Final exam Flashcards
(81 cards)
1
Q
What is motivational interviewing?
A
Motivational interviewing is a health psych interviewing technique that promotes the patient’s personal autonomy and intrinsic motivation.
Giving people advice to change is often unrewarding and ineffective; invokes a lot of resistance and is unsustainable without intrinsic motivation.
–> decisions are left up to the patient, MI helps them think through what would work for them and what is holding them back. offer expertise to add insight, not tell them what to do.
Discover their own interest in considering and/or making a change in
their life (e.g., diet, exercise, managing symptoms of physical or
mental illness, reducing and eliminating the use of alcohol, tobacco,
and other drugs)
Express in their own words their desire for change (i.e., “change-talk”)
Examine their ambivalence about the change
Plan for and begin the process of change
Elicit and strengthen change-talk
Enhance their confidence in taking action and noticing that even
small, incremental changes are important
Strengthen their commitment to change
2
Q
Health Action Process Approach
A
3 predictors of behavior change:
- Risk perception: knowledge of the risks associated with certain behaviors
-Outcome expectancies: “If I stop smoking, I will save money”. Ensure people know the strategies to produce their desired effects. - Perceived self efficacy (this is what facilitates the movement to action): - Individual’s beliefs in their capabilities to exercise control over challenging demands and over their own functioning
- Optimistic self-beliefs (I can make this change even if…)
- Self-doubt (There is no point, I can’t change, I will not succeed).
-health psychologists try to get people to optimistic self beliefs
Stages of change:
- Intention to change
– requires the 3 predictors - Planning
-Implementation interventions: make plans that specify when, where, and how of a desired action. STRUCTURE! This is important because it makes cognitive links between situational circumstances and the goal behavior.
—when planning is done well, prpocrastination is reduced. - Initiative
- actual goal pursuit - Maintenance
Requires self regulatory skills and strategies (attainable goals, incentives, social support). - Recovery
- When people pursue their goal by planning details, trying to act, invest effort and persistence, possibly failing, and recovering or disengaging.- Optimistic sense of control is key
If they feel that they out of control or like their goal is unachievable, they will become disengaged.
3
Q
How can we invoke behavior change in people?
A
Behavior change can be approached by two avenues.
Community based
- PSA’s
- Incentives or consequences (policies, taxes)
- Workplace programs (step challenges)
Individual
- Health psychologists or physicians
- Person driven change
4
Q
Precede/Proceed Model
A
- Identify health problems
- Identify lifestyle and environment elements that contribute to the targeted behavior
- Analyze background factors that predispose, enable, and reinforce these lifestyle and environmental elements
- Implement a health education program
5
Q
What are effective health education campaigns?
A
Campaigns that merely inform people
of the hazards of certain behaviors
(e.g., antismoking messages) are typically ineffective
- fear based, loss frame
Multifaceted campaigns that present information on several fronts are
generally more effective than “single-shot” campaign
combination of activities, gain frame, provide environmental changes
Successful information campaigns…
- use peer role models
- Model saying no and showing other behaviors (normalize saying no)
- Campaigns are less effective among ethnic minorities
Other government tactics are increasing aversive consequences
- increasing cigarette tax, increase punishment associated with underage smoking
- Banning smoking in public area
6
Q
Health education
A
any planned intervention involving communication
that promotes the learning of healthier behavior
7
Q
Why don’t scare tactics work?
A
People feel invincible→ it won’t happen to me.
Novelty wears off → they get used to the aversive imagery or warnings
8
Q
Transtheoretical model
A
- precontemplation
- contemplation
- preparation
- action
- maintenance
- relapse
9
Q
Premack Principle
A
More rewarding, higher-frequency behaviors could reinforce the less rewarding, low-frecuency behaviors.
10
Q
Keys to individual change
A
- Social support
Small achievable goals
Habit Reversal
Find the motivation
Have to want to do it to overcome lack of willpower
Don’t just add new behaviors to a full plate
E.g., Can’t exercise if you don’t have time to ex
11
Q
Classical conditioning
A
Association of contiguous events
12
Q
Operant conditioning
A
Role of reinforcement- antecedent, behavior, and consequence
13
Q
Benefits of exercise
A
- Improves mood
- Improved CD health
- Promotes neurogenesis
- Functional plasticity
- Increases insulin sensitivity, lowers blood sugar
- Increases sleep
- Decreases cancer risk
- Decreases anxiety and depression
- Improves leukocyte telomere length
14
Q
Recommended exercise time
A
Moderate intensity: 150 min/week
Vigorous intensity: 75 min/week
47.9% actually meet the recommended exercise time.
15
Q
Exercise and weight control
A
Lower ghrelin during
aerobic and resistance
exercise
*Elevated peptide
tyrosine-tyrosine (PYY)
after aerobic exercise
*Reported reduced
feelings of hunger after
aerobic and resistance
exercise
16
Q
Exercise and protection against chronic illness
A
*Increase physical
strength, maintain bone
density with regular
exercise
*Reduction of risk for
chronic adult illnesses:
cardiovascular disease,
certain cancers, diabetes
and metabolic syndrome
*Lowered triglycerides,
lower LDL “bad”
cholesterol levels and
higher HDL ”good”
cholesterol levels
*Delay of some agerelated declines in white
blood cells
17
Q
Psychological Well-Being
A
*Improved mood and
well-being
*Increased buffer against
stress, anxiety and
depression
*Predicts better cognitive
functioning and reduced
risk of dementia and
Alzheimer’s disease
18
Q
Factors positively associated with adult physical activity
A
- postsecondary education
- higher income
- enjoyment of exercise
- Expectation of benefits
- Self efficacy (belief in ability to exercise)
- Access to facilities
- Social support
- enjoyable scenery (green space)
- safe neighborhoods
19
Q
Who sticks with exercise?
A
- People that enjoy
- Formed a habit
- Social support
- Favorable attitude and strong self efficacy
20
Q
Hunger biological process
A
Ghrelin: secreted by the stomach wall and triggers feelings of hunger as mealtime approaches. In dieters who lose weight, ghrelin increases.
Leptin, produced by adipose tissue, suppresses appetite as its levels increases. When body fat decreases, leptin levels fall, and appetite increases.
Insulin: A rise in blood sugar levels after a meal stimulates the pancreas to secrete insulin, which suppresses appetite by acting on the brain.
PYY: The hormone PYY, secreted by the small intestine after meals, acts as an appetite suppressant that counters the appetite stimulant ghrelin.
21
Q
Roles of belief in metabolism
A
people who had the “indulgent milkshake” felt that they had eaten more and reacted as though they ate something more fattening. Lower levels of ghrelin after eating. Ghrelin levels barely changed in sensi-shake group.
(both grousp had the same shake).
- Approach eating healthy foods with an indulgent mindset??
- Restriction vs indulgence
22
Q
Obesity in the US
A
Prevalence of obesity has increased 30.5% to 42.4% from in the past 20 years.
Overall obesity rate in the US is 20%.
This tends to be more of an issue in the South.
23
Q
Obesity health implications
A
increases the risks of hypertension, stroke,
myocardial infarction, certain cancers, and,
especially, type 2 diabetes
- liver diease
- dementia
24
Q
Biopsychosocial model of obesity
A
Genes: 50% of heritability
Social/cultural eating habits and access
–food deserts and food swamps
–sedentary lifestyles
25
Ultraprocessed foods
- Low fiber
- More sodium
- Additives
- The combination changes how we process the food
- Ultraprocessed group ate more per day
- You eat more because you don’t get a sense of satiety because of the way the food in combined
- Shelf stable, cheap, convenient
- Unprocessed food takes more time and money to prepare
26
Obesity policy suggestions
- Smaller portions
- restrict ads to children
- restrict vending machines with junk food at schools
- increase subsidies for healthy foods
- Add warning labels, make nutrition labels more understandable
- Healthy hunger free kids act (2010)
- food labeling: calories
- SNAP
- nutritional options at school
- summer food service program
- sugar beverage tax at local level
27
Treating obesity
Drug therapy--> reduces body fat and reduces risk of chronic illness, provides control for diabetes, works by making people feel full.
Costs: you have to stay on it indefinitely, people use it off label and increases its price
- it would be incredibly expensive to treat every obese person in the US with drugs. May be more efficient to make lifestyle changes.
28
Diabetes
A disorder of the
endocrine system in
which body is unable
to produce insulin
(Type 1) or is unable to
properly utilize this
pancreatic hormone
(Type 2)
29
Type 1 diabetes
Autoimmune disorder. Body is unable to produce insulin.
- Young onset
- Genetic
- Insulin injections, with diet and exercise control
30
Type 2 diabetes
Cells become insulin resistant and ignore its message to absorb glucose. Pancreas also doesn’t produce enough insulin to get the cells to hear its message.
- tends to be adult onset
- associated with obesity
Symptoms:
- frequent urination
- excessive thirst
- weakness
- drowsiness
- blurred vision
Catch it early! High blood glucose can damage blood vessels overtime, which can cause irreversible health impacts.
31
Diabetes is associated with
- cog impairment
- incontinence
- fracture risk
- cancer risk
32
Diabetes risk factors
- overweight
- sedentary lifestyle
- family history
33
Diabetes in the US
11.3% of American pop has diabetes
1 in 3 American adults are prediabetic
34
Causes of diabetes
- Viral or bacterial infections that damage islet cells
- Western diet— high in fatty, processed foods that increased inflammation
35
Measurements for diabetes
- Labwork for blood markers
- Fasting glucose level
- HbA1c (glycated haemoglobin) levels
- Target is less than 8.
- Reflects level of sugar in blood over last 8-12 weeks
36
Diabetes treatment
- track nutrition and estimate how much insulin you need
- pump that continuously monitors glucose and pumps insulin
- diabetes equipment tends to be VERY expensive
- 1 in 4 Americans can’t afford their insulin
- CAUSING deaths
- Inflation reduction act: limit cost of insulin to $35 for people on Medicare. was almost $100 before!!
37
Health psych and diabetes
- Patient knowledge, beliefs and behaviors strongly affect the ability to manage diabetes
- Self management
- Motivational interviewing
- build intrinsic motivation and help them fit it into their lives in a less intrusive manner
38
Latinos and Diabetes
Special intervention:
- co-location of clinical team
- warm handoff from medical provider to behavioral health provider
- shared treatment plan
- up to four integrated medical visits
- Care coordination of shared treatment plan
- 6 culturally appropriate group healthcare education classes lead by community health worker
- all intervention providers were bilingual and or Latino.
Behavioral health 5 A’s
**Assess**: assessed participant’s behaviors, emotional factors, and environmental variables affecting diabetes self management.
**Advise**: Interventionists summarized identified problem areas, provided psychoeducation, and discussed intervention options.
**Agree**: Patient and provider use motivation interviewing and shared decision making and established SMART goals.
**Assist**: Implement interventions and help participants overcome barriers
**Arrange**: Finalized plan, assessed confidence in achieving SMART goals, provided referrals.
Classes
- Healthy eating within Latino diet
- Diabetes pathophysiology and self management
- CULTURALLY SENSITIVE
- Physical activity
- Psychosocial well-being
What was successful in the intervention?
- lowered HbA1c % (but slight difference, not clinically significant)
- Community health center, multidisciplinary, co-location of team
- Spanish speaking/Hispanic providers
- Culturally competent classes
- Not every community has an FQHC that is staffed and funded
Barriers:
- this is TOUGH to combat
- Low adherence: this intervention takes a lot of time
- Lost a lot of participants in the follow up
- getting bloodwork done (time)
Solutions
- telehealth appts?
39
Cancer
A set of diseases in which abnormal body cells multiply and spread in an uncontrolled fashion, often forming a tissue mass called a tumor.
Benign: Non cancerous
Malignant: cancerous. the cells are replicating and spreading
40
Metastasis
The process by which malignant body cells proliferate in number and spread to surrounding body tissues.
41
Cancer treatment
Chemotherapy
- kills off fast growing cells, hoping that the cancer dies first
- essentially poisoning the body
Immunotherapy
- Medications used to support or enhance immune system's ability to selectively target cancer cells
Radiation Therapy
- Using x-rays/gamma rays to destroy malignant tumors
Alternative treatments
CAR T-cell therapy: Program t-cells to target and recognize cancer cells.
- only works for small # of cancers
- Cancer can become resistant
- ONLY works for a few patients
- Can cause an overactive immune system
- Expensive and time consuming
- very individualized
42
Coping with cancer
- social support
- emotional intelligence
- gender appropriate role models
- knowledge and control
- CBT
- expressive writing exercise
43
Diabetes Prevention Programs
Lifestyle coach, CDC approved curriculum, group support over the course of a year
44
What is cardiovascular disease?
Disease of the heart, circulatory system. Is the leading cause of death for men, women, and people of most racial and ethnic groups in the US.
45
Cardiovascular disease (CVD)
Disorders of the heart and blood vessel system, including stroke and coronary disease
46
Coronary Heart disease (CHD)
Chronic disease in which the arteries that supply the heart become narrowed or clogged
47
Coronary arteries
Clogging in plumbing around the heart, leads to a heart attack
48
Carotid arteries
clogging in plumbing around the brain; leads to a stroke
49
Atherosclerosis
A chronic disease in which cholesterol and other fats are deposited on the inner walls of the coronary arteries, reducing circulation to heart tissue.
- build up of plaques. usually not dangerous til older age.
50
Arteriosclerosis
hardening of arteries. Makes it difficult to expand or contract, making them poor at handling large volumes of blood needed during physical exertion.
51
Types of CVD
Angina pectoris: Condition of extreme chest pain caused by restriction of blood supply to the heart
- tends to occur more during moments of unusual exertion.
- brief, passes in a few minutes
- predictive of future coronary incidents
Myocardial Infarction (MI): Heart attack; the permanent death of heart tissue in response to an interruption of blood supply.
Stroke: Cerebrovascular accident that results in damage to the brain due to lack of oxygen; usually caused by atherosclerosis or arteriosclerosis.
- loss of speech
- numbness
- dizziness
- weakness of paralysis of limbs or face
- blurred vision
- loss of sensation on one side of the body
Atrial fibrillation: A quivering or irregular heartbeat.
52
Stroke/CVA
Cerebrovascular accident that results in damage to
the brain due to lack of oxygen.
* Most strokes are caused by ischemic infarction
* infarctions due to tissue starvation resulting from insufficient or
absent blood flow rather than from insufficient or absent
nutrients in the blood
* 87% of strokes are ischemic
53
CVD uncontrollable risk factors
Family history
Race (AA more likely to have hypertension and be at a greater risk).
Age (most CVD patients are over 65)
Gender: Men are more at risk than women; they roughly have the same risk as a woman 10 years older.
54
Controllable risk factors
Hypertension
- Obesity, diet, exercise, and stress influence BP.
- Poor coping mechanisms → hypertension
- Family stressors as a kid → hypertension risk as adult
Cardiovascular reactivity, hemostasis, and inflammation
- Cardiovascular reactivity is an individual’s characteristic reaction to stress, including changes in heart rate, BP, and hormones.
- higher in AA
- Discrimination
Hemostasis
- The process that causes bleeding to stop via the aggregation of pallets and the coagulation of blood.
- Stress and appraisal: The activation of the sympathetic nervous system influences hemostasis.
Inflammation
- chronic inflammation increases risk of atherosclerosis by affecting the development of plaques.
- Chronic stress and depression promote inflammation
Obesity
- people with excessive weight I midsections tend to have harder arteries, which increases BP and risk of stroke.
Diabetes
55
Psych influences in CVD
Negative affect/Type A/Hostility
- The tendency to experience negative emotions (like hostility)
- Higher risk of CVD (more stress and inflammation). 2x more likely to die of cvd than low hostile people
Depression and anxiety, rumination
- raise inflammatory levels of c-reactive protein and IL-6
John Henryism
- An active coping style that deals with stressors by expending high levels of effort to the point of exhaustion.
- Promotes hypertension
- Associated with lower SES
56
Cardiac Rehab
- involves exercise training, emotional support, and education about lifestyle changes to reduce heart disease risk.
- heart healthy diet
- maintaining healthy weight
- no smoking
- Women. minorities, older people, and those with other other medical conditions are under rereferred to cardiac rehab.
- Only 10-20% of patients who have an MI enter cardiac rehab
- Who has the time and money to participate in these programs?
57
Improving participation in cardiac rehab
- better transportation options
- childcare
- culturally competent services
- follow up appts
58
HIV
Human Immunodeficiency Virus
- Infects the cells of the immune system, destroying or impairing their function
**Testing**: HIV is detected through a blood test.
**Treatment**: Antiretroviral drugs to lower the amount of HIV in blood and prevent the development of AIDS.
**Cure**: None
**Complications**: If left untreated, it is highly fatal within a decade of infection and can be passed from mother to child.
HIV has a disproportionate prevalence in Black and Latino populations.
- spreads in these communities through high risk sexual contact (multiple partners, unprotected sex)
59
How does HIV progress?
- Infects lymph tissues, where lymphocytes are developed and stored to defend against cancer and other chronic illness and protect against infection.
- Retrovirus: It injects a copy of its own genetic material into the DNA of the T cell. The infected DNA eventually activates against another virus and divides, replicating the HIV. Then, HIV particles emerge and invade other lymphocytes
Stage 1: 1 to 8 weeks. Mild symptoms. Swollen lymph nodes, sore throat, fever, chronic diarrhea, skeletal pain, gynecological infection, skin rash. Easily goes unnoticed.
Stage 2: months-years. No obvious symptoms, cells are replicating and T cell concentration falls.
Stage 3: T cells are further reduced, immune function impaired, opportunistic infections occur.
Stage 4: T cells drop to 200 cells or less per cubic millimeter of blood, almost all natural immunity is lost. HIV is now AIDS. T cells drop to 100, and the body cannot protect against microorganisms. Death generally occurs within a year or two without treatment.
60
Factors in AIDS progression
- Initial immune response. HIV progresses slower in people with strong immune responses.
- Genetic vulnerability: Some people have a genetic protection against the development of the receptor that HIV binds to.
- Access to treatment!!!
61
What is the difference between HIV and AIDS?
HIV is the retrovirus that causes AIDS. AIDS is caused by HIV and is when the body’s CD4 lymphocytes (t cells) are destroyed, leaving the individual vulnerable to opportunistic infections
62
Psychosocial model and AIDS/HIV
- Race based discrimination and social exclusion as a child is associated with more risky sexual behaviors
- Need for preventative interventions: Target sub use, sex
- Communicative parenting
- defeat stigma!! The stigma around HIV/AIDS leads to hopelessness, loss of reputation, income, poor healthcare, and general fear. It also created barriers in receiving treatment and support (housing, employment, education). Curbs access to condoms, HIV testing, and adherence to antiretroviral therapy.
- Stress/negative emotions lowers t cell and is associated with a more rapid progression of illness.
63
Social Cognitive Theory
Interaction of environmental events, our internal processes, and our behaviors.
1. Perceived social norms (what are others doing and what is their acceptance of HIV risk reducing behaviors)
2. Self efficacy beliefs
3. Social skills (ability to navigate and be assertive in risky scenarios)
64
Gender and Race/HIV
- African American women and Latinas are disproportionately affected by HIV compared with women of other races/ethnicities
- Globally, girls and women are more likely to contract HIV
- power imbalances: less able to protect them selves and are sometimes economically and culturally subordinate to men
- More of the virus is found in ejaculate
- Women progress to AIDS at a lower viral load
65
PREP
A cocktail of medicines that can be given before someone actually has HIV— preventative
New England Journal article: Thousands of HIV- women in Uganda, Zimbabwe, and South Africa. Randomized conditions with a control. Given ARV (prep preventative drug) or a placebo (pill or vaginal gel)
- Received free medical care and payment
- Community led, very involved
- Taking medication daily
Interviewed the women monthly to see if they were adhering to the treatment. They checked their product and did blood tests.
- Most said they were adhering, had product count that matched the claim BUT most did not have it in their blood test (non adherence).
Why??
- shame, didn’t want to admit that they hadn’t done it
- Stigma around actually taking it; outside the clinic they may feel stigma and shame around having HIV and treating it.
66
Major Barriers to Adherence
- Unintentional —> I forgot!
- Cost vs Benefits —> Feeling stigmatized
- Trust —> why are they testing on us?
- Social Influences —> promiscuous partner?
- Core beliefs about control, health, treatment, ideology —> Why do I need to take this powerful drug if I am healthy?
67
Why is there vaccine resistance?
- mistrust and misinformation
- low health literacy
-rumors and low minorities of adverse effects travel fast and loud
-forgot = success (we were so good at decreasing polio and communicable diseases that people don't think we need vaccines anymore-they've forgotten!
-generational truama
- natural -> our bodies can recover, we don't need something "unnatural"
-vaccines are politicized
68
Herd Immunity
Enough people in a community are vaccinated and protected against the disease, so when someone gets sick, the transmission is very limited. This protects the minority that cannot get vaccinated.
69
Health psychology interventions for public adherence
- rebuild trust
- build distance from politization
- access (cheap, quick, easy to get and find)
- schools and daycares
- Education campaigns about why its important and the dangers it poses
- laws and mandate it!
70
The state of healthcare in the US
We spend the most money on the health care system, yet have the worst performance of high income countries. We have extremely poor access to healthcare, and that makes us have a higher rate of amenable mortality than peer countries.
71
Affordable Care Act (ACA)
- Was designed to bring about changes in how the US health care is paid for and provided
- individual mandates
- affordable coverage
- employer requirements
- coverage for PREVENTATIVE health service
- Accountable care organization (not ordering procedures that are unnecessary)
Today, young adults are allowed to stay on parent’s insurance.
Got rid of a lot of loopholes that make it easier for coverage to get canceled.
More equality for women’s healthcare.
There was a mandate that everyone had to be on health insurance (you would get charged a fee for not) but in 2017 this was taken away.
72
Essential Benefits
- ambulatory patient services
- emergency services
- hospitalization
- maternity and newborn care
- mental health and substance use disorder service treatment
- prescription drugs
- rehabilitative and habilitative services and devices
- lab services
- preventative services
- pediatric services
73
Medicaid expansion
Expanded the threshold of who could get medicare in order to get the people who were initially left behind (made just enough money not to qualify but still couldn't afford healthcare).
The southeast did not adopt the medicare expansion.
74
SES and healthcare
- If you are employed, you might get health insurance through that job.
- Stress of financial instability
- Ability to afford care
- Geographic location
- access to care
- food swamps/deserts
- pollution
- High SES people generally report fewer symptoms and better health than do low SES people
- When they are sick, high SES people are more likely to seek health care
- Low SES people are overrepresented among those who are hospitalized (they wait longer before seeking treatment).
- Less access to preventative care
75
Health Equity
- reduce health inequalities
- recognize that health behaviors are not just due to individual’s choices
- Quality of experience in early years
- Education
- Personal and community resilience
- Good quality employment and working conditions
- sufficient income
- healthy environments
- priority public health conditions
Inequity vs inequality
- Rather than treating everyone equally, equity is adjusting based on context.
- Providing additional resources to people with different needs
76
Improving Local Health
- guaranteed income
- government gives a stipend to spend however people need. provides extra padding incase of emergency.
- In California, they are trying this with pilot programs, mainly for pregnant people and people aging out of foster care.
- In the new California plan, medi-cal will cover doula services.
77
Sickle cell disease
- cell collapses and makes it hard to carry blood around
- Most common in Black patients
- Often stigmatized as pain med seekers and aren’t taken seriously
- Patients with SCD wait 25-50% longer than other patients to see an ER doctor
LA changes — Sickle Cell Clinic
- sickle cell clinic with hematologist, nurses.
- serves adults
- gets them the right drug treatment
- access to vaccines
- builds trust in medical professionals
- other forms of pain relief treatment
- holistic treatment in one place
78
CRISPR (clustered, regularly interspaces, short palindromic repeat)
- can target the sickle cell anemia gene and undoes symptoms of the disease.
- uses CRISPR to allow the fetal hemoglobin not to be turned off
Ethical concerns: designer babies, access, possibility for side effects and things to go wrong
Can do single gene editing to eliminate certain diseases.
79
Factors affecting the patient provider relationship
Provider communication problems
- patients often leave a consultation feeling dissatisfied because of lack of info, poor understanding of medical advice, and the perception of being unable to comply with the medical advice.
-Not enough patient provider interaction: the more time physicians spend with patients, the more satisfied patients are.
80
What drives patient communication problems
- different education and social backgrounds
- low levels of health literacy influenced by low reading levels and numeracy
- incomplete or inaccurate understanding of medical conditions or inability to navigate the healthcare system, seek preventative care and adhere to prescribed treatment
-misunderstandings related to different ethnic and cultural backgrounds of patients and providers.
81
What do people want from their healthcare providers
Treated with dignity and respect
* Listen carefully to concerns and questions
* Easy to talk to
* Take concerns seriously
* Willing to spend enough time with them
* Truly care about them and their health
* Have good medical judgment
* Ask good questions to understand patient needs
* Be up-to-date with research
* See them on short notice if needed
