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Integrated care is a goal of many health care systems. However, operationalizing and implementing integrated care remains challenging especially in continuously evolving policy environments. We report on a policy symposium held in 2017 focused on operationalizing a particular integrated care policy in the context of policy evolution in Ontario, Canada. Forty-five participants attended the symposium including government employees, health care leaders, researchers, clinicians, and patient representatives. The symposium included presentations from representatives of each group and breakout sessions. Two trained observers recorded observational field notes. We report four recommendations and fourteen sub-recommendations which arose regarding the implementation of the policy. We highlight four important tensions which characterize challenges regarding its implementation, and discuss the recommendations in the context of Collaborative Governance. We outline how the recommendations could be strengthened by collaborative governance and identify where this framework could support governance and leadership challenges associated with implementing integrated care. We describe the unique challenges posed by working towards these goals in an evolving policy environment. We draw on collaborative governance to generate insights for leaders implementing integrated care and conclude by addressing the importance of maintaining collaborative governance initiatives under circumstances of unstable policy environments.

While there has been a rapid growth of digital health apps to support chronic diseases, clear standards on how to best evaluate the quality of these evolving tools are absent. This scoping review aims to synthesize the emerging field of mobile health app quality assessment by reviewing criteria used by previous studies to assess the quality of mobile apps for chronic disease management. A literature review was conducted in September 2017 for published studies that use a set of quality criteria to directly evaluate two or more patient-facing apps supporting promote chronic disease management. This resulted in 8182 citations which were reviewed by research team members, resulting in 65 articles for inclusion. An inductive coding schema to synthesize the quality criteria utilized by included articles was developed, with 40 unique quality criteria identified. Of the 43 (66%) articles that reported resources used to support criteria selection, 19 (29%) used clinical guidelines, and 10 (15%) used behavior change theory. The most commonly used criteria included the presence of user engagement or behavior change functions (97%, n  = 63) and technical features of the app such as customizability (20%, n  = 13, while Usability was assessed by 24 studies (36.9%). This study highlights the significant variation in quality criteria employed for the assessment of mobile health apps. Future methods for app evaluation will benefit from approaches that leverage the best evidence regarding the clinical impact and behavior change mechanisms while more directly reflecting patient needs when evaluating the quality of apps.

Background With the growing need for accessible, high-quality mental health services, especially during the COVID-19 pandemic, there has been increasing development and uptake of web-based interventions in the form of self-directed mental health platforms. The Big White Wall (BWW) is a web-based platform for people experiencing mental illness and addiction that offers a range of evidence-based self-directed treatment strategies. Drawing on existing data from a large-scale evaluation of the implementation of BWW in Ontario, Canada (which involved a pragmatic randomized controlled trail with an embedded qualitative process evaluation), we sought to investigate the influences on the extent to which people engage with BWW. Methods In this paper we drew on BWW trial participants’ usage data (number of logins) and the qualitative data from the process evaluation that explored participants’ experiences, engagement with and reactions to BWW. Results Our results showed that there were highly complex relationships between the influences that contributed to the level of engagement with BWW intervention. We found that a) how people expected to benefit from using a platform like BWW was an important indicator of their future usage, b) moderate perceived symptoms were linked with higher engagement; whereas fewer actual depressive symptoms predicted use and anxiety had a positive linear relationship with usage, and that c) usage depended on positive early experiences with the platform. Conclusions Our findings suggest that the nature of engagement with platforms such as BWW is not easily predicted. We propose a theoretical framework for explaining the level of user engagement with BWW that might also be generalizable to other similar platforms.

Over the last three decades, integrated care has emerged as an important health system strategy to improve population health while addressing the unique needs of structurally marginalised communities. However, less attention has been given to the role of integrated care in addressing issues related to inequities in health and health care. In this commentary we introduce the concept of Equity Promoting Integrated Care (EPIC) that situates integrated care in a social justice context to frame the actions necessary to center equity as a priority for integrated care. We suggest that efforts to advance the design and implementation of integrated care should focus on three avenues for future research and practice, namely, the collaborative mobilization of a global network of integrated care stakeholders to advocate for social justice and health equity, investing in equity-focused approaches to implementation science that highlight the importance of social concepts such as colonialism and intersectionality to advance the theory and practice of implementing EPIC models of care, and leveraging innovative approaches to measuring equity-related aspects of integrated care to inform continuous improvement of health systems.

High-income countries face the challenge of providing effective and efficient care to the relatively small proportion of their populations with high health and social care needs. Recent reports suggest that integrated health and social care programs target specific high-needs population segments, coordinate health and social care services to meet their clients' needs, and engage clients and their caregivers. We identified thirty health and social care programs in eleven high-income countries that delivered care in new ways. We used a structured survey to characterize the strategies and activities used by these programs to identify and recruit clients, coordinate care, and engage clients and caregivers. We found that there were some common features in the implementation of these innovations across the eleven countries and some variation related to local context or the clients served by these programs. Researchers could use this structured approach to better characterize the core components of innovative integrated care programs. Policy makers could use this approach to provide a common language for international policy exchange, and this structured characterization of successful programs could play an important role in spreading them and scaling them up.

The rapid virtualization of health services during the COVID-19 pandemic has drawn increasing attention to the impact of virtual care technologies on health equity. In some circumstances, virtual care initiatives have been shown to increase health disparities, as individuals from underserved communities are less likely to benefit from such initiatives. The purpose of this paper is to describe a protocol for a scoping review of reviews that aims to map review-level evidence that describes challenges and strategies for promoting effective engagement with virtual care technologies among underserved communities. Our methodology was adapted from seminal scoping review guidelines provided by Arksey and O'Malley, Levac at al, Colquhoun et al, and the Joanna Briggs Institute. Our search strategy was developed for the following databases: MEDLINE (on Ovid), EMBASE (on Ovid), CINAHL (on EBSCO), Scopus, and Epistemonikos. Supplementary searches will include the use of Google Scholar and reference tracking. Each citation will be independently screened by 2 researchers at the title and abstract level, and full-text screening will be performed in accordance with our eligibility criteria. The eligibility criteria focused on the inclusion of methods-driven reviews (ie, systematic reviews, scoping reviews, meta-analyses, realist reviews, and critical interpretative syntheses) to enhance rigor and quality. Other inclusion criteria included a focus on virtual care services that facilitate bidirectional patient-provider communication (ie, video, telephone, and asynchronous messaging visits) for underserved populations (ie, those who experience social disadvantage due to race, age, income, and other factors related to the social determinants of health). This scoping review of reviews will provide a broad overview of identified challenges associated with the accessibility of virtual health care services among underserved communities. In addition, strategies for improving the access to, uptake of, and engagement with virtual care technologies among underserved communities will be identified. The knowledge synthesized from this review will aid in developing and implementing virtual services that acknowledge the unique needs of populations who experience barriers to care and disproportionately worse health outcomes. The results will also inform gaps in current research. The rapid shift toward virtual health services has highlighted the urgent need to critically examine the intersection of virtual care and health equity. Although technology-driven innovations in health care generally aim to improve access, quality, and health outcomes, it is also possible for these innovations to produce intervention-generated inequities. Assessing current review-level evidence on the key challenges and strategies for improving the application of virtual care in underserved communities is imperative for ensuring that virtual care benefits all populations. PRR1-10.2196/22847.

IntroductionThe murders of Breonna Taylor and George Floyd in 2020 forced institutions to publicly acknowledge systemic racism. In the Canadian healthcare sector, some hospitals used this pivotal moment to create strategic equity plans to address anti-Black racism and ongoing health inequities.MethodsThrough a case study approach, we selected three hospitals in Toronto, Canada and analysed their most recent publicly available diversity, equity and inclusion (DEI) strategic plans.ResultsAll three hospitals released new DEI strategies following 2020 that covered similar grounds: incorporating DEI into HR practices, cultural adaptations of services, race-based data collection and investments in training. While two out of three hospitals reported progress on their anti-Black racism commitments, specific actions to be taken and metrics to monitor and track progress varied.ConclusionsDEI plans analysed are set to reach maturity as early as 2023 and as late as 2025. We provide high level recommendations to guide this work beyond these timelines. Antiracism reform and reconciliation is not a one-time event, but requires thoughtful planning, collaboration with communities, investment in labour (ie, resources and staff), reflection and deep reckoning.

Despite wide acceptance of the legitimacy of Post-Traumatic Stress Disorder (PTSD) as a diagnosis, research remains lacking on treatment options for children. The purpose of this qualitative, case study was to explore and describe the experiences and perceptions of parents whose children have been diagnosed with and treated for PTSD, shedding light on parental perceptions with regard to treatment options for children with PTSD and the efficacy of these treatments for children. The problem was that the lack of research on children diagnosed with PTSD leaves caregivers and practitioners working with children little information to guide the recognition, diagnosis, and treatment of these children. The multiple case study design was used to extract information from focus groups and individual interviews with a convenience sample of 17 parents and guardians of children diagnosed with PTSD. Case study thematic analysis was used with the support of Nvivo11 qualitative analysis software to track coding and location of codes toward identifying themes in the data. The thematic findings serve to expand the current knowledge base on treatment options for children diagnosed with PTSD through gaining an in-depth understanding of specific cases of parents with children suffering from PTSD through describing, exploring, and explaining their experiences and perceptions.

Proboscis length has been proposed as a key dimension of plant pollination niches, but this niche space has not previously been explored at regional and global scales for any pollination system. Hawkmoths are ideal organisms for exploring pollinator niches as they are important pollinators in most of the biodiverse regions of the earth and vary greatly in proboscis length, with some species having the longest proboscides of all insects. Using data sets for nine biogeographical regions spanning the Old and New World, we ask whether it is possible to identify distinct hawkmoth pollination niches based on the frequency distribution of proboscis length, and whether these niches are reflected in the depths of flowers that are pollinated by hawkmoths. We also investigate the levels of specialization in hawkmoth pollination systems at the regional and community level using data from interaction network studies. We found that most regional hawkmoth assemblages have bimodal or multimodal distributions of proboscis length and that these are matched by similar distributions of floral tube lengths. Hawkmoths, particularly those with longer proboscides, are polyphagous and at the network level show foraging specialization equivalent to or less than that of bees and hummingbirds. In the case of plants, shorter-tubed flowers are usually visited by numerous hawkmoth species, while those that are longer-tubed tend to exclude shorter-proboscid hawkmoths and thus become ecologically specialized on longer-proboscid hawkmoth species. Longer-tubed flowers tend to have greater nectar rewards, and this promotes short-term constancy by long-proboscid hawkmoths. Our results show that pollinator proboscis length is a key niche axis for plants and can account for the patterns of evolution in functional traits such as floral tube length and nectar volume. We also highlight a paradoxical trend for nectar resource niche breadth to increase according to proboscis length of pollinators, while pollinator niche breadth decreases according to the tube length of flowers.