Expert consensus on a protocol for conducting bibliometric analysis of scientific articles on global migration health (GMH).

BACKGROUND: Migration and health are key priorities in global health and essential for protecting and promoting the health of migrants. To better understand the existing evidence on migration health, it is critical to map the research publication activity and evidence on the health of migrants and mobile populations. This paper presents a search strategy protocol for a bibliometric analysis of scientific articles on global migration health (GMH), leveraging the expertise of a global network of researchers and academics. The protocol aims to facilitate the mapping of research and evidence on the health of international migrants and their families, including studies on human mobility across international borders. METHODS: A systematic search strategy using Scopus will be developed to map scientific articles on GMH. The search strategy will build upon a previous bibliometric study and will have two main search components: (1) 'international migrant population', covering specific movements across international borders, and (2) 'health'. The final search strategy will be implemented to determine the final set of articles to be screened for the bibliometric analysis. Title and abstract screening will exclude irrelevant articles and classify the relevant articles according to predefined themes and subthemes. A combination of the following approaches will be used in screening: applying full automation (ie, DistillerSR's machine learning tool) and/or semiautomation (ie, EndNote, MS Excel) tools, and manual screening. The relevant articles will be analysed using MS Excel, Biblioshiny and VOSviewer, which creates a visual mapping of the research publication activity around GMH. This protocol is developed in collaboration with academic researchers and policymakers from the Global South, and a network of migration health and research experts, with guidance from a bibliometrics expert. ETHICS AND DISSEMINATION: The protocol will use publicly available data and will not directly involve human participants; an ethics review will not be required. The findings from the bibliometric analysis (and other research that can potentially arise from the protocol) will be disseminated through academic publications, conferences and collaboration with relevant stakeholders to inform policies and interventions aimed at improving the health of international migrants and their families.

Phylogeny and Taxonomic Synopsis of the Genus Bougainvillea (Nyctaginaceae).

Bougainvillea Comm. ex Juss. is one of the renowned genera in the Nyctaginaceae, but despite its recognized horticultural value, the taxonomy and phylogeny of the genus is not well-studied. Phylogenetic reconstructions based on plastid genomes showed that B. pachyphylla and B. peruviana are basal taxa, while B. spinosa is sister to two distinct clades: the predominantly cultivated Bougainvillea clade (B. spectabilis, B. glabra, B. arborea, B. cultivar, B. praecox) and the clade containing wild species of Bougainvillea (B. berberidifolia, B. campanulata, B. infesta, B. modesta, B. luteoalba, B. stipitata, and B. stipitata var. grisebachiana). Early divergence of B. peruviana, B. pachyphylla and B. spinosa is highly supported, thus the previously proposed division of Bougainvillea into two subgenera (Bougainvillea and Tricycla) was not reflected in this study. Morphological analysis also revealed that leaf arrangement, size, and indumentum together with the perianth tube and anthocarp shape and indumentum are important characteristics in differentiating the species of Bougainvillea. In the present study, 11 species and one variety are recognized in Bougainvillea. Six names are newly reduced to synonymy, and lectotypes are designated for 27 names. In addition, a revised identification key and illustrations of the distinguishing parts are also provided in the paper.

Immunisation status of UK-bound refugees between January, 2018, and October, 2019: a retrospective, population-based cross-sectional study.

BACKGROUND: WHO's new Immunization Agenda 2030 places a focus on ensuring migrants and other marginalised groups are offered catch-up vaccinations across the life-course. Yet, it is not known to what extent specific groups, such as refugees, are immunised according to host country schedules, and the implications for policy and practice. We aimed to assess the immunisation coverage of UK-bound refugees undergoing International Organization for Migration (IOM) health assessments through UK resettlement schemes, and calculate risk factors for under-immunisation. METHODS: We undertook a retrospective cross-sectional study of all refugees (children <10 years, adolescents aged 10-19 years, and adults >19 years) in the UK resettlement programme who had at least one migration health assessment conducted by IOM between Jan 1, 2018 and Oct 31, 2019, across 18 countries. Individuals' recorded vaccine coverage was calculated and compared with the UK immunisation schedule and the UK Refugee Technical Instructions. We carried out multivariate logistic regression analyses to assess factors associated with varying immunisation coverage. FINDINGS: Our study included 12 526 refugees of 36 nationalities (median age 17 years [IQR 7-33]; 6147 [49·1%] female; 7955 [63·5%] Syrian nationals). 26 118 vaccine doses were administered by the IOM (most commonly measles, mumps, and rubella [8741 doses]). During the study, 6870 refugees departed for the UK, of whom 5556 (80·9%) had at least one recorded dose of measles-containing vaccine and 5798 (84·4%) had at least one dose of polio vaccine, as per the UK Refugee Technical Instructions, and 1315 (19·1%) had at least one recorded dose of diphtheria-containing vaccine or tetanus-containing vaccine. 764 (11·1%) of refugees were fully aligned with the UK schedule for polio, compared with 2338 (34·0%) for measles and 380 (5·5%) for diphtheria and tetanus. Adults were significantly less likely than children to be in line with the UK immunisation schedule for polio (odds ratio 0·0013, 95% CI 0·0001-0·0052) and measles (0·29, 0·25-0·32). INTERPRETATION: On arrival to the UK, refugees' recorded vaccination coverage is suboptimal and varies by age, nationality, country of health assessment, and by disease, with particularly low coverage reported for diphtheria and tetanus, and among adult refugees. These findings have important implications for the delivery of refugee pre-entry health assessments and catch-up vaccination policy and delivery targeting child, adolescent, and adults migrants in the UK, and other refugee-receiving countries. This research highlights the need for improved data sharing and clearer definition of where responsibilities lie between host countries and health assessment providers. FUNDING: UK National Institute for Health Research (NIHR300072) and Medical Research Council (MR/N013638/1).

Complete chloroplast genome sequence of the Tibetan catnip Nepeta hemsleyana Oliver ex Prain (Lamiaceae).

Nepeta hemsleyana Oliver ex Prain (1891) is one of the aromatic Tibetan herbs used to treat convulsions. In this study, the complete chloroplast genome of N. hemsleyana was analyzed and is presented here for the first time. The assembled genome, 152,171 bp in length, contained a large single-copy region (82,214 bp) and a small single-copy region (17,605 bp) separated by a pair of inverted repeats (25,676 bp). A total of 131 genes were identified, including 86 protein-coding genes, 37 transfer RNA genes, and eight ribosomal RNA genes. The phylogenetic analysis also confirmed the early divergence of N. hemsleyana from other species in subtribe Nepetinae.

The complete chloroplast genome sequence of the Tibetan herb Phlomoides rotata (Benth. ex Hook.f.) Mathiesen (Lamiaceae).

Phlomoides rotata (Benth. ex Hook.f.) Mathiesen is a perennial herb endemic to Qinghai-Tibet Plateau with important medicinal properties. Here, we sequenced and analyzed the complete chloroplast (cp) genome of P. rotata and reconstructed the phylogeny of P. rotata based on 24 cp genomes. The genome of P. rotata is 151,825 bp in length, including a large single-copy (LSC) region of 83,129 bp and a small single-copy (SSC) region of 17,398 bp. A total of 131 genes were identified, of which 86 are protein-coding genes, 37 are transfer RNA genes, and eight are ribosomal RNA genes. Phylogenetic analyses revealed that the species P. rotata is closely related to Phlomoides alpina with bootstrap support (BS) values of 100%. Overall, the genomic resources presented in this study will be beneficial for further studies on evolutionary patterns of P. rotata and its closely related species.

Complete plastid genome characterization and phylogenetic analysis of Pentasachme caudatum Wallich ex Wight (Gentianales: Apocynaceae) from Guangdong, China.

Pentasachme caudatum Wallich ex Wight is considered as one of the Asian enigmatic genera classified in the Asclepiadoideae (Apocynaceae). To determine its evolutionary relationship in the family, we sequenced and characterized the complete chloroplast genome of P. caudatum. The plastid genome of P. caudatum is 158,487 bp in length, containing a large single-copy (90,380 bp), a small single-copy (18,585 bp), and a pair of inverted repeats (24,761 bp). It has 127 annotated genes, consisting of 83 protein-coding, eight rRNA and 36 tRNA genes. Phylogenetic analysis using 76 protein-coding regions of the plastid genomes of related taxa showed that P. caudatum was resolved in a fully supported clade with Orthanthera albida. The newly sequenced P. caudatum provides essential genetic information that is useful for future phylogenetic studies in the family Apocynaceae.

Chloroplast genome organization and phylogeny of Gynochthodes cochinchinensis (DC.) Razafim. & B. Bremer (Rubiaceae).

Gynochthodes cochinchinensis previously known as Morinda cochinchinensis is considered as potential medicinal plant in family Rubiaceae. In this paper, the complete chloroplast genome of G. cochinchinensis was sequenced and characterized for the first time. The cp genome of G. cochinchinensis was 153,022 bp in length containing a large single copy region (83,799 bp), a small single copy region (17,591 bp), and a pair of inverted repeat regions (25,816 bp). It has a total of 131 genes, comprising of 86 protein-coding genes, eight rRNA genes, and 37 tRNA genes. Phylogenetic analysis revealed that Gynochthodes cochinchinensis together with Gynochthodes officinalis were closely related to genus Morinda.

Comparison of a Continuous Noninvasive Temperature to Monitor Core Temperature Measures During Targeted Temperature Management.

BACKGROUND: Temperature modulating devices (TMD) currently utilize core temperature measurements during targeted temperature management (TTM) that are currently limited to esophageal (Et), bladder (Bt), or rectal (Rt) temperatures. We assessed the ability of a continuous noninvasive temperature monitor to accurately approximate core temperature during TTM. METHODS: All patients undergoing TTM using a gel pad surface TMD and an existing core temperature monitoring device were eligible for this study. Core and continuous noninvasive temperature monitoring values were simultaneously recorded for up to 72 h of TTM. The two sets of temperature data were downloaded from a clinical data acquisition storage system at 1-min intervals. The Bland-Altman method assessed agreement between the core and continuous noninvasive temperature monitor values, by measuring the mean difference (± 2 SD) between these values. RESULTS: There were 20 subjects that underwent study between January 2018 and March 2018 (55% women, age: 57 ± 14 years old, BMI: 28.9 + 9.8 kg/m2, 100% mechanically ventilated). The comparison patient temperature source was predominantly esophageal (n = 10) followed by bladder (n = 5) or rectal (n = 5). There were a total of 999 h of paired patient temperature data from esophageal (50%), bladder (25%), and rectal (25%) temperatures. Bland-Altman analysis demonstrated good agreement with the superficial temperature monitor and core temperature measures in all patients overall, with a difference mean of 0.06 ± 0.39 C (P = 0.99) and no proportional bias noted (ß =0.002, P = 0.917). CONCLUSIONS: Continuous noninvasive temperature monitoring is a suitable alternative method for assessing core temperature during TTM. Future studies should focus on developing connectivity with a continuous noninvasive temperature monitor to approximate core temperature during TTM.

Comparative Analysis of Complete Chloroplast Genome Sequences of Wild and Cultivated Bougainvillea (Nyctaginaceae).

Bougainvillea (Nyctaginaceae) is a popular ornamental plant group primarily grown for its striking colorful bracts. However, despite its established horticultural value, limited genomic resources and molecular studies have been reported for this genus. Thus, to address this existing gap, complete chloroplast genomes of four species (Bougainvillea glabra, Bougainvillea peruviana, Bougainvillea pachyphylla, Bougainvillea praecox) and one Bougainvillea cultivar were sequenced and characterized. The Bougainvillea cp genomes range from 153,966 bp to 154,541 bp in length, comprising a large single-copy region (85,159 bp-85,708 bp) and a small single-copy region (18,014 bp-18,078 bp) separated by a pair of inverted repeats (25,377-25,427 bp). All sequenced plastomes have 131 annotated genes, including 86 protein-coding, eight rRNA, and 37 tRNA genes. These five newly sequenced Bougainvillea cp genomes were compared to the Bougainvillea spectabilis cp genome deposited in GeBank. The results showed that all cp genomes have highly similar structures, contents, and organization. They all exhibit quadripartite structures and all have the same numbers of genes and introns. Codon usage, RNA editing sites, and repeat analyses also revealed highly similar results for the six cp genomes. The amino acid leucine has the highest proportion and almost all favored synonymous codons have either an A or U ending. Likewise, out of the 42 predicted RNA sites, most conversions were from serine (S) to leucine (L). The majority of the simple sequence repeats detected were A/T mononucleotides, making the cp genomes A/T-rich. The contractions and expansions of the IR boundaries were very minimal as well, hence contributing very little to the differences in genome size. In addition, sequence variation analyses showed that Bougainvillea cp genomes share nearly identical genomic profiles though several potential barcodes, such as ycf1, ndhF, and rpoA were identified. Higher variation was observed in both B. peruviana and B. pachyphylla cp sequences based on SNPs and indels analysis. Phylogenetic reconstructions further showed that these two species appear to be the basal taxa of Bougainvillea. The rarely cultivated and wild species of Bougainvillea (B. pachyphylla, B. peruviana, B. praecox) diverged earlier than the commonly cultivated species and cultivar (B. spectabilis, B. glabra, B. cv.). Overall, the results of this study provide additional genetic resources that can aid in further phylogenetic and evolutionary studies in Bougainvillea. Moreover, genetic information from this study is potentially useful in identifying Bougainvillea species and cultivars, which is essential for both taxonomic and plant breeding studies.

Characterization of the complete chloroplast genome of Apocynum venetum L. (Apocynaceae).

Apocynum venetum L. (Apocynaceae) or Luobuma is a widely known traditional medicine use to treat hypertension, relieve anxiety, soothe the nerves and promote diuresis. In this study, the complete chloroplast genome of this medicinal plant was determined through Illumina sequencing method. The A. venetum cp genome is 150,897 bp in length, containing a small single copy region (17,256 bp), a large single copy region (81,957 bp), and a pair of IR regions (25,842 bp). It encodes for a total of 131 genes, including 86 protein-coding genes, 8 rRNA genes, and 37 tRNA genes. Phylogenetic analysis also reveals that A. venetum is relatively close to Aganosma cymosa.

Plastome structure and phylogeny of Gnetum luofuense C.Y. Cheng (Gnetaceae, Gnetales).

This article describes the complete chloroplast genome of Gnetum luofuense. The G. luofense plastome was 114,795 bp in length, containing a large single copy region (66,103 bp) and a small single copy region (9438 bp), separated by two inverted repeat regions (19,627 bp). The genome lost all ndh genes and contained 116 genes, including 68 protein-coding genes, 40 tRNA genes, and eight rRNA genes. The GC content was 33.3%, 12 genes all contained an intron, ycf3 gene contained two introns while rps12 was a transpliced gene. Phylogenetic analysis using 61 concatenated protein-coding genes suggests that G. luofuense with the rest of other gnetophytes were sister to or nested within all conifers.

Validation of a questionnaire measuring patient knowledge of atrial fibrillation in an Asian cohort.

BACKGROUND: Poor patient understanding of atrial fibrillation (AF) may contribute to underuse of anticoagulation. There are no validated instruments to measure patient knowledge in Asian cohorts. This study aims to validate a disease-specific questionnaire measuring the level of understanding of AF and its treatment among patients with AF in Singapore. METHODS: A 10-item interviewer-administered questionnaire was created based on previously published questionnaires. Face and content validity were assessed. 165 participants were identified by convenience sampling at cardiology clinics of a tertiary hospital. The questionnaire was administered in either English (n = 53) or Mandarin (n = 112). Exploratory factor analysis was performed using principal component method. Internal consistency was evaluated using Cronbach's alpha coefficient. RESULTS: Face validity was tested by surveying 10 cardiologists who could all identify what the questionnaire was designed to measure. Mean content validity ratio across items was 0.9. Participants were 68.7 (SD 10.5) years old. 55.8% were male. 95.2% were on oral anticoagulation. Kaiser-Meyer-Olkin measure was 0.67 and Bartlett's test of sphericity was significant (p < 0.01). Four factors were retained based on the eigenvalue > 1. These were knowledge of the following: disease characteristics, disease-specific treatment, role of treatment in symptom management and treatment mechanisms. Internal consistency was good (Cronbach's alpha = 0.71). CONCLUSIONS: A questionnaire on the knowledge of AF and its treatment was validated in a cohort of Asian patients in English and Mandarin. It allows quantification of patient knowledge and may be useful in Asian populations to assess the efficacy of interventions to improve patient understanding of AF.

Bilingual Text With or Without Pictograms Improves Elderly Singaporeans' Understanding of Prescription Medication Labels.

BACKGROUND AND OBJECTIVES: In Singapore, primarily English-language prescription medication labels challenge elderly Singaporeans, many of whom are unable to read English. We investigated whether bilingual text and pictograms can help them understand prescription medication labels. RESEARCH DESIGN AND METHODS: We randomized 1,414 elderly respondents of a national survey into four prescription medication labels: English-text; English-text-and-pictograms; Bilingual-text; and Bilingual-text-and-pictograms, which were similar except for the addition of another language and/or pictograms (International Pharmaceutical Federation, FIP). Respondents answered 16 label-related questions; an expert panel rated answers for correctness. Outcomes were (1) complete understanding (16 correct); (2) any understanding (≥1 correct); and (3) number of incorrect answers among those with any understanding. We evaluated associations of each prescription medication label (vs. English-text) with outcomes (1), (2), and (3) using logistic and negative binomial regression, respectively. RESULTS: The elderly respondents were similar across the four prescription medication labels (English-text, English-text-and-pictograms, Bilingual-text, Bilingual-text-and-pictograms), for which the proportions with outcomes (1) and (2) were (17.9%, 25.6%, 36.9%, 40.1%) and (50.4%, 62.6%, 75.9%, 76.5%), respectively. We observed statistically significant higher odds of outcomes (1) and (2) among those assigned the three labels (vs. English-text): English-text-and-pictograms, 1.96 and 2.51; Bilingual-text, 3.54 and 6.73; and Bilingual-text-and-pictograms, 4.51 and 7.93. Those assigned the three labels also had 0.94, 1.98, and 2.12 fewer outcome (3) on average (vs. English-text). DISCUSSION AND IMPLICATIONS: Adding bilingual text with or without pictograms on prescription medication labels considerably improved elderly Singaporeans' understanding of the labels, strongly suggesting its application in practice. Other issues in prescription medication labels design and content, including adapting FIP pictograms for elderly Singaporeans, warrant further investigation.

The Aging of a Young Nation: Population Aging in Singapore.

The juxtaposition of a young city-state showing relative maturity as a rapidly aging society suffuses the population aging narrative in Singapore and places the "little red dot" on the spotlight of international aging. We first describe population aging in Singapore, including the characteristic events that shaped this demographic transition. We then detail the health care and socioeconomic ramifications of the rapid and significant shift to an aging society, followed by an overview of the main aging research areas in Singapore, including selected population-based data sets and the main thrust of leading aging research centers/institutes. After presenting established aging policies and programs, we also discuss current and emerging policy issues surrounding population aging in Singapore. We aim to contribute to the international aging literature by describing Singapore's position and extensive experience in managing the challenges and maximizing the potential of an aging population. We hope that similar graying populations in the region will find the material as a rich source of information and learning opportunities. Ultimately, we aspire to encourage transformative collaborations-locally, regionally, and internationally-and provide valuable insights for policy and practice.

Identification and Measurement of Frailty: A Scoping Review of Published Research from Singapore.

INTRODUCTION: The Asia-Pacific Clinical Guidelines for the Management of Frailty recommended the use of validated measurement tools for identifying frailty. In an effort to contribute to the development of best practice guidelines in frailty identification and measurement, our scoping review aimed to present a summary of published research on this topic among older adults in Singapore. Our findings are important given the need to consider the context of use and the goals of measurement in using validation tools. MATERIALS AND METHODS: We searched PubMed and CINAHL® for articles describing the identification and measurement of frailty among older adults (≥60 years) in Singapore and mined the bibliographies of eligible articles. An article was eligible if it involved empirical research on frailty using a structured frailty definition. We described such articles and the conceptual definitions they used, and summarized their operationalization of frailty. RESULTS: Our search yielded 165 records. After 2-stage screening of titles/abstracts and full-text articles, we retained 32 eligible articles for data extraction and thematic analysis. The extant literature in Singapore includes observational cross-sectional and longitudinal studies and intervention studies across community and tertiary care settings. Eligible articles commonly used the frailty phenotype and the deficit accumulation models in defining frailty, and reported measuring components of physical, cognitive, and/or social frailty. CONCLUSION: Our scoping review provided a broad evidence synthesis of the underpinnings of research on frailty identification and measurement in Singapore. Consistently applying standard methods and approaches in frailty identification and measurement can support evidence-based practice and policies in Singapore.

Esophageal Cooling Device Versus Other Temperature Modulation Devices for Therapeutic Normothermia in Subarachnoid and Intracranial Hemorrhage.

Achieving and maintaining normothermia (NT) after subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) often require temperature modulating devices (TMD). Shivering is a common adverse effect of TMDs that can lead to further costs and complications. We evaluated an esophageal TMD, the EnsoETM (Attune Medical, Chicago, IL), to compare NT performance, shiver burden, and cost of shivering interventions with existing TMDs. Patients with SAH or ICH and refractory fever were treated with the EnsoETM. Patient demographics, temperature data, shiver severity, and amounts and costs of medications used for shiver management were prospectively collected. Controls who received other TMDs were matched for age, gender, and body surface area to EnsoETM recipients, and similar retrospective data were collected. All patients were mechanically ventilated. Fever burden was calculated as areas of curves of time spent above 37.5°C or 38°C. Demographics, temperature data, and costs of EnsoETM recipients were compared with recipients of other TMDs. Eight EnsoETM recipients and 24 controls between October 2015 and November 2016 were analyzed. There were no differences between the two groups in demographics or patient characteristics. No difference was found in temperature at initiation (38.7°C vs. 38.5°C, p = 0.4) and fever burden above 38°C (-0.44°C × hours vs. -0.53°C × hours, p = 0.47). EnsoETM recipients showed a nonsignificant trend in taking longer to achieve NT than other TMDs (5.4 hours vs. 2.9 hours, p = 0.07). EnsoETM recipients required fewer shiver interventions than controls (14 vs. 30, p = 0.02). EnsoETM recipients incurred fewer daily costs than controls ($124.27 vs. $232.76, p = 0.001). The EnsoETM achieved and maintained NT in SAH and ICH patients and was associated with less shivering and lower pharmaceutical costs than other TMDs. Further studies in larger populations are needed to determine the EnsoETM's efficacy in comparison to other TMDs.

Instruments Measuring Integrated Care: A Systematic Review of Measurement Properties.

Policy Points: Investigations on systematic methodologies for measuring integrated care should coincide with the growing interest in this field of research. A systematic review of instruments provides insights into integrated care measurement, including setting the research agenda for validating available instruments and informing the decision to develop new ones. This study is the first systematic review of instruments measuring integrated care with an evidence synthesis of the measurement properties. We found 209 index instruments measuring different constructs related to integrated care; the strength of evidence on the adequacy of the majority of their measurement properties remained largely unassessed. CONTEXT: Integrated care is an important strategy for increasing health system performance. Despite its growing significance, detailed evidence on the measurement properties of integrated care instruments remains vague and limited. Our systematic review aims to provide evidence on the state of the art in measuring integrated care. METHODS: Our comprehensive systematic review framework builds on the Rainbow Model for Integrated Care (RMIC). We searched MEDLINE/PubMed for published articles on the measurement properties of instruments measuring integrated care and identified eligible articles using a standard set of selection criteria. We assessed the methodological quality of every validation study reported using the COSMIN checklist and extracted data on study and instrument characteristics. We also evaluated the measurement properties of each examined instrument per validation study and provided a best evidence synthesis on the adequacy of measurement properties of the index instruments. FINDINGS: From the 300 eligible articles, we assessed the methodological quality of 379 validation studies from which we identified 209 index instruments measuring integrated care constructs. The majority of studies reported on instruments measuring constructs related to care integration (33%) and patient-centered care (49%); fewer studies measured care continuity/comprehensive care (15%) and care coordination/case management (3%). We mapped 84% of the measured constructs to the clinical integration domain of the RMIC, with fewer constructs related to the domains of professional (3.7%), organizational (3.4%), and functional (0.5%) integration. Only 8% of the instruments were mapped to a combination of domains; none were mapped exclusively to the system or normative integration domains. The majority of instruments were administered to either patients (60%) or health care providers (20%). Of the measurement properties, responsiveness (4%), measurement error (7%), and criterion (12%) and cross-cultural validity (14%) were less commonly reported. We found <50% of the validation studies to be of good or excellent quality for any of the measurement properties. Only a minority of index instruments showed strong evidence of positive findings for internal consistency (15%), content validity (19%), and structural validity (7%); with moderate evidence of positive findings for internal consistency (14%) and construct validity (14%). CONCLUSIONS: Our results suggest that the quality of measurement properties of instruments measuring integrated care is in need of improvement with the less-studied constructs and domains to become part of newly developed instruments.

A Prospective Validation Study of a Rainbow Model of Integrated Care Measurement Tool in Singapore.

INTRODUCTION: The conceptual ambiguity of the integrated care concept precludes a full understanding of what constitutes a well-integrated health system, posing a significant challenge in measuring the level of integrated care. Most available measures have been developed from a disease-specific perspective and only measure certain aspects of integrated care. Based on the Rainbow Model of Integrated Care, which provides a detailed description of the complex concept of integrated care, a measurement tool has been developed to assess integrated care within a care system as a whole gathered from healthcare providers' and managerial perspectives. This paper describes the methodology of a study seeking to validate the Rainbow Model of Integrated Care measurement tool within and across the Singapore Regional Health System. The Singapore Regional Health System is a recent national strategy developed to provide a better-integrated health system to deliver seamless and person-focused care to patients through a network of providers within a specified geographical region. METHODS: The validation process includes the assessment of the content of the measure and its psychometric properties. CONCLUSION: If the measure is deemed to be valid, the study will provide the first opportunity to measure integrated care within Singapore Regional Health System with the results allowing insights in making recommendations for improving the Regional Health System and supporting international comparison.

Tobacco use and household expenditures on food, education, and healthcare in low- and middle-income countries: a multilevel analysis.

BACKGROUND: The majority of one billion smokers worldwide live in low- and middle-income countries (LMICs) and the highest proportion of smokers in most of these countries belong to the lower socioeconomic groups. This study aimed to investigate the associations between tobacco use within households and expenditures on food, education, and healthcare in LMICs. METHODS: Using data from the World Health Survey, this cross-sectional study included a sample of 53,625 adult males aged <60 years from 40 LMICs. Multilevel, mixed-effects linear regression was used to determine the association between current tobacco use status of the main income provider (daily; occasional; no use) and three categories of (logged) household expenditures: food, education, and healthcare; controlling for age, level of education, household wealth quintile, marital status, urban-rural setting, country-level income group, and region. RESULTS: In the preferred random-slope models that controlled for covariates, daily tobacco use was associated with lower household expenditures on education and healthcare by 8.0% (95% confidence interval: -12.8 to -3.2%) and 5.5% (-10.7 to -0.3%), respectively. The association between tobacco use and food expenditure was inconsistent across models. CONCLUSIONS: Tobacco use in LMICs may have a negative influence on investment in human capital development. Addressing the tobacco use problem in LMICs could benefit not only the health and economic well-being of smokers and their immediate families but also long-run economic development at a societal level.

Implications of long-term care capacity response policies for an aging population: a simulation analysis.

INTRODUCTION: The demand for long-term care (LTC) services is likely to increase as a population ages. Keeping pace with rising demand for LTC poses a key challenge for health systems and policymakers, who may be slow to scale up capacity. Given that Singapore is likely to face increasing demand for both acute and LTC services, this paper examines the dynamic impact of different LTC capacity response policies, which differ in the amount of time over which LTC capacity is increased, on acute care utilization and the demand for LTC and acute care professionals. METHODS: The modeling methodology of System Dynamics (SD) was applied to create a simplified, aggregate, computer simulation model for policy exploration. This model stimulates the interaction between persons with LTC needs (i.e., elderly individuals aged 65 years and older who have functional limitations that require human assistance) and the capacity of the healthcare system (i.e., acute and LTC services, including community-based and institutional care) to provide care. Because the model is intended for policy exploration, stylized numbers were used as model inputs. To discern policy effects, the model was initialized in a steady state. The steady state was disturbed by doubling the number of people needing LTC over the 30-year simulation time. Under this demand change scenario, the effects of various LTC capacity response policies were studied and sensitivity analyses were performed. RESULTS: Compared to proactive and quick adjustment LTC capacity response policies, slower adjustment LTC capacity response policies (i.e., those for which the time to change LTC capacity is longer) tend to shift care demands to the acute care sector and increase total care needs. CONCLUSIONS: Greater attention to demand in the acute care sector relative to demand for LTC may result in over-building acute care facilities and filling them with individuals whose needs are better suited for LTC. Policymakers must be equally proactive in expanding LTC capacity, lest unsustainable acute care utilization and significant deficits in the number of healthcare professionals arise. Delaying LTC expansion could, for example, lead to increased healthcare expenditure and longer wait lists for LTC and acute care patients.