How do people with post-COVID syndrome in Germany experience healthcare and information provision? A qualitative interview study

Abstract

Objective

To determine how people with post-COVID syndrome in Germany experience medical care and what healthcare problems they see in relation to post-COVID.

Design

Semistructured interviews with a topic guide; audio-recording, transcription and analysis in terms of content.

Setting

13 digital interviews and one face-to-face meeting between April and June 2024.

Participants

14 German people with post-COVID syndrome (10 female; 4 male).

Results

The experiences of the study participants in the care of their post-COVID symptoms were heterogeneous and suggested the continued, at least partially persisting, presence of problems in Germany that have already been addressed in the past. While other studies focus primarily on structural hurdles, our study provides indications that the interactions between healthcare professionals and patients may be important for their satisfaction with care. In particular, physician initiative, education and communication appear to play central roles. In addition, respondents often felt inadequately informed and reported problems with obtaining information. The level of knowledge about the disease in society as a whole has also been frequently criticised.

Conclusions

Doctor–patient interaction may be a critical factor in improving the care of post-COVID patients, with both supportive and problematic experiences indicating that empathic communication and transparent education can play an important role in reducing miscommunication and perceived stigma. In addition, people with post-COVID syndrome appear to need easier access to disease-specific information, which might be facilitated by expanded digital resources and additional dedicated support information services.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• The study ensured heterogeneity by considering diverse socio-demographic backgrounds, disease progressions and durations.

• Multiple recruitment channels and varied interview formats (digital, face-to-face) improved accessibility.

• The sample included a higher proportion of female participants, consistent with the higher prevalence of post-COVID among women.

• As a qualitative study with a small sample size, limited timeframe and exclusion of minors, the findings have limited generalisability and primarily reflect the experiences of post-COVID patients in Germany, which may not be directly transferable to other countries or healthcare systems.

• The sample may be biased towards more severely affected and frustrated individuals, who were predominantly from the Würzburg area.

Introduction

The clinical picture of post-COVID was first described in the spring of 2020, when reports began to emerge of SARS-CoV-2 patients with persistent health impairments, weeks to months after acute infection. The first scientific article analysing this phenomenon was published in August 2020, highlighting the challenges to be expected in healthcare.¹ Nonetheless, there is still a lack of precise clinical case definitions, which hampers epidemiological data and research in general. The current National Institute for Health and Care Excellence and WHO definitions describe symptoms that last more than 4 weeks (long-COVID) or 12 weeks (post-COVID) after acute infection with SARS-CoV-2, are new, or have been worsened as a result of the infection.2,4

However, it became clear that post-COVID was not a completely new syndrome but had many similarities to other post-acute infection syndromes (eg, after Ebola, polio or Epstein-Barr virus infections).⁵ While the symptoms of postviral illnesses have received little attention in the past, the pandemic-related increase in incidence has brought the topic to the attention of the media and health policy institutions. In Germany, several patient initiatives and support groups have been established to deal with post-COVID issues.⁶ Various institutions, such as the German Medical Association (Bundesärztekammer), saw an urgent need for action.⁷ At an unusually short notice, health policymakers made substantial funds available for this field, such as the ‘BMG (Bundesministerium für Gesundheit; Federal Ministry of Health, Germany)-Initiative Long COVID’.⁸

Despite this, general social, political and medical interest in post-COVID seems to have waned, although the number of people affected remains high and their level of suffering is still immense.^{9 10} Both patients and clinicians see complex problems in the current care situation.^{11 12} The treatment of post-COVID patients poses extraordinary challenges and exacerbates existing structural problems in the healthcare system.¹³ A fundamental problem is the lack of adequate explanation of the pathogenesis and, consequently, the absence of objective diagnostic criteria or curative therapy.² In addition, the heterogeneity of symptoms, disease progression and resulting disabilities^{14 15} makes the overall situation very confusing.

Against this background, this study aimed to analyse the views of those affected and, particularly, their experiences of post-COVID care in Germany. The research was guided by the following questions: (1) How do people with post-COVID from Germany experience medical care and what aspects of treatment are important to them? (2) Where is there a need for information on the topic of post-COVID?

Methods

The results presented are part of the POSCOR (Post-COVID rehabilitation project, Würzburg) mixed-methods research project.

Study objective and study design

This study follows an exploratory qualitative approach by analysing individual cases to develop a deeper understanding of the experiences, problems, wishes and expectations regarding post-COVID care. Data collection and analysis were conducted as part of a doctoral thesis based on semistructured interviews, using a topic guide. Parts of the sample description have been reported previously in a German-language publication addressing other aspects of the project.¹⁶ The adopted open-ended approach has enabled previously unknown aspects to be uncovered, from which new implications for improving healthcare can be drawn.

Recruitment

Participants were recruited through personal contacts and flyers in support groups as well as in general and specialist practices in the Würzburg area. After contacting them by telephone or email, eligibility criteria were checked, the study was explained and interview dates were arranged. Access data, participant information and informed consent forms were sent out beforehand and returned signed at the interview. Participation was voluntary, with no financial or other compensation.

A total of 18 individuals of interest were identified, of whom two had to be excluded due to suspected or confirmed post-vaccination (VAC) syndrome and two others cancelled at short notice. Ultimately, 14 patients were included.

The sample size was determined by thematic data saturation, reached after ten interviews. Recruitment was therefore stopped at 14 participants, meeting the recommended minimum of 12 for qualitative research.^{17 18}

Inclusion criteria

• Self-reported medical diagnosis of U09.9! (ICD code: Post-COVID condition) by a general practitioner or specialist.

• Age 18–65 years.

• Signed informed consent, including agreement to audio recording.

• Residence in Germany.

• Sufficient German language skills.

Exclusion criteria

• Other diagnoses that adequately explain the symptoms (eg, other postinfectious conditions or postvaccination syndrome).

• Inability to provide consent.

Sample description

An overview of the participants’ self-reported sociodemographic characteristics is shown in table 1. A total of 14 interviews were conducted, 10 with women (71%). The mean age was 40.4 years (SD=14.95). Three participants were students, four employed and seven not employed (all due to post-COVID). Eight belonged to a support group (n=2 online, n=5 in person, n=1 both formats) and six had completed a rehabilitation programme. Most reported fatigue as their main impairing symptom (n=11), while others cited chronic cough (n=2), musculoskeletal complaints (n=2) and psychological impairment (n=1). Only the symptom perceived as most burdensome was explicitly asked; other symptoms were reported spontaneously and were too numerous to list. Neurocognitive symptoms, although not explicitly queried, were reported by most participants (1–8, 10–13), but not by 9 and 14. Illness duration ranged from 1 month to over 2 years.

Table 1. Summary of self-reported sociodemographic data of participants.

Pseudonym	Age group (years)	Gender	Participation in post-COVID support group	Main complaint
PAT 1	18–29	Female	No	Musculoskeletal
PAT 2	30–44	Male	No	Fatigue
PAT 3	30–44	Female	Yes	Fatigue
PAT 4	18–29	Female	Yes	Fatigue
PAT 5	45–59	Female	No	Fatigue
PAT 6	45–59	Male	No	Musculoskeletal
PAT 7	60+	Female	No	Psychological impairment
PAT 8	45–59	Male	Yes	Fatigue
PAT 9	18–29	Female	No	Fatigue
PAT 10	30–44	Female	Yes	Fatigue, chronic cough
PAT 11	45–59	Female	Yes	Fatigue
PAT 12	60+	Male	Yes	Fatigue
PAT 13	30–44	Female	Yes	Fatigue, chronic cough
PAT 14	18–29	Female	Yes	Fatigue

Data collection

Data were collected between April and June 2024. The interviews lasted 28–59 min (mean=44 min) and were conducted individually by the first author. Prior to the interview, participants were informed about the interviewer’s professional background and role as a doctoral researcher in rehabilitation research. Of the 14 study participants, 13 preferred a digital interview via Zoom (Zoom Video Communications, San Jose, California, USA), while one preferred a face-to-face meeting. Interviews were audio-recorded for subsequent analysis, with initial notes taken during the process.

Semistructured interviews were conducted using guidelines by Helfferich.¹⁹ The first draft of the interview guide was based on a preliminary literature review on post-COVID in general and typical post-COVID care problems in particular, using studies with similar research questions and approaches1220,23 as references. This version was then discussed and completed in collaboration with the coauthors. The final interview guide (online supplemental file 1) contained four topic areas ((1) health situation, (2) experience of care, (3) rehabilitation offers, (4) personal wishes/ideas for further development in general) and 23 open questions plus two closed questions in the rehabilitation section.

Data analysis

The recorded audio files were transcribed according to Dresing and Pehl’s content-semantic transcription rules²⁴ and pseudonymised in accordance with data protection regulations²⁵ using the software f4x V.2024. The transcripts were then imported into MAXQDA V.24.5.1 (VERBI Software, Berlin, Germany) and analysed using Kuckartz’s structured qualitative content analysis.²⁶

The developed category system follows clear coding rules and fulfils Kuckartz’s quality criteria.²⁶ To ensure high-quality coding, a team of a medical student and a psychologist verified the consensus coding by regularly discussing and reviewing the entire category system and unclear categorisations.

Table 2 presents the final version of this system. The work focused on the main categories of experiences, problems and wishes in general care, with the analysed categories highlighted in bold.

Table 2. Category system.

Main categories	Subcategories 1	Subcategories 2
Disease
	1.1 Symptoms
	1.2 Acute infection
	1.3 Development of symptoms over time
Resulting impairments/quality of life
	2.1 Daily life
	2.2 Work/studies
	2.3 Social environment
	2.4 Free time
	2.5 Personal attitude/acceptance
	2.6 Expected performance
	2.7 Psychological impairment
Experiences, problems and wishes in general care
	3.1 Type of care
	3.2 Subjective assessment of care
	3.3 Patient-relevant aspects in medical treatment
		3.3.1 Demand for more diagnostics/therapies
		3.3.2 HCPs’ initiative/proactiveness
		3.3.3 HCPs’ attitude towards patients
		3.3.4 Perception of professional expertise
		3.3.5 Communication and education
		3.3.6 Suitability for the fatigue
	3.4 Structural problems
		3.4.1 Institutional overload and resulting barriers to access
		3.4.2 Institutional networking and treatment coordination
		3.4.3 Care at home
	3.5 Information on post-COVID
		3.5.1 Support networks
		3.5.2 Digital platforms for patients
		3.5.3 Social and media information policy
	3.6 Financial issues
		3.6.1 Social benefits
		3.6.2 Cost coverage by the health insurance
	3.7 Support requirement
		3.7.1 Social counselling
		3.7.2 Disease-specific advice
		3.7.3 Need for support in daily life
	3.8 Consequences
Experiences/preconceptions regarding rehabilitation in particular
	4.1 Earlier participation and readiness for rehabilitation
	4.2 Type of care
	4.3 Subjective assessment of rehab programmes
	4.4 Important aspects of rehabilitation treatment from the patient’s perspective
	4.5 Structural/organisational rehab aspects
	4.6 Financial/social welfare aspects in connection with rehabilitation measures
	4.7 Rehabilitation aftercare

HCPs, healthcare professionals.

Patient and public involvement

Patients and members of the public contributed feedback on the interview questions to ensure relevance and clarity, but were not involved in the overall study design, data collection, analysis or dissemination of the findings.

Results

The following results are presented according to the Consolidated Criteria for Reporting Qualitative Research (online supplemental file 2).

Type of care

Patient reports tend to reflect a very complex treatment pathway, with multiple points of contact. The most frequently consulted institutions were general practitioners (n=14) and specialists (n=14), followed by physical treatments (eg, physiotherapy or occupational therapy) (n=13) and drug therapies (n=11).

Care and treatment experience (subjective assessment of care and patient-relevant aspects in medical treatment)

Satisfaction with, and timing and duration of the care received was very heterogeneous. The sum of all the positive (n=204) and negative (n=279) statements in the interviews can be considered almost balanced. Specialist outpatient clinics, specialist physicians and medications were rated particularly poorly, whereas apps, psychological support and relaxation exercises were largely considered helpful and valuable.

Healthcare professionals’ initiative/proactiveness

A frequently criticised aspect was the lack of medical involvement, which required patients to take a high degree of initiative, especially when seeking additional diagnostic or therapeutic measures. Many reported that they “always had to be the driving force” (PAT 4) as they “perceived the medical professionals around (…) [them] as powerless” (PAT 2). Sometimes they were even discouraged and thwarted in their desire to act and had to accept that proactive measures were not feasible, leaving them feeling isolated or overwhelmed:

But I really feel left on my own all these three years. And I still do. (PAT 7)

It would have been nice not to have to do half a medical degree on the side in this state, where you have so little strength anyway, to be able to help yourself. (PAT 3)

At the same time, proactive contributions by healthcare professionals (HCPs) to problem-solving were sometimes experienced positively and supportively:

Fortunately, I have a general practitioner who says, ‘Tell me what you need, and I’ll see how we can make it possible.’ (PAT 10)

HCPs’ attitude towards patients

Another frequently raised issue was the perceived medical attitude towards the patients. A considerable number of participants reported psychologising statements by doctors, who seemed to attribute physical post-COVID symptoms solely to psychological causes:

You’re just depressed. That suggests psychosis.’ Something like that. That’s why she prescribed antidepressants. That wasn't the right approach. (PAT 8)

Participants also complained about not being taken seriously or listened to. In some cases, their symptom descriptions were questioned or dismissed as faked:

I have never seen people doubt so blatantly (…). In the clinic (…) the doctor kept saying to me: ‘Stop saying you can't walk anymore. If you couldn't walk, you wouldn't be standing next to me.’ (PAT 1)

From the patients’ perspective, HCPs often lacked understanding and empathy, and symptoms were not infrequently downplayed and trivialised.

But then when nothing came of it, I heard statements like: ‘Be glad you don't have MS (Multiple Sclerosis)’. (PAT 1)

Nevertheless, HCPs’ attitude was also often described positively, particularly when they were seen as “professional, just as one would expect” (PAT 11) or “understanding” (PAT 8 and PAT 11).

Communication and education

Participants’ experiences with communication and education were pivotal in shaping their perceptions of care. As slightly alluded to in the HCPs’ attitude towards patients section, misunderstandings between doctors and patients were quite common, often leading to perceived stigmatisation. Open communication, however, was usually seen as positive, even if it involved the admission of overstepping one’s own boundaries:

[The doctors,] they honestly said, which I actually found a professional statement: ‘We don’t know anything about it.’ And I would a thousand times rather have a doctor say something like that than have them pretend they know, when in fact they don’t. (PAT 12)

It also was considered essential to inform patients at an earlier stage about the clinical picture of post-COVID, including pacing as a therapeutic concept. Warnings and empathic calls for physical rest by medical and non-medical professionals helped prevent overexertion or crashes:

And the continuous monitored aerobic exercise with the instructions: ‘Take it easy, Mr. (…), watch your pulse!’ (…) This discipline of self-limitation, while still exercising, gradually allowed me to build up over several weeks. (PAT 2)

In contrast, inappropriate recommendations from providers, such as “Do everything you can, just like before” (PAT 6), or insufficient warnings and guidance had the opposite effect.

I dragged myself back to work after about six weeks, against the advice of my general practitioner (…), but he never really directly said: ‘This and that will happen if you don’t take it easy now.’ Accordingly, I went back to work. (PAT 13)

Many respondents would have liked to know earlier:

What does Long-Covid actually mean (…) [and] what can happen if I do this or that? (PAT 5)

In addition, transparent explanation of potential side effects, latency periods and individual risk–benefit assessments of medications were seen as beneficial. The following lack of information negatively affected compliance, as these drugs were often discontinued before the earliest possible onset of action due to side effects:

Then why am I getting it (…) if 60 percent of patients have this reaction (…) [and] when there are alternatives. (PAT 5)

The [neurologist] also prescribed antidepressants. I didn’t take them because, first of all, he didn’t explain why. I even asked and he didn’t explain why I should take them now. (PAT 4)

Consequences

As a result of the highly mixed and not infrequently negative healthcare experiences, some respondents expressed high frustration:

So it takes a lot of energy and in the end it doesn't do me any good (PAT 11).

While some participants went on a veritable ‘doctor hopping’ due to unsatisfactory treatment, others resigned themselves to the problem and reduced their active involvement in treatment or temporarily/permanently stopped seeing their doctor.

And then I let it [going to the doctor] rest for a bit because I was so frustrated: nobody listens to me. (PAT 14)

Information on post-COVID

Support networks

The most common form of networking was participation in support groups (mainly face-to-face, sometimes online), followed by social media or sharing with friends. For those affected, the main benefit was the opportunity to share information about their experiences, tips and post-COVID news, as they assumed “(…) that other people with post-COVID were the only ones gathering knowledge about it.” (PAT 3)

In contrast, feeling understood played a subordinate role for the majority of respondents.

However, problems have also been reported, as some found the exchange too exhausting or depressing and realised that comparisons with others were damaging to them:

Because sometimes just reading that others have it so bad brings you down. But you have to deal with it (…) in a very measured way. (PAT 4)

Digital platforms for patients

The availability of information platforms for people with post-COVID was rated negatively by the participants. Actual access to websites varied greatly due to differing reading and concentration levels. The main criticism was that the information was not up to date, lacked clarity and was not tailored to the patients’ needs. Participants often lacked the necessary prior medical knowledge and additional assessments by doctors. One participant noted:

Because there are five answers on the internet, and which one is the right one? (PAT 8). For this reason, another participant wished he had just a little bit of medical guidance in this jungle of what you can try (PAT 3).

Social and media information policy

Participants felt that media often presented the care situation inaccurately and distorted. In their eyes, the clinical picture was trivialised and whitewashed, denying the need for action. In mainstream society, the issue has increasingly been forgotten:

It’s all played down a bit, as if nobody needs to worry about it. (PAT 3)

At the same time, participants called for better education to create more understanding, knowledge and awareness of the impact of the disease among the general population, while also reducing existing stigmas. One participant shared:

And invisible disabilities, that’s a big social issue in general. (…) It is difficult to judge from the outside how much a person is really disabled. (PAT 14)

Support requirement (social counselling and disease-specific advice)

While some individuals felt already well informed by their own research or “in good hands” with their general practitioner (Participant 12), most expressed a desire for further advice and support. Owing to disease-related limitations in actively searching for information online, many feared missing or having already missed important news.

Perhaps (…), something was missed (…) that could have helped me make positive progress (…). Maybe it wouldn’t have gotten this far. Perhaps I would already be back at work (…). (PAT 7)

Therefore, several participants suggested a personalised newsletter, automatically delivered without any action on their part, to provide a better overview of selected promising contact points, treatment options and research projects. This could also be useful for incident cases, so that “action can be taken more quickly [and you don’t] have to find out for yourself [what is behind the symptoms].” (PAT 9)

Discussion

Key findings

The present study suggests that post-COVID care in the German healthcare system is perceived very heterogeneously, both interindividually and intraindividually. Early in the pandemic, participants seemed somewhat more understanding of care shortcomings, whereas this tolerance seemed to decrease over time, potentially influencing overall satisfaction. Nevertheless, some evidence of recurring problems in post-COVID care has emerged, which may inform the development of strategies to further enhance care quality. Patient–doctor interactions were frequently perceived as inadequate, especially regarding education and respectful, transparent communication, though positive experiences were reported, particularly when HCPs were open, understanding, acknowledged uncertainty or showed proactive engagement. Respondents also felt that the information situation on post-COVID was incomplete, both for themselves and society in general, and expressed a desire for improved information services available at the time.

Comparison to previous studies

The results regarding the healthcare experiences are consistent with previous qualitative studies.^{27 28} A high degree of heterogeneity in treatment satisfaction was also described in an online questionnaire survey in Baden-Württemberg.²³ Other qualitative studies have found that high patient initiative is required to advance treatment.^{13 29} Roder et al¹² and Sunkersing et al³⁰ also highlight the importance of better doctor–patient communication, the desire for support, and the need to expand comprehensive and interdisciplinary care structures.^{31 32} A systematic review showed that many patient surveys describe invalidating experiences in contact with HCPs,³² sometimes referred to as ‘medical gaslighting’,¹⁰ a form of psychological abuse that causes victims to doubt their own perceptions.³³ Therefore, it should be used cautiously.

These frequently reported problems understandably affect continuity of treatment and doctor–patient relationship, which is central.^{29 34} Negative experiences often lead to frustration, anxiety and stress,³⁵ further reducing quality of life.¹⁰

Existing literature also addresses issues in post-COVID information. Nearly 300 registered support groups exist nationwide,⁶ and their numbers and interest are steadily increasing.³⁶ In this study, networking with other affected individuals, for example, in support groups, was perceived as less helpful than in other studies,^{29 30} serving mainly as an information source.³⁵ Difficulties in using digital resources for self-education occur internationally, causing confusion, overload and concerns about quality, sometimes referred to as an ‘infodemic’.^{29 35} Despite the vast quantity of information and continued media coverage, patients still call for campaigns and increased attention.^{12 27}

New information services have recently been established in Germany, which respondents were likely unfamiliar with at the time. Some requirements are probably already met, particularly via the ‘BMG-Initiative Long COVID’, which contributed valuable information, for example, therapy compass for off-label drugs and a central information platform for patients, relatives and HCPs.^{8 37}

Implications for practice

The findings of the study suggest that a strong doctor-patient relationship may exert a profound influence on patient satisfaction with care, subsequent treatment and the mental and physical well-being of the patient. Therefore, it is crucial for clinicians to ensure that patients feel seriously understood and listened to. In doing so, comments that trivialise or psychologise should be avoided. Based on this, our research indicates that perceived stigmatising assumptions are often the result of miscommunication, for example, when prescribing antidepressants for pain. The challenge here is that post-COVID individuals often seem to anticipate psychologisation by third parties, which in turn allows conclusions to be drawn about negative past experiences.

This suggests that potential approaches to improve care could be in the areas of communication and education by doctors. For instance, it would likely convey drug treatments in a highly transparent manner to patients.

While post-COVID was initially a completely new and unknown challenge, healthcare providers now have access to the first research results and reliable treatment recommendations. This could be utilised, for example, by providing more detailed information about the clinical picture and the importance of pacing at an earlier stage in future. This call is particularly relevant to all healthcare providers involved in the treatment of patients with post-COVID, particularly general practitioners, who frequently serve as the initial point of contact for these patients. These considerations also apply to private practice specialists, as can be seen from the national S1 guidelines and recently published treatment guidelines.^{3 38}

Another approach for optimising care might be the expansion of digital information services on post-COVID syndrome, as it is often difficult for severely affected individuals to obtain information on the Internet. Therefore, additional services, such as newsletters or telephone services (already existing in Germany in the form of a citizens’ telephone hotline for socio-legal reasons), may be considered.³⁹

The validity of the present study is limited particularly by the qualitative approach and the associated low representativeness of the sample, as a small number of participants and a limited period of time were used. Moreover, only individuals between 22 and 64 years and from Germany (mainly from the Würzburg area) were recruited. As a result, the findings primarily reflect the German healthcare context, although similar challenges in physician–patient interaction have been described in international studies, suggesting limited transferability. Neither children nor adolescents were interviewed, even though these groups are particularly affected by post-COVID and face specific problems.

It is also important to note that respondents were likely more severely affected, reporting above-average levels of suffering, frustration with treatment and unemployment, which presumably led to a greater need to communicate. Including more people with other major complaints might have provided a more nuanced picture and an overall more positive view of experiences.

Additionally, the participants’ diagnoses are based on self-report and not independently verified, posing a low risk of misclassification.

Consequently, although thematic data saturation was reached, the small, regionally restricted and self-selected sample still limits the scope and diversity of perspectives, reducing external validity and the transferability to individuals with milder symptoms or different predominant complaints.

One key strength of this study is the effort to ensure a heterogeneous sample, achieved by targeting a wide range of sociodemographic characteristics, disease progression and duration. Heterogeneity was further supported by differences in age, employment status, participation in rehabilitation programmes and support groups (see table 1), and varied access routes. To enable digitally inexperienced individuals to access the study, a telephone call or face-to-face meeting was offered as an alternative to digital interviews. In addition, the sample distribution was intentionally skewed towards female participants, reflecting the higher prevalence of post-COVID in women,⁹ in line with other studies.^{10 34} Furthermore, the high prevalence of neurocognitive impairment and fatigue among participants is also a strength, as these are among the most common post-COVID symptoms.⁴⁰ Overall, the study aimed to provide a differentiated and balanced view of experiences, highlighting both challenges and positive aspects of care.

Conclusions

This qualitative interview study provides a deeper insight into the post-COVID care in Germany and suggests that, despite many positive experiences, numerous problems persist. Some expressed wishes for improved care were already being addressed in various ways by healthcare organisations and institutions (specific research programmes at federal and state levels, and information platforms of the BMG). In particular, questionable shortcomings in the timeliness of available information seem to be a significant problem. In addition, the doctor–patient relationship/interaction was mentioned especially frequently, underlining its potentially crucial role in improving patient care and satisfaction.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.