• Factors associated with the utilization of community dental services among newly incarcerated adults

      Graves, Whitney; Blanks, Hairston Starla; Caplan, Lee S.; Erwin, Katherine A; Ditler, Cynthia S; Treadwell, Henrie M; Morehouse School of Medicine, Walden University, Georgia Department of Corrections (Georgia Public Health Association, 2017)
      Background: Given the high rates of risky behaviors and health conditions among incarcerated individuals and the relationship between oral and general health, receipt of quality dental care is essential to the overall health and well-being of this population. However, few recent studies have focused on access to care and the state of oral health among incarcerated populations in the U.S. For the current study, a secondary data analysis was conducted to: 1) assess factors associated with the use of dental services among a newly incarcerated prison population in Georgia and 2) consider barriers related to utilization of dental services pre- to post-release. Methods: Descriptive statistics were calculated, and bivariate and logistic regression analyses were conducted utilizing SAS 9.2 software. Results: Thirty-one percent (n=250) of survey respondents reported having a dental visit within the past year. Survey respondents who had a regular dentist (OR: 1.9; 95% CI: 1.325, 2.697), private dental insurance (OR: 1.5; 95% CI: 1.022, 2.245), or who reported pain as the reason for their last dental visit (OR: 2.2; 95% CI: 1.556, 3.130) were more likely to have utilized dental services within the past year. Conclusions: The findings highlight the role of social and economic resources and oral health needs on utilization of dental services. Additional practice and policy efforts are needed to address gaps in the dental care continuum that affect currently and formerly incarcerated adults in Georgia.
    • Fast-Track Extubation in Infancy and Early Childhood Following Heart Surgery: Outcome Analysis and Predictors of Failure

      Geister, Emma; Esquivel, Raquel; Crethers, Danielle; Weatherholt, Danalynn; Sanchez, Maria Gabriela; Munoz, Gustavo; Biological Sciences, Medical College of Georgia (Augusta University Libraries, 2020-05-05)
      This item presents the abstract for a poster presentation at the 21st Annual Phi Kappa Phi Student Research and Fine Arts Conference.
    • Feasibility of Reusable Radiochromic Plastics as Dosimeter

      Recht, Maxwell; Inglett, Chase; Hauger, Joseph; Adamovics, John; Biological Sciences, Chemistry and Physics, Rider University (Augusta University Libraries, 2020-05-04)
      This item presents the abstract for an oral presentation at the 21st Annual Phi Kappa Phi Student Research and Fine Arts Conference.
    • Financing public health in Georgia

      Denson, Dionne; Georgia Department of Public Health (Georgia Public Health Association, 2017)
      Background: The public health system in Georgia is carried out through a hybrid governance structure. The Department of Public Health and the county boards of health have responsibility for serving the public health needs for the Georgia citizens. Funding for the Georgia public health system is derived from a number of funding sources which include federal, state, local, and private funds. Methods: Georgia's public health system relies on multiple funding streams to provide services. These public health services have the potential to provide a return on investment and positive impact on the local economy. In the hybrid governance structure, local board of health members have an important role in financing of the Georgia public health system. Results: The funding relationship between state and local boards of health is essential to support the public health system in Georgia. To maintain the public health system, funding should be integrated where possible and used to enhance or expand services. The relationship with community leaders, key stakeholders, and other organizations are important to maintaining the public health system. Conclusions: Board of Health Members understanding the Georgia public health funding structure, and the importance of the role of the local county boards of health is key to sustainability.
    • Findings from a national home food environment survey: How does Georgia compare?

      Hermstad, April; Haardoeerfer, Regine; Woodruff, Rebecca; Raskind, Ilana; Kegler. Michelle; Emory University (Georgia Public Health Association, 2017)
      Background: Aspects of the home food environment, both social and physical, influence healthy eating and weight management practices. Healthy eating, according to the Dietary Guidelines for Americans, 2015, centers on balancing calories consumed and calories expended for weight management combined with consumption of nutrient-dense foods and drinks. Obesity and excess weight increase the risk of numerous chronic diseases including cancer, diabetes, and heart disease. With this presentation, we will explore how Georgia home food environments and eating behaviors are similar or different from the rest of the nation. Methods: Survey participants (n=4,942) were recruited from a reputable online survey panel service. Eligible participants were English-speaking U.S. adults ages 18-75; the final sample was representative of the U.S. population in terms of age, race/ethnicity, geographic region, and income level. Georgia participants represented 3% of the overall sample (n=158). Incentives for completing the 30-minute online survey were provided by the panel service. Survey measures included sociodemographics, healthy eating behaviors (e.g., fruit, vegetable, and fat intake), social home food environment (e.g., food shopping/preparation, household member support) physical home food environment (e.g., food/drink inventories/placement), household food security and coping strategies, and broader contextual factors (e.g., the community food environment, and community capacity and assets). Results: Descriptive data to be presented will include characteristics of participant households, including levels of social and environmental support for healthy eating. Prevalence estimates for key environmental (food/drink inventories/placement, social support among household members) and behavioral (dietary behavior) variables across the sample and among Georgia participants will also be shared. Statistically significant differences between Georgia and the nation will be highlighted. Conclusions: This study presents a unique opportunity to explore socio-environmental influences on healthy eating behaviors nationwide and specifically among Georgians. Findings may be useful in informing tailored messages, healthy eating interventions, and related public health priorities for the state of Georgia.
    • Formative research to develop a lifestyle application (app) for African American breast cancer survivors

      Smith, Selina; Whitehead, Mary; Sheats, Joyce; Fontenot, Brittney; Alema-Mensah, Ernest; Ansa, Benjamin E.; Augusta University (Georgia Public Health Association, 2016)
      Background: There is a proliferation of lifestyle-oriented mobile technologies; however, few have targeted users. Through intervention mapping, investigators and community partners completed Steps 1-3 (needs assessment, formulation of change objectives, and selection of theory-based methods) of a process to develop a mobile cancer prevention application (app) for cancer prevention. The aim of this qualitative study was to complete Step 4 (intervention development) by eliciting input from African American (AA) breast cancer survivors (BCSs) to guide app development. Methods: Four focus group discussions (n=60) and three individual semi-structured interviews (n=36) were conducted with AA BCSs (40-72 years of age) to assess barriers and strategies for lifestyle change. All focus groups and interviews were recorded and transcribed verbatim. Data were analyzed with NVivo qualitative data analysis software version 10, allowing categories, themes, and patterns to emerge. Results: Three categories and related themes emerged from the analysis: 1) perceptions about modifiable risk factors; 2) strategies related to adherence to cancer prevention guidelines; and 3) app components to address barriers to adherence. Participant perceptions, strategies, and recommended components guided development of the app. Conclusions: For development of a mobile cancer prevention app, these findings will assist investigators in targeting features that are usable, acceptable, and accessible for AA BCSs.
    • From the Editor Historical Critique of the Leading Causes of Death in the United States

      Thomas, McKinley; Mercer University (Georgia Public Health Association, 2006)
      From the Editor
    • From the Editor: State Journals of Public Health

      Thomas, McKinley; Mercer University (Georgia Public Health Association, 2009)
      From the Editor
    • Fulfilling community health assessment requirements: Lessons learned from facilitating state-wide community health forums

      Walker, Ashley; Peden, Angela; Tedders, Stuart H.; Barron, John; Jackson, Aaron; Williams, Nicholas; Ugwu, Bethrand; Georgia Southern University (Georgia Public Health Association, 2016)
      Background: A prerequisite for National Public Health Accreditation is completion of a Community Health Assessment (CHA) that presents an exhaustive profile of the population served by a particular public health agency. Methods: The Georgia Department of Public Health (GA DPH) contracted with the Center for Public Health Practice and Research at Georgia Southern University to facilitate five state-wide community health forums. Results: Evaluation of the forums yielded qualitative data illustrating current challenges faced by Georgians, as well as assets that could be leveraged to improve health status. Conclusion: Lessons learned from these state-wide community health forums can be applied to improve the overall process of gathering data for a comprehensive CHA throughout Georgia or other areas interested in pursuing public health agency accreditation.
    • Gender disparities in weight gain among offenders who are obese upon entering correctional facilities

      Gates, Madison, L.; Webb, Nancy C.; Stone, Rebecca; Ballance, Darra; Yoo, Wonsuk; Institute of Public & Preventive Health, Augusta University (Georgia Public Health Association, 2016)
      Background: Obesity is a significant health issue for offenders, who have a higher prevalence of obesity-related conditions, such as diabetes, compared to non-incarcerated populations. Within incarcerated populations, there are obesity disparities in terms of race, gender, and age, as well as excess weight gain during incarceration. Methods: This longitudinal study was conducted for 2005 – 2010 in collaboration with a Department of Corrections in the east south central region of the United States. From electronic health records of 10,841 offenders, weight, height, and demographic data were extracted. As determined from these data, 2,622 offenders met the inclusion criteria (two or more valid weight and height measurements and length of incarceration > zero). Results: Women offenders who entered corrections as obese had a mean (and standard deviation) body mass index (BMI) of 36.2 (5.3) at baseline; the mean for men was 34.2 (4.4). For women who were obese at baseline, their BMI increased by 1.0 (3.3); for men their BMI decreased by 0.7 (3.1). Gender differences for changes in BMI among the obese population were significant (χ2 = 15.8, p < 0.001). Women and men also differed in regard to weight gain (χ2 = 34.0, p < 0.001). Further, those women and men who were not obese at baseline had an increase in BMI that was greater than the increase for the group that entered corrections as obese (p > 0.001). Conclusions: Women offenders, obese or not at baseline, had greater gains in weight in comparison to men. However, there were no significant differences in BMI changes for race or correlations with age or length of incarceration. The findings related to gender warrant further investigations to explain these disparities and to evaluate the capacity of the corrections system to meet the health needs of women.
    • Geographic modelling of sickle cell trait in four US regions

      Bhattacharya, Anunay; Tabi, Marian (Georgia Public Health Association, 2017)
      Background: Many studies have been done concerning the prevalence of sickle cell trait, its incidence and screening techniques. It is most commonly observed in the Black and Hispanic population in the United States. This study used retrospective data from the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR – December 12, 2014) to model, analyze, and substantiate the geographic distribution of sickle cell trait, its incidence, prevalence and screening in 44 states divided into 4 regions in the United States. Methods: We conducted data modelling of geographic regions in the United States. The four regions were West, Midwest, South and Northeast. The research question was: How is screening rate related to sickle cell trait in the regions of the United States? The data were pooled in an Excel file and analyzed using linear regression and generalized linear modelling in SAS 9.4. Results: The results showed that (1) there is a significant relationship between incidence and the number of infants screened for region 2 (Midwest), p=0.0020; (2) a significant relationship between incidence and sickle cell trait for region 2 (Midwest), p=0.000; (3) incidence with screening and trait for region 1 (West), region 2 (Midwest) and region 3 (South), p<0.05. (4) Generalized linear modelling was also significant with interactions for the region 1, region 2, and region 3, with p<0.05. Conclusions: Findings indicate that more screening is needed to diagnose sickle cell trait, particularly among Black and Hispanic infants from the region 2 (Midwest) states. There should be more intervention programs implemented to promote early screening among newborns to reduce disparities and the burden of prevalence.
    • Georgia Latino enrollment in the Affordable Care Act: A qualitative, key informant analysis

      McCulloch, Audrey; Evans, P Dabney; Emory University (Georgia Public Health Association, 2016)
      Background: Prior to implementation of the Affordable Care Act (ACA) in 2010, one in three Latinos in the United States were uninsured. In Georgia, a state that established a federal Marketplace, nearly half of Latinos lacked health insurance coverage going into the initial enrollment period of October 1, 2013 to April 15, 2014. The ACA provided an opportunity for these uninsured Latinos to gain health insurance coverage, thus increasing their access to necessary medical services. The purpose of this qualitative study was to explore, from the perspective of key informants, knowledge of Georgia Latinos about the ACA and perceived barriers to enrollment in Marketplace health insurance coverage. Methods: A semi-structured interview guide based on a review of relevant literature and consideration of the study goal and aims was developed. Fourteen in-depth interviews with key informants (participants) from Georgia’s Latino community, including nonprofit leaders, health media professionals, and community health promoters, were conducted between June and September 2014. Results: Participants described perceived barriers to enrollment during the initial ACA enrollment period and made recommendations for the design and implementation of future outreach, education and enrollment strategies. Major themes that emerged involved basic health literacy, misinformation, enrollment opportunities, the importance of place and politics, and technology and language as barriers. Conclusions: To target Georgia Latinos, we provide seven recommendations for outreach, education and enrollment, including the organization of one-on-one services in locations of familiarity and comfort to Georgia Latinos and the hiring and training of Spanish-speaking enrollment professionals. When providing ACA education to Latinos, stakeholders should begin with basic health literacy concepts and education regarding the fundamentals of the United States health insurance system. The findings of this study may serve to guide future design and provision of culturally competent outreach, education and enrollment services.
    • Georgia’s critical access hospitals: Financial performance and process improvement

      Mase, William; Apenteng, Bettye; Carhuff, Lisa; Hanna, Mark; Boakye, Kwabena; Kimsey, Linda; Opoku, Samuel; Owens, Charles; Tedders, Stuart; Whaley, Patricia; et al. (2017)
      Background: Georgia’s Critical Access Hospitals (CAH) are in crisis. Within the last 2 years, four CAHs have closed their doors due to failed financial and operational performance. Evidence points to the risk that several more are on the brink of closure. CAH closures have far-reaching impact on residents. Negative impacts include the extra distance that patients must travel to seek care, the displacement of health professionals and the unravelling of the entire fabric of the communities these hospitals serve. We hope to help participants understand the financial and operational challenges of CAHs, and to identify realistic strategies to enhance the resilience of these hospitals. Methods: The Georgia Southern team worked with a cohort of CAHs across the state of Georgia to identify financial and operational best practices. Year 1 of this project focused on data collection, analysis and benchmarking. Year 2 is currently focused on performance improvement through Lean Six Sigma. Results: CAHs face financial constraints due to factors such as low volume, declining market share, unfavorable payer mix, challenges relating to collections, and difficulties in recruiting providers. CAHs in Georgia performed more poorly on the financial indicators assessed, in comparison to respective national medians. Many CAHs in our cohort are better organized to deal with crises – utilizing strong executive and bureaucratic structures – than to pursue ongoing improvement through employee empowerment and a process focus. Conclusions: Improvements in the operational and financial management practices of Georgia’s CAHs may significantly improve performance. Evidence-based strategies for operational and financial improvement are vital to sustainability. Opportunities exist for collaboration between public health systems and rural hospitals, including CAHs in assuring healthcare access for rural populations.
    • Georgia’s rural hospital closures: The common-good approach to ethical decision-making

      Bastian G., Randi; Garner, Marcus; Barron S., John; Akowuah A., Emmanuel; Mase A. William; Jiann-Ping Hsu College of Public Health, Department of Health Policy and Management, Georgia Southern University (2016)
      ABSTRACT Background: Critical access hospitals provide several essential services to local communities. Along with the functions associated with providing necessary medical care, they also offer employment opportunities and other economic benefits to the communities they serve. Since 2010, the number of rural hospitals closures has steadily increased. The common-good approach to ethical decision-making provides a framework that aids in evaluation of the effects that hospital closures have on rural residents and communities. Methods: This analysis includes results of a systematic overview of peer-reviewed literature to address the following research questions: 1) How have state policies and the adoption of Medicaid expansion influenced the viability or rural hospitals? 2) What are the ethical implications of Medicaid expansion and state policy reform/adoption pertaining to viability of rural hospitals? and 3) What are the ethical implications of critical access hospitals closures on rural communities in Georgia? Information related to these questions is presented, along with tactics to addressing these in an ethical manner. Results: This descriptive analysis shows that the largest number of state-specific closures have occurred in states with a federal exchange and which chose not to expand Medicaid. Characteristics of the state of Georgia and the counties with recent closures show that these counties typically have smaller populations with a high minority presence, lower education and income levels, and higher numbers of medically uninsured. Conclusions: The common-good approach to ethical decision-making is suitable for evaluating the ethical implications of policy-level decisions impacting the closure of critical access hospitals serving the rural communities of Georgia.
    • Give Rise

      Visintainer, Rachel; Communications (Augusta University Libraries, 2020-05-04)
      This item presents the abstract for an oral presentation at the 21st Annual Phi Kappa Phi Student Research and Fine Arts Conference.
    • GPHA www.jgpha.com 153 Georgia Public Health Association Impact of the Georgia Charitable Care Network on cost savings from lowering blood pressure and decreasing emergency department use

      Corso, Phaedra; Walcott, Rebecca; Ingels, Justin; University of Georgia (Journal of the Georgia Public Health Association, 2015)
      Background: The Georgia Charitable Care Network (GCCN) is a non-profit organization whose primary mission is to foster collaborative partnerships to deliver compassionate health care to low-income, uninsured individuals. Hypertension screening and management is a service provide by 90+ clinics in the GCCN statewide. Methods: With data from N=1661 patients who were screened and treated for hypertension at n=12 clinics in 2013, the impact of hypertension management on blood pressure levels, the incidence of coronary heart disease (CHD) and stroke, and utilization of emergency departments (EDs) were examined. The resulting changes in healthcare utilization were converted to changes in healthcare costs and compared to the expenditures for clinics providing screening and treatment services to the same population over a one-year period. Results: Patients with an initial diagnosis of hypertension or prehypertension experienced average reductions of 10.27 mmHg and 6.32 mmHg in systolic and diastolic blood pressure, respectively, during their follow-up visits. These changes were associated with 32.0% and 44.3% reductions in the relative risk of CHD and stroke, respectively. The savings from this reduction in blood pressure and avoided ED visits for 1661 hypertensive patients produced positive net benefits in 2013 US$, of more than $400,000, with a benefit-cost ratio of 1.6. Conclusions: For every dollar invested in GCCN clinics for hypertension screening and management, there is a benefit to the healthcare system through reduced costs of $1.60. GCCN clinics are a cost-saving delivery model for underserved communities with poor health status and high ED usage.
    • Health Literacy Levels Among Adult Support Group Members and the General Adult Public : A Focus Group Approach

      Czech, Daniel R.; Alberto, June; Joyner, A. Barry; Georgia Southern University (Georgia Public Health Association, 2007)
      Health literacy has been identified as lacking in 47% of Americans (The National Academies, 2004). While health literacy reports of studies conducted in the southern section of the United States are available (DeWalt et al., 2004; Kennen et al. 2005), this research team found limited research that provides health literacy levels of the southeast, rural Georgia population. The purpose of this exploratory study was to examine and compare health literacy of health-related support group members and non group members in southeast Georgia utilizing a focus group methodology developed by Kreuger (1994). After Institutional Review Board approval at a local university, the research team utilized 5- 10 established Health-related Support Groups of 6-10 individuals in the southeastern part of the United States. An additional four focus groups composed of persons not associated with a health-related support group were also used for comparative purposes. Participants were recruited with the assistance of local health care providers. The initial open-ended questions consisted of items such as: “Describe your experience reading health resources.” "What makes a health resource difficult to read, as well as easy to read?" The moderator utilized additional probing questions and reframing comments as necessary (Kreuger, 1994). The data were analyzed by the qualitative content analysis method described by Berg (1989). The themes that emerged across groups reflected confusion about medication directions, health terms, and communication from health care providers and doubt about the integrity of and inability to read the small print of health information. Prevention and faith in God were identified as important to self-care. Rationales for themes and future research ideas are discussed.
    • Helping public health professionals access infectious disease trainings and resources: The Region IV PHTC infectious diseases training database

      Lloyd, Laura; McCormick, Lisa; Alperin, Melissa; Carvallo, Michelle; Wilson, Cidney; Bergland, Brita; Patel, Arti; Miner, Kathleen; Emory University (Georgia Public Health Association, 2017)
      Background: The Region IV Public Health Training Center (R-IV PHTC), located at Emory University’s Rollins School of Public Health, has a mission that includes providing training and educational offerings to strengthen the competency of the current public health workforce in HHS Region IV (which includes GA). Additionally, the R-IV PHTC has been charged with serving as a national resource in the area of infectious disease. To fulfill this charge, the R-IV PHTC conducted an environmental scan to identify and increase access to existing infectious disease trainings and resources currently available to the public health workforce. Methods: From June 2015 – February 2016, the R-IV PHTC systematically reviewed infectious disease-related trainings developed by credible organizations between 2011-2015. We reviewed the websites and learning management systems of 73 different organizations including but not limited to the TrainFinder Real-time Affiliated Integrated Network (TRAIN), Centers for Disease Control and Prevention, Association of State and Territorial Health Officials (ASTHO), and other PHTCs. Trainings were identified utilizing several search terms including infectious disease, vaccination, HIV/AIDS, tuberculosis (TB), Ebola, measles, etc. Results: Altogether, the R-IV PHTC identified over 500 training programs and resources in our designated content area of Infectious Disease developed by other public health organizations between 2011-2015. The final trainings are available in an easy-to-use searchable database and can be filtered by sponsor, title, year, provision of continuing education credits, addressed competencies, cost, length, infectious disease category, and modality. The database will be updated at least once yearly to ensure currency. Conclusions: This poster will describe the methodology that the R-IV PHTC used to conduct an environmental scan of infectious diseases trainings. In addition, the poster will explain how to locate and access infectious disease trainings in one database on the R-IV PHTC website using a variety of search filters
    • Hepatitis C and HIV screening

      Perry, Merry (Georgia Public Health Association, 2017)
      Background: Chronic hepatitis C virus (HCV) affects more than 3 million people in the United States. Current HCV treatment offers a shorter treatment interval with fewer adverse reactions as well as improved cure rates of 96%. The increasing rates of hepatitis C infections in adults have been accompanied by multifaceted adverse health outcomes. The purpose of this screening program is to identify HCV-infected individuals, which will lead to clinical interventions and treatment that will improve health outcomes compared to no screening. Methods: The Centers for Disease Control and Prevention guidelines recommend that anyone with risk factors should be screened for HCV infection. In addition, all persons born between 1945 and 1965 should be screened once in their lifetime. Screening at Curtis V. Cooper Primary HealthCare Inc. (CVCPHC) includes individuals 18 and over for HCV and HIV. Results: CVCPHC’s screening program was implemented in January 2016. As of October 1, 2016, 4054 individuals had been screened for HCV with 187 antibody-positive. Of the individuals with positive antibody tests, 179 were RNA tested, and of these, 122 tested positive. Seventy four percent of those with a positive RNA test were linked to care. Eighty five percent of individuals with a positive RNA test were born between 1945 and 1965. The current case reports consist of 57 active HCV patients on medication and/or have completed therapy; 10 have a viral load not detected (ND) > 4-6 weeks after starting medication; 15 completed therapy with a ND viral load resulting in a 100% cure rate; 12 are currently on medication < 4 weeks; 15 were referred to GI; and five deferred treatment. Conclusions: Screening for HCV and HIV lead to the appropriate interventions and treatments for persons infected, preventing the progression of liver disease and reducing morbidity and possibly mortality.
    • Hepatitis C and injection drug use: Testing and linkage to care

      Sutton, Marie; Youngner, Cole; Holloway, Winona; Emory University (Georgia Public Health Association, 2016)
      Background: The recent outbreak of HIV infection in Indiana linked to injection drug use demonstrates the importance of timely HIV and Hepatitis C surveillance and rapid response to interrupt disease transmission. An estimated 2.7 – 3.9 million Americans have chronic hepatitis C virus (HCV) infection. Of those, 50 – 70% are unaware of their infection. People who inject drugs account for more than half of new HCV cases. Within 5 years of beginning injection drug use, 50 – 80% of injection drug users (IDUs) become infected with HCV. Since 2007, HCV-related deaths have surpassed HIV-related deaths. CDC reported 19,368 death certificates listing HCV as a cause of death in 2013, adding that this figure represents a fraction of deaths attributable to HCV. Method: Imagine Hope, supported by a grant from a pharmaceutical company, initiated HCV rapid testing in April 2015. The Georgia-wide project includes 10 agencies serving substance-using populations, including 4 methadone clinics. The project offers free, routine HCV testing and linkage to care. Results: Over the first 12 months of testing, 3,226 clients received HCV antibody testing. Of those, 344 (10.7%) were HCV antibody positive (Ab+), with 186 completing confirmatory RNA testing. Confirmatory tests yielded 132 (71%) RNA positive cases; 56 (42.4%) of these were linked to care. Five clients have achieved sustained viral load suppression which is considered a cure for hepatitis C. Numerous others have begun direct acting antiviral regimens. Conclusion: HCV testing in substance abuse facilities is feasible. Among substance users, HCV prevalence is high and awareness of infection risk is low. Linkage to care is enhanced by the use of a navigator. RNA screening prior to the 1st medical appointment expedites linkage to care; RNA positive clients are more motivated to keep appointments and RNA negative clients do not clog an already burdened system of care for the uninsured.