Negative Social Determinants of Health; How Can We Make an Impact?

By Samantha Lowe

At-risk youth have strong negative Social Determinants of Health (SDoH), which include conditions in which you are born, grow, live, work and age.  SDoH include biology and genetics, individual behavior, social environment, physical environment, and access of health services.

Supporting at-risk youth is of the utmost importance as they are less likely to have access to health care, health education, and formal sex education. Educating and equipping youth with personal safety, nutrition, and relationship skills, in a comfortable environment could be life changing, as at-risk youth are also more at risk for sexual violence.

A recent study conducted in Central Texas of youth enrolled in the Risk-Reduction Education about Abstinence, Contraception, and Health, or the REACH project (Wilson et al., 2018). 76 youth between the ages of 15-21 years, who were homeless, current or former foster youth, or youth who left high school prior to graduation made up the sample population (Wilson et al., 2018).

Across all groups (male, female, heterosexual and non-heterosexual), the most common topic that youth were interested in learning was Healthy Relationships and Personal Safety (Wilson et al., 2018).  Overall, youth reported wanting to learn about these topics from a nurse/doctor or a teacher, reporting that it is difficult to learn about these topics from a family member (Wilson et al., 2018). The least preferred type of educators across all groups was a Faith Based Worker, while the mode of learning across all groups was the same, youth preferred to learn in a small group class setting (Wilson et al., 2018). In a surprising result, the least preferred mode of sexuality education was learning over technology, this included apps and text messaging (Wilson et al., 2018).

Supporting at-risk youth includes listening to their educational preferences, developing innovative programs and creating new ways to engage youth within the process. This does not stop or begin with sex education, it begins with supporting the child and the community. Keeping at risk students active, engaged in community activities, and informed on health risks and supports can begin in the classroom but needs to be continued once the students leave school. For example, relationships can be a difficult topic to cover in classroom and most learning opportunities about the topic are environmental, making out of school community supports a key factor (Wilson et al., 2018).

Triple Play delivers on the belief that whole child health fosters young people’s ability to gain diverse knowledge, skills, and protective factors that enable them to overcome barriers to wellness and positively impact their future health. Triple Play provides health promotion, which encompasses health education, health literacy and a range of social and environmental interventions designed to benefit and protect health and quality of life.
— Boys and Girls Clubs of America

An organization who has been working to help at risk student populations is the Boys and Girls Clubs of America, they have been implementing a program titled, TRIPLE PLAY: GAME PLAN FOR MIND, BODY AND SOUL, a program designed to support youth who are raised in areas with poor SDoH.

The Boys and Girls Clubs of America continue to run research on how well the program is working, more information on the program along with statistics and research findings can be found at the link below!


Wilson, K., Maness, S., Thompson, E., Rosen, B., McDonald, S., & Wiley, D. (2018). Examining Sexuality Education Preferences Among Youth at Risk for Poor Sexual Health Outcomes Based on Social Determinants of Health Factors. American Journal Of Sexuality Education, 1-14. doi: 10.1080/15546128.2018.1447414

LGTB Center at University of Louisville

Mike Miller and Jamie Sparks

Mike Miller and Jamie Sparks

Jamie and I were invited by Mike Miller, a former colleague of Jamie's at the Kentucky Department of Education to a beautiful reception at a private residence in Louisville last night to celebrate 10 years of growth for the University of Louisville's LGBT Center. It was an honor to be invited among 150 other guests celebrating the support of sexual minorities on campus.

Over the years, the Center has been ranked as the most friendly campus for sexual minorities in the South. The event hosted at Steve and Karen Hall's home was a celebration of the work the Center provides, an opportunity to connect with others advocating for all young adults and an opportunity to bring awareness of the Center and funds to sustain and grow the work its doing.  The Center works to create a safe, supportive environment for all students including hosting an Ally Campaign in which allies wear a pin demonstrating their commitment to creating a safe environment for all, safe zone training events, and opportunities for healthcare providers to add their names as LGBT-friendly. The Center works to educate, advocate, create healthy and safe learning environments where students can thrive, improving patient care at UofL affiliated healthcare settings and partake in research of LGBT health.

The LGBT Center works to strengthen and sustain an inclusive campus community at the University of Louisville, one that welcomes people of all sexual orientations, gender identities, and gender expressions through support, educational resources, and advocacy. The Center works in partnership with other diversity efforts on campus supporting the Vice Provost for Diversity and International Affairs.

One of the most impressive components of this work is a national model to educate the medical students at UofL on LGBT health cultural competency and responsiveness. The program is called eQuality and you can learn more about it here. This means that when a patient is working with medical staff, of any kind, that staff has had training on how to best support their patients needs. 

This brings me back to our work in K-12 schools. As an Oregon educator, I received multiple training opportunities that built my knowledge and skills around creating a culturally competent classroom and school environment for all students, including the LGBTQ population. I know this isn't happening in most school communities around the US, but there are multiple non-profits working in this area. Teen Health Mississippi, SHIFT NC in Durham, Answer and TransActive are a few of the many organizations providing sexual health support, information, access and education to our sexual minority youth, parents and educators for the K-12 setting. 

It was great to see Stacie Steinbock, our good friend and Director of the LGBT Center Satellite Office on the Health Sciences Center Campus

It was great to see Stacie Steinbock, our good friend and Director of the LGBT Center Satellite Office on the Health Sciences Center Campus

Last night, a few people had the opportunity to talk about why they support the Center. Medical staff shared their experience and growth due to training opportunities. Kim Griffith Diamond, a parent boldly and courageously shared her story of losing her son to depression as a result of the pressures and lack of societal support of being gay. People had the opportunity to speak about why they are allies and how in truth, this all comes down to caring for all human beings, no matter who they are. It was an amazing evening of food, drink, celebration and coming together. 

There are numerous ways to show your support of the programs and policies of the LGBT Center. One way is, of course a donation. There is more information here

As a national leader in LGBT healthcare, the LGBT Center is proud to offer cutting-edge training for health care students and professionals. Our LGBT Health Certificate provides you with the knowledge and skills you need to interact successfully with LGBT patients, and demonstrates to employers and patients your commitment to serving diverse patient populations. It is free to members of the UofL community as well as all community members in Louisville and beyond.

The Case for More Love in Education

By Liz Thorne

I was recently in Austin, Texas for the 6th annual Ready by 21 Annual Meeting. Organized by the Forum for Youth Investment, the meeting focuses on ensuring all youth are ready and prepared to meet life’s demands. It brought together folks in youth development, program quality, education, government and community based organizations all focused on ensuring youth are ready.

A major focus of the meeting was on promoting equity through the lens of readiness as a right. It’s not enough to help young people beat the odds but we need to work with the adults and leaders in communities to change the odds.

Research tells us that just one supportive adult relationship can help buffer young people against risk and help them overcome challenging life circumstances. But let’s zoom out and talk about supportive communities, or as Dr. Shawn Ginwright describes, radical healing.

In his keynote, Dr. Ginwright compared the idea of radical healing to experiments conducted on plants. Researchers would place one plant in a chamber of poisonous gas to test the plant’s response. As you might expect, the plant shriveled and died. But, when the researchers placed multiple, or a community, of plants they didn’t die. Rather, they cleaned the air of the poisonous gas. Together the community of plants garnered their collective strength to change their circumstances.

How can we harness the collective strength of communities to change the odds for youth? During Dr. Ginwright’s address on radical healing, there were three thoughts going through my head as this relates to our work in adolescent and school health:

  • We have to take care of the adults in schools. Youth are often placed at the center of our work. Resources, opportunities, and training must be made available to provide physical, emotional and professional support to the adults that show up every day. Particularly, educators and professionals working in economically disadvantaged schools or communities, and those who have faced generations of trauma and marginalization.
  • We need more opportunities for Participatory Action Research or experiential learning opportunities.  PAR is one way for young people to reach into their community, examine the context and begin to understand and garner their strength as an agent of change.
  • There is room in ESSA for a focus on readiness, but we need advocates in the states. ESSA provides an opening, but we will need to focus on state-level efforts to address social, emotional and physical needs of students and staff in schools. (Check out our ESSA State Plan Page for more information). 
Power without love is reckless and abusive, and love without power is sentimental and anemic. Power at its best is love implementing the demands of justice, and justice at its best is power correcting everything that stands against love.
— Martin Luther King Jr.

Whether you call it a supportive relationship, radical healing or trauma-informed education, to me it all boils down to one thing. More love in education. Showing, not just telling our young people, that they are valued. Demonstrating they are valued by equipping them with the skills to harness their power and change their environment for the better. Dr. Enwright ended his keynote with a quote from Dr. King that I think sums up the relationship between love and power.





The Power of Policy

By Liz Thorne

Last week brought two experiences that showed the promise of policy to actualize a positive change to support young people. Suicide is the second leading cause of death among young people aged 15-24. Sexual minority youth are at increased risk of suicide attempts- in 2015 29% of LGB youth in the US attempted suicide in the last year, compared to 6% of their heterosexual counterparts (the Youth Risk Behavior Surveillance Surveydoes not ask about gender-identity).   

Schools are a really important setting to build protective factors against suicide risk, identify struggling students early, and support those who have attempted re-enter school in a safe and supportive way. Cairn Guidance is currently funded by the Oregon Health Authority to support schools to develop and strengthen their protocols around suicide, and connect staff to an excellent online training called Kognito.

What message does it send to young people when their state, their government, tells them their right to love and marry who they choose is the same as everyone else’s? That they are valued. That they belong.

Last week, I sat around a table with representatives from a large school district in Oregon. We were working through an inventory to assess the presence and strength of their school protocols, identifying gaps and action steps to address the gaps. Every professional sitting at that table brought a different perspective to the ways in which students are supported. Strengthening the systems and protocols will have a direct impact on the experience of students in this district who are struggling, and how they can access support they need. But we also questioned: What are the broader, whole school, whole community approaches to creating school environments that are safe where young people feel valued and loved?

That’s where this week’s second policy news comes in. A study published in JAMA Pediatrics this week found that found that state same-sex marriage policies were associated with a 7% reduction in the proportion of all high school students reporting a suicide attempt within the past year. The effect was concentrated among adolescents who were sexual minorities. For gay, lesbian and bisexual students in particular, the decrease was more pronounced. Rates of suicide attempts decreased from 28.5 percent to 24.5 percent (a 14 percent reduction in suicide attempts). There was no change in states that did not legalize same-sex marriage before January 2015. The effect persisted for 2 years after legalization.

While there are limitations to the study, and the exact mechanisms by which legalization impacted risk of suicide attempt, these findings show the power of public policy to effect change on the lives of young people. One hypothesis is that marriage equality laws reduce stigma- an underlying factor. Reducing rates of attempted suicide were not reasons cited for passing marriage equality. But it makes sense. What message does it send to young people when their state, their government, tells them their right to love and marry who they choose is the same as everyone else’s? That they are valued. That they belong.

Having a sense of belonging is a key protective factor for a host of issues, like substance use, mental health issues, and even supports engagement in school. These early findings reinforce that all policies are health policies. 

College Student Creative Expression of Reproductive Topics, Including Abortion

By Samantha Lowe

During my graduate studies at Morehead State I was given the opportunity to further my research and analyze student's perceptions of birth control (birth control was not defined and included all forms of contraceptives) and abortion. This further analysis was presented at the Wilma Grote Symposium for the Advancement of Women at Morehead State University.

With recent political events, such as the magnificent Global Women's March, I felt it was time to revisit this subsection of my research.  What are young Appalachians' views on women's reproductive health? And does holding a politically conservative or liberal point of view influence opinions?

Metaphors for the selected reproductive health items: “Having an abortion is like” and “Taking birth control is like” were coded for use of negative, neutral or positive language. Negative language included violent imagery, while positive language included normalizing the event. Stimuli coded by 6 independent undergraduate students was checked for agreement by inter-rater reliability statistics.

Surprisingly, holding a conservative or liberal perspective had no effect on the amount of violent imagery used to respond to our abortion stimuli. While this may seem shocking as the two parties appear as opposites on this issue; it is the regions lacking sex education programs that lead young adults to see abortions as inherently violent, rather than the medical procedure that they are. The vast majority of participants responded with “murder” to our “having an abortion is like” stimuli, taking this into consideration it is possible that for the Appalachian region the word “murder” could potentially be classified as a Frozen Metaphor (Frozen Metaphor: has been so imbedded in common language that it now viewed as literal language). Below is a table of student responses.

Metaphors for Sex Education

By Samantha Lowe

During my master’s studies at Morehead State University I oversaw the Human Sexuality Research Lab, where we focused on young adult’s ability to speak metaphorically about sexual and non-sexual stimuli. While the Human Sexuality side of the research was my passion, it was my mentor/university mother/lab director who turned me on to the educational use of metaphoric language. Below is my final research project from my Master’s studies, this research was first presented at the Midwestern Psychological Association in May of 2016 and then again as an oral presentation at Morehead State University’s Celebration of Student Scholarship.  

A Vagina is an Ugly Duckling: Metaphors for Sex Education



Metaphors have been used as teaching devices since the earliest writings of civilization, along with being used to facilitate learning of new information; metaphors can be used to communicate unobservable internal feelings and emotional states that are often difficult to describe using only literal language (Ortony, 1975). Creating a metaphor challenges the individual to look at a subject in a new light, searching for a comparison or common ground with another subject, object, or emotion. All while provoking a more extensive thought pattern associated with the subject (vehicle) of the metaphor (McClure, 1989). Metaphoric speech promotes concise and vivid communication (Fainsilber & Ortony, 1987).

Fainsilber & Ortony, (1987), outlined three hypotheses for the use of metaphoric speech:

Inexpressibility hypothesis: facilitates communication that cannot be readily expressed through literal language

Compactness hypothesis: metaphors are used for a compact means of communication

Vividness hypothesis: metaphors help capture the vividness of a phenomenal experiences that may not be expressed through literal language

Fainsilber & Ortony, (1987), found that more intense emotions lead to more metaphor production, when describing intense feeling states, people are more likely to generate striking and complex metaphors to explain how they feel. Thus, we can assume that intense subjects such as human sexuality will result in more metaphoric speech. Speaking metaphorically can create a more comfortable environment, it is because of the embedded sex negative mentality that adolescents feel intrinsically uncomfortable talking about sex in a face-to-face manner. To combat this we have taken advantage of computer based interviews, were people tend to feel less self-conscious and diminishing the chance of embarrassment (Taylor, 2003). Research on the personality profiles of liberal and conservatives found that liberals tend to score higher on measures of openness, cognitive flexibility, and integrative complexity. While conservatives tend to possess stronger needs for order, structure, and decisiveness (Carney, Jost, Gosling & Potter, 2008). Longitudinal studies of liberals and conservatives find common personality characteristics are expressed in elementary school; long before prescribing to a political affiliation (Block & Block, 2006). Future Liberals were described as energetic, emotionally expressive, gregarious, and impulsive. While future Conservatives were described as ridged, inhibited, indecisive, fearful, and over controlled.


       Liberals will produce more metaphors than their conservative counterparts.

       Metaphor production will be higher in the online condition than the face-to-face condition.


Participants are randomly assigned to the online or face-to-face condition. Participants assigned to the online condition completed the interview via SurveyMonkey, in an uncontrolled environment.

Participants assigned to the face-to-face condition were interviewed by two experimenters, a transcriber and an inquirer. Participants’ responses were audibly and visually recorded by a video camera.

The method of using alternative communicative media to facilitate openness has been used since the 1950’s, in an experiment by Aronson and Mills, where women were split into two conditions and had to read an erotic passage. In the “comfortable” group, women were able to read the passage over an intercom while the “uncomfortable” group had to read the passage in person (Aronson & Mills, 1959).

Participants in both conditions completed a demographics questionnaire with self-report virginity item, Sociocultural Attitude Scale (SCAS), Reading of a persuasive speech; either promoting metaphoric or literal speech and a Metaphor Production task about sexual and non-sexual topics.

The SCAS consisted of 15 Items in Likert scale form (1= Strongly Disagree, 4= Neutral, 7=Strongly Agree). Participants who scored over 56 were categorized as Conservative; Participants who scored under 56 were categorized as Liberal. The scale had a moderate level of internal consistency, as determined by a Cronbach’s alpha of 0.727.


  • Main effect of completion F(1,306)=10.972, MSE=311.864, P=.001, with no significant results in the interview condition.
  • Significantly less metaphors were produced in the face-to-face condition.
  • Main effect of the type of persuasive speech, F(1,306)=18.013,MSE=512.003, P=.000, with the metaphoric speech facilitating more metaphor production.
  • A significant interaction was found between type of persuasive speech and virginity, F(1,306)=9.715, MSE=276,143, P=.002, with virgins being more influenced by the type of speech
  • Surprisingly, we found males (M=9.65, SD=6.48) overall produced more metaphors than females (M=7.75, SD=6.93)



Participants with prior sexual experiences spoke metaphorically despite the type of persuasive speech, indicating that metaphoric speech is the preferred way of speaking about sexual topics. Ortony (1975), insists that metaphors are an essential element of communication and consequently can be of great educational value. Future research should analyze the possible use of metaphoric speech within sex education courses as a facilitator of openness, relatability, and comfortableness. Examining the effectiveness of instructing sex education courses via internet is another potential route for future research. There is strong technology push within public schools, and the resources to enact online/homework based sex education are more readily available. Motivation to learn about this exciting subject (sex) is present, but when the adolescent is presented with conflicting ideas pertaining to their idea of human sexuality; barriers are erected and the ability to interpret other ideas as educational grinds to halt (Chapman & Werner-Wilson, 2008). Mark, A. (1988), used song lyrics as a facilitator of conversation and openness with “hard-to-reach” adolescents, accomplished by creating an environment of acceptance and familiarity while addressing difficult and controversial topics. Song lyrics incorporate many metaphors, evidence for students being more open when presented with song lyrics can buttress the idea for the incorporation of metaphors into sex education teaching methods. 


Howard L. Bost Health Policy Forum

The 2015 Bost Health Policy Forum hosted by the Foundation for a Healthy Kentucky kicked off with a welcome from Kentucky's Lieutenant Governor Crit Luallen. She reinforced the importance of economic vitality, livability and strong communities related to the health of Kentuckians. We heard from a variety of health advocates on topics including education, the built environment, worksite wellness and food systems from Andrew Dannenberg from the University of Washington, Vera Oziransky from the Vitality InstituteMary Gwen Wheeler from 55000 Degrees, and Margo Wootan from the Center for Science in the Public Interest.

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Resources to Support School Health

Yesterday I posted a list of resources specific to the field of K-12 school health education. Today, I'm going to share a list of resources within the larger field of school health that I refer to regularly. I know there are many more out there. I'll attempt to categorize for ease of finding information! If you have others to share, email me and I'll add them to this post!



Partnering for Success: How Health Departments Work and How to Work with Health Departments- This is a great resource especially useful for schools to understand how to partner with their local health departments to work together to create a culture of health within the school environment.

How Schools Work & How to Work with Schools- Great tool for individuals or organizations that want to work with schools, but scratch their head because they function so differently! This tool is worth the $5!


Research to Support School Health

Healthier Students are Better Learners- A fabulous 'essay' written by Charles E. Basch used widely that addresses how health-related problems among youth are affecting our students' ability to achieve. Make the case to your administrator or leadership using this document!


Research Review:
School-based Health Interventions and Academic Achievement 
- Fabulous report by Julia Dilley. From document, "Research Review: School-based Health Interventions and Academic Achievement provides important new evidence that links students’ health and academic performance. It identifies proven health interventions and practical resources that can positively affect both student health and academic achievement."


Implementing a Coordinated School Health Program (CSHP)

Tools That Work! - This is a toolkit developed by the MIssissippi Department of Education and provides a CSH guide to building a healthy school.


Aligning Health and Education Accountability Measures

I have an article from CCSSO called Incorporating Health into Education Accountability Systems, however I can't find it online. Contact me if you want more information!


Safe Routes to School

School Nurses as Safe Routes to School Champions Improving the Built Environment and Increasing Physical Activity 

Safe Routes to School State Network Project: Final Report, 2007–2009; Making Change Through Partners and Policies 


Sexual Health

Oregon Youth Sexual Health Plan- this document is a part of a larger state-wide approach to increasing the sexual health of adolescents in Oregon. However, objective #5 is on Providing Education and skill building for youth and families and includes comprehensive sex education language and goals.  


Return on Investment

Investment in School Health Capacity; Payoffs in Health, Achievement and Stronger Communities - Fantastic document (yes, I helped review!) put together by Oregon Health Authority, the Public Health Division and good colleagues/friends of mine that not only defines core capacity as "(1) having a school health coordinator; (2) conducting a health focused self-assessment1; (3) having a health-related School Improvement Plan goal and objective; and (4) having a school health advisory group that includes an administrator and a community member. Together these components represent the staffing, data, leadership, accountability, and broad support that is needed to effectively support health and achievement in school settings" but discusses the dollar return on investment when schools or districts implement school health programs. A must-read document. I hope it drives further studies and is used as a tool to advocate for the fiscal reason we should be working on school health. 



State School Health Policy Matrix- From the website: "The National Association of Chronic Disease Directors (NACDD), along with the National Association of State Boards of Education (NASBE) and American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD) have worked together to develop this guide to state-level school health policies for the following topics: competitive foods and beverages, physical education and physical activity, and administration of medication in the school environment. The State School Health Policy Matrix outlines relevant state-level policies for each of these areas, including a direct link to the policy. It also it indicates which political entity or agency adopted the policy or issued guidance, helping to an­swer the question – Who has historically had the authority to make policy changes in the areas of competitive foods and beverages, physical education and physical activity, and administration of medication in each state?"


Administrative Support

What School Administrators Can Do to Enhance Student Learning by Supporting a Coordinated Approach to Health 


School Health Advisory Councils (SHACs)

Promoting Healthy Youth, Schools, and Communities- A Guide to Community-School Health CouncilsI still refer to this guide that helps support a school or district in developing what we know, is one of the most important aspects of creating a sustainable school health program. 

Gearing Up for School Health- Webinar!

I'm facilitating a webinar hosted by SPARK on Wednesday, March 19 at 3pm PST/6pm EST! More information on how to register to come, but see description below. Feel free to share with others.

“Riding the Path to a Comprehensive School Health Program”

You can’t ride a bicycle unless all the parts are working. In addition, the parts need to work cohesively for a smooth ride to your destination.  A successful comprehensive school health program (CSHP) must have multiple components working together for one common goal…. building healthier schools. Join us at the next SPARK webinar to learn about best practices and successful strategies for building your program, as well as develop action steps to support activities to make it happen. Students must be healthy in order to be educated, and they must be educated in order to stay healthy. Implementing a comprehensive school health program does not need to always be an uphill climb. Lead your school down the path by guiding the implementation of programs, policies, and activities to improve the health of children. Our guest speaker, Jessica Lawrence of Cairn Guidance will share her lessons learned and experiences in building a CSHP. Register now to start the journey towards a healthy school environment!

Attendees will:

  • Be presented with the relationship of health issues to education accountability measures (test scores, graduation rates, attendance);
  • Understand the CSHP model and how CSPAP fits into the model, and hear examples;
  • Be presented with information on best practices when building sustainable school health programs;
  • Be encouraged to set one next step goal around what you learned on the webinar.

Reading, reading and more reading

As a child, I struggled as a reader. My mom loved to read and I remember her taking my brother and I on weekly visits to the library. We would come back with a stack of books. My books would sit collecting dust most of the week, untouched until heading back the following week to return the books and check out new ones. My brother's pile, however, were all over the house. He read these books in his bed, on the orange shag carpet in the den, in the car, on the toilet (I guess?!?). I was more of a interpersonal communicator than individual reader. I talked. I acted, I danced. I read when I needed to, but it didn't come easily to me and it wasn't how I wanted to spend my time. I would rather climb the tree in the front yard or swing on the swings with my neighborhood friends.

Fast forward thirty years later and reading isn't something I choose to do in my spare time, although I'm not swinging on swings often either! However, I do read. I enjoy it. Do I love it? No. I'm currently working on a few projects that require I read. Read a lot. And, it's research. But, I'm enjoying it. I enjoy it because I love the work I'm doing. I'm trying to read as much as I can about sustainability. What makes a school program or project sustain? Even after the onsite assistance, or dollars, or resources go away? And, as I read, I come up with what I think are brilliant ideas (of course!). We should require a school health support question for every district superintendent we hire. We should make sure that at institutions of higher education include a course on school health in order to gain a school administrator license. Let's make sure schools aren't just implementing 'cool' programs, but those programs are effective and needed based on data driven decisions/prioritizing. 


So, I read as I know I need to. And with practice, it really isn't so bad. I know I'd rather be bicycling or facilitating, or talking or writing even. But, it's something I just have to do. With that, it's time to dive back into the stack of articles sitting here by my desk!