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International Journal of
eISSN: 2577-8269

Family & Community Medicine

Review Article Volume 2 Issue 3

Contextual treatment: a conceptualization and systematization from general medicine

Jose Luis Turabian

Specialist in Family and Community Medicine, Health Center Santa Maria de Benquerencia, Spain

Correspondence: Jose Luis Turabian, Health Center Santa Maria de Benquerencia Toledo, Regional Health Service of Castilla la Mancha (SESCAM), Toledo, Spain

Received: March 10, 2018 | Published: May 18, 2018

Citation: Turabian JL. Contextual treatment: a conceptualization and systematization from general medicine. Int J Fam Commun Med. 2018;2(3):137-144 . DOI: 10.15406/ijfcm.2018.02.00056

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Abstract

Family doctors do not treat illnesses but rather care for people in their contexts. And so, an important characteristic of family medicine is that you cannot separate the individual from its context, or the physical from the psychic. General / family medicine is context-oriented. Illness is a relational concept. It is related to contexts; appears between the person and their relationships with the contexts; it does not exist isolated from the contexts. The real object of the work of general practitioner is the "landscape context" formed by the living bodies of the people in a meaningful relationship with others. Contextual landscapes do not exist in isolation. Contexts are "open" systems. The importance of the context is dependent on the phenomenon of interest. Understanding the diseased body in its contextual referents changes the focus of the therapeutic procedures. The clinic emerges - it is perceived by the clinician - within its "landscape context" that qualifies the reality presented by the patient. From that moment on, there are a number of clinical strategies to manage the uncertainty of decision making focused on the context. In this scenario, a range of methodological approaches of contextual treatment are presented: 1.-The consultation relational context; 2.-The therapeutic contexts; 3.-Mental landscapes; imagining contexts; 4.-Artistic creation; 5.-Expand or concentrate time; 6.-Be aware of the ecological impact of decisions in the individual patient; 7.-Treatments or reordering situations; 8.-The constructivist treatment; 9.-The concept of cure or resolution; 10.-Treatments that favour internality; 11.-Favor the human factor; 12.-The treatment of the disease in someone other than the one who has the disease-treatment as a dyadic (at least) intervention; 13.-Changes in the external environment; and 14.-Changes in the "micro" context (the environment close to the patient). The magnitude of a health problem in general medicine is a function of scale. Increase the size of the context to be considered in a given case, in which the organism under investigation perceives and responds to the environment, will generally decrease the severity of this problem. In general, the larger the contextual landscape relative to size of the health problem/patient, more likely will be that medical interventions have positive effects on the individual patient. The "relevant treatment" is a concept always applied to the context: an intervention is relevant in an environment if it gives rise to contextual effects.

Keywords: general practitioner, family medicine, community medicine, healing, Therapeutic landscapes, health promotion, Holistic health, complexity, community, family, ecology, therapeutics, therapy, clinical protocols, physician-patient relations, empowerment, context

Introduction

Traditionally, the pathogenic point of view was concentrated in the "diseased" parts of the human body, which was increasingly divided into smaller parts and treated separately and the psychological, social and spiritual needs of the patients were largely ignored. However, from the point of view of general medicine, the focus is on patients (with their physical, psychological and social health) and on their environment or context.1 This vision concerns the understandings of what it means to be human, as physically embodied individuals and as persons within their social context or "landscape context". As the medical humanities open to new conceptualizations of being human, the nature of “context” demands greater interrogation. Further, these new engagements from general medicine concerns the understandings of what constitutes health, ill-health, and disease, and demands attention to the contextual treatment, which includes recognition of non-medical, or non-clinical sites of health and illness, and the different intersecting 'scales' of health and illness.2 Family doctors do not treat illnesses but rather care for people in their contexts. And so, an important characteristic of family medicine is that you cannot separate the individual from its context, or the physical from the psychic. It is the only medical specialty where this inevitable gap does not occur.3–5 Consequently, general / family medicine is context-oriented. Illness is a relational concept. It is related to contexts; appears between the person and their relationships with the contexts; it does not exist isolated from the contexts. What is the concept of context or landscape context? For contextualization in medicine we must: 1) add dimensions that are not well contained in the usual scientific discourse: the social or relational dimension (things occur in the context of interaction between people), the historical dimension (knowledge has to see with people who have specific history and motivation, is the specific knowledge of a specific moment in the life of people or organizations); and 2) include two visions: the verticality of the patient (their individuality understood as personal history), and the horizontality of the family group (history, myths, relationships).6,7

Just as the pathogenic clinician usually locates the problem within the individual; the biopsychosocial clinician has an alternative vision: the problem is located in the context rather than within the isolated individual. The main function of the general practitioner is to assist people in their contexts. The real object of the work of general practitioner is the "landscape context" formed by the living bodies of the people in a meaningful relationship with others. The work of the general practitioner is not a series of tasks but a series of contextual relationships-connections where the tasks are immersed.8,9 There is no reality that can be interpreted outside of a specific relational, social, environmental, historical context, etc. Problems and solutions are not born in a vacuum, but have a past and a present and a foreseeable future. They come from a context, are in a context and almost always help create a new context. Biological and social systems are inherently complex and adaptive, so it is surprising that one can say that a human disease has a single cause or cure. There are a set of individual agents with the freedom to act in ways that cannot always be totally predictable, and whose actions are interconnected so that each action in one part changes the context of other agents or actors. The disease appears by the dynamic interaction within and between these systems, not by the failure of a single component. The disease is expressed or experienced in situations "landscape contexts" of the patient's daily life: work, family, environmental situations, etc.10,11 Understanding the diseased body in its contextual referents changes the focus of the diagnostic and therapeutic procedures.12,13 Changing the context of a health problem or behaviour is often considered the best way to produce individual changes. In this sense, the process of contextual relationship is more important than the content of the problem.14 The sense of "art" or clinical expertise "is associated with the ability to manage the uncertainty of the query. The clinic emerges - it is perceived by the clinician - within its "landscape context" that qualifies the reality presented by the patient. From that moment on, there are a number of clinical strategies to manage the uncertainty of decision making focused on the context.15–19 In this scenario, this paper presents a systematization of "contextual treatment" to achieve health or healing, and make explicit the connections of space, place and time.2

Discussion

Learning to do contextual treatment in general medicine is to begin the exploration of an unknown and powerful territory. Here, a range of methodological approaches of contextual treatment are presented. It is a preliminary vision that can be deepened and expanded. Some forms of contextual treatment are presented in the Table 1.

Forms of contextual treatment

Examples

  1. The consultation relational context; placebo-nocebo effect

The directive / instructive doctor-patient relationship, the persuasive relationship, or the cooperative / participative relationship, give rise to different "contexts" that have therapeutic implications

  1. The therapeutic contexts

-Any type of assistance at home, such as long-term care for an invalid person, or planned home birth, allows using the qualities of that environment to obtain therapeutic effects.

-Walking-for-thinking as moving gestalt, an interplay between the person, environment and thinking where the rhythms of the body correlate with the rhythm of walking, affording feeling of enhanced memory and creativity

-The benefits of a reflective garden walking and the use of green spaces and nature on patients.

-In 1984, a researcher named Roger Ulrich noticed a curious pattern among patients who were recovering from gallbladder surgery at a suburban hospital in Pennsylvania. Those who had been given rooms overlooking a small stand of deciduous trees were being discharged almost a day sooner, on average, than those in otherwise identical rooms whose windows faced a wall

  1. Mental landscapes; imagining contexts

-The mental landscape of "a beach where the individual is relaxed listening to the sound of the waves", and feels with a peace and total calm

-The old home or the neighborhood where he lived formerly, where one was accepted and was comfortable.

  1. Artistic creation

-Artistic therapy through various forms of visual arts, literature or poetry

  1. . Expand or concentrate time

-Drugs that modify the sense of time

-Hypnosis

-Biofeedback

-Meditation

-Relaxation techniques

-Hobbies

#VALUE!

-Sport

-Other interventions that favour the ability to achieve total absorption in a task

  1. Be aware of the ecological impact of decisions in the individual patient

-The massive felling in Africa of a native species of the plum family, the Prunus Africanus tree (from whose bark a substance used, without a clear scientific basis, is extracted to treat prostate diseases in the West), by the European pharmaceutical companies, although it is an internationally protected species, makes this tree is now in danger of extinction in certain African regions, favouring the loss of soil fertility and the consequent food insecurity of its population

  1. Treatments or reordering situations

-The cancer works as a dissipative structure.

-The sexuality works analogously to the dissipative structures

  1. The constructivist treatment

-The empowering interview:

-Help to the patient to determine what is his problem in their context

-Help to the patient to discover why the problem exists (causes, consequences, emotions, actors, relationships, contexts), and analyze it with a "panoramic vision"

-Encourage to the patient to examine as many solutions of the problem in their context as possible (internal and external resources)

-Help to the patient choose the most appropriate solution in their situation

  1. The concept of cure or resolution

-The immunity after an infection

-The compensatory development of other senses that become part of their new personality in people with deficits in one of them, for example, in the blind

  1. Treatments that favour internality

-When patients with headaches are asked to keep a diary to document the frequency and severity of their pains, curiously, in many of them the migraines disappear when they begin to keep their diary

-The appearance of the same symptoms in a patient as those presented by a relative at present or formerly

  1. Favor the human factor

-To take into account during the consultation the health beliefs of the patient, their general opinions about medicine and specifically about the intervention of that moment, as well as the complexity of the socio-cultural effects

-Use of emotions

-Transference and counter transferences

-When the patient is a terminal, there are moments where it is better to do nothing: just be there

  1. The treatment of the disease in someone other than the one who has the disease-treatment as a dyadic (at least) intervention

-In psychotic outbreaks

-In obesity where the participation of the family is required in the treatment.

-The treatment in Alzheimer's caregivers to act on the patient with dementia

-The treatment of the family of a patient with HIV to intervene on the index patient

  1.  Changes in the external environment

-Neighborhood environments more willing to be able to walk are associated with less obesity and diabetes

  1. Changes in the "micro" context (the environment close to the patient)

-The prevention of osteoporosis based on improvements in the patient's environment (more lighting, removal of physical barriers such as stairs, adequate bathroom, correction of visual and auditory defects, use of a cane, etc.

Table 1 Forms of contextual treatment

The consultation relational context

The doctor-patient relationship is fundamental both for the diagnosis and for the treatment. All care activity is influenced, directly or indirectly, by the interpersonal relationship. Communication allows the integration of clinical reasoning by connecting the biomedical and psychosocial aspects of clinical care. The interview is a technique or a channel and place of communication, where the patient doctor relationship is produced and developed. The doctor's relationship with the patient is the true core of clinical practice.920 The doctor-patient relationship model is a "context creator" element.21 The nocebo-placebo effect is also included here.22,23 The therapeutic context induces biomedical processes in the patient's brain that may enhance or reduce the effects of chosen interventions. The context thus works as a drug, with real effects and side effects.24,25

The therapeutic contexts

They are those places, situations, contexts, etc., that achieve both physical and psychic environments associated with a therapeutic strategy or improvement of health or well-being. The "therapeutic contexts" favour the healing process by constituting physical or psychic environments that create "safe" places, literally an energetic capsule of support and care. This concept is related to the importance of space or context or landscape with thought.26 In addition, it can be including here the effect of walking in green spaces, which has long been associated with thinking and stress reduction; the anecdotal evidence of philosophers, writers, researchers, artists, business leaders and others testifies to the powers of walking to think.2729 The "landscape" or context can not only be considered as a physical environment, constructed or modified by human action, but also as a product of the human mind and material circumstances, reflecting intentions and actions as well as barriers and structures that society imposes. Contexts can provide a meaning of identity and feelings of security, such as places where family life (the home), work, the church, or usual meeting places (such as doctors' consultations) are made, where produced for a long time networks of interpersonal support, and thus these places can promote healing. These places provide a "psychological root" that has been achieved through a long stay and the establishment of certain relationships with the context, which produces feelings of self-identity and security. This environment can be understood as a "personal home" that provides an integral social network of physical, spiritual and psychological factors that emerge together to promote the creation of a healthy or healing place.30,31

Mental landscapes; imagining contexts

Therapeutic landscapes can also be achieved mentally through imagination and visualization. Human ideas modulate the landscape; human intentions create and maintain places. And our experience of place and physical space modulates human ideas. These "landscapes" can be used in diseases related to stress. The world that surrounds to each one, the environment of each one, is largely created by oneself because we are interpreting what surrounds us. Therefore, if you vary the interpretation of what surrounds you, in a certain way, it is as if you vary your environment.32,33

Artistic creation

Another way of accessing to mental landscapes images is through artistic creation, such as that carried out in artistic therapy through various forms of visual arts, literature or poetry.34

Expand or concentrate time

The symptoms experienced depend on the sensation of time. Time enters the course of the disease.35 Symbolically, the passage of the calendar - the passage of time, the change of time - can have a great meaning for the patient. This reflects for the patient a sense of change and the possibility of restarting and reordering life. Thus, many times for patients the crisis of the disease marks a "sacred" event that separates two periods of time -the before and the after- ("Before my operation last October", "before my thrombosis last summer "...), as if it were the before and after Christ of the historical dates.36 Time is an important dimension in the analysis of the meaning of the disease; for example, it connects the time of a disease with the phase of development of the family cycle. Care of a chronically ill child cause the "stop" in the time in the family; the death of a young person, "freezes" the time in the family.14 The passage of time is felt as constantly changing depending upon the modulations of experience. Therefore, judgments of the same physical duration vary considerably within and across individuals. The notion subjective time is a function of the self which refers to the fact that duration judgments are dependent upon an individual’s momentary affective and cognitive states. Cognitive models of time perception assume that prospective and retrospective time perceptions are governed by different processes. Time perceptions are influenced by perceived physiological changes (body signals).37 For example, pain. The amount of pain is related to the cause of the pain and the perceived period of time. The time we feel pain becomes eternal. A pleasant situation is passed quickly (the hours are minutes); an unpleasant situation makes us eternal (minutes become hours). A large painful stimulus can reduce its perceived intensity if time expands. When we are sick we experience the world in a different way; we distort time and space. Our time passes more slowly; we feel that we are always going to be sick, that we will never be cured. We feel separated and isolated from the healthy. We perceive our quality of space very different: we feel confined and fragmented in the disease. These distortions accentuate pain, suffering, and anguish. This fact is used in treatments: almost all medical interventions to treat pain modify the sense of time perceived by the patient.38

Be aware of the ecological impact of decisions in the individual patient

A series of relationships can be established between people and ecosystems (agricultural, urban, biophysical, socioeconomic), and associated interventions that have implications in the role of the clinical family physician who attends patients every day: 1.-The ecosystem as source of exposure to diseases (toxic air pollutants, soil and water, vectors of diseases, climate changes ...) and interventions in relation to risk management, legislation, and health protection; 2.-The ecosystem as a condition for human well-being (social and economic environment, peace, security, education, food, sustainable resources, justice and social equity, lifestyles, places of residence and work, healthy cities), and interventions in relation to healthy and sustainable environments; 3.-The ecosystem as a core of human values ​​(includes the well-being of species other than man, environmental justice: an "ethical land").39

Treatments or reordering situations

It refers us to the concept of Phase Transition (as happens to the matter that can appear in different phases, such as ice and water; ice represents the orderly, regular and rigid, and the liquid phase is the disordered phase). The treatments that evoke in the patient an awareness of psycho-physical internality help facilitate a reorganization of the structure (as described in the theory of dissipative structures: the process is embedded in the second law of thermodynamics, which predicts that, like a cup of hot coffee that cools and never warms up again, the universe tends to a similar state of disorganization). Order arises from chaos, and could not arise without chaos.40,41 When there are internal disturbances of sufficient quantity, these can lead to abrupt reorganizations, such as "escapes to a higher order", organizing themselves in a more complex way. When a patient increases contradictions or conflicts, finally there is an "explosion" with a sudden change with a reconstruction of the relational and contextual experience.42

The constructivist treatment

The treatment is to try to articulate the thematic context that surrounds the plot of the life of the client, trying to help him to experiment with new plots that open possibilities for new chapters. The process may consist of several phases not necessarily sequential:

  1. Make the dominant narratives explicit: through therapeutic dialogue, circular questions, the use of metaphors, etc. At this point it is useful to evaluate what is the problem of the patient and the context, the goal of the treatment, what is the personal explanation or theory about what is the problem, what is the interactional pattern in which it is situated, what are the alliances and coalitions between members of the contextual system, and what is the systemic function of the problem.
  2. Deconstruction of dominant narratives: in terms of their dimensions of therapeutic relevance susceptible to transformation.
  3. Facilitate the appearance of subdominant narratives: for each dominant narrative of the context there are other voices and other discourses underlying, silenced, undervalued, In this sense, it can focus on solutions, externalize the problem, identify and explore extraordinary events, confront, etc.
  4. Validation and practice of alternative narratives: Having accessed these subdominant narratives giving them the attention they deserve, the process continues through its validation in different contexts and wider than the original.4346

The concept of cure or resolution

The "cure" should be seen in general medicine as facilitating the unblocking of a situation, changing or moving from one scenario to another with new perspectives. The cure or resolution of the disease means more than achieving a homeostasis. In this sense there are defects, diseases and disorders that can play a paradoxical role, revealing capacities, developments, and evolutions; latent life forms that could never be seen, or even imagined in the absence of those.47

Treatments that favour the internality

"Internality", at a deep level, means that energetically the whole universe is united. Normally we think of the disease -headache, pneumonia, angor, etc.- as something external to us. In this way, the instruments that make us aware of the context, such as keeping a diary of symptoms, force us not only to collect the frequency and severity of the symptoms, but also the circumstances and events surrounding the symptoms, and force us to put the disease in its context -behavior, diet, sleep, exercise ... and other patterns of relationships with the world- so that the patient's attention is redirected. The disease is no longer seen as an outsider, but as part of the process of life, in an integral way.4851 The concept of integrality is also based on the application of Bell's theorem: "Two particles, which have been in contact, and which are separated even at the ends of the universe, change instantaneously when a change occurs in some of them". When you have been in union with a person for a long time, it is as if both belonged to the same energy system. When they separate, it is as if they were still united. And when something important happens to you either, you feel and transmit it in some way. No matter that you are in Japan and the other person in Canada.3552 Probably many doctors have observed this phenomenon, which occurs relatively frequently, in the clinic: the sequential development of identical diseases in patients with a certain contextual relationship.35 It is not uncommon, for example, the case of the healthy wife who suffers an acute myocardial infarction while visiting her husband in the ICU with an acute myocardial infarction, or the appearance of the same symptoms in a patient as those presented by a relative currently or formerly, etc. These events occur in defiance of the orthodox concepts of molecular medicine, which limit the effects of a biological disease to a single body (for example, coronary heart disease to a single heart). On a deeper level, it means that energetically the whole universe is united.

Favour human factor

In an experiment at Ohio State University, a group of researchers studied the effects of a high cholesterol diet on rabbits. At the end of a certain period the rabbits were sacrificed, and tests for atherosclerosis in their arteries were examined. The results were predictable, since previous studies know that a diet rich in cholesterol promotes arteriosclerotic changes in the arteries of rabbits. However, in a subgroup of rabbits, it was found that atherosclerotic changes were 60% lower than those of the rest of the group. The researchers were stunned, and there was no obvious explanation for this unexpected result. Finally, an unplanned variable was found: the less severely affected rabbits were fed and cared for by the same researcher who, during the experiment, regularly took them from their cages and fed them, talking to them. Was it a mere coincidence? To clarify this, controlled studies were carried out that showed again that the groups of rabbits that are spoken to while they are fed have 60% less atherosclerosis.35 The usual approach to atherosclerosis is therefore only partially adequate. It is a known fact that the classic risk factors of coronary disease only explain half of the new cases.53 But the main implication is that doctors who adopt a warm and patient-friendly form of consultation are more effective in their interactions with patients than those who adopt a formal style and do not offer friendly security. These most effective doctors take into account during the consultation the patient's health beliefs, their general opinions about medicine and specifically about the intervention of that moment, as well as the complexity of the socio-cultural effects.54 There can be no objective treatments without emotions. Interactions cause changes - either between the scientist and the object of scrutiny, or between the doctor and the patient. The interaction between two people generates real disturbances in the psychophysical state of both. There cannot be completely neutral treatments. The thought that there may be "objective", "non-emotional" treatments is only possible due to our blindness about the connectivity of human beings with the whole universe. The approach, rather than trying to minimize the subjective component in the healing process, is to maximize it as it is a powerful force for change. Each patient has the potential to be their own healer.55,56

The treatment of the disease in someone other than the one who has the disease; treatment as a dyadic (at least) intervention

If we consider the disease from the biomedical paradigm where the disease affects individual bodies, treating someone other than the one with the disease is absurd, but individual health is an expression of the sick context. The healing takes place through the encounter of a person with other people (the healing is a "relational" concept, of adjustment or change of the matrix of relationships or connections), rather than through interventions in the body or mind of the individual isolated.5760 The disease (in all cases, but especially when psychosocial factors predominate -for example, mental illness) is an alteration or dysfunction of communication relationships between actors and contexts (human beings, perceptions, environments ...).61 Patients are not alone, nor do they go alone to the doctor's office. Physician training focuses on an encounter between two people: the patient and the physician. In practice, a third person (companion) frequently accompanies a patient during medical encounter. The subjective experience of disease is built by patient in the family context and is expressed in the medical consultation, often, with the presence of a companion of the patient. The presence of the companion of the patient in consultation is a metaphor from the patient.6268 Despite the importance of both members of patient–care partner dyad, a majority of research on illness management is focused on the patient or the care partner. But, the basic principle of the contextual treatment is that illness management is a dyadic (at least) phenomenon; the dyad must be seen as an interdependent team. The way dyads appraise illness as a unit influences the ways in which they engage in behaviours to manage illness together in a recursive fashion that influences dyadic health. Dyadic illness management is influenced by contextual factors.69

Changes in the external environment

The healing power of nature, or vis medicatrix naturae, has traditionally been defined as an internal healing response designed to restore health. The healing power of the nature-based environment - green space, forests and parks in particular - extends into the realm of mental health and vitality.70 The relationships we establish with nature can help us in health. The natural and cultural processes, in interaction, model "landscapes", and you can intervene and take advantage of these processes to achieve the desired objectives. Human survival depends on our adaptation and that of our landscapes -cities, buildings, gardens, roads, rivers, fields, forests- to new forms capable of containing life, modelling contexts that reflect the interconnections between air, land, water, life and culture, to help us understand and feel these connections, landscapes that are functional, sustainable, full of art and meaning.71 Plants and green spaces provide more than just aesthetic benefits. Plants and green spaces not only look nice, but they can be of great importance to the health and wellbeing of the population. Natural environments can benefit mental health by reducing stress and providing familiarity and a supportive culture, as well as benefitting physical health by promoting more movement and activity outside.72,73

Changes in the "micro" context (the environment close to the patient)

The microsystem is the level closest to the patient, and includes the behaviours, roles and relationships characteristic of the everyday contexts in which he spends his days, is the place where the person can interact face to face easily, such as at home, work, friends. For example, in the case of the oncological patient, the patient's environment is often increased by environments that become routine such as: the hospital/consultation, the patients with whom it coincides in the hospital setting, associations with who come for help, etc (Figure 1).74

Figure 1 Increasing the size of the context to be considered decrease the severity of this problem.

Source: Self made.

Conclusion

The field of general medicine is not only or mainly pathologies, nor bio, or psycho or social. The field of general medicine is the relationships with the context. The justification of family medicine is in its orientation towards the context, and consequently the treatment should be contextual. But it is an unknown and powerful territory. The usefulness of systematizing the concept of contextual treatment is to give security regarding complexity and variability. Contextual landscapes do not exist in isolation. Contextual landscapes are nested within larger landscapes. In other words, each landscape or context has a "regional", particular, concrete, individual setting. Contexts are "open" systems; energy, materials, and organisms move into and out of the landscape. The importance of the context is dependent on the phenomenon of interest, but typically varies as a function of the "openness" of the landscape. The magnitude of a health problem in general medicine is a function of scale. Increase the size of the context to be considered in a given case, in which the organism under investigation perceives and responds to the environment, will generally decrease the severity of this problem favouring the unblocking of situations, the increase of resources and the network of connections of the relational matrix of the patient, and consequently increasing level of health. In general, the larger the contextual landscape relative to size of the health problem/patient, more likely will be that medical interventions have positive effects on the individual patient. The important point is that a patient ' landscape context should be defined relative to health problems mosaic. Moreover, consideration should always be given to the landscape context and the "openness" of the context relative to the phenomenon or health problem under consideration when choosing individual medical treatment. The "relevant treatment" is a concept always applied to the context: an intervention is relevant in an environment if it gives rise to contextual effects. Contextual landscapes strategies are needed giving value to the contexts, placebo effect, variability, uncertainty, etc. Contextual strategies are needed that allow the disease to unfold in your situation during the consultation, instead of biomedical clinical protocols that do not contemplate the contexts.

Acknowledgement

None.

Conflict of interest

The authors declare there is no conflict of interest.

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