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20 Joanne W.Y. CHUNG
extent of their willingness to express pain [68, 69].
Knowledge and skills related to cultural diversity
can strengthen our professional development
and practice. It is therefore necessary to have an
understanding of beliefs about appropriate pain
behaviour in order to better prepare clinicians for
the delivery of culturally sensitive pain management
regimens.
Signicance of
multidimensionality in pain
assessment
e most fundamental aspect of pain relief is the
assessment of pain. However, the psychometric
attributes are difficult to quantify, making the
manifestation of pain experience difficult to
assess. Pain is defined as “an unpleasant sensory
and emotional experience arising from actual or
potential tissue damage or described in terms of
such damage” [54]. e emphasis of this definition
is on both the sensory and emotional experience
of an individual in pain. Pain can be emotional,
behavioural, sociocultural and spiritual. e
exhibition of pain is multidimensional. erefore,
in the assessment of pain, not only a general
guideline for a quick review is needed but also a
specific tool to help the professionals to have a
more accurate assessment of the experience of pain
from a multidimensional perspective.
ere is no agreement on objective physiological
indicators associated with painful episodes. Most
of the time, assessment relies on the patients’ verbal
pain report. e value of a verbal pain report in
the diagnostic process is unquestionable. However,
the need for detail and comparatively objective
assessment strategies is prevalent and of equal
importance in pain relief management. Whether
the objectification is accurate and usable in clinical
application depends very much on the rigour of the
history taking and physical assessment.
Pain assessment in clinical practice serves two
purposes: diagnostic and algorithmic in pain
management. For the diagnostic purpose, a
careful history and focused physical assessment
are essential. For the algorithmic purpose, pain
assessment is crucial in determining the treatment
modalities and evaluating the effectiveness of the
current pain management regimen.
Pain Assessment Tools
e selection of appropriate rating scales is
considered a factor for satisfactory pain assessment
and pain management [10, 82]. Despite the growing
interest in developing multidimensional scales, the
use of a unidimensional scale in assessing clinical
pain is popular for its simplicity, efficiency and ease
of administration [34, 39]. A unidimensional scale
can be used on its own as an assessment tool. It can
also be used in combination with other scales or tools
to provide a multidimensional description of a pain
experience. e following provides a description of
unidimensional and multidimensional scales. e
visual analogue scale (VAS), numerical rating scale
(NRS) and categorical rating scale (CRS) [37, 40,
62, 66] are the examples of unidimensional scales
while the McGill Pain Questionnaire (MPQ) and
Wisconsin Brief Pain Inventory (BPI) are the
multidimensional scales. Two organisations, Partner
Against Pain and the British Pain Society, provide
multilingual pain scales in more than 16 languages.
ese scales are basically unidimensional scales.
Visual analogue scale
e VAS is a 10-cm line with zero representing no
pain at one end and 10 representing pain as bad as
it could be at the other end (Fig. 3.01). e scales
can be presented in different directions. ey can
be vertical, horizontal or curved [72]. e VAS
measures the pain intensity. Patients are asked to
report their pain intensity by indicating a point on
the line. e distance between zero and the marked
point is measured as the pain intensity. e VAS is
frequently used in the field of psychology to measure
the subjective experiences, e.g. pain, anxiety and
nausea [60]. e VAS has been widely used for
various types of clinical pain conditions, e.g. acute
pain, chronic pain and cancer pain. e VAS is also
used in the assessment of dental pain [7].
e VAS has been claimed as the simplest tool in
assessing perceived pain intensity [58]. Clinically, it
0 10
No pain Pain as bad as it could be
Figure 3.01 The visual analogue scale (10 cm)
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Principles of Pain Assessment and Evaluation Tools 21
is easy to administer and there are infinite response
options because patients can mark any point on the
line [36]. However, the use of VAS requires patients
to visualise their pain intensity along a continuum.
is requires a considerable amount of abstract
thinking. As a result, this limits the use of VAS. For
example, children, the elderly, those with cognitive
impairment, those with visual impairment and
those who are too sick to conceptualise the abstract
entity of pain fail in doing the VAS [58]. It had
been reported that about 5–7% of patients failed in
using the VAS [56, 66]. A similar study conducted
among 50 (age range 12–65 years) Chinese patients
with postoperative pain to evaluate the reliability of
the VAS [2] showed that 14% of the subjects failed
to complete the VAS. e reported failure rate is
about twice of that reported in Western countries.
ere was a significant error rate between the
vertical and horizontal VAS; in this, the Chinese
performed better with the vertical VAS.
Considering the level of measurement, the
advantage of VAS is the production of a ratio scale
judgement that indicates a higher power function
[63]. Statistically, this reflects actual perceived pain
intensity. Data from the VAS can then be compiled
and compared among individuals. However,
the statistical manipulation of pain intensity by
dividing pain into certain percentages or lengths is
deceptive because the scores in the VAS may not be
a linear relationship.
All assessment tools are subjected to measurement
error. Even with its well-established reliability
and validity [75], the VAS is no exception.
Conventionally, the VAS has to be administered in
paper and pencil format. is produces a technical
problem with duplicating the VAS because of
the alteration in length with the photocopying
machine [37]. e possibility of distortion in the
length of the VAS contributes to the measurement
errors of the instrument. Another drawback of the
VAS is that its use involves two stages, i.e. patients
marking on the line and subsequent measurement
by the assessors [37]. us, an extra step in the
measurement of scores is required. is results in
a potential source of error to the measurement. To
overcome this pitfall, there are devices designed
on the conceptual basis of a VAS [9]. e visual
analogue thermometer (VAT) is one of the
examples. e VAT is an instrument with a sliding
point along the line. is avoids the second stage
measurement otherwise required by the assessor.
Despite these drawbacks and controversial
arguments, with its simplicity in use and established
reliability and validity, the VAS is popular for
both clinical and research purposes [29]. It gives
good evidence for constructed validity in clinical
and research use [46, 58, 66, 75]. e VAS being
a validated tool for measuring subjective feelings
is therefore frequently used as a gold standard in
validating other pain assessment tools, including
cancer pain assessment tools.
Numerical rating scale
e NRS differs from the VAS in having numbers
along a line. e larger the numeral, the greater is the
intensity of the pain (Fig. 3.02). Patients are asked
to judge along an ordered dimension. For instance,
the NRS-101 requires input from a patient who
rates his/her pain intensity by indicating a whole
number from zero to 100 (Fig. 3.02-a). On the
other hand, with the BS-11 (Fig. 3.02-b), 11 boxes
are provided; the patient is asked to mark the box
that represents his/her pain intensity.
12345678910
(a) The 101-point numerical rating scale (NRS-
101)
Please indicate on the line below the
number between 0 and 100 that best
describes your pain. A zero (0) would
mean no pain, and a one hundred (100)
would mean pain as bad as it could be.
Please write only one number.
0 100
No pain Pain as bad as it could be
(b) The 11-point box scale (BS-11)
If a zero (0) means no pain, and a ten
means pain as bad as it could be, on this
scale of 0 to 10, what is your level of pain?
Put an X through that number.
Figure 3.02 Samples of numerical rating scale: (a)
NRS-101; (b) BS-11.
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22 Joanne W.Y. CHUNG
As with the VAS, difficulties in relating pain
intensity to the numerals are reported because some
abstract thinking is required [5]. is is important
from a clinical perspective because patients are
likely to be weaker and have a shorter attention
span. erefore, the same restriction on the groups
of patients using the NRS applies. In one of the
studies reviewing the significance of cancer pain
among Chinese patients, the results indicated that
about 16–19% of patients failed in using the NRS
[15].
Unlike the VAS, the level of measurement of the
NRS is ordinal. is means that the scores of the
NRS show the changes either by increasing or
decreasing but they do not tell the extent of the
meaningfulness of the score change. is is because
there are infinite points between each successive
numeral. However, the NRS has the advantages
of easy administration and can be administered in
written or verbal format.
Verbal rating scale
e verbal rating scale (VRS), a modification of
the CRS, is another unidimensional scale used
to measure pain intensity (Fig. 3.03). e VRS
measures the cognitive aspect of the perceived pain
by the use of pain descriptors. Patients are asked to
choose among several given words to quantify their
pain rated on an ordinal scale.
e advantages of using the VRS are that it is
short, easy to administer, easy to score and easily
understood by patients. However, there are some
inherent disadvantages because of the nature
of the scale. First, the VRS only allows a rank
ordering of the degree of pain sensation, i.e. the
pain intensity but not the emotional component
of pain. With cancer pain, patients tend to have
some mixed feelings and require more than one
category of words to describe them fully [38].
erefore, their expressions are restricted because
the VRS allows the choice of only one response
at each time. Second, due to its undimensional
property, it offers a restrictive choice of pain
words and leads to imprecision in describing
pain experience. ird, it has been reported that
the VRS is relatively insensitive in evaluating the
effect of therapeutic procedure, especially in mild
pain [44]. Fourth, unlike the VAS and NRS, it is
difficult to compare the results with the same patient
over time and with other patients. is is because
there is no consistency in the choice of words and
The six-point behavioural rating scale (BRS-6)
( ) No pain
( ) Pain present, but can easily be ignored
( ) Pain present, cannot be ignored, but does
not interfere with concentration
( ) Pain present, cannot be ignored, and
interferes with concentration
( ) Pain present, cannot be ignored, interferes
with all tasks except taking care of basic
needs such as toileting and eating
( ) Pain present, cannot be ignored, rest or
bed rest required
Figure 3.03 The six-point behavioural rating scale.
© The Asian versions (male and female) were developed
and copyrighted by C.H. Yeh, PhD, RN and C.H. Wang,
Taiwan, 2003.
Figure 3.04 The Asian versions of the Oucher Pain
Scale.
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Principles of Pain Assessment and Evaluation Tools 23
the number of verbal descriptions [58]. Fifth, it
shares the same mathematical problems as does
the NRS in relation to the level of measurement.
e distance between each word or descriptor is
assumed to be equidistant. erefore, it does not
assess the pain variations between patients and
the variations cannot be expressed meaningfully
and mathematically. is is especially true for
categorical scales, e.g. the Oucher Pain Scale. e
Oucher, which was originally developed by Judith
E. Beyer, is designed for assessing pain intensity
in children aged 3 to 12 years. e Asian version
of the Oucher scale was subsequently developed
for use in this ethnic group (Fig. 3.04) [78, 81].
It receives similar criticism as any other CRS. e
distance between each category is infinite, thus, the
statistical manipulation is also argumentative and
complex. Sixth, the VRS is criticised as culturally
specific. is is because patients have to understand
the meanings of the anchored words or descriptors
that largely reflect culture of the Western world.
Furthermore, illiterates cannot read the words [5].
Brief Pain Inventory
e BPI is a refined version of the Wisconsin Brief
Pain Questionnaire, which was developed in 1983.
It was designed for the assessment of cancer pain. It
measures both the location and the effects of pain
on the patients’ activities of daily living [49].
ere are two versions, the long-form and the short-
form. e long version consists of 23 questions
while the short version has only nine. e BPI
asks about the patients’ pain intensity, location of
pain, degree of pain relief, description of pain and
the interference of pain with their daily activities
[20]. Patients are asked to indicate the extent of the
problems using the NRS. For instance, patients are
asked to indicate their worst, least and average pain
in the past week using the NRS (zero to 10). For
the description of pain, patients are provided with
15 pain descriptors. ey are asked whether the
descriptors apply to their pain or not. In addition,
pain history is collected and a body chart is provided
for the patients to locate their pain. In summary,
the BPI is easy to administer but too brief to be a
comprehensive assessment scale.
McGill Pain Questionnaire
e MPQ is an example of a multidimensional
scale. e MPQ is considered to be the most
promising pain assessment tool. e MPQ now
has two versions. ey are the original long-
form MPQ and the later-developed short-form
MPQ. e MPQ is widely used in various clinical
settings.
With the introduction of the Gate Control
eory of pain in 1965, Melzack and Casey
further postulated three dimensions to elaborate
the concepts of pain [51]. e three dimensions
are motivational-affective, sensory-discriminative
and cognitive-evaluative. In 1971, Melzack
and Torgerson then developed the MPQ in an
attempt to assess clinical pain [52]. Clinical pain
is the pain experienced by the patients during the
disease process and not experimentally induced in
a laboratory environment. e MPQ comprises
a Pain Rating Index (PRI), present pain intensity
(PPI) and a choice of pain descriptors to measure
the qualities of pain in terms of sensory, affective
and evaluative dimensions of pain [51]. e
authors believed that the descriptors used could
assess the qualities of pain. In the original version
of the MPQ, there are 78 pain descriptors. ese
pain descriptors are grouped into 20 subgroups to
reflect the various dimensions of pain.
For the scoring system in the MPQ, there are four
types of data. e first is a pain rating index that
is based on the scale values of all the words chosen
in a given class or all classes. It is denoted by PRI
(S). e second index obtained is the pain rating
index based on the ranked values of the words.
It is denoted by PRI (R). e third score is the
total number of words chosen from the MPQ, i.e.
number of words chosen (NWC). e fourth one
is the present pain intensity (PPI), the numerical
value obtained from the five-point VRS. e
words of the PPI are the words obtained from the
evaluative dimensions.
e time required to complete an MPQ and its
complexity are criticised [9]. e MPQ has been
described as lengthy, taking about 15 to 20 minutes
to complete. Moreover the descriptors are complex,
especially when patients are in pain and ill. erefore,
a short form-MPQ (SF-MPQ) was developed. e
SF-MPQ consists of 15 descriptors that describe the
sensory and affective dimensions of pain, a PPI and
a VAS for the measurement of pain intensity [50].
It takes only 2 to 5 minutes to complete. e SF-
MPQ was highly correlated with the original MPQ
among cancer patients with pain [23].
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24 Joanne W.Y. CHUNG
Despite the popularity of the MPQ, there is a
limitation in its use among patients. e MPQ
requires patients to state their pain experience and
some of the patients are too ill to express themselves
verbally. Others fail to do so either because of the
deterioration in cognitive capacity, a language
barrier or no complaint of pain.
Critique on Pain Assessment
Tools
Sensitivity of unidimensional
scales
Sensitivity is defined in two different ways, i.e.
clinical and statistical. Clinically, sensitivity refers
to the number of available response categories for
the patients to express their pain. e statistical
sensitivity is originated from the psychometric
discipline. Statistically, sensitivity of a scale reflects
the ability to detect treatment effect.
ere are controversial arguments in clinical
sensitivity of scales. e VAS is claimed to be
relatively sensitive because it provides an infinite
number of possible responses on a 10-cm line
[66]. Conversely, Carlsson argued that the results
from the VAS are the subjective estimation of
pain intensity and that it is inappropriate for
parametric test manipulation [8]. erefore, the
computation in establishing sensitivity is weak.
On the other hand, the VRS is criticised as
being less sensitive because it has fewer categories
[37]. Both the NRS and VRS are criticised for
having limited vocabularies for the pain intensity
description [66]. Kremer, Atkinson and Ignelzi
conducted a study on 56 patients with chronic
pain investigating the preference and perceived
accuracy of communication for the VAS, NRS and
VRS [44]. ey concluded that the NRS was the
preferred scale because it provided more choices
and was more sensitive to changes (r=0.86).
However, arguably the sensitivity of a scale
does not rely solely on the number of categories
available. Conversely, the variability that one offers
does increase with the number of categories. is is
supported by a study conducted by Jensen, Turner
and Romano [40]. One hundred and twenty-four
patients with chronic pain were asked to rate their
least, most, current and average pain intensity
before and after treatment. e instrument used
was the NRS-101. e numbers of the ratings
were re-coded to form two-, three-, four-, six-, 11-,
and 21-point scales. e correlation coefficients
between the re-coded scales and the pain intensity
levels were computed. Results showed that the
level of sensitivity decreased when the intensity of
pain decreased below 11. e best correlation was
obtained by the 11- and 21-point scales that were
commonly used by the subjects.
Furthermore, no scale consistently demonstrates
more statistical power than others. Even for a
sensitivity scale which produces consistent results,
it may not detect a true and an absolute treatment
effect. It only provides a relative treatment outcome
because pain is subjective. It has been commented
that no scale measures the true subjective pain
intensity [79].
Validity and reliability of
unidimensional scales
Reliability is the extent of consistency of a measure
upon repeated testing, while validity refers to the
extent that a tool measures what it is intended
to measure [61]. A valid pain intensity scale
should measure pain. A scale, particularly in this
context, is for measuring a construct of pain, i.e.
intensity. Since scales with greater sensitivity do
not necessarily have greater construct validity,
the results of statistical power comparisons are
not sufficient in themselves for evaluating the
validity of an intensity measure [37]. e validity
of the scale is evaluated by the correlation between
each pain intensity scale and the derived single
composite score that best reflects the factors related
to pain. is is done by factorial analysis. e
single composite score represents the best possible
assessment of pain intensity.
With the established validity and reliability of the
VAS, the VAS is used as a gold standard for the
testing of the reliability and validity of other scales.
us, the reliability and validity of the NRS and
VRS are established on the basis of the VAS. Paice
and Cohen studied 50 cancer pain patients to test
the validity of the VAS, NRS and the Present Pain
Intensity (PPI) of the MPQ [58]. e PPI is a type
of VRS anchored from “no pain” to “excruciating”
on a 6-point scale. Results showed that there is a
strong correlation among the VAS, NRS and the
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Principles of Pain Assessment and Evaluation Tools 25
PPI of the MPQ. e basis of argument rests on
the established construct validity of the VAS [41].
Hence, the high correlations among the VAS, NRS
and PPI supported the validity of the NRS and
PPI in the measurement of pain intensity. In other
words, the validity issue of the NRS is reflected by
the strong positive correlation between the VAS
and NRS [45].
Validity and reliability of
multidimensional scales
e following discussion will focus on the MPQ.
e validity and reliability of the MPQ are well
documented [20, 27, 43, 74]. e MPQ has
been widely used in many clinical situations, e.g.
evaluation of the pain responses and the treatment
effect, but there is still a lot of disagreement
concerning the statistical manipulation. To calculate
the changes in pain ratings before and after a
pain treatment, it is suggested to change the pain
rating into a fraction by having the post-treatment
pain rating as the numerator and the sum of the
pain ratings for pre- and post-treatment as the
denominator [31]. Moreover, Kremer, Atkinson and
Ignelzi also commented that the rank order of the
pain descriptors in the MPQ affects the precision
of the measure [45]. ey suggested changing the
pain ratings obtained in each dimension into a
ratio scale. is is achieved by dividing the sum
of rank obtained in each domain by the total rank
in that domain. ey claimed that this conversion
not only provides a ratio measure but also allows
comparison among the three dimensions. e
method for calculating pain rating has not been
settled yet.
Criticism has been made that the structure of the
MPQ and its analysis methodology are clumsy,
i.e. use of factorial analysis to validate the various
component of this theory of pain. It was commented
that factor analysis of pain descriptors in the MPQ
cannot directly evaluate the semantic structure of
the questionnaire. Rather, it merely analyses the
associative meaning in a specific context [28]. In a
meta-analysis of 51 studies involving the use of the
MPQ, it was found that ethnicity of the subjects is
rarely reported [80]. erefore, issue of validity is
questioned when used across cultures.
e MPQ has been translated into different
languages and tested in their respective countries for
its reliability and validity. Apart from the English
version, there are 15 translated versions, namely,
Arabic, Chinese, Czech, Danish, Dutch, Finnish,
French, German, Hungarian, Italian, Japanese,
Norwegian, Polish, Slovak and Spanish [3, 4, 6,
22, 25, 30, 32, 35, 42, 47, 67, 70, 73, 74, 76].
e cross-cultural semantic barrier is a problem
that patients and clinicians from countries in non-
English speaking areas have to face when using the
MPQ [65].
e MPQ was also translated into Chinese for the
assessment of headache in Taiwan [35]. Considering
the linguistic pain assessment using the MPQ, the
results showed that the groups of words chosen
by the Chinese patients were different from those
of the Westerners. e average number of words
chosen (2.43) is less than that of the Westerners
(10.5–12). is may be because the words in the
Chinese version of the MPQ are translated directly
into Chinese using the dictionary. ese translated
words may not be the words that Chinese would use
or there are words that have no Chinese equivalent
meaning. us, the number 2.43 is questionable
and reflects the lack of choice for the Chinese
subjects. is is also supported by a study on the
use of pain descriptors among Chinese adults in
Hong Kong [16].
Recent Research in Pain
Assessment
Need for cultural relevance in
pain assessment
e ways in which patients respond to or interpret
pain is subject to cultural values [53]. Many
studies showed that there is a cultural difference
in perception, interpretation and behavioural
manifestation of pain [24, 26, 27, 55]. Literature
and research from Western countries support that
culture is a factor that needs to be considered in
pain assessment [71]. However, the current pain
assessment tools used in Hong Kong mostly
originate from the West. Minimal work has been
done on the testing or modification of the pain
assessment tools for use with Chinese patients.
It is necessary to have assessment tools that are
culturally specific so that patients’ experience can
best be reflected. e following two examples are
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26 Joanne W.Y. CHUNG
of the recent local work done in pain assessment
and evaluation.
Assessment of acute pain among
Chinese using a verbal rating
scale: an exemplar
A survey was conducted to explore the pain intensity
descriptors used among 986 Chinese [16]. Ten pain
intensity descriptors were extracted and were used
to construct a verbal rating scale for pain assessment
[11]. It consisted of two stages. Stage one was a
cross-sectional descriptive survey to explore the pain
intensity descriptors used among adult Chinese in
Hong Kong. Stage two was a Q-sorting technique
to array the pain intensity descriptors obtained in
stage one. Together the results are used to construct
a verbal rating scale (VRS) for pain assessment.
Nine hundred and eighty-six healthy Chinese adults
participated in stage one. e 10 pain intensity
descriptors obtained were bearable, crushing the
heart and lungs, crucifying pain, excruciating
pain, indescribable, quite painful, painful, slight
pain, unbearable and very painful. In stage two,
54 baccalaureate-nursing students participated in
the Q-sorting procedure. ey were asked to rank
the pain intensity descriptors according to a set of
psychometric criteria. A vertical VRS was constructed
with the least pain at the bottom and the most pain
on the top. A “no pain” was added to the bottom of
the scale. e order of the rank was no pain, slight
pain, quite painful, painful, very painful, bearable,
indescribable, excruciating pain, unbearable,
crushing the heart and lungs and crucifying pain
(Fig. 3.05). e psychometric properties of the scale
were established by the comparison with the VAS
using standardised experimental pain stimulation.
e intra-class correlation ranged from 0.78 to
0.90, which indicated good reliability [48]. It is
anticipated that a VRS of this kind has its value
in the measurement of pain intensity with cultural
relevancy.
Assessment of cancer pain
among Chinese cancer patients:
an exemplar
Chung developed the Chinese Cancer Pain
Assessment Tool (CCPAT) [13, 14]. e CCPAT
is meant to be a specific assessment tool for pain
among Chinese cancer patients; assessments
involving the general health condition and disease
status are not, therefore, included.
e validity and reliability of the CCPAT were
tested. Internal consistency was established with a
Cronbach’s alpha 0.88 and an inter-rater reliability
of 0.96. e Spearman Rho correlations showed
that the functional and emotional dimensions of
the CCPAT and the present pain intensity of the
MPQ were positively correlated. is indicated a
satisfactory concurrent validity. e discriminant
validity revealed that the CCPAT was able to predict
80.8% of the subjects correctly as cancer patients.
Figure 3.05 The Chinese pain intensity scale
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Principles of Pain Assessment and Evaluation Tools 27
ere are three sections in the CCPAT. e first
section consists of an instruction guide where a brief
description of the CCPAT, administration, steps of
assessment, scoring reference and interpretation
of the scores are provided. e second section
consists of the pain assessment tool. ere are six
parts in this section. e first part is the functional
dimension (13 items), second is psychosocial (5
items), third is pharmacological (8 items), fourth
is emotional (8 items), fifth is pain beliefs and
meanings (19 items) and sixth is pain intensity (1
item). e third section is a scoring sheet. Upon
completion of the assessment, the assessor enters
the scores of each part into the designated boxes.
e scores are then multiplied by their respective
weights. e grand total is obtained by adding up
all the weighted scores as instructed in the scoring
sheet. e validity of CCPAT was further cross-
validated by using beta-endorphin [12, 33].
A true reflection of Chinese cancer patients’ pain
experience in their cultural context is crucial in the
management of their pain. e developed CCPAT
is the first of its kind for the Chinese community
in Hong Kong. First, it is envisaged that the study
lays the scientific ground for a valid, reliable and
cultural-specific tool in the assessment of cancer
pain. Second, it is anticipated that the results of
the study can provide nurses and doctors with
a best possible tool to assess cancer pain. It is
significant in the evaluation of patients’ progress
and the management of cancer pain. Last but not
least, the CCPAT lays the theoretical construct for
providing health care professionals with a better
understanding of the experience of cancer pain
from a multidimensional perspective, and will
affect the development of nursing, medical and
allied health interventions.
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