Mobile Phone Penetration Rates Research Articles

Does technology affect human development? Examining some important moderating factors

Nowadays ICTs are fully integrated with human life. This may be why there is an increasing interest in understanding the role that ICTs development plays in societal transformations, especially in response to the challenges posed by human development in Africa. However, not much is known about the channels through which ICTs are likely to affect human development, allowing us to investigate other transmission channels of the ICTs-Human development nexus. For this purpose, we used data collected in the 2000–2017 period for 27 African countries and employed the system Generalized Method of Moments (GMM) for empirical estimations. Our findings indicate that ICTs, captured by mobile phone and internet penetration rates, significantly improve human development. The study also found that trade openness, financial development, electricity consumption and democracy are the main channels through which ICTs positively improve human development. In light of these empirical findings, we suggest fresh insights that can convince policymakers to care so much about trade openness, financial development, electricity consumption and democracy if ICTs are to be used as economic tools for human development improvement.

Why Digital Health Literacy Matters in Rural Sub-Saharan Africa: How Bridging the Digital Health Literacy Gap Could Improve Access to Health Services and Social Equality

Why Digital Health Literacy Matters in Rural Sub-Saharan Africa:How Bridging the Digital Health Literacy Gap Could Improve Access to Health Services and Social Equality Ismaila Ouedraogo, Roland Benedikter, Borlli Michel Jonas Some, and Gayo Diallo Digital Health Literacy Matters Around the world, mobile phones have been used for quite some years now to put healthcare systems into interactive action through various mobile health applications. The results regarding efficiency, access, greater social equality, and interconnectivity are proven, and they promise to mitigate economic and educational gaps. All this is increasingly the case in sub-Saharan Africa (SSA), where the technological prerequisites are quickly evolving. About 500 million people in SSA—more than 46 percent of the region's population—were subscribing to mobile services in 2020, and their numbers are forecast to reach 615 million in 2025 (GSMA 2022). In the meantime, coverage works also in the structurally poorest areas. In 2020, 2G mobile network coverage in Burkina Faso was 81 percent for the territory and 92.4 percent for the population (ARCEP 2020). The high penetration rate of mobile phones and the increasing coverage of the mobile network has created a vast variety of opportunities for health provision. Mobile devices can no longer be ignored in practical health delivery and disease prevention workflows. The positive potential of the application of digital health tools is obvious, and it is often said that mobile devices will be a key vehicle on the road to achieving universal health coverage in the Global South. Despite this promise, the deployment of digital health tools in SSA faces many challenges, such as an urban-rural gap, a gender divide, low digital literacy, and a shortage of electricity and interconnectivity [End Page 134] (Holst et al. 2020). Poorly designed, unsustainable, unsafe, and irresponsible digital health products circulate that waste time, energy, and physical and financial resources. Digital health literacy increasingly correlates with digital inclusion—a situation where people can access and use information and communication technologies to take charge of and improve their health. Inversely, digital health technologies become useless when users do not have the skills, connectivity, mutual exchange, or understanding to use them, or do not have access when they need them. Designing digital health solutions that fit with the digital literacy prerequisites and skills of low-qualified users matters crucially in SSA for sustainably sufficient coverage. The ability to find, understand, and use e-health resources is critical for consumers to be able to use current and future health services. Digital health literacy is therefore no longer an option but has become a fundamental requirement in SSA in the design of inclusive solutions. Innovative Mobile Health Initiatives in SSA during the COVID-19 Pandemic The advent of the global COVID-19 pandemic, which began in 2020, has accelerated the pace at which mobile technology is becoming commonplace in people's healthcare. In many countries, healthcare systems rapidly shifted to enabling medical consultations digitally. The increase in mobile phone usage was correlated with an increase in access to information, with phones acting as information relays. Cell phones were used to disseminate pandemic-related information to disadvantaged communities in SSA. Several examples catch the eye. In Burkina Faso, Viamo is a social enterprise that understood this paradigm shift early. It attempted to connect disadvantaged individuals and organizations with appropriate information via mobile devices to enable them to make better decisions (Sandwidi 2020). Through its mobile services, it had played an integral role in bridging the information gap among communities in rural areas long before the advent of the pandemic (UNDP, n.d.). Among other initiatives, it partnered in 2010 with Orange Burkina, a primarily national telecommunication company, to launch a mobile service that allows underserved communities to have free access to information in four of Burkina Faso's most spoken local languages: Mooré, Dioula, Fulfulde, and Gourmanché. Viamo instructions are provided mainly orally, in the same four languages, to include those who cannot read. These approaches, hailed by many customers, have evolved over time. Since 2017, Viamo's platform has covered many themes, including COVID-19 orientation, family planning, health, agriculture, early childhood development, weather forecasts, news, and entertainment. Each theme is usually subdivided...

Driving information communication technology for tax revenue mobilization in Sub-Saharan Africa

This study explores whether increasing Information and Technology Communication (ICT) boosts government revenue mobilization for sustainable development in 48 Sub-Saharan African countries from 2004 to 2020. While total tax revenue non-resource as a percentage of GDP and tax revenue as a percentage of GDP are used to proxy for tax revenue mobilization, three ICT measures are used, namely; the telephone penetration rate, the mobile phone penetration rate and internet penetration rate. To perform the analysis, we adopt the Generalized Method of Moments (GMM). The empirical findings are as follows. First, while the calculated net impacts are substantially positive, the corresponding marginal ICT effects utilized for calculating net effects are extremely negative. Second, an extensive study is carried out to determine complementing policy thresholds. These thresholds include: 21.959 (per 100 people) telephone penetration for total income from tax revenue; 16.333 (per 100 people) internet penetration for total income from tax; 21.125 internet penetration (per 100 people) for the income from the tax on non-resource income. This study has policy relevance, and implications as the penetration of the ICT rate can be influenced by policies to mobilize government revenue effectively.

Boundary Crossing for Education Continuity: Exploring WhatsApp’s Potential in Botswana During and Beyond the Pandemic

Based on a conceptualization of WhatsApp as a boundary object that permits educational institutions to cross over from in-school teaching to out-of-school teaching, this study investigated the viability of WhatsApp as a mobile learning (m-Learning) technology tool for the continuity of teaching and learning in Botswana during and beyond the COVID-19 pandemic. Utilizing a narrative review of the literature, we found that WhatsApp’s viability is supported by Botswana’s high mobile phone penetration rate, the extensive coverage of the country’s mobile broadband network, reduced domestic internet prices and research findings of WhatsApp’s technological, educational and academic advantages elsewhere. However, teachers require training to develop relevant technological and pedagogical competences. WhatsApp’s viability also requires inclusive access for all children including those from rural poor families and living with disabilities, and the protection of children learning online from mobile phone dependency and exposure to potentially harmful content and abuse.

Evaluation of Rural Tourism Spatial Pattern Based on Multifactor-Weighted Neural Network Algorithm Model in Big Data Era

In recent years, due to the rapid development of rural tourism, rural tourism has lost its unique rurality, which has led to a certain impact on the sustainable development of rural tourism. Primarily, based on the rural characteristics, the social environment development, population development, and economic development are taken as the research indexes, and the evaluation index system of rural tourism destination is constructed. Afterward, an empirical study on the spatial pattern of rural tourism is carried out with examples, and the model is simulated and analyzed by MATLAB software. Finally, the spatial autocorrelation method is used to analyze the evolution characteristics of the rural tourism spatial pattern. The results show that through the analysis of the evaluation error curve of the Back Propagation Neural Network (BPNN), the evaluation error and the actual error range are within 0.08%, which proves that the BPNN algorithm has good calculation accuracy. The BPNN rural tourism destination rurality evaluation model established here can make an effective evaluation of rural tourism space. The results show that the proportion of employees in the primary industry and the penetration rate of mobile phones are the decisive factors in the adjustment of industrial structure and social environmental factors, respectively. Rural per capita tourism income and the proportion of primary industry output value will also have a certain impact on rural evolution. Certain guiding significance is provided for the sustainable development of rural tourism.

Ghana: health system review 2021

Abstract A health system review provides a detailed description of a health care system and of reform and policy initiatives in progress or under development. The health system review of Ghana serves as an effort to also assess the system's performance towards the attainment of universal health coverage (UHC). A workshop was organized in 2018 to develop a template for writing the health system review of Ghana. This serves as a pilot study to test the feasibility of using a template somewhat like that of the WHO European Observatory on Health Systems and Policies for writing health system reviews of African countries. The health system review of Ghana is the first to be written for an African country modelled after the HiT reviews by the European Observatory. One key characteristics of the health system of Ghana is the introduction and reform of the national health insurance scheme (NHIS) in 2003 and 2012 respectively. About 40% of the population are enrolled and 60% enrolled are exempted from premium payments. Ghana has since 2010 scaled-up a national telemedicine programme, becoming one of the first adopters and innovators in Africa to integrate digital health technologies into mainstream health care system. Since 2018, Ghana has implemented the NHIS mobile renewal service, which allows payment of health insurance coverage using mobile money technologies. Ghana is one of the first countries to introduce a nationwide health insurance in Africa. The NHIS is one significant effort towards health systems strengthening and achieving UHC. Enrolment in in the NHIS contributes to better access to health care and improved financial protection. However, not only is population coverage low, but there is a serious concern about the system's financial sustainability. A promising approach is to improve the mobile-money based intervention through the high mobile-phone penetration rates in Ghana to enable more effective household saving arrangements towards UHC. Key messages Ghana presents important lessons, including the introduction of a national health insurance. This contributes to better access to health care and improved financial protection. Ghana is exploiting the use of mobile phone technologies and has become one of the first adopters and innovators in Africa to integrate digital health technologies into mainstream health care system.

Use of mHealth Solutions for Improving Access to Adolescents' Sexual and Reproductive Health Services in Resource-Limited Settings: Lessons From Zimbabwe.

Background: Gaps still exist in reducing new HIV infections among adolescent girls and young women (AGYW) aged 10–24 years. High Internet coverage and mobile phone penetration rates present opportunities for the use of mobile health (mHealth) to support access to health services. We present results of an FHI 360 and Zimbabwe Health Interventions-implemented mHealth intervention for reproductive health (RH) and HIV testing service (HTS) referral among AGYW aged 10–19 years between October 2019 and September 2020.Methods: Adolescent girls and young women referred for RH and HTS under the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) program had automatic reminders sent to their phones to facilitate access to services through short message service (SMS) and also using a paper-based system. These data were captured in a web-based District Health Information System (DHIS) database, which captured the referral completion status of the AGYW. Data for AGYW referred for RH and HTS for the period October 2018 to September 2019 for the paper-based system and October 2018 to September 2020 for the mHealth were extracted from District Health Information System version 2 (DHIS2) database and analyzed using SPSS to generate descriptive statistics. The Chi-square test was used to assess differences in referral completion rates by age-group; marital status, district, and type of service, as well as differences between mHealth and paper-based referral completion rates within each of the groups for the variables above.Results: A total of 8,800 AGYW referred for RH and HTS, where 4,355 and 4,445 were referred through the mHealth and paper-based systems, respectively. About 95.2% (4,148/4,355) and 87.8% (3,903/4,445) referred through mHealth and the paper-based system, respectively completed referrals. The median time for referral completion was 1 day (Range = 0–9 days) for mHealth and 11 days (Range = 0–28 days) for the paper-based system. AGYW referred through mHealth were 17.995 timesmore likely to complete the referral system than those referred through the paper-based system (OR =17.995; p <0.001).Conclusion: Compared to the paper-based referral system the mHealth solution resulted in a higher, service referral completion rates and shorter turnaround time. We recommend expansion of the mHealth solution to all DREAMS supported districts to increase uptake of RH and HTS among AGYW aged 10–19 years.

Link between Excessive Smartphone Use and Sleeping Disorders and Depression among South Korean University Students.

The purpose of this study was to explore the link between smartphone use and sleeping disorders and depression among university students in South Korea. South Korea has the highest mobile phone penetration rate as well as the highest rate of suicide of any of the Organization for Economic Cooperation and Development (OECD) nations, thus making this study of great importance. The core aim was to see whether the excessive use of smartphones has an association with sleeping disorders and depression. A cross-sectional analysis was performed to establish if there was any link between smartphone use and sleeping disorders and depression. Samples from 188 participants were used for this study. Data were collected using two well-established questionnaires, the Center for Epidemiologic Studies-Depression (CES-D) and the Athene Insomnia Scale (AIS), as well as a few questions on smartphone use. A few demographic questions were added to the questionnaire. The results of this study concluded that a significant relationship exists between smartphone use and depression. However, the finding of this research could not uncover a significant relationship between smartphone use and sleeping disorders among university students in South Korea. The excessive use of smartphones shows a relationship to an unhealthy lifestyle. There is a clear indication that the overuse of smartphones could be linked to depression. Furthermore, the study found that students with depression also tend to have sleeping disorders.

SARDO: An Automated Search-and-Rescue Drone-Based Solution for Victims Localization

Natural disasters affect millions of people every year. Finding missing persons in the shortest possible time is of crucial importance to reduce the death toll. This task is especially challenging when victims are sparsely distributed in large and/or difficult-to-reach areas and cellular networks are down. In this paper we present SARDO, a drone-based search and rescue solution that exploits the high penetration rate of mobile phones in the society to localize missing people. SARDO is an autonomous, all-in-one drone-based mobile network solution that does not require infrastructure support or mobile phones modifications. It builds on novel concepts such as pseudo-trilateration combined with machine-learning techniques to efficiently locate mobile phones in a given area. Our results, with a prototype implementation in a field-trial, show that SARDO rapidly determines the location of mobile phones (~3 min/UE) in a given area with an accuracy of few tens of meters and at a low battery consumption cost (~5%). State-of-the-art localization solutions for disaster scenarios rely either on mobile infrastructure support or exploit onboard cameras for human/computer vision, IR, thermal-based localization. To the best of our knowledge, SARDO is the first drone-based cellular search-and-rescue solution able to accurately localize missing victims through mobile phones.

Analysis on Talent Demand of Tourism Enterprises in Beijing in the Internet Plus Era

The high penetration rate of Internet and mobile phones has brought about changes in consumption and payment methods, and prompted the transformation of traditional tourism industrial structure to "Internet+Tourism", and then the demand for tourism talents has also changed. The paper is based on the analysis of talent demand in Beijing tourism enterprises, using questionnaire survey method, investigates the current situation of talent recruitment in tourism enterprises and the training of tourism talents from the perspective of tourism enterprises, and analyze the data of 252 tourism enterprises by SPSS statistical software, the results show that: tourism enterprises are in shortage of talents, and there is an urgent need for composite talents with high intersection of service technical talents and professional disciplines talent, and then changes in the demand for talents are the result of a combination of internal and external factors, the disconnect between production and demand causes a large shortage of talents in tourism enterprises while tourism talents are still difficult to be employed. Finally, the financial investment in the construction of tourism talents should be increased in Beijing, and tourism enterprises are proposed that they should cooperate with the universities offering related majors especially in practice and should accelerate the transformation of "Internet+Tourism".

Assessing the use of cell phones to monitor health and nutrition interventions: Evidence from rural Guatemala.

In-person (face-to-face) data collection methods offer many advantages but can also be time-consuming and expensive, particularly in areas of difficult access. We take advantage of the increasing mobile phone penetration rate in rural areas to evaluate the feasibility of using cell phones to monitor the provision of key health and nutrition interventions linked to the first 1,000 days of life, a critical period of growth and development. We examine response rates to calendarized text messages (SMS) and phone calls sent to 1,542 households over a period of four months. These households have children under two years old and pregnant women and are located across randomly selected communities in Quiche, Guatemala. We find that the overall (valid) response rate to phone calls is over 5 times higher than to text messages (75.8% versus 14.4%). We also test whether simple SMS reminders improve the timely reception of health services but do not find any effects in this regard. Language, education, and age appear to be major barriers to respond to text messages as opposed to phone calls, and the rate of response is not correlated with a household’s geographic location (accessibility). Moreover, response veracity is high, with an 84–91% match between household responses and administrative records. The costs per monitored intervention are around 1.12 US dollars using text messages and 85 cents making phone calls, with the costs per effective answer showing a starker contrast, at 7.76 and 1.12 US dollars, respectively. Our findings indicate that mobile phone calls can be an effective, low-cost tool to collect reliable information remotely and in real time. In the current context, where in-person contact with households is not possible due to the COVID-19 crisis, phone calls can be a valuable instrument for collecting information, monitoring development interventions, or implementing brief surveys.

Availability and use of mHealth for disease diagnosis and treatment support by health workers in sub-Saharan Africa: a scoping review protocol

IntroductionImproving healthcare for all is one of the global health priorities, particularly in disease burdened settings such as sub-Saharan Africa (SSA). Considering the high penetration rate of mobile phones in...

Evaluation of freeway travel speed estimation using anonymous cellphones as probes: a field study in China

The high penetration rate of mobile phones among drivers and passengers indicates an opportunity for obtaining detailed information on vehicle spatial movement and estimating traffic state at a lower cost than traditional traffic monitoring techniques. In this study, we examine and assess the use of cellphones as probes to measure vehicle speeds. Network-based wireless location technology is adopted and calibrated, and the cellphone signalling data are used for traffic state estimation. Then, we introduce the relationship between the cellular network and road network, and explain how it can be used to estimate link-based average travel speed. Cellular probe-based measurements are compared with those obtained by microwave detectors for each five-minute time interval on busy road links along a freeway in Zhejiang, China, on weekdays, weekends, and holidays respectively. The analysis results show that the proposed cellphone-based system can effectively estimate travel speed on freeways with high cellphone penetration rates.

Mobile phone penetration and its impact on inequality in the Western Balkan countries

Abstract The aim of this paper is to analyse the effect of the mobile phone penetration rate on inequality in Western Balkan countries and to provide empirical evidence. We explore the question of whether cell phone diffusion helps to decrease inequality and whether it has a positive income equality effect. In the developed conceptual framework, we consider that people with access to mobile telephony also have access to Wi-Fi and GPS and that individuals can perform different activities, such as engaging in e-commerce, e-governance, health, and education; paying bills; saving money; and transferring money to other persons. This represents a good foundation for poor persons exit the cycle of deprivation and leads to the development of equal opportunities. We analyse the impact of mobile phone penetration on inequality in Western Balkan countries by using ordinary least squares and two-stage least squares models (Asongu, 2015). Our results confirm the income-redistributive effect of mobile phone penetration.

Modelling departure time choice using mobile phone data

The rapid growth in passive mobility tracking technologies has led to departure time choice studies based on GPS data in recent years (e.g. Peer et al., 2013). GPS data however typically has limited sample sizes and is affected by technical issues like signal losses and battery depletion leading to gaps in the data. On the other hand, the rapid growth in mobile phone penetration rates has led to the emergence of alternative passive mobility datasets such as Global System for Mobile communication (GSM) data. GSM data covers much wider proportions of the population and can be used to infer departure time information. This motivates this research where we investigate the potential use of GSM data for modelling departure time choice. We describe practical approaches to extract relevant information from GSM data and propose a modelling framework that accounts for the fact that the desired departure times are unobserved. We assume that the preferred departure times vary randomly across the users and apply the mixed logit framework to jointly estimate the distribution parameters of the preferred departure times and the sensitivities to schedule delay. Comparison of the model results and time valuation metrics derived from the GSM data with similar metrics derived from the GPS data of a subset of the users reveals that the fewer time gaps in the GSM data lead to reliable model outputs. The proposed framework can be used for mobile phone and other passive data sources with unobserved preferred departure times.

Modelling long-distance route choice using mobile phone call detail record data: a case study of Senegal

The growing mobile phone penetration rates have led to the emergence of large-scale call detail records (CDRs) that could serve as a low-cost data source for travel behaviour modelling. However, to the best of our knowledge, there is no previous study evaluating the potential of CDR data in the context of route choice behaviour modelling. Being event-driven, the data are discontinuous and only able to yield partial trajectories, thus presenting serious challenges for route identification. This paper proposes techniques for inferring the users' chosen routes or subsets of their likely routes from partial CDR trajectories, as well as data fusion with external sources of information such as route costs, and then adapts the broad choice framework to the current modelling scenario. The model results show that CDR data can capture the expected travel behaviour and the derived values of travel time are found to be realistic for the study area.

Exploring the use of mobile phone data for national migration statistics

Statistics on internal migration are important for keeping estimates of subnational population numbers up-to-date, as well as urban planning, infrastructure development, and impact assessment, among other applications. However, migration flow statistics typically remain constrained by the logistics of infrequent censuses or surveys. The penetration rate of mobile phones is now high across the globe with rapid recent increases in ownership in low-income countries. Analyzing the changing spatiotemporal distribution of mobile phone users through anonymized call detail records (CDRs) offers the possibility to measure migration at multiple temporal and spatial scales. Based on a dataset of 72 billion anonymized CDRs in Namibia from October 2010 to April 2014, we explore how internal migration estimates can be derived and modeled from CDRs at subnational and annual scales, and how precision and accuracy of these estimates compare to census-derived migration statistics. We also demonstrate the use of CDRs to assess how migration patterns change over time, with a finer temporal resolution compared with censuses. Moreover, we show how gravity-type spatial interaction models built using CDRs can accurately capture migration flows. The results highlight that estimates of migration flows made using mobile phone data is a promising avenue for complementing more traditional national migration statistics and obtaining more timely and local data.

Enhancing ICT for quality education in sub-Saharan Africa

This research assesses the relevance of information and communication technology (ICT) in primary education quality in a panel of 49 Sub-Saharan African countries for the period 2000–2012. The empirical evidence is based on Two Stage Least Squares (2SLS) and Instrumental Quantile regressions (IQR). From the 2SLS: (i) mobile phone and internet penetration rates reduce poor quality education and enhancing internet penetration has a net negative effect of greater magnitude. From the IQR: (i) with the exception of the highest quantile for mobile phone penetration and top quantiles for internet penetration, ICT consistently has a negative effect on poor education quality with a non-monotonic pattern. (ii) Net negative effects are exclusively apparent in the median and top quantiles of internet-related regressions. It follows that enhancing internet penetration will benefit countries with above-median levels of poor education quality while enhancing internet penetration is not immediately relevant to reducing poor education quality in countries with below-median levels of poor education quality.

Measuring mobility, disease connectivity and individual risk: a review of using mobile phone data and mHealth for travel medicine.

The increasing mobility of populations allows pathogens to move rapidly and far, making endemic or epidemic regions more connected to the rest of the world than at any time in history. However, the ability to measure and monitor human mobility, health risk and their changing patterns across spatial and temporal scales using traditional data sources has been limited. To facilitate a better understanding of the use of emerging mobile phone technology and data in travel medicine, we reviewed relevant work aiming at measuring human mobility, disease connectivity and health risk in travellers using mobile geopositioning data. Despite some inherent biases of mobile phone data, analysing anonymized positions from mobile users could precisely quantify the dynamical processes associated with contemporary human movements and connectivity of infectious diseases at multiple temporal and spatial scales. Moreover, recent progress in mobile health (mHealth) technology and applications, integrating with mobile positioning data, shows great potential for innovation in travel medicine to monitor and assess real-time health risk for individuals during travel. Mobile phones and mHealth have become a novel and tremendously powerful source of information on measuring human movements and origin-destination-specific risks of infectious and non-infectious health issues. The high penetration rate of mobile phones across the globe provides an unprecedented opportunity to quantify human mobility and accurately estimate the health risks in travellers. Continued efforts are needed to establish the most promising uses of these data and technologies for travel health.

Evaluating the Effect of Using Mobile Phone Reminders on the Adherence to Children and Young Adults With Type 1 Diabetes Attending Outreach Appointments

Effective management of Type 1 Diabetes Mellitus (T1DM) requires that people living with the condition attend regular clinical visits. The Rwanda Diabetes Association (RDA) asks young T1DM patients to attend quarterly outreach visits, and prior to the visits, RDA issues reminders via local radio stations. However, adherence in attending clinical appointments has remained low.Since Rwanda has a high mobile phone penetration rate, a pilot intervention study was conducted exploring the use of mobile phone call reminders and Short Message Service (SMS) messages to increase T1DM patients’ attendance of RDA’s quarterly outreach visits. The control group was exposed to only the regular radio broadcast, while the intervention group received reminder phone calls or SMS messages 72 hours prior to their appointments in addition to the regular radio broadcast.The attendance rate was significantly different between the 14 control patients and 35 intervention patients, with 23.3% (3/14) and 76.7% (27/35) attending visits, respectively (P=0.048). The results suggest that using mHealth methods (phone call/SMS reminders) can be effective in improving health outcomes, improving the adherence of T1DM patients to follow-up visits with minimal added cost. The total cost was 0.37 USD per person, compared to potential 672.40 USD for each lost treatment, indicating the intervention is cost-effective in that it minimizes loss to follow up in resource-limited settings. Further research is needed to evaluate the feasibility of scaling up the pilot project and to understand whether improved attendance is sustained long-term.