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Duffner LA, Janssen N, Deckers K, Schroyen S, de Vugt ME, Köhler S, Adam S, Verhey FRJ, Veenstra MY. Facing the Next "Geriatric Giant"-A Systematic Literature Review and Meta-Analysis of Interventions Tackling Loneliness and Social Isolation Among Older Adults. J Am Med Dir Assoc 2024; 25:105110. [PMID: 38945174 DOI: 10.1016/j.jamda.2024.105110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVES Loneliness and social isolation are associated with adverse health outcomes, especially within the older adult population, underlining the need for effective interventions. This systematic review and meta-analysis aims to summarize all available evidence regarding the effectiveness of interventions for loneliness and social isolation, to map out their working mechanisms, and to give implications for policy and practice. DESIGN Systematic literature review and meta-analysis. SETTING AND PARTICIPANTS Older adults (≥65 years). METHODS A systematic search was conducted in MEDLINE, PsycINFO, and CINAHL for studies quantitively or qualitatively assessing effects of interventions for loneliness and social isolation in older adults, following predefined selection criteria. Risk of bias as well as small study effects were assessed and, wherever appropriate, information about effect sizes of individual studies pooled using random-effects meta-analyses. Sources for between-study heterogeneity were explored using meta-regression. RESULTS Of n = 2223 identified articles, n = 67 were eventually included for narrative synthesis. Significant intervention effects were reported for a proportion of studies (55.9% and 50.0% for loneliness and social isolation, respectively) and 57.6% of studies including a follow-up measure (n = 29) reported sustained intervention effects. Meta-analysis of n = 27 studies, representing n = 1756 participants, suggested a medium overall effect of loneliness interventions (d = -0.47; 95% CI, -0.62 to -0.32). Between-study heterogeneity was substantial and could not be explained by differences in study design, year of publication, outcome measures, intervention length, participant demographics, setting, baseline level of loneliness, or geographic location. However, non-technology-based interventions reported larger effect sizes on average (Δd = -0.35; 95% CI, -0.66 to -0.04; P = .029) and were more often significant. Qualitative assessment of potential intervention mechanisms resulted in 3 clusters of effective components: "promoting social contact," "transferring knowledge and skills," and "addressing social cognition". CONCLUSIONS AND IMPLICATIONS Interventions for loneliness and social isolation can generally be effective, although some unexplained between-study heterogeneity remains. Further research is needed regarding the applicability of interventions across different settings and countries, also considering their cost-effectiveness.
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Affiliation(s)
- Lukas A Duffner
- Alzheimer Centrum Limburg, Mental Health and Neuroscience Research Institute, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Niels Janssen
- Alzheimer Centrum Limburg, Mental Health and Neuroscience Research Institute, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
| | - Kay Deckers
- Alzheimer Centrum Limburg, Mental Health and Neuroscience Research Institute, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Sarah Schroyen
- Psychology of Aging Unit (UPsySen), Faculty of Psychology, University of Liege, Liege, Belgium
| | - Marjolein E de Vugt
- Alzheimer Centrum Limburg, Mental Health and Neuroscience Research Institute, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Sebastian Köhler
- Alzheimer Centrum Limburg, Mental Health and Neuroscience Research Institute, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Stéphane Adam
- Psychology of Aging Unit (UPsySen), Faculty of Psychology, University of Liege, Liege, Belgium
| | - Frans R J Verhey
- Alzheimer Centrum Limburg, Mental Health and Neuroscience Research Institute, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Marja Y Veenstra
- Alzheimer Centrum Limburg, Mental Health and Neuroscience Research Institute, Department of Psychiatry and Neuropsychology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
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Leton N. Senescence Seclusion Syndrome: Appraising the Efficacy of Current Interventions. Cureus 2024; 16:e62684. [PMID: 39036158 PMCID: PMC11259019 DOI: 10.7759/cureus.62684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/23/2024] Open
Abstract
The proportion of senior citizens in the global population has been on a steady rise, and the current population is forecasted to double in a few decades. Against this backdrop, the prevalence of senescence seclusion syndrome, characterized by prolonged social isolation in the elderly, is increasing concurrently. Given the profound threats this syndrome poses to the mental, physical, and social well-being of this vulnerable demographic, implementing effective interventions is imperative to mitigate these threats and enhance the quality of life. This review aims to assess the efficacy of the interventional modalities critically. Studies were reviewed following comprehensive searches in databases such as PubMed, Scopus, and Google Scholar, and focusing on empirical studies from 2019 to 2024 that evaluated the efficacy of the major intervention categories - social, technological, psychological, and physical interventions. The findings indicate that initiatives that promote consistent social engagement, such as community-organized social events and structured group activities, significantly reduced loneliness and bolstered social connections. Furthermore, technological interventions, including artificial intelligence and virtual reality, have notably enhanced elderly connectivity with their communities. Additionally, psychological interventions, such as cognitive-behavioral therapy, have also been effective in alleviating symptoms of anxiety and depression associated with the syndrome, with group sessions enhancing social interaction and significantly diminishing isolation. Moreover, physical interventions involving group exercises and other activities have fostered improvements in the physical, mental, and social well-being of the elderly. This study underscores the importance of a multifaceted approach that is individualized according to preference and circumstance in addressing senescence seclusion syndrome.
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Affiliation(s)
- Noah Leton
- Department of Physiology, Neuroscience and Behavioral Sciences, St. George's University, St. George's, GRD
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Willmott R, Martin West I, Yung P, Giri Shankar V, Perera G, Tsamakis K, Stewart R, Mueller C. An investigation of neuropsychiatric symptoms, contextual factors, and antidepressant treatment as risk factors for dementia development in people with mild cognitive impairment. Int J Geriatr Psychiatry 2024; 39:e6097. [PMID: 38782606 DOI: 10.1002/gps.6097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 05/03/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND While some people with mild cognitive impairment (MCI) progress to dementia, many others show no progression. The aim of this study was to identify factors associated with risk of dementia development in this population. METHOD A large naturalistic retrospective cohort study was assembled from mental healthcare records in a south London catchment. Patients were selected at first recorded diagnosis of MCI and subsequent dementia diagnosis was ascertained from case notes or death certificate, excluding those with dementia diagnoses and deaths within 6 months of MCI diagnosis. A range of demographic and clinical characteristics were ascertained around MCI diagnosis and Cox proportional hazards models were used to investigate independent predictors of dementia, focussing on neuropsychiatric symptoms, contextual factors, and antidepressant treatment. RESULTS Of 2250 patients with MCI, 236 (10.5%) developed dementia at least 6 months after MCI diagnosis. Aside from older age, lower cognitive function, and activities of daily living impairment, impaired social relationships and recorded loneliness were associated with a higher risk of developing dementia. Patients of Black (compared to White) ethnicity were at a lower risk. For depression and antidepressant receipt, only tricyclic use compared to no antidepressant use was associated with an increased dementia risk. CONCLUSIONS No evidence was found for co-morbid affective disorders or different antidepressant classes as risk factors for dementia development following MCI diagnosis, but loneliness and social impairment were independent predictors and would be worth evaluating as targets for interventions to delay progression.
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Affiliation(s)
- Ruth Willmott
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Paul Yung
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Gayan Perera
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Konstantinos Tsamakis
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Second Department of Psychiatry, National and Kapodistrian University of Athens, School of Medicine, University General Hospital 'ATTIKON', Athens, Greece
| | - Robert Stewart
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Christoph Mueller
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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Strkljevic I, Tiedemann A, Souza de Oliveira J, Haynes A, Sherrington C. Health professionals' involvement in volunteering their professional skills: a scoping review. Front Med (Lausanne) 2024; 11:1368661. [PMID: 38737756 PMCID: PMC11082404 DOI: 10.3389/fmed.2024.1368661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024] Open
Abstract
Background Volunteering positively affects overall health of both volunteers and recipients through social interaction, support and physical activity. Health professionals' volunteering has considerable potential to improve health outcomes in communities. Objectives This study aimed to summarize published scientific literature regarding volunteering by health professionals. Method Medine, Embase, Scopus, PsycINFO and CINAHLdatabases were searched to identify eligible studies published between 2010 and 2023. Data on study methods and findings were extracted and synthesized. Results Of the 144 eligible studies, 80 (56%) used quantitative methods, 46 (32%) used qualitative, 18 (12%) used mixed methods and 8 (6%) were interventional. Doctors (74 studies, 51%) and nurses (n = 40, 28%) were the professions with most reports of volunteering. Half the studies were from USA (n = 77, 53%), followed by UK (n = 19, 13%), Canada (n = 12, 8%), and Australia/New Zealand (n = 11, 8%). International volunteering in low-to-middle-income countries was reported in 64 studies (44%). Providing service and training were the dominant types of activities (n = 90, 62.5%), with health promotion reported in only 4 studies (3%). Studies reported positive impact from volunteering, both professionally and personally. Time and family commitments were the main barriers. Enablers, barriers and impact were summarized in a socio-ecological map. Conclusion Health professionals volunteer in diverse activities and report multifaceted benefits. Studies of volunteering interventions could enable new, sustainable approaches to health promotion.
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Affiliation(s)
- Ima Strkljevic
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Anne Tiedemann
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Juliana Souza de Oliveira
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Abby Haynes
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Cathie Sherrington
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Delolmo-Romero S, Correa-Rodríguez M, Sánchez-Martínez MC, Gil-Gutiérrez R, Ortego-Centeno N, Rueda-Medina B. Social Health and Its Influence on Metabolic Health Among a Rural Population: A Cross-Sectional Study. Clin Nurs Res 2024; 33:9-18. [PMID: 37382362 DOI: 10.1177/10547738231184935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
The aim of this study was to estimate the prevalence of metabolic syndrome (MetS) in a Spanish rural population and assess differences in prevalence according to loneliness level, social isolation, and social support. This is a cross-sectional study of 310 patients. MetS was defined by National Cholesterol Education Program-Third Adult Treatment Panel. The UCLA (University of California, Los Angeles) Loneliness Scale, Multidimensional Scale of Social Support, and Lubben Social Network Scale were used to assess loneliness, perceived social support, and social isolation. Almost half of the participants fulfilled MetS diagnosis criteria. Subjects with MetS showed significantly higher levels of loneliness, less social support, and greater social isolation. Systolic blood pressure was significantly higher in socially isolated rural adults. Environmental factors may play a key role in the prevalence of MetS, so specific screening and prevention programs could help health professionals prevent the increasing rates of MetS in rural populations under these socially specific conditions of vulnerability.
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Affiliation(s)
- Sara Delolmo-Romero
- Department of Nursing, Faculty of Health Sciences, University of Granada, Spain
- Instituto de Investigación Biosanitaria IBS GRANADA, Spain
| | - María Correa-Rodríguez
- Department of Nursing, Faculty of Health Sciences, University of Granada, Spain
- Instituto de Investigación Biosanitaria IBS GRANADA, Spain
| | | | - Rocío Gil-Gutiérrez
- Department of Nursing, Faculty of Health Sciences, University of Granada, Spain
- Instituto de Investigación Biosanitaria IBS GRANADA, Spain
| | - Norberto Ortego-Centeno
- Department of Nursing, Faculty of Health Sciences, University of Granada, Spain
- Department of Medicine, Faculty of Medicine, University of Granada, Spain
| | - Blanca Rueda-Medina
- Department of Nursing, Faculty of Health Sciences, University of Granada, Spain
- Instituto de Investigación Biosanitaria IBS GRANADA, Spain
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Wang Y, Li X, Yao L, Ren T, Wang T. Effectiveness of social support programmes on loneliness in community-dwelling older adults: study protocol for a meta-analysis of randomised controlled trials. BMJ Open 2023; 13:e073739. [PMID: 38072487 PMCID: PMC10729098 DOI: 10.1136/bmjopen-2023-073739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND The prevalence of loneliness among older adults is of great importance in the field of public health. Numerous studies have provided evidence supporting the effectiveness of social support as a powerful intervention for reducing loneliness in older individuals. However, the specific types of social support that yield positive results are yet to be determined. Therefore, this study aims to conduct a comprehensive review to compare and analyse the effectiveness of different support mechanisms in alleviating loneliness among community-dwelling older adults. METHODS AND ANALYSIS A thorough search will be conducted on various electronic databases, including EMBASE, PubMed, the Cochrane Library, Web of Science, PsycINFO, Scopus, Google Scholar, China National Knowledge Infrastructure Library, China Science and Technology Journal Database (Weipu), WanFang Database, and China Biology Medicine Disc. The search will include randomised controlled trials published in English or Chinese that focus on interventions for loneliness in older individuals, with loneliness as the primary measure of interest. The selection and choice of articles will be the responsibility of both reviewers. The JBI Critical Appraisal Checklist for Randomised Controlled Trials will be used to assess the methodological quality of the included trials. When sufficient data are obtained and the study is relatively homogeneous, a random-effects or fixed-effects model will be employed to conduct a meta-analysis, yielding a descriptive synthesis of the findings. ETHICS AND DISSEMINATION Ethics approval will not be sought for this systematic review as it will exclusively focus on published papers. The review findings will be showcased at a conference dedicated to this specific field and published in an appropriate journal that undergoes peer evaluation. PROSPERO REGISTRATION NUMBER CRD42020226523.
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Affiliation(s)
- Yinhua Wang
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | | | - Li Yao
- The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Tingting Ren
- The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Tingshu Wang
- Guizhou Medical University, Guiyang, Guizhou, China
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Roskoschinski A, Liang W, Duan Y, Al-Salehi H, Lippke S. Loneliness and depression in older adults with multimorbidity: the role of self-efficacy and social support. Front Psychiatry 2023; 14:1232067. [PMID: 37965359 PMCID: PMC10642299 DOI: 10.3389/fpsyt.2023.1232067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction As relatively little is known about self-efficacy and social support in individuals aged 65 years and older and whether they are facing a decline in life due to multimorbidity and previous COVID-19 infection, this study investigated hypotheses based on Social Cognitive Theory. Methods It was tested whether depressive symptoms in multimorbid patients who were hospitalized for COVID-19 infection, and recover post infection during their hospital stay, do not differ from those of multimorbid patients hospitalized for other conditions. Furthermore, we tested whether depressive symptoms are associated with increased loneliness scores, low self-efficacy beliefs, and poorly perceived social support. Additionally, it was investigated whether self-efficacy is a mediator variable, and social support is a moderator variable between loneliness and depression. N = 135 patients with or without previous COVID-19 infection (mean age 64.76) were recruited. Paper questionnaires were collected at the time of inpatient hospital admission in the year 2021 and in a cross-sectional study design. The study compared n = 45 multimorbid patients who survived COVID-19 infection with those n = 90 who were not infected before. Results No significant difference in depressive symptomology between these two groups revealed [t(133) = 130, p = 0.90, d = 0.024); F(3, 122) = 0.255, p = 0.86]. The study found a positive correlation between loneliness and anxiety and depression in both groups (rdepression = 0.419 and ranxiety = 0.496). Self-efficacy mediated the relation between loneliness and depression. The completely standardized indirect effect was β = 0.111, percentile Bootstrap 95% CI 0.027-0.201. Discussion The research findings suggest the importance of self-efficacy, and loneliness in the development of depressive symptoms, and have several practical implications for improving the mental health of multimorbid patients: Prospectively, treatment should not only focus on physical and cognitive health, but also on promoting self-efficacy and perceived social support, as well as address loneliness with psychoeducational interventions. Replication of the findings and conducting interventional research also employing lifestyle components should follow up, as this study tested associations but no causal relationships.
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Affiliation(s)
- Annika Roskoschinski
- Unit for Geriatrics and Physical Medicine, Helios Klinikum Berlin-Buch, Berlin, Germany
- Constructor University Bremen, Bremen, Germany
| | - Wei Liang
- School of Physical Education, Shenzhen University, Shenzhen, China
| | - Yanping Duan
- Hong Kong Baptist University, Kowloon, Hong Kong SAR, China
| | - Hayl Al-Salehi
- Constructor University Bremen, Bremen, Germany
- Bremen International Graduate School of Social Sciences (BIGSSS), Bremen, Germany
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Yu DSF, Li PWC, Lin RSY, Kee F, Chiu A, Wu W. Effects of non-pharmacological interventions on loneliness among community-dwelling older adults: A systematic review, network meta-analysis, and meta-regression. Int J Nurs Stud 2023; 144:104524. [PMID: 37295285 DOI: 10.1016/j.ijnurstu.2023.104524] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The highly prevalent late-life loneliness, together with its deleterious health impacts, calls for increasing attention to the need for effective interventions targeting on this growing public health problem. With the increasing evidence on interventions for combating loneliness, it is timely to identify their comparative effectiveness. OBJECTIVE This systematic review, meta-analysis and network meta-analysis was to identify and compare the effects of various non-pharmacological interventions on loneliness in community-dwelling older adults. METHODS Systematic search was conducted in nine electronic databases from inception to 30th March 2023 for studies investigating the effects of non-pharmacological interventions on loneliness among community-dwelling older adults. The interventions were categorized according to the nature and purpose of use. Pairwise meta-analysis and network meta-analyses were sequentially performed to identify the effects of each category of interventions and their comparative intervention effectiveness, respectively. Meta-regression was performed to examine any influence of study design and participants' characteristics on the intervention effectiveness. The study protocol was registered at PROSPERO (CRD42022307621). RESULTS A total of 60 studies with 13,295 participants were included. The interventions were categorized as psychological interventions, social support interventions (by digital and non-digital means), behavioral activation, exercise intervention with and without social engagement, multi-component intervention and health promotion. Pairwise meta-analysis identified the positive effect of psychological interventions (Hedges' g = -2.33; 95%CI [-4.40, -0.25]; Z = -2.20, p = 0.003), non-digital social support interventions (Hedges' g = -0.63; 95%CI [-1.16, -0.10]; Z = 2.33, p = 0.02) and multi-component interventions (Hedges' g = -0.28 95%CI [-0.54, -0.03]; Z = -2.15, p = 0.03) on reducing loneliness. Subgroup analysis provided additional insights: i) social support and exercise interventions which integrated active strategies to optimize the social engagement demonstrated more promising intervention effects; ii) behavioral activation and multicomponent interventions worked better for older adults who were male or reported loneliness, respectively, and iii) counseling-based psychological interventions was more effective than mind-body practice. Network meta-analysis consistently pointed to the greatest therapeutic benefits of psychological interventions, and this was followed by exercise-based interventions, non-digital social support interventions and behavioral activation. Meta-regression further suggested that the therapeutic effects of the tested interventions were independent of the various factors relating to study design and participants' characteristics. CONCLUSIONS This review highlights the more superior effects of psychological interventions in improving loneliness among older adults. Interventions which have an attribute to optimize social dynamic and connectivity may also be effective. TWEETABLE ABSTRACT Psychological intervention is the best to beat late-life loneliness, but increasing social dynamic and connectivity may add an impact.
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Affiliation(s)
- Doris Sau-Fung Yu
- School of Nursing, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong.
| | - Polly Wai-Chi Li
- School of Nursing, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Rose Sin-Yi Lin
- School of Nursing, University of Rochester, United States of America
| | - Frank Kee
- School of Medicine, Dentistry and Biomedical Sciences, Centre for Public Health, Queen's University Belfast, United Kingdom of Great Britain and Northern Ireland
| | - Alice Chiu
- Improving Health Outcomes Together Team, Alberta Health Services, Calgary, Alberta, Canada
| | - Wendy Wu
- School of Nursing, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
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