Study protocol for the Multiple Symptoms Study 3: a pragmatic, randomised controlled trial of a clinic for patients with persistent (medically unexplained) physical symptoms.

INTRODUCTION: Persistent physical symptoms (which cannot be adequately attributed to physical disease) affect around 1 million people (2% of adults) in the UK. They affect patients' quality of life and account for at least one third of referrals from General Practitioners (GPs) to specialists. These referrals give patients little benefit but have a real cost to health services time and diagnostic resources. The symptoms clinic has been designed to help people make sense of persistent physical symptoms (especially if medical tests have been negative) and to reduce the impact of symptoms on daily life. METHODS AND ANALYSIS: This pragmatic, multicentre, randomised controlled trial will assess the clinical and cost-effectiveness of the symptoms clinic intervention plus usual care compared with usual care alone. Patients were identified through GP searches and mail-outs and recruited by the central research team. 354 participants were recruited and individually randomised (1:1). The primary outcome is the self-reported Physical Health Questionnaire-15 at 52 weeks postrandomisation. Secondary outcome measures include the EuroQol 5 dimension 5 level and healthcare resource use. Outcome measures will also be collected at 13 and 26 weeks postrandomisation. A process evaluation will be conducted including consultation content analysis and interviews with participants and key stakeholders. ETHICS AND DISSEMINATION: Ethics approval has been obtained via Greater Manchester Central Research Ethics Committee (Reference 18/NW/0422). The results of the trial will be submitted for publication in peer-reviewed journals, presented at relevant conferences and disseminated to trial participants and patient interest groups. TRIAL REGISTRATION NUMBER: ISRCTN57050216.

Differences in digital health literacy and future anxiety between health care and other university students in England during the COVID-19 pandemic.

BACKGROUND: This study investigates university students' digital health literacy and web-based information-seeking behaviours during the early stages of the COVID-19 pandemic in England. It compares undergraduate and postgraduate students in non-health related subjects with health care students, many of whom were preparing for, or working in, frontline roles. The survey was conducted as part of a wider study by the COVID-HL research consortium. METHODS: A cross-sectional study was conducted among n = 691 university students aged ≥18 years from 25 universities across England using an adapted digital survey developed by COVID-HL. Data were collected regarding sociodemographic characteristics and specific measures drawn from the Future Anxiety Scale and the Digital Health Literacy Instrument (DHLI). These had been adapted for use in an English setting and to the specific context of the COVID-19 pandemic. Other data collected included students' anxiety or worries about the future using the Dark Future Scale as well as behaviours in online information-seeking. Data were analysed using correlations to test for relationships between constructs and also between group comparisons to test for differences between students studying health and non-health related subjects. RESULTS: Across digital health literacy dimensions, there was no significant difference between students studying health-related subjects and other students. Health care students did report greater difficulties in relation to how to behave online. They also relied less on public body sources for information about the pandemic. A significant difference was found between the two student populations in relation to their anxiety about the future with health care students reporting fewer fears about the future. CONCLUSIONS: Although digital health literacy is well developed in university students, a significant proportion of students still face difficulties with evaluating online information which may frustrate public health efforts. This could be addressed by ensuring health students' curriculum in particular encompasses digital health literacy.

The association of self-efficacy and health literacy to chemotherapy self-management behaviors and health service utilization.

BACKGROUND: Increasing demands on Canada's healthcare system require patients to take on more active roles in their health. Effective self-management has been linked to improved health outcomes; and there is evidence that effective behaviors, and subsequent healthcare utilization, are linked to self-efficacy and health literacy; however, this link has had minimal testing in the cancer context. Our aim is to examine the association between self-efficacy, health literacy, chemotherapy self-management behaviors, and health service utilization. DESIGN AND METHODS: A cross-sectional survey that included validated measures of self-efficacy, health literacy, chemotherapy self-management, and health service utilization was completed by participants (N = 213). Multivariable modeling using hierarchical linear regression was used to examine the association between variables. RESULTS: Self-efficacy contributed significantly to explaining variation in chemotherapy self-management score. Health literacy was not significantly associated with any of the dependent variables. CONCLUSION: Participants with higher self-efficacy had higher chemotherapy self-management scores compared to participants with low self-efficacy. Contrary to evidence in the chronic disease self-management literature, this study demonstrated that health literacy was not associated with chemotherapy self-management behavior nor was it associated with self-efficacy. Building patient self-efficacy in the context of chemotherapy self-management could be particularly helpful both in the cancer center and in the domain of oral chemotherapy management at home where patients are required to take on significant responsibility for self-management.

Health promotion preparedness for health crises - a 'must' or 'nice to have'? Case studies and global lessons learned from the COVID-19 pandemic.

The current COVID-19 pandemic has exposed missing links between health promotion and national/global health emergency policies. In response, health promotion initiatives were urgently developed and applied around the world. A selection of case studies from five countries, based on the Socio-Ecological Model of Health Promotion, exemplify 'real-world' action and challenges for health promotion intervention, research, and policy during the COVID-19 pandemic. Interventions range from a focus on individuals/families, organizations, communities and in healthcare, public health, education and media systems, health-promoting settings, and policy. Lessons learned highlight the need for emphasizing equity, trust, systems approach, and sustained action in future health promotion preparedness strategies. Challenges and opportunities are highlighted regarding the need for rapid response, clear communication based on health literacy, and collaboration across countries, disciplines, and health and education systems for meaningful solutions to global health crises.

Increasing Health Literacy May Reduce Health Inequalities: Evidence from a National Population Survey in Ireland.

Background. Health literacy has been separately associated with socio-economic status and worse health status and outcomes. However, the magnitude of the associations between health literacy and health status and outcomes may not be evenly distributed across society. This study aims to estimate and compare the associations between health status, health behaviours, and healthcare utilisation within different levels of social status in the Irish population. Materials and methods. Data from Ireland collected as part of the 2011 European Health Literacy Survey were analysed. General health literacy was measured on a 0-50 scale, low to high. There were four binary outcomes: long-standing health conditions, smoking, hospital visits in the last 12 months, and self-rated health status. Logistic regression analysis was conducted to estimate the likelihood of each health outcome. Health literacy was treated as the main independent variable. Marginal effects were calculated using the delta method to demonstrate the change in likelihood of each outcome associated with a 5-point increase in health literacy score. The sample was grouped into tertiles based on self-reported social status, and models were replicated and compared for each tertile. Models were adjusted for known correlates of health literacy and health: age, gender, and education. Analysis was conducted using Stata V14. Results. Higher health literacy scores were associated with a lower probability of having a limiting illness within the low social status group only. Higher health literacy scores were associated with a lower probability of three or more hospital visits in the past 12 months in the low and middle social status groups. For people in the low and middle social status groups, higher health literacy levels were associated with a lower probability of being a current smoker. The associations between health literacy and self-rated health status were similar in each social status group. Conclusions: Improvement in population health literacy may reduce the prevalence of long-term chronic health conditions, reduce smoking levels, and result in fewer hospital visits. Whilst improved health literacy should improve behaviours and outcomes in all groups, it should have a more marked impact in lower social status groups, and hence contribute to reducing the observed social disparities in these health outcomes.

Can patients with low health literacy be identified from routine primary care health records? A cross-sectional and prospective analysis.

BACKGROUND: People with low health literacy (HL) are at increased risk of poor health outcomes, and receive less benefit from healthcare services. However, healthcare practitioners can effectively adapt healthcare information if they are aware of their patients' HL. Measurements are available to assess HL levels but may not be practical for use within primary care settings. New alternative methods based on demographic indicators have been successfully developed, and we aim to test if such methodology can be applied to routinely collected consultation records. METHODS: Secondary analysis was carried out from a recently completed prospective cohort study that investigated a primary care population who had consulted about a musculoskeletal pain problem. Participants completed questionnaires (assessing general health, HL, pain, and demographic information) at baseline and 6 months, with linked data from the participants' consultation records. The Single Item Literacy Screener was used as a benchmark for HL. We tested the performance of an existing demographic assessment of HL, whether this could be refined/improved further (using questionnaire data), and then test the application in primary care consultation data. Tests included accuracy, sensitivity, specificity, and area under the curve (AUC). Finally, the completed model was tested prospectively using logistic regression producing odds ratios (OR) in the prediction of poor health outcomes (physical health and pain intensity). RESULTS: In total 1501 participants were included within the analysis and 16.1% were categorised as having low HL. Tests for the existing demographic assessment showed poor performance (AUC 0.52), refinement using additional components derived from the questionnaire improved the model (AUC 0.69), and the final model using data only from consultation data remained improved (AUC 0.64). Tests of this final consultation model in the prediction of outcomes showed those with low HL were 5 times more likely to report poor health (OR 5.1) and almost 4 times more likely to report higher pain intensity (OR 3.9). CONCLUSIONS: This study has shown the feasibility of the assessment of HL using primary care consultation data, and that people indicated as having low HL have poorer health outcomes. Further refinement is now required to increase the accuracy of this method.

A qualitative study about the experiences of ethnic minority pregnant women with gestational diabetes.

BACKGROUND: Gestational diabetes mellitus demands rapid health behaviour changes for the pregnant woman to obtain stable blood glucose levels. In Denmark, the general incidence of gestational diabetes mellitus is about 3%, but more than 4.5% among non-Western immigrants and descendants. Women belonging to ethnic minorities may be particularly challenged by health behaviour changes due to educational, language and cultural barriers. AIM: To explore how non-Western ethnic minority pregnant women in Denmark experience the hospital-based information about gestational diabetes mellitus and how they integrate this information into their everyday life. A secondary aim was to investigate how health literacy and distributed health literacy affect this process. METHODS: Semistructured, qualitative interviews with 11 women. Thematic analysis was conducted with a special focus on health literacy as analytical approach. RESULTS: Three themes were identified: Reaction to the diagnosis, Everyday life and Information needs. All women felt sad and worried by the diagnosis. Some struggled to implement the recommended behaviour changes, and many lacked supports from their spouse. The hospital-based information was positively evaluated, but in some cases, the information was misunderstood. Social networks, language skills, and the ability to seek and assess information were important factors influencing the degree to which the women experienced gestational diabetes mellitus to be a challenge. CONCLUSION: Women were generally satisfied with the hospital-based information. Women with low health literacy/poor Danish language skills seem to be most challenged by the diagnosis. Future research should examine ways to organise patient-centred health care while simultaneously supporting women's opportunity to increase health literacy through, for example social network and the Internet.

What is the evidence on the methods, frameworks and indicators used to evaluate health literacy policies, programmes and interventions at the regional, national and organizational levels?

The Health Evidence Network (HEN) is an information service for public health decision-makers in the WHO European Region, in action since 2003 and initiated and coordinated by the WHO Regional Office for Europe under the umbrella of the European Health Information Initiative (a multipartner network coordinating all health information activities in the WHO European Region). HEN supports public health decision-makers to use the best available evidence in their own decision-making and aims to ensure links between evidence, health policies and improvements in public health. The HEN synthesis report series provides summaries of what is known about the policy issue, the gaps in the evidence and the areas of debate. Based on the synthesized evidence, HEN proposes policy options, not recommendations, for further consideration of policy-makers to formulate their own recommendations and policies within their national context.

What is the evidence on the methods, frameworks and indicators used to evaluate health literacy policies, programmes and interventions at the regional, national and organizational levels?

Although health literacy has long been a focus of attention in the WHO European Region, survey evidence in 2011 of eight Member States indicated that more than 47% of the adult population had suboptimal personal health literacy. Initiatives to prioritize health literacy in public policies include the WHO Shanghai Declaration, Health 2020, the European policy framework that supports action across government and society for health and well-being, and the Health Evidence Network report on health literacy policies in the WHO European Region. This review identifies evidence on the methods, frameworks, measurement instruments, domains and indicators used to evaluate health literacy policies, programmes and interventions at all levels. Limited evidence was found on evaluation of national policies and programmes, but local programmes and interventions have been measured using quantitative, qualitative and mixed-methods approaches. Policy considerations include the development of frameworks and indicators covering a range of domains to enable consistent and comparable population monitoring and evaluations to determine the impact and effectiveness of national policies and programmes.

Welche Erkenntnisse gibt es zu den Methoden, Rahmen und Indikatoren für die Evaluation von Handlungskonzepten, Programmen und Interventionen zur Gesundheitskompetenz auf Landes-, Regions- und Organisationsebene?

Auch wenn Gesundheitskompetenz in der Europäischen Region der WHO schon seit Langem Beachtung findet, so ergab doch eine Erhebung aus dem Jahr 2011, dass mehr als 47% der erwachsenen Bevölkerung in den acht teilnehmenden Mitgliedstaaten über eine suboptimale persönliche Gesundheitskompetenz verfügen. Zu den Initiativen zur Priorisierung der Gesundheitskompetenz im öffentlichen Gesundheitswesen zählen die Erklärung der WHO von Shanghai, das Aktionsnetzwerk der WHO zur Messung der Gesundheitskompetenz von Bevölkerung und Organisationen und der Bericht des Health Evidence Network zu Handlungskonzepten für Gesundheitskompetenz in der Europäischen Region der WHO. Der vorliegende Bericht enthält Evidenz über die Methoden, Rahmenkonzepte, Messinstrumente, Bereiche und Indikatoren, die auf allen Ebenen zur Evaluation von Handlungskonzepten, Programmen und Interventionen für Gesundheitskompetenz angewandt werden. Zwar gibt es nur begrenzte Erkenntnisse zur Evaluation nationaler Handlungskonzepte und Programme, jedoch wurden kommunale Programme und Interventionen unter Anwendung quantitativer, qualitativer und methodisch gemischter Ansätze analysiert. Grundsätzliche Überlegungen betreffen unter anderem die Entwicklung von Rahmenkonzepten und Indikatoren für eine Vielzahl von Bereichen, die eine in sich stimmige und vergleichbare Überwachung und Evaluation auf Ebene der Bevölkerung ermöglichen und so Rückschlüsse auf die Wirkung und Effektivität nationaler Handlungskonzepte und Programme zulassen.

Que sait-on des méthodes, des cadres et des indicateurs utilisés pour évaluer les politiques, les programmes et les interventions en matière de littératie en santé aux niveaux régional, national et organisationnel ?

Bien que la Région européenne de l’OMS accorde de longue date son attention à la littératie en santé, une étude réalisée en 2011 dans huit États membres a montré que chez plus de 47 % de la population adulte, le niveau de littératie en santé n’était pas optimal. Les initiatives qui visent à accorder la priorité à la littératie en santé dans les politiques publiques comprennent la Déclaration de Shanghai de l’OMS, Santé 2020, le cadre politique européen qui soutient les interventions pangouvernementales et pansociétales pour la santé et le bien-être, et le rapport de synthèse du Réseau des bases factuelles en santé sur les politiques de littératie en santé dans la Région européenne de l’OMS. Le présent rapport répertorie les informations factuelles portant sur les méthodes, les cadres, les instruments de mesure, les domaines et les indicateurs utilisés pour évaluer les politiques, les programmes et les interventions en matière de littératie en santé à tous les niveaux. Les bases factuelles recueillies sur l’évaluation des politiques et des programmes nationaux ont été limitées, mais des programmes et des interventions locales ont été mesurés à l’aide de méthodes quantitatives, qualitatives et mixtes. Parmi les options politiques figurent la mise au point de cadres et d’indicateurs couvrant un ensemble de domaines susceptibles de permettre un suivi de la population et des évaluations cohérentes et comparables sur les effets et l’efficacité des politiques et des programmes nationaux.

Обзор имеющихся фактических данных о методах, механизмах и показателях, используемых для оценки стратегий, программ и мероприятий в сфере развития грамотности в вопросах здоровья на региональном, национальном и организационном уровнях

Хотя в Европейском регионе ВОЗ грамотности в вопросах здоровья давно уделяется большое внимание, данные проведенного в 2011 г. опросного исследования, в котором участвовали восемь государств-членов, показали, что более 47% взрослого населения этих стран обладают недостаточным уровнем личной грамотности в вопросах здоровья. К числу ключевых инициатив ВОЗ, призванных сделать развитие грамотности в вопросах здоровья приоритетным направлением государственной политики, относятся Шанхайская декларация ВОЗ, Сеть действий по оценке грамотности в вопросах здоровья среди населения и на уровне организаций, а также доклад Сети фактических данных по вопросам здоровья, посвященный мерам политики в области развития грамотности в вопросах здоровья в Европейском регионе ВОЗ. В настоящем обзоре приводятся данные о методах, рамочных механизмах, инструментах оценки, сферах и показателях, используемых для оценки эффективности стратегий, программ и мероприятий по развитию грамотности в вопросах здоровья на всех уровнях. Авторы доклада обнаружили, что объем данных об оценке национальных стратегий и программ весьма ограничен, однако при этом они установили, что в ходе оценки местных программ и мероприятий использовались количественные, качественные и смешанные методы. К числу предлагаемых к рассмотрению мер политики относится разработка рамочных механизмов и показателей, охватывающих целый ряд областей. Такие механизмы и показатели позволяют проводить последовательный мониторинг и оценку ситуации среди населения с использованием сопоставимых данных, чтобы определить уровень воздействия на ситуацию национальных стратегий и программ и оценить их эффективность.

Understanding Educational and Psychosocial Factors Associated with Alcohol Use among Adolescents in Denmark; Implications for Health Literacy Interventions.

Background. Alcohol misuse is a global public health priority, with a variation in prevalence and impact between countries. Alcohol misuse in adolescence is associated with adverse psychological, social and physical health. Adolescents in Denmark have higher alcohol consumption and problematic alcohol use than adolescents in other European countries. Associations between social determinants of health (SDH), psycho-social factors and alcohol consumption are complex and influenced by national context and cultures. This study explored these associations in Danish adolescents. Method. The European School Survey Project on Alcohol and Other Drugs (ESPAD) survey collects data on alcohol and substance use among 15⁻16-year-old European students. Data contributed by Danish students to the 2011 survey were analyzed. The outcomes of interest were alcohol consumption (any, intoxication and problematic). Health literacy was not directly measured, so self-described educational performance and knowledge about alcohol were used as proxies for health literacy. Exploratory factors thus included socio-demographic, health literacy-related (knowledge about alcohol, educational performance) and psycho-social factors, as well as expectancies of the effect of alcohol (both positive and negative) and self-reported health. Univariate and multivariate logistic regression analyses were undertaken. Results. Of the 2768 adolescents who participated in the survey, 2026 (80%) consumed alcohol during the last 30 days, 978 (38%) were intoxicated at least once during the last 30 days, and 1050 (41%) experienced at least one problem because of alcohol use during the last 12 months. Multivariable analysis showed that the factors associated with higher alcohol intake were gender, poor relationships with parents, expectancies of the impact of alcohol (both positive and negative), and the influence of peers and their alcohol use. Higher school performance was related to lower alcohol consumption. Low socio-demographic status was not associated with higher alcohol consumption. Conclusions. This study confirmed the high levels of alcohol intake, intoxication, and problem drinking amongst the Danish students in the survey and the complexity of the socio-demographic, psychosocial, health literacy-related, and environmental factors associated with alcohol behaviours. Approaches to addressing the issue of alcohol use in Danish adolescents will need to be multi-factorial, including supporting students to develop alcohol-related health literacy skills to enable them to make informed choices.

Обзор имеющихся фактических данных о реализуемых мерах политики и связанных с ними мероприятиях, а также об их эффективности с точки зрения повышения грамотности в вопросах здоровья на национальном, региональном и организационном уровнях в Европейском регионе ВОЗ

Повышение грамотности в вопросах здоровья привлекает к себе все больше внимания в качестве одного из методов укрепления здоровья. В настоящем сводном докладе рассказывается о мерах политики в области повышения грамотности в вопросах здоровья в Европейском регионе ВОЗ: об их распределении, организационных уровнях, предпосылках, реализующих их субъектах, связанных с ними мероприятиях и итогах их реализации, а также о факторах, влияющих на их эффективность. Фактические данные были получены в ходе предварительного анализа научной литературы на английском, нидерландском и немецком языках и “серой” литературы на английском, нидерландском, немецком и итальянском языках с опорой на результаты общерегиональной экспертизы. Полученные данные были направлены представителям 19 государств-членов в Регионе с целью проверки их точности и наличия возможных упущений. Особое внимание в докладе уделяется масштабной и успешной деятельности в области выработки политики в отношении грамотности в вопросах здоровья, в основном в секторах здравоохранения и образования; в нем также предлагаются направления для дальнейшего развития. В докладе представлены стратегические выводы, призванные содействовать: распространению примеров успешной политики и практики в области повышения грамотности в вопросах здоровья; разработке стратегических целей и мероприятий во всех сферах жизни общества; разработке надежных показателей уровня грамотности в вопросах здоровья с целью определения потребности в реализации соответствующих мер и проведения мониторинга их эффективности.

Welche Erkenntnisse gibt es zu bestehenden Handlungskonzepten und verbundenen Maßnahmen sowie deren Wirksamkeit zur Verbesserung der Gesundheitskompetenz auf Landes-, Regions- und Organisationsebene in der Europäischen Region der WHO?

Gesundheitskompetenz findet als Mittel der Gesundheitsförderung zunehmend Beachtung. Die vorliegende Evidenzaufbereitung beschreibt Handlungskonzepte zur Verbesserung der Gesundheitskompetenz in der Europäischen Region der WHO: ihre Verteilung, Organisationsebenen, Bezugselemente, Akteure, Maßnahmen und Ergebnisse, sowie die Faktoren, die Einfluss auf ihre Wirksamkeit haben. Die Erkenntnisse wurden mittels einer Sondierung wissenschaftlicher Literatur auf Deutsch, Englisch und Niederländisch und grauer Literatur auf Deutsch, Englisch, Italienisch und Niederländisch und einer Expertenerhebung in der gesamten Europäischen Region gewonnen. Die Ergebnisse wurden Vertretern von 19 Mitgliedstaaten der Europäischen Region zur Prüfung auf Genauigkeit und Auslassungen vorgelegt. Der Bericht hebt viele gute Maßnahmen in Zusammenhang mit Gesundheitskompetenz hervor, größtenteils in der Gesundheits- und Bildungspolitik, und schlägt Bereiche für eine künftige Entwicklung vor. Es werden Grundsatzüberlegungen zur Förderung der gemeinsamen Nutzung guter konzeptioneller Praktiken im Bereich der Gesundheitskompetenz, der Entwicklung konzeptioneller Ziele und Maßnahmen über alle sozialen Bereiche hinweg sowie der Entwicklung belastbarer Kennwerte für Gesundheitskompetenz zur Identifizierung des Bedarfs und die Überwachung der Wirksamkeit vorgestellt.

Que sait-on de l’efficacité des politiques existantes et des activités en rapport avec celles-ci, s’agissant d’améliorer l’éducation sanitaire aux niveaux national, régional et organisationnel dans la Région européenne de l’OMS ?

L’instruction en matière de santé suscite une attention croissante comme moyen de promouvoir la santé. Cette synthèse des données probantes décrit les politiques en faveur de l’éducation à la santé dans la Région européenne de l’OMS : répartition, niveaux organisationnels, antécédents, acteurs, activités et résultats, ainsi que les facteurs influençant leur efficacité. Les données probantes ont été obtenues grâce à l’examen de publications du monde universitaire en allemand, anglais et néerlandais, ainsi que de la littérature grise en allemand, anglais, italien et néerlandais, avec l’appui d’une mission d’expertise à l’échelle régionale. Les conclusions qui en ont été tirées ont été présentées aux représentants de 19 États membres de la Région afin d’en vérifier l’exactitude et de déceler les omissions. Ce rapport met en exergue une multitude d’activités en rapport avec les politiques visant une bonne instruction en matière de santé, surtout dans les secteurs de la santé et de l’éducation, et propose des axes de développement futur. On y présente des considérations sur les stratégies à appliquer afin de faciliter la diffusion des bonnes pratiques pour les politiques d’éducation sanitaire, la formulation d’objectifs stratégiques et l’organisation d’activités dans tous les secteurs de la société, ainsi que la mise au point de bons outils de mesure afin de déterminer les besoins sur le plan de l’éducation sanitaire et d’observer le degré d’efficacité en la matière.

What is the evidence on existing policies and linked activities and their effectiveness for improving health literacy at national, regional and organizational levels in the WHO European Region?

Health literacy is gaining increasing attention as a means of promoting health. This evidence synthesis describes health literacy policies in the WHO European Region: their distribution, organizational levels, antecedents, actors, activities and outcomes, along with the factors influencing their effectiveness. Evidence was obtained by a scoping review of academic literature in English, Dutch and German and of grey literature in English, Dutch, German and Italian, supported by a Region-wide expert enquiry. Emerging findings were presented to representatives from 19 Member States of the Region to check for accuracy and omissions. The report highlights much good health literacy policy-related activity, mostly in the health and education sectors, and proposes areas for future development. Policy considerations to facilitate the sharing of good health literacy policy practice, the development of policy aims and activities across all societal areas, and the development of robust health literacy metrics to identify the need for and monitor effectiveness are presented.