Training Service Users in the Use of Telehealth: Scoping Review.

BACKGROUND: The use of telehealth has rapidly increased, yet some populations may be disproportionally excluded from accessing and using this modality of care. Training service users in telehealth may increase accessibility for certain groups. The extent and nature of these training activities have not been explored. OBJECTIVE: The objective of this scoping review is to identify and describe activities for training service users in the use of telehealth. METHODS: Five databases (MEDLINE [via PubMed], Embase, CINAHL, PsycINFO, and Web of Science) were searched in June 2023. Studies that described activities to train service users in the use of synchronous telehealth consultations were eligible for inclusion. Studies that focused on health care professional education were excluded. Papers were limited to those published in the English language. The review followed the Joanna Briggs Institute guidelines for scoping reviews and was reported in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. Titles and abstracts were screened by 1 reviewer (EG). Full texts were screened by 2 reviewers (EG and JH or SC). Data extraction was guided by the research question. RESULTS: The search identified 8087 unique publications. In total, 13 studies met the inclusion criteria. Telehealth training was commonly described as once-off preparatory phone calls to service users before a telehealth visit, facilitated primarily by student volunteers, and accompanied by written instructions. The training content included guidance on how to download and install software, troubleshoot technical issues, and adjust device settings. Older adults were the most common target population for the training. All but 1 of the studies were conducted during the COVID-19 pandemic. Overall, training was feasible and well-received by service users, and studies mostly reported increased rates of video visits following training. There was limited and mixed evidence that training improved participants' competency with telehealth. CONCLUSIONS: The review mapped the literature on training activities for service users in telehealth. The common features of telehealth training for service users included once-off preparatory phone calls on the technical elements of telehealth, targeted at older adults. Key issues for consideration include the need for co-designed training and improving the broader digital skills of service users. There is a need for further studies to evaluate the outcomes of telehealth training activities in geographically diverse areas.

The use of telehealth in attention-deficit/hyperactivity disorder: a survey of parents and caregivers.

The use of telehealth became widespread during the COVID-19 pandemic, including in child and adolescent attention-deficit/hyperactivity disorder (ADHD) services. Telehealth is defined as live, synchronous phone and video appointments between a healthcare provider and a parent and/or child with ADHD. There is a dearth of research on the use of telehealth within this population. The aim of this study was to examine parents' and caregivers' perceptions of telehealth for children and adolescents with ADHD. A cross-sectional survey design was employed. Recruitment of parents and caregivers of children and adolescents with ADHD was conducted online. The survey asked participants about their views of telehealth, previous experience, and willingness to use telehealth. Quantitative data were analysed using STATA. Qualitative data were analysed using content analysis. One hundred and twelve respondents participated in the survey. Participants were mostly female (n = 97, 86.6%) and aged between 45 and 54 (n = 64, 57.1%). Of the 61 (54.5%) participants with experience of telehealth, the majority reported that that they were at least satisfied with telehealth visits (n = 36, 59%), whilst approximately half rated their quality more poorly than in-person visits (n = 31, 50.8%). The majority of respondents (n = 91, 81.3%) reported that they would be willing to use telehealth for their child's future appointments. Most common reasons selected for wanting to use telehealth included saving time, improvements to the family routine, and reducing costs. Reasons selected for not wanting to use telehealth included not being able to receive hands-on care, belief that the quality of care is poorer than in-person consultations, and distraction of the child during telehealth visits. The study demonstrates that parents recognise deficits and benefits of telehealth, suggesting a need to build their trust and confidence in remote ADHD care.

Stakeholder perspectives and experiences of the implementation of remote mental health consultations during the COVID-19 pandemic: a qualitative study.

BACKGROUND: Remote mental health consultations were swiftly implemented across mental health services during the COVID-19 pandemic. Research has begun to inform future design and delivery of telemental health services. Exploring the in-depth experiences of those involved is important to understand the complex, multi-level factors that influence the implementation of remote mental health consultations. The aim of this study was to explore stakeholder perspectives and experiences of the implementation of remote mental health consultations during the COVID-19 pandemic in Ireland. METHODS: A qualitative study was conducted whereby semi-structured, individual interviews were undertaken with mental health providers, service users, and managers (n = 19) to acquire rich information. Interviews were conducted between November 2021 and July 2022. The interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). Data were analysed thematically using a deductive and inductive approach. RESULTS: Six themes were identified. The advantages of remote mental health consultations were described, including convenience and increased accessibility to care. Providers and managers described varying levels of success with implementation, citing complexity and incompatibility with existing workflows as barriers to adoption. Providers' access to resources, guidance, and training were notable facilitators. Participants perceived remote mental health consultations to be satisfactory but not equivalent to in-person care in terms of quality. Views about the inferior quality of remote consultations stemmed from beliefs about the inhibited therapeutic relationship and a possible reduction in effectiveness compared to in-person care. Whilst a return to in-person services was mostly preferred, participants acknowledged a potential adjunct role for remote consultations in certain circumstances. CONCLUSIONS: Remote mental health consultations were welcomed as a means to continue care during the COVID-19 pandemic. Their swift and necessary adoption placed pressure on providers and organisations to adapt quickly, navigating challenges and adjusting to a new way of working. This implementation created changes to workflows and dynamics that disrupted the traditional method of mental health care delivery. Further consideration of the importance of the therapeutic relationship and fostering positive provider beliefs and feelings of competence are needed to ensure satisfactory and effective implementation of remote mental health consultations going forward.

Prevalence of attention deficit hyperactivity disorder in an adult mental health service in the Republic of Ireland.

OBJECTIVE: Attention Deficit Hyperactivity Disorder (ADHD) is well recognised in childhood. However, recognition that it commonly persists into adulthood is relatively recent. This study is the 2nd phase of a two-phase epidemiological investigation of the prevalence of adult ADHD in outpatients in Ireland. METHOD: In phase-1, 634 participants were screened with Adult ADHD Self-Report Scale (ASRS) and Wender Utah Rating Scale (WURS). Those scoring positive in both scales have been invited to participate in the 2nd phase where the scales Conners' Adult ADHD Diagnostic Interview (CAADID), Mini International Neuropsychiatric Interview (MINI), and Global Assessment of Functioning (GAF) were administered, plus clinical evaluation based in DSM-5. RESULTS: 131 were eligible, 110 participated (84.0%). Using the CAADID (DSM-IV criteria) 71 were diagnosed with ADHD. Projecting to the total sample (N = 634) the prevalence was 13.25%, CI:95%:10.71-16.14. Converting the DSM-IV criteria to DSM-5, 89 had ADHD (prevalence:16.72%, CI: 13.9-19.86). Using clinical evaluation, 86 were diagnosed with ADHD (prevalence:16.09%, CI:13.31-19.18). Only 3 cases were diagnosed before with ADHD. Comorbidity was higher in those with ADHD, with the median number of additional diagnoses 2 (min 0 max 8, IQR 3) Also, they had significantly higher rates of depression and recurred depression. Agreement between DSM-IV and DSM-5 was high (rho = 0.90, p < .0001). CONCLUSIONS: High rates of undiagnosed ADHD were found to be present among AMHS attendees. Clinicians in AMHS need to be knowledgeable and alert to possible ADHD among their caseloads, and offer appropriate intervention. Interventions are urgently required to increase the detection and treatment of adult ADHD.

Levels of stress in medical students due to COVID-19.

For medical schools, the COVID-19 pandemic necessitated examination and curricular restructuring as well as significant changes to clinical attachments. With the available evidence suggesting that medical students' mental health status is already poorer than that of the general population, with academic stress being a chief predictor, such changes are likely to have a significant effect on these students. This online, cross-sectional study aimed to determine the impact of COVID-19 on perceived stress levels of medical students, investigate possible contributing and alleviating factors, and produce recommendations for medical schools to implement during future healthcare emergencies. The majority (54.5%) of respondents reported levels of stress ranging from moderate to extreme. Higher levels of stress were significantly associated with female gender (p=0.039) and international status (p=0.031). A significant association was also noted between reported stress and the transition to online learning (p<0.0001) and online assessment formatting (p<0.0001), concerns for personal health (p<0.0001) and for the health of family members (p<0.0001). Students who reported higher stress levels were less confident in their government's management of the crisis (p=0.041). Additionally, students who reported lower stress agreed highly that their medical school had an appropriate response to the crisis (p<0.0001), had provided sufficient information regarding the crisis (p=0.015), that they trust their school in handling the continuing of their education (p=0.020) and that their school had appropriate plans in place to support the continuing of education (p=0.017).

Medical students and COVID-19: the need for pandemic preparedness.

The COVID-19 pandemic has prompted unprecedented global disruption. For medical schools, this has manifested as examination and curricular restructuring as well as significant changes to clinical attachments. With the available evidence suggesting that medical students' mental health status is already poorer than that of the general population, with academic stress being a chief predictor, such changes are likely to have a significant effect on these students. In addition, there is an assumption that these students are an available resource in terms of volunteerism during a crisis. This conjecture should be questioned; however, as those engaging in such work without sufficient preparation are susceptible to moral trauma and adverse health outcomes. This, in conjunction with the likelihood of future pandemics, highlights the need for 'pandemic preparedness' to be embedded in the medical curriculum.

A prospective longitudinal investigation of the (dis)continuity of mental health difficulties between mid- to late-childhood and the predictive role of familial factors.

Understanding individual variation in the continuity of youth mental health difficulties is critical for identifying the factors that promote recovery or chronicity. This study establishes the proportion of children showing psychopathology at 9 years, whose pathology had either remitted or persisted at 13. It describes the socio-demographic and clinical profiles of these groups, and examines the factors in 9-year-olds' familial environments that predict longitudinal remission vs. persistence of psychopathology. The study utilised data from a prospective longitudinal study of 8568 Irish children. Child psychopathology was assessed using the Strengths and Difficulties Questionnaire (SDQ). Analysis established the rates of continuity of SDQ classifications between 9 and 13 years. Analysis also investigated the familial factors that predicted the remission vs. persistence of psychopathological symptoms, controlling for socio-demographic and child factors. Average SDQ scores improved between the ages of 9 and 13, F(1, 7292) = 276.52, p < 0.001, [Formula: see text] = 0.04. Of children classified Abnormal aged 9, 41.1% remained so classified at 13, 21.4% were reclassified Borderline, and 37.6% Normal. Demographic and child risk factors for persistence of pathology were maleness (ß = -1.00, p = 0.001, CI = 0.20-0.67), one-carer households (ß = -0.71, p = 0.04, CI = 0.25-0.97), poor physical health (ß = -0.64, p = 0.03, CI = 0.30-0.92), and low cognitive ability (ß = 0.61, p = 0.002, CI = 1.26-2.70). Controlling for these factors, the only familial variable at 9 years that predicted subsequent pathological persistence was caregiver depression (ß = -0.07, p = 0.03, CI = 0.87-0.99). The analysis highlights substantial rates of psychopathological discontinuity in a community sample and identifies the children most at risk of chronic mental health problems. These results will inform the targeting of early interventions and distribution of clinical resources.

What do general practitioners know about ADHD? Attitudes and knowledge among first-contact gatekeepers: systematic narrative review.

BACKGROUND: Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood disorder with international prevalence estimates of 5 % in childhood, yet significant evidence exists that far fewer children receive ADHD services. In many countries, ADHD is assessed and diagnosed in specialist mental health or neuro-developmental paediatric clinics, to which referral by General (Family) Practitioners (GPs) is required. In such 'gatekeeper' settings, where GPs act as a filter to diagnosis and treatment, GPs may either not recognise potential ADHD cases, or may be reluctant to refer. This study systematically reviews the literature regarding GPs' views of ADHD in such settings. METHODS: A search of nine major databases was conducted, with wide search parameters; 3776 records were initially retrieved. Studies were included if they were from settings where GPs are typically gatekeepers to ADHD services; if they addressed GPs' ADHD attitudes and knowledge; if methods were clearly described; and if results for GPs were reported separately from those of other health professionals. RESULTS: Few studies specifically addressed GP attitudes to ADHD. Only 11 papers (10 studies), spanning 2000-2010, met inclusion criteria, predominantly from the UK, Europe and Australia. As studies varied methodologically, findings are reported as a thematic narrative, under the following themes: Recognition rate; ADHD controversy (medicalisation, stigma, labelling); Causes of ADHD; GPs and ADHD diagnosis; GPs and ADHD treatment; GP ADHD training and sources of information; and Age, sex differences in knowledge and attitudes. CONCLUSIONS: Across times and settings, GPs practising in first-contact gatekeeper settings had mixed and often unhelpful attitudes regarding the validity of ADHD as a construct, the role of medication and how parenting contributed to presentation. A paucity of training was identified, alongside a reluctance of GPs to become involved in shared care practice. If access to services is to be improved for possible ADHD cases, there needs to be a focused and collaborative approach to training.

"We're seen as part of the supply chain of medicines rather than as the professionals that we are": The wellbeing of community pharmacists during the COVID response.

INTRODUCTION: Challenges facing community pharmacists in delivering and adapting services during the COVID-19 response have been reported. However, few qualitative studies have examined the impact of these experiences on their wellbeing, and what supports the profession requires in the future. AIM(S): To examine the work-related experiences and psychosocial needs of community pharmacists situated in the Republic of Ireland arising from the COVID-19 response. METHOD: 11 pharmacists and 1 representative were interviewed and data analysed through inductive thematic analysis. RESULTS: Work experiences were characterised by increased workload linked to multiple roles pharmacists played during the pandemic. Remaining open, meeting the social and medical needs of patients unable to easily access other primary services exerted its toll on pharmacists while at the same time providing a sense of professional fulfilment. Participants felt contributions made to the community during COVID-19 went largely unrecognised by the wider healthcare structure. This added to a prior sense of professional disenchantment arising from long-standing under-resourcing, lack of clinical autonomy and high administrative burden eroding their sense of purpose and meaning. Informal, peer-support networks were preferred over formal psychological support initiatives. CONCLUSIONS: The post-pandemic environment is an opportune time for policy makers to reconsider the role of community pharmacists. Greater clinical autonomy beyond dispensing of medicines, for example, for example, would also serve to enhance the sense of purpose and meaning of pharmacists as healthcare professionals. The longer-term well-being of community pharmacists is contingent on recognition of the value that community pharmacy bring both to the healthcare system and wider society as a whole.

Functional impairment and quality of life in newly diagnosed adults attending a tertiary ADHD clinic in Ireland.

BACKGROUND: Attention Deficit-Hyperactive Disorder (ADHD) is a neurodevelopmental disorder, often persisting into adulthood. AIMS: To investigate the levels of functionality and quality of life (QoL) in adult patients newly diagnosed with ADHD and to compare with those without an ADHD diagnosis. METHODS: Consecutive patients who were referred to and assessed in a tertiary adult ADHD clinic enrolled in the study. Diagnosis of ADHD was based on DSM-5 criteria. Functionality was measured using the Weiss Functional Impairment Rating Scale (WFIRS) and the Global Assessment of Functioning Scale (GAF). QoL was assessed with the Adult ADHD Quality of Life Questionnaire (AAQoL). RESULTS: Three-hundred and forty participants were recruited, 177 (52.1%) females. Of them 293 (86.2%) were newly diagnosed with ADHD. Those with ADHD had significant lower functionality as it was measured with the WFIRS and GAF, and worse QoL (AAQoL) compared to those without. In addition, a significant correlation between GAF and WFIRS was found. CONCLUSIONS: The results show that adults with ADHD have decreased functionality and worse QoL when compared against those presenting with a similar symptomatology, but no ADHD diagnosis. ADHD is not just a behavioural disorder in childhood, but a lifelong condition with accumulating problems that can lead to lower QoL and impaired functioning throughout adulthood.

Payment of research participants: current practice and policies of Irish research ethics committees.

BACKGROUND: Payment of research participants helps to increase recruitment for research studies, but can pose ethical dilemmas. Research ethics committees (RECs) have a centrally important role in guiding this practice, but standardisation of the ethical approval process in Ireland is lacking. AIM: Our aim was to examine REC policies, experiences and concerns with respect to the payment of participants in research projects in Ireland. METHOD: Postal survey of all RECs in Ireland. RESULTS: Response rate was 62.5% (n=50). 80% of RECs reported not to have any established policy on the payment of research subjects while 20% had refused ethics approval to studies because the investigators proposed to pay research participants. The most commonly cited concerns were the potential for inducement and undermining of voluntary consent. CONCLUSIONS: There is considerable variability among RECs on the payment of research participants and a lack of clear consensus guidelines on the subject. The development of standardised guidelines on the payment of research subjects may enhance recruitment of research participants.

Primary care and youth mental health in Ireland: qualitative study in deprived urban areas.

BACKGROUND: Mental disorders account for six of the 20 leading causes of disability worldwide with a very high prevalence of psychiatric morbidity in youth aged 15-24 years. However, healthcare professionals are faced with many challenges in the identification and treatment of mental and substance use disorders in young people (e.g. young people's unwillingness to seek help from healthcare professionals, lack of training, limited resources etc.) The challenge of youth mental health for primary care is especially evident in urban deprived areas, where rates of and risk factors for mental health problems are especially common. There is an emerging consensus that primary care is well placed to address mental and substance use disorders in young people especially in deprived urban areas. This study aims to describe healthcare professionals' experience and attitudes towards screening and early intervention for mental and substance use disorders among young people (16-25 years) in primary care in deprived urban settings in Ireland. METHODS: The chosen method for this qualitative study was inductive thematic analysis which involved semi-structured interviews with 37 healthcare professionals from primary care, secondary care and community agencies at two deprived urban centres. RESULTS: We identified three themes in respect of interventions to increase screening and treatment: (1) Identification is optimised by a range of strategies, including raising awareness, training, more systematic and formalised assessment, and youth-friendly practices (e.g. communication skills, ensuring confidentiality); (2) Treatment is enhanced by closer inter-agency collaboration and training for all healthcare professionals working in primary care; (3) Ongoing engagement is enhanced by motivational work with young people, setting achievable treatment goals, supporting transition between child and adult mental health services and recognising primary care's longitudinal nature as a key asset in promoting treatment engagement. CONCLUSIONS: Especially in deprived areas, primary care is central to early intervention for youth mental health. Identification, treatment and continuing engagement are likely to be enhanced by a range of strategies with young people, healthcare professionals and systems. Further research on youth mental health and primary care, including qualitative accounts of young people's experience and developing complex interventions that promote early intervention are priorities.

Work-related experiences of consultant psychiatrists during the COVID-19 response: qualitative analysis.

BACKGROUND: Research has begun to draw attention to the challenges mental health professionals faced in delivering services during the COVID-19 pandemic response. However, few studies have examined the specific experiences of consultant psychiatrists. AIMS: To examine the work-related experiences and psychosocial needs of consultant psychiatrists situated in the Republic of Ireland arising from the COVID-19 response. METHOD: We interviewed 18 consultant psychiatrists and analysed data using inductive thematic analysis. RESULTS: Work-related experience of participants was characterised by increased workload associated with assumption of guardianship of physical and mental health of vulnerable patients. Unintended consequences of public health restrictions increased case complexity, limited availability of alternative supports and hindered the practice of psychiatry, including inhibiting peer support systems for psychiatrists. Participants perceived available psychological supports as generally unsuitable for their needs given their specialty. Long-standing under-resourcing, mistrust in management and high levels of burnout exacerbated the psychological burden of the COVID-19 response. CONCLUSIONS: The challenges of leading mental health services were evident in the increased complexity involved in caring for vulnerable patients during the pandemic, contributing to uncertainty, loss of control and moral distress among participants. These dynamics worked synergistically with pre-existing system-level failures, eroding capacity to mount an effective response. The longer-term psychological well-being of consultant psychiatrists - as well as the pandemic preparedness of healthcare systems - is contingent on implementation of policies addressing long-standing under-investment in the services vulnerable populations rely on, not least community mental health services.

Prevalence of Personality Disorders in Adults With Attention Deficit Hyperactivity Disorder (ADHD).

OBJECTIVE: To estimate the prevalence of PDs according to Millon's evolution-based model among adult ADHD outpatients. METHOD: Cross-sectional study of consecutive patients referred to an adult ADHD clinic. PDs were evaluated with Millon Clinical Multiaxial Inventory-III (MCMI-III). RESULTS: One-hundred-eighty-one participants had valid MCMI-III, of whom147 were diagnosed with ADHD. Mean age: 32.97, SD:11.56, females: 74 (50.3%). Among the 147 participants with ADHD, 29 (19.7%) did not meet criteria for any PD, 43 (29.3%) met the criteria for one PD, 34 (23.1%) for two PDs and the rest three or more. Most common PD was Dependent (n = 58) followed by Depressive (n = 45). Inattentive sub-type was associated with dependent PD, while combined type with antisocial, negativistic (passive/aggressive) and sadistic PD. CONCLUSION: Particular personality profiles were more common with different ADHD subtypes. Given the developmental origins of PD, further research may help identify possible links with childhood difficulties.

ADHD in Adults: A Systematic Review and Meta-Analysis of Prevalence Studies in Outpatient Psychiatric Clinics.

OBJECTIVE: Systematic review and meta-analysis to estimate the pooled prevalence of ADHD in adult attendees of outpatient mental health clinics and to investigate factors influencing prevalence rates. METHODS: The following were extracted: demographics, design of the study (screening only or two-phase), scales/criteria for diagnosis of ADHD, number of ADHD, and non-ADHD participants. RESULTS: The pooled prevalence of ADHD from screening studies (n = 9) was 26.7%, (95% CI [17.2-37.4]), ADHD = 1727, No ADHD = 3,578. From studies employing a two-stage design (n = 5), prevalence was 14.61%, CI [10.39-19.41], ADHD = 561, No ADHD = 3,578. Age and gender did not have any significant effect on the estimated prevalence. By contrast exclusion of psychotic disorders lowers prevalence. The screening scale used also influence prevalence rates. CONCLUSION: Meta-analysis shows high rates of adult ADHD among psychiatric outpatient clinics. Applying DSM-5 criteria increased prevalence rates. More methodologically robust studies, using two-stage design, need to be conducted to help assist in service planning.

COVID-19 related occupational stress in teachers in Ireland.

BACKGROUND: Sporadic school closures and a shift to online teaching have resulted in significant work changes for teachers in Ireland during the COVID-19 pandemic. Such rapid changes are likely to compound other personal or family stressors resultant from the pandemic. METHOD: This study examines occupational stress levels during COVID-19 amongst a national sample of 245 teachers in Ireland using the Copenhagen Burnout Inventory as the main outcome measure. RESULTS: Moderate or high levels of personal burnout was reported by 82% (n = 202) of the sample and 79% (n = 193) reported work burnout. COVID-19 related adverse effects were reported by teachers on physical (43%) and mental health (67%), with deterioration in eating (34%), sleeping (70%) and alcohol use (33%). 100 (42%) participants felt unable to keep safe at work. Low levels of job satisfaction were present (66%), negatively correlating with burnout scores (rs=-0.405, p<.01). 142 (58%) teachers had seriously considered changing jobs in the previous 6-12 months. CONCLUSION: Plans for continued educational access for students must urgently include interventions optimising the occupational environment and resources for teachers. This is necessary to prevent the deleterious impact of personal burnout on teacher wellbeing and to minimise the likelihood of increased staff turnover, early retirement and adverse impacts on teaching quality relating to work burnout.

Examining COVID-19 related occupational stress in teachers in Ireland through a qualitative study using a thematic analysis approach.

Background: The teaching profession was dramatically affected by COVID-19 with school closures and ultimately the move to online learning. COVID-19 brought additional stress to an already demanding profession with the introduction of online teaching, teachers experiencing fear of infection and additional workloads accompanying the pandemic. Aim: To examine COVID-19 related occupational stress in teachers in Ireland through a qualitative study using a thematic analysis approach. Method: This study implemented two recruitment strategies for participants; email invitations to all members of ILSA and INTO, and email invitations with study information to school principals. A study specific questionnaire was devised with three questions offering free text responses. All responses were anonymous and analysed collectively. The Braun and Clarke thematic analysis method was employed to analyse participants' responses. Results: 224 participants responded to the survey, however not all participants completed all three questions. Initially 98 codes were generated from the data set, and subsequently reduced to 41 final codes. The codes were arranged into three final themes; Overburdened, Abandoned, and Consequences, representing occupational stress in teachers during COVID-19. Conclusion: In the form of the three themes identified, participants described issues such as large class sizes, high workload, and out of work hours contact, among others. These issues contributed negatively to participants' mental health and wellbeing with descriptions of being exhausted, isolated, stressed and experiencing burnout. Ensuring adequate awareness of, and paying attention to, teacher wellbeing is essential, such that optimisation of school environment can occur in light of additional burden associated with COVID-19.