Enhancing effective healthcare communication in Australia and Aotearoa New Zealand: Considerations for research, teaching, policy, and practice.

Objective: In this article we present a conceptual framework for enhancing effective healthcare communication in Australia and Aotearoa New Zealand. Methods: Through an iterative, deliberative dialogue approach, we, as experts from a variety of health professions and academic disciplines, worked together to identify core values and considerations for healthcare communication across numerous health professions and disciplines and within research, teaching, policy, and practice contexts. Results: The framework developed includes five core values at its centre: equitable, inclusive, evidence-based, collaborative, reflective. Around this are concentric circles showing key elements of collaborators, modality, context, and purpose. Each of these is explored. Conclusion: This work may support benchmarking for healthcare providers, researchers, policymakers, and educators across a breadth of professions to help improve communication in clinical practice. The framework will also help to identify areas across disciplines that are shared and potentially idiosyncratic for various professions to promote interprofessional recognition, education, and collaboration. Innovation: This framework is designed to start conversations, to form the foundation of a dialogue about the priorities and key considerations for developing teaching curricula, professional development, and research programs related to healthcare communication, providing a set of values specifically for the unique contexts of Australia and Aotearoa New Zealand. It can also be used to guide interdisciplinary healthcare professionals in advancing research, teaching, policy, and practice related to healthcare communication.

Therapist Voices on a Youth Mental Health Pilot: Responsiveness to Diversity and Therapy Modality.

This article explores therapists' views on a large youth mental health pilot project (for 18-25-year-olds), which included an individual cognitive behavior therapy (CBT)-informed individual therapy component. Therapists' views on cultural responsiveness, therapy (delivery, modality and duration) and working with LGBTQIA+ youth were explored using two surveys, individual interviews and focus groups at various stages of the life of the pilot. Some therapists saw the CBT approach as imposed on them, preferring familiar therapy modalities. Many therapists were positive toward CBT for its client-centered approach and reported using CBT-informed approaches with many of their clients to good effect. Some therapists felt pressured by their workplace to see clients for fewer sessions than they needed. Therapists wanted to see a more culturally diverse workforce, to increase their cultural competence through training and to have more easily available cultural supervision. There was some acknowledgement of the importance of training therapists to work competently with LGBTQIA+ young people. Involving therapists in co-design of services from the outset will likely benefit future service development.

Patient Responses to Diagnosis in Surgeon-Patient Consultations.

How diagnosis fits within the overall activity structure of surgical consultations remains under-researched. We set out to contribute to this developing area of research with a particular focus on responses to diagnosis as an achievement of patient agency. We identified 26 diagnostic sequences in a collection of 35 video recorded surgical consultations and examined these in detail using conversation analysis. The activity of diagnosis and the transition to treatment recommendation appear to be structured somewhat differently in surgeon-patient consultations than has been reported for primary care settings. In particular, patient responses to diagnosis are more frequent and more likely to be extended. The analysis provides evidence that both parties orient to surgeons' accountability for their own diagnostic reasoning, and also the medical authority of the referring doctor and the subjective experience of the patient. In delivering the diagnosis, the surgeon must be cognizant of the opinions of both the patient and the referring doctor, which may align to a greater or lesser extent with their own diagnosis.

"It's All Just Marketing", a Qualitative Analysis of Consumer Perceptions and Understandings of Nutrition Content and Health Claims in New Zealand.

Nutrition content and health claims are widely used globally on both food labels and in food advertising. This study explored how New Zealand consumers understand, perceive, and use nutrition content and health claims on food labels. A qualitative approach was used with semi-structured in-depth online interviews and in-person focus groups including 49 participants, aged ≥25 years responsible for household food shopping. Transcripts were analysed using reflexive thematic analysis using inductive coding, with development of five themes-(1) aware of claims but did not use, (2) mistrust and scepticism, (3) confusion and misinterpretation, (4) using claims to guide food choice, and (5) not all claims are equal. For theme 1, price and habit were found to be the most influential in driving food choice. Underlying theme 2 was the perception by most of nutrition and health claims as marketing. Scepticism was exacerbated when nutrient claims were displayed on inherently unhealthy products. However participants with specific dietary requirements did find claims helpful. Restricting nutrient claims to foods meeting a healthy nutrient profile aligned to the existing Health Star Rating system, education about regulation and supporting claims with more contextual information may increase trust, the perceived value of claims and therefore their utility.

How is family health history discussed in routine primary healthcare? A qualitative study of archived family doctor consultations.

OBJECTIVES: Family health history underpins genetic medicine. Our study aimed to explore language and patterns of communication relating to family health history observed in interactions between general practitioners (GPs) and their patients within routine primary care consultations. DESIGN: Secondary analysis of patient and GP routine consultation data (n=252). PARTICIPANTS: Consultations that included 'family health history' were eligible for inclusion (n=58). PRIMARY OUTCOMES: A qualitative inductive analysis of the interactions from consultation transcripts. RESULTS: 46/58 conversations about family health history were initiated by the GP. Most discussions around family history lasted for between approximately 1 to 2 min. Patients were invited to share family health history through one of two ways: non-specific enquiry (eg, by asking the patient about 'anything that runs in the family'); or specific enquiry where they were asked if they had a 'strong family history' in relation to a particular condition, for example, breast cancer. Patients often responded to either approach with a simple no, but fuller negative responses also occurred regularly and typically included an account of some kind (eg, explaining family relationships/dynamics which impeded or prevented the accessibility of information). CONCLUSIONS: Family health history is regarded as a genetic test and is embedded in the sociocultural norms of the patient from whom information is being sought. Our findings highlight that it is more complex than asking simply if 'anything' runs in the family. As the collection of family health history is expected to be more routine, it will be important to also consider it from sociocultural perspectives in order to help mitigate any inequities in how family history is collected, and therefore used (or not) in a person's healthcare. Orientating an enquiry away from 'anything' and asking more specific details about particular conditions may help facilitate the dialogue.

How do patients and General Practitioners talk about pain and negotiate empathy in consultations? A direct observational study.

The objective of this qualitative study in New Zealand was to investigate how general practitioners and patients discuss chronic pain in consultations. Chronic pain is a complex condition that defies many commonsense understandings. It is challenging to manage and patients can come to conclude that there is an empathy deficit. To our knowledge most, if not all, studies on this topic have recruited participants whose main presenting complaint is chronic pain. Forms of chronic pain are relatively common in the population and we thought it likely that at least some discussions may be rendered invisible via these recruiting practices. The study analysed data from the Applied Research on Communication in Health repository of audio transcripts and video-recorded consultations collected from a range of studies on a variety of topics, none of which were about chronic pain specifically. We searched the 256 transcripts looking for key words that might indicate that pain was at least part of the consultation. This yielded a large number of potentially relevant transcripts. These transcripts were assessed and reduced to 18 by excluding those that were about non-physical pain or pain that was expected to resolve relatively quickly. A medical specialist in chronic pain reviewed the resulting 18 and excluded two further transcripts giving us a final sample of 16. We conducted in-depth analysis of these consultations. Rather than confirming an empathy deficit, we found a much more complex deployment of empathy in the space where the two complex systems of chronic pain and general practice meet. These findings highlight the utility of analysing data originally generated for other purposes, with permission, and in a practical sense, highlight the importance of understanding empathy as highly contextual in 'real world' practice.

'Water dripping on a stone': a feasibility study of a healthy weight management conversation approach in routine general practice consultations.

BACKGROUND: Primary health care has an important role to play in the management of weight and yet discussions of healthy weight management do not occur optimally, indicating a need for simple tools and training in brief weight counselling. The 'FABS' approach (focusing on four topic areas: Food, Activity, Behaviour and Support) was developed to address this. OBJECTIVES: To explore the feasibility of the 'FABS' approach within routine general practice consultations and its effectiveness in facilitating healthy weight conversations. METHOD: The FABS approach was run for a trial period in five New Zealand general practices. The approach entailed staff training, the addition to the practice patient management system of a template outlining potential topics for discussion and a patient handout. GPs were asked to use the approach with any adult patient with a body mass index of over 28 kg/m2. A descriptive analysis of anonymized quantitative practice data was conducted, with limited qualitative data from an online clinician questionnaire and interviews with GPs and patients. RESULTS: Over 4 months, the template was opened 862 times by 27 clinicians in 830 patient consultations. All FABS topics were raised at least once. Physical activity was raised most frequently, followed by two food-related topics. There was variation between practices and between GPs. GPs tended to raise more topics within a single consultation than the training recommended. The limited clinician survey results and patient interviews also indicated positive responses to the approach. CONCLUSIONS: It is possible to provide an infrastructure for healthy weight conversation approaches within general practice so that patients receive supportive and consistent messages on a regular basis. General practice is an appropriate setting for this due to the ongoing relationships with patients and team-based approach, but there is a need for effective training and education to ensure appropriate and effectively delivery.

Young people with a variation in sex characteristics in Aotearoa/New Zealand: identity, activism and healthcare decision-making.

Young people born with variations in sex characteristics (VSC) or disorders of sex development (DSD) face numerous challenges in navigating issues relating to identity and to their lived and embodied experience. There is limited published research amplifying the voices of young people with a VSC, especially from Aotearoa/New Zealand. This qualitative study provides an up-to-date picture of the lived experience of 10 young people with a VSC in Aotearoa/New Zealand. The research was conducted in collaboration with the advocacy group, Intersex Youth Aotearoa, and explored the level of support provided by health services, peers and advocacy groups in relation to the ways the participants viewed themselves and their bodies, and their health related decision-making. Findings reveal the pressure on young people with a VSC to conform to cultural and societal norms, specifically, heteronormative and traditional constructs of how male and female bodies should look in Aotearoa/NZ society. Such views, often held and perpetuated by health professionals and parents, contributed to complexities surrounding identity, agency and acceptance of difference experienced by these young people. The implications of these findings are discussed, including the need for better psychological and peer support for young people.

Communication in high risk ante-natal consultations: a direct observational study of interactions between patients and obstetricians.

BACKGROUND: Effective communication is crucial to any doctor-patient consultation, not least in pregnancy where the outcome affects more than one person. While higher levels of patient participation and shared decision making are recognised as desirable, there is little agreement on how best to achieve this. Most previous research in this area is based on reported data such as interviews or surveys and there is a need for more fine-grained analysis of authentic interaction. This study aimed to identify the discourse characteristics and patterns that exemplify effective communication practices in a high-risk ante-natal clinic. METHODS: We video-recorded 20 consultations in a high-risk ante-natal clinic in a large New Zealand city with patients attending for the first time. Post-consultation interviews were conducted with the 20 patients and 13 obstetricians involved. Discourse analysis of the transcripts and videos of the consultations was conducted, in conjunction with thematic analysis of interview transcripts. RESULTS: Most patients reported high quality communication and high levels of satisfaction; the detailed consultation analysis revealed a range of features likely to have contributed. On the clinician side, these included clear explanations, acknowledgement of the patient's experience, consideration of patient wishes, and realistic and honest answers to patient questions. On the patient side, these included a high level of engagement with technical aspects of events and procedures, and appropriate questioning of obstetricians. CONCLUSIONS: This study has demonstrated the utility of combining direct observation of consultations with data from patient experience interviews to identify specific features of effective communication in routine obstetric ante-natal care. The findings are relevant to improvements needed in obstetric communication identified in the literature, especially in relation to handling psychosocial issues and conveying empathy, and may be useful to inform communication training for obstetricians. The presence of the unborn child may provide an added incentive for parents to develop their own health literacy and to be an active participant in the consultation on behalf of their child. The findings of this study can lay the groundwork for further, more detailed analysis of communication in ante-natal consultations.

'Should I vaccinate my child?' comparing the displayed stances of vaccine information retrieved from Google, Facebook and YouTube.

Whether to vaccinate or not is currently a hot topic in social discourse. Despite the majority view that childhood vaccination is safe and effective, websites and social media content opposing such vaccination are common. In this study, we searched the internet platforms Google, Facebook and YouTube for childhood vaccine information. We made every attempt to minimise selection bias generated by internet algorithms. We compared the displayed stances of vaccine information retrieved. Most of the information had a clearly stated stance on vaccines or made some sort of recommendation on whether or not to vaccinate. Despite our careful attempt to search comprehensively and systematically for vaccine information with as little bias as possible, this search yielded a sizeable minority of vaccine negative information. This research shows that negative vaccine information persists and is readily accessible online despite algorithm and policy changes in recent years, even when searching in the least biased way possible. It is important that vaccine-promoting entities and agencies continue to make every effort to maximize their presence online so that parents searching the internet to answer the question 'should I vaccinate my child?' continue to receive vaccine positive information.

The handover room: a qualitative enquiry into the experience of morning clinical handover for acute medical teams.

BACKGROUND: Effective clinical handover has always been integral to delivering safe, high-quality care in medical wards. AIM: As handover activity increases in importance we wanted to explore the experience of physicians and trainee doctors. There is little research on internal medicine handover with even less based on direct observational research. METHODS: Data collection over 4 months by two general medicine physicians included participant observation of 37 meetings and 52 audio-recorded individual interviews. Inductive thematic analysis of the transcribed interviews proceeded iteratively in parallel with data collection. RESULTS: There was an excellent response rate from 27 of 28 invited trainees and 25 of 26 invited physicians. Overall the experience was positive. Acute medicine handover is a complex human endeavour, occurring daily with an unpredictable workload and areas of tension. Themes were grouped as structural (leadership role, start time, sequence, checklist, handbacks and efficiency) and relational (sensitivity, collegiality, acknowledgement, performance anxiety, tension, responsibility and leadership style). The physician leader needs to be skilled to follow the agreed and evolving process as well as being prepared, authoritative, flexible, equitable, aware and sensitive to the needs of senior colleagues and trainees. There was a tension between efficiency and teaching opportunities. CONCLUSION: This paper adds to a contextually sensitive understanding of the social dynamics of handover in acute medicine. Addressing the structural aspects is important to provide the necessary consistency and efficiency in what is an extremely complex and time-sensitive environment. As we continue to work on the evolution of the handover process in acute internal medicine, we must also attend to the relational aspects which are dynamic and central to its sustainability.

Health navigation and interpreting services for patients with limited English proficiency: a narrative literature review.

INTRODUCTION Culturally and linguistically diverse populations (CALD) have significant health outcome disparities compared to dominant groups in high-income countries. The use of both navigators and interpreters are strategies used to address these disparities, but the intersections between these two roles can be poorly understood. AIM To gain an overview of the literature on health navigation and similar roles, with particular reference to the New Zealand context, and to explore the interface between these roles and that of interpreters for CALD populations with limited English proficiency. METHODS A narrative review of the literature was conducted using a range of search strategies and a thematic analysis was conducted. RESULTS There are several barriers to health-care access relating to health systems and CALD populations. For over 50 years, health workers who are members of these communities have been used to address these barriers, but there are many terms describing workers with wide-ranging roles. There is some evidence of efficacy in economic, psychosocial and functional terms. For health navigation services to work, they need to have staff who are well selected, trained and supported; are integrated into health-care teams; and have clearly defined roles. There may be a place for integrating interpreting more formally into the navigator role for members of communities who have limited English proficiency. CONCLUSION To achieve better access to health care for CALD populations, there is an argument for adding another member to the health team who combines clearly defined aspects of the roles of interpreter, community health worker and navigator. Organisations considering setting up such a position should have a clear target population, carefully consider the barriers they are trying to address and define a role, scope of practice and training requirements best suited to addressing those barriers.

A taboo topic? How General Practitioners talk about overweight and obesity in New Zealand.

INTRODUCTION Obesity is overtaking tobacco smoking in New Zealand as the leading potentially modifiable risk to health. International obesity guidelines recommend that health professionals opportunistically encourage weight management with their patients. However, research shows consistently low rates of weight management discussion, suggesting that health professionals may not be realising their full potential to address obesity. AIM To identify communication strategies used by General Practitioners (GPs) to open the topic of weight and weight management in routine consultations. METHODS A secondary analysis was conducted of 36 video-recorded consultations in general practices, selected for relevance from a database of 205 consultations. Content and interactional analysis was conducted in the context of the entire consultation. RESULTS The topic of weight was initiated more often by GPs than patients and was raised mostly once or twice in a consultation and occasionally as many as six times. GPs employed opportunistic strategies twice as often as they used structured strategies. DISCUSSION This study of naturally occurring consultations confirmed GPs do engage in opportunistic discussions about weight. However, such discussions are challenging and interactionally delicate. Highlighting the clinical relevance of weight appears to be effective. The high frequency of patient contact with GPs provides opportunity to reach and work with people at risk of chronic conditions associated with excess weight. Further research is required to identify suitable training and brief intervention tools for use in routine consultations that may be beneficial for both GPs and patients.

Quantifying the incidence and burden of herpes zoster in New Zealand general practice: a retrospective cohort study using a natural language processing software inference algorithm.

OBJECTIVE: To investigate the incidence of primary care presentations for herpes zoster (zoster) in a representative New Zealand population and to evaluate the utilisation of primary healthcare services following zoster diagnosis. DESIGN: A cross-sectional retrospective cohort study used a natural language processing software inference algorithm to identify general practice consultations for zoster by interrogating 22 million electronic medical record (EMR) transactions routinely recorded from January 2005 to December 2015. Data linking enabled analysis of the demographics of each case. The frequency of doctor visits was assessed prior to and after the first consultation diagnosing zoster to determine health service utilisation. SETTING: General practice, using EMRs from two primary health organisations located in the lower North Island, New Zealand. PARTICIPANTS: Thirty-nine general practices consented interrogation of their EMRs to access deidentified records for all enrolled patients. Out-of-hours and practice nurse consultations were excluded. MAIN OUTCOME MEASURES: The incidence of first and repeated zoster-related visits to the doctor across all age groups and associated patient demographics. To determine whether zoster affects workload in general practice. RESULTS: Overall, for 6 189 019 doctor consultations, the incidence of zoster was 48.6 per 10 000 patient-years (95% CI 47.6 to 49.6). Incidence increased from the age of 50 years to a peak rate of 128 per 10 000 in the age group of 80-90 years and was significantly higher in females than males (p<0.001). Over this 11-year period, incidence increased gradually, notably in those aged 80-85 years. Only 19% of patients had one or more follow-up zoster consultations within 12 months of a zoster index consultation. The frequency of consultations, for any reason, did not change between periods before and after the diagnosis. CONCLUSIONS: Zoster consultations in general practice are rare, and the burden of these cases on overall general practice caseload is low.

A Longitudinal Study of Interactions Between Health Professionals and People With Newly Diagnosed Diabetes.

PURPOSE: We undertook a study to observe in detail the primary care interactions and communications of patients with newly diagnosed diabetes over time. In addition, we sought to identify key points in the process where miscommunication might occur. METHODS: All health interactions of 32 patients with newly diagnosed type 2 diabetes were recorded and tracked as they moved through the New Zealand health care system for a period of approximately 6 months. Data included video recordings of patient interactions with the health professionals involved in their care (eg, general practitioners, nurses, dietitians). We analyzed data with ethnography and interaction analysis. RESULTS: Challenges to effective communication in diabetes care were identified. Although clinicians showed high levels of technical knowledge and general communication skill, initial consultations were often driven by biomedical explanations out of context from patient experience. There was a perception of time pressure, but considerable time was spent with patients by health professionals repeating information that may not be relevant to patient need. Health professionals had little knowledge of what disciplines other than their own do and how their contributions to patient care may differ. CONCLUSIONS: Despite current high skill levels of primary care professionals, opportunities exist to increase the effectiveness of communication and consultation in diabetes care. The various health professionals involved in patient care should agree on the length and focus of each consultation.

"I can't bend it and it hurts like mad": direct observation of gout consultations in routine primary health care.

BACKGROUND: Gout is the most common form of inflammatory arthritis and is associated with considerable co-morbidity. It is usually managed in the primary care setting with a combination of lifestyle modification and pharmacological therapy. This study describes patterns of communication about gout observed in interactions between patients and primary care practitioners during routine consultations. METHODS: Secondary analysis of video-recordings of individual healthcare consultations between patients and a range of primary care practitioners (including general practitioners, practice nurses, podiatrists and dietitians) from an archived database. Consultations that included any discussion about gout were eligible for inclusion (n = 31) and were not restricted to those where gout was the main presenting complaint. The consultation transcripts were analysed using a qualitative inductive approach from clinical and linguistic perspectives and supplemented with visual observation of the interactions. RESULTS: Two main themes emerged from the data; the importance of gout and 'telling' versus 'listening' in consultations. The first theme had two distinct strands; gout as an incidental part of the consultation and the impact of gout on patients. A trend towards more didactic practitioner communication encompassed by the second theme occurred at many different consultation points including diagnosis, in more general post-diagnosis discussion, and when discussing biochemical test results and lifestyle advice. In contrast, when discussion about treatment with medicines occurred a tendency towards a greater degree of listening to patients was observed. CONCLUSION: Our observation of the communication patterns in these consultations illustrates an inherent complexity of gout consultations in primary care. Gout may be more important to patients than is often apparent to practitioners in routine consultations. Consultation management needs to take into account the impact of the condition and the balance of information provided around lifestyle advice versus long-term management with medicines.

Childhood respiratory illness presentation and service utilisation in primary care: a six-year cohort study in Wellington, New Zealand, using natural language processing (NLP) software.

OBJECTIVES: To identify childhood respiratory tract-related illness presentation rates and service utilisation in primary care by interrogating free text and coded data from electronic medical records. DESIGN: Retrospective cohort study. Data interrogation used a natural language processing software inference algorithm. SETTING: 36 primary care practices in New Zealand. Data analysed from January 2008 to December 2013. PARTICIPANTS: The records from 77 582 children enrolled were reviewed over a 6-year period to estimate the presentation of childhood respiratory illness and service utilisation. This cohort represents 268 919 person-years of data and over 650 000 unique consultations. MAIN OUTCOME MEASURE: Childhood respiratory illness presentation rate to primary care practice, with description of seasonal and yearly variation. RESULTS: Respiratory conditions constituted 46% of all child-general practitioner consultations with a stable year-on-year pattern of seasonal peaks. Upper respiratory tract infection was the most common respiratory category accounting for 21.0% of all childhood consultations, followed by otitis media (12.2%), wheeze-related illness (9.7%), throat infection (7.4%) and lower respiratory tract infection (4.4%). Almost 70% of children presented to their general practitioner with at least one respiratory condition in their first year of life; this reduced to approximately 25% for children aged 10-17. CONCLUSION: This is the first study to assess the primary care incidence and service utilisation of childhood respiratory illness in a large primary care cohort by interrogating electronic medical record free text. The study identified the very high primary care workload related to childhood respiratory illness, especially during the first 2 years of life. These data can enable more effective planning of health service delivery. The findings and methodology have relevance to many countries, and the use of primary care 'big data' in this way can be applied to other health conditions.

Juicy Conceptualizations: Increasing Alliance Through Attending to Client Metaphoric Language.

BACKGROUND: There is increasing interest in the use of metaphor in cognitive behaviour therapy. Experts advocate bringing client metaphors into case conceptualizations, but there is little empirical research to support this. AIMS: This study evaluated the effect of training 12 therapists to attend to client metaphors and bring them into case conceptualizations. METHOD: Pre- and post-training role-played therapy sessions were conducted and video-recorded. Alliance was rated by role play 'clients' and an external expert rated the quality of the sessions and of the shared conceptualizations. RESULTS: There were significant increases in some ratings of alliance, based on role play 'client' ratings and external ratings of role plays of therapy sessions before and after training. The greater the difference between therapist and 'client' on a measure of preference for producing metaphor, the lower the rating of the session by the 'client' on the Bond factor score of an alliance measure, the Working Alliance Inventory. This result suggests that working metaphorically may be most effective when the therapist and client have a similar degree of preference for speaking metaphorically. CONCLUSION: This study provides preliminary support for the idea that attending to client metaphors during conceptualization can be beneficial for alliance.

'It depends on the consultation': revisiting use of family members as interpreters for general practice consultations - when and why?

Family members continue to be used as interpreters in medical consultations despite the well-known risks. This paper examines participant perceptions of this practice in three New Zealand clinics chosen for their frequent use of interpreters and their skill in using them. It is based on a detailed study of 17 video-recorded interpreted consultations and 48 post-consultation interviews with participants (5 doctors, 16 patients and 12 interpreters, including 6 family members). All participants expressed satisfaction with the communication. Analysis of the interviews explored what participants liked or valued about family member interpreters (FMIs). Key themes were the FMIs' personal relationship and knowledge, patient comfort, trust, cultural norms, time efficiency and continued help outside the consultation. General practitioners (GPs) expressed awareness of potential risks and how to manage them, in contrast to patients and FMIs. Although the use of professional interpreters needs to be strongly promoted, a well-informed decision to use a family member is appropriate in some situations. GPs need to be well trained in how to assess and manage the risks. Rather than striving for 'best practice' (i.e. universal use of professional interpreters), it is better to aim for 'good practice' where a considered judgement is made about each situation on an individual basis.