Effects of an Osteoporosis Prevention Program Based on Health Belief Model Among Females

Determinant of Osteoporosis Preventive Behaviors among Perimenopausal Women: A Cross-Sectional Study to Explore the Role of Knowledge and Health Beliefs

Osteoporosis is a silent chronic disease, and many people did not discover it until they were diagnosed with a fracture. Therefore, regular scanning and appropriate Osteoporosis Preventive Behaviors (OPB) are the management cornerstone. OPB is strongly affected by personal knowledge and health beliefs. This study explores the role of knowledge and health beliefs as determinants of OPB among perimenopausal women. This cross-sectional study was performed on 1075 perimenopausal women in Najran City, Saudi Arabia, from January 2023 to March 2023. The data collection instrument is a self-reported questionnaire consisting of basic data, the OPB scale, an osteoporosis knowledge assessment tool, and the osteoporosis health belief scale. The current study results showed that approximately one-quarter (27.8%) of the study participants had high OPB with an overall mean of 20.83 ± 5.08 grade. The group practicing high OPB demonstrated a higher knowledge mean (11.37 ± 2.99) than the low OPB group (9.93 ± 3.51). In addition, all health beliefs constructs significantly differed among the low and high OPB groups (p ˂ 0.05). The participant's age, occupational status, educational level, attendance of training courses, and history of bone fractures were significantly associated with high OPB. Osteoporosis knowledge, perceived susceptibility, perceived seriousness, exercises' perceived benefits, and health motivations are positive predictors of high OPB (p ˂ 0.05). The study concluded that osteoporosis-related knowledge and health beliefs-especially perceived susceptibility, perceived seriousness, exercises' perceived benefits, and health motivations-are positive predictors of high OPB. The health belief model can be an effective tool used to determine high-risk groups who practice low OPB and build need-based educational interventions.

Cognitive determinants of weight control by dietary patterns among postmenopausal women with osteoporosis: An application of theory of planned behavior

Background: In this study, we aimed to assess the cognitive determinants of weight control behaviors by dietary patterns among postmenopausal women with osteoporosis.

Methods: This cross-sectional study, based on the theory of planned behavior (TPB) was conducted from July to December 2017 among 240 postmenopausal women with osteoporosis in Tabriz, Iran. A validated and reliable TPB-based instrument, namely Weight-CuRB, and the food frequency questionnaire (FFQ) were used.

Results: The results of exploratory factor analysis (EFA) indicated three dietary patterns (total variance explained=24.44%); healthy (n=71), mixed (n=78), and western (n=91). In addition, food items consumed by participants were classified into twenty-two food groups for dietary pattern analysis. In the healthy and western dietary patterns, attitude (β: 0.140, P <0.001) and subjective norms (SNs) (β: 0.498, P <0.01) were the only predictors of weight control behavior, respectively. In the women with healthy and western patterns, the TPB-based variables altogether explained 11% and 16% of variations in the behavior, respectively. Among all patients, the TPB-based variables explained 12.2% of variations in weight control behavior, within which SNs were the only significant predictor of the behavior (β=-0.199, P <0.01).

Conclusion: Our findings highlighted the remarkable role of dietary patterns in the associations between weight control and its cognitive determinants. Dietary patterns should be considered while designing weight control educational interventions among women with osteoporosis. In such interventions, promoting SNs and perceived behavioral control (PBC) should be considered as the core strategies to promote the behaviors among the patients who follow an unhealthy diet.

Effect of educational program based on theory of planned behavior on osteoporosis preventive behaviors: a randomized clinical trial

Background

The prevalence of chronic diseases is increasing worldwide. Implementing educational programs is an important step in prevention of chronic diseases in the community setting. This study was conducted to assess the effect of educational program based on the Theory of Planned Behavior (TPB) on the osteoporosis preventive behaviors in middle-aged individuals.

Methods

A randomized clinical trial was conducted on 64 middle-aged individuals presenting to primary care centers. A researcher-made questionnaire developed according to “a guide for compiling and analyzing the questionnaire based on TPB” was used for data collection. Random block sampling was applied to assign participants to control and intervention groups after ensuring the validity and reliability. An educational program on osteoporosis prevention was conducted in six educational sessions based on the TPB constructs for the intervention group in primary care centers. Control group received routine education about lifestyle changes including osteoporosis by primary care centers. Eight weeks after the intervention, the questionnaires were completed again and the data were analyzed using the SPSS V16 software.

Results

Independent t-test found no significant difference in the mean score of knowledge, osteoporosis preventive behavior, attitude, subjective norms, perceived behavioral control and behavioral intention between intervention and control groups before intervention (p > 0.05). After the intervention, however, a significant difference was found in the mean score of knowledge, attitude, subjective norms, perceived behavioral control and behavioral intention between the cases in intervention and control groups (P < 0.05). In addition, based on repeated measurement ANOVA, the intervention had a significant effect on knowledge, preventive behaviors, attitude, subjective norms, perceived behavioral control, and behavioral intention (P < 0.05).

Conclusions

The results of the present study showed that implementation of an educational intervention based on the Theory of Planned Behavior significantly increased the knowledge along with all constructs of TPB in osteoporosis preventive behaviors.

Trial registration

This study was registered in the Iranian Registry of Clinical Trials IRCT2017081735647N2 (11/10/2017).

Effects of a health-belief-model-based osteoporosis- and fall-prevention program on women at early old age

BACKGROUND

Elderly women are at high risk of osteoporosis and falls. Lifestyle modifications and regular check-ups are strongly recommended to promote their bone health. However, elderly women tend to perform low preventive behaviors due to physiological changes associated with aging. Education facilitating healthy behaviors is essential for older women. Therefore, the purpose of this study was to determine whether a Health Belief Model (HBM)-based osteoporosis- and fall-prevention program could improve osteoporosis- and fall-prevention knowledge, self-efficacy, and health behaviors among women aged 65 to 74 years.

METHODS

This study included an untreated control group with a pretest-posttest design. Women (n = 47) in the intervention group received four sessions of an HBM-based program within a 2-month period. Participants (n = 47) in the control group attended usual education sessions.

RESULTS

Women in the intervention group exhibited greater knowledge in exercise and diet for osteoporosis-prevention (t = 5.473, p < 0.001; t = 6.895, p < 0.001, respectively), fall-prevention knowledge (t = 2.354, p = 0.021), self-efficacy in exercise for osteoporosis-prevention (t = 2.736, p = 0.008), osteoporosis-prevention behavior of exercise, diet, and routine follow-ups (t = 3.019, p = 0.003; t = 2.705, p = 0.008; t = 2.368, p = 0.020, respectively), and fall-prevention behavior (t = 3.879, p < 0.001).

CONCLUSION

HBM-based osteoporosis- and fall-prevention program exhibited outstanding effectiveness in promoting osteoporosis and fall prevention among women at early old age. Further studies with more rigorous designs are needed to provide further evidence that supports this finding.

Educational booklet reinforces knowledge of osteoporosis and influences intentions to improve bone health in previously diagnosed and treated patients

We examined individuals' experiences using an educational booklet developed by the Ontario Osteoporosis Strategy. The booklet appeared to motivate individuals to make changes to their existing management of their bone health and served as a reference tool reaffirming current practices and beliefs for others.

INTRODUCTION

The purpose of this study was to examine individuals' experiences of the educational booklet and explore the influence of the booklet on individuals' beliefs and actions regarding their bone health.

METHODS

Eligible individuals were those who had been prescribed medication to treat low bone mass. One-on-one telephone interviews were conducted over an 18-month period. Participants were interviewed for approximately 1 hour and asked to provide their feedback on the booklet, and to discuss what they were doing with respect to the recommendations made in the booklet.

RESULTS

We interviewed 50 participants who ranged in age from 58 to 89. The overall impression of the booklet was positive. Participants described the language in the booklet as clear and easy to understand. Participants stated that they would have appreciated receiving this tool at the onset of their diagnosis. Forty-two participants had already taken action, or expressed an intention to make changes, to their existing routines to improve their bone health. In contrast, eight participants used the booklet to reaffirm current practices and beliefs. For these individuals, the recommendations made in the booklet were consistent with what they had already been doing.

CONCLUSION

The booklet can engage patients in discussions about bone health. The booklet appeared to motivate individuals to make changes to their existing routines in an effort to achieve better health outcomes for their bone health. Providing a tool like this to people recently diagnosed with a bone health issue may prove to be beneficial.

Development and psychometric properties of the public attitude towards vaccination scale - Health belief model

AIM

The aim of this study was to develop and psychometrically evaluate the Public Attitude Towards Vaccination Scale - Health Belief Model.

DESIGN

A methodological and prospective psychometric study.

METHOD

A three-phase construct was used to develop the Public Attitude Towards Vaccination Scale - Health Belief Model and to determine its psychometric properties: (1) creation of the item pool/conceptualization; (2) evaluation of the items; and (3) psychometric evaluation. This scale was tested using the construct validity (exploratory and confirmatory factor analyses) and the reliability analysis. A psychometric assessment of the scale was conducted with 586 individuals. Data were collected between January - April 2018.

RESULTS

Items of the scale were obtained by appraising the literature concerning vaccination and the other Health Belief Model scale and conducting interviews with mothers. The content validity ratio of this scale calculated according to experts' opinions ranged between 0.769 and 1.00. According to the exploratory factor analysis, there were five factors with an eigenvalue higher than 1 in the scale. These five factors accounted for 68.9% of the total variance. In confirmatory factor analysis, values of fit indices were excellent or acceptable. This scale had high internal consistency and test-retest reliability.

CONCLUSION

This study successfully developed the Public Attitude Towards Vaccination Scale - Health Belief Model. In addition to researchers, this scale can be used by nurses while providing counselling for people with vaccine hesitancy/refusal.

IMPACT

This measurement tool can be used to understand and address 'vaccine hesitancy' by researchers. The results of the research using this measurement tool will provide valuable information to policymakers for preventing vaccine hesitancy. The validity and reliability of this scale can easily be conducted in different languages.

Applying the information-motivation-behavioral model to explore the influencing factors of self-management behavior among osteoporosis patients

BACKGROUND

The prevalence of osteoporosis (OP) is rapidly increasing. Healthy behaviors are crucial for the management of OP. Application of the information-motivation-behavioral skills (IMB) model has been verified in various chronic diseases, but this model has not been investigated for behavioral interventions among people with OP. This study aimed to examine factors influencing OP self-management behavior and their interaction paths based on the IMB model.

METHODS

We conducted a cross-sectional study using a convenience sampling method in 20 community health service centers in Shanghai, China. Predictive relationships between IMB model variables and self-management behaviors were evaluated using an anonymous questionnaire. Structural equation modeling was used to test the IMB model.

RESULTS

In total, 571 participants completed the questionnaire, of which 461 (80.7%) were female. Participants' mean age was 68.8 ± 10.1 years. Only 101 (17.7%) participants were classified as having better OP self-management behaviors. The model demonstrated the data had an acceptable fit. Paths from information to self-efficacy (β = 0.156, P < 0.001) and self-management behaviors (β = 0.236, P < 0.001), from health beliefs to self-efficacy (β = 0.266, P < 0.001), from medical system support to self-efficacy (β = 0.326, P < 0.001) and self-management behaviors (β = 0.230, P < 0.001), and from self-efficacy to self-management behaviors (β = 0.376, P < 0.001) were all significant and in the predicted direction.

CONCLUSION

This study validated the utility of the IMB model for OP self-management behaviors in this population. Middle-aged and older adult patients with OP have poor self-management behaviors. Enhanced knowledge about OP and is important for improving self-management behaviors.

Understanding Patients' Perspectives and Educational Needs by Type of Osteoporosis in Men and Women and People with Glucocorticosteroid-Induced Osteoporosis: A Qualitative Study to Improve Disease Management

The aim of the study was to investigate similarities and differences in health beliefs, experiences and educational needs by type of osteoporosis (OP), particularly in people with glucocorticoid-induced OP (GIOP) and men. A qualitative study was conducted via focus groups involving post-menopausal women with or without osteoporotic fractures, osteoporotic men and people with GIOP. Fifty-three participants were included in eight groups. A wide range of health beliefs was found for all types of OP. Osteoporosis was considered a natural consequence of ageing except in men or conversely a serious disease associated with risk of new fractures and disability. GIOP patients had heterogeneous knowledge of OP and reported fewer prevention behaviours, and their quality of life was affected by the causal illness. Men had difficulties coping with the loss of their functional abilities and felt that OP was a "women's" disease. Beliefs about treatments ranged from confidence to fear of adverse effects or doubt about efficacy in all types of OP. Participants were interested in physical activity, fall prevention and diet, and preferred group sessions. GIOP patients and men had an interest in face-to-face education. Men were also interested in brief information including via the Internet. Patients' beliefs about OP differed by type of OP. Specific populations such as men or people with GIOP need particular care owing to experiences and needs. Offering group sessions in educational interventions is of interest to allow for sharing experiences and also face-to-face education for men and GIOP patients or the Internet for men.

Effectiveness of Health Belief Model on Oral Cancer Prevention in Smoker Men

The purpose of the present study is investigating the effect of educational intervention based on health belief model (HBM) on oral cancer prevention in smoker men. This is a quasi-experimental study carried out on 200 smoker men with the age of 40 or older (100 subjects for the experimental group and 100 subjects for control group) resident in Fasa City, Fars Province, Iran, in 2017-2018. The educational intervention for the experimental group included seven educational sessions for 50 or 55 min-based HBM. A questionnaire consisted of items about demographic information, knowledge, HBM constructs (perceived susceptibility, severity, benefits, barriers, self-efficacy, and cues to action) was used to measure the oral cancer prevention before and 6 months after the intervention. The mean age of the men was 51.35±8.41 years in the experimental group and 52.28±8.09 years in the control group. Based on the obtained results, significant enhancement is observed in average scores of knowledge, perceived susceptibility, severity, benefits, self-efficacy, cues to action, and oral cancer prevention behaviors in experimental group; however, no significant changes are observed in average scores of knowledge, perceived susceptibility, severity, benefits, self-efficacy, cues to action, and oral cancer prevention behaviors of control group. Also, results indicated that, the educational program based on HBM model have positive effect on oral cancer prevention with the improvement of subject's knowledge, perceived susceptibility, severity, benefits, and self-efficacy.

The effect of educational text message based on health belief model on osteoporosis preventive behaviors in women: a randomized controlled clinical trial

The purpose of this study was to investigate the effect of educational text messages, based on the health belief model, on osteoporosis preventive behaviors among women aged 30-45 years. This trial was conducted on 121 women from November until September 2017 in Shabestar, Iran. The intervention group received a daily educational text message about osteoporosis for one month, and the control group received educational text messages on frequently occurring cancers in women. Two months after the training, data were collected using the osteoporosis health belief scale, a food frequency questionnaire and the International Physical Activity Questionnaire. No significant differences were observed at baseline between the two groups, except for the perceived benefits construct. After the intervention, controlling for baseline score and adjusting for educational level, a statistically significant difference was observed between the two groups in HBM structures and nutrition performance, while no significant difference was observed in physical activity between the two groups. This study showed that educational text messages can be effective in increasing awareness, perceived susceptibility and severity, and nutritional behavior change related to risk of osteoporosis.

The Effect of Educational Intervention Based on Health Belief Model and Social Support on Promoting Skin Cancer Preventive Behaviors in a Sample of Iranian Farmers

Skin cancer is one of the most common cancers in Iran. Farmers are exposed to the sun's ultraviolet radiation due to their job and are susceptible to skin cancer. The aim of this study is to survey the effect of educational intervention based on health belief model and social support on promoting skin cancer preventive behaviors in farmers of Fasa City, Fars province, Iran. In this quasi-experimental study, 200 farmers (100 in experimental group and 100 in control group) in Fasa City, Fars, Iran, were selected in 2017. The educational intervention for the experimental group consisted of eight training sessions (introduction to skin cancer, risk factors, complications, benefits and barriers to proper use of sunscreen, UV sunglasses and physical protection, self-efficacy in applying preventive behaviors, role of social support). A questionnaire consisting of demographic information, knowledge, HBM constructs (perceived susceptibility, severity, benefits, barriers, self-efficacy and cues to action), and social support was used to measure skin cancer preventive behaviors before, 3 months after the intervention, and 6 months later. Data were analyzed using SPSS-22 via chi-squared, independent samples t test, Mann-Whitney, and repeated measures ANOVA at a significance level of 0.5. The mean age of the farmers was 42.21 ± 10.52 years in the experimental group and 44.28 ± 10.16 years in the control group. Three months after the intervention and 6 months after the intervention, the experimental group showed a significant increase in the knowledge, perceived susceptibility, perceived severity, perceived benefits, self-efficacy, cues to action, social support, and skin cancer preventive behaviors compared to the control group. This study showed the effectiveness of the intervention based on the HBM constructs and social support in adoption of skin cancer preventive behaviors in 3 and 6 months post intervention in farmers. Hence, these models can act as a framework for designing and implementing educational interventions for the prevention of skin cancer.

Effects of health promoting education program for Korean middle-aged women

[Purpose] This study aimed to examine the effects of health promoting education program on self-efficacy, health promoting behavior, and quality of life of Korean middle-aged women. [Participants and Methods] Participants were total 60 women (experimental: n=30, control: n=30) in the age group of 40-59, who visit community center located at G gu in Seoul. Health promoting education program was performed for 6 weeks, once a week, one hour with 20 minute group discussion. A study questionnaire was designed to measure the general characteristics, self-efficacy, health promoting behavior, and quality of life. [Results] Self-efficacy, health promoting behavior, and quality of life of middle-aged women were significantly improved in experimental group compared to the control group. [Conclusion] Health promoting education program can be utilized as an effective public health intervention in community. It would be appropriate as an addition to the public health policy for middle-aged women in community.

Knowledge of risk factors and prevention of osteoporosis: the Israeli women's health at midlife study

Wide disparities in knowledge of risk factors and prevention of osteoporosis were demonstrated among midlife Israeli minority women (Arabs and immigrants from the former USSR) compared to Jewish long-time residents. Women who believed osteoporosis to be a serious disease and those who felt susceptible to it reported better knowledge.

PURPOSE

The main goals of this study were to assess knowledge of risk factors and preventive measures for osteoporosis in middle-aged women and to evaluate the relationship of knowledge to personal risk factors and personal perceptions about osteoporosis.

METHODS

Face-to-face interviews with women aged 45-64 years were conducted during 2004-2006 within three population groups: long-term Jewish residents (LTJRs), immigrants from the former Soviet Union, and Arab women. The survey instrument included five knowledge statements related to the risk after menopause, the risk of smoking, family history of fractures, decreased risk by physical activity, and by use of medications.

RESULTS

The findings indicated wide disparities in knowledge about risk factors and preventive behavior of osteoporosis between the two minority groups (immigrants from the former Soviet Union and Arab women) and the majority group of midlife Israeli women. Knowledge of osteoporosis was related to perceived severity of the disease and partly to perceived susceptibility to osteoporosis. Past diagnosis of osteoporosis, current or past smoking status, and BMI were unrelated to knowledge in multivariate analyses.

CONCLUSIONS

There is a need to improve knowledge of osteoporosis especially among less educated and minority women. Subjective perception of risk was more strongly related to knowledge than actual risk factors and should be targeted in public campaigns. The efforts should be aimed at strengthening women's perception of their own susceptibility to osteoporosis and of the severity of this disease.

Relationships among Knowledge, Self-efficacy, and Health Behavior of Osteoporosis and Fall Prevention in Old Aged Women

PURPOSE

This study was conducted among older women to (1) identify their levels of knowledge, self-efficacy, and health behavior in dealing with osteoporosis and falls and (2) explore the relationships between the study variables based on a health-beliefs model.

METHODS

With a cross-sectional survey design, we recruited 94 older women of ages from 65 to 74 at a community setting via convenience sampling. The study participants completed two sets of structured questionnaires (on osteoporosis and fall prevention).

RESULTS

The general characteristics of the study participants demonstrated that the women were at high risk for osteoporosis and falls. Overall, the levels of knowledge about osteoporosis and falls, their self-efficacy, and their preventive behaviors were average or slightly above. The relationships between the study variables showed that self-efficacy and healthy behavior, such as doing osteoporosis exercise, eating an osteoporosis diet, and avoiding falls, were related (r=38, p < .001; r=.33, p < .05; r=.26, p < .05). In addition, there were statistically significant relationships between osteoporosis and fall prevention knowledge (r=.37~.46, p < .001), self-efficacy (r=.50~.53, p < .001), and preventive behaviors (r=.50, p < .001).

CONCLUSION

The women's scores on osteoporosis and fall knowledge, self-efficacy, and preventive behaviors suggest an urgent need for the implementation of educational programs for older women. A close relationship between self-efficacy and health behaviors implies a need for transformation of a traditional one-way lecture form.

Development and feasibility of Mandarin-language bone health scales for adolescents with cancer in Taiwan

Cancer during adolescence increases the risk for bone mass deficiency later in life. Adolescents with cancer must learn to improve their bone health to avoid osteoporosis. In the present cross-sectional study, we developed and tested scales to assess the bone health self-efficacy and beliefs of adolescents with cancer in Taiwan. Test development followed three stages: item generation and scale formatting, examination of content validity, and validation of psychometric properties with a sample of 100 adolescents with cancer. Through the validation process, this research generated the seven-item Bone Health Self-Efficacy Scale and the 13-item Bone Health Belief Scale. Multiple indices demonstrated construct validity. Cronbach's alphas (0.809 and 0.705) demonstrated internal consistency. No items caused a drop in Cronbach's alpha of 10%, all inter-item correlations were <0.800, and the factor loadings for all items reached 0.400, demonstrating item appropriateness. The present study provides initial evidence of the scales' accessibility and feasibility for adolescents with cancer who speak Mandarin. These scales might also help clinical nurses evaluate the effectiveness of bone health education provided to adolescents with cancer.

Educational Intervention on Breast Self-Examination Behavior in Women Referred to Health Centers: Application of Health Belief Model

Introduction and aims:

Screening can play a major role in reducing deaths associated with cancer. Breast self-examination (BSE) is a cheap, non-complicated and non-invasive method for breast cancer screening. This study aimed to examine the effects of an educational intervention based on the health belief model (HBM) on BSE behavior in women referred to health centers in Fasa, Iran.

Methods:

This quasi-experimental study was conducted on 92 women, divided into an experimental and a control group. Data were collected using a validated questionnaire covering demographic characteristics, knowledge, HBM constructs and breast self-examination performance. An educational program was performed in five sessions through group discussion with questions and answers and training videos for participants in the experimental group. Questionnaires were filled before and three months after the intervention in the two groups. Data were analyzed with SPSS-22 software for descriptive and analytical statistics.

Results:

The results of this study showed that the mean scores for knowledge, HBM constructs and self-examination behavior in the experimental group were elevated compared to the control group after the intervention (P<0.001).

Conclusions:

Education based on the HBM is effective in promoting breast self-examination behavior. Thus development and implementation of training programs based on the model are proposed for officers involved in education and health promotion in Iran.

Thoracolumbar kyphosis is associated with compressive vertebral fracture in postmenopausal women

The main aim of this retrospective cross-sectional study was to examine the relationship between vertebral compression fracture and thoracolumbar Cobb angles. Fracture prevalence was found to be significantly higher for patients with moderate [odds ratio (OR) = 4.78 (2.88-7.95)] or severe kyphosis [OR = 10.7 (5.11-22.40)] than for patients with mild kyphosis. The relationship between degree of thoracolumbar kyphosis and vertebral compression fracture was analyzed.

INTRODUCTION

The hypothesis that vertebral compression fracture in women is related to thoracolumbar kyphosis severity was tested, and a clinically important cutoff degree of sagittal thoracolumbar Cobb angle (TLCobb) was determined.

METHODS

Demographic data, clinical data, and quantitative computed tomography (QCT) findings were compiled for 212 postmenopausal women with thoracolumbar fracture (study group) and 150 postmenopausal women with degenerative lumbar disease (control group). Group proportions and characteristics were compared with chi-squared tests and unpaired t tests, respectively.

RESULTS

In this retrospective cross-sectional study cohort, 17 patients had T11 fractures, 79 had T12 fractures, 89 had L1 fractures, and 27 had L2 fractures. QCT findings and TLCobb differed between the study and control groups (both p < 0.001). No significant differences were found in body mass index (BMI), disk height, or coronal TLCobb. After adjustment for age, BMI, and QCT findings, fracture prevalence was found to be higher in the thoracolumbar kyphosis study group than in the control group [OR = 6.16, 95% confidence interval (CI) 3.88-9.78]. Sagittal TLCobbs of 7.5-15° and >15° were associated with an increased fracture prevalence, with ORs of 4.78 (2.88-7.95) and 10.7 (5.11-22.40), respectively.

CONCLUSION

Vertebral fracture prevalence in postmenopausal women was found to be associated with thoracolumbar kyphosis. A TLCobb sagittal angle >15° should be considered an indicator for vertebral fracture assessment.