NAPCRG 2015

2015 NAPCRG Annual Meeting Presentations with DFM faculty members as presenters, co-presenters or co-authors

14 Sessions


PR1 Preconference Workshop for Methods for Primary Care Research

Gillian Bartlett, PhD; Christopher Morley, PhD; Cristina Longo, MSc; Justin Gagnon, MA, BSC; Isabelle Vedel, MD, PhD; Jamie DeMore; Christopher Meaney, MSc; Tibor Schuster; L. Miriam Dickinson, PhD

Objectives of CASFM Research Methods Working Group: The objective of this CASFM (Committee on Advancing the Science of Family Medicine) working group is to bring together NAPCRG researchers and methodologists to disseminate and promote introductory and advanced methods for primary care research. The goal is to share methodological approaches and develop creative solutions to methodological issues that arise in the context of primary care research. This pre-conference course is being offered in response to the demand highlighted through previous methodological workshops and webinars offered by the CASFM Methods Working Group. Many primary care researchers are interested in gaining more experience in diverse methodologies that are necessary to address the complexity of primary care research so we anticipate a high attendance at these courses. Objectives of Pre-conference Course: To provide instruction in basic and advanced methods in qualitative, quantitative and mixed methods research relevant for primary care. Content: The course will be offered in three concurrent streams with topics in the morning and afternoon: Stream 1 Qualitative Research Methods: Introduction to Qualitative Methods (am) Basics of Mixed Methods (pm) Stream 2 Basic Quantitative Research Methods: Introduction to Statistics & Interpretation (am) Dealing with Missing Data in Statistical Analysis (pm) Stream 3 Advanced Quantitative Research Methods: Step Wedge Trial Design (am)  Log Linear Modelling (pm) Method: Each course topic will be offered over 3 hours and will follow an active learning model where participants will not only be provided with the substantive material but will also be actively participating in the course through engagement exercises and in-class activities. This method has been shown to promote retention of the material and minimize the time burden for the participants. In-class evaluation will be included in order to provide participants with a certificate of completion. The sessions are set up so that participants can pick and choose which two sessions of the six sessions offered in the one-day course that they would like to attend. Prerequisite Knowledge: Quantitative and/or qualitative methods knowledge and experience in practice-based research will be helpful but is not required.


P148 Characteristics of Rural Applicants to Medical School and How Admissions Committees View Rural Applicants

Carrie Roseamelia, PhD; Andrea Wendling, MD

Context: Rural students remain underrepresented in medical schools often due to educational and socioeconomic challenges. Although selective admissions targeting rural students has been proposed as a potential mitigating factor, few studies have looked at how rural applicantsdiffer from metropolitan applicants, and how differences are perceived by admission committees. Objective: Review admission data to examine how rural applicants compare to non-rural, and explore admission representatives’ perceptions of these differences. Design: Mixed methods using archived, de-identified admissions data and admission representative interviews. Numerical and categorical data analyzed using t-test and chi-square as appropriate. Qualitative data analyzed using immersion and crystallization methods. Setting: MSU College of Human Medicine and SUNY Upstate Medical University Outcome Measures: Comparisons between randomly selected applicant data from 160 rural and 160 metropolitan accepted candidates, and 160 rural and 160 metropolitan rejected/wait-listed candidates from 2011-2014 applicant pool from two medical colleges. Rural and non-rural applications from each category compared based on GPA, college tier, MCAT scores, interview ratings, employment history, dis/advantage status, clinical and research experiences, community service, and overseas experience. Perceptions of admission committee representatives of rural and non-rural candidates will be explored. Results: We expect characteristics of individual application components will vary between rural and non-rural applications, hypothesizing rural candidates will have lower MCAT scores, premedical enhancement experiences, and interview ratings. In comparison, we expect rural students to have more employment experience and longitudinal community involvement experiences. Perceptions of admission committee members may be influenced by expectations regarding applicants’ educational backgrounds, employment, service, and research opportunities, and may reflect positive or negative bias toward rural characteristics. Conclusions: Results may offer strategies for strengthening applications of rural students. Strategies may be incorporated into activities and outreach of rural pipeline programs. Results may be used to develop admission policies of schools interested in addressing rural workforce disparities.


P111 The Impact of State Vaccination Laws, Enforcement and Monitoring on Vaccine-Specific Exemptions From School Immunization Requirements Among Selected States in the US

Brittany Sprague; Christopher P. Morley, PhD; Jana Shaw, MD, MPH, MS

Context: Previous studies have shown a positive relationship between the number of philosophical exemptions to school immunization laws permitted by states, and the rate of school immunization exemptions. With the continued changes in vaccination laws in several states, an updated evaluation of the difficulty for obtaining nonmedical exemptions through state legislative code and state Department of Health (DOH) regulations is needed. Objective: To determine the impact of state vaccination laws, regulations, and enforcement on school immunization and exemption rates in the United States. Design: Retrospective study using publicly available data from CDC’s state and national school vaccination assessment reports (SchoolVaxView) and the National Immunization Survey (NIS). Populations include 19-35 month old children, kindergarten aged children, and adolescents 13-17 year old, included in data reports from 2008-2014. Individual state legislative code and DOH regulations will be categorized by level of complexity of obtaining an exemption as well as listing of enforcement. Multivariable regression analysis will be used to evaluate relationships between state levels of school immunization and exemption rates and 1) a quantitative rating of complexity of obtaining an exemption in each state; 2) level and type of enforcement listed by state legislative code and/or DOH regulations, and 3) type of exemptions allowed. Main and secondary outcome measures: State immunization rate for each vaccine type, within each applicable age category; state exemption rate for each vaccine type, within each applicable age category. Results & conclusion: Results from this study may have important implications in guiding future interventions regarding state enforcement, regulations, and laws. As vaccination hesitancy and resistance is a core issue for primary care, analysis of the comparative effects of legal and regulatory exemption provisions on vaccine rates may inform, assist, and encourage vaccine-positive legislative advocacy by primary care providers.


RC14 The Impact of Administrative Academic Units (AAU) Grants on the Family Medicine Research Enterprise in the United States External Icon

Brianna Cameron; Andrew Bazemore, MD, MPH; Christopher Morley, PhD

Context: Compared to other disciplines, Family Medicine (FM) in the United States (U.S.) has historically seen little support for research activities from the National Institutes of Health (NIH). While there are a variety of reasons that may contribute to this issue, FM departments have typically needed to fund research activities from other sources. One source,the Health Resources & Services Administration’s (HRSA) Administrative Academic Unit (AAU) program, awarded $16.8 million in grants under Title VII of the Public Health Service Act (PHSA) between 2010-14. Little is known about how primary care departments at US medical schools are currently using AAU funds to support research training, infrastructure, and outputs.. Objective: To evaluate the aims and outcomes of AAU program funding on FM research infrastructure among U.S. grant recipients Design: Multi-method descriptive study, including content analysis of public AAU grant abstracts and publications crediting AAU support on PubMed, as well as a survey of current AAU project directors. Participants: Current AAU project directors (n=23). Results: Over 75 publications in PubMed have been produced between 2006 and the present with AAU funding acknowledgements, covering a wide array of topics and study types. Themes emerging from AAU abstracts suggest that it plays a critical role in support of FM research infrastructure, seed funding for otherwise unfunded FM research projects, and research training for medical students, residents, and faculty. Other themes emerging from abstracts indicate AAU grant capacity to enable other forms of scholarship, including quality improvement, evaluations of Patient-Centered Medical Home practice transformation, and formal educational curriculum evaluation. Survey responses (n=19, 82.6% response rate) were convergent with content analysis of grant abstracts, with at least four practice-based research networks being supported via AAU funds. Conclusions: The AAU grant program provides an important source of research infrastructure support for U.S. Family Medicine


BP13 How Do Men With Low-Risk Prostate Cancer Choosing Active Surveillance Negotiate Stress and Uncertainty? External Icon

Emily Mader, MPH, MPP; Hsin Li, MPH; Kathleen Lyons, ScD, OTR; Christopher Morley, PhD; Margaret Formica, PhD; Scott Perrapato, DO, FACOS; Brian Irwin, MD; John Seigne, MBBS; Mark Hegel, PhD; Telisa Stewart, DrPH, MPH

Context: Active surveillance (AS) is a management strategy for men diagnosed with early-stage, low-risk prostate cancer (PCa) in which their cancer is monitored and treatment is delayed. Much of the research on the psychological impact of PCa has focused on men receiving active treatment for their disease. More information is needed to understand the psychosocial health and coping mechanisms of men following AS treatment to develop targeted support services and interventions. Objective: Investigate the primary coping mechanisms for men following the AS treatment plan, with a specific focus on how these men interact with their social network as they negotiate the stress and uncertainty of their diagnosis and treatment approach. Design: Thematic analysis of semi-structured interviews. Setting: Two interdisciplinary cancer centers located in two northeastern US states. Participants: 15 men diagnosed with low-risk PCa following the AS management plan. Results: Following AS management plan itself is a form of coping with the anxiety of PCa diagnosis. AS management plan allows men room to make long-term decisions and allay fears of negative side-effects from treatment. Men rely on their social networks to contextualize treatment options and support their decision. A patient’s relationship to the medical community plays a role in his ability to negotiate uncertainty of low-risk PCa diagnosis and care. Conclusions: Support systems for men with low-risk PCa do not always interface directly with the medical community. Spousal and social support play important roles in helping men understand and accept their PCa diagnosis and chosen care plan. Interventions that promote a positive connection to the medical community and emphasize social support may help men with low-risk PCa on AS maintain their psychosocial health.


WS19 Advocating for Primary Care Research and Funding: A Skill Building Workshop External Icon

Winston Liaw, MD, MPH; Sandra Balmoria, MD; Christopher Morley, PhD; Julie Phillips, MD, MPH; John Westfall, MD, MPH; Hope Wittenberg, MA; Sabrina Wong, PhD

Objectives: 1) List three NAPCRG legislative priorities; 2) List two ways that researchers can get involved with advocacy efforts; 3) Demonstrate competency in creating a clear, concise advocacy message. Content: Despite a need for more investment in the primary care research enterprise, funding for primary care research is perpetually under siege. During this session, the NAPCRG Research Advocacy Committee will outline the current legislative priorities. Participants will receive advocacy training and will participate in a mock visit with a policy maker. Prerequisite knowledge: None. Method of participation: For the mock visits, we will divide participants into groups of five, with one person as the designated policy maker who will provide feedback for the rest of the group. Participants will choose from a variety of potential advocacy requests. In preparation for the mock visits, participants will identify personal stories to support the requests and determine roles for each participant to fulfill. Audience: This workshop is appropriate for all researchers. We anticipate 25-50 participants. Rationale: Given constant threats to primary care and health services research funding, researchers need to be informed about and actively participate in advocacy. Schedule: During this workshop, we will build the case for advocating for primary care research (10 minutes), declare the current NAPCRG legislative priorities (25 minutes), and introduce advocacy concepts, including the use of patients in advocacy (20 minutes). Participants will also prepare for and conduct mock advocacy visits (35 minutes).


ET32 Clinical Training in the Rural Setting: Using Photovoice to Understand Student Experiences

Carrie Roseamelia, PhD; Melissa Arthur, PhD, LCSW, LMFT; Emily Mader, MPH, MPP

Context: Rural education programs seek to address the shortage of medical providers working in rural areas by recruiting, admitting, nurturing and educating students with an interest in rural practice and primary care. Rural medical education programs serve both medical students and students of other health professions. Objective: Evaluate the utility of a participatory research methodology to assess student experiences in the rural training environment, as well as gain insight into the impact of the rural training environment on student learning by using student-generated photography and commentary. Design: Exploratory qualitative analysis using photovoice methodology. Photovoice is a participatory research methodology combining photography with participant commentary and focus groups. Setting: Rural medical education training sites in upstate New York, USA. Participants: Twenty-two third-year medical and eight second-year physician assistant students enrolled in rural medical education curricula. Results: Most participants spoke about the professional and personal growth they experienced during rural training. Participants adopted greater responsibilities at their sites and were offered greater practice of skills, which allowed them to feel more like practicing clinicians and less like trainees. Some students utilized rural spaces to process their emotional development as they began to take greater responsibility in patient care, as well as reflect on their plans for the future. Previous research findings, including increased hands-on training opportunities and observations on patient access to care, were corroborated in this study. Conclusions: Compared to other qualitative research approaches, the primary strength of the photovoice participatory research methodology is that it allowed us to understand which aspects of the rural training experience resonated most among students in real-time, using visual representations of students’ lived experiences as defined by the students. The current study presents new insights into the student experience in a rural training program regarding mentorship, self-efficacy and personal growth.


P225 What Constitutes an EBM Culture in Training and Education? External Icon

John Epling Jr, MD, MSEd; Joel Heidelbaugh, MD, FAAFP, FACG; Donald Woolever, MD; Gregory Castelli, PharmD; Misa Mi, PhD; Emily Mader, MPH, MPP; Christopher Morley, PhD

Context: Training in evidence-based medicine (EBM) is important to equip residents and medical students with tools for lifelong learning and critical appraisal of new medical information. From a perspective of both social and constructivist learning theory, learners must experience a supportive culture with role-modeling and a facilitative environment for successful EBM training. Objective: To discover the determinants of a faculty and school/program culture that support and reinforce EBM, and to assess the current state of some of these determinants in US Family Medicine Residency (FMR) Programs. Design: Comprehensive literature review supported by a cross-sectional survey study. Setting: Email survey of FMR program directors. Data was collected from January to March of 2015. Survey Participants: FMR Directors identified by the Association of Family Medicine Residency Directors. Instrument: Survey incorporating demographic information and 14 items adapted from a validated instrument used to examine learner culture in evidence-based medicine (EBM). Survey administered via 2014Council of Academic Family Medicine Educational Research Alliance (CERA) survey of US FMR directors. Outcome Measures: From literature review: themes extracted from the literature review that would impact on faculty and school/program culture. From survey: descriptive analysis of cultural factors in FMR programs & multivariable analysis of demographic and program factors related to these cultural factors. Results: The overall response rate for the survey was 60.6% (274/452). We anticipate a list of factors that are deemed important in affecting the EBM culture in medical schools and FMR programs. We will describe the current state of FMR programs and associated program characteristics that interact with these factors. Conclusions: This project will assist EBM teachers and curriculum directors in medical schools and residencies in creating a supportive learning environment in the program and amongst the faculty that enables better acquisition of necessary EBM knowledge, skills, and attitudes.


P267 Practice Facilitation and Academic Detailing Effective Quality Improvement Method to Increase Cancer Screening in Primary Care Practices External Icon

Emily Mader, MPH, MPP; Gary Noronha, MD; John Epling Jr, MD, MSEd; Chester Fox, MD; Angela Wisniewski, PharmD; Amanda Norton, MSW; Karen Vitale, MSEd; Christopher Morley, PhD

Context: Large segments of the US population fail to receive optimal preventive cancer screening despite evidence supporting it as an effective preventive measure. Practice facilitation (PF), supported by academic detailing (AD), is one method through which primary care providers can reengineer their practices to deliver more cancer screening and track patient screening completion. Objective: Evaluate impact of 6-month PF-AD intervention on ability of safety-net primary care practices to increase breast, cervical and colorectal cancer screening rates among their patient populations. Conduct secondary assessment of practice-level barriers to implementing evidence-based interventions (EBI) to increase cancer screening. Design: Pre-post quasi-experimental design supplemented with qualitative assessment. Setting: Western and Central New York, USA. Participants: 23 safety-net primary care practices. Intervention: One-hour AD session on cancer screening guidelines and best practices, followed by 6 months of PF services to implement EBIs aimed at increasing patient screening. Main and Secondary Outcome Measures: Intervention impact assessed through pre-post screening rates, pre-post provider surveys, and post-intervention focus groups. Results: Range of baseline screening rates varied widely across practices. Practices are implementing a mixture of EHR data cleaning workflows, provider audit and feedback activities, streamlining of provider reminder systems, and patient education and outreach interventions. Practices with fully engaged staff at several levels are expected to experience the greatest change to both cancer screening rates and practice policies. Conclusions: PF is one method through which practices can achieve systems-level changes that enable them to better manage patient population health. Staff dedication and the alignment of QI project tasks with existing office workflows are essential for primary care practices to increase screening rates within a context of limited resources.


SRF21 The Effect of Acculturation Upon Health Insurance Access Among Hispanic Adults of California External Icon

Brianna Cameron, MPH; Margaret Formica, PhD; Emily Mader, MPH MPP; Martha Wojtowycz, PhD; Christopher Morley, PhD

Context: In 2011, California had 6.9 million uninsured residents, 60% of which were Hispanic. The uninsured are more likely to suffer poor health outcomes and premature death. Additionally, uninsurance places a financial burden on care seekers and providers, inflicting $84.9 billion in uncompensated care costs in the US in 2013. Previously, low acculturation has been shown to be a risk factor for uninsurance, but this effect has never been demonstrated using a multi-item proxy scale, nor has it been evaluated since the passage of the Affordable Care Act (ACA), which was partially implemented in 2011 through California’s Low Income Health Program (LIHP). Objective: To assess the effect of acculturation, as measured by the PAS-3 proxy scale, on health insurance status among Hispanic adults of California, and to determine whether this effect was mediated by the early implementation of the ACA. Design: Population-based study using the 2007, 2009, and 2011-2012 California Health Interview Survey (CHIS) public use file data sets. Binary logistic regression was used to model the effect of acculturation upon current insurance status while controlling for selected covariates. An interaction term between acculturation and year was included in one model. Participants: English or Spanish-speaking Hispanic adult residents of California (N=26,302) Results: For every one-point increase in the five-point PAS-3 acculturation scale, the likelihood of being insured increased by 19.8% (OR: 1.198, 95% CI: 1.145-1.252). This association was mediated over time, likely by the initial implementation of the ACA (p=0.027). Low acculturation individuals (PAS-3≤1) were 21.8% more likely to have health insurance post-ACA compared to pre-ACA (OR: 1.218, 95% CI: 1.023-1.450).


ET28 Predictors of Family Medicine Matching: Family Medicine Student Organization Participation, Public Health Dual Degrees, and Rural Education External Icon

Christopher Morley, PhD; Emily Mader, MPH, MPP; Elizabeth McIntosh

Context: A number of studies have confirmed existence of shortages in the U.S. primary care (PC) workforce. Strategies to foster and maintain medical student interest in selecting primary care specialties, particularly Family Medicine, often include maintaining steady contact between PC-interested students and both faculty and educational opportunities related to PC, such as rural medical education (RMED), public health (MPH), and Family Medicine student organizations (FMSOs). Objective: To test the effect of FMSO officership, dual MD/MPH education (MPH), and rural medical education (RMED) on student selection of FM and other PC specialties. Design: Retrospective study of student residency match data. Matching with FM or any PC specialty were coded as binary outcomes; bivariate relationships between FM or PC selection and FMSO participation, dual MD/MPH education, and rural medical education were assessed via χ2 analyses. Logistic regression techniques were used to estimate adjusted odds ratios for the effects of FMSO participation, dual MD/MPH education, and rural health training FM or PC matching, controlling for student characteristics. Setting: An allopathic medical school in the U.S. Participants: Graduating medical students from 2006-2015. Results: Total student cases analyzed (N=1769) included 47 FMSO participants, 80 RMED participants, and 10 MD/MPH students. Bivariate analyses revealed that FMSO participation marginally predicted matching with FM (p=.037) and predicted matching with PC (p<.01); MD/MPH education and rural training were each highly significant predictors of both FM and PC matching (p≤.001 for all comparisons). In multivariable comparisons, FMSO was not a robust predictor of FM selection, although it remained so for PC selection. MPH and RMED remained robust significant predictors of both FM and PC selection in all controlled models. Conclusions: FMSO participation alone is a weak predictor of FM selection for residency. Context-specific training in public health or rural medicine appear to be far stronger predictors of FM selection.


ET48 Student Reflections on the Socio-Economic and Political Climate Impacting Access to Care in Rural and Small Town Communities

Carrie Roseamelia, PhD; Emily Mader, MPH, MPP

Context: Rural education programs seek to address the shortage of medical providers working in rural areas by recruiting, admitting, mentoring and training medical students with an interest in rural practice and primary care. Objective: To evaluate students’ reflections on training experiences and assess their understanding of how the greater social, economic and political health care environment impacts access to care and quality of care in rural and small town communities. Design: Exploratory qualitative analysis of third year medical student narrative reflections. Setting: Rural medical education training program at SUNY Upstate Medical University in Upstate New York, USA. Participants: Thirty-two, third-year medical students enrolled in the Rural Medical Education (RMED) Program at SUNY Upstate Medical University in Syracuse, NY. Results: Third-year medical students submitted 216 narrative reflections of their experiences training in rural and small town communities across New York State. The primary theme generated from the analysis was students in rural training sites gain a greater understanding of how the social, political and economic environment, inherent to medical practice in rural and small towns, impacts access and quality of care. Four subthemes emerged from analysis,: the inconsistent demand for physicians in rural and small towns based on patient load and specialty; the over utilization of emergency rooms for primary care and substance abuse issues; the need for greater training in the administration of a health care business; and, the importance of advocating policies related to sustaining primary care initiatives, including funding for rural and small town hospital infrastructure. Conclusions: Through rural and small town placements, students are awakened to the social, economic and political issues that will impact future practice. Students recognize the harsh realities of providing care to those in need and the economic and political obstacles to providing quality care in rural and small towns.


WS47 Discourse Analysis and Interpretive Research for Enhanced Patient-Centered Care External Icon

Charo Rodriguez, MD, MSc, PhD; Emmanuelle Belanger, PhD, MSc; Nathalie Dinh; Richard Hovey; Gillian Bartlett, PhD; L. Miriam Dickinson, PhD; Douglas Fernald, MA; Christopher Morley, PhD

Objectives of the CASFM Working Group: The aim of the Committee on Advancing the Science of Family Medicine (CASFM) working group is to bring together NAPCRG researchers to discuss topics in advanced methods for primary care research. The ultimate goal is to share expertise about complex and advanced methodological approaches, and elicit creative solutions to difficult problems that arise in the context of primary care research. Objectives of workshop: (1) To discuss the application of discourse analysis and interpretive inquiry as research methodologies that allow the production of knowledge that helps enhance patient-centered care; (2) To meet the challenges of conducting these studies in family medicine and primary health care settings. Content: Presenters will first give a general description of discourse analysis approaches and interpretive inquiry, and then facilitate open discussions about the knowledge contributions and challenges of adopting these research approaches using examples of investigations conducted in primary care settings. Method: A first block of 10-minute presentations will be given to briefly introduce the philosophical underpinnings of discourse analysis and interpretive inquiry. This introductory session will be followed by a 20 minute presentation of a number of discursive and interpretive empirical investigations, emphasizing the contributions of these research methodologies to patient-centered care. Participants will then break into small groups, for approximately 30 minutes to discuss these topics with the support of the presenters, to critically examine each of the research approaches and concepts introduced, their implications for practice, and the strategies to adopt in order to face the challenges that application of these methodologies may encounter. Participants will then report back to the large group during the last 30 minutes of the workshop. This information will be documented and used to develop knowledge translation and transfer opportunities. Prerequisite Knowledge: Qualitative research knowledge and experience in practice-based research will be helpful but is absolutely not required.


P418 The Association Between Educational Debt and Reported Comments Regarding Primary Care Careers External Icon

Daniel Hanba, student; Andrea Wendling, MD; Andrea Wudyka, MD; Julie Phillips, MD, MPH; Christopher Morley, PhD

Context: The US has a shortage of primary care physicians. Medical schools are encouraging students to pursue primary care careers to mitigate these shortages. Substantial educational debt may impact the message heard by students regarding primary care. Objective: To determine whether amount of student debt influences the message heard by students regarding primary care. Design: Multicenter observational cohort study. Text messaging at point of contact was used to examine incidence and balance of positive and negative comments heard about primary care, as reported by medical students during two 30-day study periods between September 2012 and April 2013. Participants self-reported expected level of debt upon graduation and were grouped for analysis based on high (>$150,000) or low (<$150,000) expected debt. Chi-square was used to determine difference in ratio of negative and positive comments between groups. Settings: Wayne State University School of Medicine; Michigan State University College of Human Medicine; SUNY Upstate Medical University. Participants: 139 medical students recruited from all enrolled students at participating universities. Results: 133 students reported expected level of debt; 120 of these students (90.2%) participated in all aspects of study and were included in analysis. Participants reported 1449 comments regarding primary care. 54 students with low expected debt reported a ratio of negative (306) to positive (463) comments of 0.661. 66 students with high expected debt reported a ratio of negative (309) to positive (371) comments of .833 (X2=4.486, df=1, p=0.03). Conclusions: There is an association between higher medical student educational debt and negatively perceived comments regarding primary care. Study does not discern whether difference was due to a more negative message from educators or a more negative interpretation of comments by those students with more debt. Educators could potentially strengthen advocacy for primary care careers by including information regarding loan repayment or scholarship opportunities for students.