Physical Environment Research Articles

Marine Operations in the Norwegian Sea and the Ice-Free Part of the Barents Sea with Emphasis on Polar Low Pressures

The Arctic Seas are attractive for shipping, fisheries, and other marine activities due to the abundant resources of the Arctic. The shrinking ice cover allows for the opening of activities in increasingly larger areas of the Arctic. This paper evaluates the possibility of executing all-year complex marine activities, here termed “marine operations”, in the Norwegian Sea and the ice-free part of the Barents Sea. The approach used during the preparation of this review paper is to identify constraints to marine operations so users can be aware of the limitations of performing such operations. The weather conditions in the Norwegian Sea and the Barents Sea are well known, and these seas are considered representative of ice-free or partly ice-free Arctic Seas with considerable marine activities. Similar conditions could be expected for other Arctic Seas during periods without ice cover. Marine operations require safe and stable working conditions for several days. The characteristics of marine operations are discussed, and the particulars of the Norwegian Sea and the Barents Sea physical environments are highlighted. Emphasis is on the wind and wave conditions in unpredictable polar low-pressure situations. Furthermore, situations with fog are discussed. The large uncertainties in forecasting the initiation and the tracks of polar lows represent the main concern for executing marine operations all year. Improvements in forecasting the occurrence and the path of polar lows would extend the weather window when marine operations could be carried out. Discussions of the potential for similar conditions in the wider Arctic Seas during ice-free periods are presented.

Estimating ambient population density using physical features from GIS and machine learning: a study based on Japanese neighborhood

ABSTRACT This research aimed to develop an alternative method for estimating ambient population density at the neighborhood scale by utilizing a simple and universally available dataset. Physical environment data from GIS & OSM databases, basic statistics, and population density data from Mobile Spatial Statistics were combined to train tree-based Machine Learning models. The experiment resulted in an XGBoost model using 16 features capable of estimating ambient population density across three classes of outcome with 75.9% accuracy. The trained models were analyzed and visualized using SHAP and Partial Dependence Plot techniques to reveal feature importance and their threshold values. The study concludes that physical features can be effectively used as predictors of ambient population density and highlights areas for further investigation.

Environmental public health research at the U.S. Environmental Protection Agency: A blueprint for exposure science in a connected world.

Exposure science plays an essential role in the U.S. Environmental Protection Agency's (U.S. EPA) mission to protect human health and the environment. The U.S. EPA's Center for Public Health and Environmental Assessment (CPHEA) within the Office of Research and Development (ORD) provides the exposure science needed to characterize the multifaceted relationships between people and their surroundings in support of national, regional, local and individual-level actions. Furthermore, exposure science research must position its enterprise to tackle the most pressing public health challenges in an ever-changing environment. These challenges include understanding and confronting complex human disease etiologies, disparities in the social environment, and system-level changes in the physical environment. Solutions will sustainably balance and optimize the health of people, animals, and ecosystems. Our objectives for this paper are to review the role of CPHEA exposure science research in various recent decision-making contexts, to present current challenges facing U.S. EPA and the larger exposure science field, and to provide illustrative case examples where CPHEA exposure science is demonstrating the latest methodologies at the intersection of these two motivations. This blueprint provides a foundation for applying exposomic tools and approaches to holistically understand real-world exposures so optimal environmental public health protective actions can be realized within the broader context of a One Health framework. IMPACT STATEMENT: The U.S. EPA's Center for Public Health and Environmental Assessment exposure research priorities reside at the intersection of environmental decision contexts and broad public health challenges. The blueprint provides a foundation for advancing the tools and approaches to holistically understand real-world exposures so optimal environmental protection actions can be realized. A One Health lens can help shape exposure research for maximum impact to support solutions that are transdisciplinary and must engage multiple sectors.

What is effective physiotherapy for dementia and how do we get there: a qualitative study.

Dementia is a leading cause of disability. Physiotherapists play a crucial role in caring for people with dementia. However, previous research has found that physiotherapists have low knowledge and confidence working with people with dementia. To determine: 1) What are the components of effective physiotherapy care for people with dementia; and 2) What can be done to facilitate the provision of effective physiotherapy care. This was a qualitative study using an interpretive description approach. Sixteen physiotherapists experienced in dementia care participated in semi-structured interviews. Researchers analyzed data using thematic analysis. Two themes were created for each research objective. The themes explaining the components of effective physiotherapy care were: 1) engaging the person with dementia (subthemes: knowing the person with dementia; using knowledge to adapt the approach to successfully deliver physiotherapy treatments; optimizing the physical environment) and 2) collaborative care (subthemes: working with care partners; working as an interdisciplinary team). The themes describing how to facilitate provision of effective care were: 1) Physiotherapists require "greater opportunity for mentoring and education on dementia care" and 2) Physiotherapists must "advocate for the role of physiotherapy in dementia care." These findings provide important information regarding the components of effective dementia care for physiotherapists and will help guide clinical practice, inform future dementia education, research, and professional organization advocacy initiatives.

Social learning is triggered by environmental cues in immigrant birds.

After dispersal, what cues trigger social learning in immigrants? A new study in wild-caught great tits in PLOS Biology suggests that changes in the physical environment, rather than the social environment, are key in prompting social learning by immigrants.

Associations of Neighborhood Food and Physical Activity Environments in Young Adulthood With Cardiovascular Health in Midlife: The CARDIA Study.

Adults who maintain ideal cardiovascular health (CVH) profiles up to midlife have lower risk of several chronic diseases and better quality of life. Some evidence suggests that individual-level exposures earlier in life shape midlife CVH, but the impact of neighborhood-level exposures over the life course remains understudied. Participants were 3017 Black and White men and women aged 18 to 30 years at baseline (1985-1986), recruited from Birmingham, Alabama; Minneapolis, Minnesota; Chicago, Illinois; and Oakland, California, as part of the CARDIA (Coronary Artery Risk Development in Young Adults) study. Measures of the neighborhood food and physical activity environment were linked to participant addresses collected at baseline. CVH was measured on the basis of the American Heart Association's Life's Simple 7 criteria in young adulthood and 30 years later (2015-2016) when participants were midlife (aged 48-60 years). Associations of young adult neighborhood food environment and physical activity resources with midlife CVH (moderate versus high and low versus high) were examined using multinomial logistic regression. Models were adjusted for young adult sociodemographic factors. Participants who lived farther away from a major park in young adulthood were more likely to have low versus high CVH scores (odds ratio, 1.54 [95% CI, 1.22-1.96]) and more likely to have moderate versus high CVH scores (odds ratio, 1.39 [95% CI, 1.12-1.73]) in midlife. No other neighborhood measures were significantly associated with CVH. Young adulthood may be a sensitive period in which having convenient access to physical activity-promoting resources may help them establish healthy habits that can carry into midlife.

An Agent-Based Model of Human–Whale Interactions in the North Atlantic

We created an agent-based model (ABM; a computational model) for human–whale interactions in the North Atlantic area. We specifically looked at boats, lobster lines, and rogue fishnet interactions with the North Atlantic right whales (Eubalaena glacialis), and we assessed the conditions under which such interactions are more likely to result in injuries and fatalities for this critically endangered whale, such as the density of ships in the water. ABMs are a methodology particularly useful in data poor problems (where machine learning cannot be used), and are based on rules of interactions between various agents (human and nonhuman) and/or a specific physical environment; they can showcase and assess potential future scenarios. We informed our model with current data from the North Atlantic Right Whale Consortium and the National Oceanic and Atmospheric Administration and present our preliminary findings here.

Exploring the Role of the Built Environment on the Functional Ability and Social Participation in Community-dwelling Older Adults

Background and Objectives. The built environment or physical environment consists of surroundings and conditions constructed by human activity. It includes urban design, neighborhoods, transportation, and smaller scale structures like the design and layout of rooms within buildings. The built environment can affect the physical, social, and functional wellbeing of older adults, both within their own homes and in the neighborhoods in which they live, and additionally plays a part in promoting healthy aging. This narrative review of the literature aims to present the ways in which the built environment can influence the functional ability of community-dwelling older adults, and affect their ability to live independently and age in place. Methods. Narrative literature review and inductive thematic analysis. Results. Forty-five full-text, English language publications from peer-reviewed sources were selected for this review, with the majority (35) presenting quantitative research findings and originating from North America (28). Older adults in rural and developing countries were underrepresented in the literature, despite acknowledgement that health of the aging population is a worldwide problem. Three major themes emerged. First, the built environment affects older adults in the most fundamental way at home through design considerations, modifications, and technological advances promoting aging in place and accessibility. Secondly, built environments outside the home can affect older adults’ physical activity and overall function with regard to mobility, transportation, and activities of daily living. The majority (22 of 45 publications) focused on this theme. Finally, the built environment in neighborhoods can affect older adults’ perception of social support, their social participation, and quality of life. Conclusion. As the built environment is created by humans and can be substantially modified, it possesses considerable potential for enhancing functional ability, social participation, and overall quality of life in community-dwelling older adults. It is possible to design a better person-environment fit, promoting safety, independence, optimal health, and quality of life. In order to support healthy aging, improvements in the built environment need to be accompanied by appropriate health and social policies, systems, and services. These changes require political will, as well as material resources that may not be readily available especially in the global South. A socioecological approach with adequate resources directed to older adults’ health and healthcare is necessary in order to achieve the ultimate goal of healthy aging in this population.

Aligning the new work environment with OECD Goal 8: a design case of a global automobile brand from Turkey

Purpose This paper aims to investigate the economic sustainability of new work environments by exploring how interior design strategies can contribute to the Organization for Economic Co-operation and Development (OECD)’s Sustainable Development Goal (SDG) 8, which focuses on decent work and economic growth. SDG 8 aims to foster sustained, inclusive and sustainable economic development, as well as full and productive employment. Design/methodology/approach The pilot study was conducted at a global automobile brand’s largest facility in Kocaeli/Turkey, where 102 employees participated in stakeholder meetings divided into 18 groups. Additionally, 46 employees were interviewed through focus groups and one-on-one sessions across nine encounters. The collected data were analyzed using deductive thematic analysis, interpreting codes and themes related to spatial politics, timing politics and hybrid working culture in the new work environment. Findings Identified themes include individually focused tasks, virtual collaboration, agile working, socialization and urban interaction. These themes are then traced through the conceptual design proposal developed by the interior design team and discussed in relation to their alignment with SDG 8.2 (diversify, innovate and upgrade for economic productivity), SDG 8.4 (improve resource efficiency in consumption and production) and SDG 8.8 (protect labor rights and promote safe and secure working environments for all workers). Research limitations/implications These three targets (for inclusivity and innovation, for environmentally sustainable and for employee well-being) were selected for their relevance in shaping the physical work environment. Originality/value The key finding of this paper is the need for a deeper understanding of economic sustainability in interior design and the contribution of SDG 8 targets on the spatial, temporal and cultural dimensions of new work environments. Brands committed to sustainability must adopt new work models and reimagine their work environments to enhance employee satisfaction and performance, through comprehensive user research and design solutions aligned with SDG 8.

Factors that promote student well-being in schools: a scoping review of Australian and Aotearoa New Zealand literature

AbstractWell-being has been touted for many years as a critical factor in achieving positive outcomes for students in schools across Australia, Aotearoa New Zealand, and globally. Despite extensive reporting of student well-being concerns, further research is needed to fully understand this complex construct. This paper presents a scoping review aimed at developing a comprehensive understanding of student well-being by examining key factors highlighted in the literature. Using the PRISMA-ScR approach, a search was conducted using Google Scholar to identify studies published between 2010 and 2023 that focus on student well-being in Australian and Aotearoa New Zealand school contexts. Additional relevant grey literature, including policy documents, contributed to this review. A total of 46 studies met the eligibility criteria for more detailed analysis. The review identified three primary themes influencing student well-being: the role of student voice, the impact of the physical environment (which we call perivallon), and the nature of student relationships with teachers, peers, and themselves. These factors were found to be interrelated, with relationships serving as both an independent influence and a mediating factor affecting the other dimensions. The literature review leads to a multi-dimensional complexity model of well-being. This model suggests potential mechanisms by which a small change to an external factor can have far reaching, and potentially unexpected, impacts on student well-being. The implications and limitations of such a model are discussed, and avenues for future research are suggested.

Visibility, Physical Work Environment, and Stress in ICU Nurses

OBJECTIVE Relationships among coworker and patient visibility, reactions to physical work environment, and work stress in ICU nurses are explored. BACKGROUND Millions of dollars are invested annually in the building or remodeling of ICUs, yet there is a gap in understanding relationships between the physical layout of nursing units and work stress. METHODS Using a cross-sectional, correlational, exploratory, predictive design, relationships among variables were studied in a diverse sample of ICU nurses. RESULTS Visibility had a direct effect on work stress (P < 0.01). The ViPES (Visibility, Physical Environment and Stress) model can help explain relationships among study variables. The findings from this study support the notion that high visibility is a job resource and low visibility is a job demand. CONCLUSIONS Design features supporting a sense of connection may be especially important to less experienced ICU nurses. Elements of the built environment that allow nurses to see not only patients, but also their coworkers, may help mitigate work stress.

Embodied learning of science concepts through augmented reality technology

AbstractAugmented Reality (AR) revolutionizes educational approaches by providing an immersive experience that superimposes virtual 3D elements onto the physical environment. This integration of virtual and real worlds addresses the challenge of understanding abstract concepts by enabling three-dimensional visualization and interaction. This study aims to assess the role of embodied cognition in science learning through AR technology, analyze its impact on collaborative, inquiry-based learning in primary science, and understand students' perceptions of its influence on their engagement and comprehension in collaborative science tasks. Data collection methods for this study included three focus group interviews and five video observations involving ten grade 5 students, totaling 23 participants, in a primary science classroom. The analysis utilized content, thematic, and multimodal frameworks to evaluate student interactions. The findings indicated that the use of AR significantly enhanced the students' learning experiences. Students' comprehension of complex scientific concepts improved through active engagement with 3D models using the AR application. The AR app's 3D virtual shapes encouraged students to move around more during lessons, likely because these shapes were engaging and offered various perspectives. The use of embodied learning was enhanced with the support of AR technology, as students were constantly in motion around the table, using their fingers to manipulate objects and explore 3D forms from different angles.

Gender differences in the effects of urban environment on nighttime exercise behaviours: a qualitative study

ObjectiveWith the acceleration of urbanization, nighttime exercise behaviours have rapidly emerged. Existing research indicates a correlation between urban environments and physical activity; however, studies focusing specifically on nighttime are still insufficient, particularly regarding gender differences. This study aims to identify the key factors in urban environments that influence residents’ nighttime exercise behaviours and to explore the gender differences within these influences.MethodsPurposeful sampling was employed to conduct semi-structured interviews with 30 residents who regularly engage in nighttime exercise. All transcribed interviews were analyzed using Colaizzi’s phenomenological data analysis method.ResultsThe findings revealed that physical environment and environmental perception are the two primary factors influencing nighttime exercise behaviour. These factors are further divided into 10 specific sub-themes: lighting, green spaces, site facilities and layout, traffic coherence, entertainment facilities, smart sports equipment, sense of safety, convenience, pleasure, and sense of belonging.ConclusionFemales demonstrate a heightened sensitivity to the perception of the physical environment, placing greater emphasis on the feelings and experiences it provides. Males, on the other hand, focus more on the direct impact of the physical environment, such as its specific effects on exercise performance. Future urban planning and public policy should give greater consideration to gender differences in the use of urban exercise facilities, ensuring that nighttime exercise environments meet the needs of residents of different genders. This approach will contribute to enhancing overall community vitality and improving residents’ health.

High Rates of Obesity and Chronic Diseases Among North Carolina United Methodist Clergy: An Updated Analysis

Background Varied demands and stressors experienced by clergy can contribute adversely to their overall well-being. Data from United Methodist Church (UMC) clergy in North Carolina in 2008 revealed that clergy had significantly higher non-communicable disease (NCD) rates than their fellow North Carolinians. Methods Using data from the Clergy Health Initiative and Behavioral Risk Factor Surveillance Survey, the present study provided an updated analysis of obesity and 6 other NCDs among North Carolina UMC clergy compared to the general North Carolina population. First, we described the prevalence of each health condition among North Carolina UMC clergy and the general North Carolina population across multiple waves from 2008 to 2021. Then, we compared the predicted probabilities of each health condition in 2021 using logistic regressions to adjust for age, sex, and race. Results Comparing the unadjusted prevalence of health conditions between 2008 and 2021, we found that North Carolina UMC clergy have higher rates of obesity, hypertension, hypercholesterolemia, diabetes, angina, arthritis, and asthma than North Carolinians overall. Adjusting for age, sex, and race, we found that significantly higher rates of obesity, severe obesity, hypercholesterolemia, and asthma persisted among UMC clergy in 2021 compared to all North Carolinians, with the higher rates of severe obesity being particularly concerning. Limitations While the current study is limited to an update of health prevalence among UMC clergy, pastors across denominations are influential leaders in their communities, shaping the physical and social health environments of their congregations. Conclusions Further research is needed to investigate risk factors, such as relocation and adverse childhood experiences, which may influence the higher prevalence of NCDs within and potentially beyond the UMC.

A Taxonomy of Embodiment in the AI Era

This paper presents a taxonomy of agents’ embodiment in physical and virtual environments. It categorizes embodiment based on five entities: the agent being embodied, the possible mediator of the embodiment, the environment in which sensing and acting take place, the degree of body, and the intertwining of body, mind, and environment. The taxonomy is applied to a wide range of embodiment of humans, artifacts, and programs, including recent technological and scientific innovations related to virtual reality, augmented reality, telepresence, the metaverse, digital twins, and large language models. The presented taxonomy is a powerful tool to analyze, clarify, and compare complex cases of embodiment. For example, it makes the choice between a dualistic and non-dualistic perspective of an agent’s embodiment explicit and clear. The taxonomy also aided us to formulate the term “embodiment by proxy” to denote how seemingly non-embodied agents may affect the world by using humans as “extended arms”. We also introduce the concept “off-line embodiment” to describe large language models’ ability to create an illusion of human perception.

Adaptive Forecasting of Nuclear Power Plant Operational Status Under Sensor Concept Drift Using a Bridging Distribution Adaptive Network

A large number of sensors are required to collect information during the operation of nuclear power plants to ensure their absolutely safe operation. However, because of the unique nature of nuclear reactions, the physical environment of nuclear power production is prone to changes, leading to concept drift in the data collected by the sensors. Concept drift describes the phenomenon of sample distribution changing over time, which typically negatively impacts the model’s training and inference processes. We found that nongradual distribution changes could be guided by generating transitional intermediary distributions within the distribution, thereby achieving a gradual change process. Based on this, we designed a bridging distribution adaptive network (BDAN), which consisted of identical-depth TDoA (time difference of arrival) homomorphic backbone neural networks on both sides with a latent adaptive bridging module in the middle. By calculating the distribution differences over multiple timesteps, a series of bridge distributions were generated to guide the gradients in the latent space, updating the parameters of the latent adaptive guiding module in a directional manner and enabling the model to perceive nongradual distribution changes in the time domain. Experimental results showed that the BDAN outperformed the previous state-of-the-art benchmark methods by 5.6% in terms of mean squared error in the nuclear power data prediction task under concept drift, achieving the best fault prediction performance.

Advancing Indoor Epidemiological Surveillance: Integrating Real-Time Object Detection and Spatial Analysis for Precise Contact Rate Analysis and Enhanced Public Health Strategies

In response to escalating concerns about the indoor transmission of respiratory diseases, this study introduces a sophisticated software tool engineered to accurately determine contact rates among individuals in enclosed spaces—essential for public health surveillance and disease transmission mitigation. The tool applies YOLOv8, a cutting-edge deep learning model that enables precise individual detection and real-time tracking from video streams. An innovative feature of this system is its dynamic circular buffer zones, coupled with an advanced 2D projective transformation to accurately overlay video data coordinates onto a digital layout of the physical environment. By analyzing the overlap of these buffer zones and incorporating detailed heatmap visualizations, the software provides an in-depth quantification of contact instances and spatial contact patterns, marking an advancement over traditional contact tracing and contact counting methods. These enhancements not only improve the accuracy and speed of data analysis but also furnish public health officials with a comprehensive framework to develop more effective non-pharmaceutical infection control strategies. This research signifies a crucial evolution in epidemiological tools, transitioning from manual, simulation, and survey-based tracking methods to automated, real time, and precision-driven technologies that integrate advanced visual analytics to better understand and manage disease transmission in indoor settings.

A Survey of Sulfur-bearing Molecular Lines toward the Dense Cores in 11 Massive Protoclusters

Sulfur-bearing molecules are commonly detected in dense cores within star-forming regions, but the total sulfur budget is significantly lower when compared to the interstellar medium value. The properties of sulfur-bearing molecules are not well understood due to the absence of large sample studies with uniform observational configurations. To deepen our understanding of this subject, we conducted a study using Atacama Large Millimeter/submillimeter Array 870 μm observations of 11 massive protoclusters. By checking the spectra of 248 dense cores in 11 massive protoclusters, a total of 10 sulfur-bearing species (CS, SO, H2CS, NS, SO2, 33SO, 34SO2, 33SO2, SO18O, and OC34S) were identified. The parameters including systemic velocities, line widths, gas temperatures, column densities, and abundances were derived. Our results indicate that SO appears to be more easily detected in a wider range of physical environments than H2CS, despite these two species showing similarities in gas distributions and abundances. Molecules 34SO2 and H2CS are good tracers of the temperature of sulfur-bearing species, in which H2CS traces the outer warm envelope and 34SO2 is associated with high-temperature central regions. High-mass star-forming feedback (outflow and other nonthermal motions) significantly elevates the sulfur-bearing molecular abundances and detection rates specifically for SO2 and SO. A positive correlation between the SO2 abundance increasing factor (F) and temperatures suggests that SO2 could serve as a sulfur reservoir on the grain mantles of dense cores and then can be desorbed from dust to gas phase as the temperature rises. This work shows the importance of a large and unbiased survey to understand the sulfur depletion in dense cores.

Shaping Patient Loyalty through Quality Care: Analyzing Patient Satisfaction in Public Hospitals in Ghana

Public hospitals in Ghana face challenges such as limited resources and inconsistent care delivery, which impact patient satisfaction and loyalty. In this context, enhancing service quality is crucial for retaining patients and improving healthcare outcomes. This study investigates the role of service quality in shaping patient loyalty and explores patient satisfaction as a mediator in selected public hospitals in Ghana using the SERVQUAL model. A survey was conducted among 200 outpatients from five public health facilities in Kumasi, Ghana, between January and February 25, 2024. A quantitative methodology was applied to evaluate how patients' perceptions of service quality influence their loyalty toward public healthcare providers. In order to analyze the data, SPSS and the smart partial least square (PLS) software version 3.0 were used for structural equation modeling (SEM). The findings revealed that communication, the physical environment, and responsiveness significantly affect patient loyalty, whereas factors such as privacy, safety, and a customer-friendly atmosphere do not. Additionally, this study confirmed that patient satisfaction mediates the relationship between service quality and patient loyalty, underscoring the importance of service quality in enhancing both satisfaction and loyalty in health care. Based on these insights, this study recommends that health care institutions improve their service quality to strengthen public healthcare systems. The significance of this paper extends beyond regression analysis, as it also addresses the delayed effects of service quality on patient loyalty, considering both direct and indirect influences in the regression models.

Medication adherence and quality of life among geriatric patients: Insights from a hospital-based cross-sectional study in India.

Understanding the factors that influence medication adherence and the multidimensional aspects of quality of life in the elderly is of paramount importance in enhancing their overall well-being. Since geriatric patients usually suffer from multiple morbidities due to their declining age, the adherence towards their medications plays a very crucial role in their quality of life. This cross-sectional study explores the intricate relationship between medication adherence and quality of life among 310 elderly patients at a single medical college and hospital. Participants completed the Morisky Medication Adherence Scale (MMAS-8) to assess medication adherence and the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire, which comprises four domains (physical health, psychological health, social relationships, and environment) to evaluate quality of life. Statistical analyses, including correlations, paired t-tests, ANOVA, and Backward Multiple Linear Regression, were employed to examine the relationships and differences among variables. The findings indicate varying levels of medication adherence among participants, with a significant proportion exhibiting medium adherence (47.1%) and highlighting the need for interventions to address challenges in medication adherence among the elderly population. Notably, gender emerged as a significant factor influencing quality of life, with males reporting higher satisfaction across all domains compared to females. Medication adherence exhibited a significant correlation with the social relationships domain (DOM3) of the WHOQOL-BREF, underlining the importance of adherence in fostering positive social interactions. Our study revealed a significant association between medication adherence (MMAS- 8) and the quality of life (WHOQOL-BREF) among elderly patients. We also observed noteworthy gender differences in quality-of-life perceptions. It emphasizes the need for tailored interventions that consider medication adherence issues to enhance the overall quality of life among this vulnerable population.