Heterogeneity in the risk of cardiovascular disease mortality after the hypertensive disorders of pregnancy across mothers' lifetime reproductive history.

BACKGROUND: Prior studies on maternal cardiovascular disease (CVD) mortality and hypertensive disorders of pregnancy (HDP) have focused only on a woman's first birth and have not accounted for successive affected pregnancies. OBJECTIVES: The objective of this study is to identify mothers' risk of CVD mortality considering lifetime reproductive history. METHODS: We used data from the Medical Birth Registry of Norway, the Norwegian Cause of Death Registry, and the Norwegian National Population Register to identify all mothers who gave birth from 1967 to 2020. Our outcome was mothers' CVD death before age 70. The primary exposure was the lifetime history of HDP. The secondary exposure was the order of HDP and gestational age at delivery of pregnancies with HDP. We used Cox regression models to estimate hazard ratio (HR) and 95% confidence interval (CI), adjusting for education, mother's age, and year of last birth. These models were stratified by the lifetime number of births. RESULTS: Among 987,378 mothers, 86,294 had HDP in at least one birth. The highest CVD mortality, relative to mothers without HDP, was among those with a pre-term HDP in their first two births, although this represented 1.0% of mothers with HDP (HR 5.12, 95% CI 2.66, 9.86). Multiparous mothers with term HDP in their first birth only had no increased risk of CVD relative to mothers without HDP (36.9% of all mothers with HDP; HR 1.12, 95% CI 0.95, 1.32). All other mothers with HDP had a 1.5- to 4-fold increased risk of CVD mortality. CONCLUSIONS: This study identified heterogeneity in the risk of CVD mortality among mothers with a history of HDP. A third of these mothers are not at higher risk compared to women without HDP, while some less common patterns of HDP history are associated with severe risk of CVD mortality.

Prevalence and correlates of workplace violence: descriptive results from the National Transgender Discrimination Survey.

OBJECTIVE: To describe the lifetime prevalence of workplace harassment, physical violence and sexual assault against transgender and non-binary workers targeted due to their gender identity and to identify correlates of this workplace violence. METHODS: This descriptive cross-sectional study used data from 4597 transgender or non-binary respondents from the 2008-2009 National Transgender Discrimination Survey. Respondents reported if they had ever experienced harassment, physical violence or sexual assault at work specifically because of their gender identity. We estimated the prevalence of each type of violence stratified by gender identity, race/ethnicity, age, educational attainment, history of working in the street economy (eg, sex industry, drug sales) and if people at work knew their gender identity. RESULTS: Workplace violence was prevalent, with 50% of transgender and non-binary workers having ever experienced harassment, 7% physical violence and 6% sexual assault at work because of their gender identity. Harassment was common among all of these workers, but physical violence and sexual assault were more than twice as common among transfeminine and non-binary workers assigned male at birth, workers of colour, workers with low educational attainment and those who had ever worked in the street economy. CONCLUSIONS: Transgender and non-binary workers commonly face violence at work because of their gender identity. Workplace violence prevention programmes should incorporate ways to prevent gender identity-based violence and facilitate channels for workers to report the occurrence of discrimination and violence.

Trajectories of negative and positive experiences of caregiving for older adults with severe dementia: application of group-based multi-trajectory modelling.

BACKGROUND: Family caregivers of older adults with severe dementia have negative and positive experiences over the course of caregiving. We aimed to delineate joint trajectories (patterns over time) for negative and positive experiences, identify risk factors associated with membership of joint trajectories, and ascertain the association between joint trajectories and caregivers' outcomes after the death of the older adult. METHODS: Two hundred fifteen family caregivers of older adults with severe dementia in Singapore were surveyed every 4 months for 2 years, and 6 months after the death of the older adult. Using group-based multi trajectory modelling, we delineated joint trajectories for positive (Gain in Alzheimer Care Instrument) and negative (sub-scales of modified Caregiver Reaction Assessment) experiences of caregiving. RESULTS: We identified four joint trajectories - "very high positive, low negative" (23% of caregivers), "high positive, moderate negative" (28%), "very high positive, moderate negative" (28%), and "high positive, high negative" (21%). Caregivers of older adults with more behavioural symptoms, and who did not receive strong emotional support from family were more likely to have "high positive, moderate negative" or "very high positive, moderate negative" trajectory. Compared to caregivers with "very high positive, low negative" trajectory, caregivers with "very high positive, moderate negative" or "high positive, high negative" trajectories expressed greater grief and distress, with the latter also having lower spiritual well-being and quality of life at 6 months after the death of the older adult. CONCLUSION: The caregiving experiences for older adults with severe dementia vary between caregivers but remain stable over time. Modifiable risk factors identified for trajectories involving negative experiences of caregiving may be targeted in future interventions to improve the experience of caregiving and caregiver quality of life and distress after the death of the older adult. TRIAL REGISTRATION: http://www. CLINICALTRIALS: gov (NCT03382223).

Development of the Parental Experience with Care for Children with Serious Illnesses (PRECIOUS) quality of care measure.

BACKGROUND: Parent-reported experience measures are part of pediatric Quality of Care (QoC) assessments. However, existing measures were not developed for use across multiple healthcare settings or throughout the illness trajectory of seriously ill children. Formative work involving in-depth interviews with parents of children with serious illnesses generated 66 draft items describing key QoC processes. Our present aim is to develop a comprehensive parent-reported experience measure of QoC for children with serious illnesses and evaluate its content validity and feasibility. METHODS: For evaluating content validity, we conducted a three-round Delphi expert panel review with 24 multi-disciplinary experts. Next, we pre-tested the items and instructions with 12 parents via cognitive interviews to refine clarity and understandability. Finally, we pilot-tested the full measure with 30 parents using self-administered online surveys to finalize the structure and content. RESULTS: The Delphi expert panel review reached consensus on 68 items. Pre-testing with parents of seriously ill children led to consolidation of some items. Pilot-testing supported feasibility of the measure, resulting in a comprehensive measure comprising 56 process assessment items, categorized under ten subthemes and four themes: (1) Professional qualities of healthcare workers, (2) Supporting parent-caregivers, (3) Collaborative and holistic care, and (4) Efficient healthcare structures and standards. We named this measure the PaRental Experience with care for Children with serIOUS illnesses (PRECIOUS). CONCLUSIONS: PRECIOUS is the first comprehensive measure and has the potential to standardize assessment of QoC for seriously ill children from parental perspectives. PRECIOUS allows for QoC process evaluation across contexts (such as geographic location or care setting), different healthcare workers, and over the illness trajectory for children suffering from a range of serious illnesses.

Exploring perceptions of frailty, resilience, and self-efficacy in older adults and caregivers in acute care context.

This study aimed to explore the experience and perceptions of frailty in hospitalized older adults and caregivers caring for older adults, in relation to resilience and self-efficacy. A qualitative explorative descriptive study design was utilized. Face to face interviews were conducted from September 2020 to July 2021 with 24 older adults who were 65 years and above and hospitalized in the acute care hospital. Ten informal family caregivers were also recruited. Data were analysed using an inductive content analysis approach. Frailty encompassed physical elements as well as manifestations of psychological traits, fear of the unknown, and being in control. Resilience was determined by individual psychological traits and mindset, and the possession of a coping mechanism. Self-efficacy could influence both frailty and resilience through inner motivation and assistance received. Older adults and family caregivers reported that considerable decline in physical health with age and level of perseverance can determine the level of frailty. Resilience and self-efficacy play a pivotal role in the context of frailty. Understanding resilience in this context will assist nurses to facilitate the use of individual and sociocultural resources to improve the way resilience is experienced by older adults. Various coping strategies can enhance self-efficacy and build greater resilience in older adults, including maintaining their active involvement in health management and social life.

Care sequences leading to the diagnosis of Alzheimer's disease and related dementias: An analysis of electronic health records.

BACKGROUND: We examined the sequences of clinical care leading to diagnoses of Alzheimer's disease and related dementias (ADRD) using electronic health records from a large academic medical center. METHODS: We included patients aged 65+ with their first ADRD diagnoses from January 1, 2014 to December 31, 2019. Using state sequence analysis, care sequences were defined by the ordering of healthcare utilizations occurred in the 2 years before ADRD diagnosis. RESULTS: Of 3621 patients (median age 80), nearly half followed a care sequence of having one primary care visit close to their ADRD diagnosis. Additional care sequences included periodic (n = 322, 8.9%) and multiple (n = 416, 11.5%) outpatient visits to primary care and having one (n = 395, 10.9%), multiple (n = 469, 13.0%), or highly frequent (n = 357, 10.7%) outpatient visits to other specialties. Patients' sociodemographic traits contributed to the variability in care sequences. CONCLUSIONS: Several distinct patterns of care leading to ADRD diagnoses were identified. Integrated care models are needed to promote early identification of ADRD. HIGHLIGHTS: Dementia patients followed distinct care pathways prior to their dementia diagnoses. Key sociodemographic traits contributed to the variation in the sequences of care. Racial differences in the sequencing of care were also found, but only in women.

Racial difference in the association between non-alcoholic fatty liver disease and incident type 2 diabetes: findings from the CARDIA study.

AIMS/HYPOTHESIS: Type 2 diabetes and non-alcoholic fatty liver disease (NAFLD) are prevalent diseases of metabolic origin. We examined the association between NAFLD and the development of type 2 diabetes among non-Asian adults, and whether the association differs by race. METHODS: We analysed data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based prospective cohort study. Participants underwent non-contrast abdominal computed tomography (CT) at baseline (2010-2011) and assessment of glucose measures at the follow-up exam (2015-2016). NAFLD was defined as liver attenuation ≤51 Hounsfield units on CT images after exclusion for other liver fat causes. Race was self-reported. We used targeted maximum likelihood estimation (TMLE) with machine-learning algorithms to estimate difference in type 2 diabetes risk between the NAFLD and non-NAFLD groups. RESULTS: Of the 1995 participants without type 2 diabetes at baseline (mean age±SD, 50.0±3.6 years; 59% women; 55.0% White and 45.0% Black), 21.7% of White and 16.8% of Black participants had NAFLD at baseline, and 3.7% of White and 8.0% of Black participants developed type 2 diabetes at follow up. After multivariable adjustment, risk difference for type 2 diabetes associated with NAFLD vs no NAFLD was 4.1% (95% CI 0.3%, 7.9%) among White participants and -1.9% (95% CI -5.7%, 2.0%) in Black participants. CONCLUSIONS/INTERPRETATION: NAFLD was associated with a higher risk of type 2 diabetes among White participants but not among Black participants. This finding suggests that the effect of liver fat on impaired glucose metabolism may be smaller in Black than in White individuals.

Derivation, and establishment of the validity and reliability, of the CASP-11-SG quality of life scale among community-dwelling older adults.

PURPOSE: The number and proportion of older adults, aged ≥ 60 years, in Singapore is rapidly increasing. A valid and reliable quality of life (QoL) measure will enable assessment of their situation and help evaluate social and clinical interventions, potentially improving care. This study aims to evaluate the validity and reliability of the control, autonomy, self-realization, and pleasure (CASP)-12v.3 QoL scale and establish a scale suitable for use among older adults in Singapore. METHODS: Data from 3526 community-dwelling older adults from a national survey was used. Measurement properties of the CASP-12v.3 scale were evaluated. Confirmatory factor analysis (CFA; testing single- and two-factor models with residual covariances for negatively worded items and a bifactor model) was performed in half of the sample and exploratory factor analysis (EFA) was performed in the other half. The results led to revised CFA models and the CASP-11-SG scale. The CASP-11-SG scale's measurement properties, convergent, and known-groups validity, and measurement equivalence/invariance (ME/I) across English and Chinese languages were evaluated. RESULTS: Item 3 'I feel free to plan for the future' of the CASP-12v.3 scale had low correlation with other items of the control/autonomy subscale, low item-total correlation and high item-scale correlation. While CFA and EFA supported the two-factor model, removing item 3 improved model fit. The resulting CASP-11-SG scale (Cronbach's alpha: 0.81) demonstrated convergent and known-groups validity and partial ME/I across English and Chinese languages. CONCLUSION: The CASP-11-SG scale, with satisfactory psychometric properties, can be used for assessing QoL among older adults in Singapore.

Generativity and Engagement in Grandparenting Activities Among Older Adults in Northern Sri Lanka.

Generativity refers to the desire to pass on one's skills, knowledge, and wisdom to future generations; this may be a clear indicator of the likelihood of older adults investing time and effort in engagement with their grandchildren. This cross-sectional study examines the relationship between generative beliefs and an index of multiple potential grandparenting activities. The data come from a convenience sample of 79 grandparents (aged 55+) living in Sri Lanka, a society experiencing rapid growth in its population of older adults. Regression analyses demonstrate that more endorsement of generative beliefs among older adults is associated with increased engagement in various grandparenting activities, with the strongest associations with reading, singing songs, and helping grandchildren with schoolwork or teaching them. Our findings suggest that generativity may be important for understanding the relationship between grandparenting and improved well-being for older adults.

Caregivers' Absenteeism and Its Association With Health Shocks and Functional Impairment Among Persons With Severe Dementia.

Adult child caregivers of persons with severe dementia (PWSDs) experience absenteeism due to caregiving. We quantified employed adult child caregivers' absenteeism; its association with PWSDs' functional impairment and health shocks; and characteristics of caregivers not experiencing absenteeism in the presence of PWSDs' health shocks and high functional impairment. We used a prospective cohort of 111 employed adult child caregivers of community-dwelling PWSDs in Singapore surveyed every 4 months for 1 year. We calculated absenteeism days due to caregiving and the corresponding absenteeism cost. Findings showed that 43% of the caregivers experienced absenteeism due to caregiving at least once during 1 year. On average, in a month, caregivers experienced 2.3 (SD = 5.9) absenteeism days and S$758 (SD = 2120) absenteeism cost. Those caring for PWSDs with high functional impairment experienced an additional 2.5 absenteeism days and S$788 absenteeism cost versus caregivers of PWSDs with low functional impairment. Caregivers whose PWSDs experienced a health shock experienced an additional 1.8 absenteeism days and S$772 absenteeism cost versus caregivers of PWSDs without a health shock. Co-residence with PWSDs worsened the impact of PSWDs' high functional impairment on caregivers absenteeism. Caregivers not co-residing with PWSDs and not using a maladaptive coping style were less likely to experience absenteeism when caring for PWSDs with a health shock. Results suggest a need to support caregivers of PWSDs to better cope with their caregiving in order to mitigate caregivers' absenteeism.

Grandparenting activities and mental health in Northern Sri Lanka.

Grandparenting activities are of increasing interest to researchers seeking to understand reduced social engagement and depression among aging adults. Heterogeneity in the population and caretaking roles complicate its measurement. We piloted a measure of grandparenting activities among 79 grandparents (aged 55+) in Sri Lanka and correlated those activity levels with psychological distress. Second, we explored whether the aforementioned correlation varied by grandparent functional limitations. We found that greater engagement in generative grandparenting activities was correlated with lower distress, and that association was stronger among grandparents with more functional limitations. We discuss possible explanations and implications of these findings.

Elucidating the role of a positive family history in differentiating between axial and peripheral spondyloarthritis: an ancillary analysis of the ASAS-PerSpA study.

OBJECTIVES: Positive family history (PFH) of spondyloarthritis (SpA) is important in the diagnosis of SpA. However, the contribution of a PFH in differentiating the two SpA subtypes (axial and peripheral spondyloarthritis (pSpA)), in particular the importance of second-degree relative (SDR) has not been well-studied. We aimed to investigate whether PFH of radiographic axial spondyloarthritis (r-axSpA), psoriasis, uveitis, reactive arthritis and inflammatory bowel disease in first-degree relative (FDR) and second-degree relative (SDR) contributes to differentiation between axSpA and pSpA using the data from a multinational cohort study. METHODS: The ASAS-PerSpA study dataset was used to assess the effects of a PFH on differentiating between axSpA and pSpA via generalised structural equation modelling. Model building using backward selection was performed to obtain a final model. Direct, indirect and total effects of the path analysis were calculated. RESULTS: A total of 3803 patients were included: 2458 axSpA and 1345 pSpA patients. FDR (OR: 3.75, 95% CI: 2.86-4.91, p<0.001) and SDR (OR: 4.58, 95% CI: 3.19-6.59, p<0.001) with r-axSpA were positively associated while FDR (OR: 0.262, 95% CI: 0.207-0.331, p<0.001) and SDR (OR: 0.305, 95% CI: 0.221-0.420, p<0.001) with psoriasis were negatively associated with differentiating patients with axSpA from pSpA. CONCLUSIONS: The presence of r-axSpA and psoriasis in FDR or SDR are useful in differentiating axSpA from pSpA. SDR with r-axSpA may contribute greater towards the differentiation than FDR. Clinicians should consider taking an extensive family history of SpA and their subtypes to better differentiate the subtypes within the SpA spectrum.

The prevalence and incidence of pharmacologically treated diabetes among older people receiving home care services in Norway 2009-2014: a nationwide longitudinal study.

BACKGROUND: A substantial proportion of older people who receive home care services (HCS) has diabetes and requires diabetes specific monitoring, treatment and self-care assistance. However, the prevalence and incidence rates of diabetes among older people in HCS are poorly described. The aim of the study is to estimate prevalence, incidence and time trends of pharmacologically treated diabetes among older people receiving HCS in Norway 2009-2014. METHODS: This nationwide observational cohort study is based on data from two population registries. The study population consisted of persons registered in the Norwegian Information System for the Nursing and Care Sector aged ≥ 65 years receiving HCS during at least one of the years 2009-2014. The Norwegian Prescription Database was utilized to identify participants' prescriptions for glucose lowering drugs (GLD). The period prevalence was calculated each year as persons with one or more prescriptions of GLD in the current or previous year. Incident cases were defined as subjects receiving prescriptions of GLD for the first time in the given calendar year if there were no prescriptions of any GLD for that person during the previous two years. RESULTS: From 2009 to 2014, the number of older people receiving HCS increased from 112,487 to 125,593. The proportion of these who received GLD increased from 14.2% to 15.7% (p < 0.001) and was significantly higher among men than women. The annual incidence rate of diabetes among those receiving HCS showed a decreasing trend from 95.4 to 87.5 cases per 10,000 person-years from 2011 to 2014, but when stratifying on age group and gender, was significant only among the oldest women (age groups 85-89 years and 90 +). CONCLUSIONS: The increasing prevalence of older people with diabetes who receive HCS highlights the importance of attention to treatment and care related to diabetes in the HCS.

Paid sick leave among US private sector employees.

BACKGROUND: Inequities in US employees' access to paid sick leave are known, but it is not clear whether they are increasing or decreasing over time. More than two dozen state and local paid sick leave laws were recently enacted, many with the stated goal of reducing inequities in access to paid sick leave. We examined how inequities in access to paid sick leave have changed over time, focusing on the years when these laws were coming into effect. METHODS: Private sector employees participating in the National Health Interview Survey between 2006 (before laws came into effect) and 2018 (after most came into effect) reported if they had paid sick leave in their main job. We examined how differences in access to paid sick leave by Census region, race/ethnicity, work hours, and educational attainment changed over time. RESULTS: The percentage of employees with access to paid sick leave increased from 56% in 2006 to 61% in 2018, with most of the increases in access occurring in the West. Inequities by race/ethnicity decreased substantially between 2015 and 2018, the years when most paid sick leave laws came into effect. This change was driven by Hispanic and Latino workers rapidly gaining access to paid sick leave during this time. Differences in access to paid sick leave by work hours and education attainment remained stable over time. CONCLUSIONS: Inequities in access to paid sick leave remain. Paid sick leave laws could be effective means to increase access to paid sick leave and equalize access.

Antenatal depression in Sri Lanka: a qualitative study of public health midwives' views and practices.

BACKGROUND: Almost all pregnant people in Sri Lanka receive antenatal care by public health midwives. While there is strong infrastructure in Sri Lanka for postpartum mental health care, the current practices within antenatal mental health care have not been externally evaluated. The purpose of this study is to investigate the current clinical guidelines and experiences of how public health midwives diagnose and treat antenatal depression. METHODS: We conducted in-depth interviews with 12 public health midwives from four antenatal clinics in the Bope Poddala division in Galle, Sri Lanka and reviewed and extracted information on antenatal depression from clinical guidelines. Data was collected in Sinhala and translated into English. We used applied thematic analysis and worked closely with our local team to ensure data trustworthiness. RESULTS: Midwives (n = 12) reported varying degrees of knowledge on antenatal depression and did not have standardized diagnosis patterns. However, they were very consistent in their clinical practices, following guidelines for referral and follow-up of case management, building strong rapport. In their practice, midwives continue to face challenges of lack of human resources and high stigma around mental illness. They suggested that that care could be improved with use of a standardized diagnostic tool, and easier access to specialist care. We found the clinical guideline on the diagnosis and treatment of antenatal depression is lacking key details on symptoms for appropriate diagnosis, but it clearly guides on how to navigate treatment. CONCLUSIONS: Public health midwives are following the clinical guideline to refer pregnant women who need intervention for antenatal depression and follow-up for case management. However, there is a need for more specific and context-relevant guidelines, especially for diagnosis of antenatal depression. Formative research is needed to explore intervention strategies to improve antenatal depression management in Sri Lanka.

We interviewed 12 midwives at pregnancy clinics in southern Sri Lanka about what happens if a pregnant woman gets depressed. Some midwives knew a lot about depression, while others did not know very much. They all had different ideas of what the signs of depression were, and what percentage of pregnant women are usually depressed. They have a rule book about how to be a midwife, but it is not clear about how they should find out if a pregnant woman has depression. However, all midwives agreed on what they should do if they meet a depressed woman during an antenatal appointment in their clinic, following the rule book closely. They said they need to tell their supervisor, who will tell a psychiatrist who can treat the depression. However, sometimes there are problems. Midwives said that they, their supervisor and the psychiatrist are all very busy and don't have enough time to spend with pregnant women. Also, a lot of the women in their clinics don't want to get treated because they feel embarrassed about having depression, and don't want other people to know. Midwives told us they could do their jobs better if they could give a quick test for depression to every woman visiting their clinic. This would be an easy solution, because they already use a test like this for after women give birth.

How good are medical and death records for identifying dementia?

INTRODUCTION: Retrospective studies using administrative data may be an efficient way to assess risk factors for dementia if diagnostic accuracy is known. METHODS: Within-individual clinical diagnoses of Alzheimer's disease (AD) and all-cause dementia in ambulatory (outpatient) surgery, inpatient, Medicare administrative records and death certificates were compared with research diagnoses among participants of Cache County Study on Memory, Health, and Aging (CCSMHA) (1995-2008, N = 5092). RESULTS: Combining all sources of clinical health data increased sensitivity for identifying all-cause dementia (71%) and AD (48%), while maintaining relatively high specificity (81% and 93%, respectively). Medicare claims had the highest sensitivity for case identification (57% and 40%, respectively). DISCUSSION: Administrative health data may provide a less accurate method than a research evaluation for identifying individuals with dementing disease, but accuracy is improved by combining health data sources. Assessing all-cause dementia versus a specific cause of dementia such as AD will result in increased sensitivity, but at a cost to specificity.

Mental well-being in Sri Lankan medical students: a cross-sectional study.

Preventing burnout and promoting positive mental health among medical students is important. Relevant research is lacking on positive mental health in medical students, particularly in low- and middle-income countries. We conducted a cross-sectional survey of Sri Lankan students enrolled in a five-year medical program. Measures included the Mental Health Continuum-Short Form, Kessler 10 Psychological Distress Scale, and Oldenburg Burnout Inventory. We investigated relationships between year in program, mental health indicators, and academic performance. Three hundred twenty-seven students participated (35% response rate). Most students had moderate positive mental health (64.8%) and severe psychological distress (40.4%). Final year students reported more psychological distress and burnout than first year students. Female students had higher burnout scores than males. In multivariable models, fourth and fifth year students evidenced lower positive mental health than first year students. Mental health indicators were unassociated with academic performance. Overall, distress rates were higher than those reported among students in other countries. Higher burnout and distress may be driven by increased responsibilities in the final clinical years of training. Bolstering positive mental health through positive emotions, meaning, and social connection may minimize burnout and distress, although extracurricular activities require time. Interventions to reduce medical student distress in Sri Lanka are needed.

An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks.

OBJECTIVE: To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)'s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups. METHODS: We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data. RESULTS: We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO's five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO's five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups. CONCLUSION: Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence. PROTOCOL REGISTRATION: PROSPERO Identifier: CRD42020181316.

Discordance between dementia caregivers' goal of care and preference for life-extending treatments.

BACKGROUND: Many older adults with severe dementia receive potentially life-extending treatments even when caregivers do not wish to prolong their life inappropriately. OBJECTIVE: Explore factors that influence caregiver preferences for potentially life-extending treatments for older adults with severe dementia, and reasons for discordance between overall end-of-life care goal and treatment preferences. DESIGN: Semi-structured in-depth interviews asking caregivers their overall end-of-life care goal for older adults and preferences for intravenous (IV) antibiotics, tube feeding and cardiopulmonary resuscitation (CPR). PARTICIPANTS: A total of 26 caregivers of community-dwelling older adults with severe dementia in Singapore. APPROACH: Reflexive thematic analysis. RESULTS: Most caregivers' (77%) overall end-of-life care goal was 'no life extension'. Yet, 80% preferred IV antibiotics for a life-threatening infection, 60% preferred tube feeding and 45% preferred CPR. Caregivers preferred these treatments because they (1) perceived letting go by withholding treatments as unethical, (2) felt they had no choice as they deferred to the health care provider, (3) wanted to alleviate suffering rather than extend life and (4) desired trying minimally invasive treatments that had the potential to be withdrawn. Themes explaining discordance were (1) feared regret about making the 'wrong' decision, (2) considered treatments to address immediate needs even when long-term goal did not match providing that treatment and (3) anticipated disagreement with other family members on overall goal of care. CONCLUSION: To reduce discordance between caregivers' overall end-of-life care goal and preferences for life-extending treatments, clinicians can use a shared decision-making approach involving discussions of both their overall end-of-life care goal and treatment preferences.

Predictors and occurrence of antenatal depressive symptoms in Galle, Sri Lanka: a mixed-methods cross-sectional study.

BACKGROUND: There is a high prevalence of antenatal depression in low-or-middle-income countries, but information about risk factors in these settings is still lacking. The purpose of this study is to measure the prevalence of and explore risk factors associated with antenatal depressive symptoms in Galle, Sri Lanka. METHODS: This study used a mixed-method approach. The quantitative portion included 505 pregnant women from Galle, Sri Lanka, with health record data, responses to psychometric questionnaires (MSPSS and PRAQ-R2), and antenatal depression screening (EPDS). The qualitative portion included interviews with public health midwives about their experiences and routine clinical practices with women with antenatal depressive symptoms. RESULTS: Prevalence of antenatal depressive symptoms was 7.5%, highest in women over the age of 30 (13.0%, OR = 3.88, 95%CI = 1.71 - 9.97), with diabetes (21.9%, OR = 3.99, 95%CI = 1.50 - 9.56), or pre-eclampsia in a previous pregnancy (19.4%, OR = 3.32, 95%CI = 1.17 - 8.21). Lower prevalence was observed in the primiparous (3.3%, OR = 0.29, 95%CI = 0.12 - 0.64) employed outside the home (3.6%, OR = 0.33, 95%CI = 0.13 - 0.72), or upper-middle class (2.3%, OR = 0.17, 95%CI = 0.04 - 0.56). Anxiety levels were elevated in depressed women (OR = 1.13, 95%CI = 1.07 - 1.20), while perceived social support was lower (OR = 0.91, 95%CI = 0.89 - 0.93). After multivariable adjustment, only parity (OR = 0.20, 95%CI 0.05 - 0.74) and social support from a "special person" (OR = 0.94, 95%CI = 0.77 - 0.95) remained significantly associated with depressive symptoms. Qualitative findings also identified antenatal health problems and poor social support as risk factors for depressive symptoms. They also identified different contributing factors to poor mental health based on ethnicity, higher stress levels among women working outside the home, and misinformation about health conditions as a cause of poor mental health. CONCLUSIONS: Prevalence of antenatal depressive symptoms in Galle is lower than the recorded prevalence in other regions of Sri Lanka. Risk factors for antenatal depressive symptoms were identified on biological, psychological, and social axes. These variables should be considered when developing future guidelines for mental health and obstetric treatment in this context.