"Unable to Feed My Hungry Child": Experiences of Mothers Caring for Children With Prader-Willi Syndrome.

Mothers' experiences of caring for children with Prader-Willi Syndrome (PWS) is largely unknown. With no treatment for PWS, parents undertake (extra)ordinary care practices to keep children safe from overeating and self harm. Knowledge of these care practices could lead to effective interventions. Narrative inquiry was used to study everyday experience with Canadian mothers. Participants cared for a child 3 to 17 years old who had hyperphagia. Participants were interviewed 8 to 12 times each over the course of a year. Narrative accounts were co-composed through a collaborative process of analysis. Engaging with participants' everyday experiences amplified complex care needs for families and gaps in health and social care systems. Narrative threads focused on engaging in (extra)ordinary care practices, rigid care work to keep children healthy and safe, tension from others while enacting these care practices, and difficulty conforming to social expectations with childrearing and care work. Recommendations for practice and policy include (a) shifting from untenable care practices, (b) reconceptualizing care work, and (c) alternative care models.

Entangling Reciprocity With the Relational in Narrative Inquiry.

In this article, we develop, through drawing forward fragments of our experiences, a concept of reciprocity as always situated within the relational ontology of narrative inquiry. Reciprocity is most commonly understood within a transactional sense, an exchange of goods. We show important aspects of reciprocity in narrative inquiry, including the importance of intentionally creating and responding to spaces where reciprocity occurs and can be sustained over time and place, and the potential reciprocity holds to change who we, and those with whom we work, are. As we reconsider the ways in which reciprocity is not understood as a transaction in a relational methodology, new questions about the entanglement of reciprocity and recognition emerge. We understand that recognition does not necessarily have to be reciprocal, but recognition is necessary to compose a space where reciprocity can live in our ordinary interactions with others.

Interventions in maternal syphilis care globally: A scoping review.

Infectious and Congenital Syphilis rates continue to rise globally. Current recommendations for syphilis screening and treatment may be insufficient, and there is a pressing need for improved programs and services to address the increase in cases. A scoping review was conducted to examine approaches to maternal syphilis screening and treatment. Theoretical underpinnings and the key characteristics of these interventions were studied to identify gaps in the existing literature to guide future research. Developing a modified version of the socio-ecological model to guide data analysis, we included 33 academic studies spanning 31 years, covering a range of interventions, programs, and policies globally. We highlight key facets of interventions aligning with the five levels of the modified model that include: individual, interpersonal, institutional, community and policy. In this review, we provide valuable insights into the characteristics and principles of maternal syphilis screening and treatment interventions.

Even with advances in care, there remain many similarities in interventions for the improved treatment and screening of maternal syphilis over the past 30 years.There is a need for meaningful research that engages community members in study and intervention development and considers the social determinants of health in the context of maternal syphilis care.Examining interventions in relation to the socio-ecological model may help guide policymakers, researchers, and clinicians in intervention development.

Mothering a Child With Complexity and Rarity: A Narrative Inquiry Exploring Prader-Willi Syndrome.

Daily experiences of mothers caring for children with Prader-Willi syndrome (PWS) are largely unknown and unvoiced. Knowledge of PWS has generally focused on pathology of the disorder. This emphasis overlooks the challenging moments of everyday life caring for children with PWS. Storied accounts of mothers caring for children with PWS offer expanded narratives to medicalized descriptions of experience. An understanding of everyday challenges in managing physical and mental health issues of PWS including hyperphagia and anxiety may create shifts in social and clinical perspectives. This understanding could improve practices in health and social care for families with PWS. This narrative inquiry studied everyday experience using storied accounts. Participants were mothers caring for children aged 3-17 years with genetically confirmed PWS who were experiencing hyperphagia. Four participants were recruited, and each interviewed 8-12 times over 12 months. Field texts and narrative accounts were co-composed through a collaborative process of analysis. Engaging with participants' day-to-day experiences offered insights into their work of nurturing, caring, and contributing to the care of a child with PWS. Narrative threads focused on complexity and rarity and include the desire to be normal, how ordinary becomes extraordinary, isolation, behaviors and normative standards, and alternative stories of mothering. Recommendations for practice and policy include (a) challenges of mothering a child with complexity, (b) moving beyond functionality and impairment to participation and quality of life, (c) re-storying narratives and supports for families, and (d) engaging with mothers to determine care priorities.

The experiences of international students in a Canadian faculty of nursing: A narrative inquiry study.

BACKGROUND: In response to the global need for nursing faculty, and nurses in leadership and advanced clinical practice roles, students from different countries come to Canada for their graduate nursing education. The positive reputation and the perceived advantages of the education system are particularly compelling to applicants from the countries located in the Global South. However, these students come from different social, historical, political, cultural, and educational backgrounds that deeply influence their learning experiences in Canada. OBJECTIVE AND METHODOLOGY: The aim of this narrative inquiry study was to understand the experiences of international graduate nursing students. The focus was to unravel two puzzles of this inquiry: What stories across social, historical, political, cultural, and educational borders shaped students' identities and ways of knowing? How did the experience in Canada impact their identities? SETTING AND PARTICIPANTS: Participants were invited from a Master of Nursing program at a research-intensive University in Western Canada. METHODS: Participants engaged in series of conversations over a period of one year. RESULTS: Multiplicity of borders and identity making, border making, and border crossing, were the threads that resonated across the narrative accounts. CONCLUSION: These narrative threads provided insights into the lived experiences of tensions, the shifting of identities, and the day-to-day challenges that international students face while learning in Canada. Being aware of these experiences and acknowledging them could be a significant stride towards addressing the issues of racism, inequity, and exclusion for international students within Canadian graduate nursing education.

The Relationship Between Critical Social Theory and Interpretive Description in Nursing Research.

This paper is an examination of the methodological and theoretical perspectives of a study with an inquiry focus on the experiences and perspectives of staff who worked at an injectable opiate assisted (iOAT) clinic. Twenty-two staff members, including nurses, social workers, and peer support workers, were interviewed. The goal of the study was to uncover how the clinic staff provided care to the clients who attend the clinic, their perspectives on how the clinic program impacted both them and their clients, and their experiences with the program itself. This interpretive descriptive study was underpinned by critical social theory. Thematic analysis was undertaken to identify recurring, converging, and contradictory patterns of interaction, key concepts and emerging themes. In this paper we examine and discuss how the relationship between critical social theory and interpretive description enhanced the study. Examples from the study are presented to provide insight into the relationship.

Flawed reports can harm: the case of supervised consumption services in Alberta.

Supervised consumption services have been scaled up within Canada and internationally as an ethical imperative in the context of a public health emergency. A large body of peer-reviewed evidence demonstrates that these services prevent poisoning deaths, reduce infectious disease transmission risk behaviour, and facilitate clients' connections to other health and social services. In 2019, the Alberta government commissioned a review of the socioeconomic impacts of seven supervised consumption services in the province. The report is formatted to appear as an objective, scientifically credible evaluation of these services; however, it is fundamentally methodologically flawed, with a high risk of biases that critically undermine its authors' assessment of the scientific evidence. The report's findings have been used to justify decisions that jeopardize the health and well-being of people who use drugs both in Canada and internationally. Governments must ensure that future assessments of supervised consumption services and other public health measures to address drug poisoning deaths are scientifically sound and methodologically rigorous. Health policy must be based on the best available evidence, protect the right of structurally vulnerable populations to access healthcare, and not be contingent on favourable public opinion or prevailing political ideology.

RéSUMé: Les services de consommation supervisée ont été établis au Canada et à l'étranger en tant qu'impératif éthique dans le contexte d'une urgence de santé publique. Un grand nombre d'études rigoureuses démontrent que ces services préviennent les décès par empoisonnement, réduisent les comportements à risque de transmission de maladies infectieuses, et facilitent les liens avec d'autres services sociaux et de santé. En 2019, le gouvernement de l'Alberta a commandé un examen des impacts socioéconomiques de sept services de consommation supervisée dans la province. La présentation du rapport donne l'impression que l'évaluation de ces services est objective et scientifiquement crédible; cependant, il présente des faiblesses importantes au plan méthodologique, notamment en raison de la présence de biais qui compromet l'évaluation des preuves scientifiques. Ses conclusions ont été utilisées pour justifier des décisions qui mettent en péril la santé et le bien-être des personnes qui consomment des drogues, tant au Canada qu'à l'étranger. Les gouvernements doivent s'assurer que les futures évaluations des services de consommation supervisée et d'autres mesures de santé publique pour lutter contre les décès par empoisonnement dû aux drogues sont scientifiquement fondées. Les politiques en matière de santé doivent être basées sur les meilleures données disponibles, protéger les droits des populations structurellement vulnérables à accéder aux soins de santé, et ne pas dépendre de l'opinion publique ou d'une idéologie politique dominante.

Patient and Health Care Provider Perspectives on Patient Access to Test Results via Web Portals: Scoping Review.

BACKGROUND: A frequently used feature of electronic patient portals is the viewing of test results. Research on patient portals is abundant and offers evidence to help portal implementers make policy and practice decisions. In contrast, no comparable comprehensive summary of research addresses the direct release of and patient access to test results. OBJECTIVE: This scoping review aims to analyze and synthesize published research focused on patient and health care provider perspectives on the direct release of laboratory, imaging, and radiology results to patients via web portals. METHODS: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Searches were conducted in CINAHL, MEDLINE, and other databases. Citations were screened in Covidence using the inclusion and exclusion criteria. Primary studies that focused on patient and health care provider perspectives on patient access to laboratory and imaging results via web portals were included. An updated search was conducted up to August 2023. Our review included 27 articles-20 examining patient views, 3 examining provider views, and 4 examining both patient and provider views. Data extraction and inductive data analysis were informed by sensitizing concepts from sociomaterial perspectives, and 15 themes were generated. RESULTS: Patient perspectives (24 papers) were synthesized using nine themes: (1) patterns of use and patient characteristics; (2) emotional response when viewing the results and uncertainty about their implications; (3) understanding test results; (4) preferences for mode and timing of result release; (5). information seeking and patients' actions motivated by viewing results via a portal; (6) contemplating changes in behavior and managing own health; (7) benefits of accessing test results via a portal; (8) limitations of accessing test results via a portal; and (9) suggestions for portal improvement. Health care provider perspectives (7 papers) were synthetized into six themes: (1) providers' view of benefits of patient access to results via the portal; (2) effects on health care provider workload; (3) concerns about patient anxiety; (4) timing of result release into the patient portal; (5) the method of result release into the patient portal: manual versus automatic release; and (6) the effects of hospital health information technology system on patient quality outcomes. CONCLUSIONS: The timing of the release of test results emerged as a particularly important topic. In some countries, the policy context may motivate immediate release of most tests directly into patient portals. However, our findings aim to make policy makers, health administrators, and other stakeholders aware of factors to consider when making decisions about the timing of result release. This review is sensitive to the characteristics of patient populations and portal technology and can inform result release framework policies. The findings are timely, as patient portals have become more common internationally.

The Alberta Neonatal Abstinence Syndrome Mother-Baby Care ImprovEmeNT (NASCENT) program: protocol for a stepped wedge cluster randomized trial of a hospital-level Neonatal Abstinence Syndrome rooming-in intervention.

BACKGROUND: Neonatal Abstinence Syndrome (NAS), a problem common in newborns exposed to substances in-utero, is an emerging health concern. In traditional models of care, infants with NAS are routinely separated from their mothers and admitted to the Neonatal Intensive Care Unit (NICU) with long, expensive length of stay (LOS). Research shows a rooming-in approach (keeping mothers and infants together in hospital) with referral support is a safe and effective model of care in managing NAS. The model's key components are facilitating 24-h care by mothers on post-partum or pediatric units with support for breastfeeding, transition home, and access to Opioid Dependency Programs (ODP). This study will implement the rooming-in approach at eight hospitals across one Canadian Province; support practice and culture shift; identify and test the essential elements for effective implementation; and assess the implementation's impact/outcomes. METHODS: A stepped wedge cluster randomized trial will be used to evaluate the implementation of an evidence-based rooming-in approach in the postpartum period for infants born to mothers who report opioid use during pregnancy. Baseline data will be collected and compared to post-implementation data. Six-month assessment of maternal and child health and an economic evaluation of cost savings will be conducted. Additionally, barriers and facilitators of the rooming-in model of care within the unique context of each site and across sites will be explored pre-, during, and post-implementation using theory-informed surveys, interviews, and focus groups with care teams and parents. A formative evaluation will examine the complex contextual factors and conditions that influence readiness and sustainability and inform the design of tailored interventions to facilitate capacity building for effective implementation. DISCUSSION: The primary expected outcome is reduced NICU LOS. Secondary expected outcomes include decreased rates of pharmacological management of NAS and child apprehension, increased maternal ODP participation, and improved 6-month outcomes for mothers and infants. Moreover, the NASCENT program will generate the detailed, multi-site evidence needed to accelerate the uptake, scale, and spread of this evidence-based intervention throughout Alberta, leading to more appropriate and effective care and use of healthcare resources. TRIAL REGISTRATION: ClinicalTrials.gov, NCT0522662. Registered February 4th, 2022.

Sustaining hope: A narrative inquiry study exploring midwives' hope-focused practices in HIV care in Ghana.

HIV remains a statistically significant issue for women of childbearing age in Ghana. Nurses and midwives form the backbone of care providers for the prevention of mother-to-child transmission programmes. However, nurses and midwives receive little support to provide the emotional aspects of HIV/AIDS care. AIM: Our aim was to build an understanding of how midwives currently embrace their experience of hope and hoping to support mothers living with HIV. DESIGN: This is narrative inquiry study. METHODS: We engaged in two to three conversations with five midwives in rural settings in Ghana to understand their experiences of hope and hoping in their interactions with mothers living with HIV. Using the narrative inquiry common places of temporality, the social and personal, and space/place, we wrote narrative accounts for each participant and then searched for resonances across the narrative accounts. RESULTS: We highlight three emerging narrative threads that resonated across narrative accounts. The three emerging narrative threads were (1) sustaining hope by drawing on life experiences across time and place; (2) hope is sustained through a focus on relational engagement with mothers; (3) midwives embrace the possibility to learn more about hope-focused practices. CONCLUSION: The midwives began, although tentatively, to shine light on the things and events that diminished their abilities to maintain a hopeful perspective. At the same time, they became more comfortable and familiar with the notion of making hope visible and accessible in their experiences. IMPACT: Since the midwives welcomed additional support to cope with the challenges they were experiencing, we imagine one day being able to make sense of how nurses and midwives engage with a narrative pedagogy of hope. Including hope-focused practices in nursing and midwifery preservice and in-service opportunities is important. PATIENT OR PUBLIC CONTRIBUTION: There was no direct patient or public involvement in this study.

Experiences of Migrants Living with HIV from HIV-Endemic Sub-Saharan African Countries: A Systematic Review of Qualitative Research Studies.

The aim of this qualitative systematic review was to explore the experiences of migrants living with HIV from HIV endemic sub-Saharan African countries who migrated to high-income countries. In this systematic review of qualitative research studies, we focused on the experiences of migrants living with HIV and the intersections between living with HIV, migration, settlement, culture, race relations, access to health services and HIV care, treatment, and support during migration and settlement in a new host country. We searched 12 electronic databases from database inception for English-language publications. A thematic analysis of qualitative studies [n = 10] was conducted. Complexities exist across the migration and settlement trajectories of migrants living with HIV, which influenced people's level of engagement in the HIV care cascade as well as social determinants of health and social wellbeing.

Narrative Inquiry into the Professional Identity-Making of Ghanaian Midwives.

Professional identity-making is a complex life-making endeavor that is shaped by both the personal and professional knowledge landscapes in which people live and work. Using narrative inquiry, four midwives who had worked in diverse contexts in Ghana were purposively selected. We highlight how midwives' experiences across time, place, and in diverse contexts shape their professional identity-making. Three main life experiences that shape professional identity-making were discovered: 1. Childhood experiences, 2. Education experiences, and 3. Professional work experiences. Midwifery education should prepare students to attend to this complex and ongoing identity development, in order to enhance midwifery practice.

"I die silently inside". Qualitative findings from a study of people living with HIV who migrate to and settle in Canada.

We report on qualitative findings from a mixed methods study, examining enacted and internalized stigma during mandatory HIV screening among immigration applicants living with HIV in Canada. Qualitative findings show alignment with characteristics of internalized HIV stigma. We conducted 34 semi-structured interviews, and analyzed the data through thematic analysis, using Intersectionality and the Internalized HIV Stigma Scale as our theoretical and analytical frameworks. Participants described experiences of enacted and internalized HIV stigma in ways that were consistent with the four main domains of stereotypes, disclosure concerns, social relationships, and self-acceptance, but also extended the description of HIV stigma beyond these domains. Experiences of internalized HIV stigma and enacted stigma during the Canadian Immigration Medical Examination could potentially influence individuals' long-term engagement in the HIV care cascade during the process of migration to, and settlement in, Canada. We present recommendations for the broader migrant health research agenda, health and social care providers, and public health policies.

Incentive-Based Sexually Transmitted and Blood-Borne Infections Screening in High-Income Countries: A Systematic Review.

BACKGROUND: Despite increasing access to treatment and screening, rates of sexually transmitted and blood-borne infections (STBBI) continue to rise in high-income countries. The high cost of undiagnosed and untreated STBBI negatively affects individuals, health care systems, and societies. The use of monetary and nonmonetary incentives may increase STBBI screening uptake in high-income countries. Incentivized screening programs are most effective when developed specific to context and target population. METHODS: Our review was performed according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions. Inclusion criteria were as follows: English language, high-income countries, primary research studies, and older than 16 years. Study quality was assessed using Joanna Briggs Institute quality assessment tools. RESULTS: The search yielded 6219 abstracts. Thirteen articles met the inclusion criteria. Studies took place in the United States, the United Kingdom, and Australia. Populations screened included: postsecondary and tertiary students, parolees or probationers, youth, and inner-city emergency department patients. Incentivized STBBI screened were human immunodeficiency virus (n = 5), chlamydia (n = 7), and multiple infections (n = 1). Incentives offered were monetary (cash/gift cards/not specified) (n = 10), nonmonetary (n = 1), and mixed (n = 2). Both monetary and nonmonetary incentives enhance STBBI screening in high-income countries. CONCLUSION: Incentivized screening programs are most effective when developed specific to context and target population. Further research is needed to analyze incentivized screening across similar study designs and to evaluate long-term effectiveness.

An evolutionary concept analysis of learner-centered teaching.

BACKGROUND: An increasing emphasis on a paradigm shift from the traditional teacher-centered approach has led to the adoption of learner-centered teaching in many nursing education programs. However, the lack of consensus regarding the meaning warranted an analysis of learner-centered teaching. OBJECTIVE: The objective of this analysis was to clarify the concept of learner-centered teaching for nursing education and research. DESIGN: An evolutionary framework was used to perform a comprehensive review of both theoretical and empirical literature relevant to learner-centered teaching. An evolutionary concept analysis is a method of inquiry used to analyze the literature, with the purpose of identifying the attributes, antecedents, and consequences of a concept. SAMPLE AND SETTING: Empirical and theoretical literature selected from the fields of education, nursing, and medicine. METHODS: A comprehensive review and analysis of theoretical and empirical publications from nursing, medicine and education disciplines provided a rich data source for this concept analysis. RESULTS: Four defining attributes of learner-centered teaching were identified: autonomy, empowerment, collaboration, and engagement. Four antecedents, three surrogate terms, eight related concepts, and nine primary consequences of learner-centered teaching were also identified. Exemplar cases of learner-centered teaching emerged from personal teaching practice experience and the empirical literature. CONCLUSIONS: Learner-centered teaching is a complex concept with many aspects conceptualized or operationalized which make it difficult to authoritatively define the concept. However, the features of learner-centered teaching identified in this analysis offered a good basis for the evaluation, application, and further development of the concept in nursing.

Incentive-Based Human Immunodeficiency Virus Screening in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: The majority of new human immunodeficiency virus (HIV) infections that occur worldwide are in sub-Saharan Africa. While recent gains have been made in many low- and middle-income countries (LMICs), substantial disparities in sexually transmitted and blood-borne infections (STBBI) screening and treatment still exist between LMIC and high-income countries. In addition to increasing STBBI screening uptake, providing incentives for STBBI screening may decrease perceived stigma associated with STBBI screening. METHODS: Our review was conducted as part of a larger systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and guidance from the Cochrane Handbook for Systematic Reviews of Interventions. This review focuses on incentivized STBBI screening in LMIC; high-income countries were excluded. Articles were excluded if their primary focus was on children and youth (younger than 16 years), results retrieval, treatment, behavioral change only, behavior intention, treatment adherence, or provider incentive. RESULTS: The search yielded 6219 abstracts. The search and selection criteria included all STBBI; however, only articles examining incentivized HIV screening met our inclusion criteria. Five articles representing 4 distinct studies from South Africa, Uganda, and Zimbabwe were included, all of which focused on incentivized HIV screening. Populations screened included the following: men, first-time testers, population-based surveillance program families, and insurance health plan members. Incentive structures varied widely and incentives were mainly food vouchers, lottery prizes, or household items. CONCLUSIONS: Our review was conducted to determine if patient incentives increase STBBI test uptake in LMIC. Overall, incentives were associated with an increase in HIV screening uptake. Most studies included focused solely on men. There is a significant void in understanding STBBI incentive-based screening outside of this context and in complex populations who should be targeted in incentivized HIV screening. Incentives appear most effective when developed specific to context and target population. Further research is needed to analyze incentivized screening across similar study designs, to evaluate long-term effectiveness, and to explore the ethical implications of incentivized care.

Narrative care: Unpacking pandemic paradoxes.

During the coronavirus disease 2019 pandemic, public health has issued three interrelated dominant narratives through social media and news outlets: First, to care for others, we must keep physically distant; second, we live in the same world and experience the same pandemic; and third, we will return to normal at some point. These narratives create complexities as they collide with the authors' everyday lives as nurses, educators, and women. This collision creates three paradoxes for us: (a) learning to care by creating physical distance, (b) a sense of togetherness erases inequities, and (c) returning to normal is possible. To inquire into these three paradoxes, we draw on our experiences with Ingrid, an older adult who requires in-home physical care, and Matthew, a man with multiple disabilities including severe oral dyspraxia and developmental delays. We outline how narrative care is a counterstory to the dominant narratives and enables us to find ways to live our lives within the paradoxes. Narrative care allows us, through attention to embodiment, liminality, and imagination, to create forward looking stories. Understanding narrative care within these paradoxes allows us to offer more complex understandings of the ways narrative care can be embodied in our, and others', lives.

Oncology Patients' Experiences With Novel Electronic Patient Portals to Support Care and Treatment: Qualitative Study With Early Users and Nonusers of Portals in Alberta, Canada.

BACKGROUND: With the current proliferation of clinical information technologies internationally, patient portals are increasingly being adopted in health care. Research, conducted mostly in the United States, shows that oncology patients have a keen interest in portals to gain access to and track comprehensive personal health information. In Canada, patient portals are relatively new and research into their use and effects is currently emerging. There is a need to understand oncology patients' experiences of using eHealth tools and to ground these experiences in local sociopolitical contexts of technology implementation, while seeking to devise strategies to enhance portal benefits. OBJECTIVE: The purpose of this study was to explore the experiences of oncology patients and their family caregivers when using electronic patient portals to support their health care needs. We focused on how Alberta's unique, 2-portal context shapes experiences of early portal adopters and nonadopters, in anticipation of a province-wide rollout of a clinical information system in oncology facilities. METHODS: This qualitative descriptive study employed individual semistructured interviews and demographic surveys with 11 participants. Interviews were audio-recorded and transcribed verbatim. Data were analyzed thematically. The study was approved by the University of Alberta Human Research Ethics Board. RESULTS: Participants currently living with nonactive cancer discussed an online patient portal as one among many tools (including the internet, phone, videoconferencing, print-out reports) available to make sense of their diagnosis and treatment, maintain connections with health care providers, and engage with information. In the Fall of 2020, most participants had access to 1 of 2 of Alberta's patient portals and identified ways in which this portal was supportive (or not) of their ongoing health care needs. Four major themes, reflecting the participants' broader concerns within which the portal use was occurring, were generated from the data: (1) experiencing doubt and the desire for transparency; (2) seeking to become an informed and active member of the health care team; (3) encountering complexity; and (4) emphasizing the importance of the patient-provider relationship. CONCLUSIONS: Although people diagnosed with cancer and their family caregivers considered an online patient portal as beneficial, they identified several areas that limit how portals support their oncology care. Providers of health care portals are invited to recognize these limitations and work toward addressing them.