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Diverse Population And Healthcare

Diverse Population And Healthcare

Today’s healthcare model faces persistent challenges with cultural competency and racial, gender, and ethnic disparities. Many factors influence health outside of the traditional healthcare setting. Education, housing quality, and access to healthy foods are social determinants of health (SDH). According to some, racial and ethnic minorities have unfavourable SDH, contributing to their lack of access to healthcare. Furthermore, compared to Caucasian women, African American, Hispanic, and Asian women are less likely to undergo breast reconstructive surgery after a mastectomy. There is an underrepresentation of cultural, gender, and ethnic diversity in healthcare training and leadership. To meet the needs of a diverse population, the healthcare system must prioritize cultural competence and racial and ethnic diversity. Cultural competence is the ability to work effectively with people from other cultures, and it improves healthcare experiences and outcomes. Measures to improve cultural competence and ethnic diversity will aid in the reduction of healthcare disparities and the improvement of healthcare outcomes in these patient populations. To attract qualified minorities and women to the field, efforts must begin early in the pipeline. The authors are not advocating for diversity for the sake of diversity at the expense of merit or qualification; rather, these efforts must evolve to attract, retain, and promote highly motivated and skilled women and minorities. Measures to educate residents and students through national conferences and their institutions will help promote culturally appropriate health education and improve cultural competency at the trainee level. There are numerous opportunities to improve cultural competency and healthcare diversity at the medical student, resident, attending, management, and leadership levels. The authors investigate and discuss various measures to improve cultural competency and ethnic, racial, and gender diversity in healthcare in this article.

Minorities are expected to make up half the US population by 2050, and today’s healthcare system has been noted to have persistent racial and ethnic disparities.

1 To meet the healthcare needs of diverse populations, personalized approaches are required. Minorities have been shown to have less access to preventive care and treatment for chronic conditions, resulting in more emergency room visits, worse health outcomes, and a higher risk of developing cardiovascular disease, diabetes, cancer, and mental illness. 2–5

This disparity is particularly noticeable in the field of Plastic and reconstructive surgery. Sharma et al., for example, explain how there are significant racial disparities in breast reconstruction surgery. Compared to White women, African American, Hispanic, and Asian women are less likely to have breast reconstructive surgery after a mastectomy. A study using the Surveillance, Epidemiology, and End Results database discovered that more African American women than White counterparts chose not to have immediate breast reconstruction after mastectomy, with many citing financial constraints. Future studies after Medicaid expansion and coverage have backed up this disparity. 1

Many factors influence health outside of the traditional healthcare setting. Housing quality, access to healthy food, and education are social determinants of health (SDH). 6 According to some, racial and ethnic minorities have unfavourable SDH, contributing to their lack of access to healthcare. 6 Minority differences in healthcare treatment and outcomes persist even after controlling for socioeconomic factors. 3 We hypothesize that a lack of female and minority representation in Plastic surgery contributes to delayed healthcare and poor outcomes in these populations. To meet these healthcare needs in the future, we must begin efforts to attract and retain skilled female surgeons and minorities earlier in the pipeline chain. Although women account for half of all medical school graduates, only 14% of plastic surgeons and 32% of Plastic surgery residents are female. 7

In 2010, the senior author (O.A.A.) responded to Drs. Butler, Britt, and Longaker about the lack of ethnic diversity in plastic surgery. O.A.A. was a Black female in Plastic and reconstructive surgery at the time, accounting for only 3.7% of all residents and fellows. 8 It’s incredible that we’re still dealing with nearly identical statistics nearly a decade later. It is critical to prioritize diversity in plastic surgery to make significant strides toward closing this enormous disparity in representation within the next decade. The authors are not advocating for diversity at the expense of merit or qualification but rather that organizations and specialities launch initiatives to attract, retain, and promote highly motivated and skilled women and minorities.

Advocating for women and minorities in plastic surgery is one step toward recognizing and accommodating cultural differences. Culture is accumulated knowledge accumulated by a group of people over generations. 4 Cultural competence is the ability to collaborate with people from different cultures effectively, and it can help improve the healthcare experience and outcomes. 3,4

According to studies, there have been few national efforts to incorporate cultural competency into healthcare.

9 A national study of organizational efforts to reduce physician racial and ethnic disparities found that 53% of organizations surveyed had 0-1 activities to reduce disparities out of over 20 possible actions. Some examples of disparity-reducing activities include providing educational materials in a different language, providing online resources to educate physicians on cultural competence, and recognizing efforts to reduce racial disparities at national meetings. The presence of a health disparities committee and the size of the national physician organization surveyed were found to be positively associated with organizations that engaged in at least one disparity-reducing activity. Primary care organizations were more likely to participate in disparity-reducing activities, and they may serve as models for other physician organizations to follow. 9

There are numerous opportunities to improve cultural competency. One of these measures is to educate residents and students before transitioning into attending roles. The Accreditation Council for Graduate Medical Education has identified cultural competency as an important part of its professionalism competency. The Alliance of Continuing Medical Education has also dedicated lectures to cultural competency at its national annual conference. 10 Such measures will aid in increasing trainee awareness and bridging the competency gap as they transition from training to practice. Incorporating diversity training and cultural competence exercises into national Plastic surgery meetings with CME accreditation, such as Plastic Surgery: The Meeting and AAPS is a feasible way to incorporate this training. Additional efforts at the state and national levels are also required to advance cultural competency, and some are already underway. 6,10 For example, the Office of Minority Health at the Department of Health and Human Services created “Think Cultural Health,” a resource centre that allows users to earn continuing education credits in cultural competency through online case-scenario-based training. 6 Furthermore, five states have passed legislation requiring or strongly recommending cultural competency training for physicians. 10 These implementation efforts will raise awareness about the importance of cultural competency and diversity in healthcare.

On an industry level, there is a significant lack of diversity in healthcare leadership, with 98% of senior management in healthcare organizations being White.

4 This disparity in representation is exacerbated when considering minority representation in leadership roles in plastic surgery. Women comprise only 7% of department heads and chairs in plastic surgery. Improving the representation of women and ethnic minorities in White-male dominated fields such as plastic surgery can improve minority populations’ access to healthcare. Female leadership has even been linked to increased effectiveness. 11

Even when members of racially or ethnically underrepresented groups achieve high-level executive positions, the majority earn lower salaries and are overrepresented in management positions serving underserved populations.

12 Addressing healthcare gaps and disparities are critical. Some steps are being taken to achieve cultural competency, such as targeting upper-level executives and asking them to prioritize cultural competency. 4,12 Others advocate starting with medical education to address cultural competence in healthcare. Some of the problematic themes identified include a lack of exposure as well as insufficient diversity in education and teaching curricula; unfortunately, cultural competence is frequently perceived as a low priority in an overburdened academic curriculum. 13

Efforts have been made in the healthcare industry to achieve cultural competence to provide culturally congruent care.

4 Five interventions to improve cultural competence were identified in a review of culturally competent healthcare industry systems:
Cultural competency training for healthcare providers.
Use of interpreter services to ensure individuals from different backgrounds can effectively communicate.
Culturally appropriate health education materials to inform staff of different cultural backgrounds.
Provision of culturally specific healthcare settings.
14 Culture competence in Plastic surgery can be improved from the bedside to the operating room by raising awareness and incorporating these interventions.

Unfortunately, there is a lack of research linking culturally competent education to patient, professional, and organizational outcomes. Horvat et al. developed a four-dimensional conceptual framework to evaluate intervention efficacy: educational content, pedagogical approach, intervention structure, and participant characteristics. To best document progress, future studies must adhere to methodologic rigour and reproducibility. 15
According to a study of 119 California hospitals, nonprofit hospitals serve more diverse patient populations, are in more affluent and competitive markets, and have higher cultural competency. It is argued that implementing culturally competent programs will have a market incentive if cultural competency is linked to better patient experiences. 16 Policymakers and institutions can utilise this by incorporating cultural competence practices into incentive payment metrics. Enhancing public reporting on patient care and hospital quality will also increase competition in the healthcare field and encourage organizations to strive for cultural competence. 16

To adequately care for an evolving and diverse patient population, plastic surgeons must strive for ethnic diversity and cultural competency. Plastic surgery departments must implement evidence-based practices to foster cultural competency, such as encouraging the recruitment of diverse healthcare providers, the use of interpreter services, cultural competency training for healthcare team members, and the distribution of cultural competency information to hospital staff members. Plastic surgery departments must evolve to meet the needs of a diverse range of modern patients as population demographics change.
Geri-Ann Galanti, PhD discusses the challenges of serving and working with diverse populations in American hospitals.

The Diversity Factor published this article.
Dr Galanti is a member of the Doctoring Curriculum at UCLA School of Medicine, as well as the Division of Nursing and Anthropology at California State University.
Americans can take pride in achieving what the medical profession refers to as “cultural competency”, which is a goal of most healthcare institutions. However, in today’s healthcare environment, with diverse patient and provider populations, achieving this goal is no easy task. Aside from the complications brought on by the proliferation of managed health care, American hospitals are increasingly staffed by and serving diverse populations. This creates an ideal environment for conflict and misunderstanding, leading to staff tension and poor patient care.
Hospitals can be a source of stress and frustration for patients and their families because they are at their most vulnerable while in them and are at the mercy of values and beliefs that are not their own. People from other countries frequently travel here for health care because the United States provides the best medical technology and expertise. Because European Americans built our hospitals for European Americans, values such as autonomy, independence, and privacy are prevalent in our facilities. Patients who have immigrated or are visiting from other countries frequently value the family over the individual or regard the male head of household as the patient’s decision-maker.Diverse Population And Healthcare
Families may be more likely to assist the patient with “self-care” functions, whereas the medical staff believes the patient should value independence as a critical recovery goal. The United States healthcare system tries to give patients privacy by limiting visiting hours and rarely provides sleeping accommodations for visitors. Many non-Anglo patients prefer the inverse.
In this article, I will discuss some issues that can arise due to a failure to recognize cultural differences and some solutions. I chose individuals who have yet to assimilate fully and whose beliefs and behaviours differ from those expressed in the American healthcare system. It should be assumed that only some or even the majority of the members of these groups would behave in the manner described. We must also acknowledge that assimilation occurs in unpredictable stages and that many people work hard to legitimately maintain their cultural traditions in the face of dominant American values and traditions.
Generalizations vs Stereotypes
Anthropologists frequently make generalizations about groups of people; it’s what we do; we look for broad patterns of similarity among groups. However, in health care, we cannot make the mistake of assuming that all group members follow the same pattern. This is especially important when the logic of a healthcare provider can mean the difference between life and death. We can identify the point at which our healthcare system breaks down suboptimal patient care results by distinguishing between stereotypes and generalizations as they apply in a healthcare environment.
While these two thought patterns appear to be similar, they are not. A generalization is a starting point; we recognize a cultural pattern and then examine the individual to see if they fit it.
In healthcare situations, making the appropriate generalization can be a useful tool for narrowing the field of thought and can sometimes help save a life or prevent medical complications.
A Chinese nurse told me about a Mexican woman who developed a severe condition requiring immediate surgery. Knowing that older Mexican women frequently view their husbands as family decision-makers, the nurse informed the doctor that she would contact the patient’s husband. The doctor told her it was unnecessary because she would undoubtedly sign the consent form after explaining the situation to the patient. Despite the physician’s advice, the nurse called the patient’s husband. When the doctor finished speaking with the patient and asked for her permission, she refused, saying she would wait for her husband. Because time was of the essence, the doctor couldn’t wait much longer before referring her to surgery. Fortunately, her husband arrived just in time and persuaded her to consent to what turned out to be a successful surgery. The patient’s outcome might not have been as positive if the nurse had not acted on her generalising gender role patterns in traditional Mexican households.
On the other hand, a stereotype is a point of no return and can be harmful. We develop conventional, formulaic, and oversimplified conceptions and opinions in this mode of thought. It is then simple to label a patient as one of several types and make no further effort to determine whether the individual fits the stereotype. Take, for example, the statement, “Mexican women frequently express their pain loudly.” If I ignore a female Mexican patient who is moaning about her pain, thinking, “Don’t worry; Mexican women express their pain loudly,” I am guilty of stereotyping. If, on the other hand, knowing that female Mexican patients frequently express their pain loudly, I check with the family to see if this particular woman is vocal when in pain, then I am generalizing.
For example, despite his stereotypes, a 62-year-old female Mexican patient with a bypass graft on her leg could have suffered serious complications if the nurse had not acted. When she awoke in the recovery room, she screamed in agony. Her nurse immediately administered the morphine dosage prescribed by the doctor, but it was ineffective. He then checked her vital signs and pulse and discovered they were normal. Her dressing drained poorly. According to all appearances, the patient was in good health. The nurse quickly became irritated by her outbursts, labelled her as a “whining Mexican female who, as usual, was exaggerating her pain,” and took no further action.
After an hour of crying, the nurse summoned the doctor. When the surgical team opened her wound dressing, they discovered a large amount of blood pressing on the nerves and tissues in the area, causing excruciating pain. She was immediately taken back to the operating room. The patient could have suffered serious complications if the nurse had stuck to his stereotype and the physician had not discovered the problem.
In a less fortunate situation, when my student’s Irish mother-in-law was in the hospital for surgery, a physician was guilty of stereotyping and a lack of knowledge about the patient’s culture. When she suddenly began complaining of pain, her family became very concerned. They knew her stoicism was typical of the Irish, so they consulted her doctor from India. The doctor, on the other hand, was unconcerned. Women in his country were usually vocal in pain, so he assumed his female Irish patient would also be. He refused the family’s request for the surgery to be performed sooner, believing it was unnecessary.
When he finally operated, he discovered that the patient’s condition had deteriorated, so she could no longer be saved. My RN student believed that if the doctor had recognized her culturally atypical pain expressions as a sign that something was seriously wrong and operated on sooner, she might have lived. In this case, the doctor made the mistake of stereotyping the patient based on what he knew about women, oblivious to cultural differences between groups. Even if he knew nothing about the typical Irish response to pain, he could have listened to the family members who knew the patient’s complaints were out of the ordinary.
Cultural practices can obstruct accurate diagnosis and treatment.
Cultural practices can also help in determining the correct diagnosis and treatment.
A Korean man was brought into the emergency room unconscious, with red welts on his chest.
The family did not speak English, and there was no interpreter available. The staff assumed that the patient’s lack of consciousness was related to the red welts and that they were both symptoms of the same condition. They wasted precious time investigating incorrect diagnoses that could link the welts to unconsciousness. It was too late to save the patient by the time they discovered what he was suffering from. They could have saved his life if they had known to ignore the welts.
The welts were caused by “coining,” a traditional Asian practice. There are a few variations, such as heating or oiling the coin, but they all involve vigorously rubbing the body with a coin. This healing method is thought to draw the illness out of the body, as evidenced by raised welts. This practice, common in China, Korea, and Southeast Asia, has received much attention because it is frequently misinterpreted as child abuse. It is critical that healthcare providers recognize this practice and do not let it distract them from the real issue.
In another case, a Japanese man in his 60s was a patient in a rehabilitation unit after suffering a stroke that left his left side severely paralyzed. He had to relearn how to feed himself, dress, shave, use the bathroom, and do other daily tasks. His nurse spent a long time carefully explaining how to do these tasks to him, but he only listened passively. Despite detailed self-care instructions, the patient refused to do anything for himself and repeatedly barked commands at the nurse. He demanded that his wife did everything for him when she was present. He was discharged four weeks later, almost as dependent as when he arrived.
His reliance irritated the nurses, who took his “failure” personally. This is one of those cases where healthcare providers must acknowledge that they are attempting to impose their value system (“independence” as a primary value) on someone from a culture that does not share that value. Family interdependence, for example, is far more important in Japanese culture. It is critical to distinguish between when self-care is required for physical recovery (as in the case of burned skin, when self-care activities provide the exercise required to stretch the skin) or because there will be no one to care for the patient at home, and when it is simply an imposition of the American value system and family structure.
The value of efficiency in the healthcare culture frequently clashes with the value of modesty in patients. Many doctors and nurses find it difficult to be concerned about keeping patients covered when their primary focus is on performing an appropriate procedure. Following the birth of their child, an Arab man refused to allow a male lab technician into his wife’s room to draw blood. When the nurse finally persuaded him of the necessity, he reluctantly allowed the technician into the room, but only after ensuring that his wife was completely covered. Only her arm protruded from beneath the blankets, and he closely watched the three technicians throughout the procedure. The toilet in his wife’s room overflowed the next day. When three men from engineering and housekeeping were about to enter the room after knocking, he flew into a rage. He would not let them in. The toilet remained unfixed until the couple left the next day.
Both incidents stem from the fact that family honour is one of the highest values among Arabs. Because female purity is linked to family honour, extreme modesty and sexual segregation must be maintained at all times. Hospitals that lack female physicians should have a referral system in place so that one can be found when needed. Female housekeepers should clean Arab women’s rooms, and female nurses should care for them whenever possible.
Disease Religion, Etiology, and Worldview
Problems can also arise when the healthcare culture’s worldview differs from that of the patient population. If people believe God bestows both health and illness, getting them to take their medications or change their health behaviour may be difficult. They may not believe, as the healthcare culture does, that germs cause disease and that diet and exercise help one’s health.
They would see no point in being concerned about high blood pressure or bacteria if moral behaviour is the key to good health.
For example, a 75-year-old African American woman was in the hospital recovering from a heart attack. She was a devout Christian who spent most of her time praying. Her church brethren paid her daily visits, and she appeared closer to them than her family members. During her hospital stay, the patient consented only to procedures and medications she believed were ordered by God because she believed only God could heal her.
Other beliefs significantly impact a patient’s decision-making and care requirements. The belief that a healthy body is in a state of balance originated in China. It spread to influence beliefs in other parts of Asia, India, Spain, and Latin America, and it is referred to as upset body balance.
Illness occurs when it is out of balance. The balance in Asia is between yin and yang, while Latin America is between “hot” and “cold.” Soul loss, like soul theft, leaves the body weakened and ill in other cultures. The goal of treatment, in this case, is to return the soul to the body, which usually necessitates the services of a specialist, such as a shaman, who can “leave” their own body to search for and return the missing soul. Similarly, spirit possession entails a spirit taking control of the victim’s body.
Many healthcare professionals have strong moral difficulties respecting the Jehovah’s Witness position from a religious standpoint. The conflict is divided into two parts: values and worldview. According to the Jehovah’s Witnesses, when Armageddon arrives, 144,000 people who have followed God’s laws will rise from the dead to spend eternity in heaven. Those who have kept God’s laws but do not enter heaven will spend eternity in an earthly paradise. All those who have broken God’s laws (for example, received a blood transfusion, elevated themselves above God by celebrating their birthdays, or worshipped idols by saluting the American flag) will spend eternity in nothingness.
Following a horseback riding accident, a 37-year-old woman with two children was taken to the hospital. Her medical alert card identified her as a Jehovah’s Witness and stated that she would not receive blood under any circumstances. Her doctor was aware of this but felt compelled by his Hippocratic oath to save lives and administered a blood transfusion to her. His actions saved the patient’s life, but she was not grateful and filed a lawsuit against him for assault and battery, winning a $20,000 settlement. In a 1980s study of four Jehovah’s Witnesses, two-thirds of those polled said they would sue if they were transfused against their will.
Consider for a moment that the Jehovah’s Witnesses are correct. Choosing a blood transfusion can be interpreted as preceding the opportunity to spend eternity in heaven or paradise in exchange for a few more years on earth. Because they value the life of the physical body, Jehovah’s Witness patients’ worldview is in direct conflict with that of most healthcare professionals. The Jehovah’s Witnesses value the life of the soul over the life of the physical body by refusing blood. Is it legitimate for any group to impose its values and beliefs on others? Can we be so arrogant and ethnocentric that we believe we are correct and they are incorrect?
Two important points should be made about disease aetiology. First and foremost, the treatment must be appropriate for the cause. Kill the germs if they cause disease. Restore balance to the body if it is out of balance. If the soul has vanished, find it. Remove any objects that have entered the body. All of these solutions are perfectly logical. It makes no difference whether these etiologies are the true causes of the disease. Any amount of antibiotics will not cure a patient who believes they are ill due to soul loss. The placebo effect demonstrates how powerful the mind is. Both the patient’s beliefs and their body must be addressed. Many Americans, for example, believe they have not been properly treated if they do not receive an antibiotic for a virus, although antibiotics are only effective against bacteria.
They require the pill to recover psychologically.
Second, we must not allow our ethnocentrism to blind us to the value of other cultures’ beliefs. They could be correct. It’s easy to dismiss other systems, citing science to back up Western medical beliefs. All medical systems, however, are founded on observed cause-and-effect relationships. The main difference between the scientific and non-scientific approaches is that science can be falsified. A scientific hypothesis can be disproven. Other systems’ beliefs cannot.
Education is the key to bringing about change.
If healthcare professionals are serious about providing the best care possible to all patients, regardless of race, gender, or ethnic origin, they must educate themselves and become culturally competent. It is impossible to know everything about every culture, but the first critical step is recognising that different cultures have different rules of appropriate behaviour.
Many educational institutions recognize the significance of cultural education for healthcare professionals. The three-year mandatory Doctoring Curriculum at UCLA School of Medicine focuses on teaching medical students about the psychosocial and cultural aspects of being a doctor. Students practice interviewing skills with “standardized patients,” or actors dressed as patients.
Several cases involve cultural elements. CSU Dominguez Hills’ Division of Nursing requires a four-unit course on Human Diversity as part of its Bachelor of Science in Nursing program. At the hospital level, the Kaiser Permanente National Diversity Council has developed a series of handbooks on Culturally Competent Care for its membership’s diverse populations. Many other hospitals offer cultural diversity workshops for staff, but a single workshop can only be the beginning of the journey toward cultural competency. Numerous books and websites are available for healthcare professionals to read to educate themselves. Finally, healthcare providers can capitalize on workplace diversity by respectfully asking each other about their culture’s beliefs and traditions.
Diversity and Hospital Staff Relations
Cultural differences can also lead to disagreements and misunderstandings among hospital employees. A Japanese doctor, for example, may direct a nurse to administer a specific medication dosage to a patient. However, because everything the nurse knew about the medication led her to believe that the dosage would be harmful, she refused. The doctor insisted, but she refused. When the doctor reported the nurse to her supervisor, he suggested that the proper response would have been to agree to administer the medication but then not do so. Such behaviour, however, is not permitted in American hospitals. This example demonstrates the disparity in values between Asians and Americans. Asians generally believe it is critical to avoid conflict while showing respect for authority. Rather than directly refusing, agreeing to a supervisor’s face and not following through is preferable.
On the other hand, Americans believe it is critical to be direct and honest. Disagreement is unavoidable. Assertiveness is valued as an egalitarian ideal in the United States. The doctor’s main gripe wasn’t that the nurse disobeyed him but that she disagreed with him to his face, denying him proper respect.
In other countries, gender roles create conflict among hospital employees. For example, a Nigerian male nurse assistant would frequently have “a temper tantrum” whenever a female nurse asked him to do something. He would sulk and leave the room at other times. He would never take instructions from a woman. Because men are considered superior in Nigeria, they tell women what to do.
This, of course, causes issues in American hospitals. Nursing is a hierarchical profession in which orders are followed based on rank rather than gender. As a result, RNs expect nurse assistants to do as they are told. Despite his lower professional rank, the nurse assistant felt that as a Nigerian male, he should not have to take directions from women. It won’t be easy to maintain a viable working relationship on the floor unless someone with this cultural disposition is placed under the supervision of another man.
In another case, a Filipino nurse who did not get along with her coworkers felt they were exploiting her by constantly asking for her help. She was enraged by what she saw as obvious discrimination. Her only solace was the belief that she was a better nurse because she could do her work without assistance. She also took pride in the fact that she was active like them. She looked after her patients while the other nurses insisted that the patients look after themselves. An Anglo nurse on the unit eventually befriended the Filipino nurse. After they became acquainted, the Anglo nurse explained that it was standard practice for nurses to assist one another. She revealed that the other nurses thought the Filipino nurse was conceited and arrogant because she never asked for assistance. What the Filipino nurse mistook for laziness was teamwork.
The Anglo nurse also explained that American healthcare providers value independence and encourage their patients to care for themselves. The Filipino nurse was taken aback, but with the assistance of the Anglo nurse, the cross-cultural misunderstandings were resolved. The Anglo nurse explained to the others that the Filipino nurse was trying to save face by never asking for help; she didn’t want them to think she couldn’t do her job.
It would be beneficial if hospitals trained their foreign-born staff on American hospital expectations and the more egalitarian relationship between the sexes and among the staff. At the same time, American employees would be wise to remember the special value other cultures place on certain traits, such as self-esteem and dignity. Although these characteristics are important to all humans, they are emphasized even more strongly in other cultures.


God Grew Tired of Us
Watch the video God Grew Tired of Us (1:30:00). Write a 1-2 pg reflection describing your observations around the acculturation process by the Lost Boys of Sudan.

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