Changes in socioeconomic resources and mental health after the second COVID-19 wave (2020-2021): a longitudinal study in Switzerland.

BACKGROUND: During the 2020/2021 winter, the labour market was under the impact of the COVID-19 pandemic. Changes in socioeconomic resources during this period could have influenced individual mental health. This association may have been mitigated or exacerbated by subjective risk perceptions, such as perceived risk of getting infected with SARS-CoV-2 or perception of the national economic situation. Therefore, we aimed to determine if changes in financial resources and employment situation during and after the second COVID-19 wave were prospectively associated with depression, anxiety and stress, and whether perceptions of the national economic situation and of the risk of getting infected modified this association. METHODS: One thousand seven hundred fifty nine participants from a nation-wide population-based eCohort in Switzerland were followed between November 2020 and September 2021. Financial resources and employment status were assessed twice (Nov2020-Mar2021, May-Jul 2021). Mental health was assessed after the second measurement of financial resources and employment status, using the Depression, Anxiety and Stress Scale (DASS-21). We modelled DASS-21 scores with linear regression, adjusting for demographics, health status, social relationships and changes in workload, and tested interactions with subjective risk perceptions. RESULTS: We observed scores above thresholds for normal levels for 16% (95%CI = 15-18) of participants for depression, 8% (95%CI = 7-10) for anxiety, and 10% (95%CI = 9-12) for stress. Compared to continuously comfortable or sufficient financial resources, continuously precarious or insufficient resources were associated with worse scores for all outcomes. Increased financial resources were associated with higher anxiety. In the working-age group, shifting from full to part-time employment was associated with higher stress and anxiety. Perceiving the Swiss economic situation as worrisome was associated with higher anxiety in participants who lost financial resources or had continuously precarious or insufficient resources. CONCLUSION: This study confirms the association of economic stressors and mental health during the COVID-19 pandemic and highlights the exacerbating role of subjective risk perception on this association.

[Description and analysis of disease representation in chronic patients through the Illness Perception Questionnaire (IPQ-r): implications for clinical practice]. / Descrizione e analisi delle rappresentazioni di malattia nei pazienti cronici attraverso l'Illness Perception Questionnaire (IPQ-r): implicazioni per la pratica clinica.

INTRODUCTION: According to the theory of Self-Regulation, the individual develops self-regulation processes that guide the course of pathology through mental representations of disease. These should be an essential part of nursing in developing the patient's motivation and self-efficacy, and the Illness Perception Questionnaire allows us to understand the construction processes. AIM: The aim is to analyze the mental representations of illness of a group of chronically ill patients, to evaluate the implications in therapeutic adherence and clinical practice. METHODS: Pilot study conducted on a sample of 89 chronically ill patients through the Illness Perception Questionnaire. RESULTS: By correlating the illness dimensions of the Self-Regulation, the significant relationship between emotional representations and the other dimensions emerges. Negative emotions lead the individual to perceive more the cyclical duration of the disease, the severity of its consequences, have a lower perception of coherence and understanding of the disease. A greater opinion of personal control corresponds to a lower perception of serious consequences and a greater perception of control of treatment. The prevalence of negative emotions and a lower disease consistency score are highlighted in patients with low educational level. CONCLUSION: The study demonstrated the adequacy of IPQ-r in detecting disease representations, which can affect outcomes in treatment. Above all, the importance of the emotional dimension related to the perception of the disease. The application of IPQ-r can be a valid tool for nurses in detecting the perception of illness of their patients resulting in a useful strategy to promote the educational process and promote adequate therapeutic adherence.

[How do Advanced Practice Nurses participate in building health policy projects?] / Come gli infermieri di pratica avanzata partecipano alla costruzione di progetti di politica sanitaria?

INTRODUCTION: Patients' needs and the change of health professionals' roles have led researchers to reflect about the involvement of nurses in care processes development, as well as health policies. Studies confirm how advanced nursing training promotes quality of care and reduces the costs of healthcare. The introduction of the Advanced Practice Nurses (APNs) could potentially be an added value also in the Swiss healthcare context, where this figure is positioning. The study aims to investigate how APNs can participate in building health policy projects. METHOD: This is a qualitative study. Four focus groups were conducted on nurses with managerial and clinical roles. A content analysis approach with three review phases was applied. RESULTS: The identified macro-themes are: APN: Advanced training provides the skills needed to exercise the role. However, it emerges that the recognition of nurses in the field of health policies originates from a cultural change. Interprofessional collaboration: Multidisciplinary work allows overall patient care. However, requests for advice from the APN is still marginal. Health policy: The emerged needs are: defining a target population, educating the population and encouraging organizations to obtain quality certifications. Proposals for improvement: adequate training and the involvement of specialized figures are required for suitable care. CONCLUSIONS: APNs have potential impact upon health policy discussions. The authors recommend investing on education and cultural change, in order to maximize the active involvement in discussions supporting progress in nursing practice.

[What are the needs of caregivers caring for people living in chronic conditions? Qualitative research]. / Quali sono i bisogni dei caregiver di persone che vivono una condizione di cronicità: ricerca qualitativa.

BACKGROUND: The population ageing generates new challenges related to the treatment of chronic diseases. The course of the disease makes patients and caregivers (CGs) vulnerable and their ability to self-care is threatened. CGs can be supported by the Advanced Practice Nurse (APN). OBJECTIVE: The aim is to deepen the CGs' needs of people with chronic conditions in Insubrica region. METHOS: It's a qualitative descriptive survey, conducted between September 2019 and February 2020. The CGs' convenience sample of people with chronic illness was differentiated by age, gender, profession, chronic diseases and included 20 participants. Data were collected through short motivational interviews and the compilation of a socio-family genogram. The thematic analysis of the interviews' Verbatim transcription was carried out by 4 researchers. RESULTS: The thematic analysis has shown 26 themes collected in 6 macrothemes and in addition highlighted that the chronic condition and vulnerability are linked together; therapeutic adherence and self-care depend on disease awareness, and CGs make little use of the social support network; CONCLUSION: Based on the results, it can be said that the APN can meet the GCs' needs through the skills gained in training (CanMEDS and Hamric model); encourage inter-professional and integrated care, and promote the formal and informal network.

[Bullying in Ticino's healthcare contexts: Impact on employee's well being and organization]. / Il bullismo nel sistema sanitario ticinese: L'impatto sul benessere dei collaboratori e sull'organizzazione.

INTRODUCTION: Bullying in health care setting has a globally prevalence between 1% and 87% and it's in constant increase described by "WHO" as: "Bullying is a major public health problem". It is defined as a repeated ill-treatment, harmful for the health of one or more individuals by one or more people. There are different types of behaviours and they vary from verbal abuse, offensive conduct, humiliating and intimidating attitudes. Those attitudes won't help you doing your job. Different are the outcomes that those actions have on victims: anxiety, sleep disturbances, generalized pain and reduced attention. The objective of the study was to investigate the presence of the phenomenon within the Ticino (Swiss Canton) on healthcare contexts and to explain its experiences. METHODS: A qualitative study was conducted on a sample of healthcare professionals who are active in the Ticino (Switzerland) healthcare context through 18 semi-structured interviews and their thematic analysis. RESULTS: The results that emerged shows how the problem is also relevant in Ticino`s healthcare contexts, sometimes with different modalities and outcomes, moreover, experiencing these situations during one's working career leads to re-proposing such behaviours, as it is considered a rite of passage. What emerges in a predominant way is the lack of programs or structures aimed to prevent and support the victim and the perpetrator.

What Adherence Measures Should Be Used in Trials of Home-Based Rehabilitation Interventions? A Systematic Review of the Validity, Reliability, and Acceptability of Measures.

OBJECTIVE: To systematically review methods for measuring adherence used in home-based rehabilitation trials and to evaluate their validity, reliability, and acceptability. DATA SOURCES: In phase 1 we searched the CENTRAL database, NHS Economic Evaluation Database, and Health Technology Assessment Database (January 2000 to April 2013) to identify adherence measures used in randomized controlled trials of allied health professional home-based rehabilitation interventions. In phase 2 we searched the databases of MEDLINE, Embase, CINAHL, Allied and Complementary Medicine Database, PsycINFO, CENTRAL, ProQuest Nursing and Allied Health, and Web of Science (inception to April 2015) for measurement property assessments for each measure. STUDY SELECTION: Studies assessing the validity, reliability, or acceptability of adherence measures. DATA EXTRACTION: Two reviewers independently extracted data on participant and measure characteristics, measurement properties evaluated, evaluation methods, and outcome statistics and assessed study quality using the COnsensus-based Standards for the selection of health Measurement INstruments checklist. DATA SYNTHESIS: In phase 1 we included 8 adherence measures (56 trials). In phase 2, from the 222 measurement property assessments identified in 109 studies, 22 high-quality measurement property assessments were narratively synthesized. Low-quality studies were used as supporting data. StepWatch Activity Monitor validly and acceptably measured short-term step count adherence. The Problematic Experiences of Therapy Scale validly and reliably assessed adherence to vestibular rehabilitation exercises. Adherence diaries had moderately high validity and acceptability across limited populations. The Borg 6 to 20 scale, Bassett and Prapavessis scale, and Yamax CW series had insufficient validity. Low-quality evidence supported use of the Joint Protection Behaviour Assessment. Polar A1 series heart monitors were considered acceptable by 1 study. CONCLUSIONS: Current rehabilitation adherence measures are limited. Some possess promising validity and acceptability for certain parameters of adherence, situations, and populations and should be used in these situations. Rigorous evaluation of adherence measures in a broader range of populations is needed.

Professional conduct among registered nurses in the use of online social networking sites.

AIM: To explore the use of Facebook by Registered Nurses (RNs) in Italy and the United Kingdom (UK), focusing on the disclosure of personal and professional information. BACKGROUND: The use of online social network sites among medical students and doctors is posing new ethical challenges to the profession. To date, little research has explored the use of online social networking sites among nurses. DESIGN: A cross-national survey. METHODS: Data were assessed on 124 nurses' profile pages, readily available without viewing restrictions. Content analysis and inferential statistics were undertaken to describe usage and identify similarities and differences between the two country-groups of nurses. Data were collected between December 2011-January 2012. RESULTS: Overall, UK and Italian RNs showed a similar use of the online platform, tending to disclose personal pictures, home town and current home location, as well as updates and comments related to personal and work-related activities. A statistically significant higher proportion of nurses in Italy disclosed their sexual orientation. In both groups, a few cases were observed of potentially unprofessional content in relation to the use of alcohol, nudity and material of a salacious nature. CONCLUSION: Although most of the UK and Italy RNs appear to be aware of the risks posed by their online exposure, their online activity indicates the blurring of their personal and professional lives; this is posing new ethical, legal and professional challenges to members of the nursing profession. Further research and debate is encouraged at national and international level.

Psychometric Evaluation of the Complexity of Care in the Home Care Setting Instrument (COMID) in Italian Language.

AIM: To test the psychometric properties of the complexity assessment instrument for home nursing practice (COMID) Italian version. DESIGN: Cross-sectional study. METHODS: Internal consistency was determined using Cronbach's alpha, whilst the two-way mixed effects, absolute agreement, single measure intraclass correlation coefficient (ICC 3.1) was calculated to evaluate the inter-rater reliability both on individual factors and the overall score. Registered Nurses enrolled at the MSc in Nursing at the University of Applied Sciences and Arts of Southern Switzerland and homecare nurses working for several home care institutions were involved in the data collection process following ad hoc training on the use of the COMID assessment instrument. RESULTS: A total of 220 questionnaires were completed by 36 nurses. Cronbach's alpha was 0.764, in line with the original study. The inter-rater reliability ranged from good (factor 6 ICC = 0.85) to excellent (factors 1-5 ICC > 91), with the ICC assessed on the total score of the COMID also excellent (ICC = 0.95). CONCLUSION: The COMID Italian version is a valid and reliable instrument for homecare nurses to assess complex situations according to the tests performed on a sample of older people receiving home care in Southern Switzerland. IMPLICATIONS FOR PRACTICE: The use of such an instrument will enable the identification of the most relevant areas of complexity to be discussed by the nursing and multidisciplinary team to plan and deliver personalised caring interventions.

A bachelor's degree for entering the nursing profession: A scoping review for supporting informed health care policies.

Background: Numerous studies have emphasized the relevance of work environment, staffing, and educational level in nursing as determinants of safe, timely, effective, equitable, and efficient patient-centered care. However, an overview of the evidence focusing on the nursing education level is still lacking. Objective: To provide an overview of the existing evidence regarding bachelor's degree as an entry level for the nursing profession. Design: This was a scoping review. Methods: We conducted a systematic search of CINAHL, Medline via PubMed, Cochrane, and Web of Science Core Collection. Additionally, we conducted a free web search using Google and contacted international nursing associations via email. We summarized the evidence narratively. For reporting guidelines, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews. Results: We included 10 studies, 12 response letters, 24 position papers, three books, and one webpage. The sources of evidence identified agreed that the inclusion of a higher number of nurses with a bachelor's degree would lead to a higher quality of care. Conclusions: Using a bachelor's degree education as a minimum requirement to enter the nursing profession in the future is essential to generate a respected, competent, and satisfied nursing workforce that can impact the quality and safety of care; and positively influence outcome indicators for patients, nurses, healthcare organizations, and society. Tweetable abstract: Policy makers and healthcare organizations should set bachelor's degrees as standards for registration and entry to nursing.

Trajectories of Seroprevalence and Neutralizing Activity of Antibodies against SARS-CoV-2 in Southern Switzerland between July 2020 and July 2021: An Ongoing, Prospective Population-Based Cohort Study.

OBJECTIVES: The COVID-19 pandemic continues, and evidence on infection- and vaccine-induced immunity is key. We assessed COVID-19 immunity and the neutralizing antibody response to virus variants across age groups in the Swiss population. STUDY DESIGN: We conducted a cohort study in representative community-dwelling residents aged five years or older in southern Switzerland (total population 353,343), and we collected blood samples in July 2020 (in adults only, N = 646), November-December 2020 (N = 1457), and June-July 2021 (N = 885). METHODS: We used a previously validated Luminex assay to measure antibodies targeting the spike (S) and the nucleocapsid (N) proteins of the virus and a high-throughput cell-free neutralization assay optimized for multiple spike protein variants. We calculated seroprevalence with a Bayesian logistic regression model accounting for the population's sociodemographic structure and the test performance, and we compared the neutralizing activity between vaccinated and convalescent participants across virus variants. RESULTS: The overall seroprevalence was 7.8% (95% CI: 5.4-10.4) by July 2020 and 20.2% (16.4-24.4) by December 2020. By July 2021, the overall seroprevalence increased substantially to 72.5% (69.1-76.4), with the highest estimates of 95.6% (92.8-97.8) among older adults, who developed up to 10.3 more antibodies via vaccination than after infection compared to 3.7 times more in adults. The neutralizing activity was significantly higher for vaccine-induced than infection-induced antibodies for all virus variants (all p values < 0.037). CONCLUSIONS: Vaccination chiefly contributed to the reduction in immunonaive individuals, particularly those in older age groups. Our findings on the greater neutralizing activity of vaccine-induced antibodies than infection-induced antibodies are greatly informative for future vaccination campaigns.

Changes in Healthcare Utilization During the COVID-19 Pandemic and Potential Causes-A Cohort Study From Switzerland.

Objectives: To describe the frequency of and reasons for changes in healthcare utilization in those requiring ongoing treatment, and to assess characteristics associated with change, during the second wave of the pandemic. Methods: Corona Immunitas e-cohort study (age ≥20 years) participants completed monthly questionnaires. We compared participants reporting a change in healthcare utilization with those who did not using descriptive and bivariate statistics. We explored characteristics associated with the number of changes using negative binomial regression. Results: The study included 3,190 participants from nine research sites. One-fifth reported requiring regular treatment. Among these, 14% reported a change in healthcare utilization, defined as events in which participants reported that they changed their ongoing treatment, irrespective of the reason. Reasons for change were medication changes and side-effects, specifically for hypertension, or pulmonary embolism treatment. Females were more likely to report changes [Incidence Rate Ratio (IRR) = 2.15, p = 0.002]. Those with hypertension were least likely to report changes [IRR = 0.35, p = 0.019]. Conclusion: Few of those requiring regular treatment reported changes in healthcare utilization. Continuity of care for females and chronic diseases besides hypertension must be emphasized.

Interplay of Digital Proximity App Use and SARS-CoV-2 Vaccine Uptake in Switzerland: Analysis of Two Population-Based Cohort Studies.

Objectives: Our study aims to evaluate developments in vaccine uptake and digital proximity tracing app use in a localized context of the SARS-CoV-2 pandemic. Methods: We report findings from two population-based longitudinal cohorts in Switzerland from January to December 2021. Failure time analyses and Cox proportional hazards regression models were conducted to assess vaccine uptake and digital proximity tracing app (SwissCovid) uninstalling outcomes. Results: We observed a dichotomy of individuals who did not use the SwissCovid app and did not get vaccinated, and who used the SwissCovid app and got vaccinated during the study period. Increased vaccine uptake was observed with SwissCovid app use (aHR, 1.51; 95% CI: 1.40-1.62 [CI-DFU]; aHR, 1.79; 95% CI: 1.62-1.99 [CSM]) compared to SwissCovid app non-use. Decreased SwissCovid uninstallation risk was observed for participants who got vaccinated (aHR, 0.55; 95% CI: 0.38-0.81 [CI-DFU]; aHR, 0.45; 95% CI: 0.27-0.78 [CSM]) compared to participants who did not get vaccinated. Conclusion: In evolving epidemic contexts, these findings underscore the need for communication strategies as well as flexible digital proximity tracing app adjustments that accommodate different preventive measures and their anticipated interactions.

[Impact of the role of Emergency Nurse Practitioners in the clinical management of patients in a UK Emergency Ward]. / L'impatto del ruolo delle Emergency Nurse Practitioners nella gestione clinica dei pazienti nel contesto di un Dipartimento di Emergenza Urgenza nel Regno Unito.

Various professional health figures participate in the management and treatment of patients in Emergency- Casualty structures presenting diverse levels of clinical severity. This study describes and analyses the role of nursing figures who have achieved different levels of training who collaborate with medical staff in the management of low and medium priority patients, using the case study research method. Three cases treated in the See and Treat Service and in the Major Area of the Wishaw General Hospital, Glasgow, Scozia are described.

Why Vaccinate Against COVID-19? A Population-Based Survey in Switzerland.

Objectives: This study examined factors associated with COVID-19 vaccination intention at the very beginning of the vaccination campaign in a representative sample of the population in southern Switzerland. Methods: In March 2021, we measured vaccination intention, beliefs, attitudes, and trust in a sample of the Corona Immunitas Ticino study. Results: Of the 2681 participants, 1933 completed the questionnaire (response rate = 72%; 55% female; meanage = 41, SD = 24, rangeage = 5-91). Overall, 68% reported an intention to get vaccinated. Vaccination intention was higher in social/healthcare workers, and increased with age, trust in public health institutions, and confidence in the vaccine efficacy. Prior infection of a family member, predilection for waiting for more evidence on the safety and efficacy of the vaccine, and for alternative protective means were negatively associated with intention. Conclusion: In view of needs of COVID-19 vaccine boosters and of suboptimal vaccination coverage, our results have relevant public health implications and suggest that communication about vaccine safety and efficacy, and aims of vaccination programs, should be bi-directional, proportionate, and tailored to the concerns, expectations, and beliefs of different population subgroups.

The Corona Immunitas Digital Follow-Up eCohort to Monitor Impacts of the SARS-CoV-2 Pandemic in Switzerland: Study Protocol and First Results.

Objectives: To describe the rationale, organization, and procedures of the Corona Immunitas Digital Follow-Up (CI-DFU) eCohort and to characterize participants at baseline. Methods: Participants of Corona Immunitas, a population-based nationwide SARS-CoV-2 seroprevalence study in Switzerland, were invited to join the CI-DFU eCohort in 11 study centres. Weekly online questonnaires cover health status changes, prevention measures adherence, and social impacts. Monthly questionnaires cover additional prevention adherence, contact tracing apps use, vaccination and vaccine hesitancy, and socio-economic changes. Results: We report data from the 5 centres that enrolled in the CI-DFU between June and October 2020 (covering Basel City/Land, Fribourg, Neuchâtel, Ticino, Zurich). As of February 2021, 4636 participants were enrolled and 85,693 weekly and 27,817 monthly questionnaires were collected. Design-based oversampling led to overrepresentation of individuals aged 65+ years. People with higher education and income were more likely to enroll and be retained. Conclusion: Broad enrolment and robust retention of participants enables scientifically sound monitoring of pandemic impacts, prevention, and vaccination progress. The CI-DFU eCohort demonstrates proof-of-principle for large-scale, federated eCohort study designs based on jointly agreed principles and transparent governance.

Home Treatment for Acute Mental Health Care: Protocol for the Financial Outputs, Risks, Efficacy, Satisfaction Index and Gatekeeping of Home Treatment (FORESIGHT) Study.

BACKGROUND: Crisis Resolution and Home Treatment (CRHT) teams represent a community-based mental health service offering a valid alternative to hospitalization. CRHT teams have been widely implemented in various mental health systems worldwide, and their goal is to provide care for people with severe acute mental disorders who would be considered for admission to acute psychiatric wards. The evaluation of several home-treatment experiences shows promising results; however, it remains unclear which specific elements and characteristics of CRHT are more effective and acceptable. OBJECTIVE: This study aims to assess the acceptability, effectiveness, and cost-effectiveness of a new CRHT intervention in Ticino, Southern Switzerland. METHODS: This study includes an interventional, nonrandomized, quasi-experimental study combined with a qualitative study and an economic evaluation to be conducted over a 48-month period. The quasi-experimental evaluation involves two groups: patients in the northern area of the region who were offered the CRHT service (ie, intervention group) and patients in the southern area of the region who received care as usual (ie, control group). Individual interviews will be conducted with patients receiving the home treatment intervention and their family members. CRHT members will also be asked to participate in a focus group. The economic evaluation will include a cost-effectiveness analysis. RESULTS: The project is funded by the Swiss National Science Foundation as part of the National Research Program NRP74 for a period of 48 months starting from January 2017. As of October 2021, data for the nonrandomized, quasi-experimental study and the qualitative study have been collected, and the results are expected to be published by the end of the year. Data are currently being collected for the economic evaluation. CONCLUSIONS: Compared to other Swiss CRHT experiences, the CRHT intervention in Ticino represents a unique case, as the introduction of the service is backed by the closing of one of its acute wards. The proposed study will address several areas where there are evidence gaps or contradictory findings relating to the home treatment of acute mental crisis. Findings from this study will allow local services to improve their effectiveness in a challenging domain of public health and contribute to improving access to more effective care for people with severe mental disorders. TRIAL REGISTRATION: ISRCTN registry ISRCTN38472626; https://www.isrctn.com/ISRCTN38472626. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/28191.

Optimisation of complex health interventions prior to a randomised controlled trial: a scoping review of strategies used.

BACKGROUND: Many complex intervention trials fail to show an intervention effect. Although this may be due to genuine ineffectiveness, it may also be the result of sub-optimal intervention design, implementation failure or a combination of these. Given current financial constraints and the pressure to reduce waste and increase value in health services research, pre-trial strategies are needed to reduce the likelihood of design or implementation failure and to maximise the intervention's potential for effectiveness. In this scoping review, we aimed to identify and synthesise the available evidence relating to the strategies and methods used to 'optimise' complex interventions at the pre-trial stage. METHODS: We searched MEDLINE, CINAHL, AMED, PsycINFO and ProQuest Nursing & Allied Health Source for papers published between January 2000 and March 2015. We included intervention development and optimisation studies that explored potential intervention weaknesses and limitations before moving to a definitive randomised controlled trial (RCT). Two reviewers independently applied selection criteria and systematically extracted information relating to the following: study characteristics; intervention under development; framework used to guide the development process; areas of focus of the optimisation process, methods used and outcomes of the optimisation process. Data were tabulated and summarised in a narrative format. RESULTS: We screened 3968 titles and 231 abstracts for eligibility. Eighty-nine full-text papers were retrieved; 27 studies met our selection criteria. Optimisation strategies were used for a range of reasons: to explore the feasibility and acceptability of the intervention to patients and healthcare professionals; to estimate the effectiveness and cost-effectiveness of different combinations of intervention components; and to identify potential barriers to implementation. Methods varied widely across studies, from interviews and focus groups to economic modelling and probability analysis. CONCLUSIONS: The review identifies a range of optimisation strategies currently used. Although a preliminary classification of these strategies can be proposed, a series of questions remain as to which methods to use for different interventions and how to determine when the intervention is ready or 'optimised enough' to be tested in a RCT. Future research should explore potential answers to the questions raised, to guide researchers in the development and evaluation of more effective interventions.