Search

Abstract Background Since patient-centered communication is directly connected to clinical performance, it should be integrated with medical knowledge and clinical skills. Therefore, clinical communication skills should be trained and assessed as an integral part of the student’s clinical performance. We were unable to identify a tool, which helps when assessing patient-centered communication skills as an integrated component of medical history taking (‘the integrated medical interview’). Therefore, we decided to design a new tailor-made assessment tool, the BOCC (BeOordeling Communicatie en Consultvoering (Dutch), Assessment of Communication and Consultation (English) to help raters assess students’ integrated clinical communication skills with the emphasis on patient-centred communication combined with the correct medical content. This is a first initiative to develop such a tool, and this paper describes the first steps in this process. Methods We investigated the tool in a group of third-year medical students (n = 672) interviewing simulated patients. Internal structure and internal consistency were assessed. Regression analysis was conducted to investigate the relationship between scores on the instrument and general grading. Applicability to another context was tested in a group of fourth-year medical students (n = 374). Results PCA showed five components (Communication skills, Problem clarification, Specific History, Problem influence and Integration Skills) with various Cronbach’s alpha scores. The component Problem Clarification made the strongest unique contribution to the grade prediction. Applicability was good when investigated in another context. Conclusions The BOCC is designed to help raters assess students’ integrated communication skills. It was assessed on internal structure and internal consistency. This tool is the first step in the assessment of the integrated medical interview and a basis for further investigation to reform it into a true measurement instrument on clinical communication skills.

Plain English summary It is important for health care workers to know the needs and expectations of their patients. Therefore, service users have to be involved in research. To achieve a meaningful dialogue between service users, healthcare workers and researchers, participatory methods are needed. This paper describes how the application of a specific participatory methodology, Participatory Learning and Action (PLA) can lead to such a meaningful dialogue. In PLA all stakeholders are regarded as equal partners and collaborators in research. During 2011–2015, a European project called RESTORE used PLA in Austria, Greece, Ireland, The Netherlands and the UK to investigate how communication between primary health care workers and their migrant patients could be improved. Seventy eight migrants, interpreters, doctors, nurses and other key stakeholders (see Table 2) participated in 62 PLA sessions. These dialogues (involving discussions, activities, PLA techniques and evaluations) were generally 2–3 h long and were recorded and analysed by the researchers. Participants reported many positive experiences about their dialogues with other stakeholders. There was a positive, trusting atmosphere in which all stakeholders could express their views despite differences in social power. This made for better understanding within and across stakeholder groups. For instance a doctor changed her view on the use of interpreters after a migrant explained why this was important. Negative experiences were rare: some doctors and healthcare workers thought the PLA sessions took a lot of time; and despite the good dialogue, there was disappointment that very few migrants used the new interpreting service. Abstract Background In order to be effective, primary healthcare must understand the health needs, values and expectations of the population it serves. Recent research has shown that the involvement of service users and other stakeholders and gathering information on their perspectives can contribute positively to many aspects of primary healthcare. Participatory methodologies have the potential to support engagement and dialogue between stakeholders from academic, migrant community and health service settings. This paper focuses on a specific participatory research methodology, Participatory Learning and Action (PLA) in which all stakeholders are regarded as equal partners and collaborators in research. Our research question for this paper was: "Does the application of PLA lead to meaningful engagement of all stakeholders, and if so, what elements contribute to a positive and productive inter-stakeholder dialogue?". Methods We explored the use of PLA in RESTORE, a European FP7-funded project, during 2011–2015 in 5 countries: Austria, Greece, Ireland, the Netherlands and the UK. The objective of RESTORE was to investigate and support the implementation of guidelines and training initiatives (G/TIs) to enhance communication in cross-cultural primary care consultations with migrants. Seventy eight stakeholders (migrants, interpreters, doctors, nurses and others – see Table 2) participated in a total of 62 PLA sessions (discussions, activities, evaluations) of approximately 2–3 h’ duration across the five sites. During the fieldwork, qualitative data were generated about stakeholders’ experiences of engagement in this dialogue, by means of various methods including participatory evaluations, researchers’ fieldwork reports and researcher interviews. These were analysed following the principles of thematic analysis. Results Stakeholders involved in PLA inter-stakeholder dialogues reported a wide range of positive experiences of engagement, and very few negative experiences. A positive atmosphere during early research sessions helped to create a sense of safety and trust. This enabled stakeholders from very different backgrounds, with different social status and power, to offer their perspectives in a way that led to enhanced learning in the group – they learned with and from each other. This fostered shifts in understanding – for example, a doctor changed her view on interpreted consultations because of the input of the migrant service-users. Conclusion PLA successfully promoted stakeholder involvement in meaningful and productive inter-stakeholder dialogues. This makes it an attractive approach to enhance the further development of health research partnerships to advance primary healthcare.

Objective: To describe innovations in a clinical communication skills training (CCST) program, aimed at facilitating transfer of communication skills from classroom to clinical practice and report student's evaluations regarding this program., Methods: To facilitate transfer, we integrated CCS with medical and practical skills, and we developed simulation sessions closely resembling clinical practice in case-history's, length of consultation, and patient-population. Feedback was given on communication skills and medical knowledge and skills. Student's opinions about whether these elements were helpful, were evaluated using a questionnaire., Results: Responses of 144 students were analyzed. The majority of the respondents agreed that this CCST program helped them with transfer of CCS from classroom to clinical practice, as did the feedback on medical content and communication skills in the same session., Conclusion: Students indicate that simulations resembling clinical practice and feedback on both CST and medical content facilitate the transfer of their skills to clinical practice., Innovation: This CCST program is innovative because it integrates medical and practical skills, with elements aiming to create an educational environment resembling clinical practice as closely as possible in order to facilitate transfer to clinical practice., Competing Interests: No involved persons had competing interests in this study. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (© 2023 The Authors.)

Competing Interests: Competing interests: None declared.

Introduction: This paper describes the co-creation and delivery of an integrated training programme in communication and depression assessment & management for Japanese GPs., Methods: Experts in communication and depression from EACH and WONCA developed a framework and filled it with content. Through iterative discussions with the Japanese participants and experts during delivery, the training was further adjusted to match local needs. It included didactic and experiential training methods with an emphasis on practicing and feedback. A "train-the-trainer" component helped participants develop their own trainer skills to enhance dissemination of the training in Japan., Results: Six Japanese GPs participated in two one week training-modules in May and November 2018. To aid implementation participants received online supervision on depression management and on teaching between the two modules and after the second module. Evaluation of the content of the training, the teaching methods and the participatory approach was positive. More than two years after the training, many elements of the training continue to be used in daily practice with the GPs teaching communication as well as depression management skills., Conclusion: The method of co-creation is promising. Research is needed to confirm that it is effective in transfer to clinical practice., Competing Interests: Declaration of Competing Interest The authors have no financial conflicts of interest., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

In line with World Health Organization policy (WHO, 2016; 2019), primary care services need to be adapted to effectively meet the needs of diverse patient populations. Drawing from a European participatory implementation study, we present an Irish case study. In a hybrid participatory space, migrants, general practice staff and service planners (n = 11) engaged in a project to implement the use of trained interpreters in primary care over 17 months. We used Normalisation Process Theory to analyse data from 15 Participatory Learning and Action research focus groups and related sources. While stakeholders' agency and expertise produced relevant positive results for the introduction of changes in a general practice setting, structural factors limited the range and scope for sustained changes in day-to-day practice., (Copyright © 2021. Published by Elsevier Ltd.)

Feedback is a key factor in acquiring breaking bad news (BBN) communication skills and its' acceptance depends on the perceived credibility of the provider. Our aim was to investigate students' opinions on the provided feedback by different educators (surgeons, psychologists, and simulated patient (SP)) during BBN skills training. We developed a questionnaire investigating provided feedback by the surgeon, psychologist, and SP (yes or no statements), regarding (1) perceived safety of the atmosphere, (2) perceived positive feedback, (3) perceived specific feedback, and (4) perceived usefulness for improvement during BBN skills training. Five hundred twenty students returned the questionnaire after BBN skills training. Most students rated the feedback as positive, specific, and useful. Also, the atmosphere was considered safe. Feedback ratings of the SP were the same as for the surgeon and valued higher than for the psychologist. An unsafe atmosphere, or not receiving positive, specific, or useful feedback was mostly related to the psychologist's feedback. Feedback on BBN skills training by surgeons and SPs is rated equally helpful by students and is regarded specific, useful, and positive. When designing a BBN training, it is worth to consider involving SP's as well as clinicians.

In 2017, EACH celebrated its change of name from European Association for Communication in Healthcare to EACH: International Association for Communication in Healthcare. This paper aims to present the developments and achievements of EACH over the past five years with a focus on its mission in promoting and advancing the field of communication in healthcare. Specifically, the paper focuses on how EACH, first, promotes research in the field of health communication, second, provides support, resources and sharing for healthcare communication teachers and, third, aims at influencing policy through dissemination of evidence. This paper also explores future challenges and directions for EACH to further strengthen its impact by designing activities in knowledge transfer and knowledge dissemination, engaging with patients and truly benefitting from their expertise, fostering active participation and networking among its members, targeting interventions to the needs of different countries around the world and refining knowledge-sharing and cooperation both within the membership of EACH and outside the association to as wide an audience as possible. Scholars, educators and practitioners active in the field of healthcare communication are invited to comment on this paper and to actively contribute towards the goals of EACH., (Copyright © 2019. Published by Elsevier B.V.)

Background: Since patient-centered communication is directly connected to clinical performance, it should be integrated with medical knowledge and clinical skills. Therefore, clinical communication skills should be trained and assessed as an integral part of the student's clinical performance. We were unable to identify a tool, which helps when assessing patient-centered communication skills as an integrated component of medical history taking ('the integrated medical interview'). Therefore, we decided to design a new tailor-made assessment tool, the BOCC (BeOordeling Communicatie en Consultvoering (Dutch), Assessment of Communication and Consultation (English) to help raters assess students' integrated clinical communication skills with the emphasis on patient-centred communication combined with the correct medical content. This is a first initiative to develop such a tool, and this paper describes the first steps in this process., Methods: We investigated the tool in a group of third-year medical students (n = 672) interviewing simulated patients. Internal structure and internal consistency were assessed. Regression analysis was conducted to investigate the relationship between scores on the instrument and general grading. Applicability to another context was tested in a group of fourth-year medical students (n = 374)., Results: PCA showed five components (Communication skills, Problem clarification, Specific History, Problem influence and Integration Skills) with various Cronbach's alpha scores. The component Problem Clarification made the strongest unique contribution to the grade prediction. Applicability was good when investigated in another context., Conclusions: The BOCC is designed to help raters assess students' integrated communication skills. It was assessed on internal structure and internal consistency. This tool is the first step in the assessment of the integrated medical interview and a basis for further investigation to reform it into a true measurement instrument on clinical communication skills.

Objective: Breaking bad news (BBN) should be trained, preferably early and following a helical model with multiple sessions over time, including feedback on performance. It's unclear how medical students evaluate such an approach., Methods: We gathered student opinions regarding a helical BBN training programme, the feedback and emotional support they received, and the applicability of the skills training immediately after BBN skills training (Q1) and after finishing their clinical clerkships (Q2)., Results: Students find a helical curriculum useful, but this declines on follow-up. At Q2 students report less satisfaction with the amount of feedback and emotional support they received and report that the skills training was less applicable in clinical practice compared to what they reported at Q1., Conclusion: A helical BBN training programme with early exposure seems to lead to a shift from students being unconsciously incompetent to consciously incompetent. Students would have appreciated more emotional support and feedback., Practice Implications: We recommend more feedback and emotional support after BBN during clerkships. The gap between classroom and practice can be diminished by emphasizing real life role play and clinical role models should demonstrate continuity and agreement between the skills that are taught and those that are used in clinical practice., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The material practices which researchers use in research partnerships may enable or constrain the nature of engagement with stakeholder groups. Participatory learning and action (PLA) research approaches show promise, but there has been no detailed analysis of stakeholders' and researchers' experiences of PLA techniques for data generation and co-analysis., Objectives: To explore stakeholders' and researchers' experiences of PLA techniques for data generation and co-analysis., Design: The EU RESTORE implementation science project employed a participatory approach to investigate and support the implementation of guidelines and training initiatives (GTIs) to enhance communication in cross-cultural primary care consultations. We developed a purposeful sample of 78 stakeholders (migrants, general practice staff, community interpreters, service providers, service planners) from primary care settings in Austria, England, Greece, Ireland and The Netherlands. We used speed evaluations and participatory evaluations to explore their experiences of two PLA techniques-Commentary Charts and Direct Ranking-which were intended to generate data for co-analysis by stakeholders about the GTIs under analysis. We evaluated 16 RESTORE researchers' experiences using interviews. We conducted thematic and content analysis of all evaluation data., Results: PLA Commentary Charts and Direct Ranking techniques, with their visual, verbal and tangible nature and inherent analytical capabilities, were found to be powerful tools for involving stakeholders in a collaborative analysis of GTIs. Stakeholders had few negative experiences and numerous multifaceted positive experiences of meaningful engagement, which resonated with researchers' accounts., Conclusion: PLA techniques and approaches are valuable as material practices in health research partnerships., (© 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.)

Plain English Summary: It is important for health care workers to know the needs and expectations of their patients. Therefore, service users have to be involved in research. To achieve a meaningful dialogue between service users, healthcare workers and researchers, participatory methods are needed. This paper describes how the application of a specific participatory methodology, Participatory Learning and Action (PLA) can lead to such a meaningful dialogue. In PLA all stakeholders are regarded as equal partners and collaborators in research.During 2011-2015, a European project called RESTORE used PLA in Austria, Greece, Ireland, The Netherlands and the UK to investigate how communication between primary health care workers and their migrant patients could be improved.Seventy eight migrants, interpreters, doctors, nurses and other key stakeholders (see Table 2) participated in 62 PLA sessions. These dialogues (involving discussions, activities, PLA techniques and evaluations) were generally 2-3 h long and were recorded and analysed by the researchers.Participants reported many positive experiences about their dialogues with other stakeholders. There was a positive, trusting atmosphere in which all stakeholders could express their views despite differences in social power. This made for better understanding within and across stakeholder groups. For instance a doctor changed her view on the use of interpreters after a migrant explained why this was important. Negative experiences were rare: some doctors and healthcare workers thought the PLA sessions took a lot of time; and despite the good dialogue, there was disappointment that very few migrants used the new interpreting service., Abstract: Background In order to be effective, primary healthcare must understand the health needs, values and expectations of the population it serves. Recent research has shown that the involvement of service users and other stakeholders and gathering information on their perspectives can contribute positively to many aspects of primary healthcare. Participatory methodologies have the potential to support engagement and dialogue between stakeholders from academic, migrant community and health service settings. This paper focuses on a specific participatory research methodology, Participatory Learning and Action (PLA) in which all stakeholders are regarded as equal partners and collaborators in research.Our research question for this paper was: "Does the application of PLA lead to meaningful engagement of all stakeholders, and if so, what elements contribute to a positive and productive inter-stakeholder dialogue?". Methods We explored the use of PLA in RESTORE, a European FP7-funded project, during 2011-2015 in 5 countries: Austria, Greece, Ireland, the Netherlands and the UK. The objective of RESTORE was to investigate and support the implementation of guidelines and training initiatives (G/TIs) to enhance communication in cross-cultural primary care consultations with migrants.Seventy eight stakeholders (migrants, interpreters, doctors, nurses and others - see Table 2) participated in a total of 62 PLA sessions (discussions, activities, evaluations) of approximately 2-3 h' duration across the five sites. During the fieldwork, qualitative data were generated about stakeholders' experiences of engagement in this dialogue, by means of various methods including participatory evaluations, researchers' fieldwork reports and researcher interviews. These were analysed following the principles of thematic analysis. Results Stakeholders involved in PLA inter-stakeholder dialogues reported a wide range of positive experiences of engagement, and very few negative experiences. A positive atmosphere during early research sessions helped to create a sense of safety and trust. This enabled stakeholders from very different backgrounds, with different social status and power, to offer their perspectives in a way that led to enhanced learning in the group - they learned with and from each other. This fostered shifts in understanding - for example, a doctor changed her view on interpreted consultations because of the input of the migrant service-users. Conclusion PLA successfully promoted stakeholder involvement in meaningful and productive inter-stakeholder dialogues. This makes it an attractive approach to enhance the further development of health research partnerships to advance primary healthcare.

Background: Migration in Europe is increasing at an unprecedented rate. There is an urgent need to develop 'migrant-sensitive healthcare systems'. However, there are many barriers to healthcare for migrants. Despite Greece's recent, significant experiences of inward migration during a period of economic austerity, little is known about Greek primary care service providers' experiences of delivering care to migrants., Objectives: To identify service providers' views on the barriers to migrant healthcare., Methods: Qualitative study involving six participatory learning and action (PLA) focus group sessions with nine service providers. Data generation was informed by normalization process theory (NPT). Thematic analysis was applied to identify barriers to efficient migrant healthcare., Results: Three main provider and system-related barriers emerged: (a) emphasis on major challenges in healthcare provision, (b) low perceived control and effectiveness to support migrant healthcare, and (c) attention to impoverished local population., Conclusion: The study identified major provider and system-related barriers in the provision of primary healthcare to migrants. It is important for the healthcare system in Greece to provide appropriate supports for communication in cross-cultural consultations for its diversifying population.

Context: Patient-centred communication is a key component of patient centredness in medical care. Therefore, adequate education in and assessment of patient-centred communication skills are necessary. In general, feedback on communication skills is most effective when it is provided directly and is systematic. This calls for adequate measurement instruments., Objectives: The aim of this study was to provide a systematic review of existing instruments that measure patient centredness in doctor-patient communication and can be used to provide direct feedback., Methods: A systematic review was conducted using an extensive validated search strategy for measurement instruments in PubMed, EMBASE, PsycINFO and CINAHL. The databases were searched from their inception to 1 July 2016. Articles describing the development or evaluation of the measurement properties of instruments that measure patient centredness (by applying three or more of the six dimensions of a published definition of patient centredness) in doctor-patient communication and that can be used for the provision of direct feedback were included. The methodological quality of measurement properties was evaluated using the COSMIN checklist., Results: Thirteen articles describing 14 instruments measuring patient centredness in doctor-patient communication were identified. These studies cover a wide range of settings and patient populations, and vary in the dimensions of patient centredness applied and in methodological quality on aspects of reliability and validity., Conclusions: This review gives a comprehensive overview of all instruments available for the measurement of patient centredness in doctor-patient communication that can be used for the provision of direct feedback and are described in the literature. Despite the widely felt need for valid and reliable instruments for the measurement of patient-centred communication, most of the instruments currently available have not been thoroughly investigated. Therefore, we recommend further research into and enhancement of existing instruments in terms of validity and reliability, along with enhancement of their generalisability, responsiveness and aspects of interpretability in different contexts (real patients, simulated patients, doctors in different specialties, etc.). Comprehensibility and feasibility should also be taken into account., (© 2017 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Objective: This article reports experiences and challenges encountered in a cross-cultural training project in Moldova that was undertaken by tEACH, the teaching subcommittee of EACH: International Association for Communication in Healthcare, in cooperation with local and international stakeholders. As part of a major health policy reform, the aim was to equip a group of trainers with the skills to train Moldovan professionals in skills for primary mental health care, including communication skills., Methods: The project consisted of 3 weeks of training using mainly experiential teaching methods to allow participants to practice content and methods, including interactive lecturing, roleplay, feedback and video., Results: A majority of the participants reported that they acquired key facilitation skills. They valued the opportunity to practice and receive feedback. However, some reported that there was too much focus on communication skills, which was thought to be less relevant in a Moldovan context. Furthermore our learner-centered approach was occasionally experienced as a lack of structure CONCLUSION: The tEACH expertise plays an important role in supporting trainers in cross-cultural contexts with effective communication skills methods., Practice Implications: Teaching in a cross-cultural context is only successful through continuous dialogue with stakeholders and demands attention to cultural differences., (Copyright © 2017. Published by Elsevier B.V.)

Background: Cross-cultural communication in primary care is often difficult, leading to unsatisfactory, substandard care. Supportive evidence-based guidelines and training initiatives (G/TIs) exist to enhance cross cultural communication but their use in practice is sporadic. The objective of this paper is to elucidate how migrants and other stakeholders can adapt, introduce and evaluate such G/TIs in daily clinical practice., Methods: We undertook linked qualitative case studies to implement G/TIs focused on enhancing cross cultural communication in primary care, in five European countries. We combined Normalisation Process Theory (NPT) as an analytical framework, with Participatory Learning and Action (PLA) as the research method to engage migrants, primary healthcare providers and other stakeholders. Across all five sites, 66 stakeholders participated in 62 PLA-style focus groups over a 19 month period, and took part in activities to adapt, introduce, and evaluate the G/TIs. Data, including transcripts of group meetings and researchers' fieldwork reports, were coded and thematically analysed by each team using NPT., Results: In all settings, engaging migrants and other stakeholders was challenging but feasible. Stakeholders made significant adaptations to the G/TIs to fit their local context, for example, changing the focus of a G/TI from palliative care to mental health; or altering the target audience from General Practitioners (GPs) to the wider multidisciplinary team. They also progressed plans to deliver them in routine practice, for example liaising with GP practices regarding timing and location of training sessions and to evaluate their impact. All stakeholders reported benefits of the implemented G/TIs in daily practice. Training primary care teams (clinicians and administrators) resulted in a more tolerant attitude and more effective communication, with better focus on migrants' needs. Implementation of interpreter services was difficult mainly because of financial and other resource constraints. However, when used, migrants were more likely to trust the GP's diagnoses and GPs reported a clearer understanding of migrants' symptoms., Conclusions: Migrants, primary care providers and other key stakeholders can work effectively together to adapt and implement G/TIs to improve communication in cross-cultural consultations, and enhance understanding and trust between GPs and migrant patients.

This paper is based on the keynote lecture given at the ICCH conference in New Orleans in October 2015. With as background the observation that even though research and teaching of communication have been receiving attention for some time now, patients still encounter many problems when they visit clinicians because of health problems, it subsequently touches upon research on integration of communication with correct medical content, person centered communication and the role of placebo on outcomes. For teaching it emphasizes methods working best to teach clinical communication skills and lead to behavior changes in professionals: experiential teaching methods but taking care of a balance with cognitive methods. It then discusses the challenge of transfer to clinical practice and what is needed to overcome these challenges: learning from reflecting on undesired outcomes in clinical practice, feedback from clinicians who are open to communication and support learners with effective feedback in that specific context. It adds suggestions about where linking more between research, teaching and clinical practice could help moving communication in health care forward and builds the case for involving policymakers and members of hospital boards to help manage the necessary climate change in clinical settings., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Guidelines and training initiatives (G/TIs) are available to support communication in cross-cultural consultations but are rarely implemented in routine practice in primary care. As part of the European Union RESTORE project, our objective was to explore whether the available G/TIs make sense to migrants and other key stakeholders and whether they could collectively choose G/TIs and engage in their implementation in primary care settings., Setting: As part of a comparative analysis of 5 linked qualitative case studies, we used purposeful and snowball sampling to recruit migrants and other key stakeholders in primary care settings in Austria, England, Greece, Ireland and the Netherlands., Participants: A total of 78 stakeholders participated in the study (Austria 15, England 9, Ireland 11, Greece 16, Netherlands 27), covering a range of groups (migrants, general practitioners, nurses, administrative staff, interpreters, health service planners)., Primary and Secondary Outcome Measures: We combined Normalisation Process Theory (NPT) and Participatory Learning and Action (PLA) research to conduct a series of PLA style focus groups. Using a standardised protocol, stakeholders' discussions about a set of G/TIs were recorded on PLA commentary charts and their selection process was recorded through a PLA direct-ranking technique. We performed inductive and deductive thematic analysis to investigate sensemaking and engagement with the G/TIs., Results: The need for new ways of working was strongly endorsed by most stakeholders. Stakeholders considered that they were the right people to drive the work forward and were keen to enrol others to support the implementation work. This was evidenced by the democratic selection by stakeholders in each setting of one G/TI as a local implementation project., Conclusions: This theoretically informed participatory approach used across 5 countries with diverse healthcare systems could be used in other settings to establish positive conditions for the start of implementation journeys for G/TIs to improve healthcare for migrants., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Mental health problems are highly prevalent amongst undocumented migrants (UMs), and often part of their consultations with general practitioners (GPs). Little empirical data are available of how GPs and UMs engage around mental health in Greece, a country with a lack of balance between primary and secondary care and limited healthcare provisions for UMs., Objectives: To acquire insight in the barriers and levers in the provision of mental healthcare for UMs by GPs in Greece., Methods: This was a qualitative study using semi-structured interviews with 12 GPs in Crete, Greece with clinical expertise in the care of UMs. All interviews were audio-taped and transcribed verbatim and were analysed using thematic content analysis., Results: Greek GPs recognized many mental health problems in UMs and identified the barriers that prevented them from discussing these problems and delivering appropriate care: growing societal resistance towards UMs, budget cuts in healthcare, administrative obstacles and lack of support from the healthcare system. To overcome these barriers, Greek GPs provided UMs with free access to care and psychotropic drugs free of charge, and referred to other primary care professionals rather than to mental healthcare institutions., Conclusion: Greek GPs experienced substantial barriers in the provision of mental healthcare to UMs and political, economic and organizational factors played a major role.

There is a growing interest in the health of migrants worldwide. Migrants, particularly those in marginalised situations, face significant barriers and inequities in entitlement and access to high quality health care. This study aimed to explore the potential role of primary care in mitigating such barriers and identify ways in which health care policies and systems can influence the ability of primary care to meet the needs of vulnerable and marginalised migrants. The study compared routinely available country-level data on health system structure and financing, policy support for language and communication, and barriers and facilitators to health care access reported in the published literature. These were then mapped to a framework of primary care systems to identify where the key features mitigating or amplifying barriers to access lay. Reflecting on the data generated, we argue that culturally-sensitive primary care can play a key role in delivering accessible, high-quality care to migrants in vulnerable situations. Policymakers and practitioners need to appreciate that both individual patient capacity, and the way health care systems are configured and funded, can constrain access to care and have a negative impact on the quality of care that practitioners can provide to such populations. Strategies to address these issues, from the level of policy through to practice, are urgently needed., (Copyright © 2016 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

Background: Communication problems occur in general practice consultations when migrants and general practitioners do not share a common language and culture. Migrants' perspectives have rarely been included in the development of guidelines designed to ameliorate this. Considered 'hard-to-reach' on the basis of inaccessibility, language discordance and cultural difference, migrants have been consistently excluded from participation in primary healthcare research. The purpose of this qualitative study was to address this gap., Methods: The study was conducted in the Republic of Ireland, 2009 - 2011. We developed a multi-lingual community-university research team that included seven established migrants from local communities. They completed training in Participatory Learning & Action (PLA) - a qualitative research methodology. Then, as trained service-user peer researchers (SUPERs) they used their access routes, language skills, cultural knowledge and innovative PLA techniques to recruit and engage in research with fifty-one hard-to-reach migrant service-users (MSUs)., Results & Discussion: In terms of access, university researchers successfully accessed SUPERs, who, in turn, successfully accessed, recruited and retained MSUs in the study. In terms of meaningful engagement, SUPERs facilitated a complex PLA research process in a language-concordant manner, enabling inclusion and active participation by MSUs. This ensured that MSUs' perspectives were included in the development of a guideline for improving communication between healthcare providers and MSUs in Ireland. SUPERs evaluated their experiences of capacity-building, training, research fieldwork and dissemination as positively meaningful for them. MSUs evaluated their experiences of engagement in PLA fieldwork and research as positively meaningful for them., Conclusions: Given the need to build primary healthcare 'from the ground up', the perspectives of diverse groups, especially the hard-to-reach, must become a normative part of primary healthcare research. PLA is a powerful, practical 'fit-for-purpose' methodology for achieving this: enabling hard-to-reach groups to engage meaningfully and contribute with ease to academic research. PLA has significant potential to become a 'standard' or generic approach in building community-based primary health care. Community-university partnerships have a significant role to play in this, with capacity to radically influence the shape of healthcare research, expanding the research agenda to incorporate the views and needs of hard-to-reach and vulnerable populations.

Objective: The aim of this research was to involve migrants and other key stakeholders in a participatory dialogue to develop a guideline for enhancing communication in cross-cultural general practice consultations. In this paper, we focus on findings about the use of formal versus informal interpreters because dialogues about these issues emerged as central to the identification of recommendations for best practice., Design: This qualitative case study involved a Participatory Learning and Action (PLA) research methodology., Participants: The sample comprised 80 stakeholders: 51 from migrant communities; 15 general practitioners (GPs) and general practice staff; 7 established migrants as peer researchers; 5 formal, trained interpreters; and 2 service planners from the national health authority., Setting: Galway, Ireland., Results: There was 100% consensus across stakeholder groups that while informal interpreters have uses for migrants and general practice staff, they are not considered acceptable as best practice. There was also 100% consensus that formal interpreters who are trained and working as per a professional code of practice are acceptable as best practice., Conclusions: Policymakers and service planners need to work in partnership with service providers and migrants to progress the implementation of professional, trained interpreters as a routine way of working in general practice., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Guidelines and training initiatives (G/TIs) available to support communication in cross-cultural primary health care consultations are not routinely used. We need to understand more about levers and barriers to their implementation and identify G/TIs likely to be successfully implemented in practice., Objective: To report a mapping process used to identify G/TIs and to prospectively appraise their implementability, using Normalization Process Theory (NPT)., Methods: RESTORE is a 4-year EU FP-7 project. We used purposeful and network sampling to identify experts in statutory and non-statutory agencies across Austria, England, Greece, Ireland, Scotland and the Netherlands who recommended G/TI data from the grey literature. In addition, a peer review of literature was conducted in each country. Resulting data were collated using a standardized Protocol Mapping Document. G/TIs were identified for inclusion by (i) initial elimination of incomplete G/TI material; (ii) application of filtering criteria; and (iii) application of NPT., Results: 20 G/TIs met selection criteria: 8 guidelines and 12 training initiatives. Most G/TIs were identified in the Netherlands (n = 7), followed by Ireland (n = 6) and England (n = 5). Fewer were identified in Scotland (n = 2), and none in Greece or Austria. The majority (n = 13) were generated without the inclusion of migrant service users. All 20 were prospectively appraised for potential implementability by applying NPT., Conclusions: NPT is useful as a means of prospectively testing G/TIs for implementability. Results indicate a need to initiate meaningful engagement of migrants in the development of G/TIs. A European-based professional standard for development and assessment of cross-cultural communication resources is advised., (© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To explore the views and experiences of general practitioners (GPs) in relation to recognition, recording, and treatment of mental health problems of undocumented migrants (UMs), and to gain insight in the reasons for under-registration of mental health problems in the electronic medical records., Design: Qualitative study design with semi-structured interviews using a topic guide., Subjects and Setting: Sixteen GPs in the Netherlands with clinical expertise in the care of UMs., Results: GPs recognized many mental health problems in UMs. Barriers that prevented them from recording these problems and from delivering appropriate care were their low consultation rates, physical presentation of mental health problems, high number of other problems, the UM's lack of trust towards health care professionals, and cultural differences in health beliefs and language barriers. Referrals to mental health care organizations were often seen as problematic by GPs. To overcome these barriers, GPs provided personalized care as far as possible, referred to other primary care professionals such as social workers or mental health care nurses in their practice, and were a little less restrictive in prescribing psychotropics than guidelines recommended., Conclusions: GPs experienced a variety of barriers in engaging with UMs when identifying or suspecting mental health problems. This explains why there is a gap between the high recognition of mental health problems and the low recording of these problems in general practice files. It is recommended that GPs address mental health problems more actively, strive for continuity of care in order to gain trust of the UMs, and look for opportunities to provide mental care that is accessible and acceptable for UMs.

Objective: To explore health-seeking behaviour and experiences of undocumented migrants (UMs) in general practice in relation to mental health problems., Design: Qualitative study using semistructured interviews and thematic analysis., Participants: 15 UMs in The Netherlands, varying in age, gender, country of origin and education; inclusion until theoretical saturation was reached., Setting: 4 cities in The Netherlands., Results: UMs consider mental health problems to be directly related to their precarious living conditions. For support, they refer to friends and religion first, the general practitioner (GP) is their last resort. Barriers for seeking help include taboo on mental health problems, lack of knowledge of and trust in GPs competencies regarding mental health and general barriers in accessing healthcare as an UM (lack of knowledge of the right to access healthcare, fear of prosecution, financial constraints and practical difficulties). Once access has been gained, satisfaction with care is high. This is primarily due to the attitude of the GPs and the effectiveness of the treatment. Reasons for dissatisfaction with GP care are an experienced lack of time, lack of personal attention and absence of physical examination. Expectations of the GP vary, medication for mental health problems is not necessarily seen as a good practice., Conclusions: UMs often see their precarious living conditions as an important determinant of their mental health; they do not easily seek help for mental health problems and various barriers hamper access to healthcare for them. Rather than for medication, UMs are looking for encouragement and support from their GP. We recommend that barriers experienced in seeking professional care are tackled at an institutional level as well as at the level of GP., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Undocumented migrants (UM) frequently report mental health problems. It is unknown to what extent these migrants seek help for these problems in general practice and how these issues are explored, discussed, registered and treated by GPs., Objective: To gain insight in the registration and treatment of mental health problems in general practice of UM compared to documented migrants (DM)., Methods: A survey study of general practice patient records of UM and DM in nine general practices in the Netherlands. Consultation rates, registration of mental health problems, prescription of psychotropic medication and referrals to mental health care institutions of UM and DM patients were compared., Results: A total of 541 migrants were included (325 UM and 216 DM). UM consulted a GP significantly less than DM (3.1 versus 4.9 times per year). Only 20.6% of the UM had at least one mental health problem diagnosis registered compared to 44.0% of the DM. In both groups, ~10% mentioned at least one main mental health complaint during the consultation that was not coded in the record. No significant differences were found in the prescription of psychotropic medication between the two groups. UM were referred less to mental health care institutions but more often to psychiatrists than to psychologists., Conclusion: UM had less consultations with their GP, and in these consultations, less mental health problems were registered. UM were referred less to psychologists but more often to psychiatrists. GPs are advised to explore and register mental health problems more actively in UM., (© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: This is a time of unprecedented mobility across the globe. Healthcare systems need to adapt to ensure that primary care is culturally and linguistically appropriate for migrants. Evidence-based guidelines and training interventions for cultural competence and the use of professional interpreters are available across European healthcare settings. However, in real-world practice migrants and their healthcare providers 'get by' with a range of informal and inadequate strategies. RESTORE is an EU FP7 funded project, which is designed to address this translational gap., Objectives: The objective of RESTORE is to investigate and support the implementation of guidelines and training initiatives to support communication in cross-cultural consultations in selected European primary care settings., Design: RESTORE is a qualitative, participatory health project running from 2011-2015. It uses a novel combination of normalization process theory and participatory learning and action research to follow and shape the implementation journeys of relevant guidelines and training initiatives. Research teams in Ireland, England, the Netherlands, Austria and Greece are conducting similar parallel qualitative case study fieldwork, with a complementary health policy analysis led by Scotland. In each setting, key stakeholders, including migrants, are involved in participatory data generation and analysis., Expected Results: RESTORE will provide knowledge about the levers and barriers to the implementation of guidelines and training initiatives in European healthcare settings and about successful, transferrable strategies to overcome identified barriers. RESTORE will elucidate the role of policy in shaping these implementation journeys; generate recommendations for European policy driving the development of culturally and linguistically appropriate healthcare systems.

The purpose of this paper is to substantiate the importance of research about barriers and levers to the implementation of supports for cross-cultural communication in primary care settings in Europe. After an overview of migrant health issues, with the focus on communication in cross-cultural consultations in primary care and the importance of language barriers, we highlight the fact that there are serious problems in routine practice that persist over time and across different European settings. Language and cultural barriers hamper communication in consultations between doctors and migrants, with a range of negative effects including poorer compliance and a greater propensity to access emergency services. It is well established that there is a need for skilled interpreters and for professionals who are culturally competent to address this problem. A range of professional guidelines and training initiatives exist that support the communication in cross-cultural consultations in primary care. However, these are commonly not implemented in daily practice. It is as yet unknown why professionals do not accept or implement these guidelines and interventions, or under what circumstances they would do so. A new study involving six European countries, RESTORE (REsearch into implementation STrategies to support patients of different ORigins and language background in a variety of European primary care settings), aims to address these gaps in knowledge. It uses a unique combination of a contemporary social theory, normalisation process theory (NPT) and participatory learning and action (PLA) research. This should enhance understanding of the levers and barriers to implementation, as well as providing stakeholders, with the opportunity to generate creative solutions to problems experienced with the implementation of such interventions.

Objective: To study doctor-patient interaction styles in consultations with patients presenting persistent medically unexplained symptoms (MUS) and to study on which stages of the consultation patients and doctors focus within the available time., Methods: exploratory, qualitative analysis of transcripts of 20 videotaped consultations between family physicians (FP) and persistent MUS patients., Results: Patients presented many symptoms in a rather unstructured way. However, FPs hardly used structuring techniques such as agenda setting and summarizing. Patients with persistent MUS got much opportunity to tell their story, but the reasons for encounter, their beliefs and concerns were not discussed in a structured manner. Although consultations were focused on these issues, mostly patients themselves initiated discussion of their ideas, concerns and expectations. FPs' extensive explanations of the origin of the symptoms often did not take patients' beliefs and concerns into account., Conclusions: Due to patients' multiple symptom presentation and the absence of FPs' structuring techniques, consultations of persistent MUS patients proceed rather unfocused. However, patients got ample opportunity to tell their story., Practice Implications: Persistent MUS patients might benefit from structured consultations focused on the exploration of the reason for encounter., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To develop an instrument that could be used at different medical schools to assess the performance of individual simulated patients (SPs) on their ability to role-play and provide feedback, including feedback on medical students' communication skills and medical knowledge., Method: In 2011, the authors sought to develop and validate a new instrument to achieve these goals. During Phase 1, one of the authors conducted semistructured interviews with medical students, medical psychologists, physicians, and experts to explore what was required of SPs. During Phase 2, the authors assessed the reliability and feasibility of the instrument that they had developed during Phase 1, using a principal components analysis with varimax rotation. During Phase 3, they performed a confirmatory factor analysis on the items in the final instrument., Results: During Phase 1, the authors constructed the Nijmegen Evaluation of the Simulated Patient (NESP), which included three components-role-play, process of feedback, and application of feedback rules. They then determined that approximately 8 to 20 completed instruments per SP led to satisfactory to excellent reliability estimates. In Phase 3, their confirmatory analysis confirmed the three components that they had determined in Phase 2. Reliability estimates for each component (role-play, process of feedback, application of feedback rules) and the final NESP as a whole were 0.86, 0.83, 0.79, and 0.92, respectively., Conclusions: The authors concluded that the NESP is a feasible, valid, and reliable instrument that could be used at different medical schools to assess the performance of individual SPs.

Objective: To describe a program with integrated learning of communication and consultation skills developed with the intention of preventing deterioration of communication skills, and to present student evaluation data., Methods: Description and evaluation of the program through: (1) monthly student evaluations; (2) questionnaire on student perceptions about the integrated curriculum; (3) a questionnaire about the value of one specific integrated training preceding the pediatric clerkship., Results: Key components of training throughout years 3-6 are reinforcement throughout the clinical years, adapting communication training to the clinical context of clerkships using a sandwich model with cycles of preparation, clerkship, and reflection., Evaluation: response rates were 69%, 93% and 93%, respectively. Students value practicing integration of communication and medical content with SPs who represent the population of their next clerkships. They appreciate the multisource feedback during the training, feedback by clerkship specific specialists and SPs is valued most., Conclusions: This description shows an example of an integrated curriculum that helps students to feel well prepared for their communication tasks in subsequent clerkships., Practice Implications: Designing and implementing communication curricula to address the issue of integration is feasible. The effects of such integrated programs should be subject to future studies., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: The implementation of guidelines and training initiatives to support communication in cross-cultural primary care consultations is ad hoc across a range of international settings with negative consequences particularly for migrants. This situation reflects a well-documented translational gap between evidence and practice and is part of the wider problem of implementing guidelines and the broader range of professional educational and quality interventions in routine practice. In this paper, we describe our use of a contemporary social theory, Normalization Process Theory and participatory research methodology--Participatory Learning and Action--to investigate and support implementation of such guidelines and training initiatives in routine practice., Methods: This is a qualitative case study, using multiple primary care sites across Europe. Purposive and maximum variation sampling approaches will be used to identify and recruit stakeholders-migrant service users, general practitioners, primary care nurses, practice managers and administrative staff, interpreters, cultural mediators, service planners, and policy makers. We are conducting a mapping exercise to identify relevant guidelines and training initiatives. We will then initiate a PLA-brokered dialogue with stakeholders around Normalization Process Theory's four constructs--coherence, cognitive participation, collective action, and reflexive monitoring. Through this, we will enable stakeholders in each setting to select a single guideline or training initiative for implementation in their local setting. We will prospectively investigate and support the implementation journeys for the five selected interventions. Data will be generated using a Participatory Learning and Action approach to interviews and focus groups. Data analysis will follow the principles of thematic analysis, will occur in iterative cycles throughout the project and will involve participatory co-analysis with key stakeholders to enhance the authenticity and veracity of findings., Discussion: This research employs a unique combination of Normalization Process Theory and Participatory Learning and Action, which will provide a novel approach to the analysis of implementation journeys. The findings will advance knowledge in the field of implementation science because we are using and testing theoretical and methodological approaches so that we can critically appraise their scope to mediate barriers and improve the implementation processes.

Background: Efforts to address depression in primary care settings have focused on the introduction of care guidelines emphasising pharmacological treatment. To date, physician adherence remains low. Little is known of the types of information exchange or other negotiations in doctor-patient consultations about depression that influence physician decision making about treatment., Aim: The study sought to understand conversational influences on physician decision making about treatment for depression., Design: A secondary analysis of consultation data collected in other studies. Using a maximum variation sampling strategy, 30 transcripts of primary care consultations about distress or depression were selected from datasets collected in three countries. Transcripts were analysed to discover factors associated with prescription of medication., Method: The study employed two qualitative analysis strategies: a micro-analysis approach, which examines how conversation partners shape the dialogue towards pragmatic goals; and a narrative analysis approach of the problem presentation., Results: Patients communicated their conceptual representations of distress at the outset of each consultation. Concepts of depression were communicated through the narrative form of the problem presentation. Three types of narratives were identified: those emphasising symptoms, those emphasising life situations, and mixed narratives. Physician decision making regarding medication treatment was strongly associated with the form of the patient's narrative. Physicians made few efforts to persuade patients to accept biomedical attributions or treatments., Conclusion: Results of the study provide insight into why adherence to depression guidelines remains low. Data indicate that patient agendas drive the 'action' in consultations about depression. Physicians appear to be guided by common-sense decision-making algorithms emphasising patients' views and preferences.

This guideline gives recommendations for the management of depression and depressive symptoms. The diagnosis of suspected depression requires a broad exploration of symptoms, sometimes over several visits. The guideline promotes self-management and patient empowerment during the healing process. The initial step in the treatment of depressive symptoms is patient education; patients with depression are supported with activity scheduling and are offered a short course of psychological treatment. If the initial treatment in patients with depression is not effective or if the depression is associated with severe suffering, severe social dysfunctioning or severe psychiatric comorbidity, psychotherapy or an antidepressant is recommended.

Background: Medical students learn professional communication through formal training and in clinical practice. Physicians working in clinical practice have a powerful influence on student learning. However, they may demonstrate communication behaviours not aligning with recommendations in training programs., Aims: This study aims to identify more precisely what differences students perceive between role model communication behaviour during clerkships and formal training., Method: In a cross-sectional study, data were collected about physicians' communication performance as perceived by students. Students filled out a questionnaire in four different clerkships in their fourth and fifth year., Results: Just over half of the students reported communication similar to formal training. This was especially true for students in the later clerkships (paediatrics and primary care). Good examples were seen in providing information corresponding to patients' needs and in shared decision making, although students often noted that in fact the doctor made the decision. Bad examples were observed in exploring cognitions and emotions, and in providing information meeting patient's pace., Conclusions: Further study is needed on actual physician behaviour in clinical practice. From our results, we conclude that students need help in reflecting on and learning from the gap in communication patterns they observe in training versus clinical practice.

Background: The feasibility as well as the suitability of several therapies for medically unexplained symptoms (MUS) in primary care applied by the family physician (FP) appeared to be low. FPs need effective and acceptable strategies to manage these functionally impaired patients., Objective: To review important and effective elements in the treatment of patients with MUS in primary care according to experts in MUS research., Methods: We performed a systematic search of narrative reviews and scientific editorials in Medline and PsycINFO and triangulated our findings by conducting a focus group with MUS experts., Results: We included 7 scientific editorials and 23 narrative reviews. According to MUS experts, the most important elements in the treatment of MUS are creating a safe therapeutic environment, generic interventions (such as motivational interviewing, giving tangible explanations, reassurance and regularly scheduled appointments) and specific interventions (such as cognitive approaches and pharmacotherapy). Furthermore, MUS experts indicate that a multi-component approach in which these three important elements are combined are most helpful for patients with MUS. In contrast to most specific interventions, opinions of MUS experts regarding generic interventions and creating a safe therapeutic relationship seem to be more based on theory and experience than on quantitative research., Conclusions: MUS experts highlight the importance of generic interventions and doctor-patient communication and relationship. However, studies showing the effectiveness of these elements in the management of MUS in primary care is still scarce. Research as well as medical practice should focus more on these non-specific aspects of the medical consultation.

Background: Unexplained symptoms are associated with depression and anxiety. This association is largely based on cross-sectional research of symptoms experienced by patients but not of symptoms presented to the GP., Aim: To investigate whether unexplained symptoms as presented to the GP predict mental disorders., Design and Setting: Cross-sectional and longitudinal analysis of data from a practice-based research network of GPs, the Transition Project, in the Netherlands., Method: All data about contacts between patients (n = 16,000) and GPs (n = 10) from 1997 to 2008 were used. The relation between unexplained symptoms episodes and depression and anxiety was calculated and compared with the relation between somatic symptoms episodes and depression and anxiety. The predictive value of unexplained symptoms episodes for depression and anxiety was determined., Results: All somatoform symptom episodes and most somatic symptom episodes are significantly associated with depression and anxiety. Presenting two or more symptoms episodes gives a five-fold increase of the risk of anxiety or depression. The positive predictive value of all symptom episodes for anxiety and depression was very limited. There was little difference between somatoform and somatic symptom episodes with respect to the prediction of anxiety or depression., Conclusion: Somatoform symptom episodes have a statistically significant relation with anxiety and depression. The same was true for somatic symptom episodes. Despite the significant odds ratios, the predictive value of symptom episodes for anxiety and depression is low. Consequently, screening for these mental health problems in patients presenting unexplained symptom episodes is not justified in primary care.

Introduction: Patients with COPD are believed to have a high risk for the development of depression. However, it remains unclear whether or not there is a temporal relation between COPD and depression, and if the higher risk for depression is a result of having a chronic disease, or is specific for COPD. The aim of this study is to compare the risk for physician-diagnosed depression in patients with COPD, patients with diabetes mellitus (DM), and control subjects without chronic conditions., Methods: The study was a prospective cohort study based on the Continuous Morbidity Registration database. Cox proportional hazards analysis was used to identify the risk of a first episode of depression in patients with COPD compared to patients with DM and matched control subjects without chronic conditions. The following covariates were added to the model: age, the general practice the patient was listed with, socioeconomic status, comorbidity, and gender. All patients with a diagnosis of depression preceding the date of first diagnosis of COPD or DM (dummy date in control subjects) were excluded., Results: The hazard ratios for a first episode of depression in the COPD group compared to the DM group and healthy controls subjects were 1.80 (95% confidence interval [CI], 1.16 to 2.81) and 1.68 (95% CI, 1.20 to 2.35), respectively., Discussion: We found a temporal relation between COPD and physician-diagnosed depression. Patients with COPD are more likely to have depression diagnosed than patients with DM and control subjects without chronic conditions.