Do professionals change their communication behaviours following a training in hypnosis-derived communication? A feasibility study in pediatric oncology.

OBJECTIVES: The purpose of this study was to test the feasibility of a training in hypnotic communication techniques (HCTech) for pediatric nurses to prevent procedural pain and distress in children during venipunctures. Specifically, this study aimed to (1) assess nurses' mastery of HCTech and (2) nurses' experience regarding the training program. METHODS: Participants were 6 female pediatric nurses and 33 of their cancer patients. Nurses took part in a 4-day theoretical and practical training in HCTech. Venipuncture procedures were video-recorded and assessed to evaluate nurses' mastery of HCTech using a standardized scale. Pre-training use of HCTech was compared with post-training and follow-up for the entire nurse sample and across nurses with the same patients (109 nurse-patient interactions). After the follow-up, nurses were questioned about their experience in regards to the training and activities (themes and practice). RESULTS: Results showed medium pre-post changes in hypnotic communication behaviours (pre-post d = 0.74), with changes maintaining at follow-up (pre-follow-up d = 0.97). Interviews transcripts' analyses revealed moderate levels of motivation and satisfaction regarding the training content and format. Nurses suggested to emphasize on the practice of HCTech in a noisy outpatient clinic as well as offer more practical exercises. CONCLUSION: A 4-day training in hypnotic communication techniques translated into the use of HCTech by nurses practicing in pediatric oncology when comparing the same dyads at baseline, post-training and follow-up. Results support further refinement and suggest nurses could be trained to prevent pain and distress with hypnosis-derived communication strategies.

Impact of a Child Life and Music Therapy Procedural Support Intervention on Parental Perception of Their Child's Distress During Intravenous Placement.

OBJECTIVES: Child life specialists and music therapists have a unique and integral role in providing psychosocial care to pediatric patients and families. These professionals are trained to provide clinical interventions that support coping and adjustment and reduce the risk of psychological trauma related to hospital visits and health care encounters. The researchers devised a multimodal approach using a combined child life and music therapy intervention to address procedure-related distress in patients receiving intravenous (IV) placement in the pediatric emergency department. The aim of this study was to investigate the efficacy of this collaborative intervention by evaluating parental perception of their child's distress. METHODS: This study was a prospective analysis investigating the impact of a child life and music therapy intervention on children aged 4 to 11 years old receiving an IV placement in the pediatric emergency department. Efficacy was evaluated by comparing scores between a 4-question pretest and subsequent 4-question posttest that asked the child's parent to evaluate how they anticipated their child would respond to the procedure, and then to evaluate how they perceived their child to have responded after the procedure. Qualitative data were collected in the form of open-ended comments, which were accommodated at the end of the posttest. Data were analyzed by the Cochran-Mantel-Haenszel method for testing repeated ordinal responses and the PROC GENMOD procedure in the SAS system software. RESULTS: A total of 41 participants were enrolled in this study. Results of the statistical analysis revealed significant differences between all pre- and posttest scores (P < 0.05), and significant likelihood that the patient would improve relative to the 4 questions, as a result of the child life and music therapy intervention. CONCLUSIONS: Improvement was demonstrated across all 4 questions, suggesting that the child life and music therapy intervention supported healthy, adaptive coping and helped to minimize distress experienced by patients during IV placement. These results underscore the importance and potential clinical impact of child life psychological preparation and psychotherapy-based music therapy interventions in reducing distress in pediatric patients during common medical procedures.

Psychological interventions for needle-related procedural pain and distress in children and adolescents.

BACKGROUND: This is the second update of a Cochrane Review (Issue 4, 2006). Pain and distress from needle-related procedures are common during childhood and can be reduced through use of psychological interventions (cognitive or behavioral strategies, or both). Our first review update (Issue 10, 2013) showed efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents. OBJECTIVES: To assess the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents. SEARCH METHODS: We searched six electronic databases for relevant trials: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; PsycINFO; Embase; Web of Science (ISI Web of Knowledge); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). We sent requests for additional studies to pediatric pain and child health electronic listservs. We also searched registries for relevant completed trials: clinicaltrials.gov; and World Health Organization International Clinical Trials Registry Platform (www.who.int.trialsearch). We conducted searches up to September 2017 to identify records published since the last review update in 2013. SELECTION CRITERIA: We included peer-reviewed published randomized controlled trials (RCTs) with at least five participants per study arm, comparing a psychological intervention with a control or comparison group. Trials involved children aged two to 19 years undergoing any needle-related medical procedure. DATA COLLECTION AND ANALYSIS: Two review authors extracted data and assessed risks of bias using the Cochrane 'Risk of bias' tool. We examined pain and distress assessed by child self-report, observer global report, and behavioral measurement (primary outcomes). We also examined any reported physiological outcomes and adverse events (secondary outcomes). We used meta-analysis to assess the efficacy of identified psychological interventions relative to a comparator (i.e. no treatment, other active treatment, treatment as usual, or waitlist) for each outcome separately. We used Review Manager 5 software to compute standardized mean differences (SMDs) with 95% confidence intervals (CIs), and GRADE to assess the quality of the evidence. MAIN RESULTS: We included 59 trials (20 new for this update) with 5550 participants. Needle procedures primarily included venipuncture, intravenous insertion, and vaccine injections. Studies included children aged two to 19 years, with few trials focused on adolescents. The most common psychological interventions were distraction (n = 32), combined cognitive behavioral therapy (CBT; n = 18), and hypnosis (n = 8). Preparation/information (n = 4), breathing (n = 4), suggestion (n = 3), and memory alteration (n = 1) were also included. Control groups were often 'standard care', which varied across studies. Across all studies, 'Risk of bias' scores indicated several domains at high or unclear risk, most notably allocation concealment, blinding of participants and outcome assessment, and selective reporting. We downgraded the quality of evidence largely due to serious study limitations, inconsistency, and imprecision.Very low- to low-quality evidence supported the efficacy of distraction for self-reported pain (n = 30, 2802 participants; SMD -0.56, 95% CI -0.78 to -0.33) and distress (n = 4, 426 participants; SMD -0.82, 95% CI -1.45 to -0.18), observer-reported pain (n = 11, 1512 participants; SMD -0.62, 95% CI -1.00 to -0.23) and distress (n = 5, 1067 participants; SMD -0.72, 95% CI -1.41 to -0.03), and behavioral distress (n = 7, 500 participants; SMD -0.44, 95% CI -0.84 to -0.04). Distraction was not efficacious for behavioral pain (n = 4, 309 participants; SMD -0.33, 95% CI -0.69 to 0.03). Very low-quality evidence indicated hypnosis was efficacious for reducing self-reported pain (n = 5, 176 participants; SMD -1.40, 95% CI -2.32 to -0.48) and distress (n = 5, 176 participants; SMD -2.53, 95% CI -3.93 to -1.12), and behavioral distress (n = 6, 193 participants; SMD -1.15, 95% CI -1.76 to -0.53), but not behavioral pain (n = 2, 69 participants; SMD -0.38, 95% CI -1.57 to 0.81). No studies assessed hypnosis for observer-reported pain and only one study assessed observer-reported distress. Very low- to low-quality evidence supported the efficacy of combined CBT for observer-reported pain (n = 4, 385 participants; SMD -0.52, 95% CI -0.73 to -0.30) and behavioral distress (n = 11, 1105 participants; SMD -0.40, 95% CI -0.67 to -0.14), but not self-reported pain (n = 14, 1359 participants; SMD -0.27, 95% CI -0.58 to 0.03), self-reported distress (n = 6, 234 participants; SMD -0.26, 95% CI -0.56 to 0.04), observer-reported distress (n = 6, 765 participants; SMD 0.08, 95% CI -0.34 to 0.50), or behavioral pain (n = 2, 95 participants; SMD -0.65, 95% CI -2.36 to 1.06). Very low-quality evidence showed efficacy of breathing interventions for self-reported pain (n = 4, 298 participants; SMD -1.04, 95% CI -1.86 to -0.22), but there were too few studies for meta-analysis of other outcomes. Very low-quality evidence revealed no effect for preparation/information (n = 4, 313 participants) or suggestion (n = 3, 218 participants) for any pain or distress outcome. Given only a single trial, we could draw no conclusions about memory alteration. Adverse events of respiratory difficulties were only reported in one breathing intervention. AUTHORS' CONCLUSIONS: We identified evidence supporting the efficacy of distraction, hypnosis, combined CBT, and breathing interventions for reducing children's needle-related pain or distress, or both. Support for the efficacy of combined CBT and breathing interventions is new from our last review update due to the availability of new evidence. The quality of trials and overall evidence remains low to very low, underscoring the need for improved methodological rigor and trial reporting. Despite low-quality evidence, the potential benefits of reduced pain or distress or both support the evidence in favor of using these interventions in clinical practice.

The Effectiveness of Distraction (Cartoon-Patterned Clothes and Bubble-Blowing) on Pain and Anxiety in Preschool Children during Venipuncture in the Emergency Department.

In preschool children, venipuncture is considered a bodily threat that can cause pain and anxiety, as well as being a traumatic experience. If the pain and anxiety felt by a child during a venipuncture is not addressed properly, it can result in a traumatic experience, and traumatic events in childhood can have long-term consequences. Atraumatic treatment in the emergency department has been little explored in previous research; therefore, the present study assessed the effectiveness of using the distractions of cartoon-patterned clothes and bubble-blowing on the pain and anxiety of preschool children during venipuncture in the emergency department. This was a quasi-experiment that used a post-test only, control group design approach. The sample consisted of 57 preschool children who were due to undergo venipuncture and who were divided into 3 intervention groups. The results showed that distraction using bubble-blowing is effective in reducing pain and anxiety during venipuncture, while cartoon-patterned clothing is only effective in reducing anxiety. Distractions can refocus the attention of a child away from pain and anxiety during venipuncture. It can inhibit the transmission of pain impulses, such that these impulses are not transmitted to the brain. As a result, the sensation of pain is not experienced.

The Effect of Distraction on Pain Level Felt by School-age Children During Venipuncture Procedure--Randomized Controlled Trial.

The experimental study that follows was planned to determine the effectiveness of distraction on the pain level in school-age children as they underwent venipuncture. The study sample consisted of children between the ages of 7 and 12 years who underwent venipuncture at the Training and Research Hospital in Istanbul, Turkey between February and May 2012. A total of 144 children were conveniently sampled and evenly randomized into two groups of 72 children each. The primary instrument used to test children's pain level was the Faces Pain Scale-Revised (FPS-R). During the blood draw, the experimental group was given a kaleidoscope and told to look through it and describe what they saw, then rate their pain level on the FPS-R. Results showed that during venipuncture, the pain level of the control group was significantly higher (FPS-R = 3.27 ± 2.87) than the experimental group (FPS-R = 1.80 ± 1.84; p = .001) suggesting that distraction with a kaleidoscope is effective in reducing the pain children experience during venipuncture.

Can presence of a dog reduce pain and distress in children during venipuncture?

The aim of this study was to investigate the effectiveness of animal-assisted intervention as distraction for reducing children's pain and distress before, during, and after standard blood collection procedure. Fifty children (ages 4-11 years) undergoing venipuncture were randomly assigned to the experimental group (EG; n = 25) or to the control group (CG; n = 25). The blood collection procedure was carried on the children in the EG arm in the presence of a dog, whereas no dog was present when venipuncture was conducted on children in CG. In both cases, parents accompanied the child in the procedure room. Distress experienced by the child was measured with the Amended Observation Scale of Behavioral Distress, while perceived pain was measured with a visual analog scale or the Wong Baker Scale (Faces Scale); levels of cortisol in blood also were analyzed. Parental anxiety during the procedure was measured with State Trait Anxiety Inventory. Children assigned to the EG group reacted with less distress than children in the CG arm. Furthermore, cortisol levels were lower in the EG group compared with the CG group. There were no significant differences in pain ratings and in the level of parental anxiety. It appears that the presence of dogs during blood draw procedures reduces distress in children.

Doctors and vampires in sub-Saharan Africa: ethical challenges in clinical trial research.

Collecting blood samples from individuals recruited into clinical research projects in sub-Saharan Africa can be challenging. Strikingly, one of the reasons for participant reticence is the occurrence of local rumors surrounding "blood stealing" or "blood selling." Such fears can potentially have dire effects on the success of research projects--for example, high dropout rates that would invalidate the trial's results--and have ethical implications related to cultural sensitivity and informed consent. Though commonly considered as a manifestation of the local population's ignorance, these rumors represent a social diagnosis and a logical attempt to make sense of sickness and health. Born from historical antecedents, they reflect implicit contemporary structural inequalities and the social distance between communities and public health institutions. We aim at illustrating the underlying logic governing patients' fear and argue that the management of these beliefs should become an intrinsic component of clinical research.

Psychological interventions for needle-related procedural pain and distress in children and adolescents.

BACKGROUND: This review is an updated version of the original Cochrane review published in Issue 4, 2006. Needle-related procedures are a common source of pain and distress for children. Our previous review on this topic indicated that a number of psychological interventions were efficacious in managing pediatric needle pain, including distraction, hypnosis, and combined cognitive behavioural interventions. Considerable additional research in the area has been published since that time. OBJECTIVES: To provide an update to our 2006 review assessing the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents. SEARCH METHODS: Searches of the following databases were conducted for relevant randomized controlled trials (RCTs): Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; PsycINFO; the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and Web of Science. Requests for relevant studies were also posted on various electronic list servers. We ran an updated search in March 2012, and again in March 2013. SELECTION CRITERIA: Participants included children and adolescents aged two to 19 years undergoing needle-related procedures. Only RCTs with at least five participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors extracted data and assessed trial quality and a third author helped with data extraction and coding for one non-English study. Included studies were coded for quality using the Cochrane Risk of bias tool. Standardized mean differences with 95% confidence intervals were computed for all analyses using Review Manager 5.2 software. MAIN RESULTS: Thirty-nine trials with 3394 participants were included. The most commonly studied needle procedures were venipuncture, intravenous (IV) line insertion, and immunization. Studies included children aged two to 19 years, with the most evidence available for children under 12 years of age. Consistent with the original review, the most commonly studied psychological interventions for needle procedures were distraction, hypnosis, and cognitive behavioural therapy (CBT). The majority of included studies (19 of 39) examined distraction only. The additional studies from this review update continued to provide strong evidence for the efficacy of distraction and hypnosis. No evidence was available to support the efficacy of preparation and information, combined CBT (at least two or more cognitive or behavioural strategies combined), parent coaching plus distraction, suggestion, or virtual reality for reducing children's pain and distress. No conclusions could be drawn about interventions of memory alteration, parent positioning plus distraction, blowing out air, or distraction plus suggestion, as evidence was available from single studies only. In addition, the Risk of bias scores indicated several domains with high or unclear bias scores (for example, selection, detection, and performance bias) suggesting that the methodological rigour and reporting of RCTs of psychological interventions continue to have considerable room for improvement. AUTHORS' CONCLUSIONS: Overall, there is strong evidence supporting the efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents, with no evidence currently available for preparation and information or both, combined CBT, parent coaching plus distraction, suggestion, or virtual reality. Additional research is needed to further assess interventions that have only been investigated in one RCT to date (that is, memory alteration, parent positioning plus distraction, blowing out air, and distraction plus suggestion). There are continuing issues with the quality of trials examining psychological interventions for needle-related pain and distress.

Drawing blood from young children: lessons learned from a trial in Ghana.

This paper reflects on lessons learned from a trial in Ghana assessing the impact of vitamin A supplementation on children's immune responses to tetanus and polio vaccines. There were more losses to follow-up than was anticipated at visits during which blood was drawn, owing to concerns or misconceptions about blood draw. The trial initially planned to recruit 960 children but had to recruit more because the proportion of infants lost to follow-up was greater than the anticipated 15%, resulting in a longer recruitment period. Of 1085 infants who were randomised into the trial, 767 (71%) completed follow-up at 6 months of age. It was notable that at the first (6 weeks) and fourth (6 months) visits at which blood was drawn, losses to follow-up were greater than at the second (10 weeks) and third (14 weeks) visits during which blood was not drawn. Losses to follow-up pose a threat to the validity of trials as there is a chance that those lost to follow-up may differ from those who remain in the trial. Monitoring losses to follow-up as they emerged and allowing mothers to witness the blood draw, as well as holding community meetings, helped to allay anxieties in the community.

Interactive music as a treatment for pain and stress in children during venipuncture: a randomized prospective study.

OBJECTIVE: The experience of venipuncture is seen by children as one of the most fearful experiences during hospitalization. Children experience anxiety both before and during the procedure. Therefore, any intervention aiming to prevent or reduce distress should focus on the entire experience of the procedure, including waiting, actual preparation, and conclusion. This study was designed to determine whether the presence of musicians, who had attended specific training to work in medical settings, could reduce distress and pain in children undergoing blood tests. METHODS: Our sample population was composed of 108 unpremedicated children (4-13 years of age) undergoing blood tests. They were randomly assigned to a music group (n=54), in which the child underwent the procedure while interacting with the musicians in the presence of a parent or to a control group (n=54), in which only the parent provided support to the child during the procedure. The distress experienced by the child before, during and after the blood test was assessed with the Amended Form of the Observation Scale of Behavioral Distress, and pain experience with FACES scale (Wong Baker Scale) only after the venipuncture. RESULTS: Our results show that distress and pain intensity was significantly lower (p<.001; p<.05) in the music group compared with the control group before, during, and after blood sampling. CONCLUSIONS: This controlled study demonstrates that songs and music, performed by "professional" musicians, have a beneficial effect in reducing distress before, during, and after blood tests. This study shows, moreover, that the presence of musicians has a minor, but yet significant, effect on pain due to needle insertion.

Familiarity breeds content? Soothing effect of a familiar odor on full-term newborns.

OBJECTIVE: This study tested the effects of familiar and unfamiliar odors during a heel stick in full-term newborns. METHOD: Forty-four newborns were exposed to vanillin (via their mother or via their crib) or no odor prior to a heel stick. On the day of the heel stick, infants were either exposed to a familiar odor, an unfamiliar odor, or no odor before, during, and after the procedure. Crying, grimacing, and oral movements were scored. RESULTS: Infants exposed to a familiar odor displayed little distress and more oral movements during the procedure compared to the unfamiliar group. No advantage was found when infants were exposed to an odor learned via their mother compared to when the odor was learned via the crib. Exposure to an unfamiliar odor did not lessen distress compared to exposure to no odor. CONCLUSION: A familiar odor is effective in significantly reducing crying and grimacing during a minor painful procedure. Olfactory support is a useful intervention that may potentially help minimize deleterious effects of neonatal pain.

Speaking of research advance directives: planning for future research participation.

OBJECTIVE: To examine one model of research advance directive as a possible way to reduce the mismatch between patient and proxy choices and also to learn more about how patients with mild to moderate dementia may want to keep decision making or cede it to their proxies in the future. METHODS: Separate interviews were conducted with 149 dyads of dementia patients and family proxies about future enrollment in five types of research. Subsequent joint interviews were conducted with 69 of those dyads to discuss their separately articulated decisions and ask whether the patient prefers future enrollment decisions to be made as he or she directs today or as the proxy deems best in the future. RESULTS: Patients chose to cede future decision making to their proxies in 82.9% of the trials. Patients ceded decisions to their proxies in 80.7% of those trials about which the dyad had given opposite answers (n = 74, 49.7%). Patients who had expressed discomfort about the prospect of the proxy making an enrollment decision in a trial (n = 49, 32.9%) ceded decision making to their proxies in 45.7% of those trials. CONCLUSIONS: Both patients and proxies were willing to discuss future research enrollment in the context of an advance directive for research. Such a document may be helpful to proxies and researchers in the future to judge the types of research and associated risks patients are willing to enroll in. Although most patients willingly cede future decisions to their proxies, a sizeable minority do not wish to do so.

Dental and medical injections: prevalence of self-reported problems among 18-yr-old subjects in Norway.

The aim of the present study was to evaluate the prevalence of self-reported problems (fear, pain, unpleasantness, fainting) of dental and medical injections, and the extent to which such problems may lead to avoidance of necessary treatment. The study included a representative sample (n = 1385) of 18-yr-old students attending high schools in the county of Hordaland, Norway. Data were collected by use of questionnaires completed in the classrooms. More problems were reported during dental than medical injections. About 17% and 15% of participants reported high fear during their last dental and medical injection, respectively. Fainting had been experienced by 2% during a dental injection and by 7% during a medical injection. Avoidance of treatment when an injection is needed was 6.7% for dental treatment and 5.2% for medical treatment. In multiple regression analyses, fear was the only explanatory factor for the avoidance of dental treatment. It is concluded that self-reported problems of injections are prevalent in this age group, particularly among girls, and that it may lead to the avoidance of necessary treatment in 5-7% of the adolescent population.

Needle phobia--changing venepuncture practice in ambulatory care.

Needle phobia is a term used in practice to describe an anticipatory fear of needle insertion. A proportion of children display high levels of fear, pain and behavioural distress when exposed to, or anticipating, needle insertion. A difficult routine venepuncture in our ambulatory care unit led staff to review practice and develop a three-step approach to overcoming 'needle phobia': relaxation, control and graded exposure. These developments have resulted in the unit becoming a local referral centre for children and young people between the ages of 5-19 years with this problem. Time and skill are needed to prevent or overcome this distressing problem which can be caused by health care professionals not listening to children and young people.

Parents' positioning and distracting children during venipuncture. Effects on children's pain, fear, and distress.

The purpose of this study was to determine the effectiveness of parental positioning and distraction on the pain, fear, and distress of pediatric patients undergoing venipuncture. An experimental-comparison group design was used to evaluate 43 patients (20 experimental and 23 comparison) who were 4 to 11 years old. Experimental participants used parental positioning and distraction. All participants rated their pain and fear; parents and child life specialists (CLS) rated the child's fear, and CLS rated the child's distress. Self-reported pain and fear were highly correlated (p < .001) but not significantly different between the two groups. Fear rated by CLS (p < .001) and parents (p = .003) was significantly lower in experimental participants. Although no differences was found in distress between the two groups, a significant time trend was discovered (p < .001). The parental positioning-distraction intervention has the potential to enhance positive clinical outcomes with a primary benefit of decreased fear. Further research is warranted.

Olfactory experience mediates response to pain in preterm newborns.

We assessed the effects of a familiar odor during routine blood draws in healthy preterm newborns. Infants were observed as they were undergoing either a capillary puncture on the heel (heelstick) or a venous puncture on the hand. During the procedure, one third of the infants were presented with an odor they had been familiarized with prior to the procedure, one third of the infants were presented with an odor, they had not been previously exposed to, and one third were presented with no odor. Heelsticks elicited more behavioral distress than venipunctures. Infants who were presented with a familiar odor during venipuncture showed no significant increase in crying and grimacing during the procedure compared to baseline levels. By comparison, infants presented with an unfamiliar odor or with no odor either during the heelstick or the venipuncture had a significant increase in crying and grimacing. When the pain was milder, i.e., during a venipuncture, and a familiar odor was presented, infants showed little to no crying. These results are consistent with a body of evidence on early memory and olfactory competence in fetuses and newborns.

Triangulation using a meta-matrix.

BACKGROUND AND SIGNIFICANCE: Quantitative and qualitative data analysis are often undertaken as separate enterprises, as they emerge from differing philosophies of science and methodologies for data collection, management and analysis. Quantitative data analysis is sometimes seen in philosophic and methodologic conflict with a naturalistic, human science perspective of science. Researchers interested in data from both realms often rely on triangulation procedures, in which each is considered from its representative lens. Results are then projected out into a common area where data are melded and discussed. The purpose of this paper is to introduce the meta-matrix as a tool for triangulation in nursing research and to demonstrate its usefulness in an exemplar case. DESIGN/METHODS: The exploratory nature of a recent study led to the decision to manage triangulation using an emerging methodology, thereby allowing consideration of all data simultaneously through the use of a meta-matrix. Discussion of the meta-matrix as a method is presented. FINDINGS: Use of the meta-matrix facilitated data analysis and allowed pattern recognition across data sets. Discovery of several unexpected relationships deepened understanding of the results and assisted in identifying questions for further research. CONCLUSIONS/IMPLICATIONS: The meta-matrix method provides a useful alternative approach for secondary-level data analysis in mixed-methods research.