Association Of Academic Health Sciences Libraries Research Articles

Health Sciences Librarianship's Status as a Profession Is Unclear, According to Its Members

A Review of: Koenig, R. A., Rodriguez, V. A., & Sima, A. P. (2021). Attitudinal attributes of professionalism in health sciences librarians. Journal of Library Administration, 61(1), 1–20. https://doi.org/10.1080/01930826.2020.1845544 Objective – To determine health sciences librarians' attitudes toward professionalism and to examine relationships between professionalism attributes and participant characteristics as defined by the Richard H. Hall Professionalism Inventory. Design – Cross-sectional online survey using the Richard H. Hall Professionalism Inventory. Setting – Electronic mailing lists of the Medical Library Association (MLA), the Association of Academic Health Sciences Libraries (AAHSL), the Association of College and Research Libraries (ACRL) Health Sciences Interest Group, and the Canadian Health Libraries Association (CHLA). Subjects – There were 430 participants. Methods – The online survey, created in REDCap, was distributed electronically across multiple mailing lists during June and July of 2019. Quantitative analysis included descriptive statistics and ANOVA conducted in R with reliability determined by Cronbach's alpha. Main Results – Professionalism scores for health sciences librarians were lowest in public service and self-regulation, and highest in professional organization as referent, autonomy, and sense of calling. Individuals with a degree in health sciences scored lower on a sense of calling than individuals with Library and Information Science (LIS) degrees. Faculty benefits such as tenure decreased sense of calling. There were statistically significant differences according to role (e.g., archives, administration). Subject specialty librarians had lower scores in most attributes. Conclusion – Health sciences librarianship does not clearly meet the criteria of a profession. Its heterogeneity of specializations and receptiveness to diverse backgrounds and perspectives are possible threats to its ability to create a cohesive identity. Further, duties that can be considered non-library work appear to correlate with lower professionalism scores, even when they are associated with faculty status.

LGBTQ+ health research guides at North American health sciences libraries: a survey and content analysis

Objectives:Current literature recommends online research guides as an easy and effective tool to promote LGBTQ+ health information to both health care providers and the public. This cross-sectional study was designed to determine how extensive LGBTQ+ health guides are among hospital and academic libraries and which features are most prevalent.Methods:In order to locate LGBTQ+ health guides for content analysis, we searched for guides on the websites of libraries belonging to the Association of Academic Health Sciences Libraries (AAHSL) and the Canadian Association of Research Libraries (CARL). Additionally, we searched the Springshare interface for LibGuides with the word “health” and either “LGBT” or “transgender.” Content analysis was performed to identify major characteristics of the located guides, including target audience and the information type provided.Results:LGBTQ+ research guides were identified for 74 libraries. Of these, 5 were hospital libraries, and the rest were academic libraries. Of 158 AAHSL member libraries, 48 (30.4%) had LGBTQ+ guides on their websites. Nearly all guides (95.9%) provided general LGBTQ+ health information, and a large majority (87.8%) also had information resources for transgender health. Smaller percentages of guides contained information on HIV/AIDS (48.6%) and women's health (16.2%).Conclusions:Even though literature recommends creating LGBTQ+ health guides, most health sciences libraries are missing an opportunity by not developing and maintaining these guides. Further research may be needed to determine the usage and usefulness of existing guides and to better identify barriers preventing libraries from creating guides.

Academic Health Sciences Librarian Job Descriptions Do Not Frequently Reflect Emerging Skillsets and Changing Research Needs

Academic Health Sciences Librarian Job Descriptions Do Not Frequently Reflect Emerging Skillsets and Changing Research Needs

How American Academic Medical/Health Sciences Libraries Responded to the COVID-19 Health Crisis: An Observational Study

The novel coronavirus disease (COVID-19) has caused a pandemic and global health crisis. Although normal operation and services in many libraries have been greatly disrupted, academic libraries in the United States were reportedly responding to challenges by pivoting to new ways to meet the users’ needs. This observational study was designed to investigate the status, services, and resources disclosed via websites of academic medical/health sciences libraries (MHSLs) in the United States and document how they adapted and continued to provide support to help fight the health crisis and the resulting “infodemic” through various means. A complete list of members was obtained from the website of the Association of Academic Health Sciences Libraries (AAHSL). The U.S.-based AAHSL member institutions were included in this study. Each American academic MHSL website and its associated webpages were browsed; web contents were categorized and analyzed based on four research questions proposed by this study. A descriptive analysis was conducted to summarize all findings. A total of 157 AAHSL member institutions were included in the study. These libraries spread all over the United States, and 90% of them announced closures of library buildings and facilities. A significant number of MHSLs quickly adapted to the evolving situation and transitioned their services and instruction to the online environment. The COVID-19 information sources adopted by MHSLs included the following ranked by frequency from high to low: The U.S. government agencies such as Centers for Disease Control and Prevention and National Library of Medicine, the World Health Organization, publishing communities, professional journals, organizations, local institutions, government agencies, and news channels. In addition, MHSLs undertook a series of actions to support academic communities and local healthcare professionals including resource curation, clinical care support, education, and outreach to the public. Through library guides, MHSLs provided comprehensive and customized search queries to help researchers locate the latest and relevant publications to COVID-19, curated multiple data resources and data exploration, and visualization tools, and selected the latest biomedical and health evidence in a wide range of topics. Other featured resources and services were associated with ethical issues (i.e., racism and prejudice), educational and entertainment information (e.g., virtual tours of parks), and personal experience documentation. This observational study is the most recent investigation and documentation on the status, services, and resources of the academic MHSLs in the United States during the initial U.S. outbreak of the COVID-19 pandemic. Although the current health crisis is taking a heavy toll on libraries nationwide, MHSLs are still managing to play a vital role in supporting the academic communities, healthcare facilities, and the general public and fighting against the pandemic and the resulting information crisis.

Roles for Health Sciences Librarians at College and University Libraries

ABSTRACT
 
 Objectives: To meet the changing priorities of researchers and funding agencies, U.S. college and university libraries (C&ULs) that are not Association of Academic Health Sciences Libraries (AAHSL) members may want to hire librarians capable of supporting interdisciplinary health sciences research. This study sought to identify whether such roles are emerging by examining advertised position descriptions.
 
 Methods: We collected position advertisements posted to job boards and mailing lists between September 1 2018 and March 1 2019. Positions that included one of these terms in the title, qualifications, or responsibilities were eligible for inclusion: medic*, health, life, nursing, veterinary, bio*, pharma*. We categorized postings by institution type, geographic region, and position type. We used grounded theory to identify themes within the data, and NVivo to quantify how often each theme appeared within the data.
 
 Results: 104 job postings met our inclusion criteria: 60 at AAHSL institutions and 44 at C&UL institutions. Despite some minor variations among specific roles and responsibilities, we found substantial overlap in the qualifications listed for positions at both types of institution. Qualifications more often prioritized traditional librarian competencies rather than emerging areas, such as data science, grant support, and research impact. 
 
 Conclusions: Both AAHSL and C&UL institutions show an interest in hiring librarians capable of supporting health and life sciences teaching and research. Competition for a similar pool of applicants may create challenges for hiring officials, and librarians interested in these positions will likely seek out professional development opportunities in emerging areas of practice.

Academic health sciences libraries and affiliated hospitals: a conversation about licensing electronic resources.

ObjectiveLibraries in academic health centers may license electronic resources for their affiliated hospitals, as well as for their academic institutions. This study examined the current practices of member libraries of the Association of Academic Health Sciences Libraries (AAHSL) that provide affiliated hospitals with access to electronic information resources and described the challenges that the libraries experienced in providing access to the affiliated hospitals.MethodsIn September 2016, AAHSL library directors received an email with a link to an online survey.ResultsBy December 2016, representatives from 60 AAHSL libraries responded. Two-thirds of the responding libraries supplied online information resources to more than 1 hospital, and 75% of these libraries provided the hospitals with access both on site and remotely. Most (69%) libraries licensed the same resource for both the academic institution and the hospitals. Cost, license negotiation, and communication with hospital stakeholders were commonly reported challenges.ConclusionAcademic health sciences libraries with affiliated hospitals continue to grapple with licensing and cost issues.

The institutional repository landscape in medical schools and academic health centers: a 2018 snapshot view and analysis.

ObjectiveThis study uses survey research methods to gain a deeper understanding of the institutional repository (IR) landscape in medical schools and academic health centers.MethodsMembers of the Association of Academic Health Sciences Libraries (AAHSL) were surveyed about their IRs. The authors used a mixed-methods approach of a survey and qualitative content analysis to identify common themes.ResultsSurvey results indicate that a large majority of responding medical schools and academic health centers have or are implementing an IR (35 out of 50, 70%). Of these, 60% (21 institutions) participate in an institution-wide IR rather than administer their own repositories. Much of the archived content is grey literature that has not already been published, but the percentage of original content varies greatly among institutions. The majority (57.1%) of respondent institutions are not considering an open access policy or mandate. Most institutions (71.4%) reported that repository staff are depositing materials on behalf of users. DSpace and bepress Digital Commons are the most popular repository platforms in this community. The planned enhancements that were most frequently reported were implementing a discovery layer and ORCID integration. The majority of respondents (54.3%) do not plan to migrate to a different platform in the foreseeable future. Analysis of respondent comments identified the following themes: integration, redundancy, and reporting; alternatives and exploration; uniqueness; participation; and funding and operations.ConclusionsThe study results capture a view of the IR landscape in medical schools and academic health centers and help readers understand what services their peers have in place as well as their plans for future developments.

Entrustable professional activity 7: opportunities to collaborate on evidence-based medicine teaching and assessment of medical students

BackgroundThis study was conducted to examine gaps and opportunities for involvement of librarians in medical education and patient care as well as improve the teaching and assessment of Entrustable Professional Activity 7 (EPA 7) -- the ability to form clinical questions and retrieve evidence to advance patient care.MethodsThe Association of Academic Health Sciences Libraries (AAHSL) Competency-Based Medical Education Task Force surveyed all AAHSL member libraries in October 2016 on health sciences librarian awareness and involvement in teaching and assessing EPA 7.ResultsThe survey response rate was 54% (88/164 member libraries). While 90% (n = 76) of respondents were regularly engaged in teaching or assessing aspects of EPA 7 only 34 (39%) were involved explicitly in a Core EPA 7 project, 44% (15/34) of these projects were librarian initiated.ConclusionsInvolvement in teaching and assessment of EPA 7 is an untapped opportunity for librarians to collaborate in medical education and patient care. Although librarians are already deeply involved in teaching and assessment of EPA 7 related knowledge, skills, and behaviors, further librarian collaboration can help bolster the planning or updating of existing curricula and assessments of this entrustable professional activity.

Librarians’ Reported Systematic Review Completion Time Ranges Between 2 and 219 Total Hours with Most Variance due to Information Processing and Instruction

Librarians’ Reported Systematic Review Completion Time Ranges Between 2 and 219 Total Hours with Most Variance due to Information Processing and Instruction

Investigating the need for scholarly communications positions in Association of Academic Health Sciences Libraries member institutions.

BackgroundThe role of health sciences librarians has expanded in the scholarly communications landscape as a result of the increase in federal public access mandates and the continued expansion of publishing avenues. This has created the need to investigate whether academic health sciences libraries should have scholarly communications positions to provide education and services exclusively related to scholarly communication topics.MethodsA nine-question online survey was distributed through the Association of Academic Health Sciences Libraries (AAHSL) email discussion list to gather preliminary findings from and opinions of directors of health sciences libraries on the need for scholarly communications positions.ResultsThe survey received a 38% response rate. The authors found that AAHSL members are currently providing scholarly communications services, and 46% of respondents expressed the need to devote a full-time position to this role.DiscussionOur survey reveals a juxtaposition occurring in AAHSL member libraries. While administrators acknowledge the need to provide scholarly communications services, they often experience budget challenges in providing a full-time position for these services.

AAHSL Twitter Use From 2007 to 2014: An Exploratory Analysis

ABSTRACTTwitter is a popular social media platform used by organizations for communication and marketing purposes. Many libraries, including members of the Association of Academic Health Sciences Libraries (AAHSL), have Twitter accounts, but how do these libraries use Twitter to communicate with their constituents and are they using it effectively? This study is a large-scale observational study of Twitter use within AAHSL libraries and reflects on the usage patterns present in the context of social media best practices. This study also aims to expand upon best practices for implementing and maintaining a Twitter account in a health sciences library setting.

Library resource discovery.

Library resource discovery.

Libraries Take on Policy: Support for Open Access and Open Data

Anneliese Taylor Libraries Take on Policy: Support for Open Access and Open Data The growth of open access (OA) journal publishing has exploded in the last decade. The number of full, immediate OA articles went from 2% to 11% of all articles published between 2000 and 2011. When hybrid and embargoed open access articles are included in the count, the 2011 total jumps to 17% across all disciplines. And looking at biomedical journals specifically, 36% of articles published were OA 1 . Alongside this impressive growth in what’s commonly referred to as gold open access publishing has been a multi-pronged effort to expand access to published articles through “green” open access. Green OA is the process of depositing a version of a published article in an open access repository, whether that be an institutional repository (IR) or a disciplinary repository, or even placing articles on an openly accessible web site. “Self-archiving” is frequently used interchangeably with green OA. It does not require authors to pay an article processing charge as many gold OA models do. Many publishers have a history of allowing authors to self-archive a version of their article. The version is typically the accepted author’s manuscript, incorporating changes from the peer-review process, but before the publisher has copyedited, formatted, and branded the manuscript for final publication. A very few publishers allow the final, published version to be uploaded via self-archiving. There may or may not be a delay period after publication before the manuscript can be made accessible. Open access policies passed at the institutional level or by research funders are an attempt to broaden public access on a larger scale. The potential to open up access via a formalized policy is significant, but not without some effort. The next sections will highlight health sciences libraries and their roles with green OA policies in the United States. NIH Public Access Policy The single largest influencer on the growth of green OA articles in the health sciences to date is the National Institutes of Health (NIH) Public Access Policy, passed in 2008. This policy requires peer- reviewed scholarly articles published by NIH-funded researchers to be submitted to PubMed Central (PMC). The articles are made publicly available no later than twelve months after the official publication date. 2 PMC is NIH’s freely accessible, full text article repository, with close to 3 million articles currently deposited. NIH Policy manuscripts are about 10% of this amount. The rest of the content comes from publishers that voluntarily deposit their articles, usually after a publication delay. Many health sciences (HS) libraries got involved in 2008 or earlier with support for researchers at their academy needing to comply with the policy. Efforts range from offering workshops and individual consultations to notifying authors which of their articles are non-compliant and what steps to take to make them compliant. There are a number of excellent NIH Policy LibGuides (e.g. Duke University and University of Washington) and video tutorials (e.g. New York University and Harvard University) created by librarians to assist researchers. An informal survey in 2013 of Association of Academic Health Sciences Libraries (AAHSL) member involvement in supporting the Policy indicated a high level of activity amongst health sciences libraries. Of the 25 responses, all but four were actively involved with a support role. It’s remarkable that HS

Evolution, revolution, or obsolescence: an examination of writings on the future of health sciences libraries

Health sciences libraries are facing enormous challenges. While there is significant national interest in the management of health information, institutions and, concomitantly, funding are focusing on aspects of the management of information and data that falls more readily under the domain of biomedical informaticians than librarians. While learning organizations need more knowledge management (KM), something that certainly falls into the natural domain of health sciences librarians, until recently, few librarians have embraced the new roles associated with KM. For context, comparing the means of both the materials and the personnel budgets found in the 2005–2006 [1] and 2009–2010 [2] Association of Academic Health Sciences Libraries (AAHSL) Annual Statistics of Medical School Libraries in the United States and Canada, the percentage increase in expenditures for materials was 9.0% total over the 5 years, far below the increase in cost for health sciences resources during the same period, based on past trends [3]. The percentage increase in expenditures on personnel over the same period was an average of only 1.2% per year, suggesting a possible loss of full-time equivalent employees over the 5-year period. At the beginning of the new century, between 2000 and 2005, a number of articles were published in the professional literature describing innovative new roles and competencies for health sciences librarians of the future that would move the profession into a greater position of viability. However, since 2006, there has been a paucity of literature about librarians who have embraced these new roles, and, with the exception of discussions on social networking sites and other commentaries available on the web, the movement toward ensuring our place in the future of knowledge management is slow, if it exists. A brief communication, “Tomorrow's Academic Health Sciences Libraries Today,” included in this issue of the Journal of the Medical Library Association (JMLA) as a companion to this comment and opinion piece, presents the results of a survey and semi-structured interviews that establish the directions current academic health sciences libraries are taking to achieve these ends [4]. Literature focusing on the vision for health sciences librarians of the future and the skills necessary to meet that vision is briefly summarized here and compared with comments about future competencies of health sciences librarians disseminated through the web. These observations provide a basis for recommendations to move our profession into a position of strength in the current economic climate and health care environment.

Special report: symposium on transformational change in health sciences libraries: space, collections, and roles

In November 2003, the National Library of Medicine (NLM) and the Association of Academic Health Sciences Libraries (AAHSL) cosponsored a symposium, “The Library as Place: Building and Revitalizing Health Sciences Libraries in the Digital Age,” focusing on the question: “What is the role of the library in the twenty-first century?” After two days of presentations and discussions, symposium participants concluded “that both the print and the virtual electronic library are here to stay.” As Deanna Marcum observed, “The library will certainly change. And its need for space may significantly shrink. But the digital era, far from ending the physical library, may free it to facilitate learning rather than to house shelves—and may free those who work within the library spaces to do less book processing and more learning facilitation” [1]. In the summer of 2008, the National Network of Libraries of Medicine (NN/LM), Middle Atlantic Region (MAR), as a follow-up to the NLM/AAHSL symposium, announced their intention to fund a regional conference about library space planning and solicited applications for their Library Space and Its Impact Conference Award. In response to this solicitation, the George T. Harrell Health Sciences Library (Harrell HSL) applied for and received the award. The announcement proved to be timely: The Harrell HSL was in the process of repurposing 10,000 square feet of library space into the new Penn State Hershey Clinical Simulation Center [2, 3]. The Harrell HSL experience provided a firsthand, real-life example of the issues faced by libraries in a rapidly changing environment. The award funded a one-day library space planning conference, held in April 2009, which was offered to librarians both regionally and nationally.

External Reporting Lines of Academic Special Libraries: A Health Sciences Case Study

Very little literature exists on the nature of external reporting lines and funding structures of academic special libraries. This study focuses on academic health sciences libraries. The authors analyze information gathered from statistics published by the Association of Academic Health Sciences Libraries (AAHSL) from 1977 through 2007; an anonymous online survey of AAHSL library directors; and phone conversations with a select number of directors who were willing to take part in follow-up interviews. The history of changing trends in reporting lines over the years and a view of the diverse arrangements, including strengths and weaknesses, currently existing in academic institutions are examined.

It's all happening—at the hospital

As of this writing, the health care reform bill has passed the House, but the health care legislative controversy continues. Will we see real health care reform in my lifetime? Who knows? However, I am pleased looking at this issue to see that our profession continues to be focused on improving patient care, both in the hospital and out of it. The editorial by Michele Klein-Fedyshin, AHIP, sets the tone, with a convincing case for why now more than ever, physicians need ready access to the kind of quality, filtered information that librarians are trained to provide. She points to a puzzling conundrum: pressures are growing to reduce medical errors and increase the use of evidence-based treatment at the same time that requirements to fund professional librarians are declining. Klein-Fedyshin points to some positive developments and envisions a future in which hospitals will be scored on their “information readiness.” Also in this issue we are fortunate to publish the papers from an Association of Academic Health Sciences Libraries (AAHSL) symposium on electronic health records held in November in Boston. Two of the papers sound a cautionary note. Kenneth Mandl's keynote address describes structural flaws in the current generation of electronic health records (EHRs) that may prove significant obstacles to their widespread adoption. William Garrity speaks to the need to remember the setting in which EHRs are used: a busy clinician may not have time to consult the evidence even if access to it is easy. However, other papers recount positive experiences with EHRs that may encourage us to move forward in spite of these obstacles. The papers from health sciences librarians at such disparate institutions as the University of Pittsburgh, the University of Washington, the University of Arkansas, and Vanderbilt University recount how these libraries have successfully used their institutions' introduction of the EHR as a means to further their goals. Finally, Marianne Burke, AHIP, and her colleagues at the University of Vermont describe their attempt to introduce an information prescription protocol into a family medicine practice. In this case study, we learn that it can be done, but that the process is far from easy. Organizations do not change their behavior patterns overnight, and it seems, a clinic is no exception to this common observation. While not on the subject of patient care, one paper appealed to me particularly. As editor of the Journal of the Medical Library Association (JMLA), I was very interested in the results of the survey recounted by Sally Harvey, AHIP, and Janene Wandersee on the rate of publication of abstracts and papers presented at MLA annual meetings. It seems that we have a lower rate of publication than other biomedical associations. I hope their paper will encourage JMLA readers to take the time to write up their papers and posters and contribute them to the “evidence-base.” Enjoy the issue.

Health sciences libraries building survey, 1999–2009

A survey was conducted of health sciences libraries to obtain information about newer buildings, additions, remodeling, and renovations. An online survey was developed, and announcements of survey availability posted to three major email discussion lists: Medical Library Association (MLA), Association of Academic Health Sciences Libraries (AAHSL), and MEDLIB-L. Previous discussions of library building projects on email discussion lists, a literature review, personal communications, and the author's consulting experiences identified additional projects. Seventy-eight health sciences library building projects at seventy-three institutions are reported. Twenty-two are newer facilities built within the last ten years; two are space expansions; forty-five are renovation projects; and nine are combinations of new and renovated space. Six institutions report multiple or ongoing renovation projects during the last ten years. The survey results confirm a continuing migration from print-based to digitally based collections and reveal trends in library space design. Some health sciences libraries report loss of space as they move toward creating space for "community" building. Libraries are becoming more proactive in using or retooling space for concentration, collaboration, contemplation, communication, and socialization. All are moving toward a clearer operational vision of the library as the institution's information nexus and not merely as a physical location with print collections.

Scenario planning: a tool for academic health sciences libraries

Review the International Campaign to Revitalise Academic Medicine (ICRAM) Future Scenarios as a potential starting point for developing scenarios to envisage plausible futures for health sciences libraries. At an educational workshop, 15 groups, each composed of four to seven Association of Academic Health Sciences Libraries (AAHSL) directors and AAHSL/NLM Fellows, created plausible stories using the five ICRAM scenarios. Participants created 15 plausible stories regarding roles played by health sciences librarians, how libraries are used and their physical properties in response to technology, scholarly communication, learning environments and health care economic changes. Libraries are affected by many forces, including economic pressures, curriculum and changes in technology, health care delivery and scholarly communications business models. The future is likely to contain ICRAM scenario elements, although not all, and each, if they come to pass, will impact health sciences libraries. The AAHSL groups identified common features in their scenarios to learn lessons for now. The hope is that other groups find the scenarios useful in thinking about academic health science library futures.

Does it really matter who's paying for dinner?

Some of the best meals I have ever eaten were paid for by sales representatives from companies with which my library did business or could potentially do business, and some of my favorite events at professional meetings were sponsored by vendors. As the head of a technical services department in a large academic health sciences library in the 1980s, I had many opportunities to be “wined and dined” by sales representatives, and I even developed close personal relationships with a few of them. As nagging doubts about the propriety of these activities began bothering me, I sometimes “reciprocated” with giving small gifts, such as bottles of wine, or by paying for the meal myself. My doubts about the propriety of these activities were solidified in 1990, when I started working in a library for a large federal agency that was embroiled in an influence-peddling scandal. I realized during my first day of work, when I had to take an oath to accept absolutely nothing from companies with which the agency might do business, that I needed to be even more careful about how I interacted with vendors. Libraries spend a huge amount of money on information resources and services provided by outside vendors, and I think our relationships with vendors pose some of our most difficult personal ethical dilemmas. We need to have a good working relationship with our vendors so that we can get the best products and services possible. An important question to ask ourselves is: “How can we develop relationships with our vendors or potential vendors that enable us to determine which products and services we need, while avoiding conflicts of interest?” Many members of the Medical Library Association (MLA) have been involved in an ongoing informal debate about ethics issues for years. People sometimes use “ethics” and “conflict of interest” interchangeably in their discussions of these issues. The Merriam Webster's Collegiate Dictionary defines ethics as “the principles of conduct governing an individual or group (professional)” or “a guiding philosophy” [1]. A “conflict of interest” is defined in the Association of Academic Health Sciences Libraries (AAHSL) conflict-of-interest/disclosure policy as follows: A conflict of interest can be considered to exist in any economic, professional, business, political, volunteer, or personal instance in which the actions or activities of an individual on behalf of AAHSL could involve obtaining personal gain or advantage to the individual or the individual's immediate family and could be unfair to the organization. [2] Ethical issues generally fall into one of four categories: association ethics, professional ethics, institutional ethics, and personal ethics. However, the lines between these issues are overlapping, and it is hard to discuss one without the others.