Home Circumstances Research Articles

Determining the role of remote consultations in general surgical practice in Scotland: a qualitative questionnaire-based study

INTRODUCTION Telemedicine consultations became widespread during the COVID-19 pandemic to deliver healthcare while minimising viral transmission. Research around establishing the role of remote appointments in general surgery outpatient clinics after the pandemic has not been undertaken. The aim of this study was to investigate views on remote consultations to determine this. METHODS Patients attending the adult general surgical outpatient clinic at Aberdeen Royal Infirmary between August 2021 and January 2022 as well as general surgeons from three neighbouring hospitals were invited to complete an anonymous questionnaire on the acceptability of remote and face-to-face (F2F) appointments in pre and postoperative scenarios. Differences in patients’ preferences between demographic groups, and between patients’ and surgeons’ views were analysed. RESULTS A total of 51 patients and 26 surgeons responded. Patients’ views differed depending on demographic parameters and the scenario. Patients and surgeons had similar views on preoperative consultations. Given the choice of telephone, video or F2F appointments, the F2F option was overall most popular. Patients and surgeons differed in their views on remote consultations following surgery and acute admissions. In some scenarios, young patients, those who lived in remote regions and those in employment/education preferred remote appointments. CONCLUSIONS While telemedicine is feasible and acceptable in general surgery clinics, there are differences in preferences between surgeons and patients. Patients’ preferences varied depending on their background, home circumstances and clinical context. Service provision should ensure that when remote consultations are available, patient preference is prioritised rather than surgeon ease.

SP9.2 - Changes in frailty and discharge destination post emergency laparotomy

Abstract Aims Frailty affects morbidity and mortality post emergency laparotomy (EmLap). Studies have shown that some frail patients do not return to baseline post EmLap. We aim to explore the change in frailty status at 90-day post EmLap and the association between pre-EmLap frailty and changes in home environment on discharge. Methods EmLap patients age ≥65years from a district hospital were recruited from May 2022 to April 2023. Discharge data were collected prospectively, and frailty was assessed using Rockwood Clinical Frailty Scale at pre-EmLap and day-90 post-EmLap with score >4 as frail. EmLap patients with no complete 90-day follow-up were excluded. P-value of <0.05 was considered significant. Results 63 EmLap patients were included, 57.1% were female and median age was 75years. 17.5% were frail pre-EmLap and on day-90 post-EmLap, 33.3% were found frail (15.9% developed frailty). Pre-EmLap, all patients came from home with 13.6% had package of care service (POC) already in place. On discharge post-EmLap, 27% had change of home environment; 1 to care home, 1 still an inpatient at 90-day post EmLap, 2 had new POC and 13 had increased POC. Of this cohort, 52.9% were frail pre-EmLap. There was a significant association between pre-EmLap frailty and change in home circumstances on discharge (p<0.00001). Conclusion About 16% developed frailty post-EmLap with almost a third had a change in home environment on discharge. Frailty should be assessed in all EmLap patients to improve shared decision making and development of post-EmLap discharge strategies.

Life outcomes in adults living with FASD in a rural South African community: A follow-up study.

Even though adults with foetal alcohol spectrum disorder (FASD) are at risk of negative life outcomes, there is no published evidence of this in South Africa, which has the highest estimated FASD prevalence rate globally. The purpose of the study was to describe and compare the life outcomes of adults with FASD and adults without FASD in a South African rural community, 16 years after diagnosis. Participants were examined and interviewed regarding their biographical information, knowledge of FASD, information on their family, relationships, home circumstances, education, work and medical history. Adults with FASD were less likely to be in a relationship and more likely to have poor educational outcomes and to be exposed to violence as victim or perpetrator than their peers who did not have FASD. None of the participants with FASD completed secondary school successfully. No differences were found for independent living, employment, health, substance use and legal outcomes, between the foetal alcohol syndrome (FAS) or partial foetal alcohol syndrome (PFAS) and control group. While significant differences existed in certain aspects, differences are not as stark as one would expect between individuals with FASD and controls. This study highlights the importance of considering the social context in which a FASD diagnosis is made. The comparative negative impact of an FASD diagnosis and the associated challenges on life outcomes may be less pronounced in rural communities where everyone has fewer opportunities and resources. This can also make the unique needs of persons with disabilities less visible.

Students’ Attitude towards Economics, School and Home Variables as Determinants of Academic Achievement of Secondary School Students in Economics in Ogun State, Nigeria

This research explores the factors influencing academic achievement in Economics among secondary school students in Ogun State, Nigeria. It addresses a crucial knowledge gap by examining how student attitudes, school-related factors, and home circumstances collectively impact performance in a subject facing a decline in performance. Existing literature highlights the roles of attitudes, school environments, and home conditions in shaping academic outcomes, laying the foundation for this study. Using a descriptive survey design, all Senior Secondary Two (SS2) students in Ogun State were included, with 300 students selected through multistage sampling. Data was collected using a Students' Questionnaire (SQ) and an Economics Achievement Test (EAT).  Key Findings Include:  Academic achievement in Economics is significantly influenced by student attitudes, school-related factors, and home circumstances, explaining about 24.8% of the variance in performance.  Attitudes toward Economics are the strongest predictor of academic success, followed by home circumstances, with school-related factors playing a lesser role.  Gender does not significantly affect Economics performance, though males slightly outperform females.  School type does not significantly impact academic performance, though government school students perform slightly better than private school students. In conclusion, this research provides a comprehensive understanding of the multifaceted factors affecting students' academic success in Economics. It offers actionable insights for educational stakeholders, including administrators, educators, parents, and researchers, such as optimising resources, tailoring teaching methods, and creating supportive home environments. Further research can explore the nuances uncovered here, informing evidence-based educational practices and policies.

Peritoneal dialysis outcomes in a tertiary-level state hospital in Johannesburg, South Africa: Ethnicity and HIV co-infection do not increase risk of peritonitis or discontinuation.

Peritoneal dialysis (PD) is a valuable means to increase access to kidney replacement therapy in South Africa (SA). An increased rate of modality discontinuation related to an increased risk of peritonitis in patients of black African ethnicity, in those with diabetes and in those living with HIV has previously been suggested, which may lead to hesitancy in adoption of 'PD first' programmes. To analyse the safety of a PD-first programme in terms of 5-year peritonitis risk and patient and modality survival at the outpatient PD unit at Helen Joseph Hospital, Johannesburg. After exclusions, clinical data from 120 patients were extracted for analysis. The effects of patient age at PD initiation, ethnicity, gender, diabetes mellitus and HIV infection on patient and modality survival and peritonitis risk were analysed using Cox proportional hazards modelling and logistic regression analysis. Five-year technique and patient Kaplan-Meier survival curves for peritonitis and comorbidity groups were compared using the Cox-Mantel test. The Mann-Whitney U-test and Fisher's exact test were used to compare continuous and categorical variables where appropriate. Five-year patient survival was 49.9%. Black African ethnicity was associated with reduced mortality hazard (hazard ratio (HR) 0.33; 95% confidence interval (CI) 0.15 - 0.71; p=0.004), and patients with diabetes had poorer 5-year survival (19.1%; p=0.097). Modality survival at 5 years was 48.1%. Neither Black African ethnicity nor HIV infection increased the risk of PD discontinuation. Peritonitis was associated with increased modality failure (HR 2.99; 95% CI 1.31 - 6.87; p=0.009). Black African ethnicity did not increase the risk of peritonitis. HIV was not independently associated with an increased risk of peritonitis. Patient and PD survival were generally similar to other contemporaneous cohorts, and the peritonitis rate in this study was within the International Society for Peritoneal Dialysis acceptable range. PD is a safe and appropriate therapy in a low socioeconomic setting with a high prevalence of HIV infection. Consideration of home circumstances and training in sterile technique reduce peritonitis risk and improve PD modality survival. Patients with diabetes may be at risk of poorer outcomes on PD.

A qualitative exploration of continuity of TB care in clinics after discharge from hospitals in Cape Town, South Africa

BackgroundContinuity of care remains a challenge for TB patients who are discharged from hospital and referred to primary health care clinics in South Africa. The aim of this study was to explore the experiences and perceptions of patients, health care workers and family members regarding continuity of TB care in a Cape Town health district.MethodsWe conducted one-on-one interviews, using semi-structured interview guides, with TB patients and their families and health care workers. We also conducted focus group interviews with other health care workers who performed similar duties. Field notes were kept and patients’ home circumstances were also physically observed. Data saturation was achieved after 31 interviews. We used Miles and Huberman’s qualitative data analysis framework to interpret the data.ResultsThemes identified in the interviews were grouped into two categories: (1) patients’ socio-economic circumstances including complex family relationships, good or lack of family support, inadequate income, and agency; and (2) health system challenges, including inadequate referral links between the clinic and the hospital and negative emotions as a result of poor service delivery experienced by patients.ConclusionSome TB Patients experienced poor continuity of care on discharge from hospitals to primary health clinics and perceived that this resulted from socio-economic conditions and health system-related problems that triggered negative emotions. Proper communication between the hospital and clinic regarding patients’ care, adequate counselling, and patient-centred treatment are required to address poor continuity of care among patients with TB down-referred to clinics.

“It’s pretty much flying blind in the home care setting”: A qualitative study on the influence of home care specific circumstances on sedation in specialist palliative home care

Background: Existing data on sedation at the end of life indicate challenges in the home care setting, leading to deviations from guidelines or non-provision of sedation. Aim: As part of the “SedPall” study, we aimed to explore circumstances in specialist palliative home care, which influence the practice of sedation. Design: Semi-structured qualitative interviews (n = 59) and two focus groups (n = 4, n = 5). Recruitment took place via contact persons. We thematically analyzed the transcripts with the Framework Approach, using MAXQDA 2018.2. Setting/participants: Physicians, nurses, and other members of the multiprofessional team from 10 palliative care units and seven home care teams. Results: Participants reported home care specific circumstances that can be categorized into three interrelated topics. (1) Lack of 24/7 on-site availability, (2) active involvement of the family, (3) challenges regarding teamwork and multidisciplinarity. Participants drew different conclusions from the reported circumstances regarding the feasibility of different types of sedation at home: While some reported to generally use all types of sedation, others stated that some types of sedation are not feasible in home care, for example deep sedation until death. Most participants questioned the applicability of existing sedation guidelines in the home care setting. Conclusion: Our data indicate that sedation practices might currently follow the healthcare professional’s attitude or service policy rather than the patient’s need. To avoid hospital admission in manageable cases and ensure that home care specific best practice standards are met, existing guideline recommendations have to be adapted and supplemented by additional supporting measures specific for the home care setting.

Psychological Distress and Behavioural Changes in Pregnant and Postpartum Individuals During the COVID-19 Pandemic

ObjectivesTo determine the psychological and behavioural effects of the COVID-19 pandemic on a Canadian cohort of individuals during pregnancy and the postpartum period. MethodsIn 2020, individuals between 20 weeks gestation and 3 months postpartum receiving maternity care from an urban Canadian clinic were invited to complete a questionnaire. The purpose-built questionnaire used validated scales including the Medical Outcomes Study Social Support Survey (MOS), Depression, Anxiety, and Stress Scale (DASS-21), Edinburgh Postnatal Depression Scale (EPDS), and questions from a SARS study. ResultsOne hundred nine people completed the questionnaire (response rate, 55%) of whom 57% (n = 62) were postpartum. Most respondents (107, 98%) were married and had completed post-secondary education (104, 95%). Despite these protective factors, moderate to severe levels of depression (22%), anxiety (19%) and stress (27%), were recorded using the DASS-21, and 25% of participants (26) had depression (score ≥11) using the EPDS. Despite high social support in all MOS domains (median scores 84–100), a majority of participants reported loneliness (69, 67%) and were nearly or totally housebound (65, 64%). About half of participants worried about themselves (50, 46.3%) or their baby (59, 54%) contracting COVID-19, while the majority postponed (80, 74.1%) and cancelled (79, 73.2%) prenatal appointments. Being homebound or feeling lonely / lacking support were significant risk factors for psychological distress (P = 0.02) whereas exercise and strong social support were protective (P < 0.05). ConclusionPregnant and postpartum individuals experienced moderate to severe depression, anxiety, and stress during the COVID-19 pandemic. Exercise and strong social support were protective. Health care provider enquiry of home circumstances and activity may identify individuals needing enhanced supports.

The all-Wales forensic adolescent consultation and treatment service (FACTS): A 5-year referral cohort study.

FACTS is a Wales-wide mental health service for 10-17-year-olds with needs beyond the remit of mainstream child and adolescent mental health services (CAMHS). As a purely consultation-liaison service, it differs from other UK services in the field. To describe a complete cohort of referrals to FACTS 2013-2017 with service exit by June 2018. Clinical, social and offending data were extracted from FACTS records. 80 young people completed a FACTS episode, averaging nearly a year (309days; range 13-859days). Mostly boys (65, 81%) of mean age 15.4years (range 9-18), two-thirds (n=53) had three or more referral reasons, one invariably being threatened/actual harm to others; only half were criminal-justice involved. Half (41, 51%) were committing sexually harmful acts. Half were self-harming (41, 51%). All but seven had had at least one adverse childhood experience (ACE), nearly half (35, 44%) four or more. Nevertheless, post-traumatic stress disorder (PTSD) was rarely diagnosed (7, 9%); just over one-quarter (23, 29%) had no diagnosis at all. Correspondence analyses endorsed two distinct Attention deficit hyperactivity disorder groups, distinguished by presence/absence of evidenced brain damage or dysfunction. Suicide-related behaviours clustered with the other diagnoses, flashbacks and psychotic symptoms with no diagnosis. Change in home circumstances during a FACTS episode was slight. The complexity of presenting problems and service involvement evidences need for FACTS. The extent of persistently harmful sexual behaviours is a novel finding, suggesting need for more expert input for this at other service levels. Rarity of PTSD diagnoses was surprising given the extent of ACEs. This raises concerns that services focus on disorder signs rather than the child's inner life. Given the extent of problems, minimal change may be a positive outcome - especially when remaining in the community. Further development of this service should include explicit case-by-case goals and indicative outcome markers.

Using the Tools of Today to Advance the Life Course Interventions of Tomorrow.

Using the Tools of Today to Advance the Life Course Interventions of Tomorrow.

Enabling work participation for people with musculoskeletal conditions: lessons from work changes imposed by COVID-19: a mixed-method study

ObjectivesTo understand what we can learn from the impact of the COVID-19 pandemic and lockdown about what enables work participation for people with inflammatory arthritis and chronic pain conditions.DesignQualitative interviews...

The Circumstances of Children with and without Disabilities or Significant Cognitive Delay Living in Ordinary Households in 30 Middle- and Low-Income Countries

Home-based early intervention is a key component of strategic approaches to preventing the loss of developmental potential among young children in middle- and low-income countries. We undertook secondary analysis of nationally representative data collected in 30 middle- and low-income countries during Round 6 (2017-) of UNICEF’s Multiple Indicator Cluster Surveys. Our analyses, involving over 100,000 children with/without disabilities or significant cognitive delay, indicated that children with disabilities and/or significant cognitive delay were more likely than their peers to: be living in relative household poverty and in rural areas; have a mother with only primary level education; live in households where intimate partner violence was considered acceptable by the child’s mother; be less likely to be receiving any pre-school education; have a mother with disabilities; receive low levels of parental stimulation; be exposed to violent parental discipline. For many of these indicators of poorer home circumstances, the level of risk was notably higher for children with significant cognitive delay than for children with disabilities. Our study findings suggest the need to consider tailored, evidence-based approaches to reduce and (potentially) overcome the increased risks that young children with disabilities and young children with significant cognitive delay experience in middle- and low-income countries.

Associations between dimensions of behaviour, personality traits, and mental-health during the COVID-19 pandemic in the United Kingdom

The COVID-19 pandemic (including lockdown) is likely to have had profound but diverse implications for mental health and well-being, yet little is known about individual experiences of the pandemic (positive and negative) and how this relates to mental health and well-being, as well as other important contextual variables. Here, we analyse data sampled in a large-scale manner from 379,875 people in the United Kingdom (UK) during 2020 to identify population variables associated with mood and mental health during the COVID-19 pandemic, and to investigate self-perceived pandemic impact in relation to those variables. We report that while there are relatively small population-level differences in mood assessment scores pre- to peak-UK lockdown, the size of the differences is larger for people from specific groups, e.g. older adults and people with lower incomes. Multiple dimensions underlie peoples’ perceptions, both positive and negative, of the pandemic’s impact on daily life. These dimensions explain variance in mental health and can be statistically predicted from age, demographics, home and work circumstances, pre-existing conditions, maladaptive technology use and personality traits (e.g., compulsivity). We conclude that a holistic view, incorporating the broad range of relevant population factors, can better characterise people whose mental health is most at risk during the COVID-19 pandemic.

“It’s about the most needy children”: A Foucauldian analysis of school social workers’ responses to need in post-earthquake Canterbury

INTRODUCTION: After the 2011 Canterbury earthquake, the provision of school social work was extended into a larger number of schools in the greater Christchurch region to support discussions of their practice priorities and responses in post-earthquake schools.FINDINGS: Two main interpretations of need are reflected in the school social workers’ accounts of their work with children and families. Firstly, hardship-focused need, which represented children as adversely influenced by their home circumstances; the interventions were primarily with parents. These families were mainly from schools in low socioeconomic areas. Secondly, anxiety-based need, a newer practice response, which emphasised children who were considered particularly susceptible to the impacts of the disaster event. This article considers how these practitioners conceptualised and responded to the needs of the children and their families in this context.METHOD: A qualitative study examining recovery policy and school social work practice following the earthquakes including 12 semi-structured interviews with school social workers. This article provides a Foucauldian analysis of the social worker participants’ perspectives on emotional and psychological issues for children, particularly those from middle-class families; the main interventions were direct therapeutic work with children themselves. Embedded within these practice accounts are moments in which the social workers contested the predominant, individualising conceptualisations of need to enable more open-ended, negotiable, interconnected relationships in post-earthquake schools.IMPLICATIONS: In the aftermath of disasters, school social workers can reflect on their preferred practice responses and institutional influences in schools to offer children and families opportunities to reject the prevalent norms of risk and vulnerability.

Mental Health Outcomes of the COVID-19 Pandemic and a Collapsing Economy: Perspectives from a Developing Country

The COVID-19 pandemic has affected physical and mental health worldwide, particularly vulnerable populations with lower social and economic status. This study explored the independent and combined effects of the COVID-19 and economy-related variables on stress and anxiety among Lebanese adults in a developing country facing a severe socio-economic crisis and political turmoil. A cross-sectional study was conducted online between May 10 and 20, 2020, using the snowball sampling technique. All individuals over 18 were eligible. The final sample included 502 respondents. Higher stress and anxiety were associated with younger age, female gender, previous higher socio-economic status, having a family member with a chronic disease, fear of not getting access to treatment, fear of COVID-19, and physical violence at home. However, financial wellness and higher family satisfaction were significantly associated with lower stress. The multivariate analysis showed a significant interaction between fear of COVID-19 and financial wellness on estimated marginal means of stress and anxiety. The combined presence of fear of the pandemic and financial hardship is associated with higher stress and anxiety, particularly among women and younger Lebanese adults with difficult home circumstances. Thus, healthcare professionals need to screen for mental health problems among subgroups presenting multiple risk factors.

Decision-Making Dynamics in the Defense Industry During Work From Home Circumstances

This article looks at the challenges and changes in the US Defense Industry's Project Management decision-making processes during the Covid-19 pandemic. Many industries implemented work from home (WFH) policies for all employees. For the defense industry, this became particularly challenging. The industry is an “essential” function, and there was genuine concern for employee and community safety. Two streams are presented: (i) what decision-making changes were made across operational, tactical, and strategic circumstances, and (ii) how that affected the productivity and employee satisfaction. Using observational data, we examine what are the manifestation, consequence, and mitigation, through engineering employee and managerial level adjustments, in project and portfolio management business decision-making during this WFH period. We also present data from a qualitative survey related to how this affected productivity and employee sentiment. The findings show that the defense industry was unprepared for such an event. Productivity issues in operational decision-making, required line-management decision makers to be on-site. The lack of adequate team-sharing tools, especially for classified content, adversely affected productivity associated with tactical decision-making. Strategic decision-making was hampered by the industry's cultural preference for face-to-face meetings. Furthermore, we found that, as the WFH continued, employees showed a greater preference for continuing to work off-site. The article summarizes observed mitigation strategies to maintain productivity levels.

Long-term visual and treatment outcomes of whole-population pre-school visual screening (PSVS) in children: a longitudinal, retrospective, population-based cohort study.

This study reports the long-term visual and treatment outcomes in a whole-population, orthoptic-delivered pre-school visual screening (PSVS) programme in Scotland and further examines their associations with socioeconomic backgrounds and home circumstances. Retrospective case review was conducted on 430 children who failed PSVS. Outcome measures included best corrected visual acuity (BCVA), severity of amblyopia (mild, moderate and severe), binocular vision (BV) (normal, poor and none), ophthalmic diagnosis and treatment modalities. Parameters at discharge were compared to those at baseline and were measured against the Scottish index of multiple deprivation (SIMD) and Health plan indicator (HPI), which are indices of deprivation and status of home circumstances. The proportion of children with amblyopia reduced from 92.3% (373/404) at baseline to 29.1% (106/364) at discharge (p < 0.001). Eighty percent (291/364) had good BV at discharge compared to 29.2% (118/404) at baseline (p < 0.001). Children from more socioeconomically deprived areas (OR 2.19, 95% CI 1.01-4.30, p = 0.003) or adverse family backgrounds (OR 3.94, 95% CI 1.99-7.74, p = 0.002) were more likely to attend poorly and/or become lost to follow-up. Children from worse home circumstances were five times more likely to have residual amblyopia (OR 5.37, 95% CI 3.29-10.07, p < 0.001) and three times more likely to have poor/no BV (OR 3.41, 95% CI 2.49-4.66, p < 0.001) than those from better home circumstances. Orthoptic-delivered PSVS is successful at screening and managing amblyopia. Children from homes requiring social care input are less likely to attend and are more likely to have poorer visual outcomes.

Proximal Femoral Nail Unlocked versus Locked (ProFNUL): a protocol for a multicentre, parallel-armed randomised controlled trial for the effect of femoral nail mode of lag screw locking and screw configuration in the treatment of intertrochanteric femur fractures

IntroductionIntertrochanteric fractures are common fragility injuries in the elderly. Surgical fixation using intramedullary devices are one of the widely used management options. To date, evidence demonstrating the effects of lag...

Fostering patient-centredness by following patients outside the clinical setting: an interview study

BackgroundPatient-centredness is considered a core competency for health professionals. To support faculty in designing courses focused on patient-centredness, an understanding of how educational interventions lead to patient-centredness is required. This study aims to show how learning mechanisms, which potentially contribute to patient-centredness, are triggered.MethodsThirty-five third-year medical students at the UMC Utrecht followed four different patients for two years. The intervention took place in an out-of-hospital setting. Students visited patients in their home circumstances and accompanied them to clinical events. Twelve students were interviewed. The realist approach was used to construct configurations which relate components of the intervention to the context and learning mechanisms.ResultsFollowing patients in their home circumstances for a prolonged period supported the development of meaningful relationships between students and patients and provided continuity. In the context of a meaningful relationship and continuity, mechanisms contributing to learning patient-centredness were triggered. The most important learning mechanisms found in this study were: reflecting, contextualising disease in a real persons’ life, broadening perspectives and engaging with the patients.ConclusionsLearning mechanisms are triggered by continuity and by meaningful student-patient relationships. These can be enhanced by an out-of-hospital setting and longitudinal contact. Thus, a relationship between students and patients is an important enabler for the development of patient-centredness.

Designs for Learning: Focus on Special Needs

Designs for Digitalised Literacy Education in a Swedish Lower Primary School The aim of this article is to contribute knowledge about challenges to literacy development in a digitalised learning environment, with focus on pupils in need of special support. The paper is based on a section of my doctoral thesis (Forsling, 2017), centring on how digital learning environments and situations were designed and orchestrated in a Swedish lower primary school with the aim to provide all pupils, including children in need of special support, with optimal opportunities for literacy development. The theoretical and methodological framework is grounded in design-oriented theories, with emphasis on how design and orchestration make affordances for learning and meaning-making. The ethnographically inspired study is based on observations and interviews at one school in Sweden. Six teachers, one special needs teacher and one literacy-developer participated in the study. The results show that the teachers’ intentions with their designs for learning focused on children in need of special support. From a special education perspective, this is a relational and democratic approach – an intention to close gaps. Nevertheless, the results manifest a parallelism where two special education perspectives appeared side by side. On one hand, the teachers’ relational perspective, and on the other hand, the special need teachers’ compensatory perspective. Another result indicates that the unequal allocation of digital tools displayed the school’s inadequate fulfilment of its mandate to provide equal education: there were differences between the preschool-class and the lower primary classes, and differences between pupils’ home circumstances and the preschool-class.