"Vintage meds": a netnographic study of user decision-making, home preparation, and consumptive patterns of laudanum.

BACKGROUND: Reviews have commented on rising clandestine manufacture of opiate drug solutions for injecting, and to a lesser extent for oral use. Very little is known about user attempts to culture poppy seeds, widely available on the internet for manufacture of long acting medium-high potency oral solutions, both as poppy seed tea or as opium tincture (laudanum). OBJECTIVES: A netnographic research methodology aimed to provide online consumer insight into user sourcing and decision influences, experiences of home manufacture of laudanum, utilization of opium tincture recipes, and consumptive patterns. METHODS: A systematic internet search was conducted using the terms: "Laudanum," "Opium tincture," and "Tincture of Opium" in combination with "forum." Following screening of 810 forum threads with exclusion criteria and removal of duplicates, 75 fora threads on 6 online drug fora were analyzed using the empirical phenomenological psychological method. Four themes were generated. RESULTS: Findings illustrated the underpinning of user reminiscing about Victorian use of standardized laudanum, long duration shelf life, and medicinal use for opiate withdrawals with intentions to prepare. Preparation of famous recipes and use of authentic storage bottles boosted nostalgia. Participants appeared well versed in kitchen chemistry processes. Discussions centered on type and amount of alcohol used, use of additives to promote palatability and intoxication effect, homogenization of poppy seeds, and double extraction using opium tincture. Lack of detail available on intoxication experiences, with tentative dosage advised. CONCLUSIONS: Development of targeted and credible "counterpublic" harm reduction initiatives situated within online consumerism of communal drug knowledge is warranted.

The homeopathic choice for children: a qualitative research on the decision making process of the families.

AIM: To explore the experiences of parents who chose homeopathic treatment for their children, with particular regard to the decision-making process within the family and the availability of conventional and homeopathic healthcare services. METHODS: Semi-structured interview with parents immediately after or before the homeopathic visit at the Homeopathic Clinic of Campo di Marte Hospital of Lucca (Italy) from1st March, 2012 to 18 July 2012. Answers were analyzed by frequency of response and grouped into main areas: 1. Choice of homeopathy. 2. Intra-family dynamics. 3. Behaviour in emergency situations. 4. The relationship with the homeopathic doctor. 5. The role of friends and acquaintances. 6. The 'cut off' of use of homeopathy. RESULTS: Parents who choose homeopathic treatments for their children are strongly influenced by context. The choice of homeopathy is usually made by mothers and is rarely hindered by fathers, grandparents or friends, whose approval is important and encourages parents to use homeopathy for their children, both for prevention and treatment. Easy access to the homeopathic doctor was frequently requested, especially for acute situations. CONCLUSION: This research confirms the importance of context in decision making processes. Other characteristics of families which use homeopathy, such as level of education, personal coping strategies and family context should be investigated.

[Complementary and alternative medicine in the German outpatient setting: extent, structure and reasons for provision]. / Komplementäre und alternative Heilverfahren im vertragsärztlichen Bereich: Ausmaß, Struktur und Gründe des ärztlichen Angebots.

BACKGROUND: Research on complementary and alternative medicine (CAM) has mainly focused on CAM utilisation by patients. Fewer studies have analysed extent and structure of CAM provision or the reasons why physicians offer CAM as a therapeutic option in the outpatient setting. METHODS: A standardised questionnaire was developed addressing reasons and patterns of CAM provision. The questionnaire was sent by post to 2,396 general practitioners and specialists in 9 selected German districts. 553 physicians participated in the survey (23%). RESULTS: 63% of the respondents (n=350) answered that they had provided some sort of CAM to their patients within a period of 12 months preceding the study. The most frequently provided methods were acupuncture/traditional Chinese medicine, herbal remedies and homeopathy. In the sample, 90% of the orthopaedists were CAM providers, the highest rate among the participating disciplines. Several reasons for offering CAM were identified: conviction of therapeutic effectiveness regarding the patient's situation (68%), aspects of therapeutic freedom (47%) or less harmful side effects than conventional therapies (34%). 6% provide CAM for monetary reasons. CONCLUSION: Findings suggest that the provision of CAM is widespread in the German outpatient setting. However, it has to be taken into account that a selection bias may apply which may lead to an overestimation of CAM provision. Doctors' reasons to offer CAM are manifold; therapeutic reasons seem to outweigh economic motives.

The Lucretian swerve: the biological basis of human behavior and the criminal justice system.

It is widely believed, at least in scientific circles, that living systems, including mankind, obey the natural physical laws. However, it is also commonly accepted that man has the capacity to make "free" conscious decisions that do not simply reflect the chemical makeup of the individual at the time of decision--this chemical makeup reflecting both the genetic and environmental history and a degree of stochasticism. Whereas philosophers have discussed for centuries the apparent lack of a causal component for free will, many biologists still seem to be remarkably at ease with this notion of free will; and furthermore, our judicial system is based on such a belief. It is the author's contention that a belief in free will is nothing other than a continuing belief in vitalism--something biologists proudly believe they discarded well over 100 years ago.

Thoughts, beliefs and concepts concerning infectious childhood diseases of physicians practicing homeopathic, anthroposophic and conventional medicine - a qualitative study.

BACKGROUND: Physicians who include complementary medicine in their practice are thought to have an understanding of health and disease different from that of colleagues practicing conventional medicine. The aim of this study was to identify and compare the thoughts and concepts concerning infectious childhood diseases (measles, mumps, rubella, chickenpox, pertussis and scarlet fever) of physicians practicing homeopathic, anthroposophic and conventional medicine. METHODS: This qualitative study used semistructured interviews. Participating physicians were either general practitioners or pediatricians. Data collection and analysis were guided by a grounded theory approach. RESULTS: Eighteen physicians were interviewed (6 homeopathic, 6 anthroposophic and 6 conventional). All physicians agreed that while many classic infectious childhood diseases such as measles, mumps and rubella are rarely observed today, other diseases, such as chickenpox and scarlet fever, are still commonly diagnosed. All interviewed physicians vaccinated against childhood diseases. A core concern for physicians practicing conventional medicine was the risk of complications of the diseases. Therefore, it was considered essential for them to advise their patients to strictly follow the vaccination schedule. Homeopathic-oriented physicians viewed acute disease as a biological process necessary to strengthen health, fortify the immune system and increase resistance to chronic disease. They tended to treat infectious childhood diseases with homeopathic remedies and administered available vaccines as part of individual decision-making approaches with parents. For anthroposophic-oriented physicians, infectious childhood diseases were considered a crucial factor in the psychosocial growth of children. They tended to treat these diseases with anthroposophic medicine and underlined the importance of the family's resources. Informing parents about the potential benefits and risks of vaccination was considered important. All physicians agreed that parent-delivered loving care of a sick child could benefit the parent-child relationship. Additionally, all recognized that existing working conditions hindered parents from providing such care for longer durations of time. CONCLUSIONS: The interviewed physicians agreed that vaccines are an important aspect of modern pediatrics. They differed in their approach regarding when and what to vaccinate against. The different conceptual understandings of infectious childhood diseases influenced this decision-making. A survey with a larger sample would be needed to verify these observations.

Attitudes Underlying Reliance on Complementary and Alternative Medicine.

Objective: We aimed to map attitudes underlying complementary and alternative medicine (CAM) use, especially those involved in "dysfunctional CAM reliance," that is, forgoing biomedical treatment in a life-threatening situation in favor of alternative treatment. Analyses of modifiable determinants of CAM use were conducted at a sufficiently specific level to inform intervention development. Methods: We collected usable data on CAM-related attitudinal beliefs from 151 participants in Budapest with varying degrees of CAM use, which we analyzed using confidence interval-based estimation of relevance plots. Results: Although there were beliefs that the entire sample shared, there was a marked difference between the biomedical and CAM groups. These differences were beliefs concerning trust in various medical systems, the level of importance assigned to emotions in falling ill, and vitalism or Eastern concepts. Regarding CAM users in general, the most successful intervention targets are beliefs in vitalism on the one hand, and distrust in biomedicine on the other. In addressing dysfunctional CAM use specifically, the most significant beliefs pertain to "natural" cures and reliance on biomedical testing. Conclusions: Albeit much research has been carried out on the motivations behind CAM use, rarely do studies treat CAM users separately in order to scrutinize patterns of nonconventional medicine use and underlying cognition. This is the first study to begin pinpointing specific attitudes involved in dysfunctional CAM use to inform future intervention development. Such interventions would be essential for the prevention of incidents and mortality.

The Value of Treatment Processes in Germany: A Discrete Choice Experiment on Patient Preferences in Complementary and Conventional Medicine.

BACKGROUND: The effects of health interventions are often complex, and it is argued that they comprise more than pure changes in clinical parameters. Aspects of the treatment process, so-called 'benefits beyond health', are often overlooked in the evaluation of health interventions but can be of value to the patients. OBJECTIVES: The aim of this study was to assess patients' preferences and willingness to pay regarding the treatment process and its attributes in patients using acupuncture, homeopathy or general medicine (GM). METHODS: A systematic literature search, six semi-structured interviews and a stakeholder involvement were conducted to determine the attributes of the treatment process. Five process attributes and one cost attribute were used to construct the experimental design of the discrete choice experiment (DCE) (6 × 3), a cross sectional survey method. Patients were recruited by outpatient physicians practicing in Berlin and Munich, Germany. Process attributes were effects-coded. Data were analyzed in a conditional logit regression. RESULTS: Data from 263 patients were analyzed. DCE results showed that the treatment process attributes 'active listening' and 'time' were most relevant to all patients. Preferences for the attributes 'holistic treatment' (more relevant to the acupuncture and homeopathy groups) and 'information' (more relevant to the GM group) seemed to differ slightly between the groups. Willingness-to-pay values were higher in the acupuncture and homeopathy groups. CONCLUSIONS: The time physicians take and the extent to which they listen attentively are most important and are equally important to all patients. These results may contribute to the debate about more patient-centered healthcare. They support a strengthening of medical consultations in the German healthcare system. We suggest giving physicians the opportunity to spend more time with their patients, which may be achieved by changing the general conditions of remuneration (e.g., improved reimbursement of medical consultations). GERMAN CLINICAL TRIAL REGISTER: DRKS00013160.

Prostate Cancer Screening Perception, Beliefs, and Practices Among Men in Bamenda, Cameroon.

Prostate Cancer (CaP) is the most commonly diagnosed cancer among Cameroonian men. Due to inadequate infrastructure, record keeping, and resources, little is known about its true burden on the population. There are rural/urban disparities with regards to awareness, screening, treatment, and survivorship. Furthermore, use of traditional medicine and homeopathic remedies is widespread, and some men delay seeking conventional medical treatment until advanced stages of CaP. This study examined the perceptions, beliefs, and practices of men in Cameroon regarding late stage CaP diagnoses; identified factors that influence screening decision; and ascertained how men decided between traditional or conventional medicine for CaP diagnosis and treatment. Semistructured focus groups were used to collect data from men in Bamenda, Cameroon. Qualitative data analysis was used to analyze transcripts for emerging themes and constructs using a socio-ecological framework. Twenty-five men participated in the study, with an average age of 59. Most of the participants had never received a prostate screening recommendation. Socioeconomic status, local beliefs, knowledge levels, awareness of CaP and screening methods, and stigma were prominent themes. A significant number of Cameroonian men receive late stage CaP diagnosis due to lack of awareness, attitudes, cultural beliefs, self-medication, and economic limitation. To effectively address these contributing factors to late stage CaP diagnosis, a contextually based health education program is warranted and should be tailored to fill knowledge gaps about the disease, dispel misconceptions, and focus on reducing barriers to utilization of health services.

Herbs to homeopathy-medicinal products for children.

Many pediatric patients and their families use dietary supplements and homeopathy. They do not always disclose this information to their health care practitioners. It is important that health care practitioners are aware of the research available in these areas and discuss the use of these products openly with their patients. As part of that dialogue, clinicians need to consider what level of effectiveness is acceptable to support the use of these products by their patients. This risk-benefit appraisal should consider safety, effectiveness, the medical condition being treated, and the personal beliefs and preferences of patients and their families.

Considerações éticas relacionadas às condutas terapêuticas de pacientes terminais / Ethical considerations related to the therapeutic management of terminally ill patients / Consideraciones éticas relacionadas con la conducta terapéutica de los pacientes terminales

Objetivo: Conhecer as considerações éticas relacionadas às condutas terapêuticas das equipes de saúde frente aos pacientes terminais. Metodologia: Trata-se de um estudo exploratório de natureza qualitativa. Realizado no período de dezembro de 2020, através do acesso ao Banco de Teses e Dissertações da CAPES, considerando que este, coordena o Sistema de Pós-graduação brasileiro. Resultados: Foram identificadas seis classes semânticas, de modo que a mesma formulou a seguinte distribuição de contextos temáticos: Classe 1 Paciente terminal; Classe 2 Condutas médicas; Classe 3 Manejo terapêutico; Classe 4 Protocolos clínicos e aspectos metodológicos dos estudos; Classe 5 Dependências metodológicas e Classe 6 Suporte clínico na terminalidade Dependências metodológicas. Discussão: A morte e a vida tornam-se um impasse enfrentado pelos profissionais de saúde, pois existem fatores decisivos na vida de cada paciente em situação terminal com nenhuma esperança de cura, envolvendo assim questões éticas. Conclusão: Portanto, torna-se necessário que as instâncias de saúde assegurem protocolos, treinamentos e aporte psicológicos para esses profissionais que atuam diretamente com pacientes em situações terminais de vida, para que possa haver uma ressignificação do processo de cuidado com pacientes e segurança na tomada de decisões por parte dos profissionais de saúde, e assim possa preservar a ética.

Objective: To know the ethical considerations related to the therapeutic behavior of health teams towards terminal patients. Methodology: This is an exploratory study of a qualitative nature. Carried out in January 2020, through access to the CAPES Theses and Dissertations Bank, considering that it coordinates the Brazilian Postgraduate System. Results: Six semantic classes were identified, so that it formulated the following distribution of thematic contexts: Class 1 Terminal patient; Class 2 Medical conducts; Class 3 Therapeutic management; Class 4 Clinical protocols and methodological aspects of the studies; Class 5 Methodological dependencies and Class 6 Clinical support in terminality Methodological dependencies. Discusson: Death and life become an impasse faced by health professionals, as decisive there are factors in the life of each patient in a terminal situation with no hope of cure, thus involving ethical issues. Conclusion: Therefore, it is necessary that health institutions ensure protocols, training and psychological support for these professionals who work directly with patients in terminal situations, so that there can be a new meaning for the process of patient care and safety in decision-making by health professionals, and thus can preserve ethics.

Objetivo: Conocer las consideraciones éticas relacionadas con las conductas terapéuticas de los equipos de salud frente a los pacientes terminales. Metodología: Se trata de un estudio exploratorio de carácter cualitativo. Realizado en el período de diciembre de 2020, a través del acceso al Banco de Tesis y Disertaciones de la CAPES, considerando que este, coordina el Sistema de Pós-graduación brasileño. Resultados: Se identificaron seis clases semánticas, por lo que se formuló la siguiente distribución de contextos temáticos: Clase 1 Paciente terminal; Clase 2 Conductas médicas; Clase 3 Manejo terapéutico; Clase 4 Protocolos clínicos y aspectos metodológicos de los estudios; Clase 5 Dependencias metodológicas y Clase 6 Apoyo clínico en la terminalidad Dependencias metodológicas. Discusión: La muerte y la vida se convierten en un impasse al que se enfrentan los profesionales de la salud, porque hay factores decisivos en la vida de cada paciente en situación terminal sin esperanza de curación, lo que implica cuestiones éticas. Conclusión: Por lo tanto, se hace necesario que las instancias de salud garanticen protocolos, capacitación y apoyo psicológico para estos profesionales que trabajan directamente con los pacientes en situaciones de vida terminal, para que pueda haber una resignificación del proceso de atención al paciente y seguridad en la toma de decisiones por parte de los profesionales de la salud, y así poder preservar la ética.

Complementary and alternative medicine use in lung cancer patients in eight European countries.

This paper presents findings from a cross-sectional survey about the use of complementary and alternative medicine (CAM) in patients with lung cancer, forming part of a larger study. Data from 111 lung cancer patients in 8 countries in Europe were collected through a descriptive 27-item questionnaire. The data suggest that 23.6% of the lung cancer patients used CAM after the diagnosis with cancer. The most popular CAM modalities were herbal medicine (48.1%), medicinal teas (11.5%), homeopathy (11.5%), use of animal extracts (11.5%) and spiritual therapies (11.5%). Herbal use increased by three times after the diagnosis of cancer. Patients seemed quite satisfied with the CAM used. They were also spending on average about 142 Euros monthly on CAM therapies or remedies. The most common motivation to use CAM was to increase the body's ability to fight the cancer. Main sources of information about CAM were friends and family. As CAM is increasingly used by patients with lung cancer, it is important to be able to assist patients make an appropriate decision by discussing the issue of CAM openly, providing reassurance and communicating safe and appropriate information to patients.

A Life Below the Threshold?: Examining Conflict Between Ethical Principles and Parental Values in Neonatal Treatment Decision Making.

Three common ethical principles for establishing the limits of parental authority in pediatric treatment decision-making are the harm principle, the principle of best interest, and the threshold view. This paper considers how these principles apply to a case of a premature neonate with multiple significant co-morbidities whose mother wanted all possible treatments, and whose health care providers wondered whether it would be ethically permissible to allow him to die comfortably despite her wishes. Whether and how these principles help in understanding what was morally right for the child is questioned. The paper concludes that the principles were of some value in understanding the moral geography of the case; however, this case reveals that common bioethical principles for medical decision-making are problematically value-laden because they are inconsistent with the widespread moral value of medical vitalism.

Patients' choice of asthma and allergy treatments.

BACKGROUND AND OBJECTIVES: Only a few studies have focused on a comparison between general practitioner (GP) patients' and classical homeopath (CH) patients' reasons for choosing, continuing or termination of their treatment by GPs or CHs, respectively. The existing studies are mostly based on quantitative methods and dealing with patients' reasons for choosing complementary and alternative medicine (CAM). The objective of this paper is to develop concepts to understand and compare Danish GP patients' and CH patients' initial choice of, continuing choice of, and termination of treatments for asthma and allergy. DESIGN: Data originate from an explorative study based on semistructured interviews with 18 GP patients and CH patients having asthma and allergy. The selection of the patients to the interviews was based on a questionnaire study including 88 respondents (response rate 58 patients). RESULTS: In understanding the patients' initial choice and continuing choice of treatment and termination of treatment, the concepts push-from, pull, press-into, stop, and stay factors are used. These factors are connected to the patients' experiences with conventional treatment, patients' attitudes toward and personal experiences with alternative treatment, and the patients' understanding of their asthma and allergy. The results of the study indicate that patients before seeking CHs had experienced inappropriate health care within the conventional health care system. The results of the study also indicate that if the CH patients experience inappropriate health care within homeopathic treatment, they terminate the treatment. CONCLUSIONS: The study indicates the importance of health providers' insight into GP patients' and CH patients' different reflections on adverse events, the patients' different understandings of asthma and allergy, and the different learning processes that GP patients and CH patients might be involved in while living with asthma and allergy. These are important issues for understanding patients' initial and, continuing choice of and termination of GP treatment and CH treatment, respectively.

Complementary and alternative medicine use in patients with haematological malignancies in Europe.

This study reports upon a descriptive cross-sectional survey assessing the use of complementary and alternative medicine (CAM) in patients with haematological cancers. Twelve European countries contributed data from patients with haematological cancers, as part of a larger study. Sixty-eight patients with haematological cancer participated. Among the participants, 26.5% used some form of CAM after the cancer diagnosis. The most common therapies used were homeopathy (38.9%), herbal medicine (22.2%) various psychic therapies, such as use of mediums, healers, rebirthing or past life regression therapy (22.2%). A particular profile of a CAM user was not evident in the sample. Moderate levels of satisfaction with CAM were reported. Patients commonly used CAM to increase the ability of their body to fight cancer and to improve physical and emotional well-being. Information about CAM was received mainly from friends or family. As CAM use in patients with haematological malignancies is common, clinicians should assist patients who want to use CAM to make an appropriate decision, and improve communication with them about CAM use in an open and non-judgemental dialogue.

Assessing patients' participation and quality of decision-making: insights from a study of routine practice in diverse settings.

In the context of a qualitative study exploring patients' participation in decision-making, we investigated how people interpret and respond to structured questions about decision-making about their health care. Seventy-four participants who attended consultations in five clinical areas completed structured measures of decision-making and discussed their responses during interviews. They identified a range of decisions as having being made in their consultations. People who picked particular responses on measures of participation in and satisfaction with decision-making gave varied explanations for these, not all of which were consistent with the way their responses are usually interpreted. The interview data suggest that people's evaluations of decisions to follow a particular course of action were influenced by various factors including what they focused on as the alternative, their perceptions of constraints on choices, and their assessment of how good the best possible solution was. Responses to simple structured measures of participation in and satisfaction with decision-making should be interpreted with caution. They are not reliably attributable to health care providers' actions and are thus unsuitable for performance assessment purposes.

A qualitative study of patient's views on the consultation at the Glasgow Homoeopathic Hospital, an NHS integrative complementary and orthodox medical care unit.

We investigated consultations at the Glasgow Homoeopathic Hospital (GHH), by the use of in-depth, semi-structured interviews with a purposive sample of 14 patients. Interviews (lasting 1-2 h) were taped and transcribed verbatim. Analysis was based on a grounded theory approach. Two main categories of themes emerged: (1) those "outside" the consultation, related to expectations, initially formed from experiences of family and friends, but then strengthened by ongoing attendance at GHH; and (2) themes "inside" the consultation including length of consultations, the whole-person approach, being treated as an individual, and telling and having their "story" listened to in depth. Equality of relationship, mutual respect, and sharing decisions were also prominent themes. In conclusion, patients attending the GHH highly value the holistic approach, and view time, empathy, and the therapeutic relationship as being of key importance.

Use of alternative treatment in pediatric oncology.

The use of alternative treatment along with conventional cancer therapy is very popular. However, little is known about the use of alternative treatment in pediatric oncology. A study to determine which medical and demographic characteristics distinguish users from nonusers was conducted in a pediatric oncology sample of children with different survival perspectives. The parents of 84 children with cancer (43 patients in first continuous remission and 41 patients who had suffered a relapse or second malignancy) participated in the study and were surveyed with respect to the use of alternative treatment. The survival perspective appeared to be the most important variable distinguishing users of alternative treatment from nonusers. Twenty-six families (31%) had used or were using alternative treatment, of which 19 were families of children with cancer who had suffered a relapse (46%), and 7 were families of children with cancer in remission (16%). The most common types of alternative treatment used were based on homeopathy and anthroposophy (treatments based on autonomous medical concepts). Because of the finding that lower survival perspective is related to the use of alternative treatment, the use of alternative treatment conceivably could be a coping strategy based on illusions. Therefore, it is recommended that alternative treatment be discussed open-mindedly by all health care providers involved in the care of pediatric oncology patients.

Developing and evaluating complementary therapy services: Part 1. Establishing service provision through the use of evidence and consensus development.

The integration of complementary therapies within the British National Health Service (NHS) in the context of limited evidence of effectiveness has been much debated, as has the need for the provision of health services to be more evidence-based. In June 1994, a project was launched within a South-East London NHS Hospital Trust to introduce complementary therapy (acupuncture, homeopathy, and osteopathy), in the context of an evaluation program. This followed approximately 4 years of working toward raising the profile of complementary therapies within the hospital through study days, workshops, and providing a massage and osteopathic service for staff. A survey of local general practitioners highlighted areas of complementary therapy provision and interest in referring patients to a hospital-based service. A steering group was established to draw together a proposal for funding the service. Evidence for the effectiveness of acupuncture, homeopathy, and osteopathy was presented at a multidisciplinary seminar. A consensus development process, using a modified Delphi technique to establish referral indicators followed this. This study provides a useful model of service development in the absence of good quality evidence for the effectiveness of clinical interventions.

Vitalism revitalized.... Vulnerable populations, prejudice, and physician-assisted death.

One of the most potent arguments against physician-assisted death hinges on the worry that people with disabilities will be subtly coerced to accept death prematurely. The argument is flawed. There is nothing new in PAD: the risk of coercion is already present in current policies about end of life care. And to hold that any such risk is too much is tacitly to endorse vitalism and to deny that people with disabilities are capable of choosing authentically.

Economic considerations in the use of neuromuscular blocking drugs.

The acceptance of new and increasingly expensive technologies is a major component of the rising costs of health care. While the practice of anesthesia has been relatively immune from the effects of cost containment, it is inevitable that practitioners will have to justify costly practices. Available pharmacoeconomic methods can be applied to the use of all anesthetic drugs, particularly neuromuscular blocking drugs. Cost-effectiveness analysis allows the practicing anesthesiologist to prioritize the use of neuromuscular blocking drugs to maximize their benefit while reducing unnecessary costs.