Midterm Exam Review
What is the Centers for Disease Control and Prevention (CDC)?
- Federal government agency responsible for improving the overall health and safety of the people of the United States - Collaborates to create the expertise, information, and tools that people and communities need to protect their health through health promotion, prevention of disease, injury and disability, and preparedness for new health threats.
Who is Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC)?
- Federal government agency responsible for improving the overall health and safety of the people of the United States - Collaborates to create the expertise, information, and tools that people and communities need to protect their health through health promotion, prevention of disease, injury and disability, and preparedness for new health threats.
These are the two primary federal agencies involved with funding state and local public health efforts
- Health Resources and Services Administration - Centers for Disease Control and Prevention
What is Healthy People 2000?
- Presented a new national prevention strategy, identifying three broad goals: increasing the span of life, reducing health disparities, and achieving access to preventive services. The 21 areas were in three broad categories: health promotion, health protection, and preventive services.
What is policy making?
- Process by which authorities decide what actions to take to address a problem or set of problems - Health policy making involves the development, planning and enactment of programs crafted to improve quality of health for individuals.
The relationship between public health and social determinants of health is best described as - None of these are correct - Public Policy that encompasses the intentional actions or inactions by government to address a problem affecting the public. - Social Determinants of Health representingnon-medical factors affectingboth the average and distribution of health within populations - All of these are correct
All of these are correct
What is the Public Health System?
All public, private, and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction
What are the three core functions of public health services?
Assessment, policy development, and assurance
The Institute of Medicine (IOM), pivotal report, The Future of Public Health, established recommendations for a new way of organizing public health activities. Three core public health functions are: - Assessment, quality improvement, and compliance - Assessment, regulatory oversight, and assurance - Assessment, policy development, and assurance. - Assessment, policy development, and compliance
Assessment, policy development, and assurance.
One of Healthy People 2020's overarching goals are - Attain high-quality, acceptable lives with minimal preventable disease, disability, injury, and premature death - Enhance high-quality, longer lives free of preventable disease, disability, injury, and premature death - Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death - Maintain high-quality, longer lives free of preventable disease, disability, injury, and premature death
Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death
Public health aligns with the following founding principles of the Nation - Democracy, federalism, social justice, human rights, and dignity - Democracy, federalism, social injustice, human rights, and dignity - Democracy, state control, social justice, human rights, and dignity - Democracy, federalism, social justice, human rights, and quality of life
Democracy, federalism, social justice, human rights, and dignity
The basic principles of psychology—primacy and recency—apply to communication with prospective employees. Primacy means that - People form a lasting first impression based upon the first contact, or the first few minutes of an encounter. - None of these are correct - People may form lasting impressions from their last encounter or final few minutes with an organization. - People form an opinion based on good notes, references, and review of past records and accomplishments
People form a lasting first impression based upon the first contact, or the first few minutes of an encounter.
Leadership is primarily about - Neither are correct - The future, change, and assuring the organization has an appropriate vision of the future - The present, assuring operations support the vision and mission are run efficiently and effectively daily - Both of these are correct
The future, change, and assuring the organization has an appropriate vision of the future
Public health history and success is important because - Throughout history, public health efforts have not focused on control of communicable diseases, reducing environmental hazards, and providing safe drinking water - The historic emphasis of public health on protecting populations from infectious disease have expanded to include the prevention and reduction of chronic disease - Social, environmental, and biologic factors rarely interact to determine health, public health practice must utilize a broad set of skills and interventions
The historic emphasis of public health on protecting populations from infectious disease have expanded to include the prevention and reduction of chronic disease
What is Assessment, Policy Development, Assurance?
The three core functions of public health services
The US public health system infrastructure can be overcome with improved ________ _________
skilled workforce, integrated electronic information systems, public health organizations, resources, and research.
What is the state health dept?
- State public health agencies are responsible for administering specific public health programs and services on a statewide basis. - The organization of state public health agencies generally follows one of two basic models: a free-standing agency structure headed by an administrator who reports directly to the state's governor, or an organizational unit within a larger superagency structure that includes other functions such as medical 25 care and social services programs.
What is a federal pass through grant?
- The federal government permits certain recipients to act as pass-through entities, which allows the initial recipient to provide the funds to another recipient.
In 1842, Edwin Chadwick published the General Report on the Sanitary Condition of the Laboring Population of Great Britain. Name one of the two main findings
- The need for a champion for sanitary reform - A description of the prevalence of disease among the laborer populations
Health Resources and Services Administration
- The primary federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable - Seeks to ensure equitable access to comprehensive quality health care; funds community health centers, HIV/AIDS services, scholarships for health professional students - The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the primary federal agency for improving health care to people who are geographically isolated, economically or medically vulnerable. - HRSA programs help those in need of high quality primary health care, people with HIV/AIDS, pregnant women, and mothers. HRSA also supports the training of health professionals, the distribution of providers to areas where they are needed most and improvements in health care delivery.
Name 3 of the 10 Essential Public Health Services
1. Monitor health status to identify community health problems. 2. Diagnose and investigate health problems and health hazards in the community. 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8. Assure a competent public health and personal healthcare workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. 10. Research for new insights and innovative solutions to health problems.
The outcome or performance of the public health system can be measured in terms of - Ability to achieve equity (e.g., reducing disparities) between populations - None of these are correct - Efficiency (i.e., cost-beneficial) - Effectiveness (e.g., improving population health status) - All of these are correct
All of these are correct
A key strategy to enhance the current public health workforce capacity includes - Enhanced high school public education - Training for employed administrative support health workers - None of these are correct - Worksite-based training programs - All of these are correct
All of these are correct
Ethics in public health has at least three dimensions. They are - Character and virtues of the agent or decision maker and the profession of which they are members - All of these are correct - Integration of ethics throughout an organization - None of these are correct - Systematic processes for the deliberation about particular cases or ethical dilemmas
All of these are correct
Notable public health trends and issues include - None of these are correct - Improving the skills and competency of the public health workforce - Communicable and chronic disease prevention as one of the top 10 achievements - Addressing one of the biggest public health challenges: HIV/AIDS - All of these are correct
All of these are correct
States Employers Council, Inc., has identified the following 10 common errors made when interviewing candidates. Examples include - Asking direct instead of open-ended questions - Failing to establish rapport with the applicant - None of these are correct - Asking questions that identify or single out a candidate's protected group status - All of these are correct
All of these are correct
The core public health functions as defined by the Institute of Medicine (IOM) are - Assurance - Assessment - All of these are correct
All of these are correct
Organizational commitment typically involves the following three factors: - Non-belief in the goals and values of the organization, willingness to exert considerable effort on behalf of the organization, and desire to continue work with the organization - Belief in the goals and values of the organization, willingness to exert considerable effort on behalf of the organization, and desire to continue work with the organization - Belief in the goals and values of the organization, unwillingness to exert considerable effort on behalf of the organization, and desire to continue work with the organization - Belief in the goals and values of the organization, willingness to exert considerable effort on behalf of the organization, and desire to do the minimum for the organization
Belief in the goals and values of the organization, willingness to exert considerable effort on behalf of the organization, and desire to continue work with the organization
In 1842, Edwin Chadwick published the General Report on the Sanitary Condition of the Laboring Population of Great Britain. Two of the most significant findings included - The need for a champion for sanitary reform - Both of these are correct - None of these are correct - A description of the prevalence of disease among the laborer populations
Both of these are correct
Personal Competence is the foundation of emotional Intelligence, and is comprised of - Self-awareness - Self-Management - Neither are correct - Both of these are correct
Both of these are correct
can be either on a - None of these are correct - Project Basis - Formula Basis - Both of these are correct
Both of these are correct
_____ grants can either be on a project or formula basis
Categorical grants
Macro-policymaking -the policy systems model contains the following characteristics: - Complexity, actors, interrelatedness, and cyclical processes - Complexity, directors, interrelatedness, and cyclical processes - Complexity, actors, isolation of issues, and cyclical processes - Complexity, actors, interrelatedness, and predictable processes
Complexity, actors, interrelatedness, and cyclical processes
With complexity and interrelatedness, the policy process does not have a definite beginning or end, instead the process - Continues as long as organized crime exists and there are no permanent policy successes or failures - Discontinues as long as organized society exists and there are no permanent policy successes or failures - Continues as long as organized society exists and there are permanent policy successes or failures - Continues as long as organized society exists and there are no permanent policy successes or failures
Continues as long as organized society exists and there are no permanent policy successes or failures
Preventive services include - Counseling, filtering, and immunization - Counseling, screening, and hospitalization - Counseling, screening, and immunization - Assessment, screening, and immunization
Counseling, screening, and immunization
The CDC administers a range of programs designed to prevent and control specific disease, injury, and disability risks on a national level through - Epidemiologic surveillance and investigation, research, and program development and dissemination activities - Epidemiologic surveillance and investigation, oversight, and program development and archiving activities - Epidemiologic surveillance and investigation, research, and programassessmentand social media crowd sourcing activities - Medical care surveillance and investigation, research, and program development and dissemination activities
Epidemiologic surveillance and investigation, research, and program development and dissemination activities
The GLOBE study shed valuable light with the most extensive report on global leadership to date. The study revealed clear differences in - Expectations and preferences of leadership among cultures, however, some expectations of leaders are universal - Neither are correct - Expectations and preferences of leadership among cultures, however, some expectations of leaders are not universal.
Expectations and preferences of leadership among cultures, however, some expectations of leaders are universal
A key strategy to enhance the current public health workforce capacity includes enhanced high school public education - True - False
False
Effective public health protection is technically and politically difficult but can solve all, or even most, of the challenges facing public health authorities - True - False
False
Enforcement laws and regulations that protect health and ensure safety is not one of the essential functions of public health. - True - False
False
Healthy People 2020 establishes four foundational health measures to monitor progress toward achieving its goals: Measures include general health status, health-related quality of life and well-being, determinants of serenity, and equality. - True - False
False
Local governmental public health agencies retain the most indirect and immediate responsibility for performing public health activities at the national level - True - False
False
Management's focus is on the future, assuring future operations support the vision and mission are run inefficiently and effectively. - True - False
False
Professional ethics focuses on the important relationship between the individual officials and the official's organization - True - False
False
Systems thinking in public health is best described as solutions that require intervention and engagement with a known set of stakeholders and organizations - True - False
False
The US political system is designed to accelerate most major policy initiatives, in health care as elsewhere - True - False
False
The United States public health workforce consists of individuals from a specific subset of professions, technical disciplines, and educational backgrounds - True - False
False
The foundation of the human resources model is positive reinforcement of employee performance, effective use of punishment for undesirable behaviors, and concentration on building strengths. - True - False
False
The scope of public health services performed by local public health agencies has been standardized across regions and states. - True - False
False
Throughout the country, there is a vast comprehensive electronic health intelligence and information system capable of detecting unusual disease events, tracing vulnerable populations, and monitoring cases of diseases - True - False
False
WIC is an example of what type of grant?
Federal grant
Women, Infants, and Children (WIC) program is a federally funded nutrition program that provides nutrition assessments, diet counseling, and food coupons to low-income women.This is an example of a - Block grant - Nosemark - Earmark - Federal pass through grant
Federal pass through grant
Utilitarian or consequentialist theories are often criticized for - Focusing on the overall or total amount of benefit produced by an action or how the benefits are reallocation among the population based on interests - Focusing on the maximum amount of benefit produced by an action or how the benefits are discounted among the public health community - Focusing on the minimal amount of benefit produced by an action or how the benefits are distributed among the population - Focusing on the overall or total amount of benefit produced by an action or how the benefits are distributed among the population
Focusing on the overall or total amount of benefit produced by an action or how the benefits are distributed among the population
The 2003 IOM report, Who Will Keep the Public Healthy?recognized eight fields of expertise newly growing in importance for public health practice. What is not one of the eight services below? - Informatics - Cultural competence - Geological impacts - Communication - Community-based participatory research
Geological impacts
Sanitation reform in Rome was catalyzed by - Advice of the Germanic peoples who had lived through plagues and pestilence and wanted to pass on their lessons learned to others - Growth of the bureaucratic imperial state and the development of sophisticated civil engineering to provide rapid communication across the empire - Significant expansion of state interests and the lack of oversight of general working and living conditions
Growth of the bureaucratic imperial state and the development of sophisticated civil engineering to provide rapid communication across the empire
The primary federal agencies involved with funding state and local public health efforts are the - Health Care Financing Administration and the Centers for Disease Control and Prevention - Health Resources and Services Administration and the Centers for Device Control and Processing - Health Resources and Services Administration and the Centers for Disease Control and Prevention - None of these are correct
Health Resources and Services Administration and the Centers for Disease Control and Prevention
The goal of accreditation is to - Improve the performance and capacity of public health agencies to perform the ten essential services. - Improve the performance and capacity of public health agencies to perform the ten essential competencies - Sustain the performance and capacity of public health agencies to perform the ten essential services - Improve the performance and capacity of public health agencies to perform the one hundred essential services.
Improve the performance and capacity of public health agencies to perform the ten essential services.
The challenges facing the US public health system infrastructure can be overcome with - All of these are correct - None of these are correct - Improved information technology - Categorical decrements to funding in order to generate increased innovation - Shared leadership and minimal vision
Improved information technology
Population-based strategies for improving health include - Improving maternal and child health - Rotate safe drinking-water and food sources - Delegating surveillance of health problems to civil engineers - Prolong epidemics - Increase vaccine-preventable diseases
Improving maternal and child health
What was the first year that Healthy People was enacted?
In 1979 of Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention.
Healthy People 2020 strives to - Increase public awareness and understanding of the determinants of health - Engage selected sectors to take action using best available evidence and knowledge - Prevent critical research proposals - Identify worldwide health improvement priorities - Provide measurable objectives and goals for local levels only
Increase public awareness and understanding of the determinants of health
The marketplace model of policymaking is outlined most completely in Feldstein. One of the major assumptions is - None of these are correct - Individuals and groups are constantly interacting to satisfy their needs - All of these are correct - Currency used in exchanges can be money and other international health resources - Non-governmental groups will attempt to distance themselves from governmental agencies
Individuals and groups are constantly interacting to satisfy their needs
________ ethics focuses on the mission, values, and systems to create a climate for ethical behavior, practices, and policies
Organizational ethics
Formal leadership training is offered due to the following common scenario - Deliberately working to get individuals being promotedregardless of their technical expertise into positions requiring additional skills - Neither are correct - Individuals suddenly becoming leaders from being thrust into positions of authority where the potentially blinding spotlight of leadership expectation immediately hits them despite their having little or no training in leadership, per se.
Individuals suddenly becoming leaders from being thrust into positions of authority where the potentially blinding spotlight of leadership expectation immediately hits them despite their having little or no training in leadership, per se.
Population health depends on expert performance in six functional areas. Which one of the following is not one of the functional performance areas? - Infectious disease prevention - environmental safety - Injury prediction - Assurance of health care services - Disaster response and recovery
Injury prediction
The federal government's power to tax not only generates the revenue to fund federal public health programs, but it also provides an - Instrument for influencing the health-related activities of individuals and corporations - Instrument for decreasing poor health-related activities of individuals and corporations - Instrument for influencing the health-related activities of individuals only - Instrument for influencing the health-related activities of corporations only
Instrument for influencing the health-related activities of individuals and corporations
Who is the father of epidemiology?
John Snow
Block grants typically are large amounts of funding awarded to state or local governments with only general provisions as to the way the grant is to be spent. Block grants allow - None of these are correct - State and local governments to use specific approaches to solving problems - State and national governments to use different approaches to solving problems - State and county governments to use different approaches to solving problems
None of these are correct
What is Improved information technology?
Numerous opportunities for improving and transforming healthcare which includes; reducing human errors, improving clinical outcomes, facilitating care coordination, improving practice efficiencies, and tracking data over time.
Population Health refers to the - Physical and social well-being of defined groups of individuals and the differences (equalities) in health between population groups - Physical, mental, and spiritual well-being of defined groups of individuals and the differences (disparities) in health between population groups - Physical, mental, and social well-being of defined groups of individuals and the differences (equalities) in health between population groups - Physical, mental, and social well-being of defined groups of individuals and the differences (disparities) in health between population groups
Physical, mental, and social well-being of defined groups of individuals and the differences (disparities) in health between population groups
Johnson and Breckon (2007) identify seven interconnected processes and responsibilities commonly associated with the administrative role, name three
Planning, Research, and Organizing
Recognition of inputs is the first step in _____ _______
Policy Macro Policymaking: The Policy Systems Model Model - Longest's model
Despite growing mortality rates from chronic diseases, infectious diseases such as HIV/AIDS, SARS, and influenza continue to - Help justify more funding for public health officials in terms of control, monitoring, and community protection - Pose challenges for public health officials in terms of control, monitoring, and community protection - Eliminates quality improvement activities for public health officials in terms of control, monitoring, and community protection - Help public health officials elevate their status and prestige in terms of control, monitoring, and community protection
Pose challenges for public health officials in terms of control, monitoring, and community protection
Counseling, screening, and immunization is considered to be ______ services
Preventive services
What is preventive services?
Preventive services included counseling, screening, and immunization.
The performance of _____ _______ system can be measured by Effectiveness, Efficiency, Ability to achieve equity between populations
Public health system
The policy making systems model is cyclical, so strictly speaking, there is no start or finish -just a continual cycle. In Longest's model, the policy process has the following stages - Recognition of inputs, policy deletion, policy outputs, implementation, outcomes, and feedback and subsequent modification - Recognition of outputs, policy formulation, policy outputs, implementation, process metrics, and feedback and subsequent modification - Recognition of inputs, policy formulation, policy outputs, implementation, outcomes, and feedback and subsequent modification - Recognition of inputs, policy formulation, policy outputs, implementation, outcomes, and minimal feedback
Recognition of inputs, policy formulation, policy outputs, implementation, outcomes, and feedback and subsequent modification
The four limitations of government impacting the public health arena include - Reduced probability of success for interventions, proactive management, fragmentation, and competing governmental agencies - Decreased probability of success for interventions, management by crisis, fragmentation, and competing governmental agencies - Increased probability of success for interventions, management by crisis, fragmentation, and competing governmental agencies - Reduced probability of success for interventions, management by crisis, fragmentation, and competing governmental agencies
Reduced probability of success for interventions, management by crisis, fragmentation, and competing governmental agencies
The main federal policy and administrative instruments for public health are - Regulatory development and change, health resource allocation, information production and dissemination, and policy advocacy and gala event planning - Regulatory development and enforcement, health resource allocation, international social network analysis and reporting, and policy advocacy and agenda setting - Regulatory development and enforcement, health resource allocation, information production and dissemination, and policy advocacy and agenda setting
Regulatory development and enforcement, health resource allocation, information production and dissemination, and policy advocacy and agenda setting
Which of the following best describes systems thinking in public health? - All of these are correct - Solutions that require intervention and engagement with known set of stakeholders and organizations regardless of level - Requires a multi-level, multi-participant view a process of understanding how parts influence one another within a whole. - Public university medical care researchers working to solve complex population and health issues such as obesity and chronic disease
Requires a multi-level, multi-participant view a process of understanding how parts influence one another within a whole.
Johnson and Breckon(2007) identify seven interconnected processes and responsibilities commonly associated with the administrative role. Which of the following is not a responsibility? - Planning: the process of specifying goals, establishing priorities, and otherwise identifying and sequencing action steps to accomplish goals. - Research: the process of developing a study, collecting data, and producing results - Organizing: establishing a structure or set of relationships so plans can be implemented and goals accomplished. - Staffing: the assignment of personnel to specific roles or functions so the organization works as designed
Research: the process of developing a study, collecting data, and producing results
The FDA functions as the nation's largest consumer protection agency by administering regulatory programs to ensure the - Safety of animals, cosmetics, medicines, medical devices, and radiation-emitting products - Safety of farms, cosmetics, medicines, medical devices, and radiation- emitting products - Safety of food, hair dryers, medicines, medical devices, and radiation- emitting products - Safety of food, cosmetics, medicines, medical devices, and radiation- emitting products
Safety of food, cosmetics, medicines, medical devices, and radiation- emitting products
1. Planning 2. Organizing 3. Staffing 4. Directing 5. Coordinating 6. Reporting 7. Budgeting
Seven interconnected processes and responsibilities commonly associated with the administrative role
The three types of organizational structures for state public health departments are: - Stand alone, umbrella, and mixed function - Stand alone, transparent and standardized - Stand alone, umbrella, and standardized - Stand alone, transparent, and mixed function
Stand alone, umbrella, and mixed function
This federal agency Administers programs to prevent and control specific disease, injury, and disability risks through epidemiologic surveillance, investigation, research.
The CDC
Who is John Snow?
The father of epidemiology
According to the Porter and Lawler model, employee effort is determined by two factors - The value placed on certain outcomes by the individual and the extent to which the person believes his or her effort will lead to attainment of these rewards - The value placed on certain outcomes by the group and the extent to which the person believes his or her effort will lead to attainment of these rewards. - The value placed on certain inputs by the individual and the extent to which the person believes his or her effort will lead to attainment of these rewards. - The value placed on certain outcomes by the organization and the extent to which the person believes his or her effort will lead to attainment of these rewards.
The value placed on certain outcomes by the individual and the extent to which the person believes his or her effort will lead to attainment of these rewards
What is categorical grants?
These are the main source of federal aid to state and local governments for public health services.
Stand alone, umbrella, and mixed function are organizational structures for what type of dept?
They are the three types of organizational structures for state public health departments.
According to Johnson and Breckon, directing or involving others in making decisions and communicating them so they can be implemented is considered one of the seven interconnected processes and responsibilities - True - False
True
According to the 2009 report on Systems Thinking for Health Systems Strengthening published by the World Health Organization, systems thinking is a "paradigm shift" for public health and offers a more comprehensive way of anticipating synergies and mitigating negative emergent behaviors - True - False
True
Health protection strategies include environmental and regulatory activities - True - False
True
In adaptive leadership, leadership is a relational, social process through which the leader first facilitates stakeholders, communities and those responsible for issues—and carefully defining their thoughts and feelings about an issue - True - False
True
Laws are enacted to influence healthy behavior, respond to health threats, and enforce health and safety standards. - True - False
True
Most grants have a term of one year (although some may have a longer lifespan), and the recipient must use the grant funds within that time frame. The expiration of funds is a consequence of the federal budget process, which dictates any funds not used within the specified time limit revert to other uses - True - False
True
Public health history and success is important because the historic emphasis of public health on protecting populations from infectious disease have expanded to include the prevention and reduction of chronic disease. - True - False
True
Vaccination in public health has both direct and indirect (through social determinants) impacts on population health - True - False
True
As Framework for Analysis and Deliberation about Ethical Issues in Public Health, there are six justificatory conditions provided in the form of questions to guide deliberation and decisions about whether choosing one option promotes one value. They are - Utility or national medical benefit, individual liberty or justice, effectiveness, policy necessity, most infringement, and whether it can be justified - Utility or public health benefit, individual liberty or justice, effectiveness, policy necessity, least infringement, and whether it can be justified - Utility or public health benefit, individual liberty or justice, efficiency or efficacy, policy necessity, least infringement, and whether it can be justified - Utility or public health benefit, community liberty or justice, effectiveness, policy necessity, least infringement, and whether it can be defended court
Utility or public health benefit, individual liberty or justice, effectiveness, policy necessity, least infringement, and whether it can be justified
The National Center for Cultural Competence identified five essential elements of cultural competence.They are - Valuing diversity, having the capacity for cultural self-assessment, being conscious of the dynamics inherent when cultures interact, having institutionalized culture knowledge, and having developed adaptations to service delivery - De-valuing diversity, having the capacity for cultural self-assessment, being conscious of the dynamics inherent when cultures interact, having institutionalized culture knowledge, and having developed adaptations to service delivery - Valuing diversity, not worrying about cultural self-assessment, being conscious of the dynamics inherent when cultures interact, having institutionalized culture knowledge, and having developed adaptations to service delivery.
Valuing diversity, having the capacity for cultural self-assessment, being conscious of the dynamics inherent when cultures interact, having institutionalized culture knowledge, and having developed adaptations to service delivery