Resumen Objetivo principal: describir características, atributos y acciones específicas del cuidado de enfermería respetuoso del Buen Trato. Metodología: estudio de métodos mixtos basado en el análisis de contenido de Kyngäs sobre una muestra de enfermeras y estudiantes de enfermería. Se realizaron grupos focales y encuestas. Resultados principales: se identificaron cuatro dimensiones: (a) significado del Buen Trato en la atención de Enfermería, (b) conductas que reflejan una atención de enfermería que respeta el Buen Trato, (c) conductas que vulneran el Buen Trato y (d) dificultades de los estudiantes para otorgar cuidado respetuoso. Conclusión principal: El Buen Trato se basa en una relación enfermera-usuario construida sobre el respeto y reconocimiento de la dignidad de las personas. El proceso de enseñanza/aprendizaje orientado al Buen Trato en enfermería requiere que integrar conocimientos teóricos, prácticos y actitudinales, que permita a los profesionales contar con las competencias necesarias para brindar cuidado respetuoso.

Abstract Objective: to describe the characteristics and attributes and the specific actions of a respectful nursing care. Methods: Method: a mixed methods study based on the content analysis by Kyngäs was conducted with a sample of nurses and nursing students. The data was obtained through focus groups and surveys. Results: four dimensions are identified: (a) meaning of Respectful Care in Nursing care, (b) behaviors that reflect a Respectful nursing Care, (c) behaviors that violate Respectful Care and (d) difficulties of the students to include the Respectful Care in their practice. Conclusions: A Respectful Care is based on the nurse-patient relationship where patients are treated with respect for their dignity. The teaching/learning process with focus on Respectful Care in nursing requires to integrate theoretical, practical and attitudinal knowledge, which allows professionals to have the necessary skills to provide respectful care.

Background: Menopause connects a biological event with social representations related to aging Aim: To assess the meaning of menopause in a group of Chilean women attending primary health care. Material and Methods: Secondary analysis of a descriptive qualitative study of in-depth interviews to explore the meaning of menopause in fifteen women aged 55 to 71 years who experienced menopause between 2 and 29 years before. Data were collected using the method proposed by the Grounded Theory. Guba’s criteria of scientific rigor were used. Results: Relational analysis shows that menopause divides the life cycle of women into two stages related with the possibility of having children, which is heavily influenced by the cultural significance of menopause. Conclusions: Women perceive that menopause is a natural stage and that it is the end of a period focused on tasks related to reproduction and motherhood. However, that “normality” includes a suffering process, loaded with negative cultural beliefs about menopause passed down for generations.

Background: Breast cancer (BC) has a high mortality rate in developing countries due to a scarcity of early detection. Risk communication is critical to support women who face the decision to undertake BC screening. Thus, they can balance their perceived and real risk, and make informed choices. Aim: To describe experts’ views on how the provision of information related to BC screening should be made. Material and Methods: A qualitative study with focus groups with national experts was conducted. Open coding was performed. Results: Four categories on the way information about BC screening should be provided emerged: to communicate about the need of the exam; the pros and cons of the test; fear as a barrier for understanding; and involving women in the decision-making process. Conclusions: These findings emphasize the need to include risk communication strategies in the patient-provider relationship and encourage and respect women's autonomy when facing the BC screening decision.

Summary Introduction: The clinical preceptor is essential in the training of nursing students. They are a model and guide in the approach to professional work, facilitate learning and link theory and practice. In Chile, the competencies of the nursing clinical preceptor for undergraduate students have not been established. So the purpose of the manuscript is to describe the competencies of the clinical nursing preceptor for the training of Chilean nursing undergraduate students from the perspective of expert nurses. Subjects and methods: Qualitative design study. For the construction of the competency profile, an electronic Delphi was conducted with 22 expert nurses, then the content was validated with the participation of judges. Results: 12-14 nurses and 11 judges participated. The Profile of competencies for the clinical nursing preceptor composed of five dimensions: professional, clinical teaching, critical thinking, interpersonal skills and teamwork. Conclusion: The profile provides guidance and standards that ensure the quality of teaching and the training of future nurses in a framework that professionalizes the work of clinical preceptor.

Resumen Introducción: La figura del tutor clínico es esencial en la formación de los estudiantes de enfermería, dado que es modelo y guía en los procesos de aproximación al quehacer profesional y se transforma en facilitador del aprendizaje y en un nexo entre la teoría y la práctica. Pese a ello, en Chile no se han establecido las competencias del tutor clínico de enfermería para estudiantes de pregrado, por lo que el objetivo del manuscrito es describir sus competencias para la formación de estudiantes de pregrado de enfermería chilenos desde la perspectiva del personal de enfermería experto. Sujetos y métodos: Es un estudio de diseño cualitativo. Para la construcción del perfil de competencias se realizó un Delphi electrónico con 22 enfermeros expertos y luego se realizó la validación de contenido con la participación de jueces. Resultados: Participaron 12-14 enfermeros expertos y 11 jueces. Se construyó el perfil de competencias para el tutor clínico de enfermería, compuesto de cinco dimensiones: profesional, docencia clínica, pensamiento crítico, habilidades interpersonales y trabajo en equipo. Conclusión: El perfil brinda orientación y estándares que aseguran la calidad de la docencia y de la formación de futuros enfermeros en un marco que profesionaliza la labor de los tutores clínicos.

ABSTRACT Introduction: The right to health care ensures access of all individuals to equal opportunities to achieve an optimal health status. Objective: Describe the relationship between inalienable human rights and patient-centered care according to users of primary health care centers and experts in primary health care in Chile. Methods: A qualitative prospective descriptive study was conducted from January to December 2015 to analyze Krippendorff's alpha content in five focal groups of 41 users and three-round e-Delphi with 29 Chilean experts, as well as the data saturation end criterion and the agreement coefficient. Results: According to users, perception of kind treatment in health care implies that it be consistent and integrated and does not breach users' needs, all of which is directly related to respect for the right to health. This is consistent with the opinions contributed by experts, but not with the experiences undergone by users at primary health care centers, which are examples of practices related to institutional violence. Conclusions: Respect for health human rights should have a first-priority position in the health public agenda, since dignified treatment is a right to be enjoyed by the entire population.

RESUMEN Introducción: El derecho a la salud garantiza el acceso a todos los individuos a iguales oportunidades para alcanzar el grado máximo de salud. Objetivo: Describir la vinculación entre derechos humanos irrenunciables y la atención centrada en la persona según usuarios de centros de salud de Atención Primaria y expertos en Atención Primaria de Salud de Chile. Métodos: Estudio cualitativo, descriptivo y prospectivo, desarrollado entre enero y diciembre de 2015, considera análisis de contenido de Krippendorff de 5 grupos focales con 41 usuarios y Delphi electrónico de 3 rondas con 29 expertos chilenos. Criterio de finalización saturación de la información y el Coeficiente de Concordancia. Resultados: Según los usuarios, la percepción de buen trato en la atención de salud implica que esta sea coherente, integrada y que no fragmente los requerimientos de los usuarios, lo que se vincula directamente con el respeto al derecho a la salud. Esto es consistente con lo planteado por los expertos, pero es discordante respecto a la experiencia vivida por los usuarios en los centros de la Atención Primaria de Salud, lo que es parte de prácticas vinculadas a la violencia institucional. Conclusiones: El respeto de los derechos humanos en salud debe posicionarse como un tema de primer orden en la agenda pública de salud, ya que el trato digno es un derecho propio de todas las personas.

Abstract Introduction: The interpersonal relationship is one of the pillars of nursing practice. These relationships are based on the empathic understanding and acceptance of patients. Developing specific skills is a fundamental aspect to effective therapeutic relationships. Nevertheless, the Chilean nursing undergraduate programs lack this component. Aim: to analyze barriers to teach and learn interpersonal relationship skills from lecturers and students’ viewpoints. Method: A qualitative study based on content analysis was conducted, by using semi-structured interviews with lecturers and focus group with students of one Chilean school of nursing. Results: Fifteen lecturers and eight students took part. For the lecturers, the main barriers to teach interpersonal relationship skills are their scarce training on this topic and the lack of content in the undergraduate program. For the students, barriers to learn these skills include the underestimation of these by their lecturers and few opportunities to practice the skills. Conclusions: Further research is need explore the characteristics of educational interventions to train these skills, considering lecturers’ training and inclusion of the contents in the curricular program.

Resumen Introducción: La relación de ayuda interpersonal es uno de los pilares del cuidado de enfermería, basándose en la comprensión empática y aceptación incondicional del paciente. El desarrollo de habilidades específicas es fundamental para el establecimiento de relaciones de ayuda efectivas. A pesar de esto, los programas de formación de pregrado en enfermería chilenos, carecen de estrategias para potenciar en los estudiantes dichas habilidades. Objetivo: analizar las barreras percibidas por los docentes y los estudiantes de enfermería para el aprendizaje y enseñanza de habilidades de ayuda en el encuentro clínico. Método: Se realizó un estudio cualitativo descriptivo basado en el análisis de contenido, a través de entrevistas semiestructuradas con docentes de enfermería y grupo focal con estudiantes de una escuela de enfermería chilena. Resultados: Quince docentes y 8 estudiantes participaron en el estudio. Las barreras percibidas por los docentes para enseñar habilidades de ayuda incluyen la falta de formación propia en la temática y la ausencia curricular de contenidos relacionados con esta materia. Para los estudiantes, la subvaloración de estas habilidades por parte de los docentes y la falta de espacios para ejercitarlas, son las principales dificultades para aprender estas habilidades. Conclusiones: Futuras investigaciones podrían explorar las características de intervenciones educativas que faciliten la enseñanza y aprendizaje de estas habilidades, considerando la necesidad de formar a los docentes y de relevar en el currículo y evaluaciones de los estudiantes el componente relacional.

Background: The Family and Community Health Model (MAIS) establishes the continuity of care as an essential principle. The Family Study, as a clinical strategy, allows to have sufficient and timely information and knowledge about users of health care services, facilitates their accompaniment and is a source of information to improve the quality of care and the management of health centers. Aim: To develop a tool to conduct family studies, devised by experts in Primary Health Care. Material and Methods: Using a qualitative method, an electronic Delphi was conducted on 24 experts on primary health care. Afterwards, the content validation was carried out with the participation of judges. Results: The resulting tool considers two levels of family assessment. It allows to distinguish those families that would benefit from interventions of greater complexity than those derived from the usual care of health centers. Conclusions: The tool to perform family studies responds to the informational and continuity component of Continuity of Patient Care principle. It may be a proposal for the continuous improvement of Chilean primary care.

Background: Decisional conflict refers to the personal uncertainty about which course of action to take when the choice involves risk, regret, or challenge to personal life values. Aim: To determine the level of decisional conflict (DC) of people with Diabetes Mellitus (DM) or High Blood Pressure (HBP) attending primary care centers (PCC) in Chile. Patients and Methods: A Spanish version of the Decisional Conflict Scale (DCS) was applied to patients who were recruited if they had DM or HBP, were 18 years old or older, and had an appointment at the PCC the day of the recruitment. The scale was self-administered. Analysis of covariance (ANCOVA) was used to determine association between DC and other variables of interest while controlling confounding variables. Results: The scale was answered by 1075 participants from 24 PCC aged 62 ± 14 years (74% female). Average score for the DCS scale was 16.8 ± 12.9 of a maximum of 100 points indicating a higher DC. The sub-scale “information” had the highest score (19.9 ± 20.0). Low educational level and older age were significantly associated with higher DCS scores (p < 0.05). Having a bad health perception, deciding to initiate a medical treatment and being attended by a doctor were significantly associated with higher DC. These associations persisted when confounding variables such as sex, age and education were controlled. Conclusions: People with DM or HBP who have a poor health perception, who initiated their treatment and were attended by a doctor had higher levels of DC, independent of their age and educational level.

ABSTRACT Objective Describe users' experience with participation in clinical decision-making at Family Health Centers (CESFAM) in the Primary Health Care (PHC) system. Methods Qualitative descriptive study. Focus groups made up of CESFAM users were held in southeastern Santiago, Chile, and the information was thematically analyzed using Atlas.ti version 6® software. Results Five focus groups were held (n = 41). The main themes that emerged from the discussions were the passive role of users in decisions and delegated decision-making, based on their trust in the health professional. Users' passive role limits their opportunities for participation in clinical decision-making, ceding power to the health professional. However, establishing a therapeutic partnership allows users to feel that they are being treated as unique individuals whom the professional listens to and respects, ensuring that the decisions of the health team can be trusted, since they look out for the users' real interests. Conclusion Users' participation in clinical encounters is still limited in Chile. However, bolstering that participation is essential for increasing user satisfaction and promoting people-centered care.

RESUMEN Objetivo Describir la experiencia de participación en las decisiones clínicas desde la perspectiva de usuarios de Centros de Salud Familiar (CESFAM) de la Atención Primaria de Salud (APS). Métodos Estudio de diseño cualitativo descriptivo; se realizaron grupos focales con usuarios de CESFAM del área sudeste de Santiago, Chile, y análisis temático de la información utilizando el programa Atlas.ti versión 6®. Resultados Se realizaron cinco grupos focales (n = 41). Los principales temas emergentes fueron el rol pasivo de los usuarios en las decisiones y la toma de decisión delegada, basada en la confianza en el profesional. El rol pasivo de los usuarios limita las oportunidades de participación en las decisiones clínicas y mantiene el poder en los profesionales de la salud. A pesar de ello, el establecimiento de una alianza terapéutica les permita sentirse tratados como personas únicas, escuchados y respetados por los profesionales, lo que asegura que las decisiones tomadas por el equipo de salud son confiables, pues velan por sus reales intereses. Conclusión La participación de los usuarios en los encuentros clínicos es aún escasa en el país. Sin embargo, potenciar esta participación es esencial para aumentar la satisfacción usuaria y promover un cuidado centrado en la persona.

RESUMO Objetivo Descrever a experiência de participação nas decisões clínicas dos usuários dos Centros de Saúde Familiar (CESFAM) de atenção primária à saúde. Métodos Estudo qualitativo descritivo conduzido em grupos de discussão formados por usuários dos CESFAM da região sudeste da cidade de Santiago, no Chile. Foi realizada uma análise temática das informações com o uso do programa de software ATLAS.ti® versão 6. Resultados Foram formados cinco grupos de discussão (n = 41). Os principais tópicos abordados foram o papel passivo dos usuários nas decisões e a tomada de decisão delegada aos profissionais na base da confiança. O papel passivo restringe as oportunidades de participação dos usuários nas decisões clínicas e mantém o poder nas mãos dos profissionais da saúde. Apesar disso, ao ser criada uma aliança terapêutica, os usuários se sentem tratados como indivíduos únicos que são ouvidos e respeitados pelos profissionais, o que assegura que as decisões tomadas pela equipe de saúde sejam confiáveis porque protegem os reais interesses dos usuários. Conclusão Os usuários ainda têm pouca participação nas interações clínicas no Chile. Porém, é fundamental reforçar esta participação para melhorar a satisfação do usuário e promover uma atenção mais centrada na pessoa.

ABSTRACT Objective To describe the competencies for primary health care teams (PHC) in different topics related to the direct care of the user and the management of primary health centers, according to the perception of Chilean experts in PHC. Methods Mixed design studio. An electronic Delphi method was conducted with 29 national experts in APS. Results A matrix of specific competences related to direct work with families and to the management of the health center prioritized in three levels is proposed. Experts agreed that a critical mass of professionals with competencies in PHC is required. Conclusions The challenge of reorganizing health systems around a strong and quality PHC can only be achieved with the participation of professionals who understand and practice the attributes and fundamental principles of PHC. The results of this study show a competency profile for PHC professionals aligned with international recommendations achievable through continuous education strategies.

RESUMEN Objetivo Describir las competencias para equipos de atención primaria en salud (APS) en distintos tópicos vinculados a la atención directa del usuario y a la gestión de los centros de salud primarios, de acuerdo a la percepción de expertos chilenos en APS. Métodos Estudio de diseño mixto. Se realizó un Delphi electrónico con 29 expertos nacionales en APS. Resultados Se propone una matriz de competencias específicas vinculada al trabajo directo con familias y a la gestión del centro de salud priorizados en tres niveles. Los expertos concuerdan que se requiere una masa crítica de profesionales que cuenten con competencias que le conciernen a la APS. Conclusiones El reto de reorganizar los sistemas de salud en torno a una APS fuerte y de calidad solo puede lograrse con la participación de profesionales que comprendan y practiquen los atributos y principios fundamentales de la APS. Los resultados de este estudio dan cuenta de un perfil de competencias para profesionales de APS alineado con recomendaciones internacionales alcanzable a través de estrategias de educación continua.

RESUMO Objetivo Descrever as habilidades para equipes de atenção primária à saúde (APS) sobre vários tópicos vinculados com a atenção direta do usuário e gestão de centros de saúde, de acordo com a percepção de especialistas chilenos na APS. Métodos Estudo de desenho misto. Foi realizado um Delphi eletrônico com 29 especialistas nacionais em APS. Resultados É proposta uma matriz de competências específicas vinculada ao trabalho direto com famílias e à gestão do centro de saúde priorizados em três níveis. Os especialistas concordam que se requer uma massa crítica de profissionais que contem com competências em APS. Conclusões O desafio de reorganizar os sistemas de saúde em torno de uma APS forte e de qualidade só se pode conseguir com a participação de profissionais que entendem e pratiquem os atributos e os princípios fundamentais da APS. Os resultados deste estudo mostram um perfil de competências para profissionais de APS alinhados com recomendações internacionais que podem ser alcançadas através de estratégias de educação contínua.

Resumen En el mundo, la educación sexual en colegios católicos constituye un desafío. Desde el 2010, en Chile existe una ley que obliga a todos los colegios a contar con un programa de educación sexual. Sin embargo, su implementación en colegios de identidad católica ha sido poco evaluada. El artículo explora las dificultades y desafíos percibidos por los docentes a cargo de la educación sexual en colegios católicos de la Región Metropolitana de Santiago de Chile. Método: diseño cualitativo con datos recolectados con entrevistas semi-estructuradas, a partir de un guion temático sobre una muestra intencionada. Se realizó análisis descriptivo y relacional, basado en los procedimientos de la Grounded Theory. El criterio de finalización fue la saturación teórica de los datos. Las principales dificultades encontradas en la educación sexual en colegios católicos son: la tensión entre los postulados de la doctrina católica, las vivencias de los jóvenes, un entorno erotizado y adverso a los valores cristianos y las creencias de las familias y de los profesores. Además, la falta de participación de las familias y la dificultad operativa para impartir esta enseñanza, por la falta de tiempo protegido, de infraestructura adecuada y de profesores capacitados.

Abstract Sex education in Catholic schools the world over poses a challenge. Since 2010, all schools in Chile have been required by law to offer a sex education program. However, little has been done to evaluate its implementation in schools that identify as Catholic. The article explores the difficulties and challenges perceived by teachers who are in charge of sex education at Catholic schools in the metropolitan area of Santiago de Chile. Method: A qualitative design was used and data was collected through semi-structured interviews, based on a thematic script concerning an intentional sample. A descriptive and relational analysis was carried out, using grounded theory procedures. Theoretical saturation of the data was the criterion for completion. The main difficulties found with sex education in Catholic schools are: the tension between the postulates of Catholic doctrine, the experiences of young people, an environment that is erotic and adverse to Christian values; and the beliefs of families and teachers. In addition, there is a lack of participation on the part of families and the operational difficulty of imparting education of this type, due to want of protected time, adequate infrastructure and trained teachers.

Resumo Em todo o mundo, a educação sexual em colégios católicos constitui um desafio. Desde 2010, no Chile, existe uma lei que obriga os colégios a contarem com um programa de educação sexual. Contudo, sua implantação em colégios de identidade católica tem sido pouco avaliada. Este artigo explora as dificuldades e desafios percebidos pelos docentes responsáveis pela educação sexual em colégios católicos da região metropolitana de Santiago do Chile. Método: desenho qualitativo, com dados coletados em entrevistas semiestruturadas, a partir de um roteiro temático sobre uma amostra intencionada. Realizou-se análise descritiva e relacional, baseada nos procedimentos da Grounded Theory. O critério de finalização foi a saturação teórica dos dados. As principais dificuldades encontradas na educação sexual em colégios católicos são: a tensão existente nos que professam o catolicismo, as vivências dos jovens, o ambiente erotizado e adverso aos valores cristãos e crenças das famílias e dos professores. Além disso, a falta de participação das famílias e a dificuldade operativa para ensinar sobre o tema, a falta de tempo protegido, de infraestrutura adequada e de professores capacitados.

RESUMEN Objetivo: Identificar las necesidades de las madres adolescentes chilenas y las características de un servicio para apoyarlas. Métodos: Se condujo un estudio cualitativo, utilizando grupos focales y entrevistas con madres adolescentes del área sur oriente de Santiago de Chile. Se realizó un análisis temático utilizando el programa Atlas.ti versión 6. Resultados: Se realizaron tres grupos focales (n=22) y siete entrevistas con madres adolescentes. El principal tema emergente fue la necesidad de incorporar intervenciones basadas en Internet para apoyar a las adolescentes. De acuerdo a las participantes, la intervención debe incluir acceso inmediato a información (específica para el embarazo y habilidades parentales), apoyo de pares y continuidad del cuidado. Conclusión: Las madres adolescentes tienen necesidades particulares y estas pueden ser cubiertas por un espacio virtual seguro que entregue información, apoyo profesional y de pares continuo. Nuevas intervenciones deben incluir en su diseño las características tecnológicas nativas de este grupo y utilizarlas para apoyar a las madres adolescentes de manera efectiva.

Abstract Introduction Medical education is currently going through many changes, and Medical Schools must adapt in order to survive. These have to fulfil multiple roles and tasks, with research, teaching, and clinical care as a bottom line. Furthermore, and in many cases, these also include, management, community work, and continuing education courses. Previous studies show that not all of these roles are valued similarly. Objective The objective of this study was to examine the value of teaching perceived by academics from some Medical schools in Chile. Method Semi-structured interviews were conducted with twelve faculty members, all of whom have an active role in teaching. The sampling was intentional and guided by theory. Based on Grounded theory, the data was analysed using open, axial and selective coding. Finally the information was triangulated with literature ad-hoc. Results Three categories emerged from the analysis. First, the “multiple roles and tasks” performed by the faculties. The second is the “personal value of teaching”, and the third, the “institutional value of teaching”. The problem is that, even though teaching is valued, there are other activities, such as research and patient care, that are valued more,. Conclusions These results are multifactorial and they provide evidence that faculties perceive that teaching is relevant, but other activities, like research and clinical work, are valued more The results are similar to those found in the literature, and encourage us to pursue initiatives to rescue and promote the value of teaching, such as protected time for teaching, mentoring, promotion of innovation and excellence, etc.

Resumen Introducción Los académicos de las escuelas de medicina deben cumplir con múltiples roles, como investigación, docencia y asistencia clínica, además de labores de extensión y gestión. Estudios previos muestran que no todas estas labores son valoradas de similar manera. Objetivo Explorar la valoración de la docencia percibida por académicos de una escuela de medicina chilena, a nivel individual, de los pares y de la institución. Método Estudio cualitativo descriptivo que utilizó para el análisis de datos los procedimientos propuestos por la teoría fundamentada, sobre una muestra de 12 académicos que cumplieron criterio de inclusión. Los datos se obtuvieron a través de entrevistas semiestructuradas. Resultados Emergen 3 categorías de análisis: 1) multiplicidad de roles; 2) valoración personal de la docencia, y 3) valoración institucional de la docencia. Destaca que, si bien la docencia es importante, existen otras actividades más valoradas a nivel personal e institucional, como la investigación y la atención de pacientes. Conclusión Los resultados muestran una multiplicidad de factores que afectan a la valoración de la docencia en medicina. Los académicos percibieron la existencia de tareas de mayor connotación académica que la docencia, asociadas a mayores ingresos económicos o al ascenso en la carrera académica, lo que invita a buscar iniciativas institucionales para generar espacios reales de desarrollo académico con el reconocimiento que merece en instituciones que primariamente tienen como misión la formación de las personas.

Background: The Family and Community Health Model is based on three essential principles: user-centered care, comprehensive care and continuity of care. Aim: To describe the attributes and characteristics of the guiding principles of the Family and Community Health Model (FHM) from the perspective of primary care experts. Material and Methods: This was a qualitative study. An electronic Delphi was conducted with 29 national experts on primary care. Results: The experts agree that user centered care must be based on a psycho-social model integrating the multiple factors that influence health problems. It also must integrate patients’ individual features, family and environmental issues. The proposed actions promote shared decision making. To promote integral care, anticipatory guidelines should be expanded and health care of patients with chronic conditions should be improved. Continuity of care should be promoted increasing working hours of medical centers and easing access to integrated electronic medical records, thereby generating efficient links between the different care levels. Conclusions: The results of the study can guide the clinical and administrative management of health teams, allowing the strengthening of primary health care according to the local realities.