Integrated Community Care Delivered by Public Health-Care and Social-Care Systems: Results from a Realist Synthesis.

Introduction: Integrated community care (ICC) is defined as an interweaving of health-care and social-care interventions deployed in spatial and relational proximity using an interdisciplinary and cross-sectoral approach. Consideration of territory scale and time scale are at the center of ICC practices. Its deployment in public health and social care networks (HSCN) can be complex due to their broad mandate, the complexity of their management, and accountability. Therefore, we aimed to describe ICC delivered by public HSCN to determine how, why, for whom, and in what circumstances ICC works and produces outcomes. Methods: A realist synthesis was conducted consisting of five steps consistent with realist synthesis standards (RAMESES projects) to produce configurations of Context - Mechanism - Outcomes (CMOc) and development of a middle-range explanatory theory of why and how the identified outcomes may have occurred. Results: In total, 26 studies were selected and used, as evidence, to support-either partially or fully-the production of CMOc based on the initial program theory. Nine unique CMO configurations were identified based on the data analyses and team discussion. ICC middle-range theory is informed by the CMO configurations identified. Discussion: This realist synthesis allowed us to identify the central mechanisms of ICC delivered by public HSCN and to produce a middle range theory. ICC is based on a specific philosophy and deployed by a professional agency oriented toward a community agency within a local system of interdisciplinary and cross-sectoral action. Conclusion: Our middle-range theory will provide a solid analytical framework as a foundation for ICC implementation and future research.

Introduction: Les interventions en santé et services sociaux intégrées en proximité des communautés (IIPC) sont définies comme une imbrication d'interventions de soins de santé et de services sociaux à l'échelle du territoire et considérant la temporalité, déployées dans une proximité spatiale et relationnelle au moyen d'une approche interdisciplinaire et intersectorielle. Son déploiement dans les réseaux publics de santé et de soins sociaux (RSSS) peut s'avérer complexe en raison de l'étendue de leur mandat, de la complexité de leur gestion et de leur responsabilité. C'est pourquoi nous avons cherché à décrire les IIPC dispensées par les RSSS publics afin de déterminer comment, pourquoi, pour qui et dans quelles circonstances les IIPC fonctionnent et produisent des résultats. Méthodes utilisées: Une synthèse réaliste a été réalisée en cinq étapes conformes aux normes de synthèse réaliste (projet RAMESES) afin de produire des configurations Contexte ­ Mécanisme ­ Effets (CMOc) et de développer une théorie explicative de moyenne portée sur le pourquoi et le comment des résultats identifiés. Résultats: Au total, 26 études ont été sélectionnées et utilisées comme preuves pour étayer ­ partiellement ou totalement ­ la production de CMOc sur la base de la théorie initiale de programme. Neuf configurations uniques CMO ont été identifiées sur la base des analyses de données et des discussions de l'équipe. La théorie de moyenne portée des IIPC s'appuie sur les configurations CMO identifiées. Discussion: Cette synthèse réaliste nous a permis d'identifier les mécanismes centraux des IIPC déployées par les RSSS publics et de produire une théorie de moyenne portée. Les IIPC sont fondées sur une philosophie et le développement d'une capacité d'agir professionnelle mise en action vers le renforcement de la capacité d'agir de la communauté au sein d'un système local d'action interdisciplinaire et intersectoriel. Conclusion: L'utilisation de notre théorie de moyenne portée pour la mise en œuvre d'IIPC fournira un cadre analytique solide comme base pour des implantations ou des recherches futures.

Integrated Community Care Delivered by Public Health Care and Social Care Systems: Protocol for a Realist Synthesis.

INTRODUCTION: Integrated Community Care (ICC) is defined as an interweaving of territory scale and time scale health care and social care interventions implemented in proximity (spatial and relational) in an interdisciplinary and cross-sectoral manner. However, the deployment of in public health and social care networks can be complex owing to their broad mandate and the complexity of their management and accountability. Therefore, we aim to describe integrated community care in order to shed light on how they work, for whom and in what circumstances. THEORY AND METHODS: We will conduct a realist synthesis to design a flexible and scalable theory of the functioning of ICC deployed by public health and social care networks. To do so, a two-phase approach will be used: a systematic review on the topic of interest; and co-development and refinement of theory with local and international stakeholders. This data will be analyzed using both qualitative and quantitative methods. DISSEMINATION OF RESULTS: The results will be disseminated through peer-reviewed publications, academic presentations and a policy brief. This last document will include evidence on how ICC can be deployed by public health and social care networks to produce the impacts targeted.

A Conceptual Framework for Integrated Community Care.

INTRODUCTION: The various health and social care services provided in a given local area (i.e., place-based) must not only deliver primary care in proximity to the population, but act upstream on the social determinants of health. This type of care, when provided in a holistic and integrated manner, aims to improve the physical and mental health-but also the well-being and social capital-of individuals, families, groups and communities. This type of approach is known as Integrated Community Care (ICC). THEORY AND METHODS: This article was developed from a non-systematic review of scientific and grey literature followed by a qualitative analysis and researcher reflections on ICC. RESULTS: The article presents the core concepts of ICC, namely temporality, local area, health care, social care, proximity and integration. These concepts are unpacked and a conceptual diagram is set forth to put the dynamic links between the concepts into perspective. DISCUSSION AND CONCLUSION: The purpose of the article is to provide a conceptual clarification of ICC. Three examples of practise (from Switzerland, Quebec [Canada] and Italy) are used as illustrations to provide a better understanding of ICC and to open up horizons.

Male inmate profiles and their biological correlates.

OBJECTIVE: Borderline and antisocial personality disorders (PDs) share common clinical features (impulsivity, aggressiveness, substance use disorders [SUDs], and suicidal behaviours) that are greatly overrepresented in prison populations. These disorders have been associated biologically with testosterone and cortisol levels. However, the associations are ambiguous and the subject of controversy, perhaps because these heterogeneous disorders have been addressed as unitary constructs. A consideration of profiles of people, rather than of exclusive diagnoses, might yield clearer relationships. METHODS: In our study, multiple correspondence analysis and cluster analysis were employed to identify subgroups among 545 newly convicted inmates. The groups were then compared in terms of clinical features and biological markers, including levels of cortisol, testosterone, estradiol, progesterone, and sulfoconjugated dehydroepiandrosterone (DHEA-S). RESULTS: Four clusters with differing psychiatric, criminal, and biological profiles emerged. Clinically, one group had intermediate scores for each of the tested clinical features. Another group comprised people with little comorbidity. Two others displayed severe impulsivity, PD, and SUD. Biologically, cortisol levels were lowest in the last 2 groups and highest in the group with less comorbidity. In keeping with previous findings reported in the literature, testosterone was higher in a younger population with severe psychiatric symptoms. However, some apparently comparable behavioural outcomes were found to be related to distinct biological profiles. No differences were observed for estradiol, progesterone, or DHEA-S levels. CONCLUSIONS: The results not only confirm the importance of biological markers in the study of personality features but also demonstrate the need to consider the role of comorbidities and steroid coregulation.

Profiles and mental health correlates of alcohol and illicit drug use in the Canadian population: an exploration of the J-curve hypothesis.

OBJECTIVE: Alcohol and (or) illicit drug use (AIDU) problems are associated with mental health difficulties, but low-to-moderate alcohol consumption may have mental health benefits, compared with abstinence. Our study aimed to explore the hypothesis of a nonlinear, or J-curve, relation between AIDU profiles and psychological distress, psychiatric disorders, and mental health service use in the general Canadian population. METHODS: Data were collected from a representative sample of the Canadian population (n = 36 984). Multiple correspondence analyses and cluster analyses were used to extract AIDU profiles. Sociodemographics, psychological distress, psychiatric disorders, and mental health service use were assessed and compared between profiles. RESULTS: Seven AIDU profiles emerged, including 3 involving risky or problematic AIDU that correlate with major affective disorders, anxiety disorders, suicidal behaviours, and higher levels of psychological distress. No J-curve relation was found for psychiatric disorders and mental health service use. The lifetime-abstainer profile correlates with the lowest rates of psychiatric disorders and mental health service use. Lifetime abstainers are also more often female, immigrant, and unemployed. Compared with other profiles, spirituality is more important in their life. CONCLUSIONS: The hypothesis of a nonlinear relation between psychiatric disorders and AIDU was not supported. Lifetime AIDU abstainers have specific sociodemographic and cultural background characteristics in Canada.

Objectif : Les problèmes de consommation d'alcool et (ou) de drogues illicites (CADI) sont associés à des difficultés de santé mentale, mais la consommation d'alcool faible à modérée peut avoir des avantages pour la santé mentale, comparé à l'abstinence. Notre étude visait à explorer l'hypothèse d'une relation non linéaire, ou de courbe en J, entre les profils de la CADI et la détresse psychologique, les troubles psychiatriques, et l'utilisation des services de santé mentale dans la population générale du Canada. Méthodes : Les données ont été recueillies auprès d'un échantillon représentatif de la population canadienne (n = 36 984). Des analyses de correspondance multiple et des analyses typologiques ont servi à extraire les profils de la CADI. Les données sociodémographiques, la détresse psychologique, les troubles psychiatriques, et l'utilisation des services de santé mentale ont été évalués et comparés entre les profils. Résultats : Sept profils de la CADI sont ressortis, dont 3 comportaient une CADI risquée ou problématique qui se corrèle avec les principaux troubles affectifs, les troubles anxieux, les comportements suicidaires, et des taux élevés de détresse psychologique. Aucune relation de courbe en J n'a été observée pour les troubles psychiatriques et l'utilisation des services de santé mentale. Le profil de l'abstinent à vie se corrèle avec les taux les plus faibles de troubles psychiatriques et d'utilisation des services de santé mentale. Les abstinents à vie sont aussi plus souvent de sexe féminin, immigrants, et sans emploi. Comparativement à d'autres profils, la spiritualité est plus importante dans leur vie. Conclusions : L'hypothèse d'une relation non linéaire entre les troubles psychiatriques et la CADI n'a pas été soutenue. Les abstinents de la CADI de durée de vie ont des caractéristiques sociodémographiques et des antécédents culturels spécifiques au Canada.

Esquizofrenia y violencia grave: un análisis del perfil clínico que incorpora la impulsividad y los trastornos de consumo de sustancias / Schizophrenia and serious violence: a clinical-profile analysis incorporating impulsivity and substance-use disorders

Objetivos. En este estudio se explora el papel de los trastornos de consumo de sustancias (TCS) y la impulsividad en individuos con esquizofrenia que presentan un mayor riesgo de violencia grave (VG). Métodos. Se realizó un análisis de correspondencia múltiple y un análisis de agrupamiento (AA) (cluster analysis) en una muestra de 139 varones que cumplían los criterios diagnósticos del DSM-IV para los trastornos del espectro esquizofrénico (TEE). Resultados. La impulsividad fue la principal dimensión que diferenciaba a los individuos. Los TCS y la VG estaban intensamente relacionados. El AA produjo 4 grupos; uno de ellos correspondía a la violencia grave, TCS y una mayor tasa de encarcelamiento. Conclusiones. Se identificaron subgrupos del TEE en los que había riesgo de VG. Los TCS parecen ser un factor de riesgo importante para la VG y el encarcelamiento (AU)

Objectives. This study is an exploration of the role of substance use disorder (SUD) and impulsivity in individuals with schizophrenia who are at higher risk of serious violence (SV). Methods. Multiple correspondence analysis and cluster analysis (CA) were performed on a sample of 139 males meeting DSM-IV diagnostic criteria for schizophrenia-spectrum disorders (SSD). Results. Impulsivity was the main dimension differentiating individuals. SUD and SV were strongly linked. CA yielded 4 clusters; one related to serious violence, SUD and a higher incarceration rate. Conclusions. Subgroups of SSD at risk of SV were found. SUD appear to be a major risk factor for SV and incarceration (AU)

Schizophrenia and serious violence: a clinical-profile analysis incorporating impulsivity and substance-use disorders.

OBJECTIVES: This study is an exploration of the role of SUD and impulsivity in individuals with schizophrenia who are at higher risk of serious violence (SV). METHODS: Multiple correspondence analysis (MCA) and cluster analysis (CA) were performed on a sample of 139 males meeting DSM-IV diagnostic criteria for schizophrenia-spectrum disorders (SSD). RESULTS: Impulsivity was the main dimension differentiating individuals. SUD and SV were strongly linked. CA yielded four clusters; one related to serious violence, SUD and a higher incarceration rate. CONCLUSIONS: Subgroups of SSD at risk of SV were found. SUD appear to be a major risk factor for SV and incarceration.

A classification and regression tree for predicting recurrent falling among community-dwelling seniors using home-care services.

OBJECTIVES: A prospective, observational study was undertaken to identify risk profiles of subjects regarding the recurrence of falling among community-dwelling seniors using home-care services. METHODS: A convenience sample of 868 community-dwelling older persons, aged 65 years or older, who use home-care services offered by public community-based centres in the province of Québec. Subjects were recruited between 2002 and 2005, assessed for fall-related risk factors, and monitored for prospective falls. Data were examined by a classification and regression tree (CART) and survival analyses. RESULTS: Ninety-nine participants reported two falls within six months of entry to the study. Thus, the incidence of recurrent fallers was 11.4%. The tree analysis classified the population into five groups differing in risk of recurrent falling, based on history of falls in the three months prior to the initial interview, Berg balance score, type of housing, and usual alcohol consumption in the six months preceding study entry. The relative risks varied from 0.7 to 5.1. The survival analysis showed that the length of time before becoming a recurrent faller varies among risk profiles. CONCLUSION: The study permitted the construction of easily interpretable risk profiles of recurrent falling. These can guide clinicians and public health practitioners to identify high-risk individuals and to decide on the appropriate intervention and follow-up.

[Birth order, behavioural problems, and the mother-child relationship in siblings aged 4 to 11 years from a 2-child family]. / Rang de naissance, difficultés de comportement et relation mère-enfant chez des jeunes de 4 à 11 ans de fratries composées de deux enfants.

UNLABELLED: Birth Order, Behavioural Problems, and the Mother-Child Relationship in Siblings Aged 4 to 11 Years From a 2-Child Family OBJECTIVE: This study was designed to define the relation between some sibling characteristics (birth order, sex, and interval between successive births) and some behavioral problems in children, on the one hand, and certain dimensions of the mother-child relationship, on the other hand. METHOD: The sample, from National Longitudinal Survey of Children and Youth, included 1,196 families with 2 biological children aged 4 to 11 years. Behavioural problems and dimensions of the mother-child relationship were assessed by mothers. Repeated-measures multivariate analyses of variance were conducted. RESULTS: Analyses showed that first-born children have more internalized symptoms than second-born children. Second-born children also have more positive interactions with their mothers than first-born children. The interval between successive births does not affect these results. CONCLUSION: Several differences emerged between siblings. Health professionals should take these findings into account in their clinical assessments.

Sex of victims in maternal filicide.

In many societies, girls are more often killed by their parents than boys. However, not much of this is known in contemporary societies. This study had two main objectives. The first was to assess whether the number of boy and girl victims of maternal filicide differ in the literature from 1959 to 2000. Using two scientific databases, Medline and PsycINFO, 20 texts were pertinent. The second objective was to identify the variables that differentiate the mothers who killed a son and those who killed a daughter in a sample of 42 women from the province of Quebec (Canada). Analysis of the data for the first part indicate that the numbers of sons and daughters killed by their mothers are similar in the literature. For the second aim no significant differences were noted between the women who killed a son and those who killed a daughter for 30 variables studied, e.g., motivation, method of killing, age of the victims, etc.

Familial overlap between bipolar disorder and psychotic symptoms in a Canadian cohort.

BACKGROUND: Although they were once considered separate nosologic entities, there is current interest in the etiologic overlap between bipolar disorder (BD) and schizophrenia. A critical issue concerns the familial basis of the overlap, specifically, the possibility of a distinct familial subtype of BD with psychotic features. METHODS: We recruited individuals with BD from the community and compared them with a matched group diagnosed with no mental disorder to confirm familial aggregation for BD, schizophrenia, and psychotic symptoms. We then compared BD probands both with and without first-degree relatives with psychotic symptoms on several clinical indicators to determine the specificity of the familial aggregation. RESULTS: As expected, there was evidence for familial aggregation of schizophrenia and psychotic symptoms in families having probands with BD. Familial loading for schizophrenia and psychotic symptoms was especially notable in male relatives of female probands with BD. We found no differences in the clinical profile of probands with BD stratified for familial loading for psychotic symptoms. CONCLUSIONS: Findings from this sample support etiologic theories arguing for a shared but nonspecific genetic etiology for BD and schizophrenia, with psychotic symptoms being a potential key indicator for genetic studies.