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PubMed2005

Investigating the effects of communication problems on caregiver burden.

OBJECTIVE: The goal of this study was to explore the relationship between communication problems associated with dementia and caregiver burden, within the context of problem behaviors and cognitive and functional abilities of the care recipient. METHODS: A scale on communication problems associated with dementia was developed and administered to 89 family caregivers. Participants also completed measures of care-recipient cognitive and functional status, problem behavior, and caregiver burden (demand, stress, and objective burden). RESULT: Analyses using structural equation modeling showed that care-recipient cognitive and functional status indirectly predicted problem behaviors via communication problems. The status indicators also directly predicted demand burden. In addition, problem behaviors mediated the relationship between communication problems and all forms of burden. DISCUSSION: The study findings not only lend further support to the existing literature that has documented problem behaviors as strong predictors of burden but also emphasize the importance of communication problems in the caregiving process.

Adult↗

PubMed2001

Come talk with me: improving communication between nursing assistants and nursing home residents during care routines.

PURPOSE: We examined the effects of communication skills training and the use of memory books by certified nursing assistants (CNAs) on verbal interactions between CNAs (n = 64) and nursing home residents (n = 67) during care routines. DESIGN AND METHODS: CNAs were taught to use communication skills and memory books during their interactions with residents with moderate cognitive impairments and intact communication abilities. A staff motivational system was used to encourage performance and maintenance of these skills. Formal measures of treatment implementation were included. RESULTS: Results were compared with those for participants on no-treatment control units. Trained CNAs talked more, used positive statements more frequently, and tended to increase the number of specific instructions given to residents. Changes in staff behavior did not result in an increase in total time giving care to residents. Maintenance of CNA behavior change was found 2 months after research staff exited the facility. Although an increase was found in positive verbal interactions between CNAs and residents on intervention units, other changes in resident communication were absent. IMPLICATIONS: Nursing staff can be trained to improve and maintain communication skills during care without increasing the amount of time delivering care. The methodological advantages of including measures to assess treatment implementation are discussed.

Activities of Daily Living↗

PubMed2000

An evaluation of the impact of training Honduran health care providers in interpersonal communication.

OBJECTIVE: To evaluate the impact of interpersonal communication (IPC) training on practice and patient satisfaction and to determine the acceptability of this training to providers in a developing country. DESIGN: The study used a pre-post design with treatment and control groups. Data collection methods included interaction analysis of audio-taped clinical encounters, patient exit interviews, and a self-administered questionnaire for health providers. STUDY PARTICIPANTS: Interaction analysis was based on an experimental group of 24 doctors and a control group of eight with multiple observations for each provider). Exit interviews were carried out with 220 pre-test patients and 218 post-test patients. All 87 health providers who received training responded to the self-administered questionnaire. INTERVENTION: A brief in-service training programme on interpersonal communications was presented in three half-day sessions; these focused on overall socio-emotional communication, problem solving skills and counselling. MAIN OUTCOME MEASURES AND RESULTS: The IPC intervention was associated with more communication by trained providers (mean scores of 136.6 versus 94.4; P = 0.001), more positive talk (15.93 versus 7.99; P = 0.001), less negative talk (0.11 versus 0.59; P = 0.018), more emotional talk (15.7 versus 5.5; P = 0.021), and more medical counselling (17.3 versus 11.3; P = 0.026). Patients responded by communicating more (mean scores of 113.8 versus 79.6; P = 0.011) and disclosing more medical information (54.7 versus 41.7; P = 0.002). Patient satisfaction ratings were higher for providers who had received the training and providers reported training to be relevant and useful. CONCLUSIONS: Further validation of IPC skills and simplification of assessment methods are needed if IPC is to be an area for routine monitoring and quality improvement.

Ambulatory Care↗

PubMed2005

Astaxanthin diminishes gap junctional intercellular communication in primary human fibroblasts.

Astaxanthin is a carotenoid found in plants and algae; it provides the color of marine seafood such as salmon, lobster, or shrimp. Carotenoids are antioxidants and exhibit other biological functions, including effects on gap junctional communication important for homeostasis, growth control, and development of cells. Cancer cells have an impaired gap junctional intercellular communication. The objective of the present study was to determine the effects of astaxanthin and canthaxanthin on gap junctional intercellular communication in vitro. Primary human skin fibroblasts were exposed to carotenoids from 0.001 to 10 micromol/L, and gap junctional communication was measured with a dye transfer assay. After incubation with canthaxanthin for 24 and 72 h, intercellular communication increased, whereas it was strongly diminished by astaxanthin at levels > 0.1 micromol/L. Inhibition was reversed when astaxanthin was withdrawn. Western blot analysis showed that after exposure to canthaxanthin, the amount of the gap junction protein connexin43 was increased. Incubation with astaxanthin led to a change in the phosphorylation pattern of connexin43, shifting from higher to lower phosphorylation states. We suggest that astaxanthin affects channel function by changing the phosphorylation pattern of connexin43.

Anticarcinogenic Agents↗

PubMed1995

Pediatrician's communication style: relationship to parent's perceptions and behaviors.

Investigated physician-parent communication styles and the effects of concordance between parent's desired communication styles and the communication style exhibited by physicians. Subjects were 107 parents of children scheduled for an appointment with a pediatrician at a general medical clinic. Parents and physicians completed rating forms indicating the degree to which parents desired each of four communication styles (information giving, interpersonal sensitivity, partnership, and directing one's own treatment). Parents and physicians also rated the degree to which they believed the physician exhibited each of these four styles. Follow-up interviews with parents assessed the level of satisfaction with the visit, perception that parent's concerns had been addressed, and subsequent telephone calls to the physician. Results indicated that physicians underestimated the degree of interaction desired by the parents. Parent desires for particular communication styles were not predicted by characteristics of the parents. Interaction variables predicted parent perceptions and subsequent need for contact with the physician.

Adolescent↗

PubMedDate not supplied

"Come on, say something, dad!": communication and coping in fathers of diabetic adolescents.

OBJECTIVE: To investigate fathers' coping and communication behavior in families with a healthy or a diabetic adolescent. METHOD: Fathers of diabetic adolescents and healthy adolescents (N = 134) were investigated longitudinally with respect to their non-illness-specific coping behavior, their perceptions of family climate, and communicative behavior in solving a joint family task. Data were obtained through questionnaires and content analysis of recordings of verbal communication activity. RESULTS: Based on questionnaire data, few differences were found between diabetic and healthy adolescents' fathers' styles of coping with non-illness-specific family problems over time. However, several significant differences emerged, both with respect to the fathers' perceptions of family climate and to aspects of family communication, as observed by independent raters. The findings revealed the overall low communicative activity and initiative of diabetic adolescents' fathers, despite the diabetic adolescents' frequent efforts to involve their fathers in solving a joint task. CONCLUSIONS: Counseling and related support services for families of chronically ill adolescents should endeavor to reinstate or increase the father's involvement in the family, thereby encouraging him to exercise his distinctive parental functions.

Adaptation, Psychological↗

PubMed1999

New directions for risk communication research: a discussion with additional suggestions.

The papers by Huerta and Macario and Kreuter share the theme of suggesting new directions for risk communication research in cancer prevention and control. Huerta and Macario remind us once again that sociocultural factors must be considered when conducting risk communication research on underserved populations. Of special note is their recommendation to target the family, which could introduce a compelling new chapter in risk communication research in cancer prevention and control. In contrast, Kreuter challenges us to consider multiple cancer risks and risk-reducing behaviors in our research and provides a provocative framework for achieving this goal. Given this common theme and the need to position specific recommendations within the larger context of other competing research questions, this paper also highlights several additional recommendations for future research. These recommendations include the following: more research on risk presentation; establishing guidelines for measuring risk; additional research testing strategies to de-bias optimistic and pessimistic perceptions of risk and evaluating risk communication as a strategy for behavior change; more research investigating the sociology of risk communication, with a special emphasis on the family as the unit of investigation; and, finally, more research that specifically targets underserved populations in diverse community settings.

Communication↗

PubMed1992

Assistive positioning as a control parameter of social-communicative interactions between students with profound multiple disabilities and classroom staff.

This study examined the effects of assistive positioning on social-communicative interactions between 10 students, 6 to 12 years of age, with profound multiple disabilities, and their classroom staff. Interactions were videotaped in the students' classrooms when each student was positioned using a wheelchair, a sidelyer, and a mat on the floor. Data were analyzed by repeated-measures analysis of variance. During unstructured interactions, adults initiated communication at higher rates when students were positioned in their wheelchairs. During structured interactions, when students were given standardized opportunities for interaction, students functioning at lower levels of communication development were more communicative when they were supine on a mat than when in their wheelchairs or a sidelyer. In dynamic systems terms, position served as a control parameter of both adult and student communicative behaviors, which should be considered when recommending use of assistive positioning equipment for students with severe disabilities.

Adult↗

PubMed2003

Role of intracellular cyclic adenosine 3',5'-monophosphate concentration and oocyte-cumulus cells communications on the acquisition of the developmental competence during in vitro maturation of bovine oocyte.

The present study was designed to address the physiological role played by cAMP on gap junction (GJ) mediated communications between oocyte and cumulus cells during in vitro maturation. Cyclic AMP was stimulated by different collection and maturation media known to induce different rates of nuclear maturation and developmental competence as well as different levels of cumulus expansion. Cumulus-oocyte complexes (COCs) were matured for 0, 3, 7, 12, 18, and 24 h in the absence of stimulation or in the presence of serum and gonadotropins (fetal bovine serum+human menopausal gonadotropins [FCS+hMG]) or 0.01 microg/ml of invasive adenylate cyclase (iAC). For each time point, intracellular cAMP concentration ([cAMP]i) was determined either in the whole COC or oocyte after cumulus cell removal. GJ functional status was analyzed by microinjection of Lucifer yellow fluorescent dye in cumulus-enclosed oocytes and by immunohistochemical localization of connexin 43 (Cx43). In the absence of stimulation, [cAMP]i in COC and oocyte was lower than in other groups, and communications declined after 3 h of culture. In the FCS+hMG group, [cAMP]i increased significantly in COC, with a peak between 3 and 7 h that was temporally correlated with the beginning of the cumulus expansion process, which occurred only in this group and with the termination of the communications. COC matured in the presence of iAC showed a moderate increase of [cAMP]i during all of the maturation times as well as a prolongation of oocyte-cumulus cell communications. The immunohistochemical localization of Cx43 confirmed the delay in connexons protein turnover in iAC-treated COCs. Our results show that cumulus expansion and oocyte developmental competence are induced by different levels of cAMP and that its intracellular concentration may affect cell coupling between oocyte and cumulus cells. We hypothesize that the higher developmental competence of COCs matured in the presence of iAC could be achieved through a moderate increase of intracellular cAMP, which in turn determines a prolongation of communications between the two cell types.

Animals↗

PubMed2000

Gap junction communication and connexin 43 gene expression in a rat granulosa cell line: regulation by follicle-stimulating hormone.

Follicle-stimulating hormone is the major regulator of growth and development of antral follicles in the ovary. Granulosa cells (GCs) in these follicles are coupled via gap junctions (GJs) consisting of connexin 43 (Cx 43). Because we and others have found that Cx 43 and GJs, respectively, are more abundant in large antral follicles compared with small antral and preantral follicles, we hypothesized that FSH may control Cx 43 gene expression, GJ formation, and intercellular communication. To directly address these points, we chose a rat GC line (GFSHR-17) expressing the FSH receptor and the Cx 43 gene. The functionality of FSH receptors was shown by the effects of porcine FSH, namely cell rounding, reduced cellular proliferation, and stimulation of progesterone production of GFSHR-17 cells, which are effects that were detectable within hours. Treatment with FSH also statistically significantly increased Cx 43 mRNA levels, as shown after 6 to 9 h in Northern blots. These effects were antedated by altered GJ communication, which was observed within seconds. Using a single-cell/whole-cell patch clamp technique, we showed that FSH rapidly and reversibly enhanced electrical cell coupling of GFSHR-17 cells. Increased GJ communication was associated with statistically significantly decreased phosphorylation of Cx 43, which was observed within 10 min after FSH addition, during immunoprecipitation experiments. Our results demonstrate, to our knowledge for the first time, that the gonadotropin FSH acutely and directly stimulates intercellular communication of GFSHR-17 cells through existing GJs. Moreover, FSH also increases levels of Cx 43 mRNA. These changes are associated with reduced proliferation and enhanced differentiation of GFSHR-17 cells. In vivo factors in addition to FSH may be involved in the regulation of GJ/GJ communication between GCs in the follicle, but our results suggest that improved cell-to-cell coupling, enhanced Cx 43 gene expression, and possibly, formation of new GJs are direct consequences of FSH receptor activation and may antedate and/or initiate the pivotal effects of FSH on GCs.

Animals↗

PubMed1994

Improving the process of communication at the bedside.

Timely communication among health care workers, patients, and significant others is an important component of delivering quality health care. As patients' lengths of stay decrease, "flextime" among health care personnel increases, and the various types of practitioners providing patient care increases, a method for quick communication of pertinent clinical information at the bedside becomes imperative. A multidisciplinary quality improvement team was formed to improve the process of communication of pertinent clinical information such as allergies, isolation precautions, and NPO (nothing by mouth) at the bedside. The outcome of this project was the development of a bedside clinical communication system and an improvement in the process of communicating pertinent clinical information at the bedside.

Communication↗

PubMed1999

"Teach 1, do 1 ... better": superior communication skills in senior medical students serving as standardized patient--examiners for their junior peers.

PURPOSE: To see if senior medical students who had served as standardized patients (SP) demonstrated improvement in their own interpersonal communication skills. METHOD: From George Washington School of Medicine's class of 1996, 154 fourth-year students took a clinical practice examination that used professional SPs. Within the preceding six months, 28 of these students had been SP-examiners in similar examinations for first- and second-year medical students. The professional SPs rated the fourth-year examinees using checklists that measured five dimensions of interpersonal communication skills. Four of these five dimensions were identical to those measured on the examinations for which the fourth-year students had served as SPs. Hypothesizing that the SP-experienced seniors would outscore their inexperienced classmates on those four dimensions, but not on the fifth, the authors analyzed the fourth-year students' scores. P values were computed by the F test from a two-way analysis of variance. RESULTS: As predicted, the group with prior SP experience significantly outscored their inexperienced colleagues in each of the four expected dimensions of interpersonal communication skills, with p values ranging from .000 to .023. The score differential in these dimensions ranged from 3.8 to 11.8 percentage points. As further predicted, there was no significant difference between the scores of the two groups on the fifth dimension. CONCLUSION: Compared with their inexperienced peers, senior medical students with prior SP experience consistently demonstrated superior scores when their own communication skills were tested in a similar manner. The U.S. Medical Licensing Examinations propose to incorporate SP clinical examinations; in response, medical schools will use more SP examinations in their own curricula. Such examinations are expensive when using professional standardized patients; the authors believe that an SP program using senior medical students will prove an attractive alternative. Such programs may have the added advantage of making better communicators of senior medical student teachers as well as the students they teach.

Communication↗

PubMed2000

A comparison of physician examiners', standardized patients', and communication experts' ratings of international medical graduates' English proficiency.

PURPOSE: To assess the quality of ratings of interviewing skills and oral English proficiency provided on a clinical skills OSCE by physician examiners, standardized patients (SPs), and communication skills experts. METHOD: In 1998, 73 candidates to the Ontario International Medical Graduate (OIMG) Program completed a 29-station OSCE-type clinical skills selection examination. Physician examiners, SPs, and communication skills experts assessed components of oral English proficiency and interview performance. Based on these results, the frequency and generalizability of English-language flags, physician examiners' indications that spoken English skills were bad enough to significantly impede communication with patients; the reliability of the OIMG's Interview and Oral Performance Scales and generalizability of overall interview and oral performance ratings; and comparisons of repeated assessments by experts were calculated. Principal-components analysis was applied to the panels' ratings to determine a more economical expression of the language proficiency and interview communication skills results. RESULTS: The mean number of English-language flags per candidate was 2.1, the median was 1.0, and Cronbach's alpha of the ratings was 0.63. Means, SDs, and alphas of the physician examiners' and SPs' ratings of the interview performance scale were 9.15/10, 0.43, 0.36, and 9.30/10, 0. 56, 0.50, respectively. Corresponding values for overall interview performance ratings were 3.08/4, 0.30, 0.33, and 3.34/4, 0.32, 0.47. Means, SDs, and alphas of the physician examiners' and SPs' ratings of the oral performance scale were 8.54/10, 0.74, 0.78, and 8.74/10, 1.00, 0.76. Corresponding values for overall ratings of oral performance were 3.85/5, 0.51, 0.68, and 4.08/5, 0.60, 0.68. For the two experts' ratings of two contiguous five-minute interview stations, internal consistencies were 0.88 and 0.78. For the two experts' ratings of standardized ten-minute interviews, internal consistencies were 0.81 and 0.92. Correlations between the mean values of the experts' ratings of the ten- and five-minute stations were 0.45 and 0.51. Three factors emerged from the PCA, language proficiency, physician examiners' ratings of interview proficiency, and SPs' ratings of interview proficiency. CONCLUSIONS: Consistency between the physician examiners' and SPs' ratings of English proficiency was observed; less agreement was observed in their ratings of interviewing skills, and little agreement was observed between the experts' ratings. Communication skills results may be validly expressed by three measures: one overall global rating of language proficiency provided by physician examiners or SPs, and overall global ratings of interview proficiency provided separately by physician examiners and SPs.

Clinical Competence↗

PubMed2002

A communication assessment and skill-building exercise (CASE) for first-year residents.

OBJECTIVE: Good communication skills are essential for residents entering postgraduate education programs. However, these skills vary widely among medical school graduates. This pilot program was designed to create opportunities for (1) teaching essential interviewing and communication skills to trainees at the beginning of residency, (2) assessing resident skills and confidence with specific types of interview situations, (3) developing faculty teaching and assessment skills, (4) encouraging collegial interaction between faculty and new trainees, and (5) guiding residency curricular development. DESCRIPTION: During residency orientation, all first-year internal medicine residents (n = 26) at the University of Minnesota participated in the communication assessment and skill-building exercise (CASE). CASE consisted of four ten-minute stations in which residents demonstrated their communication skills in encounters with standardized patients (SPs) while faculty members observed for specific skills. Faculty and SPs were oriented to the educational purposes and goals of their stations, and received instructions on methods of providing feedback to residents. With each station, residents were provided one and a half minutes of direct feedback by the faculty observer and the SP. The residents were asked to deal with an angry family member, to counsel for smoking cessation, to set a patient-encounter agenda, and to deliver bad news. A resident's performance was analyzed for each station, and individual profiles were created. All residents and faculty completed evaluations of the exercise, assessing the benefits and areas for improvement. DISCUSSION: Evaluations and feedback from residents and faculty showed that most of our objectives were accomplished. Residents reported learning important skills, receiving valuable feedback, and increasing their confidence in dealing with certain types of stressful communication situations in residency. The activity was also perceived as an excellent way to meet and interact with faculty. Evaluators found the experience rewarding, an effective method for assessing and teaching clinical skills, a faculty development experience for themselves in learning about structured practical skills exercises, and a good way to meet new interns. The residency program director found individual resident performance profiles valuable for identifying learning issues and for guiding curricular development. Time constraints were the most frequently cited area for improvement. The exercise became feasible by collaborating with the medical school Office of Education-Educational Development and Research, whose mission is to collaborate with faculty across the continuum of medical education to improve the quality of instruction and evaluation. The residency program saved considerable time, effort, and expense by using portions of the medical school's existing student skills-assessment programs and by using chief residents and faculty as evaluators. We plan to use CASE next year with a wider variety of physician-patient scenarios for interns, and to expand the program to include beginning second- and third-year residents. Also, since this type of exercise creates powerful feedback and assessment opportunities for instructors and course directors, and because feedback was so favorable from evaluators, we will encourage participation in CASE as part of our faculty educational development program.

Clinical Competence↗

PubMed2002

Advanced communication skills: conflict management and persuasion.

OBJECTIVE: There is an increasing need in the medical school curriculum to adequately prepare students for professionalism in the workplace. This senior seminar is a four-week course designed to develop fluency in handling conflict and negotiation as well as understanding the elements of persuasive communication. Students used the Meyers-Brigg Personality Inventory as a paradigm for understanding different communication styles. DESCRIPTION: The class was piloted in October and November 2001 and consisted of four modules. In module one, each student was given the Meyers-Brigg Personality Inventory to take. Discussions and exercises provided insight into the student's own communication style as well as styles the individual student might find more problematic. The second module consisted of four sessions focusing on conflict management and negotiating skills. Students were given strategies for dealing with conflict as well as specific approaches for communicating with "difficult" patients. In the subsequent sessions, students had a chance to further incorporate these strategies by (1) discussing in a small-group setting a conflict situation that they had either witnessed or experienced in order to systematically evaluate how to incorporate conflict-management approaches into their particular communication style. (2) Role-playing four conflict situations students' were likely to encounter in their professional lives. Role-plays were videotaped and individual feedback was given immediately after the role-play by the observing students, the patient-actor, and the evaluator, who had been trained to give specific feedback on the conflict strategies. (3) Watching specific videotaped role-plays as a class allowed students to see and give feedback on particularly effective strategies that their colleagues used. The third module was devoted to giving bad news and ways that different people prefer to receive bad news, using the MBTI personality types as examples. The final module outlined the principles used in persuasion. Each student had the opportunity to make a five-to-ten-minute persuasive speech, the topic to be applicable to the student's specialty, which was reviewed by his peers. Feedback was tailored specifically to the different principles of persuasion. DISCUSSION: The curriculum was judged to be effective in changing confidence and attitudes as evidenced by pre- and post-course evaluations that students filled out during the last session of the class. Six things contributed to its success: (1) the class was offered as a fourth-year seminar; students could see its relevance and therefore were motivated to learn. (2) Activities were designed to build on learning in ways that graduated from passive to active. In such a way the theoretical was made practical. (3) Feedback was immediate and congruent. For example, the evaluators and patient-actors were all trained in the conflict management principles taught. (4) Feedback done by peer review allowed students to internalize strategies. (5) Concrete steps were given for behavioral change. (6) Small-group sessions invited camaraderie and allowed for individualized attention. Future activities include integrating this curriculum into residency teaching; the course is a continuation of a first-year course on interviewing skills taken by every student.

Conflict, Psychological↗

PubMed2004

Patient-physician communication.

PURPOSE OF REVIEW: Patient-physician communication is a vital element of the process of care. In numerous studies, communication behaviors during the medical interaction have been significantly associated with a variety of patient satisfaction and health outcomes. The purpose of this review is to synthesize recent findings in the area of patient-physician communication, particularly as they relate to patients with rheumatic disease. RECENT FINDINGS: Although there is scant research on the medical interaction with patients with rheumatic disease specifically, there is a large body of literature examining patient-doctor communication in other chronic diseases. Because many of the findings of studies conducted in patients with other diseases can be extended to patients with rheumatic disease, this review also covers the most salient literature published in the past year on patient-doctor communication in chronic diseases in general, in addition to covering publications in the field of rheumatology. SUMMARY: The literature reviewed shows that patients' expectations of medical encounters are not always fulfilled and that patients desire increased participation and information sharing. Establishing patient-centered care is a challenging goal, but fortunately, recent studies show that physicians can be trained, irrespective of the years in practice, to provide patient-centered care and increase patient participation and satisfaction with care.

Communication↗

PubMed2000

Nurse-patient communication in cancer care. A review of the literature.

Patients with cancer seem to experience distress particularly in the first period after diagnosis, and are likely to develop an affective disorder in the first 2 to 3 months. Communicative behaviors of nurses seem to play an important role in meeting the cognitive and affective needs of patients with cancer. This review of the literature examines the communicative behaviors of nurses during care activities with patients who have cancer. The studies show that emphasis is placed on the affective side, in which facilitating behaviors such as empathy, touch, comforting, and supporting are considered essential in caring for patients with cancer. Unfortunately, further studies in this review demonstrate that communication in oncologic care is complicated by such emotionally laden issues as the consequences associated with the life-threatening character of the disease and the far-reaching consequences of the medical treatment. This results in barriers to effective communication between patients with cancer and nurses. It is important, therefore, that nurses working with patients who have cancer are provided both structurally and repeatedly with continuing education programs in communication. Finally, most of the studies covered in this review have an explorative character. Future research in this area should pay attention to the use of controlled studies, large sample sizes, and observational instruments.

Communication↗

PubMed2001

Communication in intensive care settings: the challenge of futility disputes.

In intensive care settings, suboptimal communication can erode family trust and fuel so-called "futility" disputes. Presenting a teaching case used by >225 hospitals participating in the Decisions Near the End-of-Life program, we identify critical communication challenges and opportunities. We emphasize that good communication requires not only clear and sensitive language but also clinician self-awareness, psychological insight, and an institutional culture that promotes good communication with families. The article concludes with two examples of steps institutions can take to foster good communication between families and healthcare professionals.

Aged↗