survey
If you google ‘chiropractic’ you might get the impression that an unusual number of US chiros are outright perverts. Here are four current cases that I found instantly without any in-depth seraching:
A “Christian chiropractor” is facing several criminal charges after at least eight former clients have accused him of rape and sexual assault. Roc Byrd, 61, of Danville, who worked as a chiropractor for Cornerstone Chiropractic in Avon, is facing one felony count of rape, five felony counts of sexual battery and four misdemeanor counts of battery. He is accused of raping a client, touching clients inappropriately over and under their clothes during appointments without consent and pressing his genitals up against multiple patients. Byrd identified himself as a practicing Christian and reportedly began each of his chiropractic appointments by praying with clients.
A Warren chiropractor faces significant legal problems and a criminal investigation into how he allegedly treated one of his patients. Officials say he sells himself as one of only a handful of Michigan “Chiropractic Neurologists,” but the former patient claims he is a sexual predator and offers video as apparent proof. The case involves Dr. John Pispidikis of the Spinal Recovery Center. The complaint was filed Friday (April 19) morning, which surprised the doctor. The patient involved remains unnamed in the civil court documents, but she claims the doctor groped her during a physical exam last February. But she had no proof, so she claims she went out and got some.
The Oklahoma Board of Chiropractic Examiners (OBCE) has ordered the Back Stop’s only chiropractor, Mark Kimble to surrender his license by next Monday after several sexual impropriety allegations against him have surfaced. Oklahoma Board of Chiropractic Examiners confirmed with KFOR that there are seven alleged victims of Kimble’s who have come forward.
The Los Angeles County Sheriff’s Department is looking for possible victims of a chiropractor accused of sexual assault. Richard Carnow, 65, was arrested by authorities on March 13 on four felony counts of sexual battery. Carnow is a chiropractor in San Dimas in the San Gabriel Valley, the Sheriff’s Department says. He’s accused of sexually assaulting multiple adult women between June 2023 and August 2023. Officials did not say if his alleged victims were current or former patients. Investigators say the nature of the alleged crimes have led them to believe there may be additional victims and they are asking for the public’s help to find them.
Yes, I know, these are (according to chiros’ assurances) regrettable, isolated cases – nothing to worry about!
But perhaps these assertions are wrong and there is a problem after all?
I am reminded of my post from 2021; let me refresh your memory:
Two chiropractors conducted a retrospective review of publicly available data from the California Board of Chiropractic Examiners. Their aim was to determine categories of offense, experience, and gender of disciplined doctors of chiropractic (DC) in California and compare them with disciplined medical physicians in California. The DC disciplinary categories, in descending order, were
- fraud (44%),
- sexual boundary issues (22%),
- other offences (13%),
- abuse of alcohol or drugs (10%),
- negligence or incompetence (6%),
- poor supervision (2%),
- mental impairment (.3%).
The authors concluded that the professions differ in the major reasons for disciplinary actions. Two thirds (67%) of the doctors of chiropractic were disciplined for fraud and sexual boundary issues, compared with 59% for negligence and substance misuse for medical physicians. Additional study in each profession may reveal methods to identify causes and possible intervention for those who are at high risk.
The abstract of the paper does not provide comparisons to with the medical profession. Here they are; relative to doctors, chiropractors are:
- 2 x more likely to be involved in malpractice,
- 9 x more likely to commit fraud,
- 2 x more likely to transgress sexual boundaries.
________________________
Could it be, I askmyself, that there is something deeply wrong with the chiropractic profession? Could it perhaps be that chiro schools do not have a good hand when it comes to student recruitment? Could it be that chiro schools teach too little medical ethics, or none at all?
The Academy of Homeopathy Education is a US-based accredited teaching institution offering homeopathy education services to professional and medically licensed homeopathy students. This study reports on clinical outcomes from the teaching clinic from 2020 to 2021.
Data were collected using the patient-generated outcome measure, the Measure Yourself Concerns and Wellbeing (MYCaW). Mean MYCaW values for initial and subsequent consultations were analyzed for the degree of change across the intervention period in 38 clients. Each client listed up to two complaints. MYCaW scores between initial and subsequent consultations were analyzed for the degree of change (delta) across the intervention period.
A total of 95 body system-related symptoms were analyzed for change in intensity following the homeopathic intervention. Statistically significant improvements in the intensity of main symptoms were observed between initial and subsequent follow-ups. The main symptom scores showed a mean change in intensity (delta MYCaW) of −0.79 points (95% confidence interval (CI), −1.29 to −0.29; p = 0.003) at first follow-up, a mean change of −1.67 points (95% CI, −2.34 to −0.99; p = 0.001) at second follow-up compared with the initial visit, and a mean change of −1.93 points (95% CI, −3.0 to −0.86; p = 0.008) at third follow-up compared with the initial visit. For clients with four or more follow-ups, the mean delta MYCaW was −1.57 points (95% CI, −2.86 to −0.28; p = 0.039).
The authors concluded that statistically significant improvements as well as some clinically meaningful changes in symptom intensity were found across a diverse group of individuals with a variety of long-term chronic conditions. The improvement was evident across different body systems and different levels of chronicity. There are limitations to the generalizability of the study due to the research design. Further research and investigation are warranted given the promising results of this work.
There are, of course, not just limits to the generalizability of this study! I’d say there are limits to the interpretation of any of its findings.
What was the cause of the improvements?
Here are just a few questions that I asked myself while reading this paper:
- Are the guys from the Academy of Homeopathy Education not aware of the fact that even chronic conditions often get better by themselves?
- Have they heard of the placebo effect?
- Are they trying to tell us that the patients did not also use conventional treatments for their chronic conditions?
- What about regression towards the mean?
- What about social desirability?
- Why do they think that further research is needed?
- Are these really results that look ‘promising for homeopathy?
To answer just the last question: No, these findings are in perfect agreement with the fact that highly diluted homeopathic remedies are pure placebos (to be honest, they would even be in agreement with such remedies being mildly harmful).
This study aims to assess the feasibility of a pragmatic prospective study aiming to report the immediate and delayed (48-hours post-treatment) AEs associated with manual therapies in children aged 5 or younger and to report preliminary data on AEs frequency.
Between July 2021 and March 2022, chiropractors were recruited through purposive sampling and via a dedicated Facebook group for Quebec chiropractors interested in pediatrics. Legal guardians of patients aged 5 or younger were invited to fill out an online information and consent form. AEs were collected using the SafetyNET reporting system, which had been previously translated by the research team. Immediate AEs were collected through a questionnaire filled out by the legal guardian immediately after the treatment, while delayed AEs were collected through a questionnaire sent by email to the legal guardian 48 h after the treatment. Feasibility was assessed qualitatively through feedback from chiropractors and quantitatively through recruitment data.
Overall, a total of 28 chiropractors expressed interest following the Facebook publication, and 5 participated. An additional two chiropractors were enrolled through purposive sampling. In total, 80 legal guardians consented to their child’s participation, and data from 73 children were included for the analysis of AEs. At least one AE was reported in 30% of children (22/73), and AEs were mainly observed immediately following the treatment (16/22). The most common AEs were irritability/crying (11 children) or fatigue/tiredness (11 children). Feasibility analysis demonstrated that regular communication between the research team and clinicians, as well as targeting clinicians who showed great interest in pediatrics, were key factors for successful research.
The authors concluded that their results suggest that it is feasible to conduct a prospective pragmatic study evaluating AEs associated with manual therapies in private practices. Direct communication with the clinicians, a strategic clinicians’ recruitment plan, and the resulting administrative burden should be considered in future studies. A larger study is required to confirm the frequency of AEs reported in the current study.
It is hardly surprising that such a study is ‘feasible’. I could have told the authors that and saved them the trouble of doing the study. What is surprising, in my view, that chiropractors, after ~120 years of existence of the profession, ask whether it is feasible.
I suggest to do the definitive study on a much larger sample, extend the observation period, and recruit a representative rather than self-selected sample of chiros … or – much better – forget about the study and establich a functioning post-marketing surveillance system.
Looking at some ancient papers of mine, I came across a short BMJ paper from 1994. Here is a passage from it:
… A standard letter (on departmental letterhead) was written (in German) to all 189 firms that we identified as marketing herbal drugs in Germany. It asked (among other questions) for reprints of articles reporting controlled clinical trials on the company’s product(s).
Only 19 replies had reached us six weeks later. Four of these included at least one reprint. Twelve respondents regretted not knowing of clinical trials on their drug(s). In three cases we had written to a wrong address (one
instance) or to a firm which did not market phytomedicines (two instances).
These data, though far from conclusive, do not give the impression that research is in proportion to either prevalence or financial tumover of herbal remedies…
I wonder what the results would be, if we repeated this little excercise today, 30 years afteer the original investigation. I fear that the findings would be much the same or perhaps even worse. I also suspect that they would be similar regardless of the country we chose. Those who sell herbal remedies have very little incentive to do expensive clinical trials to test whether the products they earn their money with actually work. They may be doing well without it and ask themselves, why spend money on research that might not show what we hope and could easily turn out to jeopardize our financial success?
But the problem is by no means confined to herbal manufacturers (who would arguably have an important share to initiate and sponsor research). Even though fundamental questions remain unanswered, research into herbal medicine is scarce across the board.
To see whether this statement is true, I did a very quick Medline search. It showed that, in 2023, just over 13 000 papers on herbal medicine emerged. Of those, just 460 were listed as clinical trials. The latter figure is almost certainly considerably smaller than the true amount because Medline is over-generous in classifying papers as clinical trials. I thus estimate that only around 200 clinical trials of herbal medicine are conducted each year. Considering that we are dealing with thousands of herbs and ten thousands of herbal products, this figure is an embarrassment for the sector – which, as we have seen just days ago, is doing extremely well in finacial terms.
Yes, I often moan about the abundance of poor-quality prevalence surveys that we are confronted with when scanning the literaturee on so-called alternative medicine (SCAM), e.g.:
- The survey mania in so-called alternative medicine prevents progress
- A truly homeopathic survey
- A new survey of CAM-use (or is it a promotion for more nonsense on the NHS?)
- A new chiropractic survey seems to avoid all the potentially embarrassing questions
- Survey-mania in alternative medicine: a fruitless, misleading and counter-productive distraction
Here is another example that recently appeared on my screen and that allows me to explain (yet again) why these surveys are such a waste of space:
The Use of Traditional and Complementary Medicine Among Patients With Multiple Sclerosis in Morocco
Let’s assume the survey is done perfectly (a condition that most are very far from meeting). If the information generated by such a perfect survey were worthwhile, we would also need to consider possible mutations that would be just as relevant:
- We have just over 200 nations (other than Morocco) on the planet.
- I assume there are about 1000 conditions (other than multiple sclerosis) for which SCAM is used.
- There are, I estimate, 100 different definitions of SCAM (other than ‘traditional and complementary medicine’) that all include different modalities.
So, this alone would make 20 000 000 surveys that would be important enough to get published. But that’s not all. The usage and nature of SCAM change fairly quickly. That means we would need these 20 million surveys to be repeated every 2 to 3 years to be up-to-date.
For all this, we would need, I estimate, 200 000 research groups doing the work and about 20 000 SCAM journals to publish their results.
I think we can agree that this would be a nonsensical effort for producing millions of papers reaching dramatic conclusions that read something like this:
Our survey shows that patients suffering from xy living in yz use much SCAM. This level of popularity suggests that SCAM is much appreciated and needs to be made available more widely and free of charge.
I rest my case.
Millions of US adults use so-called alternative medicine (SCAM). In 2012, 55 million adults spent $28.3 billion on SCAMs, comparable to 9% of total out-of-pocket health care expenditures. A recent analysis conducted by the US National Institutes of Health’s National Center for Complementary and Integrative Health (NCCIH) suggests a substantial increase in the overall use of SCAM by American adults from 2002 to 2022. The paper published in the Journal of the American Medical Association, highlights a surge in the use of SCAM particularly for pain management.
Data from the 2002, 2012, and 2022 National Health Interview Surveys (NHISs) were employed to evaluate changes in the use of 7 SCAMs:
- yoga,
- meditation,
- massage therapy,
- chiropractic,
- acupuncture,
- naturopathy,
- guided imagery/progressive muscle relaxation.
The key findings include:
- The percentage of individuals who reported using at least one of the SCAMs increased from 19.2% in 2002 to 36.7% in 2022.
- The use of yoga, meditation, and massage therapy experienced the most significant growth.
- Use of yoga increased from 5% in 2002 to 16% in 2022.
- Meditation became the most popular SCAM in 2022, with an increase from 7.5% in 2002 to 17.3% in 2022.
- Acupuncture saw an increase from 1% in 2002 to 2.2% in 2022.
- The smallest rise was noted for chiropractic, from 79 to 86%
The analyses also suggested a rise in the proportion of US adults using SCAMs specifically for pain management. Among participants using any SCAM, the percentage reporting use for pain management increased from 42% in 2002 to 49% in 2022.
Limitations of the survey include:
- decreasing NHIS response rates over time,
- possible recall bias,
- cross-sectional data,
- differences in the wording of the surveys.
The NCCIH researchers like such surveys and tend to put a positive spin on them, i.e. SCAM is becoming more and more popular because it is supported by better and better evidence. Therefore, SCAM should be available to everyone who wants is.
But, of course, the spin could also turn in the opposite direction, i.e. the risk/benefit balance for most SCAMs is either negative or uncertain, and their cost-benefit remains unclear – as seen regularly on this blog. Therefore, the fact that SCAM seems to be getting more popular is of increasing concern. In particular, more consideration ought to be given to the indirect risks of SCAM (think, for instance, only of the influence SCAM practitioners have on the vaccination rates) that we often discuss here but that the NCCIH conveniently tends to ignore.
Patients are increasingly using and requesting so-called alternative medicine Medicine (SCAM), especially during the COVID-19 pandemic. However, it remains unclear whether they use SCAMs in conjunction with conventional medicine or to replace vaccination or other approaches and whether they discuss them with their physicians as part of shared decision-making. This study aimed to evaluate the use and initiation of SCAM during the COVID-19 pandemic, focusing on the association between SCAM-use and COVID-19 vaccination status.
It was a part of the longitudinal cohort of the CoviCare program, which follows all outpatients tested for COVID-19 at the Geneva University Hospitals. Outpatients tested for COVID-19 were contacted 12 months after their positive or negative test between April and December 2021. Participants were asked about their vaccination status and if they had used SCAM in the past 12 months. SCAM-use was defined based on a list of specific therapies from which participants could choose the options they had used. Logistic regression models adjusting for age, sex, education, profession, severe acute respiratory system coronavirus 2 (SARS-CoV-2) infection, and pre-existing conditions were used to evaluate the association between being unvaccinated and complementary medicine use. SARS-CoV-2 infection status was evaluated for effect modification in the association between being unvaccinated and complementary medicine use.
This study enrolled 12,246 individuals (participation proportion = 17.7%). Their mean age was 42.8 years, 59.4% were women, and 63.7% used SCAM. SCAM-use was higher in women, the middle-aged, and those with a higher education level, a SARS-CoV-2 infection, or pre-existing co-morbidities. A third of cases initiated SCAM as prevention against COVID-19. Being unvaccinated was associated with higher levels of SCAM-use (adjusted odds ratio [aOR] 1.22 [1.09–1.37]). SCAMs were frequently used for COVID-19 prevention (aOR 1.61 [1.22–2.12]). Being unvaccinated was associated with the use of several specific SCAMs:
- zinc (OR 2.25 [1.98–2.55]),
- vitamin D (OR 1.45 [1.30–1.62]),
- vitamin C (OR 1.59 [1.42–1.78]).
Only 4% of participants discussed using SCAM with their primary care physicians.
The authors concluded that, while SCAM is increasingly used, it is rarely discussed with primary care physicians. SCAM-use, especially for COVID-19 prevention, is associated with COVID-19 vaccination status. Communication between physicians, patients, and SCAM therapists is encouraged to facilitate a truly holistic approach to making a shared decision based on the best available information.
This survey confirmed the findings of several previous investigations. It also shows that the terminologies often employed are inadequate:
- alternative medicine: as it does not work, it cannot be an alternative;
- complementary medicine: many patients do not use it to complement real medicine.
As I have explained many times, I thus find SCAM a much more appropriate term.
The last sentence of the authors conclusion is puzzeling. What can SCAM pratitioners contribute to a ‘truly holistic approach’ to decisions about vaccinations? I feel this sentence should be changed into something like the following:
Communication between physicians and patients should be encouraged. To facilitate an effective approach to making shared decisions on vaccinations, SCAM practitioners should be excluded until they are able to convincingly demonstrate that their advice is based on sound evidence.
Representatives of six Australian professional organizations of so-called alternative medicine (SCAM) developed a survey for e-mail distribution to members. The anonymous online Qualtrics survey was based on previous surveys to identify workforce trends over time. Survey data were analyzed descriptively using Qualtrics and STATA statistical software.
Responses were recorded from 1921 participants. Respondents were predominantly female (79.7%); 71.8% were aged over 45 years. Remedial massage therapists represented 32.1% and naturopaths represented 23.7% of respondents. Highest qualifications were diplomas (37.7%), bachelor’s degrees (28.9%), and advanced diplomas (21.8%). Metropolitan locations accounted for 68.1% of practices. Solo private practice was the main practice setting (59.8%); 13.8% practiced in group private practice with SCAM practitioners; and 10.6% practiced with allied health practitioners. Approximately three quarters of respondents (73.9%) saw 0–5 new clients per week; 42.2% had 0–5 follow-up consultations per week. Collaboration rates with SCAM practitioners, other non-SCAM practitioners, and general medical practitioners (GPs) were 68.7%, 24.4%, and 9.2%, respectively. A total of 93% did not suspect an adverse event from their treatment in the past year. Businesses of 75.9% of respondents were reportedly affected by the pandemic.
The authors concluded that comparisons with previous surveys show ongoing predominance of female practitioners, an aging workforce, a high proportion of remedial massage and naturopathy practitioners, and an increasingly qualified SCAM workforce. There was little change in the very low number of adverse events suspected by practitioners, number of consultations per week, and low levels of income of most SCAM practitioners compared with the average income in Australia. Respondents collaborated at similar rates as in the past; however, more with SCAM practitioners than with GPs.
Yet another fairly useless SCAM survey to add to the endless list of similarly wasteful investigations!
If I had to extract anything potentially relevant from it, it would be just three points:
- The authors speak of an ‘increasingly qualified workforce’. The basis for this claim is that the highest qualifications were diplomas (37.7%), bachelor’s degrees (28.9%), and advanced diplomas (21.8%). Oh dear, oh dear! Anyone can issue ‘diplomas’ which are not recognised qualifications. In other words, the SCAM workforce is woefully underqualified to take charge of patients.
- Only 9% of SCAM practitioners ‘collaborated’ with GPs. By collaboration, the authors mean the very minimum of informing the GPs what type of SCAM they might be getting. Such information can be essential for avoiding harm (e.g. interactions with prescribed drugs). In other words, even the minimum of ethical and safe practice is not met in 91% of the cases.
- The fact that a total of 93% SCAM practitioners did not suspect a single adverse event from their treatment in the past year is extraordinary. It does, I fear, not demonstrate thaat SCAM id safe but that SCAM practitioners are totally oblivious to the possibility of adverse effects. In other words, they don’t inquire about adverse effects and thus don’t notice any.
Yes, these are data from Australia, and one could argue that elsewhere the situation is different. But different does not necessarily mean better. Until I see convincing evidence, I am not optimistic about the clinical practice of SCAM. Altogether, these findings do not convince me that SCAM practitioners should be let anywhere near a person who needs medical attention.
In total, 404 respondents completed the survey, of which 254 (62.9%) treated cancer patients. Most practitioners were acupuncturists and herbalists (57.1%), had (16.8 ± 9.9) years of clinical experience and see a median of 2 (1, 4) cancer patients per week. Breast cancer (61.8%) is the most common cancer type seen in SCAM clinics. Adjunctive SCAM treatments are frequently concurrent with the patient’s cancer specific treatment (39.9%), which is also reflected by the main goal of a SCAM treatment to alleviate side effects (52.4%). However, only 28.0% of the respondents are in contact with the treating oncologist. According to the respondents, pain is most effectively treated using acupuncture, while herbal medicine is best for cancer-related fatigue. SCAM practitioners mostly use certified courses (33.1%) or online databases (28.3%) but often believe that experts are more reliable to inform their practice (37.0%) than research publications (32.7%).
The authors concluded that acupuncturists and herbalists commonly treat cancer patients. Most practitioners use SCAM as an adjunct to biomedicine as supportive care and use it largely in accordance with current oncological guidelines.
You would think that the combined expertise of these institutions are capable of producing a decent survey:
- Palliative Care Unit, Division of Oncology, Department of Internal Medicine, Medical University of Graz, 8036 Graz, Austria
- Northern College of Acupuncture, York YO1 6LJ, United Kingdom
- School of Health and Society, Faculty of Education, Health and Wellbeing, University of Wolverhampton, Wolverhampton WV1 1LY, United Kingdom
- National Institute of Complementary Medicine Health Research Institute, Western Sydney University, Penrith NSW 2751, Australia
- Translational Health Research Institute, Western Sydney University, Penrith NSW 2751, Australia
- Medical Research Institute of New Zealand, Wellington 6021, New Zealand
- Translational Oncology, University Hospital of Augsburg, 86156 Augsburg, Germany
Well, you would have been mistaken! This surely is one of the worst investigations I have seen for a while. Here are just three reasons why:
- The researchers designed an anonymous self-completion questionnaire collecting data about the participating practitioners’ demographics and clinical practice of integrative oncology. Someone should tell them that one ought to validate questionnairs before using them and that validated questionnairs exist. Unvalidated questionnairs cannot tell us much of value.
- The researchers invited SCAM practitioners in Austria, Germany, USA, Australia, and New Zealand to participate in this study. Invitations were distributed through social media and emails between October 2022 and December 2022 by professional organizations. Someone should tell them that research needs to be reproducible and surveys need to cover a representative population – both criteria that are not met here.
- The survey participants had to hold a valid license to perform acupuncture, herbal medicine, or both. That excludes all other SCAM practitioners.
Despite these serious flaws, the survey shows two findings that might be worth mentioning:
- only 28.0% of the SCAM practitioners were in contact with the treating oncologist;
- SCAM practitioners believe that “experts” are more reliable to inform their practice than research publications.
For me, these two points alone would be sufficient reason to run a mile!
On this blog, we had more than our fair share of comments from the anti-vax clan. This article asked a question that I have often been pondering:
How to convince the unvaccinated proportion of the population of the benefits of a vaccination?
Designing more successful communication strategies, both in retrospect and looking ahead, requires a differentiated understanding of the concerns of those that remain unvaccinated. Guided by the elaboration likelihood model, this paper has two objectives: First, it explores by means of a latent class analysis how unvaccinated individuals might be characterized by their attitudes towards COVID-19 vaccination. Second, the researchers investigate to what extent (i) varying types of evidence (none/anecdotal/statistical) can be employed by (ii) different types of communicators (scientists/politicians) to improve vaccination intentions across these subgroups. To address these questions, the authors conducted an original online survey experiment among 2145 unvaccinated respondents from Germany where a substantial population share remains unvaccinated.
The results suggest three different subgroups, which differ regarding their openness towards a COVID-19 vaccination:
- vaccination opponents (N = 1184),
- sceptics (N = 572)
- those in principle receptive (N = 389) to be vaccinated.
On average, neither the provision of statistical nor anecdotal evidence increased the persuasiveness of information regarding the efficacy of a COVID-19 vaccine. However, scientists were, on average, more persuasive than politicians (relatively increase vaccination intentions by 0.184 standard deviations). With respect to heterogeneous treatment effects among the three subgroups, vaccination opponents seem largely unreachable, while sceptics value information by scientists, particularly if supported by anecdotal evidence (relatively increases intentions by 0.45 standard deviations). Receptives seem much more responsive to statistical evidence from politicians (relatively increases intentions by 0.38 standard deviations).
According to the authors, these insights suggest that, in the short term, receptives and sceptics are the most promising target groups for vaccination campaigns. Yet, in the medium term, opponents need not be forgotten. While mandatory vaccinations may appear as the only strategy to target strict vaccination opponents, politicians and researchers are advised to focus on ways how to rebuild trust and address beliefs in misinformation within this population group. The inconsistency in vaccine related communication has led to a loss of trust in political and scientific decision-makers. It is therefore important to rebuild this trust through evidence-based communication. The way we understand and perceive the credibility of a source significantly impacts our processing of messages and can also significantly affect related behaviours. Using evidence to validate relevant and reliable information can therefore also be vital to build trust and credibility in the vaccines themselves and their safety.
The authors concluded that our study employed sociopsychological theory to challenge the view of the existence of a single homogeneous group of unvaccinated citizens. By drawing on a large sample of unvaccinated citizens and combining latent class analysis with experimental methods, we encourage decision-makers to carefully consider heterogeneities in the effectiveness of their communication strategies, especially regarding their communicator and employed evidence type.
