In the last 10 years, political unrest, religious disputes, genocide and civil war have caused the greatest displacement of people on record . In 2015The World Health Organization (WHO) is the arm of the United Nations concerned with the delivery of public health. Their 2014-15 budget totaled US$ 4 billion. In collaboration with the World Bank, and other partners, the WHO is responsible for administering the International Health Partnership (IHF). The IHF is a partner organization linking governments, development agencies and other groups with a common goal to improve health care in developing nations. The World Health Organization therefore occupies a key financial and organizational position, and this role demands both proactive and reactive strategies in the mission to improve health care across both settled and displaced populations. The WHO’s Global Health Initiatives serve to strengthen the health systems in developing nations by delivering additional funds for specific health care interventions; such as immunization programs or fighting infectious diseases such as Malaria or Tuberculosis. Recent WHO Global Health initiatives have also included research to measure and improve global surgery outcomes ,7.“Disruptive innovation” describes technological developments which create new markets and values within an existing market, therefore displacing historic market leaders and products. This phenomenon was described by Harvard Business School Prof. Clayton . M ChrisUnderstanding economic principals behind disruptive innovation is important for those championing provision of low-cost health care products for displaced people with minimal or no disposable resources. However, increased longevity, a growing burden of chronic disease and significant health inequalities make value of health care an increasingly scrutinised metric even in more developed economies. This is true in the USA, one of the largest health care markets in the world, in the UK, and across economically developed nations worldwide .Host nations’ perceived or actual capacity to integrate refugees into existing health care systems has been exceeded . The resHealthcare quality, regardless of setting, is measured by timeliness, efficacy, evidence basis, patient centeredness and cost-effectiveness. Refugees have both similar and unique needs compared to citizens, but very different resources. In the words of philanthropist Bill Gates, “one of the biggest challenges today is to make scientific innovation improve the lives of the poorest”. Redoubled efforts in technological innovation with the explicit target of developing low cost materials, methods and applications for low cost health care delivery are one way the academic community can response to humanitarian crisis.The specific medical and surgical needs of refugees in camps depends on their demographics, the climate, season, presence of violent armed conflict and endemic or epidemic diseases. NGOs rightly focus on highly cost-effective, low-tech primary health care strategies of sanitation, vaccination, and treatment of infectious diseases. However, other common needs are treatment of fractures, burns, wounds, skin diseases and medications and monitoring for chronic diseases like asthma and diabetes. Tests, treatments, devices and data technologies for use in a refugee camps need to be durable, long-life, easy to store and transport and cheap to produce with robust quality assurance and traceability. A disruptive technological solution therefore needs to look beyond merely delivering low cost high volume replica products, but also in introducing new value and significant health care benefit from such an intervention. Medical records, documentation and data collection in these groups are challenging but vital. Simple cloud based storage systems with international access through mobile phone and telecommunication networks might allow refugee health records to be initiated, given increasing access to GPS active cell phones compared to traditional methods. This could even facilitate cross-country follow up by multiple clinicians. Such a system would give this mobile population the health care ‘structure’ to monitor and manage their chronic disease.Medical technology companies have significant research and development costs and shareholder responsibilities. The resulting expense of new medical devices and instruments is enabled and encouraged in systems using third party payment by governments, purchasing consortiums or insurance companies. This leaves cost-conscious consumers one-step removed from manufacturers and reduces the need for competitiveness based on price. To remain profitable, commercial strategy includes defending patents and maintaining market shares by periodically releasing similar designs with upgraded functions or features at higher prices. It is traditionally perceived as high risk, unprofitable and financially illogical for established companies to research entirely novel technologies and materials which could achieve adequate function for a fraction of the cost.RAND, a leading non-profit organisation which works to improve policy decisions through research and analysis, described this sea of change in disruptive innovation within a recent report .This report outlines how prior to 2010 Affordable Care Act, health care had been ring fenced from the threat of disruptive innovation. In the field of quality improvement, budget limitation is a key driver to examine processes and eliminate waste. Equally, emerging lower-budget markets invites genuine technological innovation. Many innovative breakthroughs (case studies) come from small R&D firms with Venture Capital Backing   and the


Children with attention deficit/hyperactivity disorder (ADHD) often continue to exhibit significant impairment in academic, occupational, and social functioning throughout adulthood. In addition, children with ADHD are at increased risk for developing alcoholism and other drug addictions, especially if alcoholism or ADHD exists in other family members. Alcohol and other drug (AOD) abuse may develop earlier in life  when ADHD is accompanied by certain behavioral or mood disorders. The nature of the link between ADHD and AOD use disorder is unknown, although the association may be mediated by the co-occurring disorders just mentioned. In addition, ADHD-related AOD abuse may develop initially as an attempt to alleviate symptoms of mental distress associated with chronic failure, feelings of inadequacy, and conflict with parents and peers. Therapeutic intervention should incorporate both addiction and mental health treatment, including appropriate use of psychiatric medications. Since the beginning of the century, terms such as “hyperactive” have been used to define a heterogeneous group of restless and inattentive children who display learning difficulties. Many such children exhibit the condition now known as attention deficit/hyperactivity disorder (ADHD). Children with ADHD may run about aimlessly, fidget and squirm when seated, and talk excessively. They are often irritable, impatient, and impulsive. Additional symptoms may include difficulty concentrating, forgetfulness, daydreaming, and easy distractibility. The disorder may persist into adulthood, accompanied by significant academic, occupational, and social impairment.The presence of ADHD is an important risk factor for the development of alcoholism and other disorders associated with the use of alcohol and other drugs (AODs).This article explores the co-occurrence  of ADHD and AODD and suggests possible mechanisms that may underlie their association. A discussion of ADHD treatment focuses on the use of medications that can alleviate symptoms of ADHD, thereby potentially affecting the subsequent development of AODD.Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) (The fourth revision of the (DSM–IV)  presents(DSM–IV) .Additional DSM–IV criteria help distinguish ADHD from other disorders or normal temperamental traits. For example, the symptoms must be pervasive  and persistent  and must cause significant impairment in social, academic, or occupational functioning .22ADHD affects from 6 to 9 percent of children and adolescents and up to 5 percent of adults . Data suADHD and AODD occur together in the same person, either simultaneously or sequentially, more often than would be expected by chance . SymptomStudies have identified comorbid ADHD in 25 to 30 percent of certain adolescents with AODD. However, the subjects of the studies were repeat criminal offenders and patients in residential settings who were undergoing treatment for psychiatric and addictive disorders . ConsequEvidence from family studies confirms an association between co-occurring ADHD and AODD. Elevated rates of alcoholism are consistently found in parents of youth with ADHD . ConversThe interpretation of family studies is complicated by the possible influence of prenatal exposure to AODs. For example, the offspring of alcohol- and cocaine-dependent mothers are at increased risk for psychiatric abnormalities, including ADHD . Family AODD appears at an earlier age among adults with, compared with those without, ADHD (mean age 19 versus 22) . In addiADHD also affects the rate of recovery from AODD. In one study, adults with ADHD took more than twice as long as subjects without ADHD to recover from comorbid AODD . In addition, AODD lasted more than 3 years longer in the subjects with ADHD .The underlying mechanisms that link ADHD to AODD remain unknown but may involve complex interactions among biological and psychological factors. Two possible contributory factors of particular significance to risk evaluation and treatment strategy are comorbidity with additional psychiatric disorders and the use of AODs to self-medicate psychological distress.Certain psychiatric conditions frequently co-occur in youth with combined ADHD and AODD . Among tEvidence suggests that some use of AODs represents in part an attempt to ameliorate psychiatric symptoms and their associated subjective states of distress . The acaTreatment of patients with comorbid ADHD and AODD should be based on a thorough evaluation of relevant psychiatric, social, cognitive, educational, and family factors, along with a history of the patient’s AOD use and treatment. The clinician should rule out medical and neurological conditions whose symptoms may overlap with ADHD  or result from AOD use  .The treatment of ADHD and AODD must be considered simultaneously; however, if the addiction is active, it must be treated immediately . DependiMedications play an important role in the long-term treatment of ADHD. The influence of such treatment on the subsequent development of AODD remains unclear and may depend in part on the severity of the underlying condition. Nevertheless, results of preliminary studies suggest that certain medications can alleviate ADHD symptoms in adolescents and adults while reducing co-occurring AOD use or cravings .®, methylphenidate , and pemoline (Cylert®)  . ChildrePsychostimulants themselves are subject to abuse. Of the three psycho-stimulants just mentioned, pemoline has the lowest potential for abuse, followed by methylphenidate and amphetamine . The use®], imipramine [Tofranil® and others], and venlafaxine [Effexor®]) and certain medications commonly prescribed to treat high blood pressure   . The choResearch supports a relationship between ADHD and AODD, with symptoms of ADHD appearing many years before the earliest onset of AOD abuse. AODDs that begin in adolescence run a more severe course than those that appear in adulthood. Therefore, prevention and early treatment strategies should be directed at children with ADHD before AOD use problems develop and become chronic . More st


In a recent IJHPR article, Schwartzberg and colleagues report on clinical and other specialty services offered by pharmacists in the community in Israel and in the international arena. The article covers examples of activities recently introduced due to legislative changes which expanded the pharmacist’s scope of practice, along with obstacles that are serving to slow broader expansion and availability of these services. This commentary details the success of clinical pharmacy services being provided by the United States Veterans Health Administration, and offers a framework of elements that support clinical pharmacy practice expansion. In the United States, clinical pharmacy practice has evolved moving from a profession focused on drug products to one focused on the delivery of patient care. This transition was solidified in 2000, when new standards developed by the Accreditation Council for Pharmacy Education (ACPE) went into effect and the Doctor of Pharmacy (Pharm.D.) degree became the entry-level degree for the profession. Along with this change, there has been an increased emphasis on the need for postgraduate pharmacy residency training and board certification for clinical pharmacists (CPs) engaged in direct patient care. The evolution continues today with the push to have pharmacists and pharmacists’ patient care services recognized with provider status in the United States Social Security Act, which determines eligibility for health care programs such as Medicare Part B. Several studies, including meta-analyses, indicate CPs deliver equivalent, or in some cases  superior, medication management services to patients when compared to other types of healthcare providers –6. FurthIn the Veterans Health Administration (VHA) CPs have been autonomously and collaboratively providing complex medication management activities for over 40 years , 8.The VHA is, without a doubt, one of the premier examples of what can be done with well-trained CPs serving as advanced practice providers (APP). In the VHA, CPs deliver their care under policy authority known as a Scope of Practice (SOP) which reflects an authorization to perform as an APP with the ability to autonomously and collaboratively manage all facets of a patient’s disease, condition, and medications . There aThe CP SOP is focused to cover the practice area where the CP provides Comprehensive Medication Management (CMM) services, rather than being focused on disease states that they manage or medications they may prescribe. In addition, the SOP does not only include prescriptive authority but also core elements essential to the provision of CMM services, such as ordering related laboratory tests and diagnostic studies, performing physical measurements and objective assessments, making referrals for additional patient care needs, and performing other necessary activities to facilitate patient care . It is iSome of the accomplishments the VHA has seen when incorporating the CPs in their advanced practice roles in ambulatory care are in the foundational areas of primary care, mental health, and pain management. There are over 1700 CPs with an SOP and prescriptive privileges in primary care. During Fiscal Year (FY) 2018, there were over 1.4 million patient care encounters with a primary care CP. The most common disease state interventions documented by these CPs were for diabetes management , anticoagulation , hypertension , lipid management , and tobacco cessation . In the mental health practice area there are over 360 CPs with an SOP and prescriptive privileges. During FY 2018, there were 325,358 patient care encounters with a mental health CP. These pharmacists treat a wide variety of mental health conditions, such as depression, post-traumatic stress disorder (PTSD), anxiety, insomnia, schizophrenia, bipolar disorder and substance use disorder. Additionally, VHA graduates over 600 pharmacy residents annually, of which 75 have specialized postgraduate year 2 (PGY2) mental health pharmacy residency training. In pain management, there are over 200 CPs with an SOP and prescriptive privileges. In FY 2018, those CPs provided 160,817 patient care encounters in pain management. Services provided include opioid and non-opioid medication management, high risk assessments, urine drug screening interpretation, opioid education and naloxone distribution, and non-pharmacological interventions. Applying this framework to each practice setting where CP provide direct patient care allows VHA to fully describe the roles, responsibilities, interventions and CMM services provided by the CP provider and sets the stage for practice advancement within the care setting as well as further analysis of patient care outcomes.Schwartzberg and colleagues report on clinical and other specialty services offered by pharmacists in the community in Israel and in the international arena. They rightly point out that several other countries and health systems have capitalized on the education, training and skills of the CPs in a way not yet seen in Israel or other locations. The work of CPs in the VA is an excellent example of what can be achieved when deploying these well-trained professionals broadly across the healthcare system, especially in practice areas that are pharmacotherapy intensive.This provider model, in which a healthcare team including the pharmacist, physician, and nurse work together to form a strategic partnership focused on optimizing patient outcomes, is a crucial component to ensuring patients receive the care and services that they so greatly need.


Digital health tools comprise a wide range of technologies to support health processes. The potential of these technologies to effectively support health care transformation is widely accepted. However, wide scale implementation is uneven among countries and regions. Identification of common factors facilitating and hampering the implementation process may be useful for future policy recommendations.The aim of this study was to analyze the implementation of digital health tools to support health care and social care services, as well as to facilitate the longitudinal assessment of these services, in 17 selected integrated chronic care (ICC) programs from 8 European countries.A program analysis based on thick descriptions—including document examinations and semistructured interviews with relevant stakeholders—of ICC programs in Austria, Croatia, Germany, Hungary, the Netherlands, Norway, Spain, and the United Kingdom was performed. A total of 233 stakeholders  were interviewed from November 2014 to September 2016. The overarching analysis focused on the use of digital health tools and program assessment strategies.Supporting digital health tools are implemented in all countries, but different levels of maturity were observed among the programs. Only few ICC programs have well-established strategies for a comprehensive longitudinal assessment. There is a strong relationship between maturity of digital health and proper evaluation strategies of integrated care.Notwithstanding the heterogeneity of the results across countries, most programs aim to evolve toward a digital transformation of integrated care, including implementation of comprehensive assessment strategies. It is widely accepted that the evolution of digital health tools alongside clear policies toward their adoption will facilitate regional uptake and scale-up of services with embedded digital health tools. Digital health  tools have been proposed to improve access to health care services, enhance care co-ordination and integration, enable self-management, support decision-making, enable monitoring, perform risk analysis, and facilitate proactive interventions . It is wThe use of Information and Communication Technologies in health products, services and processes, combined with organizational change in health care systems and new skills, in order to improve health of citizens, efficiency and productivity in health care delivery, and the economic and social value of health The implementation of digital health tools has constituted an area of major research and innovation in the past years ,4-7. ForIt is currently accepted that eHealth tools can be particularly useful to support Integrated Chronic Care (ICC) programs for patients with multimorbidity, that is, co-occurrence of 2 or more chronic disorders within 1 individual . InsightService delivery, (2) Leadership and governance, (3) Workforce, (4) Financing, (5) Technologies and medical products, and (6) Information and research.The Sustainable intEgrated care modeLs for multimorbidity: delivery, Financing, and performancE (SELFIE) Horizon 2020 project  aims to Technologies and medical products) and assessment of ICC programs (Information and research). For each of these 2 components, the 3 levels of the SELFIE conceptual framework  were taken into account. The micro level is where the individual with multimorbidity interacts with care professionals and informal caregivers. The meso level relates to the organizational level and the institutional setup of providers. Finally, the macro level includes legislations, governance, policies, and system-wide changes at the national and international level.This paper focuses on 2 elements out of the 6 components of the SELFIE conceptual framework , which rTechnologies and medical products, the SELFIE framework stresses the need for digital health tools to be widely available and user-friendly to provide robust support to the care processes. At a micro level, the use of technology  and patient portals) can be a facilitator of collaborative care if tailored to the needs of the patient with multimorbidity. At a meso level, a shared information system  among multiple providers and care settings can greatly facilitate communication, person-centeredness, personalized care, and care co-ordination. Finally, at a macro level, nationwide and international policies that foster technological development and innovation most likely would benefit from both implementation and continuous assessment of ICC programs for multimorbidity.For Information and research, the project stresses the successful use of collected data from digital health tools for a 3-fold objective, namely: (1) Population health management; (2) Enhanced subject-specific health care delivery; and (3) Comprehensive assessment of ICC programs. At a micro level, currently collected individual-level data  can effectively be used in the care process for individual risk prediction. At a meso level, shared information systems may further be used for service selection both at individual and group level  to strengthen the evidence base of complex integrated care interventions, as well as to develop indicators particularly relevant for the care of patients with multimorbidity. Alongside data ownership at a meso level, privacy and data protection legislation is an important consideration at macro level.For It is well accepted that the existence of an important gap between the way in which the role of digital tools is understood and the effective uptake of digital transformation by the different stakeholders in the health care systems at European level. To enable the real implementation and scale-up of the digital health tools with all their potential, we undertook this overarching analysis. Our study aims to synthesize the experiences, views, and opinions (including barriers and enabling factors) of the stakeholders and their impact on the care process, as well as the role and desirable future developments of digital health tools, to foster transformation of health care systems toward sustainability by enhancing management of patients with multimorbidity. A second aim is to characterize the different programs with respect to maturity of their supporting digital health tools and the level of assessment of the ICC program.Here, we present the results of an overarching analysis of the Thick Descriptions  of 17 prTo select the 17 ICC programs, each country participating in the SELFIE project  applied The Thick Description, a qualitative empirical research method, was used in SELFIE to gain a deep understanding of the ICC programs from the different stakeholders’ point of view ,30. The Each partner-country interviewers underwent specific training on how to conduct and analyze the semistructured interviews to ensure uniform procedures. A total of 233 stakeholders were interviewed from November 2014 to September 2016  declaring that ethical approval is not necessary for the evaluation of the two Austrian Integrated Care programs, October 3, 2017.Croatia: Statement from the Agency for Quality and Accreditation in Health Care and Social Welfare declaring that the two evaluation studies are not within the scope of work of Croatian Central Ethics Committee, August 28, 2017, with reference to Official Gazette No 121/07 and No 25/15.Germany, Gesundes Kinzigtal: Letter from the Ethical Committee, Technische Universität Berlin, declaring that the research is ethically acceptable .Germany, Casaplus: Letter from the Ethical Committee, Technische Universität Berlin, declaring that the research is ethically acceptable .Hungary, OnkoNetwork: The research plan has been authorized under approval No IG/03092–000/2016 by the Director General of Moritz Kaposi General Hospital, based on the positive opinion of the Institutional Research Committee and the responsible person of the Hospital for data protection. The Institutional Ethics Committee of the hospital double-checked the research and publication plan and confirmed that no ethical concerns were emerging related to this research and to the publication of findings .Hungary, Palliative Care Consult Service: Letter from the Medical Research Council  declaring that the research is granted with Professional-Ethical Approval .The Netherlands, Proactive Primary Care Approach for Frail Elderly (U-PROFIT): Letter from the Medical Ethical Committee (MEC) Erasmus Medical Center Rotterdam declaring that the research is exempt from the Medical Research Involving Human Subjects Act .The Netherlands, Care Chain Frail Elderly (CCFE): Letter from the Medical Ethical Committee (MEC) Erasmus Medical Center Rotterdam declaring that the research is exempt from the Medical Research Involving Human Subjects Act .The Netherlands, Better Together in Amsterdam North (BSiN): Letter from the Medical Ethical Committee (MEC) of the Free University Medical Centre declaring that the research is exempt from the Medical Research Involving Human Subjects Act .Norway, Learning Network for Whole, Co-ordinated and Safe Pathways: Letter from the Regional Committees for Medical and Health Research Ethics-West (Komité for medisinsk og helsefaglig forskningsetikk -REK vest) declaring that the research is ethically approved .Norway, Medically Assisted Rehabilitation Bergen: Letter from The Regional Committees for Medical and Health Research Ethics-West (Komité formedisinsk og helsefaglig forskningsetikk -REK vest) declaring that the research is ethically approved .Spain, Barcelona-Esquerra (AISBE): Letter from Clinic Research Ethical Committee (Comitè Ètic d’Investigació Clinica—CEIC) of the Clinic Hospital of Barcelona .Spain, Badalona Serveis Assistencials (BSA): Letter from Clinic Research Ethical Committee (Comitè Ètic d’Investigació Clinica—CEIC) of the Clinic Hospital of Barcelona .United Kingdom: Approval was granted by the National Health Service (NHS) Health Research Authority Research Ethics Committee .All participants provided written informed consent before participation.The overarching analysis provided the following valuable insights on the implementation and exploitation of digital health tools to support ICC.EMR and they are planning to enhance implementation of EMR in the future.All 17 ICC programs have at least partial implementation of specific personal health records to enhance patient engagement are not considered in programs like Health Network Tennengau (HNT), Casaplus, OnkoNetwork (ON), Palliative Care Consulting Service (PCSS), Better together in Amsterdam North (BSiN), and Medically Assisted Rehabilitation (MAR). In such programs, digital information exchange between care provider and patient are either not considered or telephone is still the dominant tool for communications. Nevertheless, the use of personal health records has been key to support various telemonitoring services for patient self-management in programs like in GeroS (eKarton). Likewise, South Somerset Symphony Program (SSSP) and Salford Integrated Care Program (SICP), both from the United Kingdom, stress the role of digital health tools  to support telemonitoring, albeit suffering from some implementation problems:However, Tele-dermatology and we’re piloting it [...] the GP will take a photograph and email it and get a decision, they’re not doing suspected cancers obviously, but rashes. Yeah, we’ve done itIP11_1—SICPWe've also got telehealth, that support. So we've got patients who are on telehealth in their homes, and each morning, the intensivists review the telehealth and see if there's any flags, like, if somebody is on [...] I'm trying to think. If somebody is on some sort of medication that they need to, you know, where fluid balance is an issue, if they've lost six pounds in weight that might flag some medication change. So they get them to weigh themselves, do their blood pressure, and so on. So, telehealth has been hugely supportive, actually, at keeping patients at homeIP08_2—SSSPpersonal health records at regional level, which is the case with the programs Area Integral de Salut Barcelona-Esquerra (AISBE) and Badalona Serveis Assistencials (BSA)   or duplicate papers because you have to present this paper here and this same paper over there [...] I think this is an important progress for the populationIP04_1—U-PROFITshared EMR among health care tiers, is at the heart of some ICC programs, such as the GeroS program. In line with organizational interoperability, the Care Chain Frail Elderly (CCFE) program focuses on structuring care and stimulating communication between all chain partners in primary care at various access levels with one another, thanks to an additional digital health tool (Care2U) that is used on top of the existing information systems to access the individual care plan and exchange information. However, although there has been much effort by the governments of these countries to have a shared EMR in place, this has not yet been fully successful, mostly due to data privacy issues. Last but not least, the AISBE program aims to consolidate a shared case management system , patient satisfaction experience, and number of contacts made.IP03_2—SSSPfull scientific assessment . TheCasaplus ,49:...was the number of hospital admissions reduced? How did they experience the effects of care ? Were the per capita costs reduced?IP04_1—Casaplusclinical criteria  or combined with rules-based clinical management [Patient management purely based on nagement   is still in its infancy, despite the fact that it seems a natural step toward customization of care to patient’s needs. Clinical predictive modelling tools are only reported to be used in some ICC programs  for individual risk assessment (which can be considered within the micro level). Within the U-PROFIT program, available data in the general practitioner EMR system are used by the U-PRIM software to screen frail patients of 60 years and older in every participating practice [In contrast, the regular use of practice . SICP anpractice  and the practice , to iden...so we’d looked at some of the higher risk patients that were identified by the Combined Predictive Model and PARS (Patient at Risk Score) exactly the same, because I’ve done that before for the unscheduled care, and we looked at that; and what you find is the high risk people that are identified by this risk stratification models that are promoted nationally, is that the only data that’s easy to count is the hospital data, is the Hospital Episode Statistics of your hospital episodic statistics and stuff.IP02_1—SICPSimilarly, Casaplus uses a clinical predictive modelling tool to identify patients in high risk for hospital admissions within the next 12 months.population-based risk assessment is only reported in BSA and AISBE . Since 2011, the Catalan Health Surveillance system collects detailed information on health care usage for the entire population of Catalonia [The use of clinical predictive modelling tools for atalonia , the regatalonia ,14.Multilevel Predictive Modelling: (1) clinical, (2) informal care; (3) biological research; and (4) outcomes from population-health risk predictive modelling , resulting in enhanced patient-based stratification and optimization of service selection. This approach aims to pave the way toward personalized medicine, provided that access to the multilevel data sources is granted. However, most legal frameworks on data privacy of the 17 ICC programs depend on the ongoing implementation of the European Union Data Protection Directive 95/46/EC to make the concept of multilevel predictive modelling operational.Furthermore, AISBE is adopting a holistic approach that fosters inclusion of covariates from multilevel data sources, namely incipient research and innovation initiatives constantly being implemented in practice, both bottom-up and top-down, using several, sometimes consecutive, project-budgets but without sustainable structural funding.A majority of the 17 ICC programs are part of consolidated research and innovation programs at state and regional level. For example, the Gesundes Kinzigtal program in Germany has been extensively evaluated in terms of prevalence of multimorbidity, polypharmacy, proportion of generic drugs, prevalence of problematic drug prescriptions, prevalence of fractures among patients diagnosed with osteoporosis, quality of services, and overall health care costs [However, Croatian, Dutch, German, Norway, and Spanish programs are aligned with re costs . Anotherstrong co-ordination of most programs from Norway, the Netherlands, Hungary, Spain, Croatia, and Germany with different European research and innovation initiatives under the umbrella of H2020 [Furthermore, the of H2020 , EIP-AHAof H2020 , EIT Heaof H2020 , and/or of H2020 , as wellTechnologies & Medical products and Information & Research. As most of the ICC programs are pilot experiences in terms of nation and region wide rollout of digital health tools, this analysis was useful to learn from them regarding requirements for a successful large-scale implementation elsewhere.The overarching analysis allowed us to assess the use of digital health tools to support the care process in the 17 ICC programs on the 2 specific aspects analyzed: Acknowledging that the 17 ICC programs are highly heterogeneous regarding the use and impact of digital health tools, the main findings are summarized below.Each program studied shows at least partial implementation of EMR, and all of them have plans in place for a future mature implementation of EMR.The use of personal health records to support telemonitoring services for patient self-management is not in place in most ICC programs, for which telephone is still the dominant means of communication.Most programs reported on the potential of secure health information exchange across providers to facilitate organizational interoperability for deployment of ICC by facilitating information sharing among heterogeneous providers and avoid generating additional burden of double-registration to health professionals. However, the maturity of implementation is currently rather poor. Moreover, the need for technological tools, on top of health information exchange platforms, supporting collaborative work across health care tiers to foster implementation of shared case management ,59 was sThe overarching analysis highlighted the lack of well-defined macro-level policies, with effective operational implementation plans, in the health care systems in which most ICC programs operate. Often, the use and scope of digital health tools depends on local or regional initiatives of individual providers involved in the ICC programs.Most programs systematically collect well-defined outcome measures to feed program-specific evaluation strategies, ranging from descriptive data analysis, comparison of trial and control groups, as well as pre- and postmeasuring. Still, some ICC programs recognize barriers for assessment such as a lack of financing, poor research capacity, concerns on data security, and misuse of data. This study clearly shows the need for formulation of structured and comprehensive evaluation and monitoring strategies for ICC including formulation of key performance indicators extensively shared across countries. Moreover, the Quadruple Aim approach ,61  are often based on project-specific budgets without well-defined, operational policies and, consequently, without sustainable structural funding. Implementing the above technological innovations frequently requires hardware and software upgrades. The costs of initial rollout and training of staff also need to be considered and weighed against the likely benefits.We acknowledge some limitation in our study such as the inherent limitations of the methodological approach adopted. Also, as the study conclusions relate only to programs based in Europe, worldwide representativeness of the study results cannot be assumed.A recent report by the European Union on Integrated Care maturity , includiIntegrated care programs for chronic patients involve complex interventions for heterogeneous populations; therefore, proper articulation of digital health tools and the different components of the evaluation process are still unmet needs that markedly hinder comparability and scale-up. The overarching analysis of the 17 ICC programs conducted in this study allowed us to identify the following potential areas for future developments:Refinement of assessment methodologies of large-scale deployment and adoption of ICC programs, likely based on implementation research approaches [proaches -65, are proaches . Moreoveproaches  considerproaches ,61. The The concept of adaptive case management explored in AISBE [in AISBE ,68 shoulDynamic health-risk assessment taking into consideration both service commissioning  and subject-specific service selection involving optimal patient allocation in the health system  should be addressed to improve outcomes [omics information) emerges as a high priority goal to properly pave the way toward personalized medicine for complex chronic patients [outcomes -71. Ultipatients . EnhanceDevelopment of pragmatic trials that incorporate real-life evidence from multilevel determinants of health may require implementation strategies, ideally using cloud computing environments, tackling privacy and regulatory constraints [straints ,72. CurrThis overarching analysis informs the current implementation status of digital health tools for management of multimorbidity in the 17 promising ICC programs selected in SELFIE. Notwithstanding the heterogeneity of the results, most studied programs are progressively evolving their supporting digital health tools from pilot prototypes to full scale-up at regional and national level. However, the majority of programs have not yet undergone full evaluation and assessment strategies. Future directions which can enable of digital transformation are based on innovation at micro and meso level with full support from the macro level. Some strategic areas that can help toward this end are the following: (1) implementation of research strategies; (2) explore an adaptive case management approach; (3) further developments of health risk assessment; and (4) holistic implementation strategies using future, regulatory compliant, cloud computing environments.


This study assesses the contribution of predisposing, enabling, and needs factors and related variables that predicted the number of healthcare professionals consulted for mental health reasons among 746 individuals with mental disorders and high psychological distress. The data were drawn from the third (T3) and fourth data collection periods (T4) of a longitudinal study conducted in a Quebec/Canada epidemiological catchment area. Hierarchical linear regression was performed on the number of types of healthcare professionals consulted in the 12 months prior to T4. Predictors were identified at T3, classified as predisposing, enabling, and needs factors  according to the Andersen Behavioral Model. Three needs factors were associated with the number of types of healthcare professionals consulted: Post-traumatic stress disorder, stressful events, and marginally suicide ideation. Three enabling factors: Having a family physician, previous use of mental health services, and employment status were also related to the dependent variable. Poor self-perception of mental health status was the only predisposing factor retained. While needs factors were the main predictors of the number of types of healthcare professionals consulted, enabling factors may reduce the influence of needs factors, by the deployment of various strategies that facilitate continuous and appropriate care. Mental disorders (MD) represent a challenge to the healthcare system due to their high prevalence, costs, and burden of disability, while negatively impacting quality of life for affected individuals and families ,2. RecurCollaborative care models have been identified as particularly successful in delivering integrated medical and MH care ,14, withConsiderable research on MH service utilization has been guided by the Andersen Behavioral Model . This moConcerning predisposing factors, previous research has found a positive association between age and use of both psychiatrists and general medical professionals . A CanadPrevious studies on MH service use have mainly focused on samples of individuals with MD only, even though an appreciable proportion of MH service users have subthreshold MD and needs that may differ from those of individuals who meet the criteria for a diagnosed MD ,27,28. IIn order to form a better picture of individuals in need of MH services, it may be useful to investigate MH service utilization among individuals without a diagnosis, but who are at high risk for MD . AccordiThis study is based on a subsample from a longitudinal population-based cohort study, conducted in an epidemiological catchment area in Southwest Montreal, Quebec (Canada), with a population of 269,720 distributed among six neighborhoods. Data for this specific study (the subsample) included the two last data collections from the full longitudinal study . The area includes a major psychiatric hospital offering specialized services for serious and complex MD, and two community health and social service centers that deliver primary MH care. Numerous private clinics employ general practitioners and psychologists, while community organizations offer supportive services such as crisis centers, day centers, and self-help groups for individuals with MH problems and their families.Study participants had to be between 15 and 65 years of age and live within the catchment area. A geographically representative sample with socio-economic and other characteristics proportional to those of the general population was sought. A random sample of 3408 home addresses was initially selected for recruitment purposes. In order to improve the recruitment process, this initial list was extended to include a range of 14 neighboring addresses for door-to-door recruitment . InterviThe first data collection period (T1: June 2007–December 2008) included N = 2434 study participants. Three additional data collection periods followed at two-year intervals ; they are summarized in The dependent variable, “number of types of healthcare professionals consulted for MH reasons”, was measured for each participant at T4. Professional consultation was defined as contact with any healthcare professional for MH reasons in the 12 months prior to the interview: General practitioner, psychiatrist, psychologist, nurse, social worker, etc. Independent variables (measured at T3) were integrated based on the literature related to predictors of MH service use ,22,38 anp < 0.10) were used to build the hierarchical linear regression model, with the alpha value set at p < 0.05 to determine which factors in the model were significant. Following the study hypothesis, clinical needs variables were entered into the model first, followed by other needs variables, then predisposing and enabling factors. Needs factors were divided into “clinical” needs factors  and “other” needs factors  to highlight the differences between them in terms of impact on service utilization. For each block of variables, the goodness-of-fit was determined with the Hosmer–Lemeshow test and the variance explained using the Nagelkerke R2. Univariate, bivariate, and multivariate analyses were performed. Missing values were also treated by imputation technics . Univariate analyses consisted of frequency distributions for categorical variables and central tendency measures  for continuous variables. A bivariate linear regression analysis was conducted for each independent variable to determine which ones were associated with a higher number of different types of healthcare professionals consulted for MH reasons. Significant independent variables in the bivariate analyses  or high psychological distress . The hierarchical linear regression model is presented in Based on this catchment area study, slightly less than one-third of the sample reported consulting healthcare professionals for MH reasons in the previous year. This result falls within the low range of consultations (from 5% in low income to 44% in high income countries) observed in previous population studies ,55,56, wThe hierarchical regression model revealed that needs factors predicted the highest number of types of healthcare professionals consulted for MH reasons, followed by enabling factors; whereas the contribution of predisposing factors was marginal. These findings confirm our hypothesis that individuals with complex or serious needs would be more inclined to consult a greater number of different types of healthcare professionals. However, it should be noted that there were equivalent numbers of significant needs factors  suicide ideation) and enabling factors  in the final model; whereas only one predisposing factor (self-perception of MH) remained significant. Interestingly, three needs factors  ceased to be associated with the dependent variable after the block of enabling factors was introduced into the model, suggesting that the presence of enabling factors substantially reduced the influence of these needs factors on number of different types of healthcare professionals consulted for MH reasons. As predicted in this study, and reported previously ,61, we fThree enabling factors predicted consultations with a greater number of different types of healthcare professionals for MH reasons: Previous use of MH services, employment status, and having a family physician. Due to the chronic nature of certain MH conditions, episodes of relapse or recurrence  may requFinally, one predisposing factor, self-perception of MH, negatively predicted the number of different types of healthcare professionals consulted for MH reasons. This corresponds to previous findings suggesting that patients who had a worse self-perception of their MH were more likely to seek help from general practitioners and MH specialists rather than relying on a single healthcare professional ,83. AnotThe findings of this study should be considered in light of certain limitations. First, the frequency of consultations with each healthcare professional was not taken into account. As such, continuity and appropriateness of care were not considered, which are key dimensions impacting quality of care and patient recovery. Second, the diversity of types of healthcare professionals consulted did not take into account the existence of actual collaboration among them, as required in collaborative care models. Third, some pertinent predictors of consultations with different types of healthcare professionals for MH reasons that may influence service utilization, including lifetime disorders, symptoms severity, suicide attempt , ethniciThis study was innovative in assessing predictors of diversity in the number of types of healthcare professional consultations for MH reasons among individuals, not only those diagnosed with MD, but mainly those affected by high psychological distress, using the Andersen Behavioral Model. This latter clientele is often overlooked by MH professionals, who focus mainly on diagnosed MD cases in their practices. Findings revealed that needs factors were most strongly associated with the number of types of healthcare professionals consulted, but that enabling factors may reduce the influence of certain needs factors, particularly those involving clinical variables. Multiple variables associated with consultations of a greater number of different types of healthcare professionals for MH reasons were identified: PTSD, stressful events, previous use of MH services, employment status, having a family physician, self-perception of MH, and  suicide ideation. The identification of specific predictors may help orient MH programs and interventions. Considering that enabling factors are easier to tackle than needs or predisposing factors, it would be important for MH managers to prioritize the development of collaborative care models to facilitate continuity and appropriateness of services for individuals who view their MH as poor. Moreover, all individuals with MH problems should have a family physician to provide an entry point to the healthcare system. Family physicians are responsible for addressing a wide range of MH needs, but also for making referrals to specialized MH services in more severe or complex cases, such as PTSD. Further extensions of employment assistance programs may facilitate better MH, as such support in the workplace may serve as an antidote to stress and related MH problems, while providing individuals with the means to consult MH specialists when needed. Finally, information on help-line services and crisis centers should be more widely disseminated, given the numbers of individuals affected by stressful events and suicide ideation.


Suaahara II (SII), a multi-sectoral program implemented in 42 of Nepal’s 77 districts to improve dietary diversity (DD) and reduce maternal and child undernutrition. Using cross-sectional data from SII’s 2017 annual monitoring survey, this study explores associations between exposure to SII and maternal and child DD. The study sample included 3635 mothers with at least one child under the age of five. We focused on three primary SII intervention platforms: interpersonal communication (IPC) by frontline workers, community mobilization (CM) via events, and mass media through a weekly radio program (Bhanchhin Aama); and also created an exposure scale to assess the dose-response relationship. DD was measured both as a continuous score and as a binary measure of meeting the recommended minimum dietary diversity of consuming foods from at least 5 of 10 food groups for mothers and at least 4 of 7 food groups for children. We used linear and logistic regression models, controlling for potentially confounding factors at the individual and household level. We found a positive association between any exposure to SII platforms and maternal DD scores , child (aged 2–5 years) DD scores , and mothers meeting minimum dietary diversity . There were significant, positive associations between both IPC and CM events and meeting minimum DD  and also between CM events and DD scores  among mothers. We found significant, positive associations between mass media and meeting minimum DD  among children aged 6–24 months and between mass media and DD scores  among children aged 2–5 years. We also found that exposure to all three platforms, versus fewer platforms, had the strongest association with maternal DD scores , child (aged 2–5 years) DD scores  and mothers meeting MDD . These findings suggest that a multi-pronged intervention package is necessary to address poor maternal and child dietary practices and that the barriers to behavior change for maternal diets may differ from those for child diets. They also highlight the importance of IPC and CM for behavior change and as a pre-requisite to mass media programs being effective, particularly for maternal diets.The prevalence of maternal and child malnutrition in Nepal is among the highest in the world, despite substantial reductions in the last few decades. One effort to combat this problem is  Although the prevalence of maternal and child undernutrition in Nepal has greatly reduced over the last two decades, the prevalence remains among the highest in the world . The mosInfant and young child feeding (IYCF), however, has not improved in Nepal for the last several decades , 4. DietSuaahara II (SII), a five-year (2016–2021) USAID-funded multisectoral program that builds on an initial five years of implementation during phase one (2011–2016), aligns with and supports the GoN’s MSNP to reduce maternal and child undernutrition. Helen Keller International (HKI) leads the implementation of SII in partnership with six core implementing partners , FHI360, Vijaya Development Resource Center (VDRC) and Nepal Technical Assistance Group (NTAG), and local organizations in each SII district. With a target of reaching 1.5 million women and children across 42 of Nepal’s 77 districts, SII’s primary objective is to reduce undernutrition and anemia among children under 5 years of age and women of reproductive age (WRA) (15–49 years). SII’s multi-sectoral activities span: nutrition, health including family planning, water, sanitation and hygiene (WASH), agriculture/homestead food production (HFP), governance, and gender equity and social inclusion (GESI).The Government of Nepal (GoN) is currently implementing the second phase (2018–2022) of its Multi-Sectoral Nutrition Plan (MSNP) with support from external development partners . SuaaharBhanchhin Aama (BA), a weekly radio program complemented by a follow-up weekly call-in show.SII works with GoN frontline workers (FLWs) such as Female Community Health Volunteers (FCHVs), health workers, and agriculture/livestock extension workers. SII also has its own complementary FLW cadre including Field Supervisors (FS), Community Nutrition Facilitators (CNF), Community WASH Facilitators/ Triggerers, and Village Model Farmers (VMFs). In 2017, SII employed 600 FS to carry out household and community-level activities, in coordination with the nearly 27,725 FCHVs present in the SII districts. SII’s Social and Behavior Change Communication (SBCC) approach uses three main platforms to reach target beneficiaries: interpersonal communication (IPC), community mobilization via events (CM), and mass media. IPC activities include home visits made by SII FS to 1000-day households to provide one on one counselling and support. Community-level fairs and interactions, including food demonstrations and key life events to celebrate pregnancy, birth, and a child turning six months of age are examples of SII community events held to promote key nutrition and health behaviors. SII’s mass media approach primarily includes Suaahara found that households exposed to Suaahara interventions had better knowledge related to child and maternal health and better sanitation practices, compared to households not exposed to the interventions [It is important to understand which and how many of these interventions are necessary to achieve desired behavioral outcomes. A previous study using data from the first phase of ventions . Evidencventions . Howeverventions .This study examines the relationship between exposure to SII overall, exposure to each SII platform, and the degree of exposure to these platforms and maternal and child DD, using data from a cross-sectional survey conducted in 2017 as part of SII’s monitoring system. The purpose is to generate hypotheses regarding the effectiveness of different types of intervention platforms to start to fill evidence gaps on the additive nature of varying intervention platforms in complex large-scale programs.The data for this study was obtained from a representative, cross-sectional survey among households with children under 5 years of age conducted one year after the start of the SII program. New ERA, an external survey firm, carried out this first annual monitoring survey for SII between June 10 to September 10, 2017, the rainy season in Nepal. Multi-stage cluster sampling was conducted to select: 16 districts, 1 rural and 1 urban municipality per district (N = 32), 3 wards per municipality (N = 96), 2 sub-wards/clusters per ward (N = 192), and 19 households with a child under 5 years of age per cluster (N = 3648). The first four stages were conducted using probability proportion to size (PPS) techniques. For the fifth stage, households with a child under 5 years of age and his/her mother in residence were selected randomly from a full list of households within each cluster, created by the survey firm in the few days prior to the survey. In total, 3643 households with at least a mother and one child (her own) below the age of 5 years were included as study participants, and we had complete data on 3635 mothers, as 1 participant refused consent and 7 study participants consented but withdrew participation during the survey.The household survey included questionnaires targeted to mothers, fathers or another male household head , and grandmothers living in the same household. Information on household socio-demographics and economics; knowledge and practices related to nutrition, health, family planning, agriculture/HFP, and WASH; empowerment; mental health; dietary intake for adults and the youngest child under 5 years of age; and exposure to SII messages, platforms, and FLWs.Bhanchhin Aama). A binary variable was created for each as follows:For this study, three exposure variables were created, one for each of the three main SII intervention platforms: IPC, CM, and mass media  in the past six months; this does not include any government workers aligned with Suaahara, for example, FCHVs.IPC: met with any Suaahara community events such as food demonstrations, ideal family celebrations, key life events, WASH triggering sessions, Community Health Score Board (CHSB) interactions and special day, week and month celebrations, which may be done in collaboration with FCHVs but absent Suaahara, are not common FCHV activities.CM: ever participated in Bhanchhin Aama (BA) weekly radio program, designed aired and promoted by SuaaharaMass media: ever listened to the A scale (0–3) was also created to categorize participants based on the extent of their exposure to these SII platforms. We generated a categorical variable with four categories: zero, one, two, and three platforms.Maternal and child DD indicators include DD scores and minimum dietary diversity (MDD). Dietary data was collected using a semi-quantitative 24-hour dietary recall method. Following the globally recommended women’s dietary diversity score, foods consumed by the mother were grouped into 10 food groups: 1) grains, white roots and tubers, and plantains; 2) pulses ; 3) nuts and seeds; 4) dairy; 5) meat, poultry and fish; 6) eggs; 7) dark green leafy vegetables; 8) other vitamin A-rich vegetables and fruits; 9) other vegetables; 10) other fruits. From this, women’s DD scores (range of 0–10) were calculated as the total number of distinct food groups consumed and MDD was defined as consumption of foods from at least 5 of these 10 food groups [Initial analysis comprised of descriptive analyses to generate means and standard deviations for continuous demographic variables such as age, years of education, number of children in the household, and DD scores. Additionally, descriptive analyses of the binary and categorical variables were performed to obtain percentage distributions of the sample population among the categories. To assess the differences in these variables between the mothers in the sample who were exposed to SII and those who weren’t, chi-square tests were conducted to generate p-values that indicated the significance of the differences.Linear regression models were used to model the relationships between exposure to each platform and the continuous outcome variables—DD scores -, which had a normal distribution. Similarly, logistic regression models were used to model the relationships between exposure to each platform and the binary MDD outcome variables. All observations were independent of each other and minimum sample sizes for all regressions were met. To assess the dose-response relationship between the degree of exposure and the outcomes of interest, a logistic regression was used for all outcomes with the exposure variable being the scale of platform exposure, and the reference point being exposure to zero platforms. The outputs from the linear regressions provided beta values and p-values and the outputs from the logistic regressions provided beta values, odds ratios, and p-values. All of these statistical outputs were assessed to determine associations between the exposures and outcomes of interest.terai (plains), hills and mountains, each of which vary in availability of diverse foods and have cultural and linguistic differences. Child age was constructed as a continuous variable referring to total number of completed months of age. Child gender was constructed as a binary variable with two categories of male and female. Any child illness was also constructed as a binary variable with one category referring to the child having any type of illness in the two weeks prior to the survey and the second category referring to the child not having any type of illness in the two weeks prior to the survey. Additionally, all regressions were adjusted for clustering at the smallest geographic unit of the survey (sub-ward).All models were adjusted for potentially confounding factors identified a-priori including mothers’ age and education level, number of children under 5 years of age in the household, household socio-economic status, caste/ethnicity, agroecological zone, and urban/rural residency. Child regression models were also adjusted for child age, child gender and any child illness in two weeks prior to the survey were also added as potential confounders. Maternal age and education level were constructed as continuous variables with education level referring to total number of years of formal education received. The number of children under 5 years of age in the household and urban/rural residence were included as binary variables. Household socio-economic status was measured with the use of the Equity Tool, which uses ownership of key assets and quality of household structures  to generate equity quintiles . Caste/eEthical approval for this survey was obtained from the Nepal Health Research Council (NHRC). Each respondent included in the survey provided written informed consent prior to beginning any interview, and the consent process was repeated after the completion of each module in the questionnaires, in order to continue the survey.Detailed background characteristics of the survey sample are presented in The significant differences found between individuals exposed versus not exposed to any SII platforms were that the exposed women had, on average, 1.5 years more of schooling. A higher percentage of the exposed women were also of a higher caste/ethnicity group, fell into the upper equity quintiles, were from the hills, and resided in rural areas. In addition, outcomes of diet diversity scores and meeting minimum dietary diversity were significantly different between exposed and unexposed mothers and children, based on chi-squared tests (p<0.001).After one year of SII implementation, slightly over one-third of the mothers in the sample had been exposed to any of the three SII platforms . ExposurWe found that exposure to any SII platform was positively associated with mothers’ DD scores  and meeting MDD  . SpecifiWe also found a positive trend of improved maternal DD with increasing exposure to SII platforms. Exposure to two of the three platforms was correlated with higher DD  for mothers and exposure to all three SII platforms had the largest association. Mothers exposed to all three platforms had DD scores that were 0.45 units higher than mothers who were exposed to none  and they were more than twice as likely to meet MDD than mothers with exposure to none  .We explored the associations between exposure to SII and child dietary indicators by splitting the sample between children 6–24 months of age and children 2 to 5 years of age because children 6–24 months of age remain within the critical 1000-day growth period, are still breastfeeding, and are also SII’s primary target population . We founWe also found a positive trend with increasing exposure to SII platforms for older children’s DD scores: those with exposure to two of the three platforms had higher DD than those exposed to one  and exposure to all three SII platforms had the largest association . Similarly, children exposed to two or three platforms were 1.4 times likely to reach MDD, but this was only significant for those exposed to two platforms .Suaahara II (SII), including three main SBCC intervention platforms–interpersonal communication, community events, and mass media–and maternal and child dietary diversity. We found that interpersonal communication, specifically interaction with SII frontline workers, and participation in SII-organized community mobilization events had positive, significant associations with maternal dietary diversity, whereas the only association with child dietary diversity was exposure to mass media. We also found that the more platforms a mother was exposed to, the stronger the positive association with maternal dietary diversity was: mothers who were exposed to 2, versus 1, platform, had a more than twofold higher DD score. A similar finding was true for children, especially those 2 to 5 years of age. This suggests that exposure to multiple intervention platforms, rather than just one type of intervention, may be important for driving improvements in dietary diversity.This study investigates associations between exposure to The overall exposure to these three SII platforms is seemingly low, although expected after only one year of implementation particularly in such an at-scale program. There is significant lag time to contract community-based NGOs, set up offices across the country, hire and train FLWs and finally, implement at the household and community levels. Furthermore, given the ratio of SII staff to the target households , we would expect the exposure levels to be low after year one, but also expect this to improve over the program duration. SII also introduced a new line of FLWs in the second program year, about 800 Community Nutrition Facilitators (CNFs), to increase coverage of program interventions.We further explored the dietary data by comparing the consumption of specific food groups among mothers and children who were exposed to any SII interventions versus those who were not (results not shown). The key differences found were that mothers who were exposed to SII consumed dairy and dark green leafy vegetables significantly more than mothers who weren’t exposed. In addition, children of mothers who were exposed to SII consumed significantly higher amounts of dairy, eggs and Vitamin-A rich fruits and vegetables. SII promotes the consumption of both dark green Vitamin A rich vegetables and animal source foods and thus this finding is consistent with the intervention theory of change. Other SII-promoted foods, such as meat, are more expensive and are not a part of the daily Nepali diet, suggesting that promotion of the consumption of dairy, eggs and dark green leafy vegetables may be a feasible way of improving dietary diversity among mothers and children in Nepal.Since SII activities are integrated and are carried out in villages covering more than half the country, dissecting which activity covered which topic  is challenging. However, to understand why IPC and CM, but not mass media, were associated with maternal dietary diversity, we looked more closely at the content of these different SBCC platforms. First, during IPC, some of the specific counselling messages given by SII during home visits vary depending on stage in the 1000-day period, such as ANC and PNC, but maternal and child diets are always a focus. Dietary diversity is also a significant focus of FLWs during nearly all community events. Food demonstrations are solely concentrated on improving diets, but key life celebrations held for each mother during her pregnancy, after delivery and when her child turns 6 months of age also revolve around food: the mother is given a nutrition-related gift basket from her community which often includes nutritious locally grown foods to discuss the importance of maternal and child dietary diversity. However, only 3 of the 35 BA episodes aired during the first year of SII covered dietary diversity. This may explain why IPC and CM events, and not BA, were associated with maternal diets.For children, only mass media had a significant association with dietary diversity. This finding may reflect on the fact that the radio program focused more on child, rather than adult, diet practices. The seemingly contradictory results around the associations between different interventions for mothers and children reveal that the determinants of maternal and child dietary practices may differ, with the same platforms having different effects on the uptake of appropriate dietary practices. This finding emphasizes that a combination of approaches may be necessary to bring about sustained positive change in household dietary practices.Exposure to all three platforms had the strongest, positive association with dietary outcomes for mothers and a similar, although less consistent and significant pattern, emerged for child dietary outcomes as well. This result that a combination of platforms had a stronger association with nutrition practices confirms findings from prior studies conducted in Nepal , BangladA major limitation of this study is that the dataset is cross-sectional and thus, we cannot infer causality from any of the significant associations identified in these results. The inability to remove potential residual confounding may have resulted in some bias which must also be considered in the interpretation of the results. We considered categorizing the exposure platforms based on intensity of exposure, for example number of FLW interactions, and also assessing the relationship between every possible combination of platforms and our outcomes. However, the sample size for each sub-group was too small and would not have allowed us to generate robust and reliable regression results. Finally, collinearity of exposure platforms is an issue. The three exposure platforms were significantly associated, which is expected since each platform would be promoted among the other platform activities–for example, during home visits FLWs promote participation in community events and that mothers listen to the BA radio program. However, we could not adjust for this in our regressions as each exposure platform would be on the causal pathway between the other exposure platforms and the outcomes and thus the findings for each would be underestimated. Additionally, we were unable to disentangle joint FCHV-SII interventions, because FCHVs are government workers and are not solely SII FLWs. Despite these limitations, the findings of this study are informative and can be used to guide decisions on where to invest programmatically, particularly for the remaining three years of SII.Additional analysis of this data and future rounds of this monitoring survey are needed to answer questions including how these platforms relate to other maternal and child nutrition and health outcomes, particularly as exposure to the platforms increases. Qualitative studies investigating the differences between exposure platforms in terms of reach and uptake would be useful to understand why some platforms work better and how the radio program could be improved to have a stronger impact. More rigorous studies such as a randomized controlled trial would be necessary to minimize bias and establish causal relationships between the platforms and specific practices.The findings of this study will have important implications on future implementation of SII and other similar large-scale nutrition programs. There needs to be a strong focus on strengthening the quality and reach of individual intervention platforms, specifically FLW interactions and community events, given the demonstrated strong individual associations with dietary outcomes. Finally, the effectiveness of the combinations of platforms suggested by the increasing association of exposure with positive diet outcomes highlight the need for nutrition programs and government policies to adopt a multi-platform model to have the highest potential for reach and positive impact on maternal and child nutrition practices.S1 Data(XLS)Click here for additional data file.


Indigenous children in Canada  are disproportionately affected by nutrition-related chronic diseases such as obesity and diabetes. Comprehensive school-based nutrition interventions offer a promising strategy for improving children’s access to healthy foods and sustaining positive eating behaviors. However, little is known about school-based nutrition interventions for Indigenous children. The objectives of this scoping review were to identify school-based nutrition interventions for Indigenous children in Canada and describe their components.The scoping review consisted of searches in seven peer-reviewed databases and a general web search for grey literature. Eligibility criteria were applied by two reviewers, and data were extracted and charted by one reviewer using components of the comprehensive school health approach  and additional components with relevance to Indigenous interventions . Numerical and descriptive summaries were used to present findings.Thirty-four unique interventions met the inclusion criteria. The majority (97%) of interventions targeted the social and physical environment, most often by offering food programs. Over half of interventions also incorporated teaching and learning (56%) and partnerships and services (59%), but fewer included a policy component (38%). Many interventions included a cultural component (56%) and most (62%) were owned and controlled by Indigenous communities (62%). Finally, over half of interventions disclosed their source(s) of funding (59%), but less than half (41%) included an evaluation component.The review suggests that school-based interventions for Indigenous children can be more comprehensive by incorporating culturally relevant nutrition education and professional development opportunities for teachers, written school nutrition policies, and activities that actively engage families and community members. The continued focus on Indigenous control and ownership and incorporation of content specific to individual communities may enhance cultural relevancy and sustainability of interventions. Furthermore, there is a need to increase intervention evaluation and the sharing of resources related to funding. These recommendations may be used by communities, as well as by researchers and professionals working with communities, in developing comprehensive school-based nutrition interventions to improve the eating behaviors of Indigenous children. Canadian Constitution Act, 1982 [. Indigenous peoples include three district groups: First Nations, Inuit, and Métis. Inuit are the original inhabitants of the Arctic regions of Canada. Most continue to live in these regions, including Nunavut, Nunavik, and Nunatsiavut [Indigenous communities in Canada face significant obstacles to healthy eating due to numerous sociocultural and environmental barriers, including a high prevalence of household and community food insecurity –3. High ct, 1982 . Indigenatsiavut . Métis aatsiavut . First Natsiavut . First Natsiavut .Indigenous peoples of Canada are linguistically, culturally, and geographically diverse; however, they share similar barriers to healthy eating as their experiences are situated within a larger macro-context of historical colonization, assimilation policies, and forced removal from traditional lands that are unique to Indigenous peoples . For insSchools are an important setting to target nutrition interventions to promote and support healthy eating, considering the time that children spend in schools during their formative years . Researcn = 303), 86.7% had a school nutrition program  and nearly two-thirds (62.3%) had a school nutrition policy [In 2008, The Assembly of First Nations performed an environmental scan of school nutrition programs and policies for children in First Nation community schools across Canada. Of the 47.9% of schools that responded to the survey  at the University of Alberta, an initial search was conducted to develop and refine the search strategy for the scientific literature. Searches were then conducted by two research librarians (JT and LH) using the following databases: Medline (Ovid), ERIC (Ovid), CINAHL Plus with Full Text (EBSCO), Agricultural & Environmental Sciences (Proquest), Academic Search Complete (EBSCO), Bibliography of Native North Americans (EBSCO), and Dissertations and Theses Global (Proquest). Searches employed both controlled vocabularies, such as Medical Subject Headings (MeSH), and keywords representing concepts such as: (Indigenous or Amerindian) AND (schools or kindergarten) AND (nutrition or diet) AND (Alberta or British Columbia). The search for the scientific literature covered articles published between January 1, 2000 and February 25, 2019. No limiters or facets were used, and search strategies were adapted for each database. The MEDLINE Search Strategy is available in Additional file In an effort to minimize the risk of omitting relevant sources of evidence, one researcher (CG) conducted a search of the grey literature on the Internet using different combinations of key search terms . Grey lin = 10) and grey (n = 10) literature. Their level of agreement was 100%. At this stage, the reviewers determined that the date criteria would not apply to websites. The reviewers felt it was unlikely that a website would be running if it was outdated by over a decade, as many website hosting platforms require a fee for maintenance. Therefore, if a website was available at the time of the review, it was considered eligible for review and selection whether it had a date listed on its pages or not.Basic eligibility criteria were defined a priori Table  and wereIn the first stage of selection, two reviewers (CG and RB) applied the eligibility criteria to determine the relevancy of sources of evidence identified in the scientific literature. First, the reviewers screened the title and abstracts for relevancy and copies of the full text were obtained for those that appeared to fit the eligibility criteria. If the relevance of a source of evidence was unclear from the abstract, or if reviewers had discrepant assessment at this stage, the full text was obtained. In the second step, each reviewer read the full text of each article to decide whether it should be chosen for inclusion in the review. Discrepancies between reviewers were discussed, and a third opinion (NDW) was sought for two of the scientific literature sources of evidence.The grey literature search followed a one-step process whereby sources of information were screened by each reviewer in full to determine both relevancy and inclusion. This one-step determination was followed out of necessity, as the majority of sources of evidence were websites that did not have an abstract or table of contents to screen. There was 100% agreement between the reviewers for all grey literature sources of evidence.A standardized data charting form  with a random sample of 5 sources of evidence from the scientific or grey literature to ensure all relevant data were captured. Eligible sources of evidence were charted independently by one reviewer (CG) using Microsoft Excel. Only data that were relevant to nutrition were charted , consistent with the a priori objectives of the review. Data extracted about the same intervention described in multiple articles were combined in the charting form. As the goal of this review was to provide an overview of the existing literature regardless of quality, a formal appraisal of the methodological quality of sources of evidence included in the review was not performed , 30, 34.Having charted characteristics of the interventions, a numerical and descriptive summary of the charting results was used to present findings. The comprehensiveness and scope of the interventions was described by drawing upon the four components of CSH and the four additional key components of Indigenous school-based nutrition interventions that were included as extraction fields and defined in Table A total of 65 sources of evidence were included in the review, representing 34 unique nutrition interventions , 35–93 . Of thesFindings related to the four components of CSH  and the four additional key components of Indigenous school-based nutrition interventions that were examined  are described in detail below.Thirty-three interventions (97%) included one or more social and physical environment component. Seven interventions (21%) contributed to the social environment by providing healthy eating messages in newsletters or websites, or by displaying posters in the school that promoted healthy eating. For example, the Hillside Elementary School and Greenwood Elementary School Active Schools programs displayed posters in classrooms that promoted healthy lifestyles and sent newsletters home that included healthy recipes . To encon = 25, 74%) offered food programs, with some of them offering breakfast, lunch, and snack , breakfast solely , breakfast and snack , breakfast and lunch , lunch solely , lunch and snack , and snack solely . One intervention (3%) mentioned offering student nutrition programs but did not specify the meal(s) that were included. Furthermore, three interventions (9%) mentioned student access to a canteen stocked with healthy snacks, and two schools (6%) had vending machines with healthy options. Six interventions (18%) included a school or community garden, and five interventions (15%) included a nutrition awareness campaign or contest. For example, Elsipogtog First Nation School in New Brunswick hosted a healthy snack challenge, in which students who ate a fruit or vegetable during snack time were entered into a draw and had a chance to win a fruit basket [Most interventions also included physical components that increased students’ access and exposure to healthy food choices. The majority of interventions (t basket .One or more teaching and learning components were used in 19 interventions (56%). Fifteen interventions (44%) included a classroom education component in which discussions of healthy food choices were incorporated into the curriculum. The Kahnawake Schools Diabetes Prevention Project (KSDPP) in Quebec, for example, implemented a comprehensive education program for diabetes prevention that included lessons on balanced meals and healthy snacks, the benefits of healthy eating, factors that influence eating habits, and food label reading , 71. Twon = 13, 38%) included a policy component; however, the scope and content of policies was highly variable. Five interventions (15%) banned or actively discouraged junk food items  from being brought to school. For example, Chief Harold Sappier Memorial Elementary School in New Brunswick discouraged parents from packing foods like potato chips, candy, and pop in student lunches in an effort to eliminate junk food from the school environment [Thirteen interventions (ironment . Four inironment . Two intironment .Twenty interventions (59%) included one or more partnerships and services component(s). Six interventions (18%) included a parent and community engagement component in which school nutrition activities were reinforced and supported by activities that engaged families and the community-at-large. For example, Yukon Food for Learning encouraged volunteer involvement in delivering school nutrition programs . Two intSixteen interventions (47%) included partnerships with local health and social organizations, local businesses, and national health promoting agencies. For example, Zhiiwapenewin Akino’maagewin: Teaching to Prevent Diabetes (ZATPD) in Ontario was implemented in partnership with several schools, local stores, and health and social services in order to extend its reach in the community , 53, 76.Nineteen interventions (56%) included one or more cultural components. Ten interventions (29%) included traditional foods – such as bannock (a quick bread) and wild game meat – in the schools’ food programs or the education curriculum. Four interventions (12%) incorporated traditional Indigenous ways of learning, such as learning through observation and practice, storytelling, and role modeling. Six interventions (18%) mentioned making culturally appropriate adaptations to education curricula and/or having community members review education materials for cultural sensitivity and relevance. Cultural adaptations included using Indigenous characters in stories and incorporating traditional stories and foods in lessons.Twenty-one interventions (62%) included a component in which the local community was actively involved in developing, implementing, and/or evaluating interventions. Seven interventions (21%) included information regarding programs or services being community initiated, driven, and/or developed. For example, the National Aboriginal Nutrition Program followed a community-led approach in which key stakeholders – including teachers, school staff, parents, and community members – collaboratively coordinated school nutrition activities . FourteeTwenty interventions (59%) reported one or more sources of funding. Twelve interventions (35%) received funding from donations, sponsorships, or funding from diverse organizations . Examples included the Heart and Stroke Foundation of Canada, the Danone Institute of Canada, Canadian Feed the Children, ONEXONE, and Breakfast for Learning. Nine interventions (26%) were supported by research grant funding, including the Canadian Institutes of Health Research and University Departments. Regional and federal funding  supported six interventions (18%). Finally, one intervention (3%) was supported by the operational budget of the local school board.Fourteen interventions (41%) performed evaluations to understand the feasibility of interventions, the barriers and enablers of their implementation, and/or their impact and outcome on student knowledge, behavior, and health. For example, the Sandy Lake Health and Diabetes Project (SLHDP) in Ontario completed two evaluations to determine changes in students’ knowledge, skills, and self-efficacy and behaviors related to diet by collecting anthropometric data and having students complete a questionnaires and dietary recalls , 60.This scoping review provides an overview of school-based nutrition interventions for Indigenous children that have been implemented in Canada as well as a discussion of the components of identified interventions. Most of the interventions found in this review were implemented for First Nations children, as few nutrition interventions were found for Inuit and Métis populations through the search strategy. In addition, most interventions were implemented in Western Canada, and few were found in the Territories. Other reviews have also noted the under-representation of Inuit and Métis within the scientific intervention literature , 28, whiAccording to the CSH approach, school-based nutrition interventions should include components that promote health and improve access to healthy foods through social and physical environments, teaching and learning, school policy, and partnerships and services , 32. AllAll but one of the interventions included components related to the social and physical environment, which indicates that this component is important and relevant in Indigenous settings. Interventions targeted the social environment through community feasts, cooking classes, and peer-mentoring, which encouraged both healthy relationships and promoted healthy eating. With respect to the physical environment, the majority of schools offered food programs that supplemented children’s diets with healthy foods. This finding supports previous research demonstrating that most band-operated First Nations schools offer food programs for students . AlthougWhile the teaching and learning component was incorporated in most interventions, this remains an area for improvement in current and future school-based nutrition interventions for Indigenous children. The incorporation of healthy eating skills and knowledge in the classroom and involvement of teachers in promoting nutrition may serve to reinforce other components of nutrition interventions . Land-baThe partnerships and services component of CSH was included in approximately two-thirds of interventions. Parent and community engagement is key in the successful implementation of school-based interventions, as it increases the potential for nutrition-related activities at school to be supported at home and for the larger community to support the nutrition needs of children . Thus, iOf the four components of CSH, policy was implemented by the fewest number of interventions. Written school nutrition policies are an integral component of CSH interventions, as they establish formal standards for all nutrition-related aspects of the school environment and coordinate other aspects of the CSH intervention  . The mosIn addition to the four recognized components of CSH, this review paid attention to four additional key components  that should be considered when developing school-based nutrition interventions for Indigenous children , 28, 33.Community control and ownership has also been recognized as an essential component of health interventions in Indigenous communities that can assist in ensuring that interventions are relevant to local contexts , 33. ComFunding is also an important consideration when developing comprehensive school-based nutrition interventions as it takes extensive resources to implement and sustain multiple intervention components. Over half of the interventions mentioned funding from a diverse range of sources. Other research has similarly shown that school interventions in Indigenous communities are funded by a myriad of donors, and lack of funding has been identified as the main barrier to implementing nutrition interventions . IndigenFinally, evaluation has been identified as an important component of interventions to demonstrate effectiveness and support the sustainability of programs and policies. Fewer than half of the interventions in this review reported an evaluation component, which highlights an important gap in the information currently available for school-based nutrition interventions for Indigenous children. The lack of evaluation of interventions limits the transferability of knowledge concerning their key components and marginalizes Indigenous communities from the evidence regarding effective comprehensive school-based nutrition interventions , 102. HoTo minimize the risk of omitting relevant sources of evidence, this review included both scientific and grey literature. Although the inclusion of grey literature expanded our range of interventions, our descriptions of these interventions was nonetheless limited to the information as provided in sources of evidence. As such, it is possible that interventions had additional components that were not identified. A more robust review would necessitate identifying, contacting, and consulting all schools attended by Indigenous children to include all nutrition interventions and their components. A review of this nature would require considerable time and resources and was not possible in this case. Finally, although the review identified interventions that had been implemented, it did not include information on how well the interventions were implemented in practice. For example, an evaluation of KSDPP found that teachers implemented the curriculum and enforced the school nutrition policy to varying degrees . SimilarAlthough many school-based nutrition for Indigenous children provide supportive social and physical environmental elements, the review suggests that interventions can be more comprehensive by incorporating culturally relevant nutrition education and professional development opportunities for teachers, written school nutrition policies to guide nutrition activities and environments, and activities that engage families and community members. Sustainable interventions must be controlled and owned by Indigenous communities and include culturally specific traditional foods and ways of learning. Finally, there is a need to increase intervention evaluation and the sharing of knowledge and resources related to funding. These recommendations may be used by communities, as well as by researchers and professionals working collaboratively with communities, in developing comprehensive school-based nutrition interventions to improve the eating behaviors of Indigenous children.Additional file 1. MEDLINE search strategy. Full electronic search strategy for MEDLINE database.Additional file 2. Web search strategy. Full grey literature search strategy.Additional file 3. Extraction grid. Full extraction grid.Additional file 4. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. PRIMSA ScR Checklist.