Susan Quine - Academia.edu (original) (raw)

Papers by Susan Quine

Aging & Mental Health, 2008

To explore outlooks for the future which exist in an older population, through construction of a ... more To explore outlooks for the future which exist in an older population, through construction of a typology of combinations of absence or presence of reported hopes and fears for the future and a detailed analysis of the characteristics of older people in each of the four outlook categories created: optimistic, pessimistic, realistic or detached. The findings are based on population survey responses from 8881 older Australians (65 + yr) living independently in the community. The Cochrane-Armitage test was used to detect the presence of trends, while logistic regression modelling was used to examine predictors of respondents expressing no main hope and/or no main fear. The logistic regression modelling identified predictors of outlook category, which have face validity and are consistent with the literature. In addition, the proportion of older people in the pessimistic category with scores indicating psychological distress (Kessler 6) was significantly higher than in the three other categories, providing support for the validity of the typology. The vast majority of independently living older Australians have realistic or optimistic outlooks about their future. The small minority who are pessimistic, and more likely to be experiencing psychological distress, can be identified through self-reported absence of hopes accompanied by presence of fears.

Australian Journal of Public Health, 2010

Objective: To determine the magnitude of differentials in mortality and hospital morbidity by Loc... more Objective: To determine the magnitude of differentials in mortality and hospital morbidity by Local Government Area (LGA) in Sydney (1 985-1 988), and to correlate these with LGA indicators of socioeconomic status.

Health Promotion Journal of Australia Official Journal of Australian Association of Health Promotion Professionals, Sep 1, 2006

To identify and describe elements of accessibility and other dimensions of quality of primary hea... more To identify and describe elements of accessibility and other dimensions of quality of primary health care for Australian young people. Five sampling frames identified relevant services and programs across New South Wales (NSW) which were then selected using purposive, convenience or snowball sampling. In-depth interviews were conducted with senior staff members, tape-recorded, transcribed, entered into the qualitative software package NUD*IST and coded under seven theme headings. Interviews with 77 services across five sectors in NSW identified seven principles of better practice in youth health. These were: accessibility, evidence-based practice, youth participation, collaboration, professional development, sustainability and evaluation. Accessibility was the principle most frequently addressed and evaluation was the least frequently addressed. Many seemingly effective programs and services had been minimally evaluated for impact or outcome related to young people's access or health. Principles of better practice in promoting or delivering adolescent health care have strong face validity across a range of sectors and service types in a heterogeneous primary health care system. These principles are applied to varying degrees in a vast array of health and health promotion programs. Despite this, there is a clear need for impact and outcome evaluation among the majority of programs.

Community Health Studies, 2010

The public health problem of head injuries contributes to considerable morbidity in the community... more The public health problem of head injuries contributes to considerable morbidity in the community and is the commonest cause of death in young adult Australians. However, estimating the incidence of head injury has been difficult. and has varied between countries and over time.

Rural and remote health

Previous research has reported rural-urban differences in health concerns and access issues. Howe... more Previous research has reported rural-urban differences in health concerns and access issues. However, very little of this has concerned young people, and what has been published has been mainly from countries other than Australia and may not generalise to Australian youth. The study described in this paper is a subset of a larger study on health concerns and access to healthcare for younger people (12-17 years) living in New South Wales (NSW), Australia. This paper reports findings on rural-urban similarities and differences. The specific study objective was to identify and describe rural-urban differences, especially those associated with structural disadvantage. The reported findings form part of a larger state-wide cross-sectional study of access to healthcare among NSW adolescents. Adolescents were drawn from high schools in ten of the 17 Area Health Services in NSW. These Area Health Services were selected because they represent most aspects of rural-urban NSW with respect to p...

Community Health Studies, 1990

The public health problem of head injuries contributes to considerable morbidity in the community... more The public health problem of head injuries contributes to considerable morbidity in the community and is the commonest cause of death in young adult Australians. However, estimating the incidence of head injury has been difficult. and has varied between countries and over time.

The American Journal of Gastroenterology, 2004

The childhood socioeconomic environment has been linked to adult health status in several studies... more The childhood socioeconomic environment has been linked to adult health status in several studies. However, its role in the pathogenesis of adult irritable bowel syndrome (IBS) remains unknown. We aim to assess the influence of the childhood environment on adult IBS, using data from a New Zealand birth cohort study. The Dunedin birth cohort was assembled in 1972-1973 and has been followed prospectively to age 26 (n = 980). IBS was classified according to both Rome and Manning criteria, using self-reported symptom data obtained at age 26 yr. Childhood social class was used as a proxy measure of the quality of the childhood socioeconomic environment and was assigned according to the highest average socioeconomic (SES) level of either parent from interviews across the first 15 yr of life. Childhood social class was significantly associated with IBS according to Manning Criteria (p = 0.05) and Rome II Criteria (p = 0.05). The prevailing trend was identical for both measures of IBS in the sex-adjusted models: this trend can be characterized as a general, and near-linear decrease in the odds of IBS across decreasing levels of social class. Contrasts with the reference group were significant on all comparisons for Manning Criteria IBS (high vs upper middle, p = 0.04; lower middle, p = 0.04; low, p = 0.01), and on comparisons involving the two lower social class groups for Rome II Criteria IBS (high vs lower middle, p = 0.03; low, p = 0.03). The associations were attenuated, but not eliminated by further adjustment for adult social class. An affluent childhood environment is an independent risk factor for adult IBS.

Australasian journal on ageing, Jan 26, 2013

To explore perspectives of three groups concerning transfers from aged care facilities to emergen... more To explore perspectives of three groups concerning transfers from aged care facilities to emergency departments. We sought to reveal factors influencing transfer decisions; how active each group was in making decisions; and to what extent groups ceded decision-making to others. Semi-structured interviews of 11 residents, 14 relatives and 17 staff with content analysis of interview transcripts. The three groups substantially differed in their involvement with initiating, and attitudes towards, transfer. Residents were least likely to be involved in the decision, yet most likely to support transfer. Staff felt conflicted between their desire to provide optimal treatment for one ill resident, and their obligations to other residents under care. Staff perspectives were largely consistent with published data, but we describe new results for other informant groups. Group expectations and preferences differ substantially. Service delivery to meet all preferences presents a challenge for he...

This study required the cooperation and sustained effort of a great many people and organisations... more This study required the cooperation and sustained effort of a great many people and organisations. Our most sincere thanks go to all of those involved. Some, however, deserve special mention. The Project Officer, Diana Bernard, managed tirelessly the myriad and complex details of recruiting, scheduling and liaising with schools, youth health services, community health centres, general practitioners, youth health workers and youth health co-ordinators from across NSW; conducted the many interviews; managed data entry and analysis; and contributed significantly to the preparation of this report. She worked to the highest standards of professionalism and competence under minimal supervision and did all of this with buoyant cheerfulness.

Journal of the American Geriatrics Society, 2011

Journal of Adolescent Health, 2004

Purpose: To identify the health concerns for which adolescent residents in New South Wales, Austr... more Purpose: To identify the health concerns for which adolescent residents in New South Wales, Australia, do not receive health care, and the associated factors, including their sociodemographic distribution.

Internal Medicine Journal, 2012

In order to design optimal systems to meet the acute healthcare needs of the frail elderly living... more In order to design optimal systems to meet the acute healthcare needs of the frail elderly living in residential care, good clinical information is essential. The aims of this study were to analyse the casemix and outcomes of patients transferred from residential aged care facilities to public hospital emergency departments in New South Wales. Individual patient data from six hospital emergency departments and inpatient wards were obtained from merged databases and analysed using descriptive and comparative statistics. Outcomes in 4680 patient transfers over a 12-month period in 2006-2007 were analysed. Transfers occur mostly in high-acuity patients, with approximately three of every four transfers admitted; one in every 12 dying; and admitted patients undergoing an average of 2.4 interventions or procedures during each hospital stay. Several variables are associated with prolonged length of emergency department stay including triage urgency, type of hospital and transfers occurring in winter or out of hours. Patients transferred from aged care facilities to emergency departments are predominantly high-acuity patients with a substantial likelihood of hospitalisation, intervention and death. Nevertheless, scope exists for some episodes of acute care, in both discharged and admitted patients, to be provided outside a hospital setting.

Geriatrics & Gerontology International, 2013

If developing policies to optimize quality acute care within residential aged care facilities (RA... more If developing policies to optimize quality acute care within residential aged care facilities (RACF) is a goal, understanding the factors that influence the decision to transfer a resident from RACF to hospital emergency departments is important. The aim of the present study was to review the published literature pertaining to transfer decisions.

Disability & Rehabilitation, 1993

This randomized controlled trial compared accelerated rehabilitation after surgical treatment of ... more This randomized controlled trial compared accelerated rehabilitation after surgical treatment of proximal femoral fracture with conventional care and was conducted in a general hospital in an outer urban area. Participating were 261 sequentially admitted patients over the age of 50 years who met predetermined inclusion criteria and all were followed up until death or 4 months after fracture. Patients who were treated with the accelerated rehabilitation programme had a 20% reduction in length of hospital stay. Improved physical independence (as measured by Barthel Index) was observed after fracture in accelerated rehabilitation programme patients with limited pre-existing disability. Non-nursing-home patients receiving accelerated rehabilitation were also less likely to be discharged to nursing-home care or die in hospital. Accelerated rehabilitation led to a substantial reduction in length of hospital stay with a modest short-term improvement in level of physical independence and accommodation status after discharge.

Australian Health Review, 2002

A qualitative study was conducted in Victoria to explore factors affecting the acceptability and ... more A qualitative study was conducted in Victoria to explore factors affecting the acceptability and use of assistive devices by older people. Four focus groups and fifteen home-based interviews were conducted with older people (mean age 77 years) who had been issued with 2 or more assistive devices. Analysis of the data indicated that almost all participants were content to be advised by professionals on suitable equipment. Most considered the equipment and home modifications safe and easy to use, and appreciated the benefits for mobility, confidence and independence. Reasons for non-use were commonly related to changes in functional ability. Cost was a major deterrent for a small number who opted to 'make do'. Recommendations are made for improvements to the existing system of equipment provision and use, including review and development of consistency of provision and payment policy among service providers; flexibility of payment options; adequate education and follow-up support for clients.

Australian and New Zealand Journal of Public Health, 2007

Australasian Journal on Ageing, 2006

The ageing of Australia's 5.5 million baby boomers (born 1946 -1965) will significantly change Au... more The ageing of Australia's 5.5 million baby boomers (born 1946 -1965) will significantly change Australian society, yet it is unclear what is known about the expectations and plans of this cohort for their retirement and old age. This paper provides a first step by reviewing the Australian literature, focusing on the areas of health, housing, work and income, and responsibility. Information from the peer-reviewed literature and the Internet published during 1996 -2005 was reviewed. One hundred ninety-five Australian references were retrieved, of which only 94 were relevant. The review identified that, despite agreement about the significance of baby boomer's ageing, empirical work directly addressing the research topics was rare. In particular, there was little coverage of baby boomers' ascription of responsibility for their welfare in older age. If policies are to be effective, empirical research obtaining information directly from baby boomers is required to fill the gaps identified through this review.

Australasian Journal on Ageing, 1999

... Carol Birks, Ken Lockwood, Ian Cameron, Susan Kurrle, Wendy Burnside, Sandra Easter and Jenni... more ... Carol Birks, Ken Lockwood, Ian Cameron, Susan Kurrle, Wendy Burnside, Sandra Easter and Jennifer Venman Hornsby Ku-ring-gai Hospital, Sydney ... Cameron ID, Lyle DM, Quine S. Cost effectiveness of accelerated rehabilitation after proximal femoral fracture. ...

Archives of Gerontology and Geriatrics, 1994

The factors that may influence compliance with wearing of external hip protectors by potential us... more The factors that may influence compliance with wearing of external hip protectors by potential users living in the community were investigated. Elderly women (median age 83 years) who were hospitalised after fracture, joint replacement or falls and were expected to return to community living participated. Five focus groups were conducted. Most participants said they would not use the hip protector demonstrated. The main objections were a perceived lack of comfort in wearing the appliance, particularly in bed, coupled with the belief that they were not at high risk. Other lesser issues were the extra effort needed to wear the device, appearance, accuracy of fit, cost and unfamiliarity with the protectors. These findings suggest that, in general, high risk elderly women living in the community will be unlikely to use external hip protectors unless there is considerable encouragement from family members and/or health professionals. Educational programmes could reduce some misconceptions about hip fracture, and reinforce the benefits of wearing a protective appliance. They may also increase awareness of personal risk. An introductory period of supervised wearing of the hip protectors, while in hospital or respite care, may enhance compliance.

Aging & Mental Health, 2008

To explore outlooks for the future which exist in an older population, through construction of a ... more To explore outlooks for the future which exist in an older population, through construction of a typology of combinations of absence or presence of reported hopes and fears for the future and a detailed analysis of the characteristics of older people in each of the four outlook categories created: optimistic, pessimistic, realistic or detached. The findings are based on population survey responses from 8881 older Australians (65 + yr) living independently in the community. The Cochrane-Armitage test was used to detect the presence of trends, while logistic regression modelling was used to examine predictors of respondents expressing no main hope and/or no main fear. The logistic regression modelling identified predictors of outlook category, which have face validity and are consistent with the literature. In addition, the proportion of older people in the pessimistic category with scores indicating psychological distress (Kessler 6) was significantly higher than in the three other categories, providing support for the validity of the typology. The vast majority of independently living older Australians have realistic or optimistic outlooks about their future. The small minority who are pessimistic, and more likely to be experiencing psychological distress, can be identified through self-reported absence of hopes accompanied by presence of fears.

Australian Journal of Public Health, 2010

Objective: To determine the magnitude of differentials in mortality and hospital morbidity by Loc... more Objective: To determine the magnitude of differentials in mortality and hospital morbidity by Local Government Area (LGA) in Sydney (1 985-1 988), and to correlate these with LGA indicators of socioeconomic status.

Health Promotion Journal of Australia Official Journal of Australian Association of Health Promotion Professionals, Sep 1, 2006

To identify and describe elements of accessibility and other dimensions of quality of primary hea... more To identify and describe elements of accessibility and other dimensions of quality of primary health care for Australian young people. Five sampling frames identified relevant services and programs across New South Wales (NSW) which were then selected using purposive, convenience or snowball sampling. In-depth interviews were conducted with senior staff members, tape-recorded, transcribed, entered into the qualitative software package NUD*IST and coded under seven theme headings. Interviews with 77 services across five sectors in NSW identified seven principles of better practice in youth health. These were: accessibility, evidence-based practice, youth participation, collaboration, professional development, sustainability and evaluation. Accessibility was the principle most frequently addressed and evaluation was the least frequently addressed. Many seemingly effective programs and services had been minimally evaluated for impact or outcome related to young people's access or health. Principles of better practice in promoting or delivering adolescent health care have strong face validity across a range of sectors and service types in a heterogeneous primary health care system. These principles are applied to varying degrees in a vast array of health and health promotion programs. Despite this, there is a clear need for impact and outcome evaluation among the majority of programs.

Community Health Studies, 2010

The public health problem of head injuries contributes to considerable morbidity in the community... more The public health problem of head injuries contributes to considerable morbidity in the community and is the commonest cause of death in young adult Australians. However, estimating the incidence of head injury has been difficult. and has varied between countries and over time.

Rural and remote health

Previous research has reported rural-urban differences in health concerns and access issues. Howe... more Previous research has reported rural-urban differences in health concerns and access issues. However, very little of this has concerned young people, and what has been published has been mainly from countries other than Australia and may not generalise to Australian youth. The study described in this paper is a subset of a larger study on health concerns and access to healthcare for younger people (12-17 years) living in New South Wales (NSW), Australia. This paper reports findings on rural-urban similarities and differences. The specific study objective was to identify and describe rural-urban differences, especially those associated with structural disadvantage. The reported findings form part of a larger state-wide cross-sectional study of access to healthcare among NSW adolescents. Adolescents were drawn from high schools in ten of the 17 Area Health Services in NSW. These Area Health Services were selected because they represent most aspects of rural-urban NSW with respect to p...

Community Health Studies, 1990

The public health problem of head injuries contributes to considerable morbidity in the community... more The public health problem of head injuries contributes to considerable morbidity in the community and is the commonest cause of death in young adult Australians. However, estimating the incidence of head injury has been difficult. and has varied between countries and over time.

The American Journal of Gastroenterology, 2004

The childhood socioeconomic environment has been linked to adult health status in several studies... more The childhood socioeconomic environment has been linked to adult health status in several studies. However, its role in the pathogenesis of adult irritable bowel syndrome (IBS) remains unknown. We aim to assess the influence of the childhood environment on adult IBS, using data from a New Zealand birth cohort study. The Dunedin birth cohort was assembled in 1972-1973 and has been followed prospectively to age 26 (n = 980). IBS was classified according to both Rome and Manning criteria, using self-reported symptom data obtained at age 26 yr. Childhood social class was used as a proxy measure of the quality of the childhood socioeconomic environment and was assigned according to the highest average socioeconomic (SES) level of either parent from interviews across the first 15 yr of life. Childhood social class was significantly associated with IBS according to Manning Criteria (p = 0.05) and Rome II Criteria (p = 0.05). The prevailing trend was identical for both measures of IBS in the sex-adjusted models: this trend can be characterized as a general, and near-linear decrease in the odds of IBS across decreasing levels of social class. Contrasts with the reference group were significant on all comparisons for Manning Criteria IBS (high vs upper middle, p = 0.04; lower middle, p = 0.04; low, p = 0.01), and on comparisons involving the two lower social class groups for Rome II Criteria IBS (high vs lower middle, p = 0.03; low, p = 0.03). The associations were attenuated, but not eliminated by further adjustment for adult social class. An affluent childhood environment is an independent risk factor for adult IBS.

Australasian journal on ageing, Jan 26, 2013

To explore perspectives of three groups concerning transfers from aged care facilities to emergen... more To explore perspectives of three groups concerning transfers from aged care facilities to emergency departments. We sought to reveal factors influencing transfer decisions; how active each group was in making decisions; and to what extent groups ceded decision-making to others. Semi-structured interviews of 11 residents, 14 relatives and 17 staff with content analysis of interview transcripts. The three groups substantially differed in their involvement with initiating, and attitudes towards, transfer. Residents were least likely to be involved in the decision, yet most likely to support transfer. Staff felt conflicted between their desire to provide optimal treatment for one ill resident, and their obligations to other residents under care. Staff perspectives were largely consistent with published data, but we describe new results for other informant groups. Group expectations and preferences differ substantially. Service delivery to meet all preferences presents a challenge for he...

This study required the cooperation and sustained effort of a great many people and organisations... more This study required the cooperation and sustained effort of a great many people and organisations. Our most sincere thanks go to all of those involved. Some, however, deserve special mention. The Project Officer, Diana Bernard, managed tirelessly the myriad and complex details of recruiting, scheduling and liaising with schools, youth health services, community health centres, general practitioners, youth health workers and youth health co-ordinators from across NSW; conducted the many interviews; managed data entry and analysis; and contributed significantly to the preparation of this report. She worked to the highest standards of professionalism and competence under minimal supervision and did all of this with buoyant cheerfulness.

Journal of the American Geriatrics Society, 2011

Journal of Adolescent Health, 2004

Purpose: To identify the health concerns for which adolescent residents in New South Wales, Austr... more Purpose: To identify the health concerns for which adolescent residents in New South Wales, Australia, do not receive health care, and the associated factors, including their sociodemographic distribution.

Internal Medicine Journal, 2012

In order to design optimal systems to meet the acute healthcare needs of the frail elderly living... more In order to design optimal systems to meet the acute healthcare needs of the frail elderly living in residential care, good clinical information is essential. The aims of this study were to analyse the casemix and outcomes of patients transferred from residential aged care facilities to public hospital emergency departments in New South Wales. Individual patient data from six hospital emergency departments and inpatient wards were obtained from merged databases and analysed using descriptive and comparative statistics. Outcomes in 4680 patient transfers over a 12-month period in 2006-2007 were analysed. Transfers occur mostly in high-acuity patients, with approximately three of every four transfers admitted; one in every 12 dying; and admitted patients undergoing an average of 2.4 interventions or procedures during each hospital stay. Several variables are associated with prolonged length of emergency department stay including triage urgency, type of hospital and transfers occurring in winter or out of hours. Patients transferred from aged care facilities to emergency departments are predominantly high-acuity patients with a substantial likelihood of hospitalisation, intervention and death. Nevertheless, scope exists for some episodes of acute care, in both discharged and admitted patients, to be provided outside a hospital setting.

Geriatrics & Gerontology International, 2013

If developing policies to optimize quality acute care within residential aged care facilities (RA... more If developing policies to optimize quality acute care within residential aged care facilities (RACF) is a goal, understanding the factors that influence the decision to transfer a resident from RACF to hospital emergency departments is important. The aim of the present study was to review the published literature pertaining to transfer decisions.

Disability & Rehabilitation, 1993

This randomized controlled trial compared accelerated rehabilitation after surgical treatment of ... more This randomized controlled trial compared accelerated rehabilitation after surgical treatment of proximal femoral fracture with conventional care and was conducted in a general hospital in an outer urban area. Participating were 261 sequentially admitted patients over the age of 50 years who met predetermined inclusion criteria and all were followed up until death or 4 months after fracture. Patients who were treated with the accelerated rehabilitation programme had a 20% reduction in length of hospital stay. Improved physical independence (as measured by Barthel Index) was observed after fracture in accelerated rehabilitation programme patients with limited pre-existing disability. Non-nursing-home patients receiving accelerated rehabilitation were also less likely to be discharged to nursing-home care or die in hospital. Accelerated rehabilitation led to a substantial reduction in length of hospital stay with a modest short-term improvement in level of physical independence and accommodation status after discharge.

Australian Health Review, 2002

A qualitative study was conducted in Victoria to explore factors affecting the acceptability and ... more A qualitative study was conducted in Victoria to explore factors affecting the acceptability and use of assistive devices by older people. Four focus groups and fifteen home-based interviews were conducted with older people (mean age 77 years) who had been issued with 2 or more assistive devices. Analysis of the data indicated that almost all participants were content to be advised by professionals on suitable equipment. Most considered the equipment and home modifications safe and easy to use, and appreciated the benefits for mobility, confidence and independence. Reasons for non-use were commonly related to changes in functional ability. Cost was a major deterrent for a small number who opted to 'make do'. Recommendations are made for improvements to the existing system of equipment provision and use, including review and development of consistency of provision and payment policy among service providers; flexibility of payment options; adequate education and follow-up support for clients.

Australian and New Zealand Journal of Public Health, 2007

Australasian Journal on Ageing, 2006

The ageing of Australia's 5.5 million baby boomers (born 1946 -1965) will significantly change Au... more The ageing of Australia's 5.5 million baby boomers (born 1946 -1965) will significantly change Australian society, yet it is unclear what is known about the expectations and plans of this cohort for their retirement and old age. This paper provides a first step by reviewing the Australian literature, focusing on the areas of health, housing, work and income, and responsibility. Information from the peer-reviewed literature and the Internet published during 1996 -2005 was reviewed. One hundred ninety-five Australian references were retrieved, of which only 94 were relevant. The review identified that, despite agreement about the significance of baby boomer's ageing, empirical work directly addressing the research topics was rare. In particular, there was little coverage of baby boomers' ascription of responsibility for their welfare in older age. If policies are to be effective, empirical research obtaining information directly from baby boomers is required to fill the gaps identified through this review.

Australasian Journal on Ageing, 1999

... Carol Birks, Ken Lockwood, Ian Cameron, Susan Kurrle, Wendy Burnside, Sandra Easter and Jenni... more ... Carol Birks, Ken Lockwood, Ian Cameron, Susan Kurrle, Wendy Burnside, Sandra Easter and Jennifer Venman Hornsby Ku-ring-gai Hospital, Sydney ... Cameron ID, Lyle DM, Quine S. Cost effectiveness of accelerated rehabilitation after proximal femoral fracture. ...

Archives of Gerontology and Geriatrics, 1994

The factors that may influence compliance with wearing of external hip protectors by potential us... more The factors that may influence compliance with wearing of external hip protectors by potential users living in the community were investigated. Elderly women (median age 83 years) who were hospitalised after fracture, joint replacement or falls and were expected to return to community living participated. Five focus groups were conducted. Most participants said they would not use the hip protector demonstrated. The main objections were a perceived lack of comfort in wearing the appliance, particularly in bed, coupled with the belief that they were not at high risk. Other lesser issues were the extra effort needed to wear the device, appearance, accuracy of fit, cost and unfamiliarity with the protectors. These findings suggest that, in general, high risk elderly women living in the community will be unlikely to use external hip protectors unless there is considerable encouragement from family members and/or health professionals. Educational programmes could reduce some misconceptions about hip fracture, and reinforce the benefits of wearing a protective appliance. They may also increase awareness of personal risk. An introductory period of supervised wearing of the hip protectors, while in hospital or respite care, may enhance compliance.