Workplace ViolenceVIA-HNCT05419687
Violence Against Health Care Workers in Fragile Settings
A study testing Training in de-escalating violence and Code of conduct delivered via a warning board in people with Workplace Violence, run by Swiss Tropical & Public Health Institute at 2 sites in 2 countries.
Trial summary
The general objective of the project is to assess whether a violence de-escalating training for health professionals and of a publicly displayed Code of Conduct (a set of rules developed through a citizen science and co-design approach) for both health professionals and clients at the level of the health facility, can… Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- Workplace Violence
- What is being tested?
- Training in de-escalating violence and Code of conduct delivered via a warning board
- Type of treatment
- Lifestyle or therapy programme
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 798 participants
- Where
- 2 sitesin 2 countries
- Study dates
- 1 Nov 2022to 31 Oct 2024
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- HCWs from selected participating health facilities in DRC, junior doctors during their first year resident and permanent health care staff from participating secondary hospitals in Iraq
- HCWs and junior medical doctors and permanent health care staff must have been employed/ or worked as HCW/ medical doctors or as permanent health care staff for at least 6 months
- All above participants must have completed the written informed consent
Who cannot join
- Age <18 years; cognitive impairment
Trial locations and contacts
2 sites in 2 countries.
2 sites in 2 countries
Democratic Republic of the Congo1 site
Catholic University of Bukavu, School of Public Health
Bukavu
About this study
Official title: Violence Against Health Care Workers: Understanding Context Through Citizen Science and Measuring a De-escalation Training Intervention Effectiveness in Eastern Democratic Republic of Congo and Iraq
The general objective of the project is to assess whether a violence de-escalating training for health professionals and of a publicly displayed Code of Conduct (a set of rules developed through a citizen science and co-design approach) for both health professionals and clients at the level of the health facility, can reduce the incidence and severity of episodes of violence, and to identify the most cost-effective way to implement these interventions in rural Democratic Republic of Congo (DRC) and in the mega city of Baghdad, Iraq.
Read the detailed description
The study will adopt a stepped-wedge cluster-randomized intervention trial (SW-CRT) design to assess the two intervention components, a violence de-escalating training and the implementation of the code of conduct co-developed during the formative qualitative phase. The study will adopt a closed cohort with repeated measurements on the same participants (nurses in DRC and junior doctors in Baghdad) and will involve the unidirectional transition of each enrolled cluster (health facilities in DRC and secondary hospitals in Baghdad) from the control (no intervention) to the intervention sequence in a randomized sequential manner according to a predefined roll out process.
- Conditions
- Workplace Violence
- Being tested
- Training in de-escalating violence, Code of conduct delivered via a warning board
- Keywords
- de-escalating, violence prevention, behavioral symptoms, code of conduct
- Medical subject headings
- Behavioral Symptoms
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Training in de-escalating violenceBehavioural
- Individual educational component through a de-escalating violence training for health care workers (verbal and non-verbal de-escalating techniques)
- Refreshment training in the form of collaborative learning
Code of conduct delivered via a warning boardBehavioural
A publicly displayed code of conduct (a co-designed set of rules) for both HCWs and clients, delivered via a warning board at the level of the health facilities and secondary hospitals
| Study group | Role | What they receive |
|---|---|---|
| Arm 1 De-escalating violence training | Experimental | The de-escalating violence training intervention will be introduced after a pre-interventional period of 3 months. A refreshment training will be introduced at month 11. Receives: Behavioral: Training in de-escalating violence |
| Arm 2 De-escalating violence training | Experimental | The de-escalating violence training intervention will be introduced before the second observation period at month 11. A refreshment training will be introduced at month 18. Receives: Behavioral: Training in de-escalating violence |
| Arm 3 De-escalating violence training | Experimental | The de-escalating violence training intervention will be introduced before the third observation period at month 18. Receives: Behavioral: Training in de-escalating violence |
| Arm 4 De-escalating violence training + Code of conduct | Experimental | The de-escalating violence training intervention will be introduced after a pre-interventional period of 3 months. The code of conduct via a warning board will be introduced at month 11. A refreshment training will be introduced at month 18. Receives: Behavioral: Training in de-escalating violence; Behavioral: Code of conduct delivered via a warning board |
| Arm 5 De-escalating violence training + Code of conduct | Experimental | The de-escalating violence training intervention and the code of conduct via a warning board will be simultaneously introduced at month 11. A refreshment training will be introduced at month 18. Receives: Behavioral: Training in de-escalating violence; Behavioral: Code of conduct delivered via a warning board |
| Arm 6 Code of conduct + De-escalating violence training | Experimental | The code of conduct via a warning board will be introduced at month 11. The de-escalating violence training intervention will be introduced at month 18. Receives: Behavioral: Training in de-escalating violence; Behavioral: Code of conduct delivered via a warning board |
| Arm 7 De-escalating violence training + Code of conduct | Experimental | The de-escalating violence training intervention is introduced after a pre-interventional period of 3 months. The code of conduct via a warning board and a refreshment training will be simultaneously introduced at month 18. Receives: Behavioral: Training in de-escalating violence; Behavioral: Code of conduct delivered via a warning board |
| Arm 8 De-escalating violence training + Code of conduct | Experimental | The de-escalating violence training intervention will be introduced before the second observation period at month 11. The code of conduct via a warning board and a refreshment training will be simultaneously introduced at month 18. Receives: Behavioral: Training in de-escalating violence; Behavioral: Code of conduct delivered via a warning board |
| Arm 9 De-escalating violence training + Code of conduct | Experimental | The code of conduct via a warning board and the violence de-escalating training will be simultaneously introduced at month 18. Receives: Behavioral: Training in de-escalating violence; Behavioral: Code of conduct delivered via a warning board |
| Arm 10 Code of conduct | Experimental | The code of conduct via a warning board will be introduced at month 11. Receives: Behavioral: Code of conduct delivered via a warning board |
| Arm 11 Code of conduct | Experimental | The code of conduct via a warning board will be introduced at month 18. Receives: Behavioral: Code of conduct delivered via a warning board |
What is being measured
The primary outcome is the main question the study is designed to answer.
Incidence and severity of self-reported non-physical aggression
Number of self-reported non-physical aggression (verbal abuse, threats, ironic language, provocative or aggressive body language etc.) during the fulfillment of a professional activity in the last 6 months
Measured: 6 months
Incidence and severity of self-reported physical aggression
Number of self-reported physical aggression during the fulfillment of a professional activity in the last 6 months
Measured: 6 months
Secondary outcomes (9)
Level of confidence in coping with patient aggression
Instrument "Clinicians confidence in coping with patient aggression (CCPAI) (Thackreys, 1987)"
Measured: 0, 6, 12, 18 months
Level of post-traumatic stress disorders (PTSD) among HCWs
Instrument "Post-traumatic stress disorder PTSD Checklist for DSM-5 (PCL-5)) (Weathers, F.W. et al. 2013)"
Measured: 0, 6, 12, 18 months
Level of burnout among HCWs
Instrument "Level of burnout" (Malach 2005), burnout measure short version (BMS). The ten-item version of the BMS are evaluated on 7-point frequency scales, with a score of 4 or above indicating burnout.
Measured: 0, 6, 12, 18 months
Psychological empathy among HCWs
Instrument "Jefferson scale of physician empathy (Hojat M et al. 2007)"
Measured: 0, 6, 12, 18 months
Absenteeism
Number of sick leave spells taken by the HCWs during the study period
Measured: 0, 6, 12, 18 months
Intent to leave among HCWs
The shortened, six-item version of the turnover intention scale (TIS-6) (Bothma \& Roodt 2013), will be used to assess turnover intentions and as well as to predict actual turnover among HCWs. The TIS-6 scale is scored on a five-point Likert-type scale with scores ranging from 1 (never) to 5 ( always). A high score indicates stronger turnover intention.
Measured: 0, 6, 12, 18 months
Economic cost of the intervention
Two types of costs will be considered: 1) direct costs of the intervention (e.g training costs, space or rent costs, costs to develop the code of conduct) and 2) direct costs due to health system disruption (e.g. health care services foregone or postponed, material etc.), cost incurred by the HCWs as a consequence of violent episodes including direct medical costs (e.g. hospital stay cost, consultation costs, laboratory costs), non-medical costs (e.g. transportation, meals etc.), and indirect costs (e.g. absenteeism, presenteeism).
Measured: 18 months
Productivity loss (presenteeism)
Work Limitation questionnaire (WLQ) (Lerner D. et al. 2002). The WLQ consists of eight items investigating four domains (time management, physical tasks, mental-interpersonal tasks, and output tasks), which are calculated into scores ranging from 0 (no limitations) to 100 (highest limitations).
Measured: 18 months
Health care workers health-related quality of life
European Quality of Life-5 Dimensions (EuroQol EQ-5D-5L) (Devlin NJ et al. 2017). The EQ-5D-5L questionnaire is self-assessed and it measures health outcomes on five dimensions (mobility, self-care, daily activities, pain/discomfort, and depression/anxiety) with five levels ranging from none to major complaints. Scores range from 0 (death) to 1 (full health).
Measured: 0, 6, 12, 18 months
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted15 Jun 2022
- Study start1 Nov 2022
- Primary completion31 Oct 2024
- Study completion31 Oct 2024
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (4)Papers the sponsor has linked to this study.
- Other trials for Workplace ViolenceStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Crossover
- Model description
- The SW-RCTs will consist of 11 sequences (11 different possibilities of timing and sequencing the introduction of the intervention components), and a maximum of four intervention periods, combining an individual de-escalating training intervention followed by a refreshment training in the form of a collaborative learning and a code of conduct board level intervention with an overall study duration of 24 months.
- Masking
- Double blind
- Who is masked
- Investigator, Outcomes assessor
- Enrolment
- 798 participants (actual)
Sponsor and investigators
- Lead sponsor
- Swiss Tropical & Public Health Institute
- Sponsor type
- University, hospital or other
- Collaborators
- International Committee of the Red Cross (ICRC), Catholic University of Bukavu, Democratic Republic of Congo, Al-Mustansiriyah University
- Responsible party
- Sponsor
- Investigators
- Sonja Merten, MD MPH PhD, Principal investigator, Swiss Tropical and Public Health Institute (Swiss TPH)
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT05419687
- Sponsor's protocol ID
- 70198
- Acronym
- VIA-H
- Status last verified
- Sep 2024
- First submitted
- 10 Jun 2022
- Last updated
- 22 Jan 2025
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
Publications
Elrha, International Committee of the Red Cross (ICRC), RAND Europe. Researching Violence Against Health Care: Gaps and Priorities. 2020
Leach, Brandi, Emily Ryen Gloinson, Alex Sutherland, and Michael Whitmore, Reviewing the Evidence Base for De-escalation Training: A Rapid Evidence Assessment. Santa Monica, CA: RAND Corporation, 2019.
Geoffrion S, Hills DJ, Ross HM, Pich J, Hill AT, Dalsbo TK, Riahi S, Martinez-Jarreta B, Guay S. Education and training for preventing and minimizing workplace aggression directed toward healthcare workers. Cochrane Database Syst Rev. 2020 Sep 8;9(9):CD011860. doi: 10.1002/14651858.CD011860.pub2.
PubMed 32898304Ferrari G, Lwamushi SM, Balaluka GB, Lafta RK, Schindler C, Bugugu D, Lurhangire E, Tediosi F, Mendoza JR, Merten S. Understanding context of violence against healthcare through citizen science and evaluating the effectiveness of a co-designed code of conduct and of a tailored de-escalation of violence training in Eastern Democratic Republic of Congo and Iraq: a study protocol for a stepped wedge randomized controlled trial. Trials. 2023 Dec 19;24(1):814. doi: 10.1186/s13063-023-07839-3.
PubMed 38110997
Study at a glance
From the registry record, last updated by the sponsor on 22 Jan 2025. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Violence Against Health Care Workers: Understanding Context Through Citizen Science and Measuring a De-escalation Training Intervention Effectiveness in Eastern Democratic Republic of Congo and Iraq
- ClinicalTrials.gov ID
- NCT05419687
- Acronym / sponsor ID
- VIA-H / 70198
- Conditions
- Workplace Violence
- Keywords
- de-escalating, violence prevention, behavioral symptoms, code of conduct
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 798 participants (actual)
- Lead sponsor
- Swiss Tropical & Public Health InstituteUniversity, hospital or other
- Collaborators
- International Committee of the Red Cross (ICRC), Catholic University of Bukavu, Democratic Republic of Congo, Al-Mustansiriyah University
- Study start
- 1 Nov 2022 (actual)
- Primary completion
- 31 Oct 2024 (actual)
- Study completion
- 31 Oct 2024 (actual)
- First posted
- 15 Jun 2022 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The general objective of the project is to assess whether a violence de-escalating training for health professionals and of a publicly displayed Code of Conduct (a set of rules developed through a citizen science and co-design approach) for both health professionals and clients at the level of the health facility, can reduce the incidence and severity of episodes of violence, and to identify the most cost-effective way to implement these interventions in rural Democratic Republic of Congo (DRC) and in the mega city of Baghdad, Iraq.
Detailed description
The study will adopt a stepped-wedge cluster-randomized intervention trial (SW-CRT) design to assess the two intervention components, a violence de-escalating training and the implementation of the code of conduct co-developed during the formative qualitative phase. The study will adopt a closed cohort with repeated measurements on the same participants (nurses in DRC and junior doctors in Baghdad) and will involve the unidirectional transition of each enrolled cluster (health facilities in DRC and secondary hospitals in Baghdad) from the control (no intervention) to the intervention sequence in a randomized sequential manner according to a predefined roll out process.
Study design
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Crossover
- Masking
- Double blind (investigator, outcomes assessor)
- Number of arms
- 11
- Model description
- The SW-RCTs will consist of 11 sequences (11 different possibilities of timing and sequencing the introduction of the intervention components), and a maximum of four intervention periods, combining an individual de-escalating training intervention followed by a refreshment training in the form of a collaborative learning and a code of conduct board level intervention with an overall study duration of 24 months.
| Arm | Type | Receives |
|---|---|---|
| Arm 1 De-escalating violence training | Experimental | Behavioral: Training in de-escalating violenceThe de-escalating violence training intervention will be introduced after a pre-interventional period of 3 months. A refreshment training will be introduced at month 11. |
| Arm 2 De-escalating violence training | Experimental | Behavioral: Training in de-escalating violenceThe de-escalating violence training intervention will be introduced before the second observation period at month 11. A refreshment training will be introduced at month 18. |
| Arm 3 De-escalating violence training | Experimental | Behavioral: Training in de-escalating violenceThe de-escalating violence training intervention will be introduced before the third observation period at month 18. |
| Arm 4 De-escalating violence training + Code of conduct | Experimental | Behavioral: Training in de-escalating violence, Behavioral: Code of conduct delivered via a warning boardThe de-escalating violence training intervention will be introduced after a pre-interventional period of 3 months. The code of conduct via a warning board will be introduced at month 11. A refreshment training will be introduced at month 18. |
| Arm 5 De-escalating violence training + Code of conduct | Experimental | Behavioral: Training in de-escalating violence, Behavioral: Code of conduct delivered via a warning boardThe de-escalating violence training intervention and the code of conduct via a warning board will be simultaneously introduced at month 11. A refreshment training will be introduced at month 18. |
| Arm 6 Code of conduct + De-escalating violence training | Experimental | Behavioral: Training in de-escalating violence, Behavioral: Code of conduct delivered via a warning boardThe code of conduct via a warning board will be introduced at month 11. The de-escalating violence training intervention will be introduced at month 18. |
| Arm 7 De-escalating violence training + Code of conduct | Experimental | Behavioral: Training in de-escalating violence, Behavioral: Code of conduct delivered via a warning boardThe de-escalating violence training intervention is introduced after a pre-interventional period of 3 months. The code of conduct via a warning board and a refreshment training will be simultaneously introduced at month 18. |
| Arm 8 De-escalating violence training + Code of conduct | Experimental | Behavioral: Training in de-escalating violence, Behavioral: Code of conduct delivered via a warning boardThe de-escalating violence training intervention will be introduced before the second observation period at month 11. The code of conduct via a warning board and a refreshment training will be simultaneously introduced at month 18. |
| Arm 9 De-escalating violence training + Code of conduct | Experimental | Behavioral: Training in de-escalating violence, Behavioral: Code of conduct delivered via a warning boardThe code of conduct via a warning board and the violence de-escalating training will be simultaneously introduced at month 18. |
| Arm 10 Code of conduct | Experimental | Behavioral: Code of conduct delivered via a warning boardThe code of conduct via a warning board will be introduced at month 11. |
| Arm 11 Code of conduct | Experimental | Behavioral: Code of conduct delivered via a warning boardThe code of conduct via a warning board will be introduced at month 18. |
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (3 listed)
- HCWs from selected participating health facilities in DRC, junior doctors during their first year resident and permanent health care staff from participating secondary hospitals in Iraq
- HCWs and junior medical doctors and permanent health care staff must have been employed/ or worked as HCW/ medical doctors or as permanent health care staff for at least 6 months
- All above participants must have completed the written informed consent
Key exclusion criteria (1 listed)
- Age <18 years; cognitive impairment
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Training in de-escalating violence* Individual educational component through a de-escalating violence training for health care workers (verbal and non-verbal de-escalating techniques) * Refreshment training in the form of collaborative learning | Behavioural | Arm 1 De-escalating violence training, Arm 2 De-escalating violence training, Arm 3 De-escalating violence training, Arm 4 De-escalating violence training + Code of conduct, Arm 5 De-escalating violence training + Code of conduct, Arm 6 Code of conduct + De-escalating violence training, Arm 7 De-escalating violence training + Code of conduct, Arm 8 De-escalating violence training + Code of conduct, Arm 9 De-escalating violence training + Code of conduct |
| Code of conduct delivered via a warning boardA publicly displayed code of conduct (a co-designed set of rules) for both HCWs and clients, delivered via a warning board at the level of the health facilities and secondary hospitals | Behavioural | Arm 10 Code of conduct, Arm 11 Code of conduct, Arm 4 De-escalating violence training + Code of conduct, Arm 5 De-escalating violence training + Code of conduct, Arm 6 Code of conduct + De-escalating violence training, Arm 7 De-escalating violence training + Code of conduct, Arm 8 De-escalating violence training + Code of conduct, Arm 9 De-escalating violence training + Code of conduct |
Primary outcome
Incidence and severity of self-reported non-physical aggression
Time frame: 6 months
Number of self-reported non-physical aggression (verbal abuse, threats, ironic language, provocative or aggressive body language etc.) during the fulfillment of a professional activity in the last 6 months
Incidence and severity of self-reported physical aggression
Time frame: 6 months
Number of self-reported physical aggression during the fulfillment of a professional activity in the last 6 months
9 secondary outcomes
Level of confidence in coping with patient aggression
Time frame: 0, 6, 12, 18 months
Level of post-traumatic stress disorders (PTSD) among HCWs
Time frame: 0, 6, 12, 18 months
Level of burnout among HCWs
Time frame: 0, 6, 12, 18 months
Psychological empathy among HCWs
Time frame: 0, 6, 12, 18 months
Absenteeism
Time frame: 0, 6, 12, 18 months
Intent to leave among HCWs
Time frame: 0, 6, 12, 18 months
Economic cost of the intervention
Time frame: 18 months
Productivity loss (presenteeism)
Time frame: 18 months
Health care workers health-related quality of life
Time frame: 0, 6, 12, 18 months
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 22 Jan 2025.
- BackgroundElrha, International Committee of the Red Cross (ICRC), RAND Europe. Researching Violence Against Health Care: Gaps and Priorities. 2020
- BackgroundLeach, Brandi, Emily Ryen Gloinson, Alex Sutherland, and Michael Whitmore, Reviewing the Evidence Base for De-escalation Training: A Rapid Evidence Assessment. Santa Monica, CA: RAND Corporation, 2019.
- Background: PubMed 32898304Geoffrion S, Hills DJ, Ross HM, Pich J, Hill AT, Dalsbo TK, Riahi S, Martinez-Jarreta B, Guay S. Education and training for preventing and minimizing workplace aggression directed toward healthcare workers. Cochrane Database Syst Rev. 2020 Sep 8;9(9):CD011860. doi: 10.1002/14651858.CD011860.pub2.
- Derived from this study: PubMed 38110997Ferrari G, Lwamushi SM, Balaluka GB, Lafta RK, Schindler C, Bugugu D, Lurhangire E, Tediosi F, Mendoza JR, Merten S. Understanding context of violence against healthcare through citizen science and evaluating the effectiveness of a co-designed code of conduct and of a tailored de-escalation of violence training in Eastern Democratic Republic of Congo and Iraq: a study protocol for a stepped wedge randomized controlled trial. Trials. 2023 Dec 19;24(1):814. doi: 10.1186/s13063-023-07839-3.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Sonja Merten, MD MPH PhD principal investigator
Swiss Tropical and Public Health Institute (Swiss TPH)
2 sites in 2 countries: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Training in de-escalating violence and Code of conduct delivered via a warning board in people with Workplace Violence, run by Swiss Tropical & Public Health Institute at 2 sites in 2 countries.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 3 inclusion and 1 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 22 Jan 2025. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 2 sites in Democratic Republic of the Congo, Iraq. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Incidence and severity of self-reported non-physical aggression (time frame: 6 months). The study lists 2 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT05419687, which also lists 4 linked publications.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 22 Jan 2025.