Through the big top: An exploratory study of circus-based artistic knowledge translation in rural healthcare services, Québec, Canada.

BACKGROUND: The conventional methods and strategies used for knowledge translation (KT) in academic research often fall short in effectively reaching stakeholders, such as citizens, practitioners, and decision makers, especially concerning complex healthcare issues. In response, a growing number of scholars have been embracing arts-based knowledge translation (ABKT) to target a more diverse audience with varying backgrounds and expectations. Despite the increased interest, utilization, and literature on arts-based knowledge translation over the past three decades, no studies have directly compared traditional knowledge translation with arts-based knowledge translation methods. Thus, our study aimed to evaluate and compare the impact of an arts-based knowledge translation intervention-a circus show-with two traditional knowledge translation interventions (webinar and research report) in terms of awareness, accessibility, engagement, advocacy/policy influence, and enjoyment. METHODS: To conduct this exploratory convergent mixed method study, we randomly assigned 162 participants to one of the three interventions. All three knowledge translation methods were used to translate the same research project: "Rural Emergency 360: Mobilization of decision-makers, healthcare professionals, patients, and citizens to improve healthcare and services in Quebec's rural emergency departments (UR360)." RESULTS: The findings revealed that the circus show outperformed the webinar and research report in terms of accessibility and enjoyment, while being equally effective in raising awareness, increasing engagement, and influencing advocacy/policy. Each intervention strategy demonstrates its unique array of strengths and weaknesses, with the circus show catering to a diverse audience, while the webinar and research report target more informed participants. These outcomes underscore the innovative and inclusive attributes of Arts-Based Knowledge translation, showcasing its capacity to facilitate researchers' engagement with a wider array of stakeholders across diverse contexts. CONCLUSION: As a relevant first step and a complementary asset, arts-based knowledge translation holds immense potential in increasing awareness and mobilization around crucial health issues.

Thematic analysis of tools for health innovators and organisation leaders to develop digital health solutions fit for climate change.

OBJECTIVES: While ethicists have largely underscored the risks raised by digital health solutions that operate with or without artificial intelligence (AI), limited research has addressed the need to also mitigate their environmental footprint and equip health innovators as well as organisation leaders to meet responsibility requirements that go beyond clinical safety, efficacy and ethics. Drawing on the Responsible Innovation in Health framework, this qualitative study asks: (1) what are the practice-oriented tools available for innovators to develop environmentally sustainable digital solutions and (2) how are organisation leaders supposed to support them in this endeavour? METHODS: Focusing on a subset of 34 tools identified through a comprehensive scoping review (health sciences, computer sciences, engineering and social sciences), our qualitative thematic analysis identifies and illustrates how two responsibility principles-environmental sustainability and organisational responsibility-are meant to be put in practice. RESULTS: Guidance to make environmentally sustainable digital solutions is found in 11 tools whereas organisational responsibility is described in 33 tools. The former tools focus on reducing energy and materials consumption as well as pollution and waste production. The latter tools highlight executive roles for data risk management, data ethics and AI ethics. Only four tools translate environmental sustainability issues into tangible organisational responsibilities. CONCLUSIONS: Recognising that key design and development decisions in the digital health industry are largely shaped by market considerations, this study indicates that significant work lies ahead for medical and organisation leaders to support the development of solutions fit for climate change.

Integrating environmental considerations in digital health technology assessment and procurement: Stakeholders' perspectives.

Background: Digital health technologies (DHTs) are promoted as means to reduce the environmental impact of healthcare systems. However, a growing literature is shedding light on the highly polluting nature of the digital industry and how it exacerbates health inequalities. Thus, the environmental footprint of DHTs should be considered when assessing their overall value to healthcare systems. The objectives of this article are to: (1) explore stakeholders' perspectives on integrating the environmental impacts of DHTs in assessment and procurement practices; (2) identify the factors enabling or constraining the operationalisation of such a change; and (3) encourage a constructive dialogue on how environmental issues fit within healthcare systems' push for more DHTs. Methods: Semi-structured interviews were conducted with 29 stakeholders involved in DHTs in a large Canadian academic healthcare centre. Data were collected and analysed through a mixed deductive-inductive process using a framework derived from diffusion of innovations theories. Results: The integration of the environmental impact of DHTs in assessment and procurement is contingent upon key micro-meso-macrosystemic factors that either enable or constrain changes in practices and processes. Innovation (micro) factors include stakeholders' recognition of the environmental issue and the extent to which it is feasible for them to address the environmental impact of DHTs. Organisational (meso) factors include the organisation's culture, leadership, policies, and practices, as well as the expertise and professional skillsets available. Finally, external (macro) factors include political and regulatory (e.g., national strategy, laws, standards, norms), economic (e.g., business models, public procurement), and professional and scientific factors (e.g., evidence, methodologies, clinical guidelines). Conclusion: Considering the environmental impact of DHTs depends on micro-meso-macrosystemic factors involving a variety of stakeholders and levels of governance, sometimes with divergent or even antagonistic objectives and expectations. It highlights the importance of better understanding the complexity inherent in the environmental shift in healthcare.

Assessing healthcare capacity crisis preparedness: development of an evaluation tool by a Canadian health authority.

Introduction: The COVID-19 pandemic presented health systems across the globe with unparalleled socio-political, ethical, scientific, and economic challenges. Despite the necessity for a unified, innovative, and effective response, many jurisdictions were unprepared to such a profound health crisis. This study aims to outline the creation of an evaluative tool designed to measure and evaluate the Vitalité Health Network's (New Brunswick, Canada) ability to manage health crises. Methods: The methodology of this work was carried out in four stages: (1) construction of an evaluative framework; (2) validation of the framework; (3) construction of the evaluative tool for the Health Authority; and (4) evaluation of the capacity to manage a health crisis. Results: The resulting evaluative tool incorporated 8 dimensions, 74 strategies, and 109 observable elements. The dimensions included: (1) clinical care management; (2) infection prevention and control; (3) governance and leadership; (4) human and logistic resources; (5) communication and technologies; (6) health research; (7) ethics and values; and (8) training. A Canadian Health Authority implemented the tool to support its future preparedness. Conclusion: This study introduces a methodological strategy adopted by a Canadian health authority to evaluate its capacity in managing health crises. Notably, this study marks the first instance where a Canadian health authority has created a tool for emergency healthcare management, informed by literature in the field and their direct experience from handling the SARS-CoV-2 pandemic.

A Comprehensive, Valid, and Reliable Tool to Assess the Degree of Responsibility of Digital Health Solutions That Operate With or Without Artificial Intelligence: 3-Phase Mixed Methods Study.

BACKGROUND: Clinicians' scope of responsibilities is being steadily transformed by digital health solutions that operate with or without artificial intelligence (DAI solutions). Most tools developed to foster ethical practices lack rigor and do not concurrently capture the health, social, economic, and environmental issues that such solutions raise. OBJECTIVE: To support clinical leadership in this field, we aimed to develop a comprehensive, valid, and reliable tool that measures the responsibility of DAI solutions by adapting the multidimensional and already validated Responsible Innovation in Health Tool. METHODS: We conducted a 3-phase mixed methods study. Relying on a scoping review of available tools, phase 1 (concept mapping) led to a preliminary version of the Responsible DAI solutions Assessment Tool. In phase 2, an international 2-round e-Delphi expert panel rated on a 5-level scale the importance, clarity, and appropriateness of the tool's components. In phase 3, a total of 2 raters independently applied the revised tool to a sample of DAI solutions (n=25), interrater reliability was measured, and final minor changes were made to the tool. RESULTS: The mapping process identified a comprehensive set of responsibility premises, screening criteria, and assessment attributes specific to DAI solutions. e-Delphi experts critically assessed these new components and provided comments to increase content validity (n=293), and after round 2, consensus was reached on 85% (22/26) of the items surveyed. Interrater agreement was substantial for a subcriterion and almost perfect for all other criteria and assessment attributes. CONCLUSIONS: The Responsible DAI solutions Assessment Tool offers a comprehensive, valid, and reliable means of assessing the degree of responsibility of DAI solutions in health. As regulation remains limited, this forward-looking tool has the potential to change practice toward more equitable as well as economically and environmentally sustainable digital health care.

A conceptualisation of scale-up and sustainability of social innovations in global health: a narrative review and integrative framework for action.

BACKGROUND: The scale-up and sustainability of social innovations for health have received increased interest in global health research in recent years; however, these ambiguous concepts are poorly defined and insufficiently theorised and studied. Researchers, policymakers, and practitioners lack conceptual clarity and integrated frameworks for the scale-up and sustainability of global health innovations. Often, the frameworks developed are conceived in a linear and deterministic or consequentialist vision of the diffusion of innovations. This approach limits the consideration of complexity in scaling up and sustaining innovations. OBJECTIVE: By using a systems theory lens and conducting a narrative review, this manuscript aims to produce an evidence-based integrative conceptual framework for the scale-up and sustainability of global health innovations. METHOD: We conducted a hermeneutic narrative review to synthetise different definitions of scale-up and sustainability to model an integrative definition of these concepts for global health. We have summarised the literature on the determinants that influence the conditions for innovation success or failure while noting the interconnections between internal and external innovation environments. RESULTS: The internal innovation environment includes innovation characteristics (effectiveness and testability, monitoring and evaluation systems, simplification processes, resource requirements) and organisational characteristics (leadership and governance, organisational change, and organisational viability). The external innovation environment refers to receptive and transformative environments; the values, cultures, norms, and practices of individuals, communities, organisations, and systems; and other contextual characteristics relevant to innovation development. CONCLUSION: From these syntheses, we proposed an interconnected framework for action to better guide innovation researchers, practitioners, and policymakers in incorporating complexity and systemic interactions between internal and external innovation environments in global health.

The 'wrong pocket' problem as a barrier to the integration of telehealth in health organisations and systems.

The COVID-19 pandemic has accelerated the deployment of telehealth services in many countries around the world. It also revealed many barriers and challenges to the use of digital health technologies in health organisations and systems that have persisted for decades. One of these barriers is what is known as the 'wrong pocket' problem - where an organisation or sector makes expenditures and investments to address a given problem, but the benefits (return on investment) are captured by another organisation or sector (the wrong pocket). This problem is the origin of many difficulties in public policies and programmes (e.g. education, environment, justice and public health), especially in terms of sustainability and scaling-up of technology and innovation. In this essay/perspective, we address the wrong pocket problem in the context of a major telehealth project in Canada. We show how the problem of sharing investments and expenses, as well as the redistribution of economies among the different stakeholders involved, may have threatened the sustainability and scaling-up of this project, even though it has demonstrated the clinical utility and contributed to improving the health of populations. In conclusion, the wrong pocket problem may be decisive in the reduced take-up, and potential failure, of certain telehealth programmes and policies. It is not enough for a telehealth service to be clinically relevant and 'efficient', it must also be mutually beneficial to the various stakeholders involved, particularly in terms of the equitable sharing of costs and benefits (return on investment) associated with the implementation of this new service model. Finally, the wrong pocket concept offers a helpful lens for studying the success, sustainability, and scale-up of digital transformations in health organisations and systems. This needs to be considered in future research and evaluations in the field.

An urgent call for the environmental sustainability of health systems: A 'sextuple aim' to care for patients, costs, providers, population equity and the planet.

Health systems have a duty to protect the health and well-being of individuals and populations. Yet, healthcare contributes about 4.6% of global greenhouse gas emissions. Health systems need to question and improve established practices, assume strong environmental leadership, and aim for ambitious, sometimes radical, actions in favour of the climate. In this paper, we interrogate the suitability and feasibility of integrating the aim of 'environmental sustainability' to form the 'Sextuple Aim.' Environmental sustainability may be in tension with, but also a potential lever to meet the other cardinal aims: (1) quality and experience of patient care; (2) population health; (3) quality of work and satisfaction of healthcare providers; (4) equity and inclusion; and (5) cost reduction. We propose policy and practical avenues to help move towards the Sextuple Aim.

Virtual Care and the Inverse Care Law: Implications for Policy, Practice, Research, Public and Patients.

Virtual care spread rapidly at the outbreak of the COVID-19 pandemic. Restricting in-person contact contributed to reducing the spread of infection and saved lives. However, the benefits of virtual care were not evenly distributed within and across social groups, and existing inequalities became exacerbated for those unable to fully access to, or benefit from virtual services. This "perspective" paper discusses the extent to which challenges in virtual care access and use in the context of COVID-19 follow the Inverse Care Law. The latter stipulates that the availability and quality of health care is inversely proportionate to the level of population health needs. We highlight the inequalities affecting some disadvantaged populations' access to, and use of public and private virtual care, and contrast this with a utopian vision of technology as the "solution to everything". In public and universal health systems, the Inverse Care Law may manifests itself in access issues, capacity, and/or lack of perceived benefit to use digital technologies, as well as in data poverty. For commercial "Direct-To-Consumer" services, all of the above may be encouraged via a consumerist (i.e., profit-oriented) approach, limited and episodic services, or the use of low direct cost platforms. With virtual care rapidly growing, we set out ways forward for policy, practice, and research to ensure virtual care benefits for everyone, which include: (1) pay more attention to "capabilities" supporting access and use of virtual care; (2) consider digital technologies as a basic human right that should be automatically taken into account, not only in health policies, but also in social policies; (3) take more seriously the impact of the digital economy on equity, notably through a greater state involvement in co-constructing "public health value" through innovation; and (4) reconsider the dominant digital innovation research paradigm to better recognize the contexts, factors, and conditions that influence access to and use of virtual care by different groups.

Strategizing Research for Impact.

In its Strategic Plan 2021-2026, the Canadian Institutes of Health Research - Institute of Health Services and Policy Research (IHSPR) convincingly expresses its desire to expand capacity for applied health services and policy research (HSPR) and better mobilize research results for health system transformation geared toward the Quadruple Aim and health equity for all (CIHR IHSPR 2021). These strategic priorities echo views widely shared within the HSPR community, and we commend IHSPR for its leadership and vision. Recognizing the systemic challenges ahead of us, this commentary considers the HSPR community's capacity to achieve the promise of learning health systems, given the obstacles likely to hinder their rapid scale-up over the next five years. Next, we consider the spread of virtual care during the pandemic to illustrate the embedded and negotiated nature of innovation in health systems and the need for vigilance as to the social distribution of their benefits and costs. Finally, a critical review of the strategic plan provides insights into how research is governed in the HSPR field. Based on this analysis, it appears essential to reconsider health system transformation as social system transformation and strengthen interdisciplinary and comparative research. Looking forward, developing a science of science to better understand the conditions associated with high-impact research should be a cross-cutting priority for Canada's HSPR community.

Challenges to the implementation and adoption of physical distancing measures against COVID-19 by internally displaced people in Mali: a qualitative study.

BACKGROUND: For almost a decade now, Mali has been facing a security crisis that led to the displacement of thousands of people within the country. Since March 2020, a health crisis linked to the COVID-19 pandemic also surfaced. To overcome this health crisis, the government implemented some physical distancing measures but their adoption proved difficult, particularly among internally displaced people (IDPs). The objective of this study is to identify the challenges relating to the implementation and adoption of physical distancing measures and to determine the main mitigation measures taken by IDPs to adjust to these new policies. METHODS: An exploratory qualitative research was conducted in Bamako and Ségou, two of the ten regions of Mali. The study counted 68 participants including 50 IDPs, seven administrative and health authorities, and 11 humanitarian actors. Sampling was guided by the principle of saturation and diversification, and data was collected through semi-structured individual interviews (n = 36) and focus groups (n = eight). Analysis was based on thematic content analysis through NVivo software. RESULTS: The main challenges identified concerning the implementation and adoption of physical distancing measures include the proximity in which IDPs live, their beliefs and values, the lack of toilets and safe water on sites, IDPs habits and economic situation, humanitarian actors' lack of financial resources and authority, and social pressure from religious leaders. Implemented mitigation measures include the building of new shelters or their compartmentalization, the creation of income-generating activities and food banks, psychosocial support, promoting awareness of IDPs, and nightly police patrols and surveillance to discourage IDPs from going out. Finally, a call for action is suggested for the actors involved in IDPs support and management. CONCLUSIONS: The study demonstrates the difficulty for IDPs to follow most of the physical distancing measures and informs about the risk of disease spreading among IDPs with its potential consequences. It also shows the inability of mitigation measures to control the outbreak and suggests actions to be considered.

How Can Health Systems Better Prepare for the Next Pandemic? Lessons Learned From the Management of COVID-19 in Quebec (Canada).

The magnitude of the COVID-19 pandemic challenged societies around our globalized world. To contain the spread of the virus, unprecedented and drastic measures and policies were put in place by governments to manage an exceptional health care situation while maintaining other essential services. The responses of many governments showed a lack of preparedness to face this systemic and global health crisis. Drawing on field observations and available data on the first wave of the pandemic (mid-March to mid-May 2020) in Quebec (Canada), this article reviewed and discussed the successes and failures that characterized the management of COVID-19 in this province. Using the framework of Palagyi et al. on system preparedness toward emerging infectious diseases, we described and analyzed in a chronologically and narratively way: (1) how surveillance was structured; (2) how workforce issues were managed; (3) what infrastructures and medical supplies were made available; (4) what communication mechanisms were put in place; (5) what form of governance emerged; and (6) whether trust was established and maintained throughout the crisis. Our findings and observations stress that resilience and ability to adequately respond to a systemic and global crisis depend upon preexisting system-level characteristics and capacities at both the provincial and federal governance levels. By providing recommendations for policy and practice from a learning health system perspective, this paper contributes to the groundwork required for interdisciplinary research and genuine policy discussions to help health systems better prepare for future pandemics.

Why is repositioning public health innovation towards a social paradigm necessary? A reflection on the field of public health through the examples of Ebola and Covid-19.

Health innovations are generally oriented on a techno-economic vision. In this perspective, technologies are seen as an end in themselves, and there is no arrangement between the technical and the social values of innovation. This vision prevails in sanitary crises, in which management is carried out based on the search for punctual, reactive, and technical solutions to remedy a specific problem without a systemic/holistic, sustainable, or proactive approach. This paper attempts to contribute to the literature on the epistemological orientation of innovations in the field of public health. Taking the Covid-19 and Ebola crises as examples, the primary objective is to show how innovation in health is oriented towards a techno-economic paradigm. Second, we propose a repositioning of public health innovation towards a social paradigm that will put more emphasis on the interaction between social and health dimensions in the perspective of social change. We will conclude by highlighting the roles that public health could play in allowing innovations to have more social value, especially during sanitary crises.

"It's not just hacking for the sake of it": a qualitative study of health innovators' views on patient-driven open innovations, quality and safety.

BACKGROUND: Open do-it-yourself (DIY) health innovations raise new dilemmas for patient-oriented and service-oriented scholars and healthcare providers. Our study aimed to generate practical insights into quality and safety issues to patient care raised by two volunteer-run, open DIY solutions: Nightscout Project (patient-driven, open-source software for type 1 diabetes management) and e-NABLE (volunteers who design and three-dimensionally print upper-limb assistive devices). To this end, we examined the views of health innovators who are knowledgeable about medical devices standards and regulations. METHODS: We applied a multimedia-based, data-elicitation technique to conduct indepth interviews with a diversified sample of 31 health innovators practising in two Canadian provinces (Quebec and Ontario). An exploratory thematic analysis approach was used to identify respondents' reasoning processes and compare their overall judgements of Nightscout and e-NABLE. RESULTS: Respondents pondered the following quality and safety issues: importance of the need addressed; accessibility; volunteers' ability to develop and maintain a safe solution of good quality; risks involved for users; consequences of not using the solution; and liability. Overall, innovators see Nightscout as a high-risk DIY solution that requires expert involvement and e-NABLE as a low-risk one that fills a hard-to-meet gap. CONCLUSION: Health innovators generally support patient-driven initiatives but also call for the involvement of professionals who possess complementary skills and knowledge. Our findings provide a list of issues healthcare providers may discuss with patients during clinical consultations to document potential risks and benefits of open DIY solutions. To inform new policy approaches, we propose the development of publicly funded umbrella organisations to act as intermediaries between open DIY solutions and regulatory bodies to help them meet quality and safety standards.

Organizational readiness for artificial intelligence in health care: insights for decision-making and practice.

PURPOSE: Artificial intelligence (AI) raises many expectations regarding its ability to profoundly transform health care delivery. There is an abundant literature on the technical performance of AI applications in many clinical fields (e.g. radiology, ophthalmology). This article aims to bring forward the importance of studying organizational readiness to integrate AI into health care delivery. DESIGN/METHODOLOGY/APPROACH: The reflection is based on our experience in digital health technologies, diffusion of innovations and healthcare organizations and systems. It provides insights into why and how organizational readiness should be carefully considered. FINDINGS: As an important step to ensure successful integration of AI and avoid unnecessary investments and costly failures, better consideration should be given to: (1) Needs and added-value assessment; (2) Workplace readiness: stakeholder acceptance and engagement; (3) Technology-organization alignment assessment and (4) Business plan: financing and investments. In summary, decision-makers and technology promoters should better address the complexity of AI and understand the systemic challenges raised by its implementation in healthcare organizations and systems. ORIGINALITY/VALUE: Few studies have focused on the organizational issues raised by the integration of AI into clinical routine. The current context is marked by a perplexing gap between the willingness of decision-makers and technology promoters to capitalize on AI applications to improve health care delivery and the reality on the ground, where it is difficult to initiate the changes needed to realize their full benefits while avoiding their negative impacts.

Guiding Pay-As-You-Live Health Insurance Models Toward Responsible Innovation in Health.

While the transition toward digitalized health care and service delivery challenges many publicly and privately funded health systems, patients are already producing a phenomenal amount of data on their health and lifestyle through their personal use of mobile technologies. To extract value from such user-generated data, a new insurance model is emerging called Pay-As-You-Live (PAYL). This model differs from other insurance models by offering to support clients in the management of their health in a more interactive yet directive manner. Despite significant promises for clients, there are critical issues that remain unaddressed, especially as PAYL models can significantly disrupt current collective insurance models and question the social contract in so-called universal and public health systems. In this paper, we discuss the following issues of concern: the quantification of health-related behavior, the burden of proof of compliance, client data privacy, and the potential threat to health insurance models based on risk mutualization. We explore how more responsible health insurance models in the digital health era could be developed, particularly by drawing from the Responsible Innovation in Health framework.

[Strategic framework to Support the evaluation of complex and innovative digital health projects] / Cadre stratégique pour soutenir l'évaluation des projets complexes et innovants en santé numérique.

Digital technologies play a central role in strategies to improve access, quality and efficiency of health care and services. However, many digital health projects have failed to become sustainable and spread across health organizations and systems. This situation is partly due to the fact that these projects are often developed and evaluated by reducing the issues linked mainly to the technological dimension. Such tradition has paid little attention to the fact that technology is introduced into pluralistic and complex sociotechnical systems such as health organizations and systems. The aim of this article is to propose practical and theorical, non-prescriptive, elements of reflection that can serve as a basis for evaluating complex and innovative digital health projects. This reflection builds on the lessons learned from the application of a strategic framework for evaluating three major complex and innovative digital health projects in Quebec over the last 15 years.

Artificial intelligence in health care: laying the Foundation for Responsible, sustainable, and inclusive innovation in low- and middle-income countries.

The World Health Organization and other institutions are considering Artificial Intelligence (AI) as a technology that can potentially address some health system gaps, especially the reduction of global health inequalities in low- and middle-income countries (LMICs). However, because most AI-based health applications are developed and implemented in high-income countries, their use in LMICs contexts is recent and there is a lack of robust local evaluations to guide decision-making in low-resource settings. After discussing the potential benefits as well as the risks and challenges raised by AI-based health care, we propose five building blocks to guide the development and implementation of more responsible, sustainable, and inclusive AI health care technologies in LMICs.

Artificial Intelligence and Health Technology Assessment: Anticipating a New Level of Complexity.

Artificial intelligence (AI) is seen as a strategic lever to improve access, quality, and efficiency of care and services and to build learning and value-based health systems. Many studies have examined the technical performance of AI within an experimental context. These studies provide limited insights into the issues that its use in a real-world context of care and services raises. To help decision makers address these issues in a systemic and holistic manner, this viewpoint paper relies on the health technology assessment core model to contrast the expectations of the health sector toward the use of AI with the risks that should be mitigated for its responsible deployment. The analysis adopts the perspective of payers (ie, health system organizations and agencies) because of their central role in regulating, financing, and reimbursing novel technologies. This paper suggests that AI-based systems should be seen as a health system transformation lever, rather than a discrete set of technological devices. Their use could bring significant changes and impacts at several levels: technological, clinical, human and cognitive (patient and clinician), professional and organizational, economic, legal, and ethical. The assessment of AI's value proposition should thus go beyond technical performance and cost logic by performing a holistic analysis of its value in a real-world context of care and services. To guide AI development, generate knowledge, and draw lessons that can be translated into action, the right political, regulatory, organizational, clinical, and technological conditions for innovation should be created as a first step.