivered in real-world settings by their agency's staff. METHODS: A replication study was conducted at 2 public sexually transmitted disease (STD) clinics (New York City and San Juan, PR). Using a controlled trial design, intervention (VOICES/VOCES) and comparison conditions (regular clinic services) were assigned in alternating 4-week blocks. Trained agency staff delivered the intervention. Effectiveness was assessed for incident STDs, redemption of coupons for condoms at neighborhood location after the visit, and improved knowledge and attitudes about STDs and condoms. RESULTS: A total of 3365 patients were recruited, completed the protocol, and followed through STD surveillance systems for an average of 17 months. Of 397 with an incident infection, 226 (13.4%) were among those enrolled during comparison blocks; 171 were among those in the intervention condition (10.2%). Controlling for site and gender, participants enrolled during intervention blocks were significantly less likely to have an incident STD reported to the surveillance system (hazard ratio, 0.78; 95% confidence interval, 0.64-0.96). Intervention block participants scored higher on scales of STD knowledge (4.89 vs. 3.87, P < 0.001) and condom knowledge, attitude, and efficacy (10.98 vs. 9.16, P < 0.001). More of those exposed to VOICES/VOCES redeemed condoms (P < 0.05). Positive effects were more consistent in New York, which may be related to fidelity of implementation. CONCLUSIONS: A packaged human immunodeficiency virus prevention intervention can be delivered by agencies, with benefits similar to those achieved in the research setting.

Especially for daughters: parent education to address alcohol and sex-related risk taking among urban young adolescent girls.

This study evaluates the Especially for Daughters intervention, which aims to provide urban Black and Latino parents with information and skills to support their daughters in delaying sexual initiation and alcohol use. In a randomized field trial, 268 families with sixth-graders were recruited from New York City public schools and assigned either to the intervention, a set of audio CDs mailed home; an attention-controlled condition (print materials); or controls. Girls completed classroom baseline and three follow-up surveys, and telephone surveys were conducted with parents. At follow-up, girls in the intervention reported fewer sexual risks (adjusted odds ratio [AOR] = 0.39, confidence interval [CI] = 0.17-0.88) and less drinking (AOR = 0.38, CI = 0.15-0.97, p < .05). Their parents reported greater self-efficacy to address alcohol and sex and more communication on these topics. This gender-specific parent education program was for communities with high rates of HIV, where early sexual onset is common and often fueled by alcohol.

Safe in the city: developing an effective video-based intervention for STD clinic waiting rooms.

There is a strong need for inexpensive, easily administered HIV and STD prevention interventions that are highly replicable and appealing to diverse clinic audiences. This article describes the four-step iterative and collaborative process used by the Safe City Study Group to design and develop a brief video-based intervention: Safe in the City. Step 1 involves identification of an appropriate intervention medium, a theoretical framework, and key messages; Step 2, collaboration with a film company to integrate the framework and key messages into an entertaining product; Step 3, facilitation of a multistep participatory process involving input from members of the priority audience (clinic patients), clinic staff, and community reviewers; and Step 4, pilot-testing to determine structural barriers to patients' viewing the video in clinic waiting rooms. Safe in the City has been demonstrated to reduce incident STDs among clinic patients in three cities in the United States.

STEPS to Care: Translating an Evidence-Informed HIV Care Coordination Program Into a Field-Tested Online Practice Improvement Toolkit.

Increasing care engagement is essential to meet HIV prevention goals and achieve viral suppression. It is difficult, however, for agencies to establish the systems and practice improvements required to ensure coordinated care, especially for clients with complex health needs. We describe the theory-driven, field-informed transfer process used to translate key components of the evidence-informed Ryan White Part A New York City Care Coordination Program into an online practice improvement toolkit, STEPS to Care (StC), with the potential to support broader dissemination. Informed by analyses of qualitative and quantitative data collected from eight agencies, we describe our four phases: (1) review of StC strategies and key elements, (2) translation into a three-part toolkit: Care Team Coordination, Patient Navigation, and HIV Self-Management, (3) pilot testing, and (4) toolkit refinement for national dissemination. Lessons learned can guide the translation of evidence-informed strategies to online environments, a needed step to achieve wide-scale implemention.

Parenting and violence toward self, partners, and others among inner-city young adults.

OBJECTIVES: We examined relationships between parenting status and multiple forms of violence perpetration among young adults in high-poverty environments. METHODS: We analyzed data obtained from a survey of 990 young adults in New York City. Respondents reported on violence they had perpetrated toward themselves, intimate partners, and others. Associations between parenting and violence were examined in logistic regressions, controlling for sociodemographics. RESULTS: Fewer young men (33.0%) than young women (48.6%) reported that they were raising children. Among young men, parenting was associated with violence toward themselves (odds ratio [OR]=1.8; 95% confidence interval [CI]=1.03, 3.16) but not with violence toward partners or others. Among young women, violence perpetration did not differ by parenting status. Correlations among forms of violence were higher among young women than among young men, especially among mothers. Community violence was associated with violence toward others for both genders. For young men, community violence was associated with violence toward partners. CONCLUSIONS: Parenting did not reduce inner-city young adults' perpetration of violence. Among fathers, parenting may be, along with unemployment, a risk for violence toward self. Understanding patterns of violence can inform interventions that support young adults, including those who are parenting, in creating nonviolent homes and communities.

Effect of a brief video intervention on incident infection among patients attending sexually transmitted disease clinics.

BACKGROUND: Sexually transmitted disease (STD) prevention remains a public health priority. Simple, practical interventions to reduce STD incidence that can be easily and inexpensively administered in high-volume clinical settings are needed. We evaluated whether a brief video, which contained STD prevention messages targeted to all patients in the waiting room, reduced acquisition of new infections after that clinic visit. METHODS AND FINDINGS: In a controlled trial among patients attending three publicly funded STD clinics (one in each of three US cities) from December 2003 to August 2005, all patients (n = 38,635) were systematically assigned to either a theory-based 23-min video depicting couples overcoming barriers to safer sexual behaviors, or the standard waiting room environment. Condition assignment alternated every 4 wk and was determined by which condition (intervention or control) was in place in the clinic waiting room during the patient's first visit within the study period. An intent-to-treat analysis was used to compare STD incidence between intervention and control patients. The primary endpoint was time to diagnosis of incident laboratory-confirmed infections (gonorrhea, chlamydia, trichomoniasis, syphilis, and HIV), as identified through review of medical records and county STD surveillance registries. During 14.8 mo (average) of follow-up, 2,042 patients (5.3%) were diagnosed with incident STD (4.9%, intervention condition; 5.7%, control condition). In survival analysis, patients assigned to the intervention condition had significantly fewer STDs compared with the control condition (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.84 to 0.99). CONCLUSIONS: Showing a brief video in STD clinic waiting rooms reduced new infections nearly 10% overall in three clinics. This simple, low-intensity intervention may be appropriate for adoption by clinics that serve similar patient populations. TRIAL REGISTRATION: http://www.ClinicalTrials.gov (#NCT00137670).

Effects of a brief video intervention on treatment initiation and adherence among patients attending human immunodeficiency virus treatment clinics.

BACKGROUND: Persons with human immunodeficiency virus (HIV) who get and keep a suppressed viral load are unlikely to transmit HIV. Simple, practical interventions to help achieve HIV viral suppression that are easy and inexpensive to administer in clinical settings are needed. We evaluated whether a brief video containing HIV-related health messages targeted to all patients in the waiting room improved treatment initiation, medication adherence, and retention in care. METHODS AND FINDINGS: In a quasi-experimental trial all patients (N = 2,023) attending two HIV clinics from June 2016 to March 2017 were exposed to a theory-based, 29-minute video depicting persons overcoming barriers to starting treatment, taking medication as prescribed, and keeping medical appointments. New prescriptions at index visit, HIV viral load test results, and dates of return visits were collected through review of medical records for all patients during the 10 months that the video was shown. Those data were compared with the same variables collected for all patients (N = 1,979) visiting the clinics during the prior 10 months (August 2015 to May 2016). Among patients exposed to the video, there was an overall 10.4 percentage point increase in patients prescribed treatment (60.3% to 70.7%, p< 0.01). Additionally, there was an overall 6.0 percentage point improvement in viral suppression (56.7% to 62.7%, p< 0.01), however mixed results between sites was observed. There was not a significant change in rates of return visits (77.5% to 78.8%). A study limitation is that, due to the lack of randomization, the findings may be subject to bias and secular trends. CONCLUSIONS: Showing a brief treatment-focused video in HIV clinic waiting rooms can be effective at improving treatment initiation and may help patients achieve viral suppression. This feasible, low resource-reliant video intervention may be appropriate for adoption by other clinics treating persons with HIV. TRIAL REGISTRATION: http://www.ClinicalTrials.gov (NCT03508310).

Continued smoking and smoking cessation among urban young adult women: findings from the Reach for Health longitudinal study.

We examined smoking and smoking cessation among 538 young inner-city women who had been followed from early adolescence to young adulthood. Results showed that 14.3% of these young women had smoked in middle school, 26.4% had smoked in high school, and 21.9% had smoked at age 19 or 20 years, when many were rearing children, pregnant, or considering pregnancy. Young women who were raising children were more likely than those who were not to currently smoke or to have smoked in the past. Partner violence victimization was an independent risk factor for continued smoking. If improvements in smoking cessation rates are to be achieved, public health efforts must address factors underlying early and continued smoking.

Effectiveness of a Brief Home Parenting Intervention for Reducing Early Sexual Risks Among Latino Adolescents: Salud y Éxito.

BACKGROUND: Teen pregnancy rates and related risks remain elevated among Latino teens. We tested the impact on youth sexual behaviors of a brief, culturally targeted, bilingual media intervention designed for parents of young adolescents. METHODS: Salud y éxito (Health & Success) uses dramatic audio stories to model positive parenting practices. After completing classroom surveys, 27 urban schools in the Northeast and Southwest serving low-income Latino communities were randomized so that all families of seventh grade students were sent either: (1) booklets on healthy eating and exercise; (2) Salud-50, where families either received booklets or the intervention, or (3) Salud-100, where all families received the intervention. Postintervention follow-up surveys were conducted at 3- and 12-months. Multilevel analyses tested intervention effects, controlling for sociodemographics. RESULTS: Compared with controls, at 12-months postintervention (8th grade spring), youth in Salud-100 report lower sexual risks (touching, AOR 1.46, CI 1.19-0.84, p < .001; lifetime sex (AOR 0.74, CI 0.61-0.90, p < .01); and sex intentions (AOR 0.78, CI 0.63-0.96, p < .05). Consistent with a dose-response, Salud-50 results are between those from Salud-100 and control schools. CONCLUSIONS: Salud y éxito is an effective parenting intervention that can augment school-based health and sexuality education and help Latino parents support their children during early adolescence.

Associations of outside- and within-school adult support on suicidality: Moderating effects of sexual orientation.

This study examined sexual-orientation differences in reports of outside- and within-school adult support, and whether sexual orientation moderates the associations between adult support and suicidality (i.e., thoughts, plans, and attempts). At 26 high schools across MetroWest Boston, 22,834 students completed surveys assessing: sexual orientation (heterosexual, gay/lesbian, bisexual, or questioning); presence of outside- and within-school adult support; and past-year suicidality. Multivariable regression analyses with General Estimating Equations (adjusting for gender, grade, and race/ethnicity) examined sexual-orientation subgroup differences in adult support, and how sexual orientation and adult support were associated with suicidality. Interaction terms tested whether relationships between adult support and suicidality were moderated by sexual orientation. Gay/lesbian, bisexual, and questioning youth were each less likely than heterosexuals to report having outside-school adult support (risk ratios range: 0.85-0.89). Each group also had greater odds than heterosexuals for suicidal thoughts (odds ratios [ORs] range: 1.86-5.33), plans (ORs range: 2.15-5.22), and attempts (ORs range: 1.98-7.90). Averaged across sexual-orientation subgroups, outside-school support was more protective against suicidality (ORs range: 0.34-0.35) than within-school support (ORs range: 0.78-0.82). However, sexual orientation moderated the protective effects of outside-school adult support, with support being less protective for bisexual and questioning youth than for heterosexuals. Adult support, and particularly outside-school adult support, is associated with lower suicidality. However, fewer gay/lesbian, bisexual, and questioning youth can rely on outside-school support and, even if present, it may be less protective against suicidality. Interventions are needed to help adults support gay/lesbian, bisexual, and questioning youth and reduce suicidality disparities. (PsycINFO Database Record

Rethinking the bystander role in school violence prevention.

Public concerns about school shootings and safety draw attention to the role bystanders can play in preventing school violence. Although school violence prevention plans are often required, there is little guidance about whether these should address the roles of bystanders and what actions bystanders should take in different circumstances, from more common instances of bullying and fighting to rare, but potentially lethal, threats and use of weapons. Literature pertaining to bystanders is reviewed and applied to the school setting. The definition of bystander is expanded, including parents, teachers, and other school staff as well as youths and those who have information about potential violence as well as those who witness its occurrence. Barriers preventing bystanders from taking positive actions are discussed. The authors call on health promotion researchers and practitioners to work with school communities to identify norms, attitudes, and outcome expectancies that shape bystander behaviors to inform prevention efforts.

Saving Sex for Later: an evaluation of a parent education intervention.

CONTEXT: Initiation of sexual intercourse prior to high school is prevalent among inner-city black and Hispanic youths, and has multiple negative health and social consequences. A promising strategy for addressing early adolescent sexual activity is parent education that addresses normal pubertal changes and the challenges of becoming a teenager. METHODS: A 2003-2005 randomized trial to test the effectiveness of Saving Sex for Later, a parent education program presented on three audio CDs, enrolled 846 families with fifth- and sixth-grade students in seven New York City schools. Parent and youth surveys were conducted at baseline and three months postintervention. Multivariate logistic and linear regression analyses were performed to assess relationships between youth and parent outcomes and treatment condition. RESULTS: At follow-up, parents in the intervention group were significantly more likely than controls to score high on indexes of communication with children about targeted risk behaviors, self-efficacy to discuss pubertal development and sexuality, and perceived influence over youths' behaviors (odds ratios, 1.9-2.5). Youths in the intervention condition were more likely than controls to report high family support, and reported more family rules and fewer behavioral risks. Family support and rules partially mediate the relationship between treatment condition and behavioral risks. CONCLUSION: Saving Sex for Later is a promising intervention for promoting youths' sexual abstinence. The intervention may also be effective in enhancing positive parenting practices among parents who are typically difficult to reach because of economic hardship, full schedules and complicated lives.