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Schicktanz S, Alpinar-Segawa Z, Ulitsa N, Perry J, Werner P. Moving Towards Ethical-Practical Recommendations for Alzheimer's Disease Prediction: Addressing Interindividual, Interprofessional, and Societal Aspects. J Alzheimers Dis 2024:JAD231137. [PMID: 39269830 DOI: 10.3233/jad-231137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024]
Abstract
Biomarkers for predicting Alzheimer's disease (AD) are advancing and their implementation in various healthcare systems is imminent. There is a need for ethical standards addressing information needs, socio-ethical concerns, and expectations of healthy and at-risk persons. We present an ethical approach that integrates different existing ethical frameworks and discussion of our empirical, cross-cultural findings in a multi-layered perspective by addressing three levels. The micro-level focuses on the communication between counseling professionals, persons at risk or in an early stage of dementia, and family members. The meso-level addresses interprofessional cooperation and exchange as a key element for best person-centered care. The macro-level considers public health promotion, the media, and public-funded research. This approach allows to address key ethical concepts including beneficence, non-maleficence, autonomy, informational self-determination, empowerment, and justice. Our contribution specifically examines the ethical challenges associated with AD prediction by means of biomarkers, based on insights from a German-Israeli comparison, and promotes a transdisciplinary discussion across different healthcare contexts. We propose a reflection on three levels to go beyond the clinical counseling context and to consider the rapidly evolving field of biomarkers in the coming years. Our ethical-practical recommendations should not be considered final, but rather procedural and will require continuous adaptation regarding culturally varying practices, new algorithms, meta-analyses, and re-evaluation of established recommendations.
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Affiliation(s)
- Silke Schicktanz
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Zümrüt Alpinar-Segawa
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
- Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany
| | - Natalie Ulitsa
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
- Department of Community Mental Health, Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel
| | - Julia Perry
- Department of Medical Ethics and History of Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Perla Werner
- Department of Community Mental Health, Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel
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Torkpoor R, Frolich K, Londos E, Nielsen TR. Diagnostic Accuracy of the Swedish Version of the Multicultural Cognitive Examination for Cognitive Assessment in Swedish Memory Clinics. J Alzheimers Dis 2024; 97:715-726. [PMID: 38143364 PMCID: PMC10836550 DOI: 10.3233/jad-230998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Cognitive assessment for foreign-born individuals is suboptimal. The Multicultural Cognitive Examination (MCE) was developed for use in culturally, linguistically and educationally diverse populations. The MCE includes the Rowland Universal Dementia Assessment Scale (RUDAS) and performs assessment of memory, verbal fluency, and visuospatial function. OBJECTIVE To compare the psychometric properties of the Swedish version of the Multicultural Cognitive Examination (MCE-S) with the Swedish versions of the RUDAS (RUDAS-S), the Mini-Mental State Examination (MMSE-SR), and the Clock Drawing Test (CDT), and to explore the ability of the MCE-S test to differentiate patients with and without dementia in a multicultural population. METHODS 117 outpatients at four memory clinics were tested using the MCE-S to complement the routine cognitive assessment. RESULTS Significant differences between patients with and without dementia were observed for all MCE-S components. There were significant differences between foreign-born and Swedish-born patients in the MMSE-SR, but not in the MCE-S or the RUDAS-S. The MCE-S, had good diagnostic performance for detecting dementia (AUC, 0.82), and was at least as good as the RUDAS-S alone (AUC, 0.79). The MCE-S also distinguished Alzheimer's disease (AD) from non-AD dementia. Contrary to expectations, the MCE-S was also at least as good as the MMSE-SR among the Swedish-born patients. CONCLUSIONS The MCE-S is adequate for detecting dementia in both foreign-born and Swedish-born populations. Based on the cultural diversity of general society, adapted cognitive tests that can be used for everyone are practical and beneficial for both patients and health-care professionals. Further studies are needed within primary care.
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Affiliation(s)
- Rozita Torkpoor
- Department of Clinical Sciences Malmö, Cognitive Disorder Research Unit, Lund University, Malmö, Sweden
- Memory Clinic, Skane University Hospital, Malmö, Sweden
| | - Kristin Frolich
- Department of Clinical Sciences Malmö, Cognitive Disorder Research Unit, Lund University, Malmö, Sweden
| | - Elisabet Londos
- Department of Clinical Sciences Malmö, Cognitive Disorder Research Unit, Lund University, Malmö, Sweden
- Department of Neurobiology, Division of Clinical Geriatrics, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - T. Rune Nielsen
- Danish Dementia Research Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Monsees J, Schmachtenberg T, René Thyrian J. Intercultural care for people of migrant origin with dementia - A literature analysis. DEMENTIA 2022; 21:1753-1770. [PMID: 35506672 DOI: 10.1177/14713012221086702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Close to 12 million people of migrant origin who are 65 years or older live in different European countries. In the European Union (EU) and the European Free Trade Association (EFTA) countries, approximately half a million are estimated to have dementia. This rate is expected to increase in the coming decades. People of migrant origin who develop dementia and their families face challenges people without migration backgrounds do, but due to cultural differences, additional challenges may arise. There is an increasing need for interculturally sensitive care. There is research on certain aspects of intercultural care and this study will be a comprehensive summary of current topics in intercultural care. RESEARCH QUESTION What factors of intercultural care for people of migrant origin with dementia can be identified? What requirements and aspects are necessary to ensure intercultural care? METHOD A systematic literature analysis in the databases PubMed, PsycInfo and Psychology and Behavioural Sciences Collection was conducted. FINDINGS Thirty-nine articles were eligible for analysis. Enhancement in the areas diagnostics, education and information, healthcare services and healthcare professionals to ensure intercultural care is needed. DISCUSSION Current evidence supports the need for (a) thorough education of people of migrant origin with dementia, their families and healthcare professionals, (b) collaborations among everyone involved, (c) embracing different cultures in healthcare services, (d) the implementation of a care navigator functioning as a contact person and connecting all relevant parties with one another and (e) dementia testing suitable to the target group to ensure culturally sensitive and appropriate care for people of migrant origin with dementia and their families.
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Affiliation(s)
- Jessica Monsees
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Rostock/Greifswald, Greifswald, Germany
| | - Tim Schmachtenberg
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Rostock/Greifswald, Greifswald, Germany
| | - Jochen René Thyrian
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE) Rostock/Greifswald, Greifswald, Germany; and Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
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Lynnerup C, Rossing C, Sodemann M, Ryg J, Pottegård A, Nielsen D. Health care professionals' perspectives on medication safety among older migrants with cognitive impairment exposed to polypharmacy – A qualitative explorative study. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 5:100128. [PMID: 35478514 PMCID: PMC9032447 DOI: 10.1016/j.rcsop.2022.100128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 02/22/2022] [Accepted: 03/14/2022] [Indexed: 12/02/2022] Open
Abstract
Background Older migrants with cognitive impairment exposed to polypharmacy constitute a vulnerable group of patients. To our knowledge, evidence on medication safety among this patient group with multiple risk factors is lacking. Objectives To explore the perspectives of health care professionals on medication safety among older migrants with cognitive impairment taking five or more medications daily. Methods A total of 34 health care professionals (general practitioners and hospital-, community pharmacy-, and home care staff) participated in the study, comprising nine focus groups and one semi-structured interview, and shared their perspectives on medication safety among older migrants with cognitive impairment exposed to polypharmacy. The analysis was inspired by Revsbæk and Tanggaard's “Analyzing in the Present” and was followed by systematic text condensation. Results Three main themes emerged: (i) the importance of relationships in medication safety, (ii) culture and finances as risk factors, and (iii) the health care system as a risk factor. Subthemes and codes were related within and across main themes and revealed a high level of complexity within the barriers to medication safety. Some of these barriers were closely related to characteristics of this specific patient group, while others were more general barriers that also affected other patient groups. Participants found that these more general problems were complicated further by language barriers and cognitive impairment when working with this patient group. Conclusion Health care professionals across various sectors and professions experienced several barriers that threatened medication safety among older migrants with cognitive impairment exposed to polypharmacy. Closer collaboration between health care professionals, patients, and relatives is required to improve medication safety.
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Affiliation(s)
- Camilla Lynnerup
- Migrant Health Clinic - Research Unit for Infectious Diseases, Odense University Hospital, Odense C, Denmark
- Centre for Global Health, University of Southern Denmark, Odense C, Denmark
- OPEN, Odense Patient Data Explorative Network, Odense, Denmark
- University of Southern Denmark, Odense C, Denmark
- Corresponding author at: Migrant Health Clinic, Odense University Hospital, J.B. Winsløws Vej 4, DK-5000 Odense C, Denmark.
| | | | - Morten Sodemann
- Migrant Health Clinic - Research Unit for Infectious Diseases, Odense University Hospital, Odense C, Denmark
- Centre for Global Health, University of Southern Denmark, Odense C, Denmark
- University of Southern Denmark, Odense C, Denmark
| | - Jesper Ryg
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark
| | - Anton Pottegård
- Hospital Pharmacy Funen, Odense University Hospital, Odense C, Denmark
- Clinical Pharmacology, Pharmacy, and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Dorthe Nielsen
- Migrant Health Clinic - Research Unit for Infectious Diseases, Odense University Hospital, Odense C, Denmark
- Centre for Global Health, University of Southern Denmark, Odense C, Denmark
- Department of Geriatric Medicine, Odense University Hospital, Odense C, Denmark
- University of Southern Denmark, Odense C, Denmark
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Jäger SC, Filbert AL, Welchowski T, Weltermann B. Effects of the dementia care toolbox on personnel's self-reported confidence in patient care: a CRT in general practices. BMC FAMILY PRACTICE 2021; 22:231. [PMID: 34789149 PMCID: PMC8597294 DOI: 10.1186/s12875-021-01577-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 11/01/2021] [Indexed: 11/24/2022]
Abstract
Background In rapidly aging populations, general practitioners (GPs) are challenged in dementia care of patients with and without migration background. Uncertainties in treating dementia in migrant patients due to language barriers or information deficits are reported. To address these deficits, we developed the Dementia Care Toolbox which was judged helpful by GP practice personnel. This two-armed cluster-randomised trial (CRT) investigated the effects of this toolbox on German GPs’ and practice assistants’ (PrAs) attitudes and confidence in dementia care, especially in patients with migration background. Methods A total of 32 GP practices were recruited and randomised into intervention (toolbox use for 3 months) and waiting-list control (toolbox after follow-up). After 3 months all participating GPs and PrAs received a standardised questionnaire addressing their levels of self-reported confidence in dementia care for patients with and without migration background. A generalized estimating equation model that took practice cluster effects into account was applied to assess GPs and PrAs self-reported confidence in dementia care in patients with and without migration background. Results Overall, the intervention had no significant effect on self-reported confidence in dementia care. However, the use of the dementia care toolbox showed a tendency for a learning effect on knowledge about local support structures for migrant patients with dementia (odds ratio 1.43; 95% CI 0.68-3.03, p = 0.35) and for less communication difficulties with dementia patients in general (odds ratio 0.72; 95% CI 0.33-1.56; p = 0.40). Moreover, intervention practices showed a tendency towards more awareness of own limitations: less self-confidence regarding answering questions (odds ratio 0.82; 95% CI 0.36-1.86, p = 0.64) and providing information for patients with migration background (odds ratio 0.60; 95% CI 0.25-1.45, p = 0.26). Conclusion The Toolbox Dementia Care increased awareness on the respective topic. Given a small sample size, further studies on its effectiveness in primary care are needed. Trial registration German Clinical Trials Register, DRKS00014632. Registered 02/08/2018.
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Affiliation(s)
- Sabine Christine Jäger
- Institute of General Practice and Family Medicine, University Hospital Bonn, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Anna-Liesa Filbert
- Institute of General Practice and Family Medicine, University Hospital Bonn, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Thomas Welchowski
- Institute of General Practice and Family Medicine, University Hospital Bonn, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.,Institute of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Birgitta Weltermann
- Institute of General Practice and Family Medicine, University Hospital Bonn, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Effects of Sociodemographic Variables and Depressive Symptoms on MoCA Test Performance in Native Germans and Turkish Migrants in Germany. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126335. [PMID: 34208085 PMCID: PMC8296159 DOI: 10.3390/ijerph18126335] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 11/17/2022]
Abstract
The validity of the Montreal Cognitive Assessment (MoCA) in migrants is questionable, as sociodemographic factors and the migration process may influence performance. Our aim was to evaluate possible predictors (age, education, sex, depression, and migration) of MoCA results in Turkish migrants and Germans living in Germany. Linear regression models were conducted with a German (n = 419), a Turkish (n = 133), and an overall sample. All predictor analyses reached statistical significance. For the German sample, age, sex, education, and depression were significant predictors, whereas education was the only predictor for Turkish migrants. For the overall sample, having no migration background and higher education were significant predictors. Migration background and education had an impact on MoCA performance in a sample of German and Turkish individuals living in Germany. Thus, culture-specific normative data for the MoCA are needed, and the development of culture-sensitive cognitive screening tools is encouraged.
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Schoenmakers B, Robben T. Barriers in screening for dementia in elderly migrants in primary care and the use of the Rowland Universal Dementia Assessment Scale. A mixed cross-sectional and qualitative study. Eur J Gen Pract 2021; 27:45-50. [PMID: 33928835 PMCID: PMC8816395 DOI: 10.1080/13814788.2021.1913116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND In the migrant population, there is a higher risk of dementia. However, dementia is underdiagnosed in this population due to the underuse of appropriate screening tools. The Rowland Universal Dementia Assessment Scale (RUDAS) is designed for culturally and linguistically diverse populations. OBJECTIVES To gain insights into the primary care cognitive screening strategy for dementia in migrants and to evaluate the experiences with the RUDAS tool by general practitioners (GPs). METHODS GPs were questioned about barriers in dementia screening in the migrant population and asked to apply the RUDAS. A mixed-methods study was conducted among Flemish GPs. In an online survey, the currently used methods for screening for dementia in migrants and the barriers were investigated. In a qualitative pilot study, the user experience of the RUDAS scale was explored. RESULTS A total of 122/322 GPs participated (response rate 38%), 102 (83.6%) of all responding GPs mentioned language problems as the most apparent barrier. Most GPs believed the Mini Mental State Examination was inappropriate for migrants but they were unaware of an alternative. Due to lack of time and target population, only two GPs effectively applied the RUDAS. The tool was found easy to understand and less challenging in case of language problems. The main reason for not using RUDAS was the suspected time consumption. CONCLUSION GPs find screening for dementia in migrant patients a challenging act, mainly due to language barriers. GPs are not confident enough with the appropriate screening strategies and tools adjusted to the needs of migrant patients. Abbreviations: GP: general practitioner; RUDAS: Rowland Universal Dementia Assessment Scale; MMSE: Mini Mental State Examination.
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Affiliation(s)
- Birgitte Schoenmakers
- Academic Centre of General Practice, Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
| | - Tom Robben
- Academic Centre of General Practice, Department of Public Health and Primary Care, University of Leuven, Leuven, Belgium
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Schmachtenberg T, Monsees J, Thyrian JR. What elements are important in current treatment and care guidelines to provide culturally sensitive care for people with a migration background and dementia? A systematic analysis. J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-021-01531-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
OBJECTIVE We assessed long-term incidence and prevalence trends of dementia and parkinsonism across major ethnic and immigrant groups in Ontario. METHODS Linking administrative databases, we established two cohorts (dementia 2001-2014 and parkinsonism 2001-2015) of all residents aged 20 to 100 years with incident diagnosis of dementia (N = 387,937) or parkinsonism (N = 59,617). We calculated age- and sex-standardized incidence and prevalence of dementia and parkinsonism by immigrant status and ethnic groups (Chinese, South Asian, and the General Population). We assessed incidence and prevalence trends using Poisson regression and Cochran-Armitage trend tests. RESULTS Across selected ethnic groups, dementia incidence and prevalence were higher in long-term residents than recent or longer-term immigrants from 2001 to 2014. During this period, age- and sex-standardized incidence of dementia in Chinese, South Asian, and the General Population increased, respectively, among longer-term immigrants (by 41%, 58%, and 42%) and long-term residents (28%, 7%, and 4%), and to a lesser degree among recent immigrants. The small number of cases precluded us from assessing parkinsonism incidence trends. For Chinese, South Asian, and the General Population, respectively, prevalence of dementia and parkinsonism modestly increased over time among recent immigrants but significantly increased among longer-term immigrants (dementia: 134%, 217%, and 117%; parkinsonism: 55%, 54%, and 43%) and long-term residents (dementia: 97%, 132%, and 71%; parkinsonism: 18%, 30%, and 29%). Adjustment for pre-existing conditions did not appear to explain incidence trends, except for stroke and coronary artery disease as potential drivers of dementia incidence. CONCLUSION Recent immigrants across major ethnic groups in Ontario had considerably lower rates of dementia and parkinsonism than long-term residents, but this difference diminished with longer-term immigrants.
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Filbert AL, Jäger SC, Weltermann B. Acceptance and self-reported use of a dementia care toolbox by general practice personal: results from an intervention study in German practices. BMC FAMILY PRACTICE 2020; 21:264. [PMID: 33297967 PMCID: PMC7726861 DOI: 10.1186/s12875-020-01345-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/02/2020] [Indexed: 11/10/2022]
Abstract
Background Dementia is an age-related syndrome that is estimated to affect 46.8 million people worldwide (2015). In ageing populations, the prevalence of dementia is expected to increase. General practitioners (GPs) are often the first to be contacted when signs of dementia appear. This cluster-randomised trial (CRT) investigates the effects of a dementia care toolbox mailed to GP practices to facilitate dementia care. It contained patient brochures and posters for the waiting room in three languages, information cards for professionals and practical tools in three languages. The GPs’ and practice assistants’ (PrAs) use of and opinion about the toolbox is reported here. Methods Three months after receiving the toolbox, participating GPs and PrAs were sent a standardised, self-administered questionnaire asking about the use and helpfulness of the various toolbox items by mail. Results A total of 50 GPs and PrAs (14 GPs and 36 PrAs) from 15 practices completed the questionnaire. Of the participants, 82.0% reported using at least one of the tools, while 18.0% had used none. In descending order, the patient brochures (70.0%), the information card (58.0%) and the poster (40.0%) were used. In general, the brochures (52.1%), the information card (44.9%) as well as the poster (28.6%) were perceived as helpful. Conclusion Overall, the dementia toolbox was widely accepted by both professional groups. Future research should investigate long-term effects of information strategies for GP practice settings. Trial registration German Clinical Trials Register, DRKS00014632. Registered 02 August 2018. Clinical register of the study coordination office of the University hospital of Bonn. Registered 05 September 2017.
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Affiliation(s)
- Anna-Liesa Filbert
- Institute of General Practice and Family Medicine, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Sabine Christine Jäger
- Institute of General Practice and Family Medicine, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Birgitta Weltermann
- Institute of General Practice and Family Medicine, University of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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