Dementia and the Power of Music Therapy

Dementia is now a leading cause of both mortality and morbidity, particularly in western nations, and current projections for rates of dementia suggest this will worsen. More than ever, cost effective and creative non‐pharmacological therapies are needed to ensure we have an adequate system of care and supervision. Music therapy is one such measure, yet to date statements of what music therapy is supposed to bring about in ethical terms have been limited to fairly vague and under‐developed claims about an improvement in well‐being. This article identifies the relevant sense of wellbeing at stake in the question of dementia therapies of this type. In broad terms the idea is that this kind of therapy has a restorative effect on social agency. To the extent that music arouses a person through its rhythms and memory‐inducing effects, particularly in communal settings, it may give rise to the recovery of one's narrative agency, and in turn allow for both carer and patient to participate in a more meaningful and mutually engaging social connection.     

Oral health-related well-being of the long-term hospitalised elderly

Objective: To investigate oral health‐related well‐being of the long‐term hospitalised elderly as reported by their primary nurses in relation to subject's oral health assessed either by primary nurses or by a clinical dental examination. Background data: Little is known about oral health‐related well‐being of the medically compromised, long‐term hospitalised elderly, most of whom are unable to express their feelings and opinions. Materials and methods: A cross‐sectional study using a questionnaire for primary nurses about oral health and oral health‐related well‐being regarding functional, pain/discomfort‐related, and psychosocial limitations of the subjects (n = 255) and assessment of oral health by clinical examination. The total number of limitations and the number of limitations in each category was calculated. Results: Most (77%) of our subjects were unable to eat normal food. Functional limitations dominated followed by psychosocial and pain/discomfort‐related limitations. Overall assessment by each subject's primary nurse ranked oral health of as good for 9% of subjects, as moderate for 44%, and as poor for 47%. Clinical examination‐based assessment ranked oral health as good for 19%, as moderate for 33%, and as poor for 48% of our subjects, with good oral health being ranked as good for more men than women (26% vs. 16%; p = 0.045). Fewer limitations were recorded for those with better oral health assessed both by primary nurse and by clinical examination. Conclusion: More efforts are called for to maintain the oral health of the long‐term hospitalised elderly so as to improve their well‐being.     

Variables influencing the origins of diverse abnormal behaviors in a large sample of captive chimpanzees (Pan troglodytes)

The developmental origin of abnormal behaviors is generally associated with early rearing environments that lack sufficient physical and sensory stimulation. However, other factors should also be considered. A large sample of captive chimpanzees (128 males and 140 females) was surveyed for the presence or absence of 18 abnormal behaviors. Origin variables included the subject's source (zoo, pet, performer, or laboratory), rearing (mother‐ or hand‐reared), and sex. Animals were assessed while held at the Primate Foundation of Arizona, University of Texas M. D. Anderson Cancer Center, or White Sands Research Center. There was a confound among origin variables; more hand‐reared animals than expected were from laboratories. Logistic regression tested the relationship of rearing and source, with sex as a secondary predictor variable, to each of the abnormal behaviors. There was no clear association between any abnormal behavior and source. However, for coprophagy, relative to animals from the laboratory, zoo animals tended to show a higher prevalence, while performers tended to show a lower prevalence (when rearing and sex were controlled). Rocking and self‐sucking were significantly more likely in hand‐reared animals. Coprophagy and depilation of self were significantly more likely in mother‐reared animals. When rearing and source were statistically controlled, the only significant sex difference was a higher prevalence of coprophagy in females and a higher prevalence of rocking in males. In a second, smaller sample of 25 males and 33 females from Southwest Foundation for Biomedical Research, no significant sex association was found for coprophagy, urophagy, rocking, or self‐depilation. In this second sample, coprophagy was also significantly more likely in mother‐reared than hand‐reared subjects. The association of some abnormal behaviors with mother‐rearing suggests that some form of social learning may be involved in the origin of some of these behavior patterns. This indicates that some abnormal behaviors may not be always be indicative of reduced psychological well‐being in captive chimpanzees. Am. J. Primatol. 48:15–29, 1999. © 1999 Wiley‐Liss, Inc.     

African communal basis for autonomy and life choices

I argue that the metaphysical capacity of autonomy is not intrinsically valuable; it is valuable only when used in relation to a community's values and instrumentally for making the proper choices that will promote one's own and the community's well‐being. I use the example of the choice to take one's life by suicide to illuminate this view. I articulate a plausible African conception of personhood as a basis for the idea of relational autonomy. I argue that this conception is better understood as a social‐moral thesis, and not a metaphysical thesis. A metaphysical thesis gives an account of the abstract nature of an atomic individual, his agency, and rational choice. The social‐moral thesis indicates that personhood and autonomy are positive and relational to the life plans, well‐being, material conditions, and the best means for achieving them that are made available and possible by harmonious living in a community. This idea of autonomy is not just having the capacity of freewill; it also involves how such freewill is used, in terms of how an individual's choices are guided by internalized communal values.     

Obesity and Physical and Emotional Well‐Being: Associations between Body Mass Index,Chronic Illness,and the Physical and Mental Components of the SF‐36 Questionnaire

Objective: To clarify the associations between obesity and health‐related quality of life by exploring the associations between physical and emotional well‐being in relation to obesity and the presence of other chronic illness. Research Methods and Procedures: The study data were collected as part of a postal‐survey within the old Oxford Regional Health Authority of England in 1997. Completed questionnaires were returned by 8889 of 13,800 randomly selected adults aged 18 to 64 years. The main outcome measures were body mass index in five categories (underweight, normal weight, overweight, moderately obese, morbidly obese); chronic illness status (any vs. none and number of such illnesses 0, 1 to 2, 3+); and mean SF‐36 questionnaire score in two summary component measures reflecting physical and emotional well‐being. Results: Of the subjects, 31% were overweight and an additional 11% were obese. Body mass index was significantly associated with health status, but the pattern varied according to whether the measure reflected physical or emotional well‐being. Physical, but not emotional, well‐being deteriorated markedly with increasing degree of overweight and was limited in subjects who were obese but had no other chronic condition; subjects with chronic illnesses other than obesity were compromised in both dimensions. In terms of the number of chronic illnesses reported, the additional presence of obesity was associated with a significant deterioration in physical but not emotional well‐being. Discussion: Overweight and obesity are associated with poor levels of subjective health status, particularly in terms of physical well‐being. The limitations in emotional well‐being that are reported here and in other studies may be a result of confounding by the presence of accompanying chronic illness.     

The severity of psychiatric disorders

The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM‐5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom‐defined disorders depends on factors extrinsic to those disorders, such as self‐efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.     

The perceived effectiveness of continuing care and group support in the long-term self-help treatment of obesity

Objective : Obesity is increasingly considered a chronic disease requiring continuing care, but professional long‐term treatment for most patients is not available. This study examined treatment recipients’ perception of the effectiveness of different components of a group self‐help, continuing‐care treatment program for obesity. Research Methods and Procedures : Members (n = 120) and volunteer leaders (n = 66) of a self‐help, continuing‐care treatment program of previously demonstrated effectiveness (mean treatment duration, 40.6 months; mean weight lost, 14.1 kg) rated how helpful and effective they found the various therapeutic strategies used by this program. The strategies examined were continuing care, group support, behavior therapy, motivational enhancement strategies involving positive reinforcement, and motivational enhancement strategies involving punishment. Results : The single most highly valued aspect of treatment was the provision of continuing care, followed by group support. Greater success at achieving one's goal weight was associated with perceptions of greater effectiveness of the program's strategies overall (r = 0.219, p < 0.005), of continuing care (r = 0.225, p < 0.005), and of positive reinforcement strategies (r = 0.223, p < 0.01). Participants who had successfully attained their goal weight perceived behavior therapy strategies as more effective than did participants who had not reached their goal weight [t (170) = 2.93, p < 0.005]. Discussion : The high ratings given to continuing care and group support strategies indicate the acceptability of supportive self‐help treatment for obesity administered over the long term. The findings suggest that continuing care and group support should be made available to participants in the self‐help treatment of obesity.     

The Case Against the Case for Procreative Beneficence (PB)

Julian Savulescu's principle of procreative beneficence (PB) states that, other things being equal, and of the possible children they could have, a couple contemplating procreation are morally obliged to (attempt to) procreate the child with the best chance of the best life. The critique of PB is in three parts. The first part argues that PB rests on a particular conception of the good life, and that alternative conceptions of the good life afford no obvious way in which PB can be rendered operational. The second part identifies six flaws in the attempt to justify PB in terms of a particular conception of the good life according to which the best life is understood as the life with the most well‐being. The third part explores some of the uncertainties that surround the potential implications and ramifications of adopting the principle. The overall purpose is not to demonstrate that the principle is untenable, but only to demonstrate that no compelling reason has yet been given for adhering to it.     

Influence of Flexibility and Variability of Working Hours on Health and Well‐Being

Flexible working hours can have several meanings and can be arranged in a number of ways to suit the worker and/or employer. Two aspects of “flexible” arrangement of working hours were considered: one more subjected to company control and decision (variability) and one more connected to individual discretion and autonomy (flexibility). The aim of the study was to analyze these two dimensions in relation to health and well‐being, taking into consideration the interaction with some relevant background variables related to demographics plus working and social conditions. The dataset of the Third European Survey on working conditions, conducted in 2000 and involving 21,505 workers, was used. Nineteen health disorders and four psycho‐social conditions were tested by means of multiple logistic regression analysis, in which mutually adjusted odds ratios were calculated for age, gender, marital status, number of children, occupation, mode of employment, shift work, night work, time pressure, mental and physical workload, job satisfaction, and participation in work organization. The flexibility and variability of working hours appeared inversely related to health and psycho‐social well‐being: the most favorable effects were associated with higher flexibility and lower variability. The analysis of the interactions with the twelve intervening variables showed that physical work, age, and flexibility are the three most important factors affecting health and well‐being. Flexibility resulted as the most important factor to influence work satisfaction; the second to affect family and social commitment and the ability to do the same job when 60 years old, as well as trauma, overall fatigue, irritability, and headache; and the third to influence heart disease, stomachache, anxiety, injury, and the feeling that health being at risk because of work. Variability was the third most important factor influencing family and social commitments. Moreover, shift and night work confirmed to have a significant influence on sleep, digestive and cardiovascular troubles, as well and health and safety at work. Time pressure also showed a relevant influence, both on individual stress and social life. Therefore, suitable arrangements of flexible working time, aimed at supporting workers' coping strategies, appear to have a clear beneficial effect on worker health and well‐being, with positive consequences also at the company and social level, as evidenced by the higher “feeling to be able to work until 60 years of age”.     

Physician self-awareness: the neglected insight.

Self-awareness is vital to a physician''s development. Understanding the impact of our internal subjective world on our attitudes and values and on the fantasies we have of reality is important to us as doctors. Some of the means of acquiring this self-knowledge include accurately perceiving the reflection of one''s self in patients, understanding one''s learning style, studying and enjoying the humanities, expressing one''s self creatively, maintaining a sense of humour and examining one''s reaction to experiences. When confronted by a person who is ill the physician must take action that is constructive and affirmative and not compromised by behaviour that originates in unexamined personal issues.     

鼻咽癌放疗患者心理弹性的影响因素及与自我感受负担的关系分析

摘要 目的：观察鼻咽癌放疗患者心理弹性的影响因素,并分析心理弹性与自我感受负担（SPB）的关系。方法：选取2019年3月~2020年8月期间我院收治的鼻咽癌患者100例,采用中文版心理弹性量表（CD-RISC）观察鼻咽癌放疗患者心理弹性,采用自我感受负担（SPB）量表观察患者SPB情况,分析患者心理弹性的影响因素及其与SPB的关系。结果：鼻咽癌放疗患者CD-RISC乐观、坚韧、自强各维度评分及总分均低于国内常模（P<0.05）,SPB量表总分为（38.10±2.74）分,处于中等负担水平。Pearson相关性分析结果显示,鼻咽癌放疗患者心理弹性和SPB呈负相关（P<0.05）。鼻咽癌放疗患者心理弹性与接受放疗宣教情况、临床分期、家庭月收入、教育程度、年龄有关（P<0.05）。本研究表明,教育程度、临床分期、年龄及家庭月收入是鼻咽癌放疗患者心理弹性的影响因素（P<0.05）。结论：鼻咽癌放疗患者的心理弹性较差,且其SPB与心理弹性有一定的联系。患者心理弹性的影响因素包括年龄、家庭月收入、临床分期、教育程度,临床可结合以上因素制定针对性方案以改善患者心理弹性。     

Philosophy of environmental enrichment: Past,present, and future

The brief tenure of environmental enrichment has been influenced both directly and indirectly by the field of psychology, from the work of B.F. Skinner to that of Hal Markowitz. Research on enrichment supports the supposition that an enriched environment does indeed contribute to a captive animal’s well‐being. Critical elements of effective environmental enrichment are 1) assessing the animal’s natural history, individual history, and exhibit constraints and 2) providing species‐appropriate opportunities, i.e., the animal should have some choices within its environment. This paper presents a historic perspective of environmental enrichment, proposes a broader, more holistic approach to the enrichment of animals in captive environments, and describes a framework or process that will ensure a consistent and self‐sustaining enrichment program. Zoo Biol 20:211–226, 2001. © 2001 Wiley‐Liss, Inc.     

Clinical,socio‐demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”

Individuals reporting persistent psychotic experiences (PEs) in the general population, but without a “need for care”, are a unique group of particular importance in identifying risk and protective factors for psychosis. We compared people with persistent PEs and no “need for care” (non‐clinical, N=92) with patients diagnosed with a psychotic disorder (clinical, N=84) and controls without PEs (N=83), in terms of their phenomenological, socio‐demographic and psychological features. The 259 participants were recruited from one urban and one rural area in the UK, as part of the UNIQUE (Unusual Experiences Enquiry) study. Results showed that the non‐clinical group experienced hallucinations in all modalities as well as first‐rank symptoms, with an earlier age of onset than in the clinical group. Somatic/tactile hallucinations were more frequent than in the clinical group, while commenting and conversing voices were rare. Participants in the non‐clinical group were differentiated from their clinical counterparts by being less paranoid and deluded, apart from ideas of reference, and having fewer cognitive difficulties and negative symptoms. Unlike the clinical group, they were characterized neither by low psychosocial functioning nor by social adversity. However, childhood trauma featured in both groups. They were similar to the controls in psychological characteristics: they did not report current emotional problems, had intact self‐esteem, displayed healthy schemas about the self and others, showed high life satisfaction and well‐being, and high mindfulness. These findings support biopsychosocial models postulating that environmental and psychological factors interact with biological processes in the aetiology of psychosis. While some PEs may be more malign than others, lower levels of social and environmental adversity, combined with protective factors such as intact IQ, spirituality, and psychological and emotional well‐being, may reduce the likelihood of persistent PEs leading to pathological outcomes. Future research should focus on protective factors and determinants of well‐being in the context of PEs, rather than exclusively on risk factors and biomarkers of disease states.     

Self‐Euthanasia,the Dutch Experience: In Search for the Meaning of a Good Death or Eu Thanatos

My main purpose in this article is to establish the meaning of a ‘good death’ when death is self‐chosen. I will take as my point of departure the new notion of ‘self‐euthanasia’ and the corresponding practice that has evolved in the Netherlands in recent years. Both physician‐euthanasia and self‐euthanasia refer to an ideal process of a good death, the first being ultimately the physician's responsibility, while the second is definitely the responsibility of the individual choosing to die. However, if we also accept the existence of a fundamental moral difference between ending another person's life and ending your own life, and if we accept this moral difference to be also relevant to the normatively laden good death, then this difference represents a strong reason for preferring self‐euthanasia to physician‐euthanasia.     

Do We Practice What We Preach? Goal Setting for Ecological Restoration

Over the last decade, several research and opinion pieces have challenged the tenets of restoration ecology but a lack of centralized data has impeded assessment of how scientific developments relate to on‐the‐ground restoration. In response, the Society for Ecological Restoration (SER) launched the Global Restoration Network (GRN) to catalog worldwide restoration efforts. We reviewed over 200 GRN projects to identify the goals governing restoration and the frequency with which they are measured. We used the SER Primer on Ecological Restoration to frame our analysis, categorizing goals by SER's attributes of restored ecosystems. We developed additional attributes to characterize goals not encompassed by the SER‐defined attributes. Nearly all projects included goals related to ecosystem form, namely similarity to reference conditions and the presence of indigenous species, and these goals were frequently measured. Most projects included goals related to ecosystem function, and many highlighted interactions between abiotic and biotic factors by either modifying abiotic conditions to support focal species or manipulating species to achieve desired ecosystem functions. Few projects had goals related to ecosystem stability, whereas the majority of projects had goals related to social values. Although less frequently measured, social goals were described as important for long‐term project success. In conclusion, science and practice frequently aligned on goals related to ecosystem composition and function, but scientific guidelines on resilience and self‐sustainability appear insufficient to guide practice. In contrast, the common inclusion of goals for human well‐being indicates that, if intended to advise practice, restoration guidelines should give direction on social goals.     

Las ganas de vivir como expresión del bienestar de las personas mayores

IntroductionWill-to-live, a central concept in well-being theories, represents a positive attitudinal component towards one's own life. It has been identified as a mediator between the self-perception of aging and longevity and health. The objective of this study is to characterise elderly people with high levels of will-to-live in the main dimensions of positive psychology.MethodThe study included the voluntary participation of 165 adults, aged between 54-89 years, users of senior centres in the Community of Madrid. Will-to-live and other dimensions of well-being and health were evaluated. The correlations between the different evaluated dimensions were analysed, and comparisons made in terms of different levels of will-to-live, as well as an analysis of the dimensions that contribute most to the will-to-live.ResultsCorrelations among the majority of variables were statistically significant, with a decrease in the coefficients being observed when controlling the effect of the will-to-live. When groups with different levels of will-to-live are compared with well-being and health, there are statistically significant differences in practically all of the dimensions. Gratitude, positive affect, and depression are the dimensions that best predict will-to-live.ConclusionOlder adults that make up the group with high will-to-live are characterised by higher levels of optimism, gratitude, positive affect, sense of life, psychological prosperity, resilience, happiness, and satisfaction with life, as well as lower levels of depression and negative self-perception of aging. The implications of these results point towards the relevance of will-to-live in successful aging.     

Environmental enrichment of brown capuchins (Cebus apella): Behavioral and plasma and fecal cortisol measures of effectiveness

No consensus exists about the quantity and variety of environmental enrichment needed to achieve an acceptable level of psychological well‐being among singly housed primates. Behavioral and plasma and fecal cortisol measures were used to evaluate the effectiveness of four levels of toy and foraging enrichment provided to eight wild‐caught, singly housed adult male brown capuchins (Cebus apella). The 16‐week‐long study comprised six conditions and began with a 4‐week‐long preexperimental and ended with a 4‐week‐long postexperimental period during which the subjects were maintained at baseline enrichment levels. During the intervening 8 weeks, the subjects were randomly assigned to a sequence of four 2‐week‐long experimental conditions: control (baseline conditions), toy (the addition of two plastic toys to each cage), box (access to a foraging box with food treats hidden within crushed alfalfa), and box & toy (the addition of two plastic toys and access to a foraging box). Behavioral responses to changes in enrichment were rapid and extensive. Within‐subject repeated‐measure ANOVAs with planned post hoc contrasts identified highly significant reductions in abnormal and undesirable behaviors (and increases in normal behaviors) as the level of enrichment increased from control to toy to box to box & toy. No significant behavioral differences were found between the control and pre‐ and postexperimental conditions. Plasma and fecal cortisol measures revealed a different response to changing enrichment levels. Repeated‐measure ANOVA models found significant changes in both these measures across the six conditions. The planned post hoc analyses, however, while finding dramatic increases in cortisol titers in both the pre‐ and postexperimental conditions relative to the control condition, did not distinguish cortisol responses among the four enrichment levels. Linear regressions among weekly group means in behavioral and cortisol measures (n = 16) found that plasma cortisol was significantly predicted by the proportions of both normal and abnormal behaviors; as the proportion of normal behaviors increased, the plasma cortisol measures decreased. Plasma cortisol weekly group means were also significantly and positively predicted by fecal cortisol weekly group means, but no behavioral measure significantly predicted fecal cortisol weekly group means. In sum, these findings argue strongly that access to a variety of toy and foraging enrichment positively affects behavioral and physiological responses to stress and enhances psychological well‐being in singly housed brown capuchins. Am. J. Primatol. 48:49–68, 1999. © 1999 Wiley‐Liss, Inc.     

When peers are not peers and don't know it: The Dunning‐Kruger effect and self‐fulfilling prophecy in peer‐review

The fateful combination of (i) the Dunning‐Kruger effect (ignorance of one's own ignorance) with (ii) the nonlinear dynamics of the echo‐chamber between reviewers and editors fuels a self‐reinforcing collective delusion system that sometimes spirals uncontrollably away from objectivity and truth. Escape from this subconscious meta‐ignorance is a formidable challenge but if achieved will help correct a central deficit of the peer‐review process that stifles innovation and paradigm shifts.     

Social attachment in giraffe: Response to social separation

Attachment relationships between animals are often studied by separating a pair of individuals and recording their subsequent behavior. Studies of non‐human primates have shown that separation results in changes that are indicative of both psychological and physiological stress. Similar results have been found in several non‐primate species with differing social structures. This study examined the behavior of two female giraffe at Zoo Atlanta after the removal of the resident male. Data were collected on the giraffe before and after separation, using an instantaneous scan sampling technique to record levels of activity, social behaviors, solitary behaviors, proximity, and habitat utilization. After the removal of the resident male, both giraffe exhibited increased levels of activity, stereotypical behavior, contact behavior (particularly neck‐rubbing), and decreased habitat utilization. These results are similar to those found in earlier primate separation studies, supporting the hypothesis that complex social structure is not necessary for the formation of social attachments. Because social separation is often accompanied by behavioral and physiological indications of stress, an understanding of the variables involved in a species' response to separation is vital to the promotion of the psychological and physical well‐being of captive animals. Zoo Biol 19:41–51, 2000. © 2000 Wiley‐Liss, Inc.     

‘One Can Always Say No.’ Enriching the Bioethical Debate on Antisocial Behaviour,Neurobiology and Prevention: Views of Juvenile Delinquents

Genomic and neuro‐scientific research into the causes and course of antisocial behaviour triggers bioethical debate. Often, these new developments are met with reservation, and possible drawbacks and negative side‐effects are pointed out. This article reflects on these scientific developments and the bioethical debate by means of an exploration of the perspectives of one important stakeholder group: juveniles convicted of a serious crime who stay in a juvenile justice institution. The views of juveniles are particularly interesting, as possible applications of current and future scientific findings are considered to be most effective if applied early in life. Based on their statements we come to the following provisional conclusions. Concerns about labelling and stigmatization are recognized and widely shared. Possible effects on one's identity are acknowledged too. Yet, a possible biological underpinning of one's antisocial behaviour is not considered to result in the development of a criminal identity. Nonetheless, psychopharmacological interventions are experienced as endangering one's current self. Concerns regarding the refusal of responsibility and the blaming of one's genes or brain can be put into perspective. Instead, participants emphasize the motive of own choice as underlying their criminal behaviour. Moreover, bioethical debate should pay attention to the role of parents of children at risk and the parent‐child relationship in families at‐risk. We argue that the short‐term and long‐term interests of children at risk, as well as their interests and those of society at large, may conflict. In order to deal appropriately with newly arising dilemmas, a normative framework needs to be developed.