Digital health to promote adherence to antiretroviral treatment in patients with HIV/AIDS: Meta review. / Salud digital para promover la adherencia al tratamiento antirretroviral en pacientes con VIH/sida: metarevisión.

INTRODUCTION: Digital health or "e-Health" is a set of applications based on Information and Communication Technologies that can be used to promote self-care and medication adherence in patients with chronic diseases. The aim of this study was to carry out a review of systematic reviews (meta-review) on efficacy studies of e-Health interventions to promote adherence to antiretroviral therapy in people living with HIV/AIDS. METHOD: A review of systematic reviews ("meta-review") was performed using the Medline-PubMed database on efficacy studies of e-Health components to promote adherence to antirretroviral therapy, in patients with HIV/AIDS, proposing a structured search strategy (PICO question). A selection process for systematic reviews was conducted based on inclusion and exclusion criteria. Subsequently, the corresponding data were extracted, and the analysis was accomplished in descriptive tables. RESULTS: A total of 29 systematic reviews were identified, from which 11 were selected. These reviews comprised 55 randomized controlled therapies with different e-Health interventions and enrolled a total of 15,311 HIV/AIDS patients. Studies included a total of 66 comparisons (experimental group vs. control group) in indirect adherence measurements based on different measurement techniques (36 statistically significant); 21 comparisons of viral load measurements (10 statistically significant); and 8 comparisons of CD4+ cell count measurements (3 statistically significant). m-Health was the most studied component followed by the telephone call and e-Learning. CONCLUSIONS: Evidence was found that supports that some e-Health interventions are effective in promoting adherence to antirretroviral therapy and improving health outcomes in patients with HIV/AIDS, although it is identified that more studies are needed for more robust evidence.

Propiedades psicométricas de la "Escala de motivación académica" adaptada para la educación profesional en enfermería / Psychometric properties of the "Academic motivation scale" adapted for the professional nursing education

Resumen Objetivo: El presente trabajo tuvo por objetivo realizar una adaptación de la Escala de Motivación Académica (EMA) para su uso en la educación profesional en enfermería (EMA-Enf) y evaluar sus propiedades psicométricas. Materiales y métodos: Se realizó una adaptación a una versión en español de la EMA para su uso en el contexto de la educación profesional en enfermería. Se desarrolló un cuestionario estructurado y se aplicó a 447 estudiantes de Licenciatura en Enfermería en Michoacán, México. Se realizó análisis factorial confirmatorio (AFC) para probar el ajuste de diferentes modelos derivados de la Teoría de la Autodeterminación (TAD). Se utilizó el software SPSS para la gestión de base de datos y software R, para la estimación de los modelos considerando la naturaleza ordinal de los ítems. Se evaluó la consistencia interna a través de los Coeficientes α y ω. Resultados: En el AFC se observó que el modelo de siete factores correlacionados propuesto en la TAD logra el mejor ajuste (χ2= 951.88 p< 0.001, CFI= 0.927, RMSEA= 0.065, SRMR= 0.072). Los siete factores tuvieron consistencia interna aceptable (Coeficiente a con un rango entre 0.624 y 0.746; y el Coeficiente ω entre 0.719 y 0.896). Conclusión: La Escala EMA-Enf puede ser una propuesta viable en la investigación y práctica educativa relacionada con la formación de profesionales de la enfermería.

Abstract Objective: The present work carries out an adaptation of the Academic Motivation Scale (EMA) to be used in professional nursing education (EMA-Enf) and to evaluate its psychometric properties. Materials and method: An adaptation to a Spanish version of the EMA was made for its use in the context of professional nursing education. A structured questionnaire was developed and applied to 447 Nursing undergraduate students in Michoacán, Mexico. Confirmatory factor analysis (CFA) was performed to test the fit of different models derived from Self-Determination Theory (SDT). SPSS software was used for database management and R software for model estimation considering the ordinal nature of the items. The internal consistency was evaluated through the Coefficients α and ω. Results: In the AFC, it was observed that the model of seven correlated factors proposed in the SDT achieves the best fit (χ2= 951.88 p< 0.001, CFI= 0.927, RMSEA= 0.065, SRMR= 0.072). The seven factors had acceptable internal consistency (Coefficient a with a range between 0.624 and 0.746; and the Coefficient ω between 0.719 and 0.896). Conclusion: The EMA-Enf Scale can be a viable proposal in educational research and practice related to professional nursing education.

Propiedades psicométricas de la Escala de Valoración de la Capacidad de Autocuidado en adolescentes mexicanos / Propiedades psicométricas de la Escala de Valoración de la Capacidad de Autocuidado en adolescentes mexicanos / Propriedades psicométricas da Escala de Avaliação da Capacidade de Autocuidado em adolescentes mexicanos

Introducción: este trabajo tuvo por objetivo contribuir en el estudio de la validez y confiabilidad de la versión en español de la Escala de Valoración de Capacidad de Autocuidado (ASA) en adolescentes. Materiales y métodos: se construyó un cuestionario con los 24 ítems de la escala ASA, junto con ítems para explorar variables sociodemográficas, conductas y condiciones de salud. Se aplicó el cuestionario a 541 adolescentes mexicanos. Se realizaron como técnicas de análisis: análisis factorial exploratorio (AfE), análisis factorial confirmatorio (AfC), determinación de consistencia interna (coeficientes α y ω) y análisis de relación con otras variables basado en comparación de grupos. Se analizó el desempeño de diferentes estructuras de la escala ASA. Resultados: se lograron obtener dos propuestas basadas en la escala ASA para su uso en adolescentes: una basada en un modelo unidimensional (20 ítems) y otra basada en un modelo de tres factores (14 ítems). Estas propuestas tuvieron buen desempeño en el AfC, así como en consistencia interna. Además, presentaron evidencia de validez basada en la relación con conductas y condiciones relacionadas con la salud. Conclusión: se presentan hallazgos de validez y confiabilidad que sustentan el uso de dos versiones reducidas de la escala ASA en adolescentes.

Introduction: This study aimed to investigate the validity and reliability of the Spanish version of the Appraisal of Self-care Agency Scale (ASA scale) in adolescents. Materials and methods: A questionnaire was created with 24 items of the ASA scale together with items that explored the sociodemographic variables as well as health-related behaviors and conditions. The questionnaire was given to 541 Mexican adolescents. Different analysis techniques were performed, including exploratory factor analysis, confirmatory factor analysis (CfA), determination of internal consistency (coefficients α and ω), and other variables relationship based on group comparisons. The performance of the different factorial structures of the ASA scale was analyzed. Results: We obtained two proposals based on the ASA Scale that can be used in adolescents; one was based on a one-dimensional model (20 items) and the other was based on a three-factor model (14 items). These proposals performed well in the CfA as well as in internal consistency analysis techniques. Furthermore, these proposals presented validity evidence based on the relationship with health-related behaviors and conditions. Conclusion: We provide evidence for the validity and reliability of the two reduced versions of the ASA scale that supports its use in adolescents.

Introdução: este trabalho teve como objetivo contribuir para o estudo da validade e confiabilidade da versão em espanhol da Escala de Valoración de Capacidad de Autocuidado (ASA) em adolescentes. Materiais e Métodos: foi construído um questionário com os 24 itens da Escala ASA juntamente com itens para explorar variáveis sociodemográficas, comportamentos e condições de saúde. O questionário foi aplicado a 541 adolescentes mexicanos. Foram realizadas como técnicas de análise: análise fatorial exploratória (AfE); análise fatorial confirmatória (AfC); determinação da consistência interna (Coeficientes α e ω); e análise de relação com outras variáveis com base na comparação de grupos. Foi analisado o desempenho de diferentes estruturas da escala ASA. Resultados: foi possível obter duas propostas baseadas na Escala ASA para a sua utilização em adolescentes, uma baseada no modelo unidimensional (20 itens) e outra baseada no modelo de três fatores (14 itens). Essas propostas tiveram um bom desempenho na AfC, bem como na consistência interna. Além disso, apresentaram evidências de validade baseadas na relação com comportamentos e condições relacionadas à saúde. Conclusão: são apresentadas evidências de validade e confiabilidade que suportam o uso de duas versões reduzidas da escala ASA em adolescentes

A Bibliometric Analysis of Mexican Bioinformatics: A Portrait of Actors, Structure, and Dynamics.

Bioinformatics is a very important informatics tool for health and biological sciences, focusing on biological data management. The objective of this work was to perform a bibliometric analysis regarding the development of Mexican bioinformatics. An exhaustive revision of the literature associated with Mexican bioinformatics in a period of 25-years was performed. Bibliometric tools, such as performance analysis and science mapping were included in the analysis. We identified the main actors as well as the structure and dynamics of Mexican bioinformatics. Some of the main findings were as follows: the thematic structure in the field is defined by the research lines of outstanding authors; the outstanding collaborations of Mexican institutions with foreign countries and institutions are influenced by the geographic proximity and binational agreements, as well as philanthropic and academic programs that promote collaborations, and there is an inclination for health issues promoted by public health financing and philanthropic organizations. It is identified that publications had an explosion since 2012, we consider that this growth may be influenced by the democratization of data, derived from the mass sequencing of biological molecules stored in public databases.

Factors Related to Internet Adoption and Its Use to Seek Health Information in Mexico.

The Internet has the potential to be a valuable resource for the dissemination of health promotion information to the general population, mainly in conditions with well-developed health and digital literacy. Few studies have been undertaken on the adoption of the Internet by the Mexican population and its use to seek health information. The aim of this paper was to identify the factors that determine Internet adoption and its use by the heads of Mexican households for obtaining health information. This study used data taken from a probabilistic and cross-sectional national survey (National Survey on the Availability and Use of Information Technologies in Households, or ENDUTIH), applying an economic approach based on utility maximization theory. We estimated a univariate probit model for Internet adoption and a consecutive bivariate probit model with sample selection for the use of the Internet to seek health information. The software package was used to adjust and estimate the proposed models. The first model (Internet adoption) identified several factors related to digital divides in the country, while the second (Internet use to seek health information) identified various factors influencing online searches for health information, such as the following: being a woman; being an adult; having a higher level of education; having a higher income; having superior digital skills; and, living in an urban area. This study highlights the need to strengthen digital policy in order to improve access to and the adoption and efficient use of the Internet, particularly in terms of improving an individual's engagement with their own health.

“Escala de valoración de capacidad de autocuidado” y su relación con conductas y condiciones de salud en adultos mayores / "Self-care capacity assessment scale" and its relationship with health behaviors and conditions in older adults

Este trabajo tuvo por objetivo contribuir en el estudio de la validez de la “Escala de valoración de la capacidad de autocuidado” (escala ASA) en adultos mayores y analizar su asociación con conductas y condiciones relacionadas con la salud. Se construyó un cuestionario y se aplicó a 165 adultos mayores residentes de Michoacán (México). Se realizó un análisis factorial confirmatorio del modelo unidimensional de la escala, así como un análisis de consistencia interna, así como un análisis de relación con otras variables basado en comparaciones de grupos, explorando el efecto de la eliminación de ítems inversos. La escala reducida tuvo mejor desempeño en general, aunque el modelo unidimensional mantuvo un ajuste limitado en el análisis factorial confirmatorio. La consistencia interna fue satisfactoria en ambas escalas (α= 0,806 y 0,826, respectivamente), además se identificaron algunas comparaciones de grupo importantes con mediciones antropométricas. En conclusión, se encontraron pruebas que apoyan la validez de la escala ASA en adultos mayores, aunque continúa pendiente generar más evidencia en cuanto a su validez de constructo y criterio (AU)

The objective of this work was to contribute to the study of the validity of the “Appraisal of Self-care Agency Scale” (ASA scale) in older adults and to analyze its association with health-related behaviors and conditions. A questionnaire was constructed and applied to 165 elderly residents of Michoacán, Mexico. A confirmatory factor analysis of the scale's one-dimensional model was carried out, and also an analysis of internal consistency, as well as an analysis of the relationship with other variables based on group comparisons, exploring the effect of the elimination of inverse items. Overall, the reduced scale performed better although the one-dimensional model maintained a limited fit in the confirmatory factor analysis. Internal consistency was satisfactory in both scales (α coefficient= .806 and .826, respectively). In addition, some important group comparisons were identified with anthropometric measurements. In conclusion, tests were found supporting the validity of the ASA scale in older adults, although more evidence is still needed regarding its construct and criterion validity (AU)

Bioinformatics in Mexico: A diagnostic from the academic perspective and recommendations for a public policy.

In this work, we present a diagnostic analysis of strengths, weaknesses, opportunities and threats (SWOT) of the current state of Bioinformatics in Mexico. We conducted semi-structured interviews among researchers and academics with key expertise in this field, identified by bibliometric analyses and qualitative sampling techniques. Additionally, an online survey was conducted reaching a higher number of respondents. Among the relevant findings of our study, the lack of specialized human resources and technological infrastructure stood out, along with deficiencies in the number and quality of academic programs, scarce public investment and a weak relationship between public and private institutions. However, there are great opportunities for developing a national Bioinformatics to support different economic sectors. In our opinion, this work could be useful to favor a comprehensive network among Mexican researchers, in order to lay the foundations of a national strategy towards a well designed public policy.

A Socio-technical Approach to Evaluating an Electronic Medical Record System implemented in the Public Health Services of Aguascalientes / Una Aproximación Socio-técnica a la Evaluación de un Expediente Médico Electrónico implementado en Servicios de Salud Públicos de Aguascalientes

Abstract The objective of this study was to explore a strategy for evaluating an Electronic Medical Record (EMR) system implemented in the public health services of Aguascalientes, Mexico. A questionnaire based on DeLone and McLean's Model of Information Systems Success (MISS) was adapted to Spanish and applied with 62 primary care physicians working in health centers of the Instituto de Servicios de Salud del Estado de Aguascalientes (ISSEA or the State of Aguascalientes Institute for Health Services). Opportunities for improving EMR systems were also explored from the informants' perspectives. Additionally, the relationships between MISS components were analyzed using Structural Equations Modeling (SEM). Some MISS components and particular items (service quality and overall satisfaction) presented low averages, reflecting opportunities for improving the development and implementation of EMR, such as the need to continuously update information pertaining to diagnostic and medicine catalogs and develop systems that are interoperable between the second and third levels of care. In conclusion, the present study contributes generating evidence on the use of the MISS to evaluating EMR systems in public health services of Mexico. More evidence should be generated in this field in order to promote the continuous improvement of these information systems.

Resumen El objetivo de este estudio fue explorar una estrategia para la evaluación de un Expediente Clínico Electrónico (ECE) implementado en servicios de salud públicos de Aguascalientes, México. Se adaptó al español un cuestionario basado en el Modelo de Éxito de Sistemas de Información (MISS) de DeLone y McLean y se aplicó a 62 médicos de atención primaria que trabajan en centros de salud del Instituto de Servicios de Salud del Estado de Aguascalientes (ISSEA). Se exploraron también las oportunidades de mejora del ECE desde la perspectiva de los informantes. Además, se analizaron las relaciones entre los componentes del MISS mediante el modelado de ecuaciones estructurales (SEM). Algunos componentes del MISS e items particulares mostraron promedios bajos (p.ej., calidad del servicio y satisfacción) que reflejan algunas oportunidades de mejora en el desarrollo e implementación del ECE, como la necesidad de una actualización continua de la información sobre diagnósticos y catálogos de medicamentos; y el desarrollo de sistemas de interoperabilidad con el segundo y tercer nivel de atención. En conclusión, el presente estudio contribuye en la generación de evidencia sobre el uso del MISS para evaluar los sistemas de EMR en servicios de salud públicos de México. Se debe generar más evidencia en este campo para promover la mejora continua de estos sistemas de información.

Salud electrónica (e-Salud): un marco conceptual de implementación en servicios de salud.

Electronic health (e-Health) is a broad concept that involves the application of information and communication technologies to systems for surveillance, prevention, promotion and health care. e-Health components mainly include supply and resource management systems (appointment schedules, clinical laboratory or pharmacy), electronic medical records, electronic prescription, clinical decision support systems, use of mobile devices, imaging systems, remote care systems, as well as teaching through digital media. Other components that can be regarded as part of e-Health are the massive data storage and analysis systems, artificial learning, as well as "internet of things" systems. In this work, a conceptual framework is proposed in order to analyze the implementation of e-Health components and their effects on the quality of health services provision.

La salud electrónica (e-Salud) es un concepto amplio que implica la aplicación de las tecnologías de la información y la comunicación en los sistemas de vigilancia, prevención, promoción y atención a la salud. Como componentes de la e-Salud se incluyen principalmente los sistemas de administración de insumos o recursos (agenda de citas, laboratorio clínico o farmacia), el expediente clínico electrónico, la prescripción electrónica, los sistemas de apoyo a la decisión clínica, el uso de dispositivos móviles, los sistemas de imagenología, los sistemas de atención a distancia, así como la enseñanza a través de medios digitales. Otros componentes que pueden considerarse parte de la e-Salud son los sistemas de almacenamiento y análisis masivo de datos, el aprendizaje artificial y los sistemas de "internet de las cosas". En este trabajo se propone un marco conceptual para analizar la implementación de componentes de e-Salud y sus efectos en la calidad de la provisión de servicios de salud.

Healthcare professionals' perceptions related to the provision of clinical pharmacy services in the public health sector: A case study.

BACKGROUND: In Mexico, the Modelo Nacional de Farmacia Hospitalaria (MNFH, or National Hospital Pharmacy Model), published in 2009, mainly aims to promote the provision of clinical pharmacy services in private and public hospitals. However, there is little scientific documentation about the quality of these services. OBJECTIVES: To explore healthcare professionals' perceptions related to the quality of clinical pharmacy services provision. METHODS: A case-study based on a qualitative approach was performed at the pharmaceutical services unit at a public hospital located in Mexico City, which operates under the administrative control of the Ministry of Health. Donabedian's conceptual model was adapted to explore health care professionals' perceptions of the quality of clinical pharmacy services provision. Semi-structured interviews were carried out with pharmacists, physicians and nurses and then transcribed and analyzed via discourse analysis and codification techniques, using the software package Atlas. ti. RESULTS: Limitations in pharmaceutical human resources were identified as the main factor affecting coverage and quality in clinical pharmacy services provision. However, the development in pharmacy staff of technical competences and skills for clinical pharmacy service provision were recognized. Significant improvements in the rational use of medicines were associated with clinical pharmacy services provision. CONCLUSIONS: The perception analysis performed in this study suggested that it is necessary to increase pharmacy staff in order to improve interprofessional relationships and the quality of clinical pharmacy services provision.

A review of fundamental topics in health systems / Revisión de temas fundamentales en sistemas de salud

Health systems are dynamic complex structures, whose main aim is to satisfy health needs of populations. According to the World Health Organization, health systems put together four key functions: 1) stewardship-governance, 2) financing, 3) resources generation, and 4) provision of health services to meet three key objectives: to maintain or improve population health conditions, to offer better response time, and to provide financial protection to the population that demands health services. The objective of this article was to carry out a conceptual review of two basic functions: stewardship-governance on one hand, and financing on the other. Two essential attributes in the provision of health services were also reviewed: quality and equity. Finally, a conceptual model for quality analysis in the provision of health services is proposed.

Los sistemas de salud son estructuras complejas en constante dinamismo que tienen por objetivo principal satisfacer las necesidades de salud de la población. De acuerdo con la Organización Mundial de la Salud en los sistemas de salud se articulan cuatro funciones básicas: 1) rectoría y gobernanza, 2) financiamiento, 3) generación de recursos y 4) provisión de servicios de salud. Estas funciones permiten cumplir con tres objetivos fundamentales: mantener o mejorar las condiciones de salud de la población, ofrecer buena capacidad de respuesta ("trato adecuado") y brindar protección financiera a la población que demanda servicios de salud. El objetivo de este trabajo fue hacer una revisión conceptual de dos funciones básicas: la rectoría y la gobernanza por un lado y por el otro, el financiamiento. También se revisan dos cualidades esenciales en la provisión de servicios de salud: la calidad y la equidad. Finalmente, se presenta una propuesta de modelo conceptual para el análisis de calidad en la provisión de servicios de salud.

Análisis de desigualdades en el trato adecuado en las Unidades de Atención Primaria de los Servicios Estatales de Salud de México / Analysis of inequalities in the appropriate treatment in the Primary Care Units of the State Health Services of Mexico

Resumen Objetivo: Analizar desigualdades en el trato adecuado en la atención a pacientes sin seguridad social que utilizan servicios de salud ambulatorios en las Unidades de Atención Primaria (UAP) de los servicios estatales de salud de la Secretaría de Salud, en México. Métodos: Se trata de un diseño transversal y ecológico que plantea como unidades de análisis las entidades federativas de México. Se utilizaron datos de tiempo de espera y percepción de calidad en la atención que reportaron los usuarios en la Encuesta Nacional de Salud y Nutrición (ENSANUT) 2012. Se plantearon algunos Indicadores de Trato Adecuado (ITA), y se calcularon indicadores de desigualdad sugeridos en la literatura. Asimismo, se recopilaron de la literatura Indicadores Proxy de Determinantes Sociales de la Salud (IPDSS) con fines de analizar la posible asociación entre ITA e IPDSS a través de análisis de correlación y regresión (índice de efecto). Resultados: Se identificaron desigualdades en los ITA planteados entre las entidades federativas de México, principalmente en los indicadores de tiempo de espera (disparidad absoluta 52.7 min y disparidad relativa 1.9 para la media estatal en tiempo de espera). Asimismo, se identificaron asociaciones significativas entre ITA e IPDSS. Particularmente, se encontró asociación entre todos los ITA propuestos y la tasa estatal de UAP, aunque con débil índice de efecto. Conclusiones: Persisten desigualdades en el trato adecuado durante la prestación de servicios ambulatorios a población sin seguridad social. Es necesario trabajar más en subsanar desigualdades y promover la equidad en salud.

Abstract Objective: To analyze responsiveness inequalities in the care of patients without social security that use outpatient health services in the Primary Care Units (PCU) of the state health services of the Ministry of Health in Mexico. Methods: It is a cross-sectional and ecological design that considers the federative entities of Mexico as units of analysis. Users reported time-out and quality perception data were used from the National Health and Nutrition Survey (ENSANUT). Some Responsiveness Indicators (RI) were proposed, and suggested inequality indicators were calculated. Likewise, proxy Indicators of Social determinants of Health (IPDSS) were collected from the literature to analyze possible association between ITA and IPDSS through correlation and regression analysis (effect index). Results: Inequalities in ITAs were identified among the federative entities of Mexico, mainly in the indicators of waiting time (absolute disparity 52.7 min and relative disparity 1.9 for the state average in waiting time). Likewise, significant associations between ITA and IPDSS were identified. In particular, we found association between all the proposed ITAs and the state rate of PCU, although with a weak effect index. Conclusions: Inequalities persist in the responsiveness during the provision of outpatient services to the population without social security. More work is needed to address inequalities and promote equity in health.

Cost-effectiveness study of oral hypoglycemic agents in the treatment of outpatients with type 2 diabetes attending a public primary care clinic in Mexico City.

INTRODUCTION: Worldwide, diabetes mellitus presents a high burden for individuals and society. In Latin America, many people with diabetes have limited access to health care, which means that indirect costs may exceed direct health care cost. Diabetes is Mexico's leading cause of death. PURPOSE: To evaluate the cost-effectiveness ratios of the most used oral hypoglycemic agents (OHA) in the treatment of outpatients with type 2 diabetes attending a public primary care clinic in Mexico City. DESIGN: A cross-sectional and analytic study was conducted in Mexico City. METHODOLOGY: Twenty-seven adult outpatients with type 2 diabetes who were treated either with metformin or glibenclamide were included. Acarbose was used as an alternative strategy. The study was carried out from the perspective of Mexican society. Direct medical and nonmedical costs as well as indirect costs were evaluated using a structured questionnaire. Efficacies of all drug treatments were evaluated retrospectively. A systematic search was conducted to select published randomized clinical trials based on predetermined inclusion criteria, and treatment success was defined as glycosylated hemoglobin factor ≤ 7%. Efficacy data of each drug and/or combination were analyzed using meta-analysis. The Monte Carlo Markov model was used. Quality-adjusted life-years (QALY) were used as the unit of effectiveness; incremental and sensitive analyses were performed and a 5% discount rate was calculated. A hypothetical cohort of 10,000 patients was modeled. RESULTS: The odds ratios of the success of each drug treatment were obtained from the meta-analyses, and were the following: 5.82 (glibenclamide), 3.86 (metformin), 3.5 (acarbose), and 6.76 (metformin-glibenclamide). The cost-effectiveness ratios found were US$272.63/QALY (glibenclamide), US$296.48/QALY (metformin), and US$409.86/QALY (acarbose). Sensitivity analysis did not show changes for the most cost-effective therapy when the effectiveness probabilities or treatment costs were modified. CONCLUSION: Glibenclamide is the most cost-effective treatment for the present study outpatient population diagnosed with type 2 diabetes in the early stages.