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Abstract Background Health disparities lead to negative COVID-19 outcomes for Hispanic/Latino communities. Rapid antigen testing was an important mitigation tool for protecting schools and their communities as in-person learning resumed. Within the context of a 3-middle-school non-inferiority trial we assessed acceptability and appropriateness of at-home and school-based COVID-19 antigen testing and implementation barriers and facilitators to facilitate district-wide scale up. Methods Guided by the Consolidated Framework for Implementation Research (CFIR) and acceptability and appropriateness implementation outcomes, we collected post-implementation qualitative (n = 30) and quantitative (n = 454) data in English and Spanish from trial participants, in-depth feedback sessions among program implementers (n = 19) and coded 137 project meeting minutes. Verbatim transcripts were thematically analyzed. We used multivariate linear models to evaluate program acceptability and appropriateness by COVID-19 testing modality and mixed qualitative and quantitative findings for interpretation. Results Questionnaire respondents closely matched school demographics (> 80% Hispanic/Latino and 8% Filipino/Asian Pacific Islander). While both testing modalities were rated as highly acceptable and appropriate, at-home testing was consistently favorable. Qualitative findings provided actionable areas for at-home testing program refinement, guiding district-wide scale up including: maintaining a learning climate to accommodate modifications as guidelines changed, needs of the school community, and implementation challenges; ensuring an engaged school leadership and sufficient human resources; improving educational communication about COVID-19 and technology ease of use; and increased time for pre-implementation planning and engagement. Conclusions Results underscore the value of the CFIR to inform program implementation, particularly programs to reduce disparities during a public health emergency. Results support optimal testing implementation strategies centering the needs and perspectives of Hispanic/Latinos.

Abstract Intimate partner violence (IPV) occurs at alarmingly high rates towards pregnant women in South Africa. Experiences of emotional, physical, and sexual IPV in pregnancy can adversely impact the health and safety of mother and fetus. Furthermore, IPV is associated with increased risk of HIV, exacerbating the public health impact of violence among pregnant women in this HIV endemic setting. In-depth understanding of cultural and contextual drivers of experiences of IPV is a critical precursor to development of interventions effectively addressing this issue among pregnant women in South Africa. The present study examines factors contributing to IPV among pregnant women to identify potential points of intervention. We conducted twenty in-depth interviews with postpartum women who used oral pre-exposure prophylaxis (PrEP) in pregnancy and reported recent experiences of IPV and/or ongoing alcohol use in a township near Cape Town, South Africa that experiences a heavy burden of both HIV and IPV. Interpretive thematic analysis was used. Several patterns of IPV during pregnancy were identified and violence was frequently described as co-occurring with male partner alcohol use. A majority of women referenced oral PrEP as their preferred method for HIV prevention, highlighting the agency and discretion it provided as beneficial attributes for women experiencing IPV. Fear of judgement from peers for remaining with an abusive partner and a lack of clear community messaging around IPV were identified as barriers to disclosure and support-seeking. Addressing the lack of social support received by women experiencing IPV during pregnancy in South Africa is essential to comprehensive IPV programming.

In South Africa, alcohol use during pregnancy is prevalent and associated with increased HIV risk. Developing locally sensitive and contextually appropriate evidence-based interventions to address alcohol use among pregnant and breastfeeding women in South Africa requires comprehensive understanding of the context of perinatal alcohol use and how relationships and lived environments may serve as barriers or supports for alcohol reduction. We conducted twenty in-depth qualitative interviews with isiXhosa speaking women who reported alcohol use during their recent pregnancy and/or recent intimate partner violence in Cape Town, South Africa between September and November 2022. We describe patterns and drivers of ongoing alcohol use during pregnancy and map them onto levels of the socioecological model. Data were analyzed utilizing the interpretivist paradigm and interpretive thematic analysis. Eight women reported alcohol use during pregnancy, sixteen reported experiencing recent IPV, and four women reported both alcohol use during pregnancy and recent IPV. In interviews, commonly cited reasons for continued alcohol use in pregnancy included stress (e.g., due to financial concerns), peer pressure, the central role of alcohol use in socialization and the persistence of misconceptions regarding the safety of alcohol use in pregnancy. Still, despite women reporting social norms that supported continued alcohol use in pregnancy, many altered who they drank with due to fear of judgement from close friends and family, leaving them isolated from their social support system. Interventions aimed at increasing interpersonal support, such as the use of peer mentors, could prove beneficial. Although the clinic provides messaging around the harms of alcohol use in pregnancy, these messages conflict with messaging received from their peers, limiting their impact on behavior. Locally sensitive tailored, relevant programming that intervenes on barriers to reducing alcohol use in pregnancy at multiple levels of the socioeconomic model are vital to effectively addressing this public health issue.

Background: In March 2020, Uganda enforced country-wide restrictions to control the spread of SARS-CoV-2, categorizing some health services, including family planning (FP), as non-essential. Globally, similar COVID-19 restrictions have been associated with increased vulnerability to reproductive coercion (RC) among women, due to changes in FP service availability and restricted access by partners. This study aims to investigate these dynamics in Uganda, specifically examining the impact of the COVID-19 lockdown on women's access to FP, their experiences of RC, and the relationship between RC and intimate partner violence (IPV). Methods: We conducted a cross-sectional analysis of data from 960 women participating in the AMBSO Population Health Surveillance Study (APHS) between August 2020 and March 2021 across Wakiso (N = 164) and Hoima (N = 796) districts in Uganda. Our analysis focused on women who were sexually active in the past month, using bivariate analyses to explore the associations between RC and recent experiences of sexual, physical, and verbal IPV. Findings: The most commonly reported FP methods were injectables (36.8 %) and implants (16 %). Despite the COVID-19 lockdown, less than one percent of participants reported an inability to access their preferred FP method. Notably, 3 % of the women experienced RC in the past 12 months. There was a significant association between RC and sexual IPV (p

Abstract Background Intimate partner violence (IPV) and alcohol use are interrelated public health issues. Heavy and frequent alcohol use increase the risk of IPV, but the relationship between alcohol use and IPV (including recent and lifetime IPV victimization and perpetration) has not been well described among persons living with HIV (PWH) in sub-Saharan Africa. Methods We used baseline data from the Drinker’s Intervention to Prevent Tuberculosis study. All participants were PWH co-infected with tuberculosis and had an Alcohol Use Disorders Identification Test – Consumption (AUDIT-C) positive score (hazardous drinking) and positive urine ethyl glucuronide test, indicating recent drinking. High-risk drinking was defined as AUDIT-C > 6 and/or alcohol biomarker phosphatidylethanol (PEth) ≥ 200 ng/mL. We measured IPV using the Conflict Tactics Scale. We estimated the association between alcohol use level and recent (prior six months) IPV victimization (recent perpetration was too low to study) using multivariable logistic regression models adjusted for gender, age, assets, education, spouse HIV status, religiosity, depressive symptoms, and social desirability. We additionally estimated the interaction of alcohol use and gender on IPV victimization and the association between alcohol use and lifetime victimization and perpetration. Results One-third of the 408 participants were women. Recent IPV victimization was reported by 18.9% of women and 9.4% of men; perpetration was reported by 3.1% and 3.6% of women and men. One-fifth (21.6%) of those reporting recent IPV victimization also reported perpetration. In multivariable models, alcohol use level was not significantly associated with recent IPV victimization (p = 0.115), nor was the interaction between alcohol use and gender (p = 0.696). Women had 2.34 times greater odds of recent IPV victimization than men (p = 0.016). Increasing age was significantly associated with decreased odds of recent IPV victimization (p = 0.004). Conclusion Prevalence of IPV victimization was comparable to estimates from a recent national survey, while perpetration among men was lower than expected. Alcohol use level was not associated with IPV victimization. It is possible that alcohol use in this sample was too high to detect differences in IPV. Our results suggest that women and younger PWH are priority populations for IPV prevention.

Abstract Background Persons who experience homelessness remain at increased risk for three viral blood-borne infections: human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). We assessed the yield of testing and linkage to care programs targeting this population for these infections in the United States (US). Methods We searched PubMed, Embase, Web of Science, and Cochrane Central for peer-reviewed articles through August 27, 2020. Additionally, we searched the grey literature. Two individuals independently reviewed all relevant studies to check for eligibility and extracted data for each step in the care cascade. We used random-effects model to generate weighted pooled proportions to assess yield at each step. Cumulative proportions were calculated as products of adjacent-step pooled proportions. We quantitatively synthesized data from the studies that focused on non-drug injecting individuals. Results We identified 24 studies published between 1996–2019 conducted in 19 US states. Seventeen studies screened for HIV, 12 for HCV, and two screened for HBV. For HIV, 72% of approached were recruited, 64% had valid results, 4% tested positive, 2% were given results, and 1% were referred and attended follow-up. Of positives, 25% were referred to treatment and started care. For HCV, 69% of approached were recruited, 63% had valid results, 16% tested positive, 14% were given results, and 3% attended follow-up. Of positives, 30% were referred for treatment and 19% started care. The yield at each care cascade step differs widely by recruitment strategy (for example, for HIV: 71.6% recruited of reached under service-based with zero yield under healthcare facility-based and outreach). Conclusions A very large proportion of this population reached for HIV and HCV care were lost in the follow-up steps and never received treatment. Future programs should examine drop-out reasons and intervene to reduce health disparities in this population.

Abstract Background Depression is a prevalent and serious mood disorder and a major source of disability adjusted life years (DALY) in Uganda. Furthermore, evidence from Uganda and other countries throughout sub-Saharan Africa suggests that nearly a third of persons living with human immunodeficiency virus (HIV) suffer from depression and it adversely affects healthcare seeking behavior. The high burden of disease attributable to depression makes data on the prevalence of depression in Uganda, a country with a generalized HIV epidemic, a public health priority. This paper describes the psychometric properties of the Center for Epidemiologic Studies-Depression (CES-D) measure when administered to men and women residing in three fishing communities along the shore of Lake Victoria. Methods We applied methods based on item response theory and classical test theory approaches to assess individual item characteristics, conducted exploratory factor analysis and assessed internal reliability, and construct and content validity of the measure. All analyses were performed in R Studio. Results The study sample consisted of 300 residents of fishing communities in Wakiso District, Uganda. Fifty-six percent of the sample was female and 19.7% reported being HIV positive. Seven items of the measure that did not perform well, either because they could not differentiate between levels of the latent trait or because they did not map onto the primary factor, were removed from the scale. A single factor structure best fit our final set of 13-items and we found an overall coefficient alpha of 0.89, indicating high internal consistency in this population. Conclusions Based on our findings, we recommend that future use of the CES-D in this population utilize our revised scale with the final set of 13-items. The addition of other measures that can improve the rigor of CES-D validation efforts, such as inclusion of a clinical depression measure and administration in both a clinical and a general population sample in this setting are needed.

In Uganda, depression is a major public health issue. Psychometric assessment of translated depression measures is critical to public health planning to ensure proper screening, surveillance, and treatment of depression and related outcomes. We examined aspects of the validity and reliability of the Patient Health Questionnaire-9 (PHQ-9) translated into Luganda and Runyoro among Ugandan adolescents and adults. Data from the ongoing AMBSO Population Health Surveillance study were analyzed from the Wakiso and Hoima districts in Uganda. Descriptive statistics were calculated for the overall sample and stratified by translated language. Construct validity was assessed for each translated scale using confirmatory factor analysis for ordinal data. The internal consistency of each translated scale was assessed using Cronbach's alpha, McDonald's omega total and omega hierarchical. Both the Luganda- and Runyoro-translated PHQ-9 had similar sample means (3.46 [SD ​= ​3.26] and 3.58 [SD ​= ​3.00], respectively), supported a single-factor structure, and demonstrated satisfactory internal consistency (Cronbach's alpha of 0.73 and 0.72, respectively). Our preliminary findings indicate that the Luganda and Runyoro translations of the PHQ-9 had satisfactory construct validity and internal consistency in our sample. Future studies should expand on this promising work by assessing additional psychometric characteristics of these translated measures in other communities in Uganda.

Abstract Background Homelessness increases the risk of tuberculosis (TB) disease and latent TB infection (LTBI), but persons experiencing homelessness often lack access to testing and treatment. We assessed the yield of TB testing and linkage to care for programs targeting homeless populations in the United States. Methods We conducted a comprehensive search of peer-reviewed and grey literature, adapting Cochrane systematic review methods. Two reviewers independently assessed study eligibility and abstracted key data on the testing to care cascade: number of persons reached, recruited for testing, tested for LTBI, with valid test results, referred to follow-up care, and initiating care. We used random effects to calculate pooled proportions and 95% confidence intervals (CI) of persons retained in each step via inverse-variance weighted meta-analysis, and cumulative proportions as products of adjacent step proportions. Results We identified 23 studies published between 1986 and 2014, conducted in 12 states and 15 cities. Among studies using tuberculin skin tests (TST) we found that 93.7% (CI 72.4-100%) of persons reached were recruited, 97.9% (89.3-100%) of those recruited had tests placed, 85.5% (78.6-91.3%) of those with tests placed returned for reading, 99.9% (99.6-100%) of those with tests read had valid results, and 24.7% (21.0-28.5%) with valid results tested positive. All persons testing positive were referred to follow-up care, and 99.8% attended at least one session of follow-up care. Heterogeneity was high for most pooled proportions. For a hypothetical cohort of 1000 persons experiencing homelessness reached by a targeted testing program using TST, an estimated 917 were tested, 194 were positive, and all of these initiated follow-up care. Conclusions Targeted TB testing of persons experiencing homelessness appears effective in detecting LTBI and connecting persons to care and potential treatment. Future evaluations should assess diagnostic use of interferon gamma release assays and completion of treatment, and costs of testing and treatment.

BackgroundGlobally, the prevalence of chronic non-communicable diseases (C-NCDs) and occurrence of multi-morbidity specifically, has been increasing and will continue to rise as life expectancy increases. The burden of mental health disorders has also been rising globally. In sub-Saharan Africa (SSA), literature on these health issues, which are interrelated, is scarce. This study assesses the prevalence of C-NCDs, and depressive and anxiety symptomology and examines the relationship between these issues among a sample of older adults in Uganda.MethodsBetween 2021-2022, 604 consenting adults aged 35 years and older were surveyed on a broad range of health issues for the ongoing AMBSO Population Health Surveillance (APHS) cohort study in Wakiso district. Descriptive analyses were performed to characterize the burden of C-NCDs (e.g. diabetes, hypertension), depression (PHQ-9 using a cutoff of ResultsMajority of participants were females (63.6%), median age was 46 (IQR: 39-54). Any C-NCDs prevalence was 18.7%, while 18.9% and 11.4%, had screening scores indicative of depressive and anxiety symptomology, respectively. Three percent (3.2%) had PHQ-9 scores indicative of moderate to severe depressive symptomology. In models adjusted for sociodemographic characteristics, there was 12% increased odds of suffering from C-NCDs for every unit increase in PHQ-9 score (AOR = 1.12, 95% CI: 1.10-1.20). Participants with any anxiety symptoms had 2.1 greater odds of suffering from C-NCD compared to those who did not have anxiety symptoms (AOR = 2.10, 95% CI: 1.21-3.70).ConclusionC-NCDs were prevalent in older adults, particularly among those experiencing mental health symptoms. Screening for C-NCDs and mental health disorders should be integrated into routine health care for older adults in the country. Early screening and identification of these health issues through primary health care could significantly reduce the public health burden attributable to mental health disorders and the incidence of multi-morbidity in Uganda.

Economic incentives to promote health behavior change are highly efficacious for substance use disorders as well as increased medication adherence. Knowledge about participants' experiences with and perceptions of incentives is needed to understand their mechanisms of action and optimize future incentive-based interventions. The Drinkers' Intervention to Prevent Tuberculosis (DIPT) trial enrolled people with HIV (PWH) in Uganda with latent tuberculosis and unhealthy alcohol use in a 2x2 factorial trial that incentivized recent alcohol abstinence and isoniazid (INH) adherence on monthly urine testing while on INH preventive therapy. We interviewed 32 DIPT study participants across trial arms to explore their perspectives on this intervention. Participants described 1) satisfaction with incentives of sufficient size that allowed them to purchase items that improved their quality of life, 2) multiple ways in which incentives were motivating, from gamification of "winning" through support of pre-existing desire to improve health to suggesting variable effects of extrinsic and intrinsic motivation, and 3) finding value in learning results of increased clinical monitoring. To build effective incentive programs to support both reduced substance use and increased antimicrobial adherence, we recommend carefully selecting incentive magnitude as well as harnessing both intrinsic motivation to improve health and extrinsic reward of target behavior. In addition to these participant-described strengths, incorporating results of clinical monitoring related to the incentive program that provide participants more information about their health may also contribute to health-related empowerment.

IntroductionUganda confirmed its first COVID-19 case in March 2020, leading to country-wide closures and a stay-at-home order. Infectious disease pandemics can overwhelm adaptive coping capacity (e.g., general self-efficacy and resilience) and increase the risk for mental distress. For individuals experiencing intimate partner violence (IPV) and cohabitating with a perpetrator, stay-at-home orders can also increase risk of violence, which can further exacerbate mental distress. The present study explores women's perceived self-efficacy and resilient coping, mental health outcomes (depression and COVID-19 related anxiety), hazardous alcohol use and IPV in the context of Uganda's national 2020 lockdown.MethodsA phone-based survey was undertaken from June-August of 2020 in Wakiso District, Uganda. The study sample consisted of Africa Medical and Behavioral Sciences Organization (AMBSO) Population Health Surveillance (APHS) study participants who agreed to be contacted for future research. The analytic sample was restricted to women aged 13-80 years. Bivariate analysis and multivariable models explored associations between experiences of IPV and measures of adaptive coping, mental health and alcohol use.ResultsA total of 556 women aged 13-79 years (mean age of 33.4 years) participated. Over half (55%) were currently married. The majority (60%) reported a decrease in alcohol use during the lockdown. Nearly half of the sample were experiencing physical or verbal IPV and reported an increase in violence during the lockdown. In adjusted analysis, alcohol use was associated with four times greater odds of recent physical IPV (aOR 4.06, 95% CI = 1.65-10.02, p = 0.0024), while participants had lower odds of experiencing any form of IPV as general self-efficacy increased (aOR 0.95, 95% CI = 0.91-0.99, p = 0.0308).ConclusionLockdown measures in Uganda may have mitigated increased alcohol consumption. IPV was exacerbated during lockdown; more than 2 in 5 IPV victims experienced increased physical or verbal violence. Development of programming and policies aimed at mitigating women's risk of IPV during future lockdowns are needed.

IntroductionUganda has one of the highest rates of alcohol use in sub-Saharan Africa but prevalence and correlates of drinking are undocumented in the Rakai region, one of the earliest epicenters of the HIV/AIDS epidemic in East Africa.MethodsWe analyzed cross-sectional data from 18,700 persons (8,690 men, 10,010 women) aged 15-49 years, living in agrarian, trading and fishing communities and participating in the Rakai Community Cohort Study (RCCS) between March 2015 and September 2016. Logistic regression models assessed associations between past year alcohol use and sociodemographic characteristics, other drug use and HIV status, controlling for age, religion, education, occupation, marital status, and household socioeconomic status.ResultsPast year alcohol prevalence was 45%. Odds of drinking were significantly higher in men (versus women) and fishing communities (versus agrarian areas). Odds of drinking increased with age, previous (versus current) marriage and past year drug use. By occupation, highest odds of drinking were among fishermen and (in women) bar/restaurant workers. Alcohol-related consequences were more commonly reported by male (vs. females) drinkers, among whom up to 35% reported alcohol dependence symptoms (e.g., unsteady gait). HIV status was strongly associated with alcohol use in unadjusted but not adjusted models.ConclusionsAlcohol use differed by gender, community type and occupation. Being male, living in a fishing community and working as a fisherman or restaurant/bar worker (among women) were associated with higher odds of drinking. Alcohol reduction programs should be implemented in Uganda's fishing communities and among people working in high risk occupations (e.g., fishermen and restaurant/bar workers).

ObjectiveAssess the effect of non-pharmacological alcohol interventions on reducing heavy episodic drinking (HED) outcomes in sub-Saharan Africa.MethodsA systematic review of the available literature through August 19, 2020 was conducted. Randomized and non-randomized controlled trials testing non-pharmacological interventions on alcohol consumption in sub-Saharan Africa were eligible for inclusion. Eligible outcomes included measures of HED/binge drinking, and measures indicative of this pattern of drinking, such as high blood alcohol concentration or frequency of intoxication. Three authors extracted and reconciled relevant data and assessed risk of bias. The review protocol is available on PROSPERO (registration number: CRD42019094509). The Cochrane Handbook recommendations for the review of interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines guided all methodology.ResultsThirteen intervention trials were identified that met our inclusion criteria and measured change in HED. Studies were judged of moderate quality. A beneficial effect of non-pharmacological interventions on HED was reported in six studies, three of which were deemed clinically significant by the review authors; no statistically significant effects were identified in the other seven studies. Interventions achieving statistical and/or clinical significance had an intervention dose of two hours or greater, used an array of psychosocial approaches, including Motivational Interviewing integrated in Brief Intervention, cognitive behavioral therapy and integrated risk reduction interventions, and were delivered both individually and in groups.ConclusionsEvidence for the effectiveness of non-pharmacological interventions to reduce HED in sub-Saharan African settings was limited, demonstrating the need for more research. To strengthen the literature, future research should employ more rigorous study designs, improve consistency of HED measurement, test interventions developed specifically to address HED, and explore structural approaches to HED reduction.

ContextAn estimated 21% of non-U.S.-born persons in the United States have a reactive tuberculin skin test (TST) and are at risk of progressing to TB disease. The effectiveness of strategies by healthcare facilities to improve targeted TB infection testing and linkage to care among this population is unclear.Evidence acquisitionFollowing Cochrane guidelines, we searched several sources to identify studies that assessed strategies directed at healthcare providers and/or non-U.S.-born patients in U.S. healthcare facilities.Evidence synthesisSeven studies were eligible. In a randomized controlled trial (RCT), patients with reactive TST who received reminders for follow-up appointments were more likely to attend appointments (risk ratio, RR = 1.05, 95% confidence interval 1.00-1.10), but rates of return in a quasi-RCT study using patient reminders did not significantly differ between study arms (P = 0.520). Patient-provider language concordance in a retrospective cohort study did not increase provider referrals for testing (P = 0.121) or patient testing uptake (P = 0.159). Of three studies evaluating pre and post multifaceted interventions, two increased TB infection testing (from 0% to 77%, p < .001 and RR 2.28, 1.08-4.80) and one increased provider referrals for TST (RR 24.6, 3.5-174). In another pre-post study, electronic reminders to providers increased reading of TSTs (RR 2.84, 1.53-5.25), but only to 25%. All seven studies were at high risk of bias.ConclusionsMultifaceted strategies targeting providers may improve targeted TB infection testing in non-U.S.-born populations visiting U.S. healthcare facilities; uncertainties exist due to low-quality evidence. Additional high-quality studies on this topic are needed.

BACKGROUND:Contact investigation is an important strategy for maintaining control of tuberculosis (TB) in the United States. However, testing and treatment outcomes specifically to foreign-born populations are poorly understood. We reviewed literature on testing and LTBI identified during contact investigations in foreign-born populations living in the US. METHODS:We conducted a comprehensive search of peer-reviewed and grey literature using Cochrane systematic review methods. We included studies with adult and adolescent populations that were at least 50% foreign-born. Pooled proportions and 95% confidence intervals (CIs) were calculated via inverse-variance weighted meta-analysis, and cumulative proportions were calculated as products of adjacent step proportions. RESULTS:We identified 22 studies published between 1997 and 2014 that included at least 50% foreign-born participants. From studies of predominantly (>90%) foreign-born populations, almost all identified contacts were recruited and had valid test results, and 54.8% (95% CI 45.1-62.5%) of contacts with valid test results tested positive. From studies of majority (50% to 90%) foreign-born populations, 78.4% (95% CI 78.0-78.9%) of identified contacts were recruited, 92.0% (95% CI 91.6-92.3%) of recruited contacts had valid test results, and 38.5% (95% CI 31.9%-44.2%) of persons with valid results tested positive. These proportions varied by test type in studies of predominantly foreign-born populations. For every 1000 contacts identified in predominantly foreign-born populations, we estimate that 535 (95% CI 438 to 625) will test positive, and 354 (95% CI 244 to 453) will complete LTBI treatment. For every 1000 contacts identified in majority foreign-born populations, these estimates are 276 (95% CI 230 to 318), and 134 (95% CI 44 to 264), respectively. CONCLUSIONS:Contact investigation is a high yield activity for identifying and treating foreign-born persons with LTBI, but must be complemented by other tuberculosis control activities in order to achieve continued progress toward TB elimination.