To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) – RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs.Guided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases.Most (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers.This is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs.The online version of this article (10.1186/s12913-019-3980-x) contains supplementary material, which is available to authorized users. Around the world, healthcare systems are experiencing significant pressures in coping with rapidly aging populations and growing multi-morbidity. Like other developed countries, Singapore’s population is also aging quickly, accompanied by the mounting prevalence of co-morbidities . Multi-mSince 2011, the Regional Health Systems (RHSs) have been established in various geographical regions in Singapore to build partnerships between different care providers, within and across care settings. Led by the acute hospital within each region, each RHS aims to foster integration and deliver seamless care for the population within the respective catchment areas in a cost-effective way , 8.Among all patients cared for under the RHS, frequent admitters (FAs)  consume a disproportionally high share of healthcare resources. In 2013, within the National University Health System (NUHS)-RHS, FAs accounted for only 1% of all patients, yet generated about 27% of all inpatient episodes and incurring higher average costs compared to those who were not FAs . A sub-oTransitional care is a set of multi-disciplinary interventions aimed at improving care coordination when patients transit between different healthcare settings . DischarIn 2012, the NUHS-RHS initiated a transitional care program for elderly patients and/or those with complex healthcare needs who had previously consumed high levels of hospital resources . ElderlyTo facilitate further development of the NUHS transitional care program, a rigorous and practical evaluation strategy was required to examine progress and identify insights for improvement and scaling-up. One way to achieve this was by assessing implementation fidelity. Implementation fidelity, the degree in which a program is implemented as intended, acts as a potential mediator of the relationship between programs and their intended outcomes . Higher To address this gap, we aimed to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program. The program had been demonstrated to result in lower mortality among FAs and higher healthcare utilization and cost compared to their matched controls .Furthermore, the study also aim to inform further development of the program. Since this gap is present in other countries too, this study may provide relevant insights to those involved in the development, implementation and/or evaluation of transitional care programs as part of integrated care initiatives beyond Singapore.The modified version of the Conceptual Framework of Implementation Fidelity (CFIF) was used in this study . The modParticipant responsiveness refers to how well participants (users receiving the program and providers delivering program) respond to, or are engaged by the program. If participants do not value the program, they will not be engaged in the program, thereby making implementation difficult. Program complexity refers to the comprehensiveness of the program as evaluated through descriptions of the program and the actual implementation. Simple but specific programs were found to be more likely implemented with high fidelity than complex and/or vaguely described programs. Adequate facilitation is expected to optimize fidelity. Quality of delivery describes whether a program is delivered appropriately to achieve what was intended. A poorly delivered program contributes to lower implementation fidelity overall. In assessing participant recruitment, the modified CFIF proposes to assess the reasons for non-participation among potential participants and subgroups that were less likely to participate. Finally, context considers surrounding social system, for example social structures and cultures.Guided by a set of selection criteria, eligible patients were recruited mainly from the inpatient wards through referrals from the physicians, nurses and other allied health professionals. Then, needs assessments were conducted and personalized care plans were developed accordingly. One or a group of dedicated CCs was assigned to every patient enrolled into the program. Every CC assumed the role of an integrator, responsible for coordinating the delivery of services through communication with patients, their families, and the various professionals and services that the healthcare users come into contact with throughout their period of enrolment in the program. The transitional care program started after patients were discharged from the hospital.The study is a part of the realist evaluation of the NUHS-RHS . In thisData were collected between June 2016 to June 2017. Components of adherence including content, frequency, and duration were assessed using non-participatory observations, reviews of medical records and program databases. We were unable to examine coverage as there was no documentation of the total number of people who were offered the program. Moderating factors were examined using interviews with healthcare providers and healthcare users (patients and caregivers). Caregivers were interviewed as proxies to patients. As there was no benchmarking available within Singapore, we did not assess the quality of delivery and comprehensiveness of policy.Program protocols were initially reviewed by study team members to provide an understanding of the program and how it aimed to achieve targeted outcomes. The intended components of the program identified were then validated against the program’s logic model, components of case management as proposed by the Kings’ Fund , and thrStudy team members conducted non-participatory observations of home visits and telephone monitoring – the core components of the program. Content of care delivery, interactions between healthcare users and providers, together with users’ responses to the service were observed and observation notes were taken. Medical records of patients enrolled into the programs were reviewed to provide a comprehensive picture of the services delivered throughout a patient’s healthcare journey from enrolment to discharge. Program databases comprised of records of patients enrolled in the program was reviewed to gather insights on the dose of the program.Then, observation notes and reviews of medical records were assessed using the checklist by study team members. Program components were scored as “yes” or “no” for whether they were conducted or not. After which, level of adherence for each component of the program was calculated as the percentage of the number of cases in which specific component was scored with “yes” over the total number of observations conducted and medical records reviewed. Levels of adherence for specific component that fall within the 80–100% range were categorised as “high”, within 51–79% as ‘moderate’ and 0–50% as ‘low’ fidelity , 31. In A convenience sampling of healthcare providers who were involved in the planning, development, and implementation of the program were recruited into the study. A contact list of all healthcare providers involved in the program was first obtained from the program manager. Based on which, invitation emails were sent out to recruit study participants. Only those who responded to the email invitations and agreed to be audio-recorded were interviewed by the study team member(s). In every interview session, an interview guide developed for the study  to take part in the interviews. Eligible healthcare users who agreed to be audio recorded were eventually interviewed. In every interview session, content of program and their responses to program were assessed using an interview guide for healthcare users  non-participatory observations were conducted, 29 at first-time home visits, 11 during follow-up visit and 2 during phone monitoring to assess adherence. For the same reason, medical records of 44 patients who were enrolled into the program were also reviewed. Out of the records reviewed, documentations regarding the program could not be found in 11 of them. Therefore, only 33 reviews of medical records were included in the assessment of adherence. Program databases containing a total of 2705 records were reviewed to determine the dose (frequency and duration) of the program.For the assessment of moderating factors influencing program implementation, 25 healthcare providers including CCs, managers, and physicians involved in the implementation of the program and 45 healthcare users (patient/caregiver) enrolled in the transitional care program were interviewed.As illustrated in Table The frequency of actualization of program specific activities was found to vary according to the needs of users, availability of CCs, and their confidence in delivering particular program components. For the period of program enrolment, a median frequency of 2 and 7 were found for home-visits and phone-monitoring respectively. Time spent on home visits was not explicitly tracked while a median of 10 min were found to be spent on every phone call monitoring. Patients were found to be enrolled in the NUHS-RHS post-discharge care program for a mean duration of 112.8 days with a standard deviation of 145.9 days.Our study findings confirmed interrelated influence of moderating factors identified by the modified CFIF on implementation fidelity of the NUHS transitional care program Fig. . A summaappreciation of the program and viewed the convenience of having empathetic, caring, proactive and knowledgeable CC visiting them at home to be most valuable. Nonetheless, the extent of responsiveness was found to fluctuate according to level of awareness. Some healthcare users were found to have limited awareness of the specific services the program offered, its goals and the role of the CC. Therefore, there was misconception; users regarded home visits as “disruptions” with little value and CCs as “doctors’ assistants” with limited capability, leading to lowered perceived value of the program. In contrast, those who valued team-based and patient-centric care were more responsive.The majority of healthcare users were observed to be responsive and had good rapport with CCs during home visits. They expressed confusion created by lack of well-developed program direction and protocols. Expectation to cope with increasing workload, yield positive outcomes within a short time and lack of training, created anxiety among healthcare providers. Uncertainty surrounding the future direction of the program and job security of the CCs perpetuated frustrations among them. Altogether, these factors lowered morale and lowered providers’ responsiveness.Healthcare providers reported initial excitement about the prospects of the program and believed that the program would enhance transition and recovery of patients. However, the level of healthcare providers’ responsiveness changed over time due to myriad complex needs driving the development of the program, heterogeneity within the healthcare users that the program serves, detail of program components, and involvement of numerous actors with different perspectives rendered the program complicated. While it would have been ideal to have a simple, standardized, and specific program protocol, it was impossible to do so given many moving parts. Changes in leadership were found to shape the behaviour of different actors of the program, requiring successive adaptations throughout the implementation. For example, throughout the short implementation period, revisions to enrolment criteria, recruitment strategies, and roles of different providers were made due to the change in leadership.The a common information system, guiding protocols and financial support were found to facilitate the implementation of the transitional care program.The use of time-consuming additional administrative work, and hence not prioritized. Besides the common EMR, a standardized care needs assessment and referral system was implemented to help facilitate appropriate placement of patients for intermediate and long-term care (ILTC) in the community. However, healthcare providers experienced difficulties in using this system, forcing them to manually search for and refer patients to ILTC after the program.All healthcare providers involved were granted access to the common electronic medical records (EMR) which functions to systematically consolidate medical information and allows sharing of information between actors across disciplines and care settings. Although the shared EMR has successfully facilitated information continuity to a great extent, its wider adoption remained a work in progress. Having to manage other work pressures, documentation was perceived by healthcare providers as Guiding protocols describing selection criteria and key steps to be taken in delivering program were developed at the beginning of the program. Protocols guided healthcare providers to standardize the delivery of program and manage patients at home independently or as a team. However, there were different levels of granularity in the details available for various program components within the protocols. Detailed description was available only for needs assessments, development of care plans, and promotion of self-care. Consequently, healthcare providers had to improvise for other components and dose of the program based on their experiences. This caused discomfort among healthcare providers as many of them were used to working within the hospitals where standard operating procedures (SOPs) were clearly defined. The lack of specific details related to referrals to other services had also resulted in difficulties in referring users to other community services.Our study revealed that block funding provided by the Ministry of Health (MOH) Singapore which covered healthcare manpower costs, transport fees, training expenses, and service costs of providing the program facilitated the implementation of the program. Subsidies available for running the program lowered the barrier for adoption as users had to pay minimal fees for the program.difficulty in reconciling the differences between their professional opinions and the program selection criteria in recruitment of patients. In response to this, exceptions with justification often had to be made.Wrong and late referrals were noted to adversely affect recruitment in the early phase of the program. This was quickly resolved through continuous engagement of healthcare providers who refer patients by the program team and clarification of selection criteria. Later, healthcare providers experienced privacy concerns, were reported to more likely to decline participation. Out of pocket costs were also found to be the other reason for patient refusal.Approximately 10–20% of the eligible patients refused to participate in the program. Those who did not appreciate the value of the program and had were also often perceived as inferior to doctors working in the hospitals. This was perpetuated with passive culture among users which contributed to the belief that it was providers’ responsibility to assist in the management of their health.At users’ level, having been used to a largely hospital-centric system with easy access to specialist care, the healthcare users preferred to be cared for in the hospitals. Hospital care was highly subsidized, making it more appealing to users compared to community care. Non-doctors and professionals providing care outside of hospitals multidisciplinary collaboration in the delivery of the program was noted where physicians, nurses, and allied health professionals worked well together. This, in turn, contributed positively to the implementation of the program. Conversely, even with the focus to provide holistic care for individuals with complex needs, the phenomena of “super specialization” in which healthcare providers specialize in an organ or certain aspect of patient care persisted. There was limited interdisciplinary training among providers. This was problematic as diversification of professions and their specialized tasks contributed to slow progress towards provision of holistic care. Also, this affected providers’ ability to adequately manage individuals with multiple needs, causing delays in care. In many occasions, CCs had to seek help from social workers from the hospitals as they were not trained and therefore not confident in managing social issues and advocating for users.At the providers level, good progress in Requirements to document on multiple systems was a great concern to healthcare providers as it consumed more time. Fragmentation in care capabilities among providers were also observed. This was largely contributed by resource constraints at the community level. In addition, the formal organization of and practices within community care in Singapore were less developed compared to the hospitals, affecting their capability to collaborate. In many instances, CCs could not discharge patients to the community providers within the NUHS-RHS after the planned program period as the community care providers did not have the capability to continue management of care.At the organization level, fragmentation was found in information systems, with varied level of adoption and sub-systems adopted by different healthcare providers. We examined the implementation fidelity of a transitional care program to integrate services for high need individuals in Singapore after discharge from hospital, using the modified version of CFIF.Our findings revealed several contributing factors to variability in implementation fidelity of components of the NUHS-RHS transitional care program. These included: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers. Our results showed these factors influenced implementation fidelity of the program in an interrelated manner.We found that healthcare providers experienced the program as a complex intervention predominantly due to difficulties faced in its implementation and its intention to be “patient-centric”- i.e. designed and organized around the needs of the healthcare users (patients and caregivers). Findings highlighted heterogeneity within the users in terms of needs and responsiveness, making it impossible to standardize program implementation. Changes that occurred over time always required personalization of care. Personalization actualized in the form of continuous adaptations in response to changing needs through revising goals and working towards what is best for and preferred by users. This was reflected as variation in implementation fidelity of the program. Similar findings were reported by Muntinga et al. , who assThe high level of fidelity found for needs assessment, development of care plans, symptoms management and promotion of self-care was due to the availability of detailed description of protocols for these program components. Providing care outside of the hospitals was new for most CCs involved in the program, thus, detailed protocols gave guidance for CC to confidently deliver care on their own and to standardize delivery of care. This finding is in line with prior studies which suggested that detailed protocols facilitated implementation of program. Another explanation for high implementation fidelity is CCs’ training and confidence. CCs were trained in the hospitals and therefore familiar with medically-oriented tasks such as needs assessment, development of care plans, symptoms management, and promotion of self-care. It was not surprising that CCs naturally prioritized tasks which they were familiar with.Low implementation fidelity found for psychological support can be explained primarily by the lack of interdisciplinary training and experience among providers involved in the program in providing this support. CCs were found to be still accustomed to providing medical care in the hospital environment and lacked training in management of psychological issues. As highlighted by Ong et al. , this isThe Singapore mental health study revealed a huge treatment gap for mental illnesses . ResultsOur results showed a lack of referrals to other services by CCs was due to: i) the lack of specific details guiding CCs on where to refer patients to, and ii) difficulties faced by CCs in using the common referral system. This was worsened by providers’ diminishing responsiveness to the program. As providers became less responsive, they were less likely to take a proactive role in overcoming the issues faced. Furthermore, suboptimal capabilities found among community providers were found to deter referrals to other services. For this reason, CCs were often forced to continue to manage patients after the planned program duration. A study by Hasson et al. suggested that providers’ responsiveness is a key driving force for achieving high implementation fidelity. In their study, frustrations associated with limited facilitation in the study was found to ease quickly with high providers’ responsiveness .We found the lack of interdisciplinary training and diminishing responsiveness among CCs to be the main reason behind low implementation fidelity of advocacy and appointment management. With the lack of interdisciplinary training, CCs were not comfortable in delivering these services as they were traditionally specialized by other providers. Advocacy was typically delivered by social workers while appointments were managed by other designated operation teams in the hospitals. Consequently, CCs often had to rely on the assumptions that advocacy and appointment management would have been delivered by other providers , since patients enrolled in the program continued to receive care from the hospitals.Based on our study findings, we propose several generalizable recommendations for decision makers to consider when designing and implementing a transitional care program as part of a strategy for integration of healthcare services. Firstly, ex-ante, efforts should be put in place to improve the responsiveness of both healthcare users and providers about the program. There should be better alignment in expectations between both parties. Secondly, the capability building of community care providers should be prioritized.For better alignment of expectations between users and providers, efforts can be put into increasing users’ awareness of the program and addressing misconceptions, roles of CC and community care. Thorough explanation by the CCs about the program and their roles together with intentional involvement of users in making shared decision related to their care can be the potential solutions. However, as the willingness, readiness, and ability of healthcare users to participate were demonstrated to be the pre-requisites required for engaging patients who were receiving transitional care programs , future In addressing the diminishing responsiveness of providers, appropriate incentives  can be put in place to motivate healthcare providers. Emphasis should also be made for providers to have more active involvement in the design and development of programs. Such a strategy was found to secure the commitment of providers, improve motivation, and ensure sustainability in implementation of a similar program . It can To further develop capability among community providers, the hospitals that have more resources can possibly take a more pro-active role in training the community care providers. Community care providers could also be empowered by making changes to the current healthcare financing model to support integrated care interventions like transitional care programs. Rather than charging patients based on episodes of care and provider type, a financing mechanism that follows the patient and incentivizes quality and continuity of care should be put in place to pool charges across services and providers.To the best of our knowledge, this is the first study that has taken the opportunity to assess context-specific implementation process of a transitional care program in the context of Southeast Asia. Particularly in the context of Singapore, where most of previously conducted evaluation on similar programs evaluation , 24–26 fWe used a validated framework, the modified CFIF, which has been used to assess implementation fidelity of complex healthcare programs , 22. ConMeasurement of adherence was challenging as the basis of assessment could not be standardised and explicitly defined due to the nature of the program. This is consistent with other studies that have attempted to examine the implementation fidelity without clearly defined reference points of measurements , 34. KeeComprehensive and accurate data gathered using multiple methods during implementation of the program added increased credibility to the study findings as they reflect the actual circumstances in which the program was being implemented. Nevertheless, it must be acknowledged that because this study is a cross-sectional study, it did not take into account the changes of the program over time. We learned that changes occurred but details of the changes remained unknown. Therefore, we were unable to explicitly point out the effects of the evolution on implementation fidelity of the program. For a more comprehensive assessment of implementation fidelity, longitudinal investigations should be conducted in the future to understand how implementation of the program changes over time.In addition, only users who were part of the program were interviewed as it was operationally challenging to recruit those who rejected enrolment into the program. For simplicity, we combined findings from patients and their caregivers. The literature highlighted distinction between the roles of patients and caregivers in transitional care , therefoIn assessing the implementation fidelity of the NUHS-RHS transitional program, we found detailed protocols coupled with CCs’ level of confidence and familiarity in specific program components to contribute to high implementation fidelity. In contrast, program complexity, diminishing participant responsiveness, lack of specific training for CCs, and limited capability of community providers have observably made the implementation of the program challenging. Such findings highlighted the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with relevant skills required for their jobs, and further development of the capability of the community providers. Finally, as illustrated by the Rainbow Model of Integrated Care , our stuOther health and social care networks within Singapore and abroad, alike to the NUHS-RHS, are experimenting with new integrated care models including transitional care programs. Findings from existing research of the (cost-)effectiveness of integrated care are to a major extent inconsistent because of the variations in the strategic outcomes, methods of implementation, contexts (i.e. system and policy) and/or applied evaluation measures . The finAdditional file 1:Topic Guide for Interviews. (DOCX 18 kb)


The field of general surgery offers many different pathologies, cases, and situations for which the general surgeons should be competent in diagnosis as well as treatment and management, including operative intervention. Most situations are complicated by delayed admission to the hospital due to the embarrassment of patient and inability to obtain satisfactory anamnesis. This article reviews the use of computed tomography as a problem-solving tool in the identification, localization, and presurgical planning for extracting the rectal foreign object. The introduction of foreign bodies (FB) through the anus is a well-described phenomenon that still remains a curiosity and a taboo nowadays. Their particularity consists of being very diverse and unusual. It is a matter of time before every surgeon will have to deal with such a case. Foreign bodies may lead to perforation, obstruction, or infection. The extraction of foreign objects requires ingenuity. Since in most situations the surgeon is unaware of its consistence, imaging is the key to solve the problem. Computed tomography helps us to locate the foreign body and determine its relationship to surrounding structures and its depth of involvement.A 33-year-old woman presented to the emergency services for pain in the lower abdomen and anorectal pain. A detailed medical history of the patient revealed that her partner had inserted a foreign object into her rectum to achieve sexual satisfaction. The patient stated that she had not seen the foreign object and she did not know the nature of the material.On physical examination, the abdomen was relaxed but at the palpation a hard object could be felt. Complete blood cell count (CBC) and biochemical parameters were within a normal range. On digital rectal examination, the base of the object was palpated as a solid object 8-9 cm proximal to the anus. Standing abdominal radiographs of the patient were obtained in an emergency department for differential diagnosis and showed a bottle in the rectum without any evidence of free air or air-fluid levels .To obtain accurate information regarding the nature and location of the foreign object, the relationships with surrounding tissues, and potential complications, a CT was done .A 17 cm foreign body is viewed at the rectosigmoid level. The thickened appearance and hyperemia of the rectal walls indicates an associated proctitis. The patient was transferred to an operating room, the anal canal was dilated under general anesthesia, and the object was removed manually by pressing on the abdomen. Digital transanal extraction was successful after 45 minutes, when a total relaxation has been achieved and by applying bimanual continuous pressure on the anterior abdominal wall. The extracted object consisted of a lubricant gel tube . The posRectal foreign bodies, in most cases, impose challenging strategies in order to remove it safely and an adequate management of care conditions during the convalescent period. In most cases, patients present several hours to days after the placement of the rectal foreign body, and on occasion, the foreign body has even been successfully removed, but the patient has delayed symptoms of bleeding, perforation, or even incontinence , 2. TherTo exclude a possible perforation or peritonitis which leads to acute abdomen, abdominal radiographs were done followed by a CT scan. The role of CT in these cases is not limited to helping detect the foreign body and its exact location, but it includes helping identify possible complications and orient you in choosing the appropriate surgical technique to remove the foreign body.Different operative techniques are used to remove rectal foreign bodies. Acute abdomen due to rectal or colonic perforation should be excluded . The choTherapeutic options for patients without signs of perforation are manual extraction, endoscopic extraction, TAMIS extraction, laparoscopic or open advancement with transanal extraction, and laparoscopic or open transmural extraction .In our case, deeper sedation assured the relaxation needed to remove the foreign body. Downward pressure on the object in the left iliac fossa greatly aids in moving the object toward the rectum and stabilizing it when attempting to grab it from below. After the foreign object is removed, another checkup is needed to make sure there is no active bleeding, additional foreign bodies, or full-thickness injury to the bowel mucosa. Recovery state relies on daily monitoring of the patient status, physical examination to determine any trauma to the rectum or surrounding tissue, and follow-up to identify the appearance of new signs and symptoms.The fast evaluation of the patient with a rectal foreign body was provided by using CT imaging. All the information provided helped in treatment decision. The clinical condition of our patient and the size and shape of the foreign body have allowed it to be grasped with the surgeon's hand and then be removed easily.


This paper presents an overview of recent technology-aided programs  designed to help people with significant disabilities (a) engage in adaptive responses, functional activities, and leisure and communication, and thus (b) interact with their physical and social environment and improve their performance/achievement. In order to illustrate the support tools, the paper provides an overview of recent studies aimed at developing and assessing those tools. The paper also examines the tools' accessibility and usability, and comments on possible ways of modifying and advancing them to improve their impact. The tools taken into consideration concern, among others, (a) microswitches linked to computer systems, and aimed at promoting  minimal responses or functional body movements in individuals with intellectual disabilities and motor impairments; (b) computer systems, tablets, or smartphones aimed at supporting functional activity engagement of individuals with intellectual disabilities or Alzheimer's disease; and (c) microswitches with computer-aided systems, elaborate communication devices, and specifically arranged smartphones or tablets, directed at promoting leisure, communication, or both. Technology-aided programs are increasingly recognized as essential means for supporting people with significant disabilities  within their daily contexts –5. TechnTechnology-aided programs for people with significant disabilities have largely focused on providing them with support in main problem areas, such as passivity and detachment, failure to carry out functional activities, and failure to engage in leisure and communication. The first area  is concerned with the inability to engage in simple responses/movements functional to interact with the environment and, possibly, carry out forms of physical activity with potential health benefits , 11–14. The second area  is concerned with the inability to engage in complex, relevant tasks, such as vocational, domestic, and self-care tasks. For example, people with moderate intellectual disabilities frequently fail to independently perform vocational tasks because they cannot remember the steps and materials involved in those tasks , 19. TheThe third area  is concerned with the inability to manage leisure activities and communication interactions independently. For example, people with severe intellectual and developmental disabilities may be unable to start and engage in leisure activities on their own and thus remain dependent on staff or caregivers –25. The per se would be inadequate to produce), or (b) use a functional body movement to reach relevant environmental events and, at the same time, manage some form of mild, potentially beneficial physical exercise  make one or few small responses available in his or her repertoire effective to produce a relevant environmental change  time cues , and step instructions  , 35, 36.If the individual's specific condition is moderate intellectual disability with sensory and/or motor impairments, or emergence from a minimally conscious state with motor and speech disabilities, support tools might be designed to promote leisure engagement, communication, or both. In the first case, the support tools would serve to present the individual with different leisure options and allow him or her to choose among them with simple responses , 37. In This paper is an effort to illustrate some of the support tools mentioned above  by providing an overview of recent studies aimed at developing and assessing those tools. Given the specific, and rather circumscribed, scope of the paper  the tools illustrated and the studies reported to describe their applicability and impact represent a non-systematically selected group of the tools and studies available. The selection was made by the authors based on two simple, intuitive criteria. The criterion used for selecting the tools was their perceived technical and practical relevance. Essentially, the tools selected were deemed to represent innovative  and effective resources for fostering favorable changes within the main problem areas identified above. The criterion used for selecting the studies concerned the fact that they represented recent evidence in the field  and provided clear illustrations of the tools' technical aspects and support potential. In summary, the paper describes the characteristics and impact of a series of support tools  with the help of studies reporting such tools. The paper is also providing comments on the tools' accessibility and usability, and possible ways of modifying and advancing them to improve their impact.As suggested above, adaptive responses may involve (a) small/minimal movements  , 39 and The support tools required to help individuals develop and strengthen small responses or functional body movements and make them relevant consist of devices that can (a) monitor the emission of those responses and (b) ensure that they trigger the occurrence of environmental events preferred by the individuals . Six recent studies are summarized in this section of the paper to provide (a) illustrative examples of the support tools available for fostering small responses and functional body movements, and (b) an informative basis for commenting on those support tools , 44–46. The first study dealing with small responses  focused The second study  focused The support tools described above can be considered the most immediate instruments for enabling individuals with pervasive impairments to have self-determined contact with the environment, control their stimulation input, and improve their social image , 47. FroFrom a practical standpoint, two considerations are in order. First, these tools were not designed to be easily portable. Indeed, while the microswitches were readily wearable and portable, the computer to which they were connected was not necessarily easy to carry around. The lack of tools' portability is not deemed a real drawback in this context, given that the participants are confined in bed or in a wheelchair. The second consideration is that one may need to look at these tools as temporary solutions for a number of participants. For example, some participants with neurodegenerative diseases  may lose the responses on which the tools initially relied and require the identification of new responses and new microswitches. Participants with acquired brain injury may improve their general level of functioning over time, and thus require more advanced support tools.New research could be directed at (a) identifying additional microswitches that would allow the possibility of monitoring a larger variety of minimal responses with reliability and low intrusion, and (b) developing and assessing portable support tools. With regard to the latter objective, for example, one could conceive the use of smartphones for both monitoring specific responses  and delivering stimulation contingent on the responses. The smartphones could be automated through available applications  so as to control the specificity and duration of the stimulation in relation to the responses .The four studies summarized in this section , 46, 48 Stasolla et al.  set up aLancioni et al.  set up aLancioni et al.  set up aThe support tools reported for promoting functional body movements (a) relied on four types of response sensors , (b) served participants with different levels of cognitive and motor functioning, and (c) focused on different responses. From a technical standpoint, one can underline the fact that the sensors on which the support tools relied were all commercially available and readily accessible in terms of costs. It may also be emphasized that while the dance pad, the photocell and the tilt device were connected to a computer system, which was to deliver stimulation, the smartphone had the dual function of sensor and stimulation device. Using a single instrument like a smartphone rather than two or more instruments (sensors and computers) would be seen as advantageous and could be easily viable in interventions such as those targeting footstep responses or leg movements.From a practical standpoint, one can (a) reflect on the lack of portability of the support tools except the one relying on the smartphone, and at the same time (b) argue that portability might be a relatively marginal aspect given that the tools are typically employed in specific intervention settings rather than across settings. It might also be noted here that the advantage of using a single instrument like the smartphone should not be taken to suggest that its employment would be immediate .Future research may focus on extending the intervention to new functional movements, to new sensors, and eventually new support tools that would be easy to arrange in addition to being commercially available. For example, one might consider the possibility of targeting functional movements such as pulling oneself to a standing position and remaining in that position for brief periods of time  for peopPeople with mild to severe intellectual disabilities with or without additional sensory or motor impairments, people with neurodegenerative diseases, in particular mild and moderate Alzheimer's disease, as well as people with acquired brain injury are often unable to carry out functional, multistep activities , 35, 53.Six recent studies adopting a technology-based approach are summarized in this section , 59–61. Mihailidis et al.  developeLin et al.  set up aO'Neill et al.  reportedThe support tools described above were developed with the objective of providing high levels of supervision and/or specific forms of interaction (closely simulating staff interaction) so as to ensure high levels of correct performance. The tool developed by Mihailidis et al. , in partFrom a practical standpoint, one can make at least two considerations. First, the tools developed by Mihailidis et al.  and O'NeNew research might be focused on setting up and assessing simpler versions of the tools to find out whether one can still ensure significant levels of success with those simplified (more accessible) versions. Another research point could be the assessment of those new tools' versions over a number of relevant tasks so as to establish their overall applicability within rehabilitation and occupation/work contexts.Cullen et al.  developeLancioni et al.  set up aLancioni et al.  designedFrom a technical standpoint, the aforementioned support tools, which were used for a single task , or a plFrom a practical standpoint, four considerations may be in order. First, those support tools are easily affordable in terms of costs and thus suitable for daily contexts. Second, their usability for a variety of tasks makes them highly helpful in supporting the participants over large parts of the day, with minimal external supervision and maximum impact on the participants' functional engagement/interaction with their physical and social environment. Third, the tools are suitable for presenting verbal instructions as well as visual instructions. This versatility makes them appropriate also for people who have hearing impairment and/or verbal comprehension problems. Fourth, participants who use only verbal reminders and instructions do not have to carry the smartphone or tablet with them. Indeed, they can receive the reminders and instructions through wireless Bluetooth earpieces linked to those devices .A primary objective of new research may be to gather additional evidence on the suitability and effectiveness of the aforementioned tools in (a) reminding participants with intellectual disabilities, Alzheimer's disease, and acquired brain damage about their daily tasks, and (b) supporting their performance of those tasks through verbal or visual instructions. Another research goal might be that of comparing the effectiveness of the tools' different instruction options  , 63.One common trait of many people with intellectual and other disabilities, neurodegenerative diseases, and acquired brain injury is the inability to engage in leisure activities independently , 64, 65.The eight studies summarized in this section represent illustrative examples of interventions with support tools relevant for this area see . SpecifiStasolla and De Pace  reportedLancioni et al.  set up aIndividuals whose condition  precludes them from reaching/accessing preferred stimuli and engaging with them freely need the help of a support tool to bypass those limitations. The tools described above were aimed at supporting individuals with traumatic brain damage and individuals with Alzheimer's disease. Similar tools have also been used with people with intellectual and multiple disabilities, with amyotrophic lateral sclerosis or various forms of brain injury , 80. FroFrom a practical standpoint, one can consider the tools fairly friendly for the participants, manageable for staff and caregivers, and reasonable in terms of costs. A possible question as to their accessibility for daily contexts may arise whenever an experimental microswitch is required. The fact that those tools are not always easy to carry around may not be a serious drawback given that most of the individuals using those tools are confined to specific contexts, and thus do not need to carry the tools across settings , 24.New research could focus on arranging and testing new technology packages so as to have a range of different solutions to address the needs of individuals with different characteristics. It is also important to recognize that support tools might be more valuable if they do not only allow leisure engagement, but also provide the conditions for communication (see below) , 79. TooThe main body of intervention studies concerning communication have addressed the participants' inability to make  requests and assessed the impact of tools such as speech-generating devices  , 67, 68.Davies et al.  set up aThe support tools described above, although generally defined as speech-generating devices, differ from those previously available in the area in that they include components that can make their use more effective  and/or fFrom a practical standpoint, two considerations are in order. First, those tools are not designed to be easily portable. Indeed, the Davies et al.'s tool involves a number of sensors that are tied to specific settings and work properly within those settings. The tool reported by Simacek et al. for the younger participant involves a relatively sophisticated computer-aided system that is generally fixed to a table stand or the participant's wheelchair and cannot always be freely moved across settings or used across individuals. Second, the cost of those tools is expected to be considerable and their set up requires a certain amount of competence.New research work could advance the development of the Davies et al.'s tool with new/cheaper commercial components  so as to make it more affordable and easier to set up and use as a real resource for individuals attending school, work and other community settings. A simpler and cheaper eye-gaze device may also need to be developed  specifically for individuals who only use it for limited purposes.Borgestig et al.  set up aLancioni et al.  set up aLancioni et al.  set up aLancioni et al.  set up aFour different support tools were described in this section, that is, commercial eye-tracking devices, a combination of computer system and microswitch, a specially arranged smartphone, and a specially arranged tablet. From a technical standpoint, the tools differ substantially, with the first two being much more complex than the other two. Indeed, the eye-tracking devices are highly sophisticated and powerful instruments that require a careful tuning with the participants under expert supervision, and thus are not readily/immediately accessible. The microswitch used in combination with the computer system is frequently an experimental device or an adaptation of a commercial device , and this requires extra preparation time and costs. The last two tools are based on common commercial technology and thus are more easily accessible and comparatively simple. Even so, adapting them for the participants' use requires, as suggested in previous sections of this paper, a certain amount of preparation work and expertise involving the management of specific applications, such as the WhatsApp Messenger and the MacroDroid.From a practical standpoint, a few considerations are in order. Eye-tracking devices may not be easily affordable in daily contexts given their complexity and costs. Their employment with individuals with pervasive motor disabilities might often be successfully replaced by the use of support tools involving the combination of computer and microswitch. These latter tools, albeit not immediately accessible (as observed above), (a) can be adapted to individuals with minimal response repertoire, and (b) are much less expensive than the eye-tracking devices. The other two support tools, based on smartphone and tablet technology, have the advantage of being fairly inexpensive/affordable and easily portable. Yet, they are applicable only when the participants have control of the basic motor responses necessary to manipulate cards or mini objects and to activate the tablet's proximity sensor, respectively.New research may be focused on the development of alternative support tools that can promote leisure activities, audio and video calls, and message exchanges, and are easily affordable and portable. One might also explore the possibility of using smartphones as microswitches for participants with no use of their hands . For exaThe paper has analyzed a number of support tools, which were used to help people with significant disabilities bypass the limits imposed by their condition and reach important objectives. The generally positive results reported by the studies summarized above are encouraging as to the beneficial role of those tools. They were successfully used (a) as extension of the individuals' body, so the individuals could engage with the environment effectively irrespective of their response limits, and (b) as extension of the individuals' cognitive dimension, so the individuals could act in a more accomplished manner and improve their occupational achievement, social contacts and communication. In essence, technology-based support tools were reported to be instrumental in fostering goal-directed interactions of the individual with disability with his or her physical and social environment, and possibly in promoting the individual's cognition and development , 82, 83.The appropriateness and friendliness of any tool are high when the tool's operation fits the individual's physical conditions and/or cognitive skills and when the goal set to be reached is feasible for the individual . In ligOne additional element that would have a decisive impact on the final results obtained with any tool is the individual's motivation to use such tool . The individual may be strongly motivated to produce high response rates  if the stimulation following the performance of those responses is significant (highly preferred) for him or her , 42, 87.Acceptance and regular use of support tools within daily contexts cannot be considered an easy-to-reach objective for a variety of reasons, some of which were discussed above. Indeed, one would assume that accessibility, affordability and friendliness of the tools represent main variables favoring their application outside of the research environment. The presence of all these variables alone, albeit essential, might not yet guarantee a positive decision of daily contexts in relation to the use of support tools. There are situational/practical issues, in fact, that may interfere with a positive decision –91. A maIn conclusion, the support tools presented and discussed above seem to have great potential for improving the situation of individuals with serious disabilities by providing those individuals with new opportunities for (a) engaging in goal-directed interaction with the environment and thus (b) enhancing cognition and development. The possibility of having those tools largely available in daily contexts may greatly depend on (a) the accessibility, affordability, and friendliness of the tools, and (b) the availability of areas of competence and responsibility in the daily contexts that would ensure a successful set up and application of the tools, and possibly a positive intervention outcome.GL was responsible for conceiving and writing the paper. MOB, NS, MO, JS, and GA were involved in defining the scope of the paper and the material to include, and contributed in the writing and editing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The reuse of business processes (BPs) requires similarities between them to be suitably identified. Various approaches have been introduced to address this problem, but many of them feature a high computational cost and a low level of automation. This paper presents a clustering algorithm that groups business processes retrieved from a multimodal search system . The algorithm is based on Incremental Covering Arrays (ICAs) with different alphabets to determine the possible number of groups to be created for each row of the ICA. The proposed algorithm also incorporates Balanced Bayesian Information Criterion to determine the optimal number of groups and the best solution for each query. Experimental evaluation shows that the use of ICAs with strength four (4) and different alphabets reduces the number of solutions needed to be evaluated and optimizes the number of clusters. The proposed algorithm outperforms other algorithms in various measures  by between 12% and 88%. Friedman and Wilcoxon non-parametric tests gave a 90–95% significance level to the obtained results. Better options of repository search for BPs help companies to reuse them. By thus reusing BPs, managers and analysts can more easily get to know the evolution and trajectory of the company processes, a situation that could be expected to lead to improved managerial and commercial decision making. The daily activities and experiences of organizations are represented in Business Processes (BPs) comprising information about the interaction between systems and partners . BPs areBPs are generally not static elements that belong to one single area or division within organizations. Rather, they are dynamic elements that may change over time, integrating various departments and/or employees. Modified BPs leads to the appearance of families of processes composed of similar BPs. The possibility of identifying these families enables analysts to make a systematic analysis of the BPs of an organization, thereby promoting reuse.In this context, several research approaches have been presented for grouping BPs together according to their similarities. Most are based on measures such as textual information, structure, and behavior. Other information retrieval (IR) techniques have similarly been applied to improve the results of such research , includiFor their part, clustering techniques aim at forming groups of BPs in accordance with common features such as structure, control flow, and tasks . This grExisting approaches organize the whole repository into groups or dendograms that simulate the organizational structure of the companies, meaning that users must search through these groups or organization charts. In contrast, the present approach provides the user with a set of BP clusters based on previously filtered results.This paper presents ICAClusterBP, an algorithm for improving the visualization of results in a BP search system. This algorithm takes as input a set of BPs retrieved from a multimodal search component ,12 and uThe present method comprises the activities:Determine the best distance measure within the grouping process. This measure makes it possible to know the closeness or similarity of the elements within each group, thus increasing the cohesion and compactness of the groups created.Calculate the lowest strength of ICA needed to obtain the desired performance, i.e., the size of the interaction between BPs in the clustering process.Identify the lowest alphabet of ICA required achieving the desired performance, i.e., determine the correct number of groups a solution must contain.The present approach enables analysts to identify families or groups of BPs and analyze them to reuse these BPs in a new BP. Grouping similar BPs may also help analysts determine the most frequent changes in BPs. These changes may be due to process updates or other issues associated with market requirements.Evaluation of the present approach was done using a BPs repository created collaboratively by experts . It was The remainder of this paper is organized as follows: Section 2 presents related work. Section 3 provides a conceptual background on ICAs. Section 4 describes the proposed approach as well as an example of its use. Section 5 describes the process to determine the parameters of the algorithm. Evaluation of grouping quality is detailed in Section 6. Finally, Section 7 depicts conclusions and future work.Grouping of BPs first requires the selection of BPs that will make up the groups. Selection is based mainly on the similarity of BPs. These BPs are commonly represented as trees or graphs (with nodes and edges). The edit distance of the graph represents the set of operations needed to transform one BP into another. Based on this representation, Dijkman et al.  propose Other approaches are based on linguistic, structural, and behavioral similarity of the BPs. Linguistic-based approaches analyze the name or the description of the activities, events, and logic gates. During the search process, some information retrieval techniques are used to create the ranking of relevant results. Those techniques include space-vector representation with a terms frequency (TF) and cosine distance value. In this group of techniques, inputs and/or outputs are matched based on linguistic or semantic information, leaving aside execution flow or behavior. Therefore, no account is taken of information regarding behavior patterns, activity type, and purpose of the task or activity ,21.Elsewhere, structure-based approaches analyze previous executions of BPs recorded in Log files. The search process detects phrases associated with BPs activities using domain ontologies. Activity patterns are similarly identified. The results list is created using a heuristic component that determines the frequency of the patterns detected. This group of techniques uses previous executions in log files and analyses nodes, connectors, and source code, among others. Among these techniques, data mining algorithms such as "Apriori" have been used to identify common elements between the BPs. It should be noted that these approaches depend on the execution time needed to perform the matching. In addition, various conditions must be fulfilled to obtain the association rules and guarantee the proper operation of this type of algorithms. These conditions include that the data in the logs must be well structured, and the most relevant information must be analyzed manually by experts (This implies that the user must have experience in BPs) ,23.Approaches based on similarity behavior meanwhile use genetic algorithms to transform BPs into a formal representation . Additional data can be included during the search process to provide higher precision, such as number of inputs and outputs per node, edge labels, node name or description. The execution time of these approaches is high because the algorithms must find a reference BP with the lowest value of the weighted distance to the BP in the repository. In these approaches, a fitness function is used to obtain an overall assessment that does not define how each part of the candidate model conforms to the reconstruction variants of the BP model to be discovered. These genetic algorithms start by reading the event logs, an activity which exponentially increases the order of the algorithm. The list of recovered BPs depends on the calculation of many variables since the dependence between activities must be analyzed. Meanwhile, the importance of each task is calculated considering only the number of times it appears in the log ,25.The grouping results of the above approaches can be improved by expanding the information features of the BP: activity description, task type, gate type, structure, and behavior, among others.The reported works related to BPs clustering can be classified into four categories:Ferreira in  proposesMeanwhile,  and 21]21] propoThese proposals present certain limitations, namely: they leave aside the flow of execution, they do not consider frequent pattern similarity, they use a random BP as a starting point to create groups, and finally, during the grouping process, task sequences that occur only once are eliminated.i = <Ni, Ai> is taken, where Ni is the set of nodes and Ai ⊆ Ni * Ni is the set of possibly labeled arcs, generating a grouping skeleton typical of substructures. The graphs are iteratively analyzed to discover in each step a group of isomorphic sub-structures. Clustering is used to compress the graphs, substituting each occurrence of the substructure with a node; this process is repeated until no further compression is possible.In  they preSimilarly,  present In these methods, the search is based on such data as activity name, activity duration and number of errors, leaving out information on activity type and behavioral semantics. Neither are sequences  considered in the course of the grouping process.k-means, which divides n observations into k groups represented by their centroids. It starts by defining a set of k random centroids and then iteratively assigns each observation to a cluster with the most similar centroid and after assigning all observations to their groups, updates the centroids that represent them. If a stop criterion is not met, the algorithm continues with the iterative loop. Otherwise, it returns the centroids of the clusters and the assignment of the observations to the groups. For a detailed description of the k-means algorithm see . Equ. Equ57].


Trypanosoma brucei rhodesiense human African trypanosomiasis (rHAT) disease transmission. The ABM model, fitted at a fine spatial scale, was used to explore the impact of a growing host population on the spread of disease along a 75 km transect in the Luangwa Valley, Zambia. The model was used to gain a greater understanding of how increases in human and domestic animal population could impact the contact network between vector and host, the subsequent transmission patterns, and disease incidence outcomes in the region. Modelled incidence rates showed increases in rHAT transmission in both humans and cattle. The primary demographic attribution of infection switched dramatically from young children of both sexes attending school, to adult women performing activities with shorter but more frequent trips, such as water and firewood collection, with men more protected due to the presence of cattle in their routines. The interpretation of model output provides a plausible insight into both population development and disease transmission in the near future in the region and such techniques could aid well-targeted mitigation strategies in the future.This paper presents the development of an agent-based model (ABM) to investigate  African trypanosomiasis is a parasitic disease which affects humans and other animals in 36 sub-Saharan African countries. The disease is transmitted by the tsetse fly, and the human form of the disease is known as sleeping sickness. With human and animal populations growing across Africa, demand for space to settle is on the rise, and people are being forced to occupy increasingly marginal spaces. This behaviour has the potential to increase exposure to pre-existing biological hazards, including vector-borne diseases. This investigation utilises agent-based modelling techniques to investigate the implications of a growing and spreading human and animal population in a region affected by Rhodesian human African trypanosomiasis. The model incorporates previously developed spatial data for the Luangwa Valley case study in Zambia, along with demographic data for its current inhabitants, and a detailed, seasonally-driven tsetse lifecycle. Tsetse and potential human and animal hosts are modelled at the individual level, allowing each contact and infection to be recorded through time. By modelling at a fine-scale, we can incorporate detailed mechanisms for tsetse birth, feeding, reproduction and death, as well as a realistic theoretical human and domestic animal population increase, before considering the possible spatial and demographic impact. Trypanosoma brucei s.l.: T. b. rhodesiense in eastern and southern Africa, and T. b. gambiense in West Africa  ..2) and tAs it is difficult to estimate the size and distribution of an increasing population, four plausible scenarios were created, using the area of land considered to have anthropogenic land uses to estimate the size of increase, and the current distribution of the populations to dictate the demography and distribution of the increasing population.With limited understanding of the predicted population increase in the study area in the future, a set of abstract population growth scenarios was selected, with a maximum population increase of approximately 60% in the final scenario compared with the original census data. To define the size of population increase, a sequentially increasing single pixel (11 m) spatial buffer was applied to all pixels categorised as crops or cultivated land, which neighbour areas of bush in the land classification. The buffer pixels classified previously as bush were transformed to crops or cultivated land to simulate an increasing region of development in the area, and the associated removal of bush . The ratio of human population to developed land area was maintained as the buffer increased and is shown in The distribution of the current human population was used to control how the additional population would be added in the future scenarios. Until the required population for a scenario was met , a pixel2 [By using a technique where population increases are defined by the local population rather than a uniform probability of increasing settlement across the region, any spatial trends in cattle ownership and ethnicity are maintained, and a process which has the potential to introduce artificially new populations of humans and cattle into areas which are inhospitable in reality is avoided. For example, regions that are encroaching on large expanses of tsetse-inhabited bush do not reach the densities where fly decline is expected , andThe distributions of humans and cattle for each scenario are illustrated in Figs The model used in this study is the most recent and advanced version of the ABM of Alderton et al. ,39, in wAs in previous work, paths between home and resource were produced using the A* pathfinding algorithm . Four agTo allow the model to initialise and stabilise, the simulation was run for a year, allowing a ‘burn-in’ period, before the results for this paper were produced. The results presented below represent years two to four of the simulation. One hundred repeat simulations were used to produce the results presented.Across the three year control simulation, the approximate incidence rate for human and cattle rHAT infections was 0.355 per 1000 person-years (SE = 0.013) and 0.281 per 1000 cattle-years (SE = 0.025). Increasing the human and cattle population size resulted in a general increase in incidence rates for both agent types . The firVariation in the spatial extent and distribution of agent infections was observed in the simulation as the populations were increased. Figs The control simulation displayed a high proportion of human infections occurring in agents while travelling long distances to and from school (50%), and an increase in population shows a reduction in this percentage to only 7.9% in scenario 4. The age groups which contain school-aged children  show the greatest decrease in approximate incidence rates between the control and scenario 4 , with onResults for the control show similar incidence rates between genders and for cattle owners and those without cattle . Howeverplausible model of reality such that experiments could be conducted in the constructed “universe”. The results of such experiments then necessarily relate to the model structure, parameters and conditions of that constructed universe. As a result, model output should be interpreted in terms of general patterns, trends and changes across the scenarios.The results and trends presented as outputs from the simulation are conditional upon a wide range of inputs and parameters across a complex system, each set with varying degrees of confidence. As such all results relate to the model, and only to the local reality on the ground, to the extent that the model is a close representation of local conditions. The objective was to construct a The approximate incidence rates for both cattle and human rHAT infections exhibit an increase between the control and the maximum population tested (scenario 4). However, the pattern observed between scenarios for each agent type is different, with a steady increase observed in the modelled cattle populations, and fluctuations in the human population. This highlights the complex relationship between vector-host contact network, feed acquisition and infection reservoir. In scenario 1, infection rate is reduced in both hosts. Although this could be attributable to a slight increase in developed ‘buffer’ around the majority of the settled area, it is likely to be a response to the way that the population increase is evenly distributed across the study area and, therefore, many of the new agents will have low exposure to tsetse risk.impeding the transmission cycle of rHAT. Tsetse flies are more susceptible to acquiring a midgut infection on their first feed [For scenario 2, the increase in cattle infection rate suggests greater connectivity between vector and the primary source of tsetse feeds than experienced in scenario 1. This availability leads to an increase in tsetse population which, in turn, increases the mobility of the parasite, and exposure of the similarly increasing human population. This is exhibited by the doubling infection rate observed in the simulation for non-cattle owning households. The plateau in cattle incidence rates for scenario 3 suggests that a threshold has been reached, such that the addition of uninfected hosts to the system is rst feed . ConsequBy scenario 4, the reduction in connectivity is countered by the growth of more spatially marginal populations, living closer to the tsetse habitat, and further away from important resources such as river water. This pattern returns a peak in both human and cattle infection rates for the study, but also peaks in tsetse population, and proportion of infections acquired when collecting water supplies and firewood. These trips are associated with more frequent collections which affect the whole demographic, a change which is mirrored in both the incidence rates of adults (age groups over 18) and female agents, who are more likely to be assigned routines associated with domestic resource collection than, for example, cattle herding.It is initially surprising that immigrant incidence rates do not increase through the scenarios in comparison to the indigenous tribe, the Kunda. However, the model does not preferentially increase migrant tribe populations, as the purpose of this study was to investigate the impact of population growth throughout the study area, including increases in the indigenous population and the development of communities of recent migrants to the region. However, the results suggest that indigenous tribes are also living in close proximity to the tsetse, as the incidence rates are increasing at a similar rate to that of the migrants. This does not represent the spatial marginality of migrants that was expected, despite the method of population growth ensuring that new villages had the same demographic make-up of neighbouring villages. Although the proportion of population attributable to migrant tribes increases by 3% (from 29% to 32%) between the control and scenario 4, The distribution of human infections becomes increasingly concentrated in the northern section of the transect, mirroring the spatial distribution of cattle infections in the region–an area shown to have limited previous exposure to cattle. The increase in population in this region occurs as it is already a populous area, being close to the river and the airport. The progressive increase in cattle population here  could be an important factor in mitigating the impacts of a growing population.The ABM could be useful for formulating policy and for local decision-makers, with the model generating data suggesting who  might be most at risk of infection in the future, and where. The model draws attention to the importance of connectivity between hosts and vectors, but also how an increase in host population should not simply be seen as an increasing reservoir, since under certain circumstances it can also reduce the rate at which the pathogen is transmitted through the landscape.The results presented in this paper update our current understanding of tsetse fly dynamics and the rHAT disease transmission system. The ABM approach is suitable for use by local decision-makers  to investigate alternative mitigation strategies . Most importantly, the individual level model presented here, which includes seasonally varying effects on tsetse populations, provides a suitable framework with which to model the impacts of many different future scenarios  in the Luangwa Valley .constrain and determine the dynamic contact network between the multiple agent classes , which ultimately is the “funnel” through which transmission must occur. The ABM also spatially references each contact event in this dynamic contact network such that the realised transmission events between agents have a dynamic, spatially explicit mapping. In this paper, we show that this spatially explicit, as well as demographically rich, information is invaluable to both our understanding of the disease transmission process in specific contexts, but also to decision-makers who aim to reduce or eradicate disease.The observed model outputs presented here cannot be created without using the ABM approach , and so may be regarded as novel in terms of rHAT transmission dynamics. Specifically, interrogation of the impacts of a wide variety of interventions and changes in system drivers is only possible through the proposed ABM modelling framework because the connection between the various agents and the geographical and temporal environments on which their lives are played out is captured explicitly. This allows the geographical environment and agents’ initial conditions to In this research, a very fine spatial resolution ABM was used to investigate the possible future impact of an increase in human and animal host population on rHAT transmission in a case study in Eastern Province, Zambia. The investigation showed that as populations increase, the level of spatial connectivity between tsetse vector and human and domestic animal hosts increases as people are forced to occupy increasingly marginal spaces. Importantly, we found that this led to an increase in the proportion of infections associated with shorter trips, as new settlements develop further from pre-existing water resources. This reflects a shift away from children being the most at risk in the control study, towards agricultural workers being most exposed which, if realised, would have implications for economic productivity in the region. The non-linear relationships observed between host population growth and both the size of the tsetse population, and the overall incidence rates, highlights the complexity of the relationship between the occupation of space in the model, and the infectious state of interacting agents, and how this relationship reacts to a modification of the population. Future research will focus on testing the applicability of this modelling framework to similar sites in other affected regions such as Zimbabwe.


The World Health Organization estimates that annually 150 million people experience severe (catastrophic) financial difficulties as a result of healthcare payments. Therefore, a systematic review was carried out to identify the determinants of household catastrophic health expenditure (CHE) in low-to high-income countries around the world. Both electronic and manual searches were conducted. The main outcome of interest was the determinants of CHE due to healthcare payments. Thirty eight studies met the inclusion criteria for review. The analysis revealed that household economic status, incidence of hospitalisation, presence of an elderly or disabled household member in the family, and presence of a family member with a chronic illness were the common significant factors associated with household CHE. The crucial finding of the current study is that socioeconomic inequality plays an important role in the incidence of CHE all over the world, where low-income households are at high risk of financial hardship from healthcare payments. This suggests that healthcare financing policies should be revised in order to narrow the gap in socioeconomic inequality and social safety nets should be implemented and strengthened for people who have a high need for health care. A World Health Organization (WHO) report in 2000 noted that one of the principle roles of the healthcare system is to provide equitable financing, which can protect people from experiencing financial hardship incurred due to the treatment of their illness . In 2010WHO estimates that annually 150 million people experience severe (catastrophic) financial difficulties and about 100 million become poor as a result of healthcare payments . Some pePreviously, it was generally agreed that if a household spent 10% or more of its income on healthcare services, the expenditure was classed as catastrophic , 10. In Several papers have been published on household CHE across the globe. However, different researchers use different measurements of CHE and cut-off points to identify the prevalence of CHE and associated factors. So far, no systematic review has been conducted on these works to identify the key determinants of CHE among households. Therefore, in order to fill this gap in knowledge, a systematic review was carried out to attempt to identify and summarise the significant factors and household characteristics that are associated with the risk of experiencing CHE.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in conducting this systematic review.Both electronic and manual searches were performed. Electronic resources included databases and web pages. The databases searched were PubMed, Medline, ScienceDirect, Web of Science, the Cochrane Library, Embase, CINAHLComplet@EBSCOhost and Scopus. Web pages such as Google Scholar were also searched for non-peer reviewed articles in order to reduce the risk of publication bias. In addition, a manual search of the indices of the included studies was done. The papers that were initially selected ranged in date of publication from January 1986 and July 2016 because most of the publications were released from 1986 onwards. The first to study the CHE determinant was from US, he defined a household as having CHE if OOP was equal or more than 10% of total income .The key words used in the search were catastrophic illness, catastrophic health expenditure, determinants, health expenditure, household factors, financial burden, out of pocket payment and their synonyms.For a study to be included in this review, the selected study had to define a household as having CHE if OOP was equal to or exceeded 40% of the household’s capacity to pay , or had The selection of articles/papers was conducted in three steps. All searches were carried out by one reviewer and checked by another. The details of all the selected studies were saved in EndNote X6 software, which was also used to screen for duplicate studies. In the first step, the articles were independently selected by two reviewers based on the title and abstract after excluding the duplicate articles in the list. Disagreement on article selection between reviewers was resolved by consensus and consultation with a third reviewer. A total of 3,188 articles were identified, of which 382 were removed because of duplication. Then, we reviewed the titles and abstracts and excluded studies if they reported on CHE without including its determinants or if they reported on the economic burden of households but did not measure CHE. Papers not written in the English language, qualitative studies, case studies, and studies on specific health problems, on specific age group (elderly) and on macrolevel comparisons were also excluded. At this point, 67 papers were eligible for full document review. After evaluating the documents in full, 27 more papers were removed because the CHE only focused on a specific health problem or purchased medication. Out of the remaining 40 studies, 38 were finally selected for this systematic review after quality assessment .The quality of the initially selected studies was assessed by using the critical appraisal checklist for survey-based studies , which cDid the study address a clearly focused issues/question?Is the research method (study design) appropriate for answering the research question?Is the method of selection of the subjects  clearly described?Could the way the sample was obtained introduce (selection) bias?Was the sample of subjects representative with regard to the population to which the findings will be referred?Was the sample size based on pre-study considerations of statistical power?Was a satisfactory response rate achieved?Are the measurements (questionnaires) likely to be valid and reliable?Was the statistical significance assessed?Are confidence intervals given for the main results?Could there be confounding factors that haven’t been accounted for?Can the results be applied to your organisation?Each criterion was scaled as either reported or not reported. Each question is scored 1 if reported and 0 if not reported. Two reviewers scored the papers independently; the third was involved in arbitration if a disagreement occurred. The final selection was done based on the result of this quality assessment. Only studies of good (7–12 points) or medium (4–6 points) quality were included in this systematic review. Two studies got less than 4 points score, for that, they were considered as low quality and we didn’t include them in this review. The results of the quality assessment are shown in The final set of 44 selected papers  were grouped by country under study into low, middle and high income according to the World Bank classification . Thus, fResidenceEighteen studies examined household residence as one of the potential determinants of CHE –32. Six Family sizeA total of 25 studies investigated the relationship between family size and incurring CHE , 31–43. Presence of an elderly person in familyThe presence of an elderly person in the household was found to be significant as a risk factor for CHE in all 19 papers that evaluated this variable in their analyses , 41–44.Presence of children aged under 5 years oldOf the 16 papers that studied this factor, six found that the presence of children aged under 5 years old is not a significant factor in determining CHE , 44, 45,Economic statusOf the 33 studies that considered the economic status of the household , 41–51, GenderThe gender of the head of household was found to be a non-significant factor in 16 papers out of the 27 that analysed this factor , 42, 45.AgeThe influence of the age of the head of household was analysed in 12 studies. Five studies found that the age of the head of household is not significant , 40, 43,Employment statusOf the 17 papers that analysed the employment status of the head of household, 11 found that an unemployed head of household is a risk factor for CHE , 39, 40,Educational statusA total of 22 articles considered educational status as a factor in CHE , 50, 51.Hospitalisation (inpatient care)Twenty one studies investigated hospitalisation as a possible determinant of CHE , 48–50. Presence of a disabled personOf the eleven studies that examined disability as one of the predictors of CHE , two reported a non-significant relationship  as follows: Healthcare utilisation in general was found to be a risk factor in studies conducted in Burkina Faso , Iran 3, India  and KenyLastly, in one study on India, land ownership and a higher level of education for the female heads of household in rural areas are considered to be protective factors that could reduce CHE . In ZambFour studies, two on high-income countries and two on middle-income countries based the calculation of CHE solely on total income. On the other hand, 27 studies measured CHE based solely on capacity to pay.Only seven studies used both methods of calculation  and compared the result on the prevalence of CHE derived from the two different methods. Six of these studies were conducted on middle-income countries and one investigated a low-income country.Thus a total of 11 studies used total income to calculate CHE , 46, 49.A total of 34 studies used capacity to pay to calculate CHE. Ten used a cut-off point ranging from 10% to 60%, which again makes it difficult to make a comparison across studies. The other 24 studies used only one cut-off point to calculate CHE.The seven studies that applied capacity to pay as well as total income to calculate CHE , 44, 49 The role of insurance was examined in 17 studies , 46, 47 This systematic review found that irrespective of the economic status of the country under study the determinants of CHE were broadly similar. For instance, people living in a rural area and belonging to the lower income quintiles were more likely to experience CHE compared to urban residents and richer people , 47, 48.The low educational level of the head of household was also found to be significant in determining CHE in several studies , 39, 50.The results for the influence of other household and head of household characteristics are varied depending on country and therefore general conclusions cannot be drawn from them. Nevertheless, it can be said that, apart from the above three indicators of socioeconomic inequality , hospitalisation, presence of an elderly person, presence of a disabled person and presence of a household member with a chronic illness were found to be consistently significant in all studies and regardless of the economic status of the country.Hospitalisation (inpatient care) was identified as an important determinant as it consumes a high share of OOP payments made by households and leads to financial hardship , 48–50.The presence of an elderly person in a household also significantly increases the probability of that household incurring CHE. This greater probability is associated with the greater need for, and utilisation of, healthcare services by the older generation compared to younger age groups . AlthougThe majority of the selected studies used the same econometric models to assess the determinants of CHE. However, several studies used different methods and cut-off points to categorise the presence of CHE in households. Therefore, standardisation of both the method and measures used in studying this issue could enable a more relevant and useful comparison of the data across the globe.Nevertheless, despite the methodological differences in reporting CHE in the various studies, some key points emerged from this review. Firstly, even in high-income countries, households still incur CHE . It is gSecondly, most of the studies identified CHE based on household capacity to pay , 47–50, It is also necessary to reach a consensus on a single method of defining CHE (either based on income or capacity to pay). Hence, to validate these two methods, it would be useful to conduct further studies that define CHE by using both methods as in previous research conducted in Thailand , India  and BrazThirdly, the role of insurance was found to vary among the included studies. In China, there are three government insurance schemes, the New Rural Cooperative Medical Scheme for rural residents and the Urban Employee Basic Medical Insurance Scheme and Urban Resident Basic Medical Insurance Scheme for urban residents . The preThe difference in the prevalence rate of CHE is not only related to the availability of health insurance, but also to the sampling used in the study design. For instance, in Thailand, the UHC policy consists of three major government schemes: the Civil Servant Medical Benefit Scheme, the Social Security Scheme, and the Universal Coverage Scheme, which provide comprehensive outpatient and inpatient coverage through somewhat different benefit packages . If the Reconsideration and upgrading of the health insurance benefits package is crucial to reach a satisfactory level of financial risk protection. In Portugal for instance, although there is an exemption policy for children, the elderly and unemployed, that exemption does not cover the cost of pharmaceutical products and as such causes high OOP expenditure and financial burden . LikewisIn some low- and middle-income countries such as Bangladesh, Kenya, Tanzania, Myanmar and India, the healthcare financing system remains dependent on OOP expenditure. Such dependency reflects a less sustainable way of financing a healthcare system and as such is unable to guarantee any financial protection for vulnerable users of the healthcare system , 40. SimIn Iran, the existing comprehensive national insurance system requires an expansion of the benefit package and a decrease in the co-payments to secure financial protection and avoid CHE . SimilarIn Brazil, private health insurance leads to a rise in the risk of CHE by increasing the demand for specialised and costly health services that further escalates the inequality of healthcare utilisation among the population . In BurkThe measurement of CHE has become increasingly important because it is one of the key parameters for financial protection in achieving UHC. However, this review discovered that there were some general weaknesses in the studies on CHE. For instance, the incidence of chronic illness is based on self-reported data rather than accurate medical diagnosis, which could lead to an over-estimation of the health expenditure on chronic illness. Moreover, payment for health care is solely based on the monetary value and the cost for institutional health care. Thus the methodology cannot capture the in-kind payments that are common in rural areas of low-income countries. Finally, CHE is estimated for households that decided to seek health care, but this does not capture the complete scenario because there are households that choose not to seek health care to avoid the financial hardship that would be incurred in making healthcare payments.For this review, papers published in languages other than English were excluded, so it is possible that some studies were missing. However, in the extensive search of databases only three papers published in non-English languages were found (and excluded). There are many non-English researches on CHE and these can be found in Google scholar. And several studies among them were in-depth studies analysed panel data. There is also a possibility that some studies which have been classified as ‘grey literature’ were missing and thus, there may be some risk of publication bias. However, this is not uncommon limitation for systematic review.The crucial finding of this study is that socioeconomic inequality plays an important role in the incidence of CHE all over the world, where low-income households are at high risk of financial hardship from healthcare payments and of falling below the poverty line as a consequence. The educational status and employment status of the head of household, need for healthcare to manage a chronic illness, and the presence of an elderly or disabled household member were also identified as predictors of CHE. Simultaneously, we would like to highlight that the representativeness of data and source of data and data collection system in different studies are different. Therefore the strength of the factors which effects catastrophic health expenditure and impoverishment may vary and may not be similar.The findings of this review suggest that healthcare financing policies should be revised in order to narrow the gap in socioeconomic inequality and social safety nets should be implemented and strengthened for people who have a high need for health care such as the elderly, people with a chronic illness and disabled persons. Also, CHE can be used as an indicator for comparing fairness in the financing of health care across countries and within a country over a period of time. It can also be used to measure the level and effectiveness of financial protection, which is an important parameter of UHC.