Behavioral and Social Sciences at the National Institutes of Health: adoption of research findings in health research and practice as a scientific priority

Feasibility of Systems Support Mapping to guide patient-driven health self-management in colorectal cancer survivors

OBJECTIVE

To evaluate feasibility of System Support Mapping (MAP), a systems thinking activity that involves creating a diagram of existing self-management activities (e.g. symptom management, health behaviors) to facilitate autonomous engagement in optimal self-management.

DESIGN

One-arm pilot study of MAP in colorectal cancer survivors (NCT03520283).

MAIN OUTCOME MEASURES

Feasibility of recruitment and retention (primary outcome), acceptability, and outcome variability over time.

RESULTS

We enrolled 24 of 66 cancer survivors approached (36%) and 20 completed follow-up (83%). Key reasons for declining participation included: not interested (n = 18), did not perceive a need (n = 9), and emotional distress/overwhelmed (n = 7). Most participants reported that MAP was acceptable (e.g. 80% liked MAP quite a bit/very much). Exploratory analyses revealed a -4.68 point reduction in fatigue from before to 2 weeks after MAP exceeding a minimally important difference (d = -0.68). There were also improvements in patient autonomy (d = 0.63), self-efficacy (for managing symptoms: d = 0.56, for managing chronic disease: d = 0.44), psychological stress (d = -0.45), anxiety (d = -0.34), sleep disturbance (d = -0.29) and pain (d = -0.32). Qualitative feedback enhanced interpretation of results.

CONCLUSIONS

MAP feasibility in colorectal cancer survivors was mixed, predominantly because many patients did not perceive a need for this approach. MAP was acceptable among participants and showed promise for improving health outcomes.

Making Sense of Theories, Models, and Frameworks in Digital Health Behavior Change Design: Qualitative Descriptive Study

BACKGROUND

Digital health interventions are increasingly being designed to support health behaviors. Although digital health interventions informed by behavioral science theories, models, and frameworks (TMFs) are more likely to be effective than those designed without them, design teams often struggle to use these evidence-informed tools. Until now, little work has been done to clarify the ways in which behavioral science TMFs can add value to digital health design.

OBJECTIVE

The aim of this study was to better understand how digital health design leaders select and use TMFs in design practice. The questions that were addressed included how do design leaders perceive the value of TMFs in digital health design, what considerations do design leaders make when selecting and applying TMFs, and what do design leaders think is needed in the future to advance the utility of TMFs in digital health design?

METHODS

This study used a qualitative description design to understand the experiences and perspectives of digital health design leaders. The participants were identified through purposive and snowball sampling. Semistructured interviews were conducted via Zoom software. Interviews were audio-recorded and transcribed using Otter.ai software. Furthermore, 3 researchers coded a sample of interview transcripts and confirmed the coding strategy. One researcher completed the qualitative analysis using a codebook thematic analysis approach.

RESULTS

Design leaders had mixed opinions on the value of behavioral science TMFs in digital health design. Leaders suggested that TMFs added the most value when viewed as a starting point rather than the final destination for evidence-informed design. Specifically, these tools added value when they acted as a gateway drug to behavioral science, supported health behavior conceptualization, were balanced with expert knowledge and user-centered design principles, were complementary to existing design methods, and supported both individual- and systems-level thinking. Design leaders also felt that there was a considerable nuance in selecting the most value-adding TMFs. Considerations should be made regarding their source, appropriateness, complexity, accessibility, adaptability, evidence base, purpose, influence, audience, fit with team expertise, fit with team culture, and fit with external pressures. Design leaders suggested multiple opportunities to advance the use of TMFs. These included improving TMF reporting, design, and accessibility, as well as improving design teams' capacity to use TMFs appropriately in practice.

CONCLUSIONS

When designing a digital health behavior change intervention, using TMFs can help design teams to systematically integrate behavioral insights. The future of digital health behavior change design demands an easier way for designers to integrate evidence-based TMFs into practice.

Effects of Desk Pedaling Work Rate on Concurrent Work Performance among Physically Inactive Adults: A Randomized Experiment

PURPOSE

Under-desk pedaling devices could help reduce health risks associated with the global decline in work-related energy expenditure. However, the optimal pedaling work rate to facilitate concurrent work performance among physically inactive adults is unclear. We examined the effects of two light-intensity pedaling work rates on physically inactive adults' work performance.

METHODS

We recruited equal numbers of older (45-65 yr) versus younger (20-44 yr), male versus female, and overweight/obese (body mass index [BMI], 25-35 kg·m -2 ) versus normal weight (BMI, 18.5-24.9 kg·m -2 ) participants. Using a Graeco-Latin square design, participants ( n = 96) completed a laboratory experiment to evaluate the effects of using an under-desk pedaling device at two seated light-intensity work rates (17 and 25 W), relative to a seated nonpedaling condition on objectively measured typing, reading, logical reasoning, and phone task performance. Ergonomic comfort under each pedaling work rate was also assessed. Equivalence tests were used to compare work performance under the pedaling versus nonpedaling conditions.

RESULTS

Treatment fidelity to the 17- and 25-W pedaling work rates exceeded 95%. Mean work performance scores for each pedaling and nonpedaling condition were equivalent under alpha = 0.025. Age, sex, and BMI did not significantly moderate the effect of pedaling on work performance. Participants reported greater ergonomic comfort while completing work tasks at the 17-W relative to the 25-W work rate.

CONCLUSIONS

Physically inactive adults obtained similar work performance scores under the 17- and 25-W pedaling and the nonpedaling conditions, suggesting that either pedaling work rate could help reduce health risks of sedentary work time. The 17-W work rate yielded greater ergonomic comfort and may be an appropriate starting point for introducing diverse inactive workers to under-desk pedaling.

Psychosocial Influences on Coping and Wellbeing during the Covid-19 Lockdown in the Early Days of the Pandemic: A Mixed Methods Research

This study focuses on the psychosocial impacts of COVID-19 restrictions on wellbeing and uses a mixed methods design to develop a more profound understanding about adaptive coping during stressful situations. The quantitative phase of this study examined the association between psychological capital, perceived stress, coping and wellbeing. The online survey was conducted in May 2020 and had 257 participants. The Structural Equation Modelling (SEM) results showed that the hypothesized model had an adequate fit [χ2(306, N = 257) = 547.185, p = 0.00]; and that both psychological capital and perceived stress were significant predictors of wellbeing. Significantly, young people reported a more negative impact on their wellbeing during the lockdowns. In the subsequent qualitative phase, in-depth interviews with 21 voluntary participants (14 females and 7 males) suggested that individuals could reappraise stressful situations and use coping strategies for psychosocial adaptation. From this research, it was identified that especially the younger age group is at risk, and that that psychosocial resources, such as psychological capital, could be developed to enhance coping and wellbeing with the ongoing impacts of the pandemic.

The use of theory in process evaluations conducted alongside randomized trials of implementation interventions: A systematic review

Interventions to implement changes into health care practice (i.e., implementation interventions) are critical to improving care but their effects are poorly understood. Two strategies to better understand intervention effects are conducting process evaluations and using theoretical approaches (i.e., theories, models, frameworks). The extent to which theoretical approaches have been used in process evaluations conducted alongside trials of implementation interventions is unclear. In this study context, we reviewed (a) the proportion of process evaluations citing theoretical approaches, (b) which theoretical approaches were cited, and (c) whether and how theories were used. Systematic review (PROSPERO: CRD42016042789). MEDLINE, PsycINFO, Embase, CINAHL, and Cochrane CENTRAL were searched up to July 31, 2017. For all studies, data extraction included names and types of theoretical approaches cited. For studies citing a theory, data extraction included study characteristics and extent of theory use (i.e., "informed by," "applied," "tested," "built/created" theory). We identified 123 process evaluations. Key findings: (a) 77 (63%) process evaluations cited a theoretical approach; (b) the most cited theory was normalization process theory; (c) 32 (26%) process evaluations used theory: 7 (22%) were informed by, 18 (56%) applied, 7 (22%) tested, and none built/created theory. Although nearly two thirds of process evaluations cited a theoretical approach, only a quarter were informed by, applied, or tested a theory-despite the potential complementarity of these strategies. When theory was used, it was primarily applied. Using theory more substantively in process evaluations may accelerate our understanding of how implementation interventions operate.

Pathways of influences leading to adoption of the Faith, Activity and Nutrition (FAN) program in a statewide initiative

RE-AIM (Reach, effectiveness, Adoption, Implementation, Maintenance) and CFIR (Consolidated Framework for Implementation Research) are complementary frameworks guiding research on dissemination and implementation of evidence-based interventions and factors influencing this process. Faith, Activity, and Nutrition (FAN) is an evidence-based program that increased physical activity and fruit and vegetable intake in faith-based settings. The aims of this adoption study were to quantify state-wide church level adoption rates and congregant reach of FAN in accordance with RE-AIM guidelines, and to explore the association of CFIR-derived constructs of the church inner setting and pastor characteristics with FAN adoption. Church recruitment was documented, and data were collected via telephone-administered surveys from 93 pastors in adopting churches and 60 pastors in non-adopting churches. Qualitative Comparative Analysis (QCA) identified combinations of CFIR-derived church and pastor characteristics sufficient for FAN adoption. As defined by RE-AIM, church-level FAN adoption was 11.7 % and congregant-level reach was 20.0 %. Fourteen pathways to adoption were identified; seven of these featured the presence of a culture of concern for congregant health along with openness to new ideas. Results suggest early assessment of these two CFIR-derived inner setting constructs may help identify faith-based organizations predisposed to undertake a comprehensive, environmental intervention to promote congregant health.

Behavioral Research in Cancer Prevention and Control: Emerging Challenges and Opportunities

It is estimated that behaviors such as poor diet, alcohol consumption, tobacco use, sedentary behavior, and excessive ultraviolet exposure account for nearly one-half of all cancer morbidity and mortality. Accordingly, the behavioral, social, and communication sciences have been important contributors to cancer prevention and control research, with methodological advances and implementation science helping to produce optimally effective interventions. To sustain these contributions, it is vital to adapt to the contemporary context. Efforts must consider ancillary effects of the 2019 coronavirus disease pandemic, profound changes in the information environment and public understanding of and trust in science, renewed attention to structural racism and social determinants of health, and the rapidly increasing population of cancer survivors. Within this context, it is essential to accelerate reductions in tobacco use across all population subgroups; consider new models of energy balance (diet, physical activity, sedentary behavior); increase awareness of alcohol as a risk factor for cancer; and identify better communication practices in the context of cancer-related decisions such as screening and genetic testing. Successful integration of behavioral research and cancer prevention depends on working globally and seamlessly across disciplines, taking a multilevel approach where possible. Methodological and analytic approaches should be emphasized in research training programs and should use new and underused data sources and technologies. As the leadership core of the National Cancer Institute’s Behavioral Research Program, we reflect on these challenges and opportunities and consider implications for the next phase of behavioral research in cancer prevention and control.

A comparative assessment of two tools designed to support patient safety culture in UK general practice

BACKGROUND

The NHS has recognised the importance of a high quality patient safety culture in the delivery of primary health care in the rapidly evolving environment of general practice. Two tools, PC-SafeQuest and MapSaf, were developed with the intention of assessing and improving patient safety culture in this setting. Both have been made widely available through their inclusion in the Royal College of General Practitioners' Patient Safety Toolkit and our work offerss a timely exploration of the tools to inform practice staff as to how each might be usefully applied and in which circumstances. Here we present a comparative analysis of their content, and describe the perspectives of staff on their design, outputs and the feasibility of their sustained use.

METHODS

We have used a content analysis to provide the context for the qualitative study of staff experiences of using the tools at a representative range of practices recruited from across the Midlands (UK). Data was collected through moderated focus groups using an identical topic guide.

RESULTS

A total of nine practices used the PC-SafeQuest tool and four the MapSaf tool. A total of 159 staff completed the PC-SafeQuest tool 52 of whom took part in the subsequent focus group discussions, and 25 staff completed the MapSaf tool all of whom contributed to the focus group discussions. PC-SafeQuest was perceived as quick and easy to use with direct questions pertinent to the work of GP practices providing useful quantitative insight into important areas of safety culture. Though MaPSaF was more logistically challenging, it created a forum for synchronous cross- practice discussions raising awareness of perceptions of safety culture across the practice team.

CONCLUSIONS

Both tools were able to promote reflective and reflexive practice either in individual staff members or across the broader practice team and the oversight they granted provided useful direction for senior staff looking to improve patient safety. Because PC SafeQuest can be easily disseminated and independently completed it is logistically suited to larger practice organisations, whereas the MapSaf tool lends itself to smaller practices where assembling staff in a single workshop is more readily achieved.

Social Determinants of Health and Implementation Research: Three Decades of Progress and a Need for Convergence

Ethn Dis. 2021;31(1):1-4

Twenty-five years of the National Institutes of Health Office of Behavioral and Social Sciences Research

Over its 25 years, the National Institutes of Health (NIH) Office of Behavioral and Social Sciences Research (OBSSR) has played a significant role in a number of behavioral and social science research advances that improve health.

Childhood obesity prevention: priority areas for future research and barriers and facilitators to knowledge translation, coproduced using the nominal group technique

Childhood obesity is a significant public health challenge, yet research priorities for childhood obesity prevention are not established. Coproduction of priorities leads to research which may be more translatable to the domains of policy and practice. The aim of the present study was to identify knowledge gaps and research priorities in addition to facilitators and barriers to knowledge translation in childhood obesity prevention. The nominal group technique involving consensus building with researchers, policymakers, and practitioners was employed during workshops at a national obesity conference held over 2 days in May 2017. Seventy-seven people participated in the first round of research prioritization on Day 1, while 14 stakeholders participated on Day 2. The top five research priorities identified were as follows: (i) Evaluate (including economic evaluation) current programs to inform practice and policy; (ii) How to change culture toward addressing the determinants of health; (iii) Implementation science: process; (iv) How to integrate obesity prevention into existing service structures; (v) How to enhance opportunities for habitual physical activity, including free play and active travel. Key themes emerging from this research prioritization exercise were the importance of funding and resources, coproduction of research, and a focus on both implementation research and social determinants within the field of childhood obesity prevention. The coproduced research priorities may help to shape the research agendas of funders and researchers, and aid in the conduct of policy-relevant research and the translation of research into practice in childhood obesity prevention.

Integrative medicine smart phrase pilot study: Evaluating an EHR tool to improve providers' attitudes, knowledge and use of herbal and dietary supplements

CONTEXT

While many patients use herbal and dietary supplements (H/DS) for wellness, disease prevention and treatment, providers still cite a lack of resources and formal training as barriers to responding to patients' inquiries about H/DS. Although the federal government, academic institutions and the private sector now offer more opportunities for education and research on H/DS, greater support in real time is needed to facilitate providers during the clinical encounter.

OBJECTIVE

This small, pilot study evaluates the effects of implementation of smart phrases in the electronic health record (EHR) and an educational intervention on providers' knowledge, attitude and use of H/DS in the clinical encounter.

DESIGN, SETTING AND PARTICIPANTS

The study was conducted at The Institute for Family Health (IFH), a Federally Qualified Health Center and academic health center which operates the Department of Family Medicine and Community Health in affiliation with the Icahn School of Medicine at Mount Sinai. Baseline and post-intervention surveys were conducted to explore providers' attitudes, knowledge and use of integrative medicine (IM) smart phrases on H/DS.

MAIN OUTCOME MEASURES

Providers' awareness of smart phrases of H/DS, knowledge of the content, confidence in using smart phrases to discuss H/DS, self-reported use of smart phrases were measured.

RESULTS

A total of 32 subjects participated in the intervention and completed the baseline survey. Only half of the participants were familiar with the IM smart phrases in our system and 12.5% felt they were aware of the information covered in these smart phrases. Eighteen of 32 participants completed the post-intervention assessment. The intervention was successful in statistically increasing participants' self-reported awareness of the information covered in the IM smart phrases (p<0.01). Increased confidence in using IM smart phrases to initiate patients on a new supplement showed statistical significance (p=0.03). There were no clear patterns in reported behavior changes following the training with the exception of a significant increase in the self-reported frequency of past month use of IM smart phrases during a patient visit (p=0.01). Lastly, there were no changes in the frequency of smart phrase use in the EHR.

CONCLUSION

The implementation and adoption of evidence-based use of H/DS in the clinical encounter requires a sustained educational component to make the availability of smart phrases via technology (EHR) an effective strategy.

Small Interventions for Big Change: Brief Strategies for Distress and Self-Management Amongst Youth with Type 1 Diabetes

PURPOSE OF REVIEW

Diabetes self-management and diabetes distress are complex processes implicated in glycemic control and other health outcomes for youth with type 1 diabetes. Growing integration of medical and behavioral care provides opportunities for brief psychosocial interventions during routine diabetes care. This review focuses on interventions for self-management and diabetes distress that can be delivered alongside usual medical care or via a single-patient encounter.

RECENT FINDINGS

Recent research underscores the potential of brief interventions delivered by both medical providers and integrated behavioral health professionals, but little is known regarding the comparative effectiveness of different interventions or the factors that impact dissemination and implementation. This article asserts that brevity is critical to maximizing the reach, scalability, and impact of psychosocial interventions for youth with type 1 diabetes. The authors review existing evidence for brief interventions, describe several untested clinical strategies, and make recommendations for accelerating the translational study of brief interventions.

Implementation Research as Applied Science: Bridging the Research to Practice Gap

Implementation research is intended to address challenges posed by the slow adoption of evidence-based science by the medical and health promotion practice community. A case study approach is used to illustrate and discuss the use of Quality improvement and Evaluation as an applied approach to implementation science in contrast of more classic purposes of research. Quality improvement was the implementation model used to facilitate organizational change needed to adopt the use of texting to report sexually transmitted infection test results in over a fifth of Florida's larger county health departments. Both quantitative and qualitative methods were used to evaluate implementation. All seven participating county health departments were successful in enrolling clients in texting with extensive variation (24% to 72%) in texting enrollment at the end of the 10-month study. Statistically significant outcomes for those enrolled in texting were recorded through Florida's online sexually transmitted infection reporting system in the form of increased number of people receiving early (1-4 days) treatment and reductions in delayed (≥8 days) or no treatment. This study illustrates an applied approach to implementation research which may be critical to adapt emerging evidence and technologies to the multiple and complex characteristics of the diverse populations served by health promotion institutions.

Multi-sensor ecological momentary assessment of behavioral and psychosocial predictors of weight loss following bariatric surgery: study protocol for a multicenter prospective longitudinal evaluation

BACKGROUND

Bariatric surgery is currently the most effective strategy for producing significant and durable weight loss. Yet, not all patients achieve initial weight loss success and some degree of weight regain is very common, sometimes as early as 1-2 years post-surgery. Suboptimal weight loss not fully explained by surgical, demographic, and medical factors has led to greater emphasis on patient behaviors evidenced by clinical guidelines for appropriate eating and physical activity. However, research to inform such guidelines has often relied on imprecise measures or not been specific to bariatric surgery. There is also little understanding of what psychosocial factors and environmental contexts impact outcomes. To address research gaps and measurement limitations, we designed a protocol that innovatively integrates multiple measurement tools to determine which behaviors, environmental contexts, and psychosocial factors are related to outcomes and explore how psychosocial factors/environmental contexts influence weight. This paper provides a detailed description of our study protocol with a focus on developing and deploying a multi-sensor assessment tool to meet our study aims.

METHODS

This NIH-funded prospective cohort study evaluates behavioral, psychosocial, and environmental predictors of weight loss after bariatric surgery using a multi-sensor platform that integrates objective sensors and self-report information collected via smartphone in real-time in patients' natural environment. A target sample of 100 adult, bariatric surgery patients (ages 21-70) use this multi-sensor platform at preoperative baseline, as well as 3, 6, and 12 months postoperatively, to assess recommended behaviors (e.g., meal frequency, physical activity), psychosocial indicators with prior evidence of an association with surgical outcomes (e.g., mood/depression), and key environmental factors (e.g., type/quality of food environment). Weight also is measured at each assessment point.

DISCUSSION

This project has the potential to build a more sophisticated and valid understanding of behavioral and psychosocial factors contributing to success and risk after bariatric surgery. This new understanding could directly contribute to improved (i.e., specific, consistent, and validated) guidelines for recommended pre- and postoperative behaviors, which could lead to improved surgical outcomes. These data will also inform behavioral, psychosocial, and environmental targets for adjunctive interventions to improve surgical outcomes.

TRIAL REGISTRATION

Registered trial NCT02777177 on 5/19/2016.

The Intersection of Behavioral Science and Digital Health: The Case for Academic-Industry Partnerships

A decade after the first health app became available, the field of digital health has produced a range of health behavior insights and an expanding product portfolio. Despite sustained interest and growth fueled by academic and industry interests, the impact of digital health on health behavior change and related outcomes has been limited. This underperformance relative to expectations may be partially attributed to a gap between industry and academia in which both seek to develop technology-driven solutions but fail to converge around respective, unique strengths. An opportunity exists for new and improved collaborative models of research, innovation, and care delivery that disrupt the field of behavioral medicine and benefit academic and industry interests. For those partnerships to thrive, recognizing key differences between academic and industry roles may help smooth the path. Here we speak specifically to concerns particular to academics and offer suggestions for how to navigate related challenges.

Society of Behavioral Medicine (SBM) position statement: Increasing funding for the NIH OBSSR to promote timely and effective behavioral medicine research

Chronic diseases are a leading cause of morbidity and mortality in the USA. Most chronic diseases have behavioral risk factors that can improve health and quality of life and reduce financial burdens. Improved methods of measurement and behavioral interventions are rapidly progressing. These changes require sufficient funding to maximize effectiveness. The National Institutes of Health (NIH) Office of Behavioral and Social Sciences Research (OBSSR) helps to coordinate and support behavioral and social science research initiatives that are designed to promote public health and reduce chronic disease burden throughout the NIH. OBSSR's budget has not increased for the past 5 years. The goals of this policy paper are to promote awareness of the OBSSR Strategic Plan FY 2017-2021's three priority areas and encourage increased and sustained funding for OBSSR to support these priority areas. Priority area 1 involves improving the quality and integration of behavioral and social science research, which can increase speed of funding natural experiments. Priority area 2 encourages the use and improvement of new technology to create methods and infrastructures to analyze big behavioral data, ensuring that health behavior interventions keep pace with the substantial data generated from new technology. Priority area 3 supports translational research between scientific data and real-world practice, ensuring the delivery of research findings to patients and populations. Adequate and sustained resources are needed to address these priority areas. Without such resources, disparities in health outcomes and the costs of treating preventable chronic diseases will continue to grow. Society of Behavioral Medicine (SBM) recommends and supports an increase for OBSSR's budget.

Implications of the 21st Century Cures Act for the Behavioral and Social Sciences at the National Institutes of Health

The 21st Century Cures Act provides funding for key initiatives relevant to the behavioral and social sciences and includes administrative provisions that facilitate health research and increase the privacy protections of research participants. At about the same time as the passage of the Act, the National Institutes of Health Office of Behavioral and Social Sciences Research released its Strategic Plan 2017-2021, which addresses three scientific priorities: (a) improve the synergy of basic and applied behavioral and social sciences research; (b) enhance and promote the research infrastructure, methods, and measures needed to support a more cumulative and integrated approach to behavioral and social sciences; and (c) facilitate the adoption of behavioral and social sciences research findings in health research and in practice. This commentary describes the implications of the Cures Act on these scientific priorities and on the behavioral and social sciences more broadly.

Better Together: The Making and Maturation of the Palliative Care Research Cooperative Group

OBJECTIVE

To describe the growth and outcomes of the Palliative Care Research Cooperative Group (PCRC).

BACKGROUND

Despite advances, significant gaps remain in the evidence base to inform care for people with serious illness. To generate this needed evidence and bolster research capacity, the Palliative Care Research Cooperative (PCRC) group was formed.

METHODS

The PCRC supports investigators in the conduct of multisite clinical studies. After developing a governance structure and completing a proof of concept demonstration study, the PCRC expanded its infrastructure to include additional resource cores (Clinical Studies; Measurement; Data Informatics and Statistics; and Caregiver Studies). The PCRC also supports an Investigator Development Center as many palliative care investigators valued opportunities to advance their skills. Additional key aspects of PCRC resources include a Scientific Review Committee, a Publications Committee, and initiatives to purposefully engage investigators in a community of palliative care science.

RESULTS

The PCRC has grown to over 300 members representing more than 130 distinct sites. To date, the PCRC has supported the submission of 51 research applications and has engaged in 27 studies. The PCRC supports investigator research development needs through webinars and clinical trials "intensives." To foster a sense of community, the PCRC has convened biannual meetings, developed special interest groups, and regularly communicates via a newsletter and its website.

CONCLUSION

With a particular focus on facilitating conduct of rigorous multisite clinical studies, the PCRC fosters an engaged multidisciplinary research community, filling an important void in generating and disseminating evidence that informs the provision of high-quality care to people with serious illness.