Participant Perceptions Research Articles

Perceptual (but not acoustic) features predict singing voice preferences.

Why do we prefer some singers to others? We investigated how much singing voice preferences can be traced back to objective features of the stimuli. To do so, we asked participants to rate short excerpts of singing performances in terms of how much they liked them as well as in terms of 10 perceptual attributes (e.g.: pitch accuracy, tempo, breathiness). We modeled liking ratings based on these perceptual ratings, as well as based on acoustic features and low-level features derived from Music Information Retrieval (MIR). Mean liking ratings for each stimulus were highly correlated between Experiments 1 (online, US-based participants) and 2 (in the lab, German participants), suggesting a role for attributes of the stimuli in grounding average preferences. We show that acoustic and MIR features barely explain any variance in liking ratings; in contrast, perceptual features of the voices achieved around 43% of prediction. Inter-rater agreement in liking and perceptual ratings was low, indicating substantial (and unsurprising) individual differences in participants' preferences and perception of the stimuli. Our results indicate that singing voice preferences are not grounded in acoustic attributes of the voices per se, but in how these features are perceptually interpreted by listeners.

A Natural Language Processing-Based Classification and Mode-Based Ranking of Musculoskeletal Disorder Risk Factors

This research explores the intricate landscape of Musculoskeletal Disorder (MSD) risk factors, employing a novel fusion of Natural Language Processing (NLP) techniques and mode-based ranking methodologies. Enhancing knowledge of MSD risk factors, their classification, and their relative severity is the main goal of enabling more focused preventative and treatment efforts. The study benchmarks eight NLP models, integrating pre-trained transformers, cosine similarity, and various distance metrics to categorize risk factors into personal, biomechanical, workplace, psychological, and organizational classes. Key findings reveal that the Bidirectional Encoder Representations from Transformers (BERT) model with cosine similarity attains an overall accuracy of 28%, while the sentence transformer, coupled with Euclidean, Bray–Curtis, and Minkowski distances, achieves a flawless accuracy score of 100%. Using a 10-fold cross-validation strategy and performing rigorous statistical paired t-tests and Cohen’s d tests (with a 5% significance level assumed), the study provides the results with greater validity. To determine the severity hierarchy of MSD risk variables, the research uses survey data and a mode-based ranking technique parallel to the classification efforts. Intriguingly, the rankings align precisely with the previous literature, reaffirming the consistency and reliability of the approach. “Working posture” emerges as the most severe risk factor, emphasizing the critical role of proper posture in preventing MSD. The collective perceptions of survey participants underscore the significance of factors like “Job insecurity”, “Effort reward imbalance”, and “Poor employee facility” in contributing to MSD risks. The convergence of rankings provides actionable insights for organizations aiming to reduce the prevalence of MSD. The study concludes with implications for targeted interventions, recommendations for improving workplace conditions, and avenues for future research. This holistic approach, integrating NLP and mode-based ranking, contributes to a more sophisticated comprehension of MSD risk factors and opens the door for more effective strategies in occupational health.

Perspectives of people with myasthenia gravis on physical activity and experience of physical activity advice from health professionals in the Australian context: a qualitative study

Purpose Physical activity is an important modifiable determinant of health. There has been a historical aversion to movement in people with myasthenia gravis (MG) due to the pathophysiology of the disease, however, research suggests engagement in physical activity is safe and does not exacerbate symptoms. There are currently no studies investigating the qualitative perspectives of people with MG on physical activity. The aim of this study was to explore perceptions of physical activity, barriers, enablers, and participants’ experiences of physical activity advice from health professionals. Materials and methods Semi-structured interviews were used, with verbatim transcripts analysed using content analysis. Results Ten adults (median age 64.5 years) living in Australia with generalised MG were interviewed. Key findings were identified: (1) Physical activity is perceived to be important for general health and for MG; (2) Medical management and social support are key enablers; (3) Fatigue and pain are potential barriers; and (4) Experiences with healthcare professionals were considered insufficient and failed to provide disease specific advice regarding MG and physical activity. Conclusion People with MG have unique barriers and enablers to physical activity engagement that clinicians should consider when providing physical activity behaviour change support to this population.

The nature and practices of the use of Machine Learning and Deep Learning Frameworks to assist Software Project Management: A Developing Country Context

The study conducted a comprehensive analysis of literature and interviews related to the use of ML and DL in SPM, identifying challenges and gaps in the field. The study adopts a qualitative research design, gathering data through semi-structured interviews with project managers involved in SPM using ML and DL frameworks. The collected data is analysed using thematic analysis to capture the participants' subjective experiences, perceptions, and opinions. The findings suggest that while the use of AI techniques for SPM has been gaining attention, it is still in its infancy, with limited research and practice in developing countries. The study also emphasizes the unique challenges faced by developing countries in SPM, including limited resources, diverse stakeholders, cultural differences, and rapid changes. It suggests that ML and DL frameworks can offer advantages in enhancing the productivity, innovation, and competitiveness of software projects in these contexts. However, the study acknowledges that there are limitations to these AI techniques for SPM, and further research is needed to address these limitations. The study bridge the gap between theory and practice by offering practical insights for project managers and recommendations for future research in utilizing ML and DL frameworks to assist SPM.

Have they arrived at Galilee? The insights of emerging leaders in a long-term spiritual and faith formation programme

This study explored the perceptions of ongoing participants in the Galilee Spiritual and Faith Formation programme on the development of their personal and faith formation. The study used a constructivist paradigm, specifically that of interpretivism and employed a symbolic interactionist perspective to explore participant perceptions. The methodology for the study was an instrumental case study. Data were collected through a focus group interview with six participants and written responses from other two participants unable to attend the focus group. The results firstly indicated that continued involvement with the Galilee Spiritual and Faith Formation programme had made a positive impact on participants’ personal efficacy and confidence in their own spirituality and faith. Secondly, continued involvement in the Galilee programme had enhanced participants’ professional efficacy or confidence to lead others in deepening their spirituality and faith.

Sociocultural interactions and self-perception of health in older adults from an active participation centre: A qualitative study

IntroductionPromoting healthy ageing is a global priority. Active Participation Centres are potentially key in fostering psychosocial and emotional health, contributing to a fulfilling and active lifestyle for older adults. AimsThe study explores self-perceived health, perceptions of sociocultural participation, emotions that emerged when sociocultural participation, and preferences among older adults engaged in community socio-cultural activities from an Active Participation Centre. MethodsWe realised a hermeneutic study; interviews with nine older participants were conducted. Hermeneutic considerations were employed for data analysis. ResultsFindings reveal the centre's significance as a therapeutic space, positively influencing emotional well-being, fostering social connections, and offering diverse activity preferences. ConclusionThis study underscores the nuanced interplay between sociocultural engagement and self-perceived health, emphasising the need for holistic approaches to promote well-being among older adults attending Active Participation Centres.

Teen Perspectives on Suicides and Deaths in an Affluent Community: Perfectionism, Protection, and Exclusion.

Clusters of youth suicide and death are tragic for communities and present long-term consequences for the surviving youths. Despite an awareness of community-based patterns in youth suicide, our understanding of the social and community factors behind these events remains poor. While links between poverty and suicide have been well documented, wealthy communities are rarely targeted in suicide research. In response to this gap, we conducted ethnographic research in a wealthy U.S. town that, over a recent 10-year period, witnessed at least four youth suicides and seven more youth accidental deaths. Our interviews (n = 30) explored community values and stressors, interpersonal relationships, and high school experiences on participant perceptions of community deaths. Youth participants characterize their affluent community as having (1) perfectionist standards; (2) permissive and sometimes absent parents; (3) socially competitive and superficial relationships; and (4) a "bubble" that is protective but also exclusionary. Our qualitative findings reveal network influence in teen suicides and accidental deaths in a wealthy community. Greater attention paid to the negative effects of subcultural values and stressors in affluent communities is warranted. Further, our work promotes the value of ethnographic, community-based methodologies for suicidology and treatment.

Perceived Utility of Jan Aushadhi Outlets and Awareness of Generic Medicines at the Andaman and Nicobar Islands: A Cross-Sectional Study.

Despite being the leading exporter of generic medicines to the world, affordable medicines are still beyond the reach of most patients in India.Analysis of the National Sample Survey data showed that in one year, more than 55 million Indians became poor only because they had to spend their own money to purchase medicines. The Jan Aushadhi Scheme launched by the Government of India is an ambitious step to make quality generic drugs affordable to the common man of the country. This study aimed to assess the knowledge, attitude, and perceptions of patients at a tertiary care teaching hospital in the Andaman and Nicobar Islands about Jan Aushadhi Kendras and generic medicines. The study was a questionnaire-based cross-sectional study. A prevalidated self-made questionnaire was distributed to 200 patients visiting the OPD of different clinical departments in the hospital. Participants' knowledge, attitude, and perception of Jan Aushadhi Kendras and generic medicines were evaluated. Analysis of collected data was done using descriptive statistical measures such as mean and percentages. It was found that most of the participants were not fully aware of the Jan Aushadhi Scheme and the facts about generic medicines. The majority of the participants were under the notion that generics were not similar in quality to the branded ones. The study observed that the patients had a very poor understanding of the Jan Aushadhi Scheme and generic medicines with the majority being ignorant and having incorrect information. To fill this gap, a more proactive approach by the healthcare workers and authorities is needed to disseminate the scheme-related facts, dispel the myths regarding generics, and accept the program wholeheartedly by the common man.

Clinicians' Experiences and Perspectives about a New Lung Cancer Referral Pathway in a Regional Health Service.

Development and implementation of the Townsville Lung Cancer Referral Pathway [TLCRP] aims to reduce delays and improve referral patterns of people with suspected lung cancer in north Queensland, Australia. Reported in this paper is the experiences and perspectives of general practitioners [GPs] and specialists of the TLCRP. This was a descriptive qualitative study nested within a larger project evaluating TLCRP, utilising a broader implementation science framework. In-depth, semi-structured interviews with GPs and specialists were conducted. An iterative, inductive thematic analysis of interview transcripts was used to derive key codes, then grouped into themes regarding participant experiences and perceptions. Data analysis identified two major themes and several sub-themes. The major themes were variation in the uptake of TLCRP and enhancing coordinated care and communication. Several enablers and barriers to implementing TLCRP were identified. Barriers to adaptation of TLCRP included lack of clinical time, resistance to changing referral patterns, lack of familiarity or experience with HealthPathways and technology issues. Emerging themes from this study may be used to reduce the barriers and improve uptake of TLCRP and other health care pathways in the local health service and may have wider relevance in other settings.

A home-based educational intervention for cervical cancer screening services in rural Uganda

Background/Aims Despite the relative ease of prevention, the incidence of cervical cancer in Uganda is increasing and there is low uptake of screening services. One of the main contributing factors to low uptake is a lack of awareness. Targeting this barrier may help increase uptake and reduce the burden of cervical cancer. This study evaluated the effect of an educational intervention on knowledge, perception, intent to use and use of cervical cancer screening among women in rural southwestern Uganda. Methods This pre-test, post-test study was conducted with 150 women from a village in southwest Uganda, selected for its low uptake of cervical screening services. The home-based educational intervention consisted of a lecture and a discussion on cervical cancer and screening services. Data on women's knowledge, perceptions and use of screening services were captured at baseline and 7 weeks after the intervention, using a questionnaire. Chi-squared tests and paired sample t-tests were used to assess differences in participants' knowledge, perception and use of screening services. Results At baseline, participants had low scores for awareness, attitude and use of cervical screening. The intervention significantly improved knowledge (P<0.001), perception (P<0.001) and screening rate (P<0.001). Some participants' unwillingness to screen after the intervention was associated with marital status or religion. Conclusions The home-based health education intervention was effective in improving knowledge and perception of cervical cancer, and use of screening services. Use of this education intervention in rural regions of Uganda could be an effective strategy to increase use of screening services and thus improve early detection and prevention of cervical cancer.

Are Technologies Useful and Easy to Use: Results of A Cross-Sectional Survey

Tools and technologies have strengths and weaknesses and can either reduce or increase complexity and make work easier or harder. This article aims to report the results of a survey that assessed the usefulness and ease of use of tools and technologies, and perceptions of participants about tools and technologies as a factor in complexity and project failure. A cross-sectional survey of 114 project managers, researchers, and decision-makers was conducted to assess if tools and technologies that participants use in their work are useful and easy to use by asking two questions based on a validated tool of user acceptance of technologies. Additionally, two questions asked participants which tools and technologies were most helpful in their work – one was an open question, and the other provided pre-selected choices of tools and technologies. Few participants chose tools and technologies as a factor that contributes to complexity and project failure, and most participants rated tools and technologies as useful and easy to use. However, the tools and technologies that were chosen by most as helpful for work, tend to be older and simpler and include tools such as checklists. In conclusion, even though tools and technologies are advancing rapidly, most participants in the current survey chose older tools and technologies as helpful in their work. The relevance of these findings is that there appears to be barriers to the adoption of newer technologies such as artificial intelligence and algorithms. The barriers to the adoption of new tools and technologies should be explored further.

177 Placing Participant Experiences at the Center of Improving Research by Empowering the Participant Voice

OBJECTIVES/GOALS: Empowering the Participant Voice (EPV) is a 6-CTSA Rockefeller-led collaboration to developcustom REDCap infrastructure to collect participant feedback using the validated Research Participant Perception Survey (RPPS), demonstrate its value in use cases, and disseminate it for broad adoption. METHODS/STUDY POPULATION: The EPV team developed data and survey implementation standards, and specifications for the dashboard and multi-lingual RPPS/REDCap project XML file. The VUMC built a custom At-a-Glance Dashboard external module that displays Top Box scores (percent best answer), with conditional formatting to aid analysis, and response/completion rates. Results populate site dashboards, and aggregate to a multi-site dashboard for benchmarking. Results can be filtered by participant/study characteristics. Sites developed individual use cases, leveraging local infrastructure, initiatives and stakeholder input. Infrastructure and guides were designed for dissemination through public websites. RESULTS/ANTICIPATED RESULTS: Five sites sent 23,797surveys via email, patient portal or SMS. 4,133 (19%) participants diverse in age, race, and ethnicity, returned responses. Sites analyzed their data and acted on selected findings, improving recruitment, communication and feeling valued. Aggregate scores for feeling listened to and respected were hight (>90%%); scores for feeling prepared by the consent process were lower (57-77%) and require action. Some groups experiences were better than others. Sites differed significantly in some scores. Dissemination of EPV is underway. Infrastructure and guides are downloadable free of charge, with advice from the EPV team. In 2023, a sixth site began piloting a lower literacy survey version and syncing data to the consortium dashboard. DISCUSSION/SIGNIFICANCE: The EPV RPPS/REDCap infrastructure enabled sites to collect participant feedback, identify actionable findings and benchmark with peers. Stakeholders and collaborators designed and tested local initiatives to increase responses and diversity, address disparities, and discover better practices.

Breast Cancer Diagnosis Among Mexican Participants: A Qualitative Study

Objective: We aimed to describe the timely perceived diagnosis of Breast Cancer (BC) among fifteen participants living in western Mexico, as well as both the time points and intervals for diagnosing BC. Design: A qualitative study with a phenomenological approach was conducted. Site: Instituto Jalisciense de Cancerología (Cancer Institute of Jalisco, IJC per the Spanish acronym), a tertiary care hospital for cancer patients run by the Ministry of Health of the State of Jalisco, Mexico, located in the city of Guadalajara, which is the capital of the state. Participants: fifteen female participants living in the state of Jalisco and whose histopathological diagnosis of BC was made at IJC during the 2013-2017 period. Methods: semi-structured interviews were conducted. The ATLAS.ti program was used for content analysis. Results: twelve participants received a late diagnosis (stages IIB-IV). However, they considered that their diagnoses were timely. Most of the participants stated they perceived a positive timely diagnosis, because they considered that being alive is attributable to a timely diagnosis, which is related to seeking medical care quickly and the work and procedures made by the health professionals. Conclusions: the perception of the female participants regarding the diagnosis timeliness can be quite different from that of the clinical stage made by the doctors. A combination of beliefs, culture, inequities in access and quality of health services, as well as the fear of having BC contributed to increase the time spent when seeking and receiving medical care. Thus, health education for early BC diagnosis is strongly recommended.

Breast Cancer Diagnosis Among Mexican Participants: A Qualitative Study

Objective: We aimed to describe the timely perceived diagnosis of Breast Cancer (BC) among fifteen participants living in western Mexico, as well as both the time points and intervals for diagnosing BC. Design: A qualitative study with a phenomenological approach was conducted. Site: Instituto Jalisciense de Cancerología (Cancer Institute of Jalisco, IJC per the Spanish acronym), a tertiary care hospital for cancer patients run by the Ministry of Health of the State of Jalisco, Mexico, located in the city of Guadalajara, which is the capital of the state. Participants: fifteen female participants living in the state of Jalisco and whose histopathological diagnosis of BC was made at IJC during the 2013-2017 period. Methods: semi-structured interviews were conducted. The ATLAS.ti program was used for content analysis. Results: twelve participants received a late diagnosis (stages IIB-IV). However, they considered that their diagnoses were timely. Most of the participants stated they perceived a positive timely diagnosis, because they considered that being alive is attributable to a timely diagnosis, which is related to seeking medical care quickly and the work and procedures made by the health professionals. Conclusions: the perception of the female participants regarding the diagnosis timeliness can be quite different from that of the clinical stage made by the doctors. A combination of beliefs, culture, inequities in access and quality of health services, as well as the fear of having BC contributed to increase the time spent when seeking and receiving medical care. Thus, health education for early BC diagnosis is strongly recommended.

A qualitative study on perceptions and experiences of overdose among people who smoke drugs in Vancouver, British Columbia

BackgroundSmoking unregulated drugs has increased substantially in British Columbia. Intersecting with the ongoing overdose crisis, drug smoking-related overdose fatalities have correspondingly surged. However, little is known about the experiences of overdose among people who smoke drugs accessing the toxic drug supply. This study explores perceptions and experiences of overdose among people who smoke drugs. MethodsWe conducted interviews with 31 people who smoke drugs. Interviews covered a range of topics including overdose experience. Thematic analysis was used to identify themes related to participant perceptions and experiences of smoking-related overdose. ResultsSome participants perceived smoking drugs to pose lower overdose risk relative to injecting drugs. Participants reported smoking-related overdose experiences, including from underestimating the potency of drugs, the cross-contamination of stimulants with opioids, and responding to smoking-related overdose events. ConclusionsFindings highlight the impact the unpredictable, unregulated, and toxic drug supply is having on people who smoke drugs, both among people who use opioids, and among those who primarily use stimulants. Efforts to address smoking-related overdose could benefit from expanding supervised smoking sites, working with people who use drugs to disseminate accurate knowledge around smoking-related overdose risk, and offering a smokable alternative to the unpredictable drug supply.

Participant perceptions of different forms of deliberative monetary valuation: Comparing democratic monetary valuation and deliberative democratic monetary valuation in the context of regional marine planning

As conceptual and theoretical discussions on environmental valuation approaches have advanced there is growing interest in the impact that valuation has on decision making. The perceived legitimacy of the outputs of valuation studies is seen as one factor influencing their impact on policy decisions. One element of this is ensuring that participants of valuation processes see the results as legitimate and would be willing to accept decisions based on these findings. Here, we test the perceived legitimacy to participants of two approaches to deliberative monetary valuation, deliberated preferences and Deliberative Democratic Monetary Valuation, in the context of marine planning in the Clyde estuary in Scotland. We compare and contrast deliberated preference and deliberative democratic monetary valuation and track their emergence as responses to critiques of conventional stated preference approaches. We then present the results of our case study where we found that deliberative democratic monetary valuation produced valuations that were perceived as more legitimate that deliberated preference as the basis for decision making by those involved in the valuation process.

Feasibility, acceptability, and initial efficacy of a wheelchair exercise training program in persons with multiple sclerosis: study protocol for a parallel group randomized controlled trial

Purpose: This study is a randomized controlled trial (RCT) that examines the feasibility, acceptability, and initial efficacy of a home-based, remotely supported and supervised exercise training program that was developed using a three-step community engaged research process for persons with multiple sclerosis (MS) who are wheelchair users.Materials and Methods: The study design is a parallel group RCT (NCT05888727). We aim to enroll 24 wheelchair users with MS who will be randomly assigned using REDCap randomization module into exercise training or attention/contact wellness control conditions. The conditions will be delivered remotely over 16 weeks and supported using online, one-onone behavioral coaching. The feasibility outcomes of interest include recruitment and retention rates, and safety outcomes collected throughout the study period. The acceptability outcomes include participant satisfaction and perceptions measured using formative surveys and interviews following the 16-week period. Efficacy outcomes include metabolic health, MS symptoms, and exercise behavior measured before and after the 16-week period. The data analysis will follow intent-to-treat principles using 2 group by 2 time mixed factor ANOVA with estimation of Cohen’s d values as effect sizes.Conclusions: The results will guide future research targeting health outcomes using exercise training among wheelchair users with MS who have largely been absent from health promotion research.

Assessing the Awareness and Practices of Physical Therapists in Managing Modifiable Risk Factors for Stroke in Saudi Arabia

Aims & Objective: The current research on physical therapists' understanding of managing modifiable risk factors for stroke in Saudi Arabia is limited. This study aims to evaluate physical therapists' knowledge in Saudi Arabia on managing modifiable stroke risk factors and their prioritization of stroke prevention. It also seeks to understand the connection between therapists' awareness, experience, perceptions, and information access with their readiness to apply stroke prevention measures. Methodology: A cross-sectional online questionnaire survey was administered to registered Physical therapists in the Riyadh region between February and July of 2022. An online questionnaire was developed with 18 questions to evaluate the knowledge and perception of the Physical therapist about the risk factors and management of stroke. Socio-demographic information, participant's knowledge and perception of stroke risk factors, and participant's stroke risk factor sources of information. Results: The results of this survey suggest that while most physical therapists in Saudi Arabia have a good understanding of stroke risk factors, there are still some knowledge gaps that need to be addressed. The fact that a significant percentage of respondents were unsure about the relationship between some risk factors and stroke highlights the need for ongoing education and training for physical therapists in this area. Conclusions: The findings underscore the importance of education, training, work experience, and sources of knowledge in shaping physical therapists' beliefs and practice behaviors.

Parental perceptions of participation in young adult-focused eating disorder treatment.

Eating disorders (ED) are serious mental illnesses affecting young adults (YA). Parent-supported treatment for this age cohort is an important consideration given the unique developmental needs and norms of familial social support, but more research is needed to understand parental perceptions of treatment involvement. 33 parent-supports of YA with ED completed self-report assessments at admission and discharge of participation in brief, intensive, young-adult focused eating disorder treatment. Assessments measured programme satisfaction, parental self-efficacy, and parent and YA report of eating disorder-related psychopathology. Repeated measures ANOVAs were used toexamine pre-post outcome differences and between group differences among parent-supports and their YA (i.e., the patients) on eating disorder psychopathology, clinical impairment, and family functioning using the EDEQ/P-EDEQ Global, P-CIA/CIA, and Family Assessment Device Family Functioning scales. Group differences across time points were examined with paired sample t-tests adjusted for multiple comparisons. Changes in parental self-efficacy were examined separately using two-tailed paired sample t-tests. Parents reported high acceptability and learning, improvements in self-efficacy, and significant reductions of YA psychopathology at post-treatment. Parents reported comparable reductions in ED psychopathology post-treatment, but significantly greater reductions in clinical impairment compared to YA. Measures of family functioning did not improve for either parent or YA at post-treatment. Results from this study suggest that parental involvement in a YA programme is feasible and acceptable from a parental perspective and improves parental self-efficacy.

Patient perceptions of behavioral flags in the emergency department: A qualitative analysis.

To combat increasing levels of violence in the emergency department (ED), hospitals have implemented several safety measures, including behavioral flags. These electronic health record (EHR)-based notifications alert future clinicians of past incidents of potentially threatening patient behavior, but observed racial disparities in their placement may unintentionally introduce bias in patient care. Little is known about how patients perceive these flags and the disparities that have been found in their placement. This study aims to investigate patient perceptions and perceived benefits and harms associated with the use of behavioral flags. Twenty-five semistructured qualitative interviews were conducted with a convenience sample of patients in the ED of a large, urban, academic medical center who did not have a behavioral flag in their EHR. Interviews lasted 10-20 min and were recorded then transcribed. Thematic analysis of deidentified transcripts took place in NVivo 20 software (QSR International) using a general inductive approach. Participant perceptions of behavioral flags varied, with both positive and negative opinions being shared. Five key themes, each with subthemes, were identified: (1) benefits of behavioral flags, (2) concerns and potential harms of flags, (3) transparency with patients, (4) equity, and (5) ideas for improvement. Patient perspectives on the use of behavioral flags in the ED vary. While many saw flags as a helpful tool to mitigate violence, concerns around negative impacts on care, transparency, and equity were also shared. Insights from this stakeholder perspective may allow for health systems to make flags more effective without compromising equity or patient ideals.