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Background: Community pharmacists are often the most accessible member of the healthcare team to many patients and play a key role in managing their chronic conditions, such as diabetes or heart disease, through expanded pharmacy services like Medication Therapy Management. Despite their accessibility, pharmacy services are often underutilized due, in part, to a lack of adequate reimbursement models for pharmacy services. There is a need for qualitative data to be collected to indicate the full impact of those services and why they are so important in a patient’s healthcare journey. Methods: An online Patient Stories Reporting Tool (PRST) was developed to allow outpatient pharmacists to document their perspectives of select direct patient care encounters that they felt showcased their value. In a pilot test, the PSRT was distributed to pharmacists from a partnering pharmacy organization. Qualitative data was collected, assessed by project team members, and organized by intervention types. For select stories, the otherwise undocumented nuances of delivered services and their impact were considered. Results: Forty-seven stories were reported by 17 pharmacists across 13 practice sites from August 2021 to March 2023. Three types of key interventions delivered were identified including General Patient Education (7 stories), Medication Optimization (20 stories), and Cost Reduction (20 stories). Given the nature and scope of this initial pilot, one story for each of the three most prevalent intervention types was identified as exemplifying the types of stories the tool can collect. Conclusions: The three selected stories help to characterize the services pharmacists provide, the important nuances of pharmacist-patient interactions, and the value of sharing these stories through tools like the PSRT. Through these stories, the PSRT also begins to record the nuances of pharmacist interventions and the impact they can make in a patient’s healthcare journey. Potential applications of the tool are multivarious including leading to improvements in the perception of pharmacists’ roles on the healthcare team and justifying reimbursement models.

Introduction: The COVID-19 pandemic disproportionally impacted people experiencing homelessness, including people sleeping rough, people in temporary accommodation and those living in boarding houses. This paper reports on intersectoral responses across six health and social care agencies in Inner Sydney, New South Wales, Australia. Prior to the pandemic the six agencies had established an Intersectoral Homelessness Health Strategy (IHHS), in recognition of the need for intersectoral collaboration to address the complex health needs of people experiencing homelessness. Description: The governance structure of the IHHS provided a platform for several innovative intersectoral responses to the pandemic. A realist informed framework was used to select, describe, and analyse case studies of intersectoral collaboration. Discussion: The resultant six critical success factors (trust, shared ways of working, agile collaboration, communication mechanisms, authorising environment, and sustained momentum), align with the existing literature that explores effective intersectoral collaboration in complex health or social care settings. This paper goes further by describing intersectoral collaboration ‘in action’, setting a strong foundation for future collaborative initiatives. Conclusion: While there is no single right approach to undertaking intersectoral collaboration, which is highly context specific, the six critical success factors identified could be applied to other health issues where dynamic collaboration and integration of healthcare is needed.

With increased availability of disaggregated conflict event data for analysis, there are new and old concerns about bias. All data have biases, which we define as an inclination, prejudice, or directionality to information. In conflict data, there are often perceptions of damaging bias, and skepticism can emanate from several areas, including confidence in whether data collection procedures create systematic omissions, inflations, or misrepresentations. As curators and analysts of large, popular data projects, we are uniquely aware of biases that are present when collecting and using event data. We contend that it is necessary to advance an open and honest discussion about the responsibilities of all stakeholders in the data ecosystem – collectors, researchers, and those interpreting and applying findings – to thoughtfully and transparently reflect on those biases; use data in good faith; and acknowledge limitations. We therefore posit an agenda for data responsibility considering its collection and critical interpretation.

BackgroundWeb-based instruction plays an essential role in health professions education (HPE) by facilitating learners’ interactions with educational content, teachers, peers, and patients when they would not be feasible in person. Within the unsupervised settings where web-based instruction is often delivered, learners must effectively self-regulate their learning to be successful. Effective self-regulation places heavy demands on learners’ motivation, so effective web-based instruction must be designed to instigate and maintain learners’ motivation to learn. Models of motivational design integrate theories of motivation with design strategies intended to create the conditions for motivated engagement. Teachers can use such models to develop their procedural and conceptual knowledge in ways that help them design motivating instruction in messy real-world contexts. Studies such as randomized controlled trials (RCTs) and other quasi-experimental designs that compare different motivational design strategies play a critical role in advancing models of motivational design. Synthesizing the evidence from those studies can identify effective strategies and help teachers and researchers understand the mechanisms governing why strategies work, for whom, and under what circumstances. ObjectiveThe planned review aims to analyze how studies comparing motivational design strategies for web-based instruction in HPE support and advance models of motivational design by (1) controlling for established risks to internal validity, (2) leveraging authentic educational contexts to afford ecological validity, (3) drawing on established theories of motivation, (4) investigating a wide breadth of motivational constructs, and (5) analyzing mediators and moderators of strategy effects. MethodsThe planned review will use database searching, registry searching, and hand searching to identify studies comparing motivational design strategies for web-based instruction, delivered to learners in HPE. Studies will be considered from 1990 onward. Two team members will independently screen studies and extract data from the included studies. During extraction, we will record information on the design characteristics of the studies, the theories of motivation they are informed by, the motivational constructs they target, and the mediators and moderators they consider. ResultsWe have executed our database and registry searches and have begun screening titles and abstracts. ConclusionsBy appraising the characteristics of studies that have focused on the motivational design of web-based instruction in HPE, the planned review will produce recommendations that will ensure impactful programs of future research in this crucial educational space. Trial RegistrationPROSPERO CRD42022359521; https://tinyurl.com/57chuzf6 International Registered Report Identifier (IRRID)DERR1-10.2196/42681

Introduction: The Healthy Homes and Neighbourhoods (HHAN) integrated care initiative was designed to break intergenerational cycles of social and health inequalities and enhance access to and engagement with health and social services for vulnerable families in the Sydney Local Health District. We sought to unearth the initial programme theory of the HHAN initiative to inform rollout to other relevant areas. Methods: We conducted a critical realist evaluation using steps. (1) Exploring the events around the HHAN initiative development. (2) Explore consumer experiences. (3) Identifying the entities and associations characterising the HHAN initiative and related outcomes. (4) Searching for different theoretical perspectives and explanations (abduction). (5) Hypothesising the mechanisms and [context] conditions that might have activated the generation of the HHAN outcomes (retroduction). Results: We identified three central mechanisms; trust, buy-in and motivation, and understanding family dynamics operating across consumer, provider and systems levels of the HHAN initiative. Discussion: These programme theories reveal that to achieve the goals of HHAN, interpersonal dynamics, fostering buy-in and ensuring motivation of both the consumers and care workers should be sought and sustained at all levels. Conclusion: The programme theories unveil that integrated care initiatives should foster positive relationships at all levels to ensure favourable consumer outcomes.

Abstract Background Leptospira are shed into the environment via urine of infected animals. Rivers are thought to be an important risk factor for transmission to humans, though much is unknown about the types of environment or characteristics that favor survival. To address this, we screened for Leptospira DNA in two rivers in rural Ecuador where Leptospirosis is endemic. Results We collected 112 longitudinal samples and recorded pH, temperature, river depth, precipitation, and dissolved oxygen. We also performed a series of three experiments designed to provide insight into Leptospira presence in the soil. In the first soil experiment, we characterized prevalence and co-occurrence of Leptospira with other bacterial taxa in the soil at dispersed sites along the rivers (n = 64). In the second soil experiment, we collected 24 river samples and 48 soil samples at three points along eight transects to compare the likelihood of finding Leptospira in the river and on the shore at different distances from the river. In a third experiment, we tested whether Leptospira presence is associated with soil moisture by collecting 25 soil samples from two different sites. In our river experiment, we found pathogenic Leptospira in only 4 (3.7%) of samples. In contrast, pathogenic Leptospira species were found in 22% of shore soil at dispersed sites, 16.7% of soil samples (compared to 4.2% of river samples) in the transects, and 40% of soil samples to test for associations with soil moisture. Conclusions Our data are limited to two sites in a highly endemic area, but the scarcity of Leptospira DNA in the river is not consistent with the widespread contention of the importance of river water for leptospirosis transmission. While Leptospira may be shed directly into the river, onto the shores, or washed into the river from more remote sites, massive dilution and limited persistence in rivers may reduce the environmental load and therefore, the epidemiological significance of such sources. It is also possible that transmission may occur more frequently on shores where people are liable to be barefoot. Molecular studies that further explore the role of rivers and water bodies in the epidemiology of leptospirosis are needed.

Background: Pharmacists can offer medication expertise to help better control diabetes and cardiovascular disease (CVD) and improve patient outcomes, particularly in rural communities. This project evaluated the impact of an awareness campaign on perceptions of expanded pharmacy services. Methods: The “Your Pharmacists Knows” campaign included a 30-s commercial, print material, and media announcements. A non-randomized pre-post study was completed using a modified theory of planned behavior (mTPB) to assess knowledge, attitude, perceived benefits and norms, and perceived control. A 73-item survey was administered to a convenience sample (n = 172) across South Dakota. Regression models to assess intent and utilization were conducted using age, gender, race, education, population, and insurance status as predictors for mTPB constructs. Results: Most common predictors were female gender and higher education level (p < 0.001). All mTPB constructs were significant predictors of intent to use services (p < 0.001). Knowledge and perceived control had the largest influence on intent. Additionally, there was significant improvement in post-campaign service utilization (p < 0.001). Conclusions: This campaign positively influenced intent to seek and utilize services in rural communities where pharmacies may be the only healthcare option for miles. Through targeted campaigns, patients with diabetes or CVD may find access to services to better manage their conditions.

BackgroundThe early language environment is important for language development and a child’s life-course trajectory. Risk factors associated with poor language development outcomes in children include maternal anxiety and depression, low educational attainment, substance misuse, and low socioeconomic status. Language Environment Analysis (LENA) is a wearable technology designed to promote caregivers’ engagement in supporting their children’s language development. LENA provides quantitative linguistic feedback, which has been shown to improve caregiver language output, thus enhancing a child’s language environment. There is limited research on the uptake of this technology by families with developmentally at-risk children. ObjectiveThis qualitative study aims to explore the conditions under which mothers with children at risk of poor developmental outcomes are willing to adopt the use of LENA to monitor and improve caregiver language output. MethodsUsing a qualitative interpretive design, semistructured, in-depth interviews were conducted with 8 mothers. Participants were recruited purposively to select the maximal variation of socioeconomic and ethnodemographic backgrounds. The transcribed interview data were analyzed thematically and interpretatively. Themes were mapped abductively to an extended Unified Theory of Acceptance and Use of Technology, which included contextual factors for LENA acceptance. ResultsFactors that influenced the intention to use LENA included both technology-specific acceptance factors and contextual factors. Technology acceptance themes included reassurance, feeling overwhelmed, and trust. These themes were mapped to performance expectancy, effort expectancy, and social influence. Contextual themes included emergent success and the intrusion of past difficulties. These were mapped to parenting self-efficacy and perceived risk. The theme of building on success described behavioral intention. Mothers were more likely to adopt LENA when the technology was viewed as acceptable, and this was influenced by parenting self-efficacy and perceived risk. ConclusionsLENA is a technology that is acceptable to mothers with children who are at risk of poor language development outcomes. Further studies are needed to establish LENA’s effectiveness as an adjunct to strategies to enrich a child’s early language environment.

Introduction: Healthy Homes and Neighbourhoods (HHAN), an integrated care programme in the Sydney Local Health District (SLHD), seeks to address the needs of disadvantaged families through care coordination, as one of its components. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, service-providers and partner organisations. Methods: Critical realist methodology was utilised to undertake a qualitative evaluation of the impact of care coordination. Purposive sampling was used to select a total of 37 participants for interview, including consumers, service-providers and key stakeholders. Thematic analysis was undertaken to derive the major modes of intervention of HHAN, and data representing these elements was coded and summarised under contexts, mechanisms and outcomes. Results: Analysis indicates that care coordination has a positive impact on clients’ sense of independence, self-awareness and outlook on life. Trust and favourable interpersonal relations were identified as major underlying mechanisms for a successful client-provider working relationship. The identified modes of intervention facilitating positive consumer outcomes included accessibility, flexibility and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery. Conclusions: This study suggests that a care coordination model may be effective in engaging disadvantaged families in healthcare, assist them in navigating the health system and can lead to beneficial health and social outcomes. Successful implementation of care coordination requires flexible programme design and experienced and skilful clinicians to fulfil the care coordinator role. There is a need to appreciate the negative impact that the complex and siloed health system can have on disadvantaged families.

Introduction: The Healthy Homes and Neighbourhoods (HHAN) Integrated Care Program seeks to enhance vulnerable family engagement with health and social services through a care coordination model. Besides servicing families in Sydney, HHAN has also established place-based initiatives (PBIs) in areas of disadvantage such as Redfern. The Redfern PBI co-locates HHAN with housing, drug and alcohol services, and financial and legal services. This integration aims to facilitate service access and multi-agency support for vulnerable families in Redfern. Hence, this study aims to evaluate for whom, when and why HHAN’s PBI at Redfern works, or not, and what are its outcomes. Methods: The project utilises critical realist methodology to undertake a qualitative evaluation of the impact of the PBI on clients, services and the community. Purposive sampling was used to identify 21 participants including HHAN clients, HHAN staff and stakeholders (HHAN partners). In-depth, semi-structured interviews were audio-recorded, transcribed, coded and analysed using a context (C), intervention (I), mechanism (M) outcome (O) (CIMO) approach to abductive analysis. Results: Five key CIMO configurations of the Redfern PBI emerged – whole-of-family involvement, flexibility, trust, building connections and co-location. Whilst each theory had specific outcomes, overall client outcomes included improved access to services, better outlook, empowerment and engagement with services. Service outcomes included increased collaboration and foundation for integration between HHAN and other services. Negative outcomes included lack of full integration, the risk associated with integration and difficulty evaluating impact. Conclusion: This study successfully refined the program theory for subsequent use in later implementation of critical realist evaluation studies.

Computer models have proven to be useful tools in studying epidemic disease in human populations. Such models are being used by a broader base of researchers, and it has become more important to ensure that descriptions of model construction and data analyses are clear and communicate important features of model structure. Papers describing computer models of infectious disease often lack a clear description of how the data are aggregated and whether or not non-epidemic runs are excluded from analyses. Given that there is no concrete quantitative definition of what constitutes an epidemic within the public health literature, each modeler must decide on a strategy for identifying epidemics during simulation runs. Here, an SEIR model was used to test the effects of how varying the cutoff for considering a run an epidemic changes potential interpretations of simulation outcomes. Varying the cutoff from 0% to 15% of the model population ever infected with the illness generated significant differences in numbers of dead and timing variables. These results are important for those who use models to form public health policy, in which questions of timing or implementation of interventions might be answered using findings from computer simulation models.

Abstract Background Optimal breastfeeding has benefits for the mother-infant dyads. This study investigated the prevalence and determinants of cessation of exclusive breastfeeding (EBF) in the early postnatal period in a culturally and linguistically diverse population in Sydney, New South Wales, Australia. Methods The study used routinely collected perinatal data on all live births in 2014 (N = 17,564) in public health facilities in two Local Health Districts in Sydney, Australia. The prevalence of mother’s breastfeeding intention, skin-to-skin contact, EBF at birth, discharge and early postnatal period (1–4 weeks postnatal) were estimated. Multivariate logistic regression models that adjusted for confounders were conducted to determine association between cessation of EBF in the early postnatal period and socio-demographic, psychosocial and health service factors. Results Most mothers intended to breastfeed (92%), practiced skin-to-skin contact (81%), exclusively breastfed at delivery (90%) and discharge (89%). However, the prevalence of EBF declined (by 27%) at the early postnatal period (62%). Younger mothers (

Introduction: Healthy Homes and Neighbourhoods (HHAN) is a care initiative that seeks to facilitate integration of multiple agencies serving vulnerable families in Sydney Australia. As part of a broader evaluation, we examined the types and quality of interagency relationships involved in HHAN, and perceptions of advantages, disadvantages and levels of support for collaboration. Methods: A purposive sample was drawn from 29 senior managers of agencies affiliated with HHAN who provided responses on behalf of their agency. The term agency indicates work units that may be stand alone or part of a larger organisation. Responses were collected between October 2017 and February 2018 through an online survey, administered at the end of a semi-structured interview that formed part of the larger research project. Respondents reported on relationships between member agencies selecting from: “we send referrals to them”, “we receive referrals from them”, “we share information about clients”, “we work together in other ways”. The quality of each of these relationships were rated on a three-point scale: (1) somewhat trusted; (2) trusted; and, (3) highly trusted. Advantages and disadvantages were presented as statements and respondents were asked to select those that had already happened, were expected to happen, or were not expected to happen. Results: Interactions were explored between selected agencies involved in HHAN (n=20) and 26 additional agencies that were nominated as collaborative partners by respondents (N=46). The General Collaboration network (pooling all types of relationship) had a relatively low density (9.2%). Most common form of collaboration was “works with in other ways.” Most partner relationships were rated as highly trusted. Sociograms of the network will be presented. Executive support for collaboration with other services ranged from medium to very strong indicating a positive perception of top down support. Support for collaboration from staff with direct client interaction was slightly lower. “Ability to serve our clients better” was reported by all respondents as a current benefit of interagency collaboration. The benefit with the most frequent report of not being expected to happen was “acquisition of additional funding or other resources.” Respondents had more varied experience of disadvantages of collaboration. The most common disadvantages selected were: “unreliable partners”, “service and time restraints,” which had been experienced by around 50% of respondents. Discussion: Interagency collaboration clearly benefits families and increases our understanding of population needs by pooling research but there are barriers and costs involved in working together that require careful management. Limitations: Our sample was drawn from a group already working towards greater integration of services. Suggestion for future research: A greater number of respondents, including agencies from outside HHAN would enhance understanding. Conclusion: Enhanced understanding of community and population needs through research and pooling of information across the network of organisations was a clear and valued vision of most respondents. Lessons Learned: While these and other benefits to collaboration were clear, the costs were also apparent. Executive staff should use a strategic approach to collaboration, ensuring goals are articulated and aligned.

An introduction (comprising background and problem statement): The Healthy Homes and Neighbourhoods (HHAN) integrated care program, which started in 2014, was developed to address the complex health and social care needs of vulnerable families, which well exceeds the capacity of the public healthcare system alone. Semi-structured, qualitative interviews took place with senior managers and executive staff from agencies which HHAN considers partners or potential partners. An agency for the purpose of this study could be within a broader organisation. The aim was to determine participant’s definition of interagency collaboration and explore enablers and barriers as viewed by them. Theory/Methods: Recruitment took place by purposive sampling. Twenty-nine invitations to participate were sent by email to participants from 11 organisations. In total, 13 interviews took place, representing 11 agencies from 6 different organisations across health and non-health in the government, non-government and charity sectors. Using a grounded theory method, questions in subsequent interviews were guided by discussions had in prior interviews though strict coherence to the methodology was not achieved nor was saturation of themes. A single coder thematic analysis of interview transcripts using NVIVO software occurred. Results: Achieving efficient, knowledgeable referrals (single client focus) between agencies was the most basic and common definition of collaboration. Collaboration was also considered to include working together on shared projects and strategic planning to advance population health initiatives. Reviewing enablers and barriers being described in the interviews, it became apparent that whether something was being characterised as an enabler or as a barrier was dependent on how the idea was being framed. Discussions: Comparative analysis to selected pre-existing literature will be presented. As well as discussion on how awareness of this literature may have influenced data collection and analysis. Conclusions (comprising key findings): A grouping system of “themes” was developed, as follows: Theme 1: Establishing and maintaining knowledgeable relationships Theme 2: Diversity of roles Theme 3: Business performance Theme 4: Clear directive and supporting infrastructure Theme 5: Organisational expectations Lessons learned: The findings from this research appear to be available in the selected pre-existing literature. This may demonstrate potential barriers exist in understanding how best to apply pre-existing knowledge. Limitations: The scope of this project was too broad to be able to achieve saturation of themes within a realistic time frame or manageable sample size. As well, a single coder reduced rigidity of the study. Suggestions for future research: Another study involves interviewing frontline staff of HHAN. Comparing the key findings of these studies may provide insight into similarities and differences these cohorts hold regarding interagency collaboration.

Introduction: Healthy Homes and Neighbourhoods (HHAN) delivers whole of family care coordination to families in communities of disadvantage in Sydney, Australia. The model of care coordination delivered is contextually-bound, and tailored to the unique characteristics of the local community. Services are delivered from place-based hubs. Evaluation work completed to date indicates that HHAN care coordination contributes to better outcomes and experience of care for enrolled patients. However, the outputs and optimal dosage of care that leads to these positive outcomes is poorly understood. Hence the research question to be addressed is: what is the optimal HHAN care coordination model(s) and what contributes to their effectiveness? Theory/Methods: An explanatory sequential mixed methods approach was used. Approximately 30 medical records of patients enrolled in HHAN care coordination were reviewed to describe the patient journey, including the nature and frequency of contact with the HHAN care coordinators. This included 10 patient records from two place-based hubs and one community health centre. Interviews were conducted with core staff involved in the delivery of HHAN care coordination, including allied health and nursing staff. Staff were asked about their role, what and how they deliver services, and what actions lead to positive outcomes for enrolled families. Results: Similarities in the amount of service events/month were noted for patients receiving care coordination via the place-based hubs, while patients receiving care from the community health centre received more service events/month. Patients receiving care from the place-based hubs had more face-to-face contact with care coordinators, despite receiving less service events/month overall. Themes were identified from interview data across four key areas: the role of the care coordinator; what and how care is delivered; essential components for success; and barriers to success. A similar episode of care with set steps/structures was evident across all sites, implemented by all clinicians, despite there being some variation in delivery across the team. Participants identified “polite persistence” and focus on the development of relationships as crucial to success with patients. Unpredictable, crisis-driven workflow was identified as a barrier to success, as well as differing levels of patient readiness for care. Discussion: This study provides more detailed information about a model of health and social care coordination that has emerged in Sydney, contributing to the wide variety of definitions that exist in the published literature. Whilst the model across sites and between clinicians is perceived to be delivered differently, a set structure with assessment, goal setting, consultation, planning and review phases is evident. This informs the development of a mechanism for governance and monitoring of patient throughput and caseload planning within this team. It may also inform scaling of the model to other regions. Conclusion: This study contributes knowledge to the gap in published literature regarding the practicalities of implementing and model of health and social care coordination, and the definition of such models. Findings may inform activities that improve the quality of services provided by this team by creating a benchmark or guideline for care coordination services. This may improve access to the service for more families.

Introduction: The Healthy Homes and Neighbourhoods (HHAN) integrated care program seeks to enhance vulnerable family access to, and engagement with, health and social services. This is achieved through a care-coordination model and other integrated care activities targeted towards capacity building at the professional and organisational level. The initiative is supported by a multiagency steering committee comprised of representatives from local government and non-government agencies who are responsible for the provision of a range of health, social and education services to the community. This study, conducted early in the HHAN implementation phase, sought to build consensus from service partners and staff on what was working, not working, areas of improvement and training needs of the program to ensure effective service delivery and ultimately better outcomes for families. Methods: A three stage process was undertaken, according to a Delphi method: Stage 1: A representative from 15 HHAN-partnered organisations were interviewed and asked to comment on what was working, not working, areas for improvement and training needs. Staff involved in this project were also interviewed. Interviews were transcribed and thematically analysed. Stage 2: Participants were then asked to rank these themes in order of importance. These responses were analysed, collated and fed back to participants. Stage 3: Participants were then asked to re-rank the most commonly identifies themes in order of importance. Results: What is working: Findings suggest that service delivery is flexible and innovative and consequently allows access to a wider range of services, joint multidisciplinary assessments, ‘soft’ entry points and assertive follow-up. What is not working: Findings suggest that the shift in delivery of services has resulted in tension as organisations adapt to a new professional culture that involves novel information-sharing methods, common language and protocol development, role clarity and change sustainment. Areas for improvement: Findings reflected two major themes: 1. Strengthening adaptive processes by improving access to protocols, promoting a shared vernacular and process and recognising that change causes professional and organisation discomfort; and 2. Improving models of care by encouraging utilisation of a breadth of integrated strategies such as step-down or exit pathways for clients. Training: Findings reflected adaptive processes including additional support, training and supervision, experience in joint planning and case conferencing, and contact with other services. These processes facilitate knowledge of available resources in the health sector. Discussion: This study suggests tension and debate should be expected between and within organisations involved in attempting to integrate care. Novel processes are adopted and organisations are required to adjust to shifting workplace culture. Limitations and suggestions for further research: It is unknown if participants ranked issues based on personal rather than organisational priorities, introducing a source of reporting bias. Involvement of researchers in organisational change may assist in developing a theoretical basis of how individuals and services can be supported to integrate care.

Introduction: In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy. The NSW Government’s Integrated Care Strategy funding enabled the establishment of an integrated care initiative called Healthy Homes and Neighbourhoods (HHAN). The Initiative was designed as a population-based, family-centered, care-coordination network that functioned across agencies to assist vulnerable families to navigate the health and social-care system, to keep themselves and their children safe, and in doing so, promote social cohesiveness. The evaluation framework is described. Methods: Since integrated care initiatives are an example of complex interventions in health and social care, we underpinned this programme of development, research and evaluation by the critical realist metatheory of science and the NSW Health Monitoring and Evaluation Framework, using the UK Medical Research Council (MRC) Framework for evaluating complex interventions.1 We adapted the iterative approach of development, feasibility/piloting, evaluation and implementation of the MRC framework to include critical realist, participatory, continuous and theory driven elements. Discussion: Both the 2008 UK Medical Research Council framework for evaluating complex interventions, and our previously reported critical realist methodology, provided the tools to enable an iterative approach to development, design, testing and continuous evaluation. The philosophical paradigms underpinning each approach are different. Both the NSW Health and MRC frameworks were developed from in the “logical positivist” inductive and deductive reasoning traditions with a strong focus on activities and outcomes but little emphasis on process. That weakness was been recognised and the MRC subsequently endorsed advice on process evaluation for complex interventions which accommodated the realist approach incorporated here. Conclusion: Integrated care initiatives are examples of complex interventions in health and social care. The interventions are multi-layered and operationalization is strongly influenced by both historical and current context. This aspect alone makes it imperative that the methodology used is post-positive and takes ontologically stratified context into account. The NSW Health Monitoring and Evaluation Framework did not make provision for assessment of context or mechanism of effect. We describe here a multilevel approach including a continuous improvement approach through constant comparison and triangulation of mixed method findings. Utilising the MRC framework for evaluating complex interventions within a critical realist methodology, enabled us to study both mechanisms of effect and context. Lessons learned: Evaluation of integrated care interventions will require a pluralist approach to methodology. It is possible to design evaluation approaches that allow study of context, mechanism, reach and efficacy in a complex layered design as used for integrated care initiatives. Limitations: The approach utilised was contrained by the requirements of the policy and funding organisation. We did not fully explore the application of Theory of Change and complexity science within the MRC framework. Suggestions for future research: We recommend that further theoretical and applied research be undertaken to advance the methods and tools available for evaluation of complex multi-layered integrated care initiatives. Reference: 1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655

Background: The integration of system-wide health and social care policies and services has long been seen as the answer to improved efficiency and outcomes for consumers of health and social care services. Recent Government reviews[1] , however, have failed to find substantial evidence that integration lead to better outcomes for patients or financial savings or reduced hospital activity. For example, there was no evidence that the widely population multidisciplinary team approach is unlikely to achieve widespread efficiencies and anticipated outcomes in constrained financial settings. Barriers identified include misaligned financial incentives, workforce challenges and reticence over information sharing. Despite these reservations optimism is widespread that integration and social care can address the challenges facing society with increasing chronic illness, mental illness, disability, homelessness, ageing and marginalised traumatised populations. The answers may not lie with large scale government policies but rather with local initiatives between primary health care, community or 3rd sector providers and hospitals. The challenge advanced by the UK Audit Office as to establish an evidence base for what works in integrating health and social care as a priority. Aims and Objectives: 1- Discuss definitions and scope for Integrating Health and Social Care 2- DIscuss the scope and purpose of an Integrating Health and Social Care Special Interest Group (IHASC SIG) 3- Modify the Scope and Purpose Document for the Integrating Health and Social Care (IHASC SIG) Format: Timing 60 minutes, One Speaker, Group work at tables, Feed back from tables, Discussion and Summation Target Audience: Health, disability, education and social care practitioners and researchers who are interested in aspects of integrated health and social care. Learnings and Takeaway: The participants will learning some of the policy and academic foundations of Integrating Health and Social Care, The workshop will define the scope and purpose of a SIG for Integrating Health and Social Care

Background: Realist philosophy and methodology is increasingly being explicitly used in the field of integrated care to research the extant context, structure and mechanisms at play, and to design and evaluation interventions. Philosophic realism is the view that entities exist independently of our perception or our theories about them. While the realist philosophy underpins much of modern health and social science, it is only recently that this philosophical approach has been popularised within main stream health and social science literature. Realist research methodology is increasingly being described in research areas that are relevant to the study of integrated care, namely, organisational management, information science, social epidemiology, economics, and health services evaluation. Importantly realist approaches are increasingly being used in mixed method research designs and to elucidate the processes at play in experimental and quasi-experimental studies. Realist researchers seek to explain the underlying “cause” or mechanism(s) that generate observed phenomenon. The realist understanding of how the world is (ontology) includes the notion of a hidden or “real” domain where mechanisms generate forces that result in the phenomena which we observe. Realists also view the world as consisting of strata or layers of reality which may interact with other layers to produce new mechanism. This approach is proving useful for studying and developing theory about complex health and social care systems, and then designing and evaluating possible interventions. The methodologies, and the dialectical debates, are complex, and therefore, deserving of special consideration within the Integrated Care community. This workshop will support evaluators and researchers to use realist methods in large scale and complex evaluations. Because realist evaluation (RE) was initially developed using smaller-scale programs, methods need to be modified for large scale programs, while remaining consistent with underlying methodological principles. The workshop will discuss the value of and the dilemmas involved in using realist methods for large and complex programs, and demonstrate strategies to address the dilemmas. Aims and Objectives: 1- Present and discuss the basic tenants of realist research, design and evaluation as it applies to the large scale and complex programs such as integrated care 2- Discuss the scope and purpose of a Realist Research, Design and Evaluation for Integrated Care Special Interest Group (RIC) 3- Modify the scope and purpose of a Realist Research, Design and Evaluation for Integrated Care - SIG Format: Timing 60 minutes, Two speakers, Group Discussion, Summation Target Audience: Integrated care practitioners and researchers who are familiar with realist research including the current focus on critical realism and realist evaluation Learning and Takeaway: The participants will learn some of the philosophical and academic foundations of realist research and evaluation as it applies to the design and evaluation of complex interventions including integrated care The workshop will define the scope and purpose of a SIG for Realist Research, Design and Evaluation for Integrated Care

Background: The integration of system-wide policies and services has long provided the foundation for promoting and protecting the health, development and wellbeing of children, young people and their families. The proverb “it takes a village to raise a child” provides the underlying ethos whereby all members of society work together to raise healthy and resilient children and young people. The United Nations Convention on the Rights of Children and the Sustainable Development Goals (SDGs) provide the global platform to addressing the needs of children young people and families. Building on the SDG goal of achieving universal health coverage, WHO developed a global strategy for people centered and integrated health services, recommending that countries consciously consider the perspectives of individuals, families, and communities, and respond to their preferences and needs. Aims and Objectives: 1- Discuss definitions and scope for Integrating Health and Social Care as it applies to Children, Young People and their Families 2- DIscuss the scope and purpose of a Integrating Care for Children Youth People and Their Families ISpecial Interest Group (IC-CYF SIG) 3- Modify the Scope and Purpose Document for the Integrating Care for Children Youth People and Their Families, Special Interest Group (IC-CYF SIG) Format: Timing 60 minutes, One Speaker, Group work at tables, Feed back from tables, Discussion and Summation Target Audience: Health, education and social care practitioners and researchers who are interested in aspects of integrated health and social care as it applies to children, young people and their families. Learnings and Takeaway: The participants will learning some of the policy and academic foundations of Integrating Care for Children Youth People and Their Families, The workshop will define the scope and purpose of a SIG for Integrating Care for Children Youth People and Their Families.

Introduction: In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy. In response, a family-centred, population-based, integrated care initiative for vulnerable families and their children in Sydney, Australia was developed. The initiative was called 'Healthy Homes and Neighbourhoods'. A realist translational social epidemiology programme of research and collaborative design is at the foundation of its evaluation. Theory and Method: The UK Medical Research Council (MRC) Framework for evaluating complex health interventions was adapted. This has four components, namely 1) development, 2) feasibility/piloting, 3) evaluation and 4) implementation. We adapted the Framework to include: critical realist, theory driven, and continuous improvement approaches. The modified Framework underpins this research and evaluation protocol for 'Healthy Homes and Neighbourhoods'. Discussion: The NSW Health Monitoring and Evaluation Framework did not make provisions for assessment of the programme layers of context, or the effect of programme mechanism at each level. We therefore developed a multilevel approach that uses mixed-method research to examine not only outcomes, but also 'what is working for whom and why'.

BACKGROUND:Leptospirosis is a zoonotic disease responsible for high morbidity around the world, especially in tropical and low income countries. Rats are thought to be the main vector of human leptospirosis in urban settings. However, differences between urban and low-income rural communities provide additional insights into the epidemiology of the disease. METHODOLOGY/PRINCIPAL FINDINGS:Our study was conducted in two low-income rural communities near the coast of Ecuador. We detected and characterized infectious leptospira DNA in a wide variety of samples using new real time quantitative PCR assays and amplicon sequencing. We detected infectious leptospira in a high percentage of febrile patients (14.7%). In contrast to previous studies on leptospirosis risk factors, higher positivity was not found in rats (3.0%) but rather in cows (35.8%) and pigs (21.1%). Six leptospira species were identified (L. borgpetersenii, L kirschnerii, L santarosai, L. interrogans, L noguchii, and an intermediate species within the L. licerasiae and L. wolffii clade) and no significant differences in the species of leptospira present in each animal species was detected (χ2 = 9.89, adj.p-value = 0.27). CONCLUSIONS/SIGNIFICANCE:A large portion of the world's human population lives in low-income, rural communities, however, there is limited information about leptospirosis transmission dynamics in these settings. In these areas, exposure to peridomestic livestock is particularly common and high prevalence of infectious leptospira in cows and pigs suggest that they may be the most important reservoir for human transmission. Genotyping clinical samples show that multiple species of leptospira are involved in human disease. As these genotypes were also detected in samples from a variety of animals, genotype data must be used in conjunction with epidemiological data to provide evidence of transmission and the importance of different potential leptospirosis reservoirs.

Excess proteolytic activity of matrix metalloproteinases (MMPs) contributes to the development of arthritis, cardiovascular diseases and cancer progression, implicating these enzymes as therapeutic targets. While many small molecule inhibitors of MMPs have been developed, clinical uses have been limited, in part by toxicity and off-target effects. Development of the endogenous tissue inhibitors of metalloproteinases (TIMPs) as recombinant biopharmaceuticals represents an alternative therapeutic approach; however, the short plasma half-life of recombinant TIMPs has restricted their potential in this arena. To overcome this limitation, we have modified recombinant human TIMP-1 (rhTIMP-1) by PEGylation on lysine residues. We analyzed a mixture of mono- and di-PEGylated rhTIMP-1 species modified by attachment of 20 kDa mPEG chains (PEG(20K)-TIMP-1), as confirmed by SELDI-TOF mass spectrometry. This preparation retained complete inhibitory activity toward the MMP-3 catalytic domain and partial inhibitory activity toward full length MMP-9. Pharmacokinetic evaluation showed that PEGylation extended the plasma half-life of rhTIMP-1 in mice from 1.1 h to 28 h. In biological assays, PEG(20K)-TIMP-1 inhibited both MMP-dependent cancer cell invasion and tumor cell associated gelatinase activity. Overall these results suggest that PEGylated TIMP-1 exhibits improved potential for development as an anti-cancer recombinant protein therapeutic, and additionally may offer potential for clinical applications in the treatment of other diseases.

Introduction On April 20, 2020, New Jersey (NJ) implemented a comprehensive ban on the sale of flavored e-cigarettes. This study compares sales of e-cigarettes, cigarettes, and cigars before and after the law. Aims and Methods Data were biweekly retailer scanner sales in NJ convenience stores for e-cigarettes, cigarettes, and cigars between August 2019 and December 2020. We used Joinpoint regression to assess sales trends for cigarettes (non-menthol and menthol), cigars (unflavored and flavored), and e-cigarettes (unflavored, fruit or sweet or concept flavor, and menthol flavor) in the 36 weeks before and 36 weeks after a statewide ban on flavored e-cigarettes. Results Flavored e-cigarette sales, not including menthol, significantly decreased over the study period while menthol e-cigarette sales significantly increased until the e-cigarette flavor ban took effect, after which these sales rapidly declined through May 2020, then slowed. Unflavored e-cigarette sales declined through September 2019, then grew modestly until the flavored e-cigarette ban, after which sales significantly increased. Flavored cigar sales increased between March and May 2020, then declined; non-flavored cigar sales increased between mid-February and early July 2020, then declined. Cigarette sales were decreasing before the flavored e-cigarette ban but after, significantly increased until June 2020. Overall, there was no significant trend in the average biweekly percent change for cigarette sales. Conclusions Flavored e-cigarette sales were declining prior to the ban but the pace of the decline accelerated following federal and state restrictions on flavored e-cigarette sales, then slowed by the second half of 2020, with a brief period of increased cigarette and cigar sales immediately following the ban. Implications NJ's 2020 statewide e-cigarette flavor ban offered the opportunity to observe how sales of e-cigarette, cigarette, and cigar products shifted after the change. The effect of the state law, at least in the short-term, was decreased sales of flavored e-cigarettes and increased sales of unflavored e-cigarettes. Research on long-term policy effects is needed. [ABSTRACT FROM AUTHOR]