The use of community advisory boards in pragmatic clinical trials: The case of the adult day services plus project.

Community advisory boards (CABs) have become increasingly common and important in translational research in health care including studies focusing on home and community-based services. CABs are composed of stakeholders who share interest in research projects and typically include patients/clients, practitioners, community members, policymakers, and researchers. CABs advise researchers on issues ranging from research design and recruitment to implementation and dissemination. In this article, the researchers detail their experiences with the CAB for a pragmatic clinical trail of Adult Day Services (ADS) Plus, an education and support intervention for family caregivers of older adults with dementia using adult day services. Lessons learned, guidelines, and best practices are then presented for developing and working with a CAB in healthcare research.

Stall the Fall: Training Non-Clinical Caregivers to Prevent Falls in Community-Dwelling Older Adults.

Fall injuries are the leading cause of injury death in older adults, yet despite this, health-care providers do not routinely incorporate fall prevention into practice. A fall prevention training program was developed for non-clinical caregivers serving community-dwelling older adults using the CDC's STEADI tool. The project outcomes revealed statistically significant increases in items related to knowledge and confidence in fall risk and assessment. Findings could guide the development of fall prevention training programs targeted at non-clinical caregivers to community-dwelling older adults.

Exploring Managers' Opinions on Planning and Designing Adult Day Care Centers.

OBJECTIVE: To explore managers' opinions on planning and design of location, building type, spatial layout, and interior design of adult day care centers (ADCCs). BACKGROUND: The planning and design of new ADCCs affect subsequent service users and workflows. Studies explore the factors affecting such planning and design using qualitative methods and from the perspective of users. Quantitative methods are rarely employed to explore factors affecting planning and opinions on the design of ADCCs from administrators' perspective. METHODS: Stratified sampling was used to collect data from managers of ADCCs in Taiwan. A mixed-method approach with an analytic hierarchy process was used to quantify the relative importance of factors affecting location and building type selections. Participants responded to open-ended interview questions followed by focus group interviews to examine the key points for spatial layout and interior design. RESULTS: The managers deemed support and attitudes from local residents (group weight = .208) and authorities (group weight = .187) as their first two critical location selection criteria. Regarding their opinions on the conditions of building type, those that prioritized the products and technologies of facility design were deemed the most critical (group weight = .193), followed by those that valued daylight quality (group weight = .161). Six key points of spatial layout and interior design were obtained from the focus group interviews. CONCLUSIONS: This study provides a reference for the effective planning of operations, including geographical location, building type, spatial layout, and interior refurbishment and design.

Photography in the planning of health interventions for the elderly.

OBJECTIVE: To analyze potentialities of the use of photo-elicitation technique as a tool of access to the real needs of the beneficiaries of the intervention of health professionals. For this purpose, the aspects of their quality of life that they considered more relevant were identified with an elderly group. METHOD: It is a qualitative investigation in which the discourse of the elderly on the changes to their quality of life is encouraged through the use of photographic images. RESULTS: Based on the data obtained, it was possible to identify the aspects of quality of life considered more relevant by the elderly, allowing, therefore, to sustain a later intervention adjusted to the needs and expectations of the elderly. FINAL CONSIDERATIONS: The use of photo-elicitation allowed verifying its potentialities as a strategy to collect significant and relevant information for the planning of interventions in the Health area.

What types of activities increase participation in community "salons"?

As part of their national long-term care prevention strategy, Japanese government has promoted "community salons" as a way to encourage social participation among community-dwelling seniors. Previous studies suggested that participation in salon activities can be an effective approach to prevent long-term disability. However, there is wide variation in the types of activities offered through salons. We sought to examine different types of salon-based activities and their relation to participation rates among older populations (age ≥65 years). The association between different types of salon activities (exercise-based, cognitive strengthening, dining, socializing, and hobby/recreational activities) and participation rate per population (cumulative number of participants per registered old population in municipalities) was assessed via Poisson regression model. Ecological data were abstracted from the Annual Report on Preventive Long-Term Care Service maintained by the Ministry of Health, Labour and Welfare of Japan. Salon activities based on hobby/recreational activities were associated with the highest participation rates among the older population (IRR = 1.0029; p < 0.001), while dining-based activities were associated with lower participation rates (IRR = 0.9955; p = 0.0012). Exercise-based salons were associated with higher participation among both women (IRR = 1.0031; p = 0.002) and men (IRR = 1.0023; p = 0.035). Municipalities where health professionals (as opposed to volunteers) were involved in running community salon programs had significantly higher participation rates (IRR = 1.3601), after adjusting for overall density of community salons, city size and prefecture level fixed effects (p = 0.001).

Photography in the planning of health interventions for the elderly / La fotografía en la planificación de intervenciones de salud dirigidas a ancianos / A fotografia no planejamento de intervenções de saúde dirigidas a idosos

ABSTRACT Objective: To analyze potentialities of the use of photo-elicitation technique as a tool of access to the real needs of the beneficiaries of the intervention of health professionals. For this purpose, the aspects of their quality of life that they considered more relevant were identified with an elderly group. Method: It is a qualitative investigation in which the discourse of the elderly on the changes to their quality of life is encouraged through the use of photographic images. Results: Based on the data obtained, it was possible to identify the aspects of quality of life considered more relevant by the elderly, allowing, therefore, to sustain a later intervention adjusted to the needs and expectations of the elderly. Final considerations: The use of photo-elicitation allowed verifying its potentialities as a strategy to collect significant and relevant information for the planning of interventions in the Health area.

RESUMEN Objetivo: Analizar las potencialidades de la utilización de la técnica de la foto-elección como instrumento de acceso a las reales necesidades de los beneficiarios de la intervención de los profesionales de salud. Con ese propósito, se identificaron, junto a un grupo de ancianos, los aspectos de su calidad de vida que consideran más relevantes. Método: Se trata de una investigación cualitativa en la que el discurso de los ancianos sobre las alteraciones a su calidad de vida es estimulado mediante el uso de imágenes fotográficas. Resultados: Con base en los datos obtenidos, fue posible identificar los aspectos de la calidad de vida considerados más relevantes por los ancianos, permitiendo así sostener una posterior intervención ajustada a las necesidades y expectativas del anciano. Consideraciones finales: La experiencia de utilización de la foto-elicitación permitió constatar sus potencialidades como estrategia de recogida de información significativa y relevante para la planificación de intervenciones en el área de la Salud.

RESUMO Objetivo: Analisar as potencialidades da utilização da técnica da foto-elicitação enquanto instrumento de acesso às reais necessidades dos beneficiários da intervenção dos profissionais de saúde. Com esse propósito, foram identificados, junto a um grupo de idosos, os aspetos da sua qualidade de vida que consideram mais relevantes. Método: Trata-se de uma investigação qualitativa em que o discurso dos idosos sobre as alterações à sua qualidade de vida é estimulado através do recurso a imagens fotográficas. Resultados: Com base nos dados obtidos, foi possível identificar os aspetos da qualidade de vida considerados mais relevantes pelos idosos, permitindo, assim, sustentar uma posterior intervenção ajustada às necessidades e expectativas do idoso. Considerações finais: A experiência de utilização da foto-elicitação permitiu constatar as suas potencialidades enquanto estratégia de recolha de informação significativa e relevante para o planejamento de intervenções na área da Saúde.

Investigating the effect of physical games on the memory and attention of the elderly in adult day-care centers in Babol and Amol.

Background: Physical activity is a behavioral strategy that increases general (public) health, including the mental performance of individuals. The goal of this study was to investigate the effect of group physical games on cognitive performance (memory, attention) of old people in adult day-care centers. Methods: In this quasi-experimental study, 50 elderly people (aged >60 years) were selected from two adult day-care centers using available sampling and divided into two groups: control and intervention. As approval was received from the Babol Hamrah Salamat adult day-care center to modify the design of the center's yard, this center was selected to conduct an intervention program. The intervention group received a physical activity program twice a week for 6 weeks. Questionnaires that were used for collecting data included demographic questions, a standard questionnaire for daily activities of living, and a short-term test, the Abbreviated Mental Test Score. Cognitive function was assessed with the Wechsler Memory Scale (WMS) (Form A), before and after the intervention. Statistical analysis of normal variables was performed using independent and paired t-tests and in non-standard cases with Mann-Whitney and Wilcoxon non-parametric tests at a significance level of P<0.05, using SPSS software (version 22). Results: Statistical analysis showed that the scores of the subjects in the intervention group, compared to the control group, had significantly improved. The calculated mean differences in the intervention groupwere, for memory function d=8.4±3.3 (P=0.001), and for attention and concentration d=4.18±2.38 (P<0.001) (WMS). This level of change in the intervention group was significant. Conclusion: The results of this study showed that a physical exercise program can improve the memory and attention/concentration of the elderly. Therefore, it seems that such activities are a useful method for maintaining cognitive function.

The role of day care in supporting older people living with long-term conditions.

PURPOSE OF REVIEW: For older people with long-term conditions, regular structured activities within a community setting meeting others are thought to improve well being and quality of life. Historically local authority-run day care centres were widely available, but austerity measures have meant that in many areas, such provision has been markedly reduced and different models of day care services are being developed. There is little known about outcomes of day care provision for older people with long-term conditions. RECENT FINDINGS: This review has critically examined the recent evidence on outcomes of day care provision for older people with long-term conditions and will focus on three areas - physical functioning, intergenerational provision and measurement of outcomes. In terms of interventions to improve physical functioning for older people with long-term conditions attending day care, there are few studies and it is difficult to generalize but there appears to be a trend for positive impact on physical functioning when activities are incorporated into a day care programme. There is a paucity of research on intergenerational provision, however, the small number of studies suggest positive benefits. Studies measuring outcomes for older people with long-term conditions attending day care services are very limited in terms of outcome data with the exception of a Canadian study, which suggested that attendance at day care could reduce hospital attendance and admissions. SUMMARY: This review reveals a lack of research of day care provision for older people with long-term conditions. There is a suggestion in the small number of articles included in this review that there can be benefits both in terms of global outcomes of attendance and in improved physical functioning; there is limited evidence of the value of intergenerational provision. Robust research with collection of meaningful outcomes is required to ensure that the increasing number of older people with long-term conditions are enabled to access high-quality day care provision.

Quality of life among people with psychiatric disabilities attending community-based day centres or Clubhouses.

BACKGROUND: People with psychiatric disability have been found to have a poorer quality of life (QOL) compared to the general population, and QOL is an important outcome from psychosocial rehabilitation. AIMS: This study aimed at comparing users of two approaches to psychosocial rehabilitation in Sweden, community-based mental health day centres (DCs) and clubhouses, regarding QOL. A further aim was to investigate predictors of QOL. METHODS: People regularly attending DCs (n = 128) or clubhouses (n = 57) completed questionnaires at baseline and a 9-month follow-up about socio-demographics, QOL, self-esteem, social network, satisfaction with daily occupations, satisfaction with services and the unit's organisation. RESULTS: Quality of life remained stable over time in both groups. QOL at follow-up was associated with baseline self-esteem, social network, satisfaction with daily occupations and QOL at baseline. The strongest indicator of a higher QOL at follow-up was attending a clubhouse programme followed by having scored high on QOL at baseline. CONCLUSION: Both approaches were suited for supporting their users in maintaining QOL. Visiting clubhouses seems, however, advantageous for QOL in a longer-term perspective. Although this study contributed some new knowledge, research should further address which circumstances are associated with maintaining stability in QOL.

Programa Centros Diurnos del Adulto Mayor: recomendaciones para mejorar su funcionamiento / Elderly day care centers: recommendations for improvement

Introducción: Chile se ha transformado en un país que continuará envejeciendo a un ritmo acelerado. Una de las piezas claves de la Política Integral de Envejecimiento Positivo para Chile es el desarrollo de centros de día para personas mayores (CDPM) dirigidos al cuidadode ancianos con dependencia leve. Objetivo: Conocer la percepción que tiene un grupo de personas mayores, sus cuidadores y profesionales de su participación en un CDPM con el propósito de diseñar recomendaciones para mejorar este nuevo tipo de servicio geriátrico instaurado en el país. Metodología: Estudio descriptivo cualitativo realizado con 30 participantes a través de cuatro grupos focales: dos en personas mayores (n = 12), uno con cuidadores (n = 8) y uno con profesionales del centro (n = 10). El análisis de contenido se realizó según Kripperdorff y se cumplieron los criterios de rigor según Guba y Lincoln. Resultados: Se identificaron dos categorías comprensivas principales: 1) percepción de beneficios para las personas mayores: mejoría de la funcionalidad, aumento del bienestar y mayor inserción social y 2)recomendaciones de mejora del CDPM: criterios de ingreso inclusivo, flexibilidad y diversidad en actividades estipuladas y mejoras en el egreso. Conclusiones: Las personas mayores, sus cuidadores y los profesionales que los atienden coinciden en señalar que la asistencia de las personas mayores a este tipo de servicio les reporta beneficios en su funcionalidad, bienestar e inserción social. Este estudio contribuye a ampliar el entendimiento de los resultados en los usuarios de los CDPM, reportando una experiencia en un contexto social particular (AU)

Introduction: Chile has become a country that continues to grow at an accelerated pace. One of the key pieces of the Comprehensive Policy for Positive Aging for Chile is the development of Day Centers for the Elderly (CDPM) directed elderly at the foot of the dependency. Objective: To know the perception of a group of PMs, their caregivers and professionals of their participation in the CDPM with the purpose of designing recommendations to improve this new type of geriatric service established in the country. Methodology: Qualitative descriptive study performed in 30 participants through 4 focus groups: 2 in elderly (n=12), 1 with caregivers (n=8) and 1 with center professionals (n=10). Results: Two main comprehensive categories were identified: 1) Perception of benefits for elderly: improvement of functionality, increase of well-being and insertion of the social mayor, 2) Recommendations for improvement of CDPM: Criteria for inclusive income, flexibility and diversity in activities stipulated and Improvements in egress. Conclusions: The elderly, their caregivers and the professionals who attend them are consistent in pointing out that elderly assistance to this type of service reports benefits in its functionality, well-being and social insertion. This study contributes to broadening the understanding of results in the uses of CDPM by reporting an experience in a particular social context (AU)

Evacuation Decision Making and Expanded Roles of Adult Daycare Services in the Great East Japan Earthquake: Qualitative Analysis Using Semistructured Interviews.

CONTEXT: The roles of adult daycare services during disaster evacuations in the relationships with community resilience are unknown. The initial 72 hours after a disaster are crucial because people in the disaster area depend on their own efforts or the resources available at the moment until the arrival of external support. OBJECTIVE: To clarify the evacuation-related decision making of the administrators of adult daycare services within 72 hours after the Great East Japan Earthquake and to describe the roles of adult daycare services during the month following the earthquake. DESIGN: Qualitative study using semistructured interviews. The transcribed interviews were analyzed anonymously through an inductive qualitative content analysis using ATLAS.ti. SETTING: Kesennuma City, Miyagi Prefecture. PARTICIPANTS: Eleven key informants (3 primary care providers and 8 administrators) from 8 institutions. RESULTS: Immediately after the disaster, 6 institutions implemented shelter-in-place. The evacuation behaviors of the adult daycare institutions were diverse, but each institution was transformed repeatedly within 72 hours. With respect to evacuation decision making, the primary issues involved whether to go to mandatory evacuation sites. However, after 3 days, the institutions relocated from these sites to other places. During a period of approximately 1 month, 7 institutions managed the evacuation of service users and care providers. The expanded institutional roles were as follows: "confirming the safety of the users' families," "substituting residential facilities," and "imposing leadership during the evacuation." CONCLUSIONS: If institutions choose to shelter-in-place, it should be sustained for as long as possible. Sufficiently planned stores of food and water to accommodate daytime users are needed. Institutions that employ shelter-in-place as an evacuation plan should maintain close contact with local governments. Furthermore, local governments should predetermine how to manage these institutions in the event of a disaster. To build community resilience for disasters, developing linkage with private organizations' resilience is beneficial.

The Strengths and Challenges of Palliative Day-Care Centers: Qualitative Study With the Professionals Involved.

BACKGROUND: Palliative day-care centers are a marginal service within the palliative care landscape. Relevant research on the potential and added value of this service model is lacking, and it may therefore be underappreciated. AIM: To examine how representatives of Belgian palliative day-care centers perceive their strengths and added value, as well as the biggest challenges to their survival. DESIGN: Qualitative study of individual interviews and an overarching focus group. Data collection was performed from December 2014 to April 2015. Inductive coding was used to extract relevant themes from the verbatim transcripts. SETTING/PARTICIPANTS: Participants were professional representatives of all 5 Flemish palliative day-care centers: 7 participants for the individual interviews and 6 participants for the focus group. RESULTS: Five strengths were identified: (1) unique care model, (2) contact with peers in a nonclinical environment, (3) a reliable and competent multiprofessional team, (4) care tailored to the individual, and (5) respite for family caregivers. The most significant challenges were (1) optimizing government funding and (2) achieving sufficiently high occupancy and referral. According to interviewees, this latter challenge was due to the low visibility of the service to professionals and the public, unclear referral criteria, and the psychological threshold for referral among patients and professionals. CONCLUSIONS: Palliative day-care centers strive to provide unique services for patients with advanced illness. However, negotiating adequate funding and raising referral by changing current perceptions are paramount to unlocking their potential. Scientific analysis of cost utility and patient outcomes associated with their use is necessary.

Develando la experiencia de un grupo de personas mayores en un centro de día / Unveiling the experience of a group of elderly people in a day care center

Objetivo: El envejecimiento de la población representa uno de los grandes desafíos para Latinoamérica, tanto para los servicios de salud como para los servicios sociales de apoyo a las personas mayores. La introducción de los centros de día para personas mayores, como un nuevo servicio gerontológico, se transformará en una pieza crítica de los servicios ofrecidos a las personas mayores que viven en la comunidad, generando las bases para construir un sistema de cuidado y atención especializada dirigida a este grupo etario. El objetivo de este estudio es evaluar la experiencia de un grupo de personas mayores pertenecientes a un centro de día de una municipalidad de Santiago, Chile. Métodos: Estudio cualitativo descriptivo con uso de técnica de grupo focal y análisis de contenido que devela la experiencia de 37 personas mayores asistentes a un centro de día. Resultados: Los principales resultados de este estudio fueron: a) mejoría en la funcionalidad, b) empoderamiento de las personas mayores y c) mayor inserción social. Conclusiones: La experiencia de las personas mayores es evaluada como positiva, reconociendo mejorías en aspectos claves de su vida cotidiana y que tienen el potencial de contribuir a mejorar y fortalecer la funcionalidad y aspectos de la salud mental de las personas mayores. Estos resultados aportan evidencia científica latinoamericana a la evaluación de la experiencia de las personas mayores con este nuevo servicio geriátrico

Background: Chile is a country that will continue aged at an accelerated rate as a result of a progressive decline in the birth rate, adequate access to health and a sustained increase in life expectancy. The aging population is one of the major challenges for the country as well as for health and for social services to support aged population. Introducing the Day Care Centers for aged people, as a new gerontological service, will become a critical part of the services offered to the elderly living in the community, creating the foundations for an specialized system of care directed this age group. The aim of this study is to evaluate the experience of a group of elderly people from a day care center of a municipality of the Metropolitan Region. Methods: Descriptive qualitative study with focus group and content analysis that reveals the experience of 37 older people attending at day care center. Results: The main results of this study were: (a) improvement in functionality, (b) empowerment of older persons, and (c) greater social inclusion. Conclusion: The experience of older persons is assessed as positive by themselves. Older people recognized improvements in key aspects of their daily lives and have the potential to contribute to improving and strengthening the functionality and mental health of elderly people. These results provide evidence for national evaluation of this new geriatric service

Knitters in a Day Center: The Significance of Social Participation for People With Mild to Moderate Dementia.

This article explores how people with dementia interact and solve problems while participating in social activities. The present article highlights social participation and interaction among elderly women with mild dementia who engaged in knitting as their main activity. The data were collected through participant observation at a day center in a Norwegian city, and the analysis revealed that the social activity of knitting facilitated conversations about different topics, required various forms of memory and problem solving, and involved different participant statuses. Being part of the knitting group appeared to help the participants maintain their skills and facilitated sociability.

Effectiveness of a community-based program for suicide prevention among elders with early-stage dementia: A controlled observational study.

The purpose of this study was to develop a small-group-focused suicide prevention program for elders with early-stage dementia and to assess its effects. This was a quasi-experimental study with a control group pretest-posttest design. A total of 62 elders diagnosed with early-stage dementia who were receiving care services at nine daycare centers in J City Korea participated in this study. The experimental group participated in the suicide prevention program twice a week for 5 weeks with a pretest and two posttests The developed suicide prevention program had a significant effect on the perceived health status, social support, depression, and suicidal ideation of elders with early-stage dementia. Nurses should integrate risk factors such as depression and protective factors such as health status and social support into a suicide prevention program. This community-based program in geriatric nursing practice can be effective in preventing suicide among elders with early-stage dementia.

Improving the quality of life of palliative and chronic disease patients and carers in remote Australia with the establishment of a day respite facility.

BACKGROUND: In the Northern Territory (NT) there is a lack of respite services available to palliative care patients and their families. Indigenous people in the NT suffer substantially higher rates of poorly controlled chronic disease and premature mortality associated with poor heath than the Australian population as a whole. The need for a flexible, community based, culturally appropriate respite service in Alice Springs was identified and, after the service had been operating for 10 months, a qualitative evaluation was conducted to investigate the experiences of people involved in the use and operation of the service. METHODS: Semi-structured interviews were conducted with patients, carers, referrers, and stakeholders. A total of 20 people were interviewed. Interpretative Phenomenological Analysis was used inductively to analyse the transcripts. Two case studies are also described which illustrate in greater detail the impact the respite service has had on people's lives. RESULTS: From the semi-structured interviews, two superordinate themes along with a number of sub themes were developed. The two superordinate themes described both "The Big Picture" considerations as well as the pragmatics of "Making the Service Work". The sub themes highlighted issues such as being stuck at home and the relief that respite provided. The case studies poignantly illustrate the difference the respite service made to the quality of life of two patients. DISCUSSION: The findings clearly indicate an improvement in quality of life for respite patients and their carers. The respite service enabled improved care coordination of chronic and complex patients as well as improved medication compliance and symptom management. As a result of this evaluation a number of recommendations to continue and improve the service are provided.

QuickStats: Distribution of Long-Term Care Staffing* Hours,(†) by Staff Member Type and Sector - United States, 2014.

In 2014, aides provided more hours of care in the major sectors of long-term care than the other staffing types shown. Aides accounted for 60% of all staffing hours in nursing homes, compared with licensed practical or vocational nurses (21%), registered nurses (13%), activities staff members (5%), and social workers (2%). Aides accounted for 75% of all staffing hours in residential care communities, in contrast to activities staff members (11%), registered nurses (7%), licensed practical or vocational nurses (6%), and social workers (1%). In adult day services centers, aides provided 41% of all staffing hours, followed by activities staff members (32%), registered nurses (12%), licensed practical or vocational nurses (9%), and social workers (6%).

Adding quality to day centre activities for people with psychiatric disabilities: Staff perceptions of an intervention.

AIM: To evaluate an intervention aimed at enriching day centres for people with psychiatric disabilities by exploring staff experiences from developing and implementing the intervention. METHOD: Each staff group developed a tailor-made intervention plan, following a manual, for how to enrich the day centre. They received supervision and support from the research team. The study was based on focus-group interviews with a total of 13 staff members at four day centres. Narrative analysis with a thematic approach was used. A first round resulted in one narrative per centre. These centre-specific narratives were then integrated into a common narrative that covered all the data. RESULTS: A core theme emerged: User involvement permeated the implementation process and created empowerment. It embraced four themes forming a timeline: "Mix of excitement, worries and hope", "Confirmation and development through dialogue, feedback and guidance", "The art of integrating new activities and strategies with the old", and "Empowerment-engendered future aspirations". CONCLUSION: The users' involvement and empowerment were central for the staff in accomplishing the desired changes in services, as were their own reflections and learning. A possible factor that may have contributed to the positive outcomes was that those who were central in developing the plan were the same as those who implemented it.

Care pathway networks as a guideline for people with Dementia in Taiwan.

Dementia is a syndrome characterized by the progressive decline in cognitive function and memory that impairs a person's ability to function normally. Although dementia mainly affects older people, it is not a normal part of aging. The population of Taiwan is experiencing a multi-decade ageing trend and regrettably the absolute numbers of people with dementia is also rapidly rising. In 2008, the Taiwan Government initiated a ``Ten-Year Long-term Care Plan'' to categorize dementia's disability and severity, and it evaluates access to home care, respite care services, daycare or home nursing care. This review figure out the features of the features of ``Taiwan Dementia Policy: A Framework for Prevention and Care'' and discuss care pathway network as a guideline for people with dementia in Taiwan. The expectation is for many Taiwanese providers and patients in need simply don't know what services are available or how to access them. A properly designed dementia website could be one such effective tool to meet this need. There is an ongoing risk that future resources allocated will not reach the intended individuals unless this implementation problem is addressed urgently.