Views Of Health Professionals Research Articles

Views on Sustainable Nutrition Among Nutrition and Dietetics Students, Dietitians, and Healthcare Professionals

Objective: In this study, the views of individuals, dietitians and health professionals who are educated in the field of nutrition and dietetics on sustainable nutrition were evaluated. Material and Method: This study, which was designed in the survey model, was conducted on 456 individuals, including Nutrition and Dietetics students, dietitians and health professionals. Sociodemographic characteristics, knowledge and attitudes towards sustainable nutrition were questioned. Results: 34.4% of the participants were nutrition and dietetics students, 13.1% were dietitians and 52.5% were health professionals. The percentage of participants who had previously received education on sustainable nutrition was 36.7%, 26.1% and 2.5% for dietitians, undergraduate students and health professionals, respectively (p

Health professionals' experiences and views on obstetric ultrasound in Victoria, Australia: A cross‐sectional survey

Health professionals' experiences and views on obstetric ultrasound in Victoria, Australia: A cross‐sectional survey

B - 23 Surveying Public Perceptions about the Coverage of Sports Concussion in the Media

Abstract Objective Public awareness of sports concussion is key for injury management. This awareness is shaped by media reporting and has been critiqued for different reasons by health professionals and sport stakeholders. The community’s view about this reporting is unknown. Methods 157 community volunteers completed an online survey, including a purpose-built multi-item measure of perceptions of sports concussion media portrayal (PoSCoMP). The PoSCoMP score was compared for groups based on concussion history, concussion education, concussion knowledge, playing a concussion-risk sport, or regular sports media consumption. Item consensus (endorsement by >50% of the sample) and free-text responses were descriptively analysed. Results The PoSCoMP had acceptable internal consistency (α > 0.79). One statistically significant group difference was found (p < 0.05). Compared to people with no concussion history, people with a concussion history had a more negative perception of the media coverage (Cohen’s d = 0.53 [medium effect]). There were nine commonly agreed perceptions (e.g., important for player safety), and four commonly disagreed perceptions (e.g., ignored in some sports). The free-text responses urged change in the media coverage of sports concussion, with some perceiving this as already underway. Conclusion Community members’ views about the media portrayal of sports concussion are largely unaffected by individual differences and share commonalities with the views of sport stakeholders and health professionals. Future efforts to improve public awareness of concussion through media reporting should consider the public’s position on this coverage. This could lead to changes that have the public’s support and are more effective in increasing public injury awareness.

An exploration of cardiopulmonary resuscitation discussions with ethnically diverse patients and their families

Background/Aims Little is known about how current UK policy for end-of-life care planning fits with the social, cultural and religious values and beliefs of ethnic minority communities. This study aimed to explore the perspectives of patients and family caregivers from ethnically diverse backgrounds, as well as the views of health professionals, regarding end-of-life care planning, including discussions about cardiopulmonary resuscitation. Methods A qualitative study was conducted, including comparative thematic and cross-case analysis from 18 longitudinal patient case studies and 19 interviews with bereaved family members. A total of 112 interviews were conducted across patients, family caregivers and health professionals. Topics included experiences of talking about illness, discussions about choices and decisions about future care, such as cardiopulmonary resuscitation decision making. Results Health professionals sought to identify when patients were ‘ready’ for end-of-life care discussions before initiating these conversations. However, little clarity was given around the characteristics that constituted this readiness by any of the health professionals. Issues around translation, such as mistranslation, confidentiality issues with external translators and the potential for family caregivers to misconstrue information in translation were also highlighted. Religious and cultural beliefs played significant roles in patients' do not attempt cardiopulmonary resuscitation decisions, with anxieties around whether the system adequately valued these beliefs. Conclusions Health professionals played a significant role in seeking an agreement on do not attempt cardiopulmonary resuscitation. Participants' accounts of the discussions highlight the importance of insightful professional recognition of ‘readiness’ to broach the topic, as well as a good knowledge of family dynamics. It also raises concerns about the risk of the patient's voice being unduly influenced by health professionals and/or family caregivers, especially in cases where an interpreter is required to mediate communication.

Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study

BackgroundMechanical thrombectomy for stroke is highly effective but time-critical. Delays are common because many patients require transfer between local hospitals and regional centres. A two-stage prehospital redirection pathway consisting of...

Stakeholders' perspectives on adverse effects of ECT: A qualitative thematic analysis.

In the Indian context, published systematic research on the opinions of mental health professionals and other stakeholders (patients and caregivers) regarding the different adverse effects of electroconvulsive therapy (ECT) is not available. This type of study allows for an in-depth exploration of complex phenomena, such as the perspectives of mental health professionals, which can provide a rich understanding of their experiences regarding ECT and also helps to understand the views of mental health professionals regarding the adverse effects of ECT during the post-ECT recovery period and its management. Conversely, the perception of patients and caregivers regarding the adverse effects of ECT can provide a more comprehensive understanding of the treatment and its impact on the patients who receive it. To explore the understanding of participants about the various adverse effects following ECT and their perception of managing different adverse effects of ECT during the post-ECT recovery period. A qualitative approach using focus group discussion (FGD) was used. A convenience sampling technique was followed for selecting the participants. FGDs were conducted with stakeholders including mental health professionals, patients, and caregivers. Five FGDs were conducted with psychiatry residents, nursing officers from the ECT suite, and different psychiatry wards at NIMHANS. Four FGDs were held separately for patients receiving ECT and their caregivers, admitted to various psychiatry wards at NIMHANS. A total of 28 mental health professionals, 20 patients, and 20 caregivers participated. The number of participants for FGDs was decided based on data saturation. The FGDs, lasting 30-40 minutes each, occurred between October 2022 and December 2022. The FGDs were audio-recorded with prior permission from the participants. All the participants were informed about the study. Written informed consent was obtained. All FGDs were transcribed. Thematic analysis was done using Atlas. ti software. The broad categories identified were adverse events associated with ECT during the ECT procedure, adverse events associated with ECT after the ECT procedure, prevalence of different adverse effects according to mental health professionals, effects of adverse effects on the continuity of ECT, and difficulties encountered by mental health professionals throughout the management. Other broad categories were found after conducting FGDs with caregivers and patients, which were patients' experience as per the caregivers over the course of ECT, caregivers' and patients' willingness to continue ECT, unfavorable impacts of ECT experienced by the patients immediately after ECT sessions, and, later till the end of that day, suggestions of the caregivers and patients to improvise the management of ECT-related adverse effects and management of adverse effects by the treating team. The findings will develop a standard operating procedure that may help nursing officers monitor and identify the adverse effects immediately after ECT and minimize the complications during the post-ECT recovery period.

Recontextualization and Imagination: The Public Health Professional and the U.S. Health Care System.

Based on a qualitative study, this paper explores how United States public health professionals view and think about the existing U.S. healthcare system, while also allowing these study participants to imagine new ways of structuring and practicing public health. Using semi-structured qualitative interviews, I show how public health professionals engage with the concept of "the social" and their personal experiences with public health to question the status quo. By giving public health professionals space in which to imagine changes and different ways of practicing public health, I demonstrate the effectiveness of imagination as a capacity that public health professionals possess to take the lead in creating the changes they hope for.

Positive Reframing of Psychosis Risk Is Seen as More Beneficial and Less Harmful Than Negative Framing by Clinicians: An Experimental Videotaped Simulated Feedback Study.

Recent studies show that, despite providing some relief, feedback about being at risk for psychosis often triggers negative emotional reactions. Inspired by Tversky and Kahneman's (1981) work on the framing effect and medical framings that favors positive framing like "life-threatening" over "high-risk for death," this study tested the hypothesis that positive reframing of psychosis risk (PR) could alleviate these concerns. To establish the justifiability and feasibility of testing this hypothesis with patients and their families, the study first sought to test whether mental health professionals (MHPs) view positive framing as superior to present state-of-the-art approaches. The study used an experimental design utilizing a simulated feedback session, recorded with professional actors, featuring a clinician, an adolescent, and his mother. One hundred forty-eight MHPs were randomly assigned to view either negatively or positively framed feedback and were asked about its induced impact on the adolescent and mother. The study results supported our main hypothesis, indicating significant benefits of positive framing over negative in areas like empathy, stress reduction, stigma, help-seeking, and hope. Contrary to our second hypothesis, familiarity with PR did not affect these results. These findings suggest that MHPs view positive reframing of PR as more beneficial and less harmful than present negative framing approaches. This sets the stage for subsequent phases that will assess the perceptions and preferences of individuals at risk and their families. The discussion highlights possible misconceptions of positive framing, such as labeling, positive psychology, and de-medicalization.

Dissonance in the face of Alzheimer's disease breakthroughs: clinician and lay stakeholder acceptance, concerns and willingness to pay for emerging disease-modifying therapies.

Introducing new disease-modifying therapies (DMTs) for Alzheimer's disease demands a fundamental shift in diagnosis and care for most health systems around the world. Understanding the views of health professionals, potential patients, care partners and taxpayers is crucial for service planning and expectation management about these new therapies. To investigate the public's and professionals' perspectives regarding (1) acceptability of new DMTs for Alzheimer's disease; (2) perceptions of risk/benefits; (3) the public's willingness to pay (WTP). Informed by the 'theoretical framework of acceptability', we conducted two online surveys with 1000 members of the general public and 77 health professionals in Ireland. Descriptive and multivariate regression analyses examined factors associated with DMT acceptance and WTP. Healthcare professionals had a higher acceptance (65%) than the general public (48%). Professionals were more concerned about potential brain bleeds (70%) and efficacy (68%), while the public focused on accessibility and costs. Younger participants (18-24 years) displayed a higher WTP. Education and insurance affected WTP decisions. This study exposes complex attitudes toward emerging DMTs for Alzheimer's disease, challenging conventional wisdom in multiple dimensions. A surprising 25% of the public expressed aversion to these new treatments, despite society's deep-rooted fear of dementia in older age. Healthcare professionals displayed nuanced concerns, prioritising clinical effectiveness and potential brain complications. Intriguingly, younger, better-educated and privately insured individuals exhibited a greater WTP, foregrounding critical questions about healthcare equity. These multifaceted findings serve as a guidepost for healthcare strategists, policymakers and ethicists as we edge closer to integrating DMTs into Alzheimer's disease care.

Enhancing the provision of cancer nutrition information to support care through experience-based co-design: a mixed-methods study.

Nutrition is essential within cancer care, yet patient and carer access to nutrition care and information is variable. This study aimed to (1) investigate patient and carer access and perceptions, and health professional views and practices, relating to cancer nutrition information and care; and (2) co-design interactive resources to support optimal nutrition care. Patients and carers completed a survey regarding access to nutrition care and information. Seven multidisciplinary health service teams were invited to participate in a survey and focus group to assess barriers and enablers in nutrition practices. Focus groups were recorded, transcribed and thematically analyzed. Eligible patients, carers, and health professionals were invited to four virtual workshops utilizing experience-based co-design methods to identify nutrition priority areas and design resources. Workshop participant acceptability of the resources was measured. Of 104 consumer survey respondents (n = 97 patients, n = 7 carers), 61% agreed that it "took too much time to find evidence-based nutrition and cancer information", and 46% had seen a dietitian. Thirty-four of 38 health professionals completed the survey and 30 participated in a focus group, and it was identified the greatest barriers to delivering nutrition care were lack of referral services, knowledge or skill gaps, and time. Twenty participants (n = 10 patients and carers, n = 10 health professionals) attended four workshops and co-designed a suite of 46 novel resources rated as highly acceptable. Improved communication, training, and availability of suitable resources could improve access to and support cancer nutrition information and care. New, co-designed cancer nutrition resources were created and deemed highly acceptable to patients, carers, and health professionals.

Patient and health professional views on risk-stratified monitoring of immune-suppressing treatment in adults with inflammatory diseases.

To explore the acceptability of an individualised risk-stratified approach to monitoring for target-organ toxicity in adult patients with immune-mediated inflammatory diseases established on immune-suppressing treatment(s). Adults (≥18 years) taking immune-suppressing treatment(s) for at-least six months, and healthcare professionals (HCPs) with experience of either prescribing and/or monitoring immune-suppressing drugs were invited to participate in a single, remote, one-to-one, semi-structured interview. Interviews were conducted by a trained qualitative researcher and explored their views and experiences of current monitoring and acceptability of a proposed risk-stratified monitoring plan. Interviews were transcribed verbatim and inductively analysed using thematic analysis in NVivo. Eighteen patients and 13 HCPs were interviewed. While participants found monitoring of immune-suppressing drugs with frequent blood-tests reassuring, the current frequency of these was considered burdensome by patients and HCPs alike, and to be a superfluous use of healthcare resources. Given abnormalities rarely arose during long-term treatment, most felt that monitoring blood-tests were not needed as often. Patients and HCPs found it acceptable to increase the interval between monitoring blood-tests from three-monthly to six-monthly or annually depending on the patients' risk profiles. Conditions of accepting such a change included: allowing for clinician and patient autonomy in determining an individuals' frequency of monitoring blood-tests, the flexibility to change monitoring frequency if someone's risk profile changed, and endorsement from specialist societies and healthcare providers such as the National Health Service. A risk-stratified approach to monitoring was acceptable to patients and HCPs. Guideline groups should consider these findings when recommending blood-test monitoring intervals.

“We don’t look too much into the communication disability”: clinicians’ views and experiences on the effect of communication disability on falls in hospital patients with stroke

Purpose Difficulty with communicating basic needs and attracting the attention of health professionals may contribute to falls for patients with communication disability after stroke. The aim of this study was to explore the views of hospital-based health professionals on: (a) the effect of communication disability on falls in patients with stroke; (b) falls prevention strategies for patients with communication disability following stroke; and (c) the roles of speech pathologists in the assessment, management, and prevention of falls in this population. Materials and Methods Online focus groups were conducted and analysed using content thematic analysis. Results In total, 11 health professionals participated in four focus groups. Clinicians viewed that: (a) the effects of falls in patients with communication disability are far-reaching; (b) communication disability complicates falls risk assessment and falls management; (c) current falls prevention strategies do not meet the needs of patients with communication disability; and (d) strong relationships have a central role in decreasing falls in this population. Conclusions Health professionals articulate concerning gaps in falls prevention strategies for patients with communication disability. Further research should investigate strategies enabling falls prevention and management to be more inclusive of patients with communication disability following stroke and consider ways in which speech pathologists could contribute to this field.

Healthcare professionals’ attitudes towards the termination of pregnancy: a qualitative analysis of survey data in Northern Ireland

Abortion was decriminalised in Northern Ireland in October 2019. Following decriminalisation, the new regulations set out legal provision for abortion up until 12 weeks, with conditions thereafter. This cross-sectional descriptive survey, conducted in late 2019 in Northern Ireland, gathered the views of health professionals on decriminalisation, and their willingness to provide abortion services. This article provides a thematic analysis of answers to narrative questions from the online survey, and identifies priority areas of engagement with healthcare professionals. We assess how healthcare professional roles and responsibilities, abortion procedures, the foetus, and women and pregnant people were discursively constructed by respondents who are willing or unwilling to provide abortion services in Northern Ireland. We identify a narrow understanding of ‘harm’, and gendered norms of women as irresponsible or duplicitous, as inhibitory factors to the normalisation of abortion services in Northern Ireland.

Views of German mental health professionals on the use of digital mental health interventions for eating disorders: a qualitative interview study

IntroductionDigital mental health interventions (DMHIs) are getting increasingly important for mental health care. In the case of eating disorders (EDs), DMHIs are still in early stages. Few studies so far investigated the views of mental health professionals for EDs on the integration of DMHIs in routine care.ObjectiveTo gain insights into the experiences, perspectives, and expectations of mental health professionals for EDs regarding DMHIs and to identify requirements for the future integration of DMHIs into routine care.MethodsSemi-structured qualitative telephone interviews with 24 German mental health professionals treating patients with EDs were conducted. A content analysis following a deductive-inductive approach asked for experiences, advantages and chances, disadvantages and boundaries, desired functions and properties, target groups, and general conditions and requirements for DMHIs for patients with EDs.ResultsOnly few professionals reported experiences with DMHIs besides video-based psychotherapy during the pandemic. From the therapists’ point of view, DMHIs have the potential to deliver low-threshold access for patients with EDs. Useful functionalities were seen in digital meal records, skills training, and psychoeducation. However, a stable therapeutic alliance was reported as an important prerequisite for the successful integration into care. Therapists expressed concerns in case of severe anorexia nervosa or suicidality. The participants felt to be informed inadequately on recent developments and on the evidence base of DMHIs.ConclusionsMental health professionals for EDs show positive attitudes towards DMHIs, however many barriers to the integration in routine care were observed. The highest potential was seen for the use of DMHIs in addition to outpatient care and in aftercare. Specific requirements for DMHIs are related to different areas of the healthcare spectrum and for the different symptom profiles in anorexia nervosa, bulimia nervosa and binge eating disorder. Targeted DMHIs are needed and appropriate especially for concepts of blended care.

The paradoxes of telehealth platforms: what did we learn from the use of telehealth platforms?

This article is an overview and reflection of the findings of an evaluative study conducted on a program called "Techno-Covid Partnership" (TCP) implemented in April 2020 at the Centre Hospitalier de l'Université de Montréal (CHUM) in Montreal, Canada. In the context of the COVID-19 pandemic, the CHUM decided in April 2020 to implement telehealth, virtual care, and telemonitoring platforms and technologies to maintain access to care and reduce the risks of contamination and spread of COVID-19 as well as to protect users of health services and health professionals. Three technological platforms for telehealth and remote care and monitoring have been developed, implemented, and evaluated in real-time within the framework of the TCP program. A cross-sectional study was carried out in which a questionnaire was used and administered to users of telehealth platforms including patients and healthcare professionals. The methods and results of the study have been published previously published. In the completion of the two articles published in this context, in this paper, we briefly recall the context of the study and the method performed. The main focus of the paper is on presenting a critical overview and reflection on the major findings of our evaluation of the use of telehealth platforms from the point of view of patients and health professionals and discuss certain paradoxes i.e., the advantages, challenges, recommendations, and other perspectives that emerged in this study.

Health professionals' experiences and views on obstetric ultrasound in Tanzania: A cross-sectional study.

Obstetric ultrasound is considered important for determining gestational age, identifying single or multiple pregnancies, locating the placenta and fetal anomalies and monitoring fetal growth and pregnancy-related complications in order to improve patient management. To explore health professionals' perspectives on different aspects of obstetric ultrasound in Tanzania regarding self-reported skills in performing ultrasound examinations and what could improve access to and utilization of obstetric ultrasound in the clinical setting. Cross-sectional study. Data was collected between November and December 2017 using a questionnaire based on previous qualitative research results from the CROss Country UltraSound Study (CROCUS Study). Seventeen healthcare facilities in 5 urban and semiurban municipalities in the Dar-es-Salaam region were included, with 636 health professionals participating (physicians, n = 307 and midwives/nurses, n = 329). Most health professionals (82% physicians, 81% midwives/nurses) believed that obstetric ultrasound was decisive in the clinical management of pregnancy. Results indicate proficiency gaps across disciplines: 51% of physicians and 48.8% of midwives/nurses reported no or low-level skills in assessing cervical length. Similarly, deficiencies were observed in evaluating the four-chamber view of the fetal heart (physicians: 51%, midwives/nurses: 61%), aorta, pulmonary artery (physicians: 60.5%, midwives/nurses: 65%) and Doppler assessments (umbilical artery: physicians 60.6%, midwives/nurses 56.1%). Compared to midwives/nurses, physicians were significantly more likely to agree or strongly agree that utilization would improve with more ultrasound machines (odds ratio (OR) 2.13; 95% confidence intervals (CI) 1.26-3.61), better quality of ultrasound machines (OR 2.27; 95% CI 1.10-4.69), more training for health professionals currently performing ultrasound (OR 2.11; 95% CI 1.08-4.17) and more physicians trained in ultrasound (OR 2.51; 95% CI 1.30-4.87). Improving the provision of obstetric ultrasound examinations in Tanzania requires more and better-quality ultrasound machines, enhanced training for health professionals and an increased number of physicians trained in ultrasound use. To further increase the accessibility and utilization of obstetric ultrasound in maternity care in Tanzania, it is essential to provide training for midwives in basic obstetric ultrasound techniques.

Evaluation of a Disaster Preparedness Curriculum and Medical Students' Views on Preparedness Education Requirements for Health Professionals.

In general, medical students perceive themselves as inadequately prepared to assist in disasters. This study evaluated the impact of a disaster preparedness curriculum and medical students' views toward required preparedness education for health care professionals. A comprehensive disaster preparedness curriculum was evaluated on its effect on medical students' views on preparedness education requirements, preparedness, and prior disaster training using self-report survey methodology. Results provide evidence to support curricular effectiveness in significantly increasing initial participant views of health professionals' education requirements, perceived preparedness for integrating professional roles into the emergency response system, and confidence in exposure risk assessment and triage skills. Most participants possessed limited recent prior disaster training and drill experience. Most interestingly, the majority consistently believed throughout the study that disaster preparedness training should be a medical license mandate. For those instructing current medical students in disaster preparedness, it is suggested that a curriculum be chosen that can create participant initial anticipation, awareness, and belief in the importance of and need for disaster preparedness training. Further investigation is recommended into the relationship between students' perceived training importance and any future curriculum delivery efforts on behalf of required or mandatory preparedness offerings in continuing professional development.

Views of Health Professionals on Acute Psychiatric Interventions in the Emergency Department: A Qualitative Study

Views of Health Professionals on Acute Psychiatric Interventions in the Emergency Department: A Qualitative Study

Perceptions of mental health providers of the barriers and facilitators of using and engaging youth in digital mental-health-enabled measurement based care.

Increased rates of mental health disorders and substance use among youth and young adults have increased globally, furthering the strain on an already burdened mental health system. Digital solutions have been proposed as a potential option for the provision of timely mental health services for youth, with little research exploring mental health professional views about using such innovative tools. In Alberta, Canada, we are evaluating the implementation and integration of a digital mental health (dMH) platform into existing service pathways. Within this paper we seek to explore mental health professionals' perceptions of the barriers and facilitators that may influence their utilization of digital MH-enabled measurement-based care (MBC) with the youth who access their services. A qualitative, descriptive methodology was used to inductively generate themes from focus groups conducted with mental health professionals from specialized mental health services and primary care networks in Alberta. As mental health professionals considered the barriers and facilitators of using dMH with youth, they referenced individual and family barriers and facilitators to consider. Providers highlighted perceived barriers, including: first, cultural stigma, family apprehension about mental health care, and parental access to dMH and MBC as deterrents to providers adopting digital platforms in routine care; second, perceptions of increased responsibility and liability for youth in crisis; third, perception that some psychiatric and neurodevelopmental disorders in youth are not amenable to dMH; fourth, professionals contemplated youth readiness to engage with dMH-enabled MBC. Participants also highlighted pertinent facilitators to dMH use, noting: first, the suitability of dMH for youth with mild mental health concerns; second, youth motivated to report their changes in mental health symptoms; and lastly, youth proficiency and preference for dMH options. By identifying professionals' perceptions of barriers and facilitators for youth users, we may better understand how to address misconceptions about who is eligible and appropriate for dMH through training and education.

Mental health professionals’ perspectives on the relevance of religion and spirituality to mental health care

BackgroundA large body of evidence indicates that spiritual and religious backgrounds, beliefs, and practices (SRBBPs) are related to better psychological health. Spirituality and religion (R/S) are also important aspects of multicultural diversity. There is evidence that clients would like to talk about their spirituality, and that including it in assessment and treatment planning can be beneficial. However, the extent to which practicing mental health professionals view SRBBPs as relevant to mental health and clinical practice is unclear.MethodsA survey examining several aspects of addressing SRBBPs in clinical practice was distributed to 894 professionals across mental health disciplines, including psychiatry, psychology, social work, marriage family therapy, licensed professional counselors, certified chemical dependency counselors, and psychiatric mental health nurses.Results89% of mental health professionals agreed that clinicians should receive training in R/S competencies. There were no differences between mental health disciplines in ratings of importance of such training. Younger individuals and those who identify as more spiritual were more likely to consider R/S training as important. Although 47.1% of professionals had not received much R/S training, many perceived themselves to be highly competent in R/S clinical integration practices (57.8% considered themselves able to display them very much or completely). In addition, respondents with more R/S training evaluated themselves as more proficient in R/S clinical integration. Nearly two-thirds (65.2%) of respondents reported encountering few to no barriers to engaging in R/S competent mental health care.ConclusionsThere is a growing consensus among mental health care professionals that mental health professionals should be trained in R/S competencies. Strong agreement exists that basic R/S competencies include respect, empathy, examination of bias, and routine assessment of R/S in mental health care. Four in five of those surveyed agree that more active competencies, such as identifying and addressing religious and spiritual struggles and problems and helping clients explore and access R/S strengths and resources should be included, whereas one in five report less comfort with these competencies.