Arabic Family Member Makes Decisons Regarding Health Care
Introduction
With the high reliance on use of folk/traditional remedies in Arab families,i understanding how family members depict on biomedical models in the direction of affliction is important for health care providers striving to provide culturally competent intendance. Information technology has been suggested that a person interested in folk remedies may use a complex arrangement of traditional remedies mostly based on psychosocial interventions, mild herbs, ritualistic behaviour or household items.ii,3 The use of folk remedies to manage illness is often influenced by family beliefs and the natural or social environment they alive in.four,5 In this instance, agreement the relationship betwixt health beliefs and traditional practices is important in conceptualising the capacity of families to manage affliction during astute or chronic illness.
Historically, several theories have been suggested to explicate this relationship, with the explanatory models of illnessvi found to exist the most accepted. Folk theories associated with the cultural formulations of explanatory models of disease accept been part of much wider conceptual models used to explain lay model of sick-health. Kleinman's explanatory model proposed that how people shape the experience of affliction and the behaviour that follows constitute their "Folk Model of Disease". The constellation of what has happened, why it has happened, and what should be done almost it were considered of import in understanding how individuals make sense of, and deal with their sick-wellness in terms of their own view of reality.7
Earlier studies have shown that biomedical models of illness that emphasise the roots of illness in anatomy, heredity, and disease processes, are more common in Western societies than elsewhere.8 Conversely, a "situational" model that describes psychosocial distress in the context of social and interpersonal situations may exist a more mutual explanatory strategy in traditional societies and ethnic minorities.ix
It is assumed that cultural and personal frameworks strongly influence handling decisions in families.10 In a state like Jordan where family ties and cultural heritage are paramount and pervasive, health beliefs may influence health outcomes or may produce certain traditional practices that may shape self-management of illnesses.2
There is increasing recognition that families are often involved in decision-making during disease; however, little is known about how health beliefs influence decisions or behaviours related to managing an illness in the Arab world. Such knowledge volition enable successful translation of culturally specific programs targeting health promotion and cocky-management of affliction in Arab societies.4 For the Arab population, despite a pocket-size torso of social and health science inquiry on this population during the terminal few years, a gap exists in research on the cultural formulations of wellness and affliction. A recently published studies of care practices and management of illnesses in Arab mothers demonstrated the importance of acknowledging traditional folklore and situating it within a family unit context.2 Understanding the underlying relationship of Arab culture to health beliefs and practices is a cardinal factor in any handling strategy that involves modifications of behaviours and other lifestyle intervention.4
Aims
This newspaper presents a new model that can be viewed as an extension to the Health Belief Model and assist clarifies the cerebral processes families use to manage affliction in an Arab family unit in Hashemite kingdom of jordan. The aim of this report was to generate an agreement of family beliefs about the causes of illness inside Arab families and family members' appraisal of how all-time to manage illness.
Method
This study employed a qualitative descriptive research design involving semi-structured family unit group interviews.
Theoretical Framework
The theory underpinning the study was Kleinman'southward explanatory model.7 It postulates that private beliefs around illness, misfortune, and health are culturally determined and that individual's health behavior might exist unlike from the ones held past their health providers.7,eleven In Kleinman'southward model, illness is culturally shaped and relates to how individuals perceive, experience, and cope with diseases.
The effect of cultural norms, Islamic values, too as family dynamics tends to influence individual's perception and feel of illness.12 For the purpose of this study, the Jordanian Arabic cultural context will exist used to empathise individual'southward perceptions of affliction in the following areas: how illness is caused, what causes it, why it started, why at a detail fourth dimension, when did information technology happen, and what (happens) next.7 Understanding this interactive relationship will shed light on how health beliefs and wellness practices interact in relation to treatment and illness self-direction in an Arab family unit.
Sample and Recruitment
A simple convenience sample was used to recruit a purposive sample of Arab families who lived in urban and metropolitan areas in Jordan. Potential participants were approached in the community setting through flyers posted in public places and social community settings. According to Zuna et al,13 the family unit unit in research is defined as "the commonage number of individuals who consider themselves to exist part of a family and who engage in the same activities together on a regular basis". For this study, the family was the unit of measurement of analysis in this research and included family members living together or related by marriage or blood. In this report, outset generation is defined as participants attending the family unit interview with their children and grandchildren, irrespective of the participant's age; second generation is defined as parents attending the family interview with or without their children; and third generation every bit participants aged 18 years or older attending the family interview with their parents and/or grandparents. Identification of eligible families was limited to families who identified themselves as having an Arab background, able to speak and understand Arabic, and willingness to be office of a family unit grouping interview. Maximal variation was pursued on demographic factors, including socioeconomic status, level of education, historic period, and size of family to ensure that the sample was as representative every bit possible. Two research assistants with prior enquiry experience (male and female) conducted all of the interviews with men and women interviewed at the same time. All interviews were conducted by one of the research assistants and lasted 1–ii hours.
Interviews
The family group interviews were conducted at a location chosen by and convenient to the participants and were mostly conducted at the participants' home. All family members joined the interview in person, yet non all of the family decided to take part in the interview. The interview questions were designed to explore health-related beliefs and practices and the utilize of ethno-medical remedies amid family unit members (see Supplementary File for the interview guide). The family group interviews varied in size from two participants to 7 participants. All interview sessions were audiotaped and transcribed.
The data from all participants are presented equally family unit level data. Twenty-five families from various geographic locations in Jordan agreed to participate in the written report. Fifteen families had experienced at to the lowest degree i chronic condition such as cancer, type 2 diabetes or hypertension and 10 families experienced acute illness including allergies, eczema and viral infections. The family members' age varied from 18 to 81 years, and the bulk of participants were from two main cities in Jordan (Amman and Zarqa) and three from rural areas (Karak). Table 1 sets out participants' demographic information past family case summary.
 | Tabular array 1 Characteristics of the Sample of 107 Participants from 25 Extended Arab Families Attended the Interview |
Information Analysis
Thematic assay was undertakenfourteen and the guidance developed past Knafl and Ayres15 fatigued upon to analyse family data. Practical issues relating to interviewing families were consideredsixteen and include preparation for the interviews, interviewer/family interactions during the interviews and closing the interview. Thematic analysis was used to make up one's mind the major recurring themes in the interviews, employing Boyatzis'south approach,14 where a theme is described as "a blueprint constitute in the information that at a minimum describes and organises the possible observations and at maximum interprets the phenomenon, p. iii".14 Analysis involved reducing the data to pregnant statements or quotes and identifying themes to draw together significant statements and coherent patterns. Assay then moved on to compare themes across transcripts and explore relationships.
The family analysis approach set out by Knafl and Ayres15 was used to guide the analysis. Three questions were drawn on throughout the analysis to explore the meaning for family: how are these findings meaningful in investigating the family experience? Does the information represent family-level information? Do these information draw an individual perception of a family member that contributes to understanding the shared family experience? Family case studies were written upwardly to capture and preserve both the individual viewpoint and family context of the data. By evaluating agreement amongst participants, homogeneity in responses betwixt cases provided testify for a shared, community-level folk model for the Arab customs. We systematically compared individual and family themes on the causes of illness and behaviours following the onset of disease. The assay was conducted by a team of two researchers and reviewed and discussed past a third.
Analysis of the family interview generated a series of structured narratives guided past the study questions. The post-obit themes were highlighted throughout our analysis causes of illness, indicators to course of action, and decision to act (decision to use folk remedies and/or modern remedies).
In this study, inquiry rigor was established through attention to the concepts of credibility, dependability, confirmability, and transferability.17 Credibility and trustworthiness of the findings were supported through the depth of the information collected with 25 families, the detailed descriptions of participants and the method used in writing instance summaries. All narratives and transcripts were conducted in the participant's native language for optimal description of beliefs and practices. To ensure dependability, the same interview guide was used for all family members, as well as an external researcher to secure dependability and reflexivity. Confirmability was generated through reflexivity and audit trials.
Upstanding Consideration
This study was conducted in accord with the Declaration of Helsinki. Prior to the interviews, the research assistants explained the study purpose to the participants and all family members provided informed consent that included publication of anonymized responses. Participants were informed of their correct to withdraw from the study at whatsoever time and for any reason. Ethical approval was obtained from the Institutional Review Board (The University of Hashemite kingdom of jordan, ethics approval dated 26/05/2016) before starting time of the written report.
Results
Grounded in an initial analysis of the information that identified relevant coding categories and themes, the family case summary served to refine and extend the analytic categories and represent a family centered approach. The following steps were followed: Beginning, substantive codes were inductively extracted from the data and applied to each interview. An example of codes that emerged at this stage were fatalistic behavior, supernatural explanations, lay-referrals and self-medication (Table 2). This stage reduced the information to manageable units for further analysis. Secondly, 2 of the inquiry team members individually reviewed the transcripts relating to each family group and prepared a brief background summary. The summaries were used to develop a guideline for completing detailed case summaries for each family unit, including analytic insights. An instance of an analytic insight showed in ane of the example summaries is presented below:
 | Table 2 Construction of Themes, Subthemes and Categories as Described by Families Prior to Their Utilise of Folk Remedies |
Brief Annotate: View of Decision to Human action
A mother (second generation) when asked "what do you lot exercise to restore your health when you are sick?" said,
I detest going to hospitals and doctors, only Ali (her son), God bless him, he ever helps me following upwardly my appointments with the GP to monitor my hypertension … I often drink herbal teas such as karkadeih (Scientific name: Roselle plants) and add medical plants such as garlic to my nutrition so I boost my wellness, but in combination with the tablet prescribed for my hypertension.
This statement illustrates the employ of lay-referral strategies and cocky-prescribed remedies such as self-medication.
An Extended Comment
The quotation above illustrates the grandmother's perception that she uses both folk remedies and modern remedies in managing illness. The case summaries presented in this study provided insight about whether family unit decisions to use folk remedies and/or modernistic remedies was based on their health beliefs, or prior experiences, and whether or not families were managing the illnesses using alternative practices. Case summaries assisted in identifying major analytic themes used in the identification and verification of thematic configurations across participating families. Examples of thematically coded data sorted by the case summaries for each family are provided in Table 3.
 | Table 3 Examples of Thematically Coded Information Sorted by Family Example Summary |
Throughout the major analytic categories, the beliefs regarding causes of illness and the social context in which families decide to self-manage their ill-health using folk and/or modern remedies were typical of the reflexive nature of qualitative research, and they were grounded in the data and contributed to farther analysis. Overall, data pertaining to the beliefs about illness and symptoms management were more often than not multifaceted, including fatalistic behavior, supernatural explanations, biomedical and/or situational factors. The main themes and illustrative quotes for the written report findings are shown in Tables iv–6.
 | Table 4 Themes and Illustrative Quotations from Families Regarding the Cause of Illness at Family unit Level |
 | Tabular array 5 Themes and Illustrative Quotations from Arab Families Regarding Indicators to Course of Action at Family Level |
 | Table six Themes and Illustrative Quotations from Arab Families Regarding Decision to Act at Family Level |
The Treatment Decision Model
A handling decision model evolved through analysis that describes how families, in this study conceptualised the cause of illness7 and central elements of family members' appraisement of how best to manage disease (see Figure one). The handling determination model unfolded as follows: causes of illness, indicators to course of action, and decision to human action (decision to use folk remedies and/or modern remedies).
 | Figure 1 Health behavior and treatment decision modelling during illness. |
Causes of Illness
Beliefs near the causes of illness were an assembly of several factors that family unit members used to try to explain why affliction has happened. The main themes and illustrative quotes are shown in Table 4. We were able to identify four explanations of illness equally office of much wider conceptual models used to make sense of illness between family members. This was through using fatalistic beliefs (God's volition) and/ or supernatural explanations including belief in an evil eye, or witchcraft to elucidate the cause of illness. Other beliefs included biomedical explanations where the roots of illness were emphasised in heredity factors, germs, faulty practices, and negligence of health, and finally, situational factors which are embedded in the context of life stressors and environment every bit mutual causes of affliction. Each family unit member used two or three explanations for the cause of illness. For example, an affliction can be caused by a germ or bad cistron (reasons), yet it is considered to be "God's will" that a germ is contracted or to inherit a gene (crusade). This suggests two forms of intertwined beliefs: core behavior (fatalistic) and secondary beliefs (biomedical, supernatural and situational behavior).
Indicators of Form of Activeness
Each family has revealed an individual estimation of illness inside a family unit and possible reactions to this illness. This personal estimation represents a general cognitive appraisal process for what to do during illness and how best to manage an illness inside family. The main themes and illustrative quotes for the key elements underpinning treatment decisions among families are shown in Tabular array 5.
The decision to run into a doctor or to use self-prescribed remedies to manage disease included 4 key factors: First, evaluating the perceived threat of affliction and possible outcomes. The majority of families (north = 23) illustrated that perception of illness severity equally (simple or mild versus life threatening or emergency) were primal in helping to shape their handling decisions and the utilize of folk and or modern remedies. Back up for the decision to rely on modern remedies and attend a health clinic came mainly from subjective cess that an disease was life threatening and fearfulness of "death". On the other hand, elements related with decisions to rely on folk remedies and/or self-medication were related to estimates of minor or low perceived threat (eg, brusque-term gastroenteritis, or mutual cold).
The second stage appraised the perceived effectiveness of handling option (modern and/or folk remedies) in reducing severity of symptoms and treating the illness in a timely manner. Thirteen families described evaluating the extent to which affliction could be managed by using folk remedies alone or in combination with modern remedies. Several family unit members described strong beliefs in the effectiveness of sure herbs and traditional practices such as hijama and cupping in treating their symptoms, while others described their concerns regarding the time it can take to achieve the desired outcome leading to the decision to apply modern medicine. In add-on, it was noted that some family unit members, in item those with chronic disease in the family who perceived poor or low effectiveness of mod remedies reconciled modern remedies with folk remedies to manage illness.
The third phase was the decision to trust the family around the treatment option in low-cal of family member's previous experiences and knowledge about the affliction or its symptoms. Cardinal here were family members' current and past feel with healthcare providers and direction regimes. Nearly 17 families stressed that they had lost trust in healthcare professionals and decided to rely on traditional remedies as first option for handling to avert unwanted side effects, medical errors, or faulty practices.
Finally, estimating the overall cost of the treatment option and its availability were described. As shown in Table 5, some families (n = 7) assessed the perceived financial consequences of attending a clinic or seeing their GP as not worthwhile. Participants described using cocky-prescribed antibiotics or herbs to self-manage their symptoms considering it was readily available to them and at depression-cost.
Decision to Human action
Most families described using "lay-referral strategies" prior to deciding whether to rely on folk and or modern remedies. The term, "lay-referral" in this written report is used to describe informal conversation and advice about whatever health concerns encountered. Lay referral in this study was an important method of getting families to use certain folk remedies, as well equally it is considered equally an important gene for choosing a particular wellness care professional for treatment.
As shown in Tabular array vi, the extended family and social network of family members had an important role to play in family level decision around treatment. For case, while well-nigh all families (northward =24) best-selling seeking medical communication from their general practitioner or healthcare provider at some point when feeling sick, fewer relied on traditional healers (northward = iii) extended family fellow member (n = 7) or social network (n = 8) for health communication. Furthermore, almost half of family members (due north = 14) described using self-medication such as or over the counter medications (antibiotics tin can be accessed without a script in Jordan), in improver to other types of folk remedies to manage disease without informing their GP. Overall, our findings suggest that the link betwixt illness beliefs and treatment decisions are tentative and non clear. While over half the family members believed that sick-health is caused by an evil middle or green-eyed, these behavior did not translate into handling decisions such as going to traditional healer or relying on folk remedies lonely).
Word
The current study used Kleinman "s framework7 to conceptualise a model that encompassed family beliefs about the causes of affliction and central factors of family members" appraisal of how best to manage illness in an Arab family unit. To our cognition, the current report is the first to provide conceptual modelling that explores and elaborates upon disease behavior and handling decisions using a family unit interview method.
As depicted in Figure one, the treatment decision model is a conceptualisation of key factors of how the family unit interpreted illness within a family unit and how to it decided to manage it (cognitive appraisement). For example, a family's initial appraisal tin can exist that an illness is elementary or balmy and therefore can be managed by lay use of self-prescribed remedies, or an disease is life threatening or emergency and necessitates the use of lay referral strategies. Embodied within this model is cognitive appraisement that facilitates family 'decision to employ' modern remedies and/or "folk remedies" in managing illness. In this model, we propose that each family has its own lay model for both chronic and acute affliction. Family unit decision to use folk remedies and or modernistic remedies in managing illness is conceptualised through the interplay of the 4 cardinal factors together and are not necessarily tied to single cognitive domains or to a unmarried central-factor.
In this study, a shared understanding of causes of illness was perceived to exist a combination of fatalistic beliefs and/or situational and biomedical explanations (multicausal explanations). Causes of disease stated by families revealed strong beliefs about green-eyed and the evil centre that are coinciding with "supernatural explanation" still crusade of disease was seen in a more multifaceted fashion. These behavior can be regarded equally share beliefs within Arab families in Jordan, but it cannot exist regarded as an exhaustive description of all illness behavior. This finding may sound contradictory from the perspective of Kleinman's theory of Explanatory Models,7 where illness beliefs are likely to autumn under either supernatural/spiritual or bio-psychosocial domain. Nevertheless, our findings are coinciding with previous studies from Muslim societies18,19 that causes of illness are often embodied in multicausal explanations combining both spiritual and bio-psychosocial factors in explaining health and affliction. This may reverberate the modification of beliefs as a office of education or exposure to Western cultures.
Some of the health beliefs emerged equally the expression of "God's volition", ordinarily used in Muslim's societies. For some participants, this may hold a deeper underlying meaning at play to decide thoughts and behaviours in an Arab family. Therefore, we suggest that fatalistic beliefs every bit "God's will" are a core belief, while other interweaved beliefs are secondary or peripheral constructs. Cadre beliefs are important to place, they are less likely to be challenged, distorted or modified during the participant's life bridge.20,21
Overall, lay utilise of self-prescribed remedies (self-medication through modernistic or folk treatments) and the utilize of lay referral strategies (visiting a clinic or seeking other's advice) relied on the evaluation of four key factors including perceived threat of illness, efficacy of treatment pick, cost or availability and family unit prior experience. Some of these factors reaffirm Champion and Skinner22 notion presented in the Health Belief Model (HBM) where health decisions are made to reduce symptoms through evaluation of motivation to act; threat posed past the symptoms; benefits of an action to reduce the threat; and barriers or costs of the action. Therefore, the model proposed in this written report can be viewed as an extension to the HBM described by Champion and Skinner.22 HBM theorises that for people to presume recommended behaviours, their perceived take chances of disease and perceived benefits of activeness must outweigh the perceived barriers to the action. Those elements were used to address the challenges of habitual unhealthy behaviours such as smoking and overeating. Even so, our current model addresses specific cultural needs related to the choice between modern remedies vs folk remedies in Arab families in Jordan.
In this study, treatment decisions suggested a relationship between type and perceived severity of condition and conclusion to self-medicate. The accounts provided do not imply a sequential approach to action or to self-medicate; they are mutually reinforcing and are pursued in parallel. We argue that each family constructs causal models of ill-health with assumptions about how best to answer to illness, still, it is less clear whether at that place is a human relationship between illness beliefs and the conclusion to act. We argue that in that location is a tendency in the evidence indicating association between illness beliefs and decisions to use folk or mod remedies. A farther report to explore the proposed model further would allow farther investigation of these relationships.
Whilst nosotros were unable to acquaintance treatment decisions with beliefs within our report, we would suggest that cultural values and norms influence family dynamics and beliefs systems within Arab family unit units and therefore the conclusion to use folk remedies and to self-medicate. This finding reflects in part the outcomes of an earlier study where the apply of folk remedies and self-medication of children was non wholly attributed to Arab customs and traditions, only rather promoted through family unit, social media and virtual support groups for mothers in the Arab world.3 This suggests that family unit still influence beliefs and behaviours within the family unit unit, although influences outside of the family are also important.
Finally, whilst this study did non attempt to quantify findings on behavior or practices, yet it revealed trends, for example, a high reliance on folk and alternative healthcare practices in Arab families in Jordan, high utilise of self-prescribed remedies amongst family members (folk herbs and/or cocky-prescribed antibiotics). This has likewise been described in other studies from Lebanon,23 and Jordan.24 The use of herbal remedies in the Eye Eastern region are historically linked to Arab family traditions, and/or the loftier floral diversity of Centre Eastern countries all year around.25 The high reliance on folk remedies may lead to a delay in seeking intendance, as well equally potential risk of using non-medically approved remedies.
Force and Limitations
Our findings are best understood in the context of Arab families in Jordan. While our written report included a multifariousness of demographic variables and representative data from unlike cities and backgrounds that makes our model transferable to the context of families in other Arab countries, farther research is needed to explore whether the findings are applicable to other countries. Information technology is important to acknowledge the possibility of selection bias related to utilise of convenience sampling every bit another limitation. Finally, we did non accept equal samples of each family structure within our example family unit summaries, yet we believe our samples of each family structure were enough for detecting meaningful association between family members with relation to their beliefs and decisions to apply folk and/or modernistic remedies.
Future enquiry should accost these shortcomings by replicating this study in different populations and by incorporating additional data well-nigh the context in which families are utilising self-prescribed remedies and its human relationship with affliction beliefs during astute and chronic illnesses. It will exist interesting also to examine how did differences in health beliefs influence outcomes. Finally, due to limitations in the interview guide, we were unable to identify if some family members were more influential in decision-making than others, or if the decisions to apply folk and herbal remedies were made as family or an individual unit. Futurity studies can refine and further adult our interview guide to elicit more than specific information about this issue.
Determination
With the high reliance on folk and alternative healthcare practices in Arab families, understanding how family members determine to manage illness should exist an of import priority for health care professionals. The present written report identified the specific key elements that contribute to the use of folk remedies guided by Kleinman.7 It too clarified the cognitive processes families use to manage illness in Hashemite kingdom of jordan.
The findings highlight that though family members appear to share many health beliefs that are congruent with biomedical concepts, wellness beliefs among families in this report were often interwoven with beliefs that are fatalistic and situational in nature. Healthcare providers should be prepared to elicit and talk over the four key factors that were identified equally underpinning the decision to use folk remedies or cocky-prescribed remedies such every bit non-prescribed antibiotics. Further attempts to understand the health belief model and related cognitive appraisal processes used by families may help assistance families in making informed and safety handling decisions.
Implications for Clinical Exercise
The electric current conceptual model may have important implications for health interventions. A recent study26 suggested that wellness care professionals in Western countries who attempted to show respect toward other cultures fear that they may inhibit their natural inclinations and intuitions—sometimes compromising their clinical judgments. Therefore, health care professionals may feel hesitant to inquire about cultural behavior and assume belief patterns. This report highlights the importance of existence curious and agreement how that individual/family unit make sense of the affliction/handling, and therefore how this influences their decision. An awareness of and understanding of the health belief model and related cerebral appraisal processes used past families in this study may assist nurses and other wellness care providers to appoint with and overcome some of the social, cultural, and structural variables that could influence how family members determine to manage disease in an Arab family unit.
This study provides an initial set of evidence that tin can help to understand the illness beliefs and cognitive process underlying the determination to employ folk and/or mod remedies in an Arab lodge. Therefore, this model can serve wellness promotion strategies directed for this population in whatsoever futurity studies. For example, it tin inform the tailoring of interventions to the family'southward culture and environment. While the Arab population is politically and religiously diverse, families share a common linguistic communication and culture4 and given the self-prescribed remedies described above, it seems that self-prescribed modern remedies as antibiotics, which can be accessed without a script, provides an of import mean for intervention and would perhaps be the most pervasive argument for intervention in Arab communities.
Data Sharing Argument
The information used to support the findings of this study have not been made available considering of the sensitive nature of its content and concerns surrounding privacy and confidentiality of research participants. In addition, families participated in this study did non requite consent for their information to exist publicly shared. Even so, the anonymised raw data relevant to the study tin exist shared upon reasonable asking on a case-by-example basis past contacting the following persons: Diana Arabiat, Associate Professor, Edith Cowan Academy, Australia, E-mail: ([electronic mail protected]).
Acknowledgments
We are grateful to all of the families who participated in the study, and we are grateful to the University of Jordan and Edith Cowan University for supporting the analysis and publication of this study.
Author Contributions
All authors made substantial contributions to formulation and design, conquering of data, or assay and estimation of data; took function in drafting the article or revising it critically for of import intellectual content; agreed to submit to the current periodical; gave final approval of the version to exist published; and concur to be answerable for all aspects of the work.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded through the University of Hashemite kingdom of jordan in Amman/ Jordan.
Disclosure
The authors declared no potential conflicts of interest in this piece of work.
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Source: https://www.dovepress.com/beliefs-about-illness-and-treatment-decision-modelling-during-ill-heal-peer-reviewed-fulltext-article-JMDH
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