Prospective Qualitative Research Research Articles

Suicidal ideation, suicidal plans and suicide attempts in patients with chronic pain: a prospective qualitative research Study 1: 2011 – 2015 Study 2: 2015 - 2019

IntroductionThe association among suicidal ideation, plans, attempts and pain has not attracted as much attention as the association between suicidal ideation and attempts and psychiatric disorder.ObjectivesThe aim of this prospective study was to establish if patients with chronic pain associated or not to psychiatric disorders with ideation and planning for a suicide attempt will aways end in a suicide act.MethodsThe patients were initially examined through structured interview, scan-schedules for clinical assessment in neuropsychiatric – version 2.0 used only to diagnose. (HDRS – 17) - Hamilton Depression Rating Scale, 17 itens version, (HAMS) Hamilton Anxiety Rating Scale, (CGI) - Clinical Global Impression: (CGI – S) Severity of illness and (CGI – I) Clinical Global Improvemnt. Pain intensity through numerical rating scale. Those were repeated throughout the research.PatientsStudy 1 - 325 patients (244W, 81M aged 19 – 58) with chronic pain, suicidal ideation or plan associated or not to psychiatric disorders.124 had chronic pain without psychiatric disorder. 54 suicidal ideation and 70 had suicidal plan.201 had chronic pain associated with phychiatric disorders. 7 with opioid dependence after pain and suicidal plans. 4 with adjustment disorders before pain and suicidal ideation.3 with somatoform disorder before pain and suicidal plan. 125 had chronic pain associated with: general anxiety disorder, mixed anxiety and depression, severe panic pain before or after pain with suicidal plans or ideation. 62 patients presented chronic pain associated with depressive disorder: recurrent severe depression without psychotic symptoms; moderate recurrent depression without psychotic symptoms. Before or after the occur of pain with suicidal ideation or suicidal plans.Study 2 -132 patients remained in treatment. (79W and 53M aged 20 to 59)54 had chronic pain without psychiatric disorder with plans or ideation suicidal. 78 Patients had chronic pain and a psychiatric disorder. 16 became dependent on opioids after pain and suicidal plans. 36 with chronic pain associated with anxiety disorder: general anxiety disorder before or after pain with suicidal plans. 26 had chronic pain associated with depressive disorder: recurrent severe depressive disorder with or without psychotic symptoms with suicidal ideation.ResultsStudy 1 - No patient attempted suicide. 54 patients with pain without psychiatric disorders considered suicidal thoughts absurd and intrusive.Study 2 - No patient died. 51 attempted suicide47 remained with suicidal ideation33 did not have suicidal ideation or suicidal plans. They adapted their lives to chronic pain regardless of presenting a psychiatric illness.ConclusionsThe authors concluded that a suicidal act is not always necessarily an expression of chronic pain associated/not with psychiatric disorder.Disclosure of InterestNone Declared

Stories Matter: A Novel Approach to Exploring Perceptions, Discourses, and the Symbolic Social Order in Pastoral Psychology

This article locates story completion (SC), a novel and underutilised qualitative data collection tool, as a valuable adjunct to traditional qualitative methods for pastoral psychology. In contrast to traditional self-reporting qualitative interviews or surveys, SC necessitates a researcher writing a story “stem” or “cue” – or, more specifically, an opening sentence – which participants are asked to continue in their own words. Uniquely, for SC, it is the stories themselves (which may be either first- or third-person perceptions, or constructions, of a phenomenon) which are subject to data analysis. Story completion has the benefit of being able to target implicit perceptions, or social constructions, depending on the epistemological framework chosen. However, this method has seldom been used in pastoral psychology, despite its potential significance. In this article, I demarcate SC as a prospective qualitative research tool for use in pastoral psychology, distinguishing it from other qualitative methodologies. I trace its emergence from psychoanalytic thought to its current usage in qualitative psychology research. I argue that SC has profound potential, especially for those looking to examine stigmatised topics or populations with sensitivity. Nevertheless, studies which utilise SC need to be theoretically cognizant and align fully with the ontological or epistemological assumptions of the researcher. I introduce and expound on varied epistemological frameworks that can be used in conjunction with story completion, further discussing their relative merits and potential drawbacks for pastoral psychology. I propose that, methodologically, SC is beneficial for accessing sociocultural discourses and broader representations surrounding religiously and culturally complex topics. I offer a case study of one recent research study, which used SC within the context of mental health and religion, to demonstrate its merit and applicability to the field. In doing so, I provide three contrasting epistemological readings of the data to show how these might be applied in practice.

Issues related to pregnancy, pregnancy prevention and abortion in the context of the COVID-19 pandemic: a WHO qualitative study protocol

IntroductionWHO has generated standardised clinical and epidemiological research protocols to address key public health questions for SARS-CoV-2 (COVID-19) pandemic. We present a standardised protocol with the aim to fill a...

Lessons from the frontline: Documenting the pandemic emergency care experience from the Pacific region – Infrastructure and equipment

BackgroundThe COVID-19 pandemic highlighted challenges for all health systems worldwide. This research aimed to explore the impact of COVID-19 across the Pacific especially with regards to emergency care (EC) and clinicians’ preparations and responses.MethodsA collaboration of Australia and Pacific researchers conducted prospective qualitative research over 18 months of the pandemic. In this three phase study data were gathered from Emergency Clinicians and stakeholders through online support forums, in-depth interviews and focus groups. A phenomenological methodological approach was employed to explore the lived experience of participants. This paper discusses the findings of the study regarding the EC building block of ‘Infrastructure and Equipment.’FindingsPre-existing infrastructure and equipment were not sufficient to help control the pandemic. Adequate space and correct equipment were essential needs for Pacific Island emergency clinicians, with donations, procurement and local ingenuity required for suitable, sustainable supplies and facilities. Adequate personal protective equipment (PPE) conferred a sense of security and increased Health Care Workers willingness to attend to patients.InterpretationInvesting in adequate infrastructure and appropriate equipment is crucial for an effective response to the COVID-19 pandemic. The sustainability of such investments in the Pacific context is paramount for ongoing EC and preparation for future surge responses and disasters.FundingPhases 1 and 2A of this study were part of an Epidemic Ethics/World Health Organization (WHO) initiative, supported by Foreign, Commonwealth and Development Office/Wellcome Grant 214711/Z/18/Z. Co-funding for this research was received from the Australasian College for Emergency Medicine Foundation via an International Development Fund Grant.

Expert Elicitation of Long-Term Survival for Pediatric Acute Lymphoblastic Leukemia Patients Receiving CTL019 in Eliana Phase II Study

Introduction: Decision-makers need to understand long-term outcomes to assess cost-effectiveness of new treatments. In the absence of long-term data from clinical trials, current practice to extrapolate overall survival (OS) is typically based on how well the model fits to the observed data without formally involving clinical experts to evaluate the plausibility of the results. At best, 1-2 clinicians may be asked to select the most ‘realistic’ model. Therefore, a more systematic and transparent process is needed to ensure clinical expertise is fully integrated in an unbiased manner. In the global multicenter ELIANA trial (NCT02435849) for CTL019 (chimeric antigen receptor T-cell (CAR-T therapy)), OS data has been reported, but only up to 1.5 years. In the absence of expert opinion regarding long-term OS, the predicted OS varies dramatically depending on the model used to extrapolate the observed data. The aim of this study was to estimate expected OS based on observed data from ELIANA and expert elicited OS rates at 2 years, 3 years, 4 years, and 5 years for patients with relapsed or refractory B-cell pediatric acute lymphoblastic leukemia (r/r/ pALL) treated with CTL019.Methods: A prospective qualitative research study was performed incorporating semi-structured interviews, adapted from the SHeffield ELicitation Framework. Pediatric oncologists and hematologists experienced with CAR-T therapies were recruited. Experts and the study sponsor were not identified to one another. Relevant evidence regarding the patient population from the CTL019 trials, historical first-line pALL data, and historical data on r/r/ pALL for FDA approved interventions was summarized to provide a common basis for expert judgments. Facilitators guided experts through a web-based application for the elicitation of OS rates at 2, 3, 4, and 5 years for patients treated with CTL019 in the ELIANA trial. Experts were first asked to estimate upper and lower plausible limits and then the most likely actual OS value at each time point. Results from each expert were combined with the observed data from ELIANA using time-to-event parametric models (i.e. fractional polynomials) in a Bayesian framework that accounted for each expert's uncertainty in their estimates, which produced an overall distribution of OS over time. In addition, the model was fully extrapolated assuming patients followed general population mortality, adjusted for having had pALL (standard mortality rate=15.2 based on Armstrong 2016).Results: Of the 19 clinical experts contacted, 7 participated in the final elicitation exercise. During a follow-up group meeting, experts agreed that the Gompertz model fit to the observed trial data reflected an appropriate consensus distribution for their estimates. When a Gompertz model was fit to the observed data (up to 1.5 years) and each expert's elicited data (24 to 60 months), the most likely values of OS for patients from the ELIANA trial treated with CTL019 at 2, 3, 4, and 5 years were estimated to be approximately 67.5% (Credible intervals (CrI): 49.5%, 83.1%), 61.1% (39.5%, 81.3%), 57.2% (31.5%, 80.7%), and 54.9% (24.5%, 80.5%) (Figure 1). In the fully extrapolated model, the 10-year OS is estimated to be 52.4% (CrI: 23.4%, 76.9%) with a median survival of approximately 13.4 years (CrI: 1.96, 35.5). Results were similar to OS rates from a phase I/II single-center study (NCT01626495) at 2 years (61%) and slightly higher at three years (52%).Conclusions: Predictions based on observed data and expert elicitations suggest that more than half of the patients in the ELIANA trial treated with CLT019 will survive up to five years. This study provides an example of how expert opinion can be elicited and synthesized with observed survival data using a transparent and unbiased process, which captures expert uncertainty and ensures that projected long-term survival is clinical plausible.Disclaimer: The study was sponsored by Novartis Pharmaceuticals Corporation [Display omitted] DisclosuresCope:Precision Health Economics: Employment; Novartis Pharmaceuticals Corporation: Consultancy. Ayers:Precision Health Economics: Employment; Novartis Pharmaceuticals Corporation: Consultancy. Shih:Precision Health Economics: Employment; Novartis Pharmaceuticals Corporation: Consultancy. Zhang:Novartis Pharmaceuticals Corporation: Employment. Jansen:Novartis Pharmaceuticals Corporation: Consultancy; Precision Health Economics: Employment. Batt:Precision Health Economics: Consultancy; Novartis Pharmaceuticals Corporation: Consultancy; Bayer: Consultancy.

Introduction to the special issue: Prospective qualitative research: new directions, opportunities and challenges

The combination of qualitative approaches and longitudinal research designs is a powerful way to explore changes in individual life courses as they occur. While qualitative research is mostly associated with retrospective studies that analyse lives ‘backwards’ in time, prospective qualitative studies that track lives as they unfold have grown in popularity over the past two decades. Their increased importance goes hand in hand with the growing attention in the social sciences to process and change versus stability and continuity through time. Prospective qualitative studies are uniquely suited to analysing continuity and change in people’s lives, offering a complex understanding of critical junctures, transitions and gradual, non-linear or contradictory processes of change as they are interpreted and revisited by individuals with the unfolding of their lives. With its intrinsic focus on time and temporalities, prospective qualitative research allows us to address not only changing meanings and perceptions, but how people examine their pasts and look into their futures, and how these temporal perspectives are modified along with life events and transitions. Together with its undoubted advantages, a range of analytical and methodological challenges arise in the process of engaging with participants in a prospective qualitative study, where time, lives, perceptions and meanings are continually shifting and under revision. The benefits of combining prospective and retrospective insights and meanings involve a complex and demanding analytical effort that addresses potentially emerging discrepancies in the reporting of the same event or transition. The notion of a linear temporality that structures social action needs to be reconciled with narratives that reflect the fluidity of past and future time, stagnation, zigzag or even reversible developments. Questions of archiving are a source of concern for researchers whose data sets are iteratively generated over time, raising issues about consent, anonymity and ownership. Ethical issues also sharpen as the level of personal involvement between researcher and participant increases with repeated interactions across the different waves. With the increased availability of qualitative prospective studies, there is a growing agreement about the benefits of using secondary data. Arguments about research costs and underexploitation of existing data are gaining ground against the traditional reluctance of qualitative researchers to make their data available for reuse. There is, hence, an emerging need to reflect on the strategies and practices of data creation and management for long-term storage and use by others. In parallel, challenges of combining different data sources with similar foci for analytical and comparative purposes are increasingly recognised. These are just a few of the challenges facing prospective qualitative researchers, but they clearly point to the need for further methodological reflection on how time impacts on the design, conduct and theoretical underpinnings of qualitative longitudinal studies. This special issue advances current debates and explores new theoretical and methodological directions in this field through a range of contributions that are both international and interdisciplinary in scope.

Social Media Listening to Understand the Lived Experience of Presbyopia: Systematic Search and Content Analysis Study.

BackgroundPresbyopia is defined as the age-related deterioration of near vision over time which is experienced in over 80% of people aged 40 years or older. Individuals with presbyopia have difficulty with tasks that rely on near vision. It is not currently possible to stop or reverse the aging process that causes presbyopia; generally, it is corrected with glasses, contact lenses, surgery, or the use of a magnifying glass.ObjectiveThis study aimed to explore how individuals used social media to describe their experience of presbyopia with regard to the symptoms experienced and the impacts of presbyopia on their quality of life.MethodsSocial media sources including Twitter, forums, blogs, and news outlets were searched using a predefined search string relating to symptoms and impacts of presbyopia. The data that were downloaded, based on the keywords, underwent manual review to identify relevant data points. Relevant posts were further manually analyzed through a process of data tagging, categorization, and clustering. Key themes relating to symptoms, impacts, treatment, and lived experiences were identified.ResultsA total of 4456 social media posts related to presbyopia were identified between May 2017 and August 2017. Using a random sampling methodology, we selected 2229 (50.0%) posts for manual review, with 1470 (65.9%) of these 2229 posts identified as relevant to the study objectives. Twitter was the most commonly used channel for discussions on presbyopia compared to forums and blogs. The majority of relevant posts originated in Spain (559/1470, 38.0%) and the United States (426/1470, 29.0%). Of the relevant posts, 270/1470 (18.4%) were categorized as posts written by individuals who have presbyopia, of which 37 of the 270 posts (13.7%) discussed symptoms. On social media, individuals with presbyopia most frequently reported experiencing difficulty reading small print (24/37, 64.9%), difficulty focusing on near objects (15/37, 40.5%), eye strain (12/37, 32.4%), headaches (9/37, 24.3%), and blurred vision (8/37, 21.6%). 81 of the 270 posts (30.0%) discussed impacts of presbyopia—emotional burden (57/81, 70.4%), functional or daily living impacts (46/81, 56.8%), such as difficulty reading (46/81, 56.8%) and using electronic devices (21/81, 25.9%), and impacts on work (3/81, 3.7%).ConclusionsFindings from this social media listening study provided insight into how people with presbyopia discuss their condition online and highlight the impact of presbyopia on individuals’ quality of life. The social media listening methodology can be used to generate insights into the lived experience of a condition, but it is recommended that this research be combined with prospective qualitative research for added rigor and for confirmation of the relevance of the findings.

Midwives' Experience of Providing Continuity of Care in a Pilot Project: Findings of a Prospective Qualitative Research Study

INTRODUCTIONThere has been a strategic drive for several years in midwifery to improve models of care and enable women to receive care from a known midwife. However over the past decade new models of care to achieve this have not been sustained and some midwives have expressed opinions that such models can never be sustainable for the staff working them. This study was designed to explore the midwives experience of working a continuity of care model, develop understanding of the lived experience of midwives, and provide insight into how such models can be sustainable from the midwives perspective. A local trust initiative to pilot a small team continuity of care model in one geographical area was introduced and a group of midwives interested in working differently were recruited onto the study to share their experiences. This article details the process and themes identified through a small qualitative research study to explore midwives' experiences of working in a new way to provide increased continuity of care for women. The study results are written in response to a local drive for change and within the context of a small group of midwives taking part in a service improvement project. The article specifically identifies themes in the midwives' experiences and lessons learnt for sustainable change in relation to continuity of care within midwifery services.METHODThe study was a qualitative descriptive study. The main purpose of the study was to gain further understanding of the personal experiences of midwives. Data was collected over a 12-month period from eight midwives who took part; reflective diaries, notes from team meetings and data from the team's “WhatsApp” group chat were used to capture the data over time. Themes identified were then verified with the participants through one to one semi structured interviews.FINDINGSThe research data has been organized into four overarching themes related to May's (2009) normalization process theory: Coherence—same difference, cognitive participation—operational workability, collective action—relationships and reflexive monitoring—personal sustainability.DISCUSSIONA key theme running throughout the data was the importance of autonomy, flexibility, and trust, enabling midwives and women to build effective therapeutic relationships. This is important to note when developing systems for care. Staff needed to feel trusted in order to work flexibly and take control over their own work/life balance. The findings indicate that where staff felt enabled to organize their own workloads they did in fact work harder to meet the needs of the women. A shift in culture in maternity systems would need to be embraced for this level of control to be afforded all midwives. It should be noted that the study was conducted in one specific area and with a small number of midwives. Hence the findings cannot be generalized and will need to be explored further across different cultures.

Relative time and life course research

Mainstream life course studies often draw on a conventional understanding of time as a unidirectional clock-based entity, which proceeds in a uniform and linear manner. This paper argues that, in order to understand the social, relational and psychological processes of change and continuity that characterise life course processes, we need to adopt a more comprehensive and explicit conceptualisation of time – a conceptualisation that goes beyond an absolute (linear, chronological, uniform) definition – to incorporate the notion of relative time. Drawing on insights from narrative and biographical research, discussions of the temporal embeddedness of human agency and multidisciplinary research on time perceptions and time perspectives, we propose a definition of relative time based on three main characteristics: its multidirectional, elastic and telescopic nature. The paper promotes the integration of absolute and relative time in the study of life course processes, and the important role of prospective qualitative research in this respect, and outlines future avenues for research in this direction.

Development of a Conceptual Model of Chronic Hand Eczema (CHE) Based on Qualitative Interviews with Patients and Expert Dermatologists.

IntroductionChronic hand eczema (CHE) is a relapsing inflammatory dermatologic disease. Signs and symptoms can have a significant impact on patients’ health-related quality of life (HRQoL). The aim of this study is to characterize the core signs, symptoms and impacts of CHE to develop a conceptual model.MethodsA structured literature search and qualitative interviews with 20 adult CHE patients in the US and 5 expert dermatologists were conducted to explore the patient experience of CHE signs, symptoms and impacts. Findings were used to support the development of a conceptual model.ResultsThere was a paucity of CHE qualitative research in the literature, supporting the need for the prospective qualitative research. The primary signs and symptoms identified from the literature review and interviews included itch, dryness, cracking, pain, thickened skin and bleeding. The most salient impacts included embarrassment and appearance concerns, frustration, impacts on work and sleep disturbance. Saturation was achieved for all signs, symptoms and impact concepts.ConclusionsFindings from this literature review and in-depth qualitative interviews supported the development of a comprehensive conceptual model documenting the signs, symptoms and impacts relevant to CHE patients. Such a model is of considerable value given the lack of existing studies in the literature focused on the qualitative exploration of the CHE patient experience. Limitations included the patient sample being only from the US and not including some CHE subtypes.

Contesting restrictive mobility norms among female mentors implementing a sport based programme for young girls in a Mumbai slum

BackgroundHarmful gender norms are known structural barriers to many public health and development interventions involving adolescent girls. In India, restrictions on girls’ liberty to move freely in public spaces contribute to school dropout and early marriage, and negatively affect girls’ health and wellbeing, from adolescence into adulthood. We report on mechanisms of change among female mentors 18 to 24 years old who contested discriminatory norms while implementing a sports-based programme for adolescent girls in a Mumbai slum.MethodsWe adopted a prospective qualitative research design. Our analysis is based on case studies derived from two rounds of face to face, in -depth interviews with 10 young women recruited to serve as mentors for the project’s young female athletes. We combined both thematic and narrative analysis.ResultsThe programme created opportunities for collective action, increasing mentors’ ability to think and relate in a collectivized manner, and challenged the traditional female identity constructed for young women, which centres on domestic duties. The mentors themselves negotiated freedoms both in and outside their homes, which required careful and strategic bargaining. They changed the nature of key day-to-day social interactions with parents and brothers, as well as with neighbours, parents of their groups of athletes and men on the streets. They formed a new reference group for each other in terms of what was possible and acceptable. Demonstrating greater negotiation skills within the family helped win parents’ trust in the mentor’s ability to be safe in public spaces. Parents became active supporters by not giving into social sanctions of neighbours and relatives thus co-producing a new identity for their daughters as respectable young women doing ‘good work’. They effectively side stepped reputational risk with their presence in public spaces becoming de-sexualised.ConclusionsMentors contested mobility restrictions by taking risks as a group first, with collective agency an important step towards greater individual agency. This research provides important insights into addressing embedded social norms that perpetuate gender discriminatory practices and the social patterning of health inequalities.

Perspectives of host faculty and trainees on international visiting faculty to paediatric academic departments in East Africa

BackgroundInvestments in faculty exchanges to build physician workforce capacity are increasing. Little attention has been paid to the expectations of host institution faculty and trainees. This prospective qualitative research study...

Informal caregivers' hopes and expectations of a referral to a memory clinic

Although only 20–50% of individuals with dementia are diagnosed, early diagnosis enables patients and families to access interventions and services, and plan for the future. The current study explored the experiences of rural family caregivers in the period leading up to a diagnostic assessment at a Canadian memory clinic, their hopes and expectations of the assessment, and their experiences in the six months following diagnosis. Using a longitudinal, retrospective and prospective qualitative research design, caregivers of 30 patients referred to the clinic were interviewed during the diagnostic assessment process and again six months after the diagnosis. Most caregivers reported first noticing symptoms two years prior to diagnosis. The pre-diagnostic interviews revealed a prevalent ‘need to know’ among caregivers that drove the help-seeking process. Caregivers hoped that the diagnosis would have the benefits of ‘naming it,’ ‘accessing treatment,’ ‘knowing what to expect,’ and ‘receiving guidance.’ When asked six months later about the impact of the diagnosis, the main theme was ‘acceptance and moving forward.’ Caregivers reported that the diagnosis provided ‘relief,’ ‘validation,’ and ‘improved access to services.’ These findings can inform care practices of primary health care providers who represent the first point of contact regarding expectations and experiences of dementia-related diagnoses.

An analysis of auditory manifestations in a group of adult with AIDS prior to antiretroviral therapy

The chief objective of the current study was to investigate the auditory status in a group of adults with AIDS before commencing antiretroviral therapy (ART) in a hospital outpatient clinic in Gauteng, South Africa. A total sample of 150 participants, aged between 20 and 46 years, was assessed following a prospective qualitative research design. All participants underwent case history interviews and medical record reviews, otoscopy and tympanometry, as well as conventional pure tone audiometry testing. Descriptive statistics was used to analyse data obtained. Prevalence, type, degree, configuration, and symmetry of the auditory manifestations; as well as type of onset of hearing loss and the possible causes of the auditory manifestations were analysed. Findings indicated that auditory manifestations in adults with AIDS are varied in nature and are possibly due to a number of causes. Manifestations including hearing loss, tinnitus and vertigo (in varied combinations) were found; with the types of hearing loss being mainly sensorineural in nature. The severity of hearing loss ranged from mild to severe, occurred either unilaterally or bilaterally; with the type of onset being mainly gradual and progressive in nature. The varied causes of hearing loss included HIV infection or AIDS illness as a primary cause, opportunistic infections, and various ototoxic therapies that the patients had undergone. Implications for future research as well as future assessment and management of patients with AIDS are raised.

Can we increase adherence to treatment recommendations of the consultation psychiatrist working in a general hospital? A systematic review

Background Adherence to advice given by the consultation–liaison (CL) psychiatrist is a prerequisite for the effectiveness and success of psychiatric consultation. It is unknown which factors are associated with better adherence to advice. Aim To review the adherence of consultees with advice given by the psychiatrist during inpatient consultation. Method Systematic literature review. Results Eighteen studies reported on the level of adherence with recommendations given by the consultation psychiatrist in a hospital setting. All were retrospective cohort studies conducted before 1998. Thirteen of these reported on the association between clinical variables and the level of adherence. The median level of adherence with diagnostic advice was 56% (range 29–75%), with medication advice 79% (range 68–98%), and with discharge advice 91% (range 85–95%). Patient-related variables were not associated with adherence, nor were consultee-related variables. Consultant-related variables associated with adherence were level of professional expertise, organizing liaison activities, following up on patients after initial consultation, and prescription of medication by the consultant during the consultation. Conclusion This review provides evidence for a role of consultant characteristics and an active approach of the consultant in terms of CL activities as well as consultation procedures, in attaining adherence to advice. Prospective qualitative research is needed to identify consultation methods that may further enhance adherence.