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Objective: There are few tools capable of measuring the personal recovery of individuals presenting with mental disorders that take into account the various dimensions of recovery. Personal recovery encompasses several objectives at the level of autonomy, positive interpersonal relationships, mental and physical health, self-acceptance, the school/professional domain, as well as developing a life project. A team of practitioners and researchers from four countries (Canada, Belgium, France, and Switzerland) adapted the Client Assessment of Strengths, Interests, and Goals (CASIG) tool to more accurately measure these different aspects of personal recovery. This study aims to validate the revised version of CASIG (CASIG-rev) in French, in terms of construct validity, test-retest reliability, convergent validity, and clinical sensitivity to change., Method: A total of 272 individuals were recruited across different French-speaking countries to respond to the CASIG-rev online, as well as Ryff's well-being measure, the Recovery Assessment Scale, and the WHODAS. A subgroup of 29 individuals responded again to the CASIG-rev after 1 month (for temporal stability), and 24 again at six months (for sensitivity to change)., Results: The confirmatory factor analysis suggests a 5-factor model, very similar to the initially proposed model of 6 factors. Convergent validity was demonstrated between the subscales of tools measuring similar concepts, and test-retest reliability was proven for the majority of scales. The CASIG-rev also appears to be sensitive to clinical or rehabilitation changes, notably at the level of the life project., Conclusion: This study supports the use of the CASIG-rev in French to measure the recovery of individuals presenting with mental disorders, as well as to support practitioners in the evaluation of their programs and interventions. Limitations, as well as the tool's relevance, are presented. An English validation is underway to make the CASIG-rev available in Anglo-Saxon countries.

Objective: To explore the housing trajectory, personal recovery, functional level, and quality of life of clients at discharge and 1 year after completing Projet Réaffiliation Itinérance Santé Mentale (PRISM), a shelter-based mental health and rehabilitation program intended to provide individuals experiencing homelessness and severe mental illness with transition housing and to reconnect them with mental health and social services., Method: Housing status, psychiatric follow-up trajectory, personal recovery (Canadian Personal Recovery Outcome Measure), functional level (Multnomah Community Ability Scale), and quality of life (Lehman Quality of Life Interview) were assessed at program entry, at program discharge and 1 year later., Results: Of the 50 clients who participated in the study from May 31, 2018, to December 31, 2019, 43 completed the program. Of these, 76.7% were discharged to housing modalities and 78% were engaged with psychiatric follow-up at the program's end. Housing stability, defined as residing at the same permanent address since discharge, was achieved for 62.5% of participants at 1-year follow-up. Functional level and quality of life scores improved significantly both at discharge and at 1-year follow-up from baseline., Conclusions: Admission to PRISM helped clients secure long-term stable housing and appropriate psychiatric follow-up. Stable housing was maintained for most clients at 1-year follow-up, and they benefited from sustained functional and quality of life outcomes in long-term follow-up.

It is commonly expected that exotic plants experience reduced herbivory, but experimental evidence for such enemy release is still controversial. One reason for conflicting results might be that community context has rarely been accounted for, although the surrounding plant diversity may moderate enemy release. Here, we tested the effects of focal tree origin and surrounding tree diversity on herbivore abundance and leaf damage in a cross-Atlantic tree-diversity experiment in Canada and Germany. We evaluated six European tree species paired with six North American congeners in both their native and exotic range, expecting lower herbivory for the exotic tree species in each pair at each site. Such reciprocal experiments have long been called for, but have not been realized thus far. In addition to a thorough evaluation of overall enemy release effects, we tested whether enemy release effects changed with the surrounding tree diversity. Herbivore abundance was indeed consistently lower on exotics across all six tree genera (12 comparisons). This effect of exotic status was independent of the continent, phylogenetic relatedness, and surrounding tree diversity. In contrast, leaf damage associated with generalist leaf chewers was consistently higher on North American tree species. Interestingly, several species of European weevils were the most abundant leaf chewers on both continents and the dominant herbivores at the Canadian site. Thus, most observed leaf damage is likely to reflect the effect of generalist herbivores that feed heavily on plant species with which they have not evolved. At the German site, sap suckers were the dominant herbivores and showed a pattern consistent with enemy release. Taken together, the consistently lower herbivory on exotics on both continents is not purely a pattern of enemy release in the strictest sense, but to some degree additionally reflects the susceptibility of native plants to invasive herbivores. In conclusion, our cross-Atlantic study is consistent with the idea that nonnative trees have generally reduced herbivory, regardless of tree community diversity and species identity, but for different reasons depending on the dominant herbivore guild., (© 2023 The Authors. Ecology published by Wiley Periodicals LLC on behalf of The Ecological Society of America.)

Exercise addiction has sparked a growing interest in the scientific and clinical literature, yet this behavioral addiction has mainly been investigated quantitatively, from a positivistic perspective. This article explores the subjective and embodied dimensions of exercise addiction, broadening current conceptions of this emerging, still unofficial mental health category. Building on carnal sociology, and through a thematic analysis of mobile interviews conducted with 17 self-proclaimed "exercise addicts" from Canada, this article examines the interrelations between the embodiment of exercise addiction and the normative social elements at stake in the shaping of the category, providing insights on how exercise is experienced as an addiction. Results show that most participants describe this addiction as "soft" and "positive", highlighting the virtues of exercising. However, their bodily accounts also reveal a suffering body, bringing forth the vices related to excessive exercising. Participants also put in relation the quantifiable and the sensible body, revealing the porous boundaries of this construct: exercise addiction can sometimes be regulatory in certain contexts and counternormative in others. Thus, it appears that "exercise addicts" enact various contemporary normative requirements, which vary from asceticism and body-ideals but also to the phenomenon of social and temporal acceleration. We argue that exercise addiction questions how certain behaviors, deemed potentially problematic, illustrate the tensions and complex articulations between embodying and resisting social normativity., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: The changing landscape of health care has led to the incorporation of powerful new technologies like artificial intelligence (AI) to assist with various services across a hospital. However, despite the potential outcomes that this tool may provide, little work has examined public opinion regarding their use., Objective: In this study, we aim to explore differences between younger versus older Canadians with regard to the level of comfort and perceptions around the adoption and use of AI in health care settings., Methods: Using data from the 2021 Canadian Digital Health Survey (n=12,052), items related to perceptions about the use of AI as well as previous experience and satisfaction with health care were identified. We conducted Mann-Whitney U tests to compare the level of comfort of younger versus older Canadians regarding the use of AI in health care for a variety of purposes. Multinomial logistic regression was used to predict the comfort ratings based on categorical indicators., Results: Younger Canadians had greater knowledge of AI, but older Canadians were more comfortable with AI applied to monitoring and predicting health conditions, decision support, diagnostic imaging, precision medicine, drug and vaccine development, disease monitoring at home, tracking epidemics, and optimizing workflow to save time. Additionally, for older respondents, higher satisfaction led to higher comfort ratings. Only 1 interaction effect was identified between previous experience, satisfaction, and comfort with AI for drug and vaccine development., Conclusions: Older Canadians may be more open to various applications of AI within health care than younger Canadians. High satisfaction may be a critical criterion for comfort with AI, especially for older Canadians. Additionally, in the case of drug and vaccine development, previous experience may be an important moderating factor. We conclude that gaining a greater understanding of the perceptions of all health care users is integral to the implementation and sustainability of new and cutting-edge technologies in health care settings., (©Karin Cinalioglu, Sasha Elbaz, Kerman Sekhon, Chien-Lin Su, Soham Rej, Harmehr Sekhon. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 28.04.2023.)

Introduction: Most existing vaccines require higher or additional doses or adjuvants to provide similar protection for people living with HIV (PLWH) compared with HIV-uninfected individuals. Additional research is necessary to inform COVID-19 vaccine use in PLWH., Methods and Analysis: This multicentred observational Canadian cohort study will enrol 400 PLWH aged > 16 years from Montreal, Ottawa, Toronto and Vancouver. Subpopulations of PLWH of interest will include individuals: (1) >55 years of age; (2) with CD4 counts <350 cells/mm 3 ; (3) with multimorbidity ( > 2 comorbidities) and (4) 'stable' or 'reference' PLWH (CD4 T cells >350 cells/mm 3 , suppressed viral load for > 6 months and < 1 comorbidity). Data for 1000 HIV-negative controls will be obtained via a parallel cohort study (Stop the Spread Ottawa), using similar time points and methods. Participants receiving > 1 COVID-19 vaccine will attend five visits: prevaccination; 1 month following the first vaccine dose; and at 3, 6 and 12 months following the second vaccine dose. The primary end point will be the percentage of PLWH with COVID-19-specific antibodies at 6 months following the second vaccine dose. Humoral and cell-mediated immune responses, and the interplay between T cell phenotypes and inflammatory markers, will be described. Regression techniques will be used to compare COVID-19-specific immune responses to determine whether there are differences between the 'unstable' PLWH group (CD4 <350 cells/mm3), the stable PLWH cohort and the HIV-negative controls, adjusting for factors believed to be associated with immune response. Unadjusted analyses will reveal whether there are differences in driving factors associated with group membership., Ethics and Dissemination: Research ethics boards at all participating institutions have granted ethics approval for this study. Written informed consent will be obtained from all study participants prior to enrolment. The findings will inform the design of future COVID-19 clinical trials, dosing strategies aimed to improve immune responses and guideline development for PLWH., Trial Registration Number: NCT04894448., Competing Interests: Competing interests: The authors declare that they have no competing interests, (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Uptake of the neurotoxicant monomethylmercury (MeHg) from fish and marine mammals continues to present a public health concern in Canada and elsewhere. However, fish and marine mammals are key diet items contributing to food security for some Indigenous populations in Canada. Mercury (Hg) exposure is estimated assuming that 100% of Hg is methylated, that 100% will be absorbed by the consumer and that cooking does not affect MeHg concentrations. Some of these assumptions do not correspond to our current state of knowledge. The aim of this study was to assess the impact of additional variables on Hg exposure equation using probabilistic risk analysis. New variables tested were (1) the proportion of methylated Hg compared to total Hg (pMeHg, %), (2) the relative absorption factor (RAF, %) expressed as bioaccessibility and (3) the mass loss factor (MLF, unitless) that represents the loss of moisture during cooking, known to increase MeHg concentration in fish and mammals. For the new variables, data from literature were used in order to set point estimate values that were further used in the probabilistic risk analysis. Modelling results for both fish and marine mammals indicate that adding these new variables significantly influenced estimates of MeHg exposure (Mood's median test, p < 0.05). This study highlights that the evaluation of exposure to MeHg is sensitive to pMeHg, RAF and MLF, and the inclusion of these variables in risk assessment should be considered with care. Further research is needed to provide better food-dependent, population-specific estimates of RAF and MLF before formal inclusion in exposure estimates.

Forests are projected to undergo dramatic compositional and structural shifts prompted by global changes, such as climatic changes and intensifying natural disturbance regimes. Future uncertainty makes planning for forest management exceptionally difficult, demanding novel approaches to maintain or improve the ability of forest ecosystems to respond and rapidly reorganize after disturbance events. Adopting a landscape perspective in forest management is particularly important in fragmented forest landscapes where both diversity and connectivity play key roles in determining resilience to global change. In this context, network analysis and functional traits combined with ecological dynamic modeling can help evaluate changes in functional response diversity and connectivity within and among forest stands in fragmented landscapes. Here, we coupled ecological dynamic modeling with functional traits analysis and network theory to analyze forested landscapes as an interconnected network of forest patches. We simulated future forest landscape dynamics in a large landscape in southern Quebec, Canada, under a combination of climate, disturbance, and management scenarios. We depicted the landscape as a functional network, assessed changes in future resilience using indicators at multiple spatial scales, and evaluated if current management practices are suitable for maintaining resilience to simulated changes in regimes. Our results show that climate change would promote forest productivity and favor heat-adapted deciduous species. Changes in natural disturbances will likely have negative impacts on native conifers and will drive changes in forest type composition. Climate change negatively impacted all resilience indicators and triggered losses of functional response diversity and connectivity across the landscape with undesirable consequences on the capacity of these forests to adapt to global change. Also, current management strategies failed to promote resilience at different spatial levels, highlighting the need for a more active and thoughtful approach to forest management under global change. Our study demonstrates the usefulness of combining dynamic landscape-scale simulation modeling with network analyses to evaluate the possible impacts of climate change as well as human and natural disturbances on forest resilience under global change., (© 2020 by the Ecological Society of America.)

Since the mid-1990s, the decline of the yellow perch population of Lake Saint-Pierre (hereinafter LSP) in Quebec, Canada has been the subject of several research programs. The combined effect of habitat deterioration, the presence of invasive species, and poor water quality negatively affected the yellow perch population in this lake. In 2013, we sampled yellow perch (larvae, juveniles and adults) at six sites along the St. Lawrence River representing a gradient of increasing human influences from upstream to downstream and measured several biomarkers including retinoid compounds (vitamin A). In the most contaminated sites (LSP, north and south shores), we found that retinoid stores were decreased in all three stages of development. To corroborate these results and to test other biomarkers, we once again sampled yellow perch (adults only) from the same sites. Results from our 2014 and 2015 samplings confirmed that LSP yellow perch appeared to be at a disadvantage compared to fish from upstream populations. Individuals from LSP have lower acetylcholinesterase (AChE) activity as well as lower retinoid levels in liver and plasma. These fish were also marked by lower levels of antioxidants such as lycopene and vitamin E. A discriminant analysis of this set of results confirmed that the yellow perch of the LSP could be easily discriminated from those of the other sites (2014 and 2015) on the basis of liver retinoid and, to a lesser extent, of the liver tocopherol and protein concentration of the muscle, as well as AChE activity and DROH (all-trans-3,4-dehydroretinol) measured in plasma., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objectives: We aimed to develop and internally validate a measure of multimorbidity burden using data from the Canadian Longitudinal Study on Aging (CLSA)., Design: Data from 40 264 CLSA participants (52% men) aged 45-85 years (a mean of 63 years) were analysed. We used logistic regression models to predict overnight hospitalisation in the last 12 months in the development dataset (random two-thirds of the total) and used these to construct 10 multimorbidity indices (5 models, each treated with and without an age interaction term). Thirty-five chronic conditions were considered for inclusion in these models, in addition to age and sex. We assessed predictive and convergent validity for these 10 different multimorbidity indices in the validation dataset (remaining one-third of the total)., Results: The absolute count of chronic conditions plus an interaction with age, displayed strong calibration properties, outperforming other candidate indices. Discrimination was modest for all of the indices that we internally validated, with C-statistics ranging from 0.66 to 0.68. The indices showed weak correlations (ie, convergent validity) with satisfaction with life, functional disability and mental health (absolute Pearson's correlation coefficients ranging from 0.11 to 0.30) but generally moderate correlations with self-rated general health (0.32-0.45)., Conclusions: We investigated alternative methods to measure the multimorbidity burden of individuals, tailored to the CLSA. Our findings show that an absolute count of conditions, along with an age interaction term, has the strongest calibration for overnight hospitalisation in the last 12 months. The utility of an age interaction term in measuring multimorbidity burden may be applicable to the study of chronic disease in cohorts other than the CLSA., Competing Interests: Competing interests: MK reports speaker and advisory fees for Eisai, Elsevier, Sunovion, Novartis, Sage Therapeutics, and UCB, unrestricted educational grants from UCB, and research grants from UCB and Eisai., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This paper presents the phenomenon of stigmatisation among injured immigrant and ethnocultural minority workers experiencing a long-standing disability. Stigmatisation was one of the main findings of our study, the aim of which was to gain insight into the work rehabilitation process in the context of intercultural relations in Quebec. Various categories of stakeholders took part in the study, which sought to describe their experiences and perspectives and to identify the constraints, barriers, facilitators, and specific needs they encounter in terms of intercultural competencies. Methods: A purposive sample of 40 individuals was selected and divided into four groups: workers ( N  = 9), clinicians ( N  = 15), workers' compensation board rehabilitation experts ( N  = 14), and workplace representatives ( N  = 2). Semi-structured interviews were conducted using the critical incident technique, combined with an "explicitation" interviewing technique. Data collection and analysis procedures were based on grounded theory. Results: This study shows that immigrant and ethnocultural minority workers may experience stigmatisation as a cumulative process involving different concomitant parts of their "identity": age, gender, social class, ethnicity, mental health, and occupational injuries. Cumulative stigma may aggravate personal distress and feelings of shame, rejection, and disqualification from full social acceptance. Negative anticipatory judgements made by practitioners may undermine the therapeutic relationship and breach mutual trust and confidence. Conclusions: The phenomenon of stigmatisation is well documented in the sociological and health literature, but studies tend to focus on only one type of stigma at a time. Future research should focus on the cumulative process of stigmatisation specifically affecting immigrant and ethnocultural minority workers and its potentially damaging impact on self-concept, healthcare delivery, rehabilitation interventions, and the return to work.Implications for rehabilitationThe repetition of certain clinical situations with people from certain groups should not lead practitioners to undue generalizations, even if they may sometimes be accurate; these generalizations must always be verified on a case by case basis.Ethnicity and culture, along with other social attributions, should serve as working hypotheses or support tools in health communication, not as hindrances to clinical reasoning.Practitioners should deepen their understanding of the patient's treatment expectations and the support available for rehabilitation in his family and community.Stigma in the context of care is linked to the idea of conforming to the proposed institutional models of care (including expected beliefs, attitudes, and behaviours). Therefore, practitioners should be aware that alleged differences, misunderstanding or disagreements can highlight an asymmetry in practitioner-patient power relationships.Organisations should also promote exchange and reflection on how to adapt their institutional models to avoid asymmetrical power relations.Intercultural training should be promoted at the various organisational levels so that managers, decision-makers, and practitioners share a common knowledge of the challenges of intervention in multi-ethnic settings.

Background: Past research shows that psychosocial stress and distress predict sedentary behavior and physical activity, but few studies focus on pregnant women. Our objective was to analyze relationships between psychosocial stress and distress with sedentary behavior and physical activity among pregnant women in Canada., Methods: We analyzed objectively-measured sedentary behavior and physical activity at 16-18, 24-26, and 32-24 weeks pregnancy in a sociodemographically diverse cohort of 70 women in Montreal, Canada. Participants completed the Perceived Stress Questionnaire and wore an accelerometer for 3 days that quantified sitting time and steps per day. We used univariate general linear models to analyze relationships between perceived stress with sedentary behavior and physical activity at each evaluation. To assess generalizability, we analyzed relationships between psychological distress with self-reported leisure-time sedentary behavior and daily energy expenditure in transportation and leisure physical activities among a sample representative of 166,095 women in the Canadian Community Health Survey., Results: In the Montreal cohort, we observed a positive association between perceived stress and sitting time, with small to moderate effect sizes (partial η 2 = 0.08-0.16). We observed negative relationships between perceived stress and steps per day at the first two evaluations only, with small to moderate effect sizes (partial η 2 = 0.08-0.11). Relationships for sedentary behavior were similar in the nationwide sample, but with smaller effect sizes (partial η 2 = 0.02). There were no relationships between distress and physical activity in the nationwide sample., Conclusion: Psychosocial stress represents one risk factor for sedentarity, with relationships evident throughout pregnancy and at the population level. Relationships with physical activity are less consistent, but stress might represent a risk factor for low physical activity in early to mid-pregnancy. Results might guide the development of more comprehensive interventions targeting stress, sedentarity, and physical activity. In particular, integrating psychosocial health into interventions to reduce sedentarity, and including concrete guidelines on sedentary behavior in psychosocial health interventions, might be prioritized.

This study aimed to better understand in situ cumulative effects of anthropogenic stressors on the health of St. Lawrence River (QC, Canada) yellow perch populations using high-throughput transcriptomics and a multi-biological level approach. Fish were collected in the upstream fluvial Lake Saint-François (LSF) with low degree of environmental perturbations; Lake Saint-Louis (LSL) considered having a moderate degree of anthropogenic stressors, and Lake Saint-Pierre (LSP) a sector where the perch population has been severely declining. Morphometric results indicated that fish from the downstream LSP showed lower body condition compared to LSF and LSL. Liver transcriptomic responses were assessed by RNA-sequencing. Two hundred and eighty genes were over-transcribed in LSP perch while 200 genes were under-transcribed compared to LSF and LSL. In LSP fish, genes transcripts related to reproduction, retinol, iron, thyroid hormones, oxidative stress, lipid metabolism and immune functions were among the most abundant suggesting that multiple metabolic and physiological pathways were impacted by environmental stressors at this site. Inhibition of liver superoxide dismutase, catalase and glutathione S-transferase activities were also observed at the cellular level. Overall, identified impacted biological pathways in perch from LSP may help understand the precarious state of this population and identify the factors inhibiting its recovery., (Crown Copyright © 2018. Published by Elsevier Ltd. All rights reserved.)

Ground-level ozone (O 3 ) is a powerful oxidizing agent and a harmful pollutant affecting human health, forests and crops. Estimating O 3 exposure is a challenge because it exhibits complex spatiotemporal patterns. The aim in this study was to provide high-resolution maps (100 × 100 m) of O 3 for the metropolitan area of Montreal, Canada. We assessed the kriging with external drift (KED) model to estimate O 3 concentration by synoptic weather classes for 2010. We compared these results with ordinary kriging (OK), and a simple average of 12 monitoring stations. We also compared the estimates obtained for the 2010 summer with those from a Bayesian maximum entropy (BME) model reported in the literature (Adam-Poupart et al., 2014). The KED model with road and vegetation density as covariates showed good performance for all six synoptic classes (daily R 2 estimates ranging from 0.77 to 0.92 and RMSE from 2.79 to 3.37 ppb). For the summer of 2010, the model using KED demonstrated the best results (R 2 = 0.92; RMSE = 3.14 ppb), followed by the OK model (R 2 = 0.85, RMSE = 4 ppb). Our results showed that errors appear to be substantially reduced with the KED model. This may increase our capacity of linking O 3 levels to health problems by means of improved assessments of ambient exposures. However, future work integrating the temporal dependency in the data is needed to not overstate the performance of the KED model., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Since 2004, the Montreal heat response plan (MHRP) has been developed and implemented on the Island of Montreal to reduce heat-related health effects in the general population. In this paper, we aimed to assess the barriers and facilitators to implementation of the MHRP and evaluate the awareness of key elements of the plan by healthcare professionals and individuals from vulnerable populations., Methods: Data were gathered from monitoring reports and a questionnaire administered to managers of healthcare institutions and healthcare workers in Montreal-area health and social services institutions. Individual interviews and focus groups with healthcare workers and with individuals with schizophrenia or suffering from drug or alcohol dependencies were performed. Data were categorized according to predefined subthemes. Coding matrices were then used to determine the most frequently occurring elements in the subthemes., Results: Our results indicate that actions are progressively implemented each year in the healthcare network. Intensification of surveillance for signs of heat-related illness is the most frequently reported measure. Identification and prioritization of clientele and homecare patients are identified as a challenge, as is ensuring the availability of sufficient personnel during a heat wave. Analysis of practice and awareness in healthcare professionals reveals that preventive measures are known and applied by the personnel. Individuals from vulnerable population groups were not uniformly aware of preventive measures, and consequently, variability was observed in their application., Conclusion: The framework proposed in this study revealed valuable information that can be useful to improve plans aimed at reducing heat-related health effects in the population.

Aim: This article presents a strategy to prevent trauma, support and care for railway personnel who experience critical incidents (CI) on the job, usually fatalities by accident or suicide., Method: We reviewed all publications on CI management, support and care practices in the railway industry, as well as practices in place in Canada (unpublished protocols). Semi structured interviews were conducted with 40 train engineers and conductors involved in CIs and the content was coded and analysed quantitatively., Results: Employees' satisfaction with the help received after the incident varies according to the behaviour of the local manager, company officers and police, the level of compliance with existing company protocols to help them, the presence of unmet expectations for support and care, their perceived competency of clinicians they consulted and the level of trust toward their employers., Conclusion: On the basis of the interview results, the review of existing railway practices and discussions with railway stakeholders, a model protocol was developed for a comprehensive workplace prevention, support and care protocol to reduce the negative impact of railway critical incidents on employees. This protocol includes preventive actions before traumatic events occur, immediate responses at the site of incident, interventions within the first few days after the incident and longer term support and interventions provided by the company and by outsourced experts.