Impact of Cancer Survivorship Care Training on Rural Primary Care Practice Teams: a Mixed Methods Approach.

With the increasing numbers of individuals surviving a diagnosis of cancer, an aging population, and more individuals experiencing multi-morbidity, primary care providers (PCPs) are seeing more patients with a history of cancer. Effective strategies are needed to adequately prepare the primary care workforce for the phase of cancer care now widely recognized as survivorship. A survivorship education program for rural primary care practices was developed using a community engagement process and delivered at the practice level by community health liaisons. A mixed method approach was used to evaluate the program impact which included a questionnaire and interviews. Descriptive analyses and generalized linear regression were used to evaluate quantitative outcomes from the questionnaires. Immersion crystallization was used to define themes from the qualitative components. Thirty-two (32) practices participated, averaging 10.3 team members/practice. The percent of correct responses to the knowledge questionnaire increased significantly, almost doubling between baseline and post-test (25% vs 46%, p < .001). Four major themes emerged from the interviews which included positive impact of the training, putting the training into practice, intention to change care delivery, contextual influences in survivorship care. Evidence from the cancer survivorship education program evaluation supports its value to key stakeholders and the potential wider dissemination of the iSurvive Program. These data also suggest the need for additional investigation into other ways beyond education that primary care practices can be supported to ensure the needs of the growing cancer survivor population in the US are met.

Associations Between Patients' Unmet Social Needs and Self-Reported Health Confidence at One Primary Care Clinic.

Social determinants of health affect a person's health at least as much as their interactions with the healthcare system. Increased patient activation and self-efficacy are associated with decreased cost and improved quality. Patient-reported health confidence has been proposed as a more easily measured proxy for self-efficacy. Evaluation of the association between unmet social needs and health confidence is limited. Our objective was to identify and address our patients' unmet social needs and assess health confidence levels. From November 2017 through July 2018 we screened 2018 patients of an urban academic family medicine residency practice for unmet social needs, measured their health confidence, and made referrals to community resources if desired. Patients reporting the presence of any social need reported lower health confidence scores on average than those with no needs (8.49 vs 9.30, median 9 vs 10, Wilcoxon test P < .001). Low health confidence scores (<7) were strongly associated with number of needs (P < .001) after adjusting for age, gender, race, ethnicity, payer, and visit type (1 vs 0 needs, odds ratio [OR] = 2.566, 95% CI 1.546-4.259; 2 or more vs 0 needs, OR = 6.201, 95% CI 4.022-9.561). Results of this quality improvement project suggest that patients with unmet social needs may have decreased perceived ability to manage health problems. Further study is needed to determine if this finding is generalizable, and if interventions addressing unmet social needs can increase health confidence.

Acute joint pain in the emerging green collar workforce: Evidence from the linked National Health Interview Survey and Occupational Information Network (O*NET).

BACKGROUND: Green jobs are a rapidly emerging category of very heterogeneous occupations that typically involve engagement with new technologies and changing job demands predisposing them to physical stressors that may contribute to the development of joint pain. METHODS: We estimated and compared the prevalence of self-reported acute (past 30 days) joint pain between green and non-green collar workers using pooled 2004-2012 National Health Interview Survey (NHIS) data linked to the Occupational Information Network Database (O*NET). RESULTS: Green collar workers have a higher prevalence of acute joint pain as compared to non-green collar workers. Green collar workers with pain in the upper extremity joints were significantly greater than in the non-green collar workforce, for example, right shoulder [23.2% vs 21.1%], right elbow [13.7% vs 12.0%], left shoulder [20.1% vs 18.2%], and left elbow [12.0% vs 10.7%]. CONCLUSIONS: Acute joint pain reported by the emerging green collar workforce can assist in identifying at risk worker subgroups for musculoskeletal pain interventions.

Chemical and Physical Exposures in the Emerging US Green-Collar Workforce.

OBJECTIVE: "Green collar" workers serve in occupations that directly improve environmental quality and sustainability. This study estimates and compares the prevalence of select physical and chemical exposures among green versus non-green U.S. workers. METHODS: Data from the U.S. 2010 National Health Interview Survey (NHIS) Occupational Health Supplement were linked to the Occupational Information Network (ONET) Database. We examined four main exposures: 1) vapors, gas, dust, fumes (VGDF); 2) secondhand tobacco smoke; 3) skin hazards; 4) outdoor work. RESULTS: Green-collar workers were significantly more likely to report exposure to VGDF and outdoor work than nongreen-collar workers [adjusted odds ratio (AOR) = 1.25; 95% CI = 1.11 to 1.40; AOR = 1.44 (1.26 to 1.63), respectively]. Green-collar workers were less likely to be exposed to chemicals (AOR = 0.80; 0.69 to 0.92). CONCLUSIONS: Green-collar workers appear to be at a greater risk for select workplace exposures. As the green industry continues to grow, it is important to identify these occupational hazards in order to maximize worker health.

Who Uses Mobile Phone Health Apps and Does Use Matter? A Secondary Data Analytics Approach.

BACKGROUND: Mobile phone use and the adoption of healthy lifestyle software apps ("health apps") are rapidly proliferating. There is limited information on the users of health apps in terms of their social demographic and health characteristics, intentions to change, and actual health behaviors. OBJECTIVE: The objectives of our study were to (1) to describe the sociodemographic characteristics associated with health app use in a recent US nationally representative sample; (2) to assess the attitudinal and behavioral predictors of the use of health apps for health promotion; and (3) to examine the association between the use of health-related apps and meeting the recommended guidelines for fruit and vegetable intake and physical activity. METHODS: Data on users of mobile devices and health apps were analyzed from the National Cancer Institute's 2015 Health Information National Trends Survey (HINTS), which was designed to provide nationally representative estimates for health information in the United States and is publicly available on the Internet. We used multivariable logistic regression models to assess sociodemographic predictors of mobile device and health app use and examine the associations between app use, intentions to change behavior, and actual behavioral change for fruit and vegetable consumption, physical activity, and weight loss. RESULTS: From the 3677 total HINTS respondents, older individuals (45-64 years, odds ratio, OR 0.56, 95% CI 0.47-68; 65+ years, OR 0.19, 95% CI 0.14-0.24), males (OR 0.80, 95% CI 0.66-0.94), and having degree (OR 2.83, 95% CI 2.18-3.70) or less than high school education (OR 0.43, 95% CI 0.24-0.72) were all significantly associated with a reduced likelihood of having adopted health apps. Similarly, both age and education were significant variables for predicting whether a person had adopted a mobile device, especially if that person was a college graduate (OR 3.30). Individuals with apps were significantly more likely to report intentions to improve fruit (63.8% with apps vs 58.5% without apps, P=.01) and vegetable (74.9% vs 64.3%, P<.01) consumption, physical activity (83.0% vs 65.4%, P<.01), and weight loss (83.4% vs 71.8%, P<.01). Individuals with apps were also more likely to meet recommendations for physical activity compared with those without a device or health apps (56.2% with apps vs 47.8% without apps, P<.01). CONCLUSIONS: The main users of health apps were individuals who were younger, had more education, reported excellent health, and had a higher income. Although differences persist for gender, age, and educational attainment, many individual sociodemographic factors are becoming less potent in influencing engagement with mobile devices and health app use. App use was associated with intentions to change diet and physical activity and meeting physical activity recommendations.

Green Collar Workers: An Emerging Workforce in the Environmental Sector.

OBJECTIVE: We describe the socio-demographic, occupational, and health characteristics of "green collar" workers, a vital and emerging workforce in energy-efficiency and sustainability. METHODS: We linked data from the 2004 to 2012 National Health Interview Surveys (NHIS) and US Occupational Information Network (O*NET). Descriptive and logistic regression analyses were conducted using green collar worker status as the outcome (n = 143,346). RESULTS: Green collar workers are more likely than non-green workers to be men, age 25 to 64 years, obese, and with less than or equal to high school (HS) education. They are less likely to be racial/ethnic minorities and employed in small companies or government jobs. CONCLUSIONS: Green collar workers have a distinct socio-demographic and occupational profile, and this workforce deserves active surveillance to protect its workers' safety. The NHIS-O*NET linkage represents a valuable resource to further identify the unique exposures and characteristics of this occupational sector.

Occupational Psychosocial Hazards Among the Emerging US Green Collar Workforce.

OBJECTIVE: To compare occupational psychosocial hazards in green collar versus non-green collar workers. METHODS: Standard Occupational Classification codes were used to link the 2010 National Health Interview Survey to the 2010 Occupational Information Network Database. Multivariable logistic regressions were used to predict job insecurity, work life imbalance, and workplace harassment in green versus non-green collar workers. RESULTS: Most participants were white, non-Hispanic, 25 to 64 years of age, and obtained greater than a high school education. The majority of workers reported no job insecurity, work life imbalance, or workplace harassment. Relative to non-green collar workers (n = 12,217), green collar workers (n = 2,588) were more likely to report job insecurity (Odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.02 to 1.26) and work life imbalance (1.19; 1.05 to 1.35), but less likely to experience workplace harassment (0.77; 0.62 to 0.95). CONCLUSIONS: Continuous surveillance of occupational psychosocial hazards is recommended in this rapidly emerging workforce.

Linking the National Health Interview Survey with the Florida Cancer Data System: A Pilot Study.

Cancer registry data are vital for the surveillance of cancer trends, but registries are limited in the number of data items that can be collected for hypothesis-driven research. Linkage with other databases can add valuable information and is a potentially effective tool for increasing our understanding of and identifying the causes of cancer and health disparities along the cancer continuum. We conducted a pilot study to link data from the 1981-2010 Florida Cancer Data System (FCDS) with data from the 1986-2009 National Health Interview Survey (NHIS). The NHIS data contain important information on sociodemographics, screening behaviors, comorbidities, risk factors, health care access, and quality of life, which are not available from FCDS. The linkage resulted in a total of 6,281 linked cases. After removing cases with a first cancer diagnosis before 1981 (prior to FCDS creation) or missing date of diagnosis information, there were 1,908 cases diagnosed with cancer prior to their NHIS interview and 4,367 cases diagnosed after their NHIS interview. The enriched data set resulting from the linkage allows us to evaluate risk factors associated with developing cancer as well as conduct analyses on cancer survivorship issues and mortality. This pilot study demonstrates the feasibility and utility of a linkage between cancer registries and national health surveys, while also acknowledging the cost and challenges associated with such linkages.

Biomarkers of Exposure to Polycyclic Aromatic Hydrocarbons and Cognitive Function among Elderly in the United States (National Health and Nutrition Examination Survey: 2001-2002).

Recent studies report a link between common environmental exposures, such as particulate matter air pollution and tobacco smoke, and decline in cognitive function. The purpose of this study was to assess the association between exposure to polycyclic aromatic hydrocarbons (PAHs), a selected group of chemicals present in particulate matter and tobacco smoke, and measures of cognitive performance among elderly in the general population. This cross-sectional analysis involved data from 454 individuals aged 60 years and older from the 2001-2002 National Health and Nutrition Examination Survey. The association between PAH exposures (as measured by urinary biomarkers) and cognitive function (digit symbol substitution test (DSST)) was assessed using multiple linear regression analyses. After adjusting for age, socio-economic status and diabetes we observed a negative association between urinary 1-hydroxypyrene, the gold standard of PAH exposure biomarkers, and DSST score. A one percent increase in urinary 1-hydroxypyrene resulted in approximately a 1.8 percent poorer performance on the digit symbol substitution test. Our findings are consistent with previous publications and further suggest that PAHs, at least in part may be responsible for the adverse cognitive effects linked to tobacco smoke and particulate matter air pollution.

Improving the Effectiveness of Medication Review: Guidance from the Health Literacy Universal Precautions Toolkit.

BACKGROUND: Although routine medication reviews in primary care practice are recommended to identify drug therapy problems, it is often difficult to get patients to bring all their medications to office visits. The objective of this study was to determine whether the medication review tool in the Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit can help to improve medication reviews in primary care practices. METHODS: The toolkit's "Brown Bag Medication Review" was implemented in a rural private practice in Missouri and an urban teaching practice in California. Practices recorded outcomes of medication reviews with 45 patients before toolkit implementation and then changed their medication review processes based on guidance in the toolkit. Six months later we conducted interviews with practice staff to identify changes made as a result of implementing the tool, and practices recorded outcomes of medication reviews with 41 additional patients. Data analyses compared differences in whether all medications were brought to visits, the number of medications reviewed, drug therapy problems identified, and changes in medication regimens before and after implementation. RESULTS: Interviews revealed that practices made the changes recommended in the toolkit to encourage patients to bring medications to office visits. Evaluation before and after implementation revealed a 3-fold increase in the percentage of patients who brought all their prescription medications and a 6-fold increase in the number of prescription medications brought to office visits. The percentage of reviews in which drug therapy problems were identified doubled, as did the percentage of medication regimens revised. CONCLUSIONS: Use of the Health Literacy Universal Precautions Toolkit can help to identify drug therapy problems.

Are Cancer Survivors Physically Active? A Comparison by US States.

BACKGROUND: Cancer survivors who engage in physical activity (PA) have improved quality of life, reduced fatigue, and lower mortality rates. We compare the percentage of cancer survivors meeting PA recommendations for US states, stratified by age and gender, to identify the need for PA education and intervention among cancer survivors. METHODS: Pooled data from the 1997-2010 National Health Interview Survey were used to determine and rank age-adjusted PA by state. American Cancer Society guidelines (≥150 min/wk of PA) were used to compare prevalence by state, stratified by age group (< 65 and ≥65) and gender. RESULTS: Thirty-three percent of cancer survivors met PA recommendations. The highest age-adjusted compliance to PA recommendations was in Vermont (59.9%, 95% confidence interval [CI], 40.8-76.3) and the lowest was in Louisiana (14.8%, 95% CI, 9.6-22.1) and Mississippi (15.5%, 95% CI, 10.4-22.3). The lowest percentages meeting recommendations were in Arkansas for males (8.6%, 95% CI, 7.0-10.6), Louisiana for females (12.5%, 95% CI, 6.8-21.9), Louisiana for survivors < 65 (15.6%, 95% CI, 10.5-22.6), and West Virginia for those ≥65 years (12.7%, 95% CI, 7.6-20.6). CONCLUSIONS: Meeting PA recommendations by cancer survivors varies markedly by state of residence. Future efforts should target states with low percentages, tailoring interventions to the special needs of this high-risk population. The importance of PA should be incorporated within cancer survivorship care plans.

Using the Health Literacy Universal Precautions Toolkit to Improve the Quality of Patient Materials.

Patient materials are often written above the reading level of most adults. Tool 11 of the Health Literacy Universal Precautions Toolkit ("Design Easy-to-Read Material") provides guidance on ensuring that written patient materials are easy to understand. As part of a pragmatic demonstration of the Toolkit, we examined how four primary care practices implemented Tool 11 and whether written materials improved as a result. We conducted interviews to learn about practices' implementation activities and assessed the readability, understandability, and actionability of patient education materials collected during pre- and postimplementation site visits. Interview data indicated that practices followed many action steps recommended in Tool 11, including training staff, assessing readability, and developing or revising materials, typically focusing on brief documents such as patient letters and information sheets. Many of the revised and newly developed documents had reading levels appropriate for most patients and--in the case of revised documents--better readability than the original materials. In contrast, the readability, understandability, and actionability of lengthier patient education materials were poor and did not improve over the 6-month implementation period. Findings guided revisions to Tool 11 and highlighted the importance of engaging multiple stakeholders in improving the quality of patient materials.

Success in the Achieving CARdiovascular Excellence in Colorado (A CARE) Home Blood Pressure Monitoring Program: A Report from the Shared Networks of Colorado Ambulatory Practices and Partners (SNOCAP).

BACKGROUND: Blood pressure (BP) control among primary care patients with hypertension is suboptimal. Home BP monitoring (HBPM) has been shown to be effective but is underused. METHODS: This study was a quasi-experimental evaluation of the impact of the A CARE HBPM program on hypertension control. Nonpregnant adults with hypertension or cardiovascular disease risk factors were given validated home BP monitors and reported monthly average home BP readings by Internet or phone. Patients and providers received feedback. Change in average home and office BP and the percentage of patients achieving target BP were assessed based on patient HBPM reports and a chart audit of office BPs. RESULTS: A total of 3578 patients were enrolled at 26 urban and rural primary care practices. Of these, 36% of participants submitted ≥2 HBPM reports. These active participants submitted a mean of 13.5 average HBPM reports, with a mean of 19.3 BP readings per report. The mean difference in home BP between initial and final HBPM reports for active participants was -6.5/-4.4 mmHg (P < .001) and -6.7/-4.7 mmHg (P < .001) for those with diabetes. The percentage of active participants at or below target BP increased from 34.5% to 53.3% (P < .001) and increased 24.6% to 40.0% (P < .001) for those with diabetes. The mean difference in office BP over 1 year between participants and nonparticipants was -5.4/-2.7 mmHg (P < .001 for systolic BP, P = .01 for diastolic BP) for all participants and -8.5/-1.5 mmHg (P = .014 for systolic BP, P = .405 for diastolic BP) for those with diabetes. CONCLUSIONS: An HBPM program with patient and provider feedback can be successfully implemented in a range of primary care practices and can play a significant role in BP control and decreased cardiovascular disease risk in patients with hypertension.

Effect of childhood victimization on occupational prestige and income trajectories.

BACKGROUND: Violence toward children (childhood victimization) is a major public health problem, with long-term consequences on economic well-being. The purpose of this study was to determine whether childhood victimization affects occupational prestige and income in young adulthood. We hypothesized that young adults who experienced more childhood victimizations would have less prestigious jobs and lower incomes relative to those with no victimization history. We also explored the pathways in which childhood victimization mediates the relationships between background variables, such as parent's educational impact on the socioeconomic transition into adulthood. METHODS: A nationally representative sample of 8,901 young adults aged 18-28 surveyed between 1999-2009 from the National Longitudinal Survey of Youth 1997 (NLSY) were analyzed. Covariate-adjusted multivariate linear regression and path models were used to estimate the effects of victimization and covariates on income and prestige levels and on income and prestige trajectories. After each participant turned 18, their annual 2002 Census job code was assigned a yearly prestige score based on the 1989 General Social Survey, and their annual income was calculated via self-reports. Occupational prestige and annual income are time-varying variables measured from 1999-2009. Victimization effects were tested for moderation by sex, race, and ethnicity in the multivariate models. RESULTS: Approximately half of our sample reported at least one instance of childhood victimization before the age of 18. Major findings include 1) childhood victimization resulted in slower income and prestige growth over time, and 2) mediation analyses suggested that this slower prestige and earnings arose because victims did not get the same amount of education as non-victims. CONCLUSIONS: Results indicated that the consequences of victimization negatively affected economic success throughout young adulthood, primarily by slowing the growth in prosperity due to lower education levels.

Association between cardiovascular fitness and metabolic syndrome among American workers.

OBJECTIVE: To explore the association between cardiovascular fitness and metabolic syndrome across occupational groups using a nationally representative sample of the US population. METHODS: Respondents aged 18 to 49 years from the 1999 to 2004 National Health and Nutrition Examination Survey were evaluated for cardiovascular fitness and classified with regard to metabolic syndrome. Comparisons were made across 40 occupational categories. RESULTS: For all occupations with and without metabolic syndrome, the estimated maximal oxygen consumption (VO2max) was 38.8 mL/kg/min (standard error = 0.5) and 41.1 mL/kg/min (standard error = 0.2), respectively. The estimated VO2max was higher for those without metabolic syndrome for most occupational groups, particularly for sales supervisors and proprietors, sales representatives, finance, business, and commodities, and freight, stock, and material movers. CONCLUSIONS: Low estimated VO2max among workers with metabolic syndrome can be addressed, in part, by workplace interventions designed to increase fitness. This study identifies priority occupational groups for these interventions.

Potential effects of polychlorinated biphenyls (PCBs) and selected organochlorine pesticides (OCPs) on immune cells and blood biochemistry measures: a cross-sectional assessment of the NHANES 2003-2004 data.

BACKGROUND: Polychlorinated biphenyls (PCBs) and organochlorine pesticides (OCPs) are widely distributed in the environment and may have adverse effects on the immune system. METHODS: Lipid adjusted serum levels of 19 Dioxin Like (DL), 17 Non Dioxin Like (NDL) PCBs, 5 OCPs, and measures of complete blood count and routine biochemistry profile were obtained from the NHANES 2003-2004 cycle. For each of the PCB/OCP variables, individuals were put into four exposure groups and blood markers were compared across these groups. RESULTS: Serum levels of PCBs and OCPs increased with age. Total white blood cell (WBC) count, red blood cells (RBC), hemoglobin, and hematocrit measures were lowest in the group with the highest serum PCBs. Results for the OCPs varied. For Mirex, WBC declined in the highest exposure; no significant differences were observed for p-p'-DDT or p-p'-DDE; and higher levels of WBC were observed at the highest exposure groups of serum trans-nonachlor and oxychlordane. Liver enzymes (AST, ALT, and GGT) were significantly higher in the highest exposure groups of PCBs/OCPs. CONCLUSIONS: We observed significant associations between PCB/OCP levels and blood markers in the general population. All of the levels were within normal ranges but the consistency of results is remarkable and may reflect subclinical effects. Largest differences were observed for NDL PCBs. Thus, routine application of toxic equivalency factors, which assume dioxin like mechanisms and aryl hydrocarbon receptor involvement, may not adequately reflect the effects of NDL PCBs in the mixture.

Linkage of 1986-2009 National Health Interview Survey with 1981-2010 Florida Cancer Data System.

BACKGROUND: National survey data linked with state cancer registry data has the potential to create a valuable tool for cancer prevention and control research. A pilot project-developed in a collaboration of the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS) and the Florida Cancer Data System (FCDS) at the University of Miami -links the records of the 1986-2009 National Health Interview Survey (NHIS) and the 1981-2010 FCDS. The project assesses the feasibility of performing a record linkage between NCHS survey data and a state-based cancer registry, as well as the value of the data produced. The linked NHIS-FCDS data allow researchers to follow NHIS survey participants longitudinally to examine factors associated with future cancer diagnosis, and to assess the characteristics and quality of life among cancer survivors. METHODS: This report provides a preliminary evaluation of the linked national and state cancer data and examines both analytic issues and complications presented by the linkage. CONCLUSIONS: Residential mobility and the number of years of data linked in this project create some analytic challenges and limitations for the types of analyses that can be conducted. However, the linked data set offers the ability to conduct analyses not possible with either data set alone.

The health of young US workers.

OBJECTIVES: To provide an overview of the health status of young US workers across four domains: functional health, physical and psychological health, health behavior, and health care utilization. METHODS: Pooled data from the 2004 to 2010 National Health Interview Survey were analyzed for 11,279 US workers aged 18 to 24 years, representing an estimated 16.9 million workers annually. Thirty-nine health indicators were examined and compared across nine occupational groups. RESULTS: Compared with other occupational groups, craft workers and laborers and helpers had the highest prevalence of risky health behaviors, including current smoking and risky drinking, as well as fewer reported visits to a primary care physician in the past year. CONCLUSIONS: Young workers engage in risky health behaviors, and may benefit from targeted workplace interventions to mitigate the potentially negative long-term effects on health and well-being.

Geographical variation in health-related quality of life among older US adults, 1997-2010.

INTRODUCTION: Health-related quality of life (HRQOL) is an important predictor of morbidity and mortality; however, its geographical variation in older adults in the United States has not been characterized. We compared HRQOL among older adults in the 50 US states and the District of Columbia using the Health and Activities Limitation Index (HALex). We also compared the HRQOL of 4 regions: South, West, Midwest, and Northeast. METHODS: We analyzed pooled data from 1997 through 2010 from the National Health Interview Survey for participants aged 65 or older. HALex scores (which range from 0 to 1.00, with higher values indicating better health) were calculated by combining data on participants' perceived health and activity limitations. We ranked states by mean HALex score and performed multivariable logistic regression analyses to compare low scores (defined as scores in the lowest quintile) among US regions after adjustment for sociodemographics, health behaviors, and survey design. RESULTS: Older residents of Alaska, Alabama, Arkansas, Mississippi, and West Virginia had the lowest mean HALex scores (range, 0.62-0.68); residents of Arizona, Delaware, Nevada, New Hampshire, and Vermont had the highest mean scores (range, 0.78-0.79). Residents in the Northeast (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.57-0.76) and the Midwest (OR, 64; 95% CI, 0.56-0.73) were less likely than residents in the South to have scores in the lowest quintile after adjustment for sociodemographics, health behaviors, and survey design. CONCLUSION: Significant regional differences exist in HRQOL of older Americans. Future research could provide policy makers with information on improving HRQOL of older Americans.