Study concerning the design and functionality of individual emergency shelters.

The divide between the rich and poor in the European housing market is fast rising. Latest research indicates that Europe is dealing with an increasing number of homeless people. Every city in Europe has them-homeless people compelled to live on street corners, frequently hiding themselves with cardboard. Rain, snow, and temperatures below zero pose a threat to their lives on a daily basis. There are many varied kinds of services that have been discovered, but it is difficult to keep track of everyone and guarantee that they have a warm night's sleep in the winter. The current article suggests accommodation as a workaround until they can receive high-intensity support, a way to keep a single person warm and safe during the winter. The focus is on devising a strategy that not only ensures the warmth and safety of individuals during the harsh winter months but also seeks to industrialize the construction of shelters, ensuring affordability below the cost of winter hospitalization for a homeless person. Crucially, the article introduces an additional layer to this initiative by highlighting the dual purpose of these individual shelters. Beyond being a means to provide respite for the homeless during severe weather, these shelters are envisioned as immediate response units in the event of emergencies such as earthquakes in urban areas. The article explores the potential impact of this multi-layered approach on transforming urban landscapes and fostering resilient communities.

Formative Assessment and Cluster Membership of Homeless Persons' Emergency Department Visits.

Background Evidence is limited on whether homeless individuals who visit emergency departments (EDs) share similar clinical characteristics as individuals from private households who, upon examination, require emergency health services beyond preventative healthcare. While the literature is rich with studies on homeless persons in the ED, a comprehensive assessment of similarities and differences with other social groups is lacking. Consequently, there is a gap in knowledge as it pertains to the appropriate approaches that will further support the development of targeted healthcare and emergency health services for the homeless person. Aim The goal is to provide a framework for targeted interventions that hospitals can develop based on behavioral, health, and social characteristics and, in the process, better meet the healthcare needs of homeless patients. Methods Data were collected from the records of 85,350 patients in the National Hospital Ambulatory Medical Care Survey (NHAMCS) database who visited the ED between the years of 2013 and 2016; each patient was classified as having either a private residence, living in a nursing home, or homeless (n = 83,446, n = 1,459, and n = 925, respectively). Results Cluster analysis of the data confirmed that individuals with multiple comorbidities, as well as substance abuse or dependency, regardless of residence type, were more likely to have recurrent ED visits within 72 hours. Nominal regression analyses revealed that cluster membership generated from ED data could predict patient residence and suggest that substance abuse and depression can predict 72-hour ED visit recurrence. Conclusion Cluster analyses have the potential to reveal social health and group characteristics and can support targeted solutions respective to group individualities in the ED.

Organizational and patient factors associated with positive primary care experiences for veterans with current or recent homelessness.

OBJECTIVE: To identify organizational service features associated with positive patient ratings of primary care within primary care clinics tailored to accommodate persons with ongoing and recent experiences of homelessness (PEH). DATA SOURCES AND STUDY SETTING: PEH receiving primary care in 29 United States Veterans Health Administration homeless-tailored clinics were surveyed about their primary care experience using the validated Primary Care Quality-Homeless (PCQ-H) survey. Characteristics of the clinics were assessed through surveys of clinic staff using a new organizational survey developed through literature review, site visits, statistical analysis, and consensus deliberation. STUDY DESIGN: Cross-sectional examination of patients' ratings of care based on surveys of patients, and of clinic characteristics, analyzed with Classification and Regression Tree (CART) analysis, a form of machine learning. DATA COLLECTION METHODS: Patient surveys (n = 3394) were obtained from a random sample of enrolled patients by both mail and telephone by an external survey contractor. Staff (n = 52 from 29 clinics) were interviewed by telephone. PRINCIPAL FINDINGS: This analysis identified service features that impact patient experience favorably, including aspects of patient-centeredness, team identity, strong external leadership support, and service that reach beyond traditional primary care clinic confines. Results varied according to the patient experience scale analyzed. Individual characteristics of PEH, such as degree of social support, general health, and unsheltered status, were also correlated with how they rate care. CONCLUSIONS: Organizational characteristics correlate with ratings of primary care from patients with recent and ongoing homelessness. Primary care programs serving homeless individuals can assure better care based on who they hire, how they foster team identity, what services they provide, and the strength of leadership support to protect a homeless-focused mission.

Policy, Design, and Critical Reflections on Behavioral Health Crisis Services for People Experiencing Homelessness.

People experiencing homelessness in crisis have unique structural vulnerabilities and social needs, most importantly lack of housing. Ideal crisis services for people experiencing homelessness must safeguard against criminalization and displacement during periods of crisis, prioritize equity, and provide housing interventions alongside mental health treatment at every stage in the crisis continuum. By outlining how to tailor crisis system financing and accountability, service component and capacity, and clinical best practices, the authors aim to provide hope and guidance for communities aiming to create an ideal crisis system for people experiencing homelessness.

Transfer to community and prison mental health care from Ireland's main remand prison over three years: 2015-2017.

Background: The post-release period is associated with an increased risk of morbidity and mortality. Previous studies have identified deficits in pre-release planning for mentally ill people in prison, particularly in remand settings. Objectives: We aimed to determine the proportion of mentally ill people in Ireland's main remand prison who were referred for mental health follow up in community and prison settings, who achieved face to face contact with the receiving service. Method: This retrospective observational cohort study was based in Ireland's main male remand prison, Cloverhill. Participants included all those individuals on the caseload of the prison inreach mental health team who were referred for mental health follow up in community and prison settings at the time of discharge, prison transfer or release from custody over a three-year period, 2015 - 2017. Successful transfer of care (TOC) was defined as face-to-face contact with the receiving service, confirmed by written correspondence or by follow up telephone call. Clinical, demographic and offence related variables were recorded for all participants. Results: There were 911 discharges from the prison inreach mental health team within the three-year study period. Of these, 121 were admitted to hospital, 166 were transferred to other prison inreach mental health services and 237 were discharged to community based mental health follow up in psychiatric outpatient or primary care settings. One third (304/911) had an ICD-10 diagnosis of schizophreniform or bipolar disorder (F20-31) and 37.5% (161/911) were homeless. Over 90% (152/166) of those referred to mental health teams in other prisons achieved successful TOC, with a median of six days to first face-to face assessment. Overall, 59% (140/237) of those referred to community psychiatric outpatient or primary care services achieved TOC following referral on release from custody, with a median of nine days from release to assessment. Clinical and demographic variables did not differ between those achieving and not achieving successful TOC, other than having had input from the PICLS Housing Support Service. Conclusion: Successful transfer of care can be achieved in remand settings using a systematic approach with an emphasis on early and sustained interagency liaison and clear mapping of patient pathways. For incarcerated individuals experiencing homelessness and mental health disorders, provision of a housing support service was associated with increased likelihood of successful transfer of care to community mental health supports.

The beliefs and practices used to promote physical and mental health in youth who identify as lesbian, gay, bisexual, transgender, intersex, or queer plus (LGBTIQ+) experiencing housing insecurity: An integrative review.

PURPOSE: The purpose of this integrative review was to explore the beliefs and practices used to promote physical and mental health among youth ages 18-25 years, identifying as LGBTIQ+ experiencing housing insecurity. METHOD: The approach used strategies described by Whittemore and Knafl. Peer-reviewed, published research articles in English were identified using eight electronic databases. Eighteen research reports using qualitative, quantitative, and mixed methods were identified. Articles were evaluated for quality using the American Association of Critical Care Nurses Evidenced-Level Hierarchy evaluation tool. Data were analyzed and synthesized using Braun and Clarke's method. FINDINGS: Four themes related to the purpose were extracted: pervasive experiences of stigma and discrimination, constantly attuned to navigating risks, inconsistent engagement in health information and care, and inner strength developed through personal and community experiences. DISCUSSION: There are strong implications for future research, public health nursing practice, and health policy. Public health nurses should incorporate social determinants of health (addressing harmful social processes such as homophobia and racism) as well as a strength-based upstream approach in research, education, and health care practices. More research must also be done to assess engagement in physical and mental health information and care.

Digital access among a national sample of currently and formerly homeless veterans in 2022.

Background: Digital technologies are essential for connecting to the Internet and communicating with others. Methods: This study used data from the 2022 Project Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) survey, which surveyed a national sample of 1992 homeless-experienced veterans (HEV) about use of cell phones, smart phones, computers, laptops, and the Internet. Data were analyzed to compare currently and formerly homeless veterans on digital access and to identify characteristics associated with never using the Internet. Results: Over 75% of HEV reported having a cellphone and over 65% reported having a smartphone. Internet use was common among HEV as 74% of currently homeless veterans and 77% of formerly homeless veterans reported using the Internet. Among HEV who used the Internet, over 70% used the Internet at least weekly. There was no significant difference between currently and formerly homeless veterans on their Internet use in the total sample and subsamples of only black and only Hispanic veterans. Overall, HEV who were older, black non-Hispanic, and living in the Southeast were more likely to never use the Internet. Conclusions: These findings highlight the potential for technology-based interventions among HEV, and suggest a digital divide based on age, race, and geography.

Why some homeless individuals are unsheltered: A narrative review of self-reported reasons.

The rising rate of unsheltered homelessness is a troubling and important public health issue. This narrative review sought to answer the question: What are the reasons that homeless individuals report for being unsheltered? To identify studies, systematic search methods were applied to PubMed, Google Scholar, and PsycINFO databases using the following eligibility criteria: English-written, peer-reviewed studies published from 2000 to 2023 that reported qualitative or quantitative data related to reasons why homeless individuals in a Western country were unsheltered. After duplicates were removed, 14,690 studies were screened and filtered to 10 final studies that fit all eligibility criteria and were included in the review. Eight of the 10 studies reported qualitative data from interviews and focus groups; the two quantitative studies reported data from interviewer-administered surveys. Across studies, eight thematic categories were identified as barriers to staying in shelters or other sheltered locations: lack of safety, triggers for substance use, strict shelter rules, triggers for substance use, perceived inadequate care, unsanitary conditions, required treatment to participate in housing program, no pet or family accommodations, and lack of accessibility for individuals with disabilities. Together, these findings indicate the delicate balance needed in homeless shelters to have both an inclusive/permissive and structured/safe environment for homeless individuals. Attention to the design and operation of homeless shelters, as well as staff training and accommodation for clients with special needs may improve some of these issues.

Ações de assistência à saúde ofertadas à população em situação de rua: estado da arte / Healthcare actions offered to homeless people: state of the art

Resumo A população em situação de rua (PSR) vem aumentando nos últimos anos. Ações governamentais são implementadas para melhorar as condições de vida dessa população, especialmente as voltadas à assistência à saúde. Este estudo tem como questão norteadora: quais são as estratégias de atenção à saúde dos serviços e programas voltados à população em situação de rua no Brasil? O objetivo é analisar quais são as estratégias de atenção à saúde adotadas pelos serviços e programas voltados à população em situação de rua no Brasil. Foi realizada uma revisão sistemática da literatura nas bases de dados Biblioteca Virtual em Saúde (BVS), Literatura Latino Americana e do Caribe em Ciências da Saúde (Lilacs) e Scientific Eletronic Library Online (SciELO), tendo como resultado 21 artigos. A análise revelou os alcances e desafios das redes de atenção à saúde, indicando o uso de drogas como principal motivo para busca dos serviços, sendo o Consultório na Rua (CnaR) um dispositivo importante, capaz de promover a criação de vínculos entre a PSR e os demais setores de saúde. A importância do trabalho em rede e a complexidade do cuidado com a saúde de populações foram temas recorrentes nas discussões, pois tratam de ações destinadas a pessoas vulnerabilizadas, estigmatizadas, apresentando necessidades e singularidades no modo de viver em sociedade.

Abstract The number of homeless people (HP) has been increasing in recent years. Government actions have been implemented to improve the living conditions for this population, especially those focused on health care. This study has as research question: What are the healthcare strategies of services and programs being offered to the homeless population in Brazil? Its objective is to analyze the health care strategies adopted by services and programs offered to the homeless population in Brazil. To achieve this purpose, a search was conducted in the Virtual Health Library (VHL), Latin American and Caribbean Literature in Health Sciences (Lilacs), and Scientific Electronic Library Online (SciELO) databases, resulting in 21 articles. The analysis revealed the scope and challenges of the health care networks, indicating drug use as the main reason for seeking the services, with the Street Clinics (CnaR, Consultório na Rua) being an important service capable of promoting the creation of links between the HP and other sectors. of health. The importance of networking and the complexity of population health care were recurring topics in the discussions, as they deal with actions aimed at vulnerable and stigmatized people, showing needs and singularities in the way of living in society.

Housing status and accidental substance-related acute toxicity deaths in Canada, 2016-2017. / Recherche quantitative originale Statut résidentiel et décès accidentels attribuables à une intoxication aiguë liée à une substance au Canada, 2016-2017.

INTRODUCTION: There is a complex relationship between housing status and substance use, where substance use reduces housing opportunities and being unhoused increases reasons to use substances, and the associated risks and stigma. METHODS: In this descriptive analysis of people without housing who died of accidental substance-related acute toxicity in Canada, we used death investigation data from a national chart review study of substance-related acute toxicity deaths in 2016 and 2017 to compare sociodemographic factors, health histories, circumstances of death and substances contributing to death of people who were unhoused and people not identified as unhoused, using Pearson chi-square test. The demographic distribution of people who died of acute toxicity was compared with the 2016 Nationally Coordinated Point-In-Time Count of Homelessness in Canadian Communities and the 2016 Census. RESULTS: People without housing were substantially overrepresented among those who died of acute toxicity in 2016 and 2017 (8.9% versus <1% of the overall population). The acute toxicity event leading to death of people without housing occurred more often in an outdoor setting (24%); an opioid and/or stimulant was identified as contributing to their death more frequently (68%-82%; both contributed in 59% of their deaths); and they were more frequently discharged from an institution in the month before their death (7%). CONCLUSION: We identified several potential opportunities to reduce acute toxicity deaths among people who are unhoused, including during contacts with health care and other institutions, through harm reduction supports for opioid and stimulant use, and by creating safer environments for people without housing.

Role of homelessness and psychiatric disorders in suicide deaths among veterans: A four-way decomposition analysis.

Homelessness and suicide are top priorities in the U.S. Department of Veterans Affairs (VA). This study examined the various pathways involving homelessness, substance use, and mental health disorders in relation to suicide deaths among veterans in the VA healthcare system. A retrospective cohort study was conducted among 6,128,921 veterans-399,125 homeless and 5,729,796 non-homeless-followed-up between 2017 and 2021 using VA/Department of Defense linked databases. Multivariable Cox regression was applied for homelessness and psychiatric disorders as predictor of suicide deaths, sequentially controlling for demographic, clinical, substance use, and mental health characteristics. Four-way decomposition analysis was used to calculate proportions of suicide deaths mediated and/or moderated by homelessness, substance use, and mental health disorders. The relationship between homelessness and suicide-specific mortality risk was reduced from 40 % greater risk in unadjusted to 9 % greater risk in fully-adjusted models. Nearly 26 % of the total effect of homelessness on suicide-specific mortality risk was mediated by substance use disorders, whereas 49 % was mediated and 36 % was moderated by mental health disorders. In conclusion, excess suicide-specific mortality risk in homeless veterans is partly explained by substance use and mental health disorders, highlighting the importance of wrap-around health and social services for homeless veterans in mitigating suicide risk.

Advancing effective street outreach to people experiencing unsheltered homelessness: Concepts for public health nursing.

Homelessness, particularly unsheltered homelessness is a public health emergency in the U.S. Street outreach programs have demonstrated efficacy in connecting people to housing, initiating or retaining people in primary care, improving access to mental health services, and increasing treatment for substance use disorder. Effective outreach is generally characterized by trained, multidisciplinary teams that visit clients where they are, forming trusting relationships over time. Public health nurses working on outreach teams have opportunities to exercise their full scope and standards of practice and advance street outreach to the benefit of a distinctly marginalized group.

Comparative treatment of homeless persons with an infectious disease in the US emergency department setting: a retrospective approach.

BACKGROUND: Research has long documented the increased emergency department usage by persons who are homeless compared with their housed counterparts, as well as an increased prevalence of infectious diseases. However, there is a gap in knowledge regarding the comparative treatment that persons who are homeless receive. This study seeks to describe this potential difference in treatment, including diagnostic services tested, procedures performed and medications prescribed. METHODS: This study used a retrospective, cohort study design to analyse data from the 2007-2010 United States National Hospital Ambulatory Medical Care Survey database, specifically looking at the emergency department subset. Complex sample logistic regression analysis was used to compare variables, including diagnostic services, procedures and medication classes prescribed between homeless and private residence individuals seeking emergency department treatment for infectious diseases. Findings were then adjusted for potential confounding variables. RESULTS: Compared with private residence individuals, persons who are homeless and presenting with an infectious disease were more likely (adjusted OR: 10.99, CI 1.08 to 111.40, p<0.05) to receive sutures or staples and less likely (adjusted OR: 0.29, CI 0.10 to 0.87, p<0.05) to be provided medications when presenting with an infectious disease in US emergency departments. Significant differences were also detected in prescribing habits of multiple anti-infective medication classes. CONCLUSION: This study detected a significant difference in suturing/stapling and medication prescribing patterns for persons who are homeless with an infectious disease in US emergency departments. While some findings can likely be explained by the prevalence of specific infectious organisms in homeless populations, other findings would benefit from further research.

Traumatic Brain Injury and Its Risk Factors in a Homeless Population.

OBJECTIVE: To characterize the traumatic brain injury (TBI) profile and its associated risk factors in homeless individuals in Santa Clara County, CA. DESIGN: Observational cohort study. SETTING: Two homeless shelter health clinics in Santa Clara County, CA. PARTICIPANTS: Currently or recently homeless individuals seeking health care at 2 homeless shelter health clinics between August 2013 and May 2014. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographics, TBI incidence and characteristics. RESULTS: The findings indicate that TBI history in the homeless population was higher (79.7%) than in the general population (12%). Almost half of the population (49.2%) reported that their TBI occurred before the age of 18. Of the participants, 68.2% reported sustaining a TBI with loss of consciousness. TBI caused by violence (60%) was lower in this cohort than other homeless cohorts but was the main cause of injury regardless of age. Alcoholism was a risk factor for having more TBIs. No differences in TBI profile were found between sexes. CONCLUSIONS: Our findings underscore the need for more research on the lifetime risk factors associated with TBI to prevent and reduce the number of brain injuries in homeless populations.

Funding Health Care for People Experiencing Homelessness: An Examination of Federally Qualified Health Centers' Funding Streams and Homeless Patients Served (2014-2019).

It is estimated that three million people annually experience homelessness, with about a third of the homeless population being served by Federally Qualified Health Centers (FQHCs). Thus, FQHCs, dependent on government funding for financial viability, are vital to the infrastructure addressing the complex issues facing people experiencing homelessness. This study examines the relationship between various government funding streams and the number of homeless patients served by FQHCs. Data for this study come from three publicly available databases: the Uniform Data System (UDS), the IRS Core files, and the Area Resource File. Fixed-effects models employed examine changes across six years from 2014 to 2019. The results suggest that, on average, an additional homeless patient served increases the expenses of FQHCs more than other patients and that federal funding, specifically Health Care for the Homeless (HCH) funding, is a vital revenue source for FQHCs. We found that the number of homeless patients served is negatively associated with contemporaneous state and local funding but positively associated with substance use and anxiety disorders. Our findings have important implications for the effective management of FQHCs in the long term and for broader public policy supporting these vital elements of the social safety net.

Antecedents and Consequences of Violence in Homeless Shelters: Perspectives and Experiences of Service Users and Shelter Staff.

Violence is a critical issue in homeless shelters that affects service users and staff, yet there is limited evidence on how shelter-based violence occurs. The objective of this qualitative study was to investigate the antecedents and consequences of shelter-based violence from the perspectives of service users and staff. Purposive sampling was used to recruit individuals experiencing homelessness and shelter staff in a large metropolitan city in Ontario, Canada. Data from in-depth interviews with 56 individuals experiencing homelessness and 30 shelter staff were analyzed. Findings showed that shelter-based violence toward service users and staff was perceived to manifest in response to three interacting factors: (a) burden of homelessness and shelter living, (b) individual histories and marginalization, and (c) interpersonal conflict. These antecedents had a hierarchical structure in that each subsequent factor exacerbated the risk of previous ones and culminated with the most proximal factor for violence. There were three primary outcomes of shelter-based violence reported by service users and staff: (a) health and environmental harms, (b), procedural enforcement, and (c) avoidant behaviors. Avoidance was often a subsequent impact following health harms, as was procedural enforcement to a lesser extent. Overall, the study findings demonstrate that shelter-based violence is a complex and dynamic problem that is perceived to be the result of interacting structural, environmental, programmatic, interpersonal, and individual factors, with similar consequences for service users and staff. Implications for preventing violence through shelter design and service delivery are discussed.

What We (Don't) Know about the Infectious Disease Burden Among Youth Experiencing Homelessness in the United States and Canada.

Youth experiencing homelessness (YEH) and sexual and gender minority (SGM) YEH may be at increased risk for infectious diseases due to living arrangements, risk behaviors, and barriers to healthcare access that are dissimilar to those of housed youth and older adults experiencing homelessness. To better understand infectious diseases among YEH populations, we synthesized findings from 12 peer-reviewed articles published between 2012 to 2020 which enumerated YEH or SGM YEH infectious disease burden in locations across the U.S. or Canada. Pathogens presented in the studies were limited to sexually transmitted infections (STIs) and bloodborne infections (BBI). Only three studies enumerated infectious diseases among SGM YEH. There was a dearth of comparison data by housing status (ex., sheltered versus unsheltered youth), SGM identity, or other relevant counterfactual groups in the identified studies. We also introduce three publicly available, national-level surveillance datasets from the U.S. or Canada that quantify certain STIs, BBIs, and tuberculosis among YEH, which may be used for future disease burden assessments. Our review calls for more comprehensive YEH-centered research that includes multimodal data collection and timely disease surveillance to improve estimates of infectious diseases among this vulnerable population.

The global prevalence of mental health disorders among runaway and homeless youth: A meta-analysis.

A meta-analysis was performed to identify the pooled prevalence of mental health disorders (MHDs) among runaway and homeless youth (RHY). Relevant studies published between December 1, 1985, and October 1, 2023, were identified in the PubMed, Scopus, Web of Science, and Cochrane Library databases. A preliminary screening of 11,266 papers resulted in the inclusion of 101 studies. The pooled-prevalence estimates were obtained using a random-effects model. The findings showed varying lifetime prevalence rates of MHDs: 47% (conduct disorders and psychological distress), 43% (depression), 34% (major depressive disorders), 33% (post-traumatic stress disorder), 27% (personality disorders), 25% (attention-deficit/hyperactivity disorder), 23% (bipolar disorders), 22% (anxiety), 21% (oppositional defiant disorders), 15% (anorexia), 15% (adjustment disorders), 14% (dysthymia), 11% (schizophrenia), 9% (obsessive-compulsive disorders), and 8% (gambling disorder). The current prevalence rates were: 31% (depression), 23% (major depressive disorder), 23% (anxiety), 21% (post-traumatic stress disorder), 16% (attention-deficit/hyperactivity disorder), 15% (bipolar disorder), 13% (personality disorders), 13% (oppositional defiant disorders), 8% (schizophrenia), and 6% (obsessive-compulsive disorders). Regular screening and the implementation of evidence-based treatments and the promotion of integration and coordination between mental health services for adolescent minors and young adults with other service systems are recommended.

Drivers of Being Unhoused and the Prevalence of Health Conditions among Unhoused Individuals in Asheville, NC.

Background: During the COVID-19 pandemic, there was an increase in the number of unhoused individuals in Asheville, North Carolina resulting in more tent encampments.Understanding the physical, mental, and socially determined health characteristics associated with being unhoused can help guide stakeholders with policy development, healthcare program planning, and funding decisions to support unhoused individuals. Methods: In this study, we used an observational cross-section methodology. Using a convenience sample approach, we interviewed 101 participants who were receiving services from 2 emergency hotel shelters, a day center, and a resource center. Data were analyzed using descriptive statistics, and open-ended responses were collected and grouped to provide context. Results: Most participants were White (71%) and identified as male (76%). Over 60% reported having a high school education or advanced degree. Of the participants, 76% reported being unhoused for more than 6 months, and their last permanent housing was in Western North Carolina. Dental disease, chronic pain, and hypertension were common physical conditions. PTSD, depression, and anxiety were common mental health conditions. A lack of transportation was the most noted socially determined challenge. Marijuana, methamphetamine, and alcohol were the most often used substances, where methamphetamine was noted to be particularly problematic for the participants. Conclusion: Understanding the physical, mental, and social issues of the complex unhoused population can assist policymakers, healthcare providers, and other stakeholders in addressing challenges and testing improvement strategies.