Community Development Model for Public Health Applications: Overview of a Model to Eliminate Population Disparities

Strategies for Effective Capacity-Building in the Fight Against Commercial Tobacco

The Center for Black Health & Equity's approach to addressing health inequities relies on the inherent ability within community-based organizations to respond to public health priorities while addressing the political and social determinants of health. By using Dr. Robert Robinson's Community Development Model as a foundational framework, communities can address systemic barriers that impede optimal health outcomes. The model includes community engagement and mobilization activities that motivate communities to achieve equity-centered policy change and offers milestones that show progress made toward their goals and objectives. We operationalized the Community Development Model into the Community Capacity Building Curriculum to train community partners to form a multicultural coalition through asset mapping as a tool for community mobilization. This curriculum is both cost effective and efficient because it enables communities to address health disparities beyond tobacco control, such as food and nutrition, housing, and environmental issues. Coalitions are prepared to identify and make recommendations to address policies that perpetuate health disparities. Facing off against a powerful tobacco industry giant is challenging for small grassroots organizations advocating for stricter tobacco regulations and policies. Such organizations struggle for resources; however, their passion and dedication to the mission of saving Black lives can promote change.

Racism, African American Women, and Their Sexual and Reproductive Health: A Review of Historical and Contemporary Evidence and Implications for Health Equity

Background: The sexual and reproductive health of African American women has been compromised due to multiple experiences of racism, including discriminatory healthcare practices from slavery through the post-Civil Rights era. However, studies rarely consider how the historical underpinnings of racism negatively influence the present-day health outcomes of African American women. Although some improvements to ensure equitable healthcare have been made, these historical influences provide an unexplored context for illuminating present-day epidemiology of sexual and reproductive health disparities among African American women. Methods: To account for the unique healthcare experiences influenced by racism, including healthcare provision, we searched online databases for peer-reviewed sources and books published in English only. We explored the link between historical and current experiences of racism and sexual and reproductive health outcomes. Results: The legacy of medical experimentation and inadequate healthcare coupled with social determinants has exacerbated African American women's complex relationship with healthcare systems. The social determinants of health associated with institutionalized and interpersonal racism, including poverty, unemployment, and residential segregation, may make African American women more vulnerable to disparate sexual and reproductive health outcomes. Conclusions: The development of innovative models and strategies to improve the health of African American women may be informed by an understanding of the historical and enduring legacy of racism in the United States. Addressing sexual and reproductive health through a historical lens and ensuring the implementation of culturally appropriate programs, research, and treatment efforts will likely move public health toward achieving health equity. Furthermore, it is necessary to develop interventions that address the intersection of the social determinants of health that contribute to sexual and reproductive health inequities.

Enrolling Minority and Underserved Populations in Cancer Clinical Research

Research suggests that community involvement is integral to solving public health problems, including involvement in clinical trials-a gold standard. Significant racial/ethnic disparities exist in the accrual of participants for clinical trials. Location and cultural aspects of clinical trials influence recruitment and accrual to clinical trials. It is increasingly necessary to be aware of defining characteristics, such as location and culture of the populations from which research participants are enrolled. Little research has examined the effect of location and cultural competency in adapting clinical trial research for minority and underserved communities on accrual for clinical trials. Utilizing embedded community academic sites, the authors applied cultural competency frameworks to adapt clinical trial research in order to increase minority participation in nontherapeutic cancer clinical trials. This strategy resulted in successful accrual of participants to new clinical research trials, specifically targeting participation from minority and underserved communities in metropolitan Washington, DC. From 2012 to 2014, a total of 559 participants enrolled across six nontherapeutic clinical trials, representing a 62% increase in the enrollment of blacks in clinical research. Embedding cancer prevention programs and research in the community was shown to be yet another important strategy in the arsenal of approaches that can potentially enhance clinical research enrollment and capacity. The analyses showed that the capacity to acquire cultural knowledge about patients-their physical locales, cultural values, and environments in which they live-is essential to recruiting culturally and ethnically diverse population samples.

Efficacy of a DVD-based smoking cessation intervention for African Americans

INTRODUCTION

Previous research suggests that African American smokers may have improved outcomes if interventions are culturally specific. However, few interventions sufficiently address the unique needs of this population in a format with large reach potential. The purpose of this study was to test the efficacy of a newly developed digital video disc (DVD)-based cessation intervention targeting African Americans.

METHODS

In a 2-arm randomized trial, smokers (N = 140) were randomly assigned to view either the new Pathways to Freedom (PTF) DVD or a standard control DVD. Participants were assessed at baseline, immediately postviewing the DVD, and at a 1-month follow-up. The primary outcomes were feasibility and process variables, including intervention evaluations, readiness to quit, and risk perceptions, and smoking-related behavior changes were examined as secondary outcomes.

RESULTS

Findings demonstrated the hypothesized positive effects of the PTF DVD compared with the control DVD on content evaluations, risk perceptions, and readiness to quit at follow-up.

CONCLUSIONS

We found initial evidence for the efficacy of the PTF DVD as a stand-alone intervention. Future research will test the efficacy of the DVD for smoking cessation in a larger randomized trial. The ultimate goal of this research is to validate a new intervention for an underserved community of smokers that can be used in multiple settings, such as community health clinics, primary care, quitlines, cessation clinics, and seminars/workshops.

Social Determinants of Health, the Chronic Care Model, and Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic inflammatory rheumatic disease that disproportionately affects African Americans and other minorities in the USA. Public health attention to SLE has been predominantly epidemiological. To better understand the effects of this cumulative disadvantage and ultimately improve the delivery of care, specifically in the context of SLE, we propose that more research attention to the social determinants of SLE is warranted and more transdisciplinary approaches are necessary to appropriately address identified social determinants of SLE. Further, we suggest drawing from the chronic care model (CCM) for an understanding of how community-level factors may exacerbate disparities explored within social determinant frameworks or facilitate better delivery of care for SLE patients. Grounded in social determinants of health (SDH) frameworks and the CCM, this paper presents issues relative to accessibility to suggest that more transdisciplinary research focused on the role of place could improve care for SLE patients, particularly the most vulnerable patients. It is our hope that this paper will serve as a springboard for future studies to more effectively connect social determinants of health with the chronic care model and thus more comprehensively address adverse health trajectories in SLE and other chronic conditions.

Community energy balance: a framework for contextualizing cultural influences on high risk of obesity in ethnic minority populations

INTRODUCTION

Increases in the availability, affordability, and promotion of high-calorie foods and beverages and decreased obligations for routine physical activity have fostered trends of increased obesity worldwide. In high-income, plural societies, above average obesity prevalence is often observed in ethnic minority communities, suggesting that obesity-promoting influences are more prevalent or potent in these communities.

METHODS

An interdisciplinary group of scholars engaged in multiple rounds of focused discussion and literature review to develop a Community Energy Balance Framework (CEB). The objective was to explore the nature of the excess obesity risk in African descent and other ethnic minority populations and identify related implications for planning and evaluating interventions to prevent obesity.

RESULTS

A key principle that emerged is that researchers and programmers working with ethnic minority communities should contextualize the food- and physical activity-related sociocultural perspectives of these communities, taking into account relevant historical, political, and structural contexts. This perspective underscores the fallacy of approaches that place the entire burden of change on the individual, particularly in circumstances of social disadvantage and rapid cultural shifts.

CONCLUSION

The CEB framework is proposed for use and further development to aid in understanding potential health-adverse effects of cultural-contextual stresses and accommodations to these stresses.

Menthol cigarettes and smoking cessation among racial/ethnic groups in the United States

AIM

To examine the association between smoking mentholated cigarettes and smoking cessation, separately for different racial/ethnic groups.

DESIGN

Secondary data analysis of the 2003 and 2006-07 Tobacco Use Supplements to the Current Population Survey.

SETTING

United States.

PARTICIPANTS

African American, Asian American/Pacific Islander, Hispanic/Latino, Native American, non-Hispanic white adults.

MEASUREMENTS

Examined relations between the use of mentholated cigarettes and measures of smoking cessation.

FINDINGS

Among African Americans (ORadj = 1.62, 95% CI: 1.35-1.95) and Hispanics/Latinos (ORadj = 1.21, 95% CI: 1.00-1.47), those who currently smoked mentholated cigarettes were more likely be seriously considering quitting in the next six months than were non-menthol smokers, after adjusting for sociodemographic factors. African Americans (ORadj = 1.87, 95% CI: 1.60-2.19) and Hispanics/Latinos (ORadj = 1.34, 95% CI: 1.11-1.62) who smoked mentholated cigarettes were also significantly more likely to have a positive estimation of successfully quitting in the next six months compared to non-menthol smokers. These associations were not found among Asian Americans/Pacific Islanders, Native Americans/Alaska Natives and Non-Hispanic Whites. Among former smokers, across racial/ethnic groups, those who smoked mentholated cigarettes (vs. non-menthols) were significantly less likely to have successfully quit for at least six months: African Americans (ORadj = 0.23, 95% CI: 0.17-0.31), Asian Americans/Pacific Islanders (ORadj = 0.22, 95% CI: 0.11-0.45), Hispanics/Latinos (ORadj = 0.48, 95% CI: 0.34-0.69) and Non-Hispanic Whites (ORadj = 0.28, 95% CI: 0.25-0.33).

CONCLUSION

Across race/ethnic groups, those who used to regularly smoke mentholated cigarettes were less likely to have experienced long-term quitting success. Cessation programs should consider the type of cigarette typically smoked by participants, particularly menthols.

Increasing community capacity to reduce tobacco-related health disparities in African American communities

OBJECTIVE

The purpose of this study was to understand the processes and interactions that African American tobacco control organizations use to engage African American communities in tobacco control efforts.

DESIGN AND SAMPLE

The study used grounded theory methods to interpret participant's perspectives on tobacco control. The study sample consisted of African American tobacco control program directors from African American tobacco control organizations throughout the United States.

MEASURES

Data collection involved 1 interview per participant using a semistructured interview at a location selected by the participant. Each interview lasted approximately 30-90 min.

RESULTS

The results showed that organizations used specific strategies to involve African Americans in tobacco control. The tobacco control organizations built community capacity using 3 processes: developing relationships and partnerships, raising awareness, and creating collective power.

CONCLUSION

Contextual, cultural processes, and historical references used by African American tobacco control organizations provide insight into how to engage African American communities in tobacco control efforts and achieve tobacco-related health parity. Public health professionals and nurses should be aware of these and other strategies that may increase the involvement of African American communities in tobacco control.

Intervention mapping as a participatory approach to developing an HIV prevention intervention in rural African American communities

Southeastern states are among the hardest hit by the HIV epidemic in this country, and racial disparities in HIV rates are high in this region. This is particularly true in our communities of interest in rural eastern North Carolina. Although most recent efforts to prevent HIV attempt to address multiple contributing factors, we have found few multilevel HIV interventions that have been developed, tailored or tested in rural communities for African Americans. We describe how Project GRACE integrated intervention mapping (IM) methodology with community-based participatory research (CBPR) principles to develop a multilevel, multigenerational HIV prevention intervention. IM was carried out in a series of steps from review of relevant data through producing program components. Through the IM process, all collaborators agreed that we needed a family-based intervention involving youth and their caregivers. We found that the structured approach of IM can be adapted to incorporate the principles of CBPR.

The Ohio Cross-Cultural Tobacco Control Alliance: understanding and eliminating tobacco-related disparities through the integration of science, practice, and policy

OBJECTIVES

We examined the development of a process designed to eliminate tobacco-related disparities in the state of Ohio and described how a cross-cultural work group used a multicomponent community planning process to develop capacity to address such disparities.

METHODS

The community development model was used as a guide in the planning process. We employed a case study, focus groups, and telephone interviews to assess the process and collect data on tobacco use and awareness. We also employed the appreciative inquiry framework to create the organizational design for the Ohio Cross-Cultural Tobacco Control Alliance (CCTCA), which was formed from the cross-cultural work group and charged with addressing tobacco-related disparities in the state.

RESULTS

Data on tobacco use and awareness were collected from 13 underserved populations. At the end of the planning process, the CCTCA was initiated along with structural capacity to serve as a new program incubator highlighting tobacco use and awareness levels in these populations.

CONCLUSIONS

The CCTCA appeared to be an effective way to begin mobilizing agencies serving underserved populations by providing an operational structure to address tobacco-related disparities. The alliance also successfully implemented culturally competent community-based programs and policies to help eliminate disparities.

Community-based participatory research from the margin to the mainstream: are researchers prepared?

Despite an increasing arsenal of effective treatments, there are mounting challenges in developing strategies that prevent and control cardiovascular diseases, and that can be sustained and scaled to meet the needs of those most vulnerable to their impact. Community-based participatory research (CBPR) is an approach to conducting research by equitably partnering researchers and those directly affected by and knowledgeable of the local circumstances that impact health. To inform research design, implementation and dissemination, this approach challenges academic and community partners to invest in team building, share resources, and mutually exchange ideas and expertise. CBPR has led to a deeper understanding of the myriad factors influencing health and illness, a stream of ideas and innovations, and there are expanding opportunities for funding and academic advancement. To maximize the chance that CBPR will lead to tangible, lasting health benefits for communities, researchers will need to balance rigorous research with routine adoption of its conduct in ways that respectfully, productively and equally involve local partners. If successful, lessons learned should inform policy and inspire structural changes in healthcare systems and in communities.

The diffusion of a community-level HIV intervention for women: lessons learned and best practices

Abstract Early in the HIV/AIDS epidemic in the United States, relatively few women were diagnosed with HIV infection and AIDS. Today, the epidemic represents a growing and persistent health threat to women in the United States, especially young women and women of color. In 2005, the leading cause of HIV infection among African American women and Latinas was heterosexual contact. In addressing HIV prevention needs among women, community-level strategies are needed to increase consistent condom use by women and their partners and to change community norms to support safer sex behaviors. The Real AIDS Prevention Project (RAPP) is a community-based HIV prevention intervention for women and their partners. RAPP is based on a community mobilization model that involves a combination of activities, including street outreach, one-on-one discussions called stage-based encounters, role model stories, community networks, and small group activities. The objectives of RAPP are to increase consistent condom use by women and their partners and change community norms associated with perceptions of condom use and high-risk behaviors in an effort to make safer sex practice more acceptable. This paper describes the Centers for Disease Control and Prevention (CDC) Division of HIV/AIDS Prevention (DHAP) effort to nationally diffuse RAPP from March 2003 through May 2007 and lessons learned from that diffusion experience. The paper specifically discusses (1) collaborating and planning with researchers, (2) a diffusion needs assessment that was designed to assess prior implementation experiences among select agencies, (3) developing the intervention package, (4) developing and piloting training for community-based organizations (CBOs), (5) a rollout of national trainings for health departments and community-based organizations interested in implementing RAPP, and (6) ongoing quality assurance activities and the provision of technical assistance and support. RAPP has been proven effective in reducing HIV transmission risk behaviors and improving communication and negotiation skills necessary for African American women and Latinas to reduce their risk for HIV infection and improve their overall health status.

Surveillance Recommendations for Developing Effective Tobacco Prevention and Control Interventions for Low-SES Populations

On October 6 and 7, 2005, a diverse panel of experts was invited to Atlanta, Georgia by the Centers for Disease Control and Prevention, Office of Smoking and Health to discuss, explore, and share their ideas on how to identify and subsequently plan effective interventions with low socioeconomic status populations in regard to tobacco prevention and control. The invited participants had expertise in three areas: surveillance and evaluation, program planning, and health communications. This article summarizes the methods, processes, discussions, and recommendations that emerged from the surveillance and evaluation group. Current surveillance systems have had success at identifying high-risk populations, but usually at the national or state level. Interventions occur at the local level, and current data are woefully inadequate in providing direction as far as programming planning. It is recommended that an eight-step approach be used for surveillance and monitoring that includes qualitative data collection and participatory planning models.

Effectiveness of tobacco control among Chinese Americans: a comparative analysis of policy approaches versus community-based programs

OBJECTIVE

To estimate the effectiveness of a tailored multicomponent community-based smoking cessation intervention among Chinese immigrants living in New York City, implemented within the context of state and city-wide tobacco control policy initiatives for the general population.

METHODS

A pre-post-test quasi-experimental design with representative samples from Chinese populations living in two communities in New York City: Flushing, Queens, the intervention community and Sunset Park, Brooklyn, the comparison community. From November 2002 to August 2003 baseline interviews were conducted with 2537 adults aged 18-74. In early 2006, 1384 participants from the original cohort completed the follow-up interview. During the intervention period (October 2003 to September 2005), both communities were exposed to tobacco control public policy changes. However, only Flushing received additional linguistically and culturally-specific community-level tobacco control interventions.

RESULTS

From 2002 to 2006 overall smoking prevalence among Chinese immigrants declined from 17.7% to 13.6%, a relative 23% decrease. After controlling for socio-demographic characteristics, there was an absolute 3.3% decrease in smoking prevalence attributed to policy changes with an additional absolute decline in prevalence of 2.8% in the intervention community relative to the control community.

CONCLUSION

City-wide tobacco control policies are effective among high-risk urban communities, such as Chinese immigrants. In addition, community-based tailored tobacco control interventions may increase the reduction in smoking prevalence rates beyond that achieved from public policies.

Qualitative study on community and primary health care involvement on alcohol and tobacco actions in seven European countries

Alcohol and tobacco use are important determinants of illness and have important country-specific dimensions. It's important to also consider them at community and primary health care (PHC) levels. A collaborative qualitative research (Delphi study and focus groups methodology) was conducted during the process of 10 new countries joining the European Union (EU) and implemented in culturally socio-economically different European countries: four EU (Belgium, Brussels region; Hungary, Pest County; Italy, Friuli Venezia Giulia region; Latvia, Riga region; Slovenia, Ljubljana region) and two Eastern European countries (Bulgaria, Sofia region; Russia, St. Petersburg region). Countries were chosen from the WHO international project according to the criteria noted in the application for EU INCO-COPERNICUS funding. Focus groups were conducted among lay people and PHC professionals in order to identify factors that influence (facilitate and prevent or minimize) PHC management of alcohol- and tobacco use-related problems. A Delphi study was conducted among four different groups in order to develop tasks for instances to be involved in community health policies. There are some limitations of such a qualitative study; e.g., such studies give ideas that cannot simply be transformed to actions in every country. In order to manage tobacco-and alcohol-related problems a comprehensive community-based approach, that also include PHC teams and policymakers, would be supported in participating countries.

The California Tobacco Control Program's effect on adult smokers: (3) Similar effects for African Americans across states

OBJECTIVE

To compare trends in African-American (AA) and non-Hispanic white (NHW) smoking between states categorised as having three different levels of tobacco control practice in the 1990s.

SETTING AND PARTICIPANTS

Analysis of 1992-3 to 2001-2 Tobacco Use Supplements to the Current Population Survey for differences in adult (20-64 years) daily smoking prevalence for AAs and NHWs across states: California (CA; high cigarette price/comprehensive programme), New York (NY) and New Jersey (NJ; high cigarette price/no comprehensive programme), and tobacco growing states (TGS; low cigarette price/no comprehensive programme).

RESULTS

From 1992-3 to 2001-2, there were large declines in AA smoking across states (2.7-3.8% decrease/year, adjusted for age, income, education, gender; p<0.05). Adjusted NHW smoking prevalence declined significantly only in CA. AA prevalence declined significantly and did not differ across state groups. In all years, in all state groups, adjusted prevalence was either not significantly different or was lower for AAs than for NHWs. More recent cohorts of AAs appeared to have taken up smoking at lower rates than older cohorts.

CONCLUSION

There were uniformly large declines in AA smoking from 1992-3 to 2001-2 across states, independent of type of tobacco control strategy. Further research is needed into factors associated with smoking declines among AAs.

Addressing tobacco-related health disparities

AIMS

The aim of this review is to outline a transdisciplinary research framework for identifying, explaining and intervening to address tobacco-related health disparities (TRHD). We will show the importance of an approach that integrates the human life-cycle (developmental) and tobacco addiction cycle (behavioral) for interventions that address group-specific vulnerabilities.

METHODS

The existing empirical knowledge base on tobacco-related health disparities is mapped onto a conceptual framework built around life-cycle and addiction cycle trajectories for disparate population groups.

FINDINGS

Current knowledge about developmental trajectories of tobacco use is based on general population studies with minimal information on group differences. At the national level, early onset of tobacco use is associated with a high level of tobacco dependence, low number of quit attempts, long-term smoking history and tobacco-related health harm. These relationships cannot be assumed for all population groups: African Americans and Asian Americans typically have a later age of tobacco use onset compared to European Americans, yet health consequences of smoking are higher among African Americans but not Asian Americans. Even less is known about group differences in the temporal progression from smoking onset to daily smoking. Determining the time-frame from initial to regular smoking seems crucial for targeted secondary prevention, before the establishment of addictive tobacco use patterns. Group-specific data characterizing the duration from daily tobacco use to a quit attempt or request for cessation treatment are also scant.

CONCLUSIONS

A comprehensive, integrated, transdisciplinary framework is needed to guide efforts to understand tobacco-related health disparities and to increase the effectiveness of evidence-based interventions delivered in culturally appropriate and economically practicable ways, while optimizing the balance between demand for and access to services.

Building capacity to address tobacco-related disparities among American Indian and Hispanic/Latino communities: conceptual and systemic considerations

AIM

To discuss systemic and conceptual issues that surround capacity building for tobacco control in traditionally underserved communities, by presenting two case studies, one in an American Indian community and another in a Hispanic/Latino community.

DESIGN

Key informant interviews, cross-sectional surveys and case study methods were used to create community-specific conceptual frameworks for building capacity for tobacco control. These models of capacity building serve as the backdrop for the development of the two case studies. SETTING, PARTICIPANTS, MEASUREMENTS: Interview and survey participants were identified through convenience and snowball sampling, using a community-based participatory process in an American Indian community in Oklahoma and among the Hispanic/Latino Tobacco Education Partnership (H/LTEP) organizations in California. Using qualitative and quantitative methods, two case studies were created based on the results of interviews with key informants in each of the respective communities, outcomes of efforts to build capacity in tobacco control are presented.

FINDINGS

The extent to which American Indian and Hispanic/Latino communities have the capacity to address effectively the disproportionate burden of tobacco abuse is contingent upon the presence of leadership, collaboration, programs, distribution of funds and resources, development of policies and an underlying understanding of community strengths, history, values and participation. Common characteristics emerge from the case studies that help bridge differences in definition and measurement across both populations and programs.

CONCLUSION

The conceptual frameworks for capacity building presented provide insight that enhances the ability of priority populations to engage in tobacco control strategies using culturally and language appropriate interventions.

Development and implementation of a curriculum on cancer screening for small groups of Latino women

BACKGROUND

Health programs tailored to serve Latino communities with limited access to health care are necessary. The methods used to develop breast and cervical cancer educational programs and to evaluate their implementation are presented.

METHODS

A 12-session curriculum was developed to guide weekly group sessions led by trained community health advisors (ie, consejeras).

RESULTS

The curriculum has been implemented and revised over time. Assessments of the extent to which the curriculum educational objectives were met were based on diaries completed by consejeras at the end of the educational sessions and observation ratings of randomly selected educational sessions. The facilitator's guide includes, for each educational session, (1) information about the materials that will be needed for the session, (2) educational objectives, and (3) scripted text to guide the session.

CONCLUSIONS

The curriculum has been successfully implemented and represents a carefully constructed tool to foster breast and cervical early detection in underserved Latino communities.

A cross-cultural and historical survey of tobacco use among various ethnic groups

This review of tobacco use in diverse historical and cultural contexts reveals a range of behaviors engaged in and perspectives held by members of respective ethnic groups, such as whether to consider tobacco as a medicine or as a problem. After its introduction to Western societies, many attributed tobacco with an array of medicinal uses, while condemning recreational use and identifying it as immoral. Tobacco has been used variously by respective ethnic groups at different times and places and these customs have flavored understandings of the relationships between tobacco and the body. Considerable ethnic variation exists not only in terms of tobacco use and abuse, but also with respect to pharmacogenetic factors that influences the consequences of tobacco exposure. There have also been different societal responses to the use of tobacco, including those related to the media, as well as to issues of treatment and prevention.

Eliminating tobacco-related health disparities: directions for future research

Certain groups in the United States remain at high risk and suffer disproportionately from tobacco-related illness and death despite progress made in reducing tobacco use. To address gaps in research on tobacco-related disparities and develop a comprehensive agenda aimed at reducing such disparities, representatives from funding agencies, community-based organizations, and academic institutions convened at the National Conference on Tobacco and Health Disparities in 2002. Conference participants reviewed the current research, identified existing gaps, and prioritized scientific recommendations. Panel discussions were organized to address research areas affecting underserved and understudied populations. We report major research recommendations made by the conference participants in several scientific domains. These recommendations will ultimately help guide the field in reducing and eliminating tobacco-related disparities in the United States.