Tackling climate change at the city level: insights from Lighthouse Cities' climate mitigation efforts

Introduction

The link between lifestyles and Greenhouse Gas (GHG) emissions has prioritized climate mitigation strategies of cities worldwide. As cities have increasingly generated GHG emissions by their industrial and transportation activities, their role in climate mitigation has gained prominence. Cities' climate mitigation policies to reduce the GHG intensity of their residents' daily lives are one of their significant efforts to tackle climate change. Lighthouse Cities (LCs), in particular, have emerged as remarkable actors in promoting lifestyle changes for their residents.

Methods

This study examines climate mitigation strategies of LCs of Climate CAMPAIGNers project, including Baku, Vilnius, Lahti, Izmir, Trujillo, Athens, Linz, Milan, Cape Town, Dublin, and Skopelos, addressing lifestyle changes by conducting an expert survey in 11 LCs involving 89 respondents. The findings of the expert survey are comparatively analyzed across 11 LCs.

Results

The results show that experts form Lighthouse Cities identify increasing awareness and information provision as a significant component of climate mitigation policies. Concerning lifestyle changes, strategies toward energy efficiency and sustainable mobility are highlighted as the primary areas to be prioritized.

Discussion

This study enhances the understanding of cities' capacity to reduce their residents' GHG emissions. The findings can be utilized to identify and tailor policies for supporting the Lighthouse Cities in their climate change mitigation efforts and provide pointers for selecting the lifestyle changes that can be promoted and prioritized in Lighthouse Cities.

Timing of Initiation of Palliative Chemotherapy in Asymptomatic Patients with Metastatic Pancreatic Cancer: An International Expert Survey and Case-Vignette Study

Background: The use of imaging, in general, and during follow-up after resection of pancreatic cancer, is increasing. Consequently, the number of asymptomatic patients diagnosed with metastatic pancreatic cancer (mPDAC) is increasing. In these patients, palliative systemic therapy is the only tumor-directed treatment option; hence, it is often immediately initiated. However, delaying therapy in asymptomatic palliative patients may preserve quality of life and avoid therapy-related toxicity, but the impact on survival is unknown. This study aimed to gain insight into the current perspectives and clinical decision=making of experts regarding the timing of treatment initiation of patients with asymptomatic mPDAC. Methods: An online survey (13 questions, 9 case-vignettes) was sent to all first and last authors of published clinical trials on mPDAC over the past 10 years and medical oncologists of the Dutch Pancreatic Cancer Group. Inter-rater variability was determined using the Kappa Light test. Differences in the preferred timing of treatment initiation among countries, continents, and years of experience were analyzed using Fisher's exact test. Results: Overall, 78 of 291 (27%) medical oncologists from 15 countries responded (62% from Europe, 23% from North America, and 15% from Asia-Pacific). The majority of respondents (63%) preferred the immediate initiation of chemotherapy following diagnosis. In 3/9 case-vignettes, delayed treatment was favored in specific clinical contexts (i.e., patient with only one small lung metastasis, significant comorbidities, and higher age). A significant degree of inter-rater variability was present within 7/9 case-vignettes. The recommended timing of treatment initiation differed between continents for 2/9 case-vignettes (22%), in 7/9 (77.9%) comparing the Netherlands with other countries, and based on years of experience for 5/9 (56%). Conclusions: Although the response rate was limited, in asymptomatic patients with mPDAC, immediate treatment is most often preferred. Delaying treatment until symptoms occur is considered in patients with limited metastatic disease, more comorbidities, and higher age.

Redesigning crop varieties to win the race between climate change and food security

Climate change poses daunting challenges to agricultural production and food security. Rising temperatures, shifting weather patterns, and more frequent extreme events have already demonstrated their effects on local, regional, and global agricultural systems. Crop varieties that withstand climate-related stresses and are suitable for cultivation in innovative cropping systems will be crucial to maximize risk avoidance, productivity, and profitability under climate-changed environments. We surveyed 588 expert stakeholders to predict current and novel traits that may be essential for future pearl millet, sorghum, maize, groundnut, cowpea, and common bean varieties, particularly in sub-Saharan Africa. We then review the current progress and prospects for breeding three prioritized future-essential traits for each of these crops. Experts predict that most current breeding priorities will remain important, but that rates of genetic gain must increase to keep pace with climate challenges and consumer demands. Importantly, the predicted future-essential traits include innovative breeding targets that must also be prioritized; for example, (1) optimized rhizosphere microbiome, with benefits for P, N, and water use efficiency, (2) optimized performance across or in specific cropping systems, (3) lower nighttime respiration, (4) improved stover quality, and (5) increased early vigor. We further discuss cutting-edge tools and approaches to discover, validate, and incorporate novel genetic diversity from exotic germplasm into breeding populations with unprecedented precision, accuracy, and speed. We conclude that the greatest challenge to developing crop varieties to win the race between climate change and food security might be our innovativeness in defining and boldness to breed for the traits of tomorrow.

Attack politics from Albania to Zimbabwe: A large-scale comparative study on the drivers of negative campaigning

There is little comparative research on what causes candidates in elections across the world to 'go negative' on their rivals - mainly because of the scarcity of large-scale datasets. In this article, we present new evidence covering over 80 recent national elections across the world (2016-2018), in which more than 400 candidates competed. For the first time in a large-scale comparative setting, we show that, ceteris paribus, negativity is more likely for challengers, extreme candidates, and right-wing candidates. Women are not more (or less) likely to go negative on their rivals than their male counterparts, but we find that higher numbers of female MPs in the country reduces negativity overall. Furthermore, women tend to go less negative in proportional systems and more negative in majoritarian systems. Finally, negativity is especially low for candidates on the left in countries with high female representation, and higher for candidates on the right in countries with proportional representation (PR).

Non-pharmacological treatments for schizophrenia in Southeast Europe: An expert survey

BACKGROUND

Non-pharmacological treatment for schizophrenia includes educational, psychotherapeutic, social, and physical interventions. Despite growing importance of these interventions in the holistic treatment of individuals with schizophrenia, very little is known about their availability in South-East European countries (SEE).

OBJECTIVE

To explore mental health care experts' opinions of the availability of non-pharmacological treatment for people with schizophrenia in SEE.

METHODS

An online survey containing 11 questions was completed by one mental health expert from each of the following SEE countries: Albania, Bosnia and Herzegovina (B&H), Bulgaria, Croatia, Greece, Kosovo^†, Montenegro, Moldova, North Macedonia, Romania, Serbia, and Slovenia. Data were collected on estimated rates of received non-pharmacological interventions, type of services delivering these interventions, and expert views of availability barriers.

RESULTS

In eight countries, the estimated percentage of people with schizophrenia who receive non-pharmacological treatments was below 35%. The primary explanations for the low availability of non-pharmacological treatments were: lack of human and financial resources, lack of training for clinicians, and pharmacotherapy dominance in the treatment for schizophrenia.

CONCLUSION

Lack of personal and institutional resources and state support were identified as primary obstacles to staff training and delivering non-pharmacological treatments to people with schizophrenia on individual and systemic levels, respectively. This evidence can be used to improve holistic, evidence-based treatment for schizophrenia in the SEE countries.

Accounting for Preference Heterogeneity in Discrete-Choice Experiments: An ISPOR Special Interest Group Report

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly used to elicit preferences for health and healthcare. Although many applications assume preferences are homogenous, there is a growing portfolio of methods to understand both explained (because of observed factors) and unexplained (latent) heterogeneity. Nevertheless, the selection of analytical methods can be challenging and little guidance is available. This study aimed to determine the state of practice in accounting for preference heterogeneity in the analysis of health-related DCEs, including the views and experiences of health preference researchers and an overview of the tools that are commonly used to elicit preferences.

METHODS

An online survey was developed and distributed among health preference researchers and nonhealth method experts, and a systematic review of the DCE literature in health was undertaken to explore the analytical methods used and summarize trends.

RESULTS

Most respondents (n = 59 of 70, 84%) agreed that accounting for preference heterogeneity provides a richer understanding of the data. Nevertheless, there was disagreement on how to account for heterogeneity; most (n = 60, 85%) stated that more guidance was needed. Notably, the majority (n = 41, 58%) raised concern about the increasing complexity of analytical methods. Of the 342 studies included in the review, half (n = 175, 51%) used a mixed logit with continuous distributions for the parameters, and a third (n = 110, 32%) used a latent class model.

CONCLUSIONS

Although there is agreement about the importance of accounting for preference heterogeneity, there are noticeable disagreements and concerns about best practices, resulting in a clear need for further analytical guidance.

A look into the future of the COVID-19 pandemic in Europe: an expert consultation

How will the coronavirus disease 2019 (COVID-19) pandemic develop in the coming months and years? Based on an expert survey, we examine key aspects that are likely to influence the COVID-19 pandemic in Europe. The challenges and developments will strongly depend on the progress of national and global vaccination programs, the emergence and spread of variants of concern (VOCs), and public responses to non-pharmaceutical interventions (NPIs). In the short term, many people remain unvaccinated, VOCs continue to emerge and spread, and mobility and population mixing are expected to increase. Therefore, lifting restrictions too much and too early risk another damaging wave. This challenge remains despite the reduced opportunities for transmission given vaccination progress and reduced indoor mixing in summer 2021. In autumn 2021, increased indoor activity might accelerate the spread again, whilst a necessary reintroduction of NPIs might be too slow. The incidence may strongly rise again, possibly filling intensive care units, if vaccination levels are not high enough. A moderate, adaptive level of NPIs will thus remain necessary. These epidemiological aspects combined with economic, social, and health-related consequences provide a more holistic perspective on the future of the COVID-19 pandemic.

Techno-Economic Prospects and Desirability of 3D Food Printing: Perspectives of Industrial Experts, Researchers and Consumers

3D food printing is an emerging food technology innovation that enables the personalization and on-demand production of edible products. While its academic and industrial relevance has increased over the past decade, the functional value of the technology remains largely unrealized on a commercial scale. This study aimed at updating the business outlook of 3D food printing so as to help entrepreneurs and researchers in the field to channel their research and development (R&D) activities. A three-phase mixed methods approach was utilized to gain perspectives of industrial experts, researchers, and potential consumers. Data were collected from two sets of interviews with experts, a survey with experts, and consumer focus group discussions. The results gave insights into key attributes and use cases for a 3D food printer system, including the techno-economic feasibility and consumer desirability of identified use cases. A business modelling workshop was then organized to translate these results into three refined value propositions for 3D food printing. Both the experts and consumers found personalized nutrition and convenience to be the most desirable aspects of 3D food printing. Accordingly, business models related to 3D printed snacks/meals in semi-public spaces such as fitness centers and hospitals were found to offer the highest business potential. While the technology might be mature enough at component level, the successful realization of such high-reward models however would require risk-taking during the developmental phase.

Delphi Technique in Health Sciences: A Map

Objectives: In health sciences, the Delphi technique is primarily used by researchers when the available knowledge is incomplete or subject to uncertainty and other methods that provide higher levels of evidence cannot be used. The aim is to collect expert-based judgments and often to use them to identify consensus. In this map, we provide an overview of the fields of application for Delphi techniques in health sciences in this map and discuss the processes used and the quality of the findings. We use systematic reviews of Delphi techniques for the map, summarize their findings and examine them from a methodological perspective.

Methods: Twelve systematic reviews of Delphi techniques from different sectors of the health sciences were identified and systematically analyzed.

Results: The 12 systematic reviews show, that Delphi studies are typically carried out in two to three rounds with a deliberately selected panel of experts. A large number of modifications to the Delphi technique have now been developed. Significant weaknesses exist in the quality of the reporting.

Conclusion: Based on the results, there is a need for clarification with regard to the methodological approaches of Delphi techniques, also with respect to any modification. Criteria for evaluating the quality of their execution and reporting also appear to be necessary. However, it should be noted that we cannot make any statements about the quality of execution of the Delphi studies but rather our results are exclusively based on the reported findings of the systematic reviews.

Drivers of future alien species impacts: An expert-based assessment

Understanding the likely future impacts of biological invasions is crucial yet highly challenging given the multiple relevant environmental, socio-economic and societal contexts and drivers. In the absence of quantitative models, methods based on expert knowledge are the best option for assessing future invasion trajectories. Here, we present an expert assessment of the drivers of potential alien species impacts under contrasting scenarios and socioecological contexts through the mid-21st century. Based on responses from 36 experts in biological invasions, moderate (20%-30%) increases in invasions, compared to the current conditions, are expected to cause major impacts on biodiversity in most socioecological contexts. Three main drivers of biological invasions-transport, climate change and socio-economic change-were predicted to significantly affect future impacts of alien species on biodiversity even under a best-case scenario. Other drivers (e.g. human demography and migration in tropical and subtropical regions) were also of high importance in specific global contexts (e.g. for individual taxonomic groups or biomes). We show that some best-case scenarios can substantially reduce potential future impacts of biological invasions. However, rapid and comprehensive actions are necessary to use this potential and achieve the goals of the Post-2020 Framework of the Convention on Biological Diversity.

Developing an ICF Core Set for adults with cerebral palsy: A Global expert survey of relevant functions and contextual factors

OBJECTIVE

To identify areas of functioning in adults with cerebral palsy that are considered relevant by experts, in order to develop an International Classification of Functioning, Disability and Health (ICF) Core Set for adults with cerebral palsy.

PARTICIPANTS

Experts from various professional backgrounds worldwide who had experience working with adults with cerebral palsy for ≥2 years and were able to complete the survey in the English language.

METHODS

A cross-sectional study using an international internet-based survey. The experts were asked to address relevant areas of functioning in adults with cerebral palsy. These areas of functioning were then linked to the ICF and the frequencies analysed.

RESULTS

A total of 126 experts from 32 countries completed the survey. From the responses, 217 unique second-level ICF categories were identified. The three most frequently mentioned categories were "design, construction and building products and technology of buildings for public use (e150, 77%) and private use" (e155, 67%), followed by "sensation of pain" (b280, 62%).

CONCLUSION

The broad diversity of ICF categories reported by the experts emphasize the known heterogeneity of cerebral palsy and the variety of func-tioning in adulthood. They also reported on many environmental factors, illustrating the importance of person-environment interactions. These findings provide information about relevant issues for use in developing an ICF Core Set for adults with cerebral palsy.

[Life Story Work in Foster Care - Results from an Expert Survey in Germany and Great Britain]

Life Story Work in Foster Care - Results from an Expert Survey in Germany and Great Britain This article presents the results of an exploratory study on the current practice of life story work in the German foster care system. As life story work with foster and adopted children has a long tradition in the UK, both German and British experts were interviewed. The comparative analysis showed that life story work in the German foster care system is characterized by a rather heterogeneous practice and is considerably less established than in Great Britain. From the point of view of the German experts surveyed, several improvements make sense, such as the introduction of quality standards for life story work and mandated training for pedagogical professionals in the foster care sector. The interviews conducted with the British experts provide valuable ideas for practical applications in Germany.

On the Suitability and Potential of Nursing Care Discussion Forums as a Health Promotion Measure for Long-Distance Caregiving Relatives: Evidence from Upper Austria

Background: The number of persons who have to overcome extensive geographical distances for caring for their older parent(s), hereinafter referred to as long-distance caregiving relatives (LDCs), is rising. However, in the non-English-speaking Global North, little is known about the LDCs’ health literacy and the design of tailor-made health promotion measures for this target-group. Using the example of nursing care discussion forums (NCDF), this paper reflects the requirements and (future) potential of professionally-lead support groups for LDCs on the case-study example of Upper Austria. Methods: In order to approach this unexplored topic considering spatial-related aspects, a qualitative-explorative study design was chosen, focusing on the providers’ perspective. A written survey among all NCDF-group leaders was carried out. Results: LDCs do not make use of NCDFs at present. It is considered that this is above all for time constraints, lack of information and location-based problems of fit. This applies for urban as well as rural contexts. Conclusions: LDCs need more attention in public health. Suitable NCDFs have to be located in the LCDs’ residential municipalities and have to fulfill different requirements from those of local caregiving relatives, particularly with regard to purpose and scope.

A multi-national expert survey

BACKGROUND

Dementia is a particularly severe societal challenge in several countries of the Danube Region due to higher-than-average increment in population longevity, disproportionate increase of the old-age dependency ratio, and selective outward migration of health care professionals. A survey was conducted among dementia experts to obtain a deeper understanding of the dementia care structures and services in this geographical area, and to identify the educational needs of health care professionals, and the availability of assistive technology.

SUBJECTS AND METHODS

A standardized questionnaire was sent out to 15 leading dementia experts/clinicians in 10 Danube Region countries inquiring about professional groups involved in dementia care, availability and reimbursement of services, inclusion of dementia in professional education and training, acceptability of Internet-based education, and availability of assistive technology. The authors are the survey respondents.

RESULTS

The majority of individuals with dementia receive care in the community rather than in institutions. The roles of medical specialties are disparate. General practitioners usually identify dementia symptoms while specialists contribute most to clinical diagnosis and treatment. Health care professionals, particularly those who work closely with patients and carers, have limited access to dementia-specific education and training. The greatest need for dementia-specific education is seen for general practitioners and nurses. An Internet-based education and skill-building program is considered to be equivalent to traditional face-to-face but offer advantages in terms of convenience of access. Assistive technology is available in countries of the Danube Region but is significantly underused.

CONCLUSION

Dementia care in the Danube Region can be improved by an educational and skill-building program for health care professionals who work in the frontline of dementia care. Such a program should also attempt to enhance interdisciplinary and intersectorial collaboration, to intensify the interaction between primary care and specialists, and to promote the implementation of assistive technology.

A European Research Agenda for Somatic Symptom Disorders, Bodily Distress Disorders, and Functional Disorders: Results of an Estimate-Talk-Estimate Delphi Expert Study

Background: Somatic Symptom Disorders (SSD), Bodily Distress Disorders (BDD) and functional disorders (FD) are associated with high medical and societal costs and pose a substantial challenge to the population and health policy of Europe. To meet this challenge, a specific research agenda is needed as one of the cornerstones of sustainable mental health research and health policy for SSD, BDD, and FD in Europe. Aim: To identify the main challenges and research priorities concerning SSD, BDD, and FD from a European perspective. Methods: Delphi study conducted from July 2016 until October 2017 in 3 rounds with 3 workshop meetings and 3 online surveys, involving 75 experts and 21 European countries. EURONET-SOMA and the European Association of Psychosomatic Medicine (EAPM) hosted the meetings. Results: Eight research priorities were identified: (1) Assessment of diagnostic profiles relevant to course and treatment outcome. (2) Development and evaluation of new, effective interventions. (3) Validation studies on questionnaires or semi-structured interviews that assess chronic medical conditions in this context. (4) Research into patients preferences for diagnosis and treatment. (5) Development of new methodologic designs to identify and explore mediators and moderators of clinical course and treatment outcomes (6). Translational research exploring how psychological and somatic symptoms develop from somatic conditions and biological and behavioral pathogenic factors. (7) Development of new, effective interventions to personalize treatment. (8) Implementation studies of treatment interventions in different settings, such as primary care, occupational care, general hospital and specialty mental health settings. The general public and policymakers will benefit from the development of new, effective, personalized interventions for SSD, BDD, and FD, that will be enhanced by translational research, as well as from the outcomes of research into patient involvement, GP-patient communication, consultation-liaison models and implementation. Conclusion: Funding for this research agenda, targeting these challenges in coordinated research networks such as EURONET-SOMA and EAPM, and systematically allocating resources by policymakers to this critical area in mental and physical well-being is urgently needed to improve efficacy and impact for diagnosis and treatment of SSD, BDD, and FD across Europe.

A Child's Concept of Pain: An International Survey of Pediatric Pain Experts

A child's 'concept of pain' refers to how they understand what pain actually is, what function pain serves, and what biological processes are thought to underpin it. We aimed to determine pediatric pain experts' opinions of: (1) the importance and usefulness of assessing a child's concept of pain in clinical and/or research settings; (2) the usefulness of the content of items within currently published adult-targeted resources for assessing a child's concept of pain; and (3) important domains of a child's concept of pain to assess. Forty-nine pediatric pain experts (response rate = 75.4%) completed an online survey. Descriptive statistics and frequency of responses were analyzed. Experts from all included disciplines reported that assessing a child's concept of pain is important and useful both clinically and in a research setting (>80% reported very or extremely useful for each item). Experts considered that the content of 13 items from currently published adult-targeted resources was useful, but the wording was too complex for children aged 8-12 years. Experts considered that all seven of the proposed domains of a child's concept of pain was important to assess. The findings can be used to inform the development of an assessment tool for a child's concept of pain.

Mainstreaming Mental Health Care in 42 Countries

Abstract-Global consensus and national policies have emphasized deinstitutionalization, or a shift in providing mental health care from institutional to community settings. Yet, psychiatric hospitals and asylums receive the majority of mental health funding in many countries, at odds with research evidence that suggests that services should be delivered in the community. Our aim is to investigate the norms, actors, and strategies that influence the uptake of deinstitutionalization internationally. Our study is informed by prior literature on management and implementation science. The success and failure of mental health care operations depend on identifying and overcoming challenges related to implementing innovations within national contexts. We surveyed 78 experts spanning 42 countries on their knowledge and experiences in expanding community-based mental health care and/or downsizing institution-based care. We also asked them about the contexts in which said methods were implemented in a country. We found that mental health care, whether it is provided in institutions or in the community, does not seem to be standardized across countries. Our analysis also showed that moving deinstitutionalization forward requires meaningful engagement of three types of actors: government officials, health care professionals, and local experts. Progress toward deinstitutionalization depends on the partnerships formed among these actors and with diverse stakeholders, which have the potential to garner resources and to scale-up pilot projects. In conclusion, different countries have adapted deinstitutionalization in ways to meet idiosyncratic situations and population needs. More attention should be given to the management and implementation strategies that are used to augment treatment and preventive services.

Towards Horizon 2020: challenges and advances for clinical mental health research - outcome of an expert survey

BACKGROUND

The size and increasing burden of disease due to mental disorders in Europe poses substantial challenges to its population and to the health policy of the European Union. This warrants a specific research agenda concerning clinical mental health research as one of the cornerstones of sustainable mental health research and health policy in Europe. The aim of this research was to identify the top priorities needed to address the main challenges in clinical research for mental disorders.

METHODS

The research was conducted as an expert survey and expert panel discussion during a scientific workshop.

RESULTS

Eighty-nine experts in clinical research and representing most European countries participated in this survey. Identified top priorities were the need for new intervention studies, understanding the diagnostic and therapeutic implications of mechanisms of disease, and research in the field of somatic-psychiatric comorbidity. The "subjectivity gap" between basic neuroscience research and clinical reality for patients with mental disorders is considered the main challenge in psychiatric research, suggesting that a shift in research paradigms is required.

CONCLUSION

Innovations in clinical mental health research should bridge the gap between mechanisms underlying novel therapeutic interventions and the patient experience of mental disorder and, if present, somatic comorbidity. Clinical mental health research is relatively underfunded and should receive specific attention in Horizon 2020 funding programs.

Toward the development of the International Classification of Functioning Core Sets for children with cerebral palsy: a global expert survey

The goal of the International Classification of Functioning is to standardize the classification of health and function of children around the world. To facilitate the application of this classification, International Classification of Functioning-based tools like the "Core Sets" are being developed. We conducted an international survey of professional experts to identify the most relevant areas of functioning in children with cerebral palsy. The questionnaire covered each component of the classification. In total, 193 professionals completed the survey (response rate 78%). Overall, 9706 answers were linked to the classification (pediatric version) by 2 professionals. From the experts' perspective, movement-related areas and social participation are the most relevant areas of functioning. Experts suggest a more comprehensive profile of functioning in particular in areas of personal capacity and social participation. The results of this survey will inform the development of the International Classification of Functioning Core Sets for children with cerebral palsy.

How do health services researchers understand the concept of patient-centeredness? Results from an expert survey

BACKGROUND

The concept of patient-centeredness has gained in importance over recent decades, including its growing importance on a health policy level. However, many different definitions and frameworks exist. This renders both research and implementation into clinical practice difficult. This study aimed at assessing how German researchers conceptualize patient-centeredness, how they translate the German equivalent into English, and what they consider the most important references on the topic.

METHODS

All researchers within a German research priority program on patient-centeredness were invited to participate in an online survey with open questions. The data regarding the definitions of patient-centeredness were analyzed using the method of conventional content analysis. Descriptive statistics were used to analyze the responses on translations and references.

RESULTS

Thirty-eight (28%) of 136 invited researchers participated in the study. The definitions given by the participants could be classified into ten categories: patient as a unique person, involvement in decision-making, patient information, essential characteristics of the physician, biopsychosocial perspective, patient empowerment, individualized services, patient-reported outcomes, involvement in health policy and coordination and teamwork. The results for the translation of the German word "Patientenorientierung" into English indicate that uncertainty regarding the appropriate English terminology exists. All participants provided a different reference on patient-centeredness that was important to them.

CONCLUSION

The results show a certain degree of "shared meaning" regarding the concept of patient-centeredness. However, they also indicate a considerable amount of "surplus meaning", which can be seen as an indicator for the fuzziness of a theoretical concept. All in all, this study has shown that the conceptual ambiguity found in the literature on patient-centeredness is partly reflected in the conceptualizations of German researchers working in that field. This calls for more conceptual work, eg, developing an integrative model on patient-centeredness grounded in the international literature.