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1.  Direct cost associated with acquired brain injury in Ontario 
BMC Neurology  2012;12:76.
Background
Acquired Brain Injury (ABI) from traumatic and non traumatic causes is a leading cause of disability worldwide yet there is limited research summarizing the health system economic burden associated with ABI. The objective of this study was to determine the direct cost of publicly funded health care services from the initial hospitalization to three years post-injury for individuals with traumatic (TBI) and non-traumatic brain injury (nTBI) in Ontario Canada.
Methods
A population-based cohort of patients discharged from acute hospital with an ABI code in any diagnosis position in 2004 through 2007 in Ontario was identified from administrative data. Publicly funded health care utilization was obtained from several Ontario administrative healthcare databases. Patients were stratified according to traumatic and non-traumatic causes of brain injury and whether or not they were discharged to an inpatient rehabilitation center. Health system costs were calculated across a continuum of institutional and community settings for up to three years after initial discharge. The continuum of settings included acute care emergency departments inpatient rehabilitation (IR) complex continuing care home care services and physician visits. All costs were calculated retrospectively assuming the government payer’s perspective.
Results
Direct medical costs in an ABI population are substantial with mean cost in the first year post-injury per TBI and nTBI patient being $32132 and $38018 respectively. Among both TBI and nTBI patients those discharged to IR had significantly higher treatment costs than those not discharged to IR across all institutional and community settings. This tendency remained during the entire three-year follow-up period. Annual medical costs of patients hospitalized with a brain injury in Ontario in the first follow-up year were approximately $120.7 million for TBI and $368.7 million for nTBI. Acute care cost accounted for 46-65% of the total treatment cost in the first year overwhelming all other cost components.
Conclusions
The main finding of this study is that direct medical costs in ABI population are substantial and vary considerably by the injury cause. Although most expenses occur in the first follow-up year ABI patients continue to use variety of medical services in the second and third year with emphasis shifting over time from acute care and inpatient rehabilitation towards homecare physician services and long-term institutional care. More research is needed to capture economic costs for ABI patients not admitted to acute care.
doi:10.1186/1471-2377-12-76
PMCID: PMC3518141  PMID: 22901094
2.  The efficacy of self-management programmes for increasing physical activity in community-dwelling adults with acquired brain injury (ABI): a systematic review 
Systematic Reviews  2014;3:39.
Background
Acquired brain injury (ABI), often arising from stroke or trauma, is a common cause of long-term disability, physical inactivity and poor health outcomes globally. Individuals with ABI face many barriers to increasing physical activity, such as impaired mobility, access to services and knowledge regarding management of physical activity. Self-management programmes aim to build skills to enable an individual to manage their condition, including their physical activity levels, over a long period of time. Programme delivery modes can include traditional face-to-face methods, or remote delivery, such as via the Internet. However, it is unknown how effective these programmes are at specifically improving physical activity in community-dwelling adults with ABI, or how effective and acceptable remote delivery of self-management programmes is for this population.
Methods/Design
We will conduct a comprehensive search for articles indexed on MEDLINE, EMBASE, CINAHL, PsychINFO, AMED, Cochrane Central Register of Controlled Trials (CENTRAL), PEDro and Science Citation Index Expanded (SCI-EXPANDED) databases that assess the efficacy of a self-management intervention, which aims to enhance levels of physical activity in adults living in the community with ABI. Two independent reviewers will screen studies for eligibility, assess risk of bias, and extract relevant data. Where possible, a meta-analysis will be performed to calculate the overall effect size of self-management interventions on physical activity levels and on outcomes associated with physical activity. A comparison will also be made between face-to-face and remote delivery modes of self-management programmes, in order to examine efficacy and acceptability. A content analysis of self-management programmes will also be conducted to compare aspects of the intervention that are associated with more favourable outcomes.
Discussion
This systematic review aims to review the efficacy of self-management programmes aimed at increasing physical activity levels in adults living in the community with ABI, and the efficacy and acceptability of remote delivery of these programmes. If effective, remote delivery of self-management programmes may offer an alternative way to overcome barriers and empower individuals with ABI to increase their levels of physical activity, improving health and general wellbeing.
Trial registration
Our protocol has been registered on PROSPERO 2013: CRD42013006748.
doi:10.1186/2046-4053-3-39
PMCID: PMC3998059  PMID: 24745356
Self-management; Physical activity; Brain injury; Stroke; Remote delivery; Internet
3.  The Role of HIV-Related Stigma in Utilization of Skilled Childbirth Services in Rural Kenya: A Prospective Mixed-Methods Study 
PLoS Medicine  2012;9(8):e1001295.
Janet Turan and colleagues examined the role of the perception of women in rural Kenya of HIV-related stigma during pregnancy on their subsequent utilization of maternity services.
Background
Childbirth with a skilled attendant is crucial for preventing maternal mortality and is an important opportunity for prevention of mother-to-child transmission of HIV. The Maternity in Migori and AIDS Stigma Study (MAMAS Study) is a prospective mixed-methods investigation conducted in a high HIV prevalence area in rural Kenya, in which we examined the role of women's perceptions of HIV-related stigma during pregnancy in their subsequent utilization of maternity services.
Methods and Findings
From 2007–2009, 1,777 pregnant women with unknown HIV status completed an interviewer-administered questionnaire assessing their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal care visit. After the visit, a sub-sample of women was selected for follow-up (all women who tested HIV-positive or were not tested for HIV, and a random sample of HIV-negative women, n = 598); 411 (69%) were located and completed another questionnaire postpartum. Additional qualitative in-depth interviews with community health workers, childbearing women, and family members (n = 48) aided our interpretation of the quantitative findings and highlighted ways in which HIV-related stigma may influence birth decisions. Qualitative data revealed that health facility birth is commonly viewed as most appropriate for women with pregnancy complications, such as HIV. Thus, women delivering at health facilities face the risk of being labeled as HIV-positive in the community. Our quantitative data revealed that women with higher perceptions of HIV-related stigma (specifically those who held negative attitudes about persons living with HIV) at baseline were subsequently less likely to deliver in a health facility with a skilled attendant, even after adjusting for other known predictors of health facility delivery (adjusted odds ratio = 0.44, 95% CI 0.22–0.88).
Conclusions
Our findings point to the urgent need for interventions to reduce HIV-related stigma, not only for improving quality of life among persons living with HIV, but also for better health outcomes among all childbearing women and their families.
Please see later in the article for the Editors' Summary.
Editors' Summary
Background
Every year, nearly 350,000 women die from pregnancy- or childbirth-related complications. Almost all these “maternal” deaths occur in developing countries. In sub-Saharan Africa, for example, the maternal mortality ratio (the number of maternal deaths per 100,000 live births) is 500 whereas in industrialized countries it is only 12. Most maternal deaths are caused by hemorrhage (severe bleeding after childbirth), post-delivery infections, obstructed (difficult) labor, and blood pressure disorders during pregnancy. All these conditions can be prevented if women have access to adequate reproductive health services and if trained health care workers are present during delivery. Notably, in sub-Saharan Africa, infection with HIV (the virus that causes AIDS) is an increasingly important contributor to maternal mortality. HIV infection causes maternal mortality directly by increasing the occurrence of pregnancy complications and indirectly by increasing the susceptibility of pregnant women to malaria, tuberculosis, and other “opportunistic” infections—HIV-positive individuals are highly susceptible to other infections because HIV destroys the immune system.
Why Was This Study Done?
Although skilled delivery attendants reduce maternal mortality, there are many barriers to their use in developing countries including cost and the need to travel long distances to health facilities. Fears and experiences of HIV-related stigma and discrimination (prejudice, negative attitudes, abuse, and maltreatment directed at people living with HIV) may also be a barrier to the use of skilled childbirth service. Maternity services are prime locations for HIV testing and for the provision of interventions for the prevention of mother-to-child transmission (PMTCT) of HIV, so pregnant women know that they will have to “deal with” the issue of HIV when visiting these services. In this prospective mixed-methods study, the researchers examine the role of pregnant women's perceptions of HIV-related stigma in their subsequent use of maternity services in Nyanza Province, Kenya, a region where 16% women aged 15–49 are HIV-positive and where only 44.2% of mothers give birth in a health facility. A mixed-methods study combines qualitative data—how people feel about an issue—with quantitative data—numerical data about outcomes.
What Did the Researchers Do and Find?
In the Maternity in Migori and AIDS Stigma (MAMAS) study, pregnant women with unknown HIV status living in rural regions of Nyanza Province answered questions about their perceptions of HIV-related stigma before being offered HIV testing during their first antenatal clinic visit. After delivery, the researchers asked the women who tested HIV positive or were not tested for HIV and a sample of HIV-negative women where they had delivered their baby. They also gathered qualitative information about barriers to maternity and HIV service use by interviewing childbearing women, family members, and community health workers. The qualitative data indicate that labor in a health facility is commonly viewed as being most appropriate for women with pregnancy complications such as HIV infection. Thus, women delivering at health facilities risk being labeled as HIV positive, a label that the community associates with promiscuity. The quantitative data indicate that women with more negative attitudes about HIV-positive people (higher perceptions of HIV-related stigma) at baseline were about half as likely to deliver in a health facility with a skilled attendant as women with more positive attitudes about people living with HIV.
What Do These Findings Mean?
These findings suggest that HIV-related stigma is associated with the low rate of delivery by skilled attendants in rural areas of Nyanza Province and possibly in other rural regions of sub-Saharan Africa. Community mobilization efforts aimed at increasing the use of PMTCT services may be partly responsible for the strong perception that delivery in a health facility is most appropriate for women with HIV and other pregnancy complications and may have inadvertently strengthened the perception that women who give birth in such facilities are likely to be HIV positive. The researchers suggest, therefore, that health messages should stress that delivery in a health facility is recommended for all women, not just HIV-positive women or those with pregnancy complications, and that interventions should be introduced to reduce HIV-related stigma. This combined strategy has the potential to increase the use of maternity services by all women and the use of HIV and PMTCT services, thereby reducing some of the most pressing health problems facing women and their children in sub-Saharan Africa.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001295.
The United Nations Children's Fund (UNICEF) provides information on maternal mortality, including the WHO/UNICEF/UNFPA/World Bank 2008 country estimates of maternal mortality; a UNICEF special report tells the stories of seven mothers living with HIV in Lesotho
The World Health Organization provides information on maternal health, including information about Millennium Development Goal 5, which aims to reduce maternal mortality (in several languages); the Millennium Development Goals, which were agreed by world leaders in 2000, are designed to eradicate extreme poverty worldwide by 2015
Immpact is a global research initiative for the evaluation of safe motherhood intervention strategies
Maternal Death: The Avoidable Crisis is a briefing paper published by the independent humanitarian medical aid organization Médecins Sans Frontières (MSF) in March 2012
Information is available from Avert, an international AIDS charity on all aspects of HIV/AIDS, including information on women, HIV and AIDS, on HIV and pregnancy, on HIV and AIDS stigma and discrimination, and on HIV in Kenya (in English and Spanish); Avert also has personal stories from women living with HIV
The Stigma Action Network (SAN) is a collaborative endeavor that aims to comprehensively coordinate efforts to develop and expand program, research, and advocacy strategies for reducing HIV stigma worldwide, including mobilizing stakeholders, delivering program and policy solutions, and maximizing investments in HIV programs and services globally
The People Living with Stigma Index aims to address stigma relating to HIV and advocate on key barriers and issues perpetuating stigma; it has recently published Piecing it together for women and girls, the gender dimensions of HIV-related stigma
The Health Policy Project http://www.healthpolicyproject.com has prepared a review of the academic and programmatic literature on stigma and discrimination as barriers to achievement of global goals for maternal health and the elimination of new child HIV infections (see under Resources)
More information on the MAMAS study is available from the UCSF Center for AIDS Prevention Studies
doi:10.1371/journal.pmed.1001295
PMCID: PMC3424253  PMID: 22927800
4.  Advocacy for active transport: advocate and city council perspectives 
Background
Effective advocacy is an important part of efforts to increase population participation in physical activity. Research about effective health advocacy is scarce, however, the health sector can learn from the experiences and knowledge of community advocates and those who are on the receiving end of this advocacy. The aim of this study is to explore advocacy for active transport from the perspectives of community advocates and representatives from City councils.
Methods
Cycling and walking advocates were identified from the local contact list of Cycling Advocates Network and Living Streets Aotearoa. Semi-structured telephone interviews were conducted with cycle and walking advocates from throughout New Zealand. Advocates also nominated a suitable council officer at their local City council to be interviewed. Interviews were recorded and transcribed and categories of responses for each of the questions created.
Results
Several processes were used by advocates to engage with council staff, including formal council submissions, meetings, stakeholder forums and partnership in running community events promoting active transport. Several other agencies were identified as being influential for active transport, some as potential coalition partners and others as potential adversaries. Barriers to improving conditions for active transport included a lack of funding, a lack of will-power among either council staff or councillors, limited council staff capacity (time or training) and a culture of providing infrastructure for motor vehicles instead of people. Several suggestions were made about how the health sector could contribute to advocacy efforts, including encouraging political commitment, engaging the media, communicating the potential health benefits of active transport to the general public and being role models in terms of personal travel mode choice and having workplaces that support participation in active transport.
Conclusions
There is potential for the health sector to make an important contribution to advocacy for active transport in New Zealand. While there are many barriers to achieving supportive environments for cycling and walking, a range of advocacy strategies were identified which could help ensure that health perspectives are considered in decisions relevant to active transport.
doi:10.1186/1479-5868-7-5
PMCID: PMC2830166  PMID: 20181003
5.  Usability of a virtual reality environment simulating an automated teller machine for assessing and training persons with acquired brain injury 
Objective
This study aimed to examine the usability of a newly designed virtual reality (VR) environment simulating the operation of an automated teller machine (ATM) for assessment and training.
Design
Part I involved evaluation of the sensitivity and specificity of a non-immersive VR program simulating an ATM (VR-ATM). Part II consisted of a clinical trial providing baseline and post-intervention outcome assessments.
Setting
A rehabilitation hospital and university-based teaching facilities were used as the setting.
Participants
A total of 24 persons in the community with acquired brain injury (ABI) - 14 in Part I and 10 in Part II - made up the participants in the study.
Interventions
In Part I, participants were randomized to receive instruction in either an "early" or a "late" VR-ATM program and were assessed using both the VR program and a real ATM. In Part II, participants were assigned in matched pairs to either VR training or computer-assisted instruction (CAI) teaching programs for six 1-hour sessions over a three-week period.
Outcome Measures
Two behavioral checklists based on activity analysis of cash withdrawals and money transfers using a real ATM were used to measure average reaction time, percentage of incorrect responses, level of cues required, and time spent as generated by the VR system; also used was the Neurobehavioral Cognitive Status Examination.
Results
The sensitivity of the VR-ATM was 100% for cash withdrawals and 83.3% for money transfers, and the specificity was 83% and 75%, respectively. For cash withdrawals, the average reaction time of the VR group was significantly shorter than that of the CAI group (p = 0.021). We found no significant differences in average reaction time or accuracy between groups for money transfers, although we did note positive improvement for the VR-ATM group.
Conclusion
We found the VR-ATM to be usable as a valid assessment and training tool for relearning the use of ATMs prior to real-life practice in persons with ABI.
doi:10.1186/1743-0003-7-19
PMCID: PMC2881048  PMID: 20429955
6.  A postal survey of data in general practice on the prevalence of Acquired Brain Injury (ABI) in patients aged 18–65 in one county in the west of Ireland 
BMC Family Practice  2009;10:36.
Background
Very little is known about the prevalence of acquired brain injury (ABI) in Ireland. ABI prevalence has previously been obtained from Belgian general practitioners using a postal survey. We attempted to ascertain the prevalence of ABI in County Mayo through a postal survey of all general practitioners in the county.
The specific objectives of this project were to:
1. identify whether general practitioners are
a. aware of patients with ABI aged 18–65 in their practices
b. able to provide prevalence data on ABI in patients aged 18–65
c. able to provide data on age, gender and patient diagnosis
2. analyse prevalence of ABI from any available data from general practitioners.
Methods
A pilot postal survey was performed initially in order to assess the feasibility of the study. It was established that general practitioners did have the necessary information required to complete the questionnaire. A main postal survey was then undertaken. A postal questionnaire was administered to all general practices in County Mayo in the west of Ireland (n = 59). The response rate was 32.2% (n = 19).
Results
General practitioners who replied on behalf of their practice could provide data on patient age, gender and diagnosis. In the nineteen practices, there were 57 patients with ABI. The age-specific prevalence of ABI in the area surveyed was estimated at 183.7 per 100,000. The mean patient population per practice was 2,833 (SD = 950). There were found to be significantly more patients with ABI in rural areas than urban areas (p = 0.006). There were also significant differences in the ages of patients in the different ABI categories. Patients whose ABI was of traumatic origin were significantly younger than those patients with ABI of haemorrhagic origin (p = 0.002).
Conclusion
Although this is a small-scale study, we have ascertained that general practitioners do have data on patients with ABI. Also, some prevalence data now exist where none was available before. These can be used to form the basis of a more substantial programme of university/community partnership research which could provide medical and psychosocial benefits for people with ABI and their families.
doi:10.1186/1471-2296-10-36
PMCID: PMC2695423  PMID: 19454016
7.  An integrated pathway for acquired brain injuries: a regional policy in Tuscany, Italy 
Introduction
Acquired brain injuries (ABI) are a crucial issue for healthcare and social services. In 2000 and 2005 two Consensus Conferences in Italy [1, 2] produced a set of recommendations to improve patients healthcare. In 2009, a regional policy identified specific goals for this health problem in Tuscany.
Aims
To improve the continuum of care for acquired brain injuries in Tuscany, Italy (3,500,000 million inhabitants).
Policy practice description
For the 2003–2007 study period, a total annual number of 465–770 incident cases of ABI with residual serious disability was estimated on the basis of integrated computerized administrative databases.
In 2008, a regional project was started to improve the continuum of care for ABI patients. A multidisciplinary workgroup drafted a technical document designing a model of care based on: five fundamental steps of care, rigorous criteria for appropriate transfers between different steps, subgroups of patients requiring different combinations of steps according to their clinical conditions.
Conclusions
The above-mentioned model of care is now being implemented throughout the region, addressing some readjustments of hospital beds, shared adoption of clinical protocols and integration between social and health care, different professional skills and subsequent levels of care.
Discussion
The strengths of this model are its flexibility and circularity: according to their clinical needs, patients belonging to different subgroups can move along the clinical pathway in several ways: through subsequent steps, bypassing intermediate steps or being readmitted to previous steps.
PMCID: PMC2807073
pathway; acquired brain injuries; incidence
8.  Organising health care services for people with an acquired brain injury: an overview of systematic reviews and randomised controlled trials 
Background
Acquired brain injury (ABI) is the leading cause of disability worldwide yet there is little information regarding the most effective way to organise ABI health care services. The aim of this review was to identify the most up-to-date high quality evidence to answer specific questions regarding the organisation of health care services for people with an ABI.
Methods
We conducted a systematic review of English papers using MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library. We included the most recently published high quality systematic reviews and any randomised controlled trials, non-randomised controlled trials, controlled before after studies or interrupted time series studies published subsequent to the systematic review. We searched for papers that evaluated pre-defined organisational interventions for adults with an ABI. Organisational interventions of interest included fee-for-service care, integrated care, integrated care pathways, continuity of care, consumer engagement in governance and quality monitoring interventions. Data extraction and appraisal of included reviews and studies was completed independently by two reviewers.
Results
A total of five systematic reviews and 21 studies were included in the review; eight of the papers (31%) included people with a traumatic brain injury (TBI) or ABI and the remaining papers (69%) included only participants with a diagnosis of stroke. We found evidence supporting the use of integrated care to improve functional outcome and reduce length of stay and evidence supporting early supported discharge teams for reducing morbidity and mortality and reducing length of stay for stroke survivors. There was little evidence to support case management or the use of integrated care pathways for people with ABI. We found evidence that a quality monitoring intervention can lead to improvements in process outcomes in acute and rehabilitation settings. We were unable to find any studies meeting our inclusion criteria regarding fee-for-service care or engaging consumers in the governance of the health care organisation.
Conclusions
The review found evidence to support integrated care, early supported discharge and quality monitoring interventions however, this evidence was based on studies conducted with people following stroke and may not be appropriate for all people with an ABI.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6963-14-397) contains supplementary material, which is available to authorized users.
doi:10.1186/1472-6963-14-397
PMCID: PMC4263199  PMID: 25228157
Brain injuries; Craniocerebral trauma; Stroke; Systematic review; Rehabilitation; Case management; Delivery of health care; Quality assurance (Health Care)
9.  The study protocol of a cluster-randomised controlled trial of family-mediated personalised activities for nursing home residents with dementia 
BMC Geriatrics  2012;12:2.
Background
Following admission to a nursing home, the feelings of depression and burden that family carers may experience do not necessarily diminish. Additionally, they may experience feelings of guilt and grief for the loss of a previously close relationship. At the same time, individuals with dementia may develop symptoms of depression and agitation (BPSD) that may be related to changes in family relationships, social interaction and stimulation. Until now, interventions to alleviate carer stress and BPSD have treated carers and relatives separately rather than focusing on maintaining or enhancing their relationships. One-to-one structured activities have been shown to reduce BPSD and also improve the caring experience, but barriers such as a lack of resources impede the implementation of activities in aged care facilities. The current study will investigate the effect of individualised activities based on the Montessori methodology administered by family carers in residential care.
Methods/Design
We will conduct a cluster-randomised trial to train family carers in conducting personalised one-to-one activities based on the Montessori methodology with their relatives. Montessori activities derive from the principles espoused by Maria Montessori and subsequent educational theorists to promote engagement in learning, namely task breakdown, guided repetition, progression in difficulty from simple to complex, and the careful matching of demands to levels of competence. Persons with dementia living in aged care facilities and frequently visiting family carers will be included in the study. Consented, willing participants will be randomly assigned by facility to a treatment condition using the Montessori approach or a control waiting list condition. We hypothesise that family carers conducting Montessori-based activities will experience improvements in quality of visits and overall relationship with the resident as well as higher self-rated mastery, fewer depressive symptoms, and a better quality of life than carers in the waiting list condition.
Discussion
We hypothesise that training family carers to deliver personalised activities to their relatives in a residential setting will make visits more satisfying and may consequently improve the quality of life for carers and their relatives. These beneficial effects might also reduce nursing staff burden and thus impact positively on residential facilities.
Trial Registration
Australian New Zealand Clinical Trials Registry - ACTRN12611000998943
doi:10.1186/1471-2318-12-2
PMCID: PMC3268081  PMID: 22236064
10.  Older adults with acquired brain injury: a population based study 
BMC Geriatrics  2013;13:97.
Background
Acquired brain injury (ABI), which includes traumatic (TBI) and non-traumatic brain injury (nTBI), is a leading cause of death and disability worldwide. The objective of this study was to examine the trends, characteristics, cause of brain injury, and discharge destination of hospitalized older adults aged 65 years and older with an ABI diagnosis in a population with universal access to hospital care. The profile of characteristics of patients with TBI and nTBI causes of injury was also compared.
Methods
A population based retrospective cohort study design with healthcare administrative databases was used. Data on acute care admissions were obtained from the Discharge Abstract Database and patients were identified using the International Classification of Diseases – Version 10 codes for Ontario, Canada from April 1, 2003 to March 31, 2010. Older adults were examined in three age groups – 65 to 74, 75 to 84, and 85+ years.
Results
From 2003/04 to 2009/10, there were 14,518 episodes of acute care associated with a TBI code and 51, 233 episodes with a nTBI code. Overall, the rate of hospitalized TBI and nTBI episodes increased with older age groups. From 2007/08 to 2009/10, the percentage of patients that stayed in acute care for 12 days or more and the percentage of patients with delayed discharge from acute care increased with age. The most common cause of TBI was falls while the most common type of nTBI was brain tumours. The percentage of patients discharged to long term care and complex continuing care increased with age and the percentage discharged home decreased with age. In-hospital mortality also increased with age. Older adults with TBI and nTBI differed significantly in demographic and clinical characteristics and discharge destination from acute care.
Conclusions
This study showed an increased rate of acute care admissions for both TBI and nTBI with age. It also provided additional support for falls prevention strategies to prevent injury leading to cognitive disability with costly human and economic consequences. Implications for increased numbers of people with ABI are discussed.
doi:10.1186/1471-2318-13-97
PMCID: PMC3849645  PMID: 24060144
Brain injury; Epidemiology; Outcomes
11.  Caregiver- and Patient-Directed Interventions for Dementia 
Executive Summary
In early August 2007, the Medical Advisory Secretariat began work on the Aging in the Community project, an evidence-based review of the literature surrounding healthy aging in the community. The Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the ministry’s newly released Aging at Home Strategy.
After a broad literature review and consultation with experts, the secretariat identified 4 key areas that strongly predict an elderly person’s transition from independent community living to a long-term care home. Evidence-based analyses have been prepared for each of these 4 areas: falls and fall-related injuries, urinary incontinence, dementia, and social isolation. For the first area, falls and fall-related injuries, an economic model is described in a separate report.
Please visit the Medical Advisory Secretariat Web site, http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html, to review these titles within the Aging in the Community series.
Aging in the Community: Summary of Evidence-Based Analyses
Prevention of Falls and Fall-Related Injuries in Community-Dwelling Seniors: An Evidence-Based Analysis
Behavioural Interventions for Urinary Incontinence in Community-Dwelling Seniors: An Evidence-Based Analysis
Caregiver- and Patient-Directed Interventions for Dementia: An Evidence-Based Analysis
Social Isolation in Community-Dwelling Seniors: An Evidence-Based Analysis
The Falls/Fractures Economic Model in Ontario Residents Aged 65 Years and Over (FEMOR)
This report features the evidence-based analysis on caregiver- and patient-directed interventions for dementia and is broken down into 4 sections:
Introduction
Caregiver-Directed Interventions for Dementia
Patient-Directed Interventions for Dementia
Economic Analysis of Caregiver- and Patient-Directed Interventions for Dementia
Caregiver-Directed Interventions for Dementia
Objective
To identify interventions that may be effective in supporting the well-being of unpaid caregivers of seniors with dementia living in the community.
Clinical Need: Target Population and Condition
Dementia is a progressive and largely irreversible syndrome that is characterized by a loss of cognitive function severe enough to impact social or occupational functioning. The components of cognitive function affected include memory and learning, attention, concentration and orientation, problem-solving, calculation, language, and geographic orientation. Dementia was identified as one of the key predictors in a senior’s transition from independent community living to admission to a long-term care (LTC) home, in that approximately 90% of individuals diagnosed with dementia will be institutionalized before death. In addition, cognitive decline linked to dementia is one of the most commonly cited reasons for institutionalization.
Prevalence estimates of dementia in the Ontario population have largely been extrapolated from the Canadian Study of Health and Aging conducted in 1991. Based on these estimates, it is projected that there will be approximately 165,000 dementia cases in Ontario in the year 2008, and by 2010 the number of cases will increase by nearly 17% over 2005 levels. By 2020 the number of cases is expected to increase by nearly 55%, due to a rise in the number of people in the age categories with the highest prevalence (85+). With the increase in the aging population, dementia will continue to have a significant economic impact on the Canadian health care system. In 1991, the total costs associated with dementia in Canada were $3.9 billion (Cdn) with $2.18 billion coming from LTC.
Caregivers play a crucial role in the management of individuals with dementia because of the high level of dependency and morbidity associated with the condition. It has been documented that a greater demand is faced by dementia caregivers compared with caregivers of persons with other chronic diseases. The increased burden of caregiving contributes to a host of chronic health problems seen among many informal caregivers of persons with dementia. Much of this burden results from managing the behavioural and psychological symptoms of dementia (BPSD), which have been established as a predictor of institutionalization for elderly patients with dementia.
It is recognized that for some patients with dementia, an LTC facility can provide the most appropriate care; however, many patients move into LTC unnecessarily. For individuals with dementia to remain in the community longer, caregivers require many types of formal and informal support services to alleviate the stress of caregiving. These include both respite care and psychosocial interventions. Psychosocial interventions encompass a broad range of interventions such as psychoeducational interventions, counseling, supportive therapy, and behavioural interventions.
Assuming that 50% of persons with dementia live in the community, a conservative estimate of the number of informal caregivers in Ontario is 82,500. Accounting for the fact that 29% of people with dementia live alone, this leaves a remaining estimate of 58,575 Ontarians providing care for a person with dementia with whom they reside.
Description of Interventions
The 2 main categories of caregiver-directed interventions examined in this review are respite care and psychosocial interventions. Respite care is defined as a break or relief for the caregiver. In most cases, respite is provided in the home, through day programs, or at institutions (usually 30 days or less). Depending on a caregiver’s needs, respite services will vary in delivery and duration. Respite care is carried out by a variety of individuals, including paid staff, volunteers, family, or friends.
Psychosocial interventions encompass a broad range of interventions and have been classified in various ways in the literature. This review will examine educational, behavioural, dementia-specific, supportive, and coping interventions. The analysis focuses on behavioural interventions, that is, those designed to help the caregiver manage BPSD. As described earlier, BPSD are one of the most challenging aspects of caring for a senior with dementia, causing an increase in caregiver burden. The analysis also examines multicomponent interventions, which include at least 2 of the above-mentioned interventions.
Methods of Evidence-Based Analysis
A comprehensive search strategy was used to identify systematic reviews and randomized controlled trials (RCTs) that examined the effectiveness of interventions for caregivers of dementia patients.
Questions
Section 2.1
Are respite care services effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?
Do respite care services impact on rates of institutionalization of these seniors?
Section 2.2
Which psychosocial interventions are effective in supporting the well-being of unpaid caregivers of seniors with dementia in the community?
Which interventions reduce the risk for institutionalization of seniors with dementia?
Outcomes of Interest
any quantitative measure of caregiver psychological health, including caregiver burden, depression, quality of life, well-being, strain, mastery (taking control of one’s situation), reactivity to behaviour problems, etc.;
rate of institutionalization; and
cost-effectiveness.
Assessment of Quality of Evidence
The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology and GRADE Working Group. As per GRADE the following definitions apply:
Summary of Findings
Conclusions in Table 1 are drawn from Sections 2.1 and 2.2 of the report.
Summary of Conclusions on Caregiver-Directed Interventions
There is limited evidence from RCTs that respite care is effective in improving outcomes for those caring for seniors with dementia.
There is considerable qualitative evidence of the perceived benefits of respite care.
Respite care is known as one of the key formal support services for alleviating caregiver burden in those caring for dementia patients.
Respite care services need to be tailored to individual caregiver needs as there are vast differences among caregivers and patients with dementia (severity, type of dementia, amount of informal/formal support available, housing situation, etc.)
There is moderate- to high-quality evidence that individual behavioural interventions (≥ 6 sessions), directed towards the caregiver (or combined with the patient) are effective in improving psychological health in dementia caregivers.
There is moderate- to high-quality evidence that multicomponent interventions improve caregiver psychosocial health and may affect rates of institutionalization of dementia patients.
RCT indicates randomized controlled trial.
Patient-Directed Interventions for Dementia
Objective
The section on patient-directed interventions for dementia is broken down into 4 subsections with the following questions:
3.1 Physical Exercise for Seniors with Dementia – Secondary Prevention
What is the effectiveness of physical exercise for the improvement or maintenance of basic activities of daily living (ADLs), such as eating, bathing, toileting, and functional ability, in seniors with mild to moderate dementia?
3.2 Nonpharmacologic and Nonexercise Interventions to Improve Cognitive Functioning in Seniors With Dementia – Secondary Prevention
What is the effectiveness of nonpharmacologic interventions to improve cognitive functioning in seniors with mild to moderate dementia?
3.3 Physical Exercise for Delaying the Onset of Dementia – Primary Prevention
Can exercise decrease the risk of subsequent cognitive decline/dementia?
3.4 Cognitive Interventions for Delaying the Onset of Dementia – Primary Prevention
Does cognitive training decrease the risk of cognitive impairment, deterioration in the performance of basic ADLs or instrumental activities of daily living (IADLs),1 or incidence of dementia in seniors with good cognitive and physical functioning?
Clinical Need: Target Population and Condition
Secondary Prevention2
Exercise
Physical deterioration is linked to dementia. This is thought to be due to reduced muscle mass leading to decreased activity levels and muscle atrophy, increasing the potential for unsafe mobility while performing basic ADLs such as eating, bathing, toileting, and functional ability.
Improved physical conditioning for seniors with dementia may extend their independent mobility and maintain performance of ADL.
Nonpharmacologic and Nonexercise Interventions
Cognitive impairments, including memory problems, are a defining feature of dementia. These impairments can lead to anxiety, depression, and withdrawal from activities. The impact of these cognitive problems on daily activities increases pressure on caregivers.
Cognitive interventions aim to improve these impairments in people with mild to moderate dementia.
Primary Prevention3
Exercise
Various vascular risk factors have been found to contribute to the development of dementia (e.g., hypertension, hypercholesterolemia, diabetes, overweight).
Physical exercise is important in promoting overall and vascular health. However, it is unclear whether physical exercise can decrease the risk of cognitive decline/dementia.
Nonpharmacologic and Nonexercise Interventions
Having more years of education (i.e., a higher cognitive reserve) is associated with a lower prevalence of dementia in crossectional population-based studies and a lower incidence of dementia in cohorts followed longitudinally. However, it is unclear whether cognitive training can increase cognitive reserve or decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs or reduce the incidence of dementia.
Description of Interventions
Physical exercise and nonpharmacologic/nonexercise interventions (e.g., cognitive training) for the primary and secondary prevention of dementia are assessed in this review.
Evidence-Based Analysis Methods
A comprehensive search strategy was used to identify systematic reviews and RCTs that examined the effectiveness, safety and cost effectiveness of exercise and cognitive interventions for the primary and secondary prevention of dementia.
Questions
Section 3.1: What is the effectiveness of physical exercise for the improvement or maintenance of ADLs in seniors with mild to moderate dementia?
Section 3.2: What is the effectiveness of nonpharmacologic/nonexercise interventions to improve cognitive functioning in seniors with mild to moderate dementia?
Section 3.3: Can exercise decrease the risk of subsequent cognitive decline/dementia?
Section 3.4: Does cognitive training decrease the risk of cognitive impairment, prevent or delay deterioration in the performance of ADLs or IADLs, or reduce the incidence of dementia in seniors with good cognitive and physical functioning?
Assessment of Quality of Evidence
The quality of the evidence was assessed as High, Moderate, Low, or Very low according to the GRADE methodology. As per GRADE the following definitions apply:
Summary of Findings
Table 2 summarizes the conclusions from Sections 3.1 through 3.4.
Summary of Conclusions on Patient-Directed Interventions*
Previous systematic review indicated that “cognitive training” is not effective in patients with dementia.
A recent RCT suggests that CST (up to 7 weeks) is effective for improving cognitive function and quality of life in patients with dementia.
Regular leisure time physical activity in midlife is associated with a reduced risk of dementia in later life (mean follow-up 21 years).
Regular physical activity in seniors is associated with a reduced risk of cognitive decline (mean follow-up 2 years).
Regular physical activity in seniors is associated with a reduced risk of dementia (mean follow-up 6–7 years).
Evidence that cognitive training for specific functions (memory, reasoning, and speed of processing) produces improvements in these specific domains.
Limited inconclusive evidence that cognitive training can offset deterioration in the performance of self-reported IADL scores and performance assessments.
1° indicates primary; 2°, secondary; CST, cognitive stimulation therapy; IADL, instrumental activities of daily living; RCT, randomized controlled trial.
Benefit/Risk Analysis
As per the GRADE Working Group, the overall recommendations consider 4 main factors:
the trade-offs, taking into account the estimated size of the effect for the main outcome, the confidence limits around those estimates, and the relative value placed on the outcome;
the quality of the evidence;
translation of the evidence into practice in a specific setting, taking into consideration important factors that could be expected to modify the size of the expected effects such as proximity to a hospital or availability of necessary expertise; and
uncertainty about the baseline risk for the population of interest.
The GRADE Working Group also recommends that incremental costs of health care alternatives should be considered explicitly alongside the expected health benefits and harms. Recommendations rely on judgments about the value of the incremental health benefits in relation to the incremental costs. The last column in Table 3 reflects the overall trade-off between benefits and harms (adverse events) and incorporates any risk/uncertainty (cost-effectiveness).
Overall Summary Statement of the Benefit and Risk for Patient-Directed Interventions*
Economic Analysis
Budget Impact Analysis of Effective Interventions for Dementia
Caregiver-directed behavioural techniques and patient-directed exercise programs were found to be effective when assessing mild to moderate dementia outcomes in seniors living in the community. Therefore, an annual budget impact was calculated based on eligible seniors in the community with mild and moderate dementia and their respective caregivers who were willing to participate in interventional home sessions. Table 4 describes the annual budget impact for these interventions.
Annual Budget Impact (2008 Canadian Dollars)
Assumed 7% prevalence of dementia aged 65+ in Ontario.
Assumed 8 weekly sessions plus 4 monthly phone calls.
Assumed 12 weekly sessions plus biweekly sessions thereafter (total of 20).
Assumed 2 sessions per week for first 5 weeks. Assumed 90% of seniors in the community with dementia have mild to moderate disease. Assumed 4.5% of seniors 65+ are in long-term care, and the remainder are in the community. Assumed a rate of participation of 60% for both patients and caregivers and of 41% for patient-directed exercise. Assumed 100% compliance since intervention administered at the home. Cost for trained staff from Ministry of Health and Long-Term Care data source. Assumed cost of personal support worker to be equivalent to in-home support. Cost for recreation therapist from Alberta government Website.
Note: This budget impact analysis was calculated for the first year after introducing the interventions from the Ministry of Health and Long-Term Care perspective using prevalence data only. Prevalence estimates are for seniors in the community with mild to moderate dementia and their respective caregivers who are willing to participate in an interventional session administered at the home setting. Incidence and mortality rates were not factored in. Current expenditures in the province are unknown and therefore were not included in the analysis. Numbers may change based on population trends, rate of intervention uptake, trends in current programs in place in the province, and assumptions on costs. The number of patients was based on patients likely to access these interventions in Ontario based on assumptions stated below from the literature. An expert panel confirmed resource consumption.
PMCID: PMC3377513  PMID: 23074509
12.  Novel insights into the rehabilitation of memory post acquired brain injury: a systematic review 
Objective: Acquired Brain Injury (ABI) frequently results in memory impairment causing significant disabilities in daily life and is therefore a critical target for cognitive rehabilitation. Current understanding of brain plasticity has led to novel insights in remediation-oriented approaches for the rehabilitation of memory deficits. We will describe 3 of these approaches that have emerged in the last decade: Virtual Reality (VR) training, Computer-Based Cognitive Retraining (CBCR) and Non-Invasive Brain Stimulation (NBS) and evaluate its effectiveness.
Methods: A systematic literature search was completed in regard to studies evaluating interventions aiming to improve the memory function after ABI. Information concerning study content and reported effectiveness were extracted. Quality of the studies and methods were evaluated.
Results: A total of 786 studies were identified, 15 studies met the inclusion criteria. Three of those studies represent the VR technique, 7 studies represent CBCR and 5 studies NBS. All 3 studies found a significant improvement of the memory function after VR-based training, however these studies are considered preliminary. All 7 studies have shown that CBCR can be effective in improving memory function in patients suffering from ABI. Four studies of the 5 did not find significant improvement of the memory function after the use of NBS in ABI patients.
Conclusion: On the basis of this review, CBCR is considered the most promising novel approach of the last decade because of the positive results in improving memory function post ABI. The number of studies representing VR were limited and the methodological quality low, therefore the results should be considered preliminary. The studies representing NBS did not detect evidence for the use of NBS in improving memory function.
doi:10.3389/fnhum.2014.00993
PMCID: PMC4267268  PMID: 25566021
acquired brain injury; memory; remediation-oriented technique; virtual reality; computer-based cognitive retraining; non-invasive brain stimulation
13.  ïSCOPE: Safer care for older persons (in residential) environments: A study protocol 
Background
The current profile of residents living in Canadian nursing homes includes elder persons with complex physical and social needs. High resident acuity can result in increased staff workload and decreased quality of work life.
Aims
Safer Care for Older Persons [in residential] Environments is a two year (2010 to 2012) proof-of-principle pilot study conducted in seven nursing homes in western Canada. The purpose of the study is to evaluate the feasibility of engaging front line staff to use quality improvement methods to integrate best practices into resident care. The goals of the study are to improve the quality of work life for staff, in particular healthcare aides, and to improve residents' quality of life.
Methods/design
The study has parallel research and quality improvement intervention arms. It includes an education and support intervention for direct caregivers to improve the safety and quality of their care delivery. We hypothesize that this intervention will improve not only the care provided to residents but also the quality of work life for healthcare aides. The study employs tools adapted from the Institute for Healthcare Improvement's Breakthrough Series: Collaborative Model and Canada's Safer Healthcare Now! improvement campaign. Local improvement teams in each nursing home (1 to 2 per facility) are led by healthcare aides (non-regulated caregivers) and focus on the management of specific areas of resident care. Critical elements of the program include local measurement, virtual and face-to-face learning sessions involving change management, quality improvement methods and clinical expertise, ongoing virtual and in person support, and networking.
Discussion
There are two sustainability challenges in this study: ongoing staff and leadership engagement, and organizational infrastructure. Addressing these challenges will require strategic planning with input from key stakeholders for sustaining quality improvement initiatives in the long-term care sector.
doi:10.1186/1748-5908-6-71
PMCID: PMC3155478  PMID: 21745382
14.  Rasch Measurement Analysis of the Mayo-Portland Adaptability Inventory (MPAI-4) in a Community-Based Rehabilitation Sample 
Journal of Neurotrauma  2011;28(5):745-753.
Abstract
The precise measurement of patient outcomes depends upon clearly articulated constructs and refined clinical assessment instruments that work equally well for all subgroups within a population. This is a challenging task in those with acquired brain injury (ABI) because of the marked heterogeneity of the disorder and subsequent outcomes. Alhough essential, the iterative process of instrument refinement is often neglected. This present study was undertaken to examine validity, reliability, dimensionality and item estimate invariance of the Mayo-Portland Adaptability Inventory – 4 (MPAI-4), an outcome measure for persons with ABI. The sampled population included 603 persons with traumatic ABI participating in a home- and community-based rehabilitation program. Results indicated that the MPAI-4 is a valid, reliable measure of outcome following traumatic ABI, which measures a broad but unitary core construct of outcome after ABI. Further, the MPAI-4 is composed of items that are unbiased toward selected subgroups except where differences could be expected [e.g., more chronic traumatic brain injury (TBI) patients are better able to negotiate demands of transportation than more acute TBI patients]. We address the trade-offs between strict unidimensionality and clinical applicability in measuring outcome, and illustrate the advantages and disadvantages of applying single-parameter measurement models to broad constructs.
doi:10.1089/neu.2010.1573
PMCID: PMC3088961  PMID: 21332409
outcome measures; rehabilitation; TBI
15.  Community capacity to acquire, assess, adapt, and apply research evidence: a survey of Ontario's HIV/AIDS sector 
Background
Community-based organizations (CBOs) are important stakeholders in health systems and are increasingly called upon to use research evidence to inform their advocacy, program planning, and service delivery. To better support CBOs to find and use research evidence, we sought to assess the capacity of CBOs in the HIV/AIDS sector to acquire, assess, adapt, and apply research evidence in their work.
Methods
We invited executive directors of HIV/AIDS CBOs in Ontario, Canada (n = 51) to complete the Canadian Health Services Research Foundation's "Is Research Working for You?" survey.
Findings
Based on responses from 25 organizations that collectively provide services to approximately 32,000 clients per year with 290 full-time equivalent staff, we found organizational capacity to acquire, assess, adapt, and apply research evidence to be low. CBO strengths include supporting a culture that rewards flexibility and quality improvement, exchanging information within their organization, and ensuring that their decision-making processes have a place for research. However, CBO Executive Directors indicated that they lacked the skills, time, resources, incentives, and links with experts to acquire research, assess its quality and reliability, and summarize it in a user-friendly way.
Conclusion
Given the limited capacity to find and use research evidence, we recommend a capacity-building strategy for HIV/AIDS CBOs that focuses on providing the tools, resources, and skills needed to more consistently acquire, assess, adapt, and apply research evidence. Such a strategy may be appropriate in other sectors and jurisdictions as well given that CBO Executive Directors in the HIV/AIDS sector in Ontario report low capacity despite being in the enviable position of having stable government infrastructure in place to support them, benefiting from long-standing investment in capacity building, and being part of an active provincial network. CBOs in other sectors and jurisdictions that have fewer supports may have comparable or lower capacity. Future research should examine a larger sample of CBO Executive Directors from a range of sectors and jurisdictions.
doi:10.1186/1748-5908-6-54
PMCID: PMC3123230  PMID: 21619682
16.  Acute Care Alternate-Level-of-Care Days Due to Delayed Discharge for Traumatic and Non-Traumatic Brain Injuries 
Healthcare Policy  2012;7(4):41-55.
Alternate-level-of-care (ALC) days represent hospital beds that are taken up by patients who would more appropriately be cared for in other settings. ALC days have been found to be costly and may result in worse functional outcomes, reduced motor skills and longer lengths of stay in rehabilitation. This study examines the factors that are associated with acute care ALC days among patients with acquired brain injury (ABI). We used the Discharge Abstract Database to identify patients with ABI using International Classification of Disease-10 codes. From fiscal years 2007/08 to 2009/10, 17.5% of patients with traumatic and 14% of patients with non-traumatic brain injury had at least one ALC day. Significant predictors include having a psychiatric co-morbidity, increasing age and length of stay in acute care. These findings can inform planning for care of people with ABI in a publicly funded healthcare system.
PMCID: PMC3359084  PMID: 23634162
17.  Experiences of health care providers with integrated HIV and reproductive health services in Kenya: a qualitative study 
Background
There is broad consensus on the value of integration of HIV services and reproductive health services in regions of the world with generalised HIV/AIDS epidemics and high reproductive morbidity. Integration is thought to increase access to and uptake of health services; and improves their efficiency and cost-effectiveness through better use of available resources. However, there is still very limited empirical literature on health service providers and how they experience and operationalize integration. This qualitative study was conducted among frontline health workers to explore provider experiences with integration in order to ascertain their significance to the performance of integrated health facilities.
Methods
Semi-structured in-depth interviews were conducted with 32 frontline clinical officers, registered nurses, and enrolled nurses in Kitui district (Eastern province) and Thika and Nyeri districts (Central province) in Kenya. The study was conducted in health facilities providing integrated HIV and reproductive health services (post-natal care and family planning). All interviews were conducted in English, transcribed and analysed using Nvivo 8 qualitative data analysis software.
Results
Providers reported delivering services in provider-level and unit-level integration, as well as a combination of both. Provider experiences of actual integration were mixed. At personal level, providers valued skills enhancement, more variety and challenge in their work, better job satisfaction through increased client-satisfaction. However, they also felt that their salaries were poor, they faced increased occupational stress from: increased workload, treating very sick/poor clients, and less quality time with clients. At operational level, providers reported increased service uptake, increased willingness among clients to take an HIV test, and reduced loss of clients. But the majority also reported infrastructural and logistic deficiencies (insufficient physical room space, equipment, drugs and other medical supplies), as well as increased workload, waiting times, contact session times and low staffing levels.
Conclusions
The success of integration primarily depends on the performance of service providers which, in turn, depends on a whole range of facilitative organisational factors. The central Ministry of Health should create a coherent policy environment, spearhead strategic planning and ensure availability of resources for implementation at lower levels of the health system. Health facility staffing norms, technical support, cost-sharing policies, clinical reporting procedures, salary and incentive schemes, clinical supply chains, and resourcing of health facility physical space upgrades, all need attention. Yet, despite these system challenges, this study has shown that integration can have a positive motivating effect on staff and can lead to better sharing of workload - these are important opportunities that deserve to be built on.
doi:10.1186/1472-6963-13-18
PMCID: PMC3599716  PMID: 23311431
Integration; HIV/AIDS; Reproductive health; Health care providers; Challenges; Benefits
18.  The challenges of achieving high training coverage for IMCI: case studies from Kenya and Tanzania 
Health Policy and Planning  2010;26(5):395-404.
Health worker training is a key component of the integrated management of childhood illness (IMCI). However, training coverage remains low in many countries. We conducted in-depth case studies in two East African countries to examine the factors underlying low training coverage 10 years after IMCI had been adopted as policy. A document review and in-depth semi-structured interviews with stakeholders at facility, district, regional/provincial and national levels in two districts in Kenya (Homa Bay and Malindi) and Tanzania (Bunda and Tarime) were carried out in 2007–08.
Bunda and Malindi achieved higher levels of training coverage (44% and 25%) compared with Tarime and Homa Bay (5% and 13%). Key factors allowing the first two districts to perform better were: strong district leadership and personal commitment to IMCI, which facilitated access to external funding and encouraged local-level policy adaptation; sensitization and training of district health managers; and lower staff turnover. However, IMCI training coverage remained well below target levels across all sites. The main barrier to expanding coverage was the cost of training due to its duration, the number of facilitators and its residential nature. Mechanisms for financing IMCI also restricted district capacity to raise funds. In Tanzania, districts could not spend more than 10% of their budgets on training. In Kenya, limited financial decentralization meant that district managers had to rely on donors for financial support. Critically, the low priority given to IMCI at national and international levels also limited the expansion of training. Levels of domestic and donor support for IMCI have diminished over time in favour of vertical programmes, partly due to the difficulty in monitoring and measuring the impact of an integrated intervention like IMCI.
Alternative, lower cost methods of IMCI training need to be promoted, and greater advocacy for IMCI is needed both nationally and internationally.
doi:10.1093/heapol/czq068
PMCID: PMC3157918  PMID: 21047808
IMCI; training coverage; Tanzania; Kenya; child health
19.  Perceptions of the ankle brachial index amongst podiatrists registered in Western Australia 
Background
The ankle brachial index (ABI) is an objective diagnostic tool that is widely used for the diagnosis of peripheral arterial disease. Despite its usefulness, it is evident within the literature that many practitioners forgo using this screening tool due to limiting factors such as time. There is also no recommended technique for ABI measurement. The purpose of this study is to investigate the perceptions of the use of ABI clinically among Western Australian podiatrists.
Methods
This study was a cross sectional survey which evaluated the perceptions of the ABI amongst registered podiatrists in Western Australia. The study sample was obtained from the register of podiatrists listed with the Podiatrists Registration Board of Western Australia. Podiatrists were contacted by telephone and invited to participate in a telephone questionnaire. Chi-square tests were performed to determine if there was a statistically significant relationship between use of the ABI and podiatrists’ profile which included: sector of employment; geographical location; and length of time in practice.
Results
There is a statistically significant relationship (p=0.004) between podiatrists’ profile and the use of ABI, with higher usage in the tertiary hospital setting than in private practice. Length of time spent in practice had no significant impact on ABI usage (p=0.098). Time constraints and lack of equipment were key limiting factors to performing the ABI, and no preferred technique was indicated.
Conclusion
Western Australian podiatrists agree that the ABI is a useful tool for lower limb vascular assessment, however, various factors influence uptake in the clinical setting. This study suggests that a podiatrists’ profile has a significant influence on the use of the ABI, which may be attributed to different patient types across the various settings. The influence of time spent in practice on ABI usage may be attributed to differences in clinical training and awareness of lower limb pathology over time. The authors recommend publication of ‘best practice’ guidelines to ABI performance, as well as further education and financial rebates from health organizations to facilitate increased utility of the ABI based on the findings of this study.
doi:10.1186/1757-1146-5-19
PMCID: PMC3520691  PMID: 22846188
20.  Knowledge and Attitudes About Methadone Maintenance Among Staff Working in a Therapeutic Community 
Research demonstrates that drug treatment staff members’ knowledge and attitudes about methadone are positively correlated with treatment success among opiate-dependent clients. However the bulk of this research is on outpatient treatment in methadone clinics. This study examined a residential treatment program that allowed clients on methadone, a rare treatment opportunity that is growing nationwide. Staff (N = 87) working in four therapeutic community (TC) facilities, were surveyed using the Abstinence Orientation Scale (AOS), Methadone Knowledge Scale (MKS), and Disapproval of Drug Use Scale (DDU). The relationships between TC staff characteristics and scores on the assessment measures were tested for differences. Staff members who affirmed having been in treatment had greater methadone knowledge than those who had not. Staff members who participated in methadone sensitivity training had greater methadone knowledge and lower abstinence orientation than those who did not attend the training. Staff in this study had stronger abstinence orientation than found in studies of methadone clinic staff, which may represent a barrier to methadone in residential settings. This study suggests that staff experience is correlated with attitudes and knowledge about methadone and that staff training is associated with changing attitudes and knowledge about methadone.
doi:10.1300/J126v03n01_05
PMCID: PMC3604981  PMID: 23525520
Methadone; residential treatment; therapeutic community; opioid dependence; Abstinence Orientation Scale; Methadone Knowledge Scale; disapproval of drug use
21.  Social determinants of health in Canada: Are healthy living initiatives there yet? A policy analysis 
Introduction
Preventative strategies that focus on addressing the social determinants of health to improve healthy eating and physical activity have become an important strategy in British Columbia and Ontario for combating chronic diseases. What has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health.
Methods
Initiatives active between January 1, 2006 and September 1, 2011 were found using provincial policy documents, web searches, health organization and government websites, and databases of initiatives that attempted to influence to nutrition and physical activity in order to prevent chronic diseases or improve overall health. Initiatives were reviewed, analyzed and grouped using the descriptive codes: lifestyle-based, environment-based or structure-based. Initiatives were also classified according to the mechanism by which they were administered: as direct programs (e.g. directly delivered), blueprints (or frameworks to tailor developed programs), and building blocks (resources to develop programs).
Results
60 initiatives were identified in Ontario and 61 were identified in British Columbia. In British Columbia, 11.5% of initiatives were structure-based. In Ontario, of 60 provincial initiatives identified, 15% were structure-based. Ontario had a higher proportion of direct interventions than British Columbia for all intervention types. However, in both provinces, as the intervention became more upstream and attempted to target the social determinants of health more directly, the level of direct support for the intervention lessened.
Conclusions
The paucity of initiatives in British Columbia and Ontario that address healthy eating and active living through action on the social determinants of health is problematic. In the context of Canada's increasingly neoliberal political and economic policy, the public health sector may face significant barriers to addressing upstream determinants in a meaningful way. If public health cannot directly affect broader societal conditions, interventions should be focused around advocacy and education about the social determinants of health. It is necessary that health be seen for what it is: a political matter. As such, the health sector needs to take a more political approach in finding solutions for health inequities.
doi:10.1186/1475-9276-11-41
PMCID: PMC3492195  PMID: 22889402
Chronic disease prevention; Social determinants of health; Canada; Health policy; Healthy living; Policy analysis
22.  ASSOCIATIONS OF BORDERLINE AND LOW NORMAL ANKLE BRACHIAL INDEX VALUES WITH FUNCTIONAL DECLINE AT FIVE YEAR FOLLOW-UP 
Objectives
We studied associations of borderline and low-normal ankle brachial index (ABI) values with functional decline over five-year follow-up.
Background
Associations of borderline and low-normal ABI with functional decline are unknown.
Methods
The 666 participants included 412 with peripheral arterial disease (PAD). Participants were categorized as follows: Severe PAD (ABI < 0.50), moderate PAD (ABI 0.50-0.69), mild PAD (ABI 0.70 to 0.89), borderline ABI (0.90 to 0.99), low normal ABI (1.00 to 1.09), and normal ABI (ABI 1.10-1.30). Outcomes were assessed annually for five years. Mobility loss was defined as loss of the ability to walk ¼ mile or walk up and down one flight of stairs without assistance among those without baseline mobility impairment. Becoming unable to walk for six minutes continuously was defined as stopping during the six minute walk at follow-up among those who walked for six minutes continuously at baseline. Results adjust for age, sex, race, comorbidities, and other confounders.
Results
Hazard ratios (HR) for mobility loss according to ABI category were as follows. Severe PAD: HR=4.16 (95% Confidence Interval (CI)=1.58-10.92), moderate PAD: HR=3.82 (95% CI=1.66-8.81), mild PAD: HR=3.22 (95% CI=1.43-7.21), borderline ABI: HR=3.07 (95% CI=1.21-7.84), low normal ABI: HR=2.61 (95% CI=1.08-6.32) (p trend=0.0018). Similar associations were observed for becoming unable to walk six-minutes continuously (p trend<0.0001).
Conclusion
At five-year follow-up, persons with borderline ABI values have a higher incidence of mobility loss and becoming unable to walk for six minutes continuously compared to persons with a normal baseline ABI. A low normal ABI is associated with an increased incidence of mobility loss compared to persons with a normal ABI.
CONDENSED ABSTRACT
We studied associations of borderline and low-normal ABI values with functional decline over five-year follow-up among 666 participants, including 412 with lower extremity peripheral arterial disease (PAD). At five year follow-up, participants with borderline ABI values at baseline (ABI 0.90 to 0.99) had significantly greater mobility loss and were more likely to become unable to walk for six-minutes continuously compared to those with a normal baseline ABI. Participants with low normal ABI values (ABI 1.00 to 1.09) had significantly greater mobility loss compared to those with a normal baseline ABI.
doi:10.1016/j.jacc.2008.09.063
PMCID: PMC3215766  PMID: 19298919
ankle brachial index; physical functioning; peripheral arterial disease; intermittent claudication
23.  Current experiences and educational preferences of general practitioners and staff caring for people with dementia living in residential facilities 
BMC Geriatrics  2009;9:36.
Background
Residential care is important for older adults, particularly for those with advanced dementia and their families. Education interventions that achieve sustainable improvement in the care of older adults are critical to quality care. There are few systematic data available regarding the educational needs of Residential Care Facility (RCF) staff and General Practitioners (GPs) relating to dementia, or the sustainability of educational interventions. We sought to determine participation in dementia education, perceived levels of current knowledge regarding dementia, perceived unmet educational needs, current barriers, facilitators and preferences for dementia education.
Methods
A mixed methods study design was utilised. A survey was distributed to a convenience sample of general practitioners, and staff in 223 consecutive residential care facilities in Perth, Western Australia. Responses were received from 102 RCF staff working in 10 facilities (out of 33 facilities who agreed to distribute the survey) and 202 GPs (19% of metropolitan GPs). Quantitative survey data were summarised descriptively and chi squared statistics were used to analyse the distribution of categorical variables. Qualitative data were collected from general practitioners, staff in residential care facilities and family carers of people with dementia utilizing individual interviews, surveys and focus groups. Qualitative data were analysed thematically.
Results
Among RCF staff and GPs attending RCF, participation in dementia education was high, and knowledge levels generally perceived as good. The individual experiences and needs of people with dementia and their families were emphasised. Participants identified the need for a person centred philosophy to underpin educational interventions. Limited time was a frequently mentioned barrier, especially in relation to attending dementia care education. Perceived educational needs relating to behaviours of concern, communication, knowledge regarding dementia, aspects of person centred care, system factors and the multidisciplinary team were consistently and frequently cited. Small group education which is flexible, individualized, practical and case based was sought.
Conclusion
The effectiveness and sustainability of an educational intervention based on these findings needs to be tested. In addition, future interventions should focus on supporting cultural change to facilitate sustainable improvements in care.
doi:10.1186/1471-2318-9-36
PMCID: PMC2733895  PMID: 19674462
24.  Costs of day hospital and community residential chemical dependency treatment 
Background
Evidence suggests that expensive hospital-based inpatient chemical dependency programs do not deliver outcomes that are superior to less costly day hospital programs, but patient placement criteria developed by the Addiction Society of Medicine (ASAM) nonetheless have identified a need for low-intensity residential treatment for patients with higher levels of severity. Community-based residential programs may represent a low-cost inpatient alternative that satisfies the ASAM criteria, but research is lacking in this area. A recent clinical trial has found similar outcomes at social model residential treatment and clinically-oriented day hospital programs, but did not report on the costs associated with treatment in that study.
Aims
This paper addresses whether the similar outcomes in the recent trial were delivered with comparable costs. It also studies costs separately for men and women, and for Whites and non-Whites, subgroups not included or identified in prior cost effectiveness work.
Method
This paper reports on clients who participated in a randomized trial conducted in three metropolitan areas served by a large pre-paid health plan. Clients were eligible if they met the first five dimensions of the ASAM criteria for low-intensity residential treatment and had not been mandated to residential treatment due to dangerous home environment (the sixth ASAM dimension). The five day hospital programs included here are typical of mainstream private chemical dependency programs that were developed as an alternative to inpatient treatment. The seven residential programs are typical of those historically developed by members of alcohol mutual-help programs. Cost data for the study sites were collected using the Drug Abuse Treatment Cost Analysis Program (DATCAP) which produces estimates of average costs per week per client treated at a particular treatment program. Lengths of stay were derived from program records. Costs per episode for each study subject were calculated by multiplying the DATCAP-based program-specific costs (per week) by the number of weeks the subject stayed in the program to which they had been randomly assigned. Differences in length of stay, and in per-episode costs, were compared between residential and day hospital subjects using the Brown-Forsythe robust test of the equality of means.
Results
Lengths of stay at residential treatment were significantly longer than at day hospital, in the sample overall and in the disaggregated analyses for both genders and for both Whites and non-Whites. This difference was especially marked among non-Whites, who had quite short stays in day hospital. The average cost per week was $575 per week at day hospital, versus $370 per week at the residential programs. However, because of the longer stays in residential programs, this lower cost per week did not always translate to lower per-episode costs. Instead, the per-episode costs were significantly higher for those treated in residential programs than in day hospital in the sample overall, and among non-Whites. Costs were comparable for Whites and for women treated in either setting, but were marginally higher for men randomized to residential programs.
Discussion
These cost results must be considered in light of the null findings comparing outcomes between subjects randomized to residential versus day hospital programs in this study, in the overall sample and by gender and race/ethnicity: That is, the longer stays in the sample overall and for non-White clients at residential programs came at higher costs but did not lead to better rates of abstinence. An important component of the cost differential arose from especially short stays in day hospital among non-Whites, calling into question the attractiveness of day hospital for minority clients.
Conclusion
Outcomes and costs at residential versus day hospital programs were similar for women and for Whites in a randomized trial of pre-paid health plan members who met ASAM criteria for low-intensity residential treatment but were not at environmental risk. For non-Whites, and marginally for men, a preference for residential care would appear to come at a higher cost.
Implications for health care provision and use
Lengths of stay in residential treatment are significantly longer than in day hospital, but costs per week are lower. Women and Whites appear to be equally well-served in residential and day hospital programs, with no significant cost differential. Provision of residential treatment for non-Whites may be more costly than day hospital, because their residential stays are likely to be 3 times longer than they would be if treated in day hospital. For men, residential care will be marginally more costly.
Implications for health policy formulation
Residential treatment appears to represent a cost-effective alternative to day hospital for female and White clients with severe alcohol and drug problems who are not at environmental risk, although it will be important that the current study be replicated with different samples and study programs.
Implications for further research
The much shorter stays in day hospital than at residential among non-Whites highlight the need for research to better understand how to best meet the needs and preferences of non-White clients when considering both costs and outcomes.
PMCID: PMC2744443  PMID: 18424874
25.  Association of Chronic Kidney Disease with the Spectrum of Ankle Brachial Index: The Cardiovascular Health Study 
Background
Chronic kidney disease (CKD) is an important risk factor for cardiovascular disease (CVD) events. A high ankle brachial index (ABI) - a marker of lower extremity arterial stiffness – is associated with CVD events and mortality. The association between CKD and high ABI is unknown.
Methods
The Cardiovascular Health Study enrolled community-living persons > 65 years, and measured kidney function and ABI. Glomerular filtration rate (GFR) was estimated using equations that incorporated either cystatin C or creatinine, and CKD was defined by estimated GFR < 60 ml/min/1.73m2. The ABI was categorized as low (< 0.90), low-normal (0.90 – 1.09), normal (1.10 – 1.40), and high (> 1.40 or incompressible). Multinomial logistic regression was used to evaluate the associations of CKD with the ABI categories.
Results
Among 4,513 participants, 23% had CKD, 13% had low ABI, and 3% had high ABI. In models adjusted for age, sex, race, hypertension, diabetes, smoking, BMI, LDL cholesterol, HDL cholesterol, and CRP, cystatin C based CKD was associated with both low ABI (relative risk [RR] 2.0; 95% confidence interval [CI] 1.6 – 2.5; P value < 0.001) and high ABI (RR 1.6; 95% CI 1.0 – 2.3; P = 0.03). Results were similar when CKD was defined by creatinine.
Conclusions
CKD is associated with both the high and low extremes of ABI in community-living older persons. Future studies should evaluate whether arterial stiffness is an important mechanism leading to CVD in persons with CKD.
doi:10.1016/j.jacc.2009.06.017
PMCID: PMC2799242  PMID: 19761940
kidney disease; chronic; atherosclerosis; calcium; cardiovascular disease; arterial stiffness

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