Factors associated with complementary feeding practices among children aged 6-23 months in Indonesia.

BACKGROUND: Complementary foods with breastfeeding are foods or drinks given to children aged 6-23 months to meet their nutritional needs. The non-optimal provision of complementary feeding influences malnutrition in children of this age. AIMS: To analyze the factors associated with complementary feeding practices among children aged 6-23 months in Indonesia. METHODS: A cross-sectional design was employed using data from the 2017 Indonesia Demographic and Health Survey. A total of 502,800 mothers with children aged 6-23 months were recruited through multistage cluster sampling. Data were analyzed using a logistic regression test to determine the correlation between predisposing, enabling, and reinforcing factors and complementary feeding practices. RESULTS: A prevalence values of analysis showed that approximately 71.14%, 53.95%, and 28.13% of the children met MMF, MMD, and MAD, respectively. The probability of achieving minimum dietary diversity (MDD) was high in the following: children aged 18-23 months (odds ratio [OR] = 9.58; 95% confidence interval [CI] = 7.29-12.58), children of mothers with higher education (OR = 5.95; 95% CI = 2.17-16.34), children from households with upper wealth index (OR = 2.53; 95% CI = 1.85-3.48), children of mothers who received childbirth assistance by professionals (OR = 1.63; 95% CI = 1.20-2.20), and children of mothers who had access to the Internet (OR = 1.26; 95% CI = 1.06-1.50). Moreover, children from households with the upper wealth index (OR = 1.40; 95% CI = 1.03-1.91), children whose mothers were employed (OR = 1.19; 95% CI = 1.02-1.39) living in urban areas (OR = 1.28; 95% CI = 1.06-1.54) and children of mothers who received childbirth assistance by professionals (OR = 1.33; 95% CI = 0.98-1.82) were more likely to meet Minimum Meal Frequency (MMF). Finally, children aged 18-23 months (OR = 2.40; 95% CI = 1.81-3.17), of mothers with higher education (OR = 3.15; 95% CI = 0.94-10.60), from households with upper wealth index (OR = 1.41; 95% CI = 1.05-2.90) and born with professional childbirth assistance (OR = 1.82; 95% CI = 1.21-2.75) were significantly associated with minimum acceptable diet (MAD). CONCLUSIONS: The findings revealed that the prevalence of MDD and MAD in Indonesia was low. Strategies such as improving health services, economic conditions, and education level of mothers are needed to improve infant and young child feeding in Indonesia.

Health Benefits of Social Participation Interventions among Community-Dwelling Older Persons: A Review Article.

BACKGROUND: Social disengagement among older persons may result from accumulated physical impact and social stressors experienced throughout life. Conversely, interventions that enhance social participation addresses social isolation with positive influences on health. This article, therefore, aimed to review the range of published studies that evaluated the health benefits of interventions on social participation among community-dwelling older persons. METHOD: We conducted a search using the databases CINAHL, MEDLINE, EBSCOhost, PubMed, ProQuest, SAGE, ScienceDirect, SpringerLink, Web of Science, and Open repository/archive. RESULTS: Twenty-five studies from Asia, Europe and America were selected. Included articles described randomized controlled trials (9), quasi-experimental studies (9), mixed-methods studies (2), participatory action research (3), and community-based intervention research (2). Social interventions described are group or cultural activities, personal/group monitoring and discussion, and communications devices. Intervention designed utilized theories, models, concepts, principles, and evidence from published literature. CONCLUSION: Most social intervention studies evaluating health outcomes have been conducted in North America and Western Europe. Group-based activities were most commonly employed, but personal/group discussions, home visits and technology-based interactions have also been used. While social isolation is now a widely accepted risk factor for ill-health, research evidence for improvement of health through reduction of social isolation remains limited.

Associations of lifestyle activities and a heathy diet with frailty in old age: a community-based study in Singapore.

Frailty is an age-related state characterized by a reduced physiological reserve, and is associated with adverse health outcomes in the elderly. We analyzed the data from 895 adults aged 60 years and above, and investigated the relationships between midlife and late-life social activities, intellectual activities, working hours, and dietary habits and frailty status. Participation in social or intellectual activities in late life was less prevalent among those who were frail than among those who were robust. A greater proportion of those who were frail had worked long hours in midlife. After adjustment for confounders, participating in social activities or intellectual activities in late life was associated with a reduced risk for prefrailty and frailty, while working long hours in midlife was associated with a higher risk for frailty. The risk of frailty decreased with increasing healthy diet scores in midlife and late life. When the results were stratified by gender, late-life participation in social activities and midlife or late-life participation in intellectual activities correlated negatively with prefrailty/frailty only in women. Our study suggests that social and intellectual activities are inversely associated with frailty status, but the association seems to differ based on gender.

Factors Associated with Health Care Professionals' Attitude Toward the Presumed Consent System.

OBJECTIVES: This paper explores health care professionals' potential attitude toward organ donation if the presumed consent system were to be implemented in Malaysia, as well as factors associated with this attitude. MATERIALS AND METHODS: We used self-administered questionnaires to investigate the attitude of 382 health care professionals from the University of Malaya Medical Center between January and February 2014. The responses were analyzed using logistic regression. RESULTS: Of the 382 respondents, 175 (45.8%) stated that they would officially object to organ donation if the presumed consent system were to be implemented, whereas the remaining 207 (54.2%) stated that they would not object. The logistic regression showed that health care professionals from the Malay ethnic group were more likely to object than those from Chinese (adjusted odds ratio of 0.342; P = .001) and Indian and other (adjusted odds ratio of 0.341; P = .003) ethnic groups. Health care professionals earning 3000 Malaysian Ringgit or below were more likely to object than those earning above 3000 Malaysian Ringgit (adjusted odds ratio of 1.919; P = .006). Moreover, respondents who were initially unwilling to donate organs, regardless of the donation system, were more likely to object under the presumed consent system than those who were initially willing to donate (adjusted odds ratio of 2.765; P < .001). CONCLUSIONS: Health care professionals in Malaysia have a relatively negative attitude toward the presumed consent system, which does not encourage the implementation of this system in the country at present. To pave the way for a successful implementation of the presumed consent system, efforts should be initiated to enhance the attitude of health care professionals toward this system. In particular, these efforts should at most target the health care professionals who are Malay, earn a low income, and have a negative default attitude toward deceased donation.

Caregiving burden in foreign domestic workers caring for frail older adults in Singapore.

ABSTRACTBackground:Although foreign domestic workers (FDWs) play a significant role in caring for frail seniors in Singapore and are vulnerable to caregiving burden, there has been little research conducted hitherto. We explored caregiver burden and its determinants in this study. METHODS: FDWs (N = 221, Mage = 32.3, SD = 6.23) recruited from a hospital geriatric unit completed the Zarit Burden Interview (ZBI) administered in English, Bahasa Melayu, or Burmese. Univariate and multivariate regression were employed to investigate factors influencing caregiving burden in FDWs. RESULTS: Majority were Indonesians (60.0%), married (57.5%) with children (62.4%), with secondary-level education (59.7%), and providing care for >1 year (79.9%). Importantly, 25.1% reported physical health problems and 23.1% encountered language difficulties with employers. Univariate analysis revealed three significant factors associated with caregiving burden: nationality (p < 0.001), lack of privacy (p = 0.029), and caring for persons with dementia (PWD) (p = 0.001). On multivariate regression, FDWs who cared for PWD were 5.47 times (p = 0.013) more likely to experience burden, while FDWs who encountered language difficulties were 5.46 times (p = 0.030) more likely to experience burden. Filipinos FDWs were 9.73 times more likely to express burden (p < 0.001) compared to their Indonesian and Burmese counterparts. CONCLUSION: The study highlights caregiver burden in FDWs and potential ways to alleviate it by empowering FDWs with dementia-specific caregiving skills, providing language training opportunities, and supporting particular FDW ethnic groups with more emotional and practical help.

The contribution of alcohol use disorder to decompensated cirrhosis among people with hepatitis C: An international study.

BACKGROUND & AIMS: The advent of direct-acting antivirals (DAAs) has led to ambitious targets for hepatitis C virus (HCV) elimination. However, in the context of alcohol use disorder the ability of DAAs to achieve these targets may be compromised. The aim of this study was to evaluate the contribution of alcohol use disorder to HCV-related decompensated cirrhosis in three settings. METHODS: HCV notifications from British Columbia, Canada; New South Wales, Australia, and Scotland (1995-2011/2012/2013, respectively) were linked to hospital admissions (2001-2012/2013/2014, respectively). Alcohol use disorder was defined as non-liver-related hospitalisation due to alcohol use. Age-standardised decompensated cirrhosis incidence rates were plotted, associated factors were assessed using Cox regression, and alcohol use disorder-associated population attributable fractions (PAFs) were computed. RESULTS: Among 58,487, 84,529, and 31,924 people with HCV in British Columbia, New South Wales, and Scotland, 2,689 (4.6%), 3,169 (3.7%), and 1,375 (4.3%) had a decompensated cirrhosis diagnosis, and 28%, 32%, and 50% of those with decompensated cirrhosis had an alcohol use disorder, respectively. Age-standardised decompensated cirrhosis incidence rates were considerably higher in people with alcohol use disorder in New South Wales and Scotland. Decompensated cirrhosis was independently associated with alcohol use disorder in British Columbia (aHR 1.92; 95% CI 1.76-2.10), New South Wales (aHR 3.68; 95% CI 3.38-4.00) and Scotland (aHR 3.88; 95% CI 3.42-4.40). The PAFs of decompensated cirrhosis-related to alcohol use disorder were 13%, 25%, and 40% in British Columbia, New South Wales and Scotland, respectively. CONCLUSIONS: Alcohol use disorder was a major contributor to HCV liver disease burden in all settings, more distinctly in Scotland. The extent to which alcohol use would compromise the individual and population-level benefits of DAA therapy needs to be closely monitored. Countries, where appropriate, must develop strategies combining promotion of DAA treatment uptake with management of alcohol use disorders, if World Health Organization 2030 HCV mortality reduction targets are going to be achieved. LAY SUMMARY: The burden of liver disease has been rising among people with hepatitis C globally. The recent introduction of highly effective medicines against hepatitis C (called direct-acting antivirals or DAAs) has brought renewed optimism to the sector. DAA scale-up could eliminate hepatitis C as a public health threat in the coming decades. However, our findings show heavy alcohol use is a major risk factor for liver disease among people with hepatitis C. If continued, heavy alcohol use could compromise the benefits of new antiviral treatments at the individual- and population-level. To tackle hepatitis C as a public health threat, where needed, DAA therapy should be combined with management of heavy alcohol use.

Evaluation of an integrated primary care-led dementia shared care program in Singapore: An effectiveness and cost-effectiveness study.

AIM: With an aging Singapore population, there is an increasing demand for dementia care. The present study aimed to evaluate the effectiveness and cost-effectiveness of the Primary Care Dementia Clinic (PCDC) in comparison with the Memory Clinic (MC; hospital-based) and other polyclinics. METHODS: A quasi-experimental design was implemented. Effectiveness of PCDC was assessed through caregiver satisfaction, quality of life (caregiver-rated) and adverse events rates. Quality-of-Life measures using the EuroQol 5 Dimension Questionnaire (EQ-5D) at baseline, 6 months and 12 months was assessed. Costs were calculated from a societal perspective. The incremental cost-effectiveness of the PCDC was compared with MC and other polyclinics. RESULTS: The present study showed that quality of life and the rate of adverse events at 12 months were similar between the three groups. Caregiver satisfaction at 12 months was higher in the PCDC group when compared with other polyclinics. There were no observed differences in societal cost between the three groups. At 6-month follow up, direct medical costs for PCDC were significantly lower that of other polyclinics. At 12-month follow up, PCDC patients had higher Quality Adjusted Life Years (QALYs) compared with the MC group. CONCLUSION: PCDC provided effective care, similar to care at MC and better than care at other polyclinics. Caregiver satisfaction was higher for the PCDC group, and PCDC patients had lower direct medical costs at 6-month follow up. Given these findings, adopting a PCDC model in other polyclinics in Singapore can be beneficial for optimal right siting of patients. Geriatr Gerontol Int 2018; 18: 479-486.

Nurses' perceptions of barriers and facilitators and their associations with the quality of end-of-life care.

AIMS AND OBJECTIVES: To examine nurses' perceptions of barriers to and facilitators of end-of-life care, as well as their association with the quality of end-of-life care. BACKGROUND: Often, dying patients and their families receive their care from general nurses. The quality of end-of-life care in hospital wards is inadequate. METHOD: A self-administered questionnaire was completed by 553 nurses working in a tertiary teaching hospital in Malaysia. RESULTS: The barrier with the highest mean score was "dealing with distressed family members." The facilitator with the highest mean score was "providing a peaceful and dignified bedside scene for the family once the patient has died." With regard to barrier and facilitator categories, the barrier category with the highest total mean score was patient-related barriers and the facilitator category with the highest total mean score concerned facilitators related to healthcare professionals. In the multivariate analysis, age, patient family-related barriers and healthcare professional-related facilitators significantly predict the quality of end-of-life care. CONCLUSION: The results of this study suggest that there is an urgent need to overcome barriers related to the patient and family members that hinder the quality of care provided for dying patients, as well as to enhance and implement the facilitators related to healthcare providers. In addition, there is also a need to enhance the quality of end-of-life care provided by younger nurses through end-of-life care courses and training. RELEVANCE TO CLINICAL PRACTICE: Helping nurses overcome barriers and implement facilitators may lead to enhanced quality of care provided for dying patients.

Increasing incidence associated with herpes zoster infection in British Columbia, Canada.

BACKGROUND: Recent studies have shown an increasing incidence of herpes zoster (HZ) infection, which may be related to the introduction of varicella vaccination programs in children. We examined the epidemiology and treatment costs of HZ and post-herpetic neuralgia (PHN) over time in British Columbia, Canada. METHODS: The cohort consisted of all cases with HZ infection from January 1, 1997 and December 31, 2012. Incident zoster was defined as a case (ICD-9 053 or ICD-10 B02) without a previous episode of HZ or PHN in the previous 12 months. We determined the incidence for HZ and PHN and the age-sex standardized rate for the overall population. We determined the association between the varicella vaccination program and increased HZ rates by evaluating the rate ratios in the publicly-funded varicella vaccine period compared to the non-publicly funded period in a regression model. We evaluated the hospitalization rates, treatment by GPs and their associated yearly costs for HZ and PHN. RESULTS: HZ incidence increased for the entire study period from 3.2 per 1000 population in 1997 to 4.5 in 2012. HZ rates were higher for females than males and all age groups had an increased incidence rate, except the 0-9 year olds, where the rate decreased. Crude and age-sex standardized incidence rates of PHN demonstrated very similar patterns to HZ incidence. Based on the regression model, rates of HZ were higher in the older individuals. No significant increase with HZ incidence was seen during the publically funded varicella vaccination program compared to the non-publicly funded period. From 1997 to 2012, the annual HZ-related costs associated with hospitalizations and GP visits were over $CDN4.9 million and $CDN537,286, respectively; treatment costs for hospitalizations have increased significantly over time. Majority of PHN-related cases are managed by GPs, with a steady increase over time in number of cases and associated annual costs. CONCLUSIONS: The incidence of zoster and PHN is increasing with time, particularly in the elderly population and the risk is greater in the over 65 year olds. Treatment costs for both HZ and PHN represent a significant burden on the Canadian healthcare system.

Automated assessment of thigh composition using machine learning for Dixon magnetic resonance images.

OBJECTIVES: To develop and validate a machine learning based automated segmentation method that jointly analyzes the four contrasts provided by Dixon MRI technique for improved thigh composition segmentation accuracy. MATERIALS AND METHODS: The automatic detection of body composition is formulized as a three-class classification issue. Each image voxel in the training dataset is assigned with a correct label. A voxel classifier is trained and subsequently used to predict unseen data. Morphological operations are finally applied to generate volumetric segmented images for different structures. We applied this algorithm on datasets of (1) four contrast images, (2) water and fat images, and (3) unsuppressed images acquired from 190 subjects. RESULTS: The proposed method using four contrasts achieved most accurate and robust segmentation compared to the use of combined fat and water images and the use of unsuppressed image, average Dice coefficients of 0.94 ± 0.03, 0.96 ± 0.03, 0.80 ± 0.03, and 0.97 ± 0.01 has been achieved to bone region, subcutaneous adipose tissue (SAT), inter-muscular adipose tissue (IMAT), and muscle respectively. CONCLUSION: Our proposed method based on machine learning produces accurate tissue quantification and showed an effective use of large information provided by the four contrast images from Dixon MRI.

Assessing Hepatitis C Burden and Treatment Effectiveness through the British Columbia Hepatitis Testers Cohort (BC-HTC): Design and Characteristics of Linked and Unlinked Participants.

BACKGROUND: The British Columbia (BC) Hepatitis Testers Cohort (BC-HTC) was established to assess and monitor hepatitis C (HCV) epidemiology, cost of illness and treatment effectiveness in BC, Canada. In this paper, we describe the cohort construction, data linkage process, linkage yields, and comparison of the characteristics of linked and unlinked individuals. METHODS: The BC-HTC includes all individuals tested for HCV and/or HIV or reported as a case of HCV, hepatitis B (HBV), HIV or active tuberculosis (TB) in BC linked with the provincial health insurance client roster, medical visits, hospitalizations, drug prescriptions, the cancer registry and mortality data using unique personal health numbers. The cohort includes data since inception (1990/1992) of each database until 2012/2013 with plans for annual updates. We computed linkage rates by year and compared the characteristics of linked and unlinked individuals. RESULTS: Of 2,656,323 unique individuals available in the laboratory and surveillance data, 1,427,917(54%) were included in the final linked cohort, including about 1.15 million tested for HCV and about 1.02 million tested for HIV. The linkage rate was 86% for HCV tests, 89% for HCV cases, 95% for active TB cases, 48% for HIV tests and 36% for HIV cases. Linkage rates increased from 40% for HCV negatives and 70% for HCV positives in 1992 to ~90% after 2005. Linkage rates were lower for males, younger age at testing, and those with unknown residence location. Linkage rates for HCV testers co-infected with HIV, HBV or TB were very high (90-100%). CONCLUSION: Linkage rates increased over time related to improvements in completeness of identifiers in laboratory, surveillance, and registry databases. Linkage rates were higher for HCV than HIV testers, those testing positive, older individuals, and females. Data from the cohort provide essential information to support the development of prevention, care and treatment initiatives for those infected with HCV.

Severe Impairment Rating Scale: A Useful and Brief Cognitive Assessment Tool for Advanced Dementia for Nursing Home Residents.

To investigate the utility of the Severe Impairment Rating Scale (SIRS) as a cognitive assessment tool among nursing home residents with advanced dementia, we conducted a cross-sectional study of 96 residents in 3 nursing homes with Functional Assessment Staging Test (FAST) stage 6a and above. We compared the discriminatory ability of SIRS with the Chinese version of Mini-Mental State Examination, Abbreviated Mental Test, and Clock Drawing Test. Among the cognitive tests, SIRS showed the least "floor" effect and had the best capacity to distinguish very severe (FAST stages 7d-f) dementia (area under the curve 0.80 vs 0.46-0.76 for the other tools). The SIRS had the best correlation with FAST staging (r = -.59, P < .01) and, unlike the other 3 tools, exhibited only minimal change in correlation when adjusted for education and ethnicity. Our results support the utility of SIRS as a brief cognitive assessment tool for advanced dementia in the nursing home setting.

Caregiver Burden: Looking Beyond the Unidimensional Total Score.

The Zarit Burden Interview allows caregiver burden to be interpreted from a total score. However, recent studies propose a multidimensional Zarit Burden Interview model. This study aims to determine the agreement between unidimensional (UD) and multidimensional (MD) classification of burden, and differences in predictors among identified groups. We studied 165 dyads of dementia patients and primary caregivers. Caregivers were dichotomized into low-burden and high-burden groups based upon: (1) UD score using quartile cutoffs; and (2) MD model via exploratory cluster analysis. We compared UD versus MD 2×2 classification of burden using κ statistics. Caregivers not showing agreement by either definition were classified as "intermediate" burden. We performed binary logistic regression to ascertain differences in predictive factors. The 2 models showed moderate agreement (κ=0.72, P<0.01), yielding 104 low, 20 intermediate (UD "low burden"/MD "high burden"), and 41 high-burden caregivers. Neuropsychiatric symptoms [odds ratio (OR)=1.27, P=0.003], coresidence (OR=6.32, P=0.040), and decreased caregiving hours (OR=0.99, P=0.018) were associated with intermediate burden, whereas neuropsychiatric symptoms (OR=1.21, P=0.001) and adult children caregivers (OR=2.80, P=0.055) were associated with high burden. Our results highlight the differences between UD and MD classification of caregiver burden. Future studies should explore the significance of the noncongruent intermediate group and its predictors.

Montreal Cognitive Assessment for screening mild cognitive impairment: variations in test performance and scores by education in Singapore.

BACKGROUND: The Montreal Cognitive Assessment (MoCA) was developed as a screening instrument for mild cognitive impairment (MCI). We evaluated the MoCA's test performance by educational groups among older Singaporean Chinese adults. METHOD: The MoCA and Mini-Mental State Examination (MMSE) were evaluated in two independent studies (clinic-based sample and community-based sample) of MCI and normal cognition (NC) controls, using receiver operating characteristic curve analyses: area under the curve (AUC), sensitivity (Sn), and specificity (Sp). RESULTS: The MoCA modestly discriminated MCI from NC in both study samples (AUC = 0.63 and 0.65): Sn = 0.64 and Sp = 0.36 at a cut-off of 28/29 in the clinic-based sample, and Sn = 0.65 and Sp = 0.55 at a cut-off of 22/23 in the community-based sample. The MoCA's test performance was least satisfactory in the highest (>6 years) education group: AUC = 0.50 (p = 0.98), Sn = 0.54, and Sp = 0.51 at a cut-off of 27/28. Overall, the MoCA's test performance was not better than that of the MMSE. In multivariate analyses controlling for age and gender, MCI diagnosis was associated with a <1-point decrement in MoCA score (η(2) = 0.010), but lower (1-6 years) and no education was associated with a 3- to 5-point decrement (η(2) = 0.115 and η(2) = 0.162, respectively). CONCLUSION: The MoCA's ability to discriminate MCI from NC was modest in this Chinese population, because it was far more sensitive to the effect of education than MCI diagnosis.

Differential perceptions of quality of life (QoL) in community-dwelling persons with mild-to-moderate dementia.

BACKGROUND: Discordance between patient- and caregiver-reported quality of life (QoL) is well recognized. This study sought to (i) identify predictors of discrepancy between patient- and caregiver-rated QoL amongst community-dwelling persons with mild-to-moderate dementia, and (ii) differentiate between patients who systematically rate their QoL lower versus those who rate their QoL higher relative to their caregiver ratings. METHODS: We recruited 165 patient-caregiver dyads with mild-to-moderate dementia. Quality of life in Alzheimer's disease (QoL-AD) scale was administered separately to patients and caregivers. Data on socio-demographics, interpersonal relationship, and disease-related characteristics (cognitive performance, mood, neuropsychiatric symptoms, functional ability, and caregiver burden) were collected. Patient-caregiver dyads were categorized based on whether patient-rated QoL was lower or higher than their respective caregiver ratings. Univariate analyses and multiple regression models were performed to identify predictors of dyadic rating discrepancy. RESULTS: Mean patient-rated QoL was significantly higher than caregiver rating (mean difference: 3.8 ± 7.1, p < 0.001). Majority (111 (67.2%)) of patients had more positive self-perceived QoL (QoL-ADp (QoL-AD self rated by the patient) > QoL-ADc (QoL-AD proxy-rated by a caregiver)), compared with those (44 (26.7%)) with poorer self-perceived QoL (QoL-ADp < QoL-ADc). Patient's education level, depressive symptoms, and severity of neuropsychiatric symptoms predicted magnitude of discrepancy. Depression (OR = 1.17, 95% CI = 1.02-1.35) and being cared for by other relative (non-spouse/adult child; OR = 7.54, 95% CI = 1.07-53.03) predicted poorer self-perceived QoL. CONCLUSIONS: Dyadic rating discrepancy in QoL should draw the clinician's attention to patient depression and neuropsychiatric symptoms. Consideration should also be given to nature of patient-caregiver relationship when discordance between patient and caregiver assessments of QoL is observed.

Worry about performance: a unique dimension of caregiver burden.

BACKGROUND: Recent studies that describe the multidimensionality of the Zarit Burden Interview (ZBI) challenge the traditional dual-factor paradigm of personal and role strains (Whitlatch et al., 1991). These studies consistently reported a distinct dimension of worry about caregiver performance (WaP) comprising items 20 and 21.The present study aims to compare WaP against conventional ZBI domains in a predominantly Chinese multi-ethnic Asian population. METHODS: We studied 130 consecutive dyads of family caregivers and patients. Factor analysis of the 22-item ZBI revealed four factors of burden. We compared WaP (factor 4) with the other three factors, personal strain, and role strain via: internal consistency; inter-factor correlation; item-to-total ratio across Clinical Dementia Rating (CDR) stages; predictors of burden; and interaction effect on total ZBI score using two-way analysis of variance. RESULTS: WaP correlated poorly with the other factors (r = 0.05-0.21). It had the highest internal consistency (Cronbach's α = 0.92) among the factors. Unlike other factors, WaP was highly endorsed in mild cognitive impairment and did not increase linearly with disease severity, peaking at CDR 1. Multiple regression revealed younger caregiver age as the major predictor of WaP, compared with behavioral and functional problems for other factors. There was a significant interaction between WaP and psychological strain (p = 0.025). CONCLUSION: Our results corroborate earlier studies that WaP is a distinct burden dimension not correspondent with traditional ZBI domains. WaP is germane to many Asian societies where obligation values to care for family members are strongly influential. Further studies are needed to better delineate the construct of WaP.

Cost of informal care for community-dwelling mild-moderate dementia patients in a developed Southeast Asian country.

BACKGROUND: Cost of informal care constitutes an important component of total dementia care cost. It also reflects resource utilization by patients and caregivers. We aim to quantify the informal cost of care for mild to moderate dementia patients. METHODS: We recruited 165 patient-caregiver dyads with mild to moderate dementia. Informal care burden was assessed using the Resource Utilization in Dementia (RUD)-Lite instrument. A generalized linear model was fitted for association between cost of informal care and cognitive impairment, taking into account patient demographics, disease factors, and use of paid domestic help. Marginal estimates were obtained from the model for the purpose of illustration and discussion. RESULTS: Total hours of informal care by primary caregiver doubled in moderate dementia patients, with 57.9% having paid domestic help to assist in care. Functional factors and use of paid domestic help were significantly associated with informal care costs. Costs were consistently higher for patients without paid domestic help for mild- and moderate dementia. CONCLUSION: This study demonstrates the informal care costs of caring for mild-moderate dementia patients in Singapore, with the unique cost savings provided by live-in paid domestic help, and potentially may aid policy-makers in allocation of resources and support to caregivers.

Multidimensionality of the Zarit Burden Interview across the severity spectrum of cognitive impairment: an Asian perspective.

BACKGROUND: We aimed to examine the multidimensionality of the Zarit Burden Interview (ZBI) beyond the conventional dual-factor structure among caregivers of persons with cognitive impairment in a predominantly Chinese multiethnic Asian population, and ascertain how these dimensions vary across the spectrum of disease severity. METHODS: We studied 130 consecutive dyads of primary caregivers and patients attending a memory clinic over a six-month period. Caregiver burden was measured by the 22-item ZBI, and disease severity was staged via the Clinical Dementia Rating (CDR) scale. We performed principal component analysis (PCA) with varimax rotation to determine the factor structure of the ZBI. The magnitude of burden in each factor was expressed as the item to total ratio (ITR) and plotted against the stages of cognitive impairment. Descriptive and inferential statistics were applied to study the relationships between dimensions with disease and caregiver characteristics. RESULTS: We identified four factors: demands of care and social impact, control over the situation, psychological impact, and worry about caregiving performance. ITRs of the first three factors increased with severity of disease and were related to recipients' functional status and disease characteristics. ITR in the dimension of worry about performance was endorsed highest across the spectrum of disease severity, starting as early as the stage of mild cognitive impairment and peaking at CDR 1. CONCLUSION: Multidimensionality of ZBI was confirmed in our local setting. Each dimension of burden was unique and expressed differentially across disease severity. The dimension of worry about performance merits further study.

The relationship among antibiotic consumption, socioeconomic factors and climatic conditions.

BACKGROUND: Antibiotic consumption in human populations is one of the factors responsible for the emergence of resistant organisms. It is important to track population-based data on an ongoing basis, and to explore the determinants of regional variation in antibiotic consumption. METHODS: Population-level data were obtained on all outpatient oral antibiotic prescriptions dispensed within British Columbia (BC) between 1996 and 2007. Prescriptions were expressed as the defined daily dose per 1000 inhabitants. Geographical information systems mapping was used to display the spatial variations of antibiotic consumption in BC. The relationships among antibiotic consumption, socioeconomic factors and climatic conditions were explored using Pearson's correlation and regression modelling. RESULTS: Overall antibiotic consumption was highest in the northern regions of BC. Higher rates of consumption were associated with a greater proportion of the Aboriginal population, lower levels of education and individuals younger than 15 years of age. An inverse correlation was found between some classes of antibiotics and the following factors: individuals older than 65 years of age, mortality rate, doctor-to-population ratio, household size and higher July temperatures. The adjusted regression analyses indicated that higher antibiotic consumption was associated with a higher proportion of Aboriginals and household income. CONCLUSION: Different rates of antibiotic consumption exist within BC. The use of antibiotics is correlated with several socioeconomic factors and climatic conditions. It may be useful to consider these factors when designing policies to address antibiotic consumption in the community.