Facilitators and barriers to communication in rehabilitation services across healthcare levels: a qualitative case study in a Norwegian context.

BACKGROUND: People with problems in functioning following severe injury or illness often need multiple and combined interventions in their rehabilitation processes. In these processes, communication and collaboration between the involved healthcare professionals are essential. Despite efforts in research and policy, communication across hospital and primary healthcare services and within the primary healthcare settings remains challenging. In one region of Norway, a new intermunicipal rehabilitation team has been established to supplement the traditional services and context-bound research is needed to gain insight into the complexity of the new communication structures that are developing. The aim of this study was to explore facilitators and barriers to communication to inform further improvement of the services. METHODS: A qualitative case study design was used to explore the exchange of patient information in the rehabilitation processes of four patients. Data collection included participant observations in communication situations and an exploration of the electronic patient records of these four patients. Reflexive thematic analysis was used to analyse the empirical data. RESULTS: The complex rehabilitation processes explored involved a large number of actors across healthcare organisational levels. Lacking a common culture for rehabilitation, poor access to written information and unclear responsibility for sharing information across organisational boundaries seemed to represent barriers to interprofessional communication. Joint meetings, the use of common rehabilitation tools and language and establishing informal communication channels served to facilitate communication. CONCLUSION: The intermunicipal team collaborating across different organisational levels added complexity to communication structures, but also facilitated interprofessional communication by promoting formal and informal ways of exchanging information. However, the intricate organisational divisions of healthcare provision in the Norwegian context represent boundaries which can be difficult to overcome. Therefore, cross-organisational coordination services should be developed.

Health Care Professionals' Experiences and Perspectives on Using Telehealth for Home-based Palliative Care: Scoping Review.

BACKGROUND: Telehealth seems feasible for use in home-based palliative care (HBPC). It may improve access to health care professionals (HCPs) at patients' homes, reduce hospital admissions, enhance patients' feelings of security and safety, and increase the time spent at home for patients in HBPC. HBPC requires the involvement of various HCPs such as nurses, physicians, allied health professionals, dietitians, psychologists, religious counselors, and social workers. Acceptance of the use of technology among HCPs is essential for the successful delivery of telehealth in practice. No scoping review has mapped the experiences and perspectives of HCPs regarding the use of telehealth in HBPC. OBJECTIVE: The aim of this review was to systematically map published studies on HCPs' experiences and perspectives on the use of telehealth in HBPC. METHODS: A scoping review was conducted using the methodology of Arksey and O'Malley. The review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. A systematic search was performed in AMED, CINAHL, Embase, MEDLINE, PsycINFO, and Web of Science for studies published in peer-reviewed journals between January 1, 2000, and August 23, 2022. The reference lists of the included papers were hand searched to identify additional studies. The inclusion criteria were (1) studies using qualitative, quantitative, or mixed methods; (2) studies including HCPs using telehealth with patients in HBPC; (3) studies on HCPs' experiences and perspectives on the use of telehealth in HBPC; (4) studies published between January 1, 2000, and August 23, 2022; and (5) studies published in English, Portuguese, Norwegian, Danish, Swedish, or Spanish. Pairs of authors independently included studies and extracted data. The first 2 stages of thematic synthesis were used to thematically organize the data. RESULTS: This scoping review included 29 papers from 28 studies. Four descriptive themes were identified: (1) easy to use but technological issues undermine confidence, (2) adds value but personal and organizational barriers challenge adoption, (3) potential to provide useful and meaningful patient-reported data, and (4) mutual trust as a prerequisite for interpersonal relationships. CONCLUSIONS: Telehealth in HBPC seems to be easy to use and may improve the coordination of care, time efficiency, clinical assessments, and help build and enhance personal and professional relationships. However, the introduction of technology in HBPC is complex, as it may not align well with the overall aim of palliative care from HCPs' point of view. Further, changes in practice and requirements for HCPs may reduce motivation for the use of telehealth in HBPC. HCPs consider themselves to have central roles in implementing telehealth, and a lack of acceptance and motivation is a key barrier to telehealth adoption. Policy makers and telehealth developers should be aware of this potential barrier when developing or implementing new technology for use in HBPC. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/33305.

Perceptions of social media challenges and benefits during the Covid-19 pandemic: Qualitative findings from a cross sectional international survey.

Since the beginning of the Covid-19 pandemic in January 2020 the need for rapid information spread grew and social media became the ultimate platform for information exchange as well as a tool for connection and entertainment. With the rapid information spread along came the various public misconceptions and misinformation which consequently influenced perceptions and behaviors of the public towards the coronavirus pandemic. Thus, there was a need for identification and collation of public perceptions information to address future public health initiatives. This cross-national study aimed to examine the challenges and benefits of using social media during the Covid-19 pandemic outbreak. This study was a content analysis of the open-ended questions from a wider cross-sectional online survey conducted in Norway, UK, USA, and Australia during October/November 2020. 2368 participants out of 3474 respondents to the survey provided the open text responses included in the qualitative analysis. Thematic analysis was conducted independently by two researchers. All statements were coded to positive and negative sentiments. Three overarching themes were identified: 1. Mental health and emotional exhaustion 2. Information and misinformation; 3. Learning and inspiration.While providing a powerful mode of connection during the pandemic, social media also led to negative impact on public perceptions, including mistrust and confusion. Clarity in communications by institutions and education about credible information sources should be considered in the future. Further research is required in exploring and documenting social media narratives around COVID-19 in this and any subsequent incidents of pandemic restrictions. Understanding the public perceptions and their social narratives can support the designing of appropriate support and services for people in the future, while acknowledging the uncertainty and overwhelming impact of the pandemic that may have skewed the experiences of social media.

Associations between social media use and loneliness in a cross-national population: do motives for social media use matter?

BACKGROUND: We aimed to examine the association between social media use and loneliness two years after the COVID-19 pandemic outbreak. METHODS: Participants were 1649 adults who completed a cross-sectional online survey disseminated openly in Norway, United Kingdom, USA, and Australia between November 2021 and January 2022. Linear regressions examined time spent on social media and participants' characteristics on loneliness, and interactions by motives for social media use. RESULTS: Participants who worried more about their health and were younger, not employed, and without a spouse or partner reported higher levels of loneliness compared to their counterparts. More time spent on social media was associated with more loneliness (ß = 0.12, p < 0.001). Three profile groups emerged for social media use motives: 1) social media use motive ratings on avoiding difficult feelings higher or the same as for maintaining contact; 2) slightly higher ratings for maintaining contact; and 3) substantially higher ratings for maintaining contact. Time spent on social media was significant only in motive profile groups 2 and 3 (ß = 0.12 and ß = 0.14, both p < 0.01). CONCLUSIONS: Our findings suggest that people who use social media for the motive of maintaining their relationships feel lonelier than those who spend the same amount of time on social media for other reasons. While social media may facilitate social contact to a degree, they may not facilitate the type of contact sought by those who use social media primarily for this reason.

Students' Mental Health, Well-Being, and Loneliness during the COVID-19 Pandemic: A Cross-National Study.

During the COVID-19 pandemic, much research has been devoted to assessing mental health in a variety of populations. Students in higher education appear to be particularly vulnerable to experiencing reduced mental health. The purpose of the study was to assess whether higher education students experienced poorer mental health compared to the general population and examine the factors associated with students' mental health during the COVID-19 pandemic. A cross-national sample of students (n = 354) and non-students (n = 3120) participated in a survey in October/November 2020. Mental health outcomes among students and non-students were compared with independent t-tests. Multiple linear regression analysis and general linear estimation were used to assess the impact of student status on mental health outcomes while adjusting for sociodemographic factors. Students reported poorer mental health than non-students. The difference in mental health between students and non-students was bigger for participants aged 30 years or older. More social media use was associated with poorer mental health outcomes. In conclusion, students had poorer mental health than the wider population. Aspects of life as a student, beyond what can be attributed to life stage, appears to increase mental health problems.

Self-Reported Long COVID in the General Population: Sociodemographic and Health Correlates in a Cross-National Sample.

We aimed to gain knowledge of possible sociodemographic predictors of long COVID and whether long COVID was associated with health outcomes almost two years after the pandemic outbreak. There were 1649 adults who participated in the study by completing a cross-sectional online survey disseminated openly in Norway, the UK, the USA, and Australia between November 2021 and January 2022. Participants were defined as having long COVID based on self-reports that they had been infected by COVID-19 and were experiencing long-lasting COVID symptoms. Logistic regression analyses were used to examine possible sociodemographic predictors, and multivariate analysis of variance was used to examine whether long COVID status was associated with health outcomes. None of the sociodemographic variables was significantly associated with reporting long COVID. Having long COVID was associated with higher levels of psychological distress, fatigue, and perceived stress. The effect of long COVID on health outcomes was greater among men than among women. In conclusion, long COVID appeared across sociodemographic groups. People with long COVID reported worsened health outcomes compared to those who had had COVID-19 but without long-term symptoms. Men experiencing long COVID appear to be particularly vulnerable to experiencing poorer health outcomes; health services may pay extra attention to potentially unnoticed needs for support among men experiencing long COVID.

Embodied meaning-making in the experiences and behaviours of persons with dementia.

BACKGROUND: The aim of the study was to explore and articulate how meaning-making appears and how meaningfulness is experienced in persons with severe dementia. Although there is little knowledge about meaning-making and experience of meaningfulness for this group, this article assumes that persons with dementia are as much in need of meaningfulness in life as any others, and hence, that they are involved in the process of meaning-making. METHODS: The study was conducted using a qualitative method with exploratory design. Ten patients with severe dementia at a specialized dementia ward at an old age psychiatric department in hospital were observed through participant observation performed over four months. The field-notes from the observation contained narratives carrying with them a dimension of meaning played out in an everyday setting and thus named Meaning-making dramas. The narratives were analyzed looking for expressions where experiences of meaning-making and meaningfulness could be identified. RESULTS: The narratives demonstrate that persons with severe dementia are involved in processes of meaning-making. The narratives include expressions of meaning-making, and of interactions that include apparent crises of meaning, but also transitions into what may be interpreted as meaningfulness based on experiences of significance, orientation and belonging. The role of the body and the senses has proved significant in these processes. The findings also suggest that experiences of meaning contribute to experience of personhood. CONCLUSIONS: The relevance to clinical practice indicates that working from a person-centred approach in dementia care also includes paying attention to the dimension of meaning. This dimension is important both for the person living with dementia and for the people caring for them. Acknowledging meaning as a central human concern, it is crucial to seek understanding and knowledge about the significance of meaning in vulnerable groups such as persons with dementia.

Health Care Professionals' Experiences and Perspectives on Using Telehealth for Home-Based Palliative Care: Protocol for a Scoping Review.

BACKGROUND: Telehealth seems feasible for use in home-based palliative care. However, acceptance among health care professionals (HCPs) is essential for the successful delivery of telehealth in practice. No scoping review has mapped the experiences and perspectives of HCPs on the use of telehealth for home-based palliative care. OBJECTIVE: The aim of this review is to systematically map published studies on HCPs' experiences and perspectives on the use of telehealth in home-based palliative care. METHODS: The proposed scoping review will employ the methodology of Arksey and O'Malley. This protocol is guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P). A systematic search will be performed in MEDLINE, PsycINFO, EMBASE, CINAHL, Allied and Complementary Medicine (AMED), and Web of Science for studies published between January 2000 and July 5, 2021. We will also hand search the reference lists of included papers to identify additional studies of relevance. The search will be updated in 2022. Pairs of authors will independently assess the eligibility of studies and extract data. The first 2 stages of thematic synthesis will be used to thematically organize the data. Because the scoping review methodology consists of reviewing and collecting data from publicly available materials, this study does not require ethics approval. RESULTS: The database searches; testing of eligibility criteria; and screening of titles, abstracts, and full-text papers will be performed by fall 2021. The results from this scoping review will be presented as a descriptive summary of the results from all included papers, and will be inductively organized into descriptive themes. A frequency table illustrating which papers were included in which descriptive themes will be made. Results are anticipated by the fall of 2022. CONCLUSIONS: A mapping of studies could identify research gaps regarding HCPs' experiences and perspectives on the use of telehealth in home-based palliative care and may determine the value and feasibility of conducting a full systematic review. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/33305.

Meaning in Life for Patients With Severe Dementia: A Qualitative Study of Healthcare Professionals' Interpretations.

The need for meaning in life is a key aspect of being human, and a central issue in the psychology of religion. Understanding experience of meaning for persons with severe dementia is challenging due to the impairments associated with the illness. Despite these challenges, this article argues that meaning in life is as important for a person with severe dementia as it is for everyone else. This study was conducted in a Norwegian hospital and nursing home context and was part of a research project on meaning in life for persons with severe dementia. The study builds on two other studies which focused on how meaning-making and experience of meaningfulness appeared in patients with severe dementia. By presenting the findings from these two studies for a group of healthcare professionals and introducing them to research on meaning in life, the aim of this study was to explore how healthcare professionals interpret the patients' experience of meaning in life in practise for patients with severe dementia in a hospital and nursing home context, and to highlight its clinical implications. The study was conducted using a qualitative method with exploratory design. The data were collected at a round table conference, a method inspired by a mode of action research called "co-operative inquiry." Altogether 27 professional healthcarers, from a variety of professions, with high competence in dementia care participated together with six researchers authoring this article. This study revealed that healthcare professionals were constantly dealing with different forms of meaning in their everyday care for people with dementia. The findings also showed clear connexions between understanding of meaning and fundamental aspects of good dementia care. Meaning corresponded well with the principles of person-centred care, and this compatibility allowed the healthcare professionals to associate meaning in life as a perspective into their work without having much prior knowledge or being familiar with the use of this perspective. The study points out that awareness of meaning in life as an integrated perspective in clinical practise will contribute to a broader and enhanced repertoire, and hence to improved dementia care. Facilitating experience of meaning calls for increased resources in personnel and competence in future dementia care.

Use and self-perceived effects of social media before and after the COVID-19 outbreak: a cross-national study.

To (i) examine the use of social media before and after the COVID-19 outbreak; (ii) examine the self-perceived impact of social media before and after the outbreak; and (iii) examine whether the self-perceived impacts of social media after the outbreak varied by levels of mental health. A cross-national online survey was conducted in Norway, UK, USA and Australia. Participants (n = 3810) reported which social media they used, how frequently they used them before and after the COVID-19 outbreak, and the degree to which they felt social media contributed to a range of outcomes. The participants also completed the 12-item General Health Questionnaire. The data were analyzed by chi-square tests and multiple linear regression analysis. Social media were used more frequently after the pandemic outbreak than compared to before the outbreak. Self-perceived effects from using social media increased after the COVID-19 outbreak, and in particular stress and concern for own and others' health. Emotional distress was associated with being more affected from using social media, in particular in terms of stress and concern for own or others' health. The use of social media has increased during the coronavirus outbreak, as well as its impacts on people. In particular, the participants reported more stress and health concerns attributed to social media use after the COVID-19 outbreak. People with poor mental health appear to be particularly vulnerable to experiencing more stress and concern related to their use of social media.

Cross-National Study of Worrying, Loneliness, and Mental Health during the COVID-19 Pandemic: A Comparison between Individuals with and without Infection in the Family.

OBJECTIVE: The objective of this study was to examine differences in worry, loneliness, and mental health between those individuals infected by COVID-19 or having someone their family infected, and the rest of the population. METHODS: A cross-sectional online survey was conducted in Norway, UK, USA, and Australia during April/May 2020. Participants (n = 3810) were recruited via social media postings by the researchers and the involved universities. Differences between those with and without infection in the family were investigated with chi-square tests and independent t-tests. Multiple regression analyses were used to assess associations between sociodemographic variables and psychological outcomes (worry, loneliness, and mental health) in both groups. RESULTS: Compared to their counterparts, participants with infection in the family reported higher levels of worries about themselves (p < 0.05) and their family members (p < 0.001) and had poorer mental health (p < 0.05). However, the effect sizes related to the differences were small. The largest effect (d = 0.24) concerned worries about their immediate family. Poorer psychological outcomes were observed in those who were younger, female, unemployed, living alone and had lower levels of education, yet with small effect sizes. CONCLUSIONS: In view of the small differences between those with and without infection, we generally conclude that the mental health effects of the COVID-19 situation are not limited to those who have been infected or have had an infection within the family but extend to the wider population.

Mental Health, Information and Being Connected: Qualitative Experiences of Social Media Use during the COVID-19 Pandemic from a Trans-National Sample.

Background: Due to the COVID-19 pandemic and the strict national policies regarding social distancing behavior in Europe, America and Australia, people became reliant on social media as a means for gathering information and as a tool for staying connected to family, friends and work. This is the first trans-national study exploring the qualitative experiences and challenges of using social media while in lockdown or shelter-in-place during the current pandemic. Methods: This study was part of a wider cross-sectional online survey conducted in Norway, the UK, USA and Australia during April/May 2020. The manuscript reports on the qualitative free-text component of the study asking about the challenges of social media users during the COVID-19 pandemic in the UK, USA and Australia. A total of 1991 responses were included in the analysis. Thematic analysis was conducted independently by two researchers. Results: Three overarching themes identified were: Emotional/Mental Health, Information and Being Connected. Participants experienced that using social media during the pandemic amplified anxiety, depression, fear, panic, anger, frustration and loneliness. They felt that there was information overload and social media was full of misleading or polarized opinions which were difficult to switch off. Nonetheless, participants also thought that there was an urge for connection and learning, which was positive and stressful at the same time. Conclusion: Using social media while in a shelter-in-place or lockdown could have a negative impact on the emotional and mental health of some of the population. To support policy and practice in strengthening mental health care in the community, social media could be used to deliver practical advice on coping and stress management. Communication with the public should be strengthened by unambiguous and clear messages and clear communication pathways. We should be looking at alternative ways of staying connected.

Video-Based Communication and Its Association with Loneliness, Mental Health and Quality of Life among Older People during the COVID-19 Outbreak.

The aim of the study was to examine the use of video-based communication and its association with loneliness, mental health and quality of life in older adults (60-69 years versus 70+ years) during the COVID-19 pandemic. A cross-sectional online survey was conducted in Norway, UK, USA and Australia during April/May 2020, and 836 participants in the relevant age groups were included in the analysis. Multiple regression analyses were conducted to examine associations between the use of video-based communication tools and loneliness, mental health and quality of life within age groups, while adjusting by sociodemographic variables. Video-based communication tools were found to be more often used among participants aged 60-69 years (60.1%), compared to participants aged 70 or above (51.8%, p < 0.05). Adjusting for all variables, the use of video-based communication was associated with less loneliness (ß = -0.12, p < 0.01) and higher quality of life (ß = 0.14, p < 0.01) among participants aged 60-69 years, while no associations were observed for participants in the oldest age group. The use of video-based communication tools was therefore associated with favorable psychological outcomes among participants in their sixties, but not among participants in the oldest age group. The study results support the notion that age may influence the association between the use of video-based communication tools and psychological outcomes amongst older people.

Loneliness and Its Associated Factors Nine Months after the COVID-19 Outbreak: A Cross-National Study.

COVID-19 has been a global healthcare concern impacting multiple aspects of individual and community wellness. As one moves forward with different methods to reduce the infection and mortality rates, it is critical to continue to study the impact that national and local "social distancing" policies have on the daily lives of individuals. The aim of this study was to examine loneliness in relation to risk assessment, measures taken against risks, concerns, and social media use, while adjusting for sociodemographic variables. The cross-sectional study collected data from 3474 individuals from the USA, the UK, Norway, and Australia. Loneliness was measured with the de Jong Gierveld Loneliness Scale. Multiple linear regression was used in the analysis of associations between variables. The results showed that concerns about finances were more strongly associated with social loneliness, while concerns about the future was more strongly associated with emotional loneliness. Longer daily time spent on social media was associated with higher emotional loneliness. In conclusion, pandemic-related concerns seem to affect perceptions of loneliness. While social media can be used productively to maintain relationships, and thereby prevent loneliness, excessive use may be counterproductive.

The Significance of Demographic Variables on Psychosocial Health from the Early Stage and Nine Months after the COVID-19 Pandemic Outbreak. A Cross-National Study.

This cross-national study explored stability and change in mental health, quality of life, well-being and loneliness during the early stage and nine months after the implementation of COVID-19 pandemic social distancing measures and periodic lockdowns as adjusted by demographic variables. In the USA, the UK, Australia and Norway, 7284 individuals responded to the invitation to take part in two cross-sectional web-based surveys (April and November 2020), including questions about sociodemographic variables and psychosocial outcomes. Independent t-tests and generalized linear models (GLM) and estimated marginal means were used to analyze differences between subgroups and countries, multiple linear regression analyses were conducted on the psychosocial outcome measures by demographic variables and time in each country and mean responses presented by time after adjusting for all demographic variables in the model. Age, gender, civil status, education, employment, place of work and living area were all significant factors for psychosocial health across the countries. Differences in mental health, quality of life, well-being and loneliness were found between the countries in both April and November 2020, while time did not contribute to reducing the toll in any of the four countries over the nine-month period.

Mental health, quality of life, wellbeing, loneliness and use of social media in a time of social distancing during the COVID-19 outbreak. A cross-country comparative study.

BACKGROUND: The COVID-19 outbreak raised questions about how people experience their mental health, quality of life (QoL), wellbeing and loneliness in the context of social distancing, and the use of social media during this time. AIMS: To examine the experience of mental health, QoL, wellbeing and loneliness and use of social media among people living in Norway, USA, UK and Australia. METHODS: A cross-country comparative survey of people living in Norway, USA, UK and Australia. Relevant statistical analyses were used to examine differences between the countries and to explore associations between demographic, mental health and psychosocial variables and use of social media. RESULTS: There were 3810 respondents from four countries, of which 50 - 74% showed a high level of emotional distress. The Norwegian population reported significantly better mental health, QoL and wellbeing and lower levels of loneliness compared to the other countries. High-frequent use of social media after the COVID-19 outbreak was associated with poorer mental- and psychosocial health. CONCLUSIONS: The results suggest that the COVID-19 outbreak took a toll on people's experience of mental health, QoL, wellbeing and experienced loneliness, and high-frequent use of social media was associated with these factors.

Employment Uncertainty and Mental Health During the COVID-19 Pandemic Initial Social Distancing Implementation: a Cross-national Study.

BACKGROUND: Social distancing during the COVID-19 pandemic has resulted in changes in the work environment and employment uncertainty. This paper reports on a cross-national comparison of four countries (Norway, UK, USA and Australia) and examines the differences in mental health between those individuals employed and those not employed during the social distancing implementation. METHODS: Participants (N = 3,810) were recruited through social media in April/May 2020 and were invited to complete a self-administered electronic survey over a 3-week period. Differences between those employed and those not employed with regard to their sociodemographic characteristics and mental health were investigated with chi-square tests, independent t tests, and one-way analysis of variances (ANOVAs). RESULTS: Compared with their counterparts, participants who were employed reported lower levels of mental health distress (p < 0.001), higher levels of psychosocial well-being (p < 0.001), better overall quality of life (p < 0.001), and lower levels of overall loneliness, social loneliness, and emotional loneliness (p < 0.001). Small to medium but consistent differences (Cohen's d = 0.23-0.67) in mental health favor those with employment or those who were retired. CONCLUSION: Further study is needed to assess mental health over time as the COVID-19 pandemic and employment uncertainty continues.

Social Media Use and Its Associations With Mental Health 9 Months After the COVID-19 Outbreak: A Cross-National Study.

Background: The covid-19 pandemic has impacted the health and well-being of millions across the globe. Strict social distancing policies and periodic lockdowns has led to an increased reliance on alternative online means of communication, including social media. Objectives: to examine (i) social media use and mental health in the general population 9 months after the COVID-19 pandemic outbreak and (ii) mental health in relation to motives for and extent of social media use, while adjusting for sociodemographic variables. Methods: A cross-national online survey was conducted in Norway, UK, USA and Australia. Participants (n = 3,474) reported extent of and motives for social media use and completed the 12-item General Health Questionnaire. The data were analyzed by chi-square tests, one-way analyses of variance, and multiple linear regression analysis. Results: Poorer mental health was associated with using social media to decrease loneliness and for entertainment motives, while better mental health was associated with using social media for personal contact and maintaining relationships. Overall increased daily time on social media was associated with poorer mental health. The social media use variables were responsible for a substantial proportion of the outcome variance explained. These findings were consistent across the four countries, with only minor variations. Conclusions: Motives for using, and time spent using, social media were associated with the participants' mental health. Guidance and recommendations for social media usage to the general public for prevention and intervention for behavioral health may be beneficial.