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This study aimed to explore how metaphors were used to interpret the pandemic and to address its challenges in primary and secondary schools in Reggio Emilia, Italy. A questionnaire was administered to educators and teachers to understand how languages, images, and metaphors were used by themselves and their students to talk about the pandemic and their experiences of living with it. The goal of the questionnaire was to guide critical reflection and encourage more informed language choices. While the existing literature points out the alleged overuse of war metaphors and military frames in public discourse, our findings show that war metaphors are relatively frequent, with other metaphorical frames widely used by teachers and educators to foster resilient attitudes in students. Moreover, in their professional contexts, teachers and educators mostly use metaphorical frames involving resilient attitudes. Our interpretation of the results supports the hypothesis that the purposeful use and deliberate production of metaphors support the choice of metaphors with positive, constructive implications. Finally, some implications of these findings on the theory of metaphor and the methodology of the research are discussed.
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The current study aimed to identify the impact of positive thinking on the anxiety of Coronavirus infection through the lockdown among UNRWA staff in Jordan. To achieve the objectives of the study, three measures were developed, the Positive Thinking Scale, the anxiety level of Coronavirus Infection Scale, and the lockdown Scale. A sample of (2036) employees responded to the measures. The results showed that the level of anxiety for COVID -19 infection among the sample was high, and statistically significant differences were found in the level of Covid-19 infection anxiety according to the sex variable for females, also statistically differences were found in the level of anxiety in COVID-19 infection according to age in favor of (31-40), and statistically differences for the social status in favor of married couples. Results also showed a direct negative impact of positive thinking variable on the level of anxiety associated with COVID-19 infection, and an effect of positive thinking on the level of anxiety during activating the lockdown. The study recommends designing training programs for employees to help them adapt to different circumstances and enable them to continue performing their assigned work. [ FROM AUTHOR] Copyright of An-Najah University Journal for Research, B: Humanities is the property of An-Najah National University and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
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In this report, a nationally representative sample of kindergarten through 12th grade (K-12) public school principals were asked about their experiences with covering classrooms and hiring staff. In the spring of the 2021-2022 school year, which coincided with the coronavirus disease 2019 (COVID-19) omicron variant surge, most principals struggled to keep classrooms consistently staffed and many reported that hiring had become more challenging since the previous school year. Principals indicated that a lack of substitute teachers -- not an increase in open teaching positions -- was the main reason for classroom coverage shortages. In addition to day-to-day coverage issues, most principals reported that teacher vacancies were on the rise. Most of these principals believed that vacancies had grown more difficult to fill than in the prior school year, largely because of declining applicant counts. Principals' preferences when hiring teachers lend further insight into potential drivers of hiring challenges. A large majority of principals expressed strong preferences for like-minded teachers whose mindsets aligned with the vision and culture of the schools. Few principals prioritized the diversity of the educator workforce at their schools.
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Objective: Is to find out which revascularization methods have less of risk factors and complications after the surgery and long-term period. Method(s): From January 2018 to December 2019 were operated 134 patients with LAD CTO. 48 of them underwent MIDCAB: 36 (75%) males and 12 (25%) females;aged 58.7 +/-8.7;7 (14.6%) with previous diabetes;10 (20.8%) with previous PCI of LAD with drug-eluting stent. In the PCI group there were 86 patients: 52 (60.5%) males and 34 (39.5%) females;aged 64.8 +/-8.3;23 (26.7%) with previous diabetes. Result(s): Hospital mortality was 0 (0%) in MIDCAB unlike 1 (1.2%) in PCI. Myocardial infarction was 0 (0%) in both the groups. In MIDCAB the number of conversions to onpump and sternotomy was 0 (0%), there were 6 (12.5%) pleuritis with pleural puncture and 3 (6.2%) with long wound-aches. The hospitalization period was 10.7+/-2.9 days for MIDCAB and 9.9 +/-3.9 days for PCI. In the PCI group 2.0 +/-1.0 drug-eluting stents were used. In-hospital costs were higher for PCI 3809 unlike 3258 for MIDCAB. After one year in MIDCAB group died 2 (4.2%) patients, from noncardiac causes. In PCI group died 3 (3.5%) patients, all from cardiac causes. Because of pandemic COVID-19 were checked only 48 patients by angiography and general clinical examination: 25 after MIDCAB and 23 after PCI. 5 patients have a graft failure, caused by surgical mistakes. 4 patients have stents restenosis and 1 has LAD's reocclusion. Conclusion(s): Both methods of revascularization for LAD CTO are demonstrated similar results. EuroSCORE II (P = 0.008) and glomerular filtrating rate (P = 0.004) are significant potential risk factors for mortality in both groups, age is potential risk factor for graft failure (P = 0.05). Dyslipidemia is significant risk factor for LAD restenosis in PCI group (P = 0.02). MIDCAB is associated with lower incidence of revascularization repeat and in-hospital mortality in the literature data and it costs lower than PCI for LAD CTO as our study has shown.
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Restrictions during the COVID-19 pandemic significantly affected people's opportunities to engage in activities that are meaningful to their lives. In response to these constraints, many people, including older adults, turned to digital technologies as alternative ways to pursue meaningful activities. These technology-mediated activities, however, presented new challenges for older adults' everyday use of technology. In this paper, we investigate how older adults used digital technologies for meaningful activities during COVID-19 restrictions. We conducted in-depth interviews with 40 older adults and analyzed the interview data through the lens of self-determination theory (SDT). Our analysis shows that using digital technologies for meaningful activities can both support and undermine older people's three basic psychological needs for autonomy, competence, and relatedness. We argue that future technologies should be designed to empower older adults' content creation, engagement in personal interests, exploration of technology, effortful communication, and participation in beneficent activities. © 2023 ACM.
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Affective computing (AC) has been regarded as a relevant approach to identifying online learners' mental states and predicting their learning performance. Previous research mainly used one single-source data set, typically learners' facial expression, to compute learners' affection. However, a single facial expression may represent different affections in various head poses. This study proposed a dual-source data approach to solve the problem. Facial expression and head pose are two typical data sources that can be captured from online learning videos. The current study collected a dual-source data set of facial expressions and head poses from an online learning class in a middle school. A deep learning neural network using AlexNet with an attention mechanism was developed to verify the syncretic effect on affective computing of the proposed dual-source fusion strategy. The results show that the dual-source fusion approach significantly outperforms the single-source approach based on the AC recognition accuracy between the two approaches (dual-source approach using Attention-AlexNet model 80.96%;single-source approach, facial expression 76.65% and head pose 64.34%). This study contributes to the theoretical construction of the dual-source data fusion approach, and the empirical validation of the effect of the Attention-AlexNet neural network approach on affective computing in online learning contexts.
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Inclusive digital financial services should welcome older populations and make them beneficiaries of the digital and financial revolution. To understand older adults' experience of using digital financial tools, we conducted an online survey of 268 older internet users aged 60 or above from urban areas of 14 Chinese provinces after China's nationwide COVID-19 lockdown in 2021. Our results revealed that older internet surfers were active in digital financial activities and engaged most with activities that were highly compatible with their lifestyles. Active users significantly differed from inactive users in sociodemographics, confirming that a digital divide related to social stratification exists among older internet users. Digital finance active users were also distinguished from inactive users' attitudes and perceptions toward digital finance. Logistic regression results indicated that perceived usefulness, access to proper devices for digital finance, risk perceptions, and perceived exclusion if not using technology were associated with their adoption of these advanced tools. Older adults reported the perceived inconvenience of in-person financial services during the lockdown. They also expressed a willingness to participate in relevant training if provided. The findings of this study could help aging-related practitioners to understand older adults' engagement in digital finance and guide policy and project design in the area of financial inclusion of the aging population.
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Community-acquired pneumonia is a potentially serious infection in children with high morbidity rate, risk of severe course and unfavorable outcomes. Specialists have noted the increased incidence of the destructive forms in the recent years. Aim. To present a clinical case of destructive pneumonia in a 1 year 2 month old child, hospitalized in the State Budgetary Healthcare Institution "Children's City Clinical Hospital of St. Vladimir Moscow Healthcare Department", and analyze it in terms of current understanding on the disease pathogenesis. Conclusion. During COVID-19 (COronaVIrus Disease 2019) pandemic, pulmonologists and pediatric surgeons encountered an unconventional course of destructive pneumonia. A large number of studies of pathophysiological processes in acute viral interstitial pneumonias have recently allowed to expand our understanding of the role of coagulation system. At the same time, new questions arose concerning the clinical course and development of the pathological infectious process.Copyright © Zaytseva O.V. et al., 2023.
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Objective. To study the characteristics of cardiotocography (CTG) and pregnancy outcomes in patients who had a mild coronavirus infection in the third trimester. Patients and methods. The parameters and variations of CTG and pregnancy outcomes were analyzed in 32 low-risk pregnant women who experienced mild COVID-19 in the third trimester (the study group) and in 30 pregnant women (matched pairs) who had no coronavirus infection (the comparison group). Results. A total of 375 CTGs were analyzed: 221 in the study group and 154 in the comparison group. Normal CTG recordings were found in 87% of pregnant women in the study group, which was significantly less frequent than in those without COVID-19 (97%) (p = 0.02), and suspicious CTG in 10 and 1.3%, respectively, which was 3.38-fold more frequent than in the comparison group (p = 0.04). Pathological CTG recordings were observed only in two women in the study group. The features of CTG in women who had a mild form of COVID-19 in the third trimester were a significant decrease in the number of accelerations, short-term variation (STV) in the range of 3 to 5 ms, long-term variation (LTV) <50 ms, a tendency toward tachycardia and low heart rate variability (<5 ms), and prolonged decelerations. The frequency of fetal asphyxia and neonatal morbidity was higher in the study group. Conclusion. COVID-19 even in its mild form may have a negative effect on the fetus, increasing the frequency of fetal hypoxia and neonatal asphyxia.Copyright © 2023, Dynasty Publishing House. All rights reserved.
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The abrupt transition to distance learning during the outbreak of the COVID-19 pandemic triggered an urgent need for online resources at higher education institutes (HIEs). Creating analogues of traditional full-time courses demanded for competencies and time resources. In this case ready-made massive open online courses (MOOCs) were supposed to be the most obvious and fastest solution for HIEs. However, analytics demonstrated that educational institutions did not consider MOOC a promising option. This contradiction served as an incentive to conduct this research, which includes the analysis of both non-reactive (MOOCs platform analytics) and reactive (online survey and interviews with instructors) data. Based on our research, we can conclude that the reasons for not integrating MOOCs at Russian HIEs during the COVID-19 pandemic are the following: the peculiarities of MOOCs format, low motivation of instructors, administrative risks, and the uncertainty of HIEs' and national policies on MOOCs integration. This article will be useful for those who determine educational policy in Russia, university administrators, methodologists responsible for the development of digital educational technologies in HIEs, as well as researchers of higher education. © 2023 Moscow Polytechnic University. All rights reserved.
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COVID-19 has had serious consequences in all areas of social life, including education. In this period, distance education appeared as an inevitable solution. Even today, when the pandemic process is over and re-normalization has begun, online teaching environments have become such an indispensable part of education systems that it has been decided that a certain proportion of the courses will be conducted online in universities. For this reason, determining student experiences in online courses is important in planning the future of distance education. Since academic performance is the output of the teaching process, students' academic performance is one of the topics of interest in higher education research. There may be different factors affecting the academic performance of students in the distance education process, which imposes more responsibility on students and requires self-control. This study aimed to examine the relationship of academic performance in the distance education with home infrastructure, student interaction, computer skills, academic satisfaction. This research is based on a large-scale study, "The impact of the COVID-19 pandemic on the lives of higher education students", examining the pandemic's impact on higher education student perceptions in 2020. It has been observed that home infrastructure has a significant impact on the student's academic performance. The infrastructure increases the interaction of the student. When home infrastructure is taken as a control variable, students' computer skills are the highest predictor of their perception of academic performance, followed by their online interactions and, finally, perceived satisfaction. Today, pandemic conditions are still ongoing. In addition, even as the pandemic ends, online education has become an indispensable part of our education system. Therefore, the findings of the research would be beneficial for the ongoing planning process.
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Objective: To analyze and compare the effects of different clinical characteristics on the negative conversion time of nucleic acid detection after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variant infection, and to provide a scientific basis for the isolation and treatment of coronavirus disease 2019 (COVID-19). Methods: The epidemiological and clinical data of 228 mild SARS-CoV-2 Omicron variant infected patients diagnosed in Shanghai were retrospectively collected from April 27, 2022 to June 8, 2022 in Wujiaochang designated Hospital, Yangpu District, Shanghai. The negative conversion time of nucleic acid detection was used as the outcome variable, and the patients were divided into A (18 days) and B (>18 days). Univariate and multivariate logistic regression analysis were used to analyze the influencing factors of the negative conversion time of nucleic acid detection. Results: The mean nucleic acid conversion time of 228 patients was (18.7+or-12.1) d, with the median time of 18 (2-46) d. Among them, 120 patients in group A had an average nucleic acid conversion time of (13.2+or-2.0) d, and 108 cases in group B had an average nucleic acid conversion time of (20.8+or-1.3) d. Univariate analysis showed that there were no statistically significant differences in the effects of hypertension, coronary heart disease, diabetes, hypokalemia, malignant tumors, neuropsychiatric diseases, chronic digestive diseases on the negative nucleic acid conversion time (P > 0.05);however, there were significant differences in the effects of combined cerebrovascular disease, leukopenia, chronic respiratory system diseases and vaccination on the negative nucleic acid conversion time (P < 0.05). Further multivariate logistic regression analysis revealed that the combination of chronic respiratory diseases and non-vaccination were significant risk factors for prolongation of negative nucleic acid conversion time (P < 0.05). Conclusions: The results of this study show that gender, age and whether hypertension, coronary heart disease, diabetes mellitus, hypokalemia, malignant tumor, neuropsychiatric disease and chronic digestive disease have no significant effect on the nucleic acid conversion time, whereas chronic respiratory disease and no vaccination are significantly correlated with the prolongation of nucleic acid conversion time in SARS-CoV-2 Omicron-infected patients.
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PurposeThe current study investigated the impact of organisational trust on emotional well-being and performance of middle leaders during the coronavirus disease 2019 (COVID-19) pandemic.Design/methodology/approachA convenience sample of 265 middle leaders in kindergartens in China responded involving trust in schools (e.g. trust in principal and trust in colleagues), emotional well-being and job performance. Both confirmatory factor analysis and structural equation modelling (SEM) were used in the investigation.FindingsThree hypotheses on the relationships between the three constructs were verified. Trust in schools significantly influenced emotional well-being and job performance of middle leaders which correlated with each other. The interactive effects of trust in principal and trust in colleagues were discussed for improving the well-being and job performance of middle leaders. Relationships between the two kinds of trust and pride were also identified in the research.Research limitations/implicationsFurther studies may put efforts towards improving these three outcomes synchronously.Practical implicationsBased on the evidence of the current study, future research may focus on how middle leaders act as a bridging role between different stakeholders such as principal and teachers, principal and parents, teachers and children, meanwhile how to boost the leaders' own well-being and performance in the early childhood education (ECE).Originality/valueThis study established the empirical linkages between school trusts, emotional well-being and job performance.
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mRNA is a new class of drugs that has the potential to revolutionize the treatment of brain tumors. Thanks to the COVID-19 mRNA vaccines and numerous therapy-based clinical trials, it is now clear that lipid nanoparticles (LNPs) are a clinically viable means to deliver RNA therapeutics. However, LNP-mediated mRNA delivery to brain tumors remains elusive. Over the past decade, numerous studies have shown that tumor cells communicate with each other via small extracellular vesicles, which are around 100 nm in diameter and consist of lipid bilayer membrane similar to synthetic lipidbased nanocarriers. We hypothesized that rationally designed LNPs based on extracellular vesicle mimicry would enable efficient delivery of RNA therapeutics to brain tumors without undue toxicity. We synthesized LNPs using four components similar to the formulation used in the mRNA COVID19 vaccines (Moderna and Pfizer): ionizable lipid, cholesterol, helper lipid and polyethylene glycol (PEG)-lipid. For the in vitro screen, we tested ten classes of helper lipids based on their abundance in extracellular vesicle membranes, commercial availability, and large-scale production feasibility while keeping rest of the LNP components unchanged. The transfection kinetics of GFP mRNA encapsulated in LNPs and doped with 16 mol% of helper lipids was tested using GL261, U87 and SIM-A9 cell lines. Several LNP formations resulted in stable transfection (upto 5 days) of GFP mRNA in all the cell lines tested in vitro. The successful LNP candidates (enabling >80% transfection efficacy) were then tested in vivo to deliver luciferase mRNA to brain tumors via intrathecal administration in a syngeneic glioblastoma (GBM) mouse model, which confirmed luciferase expression in brain tumors in the cortex. LNPs were then tested to deliver Cre recombinase mRNA in syngeneic GBM mouse model genetically modified to express tdTomato under LoxP marker cassette that enabled identification of LNP targeted cells. mRNA was successfully delivered to tumor cells (70-80% transfected) and a range of different cells in the tumor microenvironment, including tumor-associated macrophages (80-90% transfected), neurons (31- 40% transfected), neural stem cells (39-62% transfected), oligodendrocytes (70-80% transfected) and astrocytes (44-76% transfected). Then, LNP formulations were assessed for delivering Cas9 mRNA and CD81 sgRNA (model protein) in murine syngeneic GBM model to enable gene editing in brain tumor cells. Sanger sequencing showed that CRISPR-Cas9 editing was successful in ~94% of brain tumor cells in vivo. In conclusion, we have developed a library of safe LNPs that can transfect GBM cells in vivo with high efficacy. This technology can potentially be used to develop novel mRNA therapies for GBM by delivering single or multiple mRNAs and holds great potential as a tool to study brain tumor biology.
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Rapid and continuous changes in digital technologies have changed both classroom practices and teacher profiles in education. It can be argued that a new context of teaching may lead some teachers to develop a different teacher identity in order to meet the needs of the era. Within this perspective, this case study attempts to explore the impacts of Information and Communication Technologies (ICT) revolution in education on teachers' professional identity through the lens of three English instructors from three different contexts in Turkey. The study particularly focuses on reflections of teachers during the pandemic. As a theoretical framework, the study adopts Wenger's (1997) social theory of learning and, within this framework, it discusses these teachers' professional identities in relation to their ICT usage. In particular, three modes of belonging, Engagement, Imagination and Alignment, are underlined. A qualitative approach is employed based on the written history documents of the participants and semi-structured interviews as data collection tools. The findings are gathered with a deductive thematic analysis, and they illustrate that teachers have some external and internal difficulties regarding their ICT usage, and they form a new shape of professional identity mainly through collaboration, community expertise and contributing new ideas in their school contexts. Although the use of new digital technologies mostly enables them to adopt a positive and modern teacher identity in their teaching contexts, it also leads some of them to sometimes question their teacher identity due to their limited ICT knowledge and competence. Thus, the study suggests some implications both for language teachers to invest in their digital identities, and for school administrations to create a friendly atmosphere where the community of expertise can be shared freely among teachers.
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With the success of mRNA vaccines during the COVID-19 pandemic and CAR T-cell therapies in clinical trials, there is growing opportunity for immunotherapies in the treatment of many types of cancers. Lentiviral vectors have proven effective at delivery of genetic material or gene editing technology for ex vivo processing, but the benefits and promise of Adeno-associated virus (AAV) and mRNA tools for in vivo immunotherapy have garnered recent interest. Here we describe complete synthetic solutions for immuno-oncology research programs using either mRNA-vaccines or virus-mediated cell and gene engineering. These solutions optimize workflows to minimize screening time while maximizing successful research results through: (1) Efficiency in lentiviral packaging with versatility in titer options for high-quality particles. (2) A highthroughput viral packaging process to enable rapid downstream screening. (3) Proprietary plasmid synthesis and preparation techniques to maintain ITR integrity through AAV packaging and improve gene delivery. (4) Rapid synthesis, in vitro transcription, and novel sequencing of mRNA constructs for complete characterization of critical components such as the polyA tail. The reported research demonstrates a streamlined approach that improves data quality through innovative synthesis and sequencing methodologies as compared to current standard practices.
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This book explores the multifaceted obstacles to social change that India, Myanmar and Thailand face, and ways to overcome them. With a collection of essays that identify common challenges and salient features affecting diverse communities, this volume examines topics from subnational and local perspectives across the peripheries. The book argues that identity-based divisions have created a system of oppression and political contention that have led to conflicts of different kinds, and hence serving as the common cause of different social issues. At the same time, such issues have created space for marginalized groups around the world to call for change. The volume recognizes that social transformation comes into being through an active process of deconstructing and reconstructing shared norms and ideas. The contents in this book are thus centered around two focuses: The impacts of identities and grassroots. Both of these aspects are at the heart of each country's transformations towards democracy, peace, justice, and freedom. Under this framework, the chapters cover a diverse range of common issues, such as, minority grievances, gender inequality, ethnic identity, grassroots power in alliance-making towards community peace, recovery and resilience, digital freedom, democracy assistance and communication, and bridging multiple divides. As identity-based cleavages are daily lived experiences for individuals and communities, it requires grassroots initiatives and alliances as well as democratic communication to tackle obstacles at the root. Ultimately, the book convinces readers that social transformations must begin at the individual to communal level and local to national level. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022.
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This study explores how China's education responses to COVID-19 from a perspective of policy analysis. Specifically, it involves building an educational policy system for COVID-19 to examine educational governance framework, school management and teaching, policies for teachers during the epidemic. The education policy during the epidemic has achieved positive results. Those results aim to ensure the physical and mental health of teachers and students, ensure the supply of epidemic prevention materials and educational resources, ensure the quality of students' learning, and enhance the application ability of teachers' teaching technology. The process of policy changes and effects of policy implementation have been examined to analyze how China's education responses to COVID-19. The characteristics and experience of China's education policy in response to the epidemic concentrate on forming a governance system under the centralized and unified leadership of the Communist Party of China, building a pattern in which families and schools cooperate closely to promote the smooth development of education and teaching, transforming from an emergency substitute during the crisis into an important motivation to promote the transformation of education paradigm, and paying great attention to remote and poor areas and disadvantaged student groups.
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Teaching during a global pandemic has prompted many discussions about how faculty can best support students and create classrooms where deep learning and engagement occur. In this conversation, we argue there is a role for empathy in college classrooms. We present data from interviews with faculty at a small, Midwestern, teaching-focused university during the fall of 2020. We map these perspectives onto the empathy paths framework and suggest that the therapeutic and instrumental paths are most useful for understanding empathy in the classroom. We also discuss why it is important for faculty to think about empathy and the role sociology can play in these conversations. Finally, we present a series of empathetic practices individual faculty can incorporate into their pedagogy and structural supports that departments and universities can provide to help faculty engage in empathetic practices in the classroom.
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OBJECTIVES: On March 11, 2020, the WHO classified COVID-19 as a global pandemic. Measures to quell the pandemic included limiting non-essential activities including clinic visits and procedures. It is unclear if individuals with OI had disruptions in their access to healthcare or medications, and if such disruptions affected patients' symptoms. METHOD(S): A REDCap survey was distributed through the OI Foundation on August 31. Surveys completed through September 11 by individuals with OI or their caregiver are included in this analysis. Participants were asked to compare their symptoms and access to healthcare during the first 4 months of the pandemic to the 4 months before the pandemic. RESULT(S): 85 surveys were completed, and 6 were partially completed. The median age of participants was 40 years;35% were children. 32% of participants self-identified as having severe OI. Although most reported no changes in bone pain or fractures, 46% reported they were less likely to seek emergency medical care to treat a fracture, while 33% reported they were more likely to treat fractures at home (Fig 1A). There were delays in accessing all services, with greatest delays accessing dentistry (74%) and aquatic therapy (84%) (Fig 1B). 36% of participants receiving bisphosphonate infusions had delayed infusions because of the pandemic (Fig 1C). Of note, 50% of planned surgeries were delayed. CONCLUSION(S): Although many individuals with OI and their caregivers reported delays in accessing bone-related services/clinics during this 4-month period, there was not a concomitant increase in reported symptoms. This may have related to shelter-in-place restrictions and decreased activity. Limitations of this study include small sample size and potential selection bias because responses were obtained only from OIF members. To address these limitations, we are distributing the survey through healthcare providers of individuals with OI across major regions of the US from a variety of practice types including endocrine, orthopedics and multidisciplinary clinics. Furthermore, as the COVID-19 pandemic continues, we hope that this survey will provide information to address what aspects of healthcare may be in greatest need, as well as the modality through which services may be met. (Figure Presented).