Faculty Professional Development Strategies Supporting Increased Scholarship.

In this article, we describe the implementation of two nursing continuing professional development activities and a 15-week online Writing for Publication course for faculty using American Nurses Credentialing Center accreditation program criteria. The application of the criteria ensured quality continuing nursing education and assisted the provider unit in meeting its goals and outcomes. Evaluation data for the activities were collected and analyzed to determine whether the learning outcomes were met and to prepare course adjustments. [J Contin Educ Nurs. 2023;54(3):121-129.].

Social determinants of human papillomavirus vaccine series completion among U.S. adolescents: A mixed-methods study.

Introduction: Human papillomavirus (HPV) vaccination can significantly reduce HPV-associated cancers. In the US, two doses are recommended for vaccine completion for younger adolescents. However, series completion rates remain below the nation's goal of 80% coverage. Multi-faceted factors may influence adolescent series completion. The purpose of this study was to identify individual-level, relationship-level, and community-level factors of timely series completion among adolescents, ages 11-14, initiating the HPV vaccine series in 2017. Methods: A convergent, mixed-methods design was used combining adolescent electronic health record data (n = 803) and qualitative interviews with adolescents and their parents (n = 32) to assess timely series completion within 14-months (e.g., January 2018 to February 2019). Multivariable logistic regression analysis examined individual-level and community-level factors influencing timely series completion. Directed content analysis was used to identify relevant themes and subthemes. We provided an integrative summary to assess patterns of convergence or divergence between quantitative and qualitative data. Results: In the quantitative phase, 61.0% of adolescents completed the vaccine series and 47.3% completed it on-time. Higher odds of timely series completion were among younger adolescents at vaccine initiation (aOR = 1.82, 95%CI = 1.07, 3.11) and lower among adolescents who were Black (aOR = 0.57, 95%CI = 0.37, 0.89) and Hispanic (aOR = 0.54, 95%CI = 0.30, 0.95) compared to Non-Hispanic White adolescents and those without private insurance (aOR = 0.56, 95%CI = 0.37, 0.85). Qualitative findings revealed increased risk for HPV at sexual debut as a motivator for timely series completion. Family/peers and healthcare providers influenced timely series completion among minority adolescents. Community-level factors were not significantly associated with timely series completion, however, qualitative findings revealed lack of transportation as a barrier to timely series completion. Conclusion: Multi-level factors continue to influence timely series completion, despite fewer doses needed for series completion. Innovative strategies are needed to improve care coordination for receiving vaccine doses, patient-provider communication about series completion and increase access to HPV vaccine.

Self-Care Capacity and Its Relationship to Age, Disability, and Perceived Well-Being in Medicare Beneficiaries.

BACKGROUND: Self-care is a multicomponent set of capacities that influence beliefs about health and well-being. OBJECTIVES: We examined the relationship between self-care capacity, age, and disability status with two perceptions of well-being in a cohort of Medicare beneficiaries. METHODS: The current study is part of a multisite research project to determine factors associated with cross-sectional and longitudinal morbidity and mortality trajectories observed in Medicare beneficiaries. Variable selection was informed by the health disparities and outcomes model. Using data from the 2013 Medicare Current Beneficiary Survey and logistic regression models, we determined associations between self-care capacity, including indicators of self-care ability and self-care agency and two perceptions of well-being. Participants were divided into four groups based on how they qualified for Medicare: (a) over 65 years of age, and below 65 years of age and disabled because of (b) physical or (c) mental disorder, or (d) disabled and could not be classified as physically or mentally disabled as the primary cause of eligibility. RESULTS: Self-care ability limitations in activities of daily living (ADL), instrumental activities of living (IADL), and social activity participation were associated with both health perceptions. Those with physical disabilities reported more ADL and IADL limitations when compared with the other eligibility groups and were significantly more likely to have negative health perceptions. Those with serious mental illness were most likely to report the most severe IADL limitations. The over 65 years of age group reported less self-care incapacity than the other three eligibility types. Other components of self-care, including health literacy, agency, and health behaviors, significantly influenced perceptions of health. Women and people identifying as non-Whites were more likely to have negative health perceptions. DISCUSSION: Self-care capacity is a complex construct, and its varied elements have differential relationships with perceptions of well-being. Those with physical disabilities reported more self-care limitations, poorer perceived health, and more health worries than the other groups. Still, there were different patterns of self-care capacities in the serious mental illness type-especially in IADL limitations. The study adds empirical evidence to previous research documenting inequities in health outcomes for women and non-Whites. Findings provide empirical support for the health disparities and outcomes model.

Factors Associated With Human Papillomavirus Vaccine Series Completion Among Adolescents.

INTRODUCTION: Most cancers associated with the human papillomavirus are preventable through vaccination. However, adolescent series completion rates are at 75.8%. Two vaccine doses are recommended for adolescents, but factors influencing 2-dose series completion are not well explored. The purpose of this study is to examine individual-level and community-level factors associated with timely human papillomavirus vaccine series completion among adolescents in the Southeastern U.S. METHODS: Series completion was assessed from January 2018 to February 2019 among a cohort of adolescents initiating vaccination in 2017. Factors influencing overall series completion and timely series completion were assessed using multivariable logistic regression. RESULTS: Among the sample, 64.4% completed the vaccine series and 53.8% completed it timely (e.g., 14 months). Higher odds of series completion were among adolescents who were younger at vaccine initiation (AOR=1.94, 95% CI=1.50, 2.50), who traveled moderate distances to the clinic (AOR=1.62, 95% CI=1.03, 2.56), and who lived in low-deprivation neighborhoods (AOR=1.85, 95% CI=1.31, 2.60), and lower among Hispanic (AOR=0.62, 95% CI=0.45, 0.87) and non-Hispanic Black (AOR=0.66, 95% CI=0.54, 0.81) adolescents and among those without private insurance (AOR=0.68, 95% CI=0.56, 0.83). Timely series completion resulted in similar findings; however, lower odds were among Hispanic (AOR=0.63, 95% CI=0.43, 0.95) and non-Hispanic Black (AOR=0.68, 95% CI=0.50, 0.92) adolescents than among non-Hispanic other adolescents. CONCLUSIONS: Individual-level and community-level factors continue to influence adolescent series completion, despite a reduction in doses. Future research is needed to understand racial/ethnic and regional disparities in human papillomavirus vaccine series completion and to develop interventions to promote series completion.

Psychiatric-mental health nursing workforce in 2018: Implications for the future.

The workforce was examined using the 2018 National Sample Survey of Registered Nurses to determine supply characteristics and perspectives of psychiatric-mental health nurses. The study looked at the success in achieving some of the workforce related recommendations of the Future of Nursing. A strong foundation exists for increasing the contributions of psychiatric-mental health nursing to overcoming shortages of mental health professionals and to improving access to mental health care. More work needs to be done to remove regulatory barriers to promote practicing to the extent of knowledge, education and training. Overall, the psychiatric-mental health nursing workforce is primed for the future.

Identifying Individuals With Intellectual Disability Within a Population Study.

BACKGROUND: Much remains unknown about the longitudinal health and well-being of individuals with intellectual disability (ID); thus, new methods to identify those with ID within nationally representative population studies are critical for harnessing these data sets to generate new knowledge. OBJECTIVE: Our objective was to describe the development of a new method for identifying individuals with ID within large, population-level studies not targeted on ID. METHODS: We used a secondary analysis of the de-identified, restricted-use National Longitudinal Study of Adolescent to Adult Health (Add Health) database representing 20,745 adolescents to develop a method for identifying individuals who meet the criteria of ID. The three criteria of ID (intellectual functioning, adaptive functioning, and disability originating during the developmental period) were derived from the definitions of ID used by the American Psychiatric Association and the American Association on Intellectual and Developmental Disabilities. The ID Indicator was developed from the variables indicative of intellectual and adaptive functioning limitations included in the Add Health database from Waves I to III. RESULTS: This method identified 441 adolescents who met criteria of ID and had sampling weights. At Wave I, the mean age of this subsample of adolescents with ID was 16.1 years. About half of the adolescents were male and from minority racial groups. Their parents were predominately female, were married, had less than a high school education, and had a median age of 41.62 years. The adolescents' mean maximum abridged Peabody Picture Vocabulary Test standardized score was 69.6, and all demonstrated at least one adaptive functioning limitation. DISCUSSION: This study demonstrates the development of a data-driven method to identify individuals with ID using commonly available data elements in nationally representative population data sets. By utilizing this method, researchers can leverage existing rich data sets holding potential for answering research questions, guiding policy, and informing interventions to improve the health of the ID population.

Application of Behavioral Risk Factor Surveillance System Sampling Weights to Transgender Health Measurement.

BACKGROUND: Obtaining representative data from the transgender population is fundamental to improving their health and well-being and advancing transgender health research. The addition of the Behavioral Risk Factor Surveillance System (BRFSS) gender identity measure is a promising step toward better understanding transgender health. However, methodological concerns have emerged regarding the validity of data collected from transgender participants and its effect on the accuracy of population parameters derived from those data. OBJECTIVES: The aim of the study was to provide rationale substantiating concerns with the formulation and application of the 2015 BRFSS sampling weights and address the methodological challenges that arise when using this surveillance data to study transgender population health. METHODS: We examined the 2015 BRFSS methodology and used the BRFSS data to present a comparison of poor health status using two methodological approaches (a matched-subject design and the full BRFSS sample with sampling weights applied) to compare their effects on parameter estimates. RESULTS: Measurement error engendered by BRFSS data collection procedures introduced sex/gender identity discordance and contributed to problematic sampling weights. The sex-specific "raking" algorithm used by BRFSS to calculate the sampling weights was contingent on the classification accuracy of transgender by participants. Because of the sex/gender identity discordance of 74% of the transgender women and 66% of transgender men, sampling weights may not be able to adequately remove bias. The application of sampling weights has the potential to result in inaccurate parameter estimates when evaluating factors that may influence transgender health. DISCUSSION: Generalizations made from the weighted analysis may obscure the need for healthcare policy and clinical interventions aimed to promote health and prevent illness for transgender adults. Methods of public health surveillance and population surveys should be reviewed to help reduce systematic bias and increase the validity of data collected from transgender people.

The health status of transgender and gender nonbinary adults in the United States.

The goal of this exploratory study was to delineate health differences among transgender subpopulations (transgender women/TW, transgender men/TM, gender nonbinary/GNB adults). 2015 Behavioral Risk Factor Surveillance System data were analyzed to compare the health of three groups (TW:N = 369; TM:N = 239; GNB:N = 156). Logistic regression and adjusted odds ratios were used to determine whether health outcomes (fair/poor health, frequent physical and mental unhealthy days, chronic health conditions, and health problems/impairments) are related to group and its interaction with personal characteristics and socioeconomic position. Group was a significant predictor of fair/poor health and frequent mental unhealthy days, revealing significant health differences between the transgender groups. The odds of poor/fair health were approximately 2.5 times higher in TM and GNB adults relative to TW. The odds of frequent mental unhealthy days for TM were approximately 1.5-2 times greater than TW and GNB adults. Among those with health insurance, the odds of fair/poor health for GNB adults was more than 1.5-2 times higher that of TM and TW. Among those without health insurance, TM had over 7 times greater odds of fair/poor health than TW. This study underscores the importance of classifying and examining the health of the transgender population as unique subpopulations, as notable health differences were discovered. TM and GNB adults have significant health concerns, requiring the attention of clinical interventions aimed at promoting health and preventing illness.

Health Care Experiences of Transgender Adults: An Integrated Mixed Research Literature Review.

This integrated literature review, framed by the gender affirmation framework, sought to contextualize the experiences of transgender adults interfacing with health care after the release of Healthy People 2020. The constructs of the gender affirmation framework represented 4 a priori themes used to organize the findings. The 23 articles synthesized (quantitative, n = 13; qualitative, n = 7; case studies, n = 2; and mixed methods, n = 1) revealed numerous obstacles accessing health care, discrimination from health care professionals and clinicians, restricted health insurance benefits for medically necessary care, and barriers to medically necessary care, such as cross-sex hormones, as well as primary and preventative health care.

Hospital Readmission and Costs of Total Knee Replacement Surgery in 2009 and 2014: Potential Implications for Health Care Managers.

The purpose of this article is to describe changes in hospital readmissions and costs for US hospital patients who underwent total knee replacement (TKR) in 2009 and 2014. Data came from the Healthcare Cost and Utilization Project net-Nationwide Readmissions Database. Compared with 2009, overall 30-day rates of readmissions after TKR decreased by 15% in 2014. Rates varied by demographics: readmission rates were lower for younger patients, males, Medicare recipients, and those with higher incomes. Overall, costs rose 20% across TKR groups. This report is among the first to describe changes in hospital readmissions and costs for TKR patients in a national sample of US acute care hospitals. Findings offer hospital managers a mechanism to benchmark their facilities' performances.

Modeling Health Disparities and Outcomes in Disenfranchised Populations.

The Health Disparities and Outcomes (HDO) model originally created to explain the complexity of obtaining healthcare in rural settings has been revised and updated using emerging theoretical models of adversity and inequity and two decades of empirical work by the authors. With a strong orientation to explaining population-based health inequities, the HDO is applied to individuals with Serious Mental Illness (SMI), to explain their high rates of morbidity and mortality compared to the general population. Individual-, community-, and system-level factors that reflect an understanding of life-long risk, accrued hazards associated with multiple and intersecting disadvantages, and difficulty obtaining healthcare that meets accepted standards are described. The revised HDO can be applied to populations with disproportionate health challenges to identify multi-level factors that affect illness trajectory and overall health outcomes.

Reducing RN Vacancy Rate: A Nursing Recruitment Office Process Improvement Project.

OBJECTIVE: The aim of this study was to reduce the RN vacancy rate at an academic medical center by improving the hiring process in the Nursing Recruitment Office. BACKGROUND: Inability to fill RN positions can lead to higher vacancy rates and negatively impact staff and patient satisfaction, quality outcomes, and the organization's bottom line. METHODS: The Model for Improvement was used to design and implement a process improvement project to improve the hiring process from time of interview through the position being filled. RESULTS: Number of days to interview and check references decreased significantly, but no change in overall time to hire and time to fill positions was noted. RN vacancy rate also decreased significantly. Nurse manager satisfaction with the hiring process increased significantly. CONCLUSION: Redesigning the recruitment process supported operational efficiencies of the organization related to RN recruitment.

Hospital Readmission in Total Hip Replacement Patients in 2009 and 2014.

OBJECTIVE: To document changes in 30-day hospital readmission rates and causes for returning to the hospital for care in THR patients. DESIGN: Retrospective cross-sectional descriptive design. SETTING: Community-based acute care hospitals. PARTICIPANTS: Total sample size (N=142,022) included THR patients (identified as ICD-9-CM procedure code 81.51) in 2009 (n=31,232) and (n=32,863) in 2014. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: 30-Day hospital readmission. RESULTS: The overall readmission rate decreased by 1.3% from 2009 to 2014. The decrease in readmission rates varied by groups, with lesser improvements seen in THR patients who were younger, with private insurance, and residing in lower-income and rural communities. Device complications were the leading cause of readmission in THR patients, increasing from 19.8% in 2009 to 23.9% in 2014. CONCLUSIONS: There has been little decrease in hospital 30-day readmission rates for US community hospitals between 2009 and 2014. Findings from this brief report indicate patient groups at greater risk for 30-day hospital readmission as well as leading causes for readmission in THR patients which can inform the development of tailored interventions for reduction.

Self-Care and Mobility Following Postacute Rehabilitation for Older Adults With Hip Fracture: A Multilevel Analysis.

OBJECTIVE: To examine contextual (facility and community) and individual factors associated with self-care and mobility outcomes among Medicare hip fracture patients receiving inpatient rehabilitation. DESIGN: Retrospective cohort study of 3 linked data files: Inpatient Rehabilitation Facility-Patient Assessment Instrument, Provider of Services, and Area Health Resources. Multilevel modeling was used to examine the effects of contextual and individual factors on self-care and mobility outcomes. SETTING: Inpatient rehabilitation facilities (IRFs). PARTICIPANTS: Medicare hip fracture patients (N=35,264; mean age, 81y) treated in IRFs (N=1072) in 2012. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-care (eating, grooming, bathing, upper and lower body dressing, toileting) and mobility (walk/wheelchair, stairs) at discharge. RESULTS: Mean ± SD self-care and mobility scores at admission were 3.17±.87 and 1.24±.51, respectively; mean ± SD self-care and mobility scores at discharge were 5.03±1.09 and 3.31±1.54, respectively. Individual and contextual levels explained 44.4% and 21.6% of the variance in self-care at discharge, respectively, and 19.5% and 1.9% of the variance in mobility at discharge, respectively. At the individual level, age, race/ethnicity, cognitive and motor FIM scores at admission, and tier comorbidities explained variance in self-care and mobility; sex and length of stay explained variance only in self-care. At the contextual level, facilities' case mix (mean patient age, percent non-Hispanic white, mean self-care score at admission) and structural characteristics (rural location, freestanding, for-profit ownership) explained variance only in self-care; facilities' case mix (mean patient age, percent non-Hispanic white, percent living with social support, mean mobility score at admission) explained variance in mobility. Community variables were nonsignificant. CONCLUSIONS: Individual and facility factors were significant predictors of discharge self-care and mobility among Medicare hip fracture patients in IRFs. The findings may improve quality of IRF services to hip fracture patients and inform risk adjustment methods.

Inpatient Rehabilitation Outcomes in a National Sample of Medicare Beneficiaries With Hip Fracture.

Effects of patient characteristics on rehabilitation outcomes (functional status at discharge, discharged home) were assessed in a retrospective study of Medicare beneficiaries admitted to Medicare-certified inpatient rehabilitation facilities (IRFs) following hospitalization for hip fracture in 2009 (N = 34,984). Hierarchical regression analysis showed significantly higher functional status at discharge (p < .0001) for patients with these characteristics: White or Asian, younger, female, lived alone, higher functional status at admission, fewer comorbidities, no tier comorbidities, and longer IRF length of stay (LOS). Likelihood of discharged home was higher for patients with these characteristics: Hispanic (1.49 [1.32, 1.68]), Asian (1.35 [1.04, 1.74]), or Black (1.28 [1.12, 1.47]); younger (0.96 [0.96, 0.96]); female (1.14 [1.08, 1.20]); lived with others (2.12 [2.01, 2.23]); higher functional status at admission (1.06 [1.06, 1.06]); fewer comorbidities, no tier comorbidities; and longer LOS (1.61 [1.56, 1.67]). Functional status at admission, tier comorbidities, and race/ethnicity contributed the most to variance in functional status at discharge. Living with others contributed the most to variance in discharged home.

Changes in Payment Regulation and Acute Care Use for Total Hip Replacement: Trends in Length of Stay, Costs, and Discharge, 1997-2012.

PURPOSE: To describe trends in the length of stay (LOS), costs, mortality, and discharge destination among a national sample of total hip replacement (THR) patients between 1997 and 2012. DESIGN: Longitudinal retrospective design METHODS: Descriptive analysis of the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample data. FINDINGS: A total of 3,516,636 procedures were performed over the study period. Most THR patients were women, and the proportion aged 44-65 years increased. LOS decreased from 5 to 3 days. Charges more than doubled, from $22,184 to $53,901. Deaths decreased from 43 to 12 deaths per 10,000 patients. THR patients discharged to an institutional setting declined, while those discharged to the community increased. CONCLUSION: We found an increase in THR patients, who were younger, women, had private insurance, and among those discharged to community-based settings. CLINICAL RELEVANCE: Findings have implications for patient profiles, workplace environments, quality improvement, and educational preparation of nurses in acute and postacute settings.

Performance-based outcomes of inpatient rehabilitation facilities treating hip fracture patients in the United States.

OBJECTIVE: To examine the influence of facility and aggregate patient characteristics of inpatient rehabilitation facilities (IRFs) on performance-based rehabilitation outcomes in a national sample of IRFs treating Medicare beneficiaries with hip fracture. DESIGN: Secondary data analysis. SETTING: U.S. Medicare-certified IRFs (N=983). PARTICIPANTS: Data included patient records of Medicare beneficiaries (N=34,364) admitted in 2009 for rehabilitation after hip fracture. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Performance-based outcomes included mean motor function on discharge, mean motor change (mean motor score on discharge minus mean motor score on admission), and percentage discharged to the community. RESULTS: Higher mean motor function on discharge was explained by aggregate characteristics of patients with hip fracture (lower age [P=.009], lower percentage of blacks [P<.001] and Hispanics [P<.001], higher percentage of women [P=.030], higher motor function on admission [P<.001], longer length of stay [P<.001]) and facility characteristics (freestanding [P<.001], rural [P<.001], for profit [P=.048], smaller IRFs [P=.014]). The findings were similar for motor change, but motor change was also associated with lower mean cognitive function on admission (P=.008). Higher percentage discharged to the community was associated with aggregate patient characteristics (lower age [P<.001], lower percentage of Hispanics [P=.009], higher percentage of patients living with others [P<.001], higher motor function on admission [P<.001]). No facility characteristics were associated with the percentage discharged to the community. CONCLUSIONS: Performance-based measurement offers health policymakers, administrators, clinicians, and consumers a major opportunity for securing health system improvement by benchmarking or comparing their outcomes with those of other similar facilities. These results might serve as the basis for benchmarking and quality-based reimbursement to IRFs for 1 impairment group: hip fracture.

A secondary data analysis of Internet use in caregivers of persons with dementia.

AIM: This paper is a secondary data analysis to investigate relationships among caregiver stress appraisal, self-rated health and health-related Internet use. DESIGN: Cross-sectional correlation design. METHODS: National Alliance for Caregiving telephone survey conducted in the USA was a primary data source collected in 2009 from 258 caregivers of persons with dementia, who used the Internet to perform care-giving tasks. Based on Pearlin's Stress Process Model, structural equation modelling was conducted. RESULTS: Caregivers with poor health reported higher levels of caregiver stress appraised, which was associated with more Internet use for health-related purposes. It is required to develop effective Internet-based resources to meet the needs of highly stressed caregivers of persons with dementia. However, there was no relationship between self-rated health and health-related Internet use in dementia caregiver.

Population density, distance to public transportation, and health of women in low-income neighborhoods.

OBJECTIVES: The purpose of this research was to determine the impact of two neighborhood walkability (the extent to which the built environment is pedestrian friendly) metrics on health outcomes of women living in low-income urban neighborhoods, both before and after accounting for individual and neighborhood factors. DESIGN AND SAMPLE: A cross-sectional, retrospective design was used. The sample of 1800 low-income women was drawn from Welfare, Children and Families: A Three-City Study (a study of low-income women from three U.S. cities). MEASURES: Using multilevel modeling and geographic information systems, the study sought to determine the effect of distance to public transportation and residential density on health status, mental health symptoms, and health-related limitations. RESULTS: No significant relationship was found between the two walkability metrics and health outcomes. Instead, neighborhood problems that affect crime and safety impacted health status and mental health symptoms. CONCLUSIONS: As cities make changes to the built environment with the hope of affecting residents' health outcomes, public health nurses need to be aware that changing walkability characteristics in a neighborhood may not affect the health of residents of high crime, low-income neighborhoods. Without first addressing neighborhood crime, efforts to improve walkability in low-income neighborhoods may fail.

Chiropractic use, health care expenditures, and health outcomes for rural and nonrural individuals with arthritis.

OBJECTIVE: Arthritis is considered the leading cause of disability among adults in the United States today and contributes substantially to the rising cost of health care. Residents of rural areas are especially affected. The purposes of this article are to describe chiropractic use by rural and nonrural individuals with arthritis and to identify differences in other health care use and health status by those using chiropractic care plus conventional care or conventional care alone. METHODS: A longitudinal cohort from panel 12 (N = 12440) of the Medical Expenditure Panel Survey spanning 2007 to 2008 was selected for this study to represent changes in health care expenditures and use and outcomes throughout this period. The population was stratified by self-reported physician-diagnosed arthritis and rural status and compared across demographics, health status, and health care use and expenditures, including use of chiropractic services plus conventional care or conventional care alone. RESULTS: Twice as many rural people with arthritis had 1 or more visits with a doctor of chiropractic compared with nonrural persons with arthritis. More rural chiropractic users with arthritis reported their perceived health status as excellent, very good, or good compared with nonrural chiropractic users with arthritis and to rural people with arthritis who reported no chiropractic visits. Health care expenditures for other physician services were higher among rural chiropractic users with arthritis than nonrural users with arthritis. CONCLUSIONS: Differences in chiropractic use were observed between rural and nonrural individuals with arthritis. More studies are needed to investigate these differences and the impact on health care use and expenditures and outcomes of individuals with arthritis.