Recognising radical shifts in the global health research (GHR) environment, participants in a 2013 deliberative dialogue called for careful consideration of equity-centred principles that should inform Canadian funding polices. This study examined the existing funding structures and policies of Canadian and international funders to inform the future design of a responsive GHR funding landscape.We used a three-pronged analytical framework to review the ideas, interests and institutions implicated in publically accessible documents relevant to GHR funding. These data included published literature and organisational documents  from Canadian and other comparator funders. We then used a deliberative approach to develop recommendations with the research team, advisors, industry informants and low- and middle-income country (LMIC) partners.In Canada, major GHR funders invest an estimated CA$90 M per annum; however, the post-2008 re-organization of funding structures and policies resulted in an uncoordinated and inefficient Canadian strategy. Australia, Denmark, the European Union, Norway, Sweden, the United Kingdom and the United States of America invest proportionately more in GHR than Canada. Each of these countries has a national strategic plan for global health, some of which have dedicated benchmarks for GHR funding and policy to allow funds to be held by partners outside of Canada. Key constraints to equitable GHR funding included (1) funding policies that restrict financial and cost burden aspects of partnering for GHR in LMICs; and (2) challenges associated with the development of effective governance mechanisms. There were, however, some Canadian innovations in funding research that demonstrated both unconventional and equitable approaches to supporting GHR in Canada and abroad. Among the most promising were found in the International Development Research Centre and the (no longer active) Global Health Research Initiative.Promoting equitable GHR funding policies and practices in Canada requires cooperation and actions by multiple stakeholders, including government, funding agencies, academic institutions and researchers. Greater cooperation and collaboration among these stakeholders in the context of recent political shifts present important opportunities for advancing funding policies that enable and encourage more equitable investments in GHR. Global health research (GHR) prioritises health equity and improved well-being for all people worldwide. It involves transnational health issues, determinants and solutions, involves collaboration across many disciplines within and beyond the health sciences, and is undertaken in order to inform (and be informed by) policy at the local, national and global level –3. GivenCanadian investments in GHR have, like in other fields of health research, been subject to a dynamic policy environment over the last decade. Following the 2008 economic recession, there was an unprecedented reorganisation of the GHR funding landscape in Canada. As new global public health threats emerged, major funding bodies underwent reform and private investors expanded their involvement in research and development. These shifts occurred amid intensified pressure to demonstrate results and value for money. While the explicit rationale for the structural changes in Canada’s GHR funding landscape was to strengthen its position as a world leader in research, the underlying reasons for changes are difficult to discern and their future impacts unknown.In 2011, the Canadian Academy of Health Sciences called upon Canadians to play a more strategic role in global health . The CanThis study involved analysing funding policies for their alignment with equity-centred GHR, using the CCGHR Principles for GHR  as an anGrounded in a reflexive approach , 8, thisTwo distinct datasets were used for this analysis. The first dataset was generated at a 2013 CCGHR deliberative dialogue involving participants who self-identified as having some involvement in GHR. Perspectives from within the GHR community that were reflected included those from non-governmental organisations, university administration, researchers, teachers, students, funders and private organisations involved in GHR. Participants at this event voiced concerns about issues of stability, ethics and equity for GHR funding and called on the CCGHR to undertake further policy research. The data included specific reflections on formal and informal funding policies in Canada. This dataset was re-analysed in this study for content pertaining to this study’s research questions. The HealthBridge Research Ethics Board reviewed and approved the ethics application for the study in which this deliberative dialogue was held (Certificate Number: HBREB/2013_1). Participants’ consent included acknowledgment of the possibility that their data may be used for future studies.The second dataset was composed of literature and documents relating to selected national funders of GHR in Canada and major global comparators. Inclusion criteria for funders involved being an agency with explicit or implicit investments in GHR, degree of influence over strategy, and researcher accessibility to documents in English. We selected a heterogeneous set of funding organisations, including overseas development agencies, health research councils, development research centres and philanthropic foundations. We searched for documents that described these organisation’s values, strategies, programmes and granting policies. Documents retrieved were funding bodies’ strategic plans, progress reports and grant management policies relevant to GHR, although these varied widely in terms of scope, timeframe and level of detail. In addition, we searched academic databases, including Medline, PubMed, Scopus and Google Scholar, for peer-reviewed research on this topic. Key medical subject headings and search terms included ‘global health research’, ‘funding’ and ‘development assistance’.Using a content analysis approach , and guiThis section summarises the key findings from our analysis and provides a snapshot of the funding landscape in Canada and comparison countries.The global context of investments in GHR is marked by intense diversity in direction, intent and funding structures. Funders and other GHR stakeholders, both in Canada and abroad, use a varied terminology to describe the activities aligning with our definition of GHR. This may be attributable to agencies’ particular objectives and intended beneficiaries of GHR investments, which also vary widely. The stated rationale for GHR investments ranged across a wide spectrum, from the pursuit of commercialisation opportunities, through the advancement of basic and applied sciences, to eliminating the burden of diseases and poverty or supporting health as a human right. Similarly, we found that funding originating in wealthy countries flowed to a variety of targeted beneficiaries, including local researchers, institutions and populations, as well as marginalised, indigenous or resource-poor populations globally. This variability is observable among agencies that directly support GHR (e.g. funding agencies) and within general investments in global health through development assistance or other programmes that indirectly support GHR . For example, a major determinant of GHR funding among Organisation for Economic Co-operation and Development (OECD) countries is the direction and amount of foreign aid for health sector activities, which is otherwise known as development assistance for health (DAH). DAH globally climbed to a new high of US$31.3 billion in 2013, although the 3.9% growth from 2012 to 2013 falls short of the average 10% annual increases seen over the 2001–2010 period . CorrespThis rise of GHR funding may be attributed to increased public and political awareness of global vulnerability to infectious diseases, heightened by the onset of the HIV/AIDS pandemic in the 1980s and 90s. The United Nations’ Millennium Development Goals focused political attention on the inequities between countries and championed channelling investments into priorities such as HIV/AIDS, malaria and then maternal, neonatal and child health (MNCH) –19. FundCanadian researchers have a long history of involvement in global health initiatives, and are recognised for leadership in GHR and practice. Innovations in funding for GHR emerged through the 2001 establishment of the Global Health Research Initiative (GHRI), with their flagship Teasdale-Corti grants, which infused more than CA$18 million into GHR funding between 2003 and 2005 . Growth Based on open data sources, the primary GHR funders based in Canada at present are Grand Challenges Canada (GCC), the International Development Research Centre (IDRC), and the Canadian Institutes of Health Research (CIHR) highly problematic from a gender and development perspective” .ective” [IDRC]”  indicated alignment between IDRC policy and practices and the equity-centred criteria used in this analysis. This was particularly true for the criteria of authentic partnering, inclusion, shared benefits and commitment to the future. One of IDRC’s recognised strengths lies in its commitment to “agement agement  declared it would no longer fund social sciences-based health research . CIHR haoperating grants with an international connection [were] overwhelmingly — about 90 per cent — with U.S. collaborators” . promoting a healthier future through preventative action” .These would be welcome shifts, given the concerning language in the current CIHR strategic plan that listed many of the global health actions as predicated on the need for new funds . Unlike The GHRI, created in 2001, was one of the first attempts at a coordinated approach to GHR funding between Health Canada, CIDA, IDRC, the Public Health Agency of Canada and CIHR. This initiative, and its flagship CA$25 M Teasdale-Corti programme, led to new multi-year research partnerships between LMIC- and Canada-based researchers with a focus on building applied health research capacity for researchers in poor countries. Egalitarian partnerships and a concerted effort to build local capacity were central to the design of this new funding model , 58. HowIn 2010, the Canadian government created a CA$225 M Development Innovation Fund to be disbursed through the new GCC to spur innovation by global health innovators in LMICs and Canada . The entIt was difficult to find clear evidence of alignment between GCC policies and practices and the equity-centred criteria used in this analysis. The short-term project focus of GCC grant competitions, combined with a focus on technology and innovation, did not align with the criteria for responsiveness to causes of inequities and raised questions about the possibility of enabling shared benefits. GCC’s strengths lie in its focus on saving lives in LMICs, alignment with the US-based BMGF and United States Agency for International Development approaches, and its ability to engage the public, policymakers and research institutions in Canada and around the world. Importantly, GCC also has the capacity to disburse funds directly to LMIC researchers following an institutional assessment of financial management capacity . GCC doeAfter the launch of the 2010 Muskoka MNCH Initiative, the Canadian Academy of Health Sciences argued that, unlike Norway, the United States and the United Kingdom, Canada did not have a unified vision for global health. Through a wide-reaching consultative process, the Academy proposed that a strategic role for Canada in global health should be based on Canadians’ strong value for universal healthcare, a vibrant philanthropic sector and strong commitment to MNCH as key strengths . It was Participants involved in deliberative dialogues as part of the 2013–2014 CCGHR Gathering Perspectives Study raised several concerns for Canada’s approach to GHR. In particular, there was concern for how the current division of roles among Canadian funding bodies seemed to fuel an uncoordinated GHR strategy and contradictory granting policies. Additionally, the community raised concerns of the levels of tied aidThere are a number of characteristics and best practices for funding GHR that were identified from the literature, revealing a sample of government and philanthropic agencies based in Australia, Denmark, Norway, Sweden, the European Union, the United Kingdom, and the United States.The United States is traditionally the single largest DAH donor nation, although US bilateral assistance fell 7.2% from 2011 to 2012 and then a further 3.4% from 2012 to 2013, due to budget sequestration . The UniThe last decade has also seen a dramatic rise in the strategic and financial influence of private philanthropic organisations in the United States. The Clinton Foundation’s global health budget of US$134 M in 2012 was focused on increasing access to treatment for HIV/AIDS, malaria and diarrheal diseases, along with lowering costs for essential medicines and supporting health systems infrastructure in LMICs . The BMGtackling global societal challenges”  Horizon 2020 research funding scheme. Although GHR is not central to the programme, one of its strategic directions is framed broadly as “lenges” . icants”  ticants” .ntries” .innovation poses particular challenges for knowledge-based policy formulation”  onship” .This analysis revealed a complex and dynamic GHR funding landscape in Canada. Recent funding developments include renewed opportunities for GHR, including the 2017 SSHRC announcement that health-focused social science research would again be eligible for funding . Given tUniversities have an important role to play in creating enabling environments for equitable management of GHR grants and for promoting more equity-centred GHR. Although participants in the CCGHR studies directed their concerns at funding agencies, some of the barriers they described were, in actuality, rooted in the policies of their institution’s grants administration. Universities can, for example, examine their internal policies and practices related to the administration of grants. In addition, universities can encourage flag equity as a consideration in pre-submission peer review. This could involve considering how equity is reflected in different elements of grant proposals, including budgets that enable capacity building and compensation for the contributions of partners outside of Canada. Tenure review processes that create a means for assessing equity in GHR are another important policy arena where universities can promote equity-centred GHR, including principles such as those outlined in the CCGHR Principles for GHR . FinallyGreater harmonisation between Canada’s research and development funders on GHR priorities and activities could be enhanced through a joint national strategic plan, setting benchmarks for GHR funding, and with a long-term commitment to the strategy. A coordinated GHR strategy, if not more broadly for global health and development, would need to include Global Affairs Canada, CIHR, IDRC, SSHRC and GCC. Such a strategy would also benefit from contributions from bodies like the Canadian Academy of Health Sciences, the Canadian Society for International Health, the CCGHR, the Canadian Council of International Cooperation, the Canadian Network for Maternal, Newborn and Child Health, and major Canadian philanthropic foundations and academic institutions. A unified GHR strategy, and the strategies of each of its contributors, should have an integrated evaluation framework that incorporates qualitative research methods and policy analysis. Additionally, bibliometrics and spending data is needed to measure achievements and discern best practices such as the Health Economics Research Group payback model recommended by CCGHR .varying stakeholder expectations, unaligned grant cycles, and highly variable reporting requirements” . ements” , which are central to equity-oriented GHR. It is important that GHR investments remain balanced between research on innovation of biomedical sciences and technology while continuing to strengthen the fundamentals of health systems and health equity. This kind of balance will also require broad inputs from health policy research and social, economic and environmental sciences. Canadian funders should promote open sharing of knowledge including failures, an essential aspect of learning. Research grantees, aid recipients and evaluators alike should be encouraged to disseminate knowledge and share lessons learned from both successes and failures with the broader Canadian and international health community. These structural changes may help reduce some of the unintended consequences of foreign aid and GHR.Lastly, Canada would be wise to rectify the reputational and operational damage stemming from the 11% foreign aid budget cut in 2012–2013, and ensure that the new MNCH commitment of funds  is truly new money relative to 2011–2012 levels. Global Affairs Canada should also reconsider whether the amalgamation of development programming with trade and foreign affairs branches presents long-term risks to its effectiveness and ethics in aid delivery, and take this opportunity to imagine an architecture for consolidating all global health and development (including research) funding under one independent agency, free of political influence.We acknowledge certain limitations in conducting this policy analysis. First, the policy analysis was conducted primarily using non-peer reviewed government and non-government publications available in the public domain. The content of documents varied by funding body, making it difficult at times to compare information. This process required an assumption that the majority of information contained in the documents is accurate. Second, the lack of information on new GHR funders from Brazil, Russia, India, China and the private sector limited the analysis to Western governments and major philanthropic funders.With a review of strategic planning undertaken in all main Canadian funders in 2016, there is an important window of opportunity for the GHR community, in Canada and abroad, to influence policy towards a funding environment that is reflective of foundational principles for equity-centred GHR. This analysis of the current GHR funding landscape and promising practices internationally has informed the development of a core set of recommendations by CCGHR Table . A natio


In mammals, new neurons are continuously produced in two specific neurogenic niches, the subventricular zone (SVZ) and the subgranular zone (SGZ) in the dentate gyrus (DG) of the hippocampus. Adult neurogenesis recapitulates some of the key events of brain development including proliferation of neuronal progenitors, migration and morphological maturation of newly generated cells, and functional integration into brain networks. In the SGZ, neural progenitors differentiate into dentate granule cells (DGCs), which elaborate their dendritic arbor into the molecular layer and extend axons to innervate target cells in the CA3 region. To be integrated, adult born neurons start to form afferent and efferent connections, and this process of synaptogenesis is under the control of several local and environmental factors. During maturation of their physiology and connectivity, the newborn neurons exhibit increased excitability and enhanced synaptic plasticity. Due to their role in hippocampal plasticity, the adult born cells may affect hippocampus-dependent learning and memory. Recent studies have highlighted a crucial role for adult neurogenesis in the acquisition/forgetting of memories and in the discrimination of spatial and contextual information .It is well recognized that adult neurogenesis is affected in various neurological diseases associated with cognitive impairments, such as intellectual disabilities (ID), including Rett, Fragile X and Down syndromes. ID is a complex disease of the central nervous system (CNS) whose pathophysiology is not completely understood and no effective cures are available to date.Oligophrenin-1 (Ophn1) gene, located on X chromosome, encodes for a RhoGTPase-activating protein (RhoGAP) whose mutations are involved in the etiology of X-linked intellectual disability (XLID). Ophn1 is expressed in the whole brain during development and in adulthood. At the cellular level, Ophn1 is expressed in both glial and neuronal cells where it colocalizes with actin. Due to its interaction with actin, Ophn1 participates in several neuronal developmental processes, including dendrite and axon growth, axon guidance, synapse formation and cell migration . Ophn1 hIn a recent manuscript , we haveOphn1 loss of function results in persistent activation of RhoGTPases and consequent hyperstimulation of the RhoA/ROCK pathway and high levels of PKA activity. Based on previous data , we usedOne fundamental question in these studies is whether the normalization of adult neurogenesis improves cognitive functions. Our data  and thosAltogether, the data described above indicate that adult neurogenesis allows a precise dissection of alterations of neuronal maturation in IDs, and the experimental validation of novel therapeutic strategies.


The Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC) Quality Improvement Collaborative (QIC) in Eastern Canada provided an approach to spur system-level reform across multiple health systems for patients and families living with chronic disease. Developed and led by senior executives with a unique governance approach and involving clinical front-line teams, the AHC serves as a practical example of leadership creating and driving momentum for achieving success in collaborative health system improvements. To increase institutional support and sustainability, QICs require effective governance capacity.2 This article examines one approach to governing collaborative health system improvement with specific attention to:Quality improvement collaboratives (QICs) are becoming vital for disseminating improvements and bringing together healthcare organizations, frontline providers and patients toward common improvement objectives. While QICs provide structure and create shared improvement expectations,governance structure through initiating a charter agreement, forming an executive committee among senior leadership of healthcare delivery organizations, and cost-sharing opportunities and strategies;Development of a QIC governance capacity involving 17 regional health systems with shared responsibility, in partnership with a pan-Canadian improvement agency, endorsed by four provincial departments of health, with frontline clinicians and managers leading improvements; andMulti-dimensional (across systems) and -directional  sustaining improvement – be it the original interventions and/or capacity for quality improvement (QI), beyond the lifespan of the collaborative.Creating continued interest in 3 The Canadian Foundation for Healthcare Improvement (CFHI) is a non-profit, federally funded agency that accelerates spread of proven innovations across Canada by supporting healthcare organizations to adapt, implement and measure improvements in patient care, population health and value-for-money.Canadian healthcare is a decentralized, complex, primarily publicly funded model dispersed across 10 provinces, three territories and the federal government.3Facing escalating rates of chronic disease and rising healthcare costs, health systems across the four Atlantic provinces forged a QIC with CFHI to build capacity for more patient- and family-centred and sustainable care. The Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC) involved care teams working to design, implement and evaluate chronic care improvements  and carrying out “disruptive changes” that challenged usual approaches to care.4 and signed by all 17 healthcare delivery regional health authority (RHA) CEOs and CFHI. The AHCEC members co-sponsored the QIC and were accountable for enacting the charter on behalf of all 18 signatories as per the agreed upon Terms of Reference.5 Core responsibilities included:The AHC was designed and governed collectively by CFHI with chief executives and senior leaders from five participating Atlantic healthcare delivery organizations – forging the AHC Executive Committee (AHCEC). The AHCEC brought together key regional personnel to set a shared vision for achieving QI in chronic care, outlined in a charter agreementSetting the direction for the QIC by selecting priority areas;Liaising with fellow RHA CEOs and leaders within their province to advise on activities; raising concerns or suggestions;Advising on policy changes for system-level improvements, allocating QIC resources, and strategies to enable success; andActing as a forum for sharing information, assessing needs, responding to outcomes, evaluating success and adopting and spreading effective innovations.65 with the AHC charter5 and CFHI’s six levers for healthcare improvement framework, which informed the basis of the structure taken to the AHC.7 These features align with the six domains for leading improvement outlined in the Institute for Healthcare Improvement’s (IHI’s) High-Impact Leadership Framework, which outlines effective strategies for governing QI at an executive-level8:A charter holds organizations and their leadership accountable for their QI efforts; collaboration toward common improvement goals is encouraged.Driven by persons and communityCreate vision and build willDevelop capabilityDeliver resultsShape cultureEngage across boundaries8 Improvement efforts will only be effective if they appropriately engage those they seek to influence from the outset – frontline providers as well as patients, families and communities. Realizing improvement requires shifting accountability measures beyond the charter to a common performance improvement approach and capacity development interventions that support the change process. The AHC model included a refined governance structure that encompassed these components ,16 but suggesting that the AHC networks were critical drivers for success and sustainability of the CDM initiatives.16An early analysis of system priorities in the region revealed key challenges and priorities aligned across provinces, mainly those linked to chronic disease management (CDM) and patient-centred care.9Post-AHC, efforts and capacity to pursue collaborative approaches to improving healthcare were apparent. A greater number of Atlantic teams participated in CFHI-led QICs, with more than 30 organizations across seven CFHI initiatives, including four of the 11 original AHC improvement teams enrolled in subsequent CFHI QICs.Beyond continued interest in participating in QICs, some examples of continued success with local support include:Spread of the PEER (Peers Engaged in Education and Recovery) 126 model from Horizon Health Network in New Brunswick via the Transformational Research in Adolescent Mental Health (TRAM) network – a network established by the Canadian Institutes of Health Research (CIHR) to catalyze fundamental change in Canadian youth mental health over the next five years;A one-day symposium attended by all Nova Scotia Health Authority (NSHA) regions to share and spread the successes in implementing an integrated chronic disease prevention and management strategy (CDPM) across programs and services;9Ongoing work in diabetes self-management support (SMS) across three of the four teams from Newfoundland and Labrador, eg, the team from Labrador-Grenfell Health drew on the work from Western Health to develop a diabetes registry and enhance skills and educate clinicians in diabetes SMS.17The role of the Atlantic CEOs is important to continuing the QI initiated through the AHC. While CFHI continued to support teams with additional resources , this cannot replace the need for local leadership to continue to support teams and maintaining a view on common priorities.The AHC demonstrates an approach to leading a pan-regional QIC with a multi-dimensional design, specifically one that encourages multiple levels of the health system to work collaboratively toward CDM. Executive-level commitment and active involvement in supporting local QIC efforts is essential; Initiatives drawn from organizational and regional strategic priorities had the support necessary from senior leadership and policy-makers to create momentum to achieve early success.18 Health systems across Canada are no exception, where changes and improvement appear relatively slow and inadequately transformative.19 These systems may be in a state of “paradigm freeze,” unable to move past their structural limitations.20 Policy uncertainties and persistent dysfunctions drive systems to look for alternative strategies to achieve improvement besides reorganization or restructuring. The AHC offers an alternative approach, with the focus on building problem-solving and QI capacities within the health system, creating an enabling context for change, nurturing recognition and distributed capacities as well as a mix of bottom-up (provider- and patient-driven) dynamic with top-down (leadership) guidance and support.It is arguably difficult to transform public health systems to be high-performing and sustainable due to increased demands, limited resources and structural inertia.We thank the members of the Atlantic Healthcare Collaboration’s Executive Committee for their valuable contributions and support. Thanks as well to all CFHI staff involved in leading and managing the AHC, including the Medavie Health Foundation, Dartmouth, NS, Canada and Health Association Nova Scotia, Bedford, NS, Canada.Not applicable.Authors declare that they have no competing interests.All authors contributed equally to the writing of this paper.1Canadian Foundation for Healthcare Improvement, Ottawa, ON, Canada. 2Canada Research Chair on Governance and Transformation in Health Care Organizations and Systems, Université de Montréal-CRCHUM, Montreal, QC, Canada. 3Health Prince Edward Island, Charlottetown, PE, Canada. 4Canadian Patient Safety Institute, Ottawa, ON, Canada.


This commentary discusses the information needs of family caregivers and care recipients in the United States. Health sciences library services and outreach activities that support family caregivers include: (1) advocacy, (2) resource building, and (3) programming and education. Ethical issues related to the privacy and confidentiality of clients are outlined in the commentary for information service providers. Also, continuing professional education resources are identified to assist librarians in providing high-quality information services for this special family caregiver population, such as those designed by the National Library of Medicine (NLM) through the NLM 4 Caregivers program. Supporting the health information needs of individuals and families, including underserved special populations, is one of the primary competencies of health sciences librarians identified in the 2017 Medical Library Association (MLA) competency and professional success guidelines [Unpaid Eldercare in the United States, points to the large number of US family caregivers. Of the total US civilian population in 2015–2016, 41.3 million people over 14 years of age (16%) provided unpaid eldercare [A recent report from the Bureau of Labor Statistics, Family caregivers provide informal and unpaid support to adults who are patients suffering from intellectual or developmental disabilities, chronic diseases, or cognitive impairment. At the same time that caregivers are assisting a spouse, parent, sibling, or special needs adult with activities of daily living; providing nursing care; and serving as “information proxies” , they alIn contrast to the challenges and negative media images associated with caregiving, current research shows that family caregivers receive many positive benefits from their unpaid caregiving responsibilities. As Brown and Brown  and AndeDirect services to family caregivers are generally seen to be the domain of social workers, health care professionals, and government agencies such as county area agencies on aging or state departments of public aid. Yet, health sciences librarians have an opportunity for important outreach to family caregivers by collaborating with other health care professionals and community agencies. Innovative medical library partnerships with community agencies that directly serve family caregivers and care recipients establish libraries as change agents and enable librarians to transform the lives of family caregivers and their loved ones through advocacy, education, public programming, and resource-building of easily accessible in-house library and online resources.As NAC and AARP reported in 2015, the economic value of informal caregiving services provided by over 40 million US family caregivers was $470 billion annually, with 40% of caregivers unemployed and faced with financial shortfalls . Levy, aThe Centers for Disease and Control and Prevention report that family caregivers will be in short supply by 2030, with only four potential family caregivers per adult, as compared to seven potential caregivers in 2016. This caregiving shortage is due to the doubling of the number of people aged sixty-five and older between 2000 and 2030. By 2030, all baby boomers will be at least sixty-five years or older, totaling seventy-one million Americans . Based oWhat can health sciences librarians, who are employed in a variety of work organizations, do to establish effective library services and programs to support the health information literacy, resourcefulness, and resilience of the diverse family caregivers? This commentary offers recommendations, strategies, and a call to service for health sciences library decision-makers and librarians who plan and implement community outreach services and establish health promotion partnerships with local community agencies, government officials, and employers. Three strategies are recommended for developing health sciences library outreach services to family caregivers.Health sciences libraries can offer public programs that introduce current legislation, public policy, and budget priorities at the federal, state, and local levels that support basic resources for diverse family caregivers and their families. Speakers can be invited from local organizations such as AARP, the League of Women Voters, the Urban League, area agencies on aging, or city, county, and state governments to discuss topics such as the following.Introduced on July 27, 2017, by Representatives Michelle Lujan Grisham (NM) and Ileana Ros-Lehtinen (FL), the Care Corps Demonstration Act of 2017 will place volunteers in communities to work with seniors and individuals with disabilities who need extra support to live independently. In exchange, volunteers will receive health insurance and other benefits, such as tuition assistance .The RAISE Family Caregivers Act of 2017 House bill was passed by the Senate on January 9, 2018, and became public law no. 115-119 when signed by President Trump on January 22. This law authorizes the secretary of the Department of Health and Human Services to develop a national strategy to support family caregivers. An advisory agency with representatives from the public and private sectors will be formed to make recommendations and to identify specific actions for government, local communities, employers, and service providers. The intention is to support and recognize family caregivers with recommendations and specific activities updated on an annual basis .The Caring for Credit Act of 2017 was introduced May 17, 2017, by Representatives Tom Reed II (NY) and Linda Sanchez (CA). The bill amends the Internal Revenue Code to allow an eligible caregiver a new tax credit for 30% of the cost of long-term care expenses that exceed $2,000, up to $3,000 in a taxable year. The bill defines “eligible caregiver” as an individual who has earned income for the taxable year in excess of $7,500 and pays or incurs expenses for providing care to a spouse or other dependent relative with long-term care needs .Funding for the Medicaid Program (US Centers for Medicare and Medicaid Services) is provided by the states and US federal government for health services to low-income pregnant women and children, the elderly, and disabled individuals . MedicaiThe Family Medical Leave Act (FMLA) entitles eligible employees of covered employers (with fifty or more employees within seventy-miles miles of a work location) to take unpaid, job-protected leave for specified family and medical reasons and guarantees continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave .Health sciences libraries can target family caregivers with high-quality resources by:developing a web page or LibGuide for caregivers with print and online resources available in their libraries;creating a web page to easily navigate local community resources with services targeted to caregivers of seniors and people with disabilities, such as those found on the Transforming Lives and More Network Special Library’s website ;highlighting National Library of Medicine (NLM) health information resources using the NLM 4 Caregivers toolkit ;referring patrons to the National Caregivers Library website with online articles, reports, forms, checklists, and website links ; andconsulting the National Rehabilitation Information Center (NARIC) website for a portable document format (PDF) copy of “Information Resources for Caregiving & Caregivers: Quick Picks from Librarians at NARIC” to share with family caregivers as well as health care and social service professionals .Health sciences librarians can offer outreach programs to support and celebrate the contributions of family caregivers. Excellent examples include:programs for National Family Caregivers Month in November each year with programming tips from Gale Cengage  and the information literacy training programs for family caregiver support groups that are developed by medical librarians ;health education and “self-help” resource fairs similar to the Thriving Families=Healthier Communities program in Broward County, Florida, that highlighted health insurance programs such as Medicare and Medicaid, community services available for older adults and persons with disabilities, legal and financial matters, respite and adult day care, palliative and hospice care, caregiver support groups, and personal care and empowerment ;local community educational programs such as AARP TEK Careversations workshops  and Todathe Caregiver Library Project of Allegheny County’s Human Services/Area Agency on Aging, a pilot program in Pennsylvania initiated with five public libraries that quickly grew into an outreach program of fifty public libraries, offering backpacks containing a variety of information resources for caregivers to check out and take home to review ; andthe Christina Healthcare System  Medical Libraries’ “Healing through Creativity” education program for cancer patients and their families .Both the MLA and American Library Association (ALA) codes of ethics stress that information professionals are responsive and respect the privacy and confidentiality of caregivers and their care recipients. It is especially important that health sciences librarians work collaboratively with physicians and social services professionals at the point of need to supply high-quality and appropriate clinical and consumer health information for family caregivers that reflect patient preferences, needs, literacy levels, and cultural values. Health sciences librarians must deliver health information services that are consistent with Health Insurance Portability and Accountability Act (HIPAA) requirements and design programs that are in line with the patient-centered care model introduced by the Institute of Medicine . AccessiHealth sciences librarians, in supplying health information and education and offering referrals to local community agencies and services, contribute to a patient care plan that eases the transitions, frustrations, and stress that family caregivers and their care recipients experience. As members of the family-centered health care team, librarians empower family caregivers with information for informed and autonomous decision-making. Health sciences library information services and family-centered care values contribute to continuity of care, caregiver well-being, patient comfort, and a high quality of life for patients and their families.It is important that health sciences librarians pursue continuing professional education to expand their professional knowledge of family caregivers and their information needs. Continuing education opportunities include both formal and informal self-directed learning such as: (1) assessing the information needs of caregivers and older adults, (2) conducting or retrieving local community surveys, (3) studying family caregiver education websites and attending caregiver workshops or conferences, and (4) reviewing the library and health sciences literature and general news sources for best practices.Caregiving in the U.S., librarians will easily discover the types of information that caregivers seek. For example, among the 1,087 unpaid family caregivers surveyed, NAC and AARP found that more than 8 out of 10 caregivers (84%) who were providing care to someone 50 years of age or older said that they could use more information or help with caregiving topics in general. Family caregivers most often wanted information about keeping their loved ones safe at home (43%) and managing their own stress (42%). About 1 in 4 caregivers (24%) who were providing care to someone aged 50 and older would like more information about making end-of-life decisions and hospice care. Managing challenging and difficult behaviors was reported as an information need by 16% of caregivers, while a need for information about managing incontinence or toileting problems was indicated by 11% of caregivers.Results of the 2015 family caregiver survey conducted by NAC and AARP pointed to the information needs of family caregivers and the typical problems that they face . By readA local community needs analysis using available public health data sources is an important next step for librarian professional development because the future number of potential family caregivers is staggering, and community-level planning is critical for health sciences library program development . QualitaStudying family caregiver websites can aid in developing and implementing library-based family caregiving education programs. The premiere family caregiver education curriculum is offered by the Rosalynn Carter Institute for Caregiving (RCIC) . This evHealth sciences information professionals can attend local support group meetings and online conferences sponsored by self-help organizations such as AARP, the Alzheimer’s Association, the American Cancer Society, the American Heart Association, the American Diabetes Association, Caregiving.com, NAC, and Today’s Caregiver. Attendance at support group meetings and online conferences builds both knowledge and empathy. More specifically, AARP and the Alzheimer’s Association offer cost-effective training opportunities for librarians. AARP offers Careversations workshops  and the Finally, a review of the professional literature must include PubMed Health  to identFamilies Caring for an Aging America, which analyzes demographics, national policies, health care system improvements, and evidence-based programs projected into the future through 2050 to support families [A complete family caregiving literature review should include the “landmark” report, families . The Pewfamilies . Furtherfamilies  and useffamilies . To stayThis commentary is a call to service for health sciences librarians to provide outreach to family caregivers and their care recipients. This library outreach mission reinforces our professional service role as empathetic and mindful leaders in our workplaces and local communities. Strategies outlined include advocacy for caregiving legislation and public policy, library resource-building, partnership development with public libraries and community agencies, and strengths-based family caregiver training. These cutting-edge library best practices represent the trail-blazing capacity, responsiveness, and innovativeness of health sciences librarians.Receiving emotional support and authoritative information from librarians, who are part of the health care team, uplifts and unleashes the resourcefulness, resilience, and strengths of family caregivers. As proactive members of the health care team, librarians can embrace and honor family caregivers and their care recipients through expanded library outreach and information services. The recommendations for health sciences library outreach services build family caregiver strengths. As discussed by Bailey and Gordon, family empowerment, personhood, problem-solving, and a positive outlook are beneficial outcomes for caregivers, who are fully accepted as part of the patient’s care team and are offered unconditional support and acknowledgment .With our proactive and mindful professional commitment to family caregivers, health sciences librarians can creatively address caregiving challenges, introduce a wide range of practical solutions to address problems, focus mindfully on the present moment, support the establishment of a broad “circle of care” and social safety network, and advance the vision of a better world filled with hope and compassion for family caregivers, their loved ones, their health care teams, our local communities, and ourselves as librarians .


The relationship between the time duration of movement (t(dur)) and related maximum possible power output has been studied and modeled under many conditions. Inspired by the so-called power profiles known for discontinuous endurance sports like cycling, and the critical power concept of Monod and Scherrer, the aim of this study was to evaluate the numerical characteristics of the function between maximum horizontal movement velocity (HSpeed) and t(dur) in soccer. To evaluate this relationship, GPS data from 38 healthy soccer players and 82 game participations (≥30 min active playtime) were used to select maximum HSpeed for 21 distinct t(dur) values  based on moving medians with an incremental t(dur) window-size. As a result, the relationship between HSpeed and Log(t(dur)) appeared reproducibly as a sigmoidal decay function, and could be fitted to a five-parameter equation with upper and lower asymptotes, and an inflection point, power and decrease rate. Thus, the first three parameters described individual characteristics if evaluated using mixed-model analysis. This study shows for the first time the general numerical relationship between t(dur) and HSpeed in soccer games. In contrast to former descriptions that have evaluated speed against power, HSpeed against t(dur) always yields a sigmoidal shape with a new upper asymptote. The evaluated curve fit potentially describes the maximum moving speed of individual players during the game, and allows for concise interpretations of the functional state of team sports athletes. Metabolic, locomotor, and physical performance factors such as maximum sprint speed, endurance, or repeated sprint ability  contribuHowever, uncategorized time-ordered motion data from players of soccer and other team sports are generally chaotic and not obviously interpretable, nor even functionally describable, between repeated samples –8. Thus,Most past efforts to classify sports-related movements have used automated or semi-automated visual video analyses ; thus, fAt present, no distinct and automatically applicable algorithm has been established that can compare the locomotor profiles of individual players during matches. Arbitrary time intervals are currently used to analyze player performance during sports games  , but theonce during a cycling competition. Clustering all maximum power outputs measured by force-sensitive cranks to the specified time domains, individual maximum “power profiles” or envelope-curves were generated, characterizing the individual performances of the related cyclists  from the notions of maximum work and maximum time of work" [lim) is one parameter of several alternative non-linear functions that are all characterized by an asymptotic approximation of power output at [tlim = 0. Since that introduction, intense and diverse discussions have taken place regarding the best numerical interrelationship between power output and time [The relationship between maximum power output and time has been discussed primarily in the field of occupational physiology. At first, Monod and Scherrer proposed the term "of work" . This 'cutput at  or belowutput at  tlim = 0and time , with thand time –50. It tand time ,52.-1), although most of the players reached their metabolic limits. To compensate for this, we tried the weighting by acceleration, which caused interval type variations of HSpeed to be weighted higher. In spite of this, the sigmoidal characteristics of the performance/duration relationship remained the same . The other two parameters of this function, power and decreasing rate, did not vary individually, emphasizing the ubiquitousness of the described curve shape. Further work will be needed to validate the model by the modification of selective parameters over time and after certain types of training.This study shows for the first time empirical proof that the relationship between maximum running speed and ction s.  was suffS1 Appendix(PDF)Click here for additional data file.


Taking performance-enhancing drugs (PEDs) can cause serious and irreversible health consequences, which can ultimately lead to premature death. Some young people may take PEDs without fully understanding the ramifications of their actions or based on the advice from others. The purpose of this systematic review was to identify the main factors that predicted doping among young people. The literature was systematically reviewed using search engines, manually searching specialist journals, and pearl growing. Fifty-two studies, which included 187,288 young people aged between 10 and 21 years of age, 883 parents of adolescent athletes, and 11 adult coaches, who were interviewed regarding young athletes, were included in this review. Nine factors predicted doping among young people: gender; age; sports participation; sport type; psychological variables; entourage; ethnicity; nutritional supplements; and health harming behaviors. In regards to psychological variables, 22 different constructs were associated with doping among young people. Some psychological constructs were negatively associated with doping , whereas other were positively associated with doping . Policy makers and National Anti-Doping Organizations could use these findings to help identify athletes who are more at risk of doping and then expose these individuals to anti-doping education. Based on the current findings, it also appears that education programs should commence at the onset of adolescence or even late childhood, due to the young age in which some individuals start doping. According to the World Anti-Doping Agency's (WADA) most recent guide, doping is defined by the occurrence of at least one or more anti-doping rule violation (ADRV). There are 10 ADRVs, which included: (1) the presence of prohibited substances , or its metabolites or markers within an athlete's sample; (2) use or attempted use of a banned substance or method , (3) evading, failing, or refusing to provide a sample, (4) missing three tests within 12 months, (5) tampering or attempting to tamper with samples, (6) possessing a banned substance or method, (7) trafficking or attempt to traffic banned substances or methods, (8) administering banned substances or attempting to administer banned substances to athletes, (9) assisting or encouraging others to take banned substances, and (10) associating with individuals who are currently banned. ADRVs regularly feature in the media due to high profile cases with famous individual athletes, teams, or national organizations. Most of the cases portrayed in the media involve elite adult athletes, but it would be incorrect to assume that doping occurs exclusively among this population. The European School Survey Project on Alcohol and Other Drugs report ESPAD,  surveyedAddiction (1903 to 2017), Archives of Pediatrics and Adolescent Medicine (2000 to 2017), British Journal of Sports Medicine (1964 to 2017), Clinical Journal of Sports Medicine (1991 to 2017), European Journal of Clinical Pharmacology (1968 to 2017), International Journal of Sport and Exercise Psychology (2003 to 2017), International Journal of Sport Psychology (1994 to 2017), International Journal of Sport of Sports Medicine (1980 to 2017), Journal of Adolescent Health (1980 to 2017), Journal of Applied Sport Psychology (1989 to 2017), Journal of Child and Adolescent Substance Abuse (1990 to 2017), Journal of Clinical Sport Psychology (2007 to 2017), Journal of Drug Education (1971 to 2017), Journal of Drug Issues (1971 to 2017), Journal of Health Psychology, (1996 to 2017), Journal of Science and Medicine in Sport (1998 to 2017), Journal of Sport Behavior (1990 to 2017), Journal of Sport & Exercise Psychology (1979 to 2017), Journal of Sports Sciences (1983 to 2017), Psychology of Sport and Exercise (2000 to 2017), Medicine & Science in Sports & Exercise (1969 to 2017), Performance Enhancement & Health (2012 to 2017), Research Quarterly for Exercise and Sport (2001 to 2017), Scandinavian Journal of Medicine and Science in Sport (1991 to 2017), Sport, Exercise, and Performance Psychology (2011 to 2017), Substance Abuse Treatment, Prevention, and Policy (2006 to 2016), and The Sport Psychologist (1987 to 2017). Finally, all reference lists of included papers were searched, a strategy that is sometimes referred to as Pearl Growing ; and health harming.Thirteen studies reported an incidence of doping among young males and females, and one study explored gender differences in relation to the parents of adolescent athletes  influenced doping. Terney and McLain  found thTeachers and parents were the main source of information regarding supplements and AAS, although parents were less important by the time the students were 17 to 18 years old  and doping. All six studies  were cross-sectional. This represents a limitation of the doping literature, because only an association and not causation can be inferred from cross-sectional research. It should be noted, however, that cross-sectional research is useful at assessing the prevalence of a behavior  among a specific population  also impact upon doping, as do other behaviors such as using NS or the use of illegal drugs. These findings can be used to help identify young people at risk of doping, and many of the psychological factors can be manipulated through psychological interventions, which may help reduce the prevalence of PEDs among young people. Our findings can also inform pro-sport educational programs. Finally, as some people may take PEDs before their 10th birthday, young people should be exposed to anti-doping education before the onset of adolescence.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Treatment for opioid use disorder in the United States evolved in response to changing federal policy and advances in science. Inpatient care began in 1935 with the US Public Health Hospitals in Lexington, Kentucky, and Fort Worth, Texas. Outpatient clinics emerged in the 1960s to provide aftercare. Research advances led to opioid agonist and opioid antagonist therapies. When patients complete opioid withdrawal, return to use is often rapid and frequently deadly. US and international authorities recommend opioid agonist therapy . Opioid antagonist therapy  may also inhibit return to use. Prevention efforts emphasize public and prescriber education, use of prescription drug monitoring programs, and safe medication disposal options. Overdose education and naloxone distribution promote access to rescue medication and reduce opioid overdose fatalities. Opioid use disorder prevention and treatment must embrace evidence-based care and integrate with physical and mental health care. Annual Review of Public Health article by Kolodny et al.  used prescription opioids in the past year, 12.5 million (4.7% of the population) misused prescription opioids, 2 million (0.8% of the population) individuals using prescription opioids met the criteria for diagnosis of an opioid use disorder, and 822,000 received treatment . An estiy et al. .Health Affairs illustrate the challenges of receiving and providing appropriate treatment for opioid use disorder. The patient described his ordeal of withdrawing from long-term opioid use because his physician did not know how to manage his opioid withdrawal  has approved two opioid agonist medications for the treatment of opioid use disorders: methadone (a Schedule II controlled substance and a full opioid agonist) and buprenorphine . All practitioners who prescribe controlled substances are required to register with the Drug Enforcement Administration (DEA). Prescribers who treat opioid use disorder, however, have additional requirements. To dispense methadone for opioid withdrawal management or for long-term care, providers are required to register with the Drug Enforcement Administration (DEA) and supervise patients in a federally licensed opioid treatment program. The opioid treatment program regulations are demanding, and few physicians seek to meet the requirements. To prescribe buprenorphine, practitioners  are required to meet the Substance Abuse and Mental Health Services Administration (SAMHSA) training and experience requirements, be DEA registered and approved, receive a unique DEA identification number, comply with record-keeping requirements, and limit the size of their patient panel.  limits the number of patients with opioid use disorder that a physician is allowed to treat with buprenorphine. The initial regulations limited prescribers’ panels to a maximum of 30 patients, and after a year, prescribers could request an increase to 100 patients. SAMHSA and the Department of Health and Human Services amended regulations in July 2016; eligible providers may now request an increase to 275 patients. The 2016 Comprehensive Addiction Recovery Act (CARA) expanded the practitioners who are authorized to prescribe buprenorphine to include physician assistants and nurse practitioners upon the completion of opioid use disorder treatment training and DEA and SAMHSA registration.Despite the documented efficacy of opioid agonist therapy, public and political skepticism and stigma persist. The 1972 Drug Abuse Office and Treatment Act authorizing SAODAP required the Office to develop non-addictive antagonist medications to treat heroin addiction . Opioid Despite the appeal of an opioid antagonist therapy and the documentation of efficacy, oral naltrexone has poor effectiveness in clinical use because daily dosing is required. A systematic review of 13 randomized controlled trials with 1,158 study participants found that study outcomes among individuals randomized to oral naltrexone were equivalent to outcomes among individuals assigned to placebo or to no medication . To addrn = 11,836) provided outpatient care; 24%  offered residential care for detoxification (n = 954), short-term care , or long-term care ; and 5% (n = 751) were hospitals with specialty detoxification and treatment beds ; some opioid treatment programs also offered buprenorphine (n = 789) and 337 prescribed extended-release naltrexone , an annual census of specialty addiction treatment programs (clinics that rely on private insurance or self-pay are underrepresented), included data from 14,399 facilities; 82%  reported opioids as the primary drug of abuse  , and the proportion of patients reporting primary use of opioids other than heroin increased 75% between 2005 and 2015 compared with a 53% increase in admissions reporting heroin as their primary drug . The 2015 TEDS report included more than 1.5 million total admissions; 34%  . Admissiary drug . About oary drug . Medicaiary drug . Injectiary drug .A primary challenge when addressing opioid use disorder is the difficulty of tapering patients off of opioids and the rate at which individuals return to use. A 1926 report to Britain’s Ministry of Health examined the medical aspects of morphine and heroin addiction and concluded that the prognosis for cure was poor: “Relapse, sooner or later, appears to be the rule and permanent cure the exception” . Similarly, the first annual report from the Lexington Public Health Hospital noted that most voluntary patients left before treatment was completed; data from 1943 documented low rates of abstinence at 6 months post-discharge and noted that individuals assigned to the hospital as a condition of probation (27% abstinent) or parole (31% abstinent) were more likely to be abstinent than voluntary patients (13% abstinent) . CommuniContemporary research continues to find rapid rates of return to use among patients not using opioid agonist or antagonist therapy after withdrawal and cessation of opioids. The Prescription Opioid Addiction Treatment Study recruited prescription opioid users diagnosed with opioid use disorder and seeking treatment. Study participants received a brief buprenorphine stabilization (for 2 weeks) and an opioid taper (for 2 weeks) with 8 weeks of follow-up. Study participants who were unable to taper or returned to use during the follow-up period received an extended buprenorphine stabilization (for 12 weeks) and an opioid taper (4-weeks) with 8 weeks of post-medication follow-up . Few stuNational Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use recommends basing the treatment choice, as with medical decision making for other health conditions, on a shared decision-making process between the patient and clinician that includes the consideration of patient preference, treatment history, and treatment setting, as well as an assessment of the patient’s environment, co-occurring disorders, and the risk of buprenorphine diversion  iversion . Opioid iversion . Internaiversion  recommenethadone .a) a website with tools for patients and practitioners, (b) an annual conference, and (c) opioid-prescribing guidelines . Only a minority of the care models have been tested and validated in clinical trials, and no studies compare the relative effectiveness of the different models  , 94, theNational Drug Control Strategy and included four action steps to reduce prescription opioid misuse (http://www.pdmpassist.org/). The increased availability of unused pills from opioid prescriptions contributes to nonmedical use of opioids, in part because of DEA restrictions on medication disposal or return; DEA regulations were amended in 2014 to permit convenient and environmentally responsible prescription drug disposal programs to help decrease the supply of unused prescription drugs in the home. The ONDCP also sought to provide law enforcement with the tools necessary to eliminate improper prescribing practices.The Office of National Drug Control Policy (ONDCP), the Department of Health and Human Services, and the US Surgeon General developed strategies to address the opioid epidemic. The 2011 Prescription Drug Abuse Prevention Plan expanded on the Obama Administration’s d misuse . A crucid misuse . PDMPs vCDC Guideline for Prescribing Opioids for Chronic Pain  to counteract the respiratory depression associated with opioid overdose in 1971. Use was initially restricted to emergency responders and emergency departments and administered as an intravenous or intramuscular injection. As access to prescription opioids increased in the 1990s and the early decades of the twenty-first century, the need for naloxone rescue increased and community activists began overdose education and naloxone distribution programs. Overdose education teaches participants  to recognize opioid overdose symptoms and to administer naloxone . States Despite having access to evidence-based treatment, persons with opioid use disorder often continue to use opioids. Some European countries and Canadian provinces offer a greater array of treatment and harm-reduction interventions. For patients who are refractory to buprenorphine or methadone treatment and continue to use non-treatment-based opioids, the British Columbia provincial guidelines recommend that patients and physicians consider slow-release oral morphine if prescribed as a once daily witnessed dose . Vancouva) served both inmates and volunteers, (b) were the first allocation of federal funds for specialized drug treatment services, and (c) trained clinicians and investigators to address opioid and other drug use disorders  required group and individual health plans to administer equitable benefits for mental health and substance use disorders as compared with medical/surgical benefits; more restrictive quantitative  and qualitative  limits are prohibited . In theoThe 2010 Patient Protection and Affordable Care Act (ACA) was designed to reduce the number of uninsured persons and create state and federal insurance exchanges through which uninsured individuals could purchase insurance at discounted rates based on income. Tax incentives to the health insurance providers offset the reduced cost of the insurance. The ACA allowed states to expand eligibility for state Medicaid plans and identified benefits for mental health and substance use disorders as essential benefits that must be included in plans offered under the ACA. The ACA promoted integration of care for alcohol and drug use disorders. Observers anticipated that expanded access to health care and health insurance would facilitate entry into treatment for opioid use disorder , 8, 12. In 2015 and 2016, the Centers for Medicare and Medicaid Services (CMS) reduced restrictions on the use of Medicaid to purchase residential services for treatment of opioid use disorder and other substance use disorders. Medicaid has not historically covered residential services in inpatient programs with more than 16 beds for mental health and substance use disorders because the programs were classified as institutions for mental disease (known as the IMD exclusion). A July 2015 letter from the CMS Director to State Medicaid Directors announced an opportunity to apply for a Section 1115 demonstration waiver to redesign state substance use treatment systems . States Two more pieces of federal legislation addressed the opioid epidemic in 2016: the Comprehensive Addiction Recovery Act  (P.L. 114–198) and the 21st Century Cures Act (December 2016) (P.L. 114–255). CARA expanded prevention and public education on opioids and other substance use disorders, enhanced availability of naloxone for law enforcement and other first responders to reverse opioid overdoses, promoted access to opioid agonist and antagonist therapy for incarcerated individuals, authorized physician assistants and nurse practitioners to prescribe buprenorphine, expanded disposal options for unused medications, authorized grants to states for evidence-based opioid treatment and intervention demonstrations, and strengthened state PDMPs . The 21sa) reduction in overdose fatalities, (b) enhancement of treatment for opioid use disorders, and (c) development of nonaddictive medications and interventions for chronic pain (Opioid prevention and treatment efforts in the United States remain constrained and consequently stigmatized by a legacy of federal restrictions, an unwillingness to acknowledge idiopathic addiction, and a lack of science-based interventions for chronic pain. In July 2017, the Director of the National Institutes of Health and the Director of the National Institute on Drug Abuse announced a public/private research partnership to develop medications and technologies in three areas to prevent opioid-related mortality and promote recovery: (nic pain . Over th


In a bid to deliver quality health services in resource-poor settings, mobile health  is increasingly being adopted. The role of mHealth in facilitating evidence-based clinical decision-making through data collection, decision algorithms, and evidence-based guidelines, for example, is established in resource-rich settings. However, the extent to which mobile clinical decision support systems (mCDSS) have been adopted specifically in resource-poor settings such as Africa and the lessons learned about their use in such settings are yet to be established.The aim of this study was to synthesize evidence on the use of mHealth for point-of-care decision support and improved quality of care by health care workers in Africa.A scoping review of 4 peer-reviewed and 1 grey literature databases was conducted. No date limits were applied, but only articles in English language were selected. Using pre-established criteria, 2 reviewers screened articles and extracted data. Articles were analyzed using Microsoft Excel and MAXQDA.We retained 22 articles representing 11 different studies in 7 sub-Saharan African countries. Interventions were mainly in the domain of maternal health and ranged from simple text messaging  to complex multicomponent interventions. Although health workers are generally supportive of mCDSS and perceive them as useful, concerns about increased workload and altered workflow hinder sustainability. Facilitators and barriers to use of mCDSS include technical and infrastructural support, ownership, health system challenges, and training.The use of mCDSS in sub-Saharan Africa is an indication of progress in mHealth, although their effect on quality of service delivery is yet to be fully explored. Lessons learned are useful for informing future research, policy, and practice for technologically supported health care delivery, especially in resource-poor settings. Mobile health , defined as “the provision of health services and information via mobile technologies” , has gaIn poor-resource settings such as Africa, the weak capacity of health systems is further stretched by health worker shortages, leading to the devolution of some service delivery tasks to lower cadre workers such as auxiliary nurses and community health workers. Although task shifting has been recognized for improving efficiency and access to health services, concerns exist whether lower cadre health workers are competent and equipped to effectively handle additional responsibilities . The potIn high-income countries, where the health system landscape is more adapted for technological innovation than in low- and middle-income countries, knowledge on the use of technology for clinical decision-making is advanced -12. A suThe aim of this study therefore was to synthesize available evidence on the use of mobile technology as an interface for improving point-of-care clinical decision-making and the quality of care in Africa.The 5-step framework for conducting scoping reviews as proposed by Arksey and O’Malley  and furtmHealth is differentiated from the broader domain of eHealth, which includes supportive factors for the use of information and communications technology (ICT) in health such as legislation, policies, and standards. This review did not include the use of technology in health beyond mobile devices such as mobile phones, tablet computers including laptops, and personal digital assistants.Health workers are all people engaged in the promotion, protection, or improvement of population health. The World Health Organization’s international classification of health workers  was usedClinical decision-making involves making judgments about care provided in health service settings using information or knowledge, and can be defined as “...a contextual, continuous, and evolving process, where data are gathered, interpreted, and evaluated in order to select an evidence-based choice of action” (p.401 ).We adopt the Institute of Medicines’ definition of quality of care as service delivery that increases the likelihood of desired health outcomes, is aligned to current professional knowledge and is safe, effective, patient-centered, timely, efficient, and equitable . On the A mobile clinical decision support system (mCDSS) in the context of this review therefore refers to any mobile electronic or computerized system that provides evidence-based information, which enhances the ability of health care providers to deliver quality care through the prevention, diagnosis, and management of health conditions. There is sufficient literature on the use of health information from electronic medical records and surveillance data to facilitate administrative decision-making or improve clinical workflow. In this review, we included interventions in which data mining or electronic medical records were not the sole component of clinical decision support.The search syntax see  was deveIn December 2015, we searched the following peer-reviewed databases: PubMed, CINAHL, Web of Science Core Collection, and Cochrane. And, the grey literature electronic database K4Health see .Without applying date limiters, the search targeted English language articles reporting use of mHealth for clinical decision-making in African countries.Relevant articles had to be manually retrieved from the grey literature database  under the thematic heading “decision support.”Weekly email alerts were set for all databases  to allow for additional articles that could emerge between the date of initial search and when the final decision was made on study selection for full reading. Additional articles were therefore assessed for inclusion until March 5, 2016. References were managed using EndNote X7.7 , a software program for managing bibliographies and citations.A total of 1158 articles were identified from running the search. After excluding duplicates, 924 articles were retained, which were screened against predetermined inclusion or exclusion criteria. Both primary and secondary  studies were initially assessed. The reference section of secondary studies was used to identify additional primary studies, such that only relevant primary studies irrespective of study design were represented in the final list of retained studies. Mobile devices were taken to refer to mobile phones, laptops, personal digital assistants, iPads, and wearable devices, excluding ambulatory health units or desktop computers. Decision tools not integrated into a mobile device, for example, use of paper-based guidelines for decision support were also excluded. All cadres of health workers except social workers, support staff, dentists, pharmacists, and psychiatrists were included. Use of mHealth for patient shared decision-making, self-management, treatment adherence, or patient reminders was an exclusion criterion. In addition, selected interventions had to be used at the point of care, therefore excluding store and forward or remote monitoring techniques such as teleconsultation, teledermatology, and computerized provider order entry systems. We excluded nonclinical forms of decision support such as ethical or policy decision-making and managerial or administrative decision-making. Additional exclusion criteria included articles on the sole use of mHealth as a geographic information or surveillance system, or for managing patient records and data capture without an additional clinical decision support component. Finally, articles that generally discussed mHealth use or training on ICT in health with no focus on a specific intervention, were excluded.Supported by multiple discussion meetings, two authors (IOOA and BJAA) applied the inclusion-exclusion criteria on the title and abstract sections of each article, after which 36 articles were selected for full text reading. Where primary reviewers disagreed on inclusion, a third reviewer (MZ) arbitrated. Alongside 3 articles identified from snowballing the reference section of secondary studies and 1 article identified from the weekly alerts, the 36 articles were further assessed for inclusion through full-text reading. Only 22 articles were eventually retained for synthesis and analysis. The stepwise flow is presented in The subsequent stages of the review  are presented in the following subsections.Guided by the review questions, an Excel (version 14.6.6), data charting form was developed and subsequently refined as the papers were read by 2 reviewers. The following information was extracted: general study information including authors, study year, study location, and name of intervention; cadres of health workers targeted; study design and aim; characteristics of the mCDSS; contextual factors of the intervention; expected and reported outcomes of the intervention; descriptive narrative of intervention process and reported facilitators; and barriers to implementation and use of the intervention.After a clear view of the nature of information in the selected articles was obtained, all articles were exported to MAXQDA version 12.2.0 for coding and data management.The 22 articles retained in the review represented 11 different studies: m4Change , DecisioAn overview of each study is presented in Alone or as part of a multicountry study, Tanzania had the most number of studies (n=4) on the use of mHealth for clinical decision support, followed by Ghana and Kenya with two studies each. Interventions focused on different domains of health care but were predominantly used in maternal health (n=4), childhood illnesses such as malaria, pneumonia, and diarrhea (n=3), and chronic conditions such as human immunodeficiency virus, tuberculosis, and hypertension (n=2). Lower cadres of health workers  or nonclinicians  were specifically reported as the target group in the majority of studies. Some studies used broader descriptive terms such as “clinicians” , “health care professionals” , or “health workers” , which could also include community health workers and associate clinicians.Not all studies reported the years of education or clinical experience of the target group. QUALMAT involved associate clinicians having 1-4 years of training, mPneumonia considered users who had up to 2 years of training, and users in the eIMCI had up to 3 years postsecondary school training. Computer literary varied across studies, but most users had no or limited training before the interventions, some of which included training on technology use. Interventions were conducted in either rural  or mixed  settings as in the case of TBTech, ALMANACH, and eIMCI. Where reported, most studies were implemented in primary health care facilities .Studies varied in the type of decision-support; ranging from simple guideline-based two-way (txt2MEDLINE) or one-way  text messaging systems to more complex multifunctional systems, which incorporate patients’ data or decision algorithms .Devices included mobile phones , laptops (QUALMAT) and tablets , or personal digital assistants (eIMCI). With the exception of short messaging service (SMS)–based studies in Kenya  and Botswana (txt2MEDLINE) in which users’ personal phones were used, other interventions provided mobile tools and included features for collection and retrieval of patient data.Three studies incorporated additional components such as tailored motivational quotes , performance-based financial and nonfinancial incentives (QUALMAT study), supervisory feedback (CommCare), and diagnostic tools such as pulse oximeters (mPneumonia). Considering infrastructural challenges, some studies also provided batteries, generators, and solar packs . Local language support was provided in some interventions .P<.001) by about four points (from 13.3 to 17.2) in the quality of antenatal care (ANC) services delivered, although not all components of the 25-item quality score were significantly improved. For example, whereas six indicators including client satisfaction improved significantly at endline, a significant decline was recorded for tetanus toxoid coverage, with five other indicators showing no significant improvement. The Bacis study reported an overall increased compliance with using ANC guidelines (from 85.1% to 89.3%), but this was not statistically significant. However, three of nine specific ANC categories  significantly improved. Similar findings were noted in the larger multicountry QUALMAT study where quality indicators before and after the intervention were mostly not significantly different between intervention and control facilities. Indicators such as history taking, patient monitoring, and total technical performance improved with statistical significance (P<.01) postintervention, but remained below maximum satisfactory scores. Unexpectedly, including performance-based incentives (PBI) to enhance health worker motivation in the QUALMAT study did not improve the quality of care.Although the overall aim of a mCDSS should be to improve service delivery, health outcomes, and quality of care, not all papers assessed these. A few studies reported effects of mCDSS on quality of care and showed significant improvement in only a few quality indicators . The m4Change project reported statistically significant improvement  up to 6 months later . GuideliHealth workers were generally reported to have positive attitudes toward use of mCDSS, expecting it to make their work easier or simpler, improve efficiency and accuracy, and be more reliable . Although not all interventions had this feature, positive attitudes of workers toward mCDSS was linked to their expectation of automatically generated monthly reports, therefore relieving them of this administrative task (CommCare and Basics). mCDSS were additionally perceived to play a supervisory or monitoring role for health workers by ensuring that they followed standard practice. In the one-way SMS guidelines for malaria, the feeling of having an authority figure “looking over ones shoulders” reinforced adherence behavior. The effect of the supervisory feedback component of the CommCare app was not reported.Studies that included a training module such as QUALMAT were also positively judged. Health workers believed that it met their needs for continuous professional development, therefore increasing competence and self-confidence and resulting in a decreased reliance on peers or referral facilities. Although it did not have a training component, similar perceptions were echoed in the DESIRE study where nurses found the app empowering and perceived it as being able to improve quality of care. The mPneumonia study inferred that in addition to the level of experience of target users, availability of resources such as medical supplies and context of use also influenced disposition of health workers to the mCDSS.Against the background of long waiting times and understaffed facilities, SMS interventions were appreciated for being easy and concise. The frequency, length, and timing of messages in the Kenyan study on Text Messaging of Malaria Guidelines were important considerations for health workers. Although three out of every four respondents found the frequency of messages  adequate, a few considered it excessive and noted the risk of it becoming boring or repetitive.Health workers raised concerns about increased time periods needed for navigating decision support systems . Contrary to initial concerns, workflow assessments in QUALMAT showed that use of the mCDSS did not significantly increase overall time taken to deliver ANC compared with nonintervention sites, although certain tasks such as patient registration and physical examination were found to need twice as much time. This was expected since the standard preintervention paper formats had to be maintained during the intervention. It could also mean that adherence behavior had improved due to the intervention. Studies that measured effects of mCDSS compared with paper systems, such as eIMCI, report that the former was faster and easier to use and improved adherence behavior. The usability assessment of the DESIRE study found that whereas initial use of the system was challenging, given time and frequent use, users found it easier and faster (about 5-20 min) compared with standard paper practice (about 3-30 min) and eventually streamlined it into their workflow. Similar findings were reported in piloting the CommCare app. TBTech was interestingly designed such that both paper and electronic systems were integrated and aligned to existing workflow and organizational processes. This meant that the intervention was not perceived as a big deviation from routine processes of health workers, and therefore easily accepted.There were reported experiences of conflict and uncertainty when health workers disagreed with recommendations provided by the tool or felt it limited their ability to think for themselves . This unease was especially prominent for workers with insufficient training, in which case their mind-lines  were not reliable. In such situations, health workers were found to rely on patient reports (client-lines). In other studies, the supportive role of mCDSS was emphasized such that health workers realized that they had the authority to override recommendations of algorithms if they believed a different course of action was more appropriate .mCDSS was reported to play a role in stimulating or improving trust between patients and providers . For example, patients believed that the mobile tablet was communicating instructions to health workers from more specialized clinicians or from tertiary facilities, which boosted their confidence and trust .Compared with paper formats, which patients interpret to indicate lack of knowledge on the part of health workers, mCDSS improved patients’ trust in provider skills, further motivating both parties. An improvement in the technical aspects of care such as physical examination—parts of which may be otherwise skipped—made clients feel attended to and more involved in the care process. Two studies report that use of guidelines or decision algorithms created positive feedback loops whereby more clients were willing to see health workers whose confidence was in turn enhanced . A less positive effect was however reported by some nurses who felt that the tablet decreased effectiveness of patient consultation, such as missing nonverbal cues when concentrating on the tablet (DESIRE).The disposition of health care workers to use mCDSS was not consistent with perceived benefits . For example, although majority of health workers (79-86%) reported that they would use the txt2MEDLINE system daily or weekly, the initial surge in using the system dropped after a few days. Similar but yet unexplained low levels of use were reported in some study sites under the ALMANACH intervention despite high positive attitudes and enthusiasm for the support system. CommCare suspects that drop in reporting rates after the pilot period was due to technical issues or lack of effective monitoring and supervision. Use of unique motivational messages suggests that such strategies could extend the novelty effect and increase chances of long-term adoption .According to eIMCI study, time efficiency of using the device was an indicator of its sustainability for routine use. Users’ level of literacy and familiarity with technological gadgets were also reported to influence sustained use. For example, the Bacis study found that younger computer literate nurses were more enthusiastic and responsive to the intervention than older nurses.Only two interventions presented a cost analysis , whereas the Bacis study reported only total cost of study implementation . Over a 6-month period during which 33,361 text messages were sent to 150 phone numbers, US $19,342 was spent in the Text Messaging of Malaria Guidelines study. Most (45%) of this was used to develop and pretest the service with only 13% of costs going toward actual sending of text messages and monitoring of the system. Under study conditions, cost per additional child correctly managed was US $0.5. In the QUALMAT intervention, installation costs varied widely per country—US $186,000 in Tanzania and US $23,000 in Ghana, 77% and 48% of which was spent on the preoperational phases, respectively. These differences were explained by differing contexts, resources, and expenditures needed in each country. Of note is the conclusion that up to US $1060 was required to train a nurse to use the system for a year and about US $21,000 will be required to install and operate mCDSS for 1 year in a similar rural setting.Poor cellular network coverage and nonfunctional hardware were technical barriers to implementation and use of mCDSS . Programs such as TBTech built on the work process of existing systems such that decision support functions could be maintained even in situations where electricity or the Internet was unavailable. Some designs allow users input and retrieve data even when offline . One study found that by creating informal communities of practice involving peers with prior experience of mHealth, technical challenges were better managed by program managers (DESIRE).In the context of low staffing and high caseloads, the concern that mCDSS would further increase workload was a frequently reported barrier to usage . Most ALMANACH users reported that lack of financial incentives demotivated their use of the system although use of financial incentives in the QUALMAT intervention had no additional effect. Equally important is the role that perceived benefit of mCDSS use plays in facilitating its use. Where it was seen as better than current practice (DESIRE), useful for reporting (CommCare), accessing information (txt2MEDLINE), innovative and relevant to their work , health workers were more favorably disposed to its use.Multiple studies found that investing in initial and refresher training was a key facilitator and motivator for effective use of mCDSS . The need for technical training was higher in older workers (Bacis) with low computer literacy, compared with younger health workers or those who used the system on their personal mobile phones (txt2MEDLINE). Contrarily, another study reported that initial technical difficulties encountered by health workers existed irrespective of sociodemographic and computer literacy levels (ALMANACH).The role of technical and supervisory support from both the project team and formal supervisors was thought to be important in keeping users motivated . Delays between training and program implementation could lead to decreased skill, motivation, and general disposition to the intervention. The perception that decision support algorithms are based on updated best practices from a trusted source  was also reported as a facilitator of use .Multistakeholder engagement and ownership needed to be addressed as early as the design phase and before implementation . Experiences of the QUALMAT team showed that poor ownership by local stakeholders could lead to suboptimal program outcomes despite including incentives.Health system issues such as unavailability of medicines , health commodities, understaffing (ALMANACH), and the ability to trigger the referral chain when needed, served as facilitating or inhibiting factors to evidence-based practice. Taking these into account, implementation of TBTech included supply chain management, provider training on clinical knowledge, hardware purchase, and maintenance and provision of mobile radiology units. Resource barriers included the need for airtime and financial support to maintain the system .mCDSS have been used in a range of 11 interventions in sub-Saharan Africa, with a predominant focus on lower cadre workers, maternal health, and at primary health care level in rural settings.With a few exceptions, most interventions were usability or feasibility pilot studies using small sample sizes.Although individual service delivery components show improvement, existing evidence does not support the ability of mCDSS to improve quality of care or clinical outcomes in sub-Saharan Africa.Use of mCDSS can improve patient-provider relationships through increased trust and confidence in health service delivery.mCDSS may create conflicts in clinical decision-making when expert knowledge of health workers conflicts with recommendations of the expert system.Although health workers are generally enthusiastic about mCDSS use, there are concerns about its effects on increased workload, altered workflow, and technical challenges, which hinder adoption and sustainability in routine care.Facilitators and barriers to use of mCDSS include technical, infrastructural and supervisory support, ownership, and health system constraints.This review synthesized evidence on the use of mobile technology as a clinical decision support system in Africa. Evidence indicates significant support for using mCDSS to improve health worker performance and service delivery specifically within sub-Saharan Africa. However, evidence is insufficient regarding their effects on the quality of care. Key findings are highlighted in Weak study designs, short intervention periods, and small sample sizes may explain this gap, although, even from more robust studies, the link to clinical outcomes is largely lacking . Two stuUnsustained enthusiasm regarding mCDSS use reflects the novelty effect, which in addition to perceived risk or reward can influence technological adoption . High exIn a study on factors that influence decision-making of frontline health workers in Ghana, health workers’ tacit knowledge (mind-lines) was the default mode for clinical decision-making, with guidelines used only when they were easily accessible and simple to use . The risFindings that providers were more engaged in the care process during mCDSS use contradict anecdotal perceptions that interpersonal relationships are decreased with the use of electronic devices. Although inconclusive, whereas these effects on improved patient-provider relationships could be due to improved adherence to standard evidence-based practice, they could also be purely psychological and inflated. Future before-after studies that assess attitudinal and interpersonal changes are therefore needed.There were no additional studies reporting the use of PBI on implementation and use of mCDSS in sub-Saharan Africa. A US study which included financial incentives (US $500-800) to nurses and clinicians over a 6-month period reported that use of the intervention was moderately sustained even after the incentives were stopped . Other sA major concern of policy makers regarding added benefits of adopting mHealth is related to its cost and cost-effectiveness. Although only 2 of the 11 studies reported cost implications, willingness of stakeholders to share costs is important for continuity and sustainability. Studies that made use of personal phones of health workers  utilized an indirect form of cost sharing. Assessment of stakeholders’ willingness-to-pay or cost-sharing models could prompt consideration for scaling-up successful pilot interventions. Evidence points to low-cost implications and higher acceptability with SMS-based mCDSS. A Chinese study found that compared with standard paper formats, text messages were about 280 times cheaper for stimulating guideline use . AlthougClinical decision-making is only one aspect of the continuum of care. Success of using electronic support as a “magic” tool is hampered by other deficiencies in the health system such as not being able to act on recommendations . This maAlthough the evidence in this review spans interventions executed within the last ten years, resources did not allow us to engage in translations of articles in other languages, which implies that we may have excluded some relevant articles from French-speaking countries. Additionally, although we recognized that we may have gained more insight into the different interventions if we had included a consultation stage in the review process , due to The volume of evidence presented on the use of mobile technology as a clinical decision support system in sub-Saharan Africa is an indication of growth in the domain and its potential for improving health service delivery in low-resource settings. Several evidence gaps need to be addressed, including specific mechanisms underlying use, sustainability, and effects of mCDSS on quality of care and their ability to be fully integrated into routine practice. In light of the effect that differences in health worker cadre, training, and intervention context could have on utilization and outcomes of mCDSS, future research should adopt comparative analyses in order to identify for whom these programs work best. It is also needful to understand in what contexts, why, how, and at what costs, mCDSS lead to changes in health worker performance. Although quality of service delivered by these interventions on a clinical and individual level is yet to be fully explored, the evidence gathered is useful for informing future policy, practice, and research.