Abstract
Awareness of the nature and frequency of complaints against health care professionals working in police custodial health care services could provide opportunities to improve patient safety. To explore this freedom of information requests were sent to police services in England, Wales and Northern Ireland, to professional regulatory bodies and to the Independent Office for Police Conduct. Eighty-seven percent of police services responded but only a minority provided complete responses, with data not being held, or not being held in an easily retrievable format, being provided as reasons. The nature and frequency of complaints were similar to a previous 2017 study, suggesting a failure to learn lessons from the investigation of complaints and implement change in clinical practice. No evidence of an accessible complaints handling and recording procedure was provided across the police services surveyed. Regulatory bodies provided some information on the nature of complaints made against doctors and nurses working in police custodial settings, but that for paramedics was unable to do so. It is recommended that the communication loop between police services, those bodies providing health care and forensic medical services and regulatory bodies needs to be closed. A common reporting system or the application of established complaints handling procedures and reporting structures, which could be achieved by transferring these services to the National Health Service, may enhance patient safety in police custody.
Introduction
Police custody in the United Kingdom represents an especially high-risk health care setting for several reasons. First, detainees in police custody are a vulnerable patient group who frequently have complex and life-threatening health needs,1,2 including high levels of substance misuse and mental health conditions, 1 which are often combined with chaotic lifestyles, homelessness and insufficient prior interaction with health care. 1 Second, health care professionals (HCPs – doctors, nurses and paramedics) working in the police custodial setting face additional challenges not commonly encountered in other health care settings such as poor standard of physical infrastructure, limited diagnostic facilities, the existence of a dual obligation 3 to both the patient and to the police service and a high incidence of safeguarding risks for the children and vulnerable adults that they encounter. Failures on the part of HCPs can have especially serious patient safety consequences, including death, serious harm and miscarriages of justice. In 2020/2021, there were 19 deaths in or following police custody. 4 Some deaths could have been preventable.5–7 It will be noted that these latter examples are sometimes reported years after the initial incident, and final outcomes determined in inquests or criminal trials. This may mean that details of potentially preventable deaths or harm are not widely known or circulated at the time.
It is well established that complaints are a tremendously rich source of information in respect of identifying issues that pose a threat to patient safety in health care settings and that a process of routine complaints analysis can identify areas for improvement and development within health care systems.8–10 Complaints about care within the National Health Service (NHS) system may be made in a variety of ways, for example, from patients and carers via the Patient Advice & Liaison Services in most hospitals 11 and by HCPs reporting on systems such as Datix (is the reporting system for recording clinical incidents or ‘near misses’ which allows for the sharing of the details of incidents; enabling weaknesses in the system to be identified, customs and practices to be changed and staff to be retrained where necessary). Datix allows incidents to be reported in real-time reducing delays experienced with paper systems 12 and the serious incident reporting framework. 13 Currently, NHS England is developing a new Learn From Patient Safety Events service continuing the approach that ‘recording safety events, whether they result in harm or not, provides vital insight into what can go wrong in healthcare and the reasons why’. NHS England emphasises that ‘At a national level, this allows for new or under-recognised safety issues to be quickly identified and acted upon on an NHS-wide scale, ensuring providers across the country take action to reduce the risk’. 14 It allows for the sharing of the details of incidents; enabling weaknesses in the system to be identified, customs and practices to be changed and staff to be retrained where necessary.
Our research group previously investigated the frequency and nature of complaints made against HCPs who work in police custodial settings and the mechanisms by which those complaints are investigated.15,16 That study covered the years 2010–2015. The most striking and concerning finding was the very low level of information held by many police services in respect of complaints against HCPs who provide police custodial and forensic medical/health care services and an inability on the part of police services to provide such information when requested. Only a minority of police services provided information in respect of the number and nature of complaints made against HCPs. The majority of police services did not or could not provide that information. Only a small number of police services provided copies of the disciplinary procedures used to manage complaints against HCPs. Furthermore, stark inconsistencies in handling complaints about HCPs were identified between individual police services. There appear to be a range of contractual arrangements between various police services and health care providers (whether individuals or commercial enterprises) and the relationship between provider and police service is often obscure, which may impact the availability of relevant data.
A clear recommendation emerging from that study was the need for enhanced and consistent monitoring of the number and nature of such complaints in a standardised manner across all police services. Opportunities to identify improvements were being missed because of the absence of standardised complaints handling procedures by a periodic systematic review of all complaints. How could HCPs be expected to implement quality improvement measures to enhance patient safety in the absence of closed-loop feedback from complaints as they would in other settings? The previous study called for the introduction of standardised complaints handling procedures across all police custodial and forensic medical/health care services, including a mechanism to identify and disseminate ‘lessons learned’ from complaints to contribute to the continuous quality improvement of service provision. 15 Changes in terms of how health care and forensic medical services in police custody are contracted, structured, delivered and governed strengthened the call for enhanced monitoring of complaints.
Aim
This study aimed to re-explore the frequency with which complaints are made against HCPs in the provision of police custodial health care services predominantly in England, Wales and Northern Ireland, with a view to identifying whether police services had improved their handling of complaints and moved towards the aggregation of complaints data. We sought to categorise the nature of complaints made, to explore the procedures by which these complaints are investigated and to describe trends in the frequency of complaints since our previous study, which had been carried out in 2016 and published in 2017. The present research focused solely upon forensic health care provision in police custodial settings and omitted sexual offence examiner (SOE) services on the basis that most sexual assault referral centres in which SOEs work are now within the NHS and its governance, in contrast to police custodial health care services
Method
A detailed letter of request for information under the Freedom of Information Act 2000 (FOIA) was sent to all Police Service in England, Wales and Northern Ireland with the exceptions of the Civil Nuclear Constabulary, the Isle of Man Police and the Ministry of Defence Police. The specific questions asked are shown in Figure 1(a). The recipient police services were informed of the intention to publish the study findings. Care was taken to ensure that the request was valid under the requirements of the Freedom of Information Act by making the request in writing by letter, by clearly describing the information being sought and clearly providing the full name and contact details of our lead applicant. Information was sought for each of the calendar years 2016, 2017, 2018, 2019 and 2020 (to the date of request). The initial round of requests were made in November 2020. Follow-up contact was made with non-responders to maximise the response rate. Data collection was terminated on 20f March 2021, thereby having allowed four months for police services to respond to the request. That timeframe allowed Police Services significant additional time beyond the normal 20 working day requirement of the FOIA making allowance for some delays as a result of the coronavirus pandemic. Responses were collated and analysed using Microsoft Excel.
(A) Request for information under the Freedom of Information Act from Police Services. (b) Sample of request for information from the GMC, NMC, HCPC and IOPC.
In addition, a separate letter of request for information relating to complaints against HCPs was sent to each of:
A. The Nursing and Midwifery Council (NMC) – the nursing and midwifery regulator for England, Wales, Scotland and Northern Ireland. B. The Health and Care Professions Council (HCPC) – a regulator of various allied health professionals, including of relevance to the present study, paramedics. C. The General Medical Council (GMC) – the regulator with which medical practitioners practising in the United Kingdom are required to be registered. D. The Independent Office for Police Conduct (IOPC) – the body that oversees the police complaints system in England and Wales and that sets the standards by which the police should handle complaints.
Each of the above was requested to provide details on complaints and investigations regarding relevant HCPs relating to work in a custodial setting. Care was taken to ensure that each of these bodies was aware of the numerous variations in terminology commonly used to describe HCPs who work in these areas (e.g. forensic medical examiner (FME), forensic medical officer (FMO), force medical officer, forensic physician, police surgeon, forensic paramedic, custody paramedic, custody nurse practitioner, forensic nurse practitioner, forensic nurse and forensic nurse examiner). Each body was requested to provide information for the years 2016 to 2020 inclusive. They were informed of the intention to publish the study findings. Requests were sent in February 2021. An example of the questions asked of the relevant organisation is shown in Figure 1(b).
Results
Response rate from police services
Forty-seven police services were included in the study. Forty-one police services responded to the request for information made under the FOIA and in accordance with the National Project Construction Council (NPCC) guidelines. Thus, the response rate for the study was 87%.
Adequacy of responses received from police services
Of the 41 responses that were received, 27 (66%, 27 of 41) provided none of the requested information. Reasons for not providing the requested information fell into two categories. First, 14 (34% of responders; 14/41) police services issued a refusal to provide the requested information, frequently citing Section 12 of the FOIA. Section 12 of the FOIA allows a public authority to refuse to deal with a request where it estimates that the cost of complying with the request would exceed the ‘appropriate limit’, which is currently set at £450 and 18 h for the public authorities involved in the present study. 17 Many police services went on to explain that the excessive cost and time that would have been involved in sourcing the data was due to the fact that the requested information was not held in an easily retrievable format. The second category of police services that provided none of the requested information was those 13 services that explained that they held no data in relation to the request (32% of responders; 13 of 41). The most frequent explanation for police services not holding the requested information was that of health care within custody units being contracted out to an external provider. Eleven (27% of responders; 11 of 41) police services provided a partial response to the requested information and only 3 (7% of responders; 3 of 41) police services were considered to have provided the requested information in entirety.
HCPs providing police custodial and forensic medical/health care roles services within police custody suites
Eleven police services provided significant data in respect of the number of HCPs who have undertaken forensic medical and health care roles within police custody suites (Table 1). Table 2 summarises information received in respect of the numbers of HCPs working for police services in custodial settings who have had complaints made against them. Only eight police services provided the numbers of complaints made. Of those eight police services, seven went on to provide some further information on the nature of the complaints (i.e. one police service had reported zero complaints about the period under study). That information is summarised in Table 3. Complaints included failure/refusal to provide care, failure/refusal to provide medication, incivility, assault, discrimination and others. The vast majority of police services did not provide information in relation to the numbers of HCPs who have had their contracts of service or employment terminated/not renewed or the reasons for each. Responses from 4 police services that did provide information are summarised in Table 4.
Numbers of health care professionals who have undertaken forensic medical and health care roles within police custody suites. The table represents a summary of the responses from those police services that provided significant information in response to the request for information under the Freedom of Information Act. The information provided does not in every case represent the totality of the response received.
FME: force medical examiner; FTE: full-time equivalent; PIC: Police Investigation Centre.
Numbers of health care professionals working for police services in custodial settings who have had complaints made against them. The table represents a summary of the responses from those police services that provided significant information in response to the request for information under the Freedom of Information Act. The information provided does not in every case represent the totality of the response received.
The nature of complaints made against health care professionals working for police services in custodial settings. The table represents a summary of the responses from those police services that provided significant information in response to the request for information under the Freedom of Information Act. The information provided does not in every case represent the totality of the response received.
HCP: health care professional; FMO: forensic medical officer.
The numbers of health care professionals working for police services in custodial settings who have had their contracts of service or employment terminated/not renewed and the reasons for each. The table represents a summary of the responses from those police services that provided significant information in response to the request for information under the Freedom of Information Act. The information provided does not in every case represent the totality of the response received.
FME: forensic medical examiner; GMC: general medical council.
A small number of police services responded to the request to provide copies of the disciplinary process used for complaints against HCPs working in custodial settings but only three included a copy of their disciplinary process (Table 5). Police services were asked to quantify how many HCPs had complaints referred to their respective professional bodies and to identify the nature of each such complaint. Only a small number of police services provided information in this regard. Hertfordshire Constabulary referred ‘1 in 2017’. The nature of the complaint was not specifically delineated. Merseyside Police, the Metropolitan Police, North Wales Police and the Police Service of Northern Ireland all reported having made no such referrals during the time period under study.
Responses in respect of the request to provide copies of the disciplinary process used for complaints against health care professionals working in custodial settings. The table represents a summary of the responses from those police services that provided significant information in response to the request for information under the Freedom of Information Act. The information provided does not in every case represent the totality of the response received.
PSD: professional standards department; FMO: forensic medical officer; SOP: standard operating procedure.
Responses from the NMC, the HCPC, the GMC and the IOPC
An information access officer explained that the GMC does not categorise complaints in such a way that would allow electronic capture of those that specifically related to a doctor providing services in a custodial setting. The GMC did however carry out a keyword search, in response to our request, using the search-relevant terms for a doctor who were referenced in the freedom of information (FOI) request letter: FME, FMO, force medical officer, forensic physician and police surgeon. The keyword ‘custody’ was also used as a search term, taking care to exclude doctors with criminal allegations against them. Complaints that had been closed at an early stage, that is, where the GMC decided not to investigate, were not included in the search. Twelve cases were identified in this way. The GMC provided a brief summary of each. A summary is provided in Table 6. Of note, the majority of allegations fell into the category of ‘knowledge, skills and performance’. One case involved an allegation in the category of ‘safety and quality’, one other allegation in the category of ‘maintaining trust’ and one other and allegation in the category of ‘clinical care’. ‘Inadequate assessment/history taking’ was the most frequent allegation sub-type, seen in 5 of the 12 cases. Other allegations included ‘failure to offer appropriate help’, ‘inadequate examination’, ‘incomplete medical records’, ‘delay in providing report/document’, ‘dishonesty with patient/colleague’, ‘failure to refer, when appropriate’, ‘inappropriate prescribing’ and ‘inadequate knowledge of the English language’. The case outcome data reveals that 9 of the 12 cases were closed following an investigation with no action on the doctors’ registration. Another case was closed at the triage stage, again with no action on the doctor's registration. The remaining two cases were both referred to a tribunal. One resulted in a doctor being erased from the medical register and the other doctor had conditions imposed on his/her registration.
General medical council data summary. The table represents a summary of the response from the general medical council in response to the request for information under the Freedom of Information Act. The information provided does not represent the totality of the response received.
An excerpt from the response from the HCPC follows: ….Your request has been handled under the Freedom of Information Act 2000 (FOIA). This information is not held by the HCPC. We do not hold details of where registrants work as it is not a mandatory requirement for registrants to inform us of details of their employer….
The HCPC did not provide any of the requested information on the basis of the above explanation.
The IOPC also provided an explanation for not providing the information requested. An excerpt from their response is provided: ….We have considered carefully the extent to which we may be able to identify our investigations relating to serious harm and deaths in custody that involve healthcare professionals. We have decided that ‘involved’ is a broad term that could incorporate numerous circumstances. There are no automated means of identifying cases that may fall within the scope of your request, meaning that we would have to undertake a manual trawling exercise to locate any relevant data that we may hold. This is likely to result in considerable time and resource which would exceed the cost limit prescribed by the Freedom of Information Act and associated regulations, with the result that we are not obliged to respond. Such an exercise would also be unlikely to provide comprehensive data because the type of contract a healthcare professional is working under may affect they level of jurisdiction we have and what information would therefore be held. We note that you have made your request to police forces and healthcare regulatory bodies and consider that they are best placed to provide comprehensive information regarding healthcare professionals in police custodial settings….
The NMC provided a detailed response. They explained that they received 54 referrals that involved nurses working in a police custodial setting between 1 January 2017 and 31 December 2020. Of these, 17 were closed with a decision not to investigate further, 29 were investigated further and eight remained open with a decision yet to be made as to whether those referrals met the threshold to be investigated. The NMC provided details of the type of allegations linked to referrals, which had ‘the employer’ recorded as being in a police custodial setting. These included:
Dishonesty Prescribing and medicines management Registrant's health Patient care Criminal proceedings Management issues Record keeping Employment and contractual issues Behaviour or violence Other allegations Information access
The NMC also provided details on case outcomes specifically where the employer was recorded as being in a police custodial setting. Two cases had resulted in a striking-off order. One case resulted in a condition of practice order adjudication and another resulted in a suspension order.
Discussion
The most significant finding of this study is that the majority of police services did not provide information requested in respect of complaints made against HCPs who provide forensic health care to their detainees. This raises serious concern in relation to police services awareness of complaints against HCPs who they are contracting/employing to provide care to vulnerable detainees. The police have a duty to ensure the safety of their detainees. Detainees are themselves entitled to the same standard of medical care as persons in the general community.18,19 We suggest that there is a compelling ethical onus upon police services to familiarise themselves with complaints made against HCPs to ensure that they are handled appropriately, that opportunities for future mitigation of errors are identified and that poorly performing HCPs are remediated or removed.
It is concerning that the majority of police services who responded to the FOIA request did not provide the requested information. That so many police services cited Section 12 of the FOIA in their refusal (i.e. excessive cost) is somewhat surprising given that the numbers of complaints would be expected to be relatively low and given that most police services now have managerial leads for their custodial services. Apart from the cost that so many other police services grounded their refusal on the basis of not holding the requested information because health care within units was contracted out to an external provider, is again difficult to understand as it might be expected that police services should be aware of any complaints made against sub-contractors. That some police services, albeit a small minority, were able to provide the requested information, begs the important question: if some police services can provide the relevant information, why not all?
That many police services who subcontract their forensic health care service to external providers did not provide the requested information also raises concern in relation to the nature of the contract with the external provider. Whilst the FOIA provides a right of access, subject to exemptions, to information held by public authorities, the situation is not as clear in respect of public authorities who subcontract services. Information ‘held’ by a public authority includes information ‘held by another person on behalf of the authority’ (FOIA section 3(2)(b)). Thus, one would assume that where a contractor provides a service on an authority's behalf, the information which the contractor holds about that service is considered as ‘held on the authority's behalf’ and is subject to the Act. However, in practical reality, contractor-held information is only considered to be held on the authority's behalf if the contract itself entitles the authority to obtain that information from the contractor. Thus, in the absence of specific contractual provisions agreed between police services and their external forensic health care provider, neither the police nor the public will have right of access to information, such as complaints, held by the external provider. We strongly recommend that police services ensure that they are contractually entitled to information held by external providers in respect of complaints against HCPs. Further, we suggest that service providers should be required to inform police services immediately when complaints have been made against their HCP staff.
The GMC and NMC were both able to provide considerable information on the nature of complaints made against doctors and nurses working in police custodial settings. It is concerning that the HCPC was unable to provide the requested information on the basis that registrants do not have to inform the HCPC of the details of their employer. It would seem appropriate that any regulatory body regulating any HCP working in vulnerable settings be able to identify the professional activity of those who they regulate. To learn from complaints and then implement practical change that will avoid further negative outcomes, the communication loop between the investigating regulatory bodies and the workplaces needs to be closed. The investigative work of the regulatory bodies should be able to directly inform the work of the Faculty of Forensic & Legal Medicine and its clinical partners (the United Kingdom Association of Forensic Nurses & Paramedics and the College of Paramedics) in their development and promotion of minimum standards and training/qualifications for HCPs working in custody settings.
The variation in police services responses under the FOIA has been very variable in terms of speed. Ione police service that was requested to provide information as part of a previous study on this subject carried out at the beginning of 2016 responded to the request in November 2020 (i.e. just under 4 years between FOIA request being sent and response from police service). Surprisingly, even after a near 4-year wait, the police service in question was still unable to provide the requested information.
The nature and quality of health and forensic medical services for vulnerable complainants and detainees should be the same across all police services, as directly or indirectly poor quality of services can, in the extreme, lead to death or harm in custody, and miscarriages of justice. There is wide variability in police services’ use and interpretation of the FOIA. This has meant that in previous and current studies exploring health care in custody and sexual assault referral centres, we find that some police services provide little or no information relevant to our research. In contrast, a small minority are able to provide detailed and interpretable data. It is in the public interest for comparisons to be made between health care provisions in these settings, so that those police services providing inadequate health care can be identified and challenged. If some police services can provide the data under FOI, all should be able to.
The failure on the part of police services to provide the information requested under the FOIA also brings into question issues of accountability within the public sector. Accountability must be a core tenant of police service governance if the public is to have trust in the organisation. If police services are unable to disclose information on their organisational functions and procedures, then they cannot be held accountable for their actions and their use of public money. Such transparency is a necessary prerequisite for accountability. Police services need to be open about their activities. This is especially important in the arena of custody health care provision where health, life, wellbeing and justice are at stake, in addition to the possible inefficient use of public money.
Police and Crime Commissioners (PCCs) were elected for the second time on 5 May 2016 in 40 force areas across England and Wales. 20 Every force area is now represented by a PCC, except Greater Manchester and London, where PCC responsibilities lie with the Mayor. 21 PCCs are elected to be the voice of the people and to hold the police services and chief constables to account on behalf of the people. They have wider responsibilities, including responsibility for delivering community safety and reducing crime, commissioning victims’ services, the ability to make crime and disorder reduction grants within a force area, and a duty to deliver better value for money or improve the effectiveness of policing. If PCCs are truly to hold the police to account to the public, then they should be aware of the inadequacy of many police services’ response to this FOIA request and the potential health and safety consequences for detainees. We call on the PCCs and the Association of Police & Crime Commissioners (APCC) to explore how an appropriate system for handling complaints made against HCPs can be implemented and harnessed to provide education and training to avoid further adverse outcomes. We similarly call on the College of Policing and the National Police Chiefs’ Council to establish national guidance for constabularies in this regard.
Currently, it is impossible to determine how all complaints against HCPs who provide forensic health care services in custody settings are being managed. There is no open and transparent process. We do not know, for example, if a lead clinician reviews each and every complaint. We do not know if HCPs are always informed when a complaint has been made against them. We do not know if which cases may be reviewed by the IOPC. An individual who has a complaint made against them clearly deserves to know that it exists and that it is being handled within an appropriate process. The vulnerability of HCPs who are subjected to complaints cannot be underestimated. It is known that doctors who have complaints made against them often experience significant psychological impact 22 and are more likely to suffer depression and anxiety and to experience thoughts of self-harm or suicidal ideation. 23 Transparency has been highlighted as a key attribute for complaints processes that could help to reduce the negative mental health consequences for HCPs. 23
We strongly suggest the need for a standardised complaints handling procedure for all HCPs providing these roles in custody settings. Such a process would be more readily achieved if police custody forensic and health care services were provided under the governance of the NHS. The transfer of these services to the NHS would help address these issues by subjecting this area of clinical practice to the same degree of clinical governance and patient safety standards that apply throughout the NHS. An editorial in the British Medical Journal highlights expert opinion that ‘consistent NHS based commissioning arrangements across the entire criminal justice pathway would result in considerable improvement in the safety of the community and those arrested as well as cost benefits for the government’. 24 There existed previously a high-level plan for these services to transfer to the NHS, which was abandoned in 2016. We strongly advise that this process be re-activated.
Strengths and limitations of this study
In contrast to our previous publication, this study did not specifically request or investigate complaints made against HCPs providing SOE roles within Sexual Assault Referral Centres. The rationale behind that omission was that SOE services now largely fall under the remit of the NHS rather than individual police services, and are thus generally integrated into the recording and reporting systems recommended and described within the NHS previously.
To the best of our knowledge, there have been no easements made to the FOIA requirements for public bodies as a result of the Covid-19 pandemic. However, we recognise that, as for everybody working within the health care professions, clearly there have been significant pressures. Therefore, considerable additional time was allowed to police services to provide a response to our request for information. We express our gratitude to those police services who did provide information and to those who endeavoured to respond but were unable.
Conclusion
Detailed information on complaints made against HCPs who provide forensic and health care services within police custody environments remains elusive. The introduction of a standardised complaints handling procedure, such as would be achieved by transferring these services to the NHS, could significantly enhance patient safety and contribute to continuous training of HCPs and quality improvement of services in England & Wales. Professor Sir Liam Donaldson has been quoted (in a different setting): ‘To err is human, to cover up is unforgivable, and to fail to learn is inexcusable’. From a police custodial health care perspective, this could be modified to ‘To err is human, to not to be aware of mistakes is unforgivable, and to fail to learn is inexcusable’. We would hope that the APCC, the College of Policing and the NPCC, along with the health care professions regulatory bodies, might propose a standard methodology for all police services in which complaints against HCPs working within police custody are documented, made available to appropriate parties, disseminated and thus allow appropriate learning to take place.
Footnotes
Contributorship statement
Professor Jason Payne-James, Grace Payne-James, Dr Peter Green and Dr Kieran Kennedy conceptualised the study objectives and design. Jason Payne-James and Grace Payne-James sought, received and summarised the data. Grace Payne-James, Kieran Kennedy and Jason Payne-James analysed and interpreted the data and wrote the manuscript. Peter Green evaluated and edited the manuscript. Kieran Kennedy acted as the corresponding author. Jason Payne-James is the guarantor for the work.
Declaration of conflicting interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Kieran Kennedy is a Forensic Physician who provides forensic medical services in the Republic of Ireland. Dr Peter Green is a Specialist in Forensic and Legal Medicine who provides forensic medical services and child safeguarding services in the United Kingdom. Professor Jason Payne-James is a Specialist in Forensic and Legal Medicine and provides forensic medical services and expert opinion on custodial health care in the United Kingdom. Professor Payne-James and Dr Green are both Foundation Fellows of the Faculty of Forensic & Legal Medicine of the Royal College of Physicians. Ms Grace Payne-James declares no conflict of interest.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
