Insights from a Web-based survey into the psychosocial experiences of adults with dyslexia: Findings from a final comment question.

Not seemingly measuring up to Western societies' educational and occupational expectations for success, adults with dyslexia are at risk for discrimination, humiliation, low self-esteem, low self-efficacy, depression, and anxiety. We analysed 113 responses to the final comment question that was incorporated at the end of a quantitative survey on the socioemotional experiences of adults with dyslexia. The final comment question was not intended for conveying personal experiences, yet the final comment responses were personal, in-depth, and substantive - indicators of quality recommended in survey research. Thematic analysis was used to analyse the data and develop themes. One overarching theme was yearnings for understanding and acceptance. Its associated subthemes included (1) "This stuff is torture", (2) "Thank God I'm not normal, (3) educational experience, (4) coping strategies, (5) family support, and (6) generational dyslexia. This study contributes to the small but growing body of literature on the socioemotional experiences of adults with dyslexia. Among the implications for practice, policy and research, a larger challenge at the broader society level that embraces diversity, equity, and inclusion for individuals with dyslexia is forefront.

A comparison of primary care parenting programs for Latinx families.

Introduction: Primary care agencies remain an ideal setting for implementing parenting programs that meet the needs of Latinx parents. However, little to no research has been done on how well adapted primary care parenting programs (PCPPs) are to the beliefs, values, and practices of many Latinx families. Method: Using 5 inclusion criteria, 8 PCPPs were selected and compared across 8 domains: focus, age of child, composition, sequence, duration, training length, estimated start-up costs, and number of cultural adaptations. Results: PCPPs vary widely across all 8 domains, with some PCPPs being relatively brief and low cost and others more all encompassing and expensive. Only 4 of the 8 programs demonstrated cultural adaptations outside Spanish translation. Conclusion: This comparison demonstrates that there is a lack of cultural consideration among researchers who develop PCPPs. Recommendations for providing culturally attuned parenting services for Latinx families within a primary care environment are given. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Biopsychosocial-Spiritual Factors Impacting Referral to and Participation in Cardiac Rehabilitation for African American Patients: A SYSTEMATIC REVIEW.

PURPOSE: The purposes of this systematic review were to (1) review the literature related to the demographic and biopsychosocial-spiritual factors impacting cardiac rehabilitation (CR) referral and participation of African American patients with cardiovascular disease (CVD); (2) identify barriers and facilitators to CR referral and participation for this population; (3) identify gaps in the literature; and (4) make recommendations for future research studies and interventions. METHODS: The Cooper 7-step protocol for research synthesis was followed to formulate a research question and search MEDLINE via PubMed, PsycINFO via EBSCO, and CINAHL via EBSCO. A second reviewer repeated the searches performed by the first author in the initial review. RESULTS: A total of 1640 articles identified using the search strategy yielded 7 articles that fit the search criteria. Most studies measured demographic or social factors. Two studies measured biological factors, 1 study measured psychological factors, and no study measured spiritual factors. CONCLUSIONS: According to the studies reviewed, African American patients with CVD were less likely to receive a CR referral, more likely to enroll in CR with more cardiovascular risk factors, and less likely to participate in and complete CR due to factors related to low socioeconomic status (eg, lack of insurance, work conflicts, lower level of education) than non-Hispanic white patients. Further research is needed on the interaction between demographic/biopsychosocial-spiritual factors and referral to and participation of African Americans in CR in order to ensure that interventions fit the needs of this particular population.

"Moving Toward Healthy": Insights Into Food Choices of Mothers in Residential Recovery.

This study utilized participatory and potentially empowering qualitative research methods of photo-elicitation and face-to-face interviews to investigate food choices of mothers living with their children in a residential substance use disorder recovery program. Face-to-face interviews were conducted with nine women (25-40 years) living in a residential substance use disorder recovery program in the Southeastern United States. Each audio recorded and transcribed interview was coded individually before collectively developing a consensual version of the codebook and identifying themes. The recovering women in this study expressed a new or renewed desire to "eat healthy" and voiced concerns about the nutritional value of foods. Food choices were influenced by their children's nutritional needs and food preferences, their own food preferences and habits, the financial resources available to them, their personal food preparation self-efficacy and skills, and the limitations inherent in residential recovery. Understanding food choices benefits both recovering parents and their children.

Beyond repair - family and community reintegration after obstetric fistula surgery: study protocol.

BACKGROUND: Obstetric fistula is a debilitating birth injury that affects an estimated 2-3 million women globally, most in sub-Saharan Africa and Asia. The urinary and/or fecal incontinence associated with fistula affects women physically, psychologically and socioeconomically. Surgical management of fistula is available with clinical success rates ranging from 65-95 %. Previous research on fistula repair outcomes has focused primarily on clinical outcomes without considering the broader goal of successful reintegration into family and community. The objectives for this study are to understand the process of family and community reintegration post fistula surgery and develop a measurement tool to assess long-term success of post-surgical family and community reintegration. METHODS: This study is an exploratory sequential mixed-methods design including a preliminary qualitative component comprising in-depth interviews and focus group discussions to explore reintegration to family and community after fistula surgery. These results will be used to develop a reintegration tool, and the tool will be validated within a small longitudinal cohort (n = 60) that will follow women for 12 months after obstetric fistula surgery. Medical record abstraction will be conducted for patients managed within the fistula unit. Ethical approval for the study has been granted. DISCUSSION: This study will provide information regarding the success of family and community reintegration among women returning home after obstetric fistula surgery. The clinical and research community can utilize the standardized measurement tool in future studies of this patient population.

Paediatric palliative care: a review of needs, obstacles and the future.

AIM: This literature review offers a response to the current paediatric palliative care literature that will punctuate the need for a framework (i.e. the three world view) that can serve as an evaluative lens for nurse managers who are in the planning or evaluative stages of paediatric palliative care programmes. BACKGROUND: The complexities in providing paediatric palliative care extend beyond clinical practices to operational policies and financial barriers that exist in the continuum of services for patients. EVALUATION: This article offers a review of the literature and a framework in order to view best clinical practices, operational/policy standards and financial feasibility when considering the development and sustainability of paediatric palliative care programmes. KEY ASPECTS: Fifty-four articles were selected as representative of the current state of the literature as it pertains to the three world view (i.e. clinical, operational and financial factors) involved in providing paediatric palliative care. CONCLUSION: In developing efficient paediatric palliative care services, clinical, operational and financial resources and barriers need to be identified and addressed. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing management plays a crucial role in addressing the clinical, operational and financial needs and concerns that are grounded in paediatric palliative care literature.

The clinical, operational, and financial worlds of neonatal palliative care: A focused ethnography.

OBJECTIVE: Due to multiple issues, integrated interdisciplinary palliative care teams in a neonatal intensive care unit (NICU) may be difficult to access, sometimes fail to be implemented, or provide inconsistent or poorly coordinated care. When implementing an effective institution-specific neonatal palliative care program, it is critical to include stakeholders from the clinical, operational, and financial worlds of healthcare. In this study, researchers sought to gain a multidisciplinary perspective into issues that may impact the implementation of a formal neonatal palliative care program at a tertiary regional academic medical center. METHOD: In this focused ethnography, the primary researcher conducted semistructured interviews that explored the perspectives of healthcare administrators, finance officers, and clinicians about neonatal palliative care. The perspectives of 39 study participants informed the identification of institutional, financial, and clinical issues that impact the implementation of neonatal palliative care services at the medical center and the planning process for a formal palliative care program on behalf of neonates and their families. RESULTS: Healthcare professionals described experiences that influenced their views on neonatal palliative care. Key themes included: (a) uniqueness of neonatal palliative care, (b) communication and conflict among providers, (c) policy and protocol discrepancies, and (d) lack of administrative support. SIGNIFICANCE OF RESULTS: The present study highlighted several areas that are challenging in the provision of neonatal palliative care. Our findings underscored the importance of recognizing and procuring resources needed simultaneously from the clinical, operational, and financial worlds in order to implement and sustain a successful neonatal palliative care program.

Why don't younger adults in England go to have their eyes examined?

PURPOSE: Most research on attitudes to eye health has focussed on older people, reflecting the higher prevalence of eye diseases in older age groups. Little is known about younger people's attitudes to eye health. This paper explores young adults understanding of eye health and the purpose of eye examinations and the reasons why they do or do not attend for eye examinations. The aim is to provide evidence to inform policy on recommendations relating to eye health for individuals at low risk of visual impairment. METHODS: Six focus-group meetings were held in Leeds with 43 people aged 18-35 (mean age 22 years). Focus group participants were recruited using a snowballing approach from an initial group of young adults. Focus groups were transcribed and a thematic analysis approach was used. RESULTS: Children who wore spectacles were often bullied. As people grew up it became more socially acceptable to wear spectacles. Practicalities, aesthetics and fashion were important issues. Knowledge about eye disease and the eye examination were generally poor. Many claimed to value vision, but recognised that young people do not have eye examinations as often as they should. Eye examinations were only perceived to be needed for younger people experiencing problems or to update prescriptions. Eye health was seen as issue for older people. Some had no idea or were shocked about how much spectacles cost. Optometrists were seen differently to other healthcare professionals. The retail aspect of optometry was seen as too dominant. More information was wanted from the NHS on eye health. CONCLUSION: While young adults are at low risk of sight threatening disease, many do benefit from correction of refractive error. There is an argument for reducing the recommended frequency of eye examinations for low risk individuals from the 2 years currently advised. Nevertheless, young adults need to be made more aware of eye health issues, so that optometrists are seen as more than somewhere that sell spectacles. Increasing awareness of eye health in younger adulthood will also be important to ensure that services are appropriately accessed as they get older.

Teaching surgical skills using video internet communication in a resource-limited setting.

OBJECTIVE: To study the feasibility and acceptability of using video Internet communication to teach and evaluate surgical skills in a low-resource setting. METHODS: This case-controlled study used video Internet communication for surgical skills teaching and evaluation. We randomized intern physicians rotating in the Obstetrics and Gynecology Department at Mulago Hospital at Makerere University in Kampala, Uganda, to the control arm (usual practice) or intervention arm (three video teaching sessions with University of California, San Francisco faculty). We made preintervention and postintervention videos of all interns tying knots using a small video camera and uploaded the files to a file hosting service that offers cloud storage. A blinded faculty member graded all of the videos. Both groups completed a survey at the end of the study. RESULTS: We randomized 18 interns with complete data for eight in the intervention group and seven in the control group. We found score improvement of 50% or more in six of eight (75%) interns in the intervention group compared with one of seven (14%) in the control group (P=.04). Scores declined in five of the seven (71%) controls but in none in the intervention group. Both intervention and control groups used attendings, colleagues, and the Internet as sources for learning about knot-tying. The control group was less likely to practice knot-tying than the intervention group. The trainees and the instructors felt this method of training was enjoyable and helpful. CONCLUSION: Remote teaching in low-resource settings, where faculty time is limited and access to visiting faculty is sporadic, is feasible, effective, and well-accepted by both learner and teacher. LEVEL OF EVIDENCE: II.

Comparisons of pelvic floor muscle performance, anxiety, quality of life and life stress in women with dry overactive bladder compared with asymptomatic women.

UNLABELLED: Study Type - Therapy (case control) Level of Evidence 3b What's known on the subject? and What does the study add? Abnormal pelvic floor muscle function has been associated with chronic pelvic pain syndromes. This study adds evidence about pelvic muscle performance in women with dry overactive bladders. OBJECTIVES: To determine if pelvic floor muscle surface electromyography (sEMG) measurements differed between women with dry overactive bladder (OAB) symptoms and asymptomatic controls. To determine whether pelvic floor muscle performance was associated with anxiety scores, quality of life and life stress measures PATIENTS AND METHODS: We enrolled 28 women with urinary urgency and frequency without urinary incontinence, and 28 age-matched controls. sEMG was used to assess pelvic muscle performance. Participants also completed the Beck Anxiety Inventory, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire and Recent Life Changes Questionnaire. RESULTS: Anxiety scores were significantly higher in women with dry OAB than in controls. No significant differences were found in sEMG measures of pelvic muscle contraction or relaxation between the two groups. There was no significant correlation between sEMG pretest resting baseline measurements and the Beck Anxiety Inventory, the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire or life stress scores among symptomatic women. As expected, women with dry OAB had significantly higher scores on the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. CONCLUSIONS: This study supports a relationship between dry OAB symptoms and anxiety that warrants further exploration. Resting sEMG baselines were not elevated and did not support the hypothesis that women with dry OAB are unable to relax their pelvic floor muscles.

Patient preferences for different severities of and treatments for overactive bladder.

OBJECTIVE: : Symptoms of overactive bladder (OAB) can have profound effects on women's quality of life. However, quantitative data on how women value these symptoms and their treatments are limited. We sought to assess women's preferences, which are referred to as utilities, for different severities of and treatment options for OAB. METHODS: : Eighty women-40 with OAB symptoms and 40 without OAB-were recruited from urogynecology and urology practices at an academic institution from April to November 2009. A single, trained interviewer administered a computerized preference elicitation tool to measure preferences for 4 OAB severity levels (urgency/frequency and mild, moderate, and severe urge incontinence), as well as 3 OAB treatments with and without adverse effects or complications, which included (1) anticholinergic medications, (2) botulinum toxin injection, and (3) sacral neuromodulation. Preferences were assessed using the time trade-off (TTO) method. RESULTS: : Median TTO scores for OAB decreased as severity increased (urgency/frequency, 0.88; mild, 0.92; moderate, 0.85; severe, 0.73). Median TTO scores assigned to anticholinergic medications were higher (0.93) than those for botulinum (0.88) and sacral neuromodulation (0.85), and adverse effects or complications lowered the utilities for each treatment (anticholinergics, 0.88; botulinum, 0.75; and sacral neuromodulation, 0.78). CONCLUSIONS: : Women view symptoms of OAB, particularly moderate or severe symptoms, as being quite burdensome. The degree of invasiveness and the number of adverse effect/complications are important contributors to the utilities that women assign to the various treatment options.

A dialogal investigation of "Who am I as a teacher?".

Women health professionals who join academe reformulate their identities as they become professors and teachers. Teacher inquiry is a systematic intentional study of one's own professional teaching practice that framed the question "Who am I as a teacher?" Using a process of dialogal research, we explored our biases and assumptions about teaching, which served as the source for our data. We discovered that our teaching included being a "judge," "lifelong learner," "bridge to learning," and "researcher," and that our teaching was "affected by temporality" and "the environment." As teachers, we are "someone who works through challenges." We suggest that teacher inquiry can empower allied health educators, change educational practice, and provide meaningful opportunities for the professional development of faculty.

Hierarchy as a barrier to advancement for women in academic medicine.

BACKGROUND: Research on barriers to professional advancement for women in academic medicine has not adequately considered the role of environmental factors and how the structure of organizations affects professional advancement and work experiences. This article examines the impact of the hierarchy, including both the organization's hierarchical structure and professionals' perceptions of this structure, in medical school organization on faculty members' experience and advancement in academic medicine. METHODS: As part of an inductive qualitative study of faculty in five disparate U.S. medical schools, we interviewed 96 medical faculty at different career stages and in diverse specialties, using in-depth semistructured interviews, about their perceptions about and experiences in academic medicine. Data were coded and analysis was conducted in the grounded theory tradition. RESULTS: Our respondents saw the hierarchy of chairs, based on the indeterminate tenure of department chairs, as a central characteristic of the structure of academic medicine. Many faculty saw this hierarchy as affecting inclusion, reducing transparency in decision making, and impeding advancement. Indeterminate chair terms lessen turnover and may create a bottleneck for advancement. Both men and women faculty perceived this hierarchy, but women saw it as more consequential. CONCLUSIONS: The hierarchical structure of academic medicine has a significant impact on faculty work experiences, including advancement, especially for women. We suggest that medical schools consider alternative models of leadership and managerial styles, including fixed terms for chairs with a greater emphasis on inclusion. This is a structural reform that could increase opportunities for advancement especially for women in academic medicine.

Collaboration in academic medicine: reflections on gender and advancement.

PURPOSE: Collaboration in academic medicine is encouraged, yet no one has studied the environment in which faculty collaborate. The authors investigated how faculty experienced collaboration and the institutional atmosphere for collaboration. METHOD: In 2007, as part of a qualitative study of faculty in five disparate U.S. medical schools, the authors interviewed 96 medical faculty at different career stages and in diverse specialties, with an oversampling of women, minorities, and generalists, regarding their perceptions and experiences of collaboration in academic medicine. Data analysis was inductive and driven by the grounded theory tradition. RESULTS: Female faculty expressed enthusiasm about the potential and process of collaboration; male faculty were more likely to focus on outcomes. Senior faculty experienced a more collaborative environment than early career faculty, who faced numerous barriers to collaboration: the hierarchy of medical academe, advancement criteria, and the lack of infrastructure supportive of collaboration. Research faculty appreciated shared ideas, knowledge, resources, and the increased productivity that could result from collaboration, but they were acutely aware that advancement requires an independent body of work, which was a major deterrent to collaboration among early career faculty. CONCLUSIONS: Academic medicine faculty have differing views on the impact and benefits of collaboration. Early career faculty face concerning obstacles to collaboration. Female faculty seemed more appreciative of the process of collaboration, which may be of importance for transitioning to a more collaborative academic environment. A reevaluation of effective benchmarks for promotion of faculty is warranted to address the often exclusive reliance on individualistic achievement.

The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values.

BACKGROUND: Energized, talented faculty are essential to achieving the missions of academic medical centers (AMCs) in education, research and health care. The alignment of individuals' values with workplace experiences are linked to meaningfulness of work and productivity. OBJECTIVE: To determine faculty values and their alignment with institutional values. DESIGN: A qualitative hypothesis-generating interview study to understand the professional experiences of faculty and organizational approach in five AMCs that were nationally representative in regional and organizational characteristics. Analysis was inductive and data driven. PARTICIPANTS: Using stratified, purposeful sampling, we interviewed 96 male and female faculty at different career stages (early career, plateaued, senior faculty and those who had left academic medicine) and diverse specialties (generalists, medical and surgical subspecialists, and research scientists). APPROACH: Dominant themes that emerged from the data. RESULTS: Faculty described values relating to excellence in clinical care, community service (including care for the underserved and disadvantaged), teaching, intellectual rigor/freedom and discovery, all values that mirror the stated missions of AMCs. However, many faculty also described behaviors that led them to conclude that their AMCs, in practice, undervalued excellence in clinical care, and their social and educational missions. Themes were seen across gender, career stage, race and discipline, except that female leaders appeared more likely than male leaders to identify incongruence of individual values and organizational practices. CONCLUSIONS: In this study of five diverse medical schools, faculty values were well aligned with stated institutional missions; however, many perceived that institutional behaviors were not always aligned with individual faculty values.

Mixed urinary incontinence: greater impact on quality of life.

PURPOSE: We compared the impact of mixed, stress and urge urinary incontinence on quality of life in middle-aged or older women. MATERIALS AND METHODS: We analyzed cross-sectional data from a population based cohort of 2,109 ethnically diverse middle-aged or older women. Among participants reporting weekly incontinence, clinical type of incontinence was assessed by self-reported questionnaires and disease specific quality of life impact was evaluated using the Incontinence Impact Questionnaire. Multivariable logistic regression was used to compare the odds of greater quality of life impact from incontinence, defined as an Incontinence Impact Questionnaire score in the 75th percentile or greater in women with stress, urge and mixed incontinence. RESULTS: More than 28% (598) of women reported weekly incontinence, including 37% with stress, 31% with urge and 21% with mixed incontinence. Unadjusted Incontinence Impact Questionnaire scores were higher for women with mixed vs urge or stress incontinence (median score 29 vs 17 and 13, respectively, p <0.01). Adjusting for age, race/ethnicity, health status and clinical incontinence severity, women with mixed incontinence were more likely to report a greater overall quality of life impact compared to those with stress incontinence (OR 2.5, 95% CI 1.4-4.3), as well as a greater specific impact on travel (OR 2.2, 95% CI 1.3-3.7) and emotional (OR 1.8, 95% CI 1.0-3.4) Incontinence Impact Questionnaire domains. The overall impact of urge incontinence did not differ significantly from that of stress (urge vs stress OR 1.6, 95% CI 0.9-2.7) or mixed incontinence (mixed vs urge OR 1.6, 95% CI 0.9-2.8) in adjusted models. CONCLUSIONS: In middle-aged or older women mixed incontinence is associated with a greater quality of life impact than stress incontinence independent of age, race, health or incontinence severity. Identification of women with mixed incontinence symptoms may be helpful in discovering which women are most likely to experience functional limitations and decreased well-being from incontinence.

A study of the relational aspects of the culture of academic medicine.

PURPOSE: The impact of medical school culture on medical students has been well studied, but little documentation exists regarding how medical faculty experience the culture in which they work. In an ongoing project, the National Initiative on Gender, Culture and Leadership in Medicine, the authors are investigating how the existing culture of academic medical institutions supports all faculty members' ability to function at their highest potential. METHOD: The authors conducted a qualitative study of faculty in five disparate U.S. medical schools. Faculty in different career stages and diverse specialties were interviewed regarding their perceptions and experiences in academic medicine. Analysis was inductive and data driven. RESULTS: Relational aspects of the culture emerged as a central theme for both genders across all career categories. Positive relationships were most evident with patients and learners. Negative relational attributes among faculty and leadership included disconnection, competitive individualism, undervaluing of humanistic qualities, deprecation, disrespect, and the erosion of trust. CONCLUSIONS: The data suggest that serious problems exist in the relational culture and that such problems may affect medical faculty vitality, professionalism, and general productivity and are linked to retention. Efforts to create and support trusting relationships in medical schools might enhance all faculty members' efforts to optimally contribute to the clinical, education, and research missions of academic medicine. Future work will document the outcomes of a five-school collaboration to facilitate change in the culture to support the productivity of all medical faculty.

Mentoring faculty in academic medicine. A new paradigm?

In this paper, we discuss an alternative structure and a broader vision for mentoring of medical faculty. While there is recognition of the need for mentoring for professional advancement in academic medicine, there is a dearth of research on the process and outcomes of mentoring medical faculty. Supported by the literature and our experience with both formal dyadic and group peer mentoring programs as part of our federally funded National Center of Leadership in Academic Medicine, we assert that a group peer, collaborative mentoring model founded on principles of adult education is one that is likely to be an effective and predictably reliable form of mentoring for both women and men in academic medicine.

Facilitating scholarly writing in academic medicine.

Scholarly writing is a critical skill for faculty in academic medicine; however, few faculty receive instruction in the process. We describe the experience of 18 assistant professors who participated in a writing and faculty development program which consisted of 7 monthly 75-minute sessions embedded in a Collaborative Mentoring Program (CMP). Participants identified barriers to writing, developed personal writing strategies, had time to write, and completed monthly writing contracts. Participants provided written responses to open-ended questions about the learning experience, and at the end of the program, participants identified manuscripts submitted for publication, and completed an audiotaped interview. Analysis of qualitative data using data reduction, data display, and conclusion drawing/verification showed that this writing program facilitated the knowledge, skills, and support needed to foster writing productivity. All participants completed at least 1 scholarly manuscript by the end of the CMP. The impact on participants' future academic productivity requires long-term follow-up.

Helping medical school faculty realize their dreams: an innovative, collaborative mentoring program.

Junior faculty wishing to achieve successful careers in academic medicine face many challenges. To facilitate faculty in their career development, the authors implemented and evaluated an innovative collaborative, or peer-group, mentoring program at their medical school. Based on Rogerian and adult learning principles, the program incorporated development of skills in key areas for career development, a structured values-based approach to career planning, and instruction in scholarly writing. The 80-hour program has so far been conducted twice over two academic years (1999-2001) with 18 faculty (50% women). Quantitative and qualitative methods were used in the evaluation. Program attendance was 89%. All participants completed a written academic development plan, an exercise they rated as valuable. They also completed an average of one to three manuscripts for publication. Evaluation data highlighted the critical nature of a supportive learning environment and the reasons participants chose to attend the program consistently. Key meaningful outcomes for most participants were: (1) identification of their core values; (2) a structured process of short- and long-term career planning based on these core values; (3) the development of close, collaborative relationships; (4) development of skills in such areas as gender and power issues, negotiation and conflict management, scholarly writing, and oral presentation, and (5) improved satisfaction linked to participants' decisions to remain in academic medicine. Participants developed a sense of personal transformation and empowerment. The authors conclude that collaborative mentoring offers a new approach to faculty development that addresses limitations of traditional approaches in a satisfying and cost-effective way.