Northwest Spain Research Articles

Problematic Use of Video Games in Schooled Adolescents: The Role of Passion

The present study aims to determine the predictive value of sociodemographic, academic, educational clinical psychological variables—ADHD diagnosis, emotional self-regulation, passion and emotional and behavioural symptoms—and modality of use of video games in adolescents who either make potentially problematic or severely problematic use of video games. This is a descriptive cross-sectional study in which 2.533 Galician students (region located in the northwest of Spain) aged between 11 and 20 years participated, who were selected through multistage random sampling. The mean age was 14.78 years (SD = 1.76). The analysis of the data seems to indicate that in the prediction of the problematic use of video games, different variables are combined, among which passion plays a capital role. In addition, the problematic use of video games is related to poor parental control, poor academic performance, use of addictive substances or to an earlier onset, as well as with the diagnosis of ADHD and with greater negative emotional and behavioural symptoms. The results of this study may be of interest for the design and implementation of preventive and corrective actions aimed at reducing the problematic or addictive use of video games.

Anisakis spp. as indicators of latitudinal movements of short‐finned pilot whales, Globicephala macrorhynchus, in the Northeast Atlantic

AbstractIn the Northeast Atlantic, it is unclear whether short‐finned pilot whales, Globicephala macrorhynchus (SFPWs), are transient or resident above 40°N. We used Anisakis spp. to identify the latitudes recently visited by a SFPW pod stranded in NW Spain (43°N) in 2020. Analysis of cox2 gene in 30 nematodes from 6 SFPWs revealed the presence of A. simplex sensu stricto (s.s.) (93.3%) and A. pegreffii (6.7%). Morphological analysis of 972 nematodes corroborated species molecular identification and relative proportions; in males (n = 66), the estimated proportions of A. simplex s.s. and A. pegreffii were 86.4% and 13.6%, respectively. These percentages resembled those reported in fish/cetaceans above 40°N, and L4 larvae or adults of A. typica (a tropical‐temperate species found in SFPWs up to 38°N–39°N) were not detected. Population structure of A. simplex s.s. + A. pegreffii in SFPWs suggested a continuous recruitment of nematodes starting at least 3 weeks before stranding. We interpret that either the SFPW pod was within the range of the species (perhaps as a recent northern shift) or represented a vagrant group that visited waters off Northwest Spain for a protracted period. Future analysis on nematode assemblages could shed light on movements and climate‐driven shifts in cetacean distribution.

Myths and Realities of Rural Schools. The Voice of Families and Teachers

Introduction. By invoking Shakespeare’s famous query, ‘to be or not to be, that is the question,’ this study examines rural schools by exploring the beliefs and myths surrounding them and contrasting these perceptions with the realities of daily life in 6 unitary rural schools located in the northwest of Spain. Aims. This study aims to listen to and shed light on the perspectives and feelings of families and teachers in rural schools with multi-grade classrooms. Method. Using a multiple case study design and triangulating qualitative instruments (photovoice, incomplete sentence prompts, and observation), we analyzed the evaluations and experiences of 76 families and 18 teachers concerning the context, the educational practice, and the internal sphere of rural schools. The data were processed through content analysis using ATLAS.ti 22 software, resulting in the identification of 8 categories and 3 dimensions: space and resources, coexistence, teaching and learning in rural schools. Results. The findings reveal several myths and idealizations held by teachers and families regarding the following aspects: the natural rural environment; facilities, infrastructures, resources, and services; coexistence; individualisation, multi-grade classrooms, and academic performance in rural schools. Conclusions. The study concluded that some of these myths do not align with the actual conditions of the studied environment. Rural schools can offer authentic, high-quality learning experiences on equal terms with other educational institutions, dependent on the mediation of the teaching teams that work in them. The study allows for reflection and provides information not only to visibility of rural schools and empower them but also to make decisions enable their educational improvement.

The strength of migration and stay aspirations: understanding harmonious, conflicting and indeterminate aspirations

Studies on migration aspirations have provided fresh perspectives for two decades by focusing on the changing nature of aspirations, the aspirations-cap/abilities nexus, and by offering a counterpoint through the ‘aspirations to stay’. Building from these, this article proposes a model to explain the intensity and strength of (im)mobility aspirations, given that these can be strong and specific but also weak, mild, conditional, and even conflicting. To do so, I focus on the preferences to migrate or to stay by examining how the two dimensions of (im)mobility – the intrinsic and the instrumental – interact. I study the different emotions and thoughts attached to (im)mobility, how life and migration aspirations are intertwined, and the ways in which migration and stay aspirations can co-exist. In doing so, I differentiate between three ideal-type strengths of aspirations: harmonious, conflicting, and indeterminate aspirations. Harmonious aspirations capture strong convictions about what is more convenient: staying or migrating. Conflicting aspirations stress that both migration and stay aspirations can be concurrently present and equally strong. Indeterminate aspirations represent uncertainty or indifference about where to be. With this focus, the paper provides a simple approach to orient research beyond ideal-type categories by incorporating complex, often contradictory emotions. The paper draws on 37 qualitative interviews in two former mining regions in North-West Spain to advance theorization on migration aspirations and decision-making and to question if the division between migration and stay aspirations is clear-cut.

Spatial and interindustry interactions in labour productivity convergence: An Industrial Journey via Galician Shires, 2010–2018

Regions and industries are not isolated islands; so, when evaluating productivity growth, regional and sectoral growth paths should not be expected to generate independently. Moreover, accounting for spatial interactions via econometric models has become normal practice; but modelling interindustry dependencies has not. Thus, we expand labour productivity econometric convergence models by introducing interindustry spillovers in addition to spillovers that are spatial in nature. To illustrate our findings, we present an empirical application predicated upon Galicia (extreme northwest Spain), a region posing major challenges to such modelling. Our results point to the relevance of interindustry spillovers in explaining productivity growth. Furthermore, the approach allows us to better interpret covariates that explain the different growth paths across regions and industries, thus enabling more reliable policy recommendations. We find that interindustry dependencies transmit productivity shocks across regions. In addition, our results suggest that spatial and interindustry dependencies should be considered when formulating (sub)regional economic development policies. Finally, our approach corrects possible misspecification problems that arise from data scarcity. This makes it a viable alternative for multiregional econometric tests in which some sectoral detail is needed. It is particularly useful for sets of regions where data needed to populate such models is scarce.

Farmland Abandonment and Afforestation—Socioeconomic and Biophysical Patterns of Land Use Change at the Municipal Level in Galicia, Northwest Spain

Farmland Abandonment and Afforestation—Socioeconomic and Biophysical Patterns of Land Use Change at the Municipal Level in Galicia, Northwest Spain

Streamflow forecasting with deep learning models: A side-by-side comparison in Northwest Spain

Streamflow forecasting with deep learning models: A side-by-side comparison in Northwest Spain

Management Strategies for Early Blight in Potatoes: Assessment of the TOMCAST Model, Including the Aerobiological Risk Level and Critical Phenological Period

The use of pesticides is an efficient approach for pest management. However, their increasing application in recent decades has come under the spotlight of world policies. In this context, this study addresses the usefulness of a forecasting model (TOMCAST) combined with aerobiological information and a plant development model (physiological days, PDays) for the control of early blight in potatoes in Northwest Spain. Control plots were compared to treated plots, according to the original TOMCAST model and the daily Alternaria spp. concentration, meteorological factors, and phenological and epidemiological observations were monitored for better adjustment of the TOMCAST model to the weather conditions of the geographical area during three crop seasons. The results of the linear regression analysis showed a strong relationship between the parameters included in TOMCAST (leaf wetness and temperature) and the Alternaria spp. conidia concentration. In addition, an unbalanced pattern of trapped conidia was detected throughout the growing season, with an increase near the flowering stage. The epidemiological parameters (infection period, r-AUDPC, maximum severity value, and total and commercial yields) showed significant differences between the cultivars in the control and the TOMCAST plots in terms of r-AUDPC and the maximum severity value. Given the study’s results, the original TOMCAST model was improved with aerobiological and phenological information. The improved model recommends a first spray on a day when the following three requirements are met: Ten accumulated disease severity values (DSVs) according to the TOMCAST model, two days with an aerobiological level greater than 10 conidia/m3, and a PDays value greater than 200. This will reduce the number of fungicide treatments used to control early blight in potato crops, promoting the principles of sustainable agriculture.

Detecting Gaps in Knowledge: The Case of the Anisakis in Northwestern Spain

In the marine environment, fish parasites are present in most seafood species. The most common are nematodes of the genus Anisakis, which can parasitize human tissues, causing anisakiasis and allergies—in some cases with a strong reaction, such as anaphylactic shock. This happens when people ingest live or dead larvae present in the muscles or viscera of a wide range of fish and cephalopods. Consumer education has been positioned as one of the most effective alternatives for its prevention. This study, carried out in Asturias (northwest Spain), sought to identify the seafood products that present the greatest risk of anisakiasis for consumers, taking into account their consumption, the prevalence of Anisakis, and consumer knowledge about this parasitosis. In the results, hake (Merluccius merluccius) and cod (Gadus morhua), frequently consumed in the region and with high parasite prevalence, do not pose a great risk because they are consumed when well cooked. Instead, sardine (Sardina pilchardus), highly consumed and less parasitized, and anchovy (Engraulis encrasicolus), highly parasitized and less consumed, would exhibit a medium risk. Young participants know more about the risks of anisakiasis from raw seafood. The gaps detected in the knowledge about the ability of temperature treatments to eliminate parasites, especially in allergic people, must be addressed for better prevention. We suggest campaigns adapted to the population sectors.

Unlocking rivers' hidden diversity and ecological status using DNA metabarcoding in Northwest Spain.

Rivers are crucial ecosystems supporting biodiversity and human well-being, yet they face increasing degradation globally. Traditional river biomonitoring methods based on morphological identification of macroinvertebrates present challenges in terms of taxonomic resolution and scalability. This study explores the application of DNA metabarcoding analysis in both bulk and environmental DNA (eDNA) samples for comprehensive assessment of macrozoobenthic biodiversity, detection of invasive and endangered species, and evaluation of river ecological status in northwestern Spain. DNA metabarcoding of homogenized bulk samples and water eDNA revealed a mean of 100 and 87 macrozoobenthos species per sample respectively. However, the specific composition was significantly different with only 27.3% of the total species being shared. It was not possible to identify all the OTUs to species level; only 17.43% and 49.4% of the OTUs generated could be identified to species level in the bulk and eDNA samples, respectively. Additionally, a total of 11 exotic species (two first records for the Iberian Peninsula and another three first records for Asturias region) and one endangered species were detected by molecular tools. Molecular methods showed significant correlations with morphological identification for EQR values (Ecological Quality Ratio) of IBMWP index, yet differences in inferred river ecological status were noted, with bulk samples tending to indicate higher status. Overall, DNA metabarcoding offers a promising approach for river biomonitoring, providing insights into biodiversity, invasive species, and ecological status within a single analysis. Further optimization and intercalibration are required for its implementation in routine biomonitoring programmes, but its scalability and multi-tasking capabilities position it as a valuable tool for integrated monitoring of river ecosystems.

Fishing Eco-Efficiency of Ports in Northwest Spain

Fishing is an essential economic activity and source of livelihood for millions of people worldwide. However, overfishing and unsustainable practices have led to a decline in fish populations and the degradation of marine ecosystems. Moreover, fishing activities can contribute to climate change through the emission of greenhouse gases (e.g., carbon dioxide and methane) from fishing vessels and seafood transportation. To mitigate the environmental impacts of fishing activities, sustainable fishing practices must be implemented to minimize the negative impacts of fishing on the environment while maintaining the productivity and diversity of fish populations and ecosystems. These practices include using selective fishing gear, avoiding fishing in vulnerable habitats, implementing fishery management plans, and reducing the carbon footprint of the fishing industry. To this end, and as a first step in defining efficient and effective measures towards the sustainability of capture fishing activity, an analysis of the environmental sustainability of the Galician fishing sector, one of the main European regions in this field, is presented in this work. An ecosystem-based indicator (ecological footprint, calculated by adding the so-called fishing ground footprint and the carbon footprint) was employed to quantify the main impacts of capture fishing during extractive activity. The catch composition and fuel consumption of the fleet based on the vessels’ power, and economic benefits, were the parameters used in this analysis. The results showed that ports with larger vessels and fleets seem to be more eco-efficient than those concentrating smaller vessels in targeting lower trophic level species.

Dispersal history of SARS-CoV-2 in Galicia, Spain.

The dynamics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission are influenced by a variety of factors, including social restrictions and the emergence of distinct variants. In this study, we delve into the origins and dissemination of the Alpha, Delta, and Omicron-BA.1 variants of concern in Galicia, northwest Spain. For this, we leveraged genomic data collected by the EPICOVIGAL Consortium and from the GISAID database, along with mobility information from other Spanish regions and foreign countries. Our analysis indicates that initial introductions during the Alpha phase were predominantly from other Spanish regions and France. However, as the pandemic progressed, introductions from Portugal and the United States became increasingly significant. The number of detected introductions varied from 96 and 101 for Alpha and Delta to 39 for Omicron-BA.1. Most of these introductions left a low number of descendants (<10), suggesting a limited impact on the evolution of the pandemic in Galicia. Notably, Galicia's major coastal cities emerged as critical hubs for viral transmission, highlighting their role in sustaining and spreading the virus. This research emphasizes the critical role of regional connectivity in the spread of SARS-CoV-2 and offers essential insights for enhancing public health strategies and surveillance measures.

WEATHER-DRIVEN FLUCTUATIONS IN DAILY BEACH TOURISM: INSIGHTS FROM COASTAL DESTINATION DYNAMICS IN SPAIN

Tourism dynamics are profoundly influenced by weather conditions, particularly in regions celebrated for their climatic appeal. The Rías Baixas, a renowned coastal destination in northwest Spain, presents an exemplary case for examining this interplay. This study aims to enhance comprehension of how tourists alter their daily activities in response to weather changes, providing valuable insights for improved planning and management in the tourism sector. Faced with the methodological challenge of accurately measuring daily tourist flows, especially in areas such as beaches without entry registers, this study innovatively uses daily vehicle traffic intensity data in access areas to quantify tourist behavior patterns. Positive correlations are observed between the arrival of vehicles and sunshine. For tourism businesses, short-term weather forecast information, as well as a better understanding of travelers’ behavior, is crucial for decision making and operational planning.

Levels of Different Microbial Groups on Inert Surfaces of Poultry Slaughterhouses: Identification Using Matrix-Assisted Laser Desorption Ionization Time-of-Flight and Detection of Extended-Spectrum Beta-Lactamase- and Carbapenemase-Producing Enterobacteria.

Knowledge of the microbiota present in food processing environments is a significant advance that will allow for better evaluation of the risk of food contamination and a better design of the procedures for sanitization. The levels of microbial group indicators of hygienic quality were determined in different areas of the slaughter lines of two poultry slaughterhouses in the northwest of Spain (22 surfaces in each slaughterhouse were studied). The average microbial levels (cfu/cm2) were 2.15 × 102 ± 4.26 × 102 (total aerobic counts, TAC), 1.99 × 102 ± 5.00 × 102 (psychrotrophic microorganisms), 3.10 × 100 ± 1.37 × 101 (enterobacteria), 3.96 × 100 ± 2.55 × 101 (coliforms), 1.80 × 10-1 ± 7.79 × 10-1 (enterococci), and 1.12 × 10-1 ± 3.35 × 10-1 (vancomycin-resistant enterococci, VRE). TAC and psychrotrophic microorganisms were the most abundant groups in all samples (p < 0.05). The counts of both microbial groups were higher (p < 0.05) in samples of Slaughterhouse A than in those of Slaughterhouse B. Microbial loads for the rest of the bacteria were not influenced by the slaughterhouse sampled (p > 0.05). All 44 samples showed TAC and psychrotrophic microorganisms. Colonies of the rest of the microbial groups were only found in 26 samples (59.1% of the total). The isolates (one from each sample) were identified with MALDI-TOF and PCR. Gram-negative bacteria (all Enterobacteriaceae) were isolated in 23 samples, and Gram-positive bacteria were isolated in 16 (9 Enterococcus spp., 2 Enterococcus spp. and VRE, 3 VRE, 1 Enterococcus spp. and Listeria spp., and 1 Listeria spp.). The resistance of the strains to 11 (Enterococcus spp.) or 17 (Enterobacteriaceae) antibiotics was determined (disk diffusion, CLSI), finding an average of 2.05 ± 2.06 resistances per strain (3.46 ± 2.27 if reduced susceptibility reactions are included). A total of 37.3% of the Enterobacteriaceae isolates had a gene for resistance to beta-lactam antibiotics (blaTEM, blaCTX-M-15, blaKPC, blaCMY-2 or blaNDM). The high prevalence of resistant bacteria and resistance genes highlights the need to establish measures to control the spread of antibiotic resistance in poultry slaughterhouses. The findings of this work could contribute to the design of more effective sanitation procedures.

Implications of the WTO and EU fuel taxation reforms for a European fishing fleet: effects, side-effects and alternative approaches from an input–output analysis of the Galician (northwest Spain) fleet

The World Trade Organization (WTO) and European Union (EU) have both put forward tax reforms that impact fisheries’ fuel costs, which are similar in the object of taxation but quite different in the externalities addressed, goals, scope, exemptions or tax rates, creating an opportunity to compare the effects and discuss the alternatives. These proposals are the result of long and intense debates in political, social and academic spheres. However, certain aspects remain unclear. First of all, the number of empirical studies is still limited, particularly considering that fisheries governance is subject to heterogeneous management systems and institutional contexts creating room for different potential outputs. Second, coastal states have no fiscal competence beyond 12 miles, which limits the scope of the reforms to small scale fleets (SSF). All in all, the economic consequences for the fleets remain unclear. To this end, we will build on the Galician fishing sector (NW Spain) input–output tables to discuss the direct impacts, effects and side effects of these reforms on a representative European fleet. Flaws identified in both initiatives mean that targeted externalities will not be corrected and, moreover, additional ones, such as distributional effects penalising SSF or fuel spillovers, could be boosted. Alternative policy approaches are discussed.

Transgenerational Return Migration to Galicia, Spain: Discourses of Identity and Belonging

This article explores transgenerational return migration to Galicia in north-west Spain. Specifically, it focuses on a scholarship programme within Galicia’s Return Strategy 2020 – a policy aimed at incentivising return migration to Galicia to ameliorate the demographic crisis that it is experiencing due to an aging population. Drawing on 27 life-story interviews with descendants of Galician emigrants to Latin America, and discursive analysis of newspaper articles and promotional materials related to the initiative, the article argues that studying transgenerational return migration can help challenge deeply engrained notions about identity and belonging, and advance theoretical understandings of return migration.

Politicizing Children's Play: A Community Photovoice Process to Transform a School Playground.

Contextual elements at school playgrounds compromise the right to play.An occupation-based social transformation project to foster occupational justice in play at a school playground was conducted. To better understand barriers to and facilitators of children's participation in occupations at the school playground to co-create actions that enable play. Design:A participatory methodology-Photovoice-was used. The research consisted of four phases: involving the community in the research design, community-led data generation and analysis, discussion of findings to increase the community's awareness, and a community agenda for changing the playground. Public primary school playground in northwest Spain. All children (n = 450, ages 3-12 yr), families (n = 12), and teachers (n = 15) participated. A thematic analysis of visual, textual, and oral material was conducted, including member checking. Results: The study revealed several barriers toplay, including the short recess duration, poorfloor (surface) conditions, jail-like atmosphere, andviolence. However, participants identified an ad hoclending games systemandplayground muralsadvocating for children's rights as facilitators. These findings have direct implications for improving the play environment. Conflicting priorities between children's and adults' desires and needs for the playground were unveiled, displaying the relevance of invisible contexts (i.e., social or institutional contexts) in shaping play opportunities. A critical occupational stance combined with a participatory and playful methodology generated space to unveil these conflicting priorities, reconcile agendas, raise awareness, and propose collective actions to transform the playground. Plain-Language Summary: Playing is fundamental to children's development and inclusion. This study focused on making school playgrounds better places for kids to play. Researchers found that things such as short playtimes, bad playground conditions, and violence made it tough for kids to enjoy playing, but they also discovered some good things, such as a system for borrowing games and colorfulmurals promoting children' rights. These findings show that changing the playground's physical and social environment can make a big difference for kids. By listening to kids and working together, adults and children can create playgrounds where all kids can play meaningfully and safely. Occupational therapists can promote such processes.

Moving towards an ecological management of overabundant ungulates: insights from wildlife-vehicle collisions and hunting bag data

Increasing abundance of large ungulates is raising human-wildlife impacts and the effectiveness of recreational hunting to reduce their population growth is increasingly questioned. We report on long-term trends (> 15 years) in wildlife-vehicle collisions (WVC) and hunting bags, and on associations between the annual growth rate of WVC and that of hunting bags for three ungulates – the wild boar, the red deer, and the roe deer – and the grey wolf in northwest Spain to evaluate the regulating capacity of recreational hunting at large spatial scale. Wildlife-vehicle collisions increased by 332% in 16 years and 91% of all traffic accidents were caused by collisions with these three ungulates. All ungulate species showed significant positive trends in WVC and hunting bags, but we did not observe a negative association between annual growth rate of hunting bags and that of WVC except for the wild boar. Results suggest that recreational hunting was unable to reduce ungulate population growth at the regional scale. There was no upward trend of vehicle collisions with wolves over the study period, possibly reflecting stable wolf populations. Natural mortality due to predation could be promoted through the protection of apex predators, but the lethal management of apex predators, often based on sociopolitical pressures rather than damage levels, can conflict with the strategy for mitigating ungulate impacts. Ungulate management needs to be reconsidered from an ecological perspective that integrates human management measures, including recreational hunting, based on the population dynamics and the recovery of predator–prey interactions by favoring the expansion of apex predators.

Development of a convolutional neural network to accurately detect land use and land cover

The detection and modeling of Land Use and Land Cover (LULC) play pivotal roles in natural resource management, environmental modeling and assessment, and ecological connectivity management. However, addressing LULCC detection and modeling constitutes a complex data-driven process. In the present study, a Convolutional Neural Network (CNN) is employed due to its great potential in image classification. The development of these tools applies the deep learning method. A methodology has been developed that classifies the set of land uses in a natural area of special protection. This study area covers the Sierra del Cando (Galicia, northwest Spain), considered by the European Union as a Site of Community Interest and integrated in the Natura 2000 Network. The results of the CNN model developed show an accuracy of 91 % on training dataset and 88 % on test dataset. In addition, the model was tested on images of the study area, both from Sentinel-2 and PNOA. Despite some confusion especially in the residential class due to the characteristics in this area, CNNs prove to be a powerful classification tool.•Classifications based on a CNN model•LULC are classified into 10 different classes•Training and test accuracy are 91 % and 88 %, respectively

Impact of prior antihypertensive treatment on COVID-19 outcomes, by active ingredient

ObjectivesTo assess the impact of prior chronic treatment with angiotensin-converting enzyme inhibitors (ACEIs)/ angiotensin-receptor blockers (ARBs), both as a group and by active ingredient, on severity (risk of hospitalization and mortality), progression of and susceptibility to COVID-19.MethodsWe conducted a multiple population-based case–control study in Galicia (north-west Spain). The study data were sourced from medical, administrative and clinical databases. We assessed: (1) risk of hospitalization, by selecting all patients hospitalized due to COVID-19 with PCR + as cases, and a random sample of subjects without a PCR + as controls; (2) COVID-19 mortality risk; (3) risk of disease progression; and (4) susceptibility to SARS-CoV-2, considering all patients with PCR + as cases, and the same subjects used in the previous model as controls. Adjusted odds ratios (aORs) were calculated.ResultsACEIs and ARBs were shown to decrease the risk of hospitalization (aOR = 0.78 [95%CI 0.69–0.89] and aOR = 0.80 [95%CI 0.72–0.90] respectively), risk of mortality (aOR = 0.71 [95%CI 0.52–0.98] and aOR = 0.69 [95%CI 0.52–0.91] respectively), and susceptibility to the virus (aOR = 0.88 [95%CI 0.82–0.94] and aOR = 0.92 [95%CI 0.86–0.97] respectively). By active ingredient: use of enalapril was associated with a significantly lower risk of hospitalization (aOR = 0.72 [95%CI 0.61–0.85]), mortality (aOR = 0.59 [95%CI 0.38–0.92]) and susceptibility to COVID-19 (aOR = 0.86 [95%CI 0.79–0.94]); and use of candesartan was associated with a decreased risk of hospitalization (aOR = 0.76 [95%CI 0.60–0.95]), mortality (aOR = 0.36 [95%CI 0.17–0.75]) and disease progression (aOR = 0.73 [95%CI 0.56–0.95]).ConclusionThis large-scale real-world data study suggest that enalapril and candesartan are associated with a considerable reduction in risk of severe COVID19 outcomes.