Which risk understandings can be derived from the current disharmonized regulation of complementary and alternative medicine in Europe?

A review of the WHO strategy on traditional, complementary, and integrative medicine from the perspective of academic consortia for integrative medicine and health

Despite important progress in modern medicine, widely regarded as an indispensable foundation of healthcare in all highly advanced nations and regions, not all patients respond well to available treatments in biomedicine alone. Additionally, there are concerns about side effects of many medications and interventions, the unsustainable cost of healthcare and the low resolution of chronic non-communicable diseases and mental disorders whose incidence has risen in the last decades. Besides, the chronic stress and burnout of many healthcare professionals impairs the therapeutic relationship. These circumstances call for a change in the current paradigm and practices of biomedicine healthcare. Most of the world population (80%) uses some form of traditional, complementary, and integrative medicine (T&CM), usually alongside biomedicine. Patients seem equally satisfied with biomedicine and T&CM, but in the field of T&CM there are also many challenges, such as unsupported claims for safety and/or efficacy, contamination of herbal medicines and problems with regulation and quality standards. As biomedicine and T&CM seem to have different strengths and weaknesses, integration of both approaches may be beneficial. Indeed, WHO has repeatedly called upon member states to work on the integration of T&CM into healthcare systems. Integrative medicine (IM) is an approach that offers a paradigm for doing so. It combines the best of both worlds (biomedicine and T&CM), based on evidence for efficacy and safety, adopting a holistic personalized approach, focused on health. In the last decades academic health centers are increasingly supportive of IM, as evidenced by the foundation of national academic consortia for integrative medicine in Brazil (2017), the Netherlands (2018), and Germany (2024) besides the pioneering American consortium (1998). However, the integration process is slow and sometimes met with criticism and even hostility. The WHO T&CM strategies (2002-2005 and 2014-2023) have provided incipient guidance on the integration process, but several challenges are yet to be addressed. This policy review proposes several possible solutions, including the establishment of a global matrix of academic consortia for IM, to update and extend the WHO T&CM strategy, that is currently under review.

Complementary and alternative medicines and liver disease

Complementary and alternative medicines (CAM) include conventional medical treatments. Patients worldwide use CAM at alarming rates; thus, reports of CAM-related DILI have been on the rise. The clinical presentations include asymptomatic liver test abnormalities, acute hepatitis with or without jaundice, acute cholestatic liver disease (bland or with hepatitis), acute liver failure, severe hepatitis with features of portal hypertension, and acute decompensation of known or unknown cirrhosis that can lead to acute-on-chronic liver failure. Acute hepatitis with or without necrosis, hepatocellular and canalicular cholestasis, herb-induced or CAM-triggered autoimmune hepatitis, granulomatous hepatitis, severe steatohepatitis, and vanishing bile duct syndrome are common liver biopsy findings in CAM-DILI. The presence of preexisting liver disease predicts severe liver injury, risk of progression to liver failure, and decreased transplant-free survival in patients with CAM-DILI. This review discusses global epidemiology and trends in CAM-DILI, clinical presentation, assessment and outcomes, commonly emerging threats in the context of hepatotoxic herbs, pragmatic assessment of "liver beneficial" herbs and health care myths, patient communication, regulatory framework, and future directions on research in CAM.

Evidence-Based Opinions from Multidisciplinary Experts on Use of Naturopathic Herbal Remedies in Pain Management

Background

Pharmacological approaches to acute and chronic pain management, including non-steroidal anti-inflammatory drugs (NSAIDs) and opioids, are respectively associated with adverse reactions (such as gastrointestinal, cardiovascular, and renal effects) that might limit their use in patients with comorbidities and controversy related to inappropriate use. Naturopathic remedies might offer patients alternative and integrative treatments with minimal side effects.

Objective

To explore the regional variation in the acceptance and use of naturopathic remedies in pain management.

Methods

Two expert panel discussions were held by GlaxoSmithKline Consumer Healthcare (now Haleon Pte. Ltd.) over 9 and 12 hours in 2020 and 2021, respectively, and attended by multidisciplinary experts in naturopathy, Ayurvedic medicine, community pharmacy, physiotherapy, clinical pharmacy, Western medicine, academics, and naturopathic pain relief. Experts shared and discussed their experiences of naturopathic treatments and relevant clinical evidence related to different types of pain (including joint and muscle pain, migraine, sleeplessness due to pain, and general pain) and examined barriers to providing support to patients.

Results

Experts agreed on the potential for curcumin (2020, 71.4% [5/7]; 2021, 91.7% [11/12]) and fish oil (2020, 100% [7/7]) for management of osteoarthritic joint pain although these are not uniformly recommended in osteoarthritis treatment guidelines. In treatment of migraines, coenzyme Q10 and magnesium were favored by experts (2021, 90.9% [10/11] and 63.6% [7/11], respectively).

Conclusion

The need was emphasized for more and higher quality clinical studies to support naturopathic remedies, which might not be reflected in the latest treatment guidelines. The expert panel also highlighted missed opportunities for physicians and pharmacists to recommend effective naturopathic treatments.

Stakeholder Perceptions of Complementary and Integrative Medicines from People Living with Rare Diseases in Northern Ireland: A Mixed Methods Study

INTRODUCTION

Only 5% of rare diseases have an approved treatment available, therefore patients often utilise complementary and integrative medicines (CIMs) to help manage their condition. Limited high-quality evidence-based studies are available which support the effectiveness of CIM, as it is difficult to show that an outcome is a direct result of the CIM intervention and not due to bias. Patients and healthcare professionals must weigh up the evidence quality, safety, efficacy, practical logistics, and financial implications of utilising CIM for rare diseases. This study aimed to elucidate perspectives of stakeholders (individuals with rare diseases, carers, family members, CIM practitioners and healthcare professionals), on the usage of CIM for rare diseases across Northern Ireland.

METHODS

This was a mixed methods study. An online survey was open from January to February 2019 (n = 29 responses). Themes identified from the survey were then discussed with stakeholders in a semi-structured discussion workshop in March 2019.

RESULTS

A limited number of participants responded to the survey (n = 29). Some individuals with rare diseases reported CIM as effective in the management of their condition, in particular acupuncture, dietary supplements, herbal medicines, homoeopathy, hydrotherapy, kinesiology, mindfulness, pilates, reflexology, tai chi, and yoga. However, a number of respondents (n = 7) experienced a negative side effect from CIM. Workshop participants raised concerns over the lack of information available about CIM and rare disease. Both the survey and workshop identified inequality of access with participants reporting CIM to be expensive.

CONCLUSIONS

More information, high-quality research, and education about CIM are required for patients and healthcare professionals to help make informed decisions about the usage of CIM for rare diseases. Improved communication, information, and health and social care in general would help individuals be more confident and knowledgeable about therapeutic options in relation to their rare disease(s).

Einleitung

Nur für fünf Prozent der seltenen Erkrankungen existiert eine zugelassene Behandlung, weshalb Patienten häufig komplementäre und integrative Medizin (CIM) nutzen, um ihre Krankheit zu behandeln. Es liegen nur wenige qualitativ hochwertige evidenzbasierte Studien vor, die die Wirksamkeit von CIM stützen, da sich schwer nachweisen lässt, dass ein Behandlungsergebnis direkt durch die CIM-Intervention bedingt und nicht Folge einer Verzerrung ist. Patienten und Angehörige der Gesundheitsberufe müssen die Qualität der Evidenz, die Sicherheit und Wirksamkeit sowie praktische logistische Aspekte und die finanziellen Folgen der Anwendung von CIM bei seltenen Erkrankungen abwägen. Mit der vorliegenden Studie sollte die Perspektive der Betroffenen (Menschen mit seltenen Erkrankungen, Betreuungspersonen, Familienangehörige, CIM-Praktiker und Angehörige der Gesundheitsberufe) in Bezug auf die Anwendung von CIM bei seltenen Erkrankungen in Nordirland untersucht werden.

Methoden

Es handelte sich um eine Studie mit gemischten Methoden. Eine Online-Umfrage war von Januar bis Februar 2019 geöffnet (n = 29 Antworten). Die in der Umfrage ermittelten Themen wurden anschließend im März 2019 im Rahmen eines halbstrukturierten Diskussionsworkshops mit den Betroffenen erörtert.

Ergebnisse

Eine begrenzte Anzahl von Teilnehmern antwortete auf die Umfrage (n = 29). Einige Personen mit seltenen Erkrankungen gaben an, dass CIM bei der Behandlung ihrer Erkrankung wirksam war, insbesondere Akupunktur, Nahrungsergänzungsmittel, pflanzliche Arzneimittel, Homöopathie, Hydrotherapie, Kinesiologie, Achtsamkeit, Pilates, Reflexologie, Tai Chi und Yoga. Einige Befragte (n = 7) berichteten jedoch über negative Nebenwirkungen der CIM. Die Workshop-Teilnehmer äußerten Bedenken in Bezug auf den Mangel an Informationen über CIM und seltene Erkrankungen. Sowohl in der Umfrage als auch im Workshop zeigte sich eine Ungleichheit beim Zugang zu CIM und die Teilnehmer berichteten, dass CIM teuer sei.

Schlussfolgerungen

Patienten und Angehörige der Gesundheitsberufe benötigen mehr Informationen, qualitativ hochwertige Forschung und Aufklärung über CIM, um fundierte Entscheidungen über die Anwendung von CIM bei seltenen Erkrankungen treffen zu können. Eine bessere Kommunikation, Information sowie gesundheitliche und soziale Versorgung im Allgemeinen würden zu mehr Selbstvertrauen und Wissen der Betroffenen über die therapeutischen Möglichkeiten im Zusammenhang mit ihrer seltenen Erkrankung beitragen.

The engagement of psychology with complementary medicine: A critical integrative review

Amidst the global rise in complementary medicine (CM) use for mental health, a substantial number of clients consulting a psychologist also utilise at least one form of CM. Yet, how psychologists should engage with CM in their clinical practice (e.g., how to respond to a client disclosing CM use or enquiries regarding CM products or services for mental health) remains contested and unclear. In response, a systematic integrative review was conducted to examine empirical literature reporting on one or more aspects of the relationship between psychology (incorporating clinical practice, professional associations and academia) and CM, and how that relationship may relate to or inform psychologists' engagement with CM in their clinical practice. Twenty-seven peer-reviewed articles met the specific inclusion criteria and quality appraisal was employed. Analysis shows a substantial number of psychologists are engaging with, or are interested in engaging with, CM in their clinical practice. Analysis identified a dissonance between psychologists' engagement with CM in clinical practice and the limited engagement of the broader discipline of psychology with CM. Further research is required to understand these differing types of engagement with a view to helping inform relevant policy and practice guidelines, and ultimately assist psychologists in navigating CM in their clinical practice.

Design, delivery and effectiveness of health practitioner regulation systems: an integrative review

BACKGROUND

Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions.

METHODS

We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework.

FINDINGS

This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures-processes-outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners.

CONCLUSION

We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.

Dietary supplements used by otolaryngology patients in Turkey during the COVID-19 pandemic: A cross-sectional survey

Introduction

This study investigated the characteristics of dietary supplement (DS) use of patients who attended the otolaryngology clinic at a university training and research hospital in Turkey during the pandemic, including patients who had experienced Coronavirus disease 2019 (COVID-19).

Methods

This cross-sectional study was conducted between March and September 2021. 277 literate patients aged ≥ 18 years who attended the otolaryngology clinic were enrolled. A questionnaire was used to collect sociodemographic data, as well as data on DS use during the pandemic. The questionnaire was administered in a face-to-face setting by a single researcher.

Results

Approximately half of the participants (50.18%) took DSs during the pandemic and 67.18% of those who experienced COVID-19 infection used DSs during their illness. The most commonly used supplements were vitamin C (43.16%) and D (33.09%), along with herbal supplements such as lemon (54.68%), garlic (46.76%), ginger (46.04%), and thyme (43.88%). In total, 85.23% of the patients primarily used DSs to enhance their immunity, while 32.95% used them to prevent cough, and 26.14% to improve breathing. The majority of the patients (85.23%) felt benefit from DSs. Typically, the patients obtained information about DSs from doctors (32.37%) or friends and relatives (29.49%), and most of them used the supplements without first consulting a doctor (63.64%).

Conclusion

DSs were commonly used by otolaryngology patients during the COVID-19 pandemic, particularly to enhance immunity. Although the majority of patients reportedly benefited from these products, most of them did not inform their physicians that they were using them and often obtained information from unofficial sources.

To Use or Not Use Complementary and Alternative Medicine (CAM) in Psychiatric Care: Interviews with Clinical Decision-Makers in Sweden

Complementary and alternative medicine (CAM) is used as a complementary intervention in psychiatric healthcare. The reasons for using or not using CAM in psychiatric care in Sweden, and how such decisions are taken, are largely unknown. The aim was to investigate arguments for and against the use of CAM in Swedish psychiatric care, and how decisions are made. Interviews with 10 persons in decision-making positions in psychiatric health care were analysed thematically. The result shows diverging understandings of the evidence base for CAM. Arguments against CAM referred to scepticism, the importance of evidence-based practice and the obligation to follow national guidelines. Arguments in favour of CAM were that CAM was person-centred, safe, cost-effective, nursing interventions with positive effects, appreciated and demanded by patients, providing space for non-verbal communication and reflection, supporting the therapeutic alliance. Decision paths were described as top-down through a hierarchical structure, or bottom-up, driven by committed staff members. We discuss how detailed national guidelines should be to achieve equal and evidence-based care, while still allowing clinics to make local exceptions, adjusting the care according to clinical expertise and patients' preferences. Conclusion: Evidence-based, safe and cost-effective CAM methods may be relevant complementary interventions in psychiatric care, or as self-care, not to cure the psychiatric disease, but to reduce symptoms and promote sleep. With better knowledge of CAM, health professionals could guide patients through the jungle of CAM methods. Due to research problems on complex multicomponent interventions, high-quality pragmatic trials, including biomarkers, and qualitative studies are recommended.

Complementary and alternative medicine use among older adults with musculoskeletal pain: findings from the European Social Survey (2014) special module on the social determinants of health

Background:

This study describes the use of complementary and alternative medicine (CAM) among older adults who report being hampered in daily activities due to musculoskeletal pain. The characteristics of older adults with debilitating musculoskeletal pain who report CAM use is also examined.

Methods:

Cross-sectional European Social Survey Round 7 data from 21 countries were examined for participants aged 55 years and older, who reported musculoskeletal pain that hampered daily activities in the past 12 months.

Results:

Of the 4950 older adult participants reporting musculoskeletal pain that hampered daily activities, the majority (63.5%) were from the West of Europe, reported secondary education or less (78.2%), and reported at least one other health-related problem (74.6%). In total, 1657 (33.5%) reported using at least one CAM treatment in the previous year. Manual body-based therapies (MBBTs) were most used, including massage therapy (17.9%) and osteopathy (7.0%). Alternative medicinal systems (AMSs) were also popular with 6.5% using homoeopathy and 5.3% reporting herbal treatments. A general trend of higher CAM use in younger participants was noted. CAM use was associated with physiotherapy use, female gender, higher levels of education, being in employment and living in West Europe. Those reporting multiple health problems were more likely to use all CAM treatments, except MBBT.

Conclusion:

A third of older Europeans with musculoskeletal pain report CAM use in the previous 12 months. Certain subgroups with higher rates of CAM use could be identified. Clinicians should comprehensively and routinely assess CAM use among older adults with musculoskeletal pain.

Characteristics of global naturopathic education, regulation, and practice frameworks: results from an international survey

BACKGROUND

This descriptive study provides the first examination of global naturopathic education, regulation and practice frameworks that have potential to constrain or assist professional formation and integration in global health systems. Despite increasing public use, a significant workforce, and World Health Organization calls for national policy development to support integration of services, existent frameworks as potential barriers to integration have not been examined.

METHODS

This cross-sectional survey utilized purposive sampling of 65 naturopathic organisations (educational institutions, professional associations, and regulatory bodies) from 29 countries. Organizational representatives completed an on-line survey, conducted between Nov 2016 - Aug 2019. Frequencies and cross-tabulation statistics were analyzed using SPSSv.25. Qualitative responses were hand-coded and thematically analysed where appropriate.

RESULTS

Sixty-five of 228 naturopathic organizations completed the survey (29% response rate) from 29 of 46 countries (63% country response rate). Most education programs (68%) were delivered via a national framework. Higher education qualifications (60%) predominated. Organizations influential in education were professional associations (75.4%), particularly where naturopathy was unregulated, and accreditation bodies (41.5%) and regulatory boards (33.8%) where regulated. Full access to controlled acts, and to health insurance rebates were more commonly reported where regulated. Attitude of decision-makers, opinions of other health professions and existing legislation were perceived to most impact regulation, which was globally heterogeneous.

CONCLUSION

Education and regulation of the naturopathic profession has significant heterogeneity, even in the face of global calls for consistent regulation that recognizes naturopathy as a medical system. Standards are highest and consistency more apparent in countries with regulatory frameworks.

Diagnóstico situacional das Práticas Integrativas e Complementares na Atenção Primária à Saúde do Maranhão

RESUMO Esta pesquisa apresenta o diagnóstico situacional das Práticas Integrativas e Complementares na Atenção Primária à Saúde do estado do Maranhão. Foi realizado um estudo descritivo, com dados primários dos 217 municípios do estado, através de um formulário enviado a todos os secretários municipais de saúde, no período de abril a julho de 2019. A taxa de resposta foi de 100%, indicando que 25,4% dos municípios ofertam Práticas Integrativas e Complementares. Fitoterapia e massoterapia são as mais ofertadas, estando presentes em 49,1% e 29,1% dos municípios, respectivamente. Os fisioterapeutas são os profissionais que mais executam as Práticas Integrativas e Complementares (54,5% dos municípios). Em 49,1% dos municípios, essas práticas são ofertadas pela Estratégia Saúde da Família, e em 47,3%, pelo Núcleo Ampliado de Saúde da Família. No que diz respeito aos instrumentos de gestão, organização e legislação específica, observou-se que nenhum município do estado possui legislação específica para as práticas e 14,5% dos municípios preveem alguma estrutura organizacional específica para geri-las. A oferta destas práticas no Maranhão ainda é um desafio, mesmo com as orientações da Organização Mundial de Saúde e a instituição da Política Nacional de Práticas Integrativas e Complementares no Sistema Único de Saúde.

Paradigm-Specific Risk Conceptions, Patient Safety, and the Regulation of Traditional and Complementary Medicine Practitioners: The Case of Homeopathy in Ontario, Canada

While the principle of risk reduction increasingly underpins health professional regulatory models across the globe, concepts of risk are neither static nor epistemically neutral. Conventional biomedicine's risk conceptions are substantially rooted in principles of scientific materialism, while many traditional and complementary medicine systems have vitalistic epistemic underpinnings that give rise to distinctive safety considerations. The statutory regulation of traditional and complementary medicine providers has been identified by the World Health Organization as a strategy for enhancing public safety. However, complex risk-related questions arise at the intersection of medical epistemologies whose concepts are at best overlapping, and at worst incommensurable. Elaborating a theoretical concept of "paradigm-specific risk conceptions," this work employs Bacchi's poststructural mode of policy analysis ("What's the Problem Represented to Be?") to critically analyze risk discourse in government documents pertaining to the 2015 statutory regulation of homeopathic practitioners in Ontario, Canada. The Ontario government's pre-regulatory risk assessments of the homeopathic occupation discursively emphasized cultural safety principles alongside homeopathy-specific risk conceptions. These paradigm-specific concepts, rooted in homeopathy's epistemic vitalism, extend beyond materialist constructions of adverse events and clinical omission to address potential harms from homeopathic "proving symptoms", "aggravation," and "disruption," all considered implausible from a biomedical standpoint. Although the province's new homeopathy regulator subsequently articulated safety competencies addressing such vitalistic concepts, the tangible risk management strategies ultimately mandated for practitioners exclusively addressed risks consistent with the scientific materialist paradigm. This policy approach substantially echoes the implicit biomedical underpinnings evident in Ontario's broader legislative context, but leaves a significant policy gap regarding the primary safety considerations originally articulated as substantiation for homeopathy's statutory regulation. To optimally preserve patient safety and full informed consent, regulators of traditional and complementary medicine professionals should favor a pragmatic, epistemically-inclusive approach that actively negotiates paradigm-specific risk conceptions from both biomedicine and the occupation under governance.

"Then I went to a hospital abroad": acknowledging implications of stakeholders' differing risk understandings related to use of complementary and alternative medicine in European health care contexts

Background

Complementary and alternative medicine (CAM) is a rather novel issue within public healthcare and health policy-making. CAM use in Europe is widespread, patient-initiated, and patient-evaluated, and the regulation across countries has been evaluated as disharmonized. CAM users are left in an uncertain position, and patient safety may be threatened. How “risk” is understood by individuals in health policy-making and clinical encounters involving the use of CAM has not yet been much debated. The aim of this article is to explore and discuss the existence and possible consequences of differing risk understandings among stakeholders maneuvering in the complex landscape of CAM practice and CAM regulation contextualized by European public healthcare systems.

Methods

Qualitative data were derived from two studies on CAM in European healthcare contexts. Findings from the EU project CAMbrella on legislation and regulation of CAM were mixed with data from an interview study exploring risk understandings, communication, and decision-making among Scandinavian CAM users and their doctors. In a secondary content analysis, we constructed the case Sara as a typology to demonstrate important findings with regard to risk understandings and patient safety involving European citizens’ use of CAM in differing contexts.

Results

By combining and comparing individual and structural perspectives on risk and CAM use, we revealed underexplored gaps in risk understandings among individuals involved in European CAM regulation and legislation, and between CAM users and their medical doctors. This may cause health risks and uncertainties associated with CAM use and regulation. It may also negatively influence doctor-CAM user communication and CAM users’ trust in and use of public healthcare.

Conclusion

Acknowledging implications of stakeholders’ differing risk understandings related to CAM use and regulation may positively influence patient safety in European healthcare. Definitions of the concept of risk should include the factors uncertainty and subjectivity to grasp the full picture of possible risks associated with the use of CAM. To transform the findings of this study into practical settings, we introduce sets of questions relevant to operationalize the important question “What is risk?” in health policy-making, clinical encounters and risk research involving European patients’ use of CAM.

"I Could Feel It!": A Qualitative Study on How Users of Complementary Medicine Experience and Form Knowledge About Treatments

Purpose: The aim of this study was to examine how users of complementary and alternative medicine (CAM) experience various forms of treatments, form knowledge about them, and understand the boundaries between CAM and conventional health care. Method: Semistructured qualitative interviews, with 10 CAM users in Sweden, analyzed with qualitative content analysis and quantitative network analysis, and subsequent network visualizations. Findings and Conclusion: The main findings stressed the importance to CAM users of bodies and physical experiences, both in experiencing and forming knowledge about treatments. Physical experience was often contrasted with theoretical understanding. Another key finding was that the CAM users seemed to set up different standards for conventional and public health care and CAM. Although scientific explanations were considered as generally important for legitimacy, and conventional health care was expected to be evidence based, they were less important to personal use and in the use of CAM. In these cases, firsthand experience of positive effects were decisive.