Outcomes of advance care directives after admission to a long-term care home: DNR the DNH?

BACKGROUND: Residents of long-term care homes (LTCH) often experience unnecessary and non-beneficial hospitalizations and interventions near the end-of-life. Advance care directives aim to ensure that end-of-life care respects resident needs and wishes. METHODS: In this retrospective cohort study, we used multistate models to examine the health trajectories associated with Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) directives of residents admitted to LTCH in Ontario, Alberta, and British Columbia, Canada. We adjusted for baseline frailty-related health instability. We considered three possible end states: change in health, hospitalization, or death. For measurements, we used standardized RAI-MDS 2.0 LTCH assessments linked to hospital records from 2010 to 2015. RESULTS: We report on 123,003 LTCH residents. The prevalence of DNR and DNH directives was 71 and 26% respectively. Both directives were associated with increased odds of transitioning to a state of greater health instability and death, and decreased odds of hospitalization. The odds of hospitalization in the presence of a DNH directive were lowered, but not eliminated, with odds of 0.67 (95% confidence interval 0.65-0.69), 0.63 (0.61-0.65), and 0.47 (0.43-0.52) for residents with low, moderate and high health instability, respectively. CONCLUSION: Even though both DNR and DNH orders are associated with serious health outcomes, DNH directives were not frequently used and often overturned. We suggest that policies recommending DNH directives be re-evaluated, with greater emphasis on advance care planning that better reflects resident values and wishes.

Correction to: Time to move? Factors associated with burden of care among informal caregivers of cognitively impaired older people facing housing decisions: secondary analysis of a cluster randomized trial.

Following publication of the original article [1], we have been notified that one of the authors' given name and last names are reversed and misspelled and thus not reflected correctly (given name now is Painchaud-Guérard and it should be Geneviève and last name now is Geneviève and it should be Painchaud Guérard).

Variations in factors associated with healthcare providers' intention to engage in interprofessional shared decision making in home care: results of two cross-sectional surveys.

BACKGROUND: DOLCE (Improving Decision making On Location of Care with the frail Elderly and their caregivers) was a post-intervention clustered randomised trial (cRT) to assess the effect of training home care teams on interprofessional shared decision-making (IP-SDM). Alongside the cRT, we sought to monitor healthcare providers' level of behavioural intention to engage in an IP-SDM approach and to identify factors associated with this intention. METHODS: We conducted two cross-sectional surveys in the province of Quebec, Canada, one each at cRT entry and exit. Healthcare providers (e.g. nurses, occupational therapists and social workers) in the 16 participating intervention and control sites self-completed an identical paper-based questionnaire at entry and exit. Informed by the Integrated model for explaining healthcare professionals' clinical behaviour by Godin et al. (2008), we assessed their behavioural intention to engage in IP-SDM to support older adults and caregivers of older adults with cognitive impairment to make health-related housing decisions. We also assessed psychosocial variables underlying their behavioural intention and collected sociodemographic data. We used descriptive statistics and linear mixed models to account for clustering. RESULTS: Between 2014 and 2016, 271 healthcare providers participated at study entry and 171 at exit. At entry, median intention level was 6 in a range of 1 (low) to 7 (high) (Interquartile range (IQR): 5-6.5) and factors associated with intention were social influence (ß = 0.27, P <  0.0001), beliefs about one's capabilities (ß = 0.43, P <  0.0001), moral norm (ß = 0.31, P <  0.0001) and beliefs about consequences (ß = 0.21, P <  0.0001). At exit, median intention level was 5.5 (IQR: 4.5-6.5). Factors associated with intention were the same but did not include moral norm. However, at exit new factors were kept in the model: working in rehabilitation (ß = - 0.39, P = 0.018) and working as a technician (ß = - 0.41, P = 0.069) (compared to as a social worker). CONCLUSION: Intention levels were high but decreased from entry to exit. Factors associated with intention also changed from study entry to study exit. These findings may be explained by the major restructuring of the health and social care system that took place during the 2 years of the study, leading to rapid staff turnover and organisational disturbance in home care teams. Future research should give more attention to contextual factors and design implementation interventions to withstand the disruption of system- and organisational-level disturbances. TRIAL REGISTRATION: Clinicaltrials.gov (NCT02244359). Registered on September 19th, 2014.

Time to move? Factors associated with burden of care among informal caregivers of cognitively impaired older people facing housing decisions: secondary analysis of a cluster randomized trial.

BACKGROUND: Making health-related decisions about loved ones with cognitive impairment may contribute to caregiver burden of care. We sought to explore factors associated with burden of care among informal caregivers who had made housing decisions on behalf of a cognitively impaired older person. METHODS: We conducted a secondary analysis within a cluster randomized trial (cRT) conducted in 16 publicly-funded home care service points across the Province of Quebec. The cRT assessed the impact of training home care teams in interprofessional shared decision making (IP-SDM). We assessed burden of care with the Zarit Burden Interview (ZBI) scale. We adapted Pallett's framework to inform our data analysis. This framework posits that factors influencing burden of care among caregivers fall within four domains: (a) characteristics of the caregiver, (b) characteristics of the cognitively impaired older person, (c) characteristics of the relationship between the caregiver and the cognitively impaired older person, and (d) the caregiver's perception of their social support resources. We computed the ZBI score and performed multilevel linear regression modelling. RESULTS: Among 296 caregivers included in the dataset, the mean ZBI score was 29.8 (SD = 17.5) out of 88. The typical participant was 62.6 years old (SD = 11.7), female (74.7%), and caring for a mother or father (61.2%). Using multivariate analysis, factors significantly associated with caregiver burden mapped onto: caregiver characteristics (caregivers with higher burden were female, experienced higher decision regret and decisional conflict, preferred that their loved one move into the caregiver's home, into a private nursing home or a mixed private-public nursing home, and had made the decision more recently); relationship characteristics (spouses and children experienced higher burden); and caregiver's perception of social support resources (caregivers who perceived that a joint decision making process had occurred had higher burden). CONCLUSION: In line with the proposed framework used, we found that caregiver characteristics, relationship characteristics and caregiver's perception of social support resources were associated with burden of care. Our results will help design interventions to prevent and/or reduce caregivers' burden of care. TRIAL REGISTRATION: NCT02244359 . Date of registration: September 18, 2014.

Comparison of the prevalence rates of HIV infection between men who have sex with men (MSM) and men in the general population in sub-Saharan Africa: a systematic review and meta-analysis.

BACKGROUND: According to the 2015 report of the Joint United Nations Program on Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), the prevalence rates of HIV infection among men who have sex with men (MSM) varied from 6 to 37% depending on the country, far exceeding the national prevalence rates. The present study on HIV infection among men who have sex with men in sub-Saharan Africa was conducted to describe the different sampling methods used to identify this target population and compare the prevalence rates of HIV infection among MSM to that of men in the general population. METHODS: The selection of studies to be included was carried out in the principal electronic databases. The 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) directives were used throughout the entire process. Bias evaluation was performed using the Mixed Methods Appraisal Tool. For each country, HIV prevalence values in both groups were calculated. A prevalence ratio was also calculated to compare the prevalence rates of the two groups. RESULTS: Seventeen articles were selected. Most of the studies (82.35%) used the Respondent-Driven Sampling method. The average prevalence rate was 17.81% (range: 3.7-33.46) for MSM and 6.15% (range: 0.5-19.7) for men in the general population. Overall, the human HIV prevalence rate was 4.94 times higher among MSM than among men in the general population (95%CI: 2.91-8.37). The western and central regions of Africa, as well as low-prevalence countries (prevalence < 1%), had very high prevalence ratios: 14.47 (95% CI: 9.90-21.13) and 28.49 (95% CI: 11.47-72.71), respectively. CONCLUSION: MSM are at higher risk of HIV infection than men in the general population. The prevalence ratios are particularly elevated in West and Central Africa as well as in low-prevalence countries. Close monitoring of the situation, research and preventive measures are essential to control the epidemic amongst MSM.

Interventions for increasing the use of shared decision making by healthcare professionals.

BACKGROUND: Shared decision making (SDM) is a process by which a healthcare choice is made by the patient, significant others, or both with one or more healthcare professionals. However, it has not yet been widely adopted in practice. This is the second update of this Cochrane review. OBJECTIVES: To determine the effectiveness of interventions for increasing the use of SDM by healthcare professionals. We considered interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and five other databases on 15 June 2017. We also searched two clinical trials registries and proceedings of relevant conferences. We checked reference lists and contacted study authors to identify additional studies. SELECTION CRITERIA: Randomized and non-randomized trials, controlled before-after studies and interrupted time series studies evaluating interventions for increasing the use of SDM in which the primary outcomes were evaluated using observer-based or patient-reported measures. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane.We used GRADE to assess the certainty of the evidence. MAIN RESULTS: We included 87 studies (45,641 patients and 3113 healthcare professionals) conducted mainly in the USA, Germany, Canada and the Netherlands. Risk of bias was high or unclear for protection against contamination, low for differences in the baseline characteristics of patients, and unclear for other domains.Forty-four studies evaluated interventions targeting patients. They included decision aids, patient activation, question prompt lists and training for patients among others and were administered alone (single intervention) or in combination (multifaceted intervention). The certainty of the evidence was very low. It is uncertain if interventions targeting patients when compared with usual care increase SDM whether measured by observation (standardized mean difference (SMD) 0.54, 95% confidence interval (CI) -0.13 to 1.22; 4 studies; N = 424) or reported by patients (SMD 0.32, 95% CI 0.16 to 0.48; 9 studies; N = 1386; risk difference (RD) -0.09, 95% CI -0.19 to 0.01; 6 studies; N = 754), reduce decision regret (SMD -0.10, 95% CI -0.39 to 0.19; 1 study; N = 212), improve physical (SMD 0.00, 95% CI -0.36 to 0.36; 1 study; N = 116) or mental health-related quality of life (QOL) (SMD 0.10, 95% CI -0.26 to 0.46; 1 study; N = 116), affect consultation length (SMD 0.10, 95% CI -0.39 to 0.58; 2 studies; N = 224) or cost (SMD 0.82, 95% CI 0.42 to 1.22; 1 study; N = 105).It is uncertain if interventions targeting patients when compared with interventions of the same type increase SDM whether measured by observation (SMD 0.88, 95% CI 0.39 to 1.37; 3 studies; N = 271) or reported by patients (SMD 0.03, 95% CI -0.18 to 0.24; 11 studies; N = 1906); (RD 0.03, 95% CI -0.02 to 0.08; 10 studies; N = 2272); affect consultation length (SMD -0.65, 95% CI -1.29 to -0.00; 1 study; N = 39) or costs. No data were reported for decision regret, physical or mental health-related QOL.Fifteen studies evaluated interventions targeting healthcare professionals. They included educational meetings, educational material, educational outreach visits and reminders among others. The certainty of evidence is very low. It is uncertain if these interventions when compared with usual care increase SDM whether measured by observation (SMD 0.70, 95% CI 0.21 to 1.19; 6 studies; N = 479) or reported by patients (SMD 0.03, 95% CI -0.15 to 0.20; 5 studies; N = 5772); (RD 0.01, 95%C: -0.03 to 0.06; 2 studies; N = 6303); reduce decision regret (SMD 0.29, 95% CI 0.07 to 0.51; 1 study; N = 326), affect consultation length (SMD 0.51, 95% CI 0.21 to 0.81; 1 study, N = 175), cost (no data available) or physical health-related QOL (SMD 0.16, 95% CI -0.05 to 0.36; 1 study; N = 359). Mental health-related QOL may slightly improve (SMD 0.28, 95% CI 0.07 to 0.49; 1 study, N = 359; low-certainty evidence).It is uncertain if interventions targeting healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.30, 95% CI -1.19 to 0.59; 1 study; N = 20) or reported by patients (SMD 0.24, 95% CI -0.10 to 0.58; 2 studies; N = 1459) as the certainty of the evidence is very low. There was insufficient information to determine the effect on decision regret, physical or mental health-related QOL, consultation length or costs.Twenty-eight studies targeted both patients and healthcare professionals. The interventions used a combination of patient-mediated and healthcare professional directed interventions. Based on low certainty evidence, it is uncertain whether these interventions, when compared with usual care, increase SDM whether measured by observation (SMD 1.10, 95% CI 0.42 to 1.79; 6 studies; N = 1270) or reported by patients (SMD 0.13, 95% CI -0.02 to 0.28; 7 studies; N = 1479); (RD -0.01, 95% CI -0.20 to 0.19; 2 studies; N = 266); improve physical (SMD 0.08, -0.37 to 0.54; 1 study; N = 75) or mental health-related QOL (SMD 0.01, -0.44 to 0.46; 1 study; N = 75), affect consultation length (SMD 3.72, 95% CI 3.44 to 4.01; 1 study; N = 36) or costs (no data available) and may make little or no difference to decision regret (SMD 0.13, 95% CI -0.08 to 0.33; 1 study; low-certainty evidence).It is uncertain whether interventions targeting both patients and healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.29, 95% CI -1.17 to 0.60; 1 study; N = 20); (RD -0.04, 95% CI -0.13 to 0.04; 1 study; N = 134) or reported by patients (SMD 0.00, 95% CI -0.32 to 0.32; 1 study; N = 150 ) as the certainty of the evidence was very low. There was insuffient information to determine the effects on decision regret, physical or mental health-related quality of life, or consultation length or costs. AUTHORS' CONCLUSIONS: It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.

Factors associated with shared decision making among primary care physicians: Findings from a multicentre cross-sectional study.

BACKGROUND: Despite growing recognition that shared decision making (SDM) is central for patient-centred primary care, adoption by physicians remains limited in routine practice. OBJECTIVE: To examine the characteristics of physicians, patients and consultations associated with primary care physicians' SDM behaviours during routine care. METHODS: A multicentre cross-sectional survey study was conducted with 114 unique patient-physician dyads recruited from 17 primary care clinics in Quebec and Ontario, Canada. Physicians' SDM behaviours were assessed with the 12-item OPTION scale scored by third observers using audio-recordings of consultations. Independent variables included 21 physician, patient and consultation characteristics. We assessed factors associated with OPTION scores using multivariate linear regression models. RESULTS: On the OPTION scale, where higher scores indicated greater SDM behaviours, physicians earned an overall mean score of 25.7±9.8 of 100. In the final adjusted regression model, higher OPTION scores were associated with physicians' social participation (involvement in one committee ß=5.75, P=.04; involvement in two or more committees ß=7.74, P=.01), patients' status as employed (ß=6.48, P=.02), clinically significant decisional conflict in patients (ß=7.15, P=.002) and a longer duration of consultations (ß=0.23, P=.002). CONCLUSION: Physicians' social participation, patients' employment status and decisional conflict and the duration of consultations were associated with primary care physicians' SDM behaviours in routine care. These factors should be considered when designing strategies to implement SDM and promote more patient-centred care in primary care.

Effectiveness of interventions to address different types of vulnerabilities in community-dwelling older adults: An umbrella review.

Background: Frailty, social isolation, loneliness, and poverty may render older adults vulnerable to social or health stressors. It is imperative to identify effective interventions to address them especially in the context of COVID-19 pandemic. Objective: To identify effective community-based interventions to address frailty, social isolation, loneliness, and poverty among community-dwelling older adults. Design: Umbrella review. Data Source: We systematically searched PubMed, Ovid MEDLINE, Embase, Cochrane CENTRAL, EBM-Reviews, CINAHL via EBSCO, and APA PsycInfo via Ovid from January 2009 to December 2022. Eligibility Criteria: We included systematic reviews or quantitative reviews of non-pharmacologic interventions targeting community-dwelling older adults. Data Selection Extraction and Management: Two review authors independently screened the titles and abstracts, performed data extraction and appraised the methodological quality of the reviews. We used a narrative synthesis approach to summarize and interpret the findings. We assessed the methodological quality of the studies using AMSTAR 2.0 tool. Results: We identified 27 reviews incorporating 372 unique primary studies that met our inclusion criteria. Ten of the reviews included studies conducted in low-middle-income countries. Twelve reviews (46%, 12/26) included interventions that addressed frailty. Seventeen reviews (65%, 17/26) included interventions that addressed either social isolation or loneliness. Eighteen reviews included studies with single component interventions, while 23 reviews included studies with multi-component interventions. Interventions including protein supplementation combined with physical activity may improve outcomes including frailty status, grip strength, and body weight. Physical activity alone or in combination with diet may prevent frailty. Additionally, physical activity may improve social functioning and interventions using digital technologies may decrease social isolation and loneliness. We did not find any review of interventions addressing poverty among older adults. We also noted that few reviews addressed multiple vulnerabilities within the same study, specifically addressed vulnerability among ethnic and sexual minority groups, or examined interventions that engaged communities and adapted programs to local needs. Conclusion: Evidence from reviews support diets, physical activity, and digital technologies to improve frailty, social isolation or loneliness. However, interventions examined were primarily conducted under optimal conditions. There is a need for further interventions in community settings and conducted under real world settings in older adults living with multiple vulnerabilities.

Are shared decision making studies well enough described to be replicated? Secondary analysis of a Cochrane systematic review.

BACKGROUND: Interventions to change health professionals' behaviour are often difficult to replicate. Incomplete reporting is a key reason and a source of waste in health research. We aimed to assess the reporting of shared decision making (SDM) interventions. METHODS: We extracted data from a 2017 Cochrane systematic review whose aim was to determine the effectiveness of interventions to increase the use of SDM by healthcare professionals. In a secondary analysis, we used the 12 items of the Template for Intervention Description and Replication (TIDieR) checklist to analyze quantitative data. We used a conceptual framework for implementation fidelity to analyze qualitative data, which added details to various TIDieR items (e.g. under "what materials?" we also reported on ease of access to materials). We used SAS 9.4 for all analyses. RESULTS: Of the 87 studies included in the 2017 Cochrane review, 83 were randomized trials, three were non-randomized trials, and one was a controlled before-and-after study. Items most completely reported were: "brief name" (87/87, 100%), "why" (rationale) (86/87, 99%), and "what" (procedures) (81/87, 93%). The least completely reported items (under 50%) were "materials" (29/87, 33%), "who" (23/87, 26%), and "when and how much" (18/87, 21%), as well as the conditional items: "tailoring" (8/87, 9%), "modifications" (3/87, 4%), and "how well (actual)" (i.e. delivered as planned?) (3/87, 3%). Interventions targeting patients were better reported than those targeting health professionals or both patients and health professionals, e.g. 84% of patient-targeted intervention studies reported "How", (delivery modes), vs. 67% for those targeting health professionals and 32% for those targeting both. We also reported qualitative analyses for most items. Overall reporting of items for all interventions was 41.5%. CONCLUSIONS: Reporting on all groups or components of SDM interventions was incomplete in most SDM studies published up to 2017. Our results provide guidance for authors on what elements need better reporting to improve the replicability of their SDM interventions.

Enabling Healthy Aging to AVOID Frailty in Community Dwelling Older Canadians.

The Canadian population is aging. With aging, biological and social changes occur increasing the risk of developing chronic conditions and functional loss leading to frailty. Older adults living with frailty are more vulnerable to minor stressors, take longer to recover from illness, and have difficulty participating in daily activities. The Canadian Frailty Network's (CFN) mission is to improve the lives of older adults living with frailty. In September 2019, CFN launched the Activity & Exercise, Vaccination, Optimization of medications, Interaction & Socialization, and Diet & Nutrition (AVOID) Frailty public health campaign to promote assessing and reducing risk factors leading to the development of frailty. As part of the campaign, CFN held an Enabling Healthy Aging Symposium with 36 stakeholders from across Canada. Stakeholders identified individual and community-level opportunities and challenges for the enablement of healthy aging and frailty mitigation, as part of a focused consultative process. Stakeholders ranked the three most important challenges and opportunities at the individual and community levels for implementing AVOID Frailty recommendations. Concrete actions, further research areas, policy changes, and existing resources/programs to enhance the AVOID Frailty campaign were identified. The results will help inform future priorities and behaviour change strategies for healthy aging in Canada.

Involvement of Male Partners of Pregnant Women in the Prevention of Mother-to-Child Transmission (PMTCT) of HIV in Haiti: A Mixed-Methods Study.

This mixed-methods study aimed to determine the level of male involvement in the prevention of mother-to-child transmission (PMTCT) services in Haiti and identify barriers and associated factors. From May to June 2018, a questionnaire was used to measure the level of male involvement. Semistructured interviews with pregnant women were also conducted. Multivariate linear regression and qualitative content analyses were performed to explore factors associated and barriers to male partners' involvement in PMTCT services. One hundred and two pregnant women living with HIV completed the questionnaire. About 47% of male partners had a high level of involvement. Specifically, 90% financially supported their spouse, and 82% knew her appointment date at the antenatal clinic (ANC). Only 25% of male partners accompanied their spouse to the ANC, and 19% routinely used a condom during sexual intercourse. Factors associated with male involvement in PMTCT were being married and sharing HIV status with the male partner. Male partners with a positive HIV status were more likely to be involved in PMTCT. Qualitative findings revealed that barriers to male involvement included the conflict between opening hours of the ANC and the male partner's schedule, waiting time at the ANC, and the perception of antenatal care as being women's business. Overall male partners' involvement in PMTCT services is moderate. Gender relations, sociocultural beliefs, and care organization are likely to hinder this involvement. Developing and implementing contextually and culturally accepted strategies for male partners of pregnant women could contribute to strengthening their involvement in the PMTCT program.

Longitudinal Trends and Risk Factors for Depressed Mood Among Canadian Adults During the First Wave of COVID-19.

Background: The COVID-19 pandemic has raised serious concerns about the mental health impact of people directed and indirectly affected by the virus. Because this is a rapidly evolving situation, our goal was to explore potential risk factors and trends in feelings of anxiety and depression among the general population in Canada over the first 5 months of the pandemic. Methods: We completed on-line surveys of 3,127 unique individuals representative of the Canadian general population at 4 discreet periods every 6 weeks from April 15th to July 28th 2020. We assessed feelings of anxiety, depression and loss of interest with the interRAI self-reported mood scale using a multivariable generalized estimating equation model to examine factors associated with having a 5+ score on the scale (indicating potentially depressed mood). We also investigated potential longitudinal trends to examine temporal variation in mood scores. Results: More than 30% of participants felt highly anxious, depressed, and disinterested in everyday activities in the first survey (April), but this number decreased to about 20% over 4 months. Feeling lonely, younger age, feeling overwhelmed by one's health needs, having financial concerns, and living outside of Québec were significantly associated with depressed mood. Interpretation: The prevalence of depressed mood during the pandemic was between 2 and 3 times the pre-pandemic rate (especially among young people), but it can change rapidly in response to social changes. Thus, monitoring of psychological distress among vulnerable groups that may benefit from additional supports should be a priority.

Towards a taxonomy of behavior change techniques for promoting shared decision making.

BACKGROUND: There is little information about the functions and behavior change techniques (BCTs) needed to implement shared decision making (SDM) in clinical practice. To guide future implementation initiatives, we sought to develop a BCT taxonomy for SDM implementation interventions. METHODS: This study is a secondary analysis of a 2018 Cochrane review on interventions for increasing the use of shared decision making by healthcare professionals. We examined all 87 studies included in the review. We extracted relevant information on each study intervention into a spreadsheet. Coders had undergone a training workshop on intervention functions and online training on BCT Taxonomy version 1 (BCTTv1). We performed functions and BCTs coding trials, and identified coding rules. We used Michie's guide for designing behavior change interventions to code the functions and BCTs used in the interventions. Coders met to compare coding and discrepancies were discussed until consensus was reached. Data was analyzed using simple descriptive statistics. RESULTS: Overall, 7 functions, 24 combinations of functions and 32 BCTs were used in the 87 SDM implementation interventions. The mean of functions per intervention was 2.5 and the mean of BCTs per intervention was 3.7. The functions Coercion and Restriction were not found. The most common function was Education (73 studies). Three combinations of functions were most common (e.g: Education + Persuasion, used in 10 studies). The functions associated with more effective SDM implementation interventions were Modeling and Training. The most effective combination of functions was Education + Training + Modeling + Enablement. The most commonly used BCT was Instruction on how to perform the behavior (43 studies). BCTs associated with more effective SDM implementation interventions were: Instruction on how to perform the behavior, Demonstration of the behavior, Feedback on behavior, Pharmacological support, Material reward, and Biofeedback. Twenty-five BCTs were associated with less effective SDM implementation interventions. Four new BCTs were identified: General information to support the behavior, Tailoring, Exercises to conceptually prepare for the behavior, and Experience sharing and learning. CONCLUSIONS: We established a BCT taxonomy specific to the field of SDM to guide future SDM implementation interventions. Four new BCTs should be added to BCTTv1.

Impact of Pre-antiretroviral Therapy CD4 Counts on Drug Resistance and Treatment Failure: A Systematic Review.

The continuous rising of HIV drug resistance in low- and middle-income countries and its impact on treatment failure is a growing threat for the HIV treatment response. This review aimed to document pre-antiretroviral therapy (ART) CD4 counts, emerging drug resistance, and treatment failure in HIV-infected individuals initiating ART. We performed an online search in PubMed, Embase, Web of Science, African Index Medicus, Cochrane library, and The National Institute for Health Clinical Trials Registry of relevant articles published from January 1996 to June 2019. Of 1755 original studies retrieved, 28 were retained for final analysis. Treatment failure varied between 5% (95% confidence interval [CI]: 2.7-7.4) and 72% (95% CI: 55-89.6), while resistance varied between 1% (95% CI: 0.47-1.5) and 48% (95% CI: 28.4-67.6). Participants with a pre-ART CD4 count below 200 cell/µl and low adherence showed higher percentages of resistance and failure, while those with CD4 count above 200 showed lower resistance and failure regardless adherence levels. Most frequent resistance mutations included the M184I/V for the nucleoside reverse-transcriptase inhibitors (NRTIs), K103N, and Y181 for the non-NRTIs (NNRTIs), and L90M for the Protease inhibitors. Pre-ART CD4 count and adherence to treatment could play a key role in reducing drug resistance and treatment failure. The increased access to ART in resources limited settings should be accompanied by regular CD4 count testing, drug resistance monitoring, and continuous promotion of adherence. In addition, the rising of resistance mutations associated with NRTIs and NNRTIs, suggest that alternative ART regimens should be considered. (AIDS Rev. 2020;22:-0).

Decision Regret among Informal Caregivers Making Housing Decisions for Older Adults with Cognitive Impairment: A Cross-sectional Analysis.

Background. Informal caregivers are regularly faced with difficult housing decisions for older adults with cognitive impairment. They often regret the decision they made. We aimed to identify factors associated with decision regret among informal caregivers engaging in housing decisions for cognitively impaired older adults. Methods. We performed a secondary analysis of cross-sectional data collected from a cluster-randomized trial. Eligible participants were informal caregivers involved in making housing decisions for cognitively impaired older adults. Decision regret was assessed after caregivers' enrollment in the study using the Decision Regret Scale (DRS), scored from 0 to 100. We used a conceptual framework of potential predictors of regret to identify independent variables. We performed multilevel analyses using a mixed linear model by estimating fixed effects (ß) and 95% confidence intervals (CIs). Results. The mean (SD) DRS score of 296 informal caregivers (mean [SD] age, 62 [12] years) was 12.4 (18.4). Factors associated with less decision regret were having a college degree compared to primary education (ß [95% CI]: -11.14 [-18.36, -3.92]), being married compared to being single (-5.60 [-10.05, -1.15]), informal caregivers' perception that a joint process occurred (-0.14 [-0.25, -0.02]), and older adults' not having a specific housing preference compared to preferring to stay at home (-4.13 [-7.40, -0.86]). Factors associated with more decision regret were being retired compared to being a homemaker (7.74 [1.32, 14.16]), higher burden of care (0.14 [0.05, 0.22]), and higher decisional conflict (0.51 [0.34, 0.67]). Limitations. Our analysis may not illustrate all predictors of decision regret among informal caregivers. Conclusions. Our findings will allow risk-mitigation strategies for informal caregivers at risk of experiencing regret.

Extent and Predictors of Decision Regret among Informal Caregivers Making Decisions for a Loved One: A Systematic Review.

BACKGROUND: Informal caregivers often serve as decision makers for dependent or vulnerable individuals facing health care decisions. Decision regret is one of the most prevalent outcomes reported by informal caregivers who have made such decisions. OBJECTIVE: To examine levels of decision regret and its predictors among informal caregivers who have made health-related decisions for a loved one. DATA SOURCES: We performed a systematic search of Embase, MEDLINE, Web of Science, and Google Scholar up to November 2018. Participants were informal caregivers, and the outcome was decision regret as measured using the Decision Regret Scale (DRS). REVIEW METHODS: Two reviewers independently selected eligible studies, extracted data, and assessed the methodological quality of studies using the Mixed Methods Appraisal Tool. We performed a narrative synthesis and presented predictors of decision regret using a conceptual framework, dividing the predictors into decision antecedents, decision-making process, and decision outcomes. RESULTS: We included 16 of 3003 studies identified. Most studies (n = 13) reported a mean DRS score ranging from 7.0 to 32.3 out of 100 (median = 14.3). The methodological quality of studies was acceptable. We organized predictors and their estimated effects (ß) or odds ratio (OR) with 95% confidence interval (CI) as follows: decision antecedents (e.g., caregivers' desire to avoid the decision, OR 2.07, 95% CI [1.04-4.12], P = 0.04), decision-making process (e.g., caregivers' perception of effective decision making, ß = 0.49 [0.05, 0.93], P < 0.01), and decision outcomes (e.g., incontinence, OR = 4.4 [1.1, 18.1], P < 0.001). CONCLUSIONS: This review shows that informal caregivers' level of decision regret is generally low but is high for some decisions. We also identified predictors of regret during different stages of the decision-making process. These findings may guide future research on improving caregivers' experiences.

HIV incidence and risk contributing factors among men who have sex with men in Benin: A prospective cohort study.

Men who have sex with Men (MSM) are a key population in the transmission of Human Immunodeficiency Virus (HIV) infection. In Benin, there is a lack of strategic information to offer appropriate interventions for these populations who live hidden due to their stigmatization and discrimination. The objective is to identify contributing factors that affect HIV incidence in the MSM population. Study of a prospective cohort of 358 HIV-negative MSM, aged 18 years and over, reporting having had at least one oral or anal relationship with another man during the last 12 months, prior to recruitment. The monitoring lasted 30 months with a follow-up visit every six months. Univariate analyses and a Cox proportional hazards multivariate regression were used to examine the association between bio-behavioral, socio-demographic and knowledge-related characteristics with HIV incidence. The retention rate for the follow-up of the 358 participants was 94.5%. On the 813.5 person-years of follow-up, 48 seroconversions with an HIV incidence of 5.91 per 100 person-years were observed (95% CI: 4.46-7.85). Factors associated with the high risk of HIV were age (HR = 0.4; 95% CI: 0.2-0.8), living in couple (HR = 0.5 95% CI: 0.2-0.96) and the lack of condom systematic use with a male partner during high-risk sex (HR = 3.9; 95% CI: 1.4-11.1). HIV incidence is high within MSM population and particularly among young people. Targeted, suitable and cost-effective interventions for the delivery of the combination prevention package in an environment free of stigma and discrimination are necessary and vital for reaching the 90x90x90 target.

Engaging Caregivers in Health-Related Housing Decisions for Older Adults With Cognitive Impairment: A Cluster Randomized Trial.

BACKGROUND AND OBJECTIVES: Informal caregivers are rarely as involved as they want to be in the housing decisions of cognitively impaired older adults. Lack of awareness of available options and their benefits and risks may lead to decisions that do not reflect older adults' preferences, and to guilt and regret. We assessed the effect of training home care teams in interprofessional shared decision-making (SDM) on the proportion of caregivers who report being active in this decision. RESEARCH DESIGN AND METHODS: In a two-arm pragmatic cluster randomized trial with home care teams working in health centers in the Province of Quebec, we randomized health centers to receive training in interprofessional SDM (intervention) or not (control). Eligible caregivers had made a housing decision for a cognitively impaired adult aged 65 years or older who was receiving services from a home care team. The primary outcome was the proportion of caregivers reporting an active role in decision making. We performed intention-to-treat multilevel analysis. RESULTS: We consecutively enrolled a random group of 16 health centers and recruited 309 caregivers, among whom 296 were included in the analysis. In the intervention arm, the proportion of caregivers reporting an active role in decision making increased by 12% (95% CI -2% to 27%; p = .10). After removal of an influential cluster outlier, the proportion increased to 18% (95% CI: 7%-29%; p < .01). DISCUSSION AND IMPLICATIONS: Training home care teams in interprofessional SDM increased caregiver involvement in health-related housing decisions for cognitively impaired older adults.

Shared decision-making experienced by Canadians facing health care decisions: a Web-based survey.

BACKGROUND: Despite health policy that promotes shared decision-making, it is not yet the norm in clinical practice. We aimed to assess how much shared decision-making Canadians experienced in health-related decisions in 2017. METHODS: We conducted a cross-sectional online survey in January 2018 with a Web-based panel of Canadians representing all 10 provinces. We assessed their involvement in health-related decisions made with a health care professional over the previous year by asking about 1) discussion of choice of treatment or care plan, 2) presentation of advantages and disadvantages, 3) exploration of ideas and preferences, 4) discussion of preferred option and 5) match between preferred and actual level of participation. We computed an average shared decision-making score (range 1 [never] to 5 [always]). We presented characteristics of participants and responses using descriptive statistics and explored variations across sociodemographic factors, jurisdictions, geographical areas and care settings (home care or not) using multivariate weighted regressions. RESULTS: Of the 1591 participants surveyed, 1010 (63.5%) reported receiving health care in the previous 12 months. The mean of the average shared decision-making score was 2.25/5 (standard deviation [SD] 1.16). After weighting, 42.8% of respondents reported that their health care professional often or always mentioned that they had a choice of treatment or care plan, 45.4% reported that advantages and disadvantages were often or always presented, 38.8% reported that they were often or always asked for their ideas or preferences, 40.2% reported that they were often or always asked about their preferred option, and 54.1% stated that their level of participation in decision-making often or always matched their preferred level of participation. Increasing age, rural setting, living in the province of Quebec and not being white significantly decreased the level of shared decision-making experienced. Older respondents (age ≥ 65 yr) receiving home care reported the least shared decision-making (mean score 1.7 [SD 0.5]). INTERPRETATION: Canadians in all 10 provinces experienced a low degree of shared decision-making in 2017, with variations across sociodemographic factors, jurisdictions, care settings and geographical areas. Further efforts to foster implementation of shared decision-making are needed and should take these variations into account.

The pitfalls of scaling up evidence-based interventions in health.

Policy-makers worldwide are increasingly interested in scaling up evidence-based interventions (EBIs) to larger populations, and implementation scientists are developing frameworks and methodologies for achieving this. But scaling-up does not always produce the desired results. Why not? We aimed to enhance awareness of the various pitfalls to be anticipated when planning scale-up. In lower- and middle-income countries (LMICs), the scale-up of health programs to prevent or respond to outbreaks of communicable diseases has been occurring for many decades. In high-income countries, there is new interest in the scaling up of interventions that address communicable and non-communicable diseases alike. We scanned the literature worldwide on problems encountered when implementing scale-up plans revealed a number of potential pitfalls that we discuss in this paper. We identified and discussed the following six major pitfalls of scaling-up EBIs: 1) the cost-effectiveness estimation pitfall, i.e. accurate cost-effectiveness estimates about real-world implementation are almost impossible, making predictions of economies of scale unreliable; 2) the health inequities pitfall, i.e. some people will necessarily be left out and therefore not benefit from the scaled-up EBIs; 3) the scaled-up harm pitfall, i.e. the harms as well as the benefits may be amplified by the scaling-up; 4) the ethical pitfall, i.e. informed consent may be a challenge on a grander scale; 5) the top-down pitfall, i.e. the needs, preferences and culture of end-users may be forgotten when scale-up is directed from above; and 6) the contextual pitfall, i.e. it may not be possible to adapt the EBIs to every context. If its pitfalls are addressed head on, scaling-up may be a powerful process for translating research data into practical improvements in healthcare in both LMICs and high-income countries, ensuring that more people benefit from EBIs.