Assessing Disparities in Cervical Cancer Screening with Pap Test by Disability Types.

Prior research has found that women with disabilities have often experienced disparities in receipt of cervical cancer screening. However, there is a research gap regarding receipt of cervical cancer screening by types of disability. This study examined the differences in receiving cervical cancer screening through self-reported Pap testing among women by disability type. This cross-sectional study analyzed data from the 2016, 2018, and 2020 Behavioral Risk Factor and Surveillance System (BRFSS). The relative risk of cervical cancer screening through self-reported Pap tests received within the past three years among women aged 21-65 by disability type was compared using modified Poisson regression with robust error variance. A total of 307,142 women from across the USA were sampled. In every disability group, older women were significantly less likely to receive Pap tests than their counterparts without disabilities. Women with multiple disabilities (aRR=0.91; 95% CI, 0.89-0.94) and those with ambulatory disabilities (aRR=0.93; 95% CI, 0.91-0.97) reported being less likely to receive Pap tests than women with no disability. Ambulatory disability and multiple disabilities are associated with a lower likelihood of cervical cancer screening with Pap test, increasing the need to eliminate disability-specific disparities in Pap testing. Future efforts should focus on improving cancer education programs tailored to the needs of women with disabilities, addressing barriers related to mobility and access to healthcare services, and ensuring equitable access to preventive screenings.

Enrollment and use of a peer counselor mHealth texting program to support breastfeeding in low-income people: A pilot study in the District of Columbia.

OBJECTIVE: To describe the characteristics of postpartum people who did and did not enroll in a breastfeeding peer-counselor mobile health (mHealth) texting program as well as the issues raised through 2-way texting with peer counselors. DESIGN: Pilot intervention study involving two Special Supplemental Nutrition Programs for Women Infants and Children (WIC) sites in the District of Columbia over 1 year. SAMPLE: WIC recipients. MEASUREMENTS: Descriptive statistics, comparison of recipients who enrolled or not and qualitative content analysis of text messages. INTERVENTION: A breastfeeding peer counselor texting program entitled BfedDC involving routine 1-way programmed messages and 2-way texting capacity for recipients to engage with peer counselors. RESULTS: Among our sample (n = 1642), nearly 90% initiated breastfeeding. A total of 18.5% (n = 304) enrolled in the BfedDC texting program, of whom 19.7% (n = 60) utilized the 2-way texting feature. Message content covered seven content themes and included inquiries about expressing human milk, breastfeeding difficulties, breastfeeding frequency and duration, appointments and more. CONCLUSIONS: Although enrollment was relatively low in BfedDC, benefits included 1-way supportive texts for breastfeeding and the ability to 2-way text with peer counselors. This program aligns with the Surgeon General's Call to Action to Support Breastfeeding and promotes breastfeeding equity in low-income people.

School Nurses' Experiences and Roles in Promoting and Administering the HPV Vaccine: A Systematic Review Using the Socioecological Framework.

Understanding the school nurse's experience in human papillomavirus (HPV) vaccine promotion can reduce vaccine disparities. HPV vaccination is critical to cancer prevention. Despite the importance of the school nurse in vaccine promotion, there is a lack of understanding. This article aims to examine the knowledge, attitude, experience, and role of school nurses related to HPV vaccination and promotion in school settings. A systematic search for school nurses and their experiences related to HPV vaccination was conducted. A thematic synthesis was undertaken using the socioecological model. This review highlights the complexity of HPV vaccine promotion in schools over time. Multilevel factors impact nursing practice. Nurses have good vaccine knowledge and positive attitudes. Poor workflow processes, competing demands, and vaccine communication challenge school nurses. The themes that were synthesized informed the LEADS model. With the support of school nurses, reaching the goal of eliminating cervical cancer as a public health problem is possible.

Moving the Needle: A Qualitative Exploration of the School Nurses' Experience with Virginia's Human Papillomavirus Mandate.

In all US localities, students provide proof of compliance with vaccination requirements to attend school. Despite benefits, vaccine legislation remains contentious. The human papillomavirus (HPV) vaccine is recommended for adolescents and prevents cancer, but its inclusion in school immunization requirements is challenged. Virginia was the first state to mandate HPV vaccination. HPV is the only required vaccine in VA that allows caregivers to elect out. School nurses are trusted members of communities and enforce vaccine compliance. This study aims to understand Virginia school nurses' practice in implementing the HPV vaccine mandate through the exploration of their subjective experiences. Semi-structured interviews were conducted. Thematic analysis using the socioecological model guided data analysis. Factors that influence nursing practice were identified at all socioecological model levels The data from this study is intended to provide an understanding of school nursing practice so that interventions to improve HPV vaccination rates can be developed.

Exploring the influence of behavioral factors on depression and anxiety scores during the COVID-19 pandemic: insights from the Virginia statewide COVIDsmart longitudinal study.

BACKGROUND: Amidst the COVID-19 pandemic, there has been growing concern about the declining mental health and healthy behaviors compared to pre-pandemic levels. Despite this, there is a lack of longitudinal studies that have examined the relationship between health behaviors and mental health during the pandemic. In response, the statewide COVIDsmart longitudinal study was launched. The study's main objective is to better understand the effects of the pandemic on mental health. Findings may provide a foundation for the identification of public health strategies to mitigate future negative impacts of the pandemic. METHODS: Following online recruitment in spring of 2021, adults, ages 18 to 87, filled out social, mental, economic, occupational, and physical health questionnaires on the digital COVIDsmart platform at baseline and through six monthly follow-ups. Changes in the participant's four health behaviors (e.g., tobacco and alcohol consumption, physical activity, and social media use), along with sex, age, loneliness score, and reported social and economic (SE) hardships, were analyzed for within-between group associations with depression and anxiety scores using Mixed Models Repeated Measures. RESULTS: In this study, of the 669 individuals who reported, the within-between group analysis indicated that younger adults (F = 23.81, p < 0.0001), loneliness (F = 234.60, p < 0.0001), SE hardships (F = 31.25, p < 0.0001), increased tobacco use (F = 3.05, p = 0.036), decreased physical activity (F = 6.88, p = 0.0002), and both positive and negative changes in social media use (F = 7.22, p = 0.0001) were significantly associated with worse depression scores. Additionally, females (F = 6.01, p = 0.015), younger adults (F = 32.30, p < 0.0001), loneliness (F = 154.59, p < 0.0001), SE hardships (F = 22.13, p < 0.0001), increased tobacco use (F = 4.87, p = 0.004), and both positive and negative changes in social media use (F = 3.51, p = 0.016) were significantly associated with worse anxiety scores. However, no significant changes were observed in the within-between group measurements of depression and anxiety scores over time (p > 0.05). Physical activity was not associated with anxiety nor was alcohol consumption with both depression and anxiety (p > 0.05). CONCLUSIONS: This study demonstrates the longitudinal changes in behaviors within the context of the COVID-19 pandemic. These findings may facilitate the design of preventative population-based health approaches during the COVID-19 pandemic or future pandemics.

A Multilevel Analysis of School-Level Human Papillomavirus Vaccination Coverage in Virginia.

School nurses improve public health through vaccine promotion and mandate compliance. Despite recommendations and support for comprehensive adolescent HPV vaccination from organizations like the National Association of School Nurses as of 2023 only Virginia, Washington DC, Rhode Island, and Hawaii mandate HPV vaccine in schools. Virginia's mandate allows caregivers to opt out of vaccination. It is important to consider how school-level vaccine compliance is associated with school and community factors. A multilevel analysis explored the association between school and county-level factors and HPV vaccination rates. This study shows schools that report higher rates of economically disadvantaged students had higher HPV vaccine coverage. HPV vaccine rates increased from 2019 to 2021 after the implementation of a gender-inclusive mandate. Virginia HPV rates still lag behind states with no mandate. The results suggest that school nursing practice related to HPV vaccine compliance may be impacted by community factors like economic status.

Disparities in Breastfeeding Initiation Among African American and Black Immigrant WIC Recipients in the District of Columbia, 2007-2019.

Objectives. To estimate differences in breastfeeding initiation (BFI) rates between African Americans and Black immigrants enrolled in the District of Columbia Special Supplemental Nutrition Program for Women, Infants and Children (WIC) between 2007 and 2019. Methods. We used data collected as part of routine WIC program activities for first-time mothers (n = 38 142). Using multivariable logistic regression models, we identified determinants of BFI for African Americans, Black immigrants, non-Hispanic Whites, and Hispanics. To assess the trend in BFI over time, we calculated the average of the annual percentage changes. Results. Compared with African Americans, Black immigrants had a 2.7-fold higher prevalence and Hispanics had a 5.8-fold higher prevalence of BFI. The average of the annual percentage changes was 0.85 for Hispanics, 3.44 for Black immigrants, 4.40 for Non-Hispanic Whites, and 4.40 for African Americans. African Americans had the only statistically significant change (P < .05). Disparities in BFI persisted over the study period, with African Americans demonstrating the lowest rates each year. Conclusions. Significant differences exist in BFI between Black immigrants and African Americans. Combining African Americans and Black immigrants masks important differences, overestimates rates among African Americans, and may lead to missed opportunities for targeting interventions and policies to improve breastfeeding. (Am J Public Health. 2022;112(4):671-674. https://doi.org/10.2105/AJPH.2021.306652).

Survival analysis of factors affecting the timing of COVID-19 non-pharmaceutical interventions by U.S. universities.

BACKGROUND: During March of 2020 the Centers for Disease Control and Prevention (CDC) announced non-pharmaceutical intervention (NPI) guidance as the primary mitigation strategy against growing COVID-19 community spread due to the absence of a vaccine or effective treatment at that time. CDC guidance states that NPIs are most effective when instituted in an early, targeted, and layered fashion. NPIs are effective in slowing spread, and measures should be custom-tailored to each population. This study examines factors associated with implementation and timing of NPI interventions across large public and private U.S. universities at the onset of the COVID-19 pandemic. METHODS: NPI decisions of interest include when U.S. universities canceled international travel, shifted to online learning, moved faculty/staff to remote work, limited campus housing, and closed campus for all non-essential personnel. Cox proportional hazard analyses of retrospective data were conducted to assess the time to NPI events. Hazard ratios were calculated for university governance, campus setting, religious affiliation, health infrastructure, faculty diversity, and student demographics. The methods control for variance inflation factors, COVID case prevalence, and time varying covariates of spring break and states' state of emergency (SOE) orders. This study captures NPI decisions at 575 U.S. universities during spring of 2020 which affected the movement of seven million students and two million employees. RESULTS: Universities located in districts represented by Democratic party congressional members reported earlier NPI implementation than Republican (Cox proportional hazard ratio (HR) range 0.61-0.80). University religious affiliation was not associated with the timing any of the NPI decisions. Universities with more diverse faculty showed an association with earlier NPI implementation (HR range 0.65-0.76). The existence of university-affiliated health infrastructure was not associated with NPI timing. CONCLUSION: University NPI implementation was largely driven by local COVID-19 epidemiology, culture and political concerns. The timing of university NPI decisions varied by regional politics, faculty demographics, university governance, campus setting, and foreign student prevalence adjusting for COVID-19 state case prevalence and spring break timing. Religious affiliation and presence of university health infrastructure were not associated with timing.

First nationwide seroepidemiology and risk factors report of Helicobater pylori in Jordan.

BACKGROUND AND AIM: Helicobacter pylori inhabits the gastric mucosa of humans and causes 89% of all gastric cancers. This is the first study of the seroprevalence, spatial distribution, and risk factors for H pylori in Jordan. MATERIALS AND METHODS: This is a cross-sectional study of 460 healthy participants (aged between 15 and 81 years) proportionately sampled across each region of Jordan. Sera samples were tested for H pylori using Enzygnost® anti-H pylori immunoglobulin G enzyme-linked immunosorbent assay. Participants completed a validated questionnaire about potential risk factors including food consumption habits and environmental and animal exposure. Multivariate generalized linear models identified risk factors for infection. RESULTS: The results showed a high seroprevalence (88.6%; 95% confidence interval [CI]: 85.3-91.2) of H pylori in the study population. After adjusting for possible confounders, age, consumption of raw milk, and location of residence were significantly associated with seropositivity. Older participants aged 30-49 years had an 11% greater risk of seropositivity compared to participants aged 15-29 years. Participants who consume raw milk and dairy products have a 9% decreased risk in seropositivity (prevalence ratio = 0.92; 95% CI: 0.84-0.99) compared to those who do not consume these products. CONCLUSION: This study reports a negative association between consumption of raw milk and seropositivity, and this is in line with several studies that report consumption of raw milk may be protective against H pylori. However, because of the risk of other serious pathogens associated with the consumption of raw dairy products, this study recommends pasteurization of raw milk. Future studies on the effect of fermented dairy products on H pylori colorization in gastric mucosa are recommended.

The Risk of Tuberculosis among Populations Living in Slum Settings: a Systematic Review and Meta-analysis.

According to the WHO, half of the 10.4 million incident cases of TB in 2016 came from five countries where 20-50% of the urban population live in slums. Crowded living conditions and limited access to healthcare further contribute to the burden of TB in urban slums. This article aims to assess the odds of the burden of TB in urban slums through a systematic review and meta-analysis. Four electronic databases were searched for studies published between 1993 and 2017, with TB defined as at least one sputum smear-positive. The review followed the PRISMA protocol and information was extracted from articles for a full-text review to determine eligibility. Odds ratios were calculated for studies reporting sputum smear-positive TB cases in slum settings with national incidence as a comparison. Summary estimates were calculated using the random effects model (95% CI) and publication bias was assessed through funnel plot analysis. A quality assessment of included articles was also conducted. This meta-analysis was conducted across three categories: (1) across all 22 studies, (2) studies utilizing Active Case Finding, and (3) studies conducted in a high TB-HIV setting. The odds of sputum smear-positive TB were significantly higher across all three categories of analysis. Compared with national TB incidence rates, the combined odds ratio of smear-positive TB within slums was 2.96 (2.84, 3.09; p < 0.01). The combined odds ratio for smear-positive TB with active case finding across 15 studies was 2.85 (2.71, 2.99; p < 0.01). Among the 11 studies that reported incidence of smear-positive TB with prevalent TB-HIV coinfection in the community, the combined odds ratio for slum residents with the random effects model was 2.48 (2.34, 2.63; p < 0.01). Using Egger's funnel plot, publication bias was not detected within the three categories of analysis. The findings of this analysis indicate that the odds of developing TB are almost five times as great in urban slums. Reaching the most vulnerable and often overlooked groups in slums is crucial to achieving the SDGs and End TB Strategy by 2035.

Food Consumption Patterns of Infants and Toddlers: Findings from the Feeding Infants and Toddlers Study (FITS) 2016.

Background: The prevalence of obesity and type 2 diabetes continues to increase. These conditions disproportionately affect minorities and are associated with poor nutrition early in life. Current food-consumption patterns can inform pending dietary guidelines for infants and toddlers. Objective: The aim of this study was to describe infant feeding, complementary feeding, and food and beverage consumption patterns of 0- to 23.9-mo-olds in the general population. Methods: The Feeding Infants and Toddlers Study 2016 is a cross-sectional survey of caregivers of children aged <4 y. Dietary data were collected from a national random sample by using a 24-h dietary recall (n = 3235). The percentage of children consuming foods from >400 food groups was calculated. Differences in the percentage consuming between Hispanic, non-Hispanic white, and non-Hispanic black children aged 0-23.9 mo were evaluated with the use of ORs and 95% CIs. Results: Eighty-three percent of 0- to 23.9-mo-olds (n = 2635) were ever breastfed, 34% of 0- to 3.9-mo-olds (n = 305) and 15% of 4- to 5.9-mo-olds (n = 295) were exclusively breastfed, and 24% of 12- to 14.9-mo-olds (n = 412) consumed breast milk on the day of the recall. Complementary foods were more likely to be introduced before 4 mo in formula-fed infants (27%) than in infants who did not consume formula (5%). Half of 4- to 5.9-mo-olds consumed iron-fortified infant cereal, but few consumed iron-rich meats. Among toddlers (12-23.9 mo; n = 1133), >20% consumed no servings of fruit or vegetables on the day of the recall, approximately half consumed 100% fruit juice, and one-quarter to one-third consumed a sugar-sweetened beverage (SSB). Conclusions: Breastfeeding initiation and duration have improved, but exclusivity remains low. Low consumption of iron-rich foods, fruit, and vegetables and lack of variety in vegetable consumption are problems. Efforts to reduce the consumption of SSBs and 100% fruit juice are warranted in early childhood.

Major diseases, extensive misuse, and high antimicrobial resistance of Escherichia coli in large- and small-scale dairy cattle farms in Jordan.

This study aimed to determine the major diseases, antimicrobial use, and resistance in commensal Escherichia coli in dairy cattle in Jordan. Forty-three (large, n = 21; small, n = 22) farms were surveyed. A validated questionnaire was administered to the herdsmen to elicit information about disease prevalence, antimicrobial knowledge, and antimicrobial use. In addition, fecal samples were collected from 5 lactating animals on each farm. A total of 520 E. coli isolates were tested for resistance to 12 antimicrobials. From the herdsmen's perspective, the diseases that require use of veterinary services in large and small production systems were mastitis (51.2%), metritis (51.2%), and enteritis (39.5%), and the most commonly used antimicrobials were oxytetracycline and streptomycin. Dairy herdsmen (83.7%) reported that it is easy to purchase antimicrobials without a veterinary prescription and 97.7% of them more frequently changed the antimicrobial drug rather than increasing the dose when presented with nonresponse to treatment. Escherichia coli isolates exhibited high resistance to streptomycin (47.5%), tetracycline (45.4%), and ampicillin (34.2%). Less than 10% of isolates were resistant to chloramphenicol, kanamycin, gentamicin, ciprofloxacin, and ceftriaxone. Overall, 64.6 and 37.1% of the E. coli isolates exhibited resistance to ≥1 antimicrobial and multidrug resistance (resistance to ≥3 antimicrobial classes), respectively. The isolates exhibited 107 antimicrobial resistance profiles. This study indicates that antimicrobials are frequently misused in dairies in Jordan and that resistance among commensal E. coli toward antimicrobials of human and veterinary importance is high. Therefore, educational programs for herdsmen and enacting regulations and guidelines are necessary to promote the judicious use of antimicrobials in dairy animals in Jordan.

High prevalence and antimicrobial resistance of mecA Staphylococcus aureus in dairy cattle, sheep, and goat bulk tank milk in Jordan.

The aim of this study was to determine the prevalence and antimicrobial resistance of mecA and mecC methicillin-resistant Staphylococcus aureus (MRSA) in cattle, sheep, and goat dairy farms in Jordan. Milk samples were collected from bulk tanks at 117 dairy farms (44 cattle, 47 sheep, and 26 goat dairy farms) in each region of the country. MRSA were isolated on mecA and mecC chromogenic media and confirmed by PCR. The confirmed isolates were tested for resistance toward 15 antimicrobials by the disc diffusion method. None of the tested bulk milk samples were positive for mecC and 26% (95% CI 20-32%) were positive for mecA MRSA. Specifically, mecA MRSA was detected in 31.8% (95% CI 17.5-46.1) of cattle, 29.8% (95% CI 16.2-43.4) of sheep, and 11.5% (95% CI - 1.6-24.7%) of goat dairy farms. All isolates (n = 86) exhibited resistance to penicillin, oxacillin, cefoxitin; meanwhile, most isolates (70-85%) exhibited resistance toward gentamicin, clindamycin, rifampicin, neomycin, fusidic acid, erythromycin, tetracycline, and ciprofloxacin. All mecA MRSA isolates were resistant to at least one class of antimicrobials. Isolates from all goat milk, 88% of cattle milk, and 87% of sheep milk samples exhibited resistance to three classes of antimicrobials and were considered multidrug resistant (MDR). These data demonstrate widespread MDR MRSA in dairy ruminants in Jordan, and these rates are higher than those reported in other countries. Such high prevalence of MDR MRSA and mecA MRSA could lead to economic losses in the dairy industry in Jordan and poses a possible public health risk.

Knowledge Gained and Retained from a Video-Centered, Community-Based Intervention for Ebola Prevention, Congo.

There are few effective communication interventions to respond to Ebola Virus Disease (EVD) outbreaks, and their development is a continuing challenge. The largest outbreak of EVD was first recognized in 2014 and once again highlighted the need for health education communication campaigns. EVD emergence and transmission are associated with behaviors that increase exposure to infected individuals and infected wildlife. In 2008-2009, an educational video-centered intervention consisting of a film followed by a structured discussion was developed to improve EVD knowledge, attitudes, and behaviors (KABs) for prevention of EVD and care of infected people. The film was produced for a Congolese audience in local languages and features doctors and residents from the region. The objective of the study was to assess the effectiveness of this intervention to change KABs related to EVD. The intervention was conducted over 12 months and reached >60,000 people; 220 individuals were sampled before and immediately after the intervention, and a subsample of 53 who had received the intervention 1 year earlier were interviewed to assess changes in KABs related to EVD. Statistically significant improvements in EVD recognition, transmission, and mitigation of risk after the intervention were observed. This study also demonstrates significant retention of knowledge one year after the intervention. Overall, the intervention was effective in improving KABs among a limited literacy population and knowledge was retained for more than one year. The materials and approaches developed were used in 2014 as part of a social mobilization strategy in response to an Ebola outbreak in the Congo Basin.

Assessing seasonality of travel distance to harm reduction service providers among persons who inject drugs.

BACKGROUND: Prior research has examined access to syringe exchange program (SEP) services among persons who inject drugs (PWID), but no research has been conducted to evaluate variations in SEP access based on season. This is an important gap in the literature given that seasonal weather patterns and inclement weather may affect SEP service utilization. The purpose of this research is to examine differences in access to SEPs by season among PWID in the District of Columbia (DC). FINDINGS: A geometric point distance estimation technique was applied to records from a DC SEP that operated from 1996 to 2011. We calculated the walking distance (via sidewalks) from the centroid point of zip code of home residence to the exchange site where PWID presented for services. Analysis of variance (ANOVA) was used to examine differences in walking distance measures by season. Differences in mean walking distance measures were statistically significant between winter and spring with PWID traveling approximately 2.88 and 2.77 miles, respectively, to access the SEP during these seasons. CONCLUSIONS: The results of this study suggest that seasonal differences in SEP accessibility may exist between winter and spring. PWID may benefit from harm reduction providers adapting their SEP operations to provide a greater diversity of exchange locations during seasons in which inclement weather may negatively influence engagement with SEPs. Increasing the number of exchange locations based on season may help resolve unmet needs among injectors.

Vaccine Attitudes and Uptake Among Latino Residents of a Former COVID-19 Hotspot.

Early in the COVID-19 pandemic, the Centers for Disease Control and Prevention identified Prince William County (PWC), Va. as a hotspot with a high disease rate among Latinos. This study uses spatial, survey, and qualitative data to understand attitudes towards vaccine uptake among PWC Latinos. A quantitative analysis (n=266) estimates the association for vaccine acceptance among Latinos. Next, qualitative interviews with Latinos (n=37) examine vaccine attitudes. Finally, a spatial analysis identifies clusters of social vulnerability and low vaccine uptake in PWC and adjacent counties. Our findings show that a substantial proportion of PWC Latinos had low vaccination rates as of December 2022, two years after the vaccine's release. Side effects and safety and approval concerns were cited in both the quantitative and qualitative studies. Persistent vaccine disparities are concerning given the high hospitalization and mortality rates that prevailed among Latinos early in the pandemic.

Association Between Firearm Purchasing in Response to the COVID-19 Pandemic and Symptoms of Anxiety, Depression, and Stress, August 2021.

Introduction: Firearm sales and firearm-related injuries and deaths increased during the pandemic. Little is known about motivations for firearm purchasing in response to the COVID-19 pandemic and the mental health status of first-time purchasers. The purpose of this study was to estimate the association between firearm purchasing in response to the COVID-19 pandemic and anxiety symptoms, depressive symptoms, and stress. Methods: The authors analyzed data from a survey that approximated a nationally representative sample of American adults (N=3,528) who either did not own firearms (n=2,327) or purchased firearms for the first time in response to the pandemic (n=240). Self-reported stress, depressive symptoms, and anxiety symptoms were determined using standardized self-assessment questionnaires (Perceived Stress Scale, Patient Health Questionnaire, and Depression Anxiety Stress Scale, respectively). Using multivariable logistic regression, the association between firearm purchasing and each mental health measure were assessed after controlling for demographics and other determinants. Results: In each model, first-time firearm owners were more likely to be younger, live in urban areas, believe the government does too much for its citizens, stay home, stock up on items, and keep their children at home. First-time owners had significantly higher odds of anxiety and depressive symptoms than non-owners (AOR=1.05; 95% CI=1.04, 1.07 and AOR=1.15; 95% CI=1.04, 1.26, respectively). Conclusions: First-time firearm purchasers report higher depressive and anxiety symptoms than non-owners, suggesting that there may be a risk of suicide and other related firearm violence.