Organization Of Health Care System Research Articles

Understanding Rewarding and Challenging Nursing Experiences During the Pandemic in Five Countries: Toward Strengthening the Workforce.

Nurses are now more likely to leave their current role in direct patient care than they were before the COVID-19 pandemic. Country culture and the organization of health care systems drive nurses' decisions to leave or stay in the profession. In a fall 2020 survey of nurse professional quality of life, a content analysis of responses to the open-ended question, "What has been challenging or rewarding during this pandemic experience?" was performed. Results were organized within Hofstede's Cultural Dimensions Theory. Six hundred and fifty-six nurses across five countries responded to the question; 526 comments were analyzed. Most (53.6%) respondents were staff bedside nurses. Themes, such as Distress and Fatigue and Building and Experiencing Social Capital were found and understood to reflect cultural values and dimensions such as Uncertainty Avoidance and Power Distance. Recommendations include strengthening culturally tailored leadership knowledge to inform and facilitate countries' nurse retention.

Implementation of Guidelines in Heart Failure: Problems and Potential Solutions

Heart failure (HF) is a long-term condition associated with high mortality, recurrent hospitalisations and a poor quality of life. Several classes of medications (angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β-blockers, If channel blockers, angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists and sodium–glucose cotransporter inhibitors) have demonstrated substantial benefits regarding clinical outcomes and have therefore been included in international guidelines for the management of HF with a high level of recommendation. However, observational studies show that the implementation of these guidelines remains suboptimal. Rates of prescription of recommended medications are highly variable between centres and underdosage is common. Factors related to the patient, the physician, the cost, the organisation of healthcare systems and, finally, the guidelines themselves play a role in this. These affect clinical outcomes and low adherence to guidelines is associated with an increased risk of mortality or rehospitalisation for HF. Education programmes targeting both patients and physicians should be developed to improve practice and awareness. Disease management programmes that involve cardiologists, GPs, HF nurses and other health professionals are also needed to fill the gap in treatment after a hospitalisation for HF and ensure regular follow-up with rapid uptitration of HF medications if tolerated. Better collaboration is needed between patients, health professionals, policymakers and payers to reduce the burden of HF.

An Exploration of Satisfaction with Mental Health Counseling Services in Western Australia Among Sexuality and Gender Diverse Youth

ABSTRACT Clinically significant psychological distress affects approximately 29.3% of Australian adolescents and 80.6% of sexuality and/or gender diverse youth (SGD-Y). Often, SGD-Y experience inadequate access and lower satisfaction with mental health services, stemming from age- and sexuality and/or gender diversity-status. Accordingly, exploration of factors affecting SGD-Y’s access to, and satisfaction with, mental health services is critical. Using a social constructionist lens, we explored factors supporting SGD-Y’s satisfaction with mental health services, and how these needs are or could be met. Seven LGBTQA+ youth aged 15 to 21 who received counseling in Western Australia in the last year, recruited via a university student participant pool and community organizations, participated in semi-structured interviews via video-conference, phone call, or SMS. Reflexive thematic analysis was inductively applied to participants’ verbatim accounts. Satisfaction was tied to participants’ sense of control over their healthcare-system experiences, shaped by four themes: person-centered support during the service-access process, resources to guide the search for services, confidence in therapists, and healthcare-system organization. Practices and policies supporting SGD-Y’s self-determination during their service access may allow for empowering and personally meaningful therapeutic experiences. Developers of policies and initiatives may need to adopt a systems approach to foster SGD-Y’s self-determination as they access services.

COVID 19 and violence in Pregnant women: A short review

Introduction: COVID 19 pandemic made pregnant women more likely to experience domestic violence due to its unique circumstances and the unpreparedness of the health care systems. Event that led to increased episodes of violence. Purpose: This review aims to investigate the relationship between COVID-19 and violence in pregnancy. Methodology: Recent articles between the period 2019 to 2023 were included after searching Medline, Pubmed and Google Scholar. Results: The results spotted out that COVID-19 increased the prevalence of domestic violence comparatively to the period before the Pandemic due to lockdown which led the couples spending more time together and the lowest incomes. It also showed that there were negative impacts in both pregnant women and fetus, such as miscarriages and psychological impacts to women. While highlighted the need of better organized health care systems and public awareness. Conclusions: Public awareness and more supportable health care systems could help in the early recognition of pregnant women at risk and reduce the phenomenal of violence during pregnancy.

What are the barriers towards cervical cancer screening for vulnerable women? A qualitative comparative analysis of stakeholder perspectives in seven European countries

ObjectivesThe aim of this study was to map and compare stakeholders’ perceptions of barriers towards cervical cancer screening for vulnerable women in seven European countries.DesignIn Collaborative User Boards, stakeholders were...

Did Covid-19 make things worse? The pandemic as a push factor stimulating the emigration intentions of junior doctors from Poland: A mixed methods study.

Covid-19 has challenged health systems around the world and increased the global competition for medical professionals. This article investigates if the pandemic and its management became an important push factor influencing the migration intentions of medical students and junior doctors and how this factor compared in importance to others. A mixed methods study-a survey and in-depth interviews-was conducted with final-year students at public medical universities in Poland, a country already suffering from a significant emigration of medical staff. The research demonstrated that the difficulties of the Polish healthcare system in dealing with Covid-19 were a factor that slightly positively influenced the emigration intentions of medical students and junior doctors. Nevertheless, the pandemic's influence was not decisive. Factors such as the socio-political situation in Poland (.440**) (including hate speech directed at doctors by politicians and patients), the participants' family situation (.397**), healthcare system organization (.376**), or the opportunity of pursuing a planned career path (.368**) proved more influential. Salary is still important but did not turn out to be among the decisive factors. This allows us to conclude that migration decisions of medical students have a very well-established basis that does not fundamentally change even under the influence of such dramatic situations as the pandemic. This conclusion has important implications for healthcare management and the ongoing discussion in migration studies on the evolution of push and pull factors in place and time.

COVID-19 prophylaxis, diagnostics, and treatment in patients with rheumatic diseases. The Polish experts panel opinion.

As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) evolves, infection management in vulnerable populations requires formalized guidance. Although low-virulence variants of SARS-CoV-2 remain predominant, they pose an increased risk of severe illness in adults with rheumatic and musculoskeletal diseases (RMDs). Several disease-specific (chronic long-grade inflammation, concomitant immunosuppression) and individual (advanced age, multimorbidity, pregnancy, vaccination status) factors contribute to excess risk in RMD populations. Various post-COVID-19 manifestations are also increasingly reported and appear more commonly than in the general population. At a pathogenetic level, complex interplay involving innate and acquired immune dysregulation, viral persistence, and genetic predisposition shapes a unique susceptibility profile. Moreover, incident cases of SARS-CoV-2 infection as a trigger factor for the development of autoimmune conditions have been reported. Vaccination remains a key preventive strategy, and encouraging active education and awareness will be crucial for rheumatologists in the upcoming years. In patients with RMDs, COVID-19 vaccines' benefits outweigh the risks. Derivation of specialized diagnostic and therapeutic protocols within a comprehensive COVID-19 care plan represents an ideal scenario for healthcare system organization. Vigilance for symptoms of infection and rapid diagnosis are key for introducing antiviral treatment in patients with RMDs in a timely manner. This review provides updated guidance on optimal immunization, diagnosis, and antiviral treatment strategies.

Orthopedic surgery in Palau-Current capacity, needs, and future directions.

Palau, an island nation in Micronesia, is a medically underserved area with a shortage of specialty care services. Orthopedic diagnoses in Palau remain among the three most common reasons for costly off-island medical referral. The purpose of this study was to assess Palau's current orthopedic surgery capacity and needs to inform interventions to build capacity to improve care access and quality. Orthopedic needs and capacity assessment tools developed by global surgical outreach experts were utilized to gather information and prompt discussions with a broad range of Palau's most knowledgeable stakeholders (n=6). Results were reported descriptively. Finance, community impact, governance, and professional development were the lowest-scored domains from the Capacity Assessment Tool for orthopedic surgery (CAT-os), indicating substantial opportunity to build within these domains. According to administrators (n=3), governance and finance were the greatest capacity-building priorities, followed by professional development and partnership. Belau National Hospital (BNH) had adequate surgical infrastructure. Skin grafting, soft tissue excision/resection, infection management, and amputation were the most commonly selected procedures by stakeholders reporting orthopedic needs. This study utilizes a framework for orthopedic capacity-building in Palau which may inform partnership between Palau's healthcare system and orthopedic global outreach organizations with the goal of improving the quality, safety, and value of the care delivered. This demonstration of benchmarking, implementation planning, and subsequent re-evaluation lays the foundation for the understanding of capacity-building and may be applied to other medically underserved areas globally to improve access to high-quality orthopedic care.

Challenges for healthcare Managers in 2023

Introduction: Managers in the field of healthcare face many challenges that are specific to this area and are caused by the dynamic and constantly changing healthcare environment. Research sample and research objective: The main research objective was to evaluate significant aspects of financing and organizing healthcare systems, summarize assumptions for the successful functioning of a healthcare system, assess factors influencing healthcare spending, and predict the challenges that healthcare managers will face in 2023 at both the micro (individual healthcare facilities) and macro (healthcare system in Slovakia) levels. The research sample was selected by deliberate selection and consisted of 109 respondents: healthcare managers (n=16), experts from the field of health management (n=15), experts from the field of human resources (n=19), directors of health facilities (n=10), medical (n=28) and paramedical staff (n=21). Methods: Statistical testing was carried out using the methods of inferential statistics: the independent samples t-test was used to compare mean scores between two groups (RQ1 and RQ2) and a one-way analysis of variance (ANOVA) to compare mean scores among three groups (RQ 3). Results: We found out there are no differences in the respondents’ opinions on the challenges for healthcare managers in 2023 based on their job titles, the type of health facility in which they work or according to the length of practice. Conclusion: According to the respondents, the most current trends and challenges for Slovak healthcare are: the need for qualified medical personnel, a focus on retaining employees and solving the growing costs of healthcare.

Facilitators and Barriers to Scaling-Up Integrated Care for Arterial Hypertension and Type 2 Diabetes in Slovenia: Qualitative Study.

Arterial hypertension and type 2 diabetes are significant contributors to global non-communicable disease-related mortality. Integrated care, centred on person-centred principles, aims to enhance healthcare quality and access, especially for vulnerable populations. This study investigates integrated care for these diseases in Slovenia, providing a comprehensive analysis of facilitators and barriers influencing scalability. Qualitative methods, including focus group discussions and semi-structured interviews, were employed in line with the grounded theory approach. Participants represented various levels (micro, meso and macro), ensuring diverse perspectives. Data were collected from May 2019 to April 2020, until reaching saturation. Transcripts were analysed thematically using NVivo software. Nine categories emerged: Governance, Health financing, Organisation of healthcare, Health workforce, Patients, Community links, Collaboration/Communication, Pharmaceuticals, and Health information systems. Some of identified barriers were political inertia and underutilisation of research findings in practice; outdated health financing system; accessibility challenges, especially for vulnerable populations; healthcare workforce knowledge and burnout; patients' complex role in accepting and managing their conditions; collaboration within healthcare teams; and fragmentation of health information systems. Peer support and telemedicine were the only two potential solutions identified. This study offers a comprehensive evaluation of integrated care for hypertension and type 2 diabetes in Slovenia, featuring insights into facilitators and barriers. These findings have implications for policy and practice. Monitoring integrated care progress, refining strategies, and enhancing care quality for patients with these two diseases should be priorities in Slovenia.

Organization of local healthcare systems in remote rural Brazilian municipalities to combat the COVID-19 pandemic

During the COVID-19 pandemic, populations living further away from urban centers faced immense difficulties accessing health services. This study aims to analyze how Brazilian remote rural municipalities faced the COVID-19 pandemic based on their political, structural, and organizational response to access to healthcare. A qualitative study of multiple cases was conducted with thematic and deductive content analysis of 51 interviews conducted with managers and healthcare professionals in 16 remote rural municipalities in the states of Rondônia, Mato Grosso, Tocantins, Piauí, Minas Gerais, and Amazonas. With their socio-spatial dynamics and long distances to reference centers, the remote rural municipalities responded to the demands of the pandemic but did not have their needs met promptly. They preserved communication with the population, reorganized the local system centered on primary health care (PHC), and changed the functioning of healthcare units, exceeding the limits of their responsibilities to provide the necessary care and awaiting referral to other levels of complexity. They faced a shortage of services, gaps in assistance in the regional network, and inadequate healthcare transport. The pandemic reiterated PHC's difficulties in coordinating care, exposing care gaps in reference regions. The equitable and resolute provision of the local health system in the remote rural municipalities implies inter-federative articulation in formulating and implementing public policies to ensure the right to health.

Medicinos rezidento autonomiją sąlygojantys veiksniai Lietuvos gydytojų hierarchinėje struktūroje

The purpose of this paper is to analyze the factors determining the autonomy of the medical resident in the hierarchical structure of Lithuanian doctors. Due to the different legal practices that have a direct impact on the autonomy of the medical resident, a three-level model is constructed: macro, meso, micro, according to which the impact of the system on the autonomy of the medical resident is analyzed. At the meso level, the requirements and regulations of the macro level affect the individual on micro level by creating an environment for acceptable relationships and actions. At the macro level, health care system organizations recognize the medical resident as a specialist and coordinate residency by implementing laws. According to the Medical Practice Act, which defines a medical resident, medical residents must follow the instructions of a residency supervisor or other professional until they complete their training. The autonomy of the medical resident is influenced both by the medical community due to its low hierarchical position and by health care system organizations that control the regulation of medical residency itself. The position of a student directs the medical resident to practical learning, when only acquired additional qualifications grant the license of a medical specialist, and the status of an employee in the residency bases enables direct participation in the Lithuanian medical community through working relationships. Participating in direct relationships with doctors is part of the professionalization process, when the social norms of doctors are adopted and competences are acquired. Due to the hierarchical structure of the medical community, medical residents, as holders of only the first license, are at the bottom of the hierarchy and do not have extensive autonomy to make their own decisions.

Geoinformation analysis russian health system: modeling, visualization, analysis

In the Russian Federation, noticeable differences remain among its constituent entities in terms of citizens’ access to high-quality medical care. The primary challenges in the development of the nation’s healthcare system and its various regions are closely linked to demographic trends and the need to address mortality problems. The state of regional healthcare systems plays a pivotal role in influencing mortality rates, which, in turn, serves as a reflection of the regional and municipal healthcare systems’ overall development. Consequently, the development of an algorithm or methodology for assessing the effectiveness of healthcare systems, as mandated by strategic and territorial planning documents at all administrative levels, has become a pressing scientific concern and the focal point of this research. The development of the algorithm involved a multifactor analysis and geoinformation mapping methods. The authors have developed specific criteria to evaluate the current state of healthcare systems in the constituent entities of the Russian Federation and municipalities, taking into account their impact on target socio-economic indicators and mortality rates aligned with the national objectives of the Russian Federation, as well as the goals outlined in the National Projects «Healthcare» and «Demography.» Through a comprehensive analysis of demographic and socio-economic factors, the research has unveiled distinctive characteristics in the spatial organization and structure of healthcare systems, both at the municipal and constituent entity levels within the Russian Federation. This analysis has facilitated the development of typologies for the constituent entities based on a comprehensive composite indicator that encompasses both medical and non-medical factors. The authors have introduced a system of cartographic indicators designed to evaluate the efficiency of the spatial organization of healthcare systems at various territorial levels, encompassing constituent entities of the Russian Federation, municipalities, and settlements. To support this evaluation, the authors have prepared a series of original cartographic materials for each level, featuring corresponding assessment indicators.

Resilience of traditional midwifery in Southern Cameroons: 1922-1961

It is instructive that well organized healthcare systems existed in Africa before contacts with the outside world. During this period, midwifery services were prioritized because societal wellbeing depended on the quality and availability of child and maternity services. The arrival of European colonial imperialists with their assumed superior culture/civilization and their colonial economic agenda caused the introduction of Western biomedicine. This was intended in part to maintain a constant and healthy work force for colonial exploitation. Drawing from the case of Southern Cameroons, this paper sets out to examine the resilience of local midwifery practices in the face of an imposed Western biomedicine. The paper was informed by both primary and secondary sources. Archival information and oral interviews made up the primary sources while books, published articles and dissertations constituted the secondary sources. The discriptive historical approach was employed in the analysis of the work. This study submits that: African women were not passive subjects on issues of their reproductive life but agents that could reject imposed values and stick to their tested practices. The ideological and cultural arrogance that characterized the introduction of Western biomedicine had the unintended impact of galvanizing an unexpected resilience of traditional medical practices. Consequently appreciable change in favor of Western biomedicine was only witnessed in the period after independence.

Precision medicine and the problem of structural injustice

Many countries currently invest in technologies and data infrastructures to foster precision medicine (PM), which is hoped to better tailor disease treatment and prevention to individual patients. But who can expect to benefit from PM? The answer depends not only on scientific developments but also on the willingness to address the problem of structural injustice. One important step is to confront the problem of underrepresentation of certain populations in PM cohorts via improved research inclusivity. Yet, we argue that the perspective needs to be broadened because the (in)equitable effects of PM are also strongly contingent on wider structural factors and prioritization of healthcare strategies and resources. When (and before) implementing PM, it is crucial to attend to how the organisation of healthcare systems influences who will benefit, as well as whether PM may present challenges for a solidaristic sharing of costs and risks. We discuss these issues through a comparative lens of healthcare models and PM-initiatives in the United States, Austria, and Denmark. The analysis draws attention to how PM hinges on—and simultaneously affects—access to healthcare services, public trust in data handling, and prioritization of healthcare resources. Finally, we provide suggestions for how to mitigate foreseeable negative effects.

Analysis of intermunicipal journeys for cardiac surgery in Brazilian Unified Health System (SUS): an approach based on network theory

IntroductionThe transformation of data into information is important to support decision making and, thus, to induce improvements in healthcare services. The regionalized organization of healthcare systems is necessary to ensure the integrity of citizen care. From this perspective, the creation of mechanisms to guide and assess the behavior of a healthcare services network becomes necessary. However, these mechanisms must consider the interaction between different municipalities. The objective of this study is to apply network analysis as a supporting tool in the Brazilian Unified Health System (Sistema Único de Saúde—SUS) management.MethodsThe stages of the proposed method are described and applied in a real situation, analyzing the intermunicipal interaction network for cardiovascular surgery in the municipality of Vitória da Conquista, Bahia, Brazil, from 2008 to 2020. The metrics analyzed were journeys indices, flow of patients and distance of the journeys, considering the journeys from and to the municipality in focus.ResultThere was an increase of the incoming flow and in-degree indices combined with a decrease in outgoing flow, showing the growing importance of this municipality as a provider of these services.ConclusionThe method used in the study has potential to be adopted as a management tool to assess the behavior of the interactions network of the selected service, aiding the regionalized organization of the healthcare system.

Evaluation of the Strength at Home Group Intervention for Intimate Partner Violence in the Veterans Affairs Health System

Intimate partner violence (IPV) is a serious and prevalent public health issue that is interconnected with experiences of trauma, mental and physical health difficulties, and health disparities. Strength at Home (SAH) is a group intervention for persons using IPV in their relationships. Although previous studies have provided evidence of SAH's effectiveness in reducing IPV, its patient outcomes as implemented within organized health care have not been examined. To evaluate patient outcomes from implementation of SAH in the Department of Veterans Affairs (VA) health system. This quality improvement study evaluated patient outcomes from a national implementation and training program conducted between December 11, 2015, and September 24, 2021. Data were collected as part of treatment and submitted by clinicians at 73 VA health care facilities. Patients were 1754 veterans seeking care aimed at addressing and/or preventing their use of aggression in intimate relationships. They completed 1 pretreatment assessment and 1 follow-up assessment in the immediate weeks after group completion. Strength at Home is a 12-week trauma-informed and cognitive behavioral group intervention to address and prevent the use of IPV in relationships. Changes in IPV were measured with the Centers for Disease Control and Prevention 2010 National Intimate Partner and Sexual Violence Survey. Changes in posttraumatic stress disorder (PTSD) symptoms were measured with the PTSD Checklist for DSM-5, and alcohol misuse was measured with the Alcohol Use Disorders Identification Test. The study included 1754 participants (mean [SD] age, 44.3 [13.0] years; 1421 men [81%]), of whom 1088 (62%) were involved with the criminal legal system for IPV charges. Analyses indicate that SAH was associated with reductions in use of physical IPV (odds ratio, 3.28; percentage difference from before to after treatment, -0.17 [95% CI, -0.21 to -0.13]) and psychological IPV (odds ratio, 2.73; percentage difference from before to after treatment, -0.23 [95% CI, -0.27 to -0.19]), coercive control behaviors (odds ratio, 3.19; percentage difference from before to after treatment, -0.18 [95% CI, -0.22 to -0.14), PTSD symptoms (mean change, -4.00; 95% CI, 0.90-7.09; Hedges g = 0.10), and alcohol misuse (mean change, 2.70; 95% CI, 1.54-3.86; Hedges g = 0.24). In this quality improvement study of the patient outcomes after implementation of SAH, results suggested that the program was associated with reductions in IPV behaviors, PTSD symptoms, and alcohol misuse. Results also suggest that IPV intervention in routine health care at VA health care facilities was successful; extension to other organized health care systems could be warranted.

The Burnout and Professional Deformation of Latvian Healthcare Workers during the COVID-19 Pandemic at the Traumatology and Orthopaedics Hospital

The COVID-19 pandemic is a global health crisis, which has created an additional burden on the healthcare system and has caused enormous stress and emotional burnout among healthcare workers (HCWs). The purpose of the study is to investigate the phenomena of emotional burnout and the professional deformation of HCWs. The emotional burnout phenomenon of the HCWs was studied using the Maslach Burnout Inventory–Human Services Survey. In addition, the Professional Deformation Survey, based on scientific literature and research works, was developed. The survey consisted of 4 subscales distinguishing: aggression, authoritarianism, demonstrativeness, and conservatism. The survey results showed a high level of emotional exhaustion, a medium level of depersonalization, and a low level of personal achievement reduction. The Professional Deformation Survey showed good reliability for the whole sample in all four subscales. Results of the professional deformation study revealed that 29% of respondents manifest aggression while performing their professional activities. Authoritarianism can be observed in 18% of respondents, demonstrativeness in—31%, and professional deformation manifested as conservatism in—22% of HCWs. Data obtained on burnout and the professional deformation of the HCWs proves that the healthcare system and health organizations have reason to be concerned about the mental well-being of HCWs and the quality of healthcare service provision.

Organization of healthcare systems to confront COVID-19: a scoping reviewOrganización de los sistemas de salud para hacer frente a la COVID-19: revisión del alcance

To identify evidence in the literature on the response of managers regarding the organization of global healthcare systems to face the COVID-19 pandemic. For this scoping review, searches were performed in 11 databases accessible through the Virtual Health Library. Eleven studies, published in 2019 and 2020, were selected based on the following guiding question: "How did managers act to organize healthcare systems to face the coronavirus pandemic?". The results were organized in terms of the categories outlined in the Pan-American Health Organization's Framework for the response of Integrated Health Service Delivery Networks to COVID-19: governance; model of care; organizational and management; financial allocations. Managers in countries that invested and articulated actions in the categories of the Reference Framework, with coordination of care at the primary healthcare level, achieved better outcomes in coping with the COVID-19 pandemic. Situating the coordination of healthcare systems at the primary care level, preparing managers and ensuring the continued allocation of financial resources to healthcare are important factors to secure a satisfactory response to crises such as the covid-19 pandemic.

Axillary Treatment Management in Breast Cancer during COVID-19 Pandemic (Association between ACOSOG Z0011 Criteria and OSNA Test).

The outbreak of the SARS-COVID-2 pandemic (COVID-19) had a significant effect on the organisation of healthcare systems. Surgical units saw a significant reduction in the volume of surgical procedures performed, with lengthening waiting lists as a consequence. We assessed the surgical activity in relation to breast cancer that took place at the University Hospital of Cagliari, Italy, from February 2018 to March 2022. Two phases were identified based on the epidemiological circumstances: Phase 1-February 2018 to February 2020; Phase 2-March 2020 to March 2022. The surgery performed in the two phases was then compared. All the patients in our sample underwent a breast surgical procedure involving a lymph node biopsy using OSNA associated with the ACOSOG Z0011 criteria. In the study period overall at our facility, there were 4214 procedures, 417 of which involved breast surgery. In Phase 2, 91 procedures were performed using the OSNA method and ACOSOG Z0011 criteria, enabling the intraoperative staging of axillary nodes. Axillary treatment in breast cancer using this approach resulted in a significant reduction in the number of reoperations for the radicalisation of metastatic sentinel lymph nodes.