Occupational Therapy Intervention Research Articles

Current Practice in Occupational Therapy for COVID-19 and Post-COVID-19 Conditions.

The onset of the pandemic highlighted the need for a review of rehabilitation practices to ensure coordinated, effective, and efficient services for people affected by COVID-19. This paper reports on a global survey highlighting the delivery of occupational therapy services to people with COVID-19/post-COVID-19 condition (PCC) and makes recommendations to facilitate quality service delivery for this population. An online cross-sectional descriptive survey was developed and distributed to the global occupational therapy community via member organisations and communication channels of the World Federation of Occupational Therapists to collect information for this study. The survey obtained qualitative and quantitative data from respondents who were occupational therapists or occupational therapy assistants regarding (i) demographic characteristics, (ii) work experience with persons with COVID-19 and PCC, (iii) modes of working, (iv) education and training, (iv) occupational therapy intervention provided to persons with COVID-19 and PCC, and (v) the perceived quality of the occupational therapy services provided. Findings indicate that respondents provided a range of occupational therapy interventions for people affected by COVID-19/PCC aligned with evidence-based practice guidelines. While respondents identified a strong role for occupational therapy and generally rated their services as effective, issues related to the accessibility of their services impacted quality and user satisfaction. The study highlighted the need to advocate for access to occupational therapy to facilitate engagement in desired and needed occupations for COVID-19 survivors. Other recommendations emerging from the findings include the need to develop, disseminate, and use research evidence for guiding services for people with COVID-19/PCC, create quality service standards, and ensure the availability of necessary resources and supports such as referral pathways and screening criteria, availability of staff, training, personal protective equipment, and assistive devices and technology.

Impact on occupations and social participation derived from communication processes in people with amyotrophic lateral sclerosis

ABSTRACT Introduction: Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative disease that in its evolution affects the occupational performance of the person. This may require the use of different assistive technology in order to improve the communication possibilities and, by extension, personal autonomy. Objective: to identify the perspective of people with ALS in relation to the influence of communication processes in their occupations and to explore possible Augmentative and Alternative Communication (AAC) in the occupational therapy intervention process. Methods: A descriptive and observational quantitative study of a series of cases with a transversal temporal perspective. The ALS-FRS-R, ACIS, ATD PA and PIADS instruments have been used. The sample consisted of 10 people with ALS. Results: The level to which the person normally incorporates the device into his life does not depend on the functional health situation derived from ALS. The AAC that has had the greatest impact on the participants has been the APP voice assistant. An informative guide on AAC has been developed for people with ALS and families. Conclusions: The functions of the occupational therapist in the intervention with support products for communication (assessment, planning, intervention and monitoring) are transcendental for the promotion of personal autonomy of people with ALS because thanks to the incorporation of the communication device they can continue to develop, participate and make their own decisions in freedom.

Building Families' Capacities: Community Forums with Parents and Occupational Therapists.

Background. Parents of a child considered to have special needs are at greater risk of stress and exhaustion. Although many occupational therapy interventions can help these children, they often require significant time and energy from families. Purpose. To document the perspectives of parents and occupational therapists regarding ways to offer services that help build families' capacities without overloading them. Method. A qualitative descriptive design guided online community forums with 41 parents and occupational therapists in Quebec, Canada. Findings. Nine key principles to build the capacities of families without overburdening them were identified. These include being sensitive to possible negative impacts of services, avoiding overwhelming the family with information or recommendations, taking the needed time, highlighting the positive, and offering flexible conditions for services. Implications. Our findings help identify how capacity-building rehabilitation services can be offered to families to optimize positive outcomes and minimize harms.

The effectiveness of occupational therapy supporting return to work for people who sustain serious injuries or develop long-term (physical or mental) health conditions: A systematic review

Introduction: People with long-term conditions or recovering from serious injuries can struggle to return to work. The evidence for occupational therapy supporting return to work is limited. We aimed to identify and explain how occupational therapy interventions work. Methods: Systematic review. Seven databases were searched between 1 January 1980 and 15 June 2022. Studies measuring work-related outcomes among individuals receiving occupational therapy during absence from paid work were included. Multiple reviewers independently contributed to screening, quality appraisal and data extraction processes. Data were analysed as a narrative. Results: Twenty studies with 3866 participants were included; 17 were assessed as having high risk of bias. Occupational therapy was inconsistently acknowledged affecting study identification and occupational therapy components were poorly described. Meta-analysis was unfeasible due to outcome heterogeneity. Individually tailored occupational therapy focused on return to work in musculoskeletal conditions indicated the most promising outcomes. Key intervention components included vocational assessment, goal setting and self-management. Key mechanisms of action included early intervention, individualised support and being responsive to needs. Conclusion: Occupational therapists’ contributions supporting return to work should be clearly attributed. Future effectiveness research should standardise the measurement of work outcomes to support meta-analysis. Developing a taxonomy for occupational therapy supporting return to work could facilitate comparisons across studies, highlighting occupational therapists’ roles and facilitating training and benefits to patients.

Occupational therapy in the rehabilitation management of obesity in adults

Obesity is a global human problem due to its high prevalence and negative consequences for health, life duration and quality of life of the population. This situation makes it necessary to pay more attention to effective rehabilitation of overweight and obese persons. The article considers approaches to the application of occupational therapy measures in the rehabilitation management of obesity: the impact of the disease on occupation is described, the methods of occupational therapy assessment and the goals of occupational therapy interventions are defined, the role of occupational therapy measures is substantiated, an overview of the main occupational therapy strategies that have confirmed their effectiveness in the treatment of obesity in the adult population is provided. A client-centered approach to occupational therapy has been found to be particularly valuable in the treatment of chronic relapsing obesity. Using analysis of occupation performance and understanding the client's performance skills helps occupational therapists implement meaningful and effective interventions that promote the client's active participation in changing the daily life habits, roles, and patterns that underlie the development of obesity. Prospects for further research are practical testing and research of the effectiveness of occupational therapy programs for people with obesity in the context of the Ukrainian health care system.

Telehealth Lifestyle Redesign Occupational Therapy for Diabetes: Preliminary Effectiveness, Satisfaction, and Engagement.

Telehealth delivery of Lifestyle Redesign®, an occupational therapy intervention framework addressing health and quality of life among people with chronic conditions, is understudied. The objective of this study was to evaluate the effectiveness, satisfaction, and engagement of telehealth Lifestyle Redesign for young adults with diabetes. Using process data from two randomized controlled trials, we compared in-person and telehealth intervention effects. Among telehealth clients, effectiveness was assessed using pre-post changes in occupational performance, occupational satisfaction, and health management; a survey captured telehealth satisfaction. Attendance and engagement in in-person versus telehealth therapy were compared. Preliminary results indicate telehealth clients had significant increases in occupational performance, occupational satisfaction, and health management (all p < .02), and high levels of telehealth satisfaction. Intervention engagement (p = .59) and attendance (p = .42) were similar across treatment modalities. Telehealth delivery of Lifestyle Redesign occupational therapy is feasible and potentially efficacious, and continued advocacy is needed to ensure access to occupational therapy through telehealth.

The Experience of Pregnancy-Related Lumbopelvic Pain: A Qualitative Evidence Synthesis.

Background. Pregnancy-related lumbopelvic pain is common and can impact quality of life. Purpose. To synthesize existing qualitative research on people's experiences of pregnancy-related lumbopelvic pain in pregnancy and during the postpartum period. Method. A keyword search of four electronic databases between 2000 and 2022 was completed. Included studies were appraised and synthesized using a meta-ethnographic approach. Findings. Twenty-three studies were included. Analysis identified four core themes: (1) uncertainties about pregnancy-related lumbopelvic pain, (2) struggles to attain achieve treatment and pain management, (3) profound activity consequences, and (4) emotional wellbeing, relationship, and identity impacts of pregnancy-related lumbopelvic pain. Implications. The occupational therapy role with this population has not to our knowledge yet been described. Given the centrality of occupational disruption to the experience of this population we argue that developing and evaluating occupational therapy interventions to address functional, work, parenting and wellbeing outcomes for this population is warranted and should be prioritized.

Occupational therapy in multiple sclerosis

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: Main objective To assess the benefits and harms of occupational therapy interventions for improving daily functioning, participation, and quality of life in people with multiple sclerosis. Secondary objectives To assess whether the effects of occupational therapy interventions differ according to the format of intervention delivery (individually versus group) and to the location of service delivery (outpatient, inpatient, or home‐based therapy).

Picky eating in children: Current clinical trends, practices, and observations within the Australian health-care context.

Childhood picky eating occurs when there is limited intake or variety of food and/or unwillingness to try new foods. Within research settings, standardised assessments are used to describe picky eating behaviours in children. However, little is known about assessment practices of occupational therapists. Similarly, occupational therapy interventions for picky eating in the literature focus on; providing strategies for parents, and working with the child on self-feeding skills. Despite this, interventions and strategies utilised by occupational therapists in clinical practice within an Australian health-care context are unknown. This study examines Australian health professionals' observations of picky eating behaviours, the use of childhood picky eating assessments and interventions, and differences between occupational therapists and other professionals. Health professionals (n= 179) were recruited through professional organisations, such as Occupational Therapy Australia. Participants completed an online survey between March and May 2021. Independent variables were reported using descriptive statistics, with logistic regression used to consider differences between occupational therapists and other health professionals. Conventional content analysis was used to analyse responses to open-ended questions. The final sample included 109 eligible participants, with an average of 8.5 years working with picky eaters. Results indicated picky eating behaviours aligned with those reported in the literature. Participants relied on clinical observations and workplace designed assessments. The most common interventions were education, coaching, and the sequential oral sensory approach to feeding. Occupational therapy participants were significantly more likely than other health professional participants to report always using coaching and education. Although few health professionals used standardised or validated assessments, the use of education and coaching by occupational therapists aligned with the literature. Results highlight the need for more rigorous investigation to determine the sensitivity of current assessments to differentiate between clinical and typical picky eating, and the effectiveness of interventions for childhood picky eating.

Including a relationship-focus in paediatric occupational therapy interventions: Introducing the PAIR Model

ABSTRACT The importance of parent-child relationships for child developmental outcomes suggests a need to incorporate a relationship focus into early intervention programs for children with developmental delays. Nevertheless, confusion exists about the definition and application of relationship-focussed interventions, and occupational therapists remain more developmentally- and child-focussed. There is a need to operationalize relationship-focussed interventions to make these approaches clinically accessible. This report defines, and provides a rationale for, including parent-child relationship-focussed interventions in early childhood occupational therapy interventions. A new conceptual model, the “Phased Approach to Incorporating a Relationship-focus” (PAIR), is detailed for consideration in pediatric therapy settings. The PAIR model can support professional education, inform practice, and guide future research regarding relationship-focussed interventions. Research is needed to test the usefulness of this model in occupational therapy practice.

Development of a Decision Support System to Provide an Occupational Therapy Service for Students with Disabilities During Transition Periods

ABSTRACT The decision support system (DSS) provides systematic data for improving effective decision-making by school-based occupational therapists (SBOTs) in healthcare services. The purposes of this study were to develop the DSS and investigate its usability in providing the occupational therapy (OT) service for students with disabilities during transition periods. This study was conducted by using the Research and Development (R&D) design. There were two phases of methodology. Phase I explored the needs of SBOTs regarding DSS development. Six SBOTs were appointed for their opinions by in-depth interview with semi-structured questions. Content analysis was conducted in this phase. Phase II investigated usability of the DSS in providing the OT service to students with disabilities during transition periods. The participants comprised 18 SBOTs and 18 teachers, who worked together in providing educational programs for students with disabilities. The System Usability Scale (SUS) was used for investigating efficiency of the web-based DSS. Results found that the web-based DSS comprised two main parts of content and three main functions. In terms of content, the web-based DSS included personal and OT service information. In terms of function, syncing information from the Special Education Technology (SET) software program, making decisions on OT intervention programs and sharing OT service information were included. The SUS was used for investigating usability of the web-based DSS. The SUS score was 72.98, which indicated good usability. These findings indicated that the web-based DSS was meant to support decisions made by the SBOTs in providing OT intervention for students with disabilities during transition periods. In addition, it could be a collaborative tool, which supports sharing student information between SBOTs, teachers and other professionals in preparation for transition planning before moving to higher education levels.

Occupational Therapy for Mental Health Conditions and Substance Use Disorders

&#x0D; Occupational therapy interventions may be effective for reducing symptoms of depression and anxiety and improving function and participation with the interventions in adult patients diagnosed with depression and/or anxiety.&#x0D; In patients with schizophrenia, occupational therapy interventions may improve social functioning, cognitive performance, executive function, and motivation; and reduce the duration and rate of rehospitalization.&#x0D; We did not find any evidence regarding the clinical effectiveness of occupational therapy for the treatment of bipolar disorders, obsessive-compulsive disorder, and post-traumatic stress disorder that met the inclusion criteria for our review.&#x0D; We did not find any evidence meeting our inclusion criteria about the cost-effectiveness of occupational therapy for the treatment of mental health conditions, as well as the clinical effectiveness and cost-effectiveness of occupational therapy for the treatment of substance use disorders.&#x0D;

Occupational therapy assessment and interventions for young autistic children in South Africa.

Occupational Therapy is among the top interventions for autistic children, hence the need for equitable and effective services in the public and private health and education sectors. Ongoing research into the therapies for autism spectrum disorders in different contexts is also required. To explore and describe occupational therapists' assessment and intervention for autistic children in South Africa. A descriptive qualitative research design using semi-structured interviews to gather data from purposively recruited OTs (n=20). Data were audio-recorded, transcribed and analysed thematically, and compared across three sectors public health, special needs schools and private practice. South African practice across all three sectors was similar to international patterns of informal play-based assessment, sensory processing and Ayres Sensory Integration (ASI®) treatment. Developmental frameworks guided specific approaches. Strong team collaboration was present across sectors, with some transdisciplinary teamwork and co-treatment. Undergraduate and postgraduate training opportunities were, however limited. Occupational therapy assessments had diagnostic value. Informal tools such as developmental checklists were found to have clinical utility, whilst standardised tools were most commonly used to assess sensory processing and visual perception. Recommendations included incorporating ASI® into undergraduate curricula and postgraduate training opportunities with multidisciplinary input to develop ASD professionals in South Africa. It is imperative to advocate for services in under-resourced rural areas and marginalised communities that lack financial and social resources. Occupational therapists need to find new ways of working collaboratively across sectors to ensure effective and comprehensive services in public health and special schools.

Development and pilot testing of an occupational therapy intervention program based on Occupational Adaptation Model for caregivers of people with multiple sclerosis

Introduction: Multiple sclerosis (MS) can have negative consequences on caregivers’ level of performance and adaptive process. This study aimed to (i) describe the steps of developing an occupation-based program based on the Occupational Adaptation Model (OAM), and (ii) make a preliminary assessment of the feasibility of the program prepared for caregivers of people with MS. Method: In a mixed-method approach, the occupation-based program of “Adapting to the Occupational Challenges of Caregivers of people with MS” (AOCCMS) was developed in four steps. During Steps 1, 2, and 3 the AOCCMS program was developed and in step 4, the feasibility and acceptability of the program were evaluated. Results: Based on the results of step 1 that have been published in the past; time limitations in occupation implementation; care needs in occupation implementation; psychological reactions affecting occupations were occupational challenges affecting the daily occupations of caregivers. Also, occupational adaptation strategies were strategies to alleviate intrapersonal challenges of occupational adaptation and strategies to alleviate environmental challenges of occupational adaptation. In step 2, the intervention programs of studies on caregivers were reviewed. During step 3, the data obtained from steps 1 and 2 were merged and integrated. Finally, the AOCCMS program was developed. In step 4, during the feasibility and acceptability of the program, 75% caregivers were satisfied with the program content. The quality of the program content was excellent and very good for 100%. Conclusion: The AOCCMS is an occupation-based program which was evaluated to be feasible and acceptable, which may be further addressed in future research and clinical practice.

Inpatient rehabilitation therapy in stroke patients with reperfusion therapy: a national prospective registry study

BackgroundLittle is known about the rate of real-world inpatient rehabilitation therapy (IRT) after stroke. We aimed to determine the rate of inpatient rehabilitation therapy and its associated factors in patients who undergo reperfusion therapy in China.MethodsThis national prospective registry study included hospitalized ischemic stroke patients aged 14–99 years with reperfusion therapy between January 1, 2019, and June 30, 2020, collecting hospital-level and patient-level demographic and clinical data. IRT included acupuncture or massage, physical therapy, occupational therapy, speech therapy, and others. The primary outcome was the rate of patients receiving IRT.ResultsWe included 209,189 eligible patients from 2191 hospitals. The median age was 66 years, and 64.2% were men. Four in five patients received only thrombolysis, and the rest 19.2% underwent endovascular therapy. The overall rate of IRT was 58.2% (95% CI, 58.0–58.5%). Differences in demographic and clinical variables existed between patients with and without IRT. The rates of acupuncture or massage, physical therapy, occupational therapy, speech therapy, and other rehabilitation interventions were 38.0%, 28.8%, 11.8%, 14.4%, and 22.9%, respectively. The rates of single and multimodal interventions were 28.3% and 30.0%, respectively. A lower likelihood of receiving IRT was associated with being 14–50 or 76–99 years old, female, from Northeast China, from Class-C hospitals, receiving only thrombolysis, having severe stroke or severe deterioration, a short length of stay, Covid-19 pandemic and having intracranial or gastrointestinal hemorrhage.ConclusionAmong our patient population, the IRT rate was low with limited use of physical therapy, multimodal interventions, and rehabilitation centers and varied by demographic and clinical features. The implementation of IRT remains a challenge for stroke care, warranting urgent and effective national programs to enhance post-stroke rehabilitation and the adherence to guidelines.

Recent Trends in Occupational Therapy Specific to Motor Intervention for Adults with Traumatic Brain Injury: A Scoping Review

Abstract Background: According to the National Crime Records Bureau (2014), traumatic brain injury (TBI) is increasingly being recognized as a public health problem of immense proportions with the substantial burden of disability and death occurring in low- and middle-income countries. Many people with TBI experience various degrees of motor function impairment which can have a significant impact on participation in all the areas of occupation. There is a dearth of evidence-based occupational therapy (OT)-specific motor intervention. Moreover, it is necessary to be aware of the current literature available on OT interventions to support recovery of patients with TBI. Objective: To describe the recent trends in OT-specific motor interventions for adults with TBI. Study Design: A scoping review was employed for this study. Methods: Arksey and O’Malley’s six-stage framework for scoping reviews guided our study. A search was conducted in various databases, including PubMed, Cochrane Database of Systematic Reviews, National Institute for Health and Care Excellence, and the Cumulative Index to Nursing and Allied Health Literature–CINAHL for papers published between 2016 and 2021. The search strategy was developed based on the concepts and keywords used in the Population, Intervention, Comparison, Outcomes, and Study design framework. Numerical and thematic analyses were employed. Results: Of the 35 articles identified in the review process, 13 papers were included in the scoping review. On performing analyses, 6 major themes were identified which were as follows: (1) The centrality of occupation (top-down approach), (2) Should bottom-up approach be used? When? (3) Contemporary approaches to intervention, (4) Traditional approaches to intervention, (5) Outcome measures for motor intervention, and (6) Futuristic intervention concepts and opportunities. Conclusion: Several recent trends in OT-specific to motor intervention have emerged in the yesteryears which may be considered for integration into practice with TBI survivors. Whilst there have been some advancements in TBI literature including “occupation” in the limelight, multidisciplinary or interdisciplinary collaboration and several contemporary approaches with unique and new concepts, there are still undeniable challenges to the practicing occupational therapists with regard to understanding its implementation, limited evidence, and equivocacy of its effectiveness.

A scoping review of occupational therapy scoping reviews – utilisation of the WFOT proposed international occupational therapy research priority

Introduction: This study aims to map existing occupational therapy scoping reviews to identify their characteristics and highlight research priorities to help occupational therapy researchers conduct further research in the eight prioritized research areas proposed by the WFOT Delphi study. Method: The review followed the scoping review guidelines from Arksey and O'Malley (2005). Six electronic databases (PubMed, ProQuest Central, Scopus, CINAHL and AHMED, and Web of Science) were used for the search. The inclusion criteria were set as follows: written in English; related to occupational therapy and scoping reviews. Results: A total of 189 articles were mapped to the WFOT research priorities: Effectiveness of occupational therapy interventions (n = 57); evidence-based practice and knowledge translation (n = 74); healthy aging (n = 26); participation in everyday life (n = 29); occupational therapy professional issues (n = 29); community development and population (n = 10); occupational therapy and chronic conditions (n = 41); technology and occupational therapy (n = 11); and some non-categorized studies. Conclusion: Our findings also support the WFOT study findings indicating the current research focus in evidence-based practice and knowledge transition.

Tailored medication management intervention delivered by occupational therapists for older adults: A study protocol

Introduction: Medication management is an essential instrumental activity of daily living for older adults; however, 40–70% of older adults fail to take their medications correctly. Addressing medication management falls under the scope of occupational therapy, but there is a lack of evidence supporting occupational therapy interventions to improving medication management. This study’s primary aims are to examine the feasibility, acceptability, and preliminary efficacy of a Tailored Intervention for Medication Management delivered by occupational therapists to improve medication management. Method/Design: Single-blind, parallel-group randomized controlled equivalency trial, with two phases. Thirty community-dwelling older adults will be enrolled in this study. In Phase 1, participants in the treatment group will receive Tailored Intervention for Medication Management delivered remotely; those in the waitlist control will receive attention visits. In Phase 2, waitlist control participants will receive Tailored Intervention for Medication Management in person. The primary outcomes are feasibility and acceptability; secondary outcomes include preliminary efficacy of the intervention delivered by an occupational therapist remotely and in person. Additionally, the remote and in-person delivery methods will be compared to each other for equivalency. Discussion: Inability to manage medication and inappropriate polypharmacy are significant and prevalent problems that must be addressed so older adults can safely perform this essential instrumental activity of daily living. Trial Registration: ClinicalTrials.gov identifier NCT04717297.

Physical therapy and occupational therapy management of a person with bilateral transradial amputations: a case report

Objective This longitudinal case study describes the physical and occupational therapy interventions and recommendations for treatment of a person with bilateral transradial amputations during subacute rehabilitation, as there are currently few recommendations. Materials and methods A 53-year-old female with subacute bilateral transradial amputations received inpatient rehabilitation. Impairments include decreased balance, global weakness, and need for assistance with ADLs and transfers. Physical therapy, occupational therapy, nursing, a peer mentor, and a prosthetist collaborated. Interventions included task-specific and generalized strengthening, standing balance re-education, assistive device prescription, education using body-powered prostheses, home adaption recommendations, and activities of daily living practice. Results Patient progressed to independent functional mobility but required assist for activities of daily living and stairs negotiation due to limited caregiver support and poor prosthetic dexterity. She discharged to a skilled nursing facility. Conclusion Rehabilitation of a person with bilateral transradial amputations requires clinicians experienced with prostheses; excellent interdisciplinary coordination; early discernment of the available social support system; task-specific strengthening and coordination exercises to prepare the patient for prostheses; significant task-practice with prostheses; and a working knowledge of home modifications and adaptive equipment. This article describes recommendations, successful interventions, and lessons learned for future therapists when rehabilitating someone with bilateral transradial amputations. IMPLICATIONS FOR REHABILITATION Bilateral transradial amputations (BTAs) are a life-altering, but rare condition, meaning that literature surrounding this population is sparse and that guidelines for rehabilitation are unclear. This article provides recommendations so that clinicians can be better informed when treating BTA patients in the subacute phase and more quickly progress patients toward functional independence and discharge to the community.

Outcomes for children and adolescents with Juvenile idiopathic arthritis addressed by occupational therapy services in specialist rheumatology clinics in South Africa

Introduction: International guidelines for best practice indicate specialised treatment is required for Juvenile idiopathic arthritis (JIA). While occupational therapy intervention for functional limitations in this chronic condition is conditionally recommended, the extent to which this is provided in public specialist rheumatology clinics in South Africa is unknown. The aim of this study was to determine which needs related to outcomes for occupational performance or functional status, condition-related factors and health-related quality of life, reported by children and adolescents with JIA were addressed by current occupational therapy services. Methods: The study used two descriptive, quantitative studies with limited samples of 37 clients with JIA attending specialist rheumatology clinics and nine occupational therapists who currently provide intervention for clients with JIA. Results: Functional deficits reported by 30–63% of clients with JIA were increased symptoms of active disease and difficulties with school activities. Occupational therapy services addressed condition-related factors and participation in personal management but not many related to the social, educational and psychosocial needs of clients with JIA. Conclusion: Occupational therapy services followed international guidelines but based on the reductionist biomedical model approach used within specialist services in tertiary hospitals, which limit context-based therapy for children and adolescents with JIA in the community.