Background Despite increasing attention to the involvement of family members or informal caregivers in patient care, their role remains underdeveloped in medical decision-making (MDM) models implemented in clinical practice. Moreover, family involvement in MDM may conflict with patient rights, particularly the patient's right to self-determination. This study aimed to assess whether Belgian general practitioners (GPs) endorse legally impermissible strategies for family involvement in MDM, and how this relates to their knowledge of the legal framework, attitudes toward MDM, sociodemographic and professional characteristics. Methods An online vignette survey was distributed among Dutch-speaking GPs in Belgium. The vignettes were designed using a nominal group technique, in which complex real-life cases of family involvement in MDM were discussed with GPs and medical lawyers. The survey assessed GPs' endorsement of legally impermissible strategies for family involvement in MDM, described in four vignettes, along with their knowledge of the legal permissibility of these strategies. Regression analyses were run to examine the associations between GPs' endorsement and their legal knowledge, attitudes toward MDM, sociodemographic and professional background variables. Results The final sample consisted of 290 GPs. Depending on the vignette, 26.9% to 43.8% of respondents endorsed legally impermissible strategies, and 26.2% to 35.9% demonstrated insufficient knowledge of the relevant legal framework. Greater legal knowledge emerged as the strongest protective factor against endorsing legally impermissible strategies. However, 10.3% to 20% of respondents still endorsed such strategies despite having sufficient knowledge. Conclusions A considerable proportion of GPs endorsed the use of legally impermissible strategies for family involvement in MDM. Considering that some of these respondents had adequate legal knowledge, findings suggest a need to reassess the responsiveness and practical applicability of the legal framework to clinical realities.

The burden of type-2 diabetes (T2D) and hypertension (HTN) in Cambodia is a major concern. The government and donors have introduced several interventions, yet human resource shortages hamper their implementation. Community health workers (CHWs) can be a valuable additional resource for health in T2D and HTN management. The current study aimed to assess (1) CHWs' knowledge, attitude, and practices (KAP) in T2D and HTN management and (2) the potential health system barriers for incorporating CHWs in T2D and HTN management. This mixed-method study comprised a survey among 153 active CHWs to assess their KAP towards T2D and HTN, and semi-structured interviews with key informants were conducted to understand the challenges of the health system and propose solutions in incorporating CHWs in T2D and HTN management. Approximately 90% of CHWs correctly answered general knowledge questions on NCDs, risk factors, and prevention; however, only around 20-40% correctly answered questions on family history or tobacco use as risk factors. Most respondents appeared to have positive attitudes and have been practicing some activities related to T2D and HTN. Both financial and non-financial resource constraints were cited as challenges of the health system; therefore, re-structuring the definition of CHWs' roles and responsibilities, and assessing the need and workload have been proposed as ways forward to effectively incorporate CHWs in T2D and HTN care. CHWs in Cambodia have shown their potential in T2D and HTN management; however, a well-designed strategy, including technical training, clearly defined roles and responsibilities, and strong support structure, is important to maximize their potential in the health system.

The COVID-19 crisis gave rise to measures such as physical distancing, sheltering in place, and social bubbles that impacted sexual lives profoundly. One group particularly badly impacted by COVID-19 containment, and at risk of sexual and mental health consequences as a result, comprised gay, bisexual and other men who have sex with men -- many of whom were more likely to live alone, to have had multiple partners before the epidemic, and some of whom were lacking in peer support for their mental health. This study investigated how members of this group living in Flanders (Belgium) experienced sex and sexuality during the COVID-19 epidemic. We conducted 29 in-depth interviews with gay, bisexual and other men who have sex with men who practised consensual nonmonogamy and/or sociosexuality, and used reflexive thematic analysis to analyse the data. Interviewees provided a nuanced and emotionally resonant account of sex as a pathway to intimacy, rather than just a physical act. In their descriptions, Intimacy was framed as a protective factor against the mental health challenges exacerbated by pandemic isolation.

The prevalence of hypertension (HTN) of adults aged ≥ 40 years in Cambodia was high (35.2

Social norms around PrEP act as both barriers to and stimulants of the use of PrEP across a wide range of target populations, yet remain relatively understudied. To stimulate theoretical innovation and provide a quantitative check for qualitative findings, we integrate norm types from the Behavioral Models (BM) and the Social Norms Approach (SNA) into the socio-ecological model (SEM) and analyze their relationship with PrEP-intention. We include attitude and role belief at the individual level, injunctive norms at the interpersonal level and descriptive norms and self-comparison to peers at the community level. The data were drawn from a survey on sexual health distributed on social media by Flemish MSM community organizations from October 19th, 2022, to December 19th, 2022, resulting in a total convenience sample of 610. Structural Equation Modelling analyses, including confirmatory factor analysis of the latent variables and path analysis of the relationship between norm types and PrEP intention, were conducted on a convenience sample of 350 Belgian MSM who were not living with HIV. At the individual level, attitude towards PrEP was positively and moderately to strongly associated with intention, while role belief that ‘It is inappropriate for someone with my relationship(s) to use PrEP’ was negatively and moderately to strongly associated with intention. At the interpersonal level, injunctive norms, the expectation of a positive reaction to the respondent’s PrEP use, were positively and moderately to strongly associated with intention. At the community level, descriptive norms, thinking more peers use PrEP, were positively and weakly associated with intention. While self-comparison to peers, estimating one’s own sexual behaviour as safer than peers, was negatively and weakly associated with intention. All norm types included in the analysis, at the individual level (attitude and role belief), interpersonal level (injunctive norms), and the community level (descriptive norms and self-comparison to peers), were associated with PrEP-intention among MSM. Most PrEP interventions target cognition, while our analysis shows significant untapped potential for norm-based interventions to increase intention to use PrEP.

BACKGROUND:Family involvement (FI) in medical decision making (MDM) is increasingly recognized as a dimension of patient-centered care; however, patient preferences for FI vary across clinical and cultural contexts. In health care systems emphasizing autonomy and direct communication, less is known about how patient characteristics and illness scenarios (cancer vs depression; and mild vs severe depression) influence FI preferences. METHODS:We analyzed data from a subsample of a national online probability panel (N = 1,175) collected in 2024. In a survey experiment, respondents evaluated vignettes describing skin cancer and depression; the depression vignette was randomly assigned as mild or severe. Ordered logistic regression models assessed associations between FI preferences and sociodemographic and economic factors as well as religious affiliation. RESULTS:Preference for family-led decision making was uncommon across vignettes (skin cancer: 1.2%; severe depression: 2.7%; mild depression: 1.4%), while the majority preferred patient-led decision making (77.4%, 70.9%, and 81.0%, respectively). Making medical decisions together with family members was most often preferred in cases of severe depression (26.4%), followed by cancer (21.4%) and mild depression (17.6%). Living with a partner and having a migration background (European or non-European) were associated with a greater preference for FI. Respondents identifying as Christian (vs nonreligious/liberal) showed stronger preferences for FI in the cancer and severe depression vignette. Higher educational attainment was associated with weaker preferences for FI, particularly in the cancer vignette. CONCLUSIONS:Preferences for family-led decision making were low, with most respondents favoring autonomous decision making. FI preferences varied modestly by illness context and sociodemographic characteristics, particularly migration background, living situation, education, and religious affiliation. These findings underscore the importance of flexible MDM approaches that accommodate heterogeneity in patient preferences.

This study aims to broadly explore the preferences and challenges regarding medical decision-making (MDM) among patients with a migration background in Belgium, from the perspectives of patients and general practitioners (GPs). According to existing literature, MDM involving patients with a migration background may be complicated not only by general challenges arising in intercultural health communication, but also by specific cultural preferences concerning patient autonomy. Data were collected through five focus group discussions (FGDs), organised in November and December 2023. Three FGDs involved patients from the major non-EU migrant population groups in Belgium (Moroccan (n = 6), Turkish (n = 6), and sub-Saharan African (n = 7)), and two FGDs involved GPs (n = 13). The data were analysed through reflexive thematic analysis. Our results show that preferences and challenges revolved around four key components of MDM: Exchange of medical information, decision-making agency, patient-provider relationship, and treatment plan. Preferences and challenges were shaped by a complex interplay of factors at the individual (e.g., patient education, provider attitudes), interpersonal (e.g., family dynamics, language barriers), institutional (e.g., legal framework, medical education), and cultural levels (e.g., religion, health beliefs). Our study highlights the importance of adopting an intersectional and multilayered perspective on MDM, which considers how various factors interact and shape preferences and challenges in MDM, depending on the individual and their context. Although it is impossible for GPs to be aware of every cultural preference, this study shows how GPs can engage in more culturally sensitive interactions with their patients. By also addressing the institutional factors that contribute to challenges in MDM, this approach can improve person-centred care by better accommodating each patient’s unique needs and preferences.

BackgroundAlthough the Chronic Care Model (CCM) provides the essential structural components of practice organisation to deliver high-quality type 2 diabetes (T2D) care, little is known about which of its elements are most important, and the extent to which it may reduce social inequities in the quality of T2D care. This study aims to assess the association between the implementation of CCM's structural elements and the quality of T2D care processes and outcomes in Flanders (Belgium), paying specific attention to differences by patients' socioeconomic vulnerability.MethodsWe developed a longitudinal database combining information on primary care practices' CCM implementation, with individual-level health insurance and medical lab data. Our sample included 7,593 T2D patients aged 40 years and above from 58 primary care practices in Flanders, followed up from 2017 to 2019. Medical lab data were available for a subsample of 4,549 patients. By estimating a series of hierarchical mixed-effects models, we assessed the association between primary care practices' CCM implementation and two process and two outcome indicators of T2D care. In addition, we explored cross-level interactions with patients' socioeconomic vulnerability.ResultsPatients were more likely to have their HbA1c tested twice a year and LDL cholesterol tested yearly in practices with a higher overall CCM implementation. Regarding the different CCM elements, the clinical information system and linkages to the community were significantly associated with higher odds of being up-to-date with HbA1c testing, whereas stronger community linkages was the only dimension significantly associated with yearly LDL cholesterol testing. While socioeconomic vulnerable patients were less likely to have their HbA1c tested twice yearly, this difference disappeared in the highest-scoring practices. Regarding the outcome indicators, only a negligible proportion of variation in HbA1c and LDL cholesterol levels was due to systematic differences between practices, and hence, no clinically relevant associations with the CCM elements were found.ConclusionOur pioneering findings support the social capital pathway, as CCM implementation is associated with a reduction in the healthcare inequity gap in the T2D care process. This suggests that promoting CCM implementation may improve healthcare equity, particularly in regions with significant socioeconomic disparities or high concentrations of deprived individuals.

Introduction:We built Cascades of Care (CoC) for hypertension in Belgium, Slovenia and Cambodia, and assessed CoC stratifications across patients' gender and socioeconomic status. Differences between the CoCs were studied by looking at the level of implementation of the integrated care package and other health system characteristics. Methods:A mixed methods design: Age-standardized gender-specific hypertension cascades were built from survey and register data and logistic regression analyses were performed. Focus group discussions with experts were used to interpret these results. Results:In Belgium, the largest gap is between 'prevalence' and 'diagnosis'. In Cambodia, a large drop -especially among men- is found at the beginning and the end of the cascade. In Slovenia, only a limited number of patients is tested and linked to care, but once registered, attrition is quite low. Poor financial situation was a significant determinant of drop-out across the countries but at different stages of the CoC, and especially in Cambodia large gender differences were observed with women being better retained throughout the CoC. Discussion and conclusion:Despite contextual differences between the countries and difficulties in comparability of the cascades, lessons can be learnt from each country's strengths and weaknesses to improve quality of integrated hypertension care.

Hazardous alcohol use tends to be more prominent among higher education students. The COVID-19 pandemic severely altered student life, raising questions on its impact on students’ alcohol use patterns. The current study examined cross-country variations in drinking behaviors (weekly drinking and binge drinking), and the extent to which these variations were associated with containment measures implemented during the first wave of the COVID-19 pandemic. Data were obtained from the COVID-19 International Student Well-being Study, covering students in 25 middle- and upper-high income countries. Data on government responses were retrieved from the Oxford COVID-19 Government Response Tracker. Multilevel multinomial logistic regression analyses were performed on weekly drinking (n = 44,212) and binge drinking (n = 32,785). Considerable cross-country variation existed for weekly drinking and binge drinking. In the majority of countries, a self-reported decrease in weekly drinking and a substantial self-reported decrease in binge drinking were observed. Closings of schools were associated with decreases in weekly drinking, while limitations on social gatherings were associated with increases in weekly drinking. The stringency index was associated with reporting decreased binge drinking. The study findings demonstrate a number of small yet significant associations between containment measures and changes in student drinking behaviors. Future studies are required to uncover why some students increased their alcohol consumption, particularly in countries with stricter limitations on social gatherings.

BackgroundObtaining a representative sample is a substantial challenge when undertaking health research among hidden and hard-to-reach populations such as men who have sex with men Web-based respondent-driven sampling (WEB RDS) was developed to overcome such sampling challenges and to create population estimates based on network and sampling characteristics. Despite a decade of research, it remains unclear whether WEB RDS is suitable for sampling hidden populations such as men who have sex with men. ObjectiveThis study aims to evaluate how viable the WEB RDS methodology is for obtaining a nationwide sample of men who have sex with men, suitable for population inference of sexual health characteristics, in Belgium. MethodsWe adapted the Medical Resource Council process evaluation framework for interventions, to evaluate an empirical WEB RDS. Viewing “WEB RDS” as a complex intervention with respondent-driven recruitment as the aim, we evaluated indicators of context, implementation, mechanisms of impact, and performance. We analyzed the data using a mixed methods approach that integrated findings from quantitative analysis, such as RDS diagnostics, and qualitative thematic analysis. ResultsSampling did not reach a sufficient sample size (n=193) to compensate for an RDS design effect of 3 and the number of recruitment waves was low (waves=7). A visual examination of the convergence and bottleneck plots indicates that many more waves of recruitment would be needed for population estimates to become independent of the seeds. However, producing further waves was impeded by challenges inherent to the research context and process. Men who have sex with men and their community organization representatives indicated that, in Belgium, men who have sex with men are overresearched, with low motivation for the topic of sexual health and digital etiquette dictating not sharing survey links. A moderate reward of €10-€30 (US $11.2-$33.6) with a dual incentive structure was insufficient to overcome these barriers. ConclusionsThis study indicates that WEB RDS, even with a moderate incentive, is not a viable sampling strategy for obtaining valid population estimates of sexual health traits of men who have sex with men in Belgium. The study emphasizes the need to understand men who have sex with men research motivation and topic saliency. Additionally, the study highlights the importance of digital etiquette. Finally, the study showcases the use of the adapted Medical Research Council framework for evaluating WEB RDS methodology.

The childcare sector is experiencing major staff shortages, putting pressure on the quality provided within childcare centers and consequently on the children. One cause of these shortages is the insufficient supply of new childcare professionals. This study examines pre-service childcare professionals' intentions to enter the field in relation to the following three aspects: study choice motivation, practicum experiences and perceptions of working conditions. Data were cross-sectional collected through an online survey via schools from students (n = 177) enrolled in a 7th-year secondary vocational education program in Flanders (Belgium). Results indicate that only a minority of pre-service childcare professionals intend to enter the profession. Logistic regression analysis reveals that those who perceive good career opportunities (i.e. advancement to staff leadership) are more likely to enter the profession, as do those who showed a high degree of appreciation for the work during their practicum. However, study choice motivation did not affect their intentions to enter the profession, as motivation was uniformly high across all pre-service childcare professionals. These results suggest that only a minority of the pre-service childcare professionals are likely to enter the profession. Those who do, may advance to leadership roles and subsequently leave the childcare profession, exacerbating workforce shortages.

The growing cultural diversity in Belgium, with over one third of the population having a migration background, presents distinct challenges for primary healthcare, particularly in doctor-patient interactions. Medical decision-making (MDM) is at the core of clinical practice in primary healthcare. According to existing literature, MDM may be complicated not only by general challenges arising in intercultural health communication, but also by specific cultural preferences concerning patient autonomy. This study aims to examine preferences and challenges regarding MDM among patients with a migration background in Belgium, from the perspectives of patients and general practitioners (GPs). Data were collected through five focus group discussions (FGDs), organised in November and December 2023. Three FGDs involved patients from the major migrant population groups in Belgium (Moroccan (n = 6), Turkish (n = 6), and sub-Saharan African (n = 7), and two FGDs involved GPs (n = 13). The data were analysed through reflexive thematic analysis. Our results show that preferences and challenges revolved around four key components of MDM: Exchange of medical information, decision-making agency, patient-provider relationship, and treatment plan. These preferences and challenges were shaped by a complex interplay of factors at the individual (e.g., patient education, provider attitudes), interpersonal (e.g., family dynamics, language barriers), institutional (e.g., legal framework, medical education), and cultural levels (e.g., religion, health beliefs). Our study highlights the importance of adopting an intersectional and multilayered perspective on MDM, which considers how various factors interact and shape preferences and challenges in MDM, depending on the individual and their context. Although it is impossible for GPs to be aware of every cultural preference, this study shows how GPs can engage in more culturally sensitive interactions with their patients. By also addressing the institutional factors that contribute to challenges in MDM, this approach can improve person-centred care by better accommodating each patient’s unique needs and preferences.

This study mapped self-reported sexual acts among students during the COVID-19 pandemic, as well as how they changed compared to the year preceding the pandemic, within the context of Flanders, Belgium. Given the growing literature that has identified students as a risk group for mental health problems, particularly during the COVID-19 pandemic, and the importance of sexual development during emerging adulthood, the current study additionally examined whether these (changes in) sexual acts were related to students’ mental health. A representative sample of higher education students from a major Belgian university was used (N = 1580, 41.60

Background The prevalence of hypertension (HTN) in Cambodia was high (35.2%) in 2020 and only one-third achieved well-control. Effective HTN management strategies are needed but with focus on some key potential factors related to the poor adherence to treatment. Social support, especially from family members, is considered as a potential factor determining treatment adherence; however, evidence remains inconsistent with limited research conducted in Asia. Therefore, we assessed the role of social support on HTN treatment adherence in Cambodia to get a better understanding of the role of social support from family members in HTN management. Methods We performed a population-based survey among individuals aged ≥ 40 years and included 948 patients who were in-treatment in this study. Further key information was collected on adherence using the Medication Adherence Self-Report Scale (MARS-5) and family social support with eight-item modified Medical Outcomes Study Social Support (mMOS-SS) scale. Descriptive statistics were used to present the basic characteristics of the respondents. Chi-square test was used for the bivariate analysis of factors for treatment adherence. Multiple logistic regression was used to assess the association between family social support and HTN treatment adherence while controlling for some potential covariates. Results Among the 948 study participants, 43.5% reported non-adherence and 56.5% reported adherence to HTN treatment. For family social support, 19.7% reported poor level, 31.3% reported fair level, and 49.9% reported good level of support. Of those with adherence to HTN treatment, 29.2% had fair level of family social support, and 54.1% had good level of family social support. Unadjusted odd ratios (OR) from the univariate analysis showed a significant association between HTN treatment adherence and level of social support (P = 0.001). After controlling for covariates, having a good level of family social support increased the rate of adherence to HTN treatment by two-fold (AOR = 2.16, 95%CI = 1.49–3.14) compared to poor level. Conclusions The role of social support from family members was very positive in enhancing treatment adherence among patients with HTN in Cambodia. Potential strategic interventions should include focus on establishing an intervention involving family members to provide support for HTN treatment.

BACKGROUND:Hypertension is a major risk factor for cardiovascular disease and all-cause mortality worldwide. Despite the widespread availability of effective antihypertensives, blood pressure (BP) control rates remain suboptimal, even in high-income countries such as Belgium. In this study, we used a cascade of care approach to identify where most patients are lost along the continuum of hypertension care in Belgium, and to assess the main risk factors for attrition at various stages of hypertension management.METHODS:Using cross-sectional data from the 2018 Belgian Health Interview Survey and the Belgian Health Examination Survey, we estimated hypertension prevalence among the Belgian population aged 40-79 years, and the proportion that was (1) screened, (2) diagnosed, (3) linked to care, (4) in treatment, (5) followed up and (6) well-controlled. Cox regression models were estimated to identify individual risk factors for being unlinked to hypertension care, untreated and not followed up appropriately.RESULTS:The prevalence of hypertension based on self-reported and measured high BP was 43.3%. While 98% of the hypertensive population had their BP measured in the past 5 years, only 56.7% were diagnosed. Furthermore, 53.4% were linked to care, 49.8% were in treatment and 43.4% received adequate follow-up. Less than a quarter (23.5%) achieved BP control. Among those diagnosed with hypertension, males, those of younger age, without comorbidities, and smokers, were more likely to be unlinked to care. Once in care, younger age, lower BMI, financial hardship, and psychological distress were associated with a higher risk of being untreated. Finally, among those treated for hypertension, females, those of younger age, and without comorbidities were more likely to receive no adequate follow-up.CONCLUSION:Our results show that undiagnosed hypertension is the most significant barrier to BP control in Belgium. Health interventions are thus needed to improve the accurate and timely diagnosis of hypertension. Once diagnosed, the Belgian health system retains patients fairly well along the continuum of hypertension care, yet targeted health interventions to improve hypertension management for high-risk groups remain necessary, especially with regard to improving treatment rates.

Obtaining a representative sample is a substantial challenge when undertaking health research among hidden and hard-to-reach populations such as men who have sex with men (MSM). Web based Respondent Driven Sampling (WEB RDS) was developed to overcome such sampling challenges and to create population estimates based on network and sampling characteristics. Despite a decade of research in low- and middle-income countries it remains unclear whether WEB RDS is suitable for sampling hidden populations in high-income countries. This study’s objective was to evaluate how viable WEB RDS methodology is for obtaining a nationwide sample of MSM, suitable for population inference of sexual health characteristics, in a high income setting such as Belgium. We adapted the MRC (Medical Resource Council) process evaluation framework for interventions, to evaluate an empirical WEB RDS. Viewing ‘WEB RDS’ as a complex intervention with respondent driven recruitment as the aim, we evaluated indicators of context, implementation, mechanism of impact and performance. We analysed the data using a mixed-methods approach that integrated findings from quantitative analysis such as RDS diagnostics and qualitative thematic analysis.. Sampling did not reach a sufficient sample size (n=193) to compensate for an RDS design effect of 3 and the number of recruitment waves was low (waves=7). Homophily values (age=1.51, education=0.88, place of residence =1.13) signal a high degree of clustering in the network, and qualitative data indicates MSM in Belgium are likely not one network at the national level. Bottleneck plots indicate that many more waves of recruitment would be needed for population estimates to become independent of the initial respondents, yet we found difficulties inherent to producing more waves in the research context. MSM and MSM community organization representatives indicated that, in Belgium, MSM are over-researched, with low motivation for the topic of sexual health and that digital etiquette dictates not sharing survey links. A moderate reward of 10-30 euro’s with a dual incentive structure was insufficient to overcome these barriers. In conclusion, our study shows that WEB RDS with a moderate incentive is not a viable sampling strategy for obtaining national population estimates of sexual health traits of MSM in Belgium. The study emphasizes the need for understanding MSM research motivation and topic saliency, exploring optimal incentive levels in a high income context, addressing over-research, and considering alternative methods, such as offline RDS or hybrid approaches, to capture diverse subpopulations. Additionally, the study highlights the importance of online etiquette and geographical clustering considerations for successful WEB RDS implementation. Finally, the study showcases the utility of the adapted MRC framework for evaluating WEB RDS methodology.

Aims: The Red Noses Culturally-Sensitive Stigma Survey (RN-CSS) contributes to the underexplored research domain of adolescents’ stigmatising attitudes and behaviours towards peers with mental health difficulties and mental healthcare services. It also addresses the need for comprehensive and culturally-sensitive tools to assess stigma in this context. Methods: Drawing on insights from focus groups and building upon the existing Stigma in Global Context-Mental Health Study, we have successfully developed and implemented the first culturally-sensitive stigma survey tailored for school-aged adolescents of different migration/cultural backgrounds. The questionnaire includes an unlabelled case vignette depicting a peer with symptoms of depression and gathers data on various domains, including (1) sociodemographic variables; (2) education-related information; (3) COVID-19; (4) perceptions of mental health difficulties and mental healthcare services (i.e. severity assessment, causal attributions, care recommendations, personal stigma, perceived stigma, and service stigma); (5) subjective wellbeing and familiarity with mental health difficulties; (6) social support; (7) school context; (8) bullying; and (9) knowledge of anti-stigma campaigns. Results: Our final sample comprises 5075 pupils from 38 secondary schools in Flanders, Belgium. Conclusions: In this article, we present the study’s background and rationale, the development of the questionnaire, and the sampling and recruitment methods employed. Furthermore, we provide a summary of the sample characteristics and preliminary descriptive results of the RN-CSS. Subsequent empirical studies will address the research objectives outlined in this protocol paper. The research opportunities provided by the developed materials and dataset are being discussed.