Resilience of the primary healthcare system: perspectives of German stakeholders at primary care interfaces during the second wave of the COVID-19 pandemic.

Introduction: Worldwide, the primary care sector played a key role in coping with the challenges of the SARS-CoV-2 pandemic. Methods: The aim of this study was to explore the resilience of the German primary healthcare system during the second wave of the pandemic from the perspective of identified interface stakeholders, i.e., representatives of hospitals, district offices, and medical associations. Qualitative data from interviews and focus groups were analyzed according to a resilience framework. Results: The main findings include a gap in knowledge transfer, unstructured allocation of responsibilities, and a resulting unregulated flow of patients. Social brokers supported care coordination and knowledge transfer. The response to the capacity to cope with uncertainties was slow and chaotic at the system level and heterogeneous at the individual level. Building on previous relationships fostered functioning communication, while competition in primary care was identified as a barrier to resilience. Conclusion: Implications for further research and for strengthening the resilience of primary care can be derived based on this study.

Building climate resilience: awareness of climate change adaptation in German outpatient medical practices.

BACKGROUND: Climate change is seen as the biggest health threat of the twenty-first century. Making outpatient medical practices resilient is therefore crucial to protect vulnerable groups and maintain quality of care. Awareness is a precondition for action. This study aims to explore awareness (knowledge, experience and attention) of climate change adaptation among stakeholders of outpatient medical practices. METHODS: Semi-structured interviews and focus groups with stakeholders of outpatient medical practices were conducted. The qualitative data were analysed in a two-step Thematic Analysis process. RESULTS: In total, n = 40 stakeholders participated in two focus groups and 26 interviews. The findings show a mixed degree of awareness in outpatient medical practices. The spectrum ranged from a passive role with curative acting only, handing over responsibility to others and a low perceived self-efficacy to a proactive and responsible implementation of adaptation strategies. Participants who saw the need and responsibility of climate change adaptation in medical practices perceived low additional workload. In general, implementation of climate change adaptation measures and general awareness of climate change adaptation appeared to be depending on a certain tension for change and a higher self-efficacy. CONCLUSION: Medical practices, and specifically primary care, plays a crucial role in climate change adaptation, and awareness needs to be increased further in order to cope with consequences of climate change. To facilitate this, there should be a strong emphasis on climate change adaptation strategies being part of outpatient care provider roles rather than being perceived as an "add-on" to already high workloads.

[Between New Responsibility and Daily Routines - The Role of the VERAH in GP Care: A Qualitative Secondary Data Case Study of the Introduction of Software-Based Case Management]. / Zwischen neuer Verantwortung und Routinetätigkeit: Die Rolle der VERAH in der hausärztlichen Versorgung ­ Eine qualitative Sekundärdatenanalyse am Beispiel des softwaregestützten Case Management.

BACKGROUND: The concept of Care Assistant in General Practice (VERAH) was developed in order to integrate non-medical staff more strongly into primary care and thus to meet the increasing demand for care and the simultaneous shortage of medical staff. VERAHs are increasingly responsible for software-supported case management and are thus confronted with new tasks. The aim of this study was therefore to explore the role of the VERAH in primary care practices. METHODS: The present study is a qualitative secondary data analysis; the data collection took place within the projects VESPEERA and TelePraCMan. Twenty individual interviews and two focus group meetings were conducted with a total of 30 physicians, VERAHs and medical assistants from primary care. The data were analysed qualitatively according to Emerson. Contextual and socio-demographic data were collected with an accompanying questionnaire. RESULTS: The VERAHs of all primary care practices from which interview partners participated performed tasks within software-supported case management. Concerning the role of the VERAH, three themes were identified in the interviews: a) concrete tasks of the VERAH in software-supported case management within the practice team, b) relevance of software-supported case management within the activities of the VERAHS and c) relationship between VERAHs and patients. CONCLUSION: Taking over tasks in software-supported case management can contribute to strengthening and expanding the role of the VERAH. In the future, more attention should be paid to a clear description of the new role, and the conditions of the VERAHs' task fulfilment should be considered.

Climate change mitigation: Qualitative analysis of environmental impact-reducing strategies in German primary care.

BACKGROUND: The German healthcare system is responsible for 5,2% of the national emissions of greenhouse gases. Therefore, mitigation actions to reduce the carbon footprint are crucial. However, there have been few approaches to achieve this in German primary care. OBJECTIVES: This study aimed to identify environmental impact-reducing strategies of German primary care practices. METHODS: During the summer of 2021, a qualitative study was conducted using interviews and focus groups with experts in primary care across Germany, such as physicians, medical assistants, health scientists and experts on the health system level. Verbatim transcribed data were analyzed using Thematic Analysis. RESULTS: The sample comprised 26 individual interviews and two focus groups with a total of N = 40 participants. Findings provide a first overview of pursued mitigation strategies and contextual factors influencing their implementation. Strategies referred to the use of water and energy, recycling and waste management, supply chains and procurement, digitisation, mobility, patient care, behavioural changes and system level. Implementing sustainable actions in daily care was considered expensive and often unfeasible due to lack of staff, time and restrictive hygiene regulations. Participants called for more instruction on implementing mitigating actions, for example, through websites, podcasts, guidelines or quality indicators. CONCLUSION: This study's findings can support the development of future environmental impact-reducing strategies in primary care. Potential options for guidance and support should be considered to facilitate sustainability.

Prevention of invasive ventilation (PRiVENT)-a prospective, mixed-methods interventional, multicentre study with a parallel comparison group: study protocol.

BACKGROUND: Invasive mechanical ventilation (IMV) is a standard therapy for intensive care patients with respiratory failure. With increasing population age and multimorbidity, the number of patients who cannot be weaned from IMV increases, resulting in impaired quality of life and high costs. In addition, human resources are tied up in the care of these patients. METHODS: The PRiVENT intervention is a prospective, mixed-methods interventional, multicentre study with a parallel comparison group selected from insurance claims data of the health insurer Allgemeine Ortskrankenkasse Baden-Württemberg (AOK-BW) conducted in Baden-Württemberg, Germany, over 24 months. Four weaning centres supervise 40 intensive care units (ICUs), that are responsible for patient recruitment. The primary outcome, successful weaning from IMV, will be evaluated using a mixed logistic regression model. Secondary outcomes will be evaluated using mixed regression models. DISCUSSION: The overall objective of the PRiVENT project is the evaluation of strategies to prevent long-term IMV. Additional objectives aim to improve weaning expertise in and cooperation with the adjacent Intensive Care Units. TRIAL REGISTRATION: This study is registered at ClinicalTrials.gov (NCT05260853).

Hospital Admission and Discharge: Lessons Learned from a Large Programme in Southwest Germany.

Introduction: In the context of a GP-based care programme, we implemented an admission, discharge and follow-up programme. Description: The VESPEERA programme consists of three sets of components: pre-admission interventions, in-hospital interventions and post-discharge interventions. It was aimed at all patients with a hospital stay participating in the GP-based care programme and was implemented in 7 hospitals and 72 general practices in southwest Germany using a range of strategies. Its' effectiveness was evaluated using readmissions within 90 days after discharge as primary outcome. Questionnaires with staff were used to explore the implementation process. Discussion: A statistically significant effect was not found, but the effect size was similar to other interventions. Intervention fidelity was low and contextual factors affecting the implementation, amongst others, were available resources, external requirements such as legal regulations and networking between care providers. Lessons learned were derived that can aid to inform future political or scientific initiatives. Conclusion: Structured information transfer at hospital admission and discharge makes sense but the added value in the context of a GP-based programme seems modest. Primary care teams should be involved in pre- and post-hospital care.

[Motives, goals and anticipated barriers as experienced by employees engaged in an initiative promoting sustainability at a general hospital - A qualitative analysis]. / Motive, Ziele und erwartete Barrieren engagierter Mitarbeiter*innen einer Nachhaltigkeitsinitiative an einem Krankenhaus der Maximalversorgung ­ eine qualitative Analyse.

BACKGROUND: As a consequence of the climate crisis, a drastic reduction of greenhouse gas emissions and a transformation towards a sustainable economy are indispensable for the health care sector. METHODS: For the present study, barriers and facilitators in implementing a transformation towards more sustainability were evaluated in qualitative interviews with members of an initiative attempting to establish more sustainability at a general hospital. RESULTS: In 12 interviews, the interviewees were asked about the necessary personal characteristics for their commitment, short- and long-term ideas about how to reduce green house gas emissions, as well as barriers and facilitators of the organization's structure and of the societal context. CONCLUSION: The methods for implementing more sustainability at a general hospital are mostly known. However, more knowledge is needed about the capacity to withstand both organizational barriers and feelings of hopelessness and impotence in order to preserve one's ability to act.

Interprofessional weaning boards for invasively ventilated patients in intensive care units: Qualitative interview study with healthcare professionals in Germany.

Numbers of mechanically ventilated patients are increasing worldwide. Weaning Boards could support weaning from the ventilator by facilitating interprofessional consultations between Weaning Centers and nonpneumological intensive care units. This study, which is linked to the project Prevention of invasive Ventilation, aimed to explore the design and implementation of future Weaning Boards. Semistructured interviews were conducted with physicians, nurses, respiratory therapists, and physiotherapists of intensive care units and Weaning Centers in Baden-Wuerttemberg, Germany. Participants were asked to share their views on (a) required characteristics of Weaning Boards and (b) the current care of weaning patients in their wards. Qualitative data analysis included inductive and deductive steps referring to the Template for Intervention Description and Replication checklist and the Consolidated Framework for Implementation Research. The 14 interviewed healthcare professionals addressed characteristics of future Weaning Boards including (a) preconditions, (b) procedure, (c) interprofessional participants, (d) type of performance, and (d) time frame. Identified determinants for successful implementation were related to (a) individual characteristics of healthcare professionals, (b) ward characteristics, and (c) healthcare system characteristics. Weaning Boards could be a useful tool to advance knowledge sharing between professionals, improve education about weaning protocols, and support patient-oriented care. The implementation of Weaning Boards can be influenced by individual characteristics of participating professionals, difficulties in the interaction between professional groups, the present workplace culture, and the current coronavirus disease 2019 (COVID-19) pandemic.

How to fall into a new routine: factors influencing the implementation of an admission and discharge programme in hospitals and general practices.

INTRODUCTION: The VESPEERA programme is a multifaceted programme to enhance information transfer between general practice and hospital across the process of hospital admission, stay and discharge. It was implemented in 7 hospitals and 72 general practices in Southern Germany. Uptake was heterogeneous and overall low. A process evaluation aimed at identifying factors associated with the implementation of the VESPEERA programme. METHODS: This was a qualitative study using semi-structured interviews in a purposeful sample of health workers in hospitals and general practices in the VESPEERA programme. Qualitative framework analysis using the Consolidated Framework for Implementation Research was performed and revealed the topic of previous and new routines to be protruding. Inductive content analysis was used for in-depth examination of stages in the process of staying in a previous or falling into a new routines. RESULTS: Thirty-six interviews were conducted with 17 participants from general practices and 19 participants from hospitals. The interviewees were in different stages of the implementation process at the time of the interviews. Four stages were identified: Stage 1,'Previous routine and tension for change', describes the situation in which VESPEERA was to be implemented and the factors leading to the decision to participate. In stage 2,'Adoption of the VESPEERA programme', factors that influenced whether individuals decided to employ the innovation are relevant. Stage 3 comprises 'Determinants for falling into and staying in the new VESPEERA-routine' relates to actual implementation and finally, in stage 4, the participants reflect on the success of the implementation. CONCLUSIONS: The individuals and organisations participating in the VESPEERA programme were in different stages of a process from the previous to the new routine, which were characterised by different determinants of implementation. In all stages, organisational factors were main determinants of implementation, but different factors emerged in different implementation stages. A low distinction between decision-making power and executive, as well as available resources, were beneficial for the implementation of the innovation. TRIAL REGISTRATION: DRKS00015183 on DRKS / Universal Trial Number (UTN): U1111-1218-0992.

Building resilience in German primary care practices: a qualitative study.

BACKGROUND: In recent years, healthcare has faced many different crises around the world such as HIV-, Ebola- or H1N1-outbrakes, opioid addiction, natural disasters and terrorism attacks). In particular, the current pandemic of Covid-19 has challenged the resilience of health systems. In many healthcare systems, primary care practices play a crucial role in the management of crises as they are often the first point of contact and main health care provider for patients. Therefore, this study explored which situations are perceived as crises by primary care practice teams and potential strategies for crisis management. METHODS: A qualitative observational study was conducted. Data were collected in interviews and focus groups with experts from primary care practices and stakeholders focusing on primary care practices in Germany such as physicians, medical assistants, practice managers, quality managers, hygiene managers and institutions on health system level (politics, research and health insurance). All interviews and focus groups were audio-recorded and transcribed verbatim. A qualitative content analysis was performed using a rapid qualitative analysis approach first, followed by a thematic analysis. RESULTS: Two focus groups and 26 interviews including 40 participating experts were conducted. Many different situations were perceived as crises, varying from issues in the practice organization to problems on health system level and international disasters. Distinct aspects associated with the perception of a crisis situation by interviewees were the presence of emotional reactions, a need for organizational changes and a lack of necessary resources. A broad spectrum of possible strategies was discussed that could help to cope with or even prevent the emergence of an actual crisis. In particular, strengthening communication within practice teams and resilience among employees was perceived to be fundamental for improving responses to crises or preventing them. CONCLUSIONS: The study provides perspectives of primary health care workers on crises in health, that could inform health policy regarding prevention and management of future crises in primary care facilities.

Effects and Processes of an mHealth Intervention for the Management of Chronic Diseases: Prospective Observational Study.

BACKGROUND: Mobile health (mHealth) interventions for self-management are a promising way to meet the needs of patients with chronic diseases in primary care practices. Therefore, an mHealth intervention, TelePraCMan, was developed and evaluated for patients with type 2 diabetes mellitus, chronic obstructive pulmonary disease, high blood pressure, or heart failure in a German primary care setting. TelePraCMan entails a symptom diary, an appointment manager, a manager to document goals, and a warning system. The app should foster the self-management of participating patients. OBJECTIVE: We aimed to examine the effects of TelePraCMan on patient activation and quality of life and explored the underlying contextual factors, impacts, and degree of implementation. METHODS: In a prospective observational study design, we collected data by using interviews and written questionnaires from participating patients (intervention and control groups) and primary care workers (physicians and practice assistants). The primary outcomes of interest were patient-reported quality of life (12-Item Short Form Survey) and patient activation (patient activation measure). The quantitative analysis focused on differences between patients in the intervention and control groups, as well as before (T0) and after (T1) the intervention. Interviews were analyzed by using qualitative content analysis via MAXQDA (VERBI GmbH). RESULTS: At baseline, 25 patients and 24 primary care workers completed the questionnaire, and 18 patients and 21 primary care workers completed the follow-up survey. The patients were predominantly male and, on average, aged 64 (SD 11) years (T0). The primary care workers were mostly female (62%) and, on average, aged 47 (SD 10) years (T0). No differences were observed in the outcomes before and after the intervention or between the intervention and control groups. In the additional interviews, 4 patients and 11 primary care workers were included. The interviewees perceived that the intervention was useful for some patients. However, contextual factors and problems with implementation activities negatively affected the use of the app with patients. The main reasons for the low participation were the COVID-19 pandemic and the target group, which seemed to have less interest in mHealth; the interviewees attributed this to the older age of patients. However, the respondents felt that the app would be better accepted in 5 or 10 years. CONCLUSIONS: Although the TelePraCMan app was rated as very good and important by the participants, few patients used it. The digital intervention was hardly implemented and had limited impact in the current setting of German primary care. TRIAL REGISTRATION: German Clinical Trials Register DRKS00017320; https://tinyurl.com/4uwrzu85.

[An exploratory cross-sectional study on technical affinity and smartphone use among practice staff and patients: development of an app for multimorbid patients in general practice]. / Eine explorative Querschnittsstudie zur Technikaffinität und Smartphone-Nutzung von Praxispersonal und PatientInnen ­ Entwicklung einer App für multimorbide PatientInnen in der allgemeinmedizinischen Versorgung.

INTRODUCTION: Due to individual care needs, the provision of care to patients with two or more chronic diseases (multimorbidity) is described as complex. In addition, the number of chronically ill people is increasing, due in part to demographic changes which pose a challenge, especially for outpatient primary care. In order to fulfil patients' needs and to promote self-management as a central care element of chronically ill patients, the use of eHealth applications increases. TelePraCMan will be developed as one of these applications and includes a symptom-based electronic diary, which will be implemented in the established German disease management programme 'PraCMan'. This study is conducted as a part of the TelePraCMan project and aims to detect the needs of potential end users (physicians, medical assistants, patients). METHODS: In the TelePraCMan development phase, an explorative cross-sectional study was conducted with potential end users of the TelePraCMan app (patients, physicians and medical assistants). For this purpose, a written survey was conducted in Baden-Wurttemberg between April 2019 and March 2020. The survey covered smartphone usage behaviour, technology affinity using the standardised questionnaire TA-EG, support network for technical questions and sociodemographic data. RESULTS: A total of n=202 patients (n=98), physicians (n=58) and medical assistants (n=43) participated in the survey. Concerning smartphone use, 78.2 % of the participants stated that the function used most frequently was writing short messages. Health apps were the least used function (9.6 %). Furthermore, patients (12.6 %) use health apps more often than medical assistants (10.3%) and doctors (4.4 %). Participants aged 50 and younger were found to have a higher affinity for technology (mean=3.20, SD=0.51) than participants over 50 years of age (mean=2.98, SD=0.67). Older, multimorbid respondents had a particularly low affinity for technology (mean=2.52, SD=0.69). 10.9 % of the over-fifties and 12.5 % of the multimorbid persons felt able to fix any technical problems on their own without help. Multimorbid participants over the age of 50 were observed to prefer personal support over internet-based support. DISCUSSION: On average, multimorbid respondents in the age group over 50 have a lower affinity for technology than respondents aged under 50 without multimorbidity. The most frequent negative attitude towards electronic devices is also found among patients over 50 years of age, who are expected to be the main target group of the TelePraCMan app. These findings can be used to derive requirements for the design and development of functions of the app, as well as accompanying measures, such as intuitive and simple user interface, a telephone hotline to support users, close consultation with users on the planned functions, and more. CONCLUSION: Based on this survey, we were able to determine the needs of the future target group of the TelePraCMan app. This is seen as a starting point for the development of an implementation strategy and the pilot testing of the app in primary care.

[Climate protection in practices - current status, motivation and challenges in outpatient care]. / Klimaschutz in der Praxis ­ Status quo, Bereitschaft und Herausforderungen in der ambulanten Versorgung.

INTRODUCTION: The impact of climate change on health and the necessity to reduce emissions in the health sector is becoming an increasingly discussed topic. Little is known about medical doctors' (MDs) attitude towards climate protection measures in outpatient practices. METHODS: Between October 2020 and February 2021, a survey was conducted among MDs in German practices. 1,683 participants answered 39 questions on energy use, transportation, disposable materials, budget and patient counselling. Data were collected on status, motivation, obstacles and needs regarding climate protection in practices. RESULTS: 83% considered climate change an urgent problem requiring immediate action. A majority reported climate effects on their patients' health. Most MDs felt responsible for climate protection in their practices, showing a high degree of willingness to implement climate-friendly measures. Obstacles reported include lack of information and institutional support as well as the expected financial burden. A majority of MDs called on professional associations and politics to develop climate-friendly strategies. CONCLUSION: In view of national climate targets and the willingness of outpatient MDs to contribute to climate protection, support from medical associations is required, e. g. through practical recommendations and financial help, in order to transform the health sector in accordance with the idea of Planetary Health. Accompanying studies should provide further evidence on effective measures to reduce greenhouse gas emissions in practices.

[Impact of the COVID-19 pandemic on outpatient physical therapy in Germany]. / Einfluss der COVID-19 Pandemie auf die ambulante Physiotherapie.

INTRODUCTION: Due to the COVID-19 pandemic, the German health system has faced major challenges since spring 2020. In addition to restrictions in the inpatient health care sector, the maintenance of outpatient care by health care providers has also been affected by the pandemic-related restrictions. Both a decline in treatment frequencies and temporary practice closures have been observed. The aim of the study was to survey the work and care situation in outpatient physiotherapy practices during the first wave of the pandemic. METHODS: An anonymous online survey including quantitative and qualitative items was conducted among physiotherapists in the outpatient sector in Germany between June 1 and August 31, 2020. The survey is part of the mixed-methods study "ArTheCo", which was conducted throughout Germany including outpatient therapists and patients in physiotherapy, speech therapy and occupational therapy. RESULTS: In total, 577 physiotherapists from all over Germany took part in the survey. During the first wave of the pandemic, the occupancy rate fell below 50% at 45% of the facilities. 15% of the facilities had to close temporarily. Short-time work was announced at 58% of the respondents' practices. This and the implementation of hygiene measures restricted the provision of physiotherapy. This mainly affected patients with a higher risk of a severe clinical course of disease, such as nursing home patients. Due to complex changes in practice organisation and patient care, many of the interviewees felt that their economic existence was threatened and also described a large physical and psychological burden. Existing dissatisfaction seemed to have increased by the pandemic. DISCUSSION: To maintain continuous physical therapy, a reorganisation of the reimbursement system as well as easily accessible, consistent and feasible action plans for practices are needed. In combination with threats to existence due to the pandemic and increasing skill shortage, the outpatient physiotherapeutic care also appears to be threatened beyond the pandemic. CONCLUSION: The current pandemic has highlighted long-standing challenges causing dissatisfaction and making the profession increasingly unattractive for some of the respondents. Political action to support physiotherapists needs to be initiated. This study indicates potential starting points.

The role of personalised professional relations across care sectors in achieving high continuity of care.

BACKGROUND: High continuity of care has a positive impact on health outcomes, but insight into the mechanisms underlying this impact is limited. Information continuity, on which our study focuses, is especially important when relational continuity is not given, which is often the case at hospital admission or hospital discharge. The aim of this study is to provide insight into the information flows between general practices and hospitals in Germany, and to identify factors associated with these flows of information. METHODS: This is a qualitative interview study in a purposeful sample of staff from hospitals and general practices (general practitioners, care assistants in general practice, hospital management, hospital physicians, and nursing staff). Interviews were conducted via telephone or face-to-face using a self-developed semi-structured interview guide. Stepwise systematic content analysis was used to structure collected material into themes and sub-themes that related to the study aim. Data was analysed by two researchers in several cycles, alternating between inductive and deductive approaches. RESULTS: A total of 49 interviews were conducted. Duration of the interviews varies between 21 and 78 min (mean duration 43 min). Across all groups, more than two thirds of participants were female (n = 34, 69%). The analysis highlighted six interdependent main themes regarding factors that affect information flows between hospitals and general practices: organisational, legal, financial, patient factors, individual characteristics, and emotional & social factors. The latter theme emerged as particularly rich and was therefore divided into four subthemes: appreciation and understanding of the respective other, (intrinsic) motivation, socialisation, and relationships. Organised meetings and events were mentioned as strategies to address emotional and social factors. CONCLUSIONS: Digitalisation can facilitate information flows between care providers. However, knowing each other and good personal relations remain important for effective collaboration. Cooperation between all stakeholders is needed to aim to achieve continuity of care. TRIAL REGISTRATION: DRKS00015183 on DRKS/ Universal Trial Number (UTN): U1111-1218-0992. Date of registration 23/08/2018.

German translation and validation of the Reporting of Clinical Adverse Events Scale (RoCAES-D).

BACKGROUND: Reporting of adverse events is an important aspect of patient safety management in hospitals, which may help to prevent future adverse events. Yet, only a small proportion of such events is actually reported in German hospitals. Therefore, it is crucial to evaluate attitudes of clinical staff towards reporting of adverse events. The aim of this study was to translate the Reporting of Clinical Adverse Events Scale (RoCAES) developed by Wilson, Bekker and Fylan (2008) and validate it in a sample of German-speaking health professionals. METHODS: The questionnaire covers five factors (perceived blame, perceived criteria for identifying events that should be reported, perceptions of colleagues' expectations, perceived benefits of reporting, and perceived clarity of reporting procedures) and was translated into German language according to translation guidelines. Within a cross-sectional study in a sample of 120 health professionals in German hospitals, internal consistency (omega) and construct validity (confirmatory factor analysis) of the German scale RoCAES-D was assessed. RESULTS: The reliability was high (omega = 0.87) and the factor analysis showed a poor model fit (RMSEA: 0.074, χ2/df: 1.663, TLI: 0.690). Resulting from lower model fit of the original model (RMSEA: 0.082, χ2/df: 1.804, TLI: 0.606), one item was deleted due to low factor loadings and a low R2 (0.001), and two items were reallocated from the factor 'perceived benefits' to 'perceived blame'. CONCLUSION: The successful translation and initial validation of the RoCAES-D might be a good starting point for further research. A cultural adaptation of the scale needs to be done to initiate a large-scale usage of the questionnaire.