Communication and relationships: how patients’ perceived informational and interactional justice can improve patient-centered care

doi:10.21203/rs.3.rs-3801299/v1

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Communication and relationships: how patients’ perceived informational and interactional justice can improve patient-centered care

https://doi.org/10.21203/rs.3.rs-3801299/v1

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Background: After analyzing the three tenants of patient-centered care (i.e., communication, relationships and health promotion), we tested the role of patients’ perceived interactional and informational organizational justice in health service performance with respect to patients’ behaviors of adhering to professional advice and loyalty to the service. Literature shows that organizational variables as perceived organizational justice can influence patients’ behaviors. We have the ultimate goal of better understanding patients’ experiences with health care organizations, so health care service management can adjust to provide a better-quality patient-centered care considering patients’ inputs.

Methods: We conducted a cross-sectional study using two data samples from Spain and the U.S. The sample comprised 473 (male 59.2%) health care users from Spain and 450 (male 52.0%) from the U.S. over 18 years old. We measured the interactional and informational dimensions of perceived organizational justice, participants’ trust in the health care provider, their satisfaction with health care services, their adherence to professional advice and their loyalty to the service through a self-administered survey.

Results: Significant correlations were found in both samples for each justice dimension with both behaviors: adherence to advise (interactional, r=.15/.18, p<.01; informational, r=.19/.19, p<.01) and loyalty to the service (interactional, r=.45/.79, p<.01; informational, r=.45/.70, p<.01).

When we tested the model that included mediating patients' attitudes of trust and satisfaction, we found that the direct relationship between informational justice and adherence still held (standardized trajectory coefficient =.13, p <.01) showing their consolidated relationship. For interactional fairness, trust and satisfaction significantly mediated the relationship with adherence. On the other hand, the relationships between both justices and patient loyalty to the service were always partially mediated by patient trust and satisfaction (model fit for interactional justice perceptions RMSEA=.101, CFI=.959, GFI=.959; model fit for informational justice perceptions RMSEA=.136, CFI=.937, GFI=.946).

Conclusions: Patients’ perceptions of interactional and informational justice play an essential role in their adherence to professional advice, their loyalty to the service, and their ability to foster trust and satisfaction in health services. When discussing communication and relationships in patient-centered care, we should also consider fostering patients’ perceptions of fairness to improve health services results. Policies, programmes and procedures for patient-centered care should consider these patients’ perceptions.

Article classification: Empirical research paper

patient-centered care

fairness perceptions

health care quality

care management

informational justice

interactional justice

communication

relationships

1.- Patients perceive how fairly treated they are by policies and practitioners when using health care services, and these perceptions influence their health behaviors.

2.- Patients’ perceptions of organizational justice in relation to information handling (perceived as sufficient, accurate, suitable, clear, thorough, or timely) directly relate to adherence to professional advice (e.g., changes in diet, exercise habits, or drug prescriptions).

3.- Patients’ interactional and informational perceived organizational justice relates to service loyalty through the mediation of patient trust and satisfaction with the service.

Worldwide, the major causes of death by 2030 are expected to be HIV/AIDS, depressive disorders, and heart disease; as chronic diseases, their trajectory may be influenced by the application of effective health behavior interventions, as individual behaviors increase the risk of morbidity and mortality [1]. In this context, health care service management should improve connections with patients to enhance their performance and strengthen efforts toward accomplishing general public health [2]. This patient-centered care approach is recognized as an essential dimension of healthcare systems' missions worldwide and an important condition for ensuring the quality of care [3–6]. Thus, health policy makers have advocated for patient-centered care, shared decision-making, and the engaged patient as a more accurate conceptualization of this new patient role [7, 8].

There is evidence that a better connection with patients and good patient-centered care imply the consideration of multiple streams, from an individual one focusing on preferences or characteristics of the patient in the health care process [9] to a dyadic stream centered on interactions and communications [10] and even an organizational approach including structural levers (design, technology, spaces, organizational models); procedural levers (e.g., care pathways); cultural levers (organizational climate, professional cultures such as the interprofessional collaboration level [11]; and professional and job training to convey relational skills [12]. Additionally, patients' levels of information preference and perceived autonomy support are important for their trust, satisfaction, and mental health-related quality of life [13]. However, there is a lack of research on patients’ psychological variables that can help in enhancing the effectiveness of patient-centered care.

Theories of social cognition guide investigations aimed at identifying the determinants of health behaviors and, importantly, the processes by which these determinants relate to each other and to behavior [14, 15]. To better understand health-related behaviors and patients’ experiences with health care, we consider patients’ perceptions of interactional and informational organizational justice, as well as some of their attitudes and emotions, for the first time in this field of research following the theory of reasoned action (TRA) [16], a widely used theory of social cognition. Perceived interactional justice refers to patients’ subjective perception of the quality of the interactions between health care providers and users. This dimension measures the extent to which users felt listened to and treated with respect and dignity [17]. Perceived informational justice refers to users’ perceptions of information as sufficient, accurate, suitable, clear, thorough, and timely in their exchanges with health care services [17]. These two dimensions of organizational justice will add detail and accuracy to understanding the patient-centered care tenants of communication and relationship principles of patient-centered care provision [6, 18].

In response to the calls in recent research to explore nonconscious and automatic processes to explain engagement in health behaviors [14], our study also considered satisfaction and trust. Satisfaction has been linked to treatment adherence [17] and loyalty to service [19]. In addition, user satisfaction is related to perceived organizational justice in health care [20, 21]. Patient‒physician trust promotes medical adherence and is a mediator between health consciousness and medical adherence [22] and between patient-centered communication and patients’ perceptions of healthcare quality [23].

Therefore, the main objective of this study was to test the role of patients’ perceived interactional and informational organizational justice in health service performance with respect to their adherence to professional advice and loyalty to the service as indicators of health-related behaviors. Furthermore, we studied the mediating effect of patient satisfaction with health services and trust in health providers in two different health care systems and countries. These are graphically represented in Fig. 1.

We conducted a cross-sectional study using two data samples from Spain and the U.S. The data were collected with the help of a self-administered survey at one point in time in each country. All methods were carried out in accordance with relevant guidelines and regulations.

Sample recruitment

Patients included in the study were aged 18 years or older and had visited a health care center in the last 6 months. The study was approved by the Ethics Committee of the Health Area of the Hospital of Salamanca (Spain) in accordance with international standards and the Institutional Review Board for the Protection of Human Subjects of Duke University (NC, The U.S.) in accordance with current law. Informed consent was obtained from all subjects.

Description of Spanish sample recruitment

The sample comprised 473 participants who visited two health care services in a medium-sized city in Spain located in two distinct neighborhoods of the urban area. Considering the list of physicians currently working at the health care service, we randomly selected one of them and made appointments with the patients for the next day, inviting them to arrive early to participate in our study. Subsequently, two new doctors and their patients were selected every day. Informed consent was provided to the patients, who read and signed the form. The general purpose of the study was explained, and anonymity was guaranteed. The survey was then conducted with the help of a research assistant who provided the required instructions to the patients.

Description of the US sample recruitment

A sample of 450 participants was selected using a national paid panel of adult respondents on a web platform following previous studies [24]. The survey design included quality control procedures for the data. The information provided by participants who completed the survey in less than 10 minutes was excluded from the analyses because of unreliable information. First, participants were invited to participate in the survey. Second, they read an informed consent statement with details regarding the characteristics of the survey and guarantee anonymity. After providing their consent, we proceeded with the survey.

Measures

The demographics and characteristics of health care customers and the Perceived Organizational Justice in Care Services scale (PJustCS) were used to measure the interactional and informational dimensions of justice [20]. The interactional justice measure included seven items. An example of these is “In terms of how people treated you personally during this health care experience, to what extent were they really concerned with you as a person?”. Informational justice was measured using six questions. An example of these: “In terms of the information you received during your visit to the health care service, to what extent were your questions answered clearly?”

We used the Satisfaction With Health Care Services Scale [25] to measure satisfaction with different aspects of health services, including practitioner staff, support staff, center facilities, and center accessibility and procedures, by utilizing 11 items. An example of these is “To what extent were you satisfied with the time spent with your health care provider (nurse/physician)?”

Trust in the health provider was assessed using two items: “Were you willing to rely on the health care professional’s judgment on important matters?”, and “Did you trust the health care provider you dealt with?” [26].

To measure adherence, participants were required to respond to the following item about how far they followed the advice provided on their visit [17, 27]: “To what extent did you follow the advice or take the prescription provided by the health care worker?”.

The user loyalty to the service measure included two items: 1) the intention to give a positive word of mouth, which was inferred from “Would you recommend this service to your friends and family?”, and 2) the intention to return to the service, which was inferred from “Would you willingly visit this health care center again if you needed health care?”[28, 29]. All the items were answered on a five-point Likert scale ranging from 1 “not at all” to 5 “totally.” The Cronbach’s alpha of each measure can be found in the Results section.

Data analysis

The results are expressed as the means and standard deviations for quantitative variables and as frequency distributions (n and %) for qualitative variables. Student’s t test (2-tailed) and the chi-square test were used to determine differences in baseline characteristics between the two samples (Spanish and American). Pearson correlations were used to analyze the relationship between quantitative variables in each sample. The internal consistency and reliability of each scale were assessed using Cronbach’s alpha. We performed multigroup path analysis using Amos software to test the hypothesized, best-fitting models and multigroup analysis.

The hypotheses established an alpha of.05. The data were analyzed using SPSS version 23.0 (IBM Corp, Armonk, NY, USA) and AMOS version 16.

Sample characteristics

Table 1 shows the demographic characteristics of the participants. In the Spanish sample, the proportion of women is slightly greater. In addition, visits to health care services are more recent in Spain than in the US. The number of people with private health insurance is greater in the U.S. than in Spain.

Table 1

Demographic characteristics of the data samples
	Spain	United States	Level of significance
N	473	406
Women (%)	59.20%	52%	< 0.05
Age (M ± SD)	55.75 ± 16.77	52.24 ± 14.06	< 0.01
Years of schooling (M ± SD)	10.67 ± 3.70	13.23 ± 2.21	< 0.01
Recent health service visits (in the last month) (%)	65.80%	57.10%	< 0.05
Contact professional: doctor (%)	81%	72.2%	< 0.01
Private insurance (%)	14.20%	70%	< 0.01
Note. N: number of observations, %: percentage, M: mean, SD: standard deviation.

Descriptive results

The mean values of the variables analyzed in the model by country of sample origin and the differences between them are shown in Table 2. In the U.S. sample, informational justice, satisfaction and loyalty scores were higher, and in the Spanish sample, adherence was greater.

Table 2

Correlations and descriptive data of each variable for both samples of health care users (below Spain/ above U.S)
	1	2	3	4	5	6
1. Informational Justice	(.96/.95)	.79^**	.70^**	.75^**	.70^**	.19^**
2. Interactional Justice	.66**	(.91/.94)	.76^**	.81^**	.79^**	.18^**
3. Trust	.61**	.56**	(.89/.93)	.75^**	.76^**	.18^**
4. Satisfaction	.57**	.50**	.50**	(.89/.96)	.82^**	.18^**
5. Loyalty	.45**	.45**	.46**	.59**	(.87/.88)	.16^**
6. Adherence	.19**	.15**	.17**	.09	.15**	n.a.
Mean ± SD (Spain)	4.24 ± 1.02	4.40 ± 0.79	4.52 ± 0.87	3.87 ± 0.67	3.91 ± 0.59	4.75 ± 0.68
Mean ± SD (U.S.)	4.47 ± 0.81	4.48 ± 0.80	4.51 ± 0.82	4.32 ± 0.86	4.46 ± 0.97	4.64 ± 0.73

Note. Cronbach’s alpha for each scale in each sample are given in the diagonal between brackets (Spain/U.S.) where n.a.: not available; SD: standard deviation, significance level: *p < .05, **p < .01.

The correlation coefficients and reliability of the scales for each sample are also presented in Table 2. All reliabilities are shown on the diagonal for the Spanish/U.S. samples, indicating a good level of reliability in all the cases (all above .87). Significant Pearson’s correlations are found in both samples for each justice dimension.

Additionally, patients’ attitudes, such as trust in the clinician and satisfaction with the service, are strongly related (significant Pearson’s correlations in all cases, except between patients’ satisfaction and adherence for the Spanish sample).

Model tests

We present two models computed with the whole sample (n = 923), the hypothesized (Fig. 1, I & III) and the best-fitting models (Fig. 1, II & IV), for interactional justice perception and for informational justice perception (see Fig. 1). The fit indices can be found in Table 3. Afterwards, a multigroup analysis was computed using the country-of-origin data separately for each justice perception to test the model in both the U.S. and Spain.

Interactional justice perception path analyses

The fit indices were acceptable in the case of the hypothesized model (see Table 3), but they could be improved. The best-fitting model showed that the effect of satisfaction on adherence (g) was not maintained in the case of interactional justice [Δχ² = 0.1, df = 1, p = 1.00]. The best-fitting model (see Fig. 1, II) excluded the direct effect of interactional justice on adherence and the effect of satisfaction on adherence, showing a satisfactory better fit with respect to the hypothesized model [Δχ² = 2.3, df = 2, p = .86].

Table 3

Path analysis data of the nested interactional and informational justice models to test trust and satisfaction mediation hypotheses
Models for Interactional J.		χ2	df	Δ χ2		Δdf	RMSEA	IFI	CFI	GFI
Hypothesized Model		236.7	17	-		-	.131	.958	.958	.960
Model 1	Without b	238.3	18	2.4		1	.113	.959	.959	.959
Model 2	Without c	293.1	18	56.4		1	.145	.932	.931	.933
Model 3	Without g	236.8	18	0.1		1	.112	.959	.959	.960
Model 4	Without b and g	239.0	19	2.3		2	.101	.959	.959	.959
Models for Informational J.		χ²	df	Δ χ²	Δdf		RMSEA	IFI	CFI	GFI
Hypothesized Model		281.7	17	-	-		.155	.938	.938	.948
Model 1	without b	293.4	18	11.7	1		.140	.933	.933	.942
Model 2	without c	296.5	18	14.8	1		.143	.931	.930	.939
Model 3	without g	283.9	18	2.2	1		.136	.937	.937	.946
Note. Model 1 excludes the relationship between justice and adherence (b). Model 2 excludes the relationship between justice and loyalty (c). Model 3 excludes the relationship between satisfaction and adherence (g). Model 4 excludes the relationship between justice and adherence as well as satisfaction and adherence (b & g). RMSA = root mean square error of approximation; IFI = incremental fit index; CFI = comparative fit index; GFI = goodness of fit index.

According to our multigroup analysis, the CFI was close to the critical recommended value of 0.01 (χ2 = 95.18, df = 6, p < .001; CFI = 0.042). Testing the final model for each of the samples yielded a good fit for Spain [χ² (4) = 34.0, p < .001; CFI = .961, RMSEA = .126, TLI = .902] and the US [χ² (4) = 51.7, p < .001; CFI = .965, RMSEA = .172, TLI = .914]. Nevertheless, significant differences appeared in specific relationships, between interactional justice and trust (z = 2.94, p < .05), interactional justice and satisfaction (z = 9.04, p < .05), and satisfaction and loyalty (z = -2.50, p < .05), with loadings in the same direction but significantly greater in the U.S. sample. The model that did not include these three relationship parameters was invariant between samples (χ2 = 8.19, df = 3, p = .04; CFI = 0.003), indicating a proper fit [χ² (13) = 106.8, p < .001; CFI = .956, RMSEA = .091, TLI = .933].

Informational justice perception path analyses

In this case, the direct effect of informational justice on adherence must be maintained (see Fig. 2, III & IV, and fit indices in Table 3). Otherwise, the model worsened significantly when it was eliminated [Δχ² = 11.7, df = 1, p < .001]. Additionally, we found that satisfaction had no influence on adherence, in contrast to what was hypothesized [Δχ² = 2.2, df = 1, p = .14]. The modification indices with respect to this model indicated that if covariance was added between the measurement errors of trust and satisfaction, the model fit improved substantially [χ² (17) = 174.2, p < .001; CFI = .996, RMSEA = .040, TLI = .986].

When we performed the multigroup analysis, the group fit of the final model for each sample did not work invariably for the two samples (χ2 = 95.54, df = 7, p < .001; CFI = 0.04), although its fit was good in both Spain [χ² (2) = 5.4, p < .001; CFI = .996, RMSEA = .060, TLI = .979] and the US [χ² (2) = 0.05, p < .001; CFI = 1.00, RMSEA = .00 (.00-.00), TLI = 1.008]. Specifically, differences in the characteristics of the countries appeared in the relationship between informational justice and trust (z = 3.97, p < .05), informational justice and satisfaction (z = 9.59, p < .05), and trust with patient loyalty (z = 2.58, p < .05), with higher loadings in the U.S. sample.

This paper answers how patients’ perceived organizational justice matters and how it should be considered when delivering patient-centered care and providing better health care results (i.e., adherence to clinical advise and loyalty to the service) and health care policies. In this sense, we showed that patients' perception of informational justice directly influenced adherence to professional advice, whereas their perceptions of interactional or informational justice fostered their satisfaction with health services, trust in health providers, and loyalty to services. In addition, trust in health providers acted as a mediator of the influence of interactional justice on adherence. These findings have major implications for the management of healthcare services and policies and, ultimately, for contributing to the quality of healthcare and patient-centered care. We will offer guidelines of the implications of each finding next.

1. Perceived organizational justice and adherence to clinical advice and loyalty to the service

Perceptions of interactional and informational justice were related to adherence to professional advice, which is in line with the findings of previous studies highlighting the importance of the communication process with health care users [30, 31] but here we add the necessary characteristics of patients’ perceived justice to foster adherence and then, to generate good patient-centered care results [32]. The direct effects of perceived justice on loyalty to the service are also aligned with previous research involving workers and users of other services. This finding demonstrates the importance of the perception of interactional justice in variables related to loyalty, such as the intention to leave an organization [26], behaviors related to reusing the same service [33], or providing positive references [34]. Therefore, the connection between health service management and users can be improved by fostering interactional and informational justice perceptions related to creating spaces and procedures that allow interactional exchanges, sufficient time to interact and an adequate exchange of information [20].

2. Adherence to professional advice

2.1. Perceived interactional justice

In the context of best-fitting models, the results of the present study indicate that trust in the health provider acts as a mediator in the influence of interactional justice on adherence to professional advice. Thus, the perception that interactions with professionals show respect and dignity seems to foster the trust that generates adherence to advice, which is consistent with the findings of previous research [22, 35]. The quality of interaction with health personnel is essential in building trust [35], especially in contexts in which building trust is particularly challenging, such as those imposed by the COVID-19 pandemic and the use of masks [36]. In our study, we verified that the interactional dimension of organizational justice perception supports these assertions. Thus, perceiving interactions characterized by showing interest in the patient, willingness to listen, respect for their dignity, or treating the patient with respect and politeness are characteristics of interactional justice perception that foster the patient's trust in the health provider. This trust leads to better treatment adherence, service performance, and service-user connection as an important condition for ensuring the quality of care [37].

2.2. Perceived informational justice

However, informational justice has such a powerful relationship with treatment adherence that the effect of total mediation of trust in the health provider can be neglected. This finding also adds to the trend regarding the importance of the quality of the information provided for treatment, which is essential in patient-centered care [38, 39]. Patients’ positive perceptions of the information provided and clarity regarding the effects, dosage, and characteristics of treatments increase the probability of adherence to the professional’s recommendations. Additionally, we know that when patients are ready for future procedures or outcomes through informational interventions, uncertainty levels decrease, and clinical outcomes improve [2]. Therefore, service design should try to provide well-tailored information to patients because if they do not perceive it as sufficient, accurate, suitable, clear, thorough, and timely (i.e., fair), the likelihood of adherence decreases.

2.3. Patients’ satisfaction

Several contradictions have been found in previous research on the relationship between patient satisfaction and adherence. While certain studies [40] have found evidence of the existence of such a relationship, others have contradicted it [41]. In our study, satisfaction was not related to adherence in any of the models that we computed. This could be related to differences in satisfaction and adherence in terms of time, with satisfaction being an immediate and ephemeral reaction, while adherence is a behavior requiring long-term motivation. As both variables were at different levels, the relationship was ambiguous. These results suggest that satisfaction could have limited explanatory power for users’ long-term behavior.

3. Loyalty to the service

Regarding patient loyalty, the current study showed that both dimensions of organizational justice have such a strong influence on this behavior that the loyalty of patients to health services is linked directly to their perceptions of justice and through their trust and satisfaction with the service. This result corroborates previous findings on the promotion of loyalty through patient satisfaction and trust [42–46].

Consequently, this research supports the importance of implementing a health service design that promotes the perception of organizational interactional and informational justice in health services, as these factors are directly and indirectly associated with patients returning to health services and their tendency to provide positive references. This would lead not only to better service performance, cost savings in resources, and an improved image of the services [44] but also to better patient-centered care.

4. Country comparison

Testing the relational models with each country’s sample separately confirmed their robustness since the relationships were maintained in the health care systems of both countries. Differences were found only in terms of the strength of certain relationships but not in the direction of the proposed links. There may be various reasons why the perception of justice is more closely linked to trust and satisfaction among users in the U.S. than in Spain, given that health care systems and types of users in both countries differ in many ways. Although the two contexts involve very different ways of organizing service delivery, we can conclude that patients' cognitions, emotions and behaviors and their relationships were similar in both contexts.

5. Strengths and limitations

The current study has several strengths, including the use of a comprehensive model that encompasses constructs to understand patients’ experience and how to use this understanding in health care services management, and also, that it was confirmed in two countries with different healthcare systems.

The usual limitations of cross-sectional designs regarding the difficulties of establishing causality apply to the present study. Although we have a well-established theoretical basis, longitudinal studies that strengthen the relationships found need to be conducted. The data collection method was the same for all variables. Thus, the possible variance common to the method should be considered because it may artificially strengthen the relationships between the variables. In general, self-reports have proven to be a valid data collection method; however, they tend to yield slightly overestimated results [47].

Patients’ perceptions of interactional and informational justice play an essential role in fostering trust and satisfaction in health services. Trust is always related to adherence to treatments and loyalty to the service, while patient satisfaction relates to loyalty but not adherence. We also found that the perception of informational justice has remarkable influence on patients’ adherence to professional advice. Thus, if we want better patient-centered care and better health results, health service design and practitioner behaviors should aim to foster organizational interactional and informational justice perceptions.

Future lines of research include the design and test of health services aimed at supporting organizational justice, as well as the evaluation of their results from a patient-centered care approach.

• Ethics approval and consent to participate: The study was approved by the Ethics Committee of the Health Area of the Hospital of Salamanca (Spain) in accordance with international standards and the Institutional Review Board for the Protection of Human Subjects of Duke University (NC, The U.S.) in accordance with current law. Informed consent was obtained from all subjects.

• Consent for publication: All authors consent to publication

• Availability of data and materials: Both data bases are available to the researchers. They are not provided for public use due to current extra analysis.

• Competing interests: There are not competing interests.

• Funding: This study was funded by the Spanish Ministry of Science and Innovation, Instituto de Salud Carlos III (ISCIII) and cofunded by the European Union-Next Generation EU, Facility for Recovery and Resilience (MRR) and Investing in your Future Plan through Health Outcomes-Oriented Cooperative Research Networks (RICORS) (RD21/0016/0010). The Government of Castilla y León also collaborated with the funding of this study through the research projects BioSan 2009 and BioSan 2011. The authors played no role in the study design, data analysis, reporting of the results, or the decision to submit the manuscript for publication.

• Authors' contributions: Concept and design: Pérez-Arechaederra, Briones; Acquisition of data: Pérez-Arechaederra; Analysis and interpretation of data: Pérez-Arechaederra, García; Drafting of the manuscript: Pérez-Arechaederra; Critical revision of the paper for important intellectual content: Briones, Garcia; Obtaining funding: Garcia; Supervision: Briones, Garcia.

• Authors' information (optional): Diana Pérez-Arechaederra, PhD ¹* ([email protected]), Elena Briones, PhD ² ([email protected]), Luis García-Ortiz, MD, PhD ^3,4([email protected]).

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No competing interests reported.

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Editorial decision: Revision requested
08 Jan, 2024
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04 Jan, 2024
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You are reading this latest preprint version

Communication and relationships: how patients’ perceived informational and interactional justice can improve patient-centered care

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Version 1

Abstract

Figures

Highlights

Introduction

Methods

Sample recruitment

Description of Spanish sample recruitment

Description of the US sample recruitment

Measures

Data analysis

Results

Sample characteristics

Descriptive results

Model tests

Interactional justice perception path analyses

Informational justice perception path analyses

Discussion

1. Perceived organizational justice and adherence to clinical advice and loyalty to the service

2. Adherence to professional advice

2.1. Perceived interactional justice

2.2. Perceived informational justice

2.3. Patients’ satisfaction

3. Loyalty to the service

4. Country comparison

5. Strengths and limitations

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1