Article Text
PDF
Abstract
Introduction Ageing entails a variety of physiological changes that increase the risk of chronic non-communicable diseases. The prevalence of these diseases leads to an increase in the use of health services. The care models implemented by health systems should provide comprehensive long-term healthcare. We conducted this systematic review to determine whether any model of care for older persons have proven to be effective.
Methods A systematic review of literature was carried out to identify randomised clinical trials that have assessed how effective a care model for older patients with chronic diseases. A searches electronic databases such as MEDLINE, Turning Research Into Practice Database, Cochrane Library and Cochrane Central Register of controlled Trials was conducted from January 1966 to January 2021. Two independent reviewers assessed the eligibility of the studies. Interventions were identified and classified according to the taxonomies developed by the Cochrane Effective Practice and Organisation of Care and Cochrane Consumers and Communication groups.
Results Of the 4952 bibliographic references that were screened, 577 were potentially eligible and the final sample included 25 studies that evaluated healthcare models in older people with chronic diseases. In the 25 care models, the most frequently implemented interventions were educational, and those based on the provision of healthcare. Only 22% of the outcomes of interventions were identified as being effective, whereas 21% were identified as being partially effective; thus, more than 50% of the outcomes were identified as being ineffective.
Conclusions It was not possible to determine a care model as effective. The interventions implemented in the models are variable. The most effective outcomes were focused on improving the patient–healthcare professional relationship in the early stages of the intervention. The interventions addressed in the studies were similar to public health interventions as their main objectives focused on promoting health. Most studies were of low methodological quality.
- geriatric medicine
- international health services
- organisation of health services
- primary care
- public health
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
- geriatric medicine
- international health services
- organisation of health services
- primary care
- public health
Strengths and limitations of this study
This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and recommendations of the Cochrane Collaboration, which are well recognised approaches for conducting of systematic reviews.
A wide search strategy was carried out in the main electronic databases. In addition, the Cochrane Central Register of controlled Trials was reviewed.
Two reviewers independently completed the studies selection, data extraction and assessment risk of bias of the studies; disagreements were resolved by consensus and discussion.
All the interventions addressed in the 25 studies are similar to public health interventions as their main aims were the promotion of health. The most important problem identified refers to the low quality of the studies based on the results assessed using the risk of bias tool.
Introduction
Ageing increases the risk of suffering from chronic non-communicable diseases (CNCDs), especially cardiovascular diseases, cancer, chronic respiratory diseases and diabetes.1 According to estimates by the WHO, the population aged over 60 years may increase from 605 million in 2000 to two billion by 2050,1 2 with a subsequent increase in the prevalence of CNCDs. Estimates in the United States indicate that in 2020, around 157 million people were living with some CNCD and more than 81 million were suffering from more than one CNCD, a condition known as multimorbidity (defined as the concomitant presence of two or more CNCDs.).1 3 CNCDs are the leading cause of premature death and morbidity among adults aged 30–69 years, with over 12 million deaths annually in low-income to middle-income countries.4 5 As these countries continue to progress through the demographic transition, the prevalence of CNCDs and multimorbidity in older individuals will continue to rise.4 5
The health status tends to deteriorate among those with CNCDs, which translates into increases in the use of healthcare services, associated costs and mortality.1 This phenomenon affects both high-middle-income and low-income countries. In the USA, CNCDs will account for an annual economic burden (treatment costs and loss of economic output) of US$4.2 trillion by 2023.6 On their part, middle-income countries in Latin America will have to cope with the increase in CNCDs, including chronic mental health diseases such as depression, dementia and alcohol-related disorders.4
As health is determined by multiple genetic, cultural, environmental, educational, social and economic factors,7 the care models implemented by health systems should provide services that meet multifactorial needs through a multidisciplinary care model that adapts to the needs of each person and, to the different contexts in which they live and age.8 Therefore, the provision of long-term care at home, in institutions (nursing homes or prolonged hospital stays), and in the community needs to be considered.2
There are different models of comprehensive integrated care for older individuals, among which the Integrated Care for Older People guidelines by the WHO is notable. This model promotes the detection and management of the decrease in the intrinsic capacity of older individuals as well as interventions to support caregivers. However, these guidelines do not provide for the specific care of CNCDs or multimorbidity.9
Various studies have analysed the impacts of multimorbidity in older people and the effects of implementing care models for older people with multimorbidity.10–14 For instance, the outcomes from a systematic review have revealed that multimorbidity is associated with disability and negatively affects the quality of life while increasing health service use and health care-related costs. Part of these costs result from preventable complications.10 11 Another review evidenced that personalised and collaborative care planning tends to yield modest beneficial effects in terms of physical and psychological health along with self-care and that these effects become more evident when the intervention is more intensive and comprehensive and is integrated into routine patient care.12
Most of the older people, especially those in low-income and middle-income countries, live and age within the community and have limited access to high-specialty care. For this reason, it would be necessary to focus the provision of healthcare services for older individuals on the community and in the primary healthcare level.1
In response to the need for improving healthcare for older persons there have appeared different care models focused on providing continuous care for chronic problems within the community or at the first level of care.9–14 These models of care tend to have multiple components and different interventions. Their effectiveness has been measured in terms of various outcomes and there have been few efforts at doing systematic evaluations of the results. This systematic review is intended to identify and describe the effectiveness of different models of care for people aged 60 years and above with a focus on the management of CNCDs at the first level of care or on a community basis.
Methods
A systematic review of literature was carried out to identify randomised clinical trials that had assessed a model of care for the comprehensive care and management of older patients with CNCDs. Chronic disease was defined as any slowly progressive long-lasting NCD, which usually requires long periods of supervision, observation or care.15
Studies with institutionalised, terminally ill and hospitalised patients or studies with patients in emergency units were excluded.
We considered a model of care to be effective when the study presented statistically significant improvement or benefits in the outcomes they assessed.
Literature search
MEDLINE, Turning Research Into Practice Database, Cochrane Library and Cochrane Central Register of controlled Trials were searched during the period from January 1966 to January 2021 to identify articles published in English and Spanish. The search strategies were based on free text terms and Medical Subject Headings terms (see online supplemental file 1). The terms used included elderly, oldest, old, aged, older, adults, chronic disease, chronic condition, illness, chronic illness, chronically, multiple chronic conditions, comorbidity or multimorbidity, primary healthcare, community health services, and health planning, model of care, integrated care, healthcare intervention programmes, clinical trial, randomised clinical trial, among others.
Supplemental material
Data collection and extraction
Two independent reviewers assessed the studies’ eligibility for inclusion. Disagreements were resolved by consensus with the aid of a third reviewer.
A reviewer entered the data obtained in predesigned Excel tables (Microsoft Office Excel 2007) and a second reviewer double-checked them.
Data analysis
The interventions were categorised according to the taxonomy developed by the Cochrane Effective Practice and Organisation of Care (EPOC) group, which is used to classify interventions from healthcare systems. The taxonomy in detail had been previously published,16 and the four main domains assessed in the taxonomy were: delivery arrangements, financial arrangements, governance arrangements and implementation strategies.
In addition, the data were categorised according to the Cochrane Consumers and Communication group’s taxonomy.17 This taxonomy identifies outcomes that are potentially relevant and meaningful for healthcare professionals, patients (consumers), general public, administrators as well as policy or decision-makers. This tool provides a comprehensive list with three main domains (consumer-oriented outcomes, healthcare provider-oriented outcomes and health service delivery-oriented outcomes).18 The outcomes were classed into three epigraphs based on their efficacy. The first epigraph, which was named ‘effective’, included the outcomes with clinical and statistical significance in favour of the group that received the intervention during each of the periods measured. The second epigraph, named as ‘partially effective’, included the outcomes that showed clinical significance (according to the author) but not statistical significance. This epigraph also included the outcomes that had been measured using different scales as well as those that showed clinical or statistical significance in favour of the intervention, although only in some of its measurements, within the intervention period. The last epigraph, named ‘ineffective’, included those outcomes with no significant clinical or statistical difference between the group that received the intervention and the control group. Finally, the outcomes were identified as primary or secondary based on the Cochrane EPOC group classification, which indicates the outcomes that are most relevant to patients as well as decision-makers.
Additionally, two independent reviewers assessed the methodological quality of the studies using the risk of bias tool.19
A qualitative synthesis of the outcomes was performed and the results of the same are shown in tables. However, a combined analysis of the effect of the interventions was not possible given the heterogeneity in the results and measures of effect.
Patient and public involvement
In this review, the participation of patients and the public has not been considered. However, we consider that knowing the interventions implemented in care models focused on elderly, as well as their effectiveness, can support and improve patient care. In addition, it will allow to know needs and future strategies to be implemented.
Results
A total of 4952 bibliographic references related to the study topic were identified. Once duplicated entries were eliminated, 3193 titles and abstracts were reviewed for eligibility; among these, 577 articles that had been identified as relevant were reviewed in full text, to finally select 25 studies (figure 1). A total of 20 randomised controlled trials (RCTs) and 5 cluster RCTs, evaluating 25 healthcare models implemented in older people with CNCDs, were included. Most studies were conducted in the USA (n=14); three in the Netherlands; two in Germany and the rest were in UK, Canada, Australia, Italy, Spain and Sweden.
Flow chart demonstrating the study selection process. TRIP, Turning Research Into Practice.
Characteristics of the care models and type of interventions
The studies included a total of 15 888 adults aged over 60 years with multimorbidity. Of these, 9187 belonged to the group that received care through one of the models, whereas 6701 belonged to the group that received the usual care. The most commonly reported CNCDs in the studies were cardiovascular diseases, arthritis, mental illness (depression), nervous system disease (chronic pain), diabetes, chronic obstructive pulmonary disease and cancer.
The different models assessed in the studies included multidisciplinary care teams, including health professionals such as nurses, pharmacists, social workers, primary care doctors, physiotherapists, specialist doctors (cardiology and endocrinology), psychologists, occupational therapists and people who had previously received training on care for older adults. Eight studies revealed that the care models only considered one type of health professional to provide patient care (doctor, nurse or pharmacist).20–27 One study reported that there was no requirement for a health professional, but caregivers with experience caring for patients with Alzheimer’s or other dementias as well as people with multimorbidities at the community level were required (see table 1).28
Characteristics of the studies included
The follow-up of the studies ranged between 3 and 32 months. Regarding the funding, 10 studies20 21 29–36 received at least one type of support or funding from a combination of different funders, including public hospitals, medical or pharmaceutical benefit schemes, support from the department of veterans affairs, regional home services, fee-for-service, prepaid plans or health plans and even a non-profit model. The remaining 15 studies22–28 37–44 did not report having received any funding whatsoever. The main features of the studies are described in table 1.
Each intervention of the identified models was analysed and subsequently classified based on its characteristics into one or more subcategories following the taxonomy proposed by the Cochrane EPOC group. A total of 23 different subcategories were identified. Table 2 represents the frequencies of use of each subcategory for the 25 studies analysed. The most commonly used type of intervention corresponds to the subcategory called ‘educational meetings’, which is defined as the attendance of courses, workshops, conferences or other educational events. This type of intervention belongs to the ‘Implementation Strategies’ domain. Online supplemental table 1 shows the topics covered by the ‘educational meetings’ intervention. Despite the fact that the studies reported having implemented a care model or programme, eight studies were identified as having administered a single intervention (table 2).23 26 28 32 38 42–44
Supplemental material
Type of interventions classified based on care models
Based on the taxonomy proposed by the Cochrane EPOC group. Implementation strategies are interventions designed to bring about changes in healthcare organisations, the behaviour of healthcare professionals or the use of health services by healthcare recipients.
In 12 studies, the administered intervention included the combination of 2 different subcategories.22 24 27 29–31 33 35 37 39–41 In most studies, at least one subcategory corresponded to ‘implementation strategies (educational)’22 24 27 29–31 33 35 37 39 41 in combination with some other strategy. For example, with the intervention of ‘prescribing’ which is defined as ‘the selection of a drug by a duly qualified health worker to treat a patient’s health condition’,17 or the ‘site of service delivery’, which is defined as ‘changes in the place where care is provided; for example, home vs health centre, hospitalisation vs outpatient, specialised centre versus non-specialised centre’.17
In two studies, a combination of three subcategories to conduct the intervention21 34 was observed. In these studies, there was at least one educational subcategory, which was not necessarily intended for the patient but for the health providers, for example, through the intervention called ‘interprofessional education’, which is defined as ‘continuing education for health professionals involving more than one profession in combined and interactive learning’.17 By way of example, other types of interventions administered included ‘site of service delivery’, ‘voucher schemes’, defined as ‘the provision of vouchers that can be exchanged for health services at specific facilities’.17 Finally, in two studies, the intervention was classified into four different subcategories. A study by Battersby et al35 sought to verify whether coordinated care could improve health outcomes. To do this, the intervention subcategories used comprised of ‘care pathways’ (defined as the link between evidence and daily practice in specific conditions), ‘case management’ (defined as the introduction, modification or elimination of strategies to improve the management of patients), ‘teams’ (defined as the delivery of care through a multidisciplinary team of healthcare workers), ‘audit and feedback’ (defined as a summary of the performance of health workers over a specified period of time).17 In a study by Coleman et al,31 the objective was to try to reorganise the provision of primary care services to better meet the needs of older people with chronic diseases, and the following subcategories were used: ‘interprofessional education’, ‘educational outreach visits’ (defined as personal visits by a trained person to health workers in their own working settings to provide information aimed at changing practice), ‘tailored interventions’ (defined as interventions intended to change the selected practice based on an assessment of the obstacles that need change), and ‘shared care’ (continuous collaborative clinical care provided by primary care physicians and specialists).
Effectiveness of interventions
The types of outcomes were classified according to the taxonomy proposed by the Cochrane Consumers and Communication group. This tool allowed for the stratification and identification of 42 categories to which each of the outcomes were assigned. Effectiveness was in turn classified into three categories: ‘effective’, ‘partially effective’ and ‘ineffective’ (table 3 and online supplemental table 2). Table 3 shows how more than 50% of the total outcomes evaluated are concentrated in the consumer-oriented outcomes domain. The classification of the type of result allowed the assignment within the same subcategory (table 4); however, to obtain it, each study required different scales and measures of effect.
Supplemental material
Effectiveness of interventions in the studies (care models)
Type of outcomes based on healthcare models
One of the model characteristics identified as ‘effective’ is, for example, the training received by health professionals before the commencement of the intervention, which was focused on improving professional–patient communication skills25 or on the management of depression in older people.23 Another common factor shared by the models is that their interventions sought to establish a close relationship between the professional and the patient during the initial phases of each intervention, despite being carried out according to different methods. For example, in one of the models, the objective of the first stage was for the patient to share his/her feelings with the healthcare professional and for the latter to understand the origin of the symptoms as well as the patient’s daily routine.23 In another model, healthcare professionals adhered to the following principles during the development of the intervention: (1) to resist the urge to correct, (2) to understand the patient’s own motivations, (3) to listen with empathy and (4) to empower the patient.25 Finally, another model allowed the professional to know details about each patient’s personal situation by carrying out an interview as part of the exhaustive phase for the medication review.40 This approach in the three models allowed the health professionals to understand aspects that were relevant in the daily life of older adults, and therefore, their motivations or needs. Thus, the suggestions made by the professionals with regard to the changes needed to be made by the patients became more precise.
We identified three studies23 25 40 that reported favourable outcomes in the group of older adults integrated into some of the models of care (Minimal Psychological Intervention, Motivational Interviewing and Case Management) compared with the usual care. None of the outcomes provided by these three studies reported data on clinical outcomes. Besides, most of these types of studies prioritised outcomes related to the quality of life or the reduction of hospital admissions.45
On the other end, we find three models of care28 37 39 that evidence that none of the implemented interventions improved the outcome for the patients whatsoever. The remaining models20–22 24 26 27 29–36 38 41–44 did not evidence a clear benefit for the participants, that is, despite some of their measurements indicating some type of improvement, the remaining outcomes shared a similar or lower value than that obtained in the control group (online supplemental table 2).
Out of the 25 healthcare models, only 22% of the 119 reported outcomes improved the conditions of patients. A total of 57% of the outcomes did not provide any benefit for the model’s experimental group, whereas 21% of the outcomes did not show a clear effect regarding the benefit granted to the patients, mainly because they did not remain constant throughout the study period (table 4).
For the assessment of the methodological quality of the studies, the risk of bias tool was applied, which allowed us to observe that most of the studies had a high risk of bias (18 studies) or were at least unclear (7 studies). This indicates that the studies had low methodological quality as they did not use an appropriate method to allocate the interventions or for the randomisation process and were not blinded or did not describe the methods used during the study performance (online supplemental figures 1 and 2).
Supplemental material
Supplemental material
Discussion
A total of 25 models of care were found in this systematic review that included 20 RCTs, and 5 cluster RCTs. The models of care were highly heterogeneous, as was expected since no restriction was set on the condition or disease at which they were aimed. Multiple strategies and interventions were found to be part of these models of care and it is not possible to assess accurately whether any specific combination of them rendered the outcomes observed for each model. However, some observations can be made.
Effective interventions
Across the 25 models of care, we identified 26 positive outcomes, which were the ones categorised as effective using the Cochrane Consumers and Communication group’s taxonomy. We looked at the specific strategies or interventions that were present in the models of care that produced such positive outcomes and found a total of 14 different interventions. The most frequent interventions that rendered positive outcomes were strategies for modifying site of service delivery, educational meetings, interprofessional education, educational outreach visits or academic detailing, and prescribing.
Regarding the site of service delivery, six out of eight studies which included a variant of this strategy—usually some form of home care—rendered significant outcomes, although in every case they were combined with a different set of interventions. An overview of systematic reviews examined the impact of home care versus alternative locations of care on health outcomes for older persons. They found heterogeneous evidence favouring home support but insufficient evidence to determine whether alternate locations of care had better impact than home care.46 Our findings suggest that some forms of home care may contribute to produce favourable outcomes of the following types: quality of life, life satisfaction, morbidity, mortality, satisfaction with care, level of anxiety, depression, mood, well-being, provision of or use of technical aids, quality of care and reporting of adverse events.
Educational strategies were also frequent among the implementation strategies included in the models of care with effective outcomes in our systematic review.
Three studies were noticeable for having the most relevant outcomes.23 25 40 Of these, two studies focused on improving drug management and therapeutic adherence,25 40 whereas the third focused on reversing symptoms associated with depression, for example, to improve self-efficacy, daily functioning and social participation.23 Another element shared by the studies is that their interventions intended to establish a close relationship between the professional and the patient during the initial phases of each intervention. In the model proposed by Jonkers et al23 the objective of the first stage was for the patient to share his/her feelings with the health professional and for the latter to understand the origin of the symptoms as well as the patient’s daily routine. In the model of a study by Moral et al,25 healthcare professionals adhered to the principles of resisting the urge to make corrections, understanding the patient’s own motives, listening with empathy and empowering the patient. Finally, the model evaluated by Köberlein-Neu et al40 allowed for the professional to find out details about the personal situation of each patient through an interview as part of the exhaustive phase of the medication review.
Ineffective interventions
Three studies produced only ineffective outcomes.28 37 39 Interestingly, these studies implemented interventions proved effective in other studies included in the review. Specifically, Duggleby et al implemented educational meetings28; Schäfer et al implemented educational outreach visits and prescribing39 and Poot et al implemented a combination of educational outreach visits, audit and feedback, and multidisciplinary teams.37 However, neither attained any effective outcomes. Moreover, selection bias, lack of blinding of participants or outcome, were not reported in these three studies. It is not uncommon in systematic reviews to find similar studies producing contradicting results. These contradictory findings might be attributed to methodological reasons.
Remarks
Each of the 25 identified studies presented interventions with specific scopes. These interventions were integrated through different components, which allowed them to interact; however, establishing causal chains linking the intervention with the outcome is highly complex47 and hence, the effectiveness of each of the studies depend on the objectives of the study or the needs of the participating population.
In addition, the lack of a standard definition or consensus on which conditions should be considered within multimorbidity, the impact of the context in which the intervention is developed (eg, the differences between countries in terms of the type of income, funding modes, the target population, ie, the general public or a specific socioeconomic level) as well as the source of the identified and collected measurements (electronic files, interviews, evaluation scales, as well as the context of the study) should also be considered as they are variables that affect the outcomes and hinder the comparability among studies.1
The scarcity of effective interventions found in this review is in line with the findings of another systematic review by Smith et al that focused on interventions for improving outcomes for patients with multimorbidity in primary care and community settings.11 Although it did not focus exclusively on older persons, most of the 17 RCTs included in it recruited participants in that age group. The single most relevant outcome found in that systematic review was an improvement in mean depression scores, with high-quality evidence supporting it. There was moderate-quality evidence that some interventions improved the healthcare providers’ behaviour and enhanced health-related patient behaviours such as increased physical activity. The effect in other outcomes was less clear, with probable slight improvements in patient reported outcomes and medication adherence. However, no clear effect on clinical outcomes or in health service use was noted. Moreover, it was not possible to compare costs across studies.11
Both in our systematic review and the one by Smith et al, the most common intervention types were educational strategies aimed either at patients or healthcare providers, implementation or enhancement of multidisciplinary care and organisational modifications to delivery of care.11 However, there is a growing claim for the inclusion of diverse approaches tailored to people living with complex multimorbidity or advanced illnesses. Mas Miquel et al propose an integrated model of care for older persons with complex chronic conditions, after identifying the following evidence-based clinical practices to include in the comprehensive care of these populations: multidimensional assessment by a multidisciplinary team; education of the patient and caregiver; anticipation to health crises; activation to alternatives to conventional hospitalisation; proactive care provision in case of hospital admission; health and social status changes monitoring in transitions; end-of-life care planning.48 While these methods and arguments are compelling, these models will be empirically tested in the near future.
Conclusions
Out of the 25 studies identified, 3 studies were rated as effective, overall.
All the interventions addressed in the 25 models are similar to public health interventions as their main aims were the promotion of health and the prevention of disease complications at the community level. The most effective outcomes focused on improving the relationship between the patient and the healthcare professional in the early stages of the intervention; therefore, following this guideline is recommended. However, the most important problem identified in this review refers to the low quality of the studies based on the results assessed using the risk of bias tool. The multiplicity of variables and outcomes measured in each study also hinder their interpretation. To improve comparability among studies, a standardised reporting system for outcomes is warranted.
The evidence here presented suggests that enhancing, rearranging or building on the status quo is not enough where effectiveness of care delivery for older persons with chronic diseases is concerned. There is a need for innovative approaches that emphasise on patient-centredness, but also on integrated, continuous, easy-to-navigate care, while addressing methodological issues that guarantee good-quality evidence.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors All authors are responsible for reported research, and they have all approved the manuscript as submitted. LAB-N: Study design, review of the literature, analysis and interpretation of data, preparation of the first draft. JG-E: Concept of the study, interpretation of data, critical review of the manuscript JMMD: Review of the literature, analysis of data, preparation of the first draft. RM-C: Original idea, interpretation of data, critical review of the manuscript. MCG-P: Original idea, critical review of the manuscript, guarantor of the manuscript.
Funding This article was partially supported by a grant from the Secretaría de Educación, Ciencia, Tecnología e Innovación de la Ciudad de México CM-SECTEI/200/2020 ‘Red Colaborativa de Investigación Traslacional para el Envejecimiento Saludable de la Ciudad de México (RECITES)’.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.