Background:With the global increase in population aging, promoting walking as a health behavior to maintain and enhance well-being among older adults has become increasingly important. In recent years, advances in information and communication technology and mobile health have supported the development of health interventions delivered through smartphone apps. However, no review to date has included psychological aspects such as motivation or intention to walk, and the behavior change techniques (BCTs) embedded in smartphone apps that effectively promote walking remain unclear. Objective:This study had 2 primary aims: (1) to evaluate the effects of smartphone app use on walking behavior and intention to walk among community-dwelling older adults and (2) to identify the specific BCTs delivered through these apps that may promote walking behavior and intention effectively. Methods:Eligible studies were those published in English or Japanese between March 1, 2015, and February 28, 2025, that focused on community-dwelling older adults, implemented smartphone app-based interventions, and reported walking-related outcomes. A systematic search strategy was designed using keywords such as "older," "smartphone," and "walking." Risk of bias was evaluated using the Study Quality Assessment Tools. The features of the apps described in the selected studies were examined to identify the BCTs they used, as categorized by the BCT Taxonomy. Results:Of the 296 studies initially retrieved, 8 met the inclusion criteria. These studies varied in terms of participant characteristics, intervention duration, app features, and outcomes, and most were pilot studies. While several apps were designed specifically to increase walking, others included features that facilitated social interaction among users. In addition, 2 studies also reported improved motivation to walk. Apps that were associated with statistically significant improvements in walking behavior frequently used BCTs from the following clusters: (1) goals and planning, (2) feedback and monitoring, and (4) shaping knowledge. Notably, 5 BCTs were not incorporated into any of the reviewed apps. Conclusions:Although smartphone apps have the potential to improve walking behavior and intention among community-dwelling older adults, the current body of evidence remains limited. Apps that deliver walking-related knowledge, facilitate goal setting, and support behavioral monitoring appear especially effective and may strengthen walking behavior and intention in this population.

Objective　Focusing on novice public health nurses with prior work experience, this study aimed to identify the characteristics of human resource development systems related to career development, and to examine the importance of achievement levels in home visits within such systems.Methods　A web-based survey was conducted targeting all public health nurses newly employed by prefectural and municipal governments across Japan in fiscal years 2023 and 2024. In this study, we analyzed data from individuals with prior work experience. The survey items included demographic characteristics, the Comprehensive Career Development Scale for public health nurses (career score), the human resource development system, and levels of achievement during home visits for basic cases (home-visit achievement). Using hierarchical multiple regression, the career score was set as the dependent variable. In Model 1, all independent variables except home-visit achievement were entered; in Model 2, home-visit achievement was added. The adjusted coefficient of determination (R2) and its change were calculated to examine the contribution of home-visit achievement.Results　A total of 1,679 questionnaires were returned, of which 1,572 were valid, and 734 respondents had prior work experience. In the hierarchical multiple regression analysis, the adjusted R2 values were 0.095 for Model 1 and 0.114 for Model 2, indicating a significant increase of 0.02. In Model 2, variables significantly associated with the career score were workplace consultation (β＝0.19), experience in presenting at academic conferences (β＝0.08), reading journals/books purchased by the workplace (β＝0.14), self-purchased journals/books (β＝0.08), and home-visit achievement (β＝0.15).Conclusion　The adjusted R2 of Model 2 was 0.114, indicating that the career development of novice public health nurses with prior work experience could not be explained sufficiently by the variables examined in this study alone. However, workplace consultation, presentation experience, journal and book reading, and home-visit achievements were significantly associated with career score, with the inclusion of home-visit achievements further improving the explanatory power of the model. These findings suggest that, even for novice public health nurses with prior work experience, human resource development that provides systematic instruction and ensures achievement levels during home visits, together with well-developed consultation systems and learning opportunities, is important for supporting career development during the initial employment period.

AIM:This study aimed to examine whether home visits by nurses improve the parenting practices of pregnant and postpartum females through a systematic review and meta-analysis. METHODS:We searched PubMed, MEDLINE, Cochrane Library, and Ichushi for randomized controlled trials of regular home visits by nurses or midwives during pregnancy or before the child entered school, published up to March 2023. The primary outcomes were: (1) positive parenting behaviors; (2) negative parenting behaviors; (3) parental confidence; (4) child-parent relationships; and (5) parent-child closeness. We performed random-effects meta-analyses and applied risk of bias assessment and GRADE (Grading of Recommendations, Assessment, Development, and Evaluation)-based evaluation frameworks. The study has been registered in PROSPERO (CRD 42024527084). RESULTS:In total, 1879 articles were screened and eight were included in analyses. The eight articles involved five home visit projects targeting high-risk females and one focused on the general population. Moderate certainty of evidence indicated that nurse home visits increased positive parenting behavior (SMD = 0.16, 95% CI [0.07; 0.26]), decreased negative parenting behavior (SMD = -0.11, 95% CI [-0.21; -0.01]), and had no significant effect on parental confidence (SMD = 0.26, 95% CI [-0.12; 0.64]). No significant intervention effects were observed for child-parent relationships or parent-child closeness, with weak certainty of evidence based on a single article. CONCLUSIONS:Home visits by nurses and midwives increased positive parenting behaviors and decreased negative behaviors. These findings suggest that regular home-visit interventions by nurses are effective in improving the child-rearing behaviors of pregnant and postpartum females.

Objectives　Social isolation among older individuals whose living environment is changing is an issue that should be addressed. Retirement, social inclusion (SI), and building connections with community-dwelling individuals are important for preventing social isolation. Particularly in the case of older adults, it is important to clarify their subjective connections with community-dwelling individuals to build connections with them. The aim of this study was to clarify older adults' perceptions of community-based connectedness and related factors.Methods　The participants, 800 men and women in their 70s and 80s living in urban areas, were surveyed in February 2024 using a self-administered, anonymous postal questionnaire. The survey items included attributes, perceptions of community-based connectedness, social networks (SN), SI, and community relationships. Multiple regression analysis using the forced entry method was conducted, with perceptions of community-based connectedness with people as the dependent variable; SN, SI, and community relationships as independent variables; and attributes as covariates.Results　We collected 338 questionnaires and 316 valid responses (valid response rate: 39.5%). The participants' mean age was 79.0 ± 5.4 years, and 172 (54.4%) were men. The mean score for perceptions of community-based connectedness with people was 83.4 ± 17.6, with minimum and maximum scores of 36 and 131, respectively. Multiple regression analysis showed that SN (standardized partial regression coefficient (β) = 0.124, P = 0.012) and SI "connectedness" (β = 0.132, P = 0.023), SI "participation" (β = 0.100, P = 0.047), and community relationships (β = 0.469, P < 0.001) were significantly asso-ciated with perceptions of community-based connectedness with people.Conclusion　The subjective connectedness of older adults was related to the objective connectedness of SN and SI in terms of "connectedness" and "participation." The results suggested that the perception of the community as a whole as connected is related to older adults' perceptions of community-based connectedness with people. We concluded that the spread of individual behaviors within the community and improvements in overall community quality are linked to perceptions of community-based connectedness.

An effective and efficient response to health needs requires the development of an evidence-based health service. Public health nurses are considered to be key practitioners of health service development in Japanese health administration, increasing the importance of the role of health service development. The purpose of this study is to build a practice model for evidence-based health service development adapted to the context of public health nursing in Japan (“Practice Model”). The draft Practice Model consisted of 17 items grouped into three stages, was developed through literature research and regular consultations by the study team and feedback at two public gatherings. The framework and item-pool of the initial draft were built on implementation science models meeting one or more of the criteria set by the study team. The survey was conducted using the Delphi method, a consensus formation technique, and consisted of three rounds of self-administered questionnaires. The expert panel was formed by sending a request letter to supervising PHNs and PHN training course professors nationwide, and selecting those who expressed their willingness to cooperate and met the selection criteria. 99 expert panel joined in Round 1 (52 practitioners and 47 faculty), of whom 81 cooperated in all three surveys. As a result of three rounds of opinion gathering and revision, high percentages of agreement of 80

Objectives　To acquire public health nursing skills, it is important to comprehensively address and name all the skills. This study focused on intervention skills, aiming to systematize intervention skill items and structures in public health nursing. Furthermore, based on the Intervention Wheel-an intervention model for public health nursing systematized in Minnesota, USA-the characteristics of intervention skills in Japan were considered.Methods　Public health nursing interventions were systematized into three stages: draft creation, validity verification, and public health nursing intervention skills system development. Thirty-two meetings of approximately two hours each were conducted, attended by four investigators with experience in public health nursing practice and research. The draft creation had four stages: (1) extracting public health nursing intervention skills from public health nursing textbooks and the Intervention Wheel and organizing them inductively; (2) using the Intervention Wheel to deductively examine skill items; (3) considering the structural framework of intervention skills based on the functional aspects of public health nursing and incorporating the Intervention Wheel; and (4) illustrating a model of public health nursing intervention skills. Ten experts in public health nursing practice, education, and research were interviewed to verify the validity of the original framework and intervention skills. The results from the interviews were revised through discussions with the investigators to formulate a system of intervention skills for public health nursing. The Intervention Wheel functioned as a reference for the characteristics of these skills in Japan.Results　Twenty-one major skills required for public health nursing interventions in Japan were identified: social resource management and development; care system construction; outsourcing projects and quality monitoring; and systems, community, and case management. These skills differ from those of the Intervention Wheel. It was also demonstrated that these skills function at the system, community, and individual and family levels to solve health problems. Intervention skills functioned at all three levels; however, some were ineffective at the system or individual and family levels.Conclusion　Twenty-one major public health nursing intervention skills were identified to address health issues, ensuring that each of the three levels (system, community, and individual/family) function differently. In addition, the scenarios where these skills perform different yet complementary functions across the three levels were organized and systematized.

Objective　Connectedness is essential for maintaining the physical and mental health of older adults. However, measurements that consider the presence of community-dwelling people and explicitly focus on an individual's subjective sense of connectedness have not yet been established. This pilot study aimed to develop a draft scale that comprehensively measured older adults' perceptions of community-based connectedness with people.Methods　The scale development comprised three phases; item review, pre-test, and field verification. Phase 1 (item review) involved creating an item pool and evaluating content validity. Phase 2 (pretest) involved evaluating face validity and conducting item analysis on the preliminary version of the scale. Phase 3 (field verification) involved distributing the preliminary scale to 800 Japanese men and women aged ≥ 65 years residing in Asahikawa, Hokkaido, Japan. Validity was assessed by factorial validity using exploratory factor analysis and concurrent validity using correlation analysis. Reliability was confirmed by Cronbach's α coefficient using the internal consistency method.Results　The evaluation of content validity in Phase 1 and face validity in Phase 2 yielded 30 items. In phase 3, of the 800 questionnaires that were distributed, 343 were returned, of which 309 included responses to all items and were analyzed. Exploratory factor analysis resulted in a 22-item scale comprising three factors that assessed perceptions of community-based connectedness. The Cronbach's α for the total scale was 0.967, and the α coefficients for inclusion, reciprocity through provision, and reciprocity through reception were 0.941, 0.915, and 0.928, respectively. The total scale scores were significantly positively correlated with purpose in life (rs = .453, P < .001) and negatively correlated with loneliness (rs = -.307, P < .001).Conclusion　The 22-item draft scale exhibited adequate reliability and validity. Perceptions of connectedness measured by this scale can be used to support public healthcare interventions for community-dwelling older adults.

Given the rapid increase in health information available, health literacy is now more important than ever when searching for health information online. Furthermore, health literacy and online health information searching are reported to be associated with support from others. In this study, we examined the associations of health literacy and social support with online health information searching among individuals in their 50s and 60s. Between March and May 2022, an anonymous self-administered questionnaire was administered among 750 middle-aged and older adults (age 50-69) living in northern Japan. The questionnaire items included personal characteristics, frequency of online health information searching, health literacy domains, and social support. A total of 237 respondents answered all the items (response rate: 31.6%). Multiple logistic regression analysis revealed that communicative health literacy was significantly associated with searching for information about illnesses and health promotion, while critical health literacy was significantly associated with searching for information about medical institutions. Controlling for personal characteristics, health literacy, was associated with online health information searching, suggesting that improving health literacy is important in a digital and information society.

OBJECTIVE:To clarify the circumstances of help-seeking preference among older adults in depopulated areas and the relationship between help-seeking preference and social support.METHODS:This was a cross-sectional study that included a sample of 271 men and women aged 65-79 years living in Japan. A questionnaire survey was conducted to assess help-seeking preference, social cohesion (community trust, norms of reciprocity and community attachment), socialising (interaction with neighbors and social network) and social support. Multiple regression analysis was performed with items that were found to be significantly associated with social support in the univariate analysis. Then, we examined the significance of the change in the coefficient of determination between a model that included help-seeking preference as an independent variable and a model that did not.RESULTS:Social support was related to help-seeking preference, living arrangements, economic status, norms of reciprocity and social networks. There was a significant difference in the coefficient of determination between the models with and without help-seeking preference.CONCLUSIONS:For older adults in depopulated areas to obtain social support, it is important to build trusting relationships with others and shows a willingness to seek and accept help.

AIM:We developed a self-assessment scale-Older Adults' Perceptions of Community-based Connectedness with People-to assess older adults' comprehensive perceptions of their connectedness with others in the community. A specific aim of this study is to evaluate the reliability and validity of this scale.METHODS:Participants consisted of 1000 men and women aged 65 years or older, living in Sapporo, Hokkaido, Japan. Factorial validity was assessed using exploratory and confirmatory factor analysis, while concurrent validity was assessed using correlation analysis. Reliability was confirmed by Cronbach's α coefficient using the internal consistency method, and the stability coefficient was confirmed using the test-retest method.RESULTS:Responses were received from 380 participants, and 358 participants who responded to all items were included in the analysis. The developed scale comprised 22 items with three factors: "Perception of Inclusion" (α = .947), "Perception of Reciprocity through Reception" (α = .937), and "Perception of Reciprocity through Provision" (α = .910). Correlation analyses indicated that concurrent scales were positively correlated with Ikigai and negatively correlated with loneliness on the total scale. The model fit was comparative fit index = 0.933, goodness-of-fit index = 0.854, adjusted goodness-of-fit index = 0.818, and root mean square of approximation = 0.081. The stability coefficient of the total scale scores was 0.875 (95% CI: [0.830, 0.908]).CONCLUSIONS:The developed scale had adequate reliability and validity. The perceptions of connectedness measured using this scale can be used by public health and nursing care professionals to prevent loneliness and isolation among older adults living in the community.

Objectives　Solitude is a state of being without social contact; it occurs when a person chooses not to interact with others, even when they are in the company of others. It is not necessarily accompanied by negative feelings. In contrast, loneliness, is a psychological state characterized by the feeling of needing the company of others. Most Japanese studies have regarded loneliness as an unpleasant and painful experience. In this study, focusing on solitude, we developed the Japanese version of Positive Solitude Scale (JPSS) developed by Palgi et al. and evaluated its reliability and validity. This scale assesses the "conscious and voluntary decision to be alone as a positive experience."Methods　A self-administered, anonymous questionnaire survey was conducted between May and August 2023, with 700 men and women participants aged 20 years or older living in Ward A, Sapporo. The survey items comprised basic attributes, the JPSS, subjective sense of health, subjective sense of well-being, and depression to verify convergent validity and social network and loneliness to verify discriminant validity. Additionally, principal component and correlation analyses were performed.Results　A total of 245 questionnaires were collected, and 237 valid responses were obtained (valid response rate: 33.9%). The participants' mean age was 58.5±1.2 years and 111 (46.8%) were men; the Cronbach's alpha coefficient for the JPSS was 0.92. The principal component analysis revealed that all nine items had principal component loadings above 0.6, with a cumulative contribution of 62.3% to the overall scale. The total scale score was significantly positively correlated with subjective health (ρ=0.210, P=0.001), positive affect (ρ=0.302, P<0.001), and life satisfaction (ρ=0.241, P<0.001). There were no significant correlations among depression, negative affect, social networks, and loneliness.Conclusions　The JPSS is a reliable and valid instrument unaffected by social networks and other social relationships. It is expected to be a promising new scale that can measure perceptions of time as a positive emotion, distinct from loneliness.

BACKGROUND:Frailty is a syndrome related to declining functioning attributed to aging. As a reversible, often improved condition, preventive measures for frailty can be effective.OBJECTIVE:This study aimed to evaluate a frailty prevention program for older men comprising face-to-face meetings and an original social mobile application. We also examined the effect of COVID-19-associated social isolation on the implementation of this program.METHODS:We conducted a mixed-methods pilot study featuring a single group before and after comparison of 11 man participants, ≥65 years, living in Japanese cities with a spouse or relatives. Program outcome measures included frailty, loneliness, grip strength, step count and mental health status. Process evaluation considered the experience of participants through a semi-structured interview.RESULTS:The intervention period included an interval of self-isolation owing to the spread of COVID-19. Among the outcomes, grip strength decreased after intervention. No significant negative changes were observed in other items. Themes emerging from participant experiences with the program included 'Cooperation with researchers and contributing to research', 'Greater awareness of health', 'Interest in and experience of "newness"', 'Hesitation over active engagement', 'Casual ties with members' and 'Relationships that do not breach personal boundaries'.CONCLUSIONS:Although the COVID-19 pandemic overlapped with the intervention, participants maintained their mental health. The program was a novel, stimulating experience for older men and demonstrated the usefulness of information and communication technology in supporting their social activities.IMPLICATIONS FOR PRACTICE:As a community health nursing initiative for older people, we propose activities that combine group and online support. Frailty prevention programs for older men must contain content that stimulates their interests, such as 'health' and 'newness'.

BACKGROUNDWe developed a program that encourages interaction among older people living at home by combining face-to-face and online activities and examined its effects on older adults' psychosocial health.METHODSIn this mixed-methods study, we recruited 11 women and 6 men (Mage = 79.5 ± 6.4 years), who lived in a rural community and participated in a senior citizen club. The intervention was conducted for 13 months, comprising monthly face-to-face group and social media activities. For the program process evaluation, we collected focus-group interview data on participants' perceptions of their personal lives, club membership, and community post-intervention. For the outcome evaluation, we collected six outcome measures pre- and post-intervention: loneliness, subjective health, subjective well-being, self-esteem, social support and social activity satisfaction. Finally, through the integration of the process-outcome evaluation, we inferred what effects the program had on participants' psychosocial health.RESULTSIn the process evaluation, we identified four themes: 'Stimulation brought about by relationships with peers,' 'Realization as to where they feel they belong,' 'Rethinking of oneself in the community,' and 'Awareness of attachment to and coexistence with the community.' In the outcome evaluation, the outcome measures were maintained without significant decline post-intervention.CONCLUSIONThrough the integration of the process-outcome evaluation, we deduced three effects of the program on psychosocial health: (1) fulfilment of subjective health, (2) maintenance and assurance of moderate distance connectedness and (3) orientation toward aging in place.IMPLICATIONS FOR PRACTICEThis study offers a promising opportunity for further development and research into community-based preventive nursing care intervention strategies to maintain the psychosocial health of homebound older people in communities with social activity groups.

Research evidence on parenting in a digital society has not kept pace with the growing use of digital resources by mothers (e.g., smartphones, the internet), along with human resources (i.e., partners, family members, friends), to overcome parental control challenges. Overcoming these challenges helps mothers attain a sense of maternal achievement. This study explored the effects of using human and digital resources to address parental control challenges on the sense of maternal achievement. A survey was conducted with a random sample of 373 mothers of 3-year-old children, who were more likely to face parental control challenges. The questionnaire focused on participants' characteristics, human and digital resource use, and maternal achievement. An exploratory factor analysis confirmed the validity of an original scale to measure resource use in addressing control challenges. Multiple regression analysis was then used to examine its effects on the sense of maternal achievement. Significant main effects on sense of maternal achievement were found only for partner support but not for digital resources. A moderating effect was identified between digital resources and family support, with digital resources being unrelated to a sense of maternal achievement in situations of high family support. In contrast, digital resources predicted a lower sense of maternal achievement in situations of low family support. Consequently, digital resources may play a limited role as a complement or substitute for human resources. Therefore, even in a digital society, it is desirable for parents to focus on human resources in the context of overcoming parental control challenges.

We developed 'Kikoeru', a pedometer and communication application (app) for older people, with functions that include voice conversations and messages, photograph sharing, and pedometer sharing among users. This pilot study aimed to clarify the effects of Kikoeru on social connectedness related to interactions through the app, subjective health, loneliness, and setting a target number of steps for seven men aged 65 and older who lived at home. Survey items consisted of the Ando-Osada-Kodama loneliness scale, target number of steps, and subjective health ratings. We utilized interviews, seeking to determine whether users felt connected when using the app. The app usage days were collected from the server. The social and physical effects of the app were assessed using a mix of quantitative and qualitative methods. Participants used the app for 54.9 days on average during the 60-day intervention period. Interviews revealed four social connectedness benefits: 'constructing reliance', 'remembering to consider friends', 'awareness of friends' daily lives and encouragement for me', and 'taking an interest in friends'. Loneliness decreased for four out of seven people, remained the same for three, and did not worsen for anyone. The target number of steps increased for three people, remained the same for four, and did not decrease for anyone. Average subjective health improved from 63.6 to 72.9 points out of 100 after the intervention. Results showed participants experienced social connectedness, reduced loneliness, and improved their target steps and health by using Kikoeru. Future large-scale studies with expanded sample sizes should be conducted.

This study aimed to verify the effectiveness of an application (app) in establishing social connectedness among unacquainted older men, as well as improving their physical health. The nine participants were men aged 65 and older in the subarctic zone of Hokkaido, Japan. A mix of quantitative and qualitative methods were adopted as the study design. A questionnaire survey was completed before and after the intervention, and a semi-structured interview was conducted after the intervention. An app-installed smartphone was loaned to the participants, which allowed them to share pictures, voice recordings, and their step count. Quantitative data were analyzed using descriptive statistics and the Wilcoxon signed-rank test, and qualitative data were analyzed using qualitative descriptive analysis to generate categories. The average age of the participants was 77.7 years. The relationship between participants who were interacting for the first time through the app advanced as their understanding of each other’s personalities deepened. The average step count during the third and fourth months was significantly higher than in the first two months. By using the app, older men were able to build relationships with one another. In addition, visualizing the number of steps on the app was effective in improving the number of steps.

AIM:This study aimed to clarify the concept of older people's connectedness with people in the community within the literature.METHODS:This study was based on Walker and Avant's concept analysis method. We used PubMed, MEDLINE, CINAHL, and Web of Science databases and included peer-reviewed articles that were published in English between January 2010 and April 2023. After assessing eligibility and applying exclusion criteria, 25 articles were analyzed.RESULTS:Attributes included sense of belonging to the community achieved through interactions and feeling of togetherness through interrelationships, which consequently led to the maintenance of healthy physical and mental states and independent living, the acquisition of the ability to overcome difficulties, and the creation of a sense of meaning in life through coexistence.CONCLUSION:We identified the concept of older people's connectedness with people in the community in a contemporary context. Connectedness is a useful concept to consider in nursing care because it seems to evolve into comprehensive health, including the physical and psychosocial health of older adults.

The spread of COVID-19 is considered to have strengthened people’s awareness of others. Additionally, the COVID-19 pandemic has reduced connection with others among older adults and increased loneliness. This study aimed to investigate the factors affecting loneliness among older adults in rural areas during the COVID-19 pandemic by focusing on the connection with others. The target group included 932 rural Japanese adults, aged 65–74 years. An anonymous, self-administered questionnaire survey was conducted. Valid responses were obtained from 405 participants (valid response rate: 43.5%). A multiple regression analysis was performed using the forced entry method with loneliness as the dependent variable. The independent variables were those showing significant associations with loneliness based on the univariate analysis. Sex (β = −0.139), economic situation (β = −0.103), neighborhood ties (β = −0.260), independent view of self (β = −0.213), interdependent view of self (β = 0.171), and communication through phone (β = −0.128) were significantly associated with loneliness. Connection with others and subjective views of the relationship between self and others were associated with loneliness in situations where one was more aware of the behavior of oneself and others in an infectious disease pandemic.

Connectedness among older people is essential for healthy communities, especially among rural populations where limited social interaction and associated health effects may be cause for concern. In this qualitative descriptive study, we explored older rural people's perception of connectedness through a communication application. The study assessed 10 participants (mean age = 76.2 years) living in rural Japan who regularly participated in a senior citizens' club. From July 2019 to January 2020, the participants used a social media application developed by our research team to meet the needs of older people. Semi-structured interviews were conducted. Six themes representing older rural people's perception of connectedness were identified: (1) thoughtful consideration for members strengthened even without them meeting face-to-face, (2) encouragement received from familiar members, (3) joy in sharing daily routine with neighbors, (4) courage to advance through face-to-face interaction, (5) willingness to continue club membership, and (6) fear of disrupting club's harmony. Participants who used the application felt compensated for the lack of social interaction opportunities in rural settings and strengthened their existing relationships.