SUPPORT
INGINFORMALCAREG
IVERSTHROUGHTHEDEMENT
IA
JOURNEY
:
APR
IMARYCAREAPPROACH
by
AmandaL
.M
cKn
igh
t
BS
cN
,Un
iv
e
r
s
i
tyo
fth
eF
r
a
s
e
rV
a
l
l
ey
,2004

PRO
JECTSUBM
ITTEDINPART
IALFULF
ILLMENTOF
THEREQU
IREMENTSFORTHEDEGREEOF
MASTEROFSC
IENCEIN NURS
ING
:FAM
ILYNURSEPRACT
IT
IONER

UN
IVERS
ITYOFNORTHERNBR
IT
ISHCOLUMB
IA
Jun
e2016
©Am
and
aM
cKn
igh
t
,2016

i
i

	
  
Ab
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A
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iv

	
  
TABLEOFCONTENTS
Ab
s
t
r
a
c
t

i
i

A
cknow
l
edg
em
en
t
s

i
i
i

T
ab
l
eo
fCon
t
en
t
s

iv

L
i
s
to
fF
igu
r
e
s

v
i
i

In
t
rodu
c
t
ion

1

Ch
ap
t
e
rOn
e

B
a
ckg
roundandCon
t
ex
t
5
Th
eC
a
r
eg
iv
ingJou
rn
ey
5
D
em
en
t
i
a
:Th
eImp
e
tu
so
fth
eJou
rn
ey
9
G
e
t
t
ingtoKnowth
eT
r
av
e
l
e
r
s
: Whoa
r
eTh
eC
a
r
eg
iv
e
r
sandWh
a
ti
sth
e
Ro
l
eo
fE
a
chTyp
e
?
13
Th
eRo
adL
e
s
sT
r
av
e
l
ed
:Th
eImp
a
c
to
fC
a
r
eg
iv
ingonIn
fo
rm
a
l
C
a
r
eg
iv
e
r
s
18
S
t
r
e
s
so
rs
18
Phy
s
i
c
a
lImp
a
c
t
s
19
P
sy
cho
log
i
c
a
lImp
a
c
t
s
21
So
c
i
a
lImp
a
c
t
s
23
F
in
an
c
i
a
lImp
a
c
t
s
23
Bu
rd
en
24
Ch
ang
ingW
e
a
th
e
rA
longth
eJou
rn
ey
:F
a
c
to
r
sth
a
tIn
f
lu
en
c
eBu
rd
en 25
E
thn
i
c
i
ty
26
Ag
eandG
end
e
r
27
R
e
l
a
t
ion
sh
ipB
e
tw
e
enth
eC
a
r
eg
iv
e
randC
a
r
eR
e
c
ip
i
en
t
28
C
a
r
eg
iv
e
r
s
’OwnT
r
a
i
t
s
29
S
ev
e
r
i
tyo
fD
i
s
e
a
s
eandC
a
r
eR
e
c
ip
i
en
tB
eh
av
iou
r
s
29
So
c
i
a
lSuppo
r
t
30
S
e
rv
i
c
eU
t
i
l
i
z
a
t
ion
32
Th
eT
r
av
e
lGu
id
e
:Ro
l
eo
fth
ePCPinSuppo
r
t
ingICPWD
34
E
f
f
e
c
t
iv
e
lyGu
id
ingICPWDTh
roughth
e
i
rJou
rn
ey
s
:AnApp
ro
a
chto
C
a
r
e
35
A
s
s
e
s
sm
en
to
fICPWD
:D
e
t
e
rm
in
ingN
e
ed
sTh
roughth
eJou
rn
ey
39
P
rov
id
ing“Ro
ad
s
id
eA
s
s
i
s
t
an
c
e
”
:Int
e
rv
en
t
ion
sandE
th
i
c
a
lI
s
su
e
s 40

Ch
ap
t
e
rTwo

S
e
a
r
ch M
e
thod
In
c
lu
s
ionandEx
c
lu
s
ionC
r
i
t
e
r
i
afo
rL
i
t
e
r
a
tu
r
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s
id
e
r
a
t
ion
R
e
su
l
t
sandS
e
l
e
c
t
iono
fA
r
t
i
c
l
e
sfo
rR
ev
i
ew

44
45
47

Ch
ap
t
e
rTh
r
e
e

F
ind
ing
s
Th
eC
a
r
eg
iv
e
rJou
rn
ey
:F
romth
eB
eg
inn
ingtoth
eEnd
Pu
l
l
ingOu
to
fth
eD
r
iv
ew
ay
:Th
eB
eg
inn
ingo
fth
eJou
rn
ey

49
49
49

v

	
  

Onth
eRo
ad
:Th
ejou
rn
eyCon
t
inu
e
sTh
roughth
eM
idd
l
eS
t
ag
e
s 53
R
e
a
ch
ingth
eEndo
fth
eRo
ad
:N
e
arth
eEndo
fth
eJou
rn
ey
64
In
fo
rm
a
lC
a
r
eg
iv
e
rN
e
ed
sTh
roughou
tth
eC
a
r
eg
iv
ingJou
rn
ey
65
In
fo
rm
a
lC
a
r
eg
iv
e
rA
s
s
e
s
sm
en
t
69
P
rov
id
ing‘Ro
ad
s
id
eA
s
s
i
s
t
an
c
e
’
:HowE
f
f
e
c
t
iv
eA
r
eP
r
im
a
ryC
a
r
eB
a
s
edIn
t
e
rv
en
t
ion
s
?
70
P
sy
cho
so
c
i
a
lIn
t
e
rv
en
t
ion
s
71
Edu
c
a
t
ion
a
lIn
t
e
rv
en
t
ion
s
74
Co
l
l
abo
r
a
t
iv
eC
a
r
eIn
t
e
rv
en
t
ion
s
78
C
l
in
i
c
a
lP
r
a
c
t
i
c
eGu
id
e
l
in
e
s
82
Ch
ap
t
e
rFou
r

	
  
Ch
ap
t
e
rF
iv
e

D
i
s
cu
s
s
ion
87
N
e
ed
sandExp
e
r
i
en
c
e
so
fICPWD
:Th
eImp
a
c
to
fth
eC
a
r
eg
iv
ing
Jou
rn
ey
88
Th
eH
e
a
l
thSy
s
t
em
D
i
agno
s
i
s
88
Edu
c
a
t
ion
90
Commun
i
c
a
t
ionB
e
tw
e
enPCP
sandICPWD
91
T
r
an
s
i
t
ion
a
lC
a
r
e
91
Suppo
r
tS
e
rv
i
c
e
s
92
F
am
i
lyandCommun
i
ty
93
R
e
l
a
t
ion
sh
ipw
i
thth
eC
a
r
eR
e
c
ip
i
en
t
95
P
e
r
son
a
lJou
rn
ey
96
Po
s
i
t
iv
eA
sp
e
c
t
so
fC
a
r
eg
iv
ing
97
“Ro
ad
s
id
eA
s
s
i
s
t
an
c
e
”
:Th
eE
f
f
e
c
t
iv
en
e
s
so
fSuppo
r
t
iv
eIn
t
e
rv
en
t
ion
s98
C
l
in
i
c
a
lP
r
a
c
t
i
c
eGu
id
e
l
in
e
s
101
Th
eRo
l
eo
fth
eNPandImp
l
i
c
a
t
ion
sfo
rNPP
r
a
c
t
i
c
e
102

R
e
comm
end
a
t
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s
R
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comm
end
a
t
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sfo
rC
l
in
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c
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lP
r
a
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t
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c
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im
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lyD
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Endo
fL
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ann
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Suppo
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rov
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r
e
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
	
  
F
am
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ip
a
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s
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c
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l
i
c
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end
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e
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111
111
111
112
113
115
116
117
118
119
119
119
120
121
121
122

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c
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124

	
  

v
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152

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end
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153

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end
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end
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158

v
i
i

	
  
L
i
s
to
fF
igu
r
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s

	
  
F
igu
r
e1
.Commonsubtyp
e
so
fd
em
en
t
i
a

F
igu
r
e2
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ep
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r
e
s
s
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fc
a
r
edu
r
ingth
ep
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a
	
  
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igu
r
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c
i
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i
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11
14
107

1

	
  

In
t
rodu
c
t
ion
Fo
rm
e
rF
i
r
s
tL
adyRo
s
a
lynnC
a
r
t
e
ron
c
es
t
a
t
ed
,“
th
e
r
ea
r
eon
lyfou
rk
ind
so
fp
eop
l
e
inth
i
swo
r
ld
:tho
s
ewhoh
av
eb
e
enc
a
r
eg
iv
e
r
s
;tho
s
ewhocu
r
r
en
t
lya
r
ec
a
r
eg
iv
e
r
s
;tho
s
ewho
w
i
l
lb
ec
a
r
eg
iv
e
r
s;andtho
s
ewhow
i
l
ln
e
edc
a
r
eg
iv
e
r
s
”(C
a
r
t
e
r&Go
l
an
t
,1994
,p
.3
)
.Th
i
s
s
t
a
t
e
m
en
ta
cknow
l
edg
e
sth
es
ign
i
f
i
c
an
c
eo
fth
ec
a
r
eg
iv
ingro
l
e
,a
sw
e
l
la
sth
eimpo
r
t
an
c
eo
f
r
e
cogn
i
z
ingandsuppo
r
t
ingind
iv
idu
a
l
swhop
rov
id
eth
i
sc
a
r
e
.Po
l
i
cym
ak
e
r
s
,r
e
s
e
a
r
ch
e
r
s
,
andh
e
a
l
thc
a
r
ep
rov
id
e
r
sa
r
ein
c
r
e
a
s
ing
lya
cknow
l
edg
ingth
ev
a
lu
eandb
en
e
f
i
to
fin
fo
rm
a
l
c
a
r
ep
rov
i
s
iontobo
thc
a
r
er
e
c
ip
i
en
t
sandtoso
c
i
e
tya
sawho
l
e(P
e
a
co
cke
ta
l
.
,2010
;Ro
s
ae
t
a
l
.
,2010
;S
chu
l
t
z& M
a
t
i
r
e
,2004
)
.How
ev
e
r
,S
a
l
f
i
,P
lo
eg
,andB
l
a
ck(2005
)r
epo
r
t
edth
a
t
in
fo
rm
a
lc
a
r
eg
iv
e
rn
e
ed
sa
r
eo
f
t
enun
a
r
t
i
cu
l
a
t
edandunm
e
t
.Fu
r
th
e
r
,ev
id
en
c
eb
a
s
ed
in
fo
rm
a
t
ionabou
tth
eapp
l
i
c
a
t
iono
fbo
thin
fo
rm
a
lc
a
r
eg
iv
e
rn
e
ed
sa
s
s
e
s
sm
en
t
sand
suppo
r
t
iv
ein
fo
rm
a
lc
a
r
eg
iv
e
rin
t
e
rv
en
t
ion
sinth
ep
r
im
a
ryc
a
r
es
e
t
t
ingi
sno
t
ab
lyl
a
ck
ing
(F
e
inb
e
rg
,2002
;S
chu
l
z& M
a
t
i
r
e
,2004
)
.
P
eop
l
eo
fa
l
lag
e
sandw
i
thd
iv
e
r
s
eh
e
a
l
thc
a
r
en
e
ed
sw
i
l
lpo
t
en
t
i
a
l
lyr
equ
i
r
ec
a
r
ea
t
som
epo
in
tinth
e
i
rl
iv
e
s
;how
ev
e
r
,i
ti
so
ld
e
radu
l
t
swhop
r
edom
in
an
t
lyp
rov
id
eandr
e
c
e
iv
e
in
fo
rm
a
lc
a
r
e
.A
sth
enumb
e
ro
fo
ld
e
radu
l
t
sinou
rpopu
l
a
t
ioncon
t
inu
e
stor
i
s
e
,th
en
e
edfo
r
in
fo
rm
a
lc
a
r
eg
iv
e
r
sw
i
l
lcon
cu
r
r
en
t
lyin
c
r
e
a
s
e
.Th
eag
ingpopu
l
a
t
ioni
s
,inf
a
c
t
,th
ef
a
s
t
e
s
t
g
row
ings
e
c
to
ro
fou
rpopu
l
a
t
ion(K
an
e
,2011
)
.Th
ein
c
r
e
a
s
einth
enumb
e
ro
fs
en
io
r
sinou
r
commun
i
t
i
e
sm
e
an
sth
a
tth
enumb
e
ro
find
iv
idu
a
l
sw
i
thd
em
en
t
i
aw
i
l
lcon
t
inu
etor
i
s
ea
s
w
e
l
l
.Th
eGov
e
rnm
en
to
fC
an
ad
a(2016
)r
epo
r
t
sth
a
tapp
rox
im
a
t
e
ly395
,000C
an
ad
i
an
sov
e
r
th
eag
eo
f40l
iv
ew
i
thd
em
en
t
i
a
,andth
enumb
e
ro
fp
eop
l
ed
i
agno
s
edw
i
thd
em
en
t
i
ai
s
p
r
ed
i
c
t
edtodoub
l
eby2030andmo
r
eth
ant
r
i
p
l
eby2050(C
an
ad
i
anIn
s
t
i
tu
t
e
so
fH
e
a
l
th
R
e
s
e
a
r
ch[C
IHR
]
,2015
)
.

2

	
  
H
e
a
l
thcond
i
t
ion
ssu
cha
sd
em
en
t
i
a
,wh
i
cha
r
emo
s
to
f
t
ena
s
so
c
i
a
t
edw
i
thsu
chan

ag
ingpopu
l
a
t
ion
,a
r
ec
au
s
inganin
c
r
e
a
s
edd
em
andfo
rr
e
s
id
en
t
i
a
lc
a
r
eb
ed
sandfo
rm
a
lc
a
r
e
s
e
rv
i
c
e
s(C
an
ad
i
anIn
s
t
i
tu
t
efo
rH
e
a
l
thIn
fo
rm
a
t
ion[C
IH
I
]
,2010
a
)
.Th
i
sth
enr
e
su
l
t
sina
n
in
c
r
e
a
s
edn
e
edfo
rgov
e
rnm
en
t
fund
edh
e
a
l
thc
a
r
eexp
end
i
tu
r
e
s
.Th
esu
s
t
a
in
ab
i
l
i
tyo
fth
e
h
e
a
l
thc
a
r
esy
s
t
emi
sd
ep
end
en
tonan
e
two
rko
fin
fo
rm
a
lc
a
r
eg
iv
e
r
swhop
rov
id
ec
a
r
eand
s
uppo
r
ttos
en
io
r
sa
thom
eino
rd
e
rtoavo
idth
ep
ro
sp
e
c
to
fin
s
t
i
tu
t
ion
a
l
i
z
a
t
ionfo
ra
slonga
s
po
s
s
ib
l
e(C
IH
I
,2010b
)
.H
e
a
l
thc
a
r
esy
s
t
em
sw
i
th
inC
an
ad
aa
r
ecu
r
r
en
t
lysh
i
f
t
ingth
efo
cu
s
aw
ayf
romr
e
s
id
en
t
i
a
landa
cu
t
ec
a
r
etow
a
rdcommun
i
ty
b
a
s
edc
a
r
efo
rs
en
io
r
sino
rd
e
rto
en
su
r
easu
s
t
a
in
ab
l
eh
e
a
l
thc
a
r
esy
s
t
emfo
rC
an
ad
i
an
s(C
IH
I
,2010
a
)
.How
ev
e
r
,th
i
ssh
i
f
th
a
s
th
es
imu
l
t
an
eou
se
f
f
e
c
to
fp
l
a
c
ingin
c
r
e
a
s
ingp
r
e
s
su
r
eonin
fo
rm
a
lc
a
r
eg
iv
e
r
s
,in
c
lud
ing
in
fo
rm
a
lc
a
r
eg
iv
e
r
so
fp
e
r
son
sw
i
thd
em
en
t
i
a(
ICPWD
)
,top
rov
id
ec
a
r
efo
rth
e
i
rlov
edon
e
s
fo
rlong
e
rp
e
r
iod
so
ft
im
einth
ehom
eenv
i
ronm
en
t
.
A
l
thoughc
a
r
ep
rov
i
s
ionbyICPWDmo
s
to
f
t
enb
en
e
f
i
t
sbo
thth
ec
a
r
er
e
c
ip
i
en
tand
so
c
i
e
tya
sawho
l
e
,th
en
eg
a
t
iv
ee
f
f
e
c
t
so
fc
a
r
eg
iv
ingonICPWDc
ana
l
sob
econ
s
id
e
r
a
b
l
e
andshou
ldno
tb
ed
i
s
coun
t
ed(S
chu
l
t
z& M
a
t
i
r
e
,2004
)
.Thu
s
,th
e
r
ei
sac
ru
c
i
a
ln
e
edtof
ind
th
emo
s
te
f
f
e
c
t
iv
ew
ay
sbywh
i
chtosuppo
r
tth
e
s
ein
fo
rm
a
lc
a
r
eg
iv
e
r
s(Dugg
l
eby
,Sw
ind
l
e
,
&P
e
a
co
ck
,2014
;W
in
t
e
r&G
i
t
l
in
,2006
)
.F
ind
ingw
ay
stom
e
e
tth
en
e
ed
so
fICPWD
th
roughou
tth
e
i
rc
a
r
eg
iv
ingjou
rn
ey
si
sac
r
i
t
i
c
a
lcon
t
r
ibu
t
ionth
a
tp
r
im
a
ryc
a
r
ep
rov
id
e
r
s
(PCP
s
)mu
s
tend
e
avou
rtoa
ch
i
ev
e
.
I
s
su
e
sth
a
tICPWDf
a
c
ea
r
eo
fp
a
r
t
i
cu
l
a
rimpo
r
t
an
c
einp
r
im
a
ryc
a
r
e(N
i
cho
l
se
ta
l
.
,
2009
)
,a
sm
o
s
tind
iv
idu
a
l
sw
i
thd
em
en
t
i
aandth
e
i
rf
am
i
lym
emb
e
r
sr
e
c
e
iv
ec
a
r
ev
i
ap
r
im
a
ry
c
a
r
ec
l
in
i
c
s(Au
s
t
rome
ta
l
.
,2004
)
.PCP
s
,su
cha
sF
am
i
lyPhy
s
i
c
i
an
sandNu
r
s
eP
r
a
c
t
i
t
ion
e
r
s
(NP
s
)
,a
r
eo
f
t
enth
ef
i
r
s
tandr
e
cu
r
r
en
tcon
t
a
c
tfo
rICPWD(B
e
l
l
ee
ta
l
.
,2006
;F
i
l
l
i
t
,

3

	
  
Knopm
an
,Cumm
ings
,&App
e
l
,1999
;G
r
e
enwood
,P
e
lon
e
,&H
a
s
s
enk
amp
,2016
)
.PCP
s

a
r
emo
s
to
f
t
eninanid
e
a
lpo
s
i
t
iontoconn
e
c
tw
i
thin
fo
rm
a
lc
a
r
eg
iv
e
r
s
,id
en
t
i
fyth
ech
ang
ing
n
e
ed
so
ftho
s
ec
a
r
eg
iv
e
r
s
,andtod
ev
e
lopandimp
l
em
en
tsuppo
r
t
iv
ein
t
e
rv
en
t
ion
sth
a
ta
r
e
mo
s
tapprop
r
i
a
t
efo
re
a
chind
iv
idu
a
lc
a
r
eg
iv
e
r
.Th
i
si
sap
ro
found
lyimpo
r
t
an
ttop
i
cfo
r
PCP
stocon
s
id
e
rs
in
c
em
a
in
t
a
in
ingth
ew
e
l
lb
e
ingo
fin
fo
rm
a
lc
a
r
eg
iv
e
r
si
sno
ton
ly
b
en
e
f
i
c
i
a
ltoth
ec
a
r
eg
iv
e
r
,a
si
tg
en
e
r
a
t
e
sf
avou
r
ab
l
eou
t
com
e
sfo
rth
ec
a
r
er
e
c
ip
i
en
tw
i
th
d
em
en
t
i
a
,bu
ti
ta
l
somo
r
eb
ro
ad
lysuppo
r
t
sasu
s
t
a
in
ab
l
eh
e
a
l
thc
a
r
esy
s
t
em
.Fo
rin
s
t
an
c
e
,
th
ew
e
l
l
b
e
ingo
fth
eICPWDi
so
f
t
enfund
am
en
t
a
ltoth
ec
a
r
er
e
c
ip
i
en
tb
e
ingab
l
etor
e
c
e
iv
e
suppo
r
t
iv
es
e
rv
i
c
e
sinth
ecommun
i
tyin
s
t
e
ado
fb
e
ingp
l
a
c
edinr
e
s
i
d
en
t
i
a
lc
a
r
e(F
am
i
ly
C
a
r
eg
iv
e
rA
l
l
i
an
c
e
,2003
)
.W
i
l
z
,S
ch
inkö
th
e
,andSo
e
l
ln
e
r(2011
)ag
r
e
e
,s
t
a
t
ingth
a
ti
ti
s“
a
so
c
i
a
ln
e
c
e
s
s
i
ty
”(p
.115
)top
rov
id
esuppo
r
ttoICPWDino
rd
e
rtom
a
in
t
a
inagoodqu
a
l
i
ty
o
fl
i
f
e(QOL
)fo
rbo
thICPWDandth
e
i
rc
a
r
er
e
c
ip
i
en
t
s
.ICPWDwhosu
c
c
e
s
s
fu
l
lym
an
ag
e
th
ec
a
r
eg
iv
e
rro
l
eno
ton
lyp
rov
id
eb
e
t
t
e
rc
a
r
etoth
ec
a
r
er
e
c
ip
i
en
tbu
tth
eya
l
soa
c
ta
sa
v
a
lu
ab
l
esou
r
c
eo
fin
fo
rm
a
t
ionfo
rth
ePCPandc
anth
e
r
ebya
s
s
i
s
tinmo
r
ee
f
f
e
c
t
iv
e
ly
gu
id
ingth
ec
a
r
eo
fth
ep
a
t
i
en
tw
i
thd
em
en
t
i
a
.Fo
rex
amp
l
e
,con
t
r
ibu
t
ion
sbyICPWDo
f
t
en
p
rov
id
eth
ein
f
r
a
s
t
ru
c
tu
r
euponwh
i
chd
em
en
t
i
ac
a
r
ep
l
an
sfo
rp
a
t
i
en
t
sa
r
ebu
i
l
t(And
e
r
son&
J
eh
a
an
and
an
,2011
)
.B
e
r
th
e
l
s
enandK
r
i
s
t
en
s
son(2015
)ag
r
e
e
,s
t
a
t
ingth
a
tICPWDa
r
enow
f
r
equ
en
t
lya
c
t
inga
sane
s
s
en
t
i
a
lr
e
sou
r
c
etoth
ep
a
t
i
en
ta
sw
e
l
la
stoth
eh
e
a
l
thc
a
r
e
p
rov
id
e
r
s
.
Th
epu
rpo
s
eo
fth
i
sin
t
eg
r
a
t
iv
el
i
t
e
r
a
tu
r
er
ev
i
ewi
stoan
sw
e
rth
er
e
s
e
a
r
chqu
e
s
t
ion
:
howc
anPCP
sb
e
s
tsuppo
r
tICPWDth
roughth
ed
em
en
t
i
ajou
rn
ey
?Ino
rd
e
rtoan
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rth
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abov
equ
e
s
t
ion
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i
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e
r
a
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r
ew
a
sid
en
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i
f
i
edth
roughanex
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en
s
iv
es
e
a
r
chth
a
tadd
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s
ede
i
th
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r
th
el
iv
edexp
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r
i
en
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e
sandn
e
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so
fICPWDo
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ep
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im
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ryc
a
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b
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edin
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en
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ion
sa
im
eda
t

4

	
  
imp
rov
ingth
ec
a
r
eg
iv
ingexp
e
r
i
en
c
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sfo
rICPWD(
i
ti
stob
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ronym
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r
ev
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ef
ind
ing
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th
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.
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efo
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ek
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rov
id
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igh
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toth
ep
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son
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emch
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eth
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roupo
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igh
l
igh
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5

	
  
Chap
t
e
r1
:Ba
ckg
roundandCon
t
ex
t
Th
eCa
r
eg
iv
ingJou
rn
ey

Anody
s
s
eyc
anb
ed
e
f
in
eda
s“
alongs
e
r
i
e
so
fw
and
e
r
ing
so
radv
en
tu
r
e
s
,e
sp
e
c
i
a
l
ly
wh
enf
i
l
l
edw
i
thno
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ab
l
eexp
e
r
i
en
c
e
s[o
r
]h
a
rd
sh
ip
s…
”(
“Ody
s
s
ey
”
,2016
)
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ec
a
r
eg
iv
e
r
’
s
exp
e
r
i
en
c
e
sinc
a
r
ingfo
rap
e
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sonw
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em
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t
i
ac
anc
e
r
t
a
in
lyb
eequ
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edtoth
i
styp
eo
f
jou
rn
ey
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ti
sth
etyp
eo
fjou
rn
eyth
a
tnoon
ebook
sinadv
an
c
e
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ep
a
ck
sfo
r
,andnoon
e
w
i
sh
e
stot
ak
e
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ti
ti
sanadv
en
tu
r
enon
e
th
e
l
e
s
s
.Fo
rsom
e
,i
ti
safo
rmo
fsp
i
r
i
tu
a
ljou
rn
ey
,
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sv
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tuou
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ep
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et
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ays
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6

	
  
G
r
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k
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7

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ls
ta
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em
en
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s
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ta
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eban
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sa
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es
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ea
l
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romh
im
.Y
e
tano
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da
ytha
tm
yAun
tm
i
s
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e
swo
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ktod
r
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t
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e
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eth
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iagno
s
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ea
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en
tp
lan
s
.Y
e
tano
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e
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ya
s
G
randmal
ea
v
e
stop
i
c
kh
imupf
romh
i
sr
e
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i
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eda
yp
rog
ram
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et
e
l
l
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e“dono
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l
i
tda
y
ca
r
e
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rh
ew
i
l
ln
e
v
e
rgoaga
in”
.“Som
eda
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sh
el
i
k
e
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t
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eda
y
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e
sn
’
t
”.“H
e
do
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sn
’
tl
i
k
eth
efood
”.“
If
e
e
lgu
i
l
t
ys
end
ingh
imwh
enh
edo
e
sn
’
twan
ttogo”
,sh
esa
y
s
.Y
e
t
ano
th
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tG
randmaha
st
ea
r
sinh
e
re
y
e
s
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su
r
ei
fh
ew
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em
emb
e
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enam
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fh
i
s
g
rand
ch
i
ld
r
enwh
enth
e
yca
l
l
.Y
e
tano
th
e
rda
yinwh
i
chG
randmac
lamp
sth
elo
c
konth
e
s
t
e
e
r
ingwh
e
e
lo
fth
eca
rfo
rf
ea
rh
ema
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rg
e
th
ecannolong
e
rd
r
i
v
eanda
t
t
emp
ttog
e
t
b
eh
indth
ewh
e
e
l
.Sh
ef
e
e
l
stha
tsh
ecan
’
tta
k
eh
i
sk
e
y
sawa
y
,can
’
tta
k
eawa
ywha
tl
i
t
t
l
e
ind
ep
end
en
c
er
ema
in
s
.Y
e
tano
th
e
rda
ywh
e
r
eG
randmai
sa
tasp
e
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ia
l
i
s
tappo
i
n
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en
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r
h
e
rownh
ea
l
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s
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e
s
.Y
e
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esh
es
ign
sh
e
r
s
e
l
fou
to
fth
eho
sp
i
ta
l
p
r
ema
tu
r
e
l
yino
rd
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rtog
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thom
etoca
r
efo
rh
e
rhu
sband
.Y
e
tano
th
e
rda
yinwh
i
chh
ei
sin
th
eba
c
ko
fanambu
lan
c
ew
i
ths
e
v
e
r
eh
ypog
l
y
c
em
iaa
f
t
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rinad
v
e
r
t
en
t
l
ym
i
x
inguph
i
slong
andsho
r
ta
c
t
ingin
su
l
in
.Y
e
tano
th
e
rda
ywh
enth
e
ys
i
tinth
eho
sp
i
ta
lf
e
ed
ingh
imfoodf
rom
hom
etoen
su
r
eh
eea
t
s
.Y
e
tano
th
e
rda
ywh
e
r
eh
ei
sh
ea
v
i
l
ys
eda
t
eda
f
t
e
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enu
r
s
ings
ta
f
f
adm
in
i
s
t
e
r
edm
ed
i
ca
t
iontod
ea
lw
i
thh
i
sag
i
ta
t
ion
.Y
e
tano
th
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rda
ytha
tm
yAun
ta
im
l
e
s
s
l
y
wand
e
r
sa
roundh
e
rhom
e
,soo
v
e
rwh
e
lm
edw
i
thg
row
ingr
e
spon
s
ib
i
l
i
t
i
e
sands
t
r
e
s
stha
tsh
e
i
sunab
l
etocomp
l
e
t
eth
es
imp
l
eta
s
ktha
tsh
eo
r
ig
ina
l
l
ys
e
tou
ttodo
.Y
e
tano
th
e
rda
ytha
t
th
e
ys
t
rugg
l
etona
v
iga
t
eth
eh
e
a
l
thca
r
es
y
s
t
em
,jugg
l
ingp
e
rp
e
tua
lm
ed
i
ca
lappo
in
tm
en
t
s
,
a
s
s
e
s
sm
en
t
s
,andcommun
i
t
ys
e
r
v
i
c
e
s
.Y
e
tano
th
e
rda
yinwh
i
ch
,a
l
thoughh
ei
sph
y
s
i
ca
l
l
y

8

	
  
p
r
e
s
en
t
,th
e
yg
r
i
e
v
eth
elo
s
so
fth
ehu
sbandandfa
th
e
rth
e
yon
c
ekn
ew
.Y
e
tano
th
e
rda
yin

wh
i
chth
e
ye
xp
e
r
ien
c
eu
t
t
e
rlon
e
l
in
e
s
sa
sf
r
i
end
sandfam
i
l
ys
topv
i
s
i
t
ingb
e
cau
s
ep
eop
l
edo
no
tknowhowtoh
e
lpo
rwha
ttosa
ytoth
e“
c
ra
z
yo
ldcoo
t”
.F
i
f
t
y
f
i
v
ey
ea
r
o
ldf
r
i
end
sh
ip
s
ha
v
ed
i
s
s
ipa
t
ed
,w
i
thon
l
yfad
ingm
emo
r
i
e
stoc
l
ingtonow
.“
I
fsom
eon
ei
sd
iagno
s
edw
ith
can
c
e
r
,p
eop
l
eb
r
ingca
s
s
e
ro
l
e
sandhug
s
. Wh
ensom
eon
ei
sd
iagno
s
edw
i
thd
em
en
t
ia
,
p
eop
l
es
topcom
ing
”.Tha
t
’
sth
eha
rd
e
s
tpa
r
to
fth
i
sd
i
s
ea
s
e”sh
et
e
l
l
sm
e
,“
f
e
e
l
ingso
a
lon
e”
.
Th
eev
en
t
sp
r
e
s
en
t
edabov
ei
l
lus
t
r
a
t
eju
s
tsom
eo
fth
em
anych
a
l
l
eng
e
sth
a
tmyown
G
r
andmo
th
e
randAun
tf
a
c
edinth
econ
t
ex
to
fb
e
ingth
ein
fo
rm
a
lc
a
r
eg
iv
e
r
so
fmyG
r
andp
a
.
How
ev
e
r
,su
chexp
e
r
i
en
c
e
sa
r
eno
tun
commonfo
rm
anyICPWD
.Th
ec
a
r
eg
iv
ingexp
e
r
i
en
c
e
i
sdyn
am
i
candcomp
l
ex
,y
e
td
em
en
t
i
ac
a
r
eg
iv
e
r
so
f
t
enf
a
c
esu
chd
a
i
lys
t
rugg
l
e
se
i
th
e
ra
lon
e
o
rw
i
thm
in
im
a
lou
t
s
id
esuppo
r
t
.Th
i
so
f
t
enl
e
ad
stoth
ec
a
r
eg
iv
e
rt
ak
ingth
ec
a
r
er
e
c
ip
i
en
tto
th
eho
sp
i
t
a
la
safo
rmo
fr
e
sp
i
t
ewh
enth
ein
fo
rm
a
lc
a
r
eg
iv
e
rb
e
com
e
sun
ab
l
etocop
ew
i
th
th
et
r
em
endou
sd
em
and
so
fth
ec
a
r
eg
iv
ingro
l
eo
rw
i
thana
cu
t
ech
ang
einth
ec
a
r
e
r
e
c
ip
i
en
t
’
sh
e
a
l
ths
t
a
tu
s
.Ro
s
eandLop
e
z(2012
)ag
r
e
e
,s
t
a
t
ingth
a
tind
iv
idu
a
l
sw
i
th
d
em
en
t
i
aexp
e
r
i
en
c
emo
r
eho
sp
i
t
a
landnu
r
s
inghom
es
t
ay
scomp
a
r
edtoo
th
e
re
ld
e
r
lyadu
l
t
s
.
Th
roughou
tmy12y
e
a
rc
a
r
e
e
ra
saR
eg
i
s
t
e
r
edNu
r
s
e
,Ih
av
ew
i
tn
e
s
s
edm
anyp
a
t
i
en
t
s
w
i
thd
em
en
t
i
aadm
i
t
t
edtoth
eho
sp
i
t
a
lw
i
thav
agu
ed
i
agno
s
i
so
f“
f
a
i
lu
r
etoth
r
iv
e
”o
r
“
c
a
r
eg
iv
e
rbu
rnou
t
”
.Io
f
t
enf
e
l
th
e
lp
l
e
s
sw
a
t
ch
ingexh
au
s
t
edc
a
r
eg
iv
e
r
scon
t
endw
i
thth
e
d
em
and
so
fth
e
i
rr
e
spon
s
ib
i
l
i
t
i
e
s
,a
sw
e
l
la
sw
a
t
ch
ingp
a
t
i
en
t
sth
em
s
e
lv
e
ss
t
rugg
l
ew
i
th
b
e
inginanun
f
am
i
l
i
a
randov
e
r
s
t
imu
l
a
t
inga
cu
t
ec
a
r
eenv
i
ronm
en
t
.Th
e
s
ep
a
t
i
en
t
s
con
s
i
s
t
en
t
lyexp
e
r
i
en
c
edp
ro
long
edho
sp
i
t
a
ladm
i
s
s
ion
s
,ev
en
tu
a
l
lyfo
l
low
edbyat
r
an
s
f
e
rto
ar
e
s
id
en
t
i
a
lc
a
r
ef
a
c
i
l
i
tya
sth
e
i
rc
a
r
eg
iv
e
rb
e
c
am
ee
i
th
e
run
ab
l
eo
runw
i
l
l
ingtoh
av
eth
e

9

	
  

p
a
t
i
en
tr
e
tu
rnhom
e
.Su
chl
eng
thy“
so
c
i
a
ladm
i
s
s
ion
s
”no
ton
lyh
av
en
eg
a
t
iv
eimp
l
i
c
a
t
ion
s
fo
rth
ep
a
t
i
en
t
sandc
a
r
eg
iv
e
r
s
,bu
ta
l
sop
l
a
c
eas
ign
i
f
i
c
an
te
conom
i
cbu
rd
enonth
eh
e
a
l
th
c
a
r
esy
s
t
em(Ax
am
,H
a
sn
ip
,&Lux
fo
rd
,2013
)
.
Th
roughou
tmynu
r
s
ingc
a
r
e
e
r
,Ih
av
ew
i
tn
e
s
s
edth
e
s
e“
so
c
i
a
ladm
i
s
s
ion
s
”inbo
th
ru
r
a
landl
a
rg
eu
rb
anc
en
t
r
e
sinAu
s
t
ra
l
i
a
,Eng
l
and,andC
an
ad
a
.A
l
thoughin
fo
rm
a
l
c
a
r
eg
iv
e
r
sinru
r
a
ls
e
t
t
ing
sm
ayf
a
c
ech
a
l
l
eng
e
sw
i
thr
eg
a
rd
stomo
r
el
im
i
t
edav
a
i
l
ab
i
l
i
tyfo
r
r
e
sou
r
c
e
sandsuppo
r
t
iv
es
e
rv
i
c
e
s
,m
anyo
fth
ech
a
l
l
eng
e
sa
s
so
c
i
a
t
edw
i
thc
a
r
eg
iv
inga
r
e
s
im
i
l
a
rtotho
s
eexp
e
r
i
en
c
edbyc
a
r
eg
iv
e
r
sinu
rb
ans
e
t
t
ing
s(B
ed
a
rd
,Ko
ivu
r
an
t
a
,&S
tu
ck
ey
,
2004
)
.Fo
rex
amp
l
e
,ru
r
a
lc
a
r
eg
iv
e
r
sinB
ed
a
rde
ta
l
.
’
s(2004
)s
tudyr
epo
r
t
eds
im
i
l
a
rh
e
a
l
th
s
t
a
tu
s
,l
ev
e
l
so
fbu
rd
en
,andunh
e
a
l
thyb
eh
av
iou
r
scomp
a
r
edtou
rb
anc
a
r
eg
iv
e
r
s
.L
i
l
lye
ta
l
.
(2012
)a
rgu
edth
a
t
,a
l
thoughch
a
l
l
eng
e
sa
s
so
c
i
a
t
edw
i
ths
e
rv
i
c
ep
rov
i
s
ionini
so
l
a
t
ed
commun
i
t
i
e
sdoex
i
s
t
,h
e
a
l
thsy
s
t
emr
a
t
ion
inginu
rb
ana
r
e
a
sh
a
sa
l
soa
f
f
e
c
t
edth
e
i
r
suppo
r
t
iv
es
e
rv
i
c
e
sandh
a
ss
im
i
l
a
r
lyl
edtod
e
t
r
im
en
t
a
limp
a
c
t
sonc
a
r
eg
iv
e
r
s(W
i
l
e
s
,2003
)
.
Ov
e
r
a
l
l
,a
l
thoughICPWDf
romd
i
f
f
e
r
en
tg
eog
r
aph
i
c
a
la
r
e
a
sm
ayb
econ
f
ron
t
edw
i
th
p
a
r
t
i
cu
l
a
rch
a
l
l
eng
e
sr
e
l
a
t
edtos
e
rv
i
c
ep
rov
i
s
ion
,m
anyICPWDsh
a
r
es
im
i
l
a
rexp
e
r
i
en
c
e
sin
th
ec
a
r
eg
iv
ingcon
t
ex
t
.
D
em
en
t
ia
:Th
eImp
e
tu
so
fth
eJou
rn
ey
Ac
l
e
a
rund
e
r
s
t
and
ingo
fd
em
en
t
i
aa
sad
i
agno
s
i
sp
rov
id
e
sin
s
igh
tin
toth
ew
ay
sin
wh
i
chsymp
tomm
an
i
f
e
s
t
a
t
ion
sc
ana
f
f
e
c
tth
ein
fo
rm
a
lc
a
r
eg
iv
ingexp
e
r
i
en
c
eandc
an
con
t
r
ibu
t
etoch
ang
ingc
a
r
eg
iv
e
rn
e
ed
s
.F
i
r
s
t
,i
ti
simpo
r
t
an
ttor
e
cogn
i
z
eth
a
td
em
en
t
i
ai
sno
t
asp
e
c
i
f
i
cd
i
s
e
a
s
eini
t
s
e
l
fbu
ti
sin
s
t
e
adag
roupo
fsymp
tom
sc
au
s
edbyd
i
so
rd
e
r
sth
a
ta
f
f
e
c
t
th
eb
r
a
in(A
l
zh
e
im
e
rSo
c
i
e
tyo
fC
an
ad
a
,2015
)
.Sp
e
c
i
f
i
c
a
l
ly
,d
em
en
t
i
ap
r
e
s
en
t
sa
s“
an
a
cqu
i
r
edp
e
r
s
i
s
t
en
tandp
rog
r
e
s
s
iv
eimp
a
i
rm
en
tinin
t
e
l
l
e
c
tu
a
lfun
c
t
ion
,w
i
thcomp
rom
i
s
eo
f

10

	
  

m
emo
ryanda
tl
e
a
s
ton
eo
th
e
rcogn
i
t
iv
edom
a
in
”(H
a
rp
e
r
,John
s
ton
,&L
and
e
f
e
ld
,2014
,p
.
56)
.Th
efou
rdom
a
in
so
fd
em
en
t
i
aa
r
eo
f
t
enr
e
f
e
r
r
edtoa
sth
e“
fou
rA
’
s
”(A
l
zh
e
im
e
r
’
s
Found
a
t
iono
fAm
e
r
i
c
a[AFA
]
,2016
)
.Th
e
s
efou
rk
eyt
e
rm
sa
r
ed
e
f
in
edb
e
low
:
•
	
  Amn
e
s
ia:sho
r
tt
e
rmo
rlongt
e
rmm
emo
rylo
s
s
,a
l
thoughsho
r
tt
e
rmm
emo
ryi
s
p
r
im
a
r
i
lya
f
f
e
c
t
edf
i
r
s
t(AFA
,2016
)
;
•
	
  Apha
s
ia
:th
ein
ab
i
l
i
tytocommun
i
c
a
t
ec
ap
ab
ly
,e
i
th
e
rth
roughth
ein
ab
i
l
i
tyto
und
e
r
s
t
andw
r
i
t
t
eno
rspok
enl
angu
ag
e
,o
rth
ein
ab
i
l
i
tytofo
rmspok
enwo
rd
s(AFA
,
2016
)
;
•
	
  Ap
ra
x
ia:th
ein
ab
i
l
i
tytoc
a
r
ryou
tinh
e
r
en
tmo
to
rsk
i
l
l
ssu
cha
sb
ru
sh
ingon
e
’
st
e
e
th
,
du
eton
eu
ro
log
i
c
a
ldy
s
fun
c
t
ioninth
eb
r
a
in(N
a
t
ion
a
lIn
s
t
i
tu
t
eo
fN
eu
ro
log
i
c
a
l
D
i
so
rd
e
r
sandS
t
rok
e[N
INDS
]
,2015
)
;
•
	
  Agno
s
ia:a
l
t
e
r
a
t
ion
sins
en
so
ryp
e
r
c
ep
t
ion
,c
au
s
ingpoo
rr
e
cogn
i
t
iono
fs
ign
a
l
s
,su
ch
a
sp
a
ino
rafu
l
lb
l
add
e
r(AFA
,2016
)
.
Ind
iv
idu
a
l
sw
i
thd
em
en
t
i
am
ayb
ea
f
f
e
c
t
edbyanyo
ra
l
lo
fth
e
s
efou
rcond
i
t
ion
sdu
r
ing
d
i
f
f
e
r
en
ts
t
ag
e
so
fth
e
i
rd
i
s
e
a
s
e
;how
ev
e
r
,th
eya
r
emo
s
to
f
t
enev
id
en
tinth
el
a
t
e
rs
t
ag
e
sand
h
av
eb
e
enfoundtod
ev
e
lopmo
r
er
ap
id
lyintho
s
ed
i
agno
s
edw
i
thA
l
zh
e
im
e
r
’
sd
i
s
e
a
s
e(AD
)
comp
a
r
edtoo
th
e
rfo
rm
so
fd
em
en
t
i
a(W
e
in
e
r
,2009
)
.
A
l
thoughAD
,v
a
s
cu
l
a
rd
em
en
t
i
a
,andd
em
en
t
i
aw
i
thL
ewybod
i
e
stog
e
th
e
rcomp
r
i
s
e
upto90%o
fd
em
en
t
i
ad
i
agno
s
e
s(Sh
e
eh
an
,2012
)
,s
ev
e
r
a
lo
th
e
rd
i
so
rd
e
r
sc
ana
l
soc
au
s
e
d
em
en
t
i
a
.L
e
s
scommonc
au
s
e
so
fd
em
en
t
i
am
ayh
av
er
ev
e
r
s
ib
l
ee
t
io
log
i
e
s
;how
ev
e
r
,
d
em
en
t
i
ai
smo
s
to
f
t
eni
r
r
ev
e
r
s
ib
l
e
,p
rog
r
e
s
s
iv
e
,andc
au
s
edbyd
eg
en
e
r
a
t
iv
eo
r
n
eu
rod
eg
en
e
r
a
t
iv
ep
ro
c
e
s
s
e
s
.D
eg
en
e
r
a
t
iv
ed
em
en
t
i
ac
anb
er
e
l
a
t
edtoin
f
e
c
t
iou
sp
ro
c
e
s
s
e
s
(
su
cha
sC
r
eu
t
z
f
e
ld
t
J
a
cobd
i
s
e
a
s
e[C
JD
]
,po
s
t
en
c
eph
a
l
i
t
i
cd
em
en
t
i
a
,andhum
an

11

	
  

immunod
e
f
i
c
i
en
cyv
i
ru
s
)
,v
a
s
cu
l
a
rd
i
so
rd
e
r
s(
su
cha
sin
f
a
r
c
t
s
,v
a
s
cu
l
a
rd
em
en
t
i
a
,amy
lo
id
ang
iop
a
thy
,andB
in
sw
ang
e
rd
i
s
e
a
s
e
)
,o
rn
eu
rod
eg
en
e
r
a
t
iv
ed
i
so
rd
e
r
s(
su
cha
sP
a
rk
in
son
d
i
s
e
a
s
e
,Hun
t
ing
tond
i
s
e
a
s
e
,P
i
ckd
i
s
e
a
s
e
,f
ron
to
t
empo
r
a
ld
em
en
t
i
a
,d
em
en
t
i
aw
i
thL
ewy
bod
i
e
s
,andAD
)(Bo
s
s
,2010
)
.Fu
r
th
e
rd
e
s
c
r
ip
t
ion
so
fth
emo
s
tcommonfo
rm
so
fd
em
en
t
i
a
l
i
s
t
edabov
ec
anb
efoundinApp
end
ixA
.Fo
rth
epu
rpo
s
e
so
fth
i
sr
ev
i
ew
,th
et
e
rmd
em
en
t
i
a
w
i
l
lb
eu
s
edinr
e
f
e
r
en
c
etoth
emo
s
tcommonfo
rm
so
fp
rog
r
e
s
s
iv
ed
em
en
t
i
a
:AD
,v
a
s
cu
l
a
r
d
em
en
t
i
a
,m
ix
edd
em
en
t
i
a
,f
ron
to
t
empo
r
a
ld
em
en
t
i
a
,andd
em
en
t
i
aw
i
thL
ewybod
i
e
s(
s
e
e
Figu
r
e1
)
.

F
igu
r
e1.Commonsubtyp
e
so
fd
em
en
t
i
a
.Ad
ap
t
edf
rom
“Cogn
i
t
iv
eImp
a
i
rm
en
tR
e
cogn
i
t
ion
,D
i
agno
s
i
sand M
an
ag
em
en
tinP
r
im
a
ryC
a
r
e
”
,byTh
eGu
id
e
l
in
e
sand
P
ro
to
co
l
sAdv
i
so
ryComm
i
t
t
e
e
,2014,BCGu
id
e
l
in
e
s
.
ca,p
a
r
a
.3
.Copy
r
igh
t2016by
P
rov
in
c
eo
fB
r
i
t
i
shCo
lumb
i
a
.
R
eg
a
rd
l
e
s
so
fth
etyp
eo
fp
rog
r
e
s
s
iv
ed
em
en
t
i
ath
a
tap
e
r
sonh
a
s
,c
l
in
i
c
a
l
m
an
i
f
e
s
t
at
ion
ssu
cha
sm
emo
rylo
s
s
,e
r
ron
eou
sex
e
cu
t
iv
efun
c
t
ion
ing
,poo
rcon
c
en
t
r
a
t
ion
,
poo
rjudgm
en
t
,moodch
ang
e
s
,emo
t
ion
a
ll
ab
i
l
i
ty
,agg
r
e
s
s
iv
eb
eh
av
iou
r
s
,l
angu
ag
ed
e
f
i
c
i
t
s
,
o
rd
e
c
r
e
a
s
ingmob
i
l
i
ty
,m
ayb
e
com
eev
id
en
tov
e
rt
im
e(Bo
s
s
,2010
)
.Add
i
t
ion
a
l
ly
,p
rob
l
em
s
w
i
thsu
c
c
e
s
s
fu
l
lya
c
comp
l
i
sh
inga
c
t
iv
i
t
i
e
so
fd
a
i
lyl
iv
ing(
ADL
s)
,su
cha
sd
r
e
s
s
ing
,b
a
th
ing
,
andto
i
l
e
t
ing
,o
rin
s
t
rum
en
t
a
la
c
t
iv
i
t
i
e
so
fd
a
i
lyl
iv
ing(
IADL
s
)
,su
cha
sg
ro
c
e
ryshopp
ing
,

12

	
  

b
ank
ing
,c
l
e
an
ing
,m
ed
i
c
a
t
ionm
an
ag
em
en
t
,o
rd
r
iv
ing
,f
r
equ
en
t
lyo
c
cu
r(Bo
s
s
,2010
)
.I
ti
s
v
a
lu
ab
l
efo
rc
a
r
eg
iv
e
r
stound
e
r
s
t
andth
esymp
tom
sth
a
tth
e
i
rlov
edon
em
ayexp
e
r
i
en
c
e
,a
s
w
e
l
la
sth
eb
eh
av
iou
r
sth
eym
ayexh
ib
i
t
,ino
rd
e
rtob
e
s
tan
t
i
c
ip
a
t
eandp
r
ep
a
r
efo
rth
eo
f
t
end
i
s
t
r
e
s
s
ingsymp
tomo
logy
.Th
ep
rog
r
e
s
s
iv
ena
tu
r
eo
fth
ed
i
s
e
a
s
em
e
an
sth
a
tth
eh
e
a
l
thc
a
r
e
andfun
c
t
ion
a
ln
e
ed
so
fth
ea
f
f
e
c
t
edind
iv
idu
a
l
st
endtoe
s
c
a
l
a
t
eth
roughou
tth
ed
i
s
e
a
s
e
p
rog
r
e
s
s
ion
,mo
s
to
f
t
enr
equ
i
r
ingcon
s
t
an
tsup
e
rv
i
s
ionanda
s
s
i
s
t
an
c
ew
i
tha
l
lADL
sand
IADL
sbyth
eendo
fth
ed
i
s
e
a
s
et
r
a
j
e
c
to
ry
.
Ro
s
eandLop
e
z(2012
)a
s
c
e
r
t
a
in
edth
a
t
,a
l
thoughth
er
a
t
eo
fp
rog
r
e
s
s
ionand
symp
tom
so
fth
ed
i
s
e
a
s
edo
e
sv
a
ryb
e
tw
e
enp
a
t
i
en
t
s
,th
e
r
ea
r
es
ev
e
r
a
lch
a
r
a
c
t
e
r
i
s
t
i
c
t
r
an
s
i
t
ion
sth
a
to
c
cu
ra
sp
a
r
to
fth
ed
em
en
t
i
ap
a
thw
ay
.P
rov
id
ingac
l
e
a
rund
e
r
s
t
and
ingo
fth
e
s
t
ag
e
so
fd
em
en
t
i
atoICPWDm
ayh
e
lpth
emtob
e
t
t
e
rund
e
r
s
t
andth
eexp
e
c
t
edp
rog
r
e
s
s
ion
o
fd
em
en
t
i
aandtoan
t
i
c
ip
a
t
eth
et
r
an
s
i
t
ion
sth
a
tth
eym
ayf
a
c
e
.D
e
sp
i
t
ed
i
f
f
e
r
en
tc
l
in
i
c
a
l
m
an
i
f
e
s
t
a
t
ion
sb
e
tw
e
enth
etyp
e
so
fp
rog
r
e
s
s
iv
ed
em
en
t
i
a
,cogn
i
t
iv
eandfun
c
t
ion
a
l
d
e
t
e
r
io
r
a
t
iona
r
eh
a
l
lm
a
rks
ign
so
fa
l
lo
fth
em
.V
a
l
id
a
t
edd
em
en
t
i
as
t
ag
ings
c
a
l
e
sh
av
e
th
e
r
e
fo
r
eb
e
end
ev
e
lop
edtoh
e
lpgu
id
em
an
ag
em
en
tandt
r
e
a
tm
en
tinp
r
im
a
ryc
a
r
ep
r
a
c
t
i
c
e
,
in
c
lud
ingth
eC
l
in
i
c
a
lD
em
en
t
i
aR
a
t
ing(CDR
)(Mo
r
r
i
s
,1993
)
,Fun
c
t
ion
a
lA
s
s
e
s
sm
en
t
S
t
ag
ing(FAST
)(S
c
l
an&R
e
i
sb
e
rg
,1992
)
,andth
eG
lob
a
lD
e
t
e
r
io
r
a
t
ionS
c
a
l
e(GDS
)
(R
e
i
sb
e
rge
ta
l
.
,1982
)
.Nol
i
t
e
r
a
tu
r
eh
a
sb
e
enfoundd
e
s
c
r
ib
ingwh
e
th
e
rth
e
s
es
c
a
l
e
sa
r
eu
s
ed
mo
r
eo
f
t
eninp
r
im
a
ryc
a
r
es
e
t
t
ing
scomp
a
r
edtosp
e
c
i
a
l
i
s
ts
e
t
t
ing
s
.How
ev
e
r
,th
eu
seo
fth
e
GDSi
ssugg
e
s
t
edinth
eBCGu
id
e
l
in
e
sfo
ru
s
einp
r
im
a
ryc
a
r
es
e
t
t
ing
stoh
e
lpw
i
th
d
i
agno
s
i
s(Gu
id
e
l
in
e
sandP
ro
to
co
l
sAdv
i
so
ryComm
i
t
t
e
e
,2014
)
.Th
es
t
ag
e
so
fd
em
en
t
i
a
l
i
s
t
edinth
e
s
es
t
ag
ings
c
a
l
e
sc
anb
eapp
l
i
edtoa
l
lp
rog
r
e
s
s
iv
ed
em
en
t
i
a
san
dc
anb
eu
s
edto
d
e
s
c
r
ib
eth
ed
i
f
f
e
r
en
ts
t
ag
e
stoICPWD
.Th
es
c
a
l
e
sa
r
es
im
i
l
a
r
,d
e
s
c
r
ib
ingth
ed
eg
r
e
eo
f

13

	
  
cogn
i
t
iv
eandfun
c
t
ion
a
ld
e
c
l
in
eine
i
th
e
rf
iv
es
t
ag
e
s(CDR
)o
rs
ev
ens
t
ag
e
s(GDSand
FAST
)ina
c
co
rd
an
c
ew
i
thth
ed
eg
r
e
eo
fcogn
i
t
iv
eandfun
c
t
ion
a
ld
e
c
l
in
e
.Ino
rd
e
rto

i
l
lu
s
t
r
a
t
eth
es
t
ag
e
so
fd
em
en
t
i
a
,th
eth
r
e
es
c
a
l
e
sd
e
s
c
r
ib
edabov
ea
r
ecomp
a
r
edinApp
end
ix
B
.
Som
eau
tho
r
s(Mon
tgom
e
ry&Ko
s
lo
sk
i
,2000
;W
a
ld
,F
ahy
,W
a
lk
e
r
,&L
iv
ing
s
ton
,
2003
)sugg
e
s
tth
a
th
igh
l
igh
t
ingth
es
t
ag
e
so
fc
a
r
eg
iv
ingr
a
th
e
rth
anth
es
t
ag
e
so
fd
em
en
t
i
a
w
i
l
lb
e
t
t
e
rp
r
ep
a
r
ePCP
stocon
c
en
t
r
a
t
eonth
en
e
ed
so
fICPWD
.Ro
s
eandLop
e
z(2012
)
d
i
s
ag
r
e
e
,a
rgu
ingth
a
tth
econ
s
id
e
r
a
t
iono
fth
es
t
ag
e
so
fd
em
en
t
i
aa
l
low
sPCP
stop
rov
id
e
an
t
i
c
ip
a
to
rygu
id
an
c
e
,a
sw
e
l
la
so
th
e
rsuppo
r
t
iv
ein
t
e
rv
en
t
ion
s
,toth
eICPWDa
t
app
rop
r
i
a
t
ejun
c
tu
r
e
so
fth
ed
i
s
e
a
s
ep
ro
c
e
s
s(Ro
s
e&Lop
e
z
,2012
)
.Am
a
lg
am
a
t
ingbo
thth
e
s
t
ag
e
so
fc
a
r
eg
iv
ing
,su
cha
sth
eE
l
i
z
zF
iv
eL
i
f
eS
t
ag
e
so
fC
a
r
eg
iv
ing(E
l
i
z
z
,2015
)
,w
i
thth
e
s
t
ag
e
so
fd
em
en
t
i
am
ayp
rov
ev
a
lu
ab
l
efo
rbo
thICPWDandPCP
s
.Th
ef
iv
es
t
ag
e
so
f
c
a
r
eg
iv
ingp
rog
r
e
s
sth
roughth
eh
e
lp
ings
t
ag
e
,invo
lv
eds
t
ag
e
,in
t
en
s
iv
es
t
ag
e
,a
l
l
en
comp
a
s
s
ings
t
ag
e
,andc
lo
s
ings
t
ag
e
.D
ev
e
lop
ingacon
so
l
id
a
t
edund
e
r
s
t
and
ingo
fth
e
d
i
s
e
a
s
ep
ro
c
e
s
sandan
t
i
c
ip
a
t
edt
r
a
j
e
c
to
ryw
i
l
lh
e
lpPCP
stochoo
s
eth
eapp
rop
r
i
a
t
e
suppo
r
t
iv
ein
t
e
rv
en
t
ion
s
,andc
anh
e
lpbo
thICPWDandc
a
r
er
e
c
ip
i
en
t
ssu
c
c
e
s
s
fu
l
ly
t
r
an
s
i
t
ionth
roughth
ed
i
f
f
e
r
en
ts
t
ag
e
so
fth
ed
em
en
t
i
ajou
rn
ey
.
G
e
t
t
ingtoKnowth
eT
rav
e
l
e
r
s
: Whoa
r
eTh
eCa
r
eg
iv
e
r
sand Wha
ti
sth
eRo
l
eo
fEa
ch
Typ
e?
P
a
t
i
en
t
sw
i
thd
em
en
t
i
aw
i
l
lin
ev
i
t
ab
lyr
equ
i
r
ec
a
r
ep
rov
i
s
ionf
rome
i
th
e
rin
fo
rm
a
lo
r
fo
rm
a
lc
a
r
eg
iv
e
r
s
,o
rbo
th
.Th
et
e
rm“
fo
rm
a
lc
a
r
eg
iv
e
r
s
”r
e
f
e
r
stop
a
idh
e
a
l
thc
a
r
e
p
ro
f
e
s
s
ion
a
l
s
,su
cha
sc
a
r
ea
id
e
s
,nu
r
s
e
s
,andPCP
s
,whofu
l
f
i
l
lth
ev
i
t
a
lro
l
eo
fp
rov
id
ing
c
a
r
etoc
l
i
en
t
sinr
e
s
id
en
t
i
a
lc
a
r
ef
a
c
i
l
i
t
i
e
s
,a
cu
t
ec
a
r
ef
a
c
i
l
i
t
i
e
s
,ho
sp
i
c
e
s
,o
rw
i
th
inth
e

	
  

14

c
l
i
en
t
’
shom
e(G
a
l
l
agh
e
r
Thomp
sone
ta
l
.
,2009
)
.Th
e
s
efo
rm
a
lc
a
r
eg
iv
e
r
sm
ayb
eh
i
r
edand
p
a
idbyap
r
iv
a
t
ecomp
any
,byapub
l
i
cb
odysu
cha
sap
rov
in
c
i
a
lH
e
a
l
thAu
tho
r
i
ty
,o
rbyth
e
c
l
i
en
td
i
r
e
c
t
ly
.Incomp
a
r
i
son
,in
fo
rm
a
lc
a
r
eg
iv
e
r
sa
r
emo
s
to
f
t
enf
am
i
lym
emb
e
r
s
,u
su
a
l
ly
th
espou
s
eo
ranadu
l
tch
i
ldo
fth
eind
iv
idu
a
la
f
f
e
c
t
ed
,a
l
thoughsu
chc
a
r
eg
iv
e
r
sm
aya
l
sob
e
th
ec
a
r
er
e
c
ip
i
en
t
’
sf
r
i
end
so
rn
e
ighbou
r
s
.In
fo
rm
a
lc
a
r
eg
iv
e
r
sa
r
eg
en
e
r
a
l
lyunp
a
id
;
how
ev
e
r
,th
eym
ayr
e
c
e
iv
eagov
e
rnm
en
tsub
s
idy
,t
axb
en
e
f
i
to
ro
th
e
rcomp
en
s
a
t
ionin
ex
ch
ang
efo
rp
rov
id
ingc
a
r
e
.Inth
ee
a
r
lys
t
ag
e
so
fth
ed
i
s
e
a
s
einp
a
r
t
i
cu
l
a
r
,th
em
a
jo
r
i
tyo
f
c
a
r
ep
ro
v
id
edtop
eop
l
ew
i
thd
em
en
t
i
at
end
stob
ed
e
l
iv
e
r
edbyin
fo
rm
a
lc
a
r
eg
iv
e
r
s(D
a
ly
,
M
cC
a
r
ron
,H
igg
in
s
,& M
cC
a
l
l
ion
,2012
;Ro
s
e&Lop
e
z
,2012
)whoo
f
t
enh
av
el
i
t
t
l
eo
rno
p
r
io
rexp
e
r
i
en
c
eind
em
en
t
i
ac
a
r
eg
iv
ing(S
avv
a&B
r
ayn
e
,2009
)
.Bo
thfo
rm
a
landin
fo
rm
a
l
c
a
r
eg
iv
e
r
sc
anp
l
aye
s
s
en
t
i
a
lro
l
e
sina
s
s
i
s
t
ingtho
s
einn
e
edo
fc
a
r
eandbo
thtyp
e
so
f
c
a
r
eg
iv
e
r
sw
i
l
lo
f
t
encon
cu
r
r
en
t
lyp
rov
id
ec
a
r
etoind
iv
idu
a
l
sw
i
thd
em
en
t
i
a
,e
sp
e
c
i
a
l
lyin
th
el
a
t
e
rs
t
ag
e
so
fth
ed
i
s
e
a
s
ep
ro
c
e
s
s
.F
igu
r
e2i
l
lu
s
t
r
a
t
e
sth
ecommonp
rog
r
e
s
s
ionf
rom
in
fo
rm
a
ltofo
rm
a
lc
a
r
ew
i
th
inth
econ
t
ex
to
fd
em
en
t
i
a
.

F
igu
r
e2
.Th
ep
rog
r
e
s
s
iono
fca
r
edu
r
ingth
ep
rog
r
e
s
s
iono
fd
em
en
t
ia
.Adap
t
edf
rom
“Th
eFou
rS
t
ep
so
fLongT
e
rmC
a
r
eP
l
ann
ing
”
,byTh
eN
a
t
ion
a
lC
a
r
eP
l
ann
ingCoun
c
i
l
,
2013
,Th
eA
c
c
iden
ta
lCa
r
eg
i
v
e
r
,p
a
r
a
.13
.Copy
r
igh
t2016byTh
eN
a
t
ion
a
lC
a
r
eP
l
ann
ing
Coun
c
i
l
.

15

	
  

Bo
thtyp
e
so
fc
a
r
eg
iv
e
r
sm
ayho
ldv
a
r
i
edr
e
spon
s
ib
i
l
i
t
i
e
s
,in
c
lud
ingc
l
e
an
ing
,m
e
a
l
p
r
ep
a
r
a
t
ion
,runn
inge
r
r
and
s
,d
r
iv
ing
,m
ed
i
c
a
t
ionsup
e
rv
i
s
ion
,p
e
r
son
a
lc
a
r
e
,andemo
t
ion
a
l
suppo
r
t(F
a
s
t
,N
i
eh
au
s
,E
a
l
e
s
,&K
e
a
t
ing
,2002
)
.How
ev
e
r
,inadd
i
t
iontoth
eexp
e
c
t
a
t
iono
f
su
chrou
t
in
etyp
e
so
ft
a
sk
s
,c
a
r
eg
iv
e
r
so
ftho
s
ew
i
thd
em
en
t
i
amu
s
to
f
t
encon
t
endw
i
thth
e
c
a
r
er
e
c
ip
i
en
t
’
sd
i
s
e
a
s
e
indu
c
edr
e
a
c
t
ion
stoc
a
r
e
,su
cha
sc
a
r
er
e
s
i
s
t
a
n
c
e
,ad
im
in
i
sh
ed
ab
i
l
i
tytocommun
i
c
a
t
e
,andfu
r
th
e
rcon
c
e
rn
ssu
cha
sw
and
e
r
ing
,p
e
r
s
ev
e
r
a
t
ion
,ag
i
t
a
t
ion
,
p
a
r
ano
i
a
,s
ign
i
f
i
c
an
tp
e
r
son
a
l
i
tych
ang
e
s
,andin
somn
i
a(Au
s
t
rome
ta
l
.
,2004
;F
am
i
ly
C
a
r
eg
iv
e
rA
l
l
i
an
c
e
,2015
)
.In
fo
rm
a
lc
a
r
eg
iv
e
r
sm
ayf
indm
an
ag
ingth
e
s
eb
eh
av
iou
r
smo
r
e
d
i
f
f
i
cu
l
tth
anfo
rm
a
lc
a
r
eg
iv
e
r
s
,a
sth
eyo
f
t
enl
a
ckth
eknow
l
edg
e
,sk
i
l
l
s
,andexp
e
r
i
en
c
ein
d
em
en
t
i
ac
a
r
eth
a
tfo
rm
a
lc
a
r
eg
iv
e
r
spo
s
s
e
s
s(S
ad
avoy& W
e
s
s
en
,2012
)
.Th
i
scon
t
en
t
ioni
s
suppo
r
t
edbyC
z
a
j
ae
ta
l
.(2013
)whofoundth
a
tm
anyin
fo
rm
a
lc
a
r
eg
iv
e
r
sr
epo
r
tf
e
e
l
ing
in
su
f
f
i
c
i
en
tcomp
e
t
en
c
etoe
f
f
e
c
t
iv
e
lyfu
l
f
i
l
lth
ec
a
r
eg
iv
ingro
l
e
.In
fo
rm
a
lc
a
r
eg
iv
e
r
s(
i
fa
spou
s
eo
radu
l
tch
i
ld
)mu
s
to
f
t
enl
e
a
rntoad
ap
tandp
rov
id
ec
a
r
ew
i
th
inacomp
l
i
c
a
t
ed
emo
t
ion
a
lenv
i
ronm
en
t
,r
e
su
l
t
ingi
nsu
chf
e
e
l
ing
sa
sapp
r
eh
en
s
ion
,lon
e
l
in
e
s
s
,andg
r
i
e
f
.In
con
t
r
a
s
t
,fo
rm
a
lc
a
r
eg
iv
e
r
sm
ayno
texp
e
r
i
en
c
esu
chemo
t
ion
a
lcon
f
l
i
c
tb
e
c
au
s
eo
fth
el
a
ck
o
fap
r
e
ex
i
s
t
ingr
e
l
a
t
ion
sh
ipw
i
thth
eind
iv
idu
a
lr
equ
i
r
ingc
a
r
e(S
ad
avoy& W
e
s
s
en
,2012
)
.
Fu
r
th
e
r
,m
anyICPWDf
a
c
eth
er
e
spon
s
ib
i
l
i
tyo
fh
av
ingtop
rov
id
ec
a
r
e24hou
r
sp
e
rd
ay
,
s
ev
end
ay
sp
e
rw
e
ek
,w
i
thl
im
i
t
eda
c
c
e
s
stor
e
sp
i
t
ec
a
r
e
,andcon
f
in
em
en
tw
i
th
inth
ehom
e
wh
enth
ec
a
r
er
e
c
ip
i
en
ti
sun
ab
l
etob
el
e
f
ta
lon
e
.
L
ev
in
e(2006
)add
sth
a
tth
eb
igg
e
s
tch
al
l
eng
esh
ef
a
c
eda
sanin
fo
rm
a
lc
a
r
eg
iv
e
rw
a
s
no
twh
a
tsh
eh
adtodobu
tr
a
th
e
rl
a
ck
ingad
equ
a
t
et
im
einwh
i
chtodoi
t
.Fo
rex
amp
l
e
,sh
e
o
f
t
enfoundh
e
r
s
e
l
fc
l
e
an
ingo
rp
ay
ingb
i
l
l
sl
a
t
ea
tn
igh
ts
in
c
esh
eh
adnot
im
edu
r
ingth
ed
ay
top
e
r
fo
rmth
e
s
et
a
sk
s
.Sh
efoundi
tf
ru
s
t
r
a
t
ingth
a
ta
s
s
e
s
sm
en
t
sfo
rfo
rm
a
lc
a
r
es
e
rv
i
c
e
s

16

	
  

in
c
lud
edqu
e
s
t
ion
sabou
tth
ep
e
r
son
a
la
c
t
iv
i
t
i
e
sw
i
thwh
i
chh
e
rhu
sb
andn
e
ed
edh
e
lp
,bu
t
th
eyf
a
i
l
edtoa
skabou
tm
anyo
fth
ea
s
so
c
i
a
t
edi
s
su
e
s
,su
cha
sth
ed
i
f
f
i
cu
l
tya
s
so
c
i
a
t
edw
i
th
su
c
ht
a
sk
s
,h
e
rownr
e
su
l
t
ings
l
e
epd
ep
r
iv
a
t
ion
,andhowsh
ew
a
sab
l
etocomp
l
e
t
ea
l
lo
fh
e
r
r
e
spon
s
ib
i
l
i
t
i
e
sdu
r
ingth
ed
ay
.L
ev
in
e(2006
)r
e
c
a
l
l
sth
a
tmu
cho
fh
e
rt
im
ea
sac
a
r
eg
iv
e
r
w
a
ssp
en
tw
a
i
t
ing
,“
ju
s
tb
e
ingth
e
r
e
,w
a
i
t
ingfo
rth
en
ex
tt
im
etodosom
eth
ing
,th
en
ex
tt
im
e
th
e
r
ei
sac
a
l
lfo
rw
a
t
e
r
,ch
ang
ingth
eTVch
ann
e
l
,f
ix
ingth
ep
i
l
low
,o
ranyo
fcoun
t
l
e
s
s
un
c
a
t
ego
r
i
z
ab
l
er
equ
e
s
t
s
”(p
.9
)
.
I
ti
so
f
t
enth
ep
e
r
s
i
s
t
en
td
em
and
so
fc
a
r
e
,su
cha
stho
s
einth
eabov
eex
amp
l
e
s
,a
s
w
e
l
la
sh
av
ingtop
rov
id
eongo
ingc
a
r
eev
e
rym
inu
t
eo
fev
e
ryd
ay
,th
a
tp
r
ed
i
spo
s
ec
a
r
eg
iv
e
r
s
tod
i
s
t
r
e
s
s
,poo
rad
ap
t
a
t
ion
,o
rp
l
a
c
em
en
to
fc
a
r
er
e
c
ip
i
en
t
sinr
e
s
id
en
t
i
a
lc
a
r
e(G
aug
l
e
r
,
K
an
e
,K
an
e
,C
l
ay
,&N
ew
com
e
r
,2003
;P
inqu
a
r
t&So
r
en
s
en
,2003
)
.Exp
e
r
i
en
c
e
ssu
cha
s
L
ev
in
e
’
s(2006
)h
igh
l
igh
tsom
eo
fth
ed
i
f
f
i
cu
l
t
i
e
sth
a
tin
fo
rm
a
lc
a
r
eg
iv
e
r
sf
a
c
e
.Thu
s
,th
e
impo
r
t
an
c
eo
fin
fo
rm
a
lc
a
r
eg
iv
e
rn
e
ed
sa
s
s
e
s
sm
en
t
sb
e
com
e
sin
c
r
e
a
s
ing
lyev
id
en
ti
faPCP
i
stochoo
s
eandimp
l
em
en
tth
emo
s
tapp
rop
r
i
a
t
ein
t
e
rv
en
t
ion
sfo
rag
iv
enc
a
r
eg
iv
e
r
.
Inadd
i
t
iontog
a
in
inganund
e
r
s
t
and
ingo
fth
et
a
sk
sinvo
lv
edw
i
thin
fo
rm
a
l
c
a
r
eg
iv
ing
,i
ti
su
s
e
fu
lfo
rPCP
stoh
av
eanund
e
r
s
t
and
ingo
fin
fo
rm
a
lc
a
r
eg
iv
e
r
d
emog
r
aph
i
c
sino
rd
e
rtomo
s
tapp
rop
r
i
a
t
e
lyt
a
i
lo
rin
t
e
rv
en
t
ion
stoind
iv
idu
a
l
sandto
p
ro
a
c
t
iv
e
lyid
en
t
i
fyanyh
ighr
i
skg
roup
s
.S
ad
avoyand W
e
s
son(2012
)h
av
eid
en
t
i
f
i
edth
a
t
,
inC
an
ad
a
,97%o
fp
e
r
son
sw
i
thd
em
en
t
i
ah
av
ea
tl
e
a
s
ton
ein
fo
rm
a
lc
a
r
eg
iv
e
r
,w
i
th50%o
f
tho
s
ec
a
r
eg
iv
e
r
sb
e
ingov
e
rth
eag
eo
f65
.Th
em
a
jo
r
i
tyo
fth
e
s
ein
fo
rm
a
lc
a
r
eg
iv
e
r
sa
r
e
wom
en(S
ad
avoy& W
e
s
son
,2012
;S
inh
a
,2012
)
.Th
eA
l
zh
e
im
e
r
’
sA
s
so
c
i
a
t
ion(2016
)
r
epo
r
t
sth
a
t75%o
fICPWDh
av
eb
e
enp
rov
id
ingc
a
r
efo
ra
tl
e
a
s
ton
ey
e
a
rwh
i
l
e33%h
av
e
b
e
enp
rov
id
ingc
a
r
efo
rf
iv
eo
rmo
r
ey
e
a
r
s
.

17

	
  

A
l
thoughf
em
a
l
ein
fo
rm
a
lc
a
r
eg
iv
e
r
sou
tnumb
e
rm
a
l
e
s(59%wom
encomp
a
r
edto
41%m
en
)
,th
e
r
ea
r
eas
ign
i
f
i
c
an
tnumb
e
ro
fm
a
l
ec
a
r
eg
iv
e
r
sinC
an
ad
a(E
a
l
e
s
,K
im
,&F
a
s
t
,
2015
)
.Th
i
sm
ay
,inp
a
r
t
,b
er
e
l
a
t
edtoth
ef
a
c
tth
a
tmo
r
ewom
en(72%
)a
r
ed
i
agno
s
edw
i
th
d
em
en
t
i
ath
anm
enannu
a
l
ly
,andth
e
s
ewom
ena
r
eo
f
t
enth
enc
a
r
edfo
rbyth
e
i
rhu
sb
and
s
(A
l
zh
e
im
e
rSo
c
i
e
tyo
fC
a
lg
a
ry
,2013
)
.Th
eg
r
e
a
t
e
rnumb
e
ro
ff
em
a
l
ec
a
r
eg
iv
e
r
sov
e
r
a
l
li
s
l
ik
e
lydu
etoth
enumb
e
ro
fwom
enp
rov
id
ingc
a
r
etoe
ld
e
r
lyp
a
r
en
t
so
ro
th
e
rr
e
l
a
t
iv
e
sin
add
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t
iontoth
e
i
rspou
s
e
s
.Comp
a
r
edtoth
e
i
rm
a
l
ecoun
t
e
rp
a
r
t
s
,i
th
a
sa
l
sob
e
enfoundth
a
t
w
iv
e
sandd
augh
t
e
r
ssp
endmo
r
et
im
eonc
a
r
eg
iv
ingr
e
spon
s
ib
i
l
i
t
i
e
sp
e
rw
e
ek(F
am
i
ly
C
a
r
eg
iv
ingA
l
l
i
an
c
e
,2011
;S
inh
a
,2012
)
.S
inh
a(2012
)p
ropo
s
e
sth
a
tth
eg
r
e
a
t
e
rnumb
e
ro
f
c
a
r
eg
iv
inghou
r
sth
a
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enp
rov
id
em
ayp
a
r
t
lyb
er
e
l
a
t
edtoth
etyp
eo
ft
a
sk
srou
t
in
e
ly
p
e
r
fo
rm
ed
. Wom
ena
r
emo
r
el
ik
e
lytoh
e
lpw
i
thth
ep
rov
i
s
iono
fp
e
r
son
a
lc
a
r
e
,d
r
e
s
s
ing
,
to
i
l
e
t
ing
,m
ed
i
c
a
lt
r
e
a
tm
en
t
s
,andhou
s
ewo
rk
,wh
e
r
e
a
sm
ena
r
emo
r
el
ik
e
lytoa
s
s
i
s
tw
i
th
ou
tdoo
rwo
rko
rm
a
in
t
en
an
c
e(S
inh
a
,2012
)
.
At
r
endtow
a
rd
sd
e
l
ay
edch
i
ldb
e
a
r
ing
,a
sw
e
l
la
sth
ein
c
r
e
a
s
ednumb
e
ro
fwom
enin
th
ewo
rk
fo
r
c
e
,sugg
e
s
t
sth
a
tanin
c
r
e
a
s
ingnumb
e
ro
fwom
ena
r
ea
l
soinvo
lv
edinth
e
“
s
andw
i
chg
en
e
r
a
t
ion
”whop
rov
id
ec
a
r
efo
rch
i
ld
r
enande
ld
e
r
lyr
e
l
a
t
iv
e
swh
i
l
e
s
imu
l
t
an
eou
s
lywo
rk
ingou
t
s
id
eth
ehom
e(A
l
zh
e
im
e
r
’
sA
s
so
c
i
a
t
ion
,2015b
;D
ang
,B
ad
iy
e
,
&K
e
lk
a
r
,2008
)
. MyAun
ti
sanex
amp
l
eo
fap
e
r
soninth
i
ss
i
tu
a
t
ion
,a
ssh
ew
a
ssub
j
e
c
t
ed
tonum
e
rou
sco
mp
e
t
ingandcon
cu
r
r
en
temp
loym
en
t
,f
am
i
ly
,andc
a
r
eg
iv
ingd
em
and
s
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e
f
r
equ
en
t
lyh
adtor
equ
e
s
tt
im
eo
f
fo
fwo
rktoa
t
t
endtoth
en
e
ed
so
fmyg
r
andp
a
r
en
t
s
.
Add
i
t
ion
a
l
ly
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ewou
ldh
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etof
lyb
a
cktoOn
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a
r
iofo
ro
th
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rf
am
i
lycomm
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en
t
sfo
rh
e
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son
so
rhu
sb
and
’
sf
am
i
ly
.Aw(2013
)r
epo
r
t
sth
a
tth
r
e
el
a
rg
es
c
a
l
ewo
rk
l
i
f
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rv
ey
sw
e
r
e
condu
c
t
edbyDuxbu
ryandH
igg
in
s(2012
)ov
e
rth
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a
s
t20y
e
a
r
s
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er
e
s
e
a
r
ch
e
r
sfound

18

	
  
th
a
tth
enumb
e
ro
fC
an
ad
i
an
sinth
ewo
rk
fo
r
c
ep
rov
id
ingc
a
r
etoe
ld
e
r
lyr
e
l
a
t
iv
e
s

s
ign
i
f
i
c
an
t
lyin
c
r
e
a
s
edf
rom5%in1991to73%in2012
.On
einth
r
e
er
e
spond
en
t
stoth
e
s
e
su
rv
ey
sb
e
long
edtoth
es
andw
i
chg
en
e
r
a
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ion
,o
fwh
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ch21%r
epo
r
t
edf
e
e
l
ingov
e
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ed
a
tl
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a
s
tw
e
ek
ly
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eag
a
in
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i
sw
a
si
l
lu
s
t
r
a
t
edinmyAun
t
’
sexp
e
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i
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c
e
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i
thc
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r
eg
iv
ing
,
a
ssh
eo
f
t
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l
tov
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thth
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tu
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ion
sth
a
tsh
ef
a
c
eda
sp
a
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to
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ec
a
r
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exp
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i
en
c
e
.
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eRoadL
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s
sT
rav
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l
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:Th
eImpa
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to
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r
eg
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ingonIn
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lCa
r
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r
s
Fo
rICPWD,th
ed
em
en
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i
ajou
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eyc
anb
ecomp
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edtot
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av
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l
ingdownas
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e
ep
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ind
ing
,bumpyro
adw
i
thnof
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rmid
e
ao
fth
ed
i
r
e
c
t
ioninwh
i
chon
ei
sa
c
tu
a
l
lyh
e
ad
ed
.
In
fo
rm
a
lc
a
r
eg
iv
ingfo
rind
iv
idu
a
l
sw
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thd
em
en
t
i
ac
anb
ech
a
r
a
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t
e
r
i
z
edbyun
iqu
ech
a
l
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e
s
andp
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l
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f
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cs
t
r
e
s
sth
a
to
f
t
enin
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r
e
a
s
eov
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rt
im
edu
etoth
ep
rog
r
e
s
s
iv
en
a
tu
r
eo
fth
ed
i
s
e
a
s
e
(Co
t
r
e
l
l
,1997
;C
z
a
j
ae
ta
l
.
,2013
;D
av
i
s
,H
end
r
ix
,&Sup
e
rv
i
l
l
e
,2011
)
.As
ign
i
f
i
c
an
tamoun
t
o
fr
e
s
e
a
r
chh
a
sd
emon
s
t
r
a
t
edth
a
tin
fo
rm
a
lc
a
r
eg
iv
e
r
sm
aysu
f
f
e
radv
e
r
s
ephy
s
i
c
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land
m
en
t
a
lh
e
a
l
thou
t
com
e
s(B
e
l
l
ee
ta
l
.
,2006
;B
lome
ta
l
.
,2015
;C
roog
,Bu
r
l
e
son
,Sud
i
lov
sky
,
&B
aum
e
,2006
;D
i
amond
,G
l
eu
ck
au
f
,&Loom
i
s
,2003
;F
e
r
r
e
i
r
a
,Agu
i
a
r
,& M
en
e
s
e
s
,2014
;
S
imon
,2001
;T
r
emon
t
,2011
)
,a
sw
e
l
la
sn
eg
a
t
iv
eso
c
i
a
landf
in
an
c
i
a
lcon
s
equ
en
c
e
s
,a
sa
r
e
su
l
to
fc
a
r
ingfo
rp
a
t
i
en
t
sw
i
thd
em
en
t
i
a(L
a
i
,2012
)
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tudybyS
chu
l
zandB
e
a
ch(1999
)
r
epo
r
t
edth
a
tmo
r
t
a
l
i
tyr
e
l
a
t
edtop
sy
cho
log
i
c
a
ls
t
r
a
inw
a
sfoundtob
e63%h
igh
e
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in
fo
rm
a
lc
a
r
eg
iv
e
r
sth
aninnon
c
a
r
eg
iv
e
r
s
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r
th
e
r
,as
tudybyS
cho
enm
ak
e
r
se
ta
l
.(2010
)
foundth
a
tICPWDinth
ecommun
i
tye
xp
e
r
i
en
c
emo
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ebu
rd
en
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a
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phy
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l
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rm
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eg
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t
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e
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so
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s
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ti
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e
l
lknownth
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tch
ron
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r
e
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l
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e
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e
ingo
fanind
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a
l
.Kh
a
l
s
a

19

	
  

(2010
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epo
r
t
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a
t
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c
a
r
eg
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e
r
sa
r
etw
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ea
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ik
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lytor
epo
r
tphy
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c
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ls
t
r
a
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ighl
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e
l
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f
emo
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ion
a
ls
t
r
e
s
sa
sad
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r
e
c
tr
e
su
l
to
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a
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eg
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s
ib
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l
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t
i
e
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r
edtonon
c
a
r
eg
iv
e
r
s
(p
.1025
)
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chub
e
r
te
ta
l
.(2008
)r
epo
r
t
edonan
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t
ion
a
lsu
rv
eycondu
c
t
edinth
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s
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t
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a
r
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son
toin
fo
rm
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eg
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r
so
ftho
s
ew
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thphy
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c
a
ld
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l
i
tybu
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a
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eg
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e
s
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ex
c
e
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t
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e
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s
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l
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.
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sth
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s
e
a
s
et
r
a
j
e
c
to
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em
en
t
i
ac
anb
el
eng
thy
,ICPWDo
f
t
enb
e
com
eh
igh
ly
vu
ln
e
r
ab
l
etov
a
r
iou
ss
t
r
e
s
s
fu
lo
c
cu
r
r
en
c
e
s(Coh
en&L
e
e
,2007
)
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im
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ryands
e
cond
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ry
s
t
r
e
s
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r
sm
ayl
e
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r
th
e
rc
a
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eg
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rd
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r
e
s
s
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f
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e
c
t
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e
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l
thandw
e
l
l
b
e
ingand
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ein
fo
rm
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a
r
eg
iv
e
r
’
sab
i
l
i
tytoe
f
f
e
c
t
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lyp
rov
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ec
a
r
etoano
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e
rp
e
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son
.
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im
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ry(ob
j
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)s
t
r
e
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sth
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agno
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em
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ech
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sth
ed
i
s
e
a
s
e
p
rog
r
e
s
s
e
s
.R
e
l
ev
an
ts
e
cond
a
ry(
sub
j
e
c
t
iv
e
)s
t
r
e
s
so
r
swou
ldin
c
lud
ef
in
an
c
i
a
lbu
rd
en
th
roughlo
s
so
fw
ag
e
s
,f
am
i
lycon
f
l
i
c
t
s
,r
e
l
a
t
ion
sh
iph
a
rd
sh
ip
s
,andin
c
r
e
a
s
ingso
c
i
a
l
i
so
l
a
t
iona
sth
en
e
ed
so
fth
ec
a
r
er
e
c
ip
i
en
tin
c
r
e
a
s
e(Em
l
e
t
,1996
;F
a
r
cn
ik&P
e
r
syko
,2002
;
S
avv
a&B
r
ayn
e
,2009
)
.Fu
r
th
e
r
,a
sd
em
en
t
i
ai
san
eu
rod
eg
en
e
r
a
t
iv
econd
i
t
ionw
i
thnocu
r
e
,
un
c
e
r
t
a
in
tyabou
twh
a
tth
efu
tu
r
eho
ld
sa
f
t
e
rd
i
agno
s
i
sc
anb
eex
c
e
ed
ing
lys
t
r
e
s
s
fu
l
.I
fth
e
in
fo
rm
a
lc
a
r
eg
iv
e
rb
e
com
e
sun
ab
l
etocop
ew
i
thth
ech
ron
i
cs
t
r
a
inands
t
r
e
s
sa
s
so
c
i
a
t
edw
i
th
c
a
r
eg
iv
ing
,h
eo
rsh
em
ayb
e
com
ed
i
s
t
r
e
s
s
edandun
ab
l
etocon
t
inu
etop
rov
id
ec
a
r
efo
rth
e
p
e
r
sonw
i
thd
em
en
t
i
a
.
Phy
s
i
ca
limpa
c
t
s
.A
l
thoughm
anyin
fo
rm
a
lc
a
r
eg
iv
e
r
sm
ayr
a
t
eth
e
i
rh
e
a
l
tha
sgood
o
rev
enex
c
e
l
l
en
t
,th
es
t
r
e
s
sinvo
lv
edw
i
thd
em
en
t
i
ac
a
r
eg
iv
ingh
a
sb
e
ena
s
so
c
i
a
t
edw
i
th
num
e
rou
sn
eg
a
t
iv
eimp
l
i
c
a
t
ion
sr
eg
a
rd
ingphy
s
i
c
a
lh
e
a
l
th
,in
c
lud
ingf
a
t
igu
e
,w
e
ig
h
t

20

	
  
ch
ang
e
s
,andin
somn
i
a(G
a
l
l
an
t&Conn
e
l
l
,2003
;K
r
a
ch&B
rook
s
,1995
;S
an
son
ie
ta
l
.
,
2004
)
.Add
i
t
ion
a
l
ly
,i
th
a
sb
e
enhypo
th
e
s
i
z
edth
a
tc
a
rd
iov
a
s
cu
l
a
rp
rob
l
em
s
,su
cha
s

hyp
e
r
t
en
s
ionandco
ron
a
rya
r
t
e
ryd
i
s
e
a
s
e
,a
r
ea
s
so
c
i
a
t
edw
i
thc
a
r
eg
iv
ing(V
i
t
a
l
i
anoe
ta
l
.
,
2002
)
.Phy
s
io
log
i
c
a
l
ly
,ch
ron
i
cs
t
r
e
s
s“…imp
a
i
r
sh
ippo
c
amp
a
l
d
ep
end
en
tcogn
i
t
iv
e
fun
c
t
ion
,supp
r
e
s
s
e
sn
eu
rog
en
e
s
i
s
,andc
au
s
e
sd
end
r
i
t
i
csh
r
ink
ag
e
,wh
i
chs
e
rv
e
sa
sa
m
e
ch
an
i
sminth
ep
a
thog
en
e
s
i
so
fhum
and
ep
r
e
s
s
iv
ei
l
ln
e
s
sandcogn
i
t
iv
ed
e
c
l
in
e
”(Kh
a
l
s
a
2010
,p
.1025
)
.Th
i
sc
anm
an
i
f
e
s
ta
spoo
rd
e
c
i
s
ion
m
ak
ingandc
a
r
ep
rov
i
s
ionbyth
e
in
fo
rm
a
lc
a
r
eg
iv
e
r(Kh
a
l
s
a
,2010
)
.Am
e
t
aan
a
ly
s
i
scondu
c
t
edbyV
i
t
a
l
i
ano
,Zh
ang
,and
S
c
an
l
an(2003
)foundth
a
tc
a
r
eg
iv
e
r
sc
anh
av
ed
e
c
r
e
a
s
edan
t
ibodyr
e
spon
s
e
sincomp
a
r
i
son
tonon
c
a
r
eg
iv
e
r
s
,a
sw
e
l
la
sg
r
e
a
t
e
rl
ev
e
l
so
fc
i
r
cu
l
a
t
ings
t
r
e
s
sho
rmon
e
s
.In
c
r
e
a
s
edl
ev
e
l
s
o
fs
t
r
e
s
sho
rmon
e
ssu
cha
sco
r
t
i
so
l
,ad
r
eno
co
r
t
i
co
t
rop
in(ACTH
)
,8
l
ipo
t
rop
inand3
endo
rph
in
,a
sw
e
l
la
sc
a
t
e
cho
l
am
in
e
sr
e
l
e
a
s
eddu
r
ingp
ro
long
eds
t
r
e
s
s
,c
anl
e
adtod
am
ag
ing
sy
s
t
em
i
ca
f
f
e
c
t
s(R
an
ab
i
r&R
e
e
tu
,2011
)
.Ch
ron
i
cs
t
r
e
s
sc
ana
l
soc
au
s
ea
l
t
e
r
edendo
c
r
in
e
r
e
spon
s
e
s
,su
cha
sin
c
r
e
a
s
edd
i
s
s
em
in
a
t
iono
fv
a
sop
r
e
s
s
in
,gon
ado
t
rop
insupp
r
e
s
s
ion
,
supp
r
e
s
s
edthy
ro
idfun
c
t
ion
,ad
e
f
i
c
i
en
cyo
fg
row
thho
r
mon
es
e
c
r
e
t
ion
,ch
ang
e
sinp
ro
l
a
c
t
in
l
ev
e
l
s
,andd
e
c
r
e
a
s
edin
su
l
ins
e
c
r
e
t
ion(R
an
ab
i
r&R
e
e
tu
,2011
)
.
Ch
ron
i
cs
t
r
e
s
sc
anl
e
adtoth
ed
ev
e
lopm
en
t
,o
rex
a
c
e
rb
a
t
ion
,o
fnum
e
rou
sd
i
s
e
a
s
e
s
t
a
t
e
sandc
anadv
e
r
s
e
lya
f
f
e
c
timmun
eandin
f
l
amm
a
to
ryr
e
spon
s
e
s(Fo
r
sh
e
e
,C
l
ay
ton
,&
M
cC
an
c
e
,2010
)
.Inth
e
i
rs
tudyinv
e
s
t
ig
a
t
ingth
er
e
l
a
t
ion
sh
ipb
e
tw
e
enc
a
r
eg
iv
e
rs
t
r
e
s
s
,
immun
esy
s
t
emsupp
r
e
s
s
ion
,andsymp
a
th
e
t
i
cn
e
rvou
ssy
s
t
ema
c
t
iv
a
t
ion
,M
i
l
l
se
ta
l
.(2004
)
con
c
lud
edth
a
timmun
i
tyw
a
ssupp
r
e
s
s
edina
t
r
i
skc
a
r
eg
iv
e
r
s
,a
sd
emon
s
t
r
a
t
edbyth
e
i
r
d
e
c
r
e
a
s
edb
e
t
a
2ad
r
en
e
rg
i
cr
e
c
ep
to
rs
en
s
i
t
iv
i
tyandd
en
s
i
ty
.E
ld
e
r
lyin
fo
rm
a
lc
a
r
eg
iv
e
r
s
m
ayb
ea
tev
enh
igh
e
rr
i
skfo
rpoo
rad
ap
t
a
t
iontos
t
r
e
s
sdu
eton
eu
roho
rmon
a
l
,c
e
l
lu
l
a
r
,and

21

	
  

immun
ech
ang
e
swh
i
cha
r
eco
l
l
e
c
t
iv
e
lyr
e
f
e
r
r
edtoa
s“
s
t
r
e
s
s
ag
esynd
rom
e
”(Fo
r
sh
e
ee
ta
l
.
,
2010
,p
.365
)
.
A
sd
em
en
t
i
ap
rog
r
e
s
s
e
s
,th
el
ev
e
lo
fr
equ
i
r
eda
s
s
i
s
t
an
c
ew
i
thADL
sandIADL
sby
th
eind
iv
idu
a
lw
i
thd
em
en
t
i
ao
f
t
enin
c
r
e
a
s
e
s
,r
e
su
l
t
inginth
ein
fo
rm
a
lc
a
r
eg
iv
e
rt
ak
ingon
ev
e
r
g
r
e
a
t
e
rr
e
spon
s
ib
i
l
i
t
i
e
s(Nguy
en
,2009
)
.Th
e
s
ephy
s
i
c
a
ld
em
and
sa
longw
i
thth
e
in
c
r
e
a
s
edmo
rb
id
i
tya
s
so
c
i
a
t
edw
i
thag
ingp
l
a
c
e
se
ld
e
r
lyc
a
r
eg
iv
e
r
sa
tp
a
r
t
i
cu
l
a
rr
i
skfo
r
poo
rphy
s
io
log
i
c
a
lou
t
com
e
s(Aue
ta
l
.
,2010
;P
inqu
a
r
t&Sö
r
en
s
en
,2006
;S
chu
l
z&
P
a
t
t
e
r
son
,2004
;V
i
t
a
l
ianoe
ta
l
.
,2003
)
.Inadd
i
t
iontoth
er
i
skfo
rin
ju
ryth
a
ti
sr
e
l
a
t
edtoth
e
phy
s
i
c
a
l
lych
a
l
l
eng
ingt
a
sk
sinvo
lv
edinc
a
r
eg
iv
ing
,ICPWDm
aya
l
sob
ea
tr
i
sko
fin
ju
ry
f
romagg
r
e
s
s
iv
eandimpu
l
s
iv
eb
eh
av
iou
r
sin
f
l
i
c
t
eduponth
embyth
ec
a
r
er
e
c
ip
i
en
t
.Th
e
r
e
l
a
t
ion
sh
ipb
e
tw
e
enlong
t
e
rmc
a
r
eg
iv
ing
,ch
ron
i
cs
t
r
e
s
sandd
e
t
r
im
en
t
a
lphy
s
i
c
a
le
f
f
e
c
t
s
h
av
eimpo
r
t
an
tc
l
in
i
c
a
ls
ign
i
f
i
c
an
c
ea
si
tc
anp
rov
id
eon
em
e
a
su
r
ebywh
i
chtoid
en
t
i
fya
t
r
i
skICPWDa
sw
e
l
la
stogu
id
eth
echo
i
c
eo
fapp
rop
r
i
a
t
ein
t
e
rv
en
t
ion
s(S
chu
l
z&P
a
t
t
e
r
son
,
2004
)
.
P
sy
cho
log
i
ca
limpa
c
t
s
.Inadd
i
t
iontoth
ephy
s
i
c
a
le
f
f
e
c
t
so
fch
ron
i
cs
t
r
e
s
sr
e
l
a
t
edto
th
ed
i
f
f
e
r
en
ta
sp
e
c
t
so
fc
a
r
eg
iv
ing
,m
en
t
a
landemo
t
ion
a
le
f
f
e
c
t
sc
ana
l
sog
r
e
a
t
lyimp
a
c
t
ICPWD
,l
e
ad
ingtod
i
s
t
r
e
s
sandpoo
rad
ap
t
a
t
iontoth
ec
a
r
eg
iv
e
rro
l
e
.N
eg
a
t
iv
e
p
sy
cho
log
i
c
a
le
f
f
e
c
t
sr
e
l
a
t
edtop
e
r
son
a
ls
a
c
r
i
f
i
c
e
,h
av
ingtop
e
r
fo
rmth
em
anyt
a
sk
s
invo
lv
edw
i
thc
a
r
eg
iv
ing
,in
c
r
e
a
s
ingr
i
sko
fso
c
i
a
li
so
l
a
t
ion
,andf
e
e
l
ing
so
fbu
rd
en
,bu
rnou
t
,
gu
i
l
t
,f
ru
s
t
r
a
t
ion
,andf
e
a
r(
r
e
l
a
t
edtoe
i
th
e
rp
e
r
son
a
ls
a
f
e
tyo
rth
es
a
f
e
tyo
fth
ec
a
r
e
r
e
c
ip
i
en
t
)
,m
aym
an
i
f
e
s
tinth
ec
a
r
eg
iv
e
ra
sd
ep
r
e
s
s
ion
,anx
i
e
ty
,ang
e
r
,andbu
rd
en
(M
cK
ibb
in
,W
a
l
sh
,R
ink
i
,Ko
in
,&G
a
l
l
agh
e
r
Thomp
son
,1999
;S
chu
l
z&P
a
t
t
e
r
son
,2004
)
.
Th
e
r
ei
sfo
rm
id
ab
l
econ
cu
r
r
en
c
eth
roughou
td
emen
t
i
ac
a
r
eg
iv
ingl
i
t
e
r
a
tu
r
e
,ind
i
c
a
t
ingth
a
t

22

	
  

p
rov
id
ingc
a
r
efo
rap
e
r
sonw
i
thd
em
en
t
i
ac
anl
e
adtoth
e
s
etyp
e
so
fn
eg
a
t
iv
eimp
a
c
t
sonth
e
in
fo
rm
a
lc
a
r
eg
iv
e
r(S
chu
l
z&P
a
t
t
e
r
son
,2004
)
.In
c
r
e
a
s
edl
ev
e
l
so
fs
t
r
e
s
sandanx
i
e
tym
ayb
e
exp
r
e
s
s
edbyICPWDwh
ent
h
e
r
ea
r
er
epo
r
t
so
fs
l
e
epd
ep
r
iv
a
t
ion
,f
r
equ
en
ts
l
e
ep
in
t
e
r
rup
t
ion
sa
tn
igh
t
,o
rv
e
rb
a
lo
rphy
s
i
c
a
labu
s
e(Du
ry
,2014
)
.
Th
es
t
r
e
s
sinvo
lv
edw
i
thc
a
r
eg
iv
inga
l
sop
l
a
c
e
sICPWDa
tin
c
r
e
a
s
edr
i
skfo
rm
en
t
a
l
h
e
a
l
thi
s
su
e
s
,p
a
r
t
i
cu
l
a
r
lyd
ep
r
e
s
s
ion(Cu
i
jp
e
r
s
,20
05
;Ep
s
t
e
in
Lubow
,D
av
i
s
,M
i
l
l
e
r
,&
T
r
emon
t
,2008
;Ow
ene
ta
l
.
,2002
;S
cho
enm
ak
e
r
se
ta
l
.
,2010
;S
chub
e
r
te
ta
l
.
,2008
)
.
Num
e
rou
ss
tud
i
e
sh
av
efoundth
a
td
ep
r
e
s
s
iont
end
stob
econn
e
c
t
edtos
ev
e
r
a
lf
a
c
to
r
s
invo
lv
edinc
a
r
eg
iv
ing
,in
c
lud
ingd
eg
r
e
eo
fp
e
r
c
e
i
v
edbu
rd
en
,l
ev
e
lo
fh
e
a
l
th
,in
com
eo
fth
e
c
a
r
eg
iv
e
r
,andd
eg
r
e
eo
fl
i
f
es
a
t
i
s
f
a
c
t
ion(Cu
i
jp
e
r
s
,2005
;S
chub
e
r
te
ta
l
.
,2008
;Ow
ene
ta
l
.
,
2002
)
.Th
ein
c
id
en
c
eandp
r
ev
a
l
en
c
eo
fd
ep
r
e
s
s
ioni
sg
r
e
a
t
e
rinICPWDcomp
a
r
edtonon
c
a
r
eg
iv
e
r
s(Cu
i
jp
e
r
s
,2005
;Ngu
y
en
,2009
;S
chub
e
r
te
ta
l
.
,2008
)
.S
im
i
l
a
r
ly
,S
cho
enm
ak
e
r
s
e
ta
l
.(2010
)foundth
a
tICPWDh
av
emo
r
ed
i
agno
s
e
so
fd
ep
r
e
s
s
ionth
ano
th
e
r
so
fth
e
i
rag
e
,
w
i
thc
a
r
eg
iv
e
rr
a
t
e
sr
ang
ingf
rom30%to80%
.
Aw(2013
)s
t
a
t
e
sth
a
tin
fo
rm
a
lc
a
r
eg
iv
e
r
sinth
es
andw
i
chg
en
e
r
a
t
iona
r
ea
l
soa
t
p
a
r
t
i
cu
l
a
rr
i
skfo
r“
comp
a
s
s
ionf
a
t
igu
e
”
.Comp
a
s
s
ionf
a
t
igu
er
ep
r
e
s
en
t
sasynd
rom
eth
a
tw
a
s
o
r
ig
in
a
l
lyu
s
edtod
e
s
c
r
ib
eth
ephy
s
i
c
a
landemo
t
ion
a
lexh
au
s
t
ionexp
e
r
i
en
c
edbym
e
d
i
c
a
l
p
ro
f
e
s
s
ion
a
l
swhop
rov
id
eag
r
e
a
td
e
a
lo
femp
a
thyandc
a
r
eg
iv
inginth
ewo
rkp
l
a
c
e
.
R
e
s
e
a
r
chh
a
snowd
emon
s
t
r
a
t
edev
id
en
c
eo
fcomp
a
s
s
ionf
a
t
igu
einICPWD(D
ay
,And
e
r
son
,
&D
av
i
s
,2014
)
.Th
esynd
rom
ei
sch
a
r
a
c
t
e
r
i
z
edbyphy
s
i
c
a
l
,emo
t
ion
a
l
,andsp
i
r
i
tua
l
co
l
l
ap
s
er
e
l
a
t
edtocon
s
t
an
tc
a
r
eg
iv
ingandc
anl
e
adtof
e
e
l
ing
so
fanx
i
e
ty
,ap
a
thy
,
d
ep
r
e
s
s
ion
,r
e
s
en
tm
en
t
,andh
e
lp
l
e
s
sn
e
s
s(Aw
,2013
;D
aye
ta
l
.
,2014
)
.

23

	
  
So
c
ia
limpa
c
t
s
.Inadd
i
t
iontoth
ephy
s
i
c
a
l
,m
en
t
a
l
,andemo
t
ion
a
limp
a
c
tth
a
t

c
a
r
eg
iv
ingc
anh
a
v
eonICPWD
,su
chc
a
r
eg
iv
e
r
sa
l
sor
epo
r
tf
r
equ
en
tf
e
e
l
ing
so
fi
so
l
a
t
ion
andp
r
e
s
su
r
e
.Th
e
s
en
eg
a
t
iv
ef
e
e
l
ing
sc
anr
e
su
l
tinf
in
an
c
i
a
landso
c
i
a
limp
l
i
c
a
t
ion
sa
sw
e
l
l
(S
cho
enm
ak
e
r
se
ta
l
.
,2010
)
.Co
t
r
e
l
landEng
e
l(1999
)con
cu
r
,s
t
a
t
ingth
a
t
,a
sc
a
r
eg
iv
ing
d
em
and
sa
c
cumu
l
a
t
e
,th
ein
fo
rm
a
lc
a
r
eg
iv
e
rc
ans
imu
l
t
an
eou
s
lyb
e
com
ein
c
r
e
a
s
ing
ly
so
c
i
a
l
lyi
so
l
a
t
edf
romou
t
s
id
er
e
so
u
r
c
e
sandsuppo
r
t
s
.Fu
r
th
e
rmo
r
e
,lon
e
l
in
e
s
sinsu
ch
s
i
tu
a
t
ion
si
scommonandh
a
sap
rov
ena
s
so
c
i
a
t
ionw
i
thin
c
r
e
a
s
edmo
rb
id
i
tyandmo
r
t
a
l
i
t
y
(Ch
a
r
l
e
swo
r
the
ta
l
.
,2008
)
.M
anyadu
l
tch
i
ld
r
enp
rov
id
ingc
a
r
etoane
ld
e
r
lyp
a
r
en
tf
indth
a
t
th
eymu
s
td
e
c
r
e
a
s
eth
enumb
e
ro
fwo
rk
inghou
r
sth
a
tth
eyc
anp
e
r
fo
rmp
e
rw
e
ekino
rd
e
rto
con
t
inu
etop
rov
id
ec
a
r
e
.Th
er
e
su
l
t
inglo
s
so
fin
com
em
aya
f
f
e
c
tth
e
i
rf
am
i
lyandb
e
com
ea
s
ign
i
f
i
c
an
tadd
i
t
ion
a
lsou
r
c
eo
fs
t
r
a
in
.
F
inan
c
ia
limpa
c
t
s
.Th
ee
conom
i
cimp
l
i
c
a
t
ion
sr
e
l
a
t
edtoc
a
r
eg
iv
ingc
anb
e
d
e
t
r
im
en
t
a
ltom
anyICPWD
.Th
eco
s
t
sa
s
so
c
i
a
t
edw
i
tha
cqu
i
r
ingsuppo
r
t
iv
es
e
rv
i
c
e
s
,o
r
p
l
a
c
ingaf
am
i
lym
emb
e
rinar
e
s
id
en
t
i
a
lc
a
r
ef
a
c
i
l
i
ty
,c
anb
eexo
rb
i
t
an
tandp
roh
ib
i
t
iv
e
.Th
e
f
in
an
c
i
a
lco
s
t
so
fc
a
r
ingm
aya
l
soin
c
lud
ed
i
r
e
c
tnon
r
e
imbu
r
s
ab
l
eh
e
a
l
thc
a
r
eco
s
t
sfo
rth
e
c
a
r
er
e
c
ip
i
en
t
,a
sw
e
l
la
sth
eco
s
to
ffo
rgon
ew
ag
e
s(L
a
i
,2012
)
.Th
ef
in
an
c
i
a
limp
a
c
ton
young
e
rICPWDwhor
em
a
ininth
ewo
rk
fo
r
c
ec
anb
econ
s
id
e
r
ab
l
ea
sm
anyin
fo
rm
a
l
c
a
r
eg
iv
e
r
sf
indth
a
tth
eymu
s
tn
e
c
e
s
s
a
r
i
lyd
e
c
r
e
a
s
eth
eamoun
to
fhou
r
sth
a
tth
eya
r
eab
l
eto
wo
rke
a
chw
e
ek
.F
a
r
cn
ikandP
e
r
syko(2002
)s
t
a
t
eth
a
tasub
s
t
an
t
i
a
lnumb
e
ro
fin
fo
rm
a
l
c
a
r
e
g
iv
e
r
sa
r
ea
c
tu
a
l
lyfo
r
c
edtoqu
i
two
rk
ingen
t
i
r
e
lyino
rd
e
rtot
ak
eonth
ec
a
r
eg
iv
ingro
l
e
.
Th
ef
in
an
c
i
a
limp
a
c
to
fc
a
r
eg
iv
ingc
ana
l
sob
ep
a
r
t
i
cu
l
a
r
lys
ign
i
f
i
c
an
tfo
re
ld
e
r
lyspou
s
e
s
whoa
r
enolong
e
rinth
ewo
rk
fo
r
c
eo
rwhoa
r
er
e
c
e
iv
ingl
im
i
t
edp
en
s
ions
.

24

	
  
Bu
rd
en
.Em
l
e
t(1996
)d
e
s
c
r
ib
e
sbu
rd
ena
sacomp
l
exph
enom
enoninvo
lv
ing

num
e
rou
sob
j
e
c
t
iv
eandsub
j
e
c
t
iv
ef
a
c
to
r
s
.S
im
i
l
a
r
ly
,T
ebb(1995
)s
t
a
t
e
sth
a
tbu
rd
en
,“o
rth
e
in
ab
i
l
i
tytob
er
e
s
i
l
i
en
t
,i
sth
eex
t
en
ttowh
i
chth
ec
a
r
eg
iv
e
rp
e
r
c
e
iv
e
sth
a
th
i
so
rh
e
rphy
s
i
c
a
l
,
so
c
i
a
l
,m
en
t
a
l
,andsp
i
r
i
tu
a
ls
t
a
tu
si
ssu
f
f
e
r
inga
sar
e
su
l
to
fp
rov
id
ingc
a
r
e
”(p
.88
)
.
D
e
t
e
rm
in
ingac
a
r
eg
iv
e
r
’
sl
ev
e
lo
fp
e
r
c
e
iv
edbu
rd
eni
se
s
s
en
t
i
a
l
,no
ton
lyfo
rth
epu
rpo
s
eo
f
en
su
r
ingth
eh
e
a
l
thandw
e
l
l
b
e
ingo
fICPWD
,bu
ta
l
sotoi
d
en
t
i
fyanyn
eg
a
t
iv
eimp
a
c
ton
th
ec
a
r
er
e
c
ip
i
en
t
.Ino
rd
in
a
t
ec
a
r
eg
iv
e
rbu
rd
enh
a
sb
e
ena
s
so
c
i
a
t
edw
i
thn
eg
a
t
iv
e
imp
l
i
c
a
t
ion
sfo
rth
ec
a
r
er
e
c
ip
i
en
t
,in
c
lud
inganin
c
r
e
a
s
edr
i
sko
fr
e
s
id
en
t
i
a
lc
a
r
ep
l
a
c
em
en
t
a
sw
e
l
la
sah
igh
e
rpo
t
en
t
i
a
lfo
re
ld
e
rabu
s
e(E
m
l
e
t
,1996
;Y
a
f
f
ee
ta
l
.
,2002)
.
S
ev
e
r
a
lfo
rm
so
fbu
rd
en
,su
cha
sphy
s
i
c
a
l
,p
sy
cho
log
i
c
a
l
,so
c
i
a
l
,emo
t
ion
a
l
,and
f
in
an
c
i
a
lbu
rd
en
,m
ayb
eexp
e
r
i
en
c
edbyICPWD(Don
a
ld
son&Bu
rn
s
,1999
;Em
l
e
t
,1996
)
.
Su
chc
a
r
eg
iv
e
r
so
f
t
enexp
e
r
i
en
c
eamu
l
t
i
f
a
c
e
t
edr
e
spon
setonum
e
rou
ss
t
r
e
s
so
r
sa
s
so
c
i
a
t
ed
w
i
thth
ec
a
r
eg
iv
ingexp
e
r
i
en
c
e(Ep
s
t
e
inLubowe
ta
l
.2008
;K
a
suy
a
,Po
lg
a
rB
a
i
l
ey
,&
T
ak
eu
ch
i
,2000
)
.C
a
r
eg
iv
e
rbu
rd
enc
anb
efu
r
th
e
rin
f
lu
en
c
edbyo
th
e
rf
a
c
to
r
s
,in
c
lud
ingth
e
ICPWD
’
sp
e
r
c
ep
t
iono
ff
am
i
lyr
e
l
a
t
ion
sh
ip
s
,cu
l
tu
r
e
,andso
c
i
a
limp
a
c
t
s(E
t
t
e
r
s
,Good
a
l
l
,&
H
a
r
r
i
son
,2008
)
.Th
ecu
l
tu
r
a
lb
a
ckg
roundo
fth
eind
iv
idu
a
l
sinvo
lv
edc
anin
f
lu
en
c
ea
c
a
r
eg
iv
e
r
’
sp
e
r
c
ep
t
iono
ff
am
i
l
i
a
lob
l
ig
a
t
ion
sandcon
s
equ
en
t
lyi
n
f
lu
en
c
eth
e
i
rp
e
r
c
ep
t
iono
f
th
ebu
rd
enth
eyc
a
r
ryr
e
l
a
t
edtoth
ec
a
r
eg
iv
ingro
l
e(E
t
t
e
r
se
ta
l
.
,2008
)
.Fo
rex
amp
l
e
,f
i
r
s
t
g
en
e
r
a
t
ionCh
in
e
s
eC
an
ad
i
an
sw
i
thas
t
rongs
en
s
eo
ff
i
l
i
a
lr
e
spon
s
ib
i
l
i
tym
ayp
e
r
c
e
iv
el
e
s
s
bu
rd
ena
s
so
c
i
a
t
edw
i
thc
a
r
eg
iv
ingth
ana
na
c
cu
l
tu
r
a
t
edth
i
rd
g
en
e
r
a
t
ionCh
in
e
s
eC
an
ad
i
an
who
s
eexp
e
r
i
en
c
e
sh
av
eb
e
enin
f
lu
en
c
edby W
e
s
t
e
rncu
l
tu
r
e(M
iy
aw
ak
i
,2015
)
.I
ti
sc
r
i
t
i
c
a
l
fo
rPCP
stoa
cknow
l
edg
eth
a
tac
a
r
eg
iv
e
r
’
sp
e
r
c
ep
t
iono
fbu
rd
eni
sam
a
jo
rr
i
skf
a
c
to
rfo
r

25

	
  

poo
rad
ap
t
a
t
iontoth
ec
ar
eg
iv
e
rro
l
eandmo
s
to
f
t
enp
r
e
s
en
t
sinp
r
im
a
ryc
a
r
ea
spoo
rh
e
a
l
th
andd
ep
r
e
s
s
ion(Don
a
ld
son&Bu
rn
s
,1999
;Ep
s
t
e
in
Lubowe
ta
l
.
,2008
)
.
Num
e
rou
ss
t
r
e
s
so
r
s
,su
cha
sch
a
l
l
eng
ingb
eh
av
iou
r
sbyth
ep
a
t
i
en
tw
i
thd
em
en
t
i
a
,
co
r
r
e
l
a
t
ew
i
tha
l
lf
a
c
e
t
so
fc
a
r
eg
iv
e
rbu
rd
en
,wh
e
r
e
a
sin
c
r
e
a
s
ingl
im
i
t
a
t
ion
so
fADL
sand
IADL
sinth
ed
em
en
t
i
ap
a
t
i
en
tco
r
r
e
l
a
t
ew
i
thg
r
e
a
t
e
rp
e
r
son
a
lbu
rd
enfo
rth
ein
fo
rm
a
l
c
a
r
eg
iv
e
r(D
iw
an
,2004
)
.A
sth
ed
i
s
e
a
s
ep
rog
r
e
s
s
e
sandc
a
r
en
e
ed
sin
c
r
e
a
s
e
,sodo
e
sth
e
l
ev
e
lo
fc
a
r
eg
iv
e
rbu
rd
ens
i
n
c
eth
ein
fo
rm
a
lc
a
r
eg
iv
e
rw
i
l
ln
e
c
e
s
s
a
r
i
lyh
av
el
e
s
sab
i
l
i
tyand
t
im
etoadd
r
e
s
sth
e
i
rownn
e
ed
sandp
e
r
son
a
lh
e
a
l
thr
equ
i
r
em
en
t
s(Nguy
en
,2009
)
.C
rooge
t
a
l
.(2006
)s
t
a
t
eth
a
th
igh
e
rl
ev
e
l
so
fp
e
r
c
e
iv
edbu
rd
enm
aym
an
i
f
e
s
ta
sanx
i
e
ty
,ang
e
ro
r
r
e
s
en
tm
en
ttow
a
rd
sth
ec
a
r
er
e
c
ip
i
en
tinadd
i
t
iontof
e
e
l
ing
so
fcon
s
t
r
a
in
t
,f
e
e
l
ing
so
f
in
ad
equ
a
cyinc
a
r
ep
rov
i
s
ion
,andf
e
e
l
ing
so
fso
c
i
a
lr
e
s
t
r
i
c
t
ion
.
W
i
thou
tad
equ
a
t
esuppo
r
t
,sub
s
equ
en
tro
l
es
t
r
a
inandbu
rd
enc
anl
e
adtod
i
s
t
r
e
s
s
,
g
en
e
r
a
t
ingpoo
rou
t
com
e
sfo
rth
ein
fo
rm
a
lc
a
r
eg
iv
e
ra
sw
e
l
la
sfo
rth
ec
a
r
er
e
c
ip
i
en
t
(Fow
l
e
r
,H
an
ey
,&Ru
t
l
edg
e
,2014
)
.Agg
a
rw
a
le
ta
l
.(2003
)ag
r
e
e
,s
t
a
t
ingth
a
tin
ad
equ
a
t
e
c
a
r
eg
iv
e
rsuppo
r
tc
anadv
e
r
s
e
lya
f
f
e
c
tth
equ
a
l
i
tyo
fc
a
r
eth
a
tICPWDa
r
eab
l
etop
rov
id
e
.
Fu
r
th
e
rmo
r
e
,i
fICP
WDb
e
com
ein
c
ap
ab
l
eo
fcon
t
inu
ingth
e
i
rro
l
edu
etod
i
s
t
r
e
s
s
,th
e
r
ei
san
in
c
r
e
a
s
edr
i
skfo
rin
s
t
i
tu
t
ion
a
l
i
z
a
t
ion
,con
c
e
iv
ab
lyfo
rbo
thth
ec
l
i
en
tandth
ein
fo
rm
a
l
c
a
r
eg
iv
e
r(C
IH
I
,2010b
)
.Con
s
equ
en
t
ly
,th
ee
f
f
e
c
t
so
fc
a
r
eg
iv
ingonth
eh
e
a
l
tho
fICPWD
“
con
t
inu
etob
eimpo
r
t
an
ta
tbo
thth
eind
iv
idu
a
landso
c
i
e
t
a
ll
ev
e
l
”(Gon
z
a
l
e
z
,Po
l
an
sky
,
L
ipp
a
,W
a
lk
e
r
,&F
eng
,2011
,p
.528
;S
chub
e
r
te
ta
l
.
,2008
,p
.1737
)
.
Chang
ing W
ea
th
e
rA
longth
eJou
rn
ey:Fa
c
to
r
stha
tIn
f
lu
en
c
eBu
rd
en
Und
e
r
s
t
and
ingtho
s
ef
a
c
to
r
sth
a
tin
f
lu
en
c
eanin
fo
rm
a
lc
a
r
eg
iv
e
r
’
sl
ev
e
lo
fbu
rd
en
,
w
e
l
lb
e
ing
,andad
ap
t
a
t
ionh
a
ss
ign
i
f
i
c
an
timp
l
i
c
a
t
ion
sfo
rPCP
s
,p
a
r
t
i
cu
l
a
r
lyw
i
thr
e
sp
e
c
tto

26

	
  

th
eid
en
t
i
f
i
c
a
t
ionandu
t
i
l
i
z
a
t
iono
fac
a
r
eg
iv
e
r
’
sownr
e
sou
r
c
e
stop
rov
id
esuppo
r
tandd
i
r
e
c
t
in
t
e
rv
en
t
ion
s
.Th
e
r
ea
r
es
ev
e
r
a
ld
e
t
e
rm
in
an
t
sth
a
tm
aypo
s
i
t
iv
e
lyo
rn
eg
a
t
iv
e
lyin
f
lu
en
c
e
c
a
r
eg
iv
e
rbu
rd
en
,w
e
l
l
b
e
ing
,andad
ap
t
a
t
ioninICPWD
.D
emog
r
aph
i
cf
a
c
to
r
sin
c
lud
e
c
a
r
eg
iv
e
rag
e
,g
end
e
r
,l
iv
inga
r
r
ang
em
en
t
s
,r
e
l
a
t
ion
sh
ipw
i
thth
ep
a
t
i
en
t(Don
a
ld
son&
Bu
rn
s
,1999
;Em
l
e
t
,1996
)
,andcu
l
tu
r
a
lch
a
r
a
c
t
e
r
i
s
t
i
c
s(E
t
t
e
r
se
ta
l
.
,2007
)
.Impo
r
t
an
t
con
t
ex
tu
a
lf
a
c
to
r
sin
c
lud
ec
a
r
eg
iv
e
rch
a
r
a
c
t
e
r
i
s
t
i
c
s(Don
a
ld
son&Bu
rn
s
,1999
;Em
l
e
t
,
1996
)
,a
c
c
e
s
s
ib
i
l
i
tyo
rr
e
t
en
t
iono
fso
c
i
a
lsuppo
r
t
,andb
eh
av
iou
r
a
li
s
su
e
sth
a
tm
ayb
e
d
em
on
s
t
r
a
t
edbyc
a
r
er
e
c
ip
i
en
t
s(
Co
t
r
e
l
landEng
e
l
,1999
;Don
a
ld
son&Bu
rn
s
,1999
;Em
l
e
t
,
1996
;T
r
emon
t
,2011
)
.Th
e
s
ef
a
c
to
r
sw
i
l
lb
ed
i
s
cu
s
s
edinmo
r
ed
ep
thinth
efo
l
low
ing
s
e
c
t
ion
s
.
E
thn
i
c
i
ty.
I
ti
simpo
r
t
an
ttocon
s
id
e
re
thn
i
c
i
tyandcu
l
tu
r
einanyd
i
s
cu
s
s
iono
fth
e
exp
e
r
i
en
c
e
so
fICPWDa
si
tc
anb
ein
f
lu
en
t
i
a
lth
roughth
een
t
i
r
ed
em
en
t
i
ajou
rn
ey
.Cu
l
tu
r
a
l
v
a
lu
e
s
,su
cha
sf
i
l
i
a
lr
e
spon
s
ib
i
l
i
tyandf
am
i
l
i
smc
ane
i
th
e
rpo
s
i
t
iv
e
lyo
rn
eg
a
t
iv
e
lyimp
a
c
t
th
ec
a
r
eg
iv
ingexp
e
r
i
en
c
e
so
fcu
l
tu
r
a
l
lyandl
i
ngu
i
s
t
i
c
a
l
lyd
iv
e
r
s
e(CALD
)ICPWD
(Bough
twood
,Ad
am
s
,Sh
an
l
ey
,S
an
t
a
lu
c
i
a
,&Ky
r
i
a
zopou
lo
s,2011
;M
iy
aw
ak
i
,2015
)
.Fo
r
ex
amp
l
e
,f
i
l
i
a
lr
e
spon
s
ib
i
l
i
tyh
a
sb
e
enid
en
t
i
f
i
eda
sap
r
ev
a
i
l
ingcop
ingm
e
ch
an
i
sm
(Bough
twoode
ta
l
.
,2011
)
;how
ev
e
r
,as
t
rongs
en
s
eo
ff
am
i
l
i
sm(
acu
l
tu
r
a
lv
a
lu
e“…
in
wh
i
chth
en
e
ed
so
fth
ef
am
i
lya
sag
roupa
r
emo
r
eimpo
r
t
an
tth
anth
en
e
ed
so
fanyind
iv
idu
a
l
f
am
i
lym
emb
e
r
”[
“F
am
i
l
i
sm
”
,2016
]
)
,h
a
sb
e
ena
s
so
c
i
a
t
edw
i
thn
eg
a
t
iv
eimp
a
c
t
son
in
fo
rm
a
lc
a
r
eg
iv
e
rh
e
a
l
thandh
igh
e
ra
c
coun
t
so
fbu
rd
enandd
i
s
t
r
e
s
s(Kn
igh
te
ta
l
.
,2002
)
.
In
t
e
r
e
s
t
ing
ly
,no
ta
l
ls
tud
i
e
sh
av
efoundas
ign
i
f
i
c
an
tconn
e
c
t
ionb
e
tw
e
enf
am
i
l
i
sm
andh
e
a
l
thou
t
com
e
s
.As
tudybyKn
igh
tandS
ay
egh(2010
)foundnoev
id
en
c
etosuppo
r
tan
a
s
so
c
i
a
t
ionb
e
tw
e
enf
am
i
l
i
sm
,bu
rd
en
,a
ndh
e
a
l
thou
t
com
e
sinanyo
fSp
an
i
sh
,Ko
r
e
an
,

27

	
  
A
f
r
i
c
anAm
e
r
i
c
an
,C
au
c
a
s
i
anAm
e
r
i
c
an
,o
rKo
r
e
anAm
e
r
i
c
ans
i
tu
a
t
ion
s
.I
tw
a
sin
s
t
e
ad

foundth
a
tind
iv
idu
a
lcop
ings
ty
l
e
s
,wh
i
chadm
i
t
t
ed
lyc
anb
ein
f
lu
en
c
edbycu
l
tu
r
e
,h
ada
g
r
e
a
t
e
rimp
a
c
tonbu
rd
enandh
e
a
l
thou
t
com
e
s
.	
  
S
tud
i
e
sh
av
efoundth
a
tth
ep
e
r
c
ep
t
iono
fbu
rd
eni
sin
f
lu
en
c
edbye
thn
i
c
i
ty
.Th
e
s
tudybyKn
igh
te
ta
l
.(2002
)d
e
t
e
rm
in
edth
a
tA
f
r
i
c
anAm
e
r
i
c
anc
a
r
eg
iv
e
r
sr
epo
r
t
edl
e
s
s
bu
rd
enth
anth
e
i
rC
au
c
a
s
i
ancoun
t
e
rp
a
r
t
s
.Th
i
sf
ind
ingi
sfu
r
th
e
r
suppo
r
t
edbyD
i
lwo
r
th
And
e
r
sone
ta
l
.(2002
)
,whofoundth
a
td
ep
r
e
s
s
ionandbu
rd
enw
e
r
eh
igh
e
ramong
s
t
C
au
c
a
s
i
anc
a
r
eg
iv
e
r
sth
anamong
s
tA
f
r
i
c
anAm
e
r
i
c
anc
a
r
eg
iv
e
r
s
.Th
el
a
t
t
e
rau
tho
r
ss
t
a
t
e
th
a
tth
i
sm
ayb
ea
t
t
r
ibu
t
edtoth
ecu
l
tu
r
a
lso
c
i
a
l
i
z
a
t
ionw
i
th
inA
f
r
i
c
anAm
e
r
i
c
an
commun
i
t
i
e
sth
a
tsh
ap
eexp
e
c
t
a
t
ion
sandf
e
e
l
ing
stow
a
rd
sc
a
r
eg
iv
ing(D
i
lwo
r
th
And
e
r
sone
t
a
l
.
,2002
)
,su
cha
sth
ed
ev
e
lopm
en
to
fin
t
e
rd
ep
end
en
c
eandexp
e
c
t
edr
e
c
ip
ro
c
i
tyw
i
th
in
f
am
i
lym
emb
e
r
s(F
r
ank
l
in
,1997
)
.A
f
r
i
c
anAm
e
r
i
c
anf
am
i
l
i
e
sm
aya
l
soid
en
t
i
fymo
r
ew
i
th
t
r
ad
i
t
ion
a
lv
a
lu
e
sth
a
ten
cou
r
ag
ec
a
r
ep
rov
i
s
ionfo
rd
ep
end
en
tr
e
l
a
t
iv
e
s(L
aw
ton
,R
a
j
agop
a
l
,
B
rody
,&K
l
eb
an
,1992
)
.L
ik
ew
i
s
e
,as
tudybyRo
f
fe
ta
l
.(2004
)po
s
i
t
sth
a
tA
f
r
i
c
an
Am
e
r
i
c
anin
fo
rm
a
lc
a
r
eg
iv
e
r
sexp
e
r
i
en
c
emo
r
epo
s
i
t
iv
ea
sp
e
c
t
so
fc
a
r
eg
iv
ingth
anth
e
i
r
C
au
c
a
s
i
ancoun
t
e
rp
a
r
t
sa
sw
e
l
la
slow
e
rr
epo
r
t
edl
ev
e
l
so
fanx
i
e
tyandd
i
s
t
r
e
s
sinr
e
spon
s
eto
b
eh
av
iou
r
a
landp
sy
cho
log
i
c
a
lsymp
tom
so
fd
em
en
t
i
a(BPSD
)inth
ec
a
r
er
e
c
ip
i
en
t
.
Ag
eandg
end
e
r
.A
l
thoughas
tudybyC
IH
I(2010b
)foundth
a
tth
eg
end
e
randag
e
o
fth
ein
fo
rm
a
lc
a
r
eg
iv
e
rd
idno
tg
r
e
a
t
lyimp
a
c
tth
el
ev
e
lo
fth
e
i
rd
i
s
t
r
e
s
s
,p
r
ev
iou
sr
e
s
e
a
r
ch
h
a
sshownag
r
e
a
t
e
ra
s
so
c
i
a
t
ionb
e
tw
e
enbu
rd
enandd
i
s
t
r
e
s
sinf
em
a
l
ein
fo
rm
a
lc
a
r
eg
iv
e
r
s
comp
a
r
edtoth
e
i
rm
a
l
ecoun
t
e
rp
a
r
t
s
.Fo
rex
amp
l
e
,along
i
tud
in
a
ls
tudybyG
r
a
f
s
t
romand
W
inb
l
ad(1995
)foundth
a
td
augh
t
e
r
sr
epo
r
t
edmo
r
ebu
rd
enandn
eg
a
t
iv
ephy
s
i
c
a
le
f
f
e
c
t
s
f
romc
a
r
eg
iv
ingth
anson
s
.Don
a
ld
son
,T
a
r
r
i
e
r
,andBu
rn
s(1998
)a
l
sofoundth
a
tf
em
a
l
e

28

	
  

ICPWDexp
e
r
i
en
c
eg
r
e
a
t
e
rd
i
s
t
r
e
s
sandsu
b
j
e
c
t
iv
ebu
rd
enth
anm
a
l
eICPWD
.S
im
i
l
a
r
ly
,ina
s
tudybyB
rod
a
tye
ta
l
.(2014
)
,f
em
a
l
eICPWDr
epo
r
t
edh
igh
e
rl
ev
e
l
so
fbu
rd
enth
anth
e
i
r
m
a
l
ecoun
t
e
rp
a
r
t
s
.Th
i
si
ssuppo
r
t
edbymo
r
er
e
c
en
tr
e
s
e
a
r
chbyPöy
s
t
ie
ta
l
.(2012
)who
foundth
a
tm
a
l
eICPWDexp
e
r
i
e
n
c
el
e
s
sbu
rd
enth
a
tf
em
a
l
eICPWDr
eg
a
rd
l
e
s
so
fth
e
s
ev
e
r
i
tyo
fth
ec
a
r
er
e
c
ip
i
en
t
’
sd
em
en
t
i
a
.Comp
a
r
edtom
a
l
ein
fo
rm
a
lc
a
r
eg
iv
e
r
s
,f
em
a
l
e
in
fo
rm
a
lc
a
r
eg
iv
e
r
sh
adin
c
r
e
a
s
edr
epo
r
t
so
fpoo
rp
sy
cho
so
c
i
a
lh
e
a
l
thandw
e
l
l
b
e
ing
(Ch
iou
,Ch
en
,& W
ang
,2005
;S
ch
u
l
z&B
e
a
ch
,1999
)
,h
igh
e
rl
ev
e
l
so
fs
t
r
e
s
s(M
e
l
l
e
r
,2001
)
,
andh
igh
e
rr
a
t
e
so
fd
ep
r
e
s
s
ion(Ch
ioue
ta
l
.
,2005
;Du
r
a
,S
tuk
enb
e
rg
,&K
i
e
co
l
t
G
l
a
s
e
r
,
1991
;Fudg
e
,N
eu
f
e
ld
,&H
a
r
r
i
son
,1997
)
.H
igh
e
rr
epo
r
t
so
fbu
rd
eninyoung
e
rf
em
a
l
e
ICPWDm
ayinp
a
r
tb
er
e
la
t
edtoth
enum
e
rou
scomp
e
t
ingd
em
and
sm
anysu
chwom
enf
a
c
e
,
s
in
c
eth
eym
ayb
ec
a
r
ingfo
rane
ld
e
r
lyr
e
l
a
t
iv
e
,b
eth
ep
r
im
a
ryc
a
r
eg
iv
e
rfo
rth
e
i
rown
ch
i
ld
r
en
,b
em
a
in
t
a
in
ingahou
s
eho
ld
,andho
ldemp
loym
en
tcomm
i
tm
en
t
s
.
R
e
la
t
ion
sh
ipb
e
tw
e
enth
eca
r
eg
iv
e
randca
r
er
e
c
ip
i
en
t
.Th
en
a
tu
r
eo
fth
e
r
e
l
a
t
ion
sh
ipb
e
tw
e
enth
eICPWDandc
a
r
er
e
c
ip
i
en
th
a
sa
l
sob
e
enfoundtoco
r
r
e
spondto
l
ev
e
l
so
fs
t
r
e
s
sinth
ein
fo
rm
a
lc
a
r
eg
iv
e
r
.A
scou
ldb
eexp
e
c
t
ed
,apoo
rr
e
l
a
t
ion
sh
ipb
e
tw
e
en
th
ein
fo
rm
a
lc
a
r
eg
iv
e
randc
a
r
er
e
c
i
p
i
en
tp
r
io
rtoth
ecomm
en
c
em
en
to
fc
a
r
eg
iv
ing
co
r
r
e
l
a
t
edw
i
thin
c
r
e
a
s
edc
a
r
eg
iv
e
rbu
rd
en(R
in
a
ld
ie
ta
l
.
,2005
)
.Ac
ro
s
ss
e
c
t
ion
a
ls
tudyby
C
ampb
e
l
le
ta
l
.(2008
)id
en
t
i
f
i
edth
a
tapoo
rr
e
l
a
t
ion
sh
ipb
e
tw
e
enth
ein
fo
rm
a
lc
a
r
eg
iv
e
rand
c
a
r
er
e
c
ip
i
en
t
,a
sev
i
d
en
c
edbypoo
rcommun
i
c
a
t
iono
ral
a
cko
fa
f
f
e
c
t
ionandr
appo
r
t
,tob
e
as
ign
i
f
i
c
an
tp
r
ed
i
c
to
ro
fbu
rd
en
.Spou
s
e
sh
av
ea
l
sob
e
enfoundtob
ea
tin
c
r
e
a
s
edr
i
skfo
r
bu
rd
encomp
a
r
edtoo
th
e
rin
fo
rm
a
lc
a
r
eg
iv
e
r
s(Em
l
e
t
,1996
)
.A
ssuppo
r
tfo
rth
i
sa
s
s
e
r
t
ion
,
C
IH
I(2010b
)foundth
a
ti
ti
smo
r
el
ik
e
lyfo
rspou
s
e
stoexp
e
r
i
en
c
ed
i
s
t
r
e
s
sandbu
rd
enth
an

29

	
  

o
th
e
rin
fo
rm
a
lc
a
r
eg
iv
e
r
sfo
rs
ev
e
r
a
lr
e
a
son
s
:th
eyo
f
t
enl
iv
ew
i
thth
ec
a
r
er
e
c
ip
i
en
t
,p
rov
id
e
mo
r
ec
a
r
e
,a
c
ta
sth
ep
r
im
a
ryc
a
r
eg
iv
e
r
,anda
r
eo
f
t
ene
ld
e
r
lyth
em
s
elv
e
s
.
Ca
r
eg
iv
e
r
s
’ownt
ra
i
t
s
.I
th
a
sh
i
s
to
r
i
c
a
l
lyb
e
ena
s
sum
edth
a
ton
lyth
ecogn
i
t
iv
e
ch
ang
e
sandin
c
ap
a
c
i
t
i
e
so
fth
ep
a
t
i
en
tw
i
thd
em
en
t
i
awou
ldimp
a
c
tth
el
ev
e
lo
fbu
rd
enand
s
t
r
e
s
sexp
e
r
i
en
c
edbyth
e
i
rin
fo
rm
a
lc
a
r
eg
iv
e
r
s
.How
ev
e
r
,r
e
c
en
tl
i
t
e
r
a
tu
r
eh
a
sexp
lo
r
edth
e
w
ay
sinwh
i
chth
ec
a
r
eg
iv
e
r
’
sowna
t
t
r
ibu
t
e
sandt
r
a
i
t
sc
ana
f
f
e
c
tth
e
i
rp
e
r
c
ep
t
ion
so
fbu
rd
en
(Don
a
ld
son&Bu
rn
s
,1999
)
.Aue
ta
l
.(2010
)s
t
a
t
edth
a
tth
eimp
a
c
to
fc
a
r
eg
iv
ingth
a
th
a
s
b
e
enc
au
s
edbyth
ec
a
r
er
e
c
ip
i
en
t
’
sd
i
s
e
a
s
em
aya
c
tu
a
l
lyb
emodu
l
a
t
edbyanin
fo
rm
a
l
c
a
r
eg
iv
e
r
’
sownp
e
r
son
a
lch
a
r
a
c
t
e
r
i
s
t
i
c
s
.As
tudybyG
aug
l
e
r
,K
an
e
,andN
ew
com
e
r(2007
)
sugg
e
s
t
sth
a
tc
a
r
eg
iv
e
rr
e
s
i
l
i
en
c
e(m
e
a
su
r
edbyh
ighc
a
r
eg
iv
ingd
em
and
sa
s
so
c
i
a
t
edw
i
th
lowbu
rd
en
)i
sapo
s
i
t
iv
ef
a
c
to
rinad
ap
t
a
t
ion
,w
i
thg
r
e
a
t
e
rp
ro
f
i
c
i
en
cyinth
ec
a
r
eg
iv
ingro
l
e
andw
i
thd
e
l
ay
ednu
r
s
inghom
ep
l
a
c
em
en
to
fth
ec
a
r
er
e
c
ip
i
en
t
.Add
i
t
ion
a
l
ly
,C
ampb
e
l
le
t
a
l
.(2008
)d
e
t
e
rm
in
edth
a
td
e
c
r
e
a
s
edcon
f
id
en
c
einth
ein
fo
rm
a
lc
a
r
eg
iv
e
ri
sp
r
ed
i
c
t
iv
eo
f
in
c
r
e
a
s
edbu
rd
enandd
i
s
t
r
e
s
s
.Incomp
a
r
i
son
,tho
s
ein
fo
rm
a
lc
a
r
eg
iv
e
r
swhod
emon
s
t
r
a
t
ea
mo
r
epo
s
i
t
iv
ecop
ings
ty
l
eandah
igh
e
rl
ev
e
lo
fp
e
r
c
e
iv
eds
e
l
f
e
f
f
i
c
a
cyw
e
r
emo
r
el
ik
e
lyto
exp
r
e
s
sar
edu
c
edl
ev
e
lo
fc
a
r
eg
iv
ingbu
rd
en(V
anD
en W
i
jng
a
a
r
t
,V
e
rnoo
i
j
D
a
s
s
en
,&
F
e
l
l
ing
,2007
)
.
S
ev
e
r
i
tyo
fd
i
s
ea
s
eandca
r
er
e
c
ip
i
en
tb
ehav
iou
r
s
.C
IH
I(2010b
)foundth
a
t
cogn
i
t
iv
eimp
a
i
rm
en
tandth
enumb
e
ro
fin
fo
rm
a
lc
a
r
ehou
r
sr
e
c
e
iv
edw
e
r
einv
e
r
s
e
lyr
e
l
a
t
ed
toc
a
r
eg
iv
e
rd
i
s
t
r
e
s
s
.Inf
a
c
t
,C
IH
I(2010b
)foundth
a
ttho
s
ec
a
r
er
e
c
ip
i
en
t
swhor
e
c
e
iv
ed21
o
rmo
r
ehou
r
so
fin
fo
rm
a
lc
a
r
ep
e
rw
e
ekw
e
r
efou
rt
im
e
smo
r
el
ik
e
lytoh
av
eanin
fo
rm
a
l
c
a
r
eg
iv
e
rind
i
s
t
r
e
s
sth
antho
s
ewhor
e
c
e
iv
edl
e
s
sth
an10hou
r
sp
e
rw
e
ek
.Th
i
si
sl
ik
e
ly
r
e
l
a
t
edtoth
eth
ef
a
c
tth
ec
a
r
er
e
c
ip
i
en
ti
sinal
a
t
e
rs
t
ag
eo
fd
em
en
t
i
a
,p
l
a
c
ingg
r
e
a
t
e
rs
t
r
a
in

30

	
  

onth
ec
a
r
eg
iv
e
rint
e
rm
so
fphy
s
i
c
a
lc
a
r
eandm
an
ag
ingBPSD
,wh
i
chin
c
r
e
a
s
e
sth
roughou
t
th
ed
i
s
e
a
s
et
r
a
j
e
c
to
ry
.F
e
e
l
ing
so
fbu
rnou
tr
e
l
a
t
edtoc
a
r
eg
iv
ingd
em
and
sp
l
a
c
ec
a
r
eg
iv
e
r
sa
t
h
ighr
i
skfo
rbu
rd
en
.How
ev
e
r
,S
chub
e
r
te
ta
l
.(2008
)a
rgu
eth
a
tth
ec
a
r
er
e
c
ip
i
en
t
’
sd
e
c
l
in
e
incogn
i
t
iv
efun
c
t
iondo
e
sno
tcon
t
r
ibu
t
etoc
a
r
eg
iv
e
rbu
rd
ena
smu
cha
sBPSDdo
e
s
.A
co
r
r
e
l
a
t
ionh
a
sb
e
enfoundinnum
e
rou
ss
tud
i
e
sb
e
tw
e
enth
ef
e
e
l
ingo
fc
a
r
eg
iv
e
rbu
rd
enand
th
ein
c
id
en
c
eo
fch
a
l
l
eng
ingb
eh
av
iou
r
sexh
ib
i
t
edbyth
ec
a
r
er
e
c
ip
i
en
t
,su
cha
sr
e
s
i
s
t
an
c
eto
p
e
r
son
a
lc
a
r
eo
rphy
s
i
c
a
labu
s
eo
fth
ein
fo
rm
a
lc
a
r
eg
iv
e
r(B
rod
a
tye
ta
l
.
,2014
;C
IH
I
,2010b
;
Y
a
f
f
ee
ta
l
.
,2002
)
.
So
c
ia
lsuppo
r
t
.So
c
i
a
lsuppo
r
t
,o
rl
a
ckth
e
r
eo
f
,c
ana
l
socon
s
id
e
r
ab
lyimp
a
c
tth
e
exp
e
r
i
en
c
e
so
fICPWDth
roughth
ed
em
en
t
i
ajou
rn
ey
.I
tc
anb
ed
iv
id
edin
toth
r
e
ee
l
em
en
t
s
:
(
a
)asuppo
r
tn
e
two
rkcomp
r
i
s
edo
fr
e
sou
r
c
e
s
;(b
)fun
c
t
ion
a
lsuppo
r
t
,a
sinhom
esuppo
r
t
s
;
and(
c
)p
e
r
c
e
iv
edsuppo
r
t
,a
sinth
ec
a
r
eg
iv
e
r
’
ss
a
t
i
s
f
a
c
t
ionw
i
th
,andsub
j
e
c
t
iv
eev
a
lu
a
t
ion
o
fth
esuppo
r
tav
a
i
l
ab
l
etoh
im
/h
e
r(B
a
r
r
e
r
a
,1986
;Hou
s
e
,Umb
e
r
son
,&L
and
i
s
,1988
;
V
aux
,1988
)
.O
fth
eth
r
e
e
,th
el
ev
e
lo
fp
e
r
c
e
iv
edsuppo
r
th
a
sb
e
ensugg
e
s
t
edtob
eth
e
g
r
e
a
t
e
s
tmod
e
r
a
to
ro
fc
a
r
eg
iv
e
rh
e
a
l
thou
t
com
e
s(Lubb
en
,1988
;Tu
rn
e
r& M
a
r
ino
,1994
)
.A
s
tudyby W
i
lk
sandC
room(2008
)foundth
a
tso
c
i
a
lsuppo
r
tno
ton
lya
f
f
e
c
t
sh
e
a
l
th
ou
t
com
e
s
,bu
tl
ik
e
lya
l
socon
t
r
ibu
t
e
stor
e
s
i
l
i
en
c
einICPWDdu
r
ings
t
r
e
s
s
fu
lt
im
e
s
.Th
e
au
tho
r
sfoundth
a
tin
fo
rm
a
lc
a
r
eg
iv
e
r
sw
e
r
e“4
.9t
im
e
smo
r
el
ik
e
lytoexp
e
r
i
en
c
eh
igh
r
e
s
i
l
i
en
c
ew
i
thh
ighf
am
i
lysuppo
r
t
;1
.8t
im
e
smo
r
el
ik
e
lytoexp
e
r
i
en
c
eh
ighr
e
s
i
l
i
en
c
ew
i
th
h
ighf
r
i
endsuppo
r
t
;and3
.8t
im
e
smo
r
el
ik
e
lytoexp
e
r
i
en
c
eh
ighr
e
s
i
l
i
en
c
ew
i
thh
ighov
e
r
a
l
l
so
c
i
a
lsuppo
r
t(p<0
.01
)
”(p
.361
)
.Th
eICPWD
’
sp
e
r
c
ep
t
ion
so
fin
fo
rm
a
t
iond
i
s
s
em
in
a
t
ion
ands
e
rv
i
c
ep
rov
i
s
ionm
aya
l
soin
f
lu
en
c
eth
e
i
ra
c
c
ep
t
anc
eo
fsuppo
r
t
,andcon
s
equ
en
t
lyth
e
amoun
to
fsuppo
r
tth
eya
c
tu
a
l
lyr
e
c
e
iv
e
.

31

	
  
M
emb
e
r
so
fth
ep
r
im
a
ryc
a
r
et
e
am
,in
c
lud
ingPCP
s
,a
r
ef
r
equ
en
t
lyth
ep
r
in
c
ip
a
l
fo
rm
a
lc
a
r
ep
rov
id
e
r
sanda
r
eo
f
t
enth
ef
i
r
s
tconn
e
c
t
ionfo
ra
c
c
e
s
stosuppo
r
ts
e
rv
i
c
e
sfo
r
bo
thc
a
r
er
e
c
ip
i
en
t
sandth
e
i
rin
fo
rm
a
lc
a
r
eg
iv
e
r
s(M
c
In
to
sh
,Sw
an
son
,Pow
e
r
,&R
a
e
,

1998
)
.PCP
smu
s
tth
e
r
e
fo
r
emov
eb
eyonds
imp
lyp
rov
id
ingc
a
r
etoth
ep
a
t
i
en
tw
i
thd
em
en
t
i
a
andin
s
t
e
ada
l
socomm
i
ttosuppo
r
t
ingth
eICPWD(Agg
e
rw
a
le
ta
l
.
,2003
)anda
s
s
i
s
t
ing
th
emtob
e
t
t
e
rund
e
r
s
t
andandn
av
ig
a
t
eth
eh
e
a
l
thc
a
r
esy
s
t
em(H
e
rk
lo
t
s
,2015
)
.
A
l
thoughth
ec
a
r
ecoo
rd
in
a
t
ionb
e
tw
e
enPCP
sandsuppo
r
t
iv
es
e
rv
i
c
e
s“
i
sad
e
f
in
ing
ch
a
r
a
c
t
e
r
i
s
t
i
co
fp
r
im
a
ryc
a
r
e
”(Ro
thm
an& W
agn
e
r
,200
3
,p
.256
)
,m
anysu
chs
e
rv
i
c
e
sa
r
e
o
f
f
e
r
edinaw
ayth
a
ti
sf
r
agm
en
t
edandpoo
r
lycoo
rd
in
a
t
ed
,o
f
t
enl
e
ad
ingtod
i
s
s
a
t
i
s
f
a
c
t
ion
among
s
tin
fo
rm
a
lc
a
r
eg
iv
e
r
s(G
i
l
l
,Ku
lu
sk
i
,J
a
akk
im
a
in
en
,Up
shu
r
,& Wod
ch
i
s
,2013
)
.
R
e
inh
a
rd
,G
iv
en
,P
e
t
l
i
ck
,andB
em
i
s(2008
)s
t
a
t
eth
a
t
,inadd
i
t
iontof
r
agm
en
t
edh
e
a
l
thc
a
r
e
s
e
rv
i
c
e
s
,in
fo
rm
a
lc
a
r
eg
iv
e
r
sh
av
eh
i
s
to
r
i
c
a
l
lyr
e
c
e
iv
edin
ad
equ
a
t
esuppo
r
tf
romh
e
a
l
th
p
ro
f
e
s
s
ion
a
l
sw
i
thr
eg
a
rd
stom
an
ag
ingth
e
i
rcon
cu
r
r
en
tc
a
r
eg
iv
ingd
em
and
sando
th
e
r
r
e
spon
s
ib
i
l
i
t
i
e
s
.In
fo
rm
a
lc
a
r
eg
iv
e
r
sa
r
eo
f
t
enl
e
f
tun
aw
a
r
eo
fav
a
i
l
ab
l
ecommun
i
tys
e
rv
i
c
e
s
andsuppo
r
t
swh
enth
ein
fo
rm
a
t
ionsh
a
r
ingbyPCP
s
,andth
ed
i
r
e
c
t
ionf
romth
em
,a
r
e
in
su
f
f
i
c
i
en
ttom
e
e
tth
er
equ
i
r
em
en
t
so
fth
ec
a
r
eg
iv
e
r
’
ss
i
tu
a
t
ion(Agg
e
rw
a
le
ta
l
.
,2003
;
Rob
in
son
,Bu
ckw
a
l
t
e
r
,&R
e
ed
,2013
)
;th
i
sc
anb
eam
a
jo
rb
a
r
r
i
e
rtos
e
rv
i
c
eu
t
i
l
i
z
a
t
ion
(S
t
r
a
in&B
l
and
fo
rd
,2002
)andm
ayp
r
e
c
ip
i
t
a
t
eunm
e
tn
e
ed
sfo
rbo
thth
ec
a
r
er
e
c
ip
i
en
ta
s
w
e
l
la
sth
ein
fo
rm
a
lc
a
r
eg
iv
e
r(D
iw
ane
ta
l
.
,2004
)
.Fu
r
th
e
r
,H
in
tone
ta
l
.(2007
)po
s
i
tth
a
t
suppo
r
t
sa
r
eo
f
t
enno
tpu
tfo
rw
a
rdun
t
i
li
s
su
e
ssu
cha
sBPSDb
e
com
eunm
an
ag
e
ab
l
e
,a
ph
enom
enonknowna
s“
r
e
a
c
t
iv
ec
a
r
e
”(p
.1489
)
.Ap
ro
a
c
t
iv
e
,r
a
th
e
rth
anr
e
a
c
t
iv
e
,app
ro
a
ch
th
a
ti
sah
a
l
lm
a
rko
fp
r
im
a
ryc
a
r
ep
r
a
c
t
i
c
ec
anb
eapp
l
i
edtoth
ep
rov
i
s
iono
fsuppo
r
tto

32

	
  

ICPWD
,u
t
i
l
i
z
ingth
es
t
ag
e
so
fd
em
en
t
i
aa
sagu
id
ea
longw
i
thth
es
t
a
t
edn
e
ed
so
find
iv
idu
a
l
c
a
r
eg
iv
e
r
s
.
S
e
rv
i
c
eu
t
i
l
i
za
t
ion
.R
e
su
l
t
so
fas
tudybyRob
in
sone
ta
l
.(2013
)foundth
a
th
igh
e
r
l
ev
e
l
so
fbu
rd
enandd
ep
r
e
s
s
ion
,a
sw
e
l
la
sl
im
i
t
edso
c
i
a
lsuppo
r
t
,w
e
r
er
epo
r
t
edbyICPWD
c
a
r
eg
iv
e
r
swhod
idno
tu
s
eav
a
i
l
ab
l
es
e
rv
i
c
e
s
,su
cha
sr
e
sp
i
t
eo
rsuppo
r
tg
roup
s
.A
l
though
ICPWDwhor
em
a
ininth
ewo
rk
fo
r
c
eandpo
s
s
e
s
smu
l
t
ip
l
ero
l
e
sc
anf
e
e
lcomp
e
l
l
edto
u
t
i
l
i
z
eth
e
s
etyp
e
so
fs
e
rv
i
c
e
sino
rd
e
rtom
a
in
t
a
inth
e
i
rr
e
spon
s
ib
i
l
i
t
i
e
s(Rob
in
sone
ta
l
.
,
2013
),ICPWDg
en
e
r
a
l
lyt
endno
ttou
s
eth
em
;su
chat
end
en
cyi
sw
e
l
l
do
cum
en
t
ed
th
roughou
tth
ec
a
r
eg
iv
e
rl
i
t
e
r
a
tu
r
e(Chodo
she
ta
l
.
,2006
;Jo
l
inge
ta
l
.
,2008
;P
lo
ege
ta
l
.
,
2009
;Rob
in
son
,2005
)
.Wh
enICPWDdoac
c
e
s
ss
e
rv
i
c
e
s
,th
eyw
i
l
lo
f
t
enh
av
ecommon
ly
w
a
i
t
edun
t
i
ll
a
t
einth
ed
i
s
e
a
s
ep
ro
c
e
s
stoa
skfo
ra
s
s
i
s
t
an
c
e(Rob
in
sone
ta
l
.
,2013
)o
rwh
en
c
a
r
er
e
c
ip
i
en
t
sh
av
eo
f
t
enb
e
com
etoof
r
ag
i
l
etob
en
e
f
i
tf
romth
em(Z
a
r
i
t
,S
t
eph
en
s
,
Town
s
end
,G
r
e
en
e
,&L
e
i
t
s
ch
,1999
)
.W
a
i
t
ingtoa
c
c
e
s
sfo
rm
a
ls
e
rv
i
c
e
ssu
cha
shom
e
suppo
r
t
,r
e
sp
i
t
e
,o
radu
l
td
ayp
rog
r
am
sc
ana
l
soimp
a
c
tICPWDa
s
,byth
et
im
eth
eya
c
c
e
s
s
th
e
s
es
e
rv
i
c
e
s
,th
eym
aya
l
sob
eexp
e
r
i
en
c
ingtho
s
en
eg
a
t
iv
ee
f
f
e
c
t
so
fth
ec
a
r
eg
iv
ingro
l
e
th
a
tc
anl
e
adtod
i
s
t
r
e
s
sandbu
rnou
t
.Fu
r
th
e
r
,i
fICPWDw
a
i
tun
t
i
lac
r
i
s
i
so
c
cu
r
stoa
c
c
e
s
s
s
e
rv
i
c
e
s
,th
es
e
rv
i
c
e
sm
ayno
tb
er
e
ad
i
lyav
a
i
l
ab
l
e
,po
t
en
t
i
a
l
lyl
e
ad
ingtoth
ec
a
r
eg
iv
e
r
tu
rn
ingtosuppo
r
tf
romana
cu
t
ec
a
r
ef
a
c
i
l
i
tywh
enth
eyc
annolong
e
rcop
e
.
Ac
ro
s
ss
e
c
t
ion
a
ld
e
s
c
r
ip
t
iv
es
tudyp
e
r
fo
rm
edbyP
lo
ege
ta
l
.(2009
)foundth
a
t
c
a
r
eg
iv
e
r
swhod
idpu
r
su
eadd
i
t
ion
a
lh
e
lpsough
tth
i
sa
s
s
i
s
t
an
c
ef
romf
am
i
ly
,f
r
i
end
s
,hom
e
h
e
a
l
ths
e
rv
i
c
e
s
,commun
i
tysuppo
r
ts
e
rv
i
c
e
s
,and
/o
rth
e
i
rphy
s
i
c
i
an
s
.In
t
e
r
e
s
t
ing
ly
,th
e
h
igh
e
s
tnum
b
e
ro
fs
tudyp
a
r
t
i
c
ip
an
t
s(37
.2%
)n
am
edth
e
i
rphy
s
i
c
i
ana
sth
e
i
rf
i
r
s
tsou
r
c
eo
f
suppo
r
t(P
lo
ege
ta
l
.
,2009
)
.Inf
a
c
t
,PCP
sa
r
emo
s
to
f
t
enth
ef
i
r
s
tr
e
sou
r
c
eth
a
tin
fo
rm
a
l

33

	
  

c
a
r
eg
iv
e
r
scon
t
a
c
ta
sasou
r
c
eo
fn
e
ed
edsuppo
r
t(A
l
zh
e
im
e
r
’
sA
s
so
c
i
a
t
ion
,2001
;F
il
l
i
te
ta
l
.
,
1999
).A
l
thoughin
fo
rm
a
lc
a
r
eg
iv
e
r
sr
epo
r
t
eda
c
c
e
s
s
ingh
e
a
l
thc
a
r
esuppo
r
tbyw
ayo
fth
e
i
r
phy
s
i
c
i
an
,P
lo
ege
ta
l
.(2009
)a
l
sono
t
edth
a
tm
anyc
a
r
eg
iv
e
r
sind
i
c
a
t
eanapp
r
eh
en
s
ion
abou
tu
s
ingcommun
i
tys
e
rv
i
c
e
sdu
etoin
con
s
i
s
t
en
tc
a
r
ep
rov
i
s
io
n
,th
esub
s
t
an
t
i
a
lco
s
t
a
s
so
c
i
a
t
edw
i
ths
e
rv
i
c
e
s
,in
f
l
ex
ib
l
et
im
ef
r
am
e
sfo
rs
e
rv
i
c
ep
rov
i
s
ion
,andal
a
cko
fcoh
e
s
ion
b
e
tw
e
enhom
eandcommun
i
tys
e
rv
i
c
e
s
.Ro
thm
anand W
agn
e
r(2003
)a
l
soa
cknow
l
edg
ed
th
a
tc
a
r
ecoo
rd
in
a
t
iont
end
stob
ein
ad
equ
a
t
eb
e
tw
e
enco
mmun
i
tys
e
rv
i
c
e
sandp
r
im
a
ryc
a
r
e
sy
s
t
em
s
.
Inas
tudybyRob
in
sone
ta
l
.(2013
)
,mo
s
to
fth
eICWPDp
a
r
t
i
c
ip
an
t
sp
rov
id
edth
e
m
a
jo
r
i
tyo
fth
en
e
ed
edc
a
r
ea
lon
e
,u
s
inganav
e
r
ag
eo
fon
lyn
in
ehou
r
sp
e
rw
e
eko
f
add
i
t
ion
a
lin
fo
rm
a
lh
e
lp
,su
cha
sth
ea
s
s
i
s
t
an
c
eo
fano
th
e
rf
am
i
lym
emb
e
r
,andfou
rhou
r
so
f
p
ro
f
e
s
s
ion
a
lh
e
lpp
e
rw
e
ekf
romfo
rm
a
lsuppo
r
t
iv
es
e
rv
i
c
ep
rov
id
e
r
s
,su
cha
shom
esuppo
r
t
.
Rob
in
sone
ta
l
.(2013
)foundth
a
tth
eu
s
eo
fth
e
s
es
e
rv
i
c
e
sw
a
sr
e
l
a
t
edtoth
er
e
l
a
t
ion
sh
ip
b
e
tw
e
enth
ec
a
r
eg
iv
e
randc
a
r
er
e
c
ip
i
en
t(p=0
.001
)
;c
a
r
eg
iv
e
r
swhocho
s
eno
ttoa
c
c
e
s
sth
e
s
e
rv
i
c
e
sw
e
r
emo
r
eo
f
t
enspou
s
e
so
fth
ec
a
r
er
e
c
ip
i
en
tr
a
th
e
rth
anadu
l
tch
i
ld
r
en
.Th
i
s
r
e
l
a
t
ion
sh
ipw
a
sr
e
f
l
e
c
t
edinth
es
tudya
si
tw
a
sfoundt
h
a
tc
a
r
eg
iv
e
r
swhosough
tsuppo
r
t
iv
e
s
e
rv
i
c
ep
rov
i
s
ionandr
e
sp
i
t
es
e
rv
i
c
e
sw
e
r
emu
chyoung
e
rth
antho
s
ec
a
r
eg
iv
e
r
swhou
s
ed
n
e
i
th
e
r(p=0
.010
)(Rob
in
sone
ta
l
.
,2013
)
.
O
ld
e
rICPWDa
r
eo
f
t
enspou
s
e
sandth
eyw
i
l
lp
r
edom
in
an
t
lyh
av
eh
adlong
e
r
r
e
l
a
t
ion
sh
ip
sw
i
thth
ec
a
r
er
e
c
ip
i
en
t
.A
sar
e
su
l
t
,th
e
s
ec
a
r
eg
iv
e
r
sm
ayf
e
e
lth
a
tth
ec
a
r
eg
iv
e
r
ro
l
ei
sbo
thacu
s
tom
a
ryandexp
e
c
t
edp
a
r
to
fth
er
e
l
a
t
ion
sh
ipt
r
a
j
e
c
to
ry(Rob
in
sone
ta
l
.
,
2013
)
.On
c
ein
fo
rm
a
lc
a
r
eg
iv
e
r
sh
av
ee
s
t
ab
l
i
sh
edth
em
s
e
lv
e
sinac
a
r
eg
iv
e
rro
l
e
,th
eyo
f
t
en
b
eg
intof
e
e
lth
a
tth
eya
r
eth
eon
lyon
e
scomp
e
t
en
tenoughtop
rov
id
eth
ec
a
r
e
;th
eyth
en

34

	
  
o
f
t
enb
e
com
eunw
i
l
l
ingandf
r
igh
t
en
edtosh
a
r
ec
a
r
ep
rov
i
s
ionw
i
tho
th
e
r
s(Bo
l
andand

S
im
s
,1996
;Rob
in
sone
ta
l
.
,2005;Z
a
r
i
te
ta
l
.
,1999
).Add
i
t
ion
a
l
ly
,s
e
rv
i
c
eu
t
i
l
i
z
a
t
ionc
an
h
av
eemo
t
ion
a
limp
l
i
c
a
t
ion
sfo
rth
ec
a
r
eg
iv
e
r
,su
cha
sf
e
e
l
ing
so
fgu
i
l
ti
fth
ec
a
r
er
e
c
ip
i
en
ti
s
r
e
s
i
s
t
iv
etos
e
rv
i
c
e
s
,o
rf
e
e
l
ing
so
fw
e
akn
e
s
si
fth
ec
a
r
eg
iv
e
rdo
e
sno
tf
e
e
lc
ap
ab
l
eo
f
fu
l
f
i
l
l
ingth
ec
a
r
eg
iv
ingro
l
e(Rob
in
sone
ta
l
.
,2005
)
.Du
etoth
e
i
remo
t
ion
a
lt
i
e
stoth
e
s
i
tu
a
t
ion
,th
espou
s
a
lc
a
r
eg
iv
e
rm
ayno
tev
enr
e
cogn
i
z
eth
epo
t
en
t
i
a
lb
en
e
f
i
t
so
f
f
e
r
edby
s
e
rv
i
c
eu
t
i
l
i
z
a
t
ion(Rob
in
sone
ta
l
.
,2005
)
.Th
i
sc
anth
enl
e
adtoani
so
l
a
t
edc
a
r
er
e
c
ip
i
en
t
/
c
a
r
eg
iv
e
rdy
ada
sth
ec
a
r
eg
iv
e
rb
e
com
e
sl
e
s
sl
ik
e
lytoa
c
c
ep
ta
s
s
i
s
t
an
c
e
,r
eg
a
rd
l
e
s
so
fth
e
po
t
en
t
i
a
ld
e
t
r
im
en
ttoth
e
i
rownh
e
a
l
th(Bo
l
and&S
im
s
,1996
)
.
Th
eT
rav
e
lGu
id
e
:Ro
l
eo
fth
ePCPinSuppo
r
t
ingICPWD
In
fo
rm
a
lc
a
r
eg
iv
e
r
sexp
e
r
i
en
c
ech
ang
ingn
e
ed
sov
e
rt
im
eandth
i
sb
e
co
m
e
sev
id
en
t
th
roughou
tth
ec
a
r
eg
iv
ingp
ro
c
e
s
sandjou
rn
ey(S
a
l
f
ie
ta
l
.
,2005
;W
a
lde
ta
l
.
,2003
)
.
A
l
thoughth
en
e
ed
so
fICPWDv
a
ryb
e
tw
e
enind
iv
idu
a
l
sandth
es
i
tu
a
t
ion
sth
eyf
a
c
e
,m
any
n
e
ed
sc
ana
l
sob
ean
t
i
c
ip
a
t
eda
sth
ec
a
r
er
e
c
ip
i
en
tp
rog
r
e
s
s
e
sth
roug
hth
ed
i
s
e
a
s
ep
ro
c
e
s
s
.
Su
chc
a
r
eg
iv
e
rn
e
ed
sm
ayin
c
lud
eemo
t
ion
a
lsuppo
r
t
,edu
c
a
t
ion
,adv
i
c
e
,f
a
c
i
l
i
t
a
t
iono
f
suppo
r
ts
e
rv
i
c
ep
rov
i
s
ion
,r
e
f
e
r
r
a
l
stocommun
i
tysuppo
r
t
sandp
rog
r
am
s
,anda
s
s
i
s
t
an
c
e
w
i
thh
e
a
l
thc
a
r
esy
s
t
emn
av
ig
a
t
ion(Down
se
ta
l
.
,2006
;S
al
f
ie
ta
l
.
,2005
)
.PCP
sh
av
ea
c
r
i
t
i
c
a
lro
l
einm
e
e
t
ingth
en
e
ed
so
fICPWDandth
e
i
rc
a
r
er
e
c
ip
i
en
t
s
.Th
i
si
sp
a
r
t
i
cu
l
a
r
ly
impo
r
t
an
tfo
rPCP
sfo
rth
r
e
er
e
a
son
s
:1
)p
r
im
a
ryc
a
r
ep
r
a
c
t
i
c
ei
son
eo
fth
ea
c
c
e
s
spo
in
t
sfo
r
commun
i
tys
e
rv
i
c
e
s
;2
)PCP
sa
r
eo
f
t
enth
ep
r
e
f
e
r
r
edsou
r
c
eo
fh
e
a
l
thandr
e
sou
r
c
e
in
fo
rm
a
t
ionfo
rICPWD(Down
se
ta
l
.
,2006
)
;and3
)PCP
sc
anadvo
c
a
t
efo
rch
ang
einth
e
po
l
i
cya
r
en
a
.Th
e
r
e
fo
r
e
,PCP
sando
th
e
rm
emb
e
ro
fth
ep
r
im
a
ryc
a
r
et
e
ama
r
einap
ivo
t
a
l
po
s
i
t
iontoe
f
f
e
c
t
iv
e
lysuppo
r
tICPW
Dandtom
ak
ead
i
f
f
e
r
en
c
einth
e
i
rou
t
com
e
s

35

	
  
(Don
a
ld
son&Bu
rn
s
,1999
;K
a
tb
amn
a
,Bh
ak
t
a
,Ahm
ad
,B
ak
e
r
,&P
a
rk
e
r
,2002
;S
imon
,
2001
)
.
Th
ero
l
eo
fth
ePCPm
ayb
el
ik
en
edtoa‘
t
r
av
e
lgu
id
e
’
,a
sPCP
sc
anh
e
lpth
e
s
e

c
a
r
eg
iv
e
r
stomo
r
ee
f
f
e
c
t
iv
e
lyn
av
ig
a
t
eth
e
i
rc
a
r
eg
iv
ingjou
rn
ey
.Fu
r
th
e
r
,PCP
sc
anp
rov
id
e
ane
s
s
en
t
i
a
l‘
ro
adm
ap
’toh
e
lpd
i
r
e
c
tICP
WDind
i
r
e
c
t
ion
sth
eyn
e
edtot
r
av
e
l du
r
ingth
e
i
r
jou
rn
ey
,a
sw
e
l
la
sap
l
antod
e
a
lw
i
thd
e
tou
r
swh
enc
a
r
eg
iv
e
r
scom
eupag
a
in
s
tob
s
t
a
c
l
e
s
a
longth
ew
ay
,su
cha
sana
cu
t
ed
e
c
l
in
einth
ec
a
r
er
e
c
ip
i
en
t
’
sfun
c
t
iondu
etoi
l
ln
e
s
s
.Fo
r
ex
amp
l
e
,PCP
sc
angu
id
eICPWDtow
a
rd
ssp
e
c
i
f
i
cr
e
sou
r
c
e
sth
a
tc
anh
e
lptoa
l
l
ev
i
a
t
eth
e
s
t
r
e
s
sandbu
rd
enth
eym
ayb
eexp
e
r
i
en
c
ing(
Jo
l
inge
ta
l
.
,2008
;S
cho
en
m
ak
e
r
s
,Bun
t
inx
,&
D
eL
ep
e
l
e
i
r
e
,2010
)
.PCP
sc
ana
l
sou
s
ea
s
s
e
s
sm
en
tandc
e
r
t
a
inin
t
e
rv
en
t
ion
stoh
e
lpICPWD
p
r
ep
a
r
efo
ri
s
su
e
sth
a
tm
aya
r
i
s
edu
r
ingth
ec
a
r
eg
iv
ingjou
rn
ey
.Th
e
s
ein
t
e
rv
en
t
ion
sm
ayb
e
s
imp
l
e
,su
cha
sl
end
inganemp
a
th
e
t
i
ce
a
rtoth
ec
a
r
eg
iv
e
rdu
r
ingano
f
f
i
c
ev
i
s
i
t
,o
rth
eym
ay
b
emo
r
ecomp
l
ex
,su
cha
sr
e
comm
end
ingaco
l
l
abo
r
a
t
iv
ec
a
r
ep
rog
r
am
.Cu
r
r
anand W
a
t
t
i
s
(2004
)s
t
a
t
eth
a
tin
fo
rm
a
lc
a
r
eg
iv
e
rsuppo
r
to
f
t
enr
equ
i
r
e
sco
l
l
abo
r
a
t
iv
ee
f
fo
r
t
sb
e
tw
e
en
h
e
a
l
thc
a
r
eo
rg
an
i
z
a
t
ion
sands
e
rv
i
c
ep
ro
v
id
e
r
s
.Th
e
r
ei
san
e
edtoe
s
t
ab
l
i
shandan
a
ly
z
e
s
t
r
a
t
eg
i
e
s
,su
cha
sd
id
a
c
t
i
cin
t
e
rv
en
t
ion
sandsyn
e
rg
i
s
t
i
cmu
l
t
id
i
s
c
ip
l
in
a
ryco
l
l
abo
r
a
t
ion
s
,to
h
e
lpPCP
ss
t
r
eng
th
enth
econn
e
c
t
ion
sb
e
tw
e
enin
fo
rm
a
lc
a
r
eg
iv
e
r
sandav
a
i
l
ab
l
esuppo
r
t
s
e
rv
i
c
e
s(P
lo
ege
ta
l
.
,2009
)
.
E
f
f
e
c
t
iv
e
lyGu
id
ingICPWDTh
roughth
e
i
rJou
rn
ey
s
:AP
e
r
sonC
en
t
r
edApp
roa
chto
Ca
r
e
Ap
e
r
sonc
en
t
r
edph
i
lo
sophyi
sr
e
comm
end
edind
em
en
t
i
ac
a
r
ea
si
ten
su
r
e
s
ind
iv
idu
a
l
sw
i
thd
em
en
t
i
aa
r
et
r
e
a
t
edw
i
thr
e
sp
e
c
tandd
ign
i
ty
,wh
i
l
ep
romo
t
ing
und
e
r
s
t
and
ingo
fth
e
i
rp
r
io
rl
i
f
eexp
e
r
i
en
c
e
sandth
ed
ev
e
lopm
en
to
fm
e
an
ing
fu
l

36

	
  
r
e
l
a
t
ion
sh
ip
sb
e
tw
e
enc
a
r
ep
rov
id
e
r
sandc
a
r
er
e
c
ip
i
en
t
s(A
l
zh
e
im
e
rSo
c
i
e
tyo
fC
an
ad
a
,
2013
)
.P
e
r
son
c
en
t
r
edc
a
r
efo
cu
s
e
sont
a
i
lo
r
ingc
a
r
etoe
a
chind
iv
idu
a
l
’
sn
e
ed
s
,w
i
sh
e
s
,
v
a
lu
e
s
,an
db
e
l
i
e
f
s(A
l
zh
e
im
e
rSo
c
i
e
tyo
fC
an
ad
a
,2013
)
.Th
eu
s
eo
fap
e
r
son
c
en
t
r
ed
app
ro
a
chw
i
thICPWDm
ayp
rov
eb
en
e
f
i
c
i
a
lfo
rbo
thICPWDandPCP
sa
si
ten
cou
r
ag
e
s

PCP
stog
a
ing
r
e
a
t
e
rund
e
r
s
t
and
ingo
fth
en
e
ed
sandexp
e
r
i
en
c
e
so
fICPWD;th
i
sknow
l
edg
e
andund
e
r
s
t
and
ingc
anb
eu
s
eda
sth
efound
a
t
iononwh
i
chtobu
i
ldr
e
l
a
t
ion
sh
ip
sandgu
id
e
th
echo
i
c
eo
fsuppo
r
t
iv
ein
t
e
rv
en
t
ion
s
.
Rog
e
r
s
’(1979
)p
e
r
sonc
en
t
r
edapp
ro
a
cha
f
fo
rd
sc
a
r
eb
a
s
edonth
ec
a
r
eg
iv
e
r
’
s
sub
j
e
c
t
iv
eund
e
r
s
t
and
ingo
fth
e
i
rexp
e
r
i
en
c
e
sr
a
th
e
rth
anj
u
s
tth
eop
in
iono
fth
ePCP
.Rog
e
r
s
(1979
)m
a
in
t
a
in
sth
a
tind
iv
idu
a
l
sr
e
a
c
ttoth
e
i
rexp
e
r
i
en
c
e
sb
a
s
edonth
e
i
rownp
e
r
c
ep
t
ion
s
o
fth
es
i
tu
a
t
ion
,ana
s
s
e
r
t
ionwh
i
chi
sex
t
en
s
iv
e
lyr
e
f
l
e
c
t
edandsuppo
r
t
edinc
a
r
eg
iv
ing
l
i
t
e
r
a
tu
r
e
.Fo
rin
s
t
an
c
e
,S
cho
enm
ak
e
r
se
ta
l
.(2010
)s
t
a
t
edth
a
t
,“
th
ew
ayc
a
r
eg
iv
e
r
sp
e
r
c
e
iv
e
th
e
i
rc
a
r
ingro
l
eandd
e
a
lw
i
thp
rob
l
em
a
t
i
cs
i
tu
a
t
ion
smo
r
ec
lo
s
e
lyp
r
ed
i
c
t
sth
ec
a
r
ebu
rd
en
”
(p
.44
)
.
S
e
l
fcon
c
ep
ti
sac
en
t
r
a
lid
e
ao
fth
ep
e
r
son
c
en
t
r
edapp
ro
a
chandi
sin
t
e
r
conn
e
c
t
ed
w
i
thc
a
r
eg
iv
e
r
s
’p
e
r
c
ep
t
ion
so
fth
e
i
rexp
e
r
i
en
c
e
s(M
cL
eod
,2015
)
.Ac
a
r
eg
iv
e
rm
ayno
tv
i
ew
th
em
s
e
lv
e
sa
sap
a
r
t
i
cu
l
a
r
lyp
ro
f
i
c
i
en
tc
a
r
eg
iv
e
r
,y
e
tth
eym
ayb
ev
i
ew
eda
ssu
chbyth
ePCP
i
fth
ec
a
r
er
e
c
ip
i
en
td
emon
s
t
r
a
t
e
sgoodh
e
a
l
thandw
e
l
l
b
e
ing
.Conv
e
r
s
e
ly
,th
ec
a
r
eg
iv
e
rm
ay
p
e
r
c
e
iv
eth
em
s
e
lv
e
stob
eacomp
e
t
en
tc
a
r
eg
iv
e
r
,y
e
tev
id
en
c
eo
fn
eg
l
e
c
tinbo
thth
ec
a
r
e
r
e
c
ip
i
en
tandc
a
r
eg
iv
e
rm
aysugg
e
s
to
th
e
rw
i
s
etoth
ePCP
.Insu
chas
i
tu
a
t
ion
,th
e
invo
lv
em
en
to
fso
c
i
a
lwo
rkandhom
eh
e
a
l
ths
e
rv
i
c
e
s
,p
rov
id
edinco
l
l
abo
r
a
t
ionw
i
thth
e
PCP
,b
e
com
e
so
fp
a
r
amoun
timpo
r
t
an
c
e
.

37

	
  
Rog
e
r
s
’(1979
)th
eo
ryi
sb
a
s
edonth
r
e
ep
r
in
c
ip
l
e
s
:cong
ru
en
c
e(g
enu
in
en
e
s
s
)
;
un
cond
i
t
ion
a
lpo
s
i
t
iv
er
eg
a
rd(m
a
in
t
a
in
ingapo
s
i
t
iv
ea
t
t
i
tud
etow
a
rd
sth
ec
a
r
eg
iv
e
r
)
;and

emp
a
thy
.I
faPCPv
i
ew
sth
ein
fo
rm
a
lc
a
r
eg
iv
e
ra
sa“po
t
en
t
i
a
l
lycomp
e
t
en
tind
iv
idu
a
l
”
,th
i
s
c
anh
e
lptoin
c
r
e
a
s
eth
ec
a
r
eg
iv
e
r
’
sf
e
e
l
ing
so
fs
e
l
f
wo
r
thandf
e
e
l
ing
so
fm
a
s
t
e
ryinth
e
c
a
r
eg
iv
ingro
l
e(M
cL
eod
,2015
)
.Fu
r
th
e
r
,i
fth
ePCPt
r
e
a
t
sth
ec
a
r
eg
iv
e
ra
sap
a
r
tn
e
rinc
a
r
e
,
th
enth
ec
a
r
eg
iv
e
rm
ayf
e
e
lth
a
tth
e
i
rknow
l
edg
eandsk
i
l
li
sb
e
ingmo
r
eexp
l
i
c
i
t
ly
r
e
cogn
i
z
ed
.App
ly
ingth
e
s
ep
r
in
c
ip
l
e
sdu
r
ingo
f
f
i
c
ev
i
s
i
t
sw
i
l
lh
e
lpen
su
r
eth
a
tth
eICPWD
f
e
e
l
ssuppo
r
t
ed
,thu
sm
e
e
t
ingth
en
e
ed
sexp
r
e
s
s
edbym
anyo
fth
ec
a
r
eg
iv
e
r
sinth
el
i
t
e
r
a
tu
r
e
(K
a
r
l
s
sone
ta
l
.
,2015
;P
ro
rok
,Ho
rg
an
,andS
e
i
t
z
,2013
;Sh
an
l
ey
,Ru
s
s
e
l
l
,M
idd
l
e
ton
,&
S
imp
sonYoung
,2011)
.
Anex
amp
l
eo
fap
e
r
sonc
en
t
r
edin
t
e
rv
en
t
ionth
a
th
a
sb
e
end
ev
e
lop
edtoimp
rov
e
commun
i
c
a
t
ionb
e
tw
e
enfo
rm
a
lc
a
r
ep
rov
id
e
r
sandin
fo
rm
a
lc
a
r
eg
iv
e
r
s
,andimp
rov
e
inp
a
t
i
en
tc
a
r
eo
fc
a
r
er
e
c
ip
i
en
t
sw
i
thd
em
en
t
i
ai
sth
es
t
r
a
t
egyc
a
l
l
ed“Top5
”(C
l
in
i
c
a
l
Ex
c
e
l
l
en
c
eComm
i
s
s
ion,2016
)
.
	
  
Top5i
sana
c
ronymu
s
edtogu
id
eth
ec
a
r
eo
fp
e
r
son
sw
i
th
d
em
en
t
i
a
.Uptof
iv
es
t
r
a
t
eg
i
e
sc
anb
edo
cumen
t
edonaTop5fo
rmth
a
tc
anb
esh
a
r
ed
b
e
tw
e
enh
e
a
l
thc
a
r
ep
rov
id
e
r
sinbo
tha
cu
t
ec
a
r
es
e
t
t
ing
sandth
ecommun
i
ty
.Top5invo
lv
e
s
ad
i
s
cu
s
s
ionb
e
tw
e
enac
l
in
i
c
i
anandth
eICPWDinwh
i
chth
es
t
r
a
t
eg
i
e
sa
r
ed
e
t
e
rm
in
edto
p
e
r
son
a
l
i
z
eandgu
id
eth
ep
a
t
i
en
t
’
sc
a
r
e(Lux
fo
rde
ta
l
.
,2015
)
.U
s
eo
fth
es
t
r
a
t
eg
i
e
sc
anh
e
lp
tod
e
c
r
e
a
s
eag
i
t
a
t
ionandch
a
l
l
eng
ingb
eh
av
iou
r
sth
a
tm
ayb
ed
emon
s
t
r
a
t
edbyth
ep
e
r
son
w
i
thd
em
en
t
i
a
.Top5s
t
and
sfo
r
:
Ta
lktoth
ec
a
r
e
r
;
Ob
t
a
inth
ein
fo
rm
a
t
ion
;
Pe
r
son
a
l
i
z
eth
ec
a
r
e
;and

38

	
  
“5
”s
t
r
a
t
eg
i
e
sd
ev
e
lop
ed(C
l
in
i
c
a
lEx
c
e
l
l
en
c
eComm
i
s
s
ion
,2016
)
.
TheTop5s
t
r
a
t
egyw
a
sd
ev
e
lop
edbyth
eC
a
r
e
rSuppo
r
tUn
i
tandC
en
t
r
a
lCo
a
s
t
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c
a
lH
e
a
l
thD
i
s
t
r
i
c
t(CCLHD
)inN
ewSou
th W
a
l
e
s
,Au
s
t
r
a
l
i
a
.Top5w
a
sf
i
r
s
t

imp
l
em
en
t
edin21ho
sp
i
t
a
l
sw
i
th
inC
CLHD
,fo
l
low
edbyimp
l
em
en
t
a
t
ioninr
e
s
id
en
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i
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lc
a
r
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a
c
i
l
i
t
i
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s
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es
t
r
a
t
egyd
r
aw
suponth
ein
fo
rm
a
lc
a
r
eg
iv
e
r
’
sknow
l
edg
eandexp
e
r
t
i
s
eabou
t
th
ec
a
r
er
e
c
ip
i
en
tandi
sa
im
eda
td
e
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r
e
a
s
inganx
i
e
tyandd
i
s
com
fo
r
tfo
rbo
thth
ec
a
r
e
r
e
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ip
i
en
tandth
eICPWDw
h
enth
ec
a
r
er
e
c
ip
i
en
tt
r
an
s
i
t
ion
sb
e
tw
e
enhom
e
,a
cu
t
ec
a
r
e
,o
r
longt
e
rmc
a
r
ef
a
c
i
l
i
t
i
e
s(C
l
in
i
c
a
lEx
c
e
l
l
en
c
eComm
i
s
s
ion
,2016
)
.
	
  
	
  
On
eex
amp
l
eo
faTop5s
t
r
a
t
egyi
s
:Th
ePCPt
a
lk
sto M
a
ry(whoh
a
sb
e
enp
rov
id
ing
c
a
r
efo
rh
e
rhu
sb
andJ
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ckfo
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ey
e
a
r
s
)abou
tJ
a
ck
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su
su
a
lrou
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in
ea
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l
e
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tin
fo
rm
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ionabou
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tm
ayc
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e
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i
t
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t
edo
rexh
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i
tch
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l
l
eng
ing
b
eh
av
iou
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si
fh
emu
s
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eadm
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t
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i
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a
l
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a
ry s
t
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a
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ay
sl
e
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rdog
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i
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zyou
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toth
ey
a
rda
t4
:00p
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fJ
a
cki
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i
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sp
i
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a
lh
em
ayb
e
com
e
ag
i
t
a
t
eda
tth
i
st
im
eo
fd
ay
,th
ink
ingth
a
tth
i
srou
t
in
ei
sno
tb
e
ingfo
l
low
edwh
enh
ei
sno
ta
t
hom
e
.S
t
a
f
fshou
ldre
a
s
su
r
eJ
a
ckth
a
tM
a
ryh
a
sl
e
tM
i
t
zyou
tandh
ew
i
l
ls
e
t
t
l
e
.Th
i
ss
t
r
a
t
egy
c
anb
edo
cum
en
t
edands
en
ttoth
eho
sp
i
t
a
lw
i
thJ
a
ckfo
rs
t
a
f
ftofo
l
low
.Th
i
sex
amp
l
e
d
emon
s
t
r
a
t
e
sth
e‘why
’(
J
a
ckm
ayb
e
com
eag
i
t
a
t
ed
)
,th
es
t
r
a
t
egy
,andth
e
in
t
end
edou
t
com
e
,
a
l
la
sr
e
comm
end
edfo
rTop5(C
l
in
i
c
a
lEx
c
e
l
l
en
c
eComm
i
s
s
ion
,2016
)
.	
  
Ev
a
lu
a
t
ionofth
i
slow
co
s
ts
t
r
a
t
egyd
emon
s
t
r
a
t
edno
ton
lypo
t
en
t
i
a
lh
e
a
l
thsy
s
t
em
co
s
ts
av
ing
s
,bu
ts
ign
i
f
i
c
an
timp
rov
em
en
t
sinICPWD
’
sexp
e
r
i
en
c
e
s
,p
a
t
i
en
tou
t
com
e
s
,and
s
a
t
i
s
f
a
c
t
ionbys
t
a
f
fc
a
r
ingfo
rp
a
t
i
en
t
sw
i
thd
em
en
t
i
a(C
l
in
i
c
a
lEx
c
e
l
l
en
c
eComm
i
s
s
ion
,
2016
)
.	
  
Fo
rex
amp
l
e
,89%o
fc
l
in
i
c
i
an
sfoundth
a
tu
t
i
l
i
z
a
t
iono
fth
eTop5s
t
r
a
t
egyimp
rov
ed
r
e
l
a
t
ion
sh
ip
sw
i
thICPWD(Lux
fo
rde
ta
l
.
,2015
)
.Fu
r
th
e
r
,ICPWDfoundth
a
tu
s
ag
eo
fth
e

39

	
  
Top5s
t
r
a
t
egym
ad
eth
emf
e
e
lr
e
sp
e
c
t
edbyc
l
in
i
c
i
an
swh
i
l
e88
.5%r
epo
r
t
edf
e
e
l
ingmo
r
e

eng
ag
edinth
ep
a
t
i
en
t
’
sc
a
r
e(Lux
fo
rde
ta
l
.
,2015
)
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eg
r
e
t
t
ab
ly
,nol
i
t
e
r
a
tu
r
eh
a
sb
e
enfound
sugg
e
s
t
ingth
a
tTop5o
ras
im
i
l
a
rs
t
r
a
t
egyh
a
sb
e
end
ev
e
lop
edo
rimp
l
em
en
t
edinC
an
ad
a
;
how
ev
e
r
,i
t
su
s
eh
a
sth
epo
t
en
t
i
a
ltog
r
e
a
t
lyimp
rov
eou
t
com
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sfo
rbo
thICPWDandp
a
t
i
en
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s
w
i
thd
em
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ainC
an
ad
a
.
I
fICPWDf
e
e
la
te
a
s
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thth
ec
a
r
eth
a
tth
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er
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a
r
e
f
a
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eya
r
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lytoexp
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i
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ss
t
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sandbu
rd
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r
andp
a
’
sb
iog
r
aphy
w
a
sd
ev
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lop
edinl
in
ew
i
thTop5s
t
r
a
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egyandw
a
ssu
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l
lyu
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ingh
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a
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ay
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c
eth
eb
iog
r
aphyw
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sin
t
eg
r
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edin
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andp
a
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sch
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r
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i
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i
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r
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en
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App
end
ixC.
A
s
s
e
s
sm
en
to
fICPWD
:D
e
t
e
rm
in
ingN
e
ed
sTh
roughth
eJou
rn
ey
As
ign
i
f
i
c
an
tamoun
to
fl
i
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a
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r
ag
e
sPCP
stot
r
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a
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sw
i
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em
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t
i
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andth
e
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rICPWDa
sdy
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s
,wh
i
chin
c
lud
e
sp
e
r
fo
rm
ingcomp
r
eh
en
s
iv
ea
s
s
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i
thth
e
c
a
r
eg
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stoadd
r
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s
sth
e
i
rn
e
ed
sandimp
l
em
en
t
ingin
t
e
rv
en
t
ion
sino
rd
e
rtom
e
e
tth
e
s
e
n
e
ed
s(F
am
i
lyC
a
r
eg
iv
e
rA
l
l
i
an
c
e
,2006
;K
a
r
l
s
sone
ta
l
.
,2015
;S
ad
avoy& W
e
s
son
,2012
)
.
Th
eF
am
i
lyC
a
r
eg
iv
e
rA
l
l
i
an
c
e(2006
)sugg
e
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t
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sm
en
t
,gu
id
edbya
con
c
ep
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a
lf
r
am
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rk
,shou
ldb
ep
e
r
fo
rm
eda
tth
eb
eg
inn
ingo
fac
a
r
eg
iv
ingjou
rn
eyand
wh
en
ev
e
rt
r
an
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so
c
cu
rth
roughth
ec
a
r
eg
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ingjou
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ra
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edu
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ign
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,comp
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eh
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ands
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ru
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eda
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sm
en
ttoo
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sbyPCP
sm
aycon
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ibu
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etoth
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i
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en
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fo
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a
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r
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s(F
am
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lyC
a
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eg
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rA
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l
i
an
c
e
,

40

	
  
2012
)
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eF
am
i
lyC
a
r
eg
iv
e
rA
l
l
i
an
c
e(2012
)h
a
scomp
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l
edanex
t
en
s
iv
el
i
s
to
ftoo
l
sth
a
t
m
ayb
eu
s
edtoa
s
s
e
s
sc
a
r
eg
iv
e
r
s
;how
ev
e
r
,D
e
ek
ene
ta
l
.(2009
)s
t
a
t
eth
a
ta
l
though

num
e
rou
stoo
l
sh
av
eb
e
end
ev
e
lop
ed
,f
ewa
r
eac
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a
l
lyu
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t
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t
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e
s
s
th
en
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fc
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r
eg
iv
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r
s
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i
sm
ay
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a
r
t
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edu
etoth
el
im
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t
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e
ro
fsu
i
t
ab
l
e
,
comp
r
eh
en
s
iv
etoo
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sd
ev
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lop
edsp
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c
i
f
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a
l
lyfo
ru
s
einth
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r
im
a
ryc
a
r
es
e
t
t
ing
. Mo
r
eov
e
r
,
twotoo
l
sth
a
th
av
eb
e
end
e
s
ign
edandr
e
s
e
a
r
ch
edtoadd
r
e
s
sth
esp
e
c
i
f
i
candun
iqu
en
e
ed
so
f
ICPWDa
c
tu
a
l
lyh
av
enoev
id
en
c
esuppo
r
t
ingth
e
i
ru
s
einc
l
in
i
c
a
lp
r
a
c
t
i
c
es
e
t
t
ing
s(C
z
a
j
ae
t
a
l
.
,2009
;K
e
e
f
ee
ta
l
.
,2009
)
.
Inadd
i
t
iontoth
el
a
cko
fsu
i
t
ab
l
ea
s
s
e
s
sm
en
ttoo
l
sfo
ru
s
einp
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im
a
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yc
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t
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s
,
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rm
inganin
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en
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ep
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,
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ingacomp
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eh
en
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sa
s
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en
ti
smo
r
eth
anmo
s
tPCP
sp
r
e
s
en
t
lyh
av
eth
e
t
im
etop
e
r
fo
rm(R
i
ch
,L
ip
son
,L
ib
e
r
sky
,&P
a
r
ch
em
an
,20
12
)
.Mo
r
eov
e
r
,i
fth
ein
fo
rm
a
l
c
a
r
eg
iv
e
ri
sno
tap
a
t
i
en
to
fth
ePCP(wh
i
chi
so
f
t
enth
ec
a
s
e
)
,th
en
th
ePCPw
i
l
lb
eun
ab
l
eto
t
r
e
a
tth
ec
a
r
eg
iv
e
ra
ssu
ch
.Toadd
r
e
s
sth
ech
a
l
l
eng
e
sth
a
tPCP
sm
ayf
a
c
einth
i
sr
eg
a
rd
,
app
l
i
c
ab
l
ec
l
in
i
c
a
lp
r
a
c
t
i
c
egu
id
e
l
in
e
sandar
epo
r
tbyth
eF
am
i
lyC
a
r
eg
iv
e
rA
l
l
i
an
c
e(2006
)
w
i
l
lb
ean
a
ly
z
edinCh
ap
t
e
rTh
r
e
eands
t
r
a
t
eg
i
e
sfo
ra
s
s
e
s
sm
en
tw
i
l
lb
ed
i
s
cu
s
s
edinCh
ap
t
e
r
Fou
r
.
P
rov
id
ing“Road
s
id
eA
s
s
i
s
tan
c
e”
:In
t
e
rv
en
t
ion
sandE
th
i
ca
lI
s
su
e
s
B
a
rn
a
rdandY
a
f
f
e(2014
)s
t
a
t
eth
a
te
th
i
c
a
li
s
su
e
sa
r
el
ik
e
lytob
ep
r
e
s
en
tinm
any
in
fo
rm
a
lc
a
r
eg
iv
e
r
/
c
a
r
er
e
c
ip
i
en
tc
a
s
e
s
.A
l
thoughsuppo
r
t
ingth
ein
fo
rm
a
lc
a
r
eg
iv
e
ri
so
f
c
r
i
t
i
c
a
limpo
r
t
an
c
e
,th
ep
a
t
i
en
t
’
sn
e
ed
sandw
i
sh
e
smu
s
tb
et
ak
enin
toa
c
coun
tbyth
ePCP
.
Th
i
sc
anl
e
adtod
i
f
f
i
cu
l
tandcomp
l
exs
i
tu
a
t
ion
sfo
rth
ePCP
.I
fth
ep
a
t
i
en
tdo
e
sno
tw
i
shto
comm
en
c
es
e
rv
i
c
e
ssu
cha
shom
esuppo
r
t
s
,y
e
tth
ein
fo
rm
a
lc
a
r
eg
iv
e
rf
e
e
l
sth
a
tth
e
s
e

41

	
  
s
e
rv
i
c
e
sa
r
en
e
ed
ed
,howshou
ldth
ePCPb
e
s
ts
t
ru
c
tu
r
eandimp
l
em
en
tar
e
spon
s
eand
suppo
r
t
iv
ein
t
e
rv
en
t
ion
s
?Th
i
squ
e
s
t
ionr
a
i
s
e
sth
etho
rnyi
s
su
eo
fp
a
t
e
rn
a
l
i
smi
fth
ePCP

f
e
e
l
sth
a
tth
ep
a
t
i
en
t
’
sw
i
sh
e
stor
e
fu
s
ehom
esuppo
r
t
sshou
ldb
eov
e
r
r
idd
enfo
rh
i
so
rh
e
r
b
e
s
tin
t
e
r
e
s
t(B
a
rn
a
rd&Y
a
f
f
e
,2014
)
.Th
ePCP
’
sob
l
ig
a
t
ion
sr
e
l
a
t
edtocon
f
id
en
t
i
a
l
i
tymu
s
t
a
l
sob
et
ak
enin
toa
c
coun
ti
fth
ePCPf
e
e
l
sth
a
ti
ti
simpo
r
t
an
ttoh
av
ead
i
s
cu
s
s
ionw
i
thth
e
c
a
r
eg
iv
e
rr
eg
a
rd
ingsuppo
r
t
,y
e
tth
ep
a
t
i
en
tdo
e
sno
tw
i
shth
ePCPtoeng
ag
einsu
cha
d
i
s
cu
s
s
ion
.
B
a
rn
a
rdandY
a
f
f
e(2014
)sugg
e
s
tth
a
tv
i
ew
ingth
i
styp
eo
fqu
es
t
ionth
roughth
el
en
s
o
fc
a
r
eg
iv
e
rbu
rd
enc
anb
ee
s
s
en
t
i
a
lind
ev
e
lop
inganund
e
r
s
t
and
ingo
fbo
thth
epo
s
i
t
iv
e
a
sp
e
c
t
so
fc
a
r
eg
iv
ingandi
t
sa
s
so
c
i
a
t
edch
a
l
l
eng
e
s
.A
l
thoughth
ep
a
t
i
en
t
’
sau
tonomyshou
ld
a
lw
ay
sb
er
e
sp
e
c
t
edbyth
ePCP
,i
th
a
sb
e
ensugg
e
s
t
edinth
el
i
t
e
r
a
tu
r
eth
a
ti
ti
sapp
rop
r
i
a
t
e
fo
rth
ePCPtosuppo
r
tICPWDi
fi
ts
e
rv
e
stob
en
e
f
i
tbo
thth
ec
a
r
eg
iv
e
randc
a
r
er
e
c
ip
i
en
t
(B
a
rn
a
rd&Y
a
f
f
e
,2014
)
. Mo
r
eov
e
r
,B
a
rn
a
rdandY
a
f
f
e(2014
)po
s
i
tth
a
ti
ti
se
th
i
c
a
l
ly
r
e
spon
s
ib
l
efo
rPCP
stosu
ppo
r
tin
fo
rm
a
lc
a
r
eg
iv
e
r
sinp
rov
id
ingc
a
r
efo
rth
e
s
ep
a
t
i
en
t
sand
toadvo
c
a
t
efo
rtho
s
eso
c
i
a
lpo
l
i
c
i
e
sth
a
tm
ayimp
rov
eth
el
iv
e
so
fin
fo
rm
a
lc
a
r
eg
iv
e
r
s
.
Th
en
eg
a
t
iv
eimp
a
c
tth
a
tc
a
r
eg
iv
ingc
anh
av
eonICPWDh
a
sp
rop
ag
a
t
eds
ign
i
f
i
c
an
t
in
t
e
r
e
s
tinth
eh
e
a
l
thc
a
r
ea
r
en
a
.Th
i
sh
a
sl
e
adtoanin
c
r
e
a
s
ing
lyfo
cu
s
ede
f
fo
r
ton
condu
c
t
ingr
e
s
e
a
r
chth
a
th
a
sex
am
in
edsuppo
r
t
iv
ein
t
e
rv
en
t
ion
sfo
rICPWD(B
e
l
l
ee
ta
l
.
,
2006
)
.E
t
t
e
r
s
,Good
a
l
landH
a
r
r
i
son(2007
)
,a
sw
e
l
la
sT
r
emon
t(2011
)
,s
t
a
t
edth
a
t
,w
i
thth
e
imp
l
em
e
n
t
a
t
iono
fjud
i
c
iou
s
lyd
e
s
ign
edin
t
e
rv
en
t
ion
s
,th
ew
e
l
l
b
e
ingandh
e
a
l
tho
fbo
th
p
a
t
i
en
tandc
a
r
eg
iv
e
rc
anv
e
ryo
f
t
enimp
rov
e
.How
ev
e
r
,i
tmu
s
tb
eemph
a
s
i
z
edth
a
tsu
ch
in
t
e
rv
en
t
ion
smu
s
tb
es
e
l
e
c
t
edandimp
l
em
en
t
eda
c
co
rd
ingtoc
a
r
eg
iv
e
r
s
’sp
e
c
i
f
i
cn
e
ed
s
(
D
ah
lb
e
rg
,D
em
a
ck
,&B
amb
r
a
,2007
;E
t
t
e
r
se
ta
l
.
,2008
)
.

42

	
  
Wh
i
l
easy
s
t
em
a
t
i
cr
ev
i
ewo
fth
eimp
a
c
to
fp
sy
cho
so
c
i
a
lin
t
e
rv
en
t
ion
sfound

ev
id
en
c
esuppo
r
t
ingth
eimp
rov
em
en
to
fICPWD
’
sw
e
l
l
b
e
ingth
roughth
eu
s
eo
fbo
thg
roup
andind
iv
idu
a
ls
e
s
s
ion
s
,ind
iv
idu
a
ls
e
s
s
ion
sd
emon
s
t
r
a
t
edg
r
e
a
t
e
re
f
f
i
c
a
cyfo
rmo
r
eo
fth
e
c
a
r
eg
iv
e
r
s(Ro
s
ae
ta
l
.
,2010
)
.In
t
e
r
e
s
t
ing
ly
,anex
am
in
a
t
iono
ff
i
f
t
e
ensy
s
t
em
a
t
i
cr
ev
i
ew
sby
S
a
l
f
ie
ta
l
.(2005
)foundth
a
tsuppo
r
tg
roup
s
,r
e
sp
i
t
e
,coun
s
e
l
ing
,andedu
c
a
t
ions
e
s
s
ion
s
,a
l
l
o
fwh
i
cha
r
ein
t
e
rv
en
t
ion
sth
a
tm
ays
imp
lyb
ea
s
sum
edtob
eh
e
lp
fu
ltoin
fo
rm
a
lc
a
r
eg
iv
e
r
s
,
d
idno
ta
c
tu
a
l
lyl
e
adtoanimp
rov
em
en
tinr
epo
r
t
so
fin
fo
rm
a
lc
a
r
eg
iv
e
rbu
rd
en
.Th
i
si
s
impo
r
t
an
tb
e
c
au
s
e
,a
sno
t
edp
r
ev
iou
s
ly
,ah
igh
e
rd
eg
r
e
eo
fp
e
r
c
e
iv
edbu
rd
enonth
ep
a
r
to
f
th
ec
a
r
eg
iv
e
rc
ann
eg
a
t
iv
e
lyimp
a
c
tc
a
r
eg
iv
e
rw
e
l
l
b
e
ing
.
M
anys
tud
i
edin
t
e
rv
en
t
ion
sh
av
ep
rov
entob
eb
en
e
f
i
c
i
a
lfo
rin
fo
rm
a
lc
a
r
eg
iv
e
r
s
.Fo
r
ex
amp
l
e
,s
tud
i
e
sth
a
tex
am
in
edyog
aandm
ind
fu
ln
e
s
st
r
a
in
ingfo
rICPWDr
ev
e
a
l
edth
a
t
d
a
i
lym
ed
i
t
a
t
iv
es
e
s
s
ion
simp
rov
eds
t
r
e
s
sl
ev
e
l
s(B
l
a
cke
ta
l
.
,2013
;Hu
r
l
ey
,P
a
t
t
e
r
son&
Coo
l
ey
,2014
;J
a
in
,N
a
z
a
r
i
an
,&L
av
r
e
t
sky
,2014
;Ok
ene
ta
l
.
,2010
;W
a
e
ld
e
,Thomp
son
,&
G
a
l
l
agh
e
rThomp
son
,2004
)
,cogn
i
t
iv
efun
c
t
ion(W
a
e
ld
ee
ta
l
.
,2004
)
,m
en
t
a
lh
e
a
l
th
,and
d
e
c
r
e
a
s
edd
ep
r
e
s
s
ionl
ev
e
l
s(Hu
r
l
eye
ta
l
.
,2014
;L
av
e
t
r
skye
ta
l
.
,2013
;W
a
e
ld
ee
ta
l
.
,2004
)
.
S
a
l
f
ie
ta
l
.(2005
)foundth
a
tat
e
l
ephon
ein
t
e
rv
en
t
ion
,inwh
i
chah
e
a
l
thc
a
r
ep
ro
f
e
s
s
ion
a
l
p
rov
id
edsuppo
r
ttoICPWDov
e
rth
et
e
l
ephon
e
,p
rov
id
edb
en
e
f
i
c
i
a
lemo
t
ion
a
ls
uppo
r
tand
edu
c
a
t
ion
.T
e
l
ephon
ein
t
e
rv
en
t
ion
sm
ayb
ep
a
r
t
i
cu
l
a
r
lyu
s
e
fu
lfo
rtho
s
ec
a
r
eg
iv
e
r
swho
r
e
s
id
einru
r
a
lo
rr
emo
t
ea
r
e
a
sw
i
thl
im
i
t
edav
a
i
l
ab
l
es
e
rv
i
c
e
s(
G
lu
e
ck
au
fe
ta
l
.
,2007
)
.
On
l
in
ein
t
e
rv
en
t
ion
sm
aya
l
sop
rov
es
im
i
l
a
r
lyu
s
e
fu
lfo
rind
iv
idu
a
l
sr
e
s
id
inginru
r
a
lo
r
r
emo
t
ea
r
e
a
s
.As
tudybyG
l
eu
ck
au
fandLoom
i
s(2003
)foundth
a
tanon
l
in
esuppo
r
t
p
rog
r
amimp
rov
edbo
thc
a
r
eg
iv
e
rsub
j
e
c
t
iv
ebu
rd
enandth
e
i
rl
ev
e
lo
fs
e
l
f
e
f
f
i
c
a
cy
.
P
sy
cho
so
c
i
a
lsuppo
r
tp
rog
r
am
sth
a
to
f
f
e
rs
e
rv
i
c
e
ssu
cha
ssuppo
r
tg
roup
s
,edu
c
a
t
ion
,and

43

	
  
coun
s
e
l
ing
,h
av
ep
rov
enu
s
e
fu
lind
e
l
ay
ingin
s
t
i
tu
t
ion
a
l
i
z
a
t
iono
fc
a
r
er
e
c
ip
i
en
t
sw
i
th
d
em
en
t
i
a(D
rö
e
s
,M
e
i
l
and
,S
chm
i
t
z
,&v
anT
i
lbu
rg
,2006
)andd
e
c
r
e
a
s
ingd
ep
r
e
s
s
ionin
ICPWD(Chue
ta
l
.
,2011
)
.
D
e
sp
i
t
eth
eb
en
e
f
i
t
sr
epo
r
t
edinsom
es
tud
i
e
s
,i
ti
simpo
r
t
an
ttor
e
cogn
i
z
eth
a
t
b
a
r
r
i
e
r
stosu
c
c
e
s
s
fu
limp
l
em
en
t
a
t
iono
fin
t
e
rv
en
t
ion
sdo
,un
fo
r
tun
a
t
e
ly
,ex
i
s
t
.Su
ch
po
t
en
t
i
a
lb
a
r
r
i
e
r
sin
c
lud
et
r
an
spo
r
t
a
t
ioni
s
su
e
s
,l
a
cko
ff
am
i
l
i
a
lsuppo
r
t
,in
su
f
f
i
c
i
en
t

know
l
edg
eo
fav
a
i
l
ab
l
ein
t
e
rv
en
t
ion
sbyPCP
s
,a
sw
e
l
la
scu
l
tu
r
a
landso
c
io
e
conom
i
cf
a
c
to
r
s
th
a
tm
ayl
im
i
ta
c
c
e
s
s
ib
i
l
i
tytosu
chs
e
rv
i
c
e
sandth
e
r
ebyd
e
c
r
e
a
s
ep
a
r
t
i
c
ip
a
t
ionbysom
e
c
a
r
eg
iv
e
r
s(C
z
a
j
ae
ta
l
.
,2013
)
.Fu
r
th
e
rmo
r
e
,th
en
e
c
e
s
s
a
rytyp
e
so
fin
t
e
rv
en
t
ion
sa
r
eno
t
a
lw
ay
scon
s
id
e
r
edf
o
rimp
l
em
en
t
a
t
ionbyPCP
sandm
ayno
tev
enb
eav
a
i
l
ab
l
einm
any
commun
i
t
i
e
s
.Fo
rtho
s
ep
a
t
i
en
t
sw
i
thd
em
en
t
i
aandth
e
i
rin
fo
rm
a
lc
a
r
eg
iv
e
r
swhodoh
av
e
a
c
c
e
s
stoaPCP
,p
r
im
a
ryc
a
r
e
b
a
s
edin
t
e
rv
en
t
ion
sm
ayh
e
lptoe
l
im
in
a
t
esom
eo
fth
e
s
e
id
en
t
i
f
i
edb
a
r
r
i
e
r
sandimp
rov
esuppo
r
ts
e
rv
i
c
ea
c
c
e
s
sandup
t
ak
e
;how
ev
e
r
,r
e
s
e
a
r
chon
in
t
e
rv
en
t
ion
simp
l
em
en
t
edw
i
th
inp
r
im
a
ryc
a
r
es
e
t
t
ing
si
ssu
rp
r
i
s
ing
lys
c
a
r
c
e(Bu
rn
se
ta
l
.
,
2003
)
.Th
i
sl
a
cko
fr
e
s
e
a
r
chm
ay,inp
a
r
t
,b
er
e
l
a
t
edtot
im
econ
s
t
r
a
in
t
so
fc
l
in
i
cv
i
s
i
t
s
,l
a
ck
o
fPCPknow
l
edg
eo
fr
e
sou
r
c
e
so
rqu
a
l
i
tyd
em
en
t
i
ac
a
r
e
,l
a
cko
ff
in
an
c
i
a
lr
e
imbu
r
s
em
en
t
(B
ro
tm
an&Y
a
f
f
e
,1994
)
,o
rp
e
r
c
e
iv
edun
r
e
a
l
i
s
t
i
cexp
e
c
t
a
t
ion
so
fin
fo
rm
a
lc
a
r
eg
iv
e
r
s
.
Th
epu
rpo
s
eo
fth
i
sl
i
t
e
r
a
tu
r
er
ev
i
ewi
stoex
am
in
eth
esp
e
c
i
f
i
cw
ay
sinwh
i
chPCP
s
c
anb
e
s
tsuppo
r
tICPWD
.Ink
e
ep
ingw
i
thap
e
r
son
c
en
t
r
edapp
ro
a
chtoc
a
r
eg
iv
e
rc
a
r
efo
r
ICPWD
,Ch
ap
t
e
rTh
r
e
ew
i
l
lexp
lo
r
eexp
e
r
i
en
c
e
sandr
epo
r
t
edn
e
ed
so
fICPWD
,a
sw
e
l
la
s
p
r
im
a
ryc
a
r
e
b
a
s
eda
s
s
e
s
sm
en
tandin
t
e
rv
en
t
ion
s
,w
i
thth
ea
imo
fd
ev
e
lop
ingfu
r
th
e
r
know
l
edg
eandr
e
comm
end
a
t
ion
sinwh
i
chtogu
id
eth
ep
r
a
c
t
i
c
eo
fPCP
sinth
ep
r
im
a
ryc
a
r
e
s
e
t
t
ing
.

44

	
  
Chap
t
e
r2
:S
ea
r
ch M
e
thod	
  
	
  
Th
ein
t
en
to
fth
i
sl
i
t
e
r
a
tu
r
er
ev
i
ewi
stod
e
t
e
rm
in
eth
ew
ay
sinwh
i
chPCP
sc
an
f
a
c
i
l
i
t
a
t
ead
ap
t
a
t
ionandw
e
l
l
b
e
inginICPWD
.M
e
thodo
log
i
c
a
ls
t
r
a
t
eg
i
e
sd
ev
e
lop
edby
Wh
i
t
t
emo
r
eandKn
a
f
l(2005
)w
e
r
eimp
l
em
en
t
edino
rd
e
rtos
t
r
eng
th
enth
er
igou
ro
fth
e

r
ev
i
ewp
ro
c
e
s
sandtoe
f
f
e
c
t
iv
e
lyan
sw
e
rth
er
e
s
e
a
r
chqu
e
s
t
ion
.Th
eu
s
eo
f Wh
i
t
t
emo
r
eand
Kn
a
f
l
’
smod
i
f
i
edr
ev
i
ewf
r
am
ewo
rkw
a
ssp
e
c
i
f
i
c
a
l
lycho
s
ena
si
ta
f
fo
rd
sg
r
e
a
t
e
rr
igou
rw
i
th
th
eu
s
eo
fd
i
sp
a
r
a
t
er
e
s
e
a
r
chm
e
thod
s
,a
sw
e
l
la
sw
i
thbo
themp
i
r
i
c
a
landth
eo
r
e
t
i
c
a
l
l
i
t
e
r
a
tu
r
e(Wh
i
t
t
emo
r
e&Kn
a
f
l
,2005
)
.Th
ef
i
r
s
tp
a
r
to
fth
es
e
a
r
chs
t
r
a
t
egyfo
rth
i
sp
ro
j
e
c
t
in
c
lud
edth
ed
ev
e
lopm
en
to
fas
e
a
r
chp
l
an
.Aw
r
i
t
t
ent
ab
l
ew
a
sc
r
e
a
t
edinwh
i
chtot
r
a
ck
e
a
chs
e
a
r
chandth
esub
s
equ
en
tnumb
e
ro
fr
e
su
l
t
sfo
re
a
cho
fth
es
e
a
r
ch
e
s
.Endno
t
eB
a
s
i
c
w
a
su
t
i
l
i
z
eda
sth
er
e
f
e
r
en
c
em
an
ag
em
en
tp
rog
r
amtot
r
a
ckando
rg
an
i
z
etho
s
er
e
f
e
r
en
c
e
s
th
a
tw
e
r
eapp
l
i
c
ab
l
etoth
er
e
s
e
a
r
chtop
i
c
.
D
a
t
ab
a
s
e
sw
e
r
ea
c
c
e
s
s
edth
roughth
eUNBCl
ib
r
a
ryw
ebp
ag
eandF
r
a
s
e
rH
e
a
l
th
l
ib
r
a
ryw
ebp
ag
eino
rd
e
rtoob
t
a
injou
rn
a
la
r
t
i
c
l
ec
i
t
a
t
ion
s
.Th
e
s
er
e
sou
r
c
e
sa
l
low
edth
e
s
e
a
r
chfo
ra
r
t
i
c
l
e
su
s
ingCumu
l
a
t
iv
eInd
exo
fNu
r
s
ingandA
l
l
i
edH
e
a
l
thL
i
t
e
r
a
tu
r
e
(C
INAHL
)Comp
l
e
t
e
,Ov
id M
ed
l
in
e
,P
sy
chIn
fo
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c
ad
em
i
cS
e
a
r
chComp
l
e
t
e
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c
i
a
l
S
c
i
en
c
e
sAb
s
t
r
a
c
t
s
,andB
iom
ed
i
c
a
lR
e
f
e
r
en
c
eCo
l
l
e
c
t
ion
:Comp
r
eh
en
s
iv
e
.V
a
r
iou
styp
e
so
f
l
i
t
e
r
a
tu
r
ew
e
r
econ
s
id
e
r
edfo
rth
i
sr
ev
i
ew
:qu
a
l
i
t
a
t
iv
e
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an
t
i
t
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t
iv
eo
rm
ix
ed
m
e
thods
tud
i
e
s
,
sy
s
t
em
a
t
i
cr
ev
i
ew
s
,n
a
r
r
a
t
iv
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i
ew
s
,in
t
eg
r
a
t
iv
er
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i
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s
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l
in
i
c
a
lp
r
a
c
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i
c
egu
id
e
l
in
e
s
,
ed
i
to
r
i
a
l
s
,andg
r
eyl
i
t
e
r
a
tu
r
esu
cha
sr
epo
r
t
sandcon
f
e
r
en
c
ep
ro
c
e
ed
ing
s
.
Tob
eg
in
,th
efo
l
low
ing M
ed
i
c
a
lSub
j
e
c
tH
e
ad
ing
s(M
eSH
)h
e
ad
ing
sr
e
l
a
t
edtomy
qu
e
s
t
ionw
e
r
eu
s
ed
:d
em
en
t
ia
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r
eg
i
v
ing
,ca
r
eg
i
v
e
r
,ca
r
e
r
,in
fo
rma
lca
r
eg
i
v
e
r
,adap
ta
t
ion
,
t
ran
s
i
t
ion
s
,p
r
ima
r
yca
r
e
,p
r
ima
r
yca
r
ep
ro
v
id
e
r
,nu
r
s
ep
ra
c
t
i
t
ion
e
r
,ca
r
eg
i
v
e
rn
e
ed
s
,

45

	
  

a
s
s
e
s
sm
en
t
,andin
t
e
r
v
en
t
ion
sino
rd
e
rtoexp
lo
r
ewh
a
ttyp
e
so
fa
r
t
i
c
l
e
swou
ldr
e
su
l
t
.Th
eu
s
e
o
fth
e
s
eb
ro
adh
e
ad
ing
sr
e
su
l
t
edinthou
s
and
so
fa
r
t
i
c
l
e
s
.Byu
s
ingth
eBoo
l
e
anop
e
r
a
to
r
‘
and
’ino
rd
e
rtom
a
r
ryt
e
rm
ssu
cha
sadap
ta
t
ion‘
and
’ca
r
eg
i
v
e
r
s‘
and
’d
em
en
t
iao
r
d
em
en
t
ia‘
and
’ca
r
eg
i
v
e
r‘
and
’p
r
ima
r
yh
ea
l
thca
r
e‘
and
’in
t
e
r
v
en
t
ion
s
,th
efo
cu
so
fth
e
s
e
a
r
ch
e
sw
a
sn
a
r
row
edandth
i
sr
e
su
l
t
edinmo
r
er
e
l
ev
an
tc
i
t
a
t
ion
s
.
Th
es
e
a
r
chfo
ra
r
t
i
c
l
e
sa
l
soin
co
rpo
r
a
t
edth
eu
s
eo
fGoog
l
eS
cho
l
a
r
,T
r
ipD
a
t
ab
a
s
e(
a
c
l
in
i
c
a
ls
e
a
r
cheng
in
econ
t
a
in
ingh
ighqu
a
l
i
tyev
id
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c
e
b
a
s
edl
i
t
e
r
a
tu
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e
)
,andth
eAg
en
cyfo
r
H
e
a
l
thC
a
r
eR
e
s
e
a
r
chandQu
a
l
i
tyw
eb
s
i
t
e
,a
si
tcon
t
r
ibu
t
e
sbo
thr
e
s
e
a
r
chsyn
th
e
s
e
sand
o
r
ig
in
a
lr
e
s
e
a
r
cha
r
t
i
c
l
e
s
.On
c
eth
e
s
ed
a
t
ab
a
s
es
e
a
r
ch
e
sw
e
r
eexh
au
s
t
ed
,andino
rd
e
rto
comp
l
e
t
eacomp
r
eh
en
s
iv
es
e
a
r
ch
,g
r
eyl
i
t
e
r
a
tu
r
ew
a
sex
am
in
eda
sw
e
l
lu
s
ingth
eN
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rk
A
c
ad
emyo
fM
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i
c
in
eG
r
eyL
i
t
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r
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eR
epo
r
t
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eIn
s
t
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tu
t
eo
fH
e
a
lthE
conom
i
c
sw
eb
s
i
t
e
andth
e Wo
r
ld W
id
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ebs
e
a
r
cheng
in
e
sw
e
r
ea
l
soexp
lo
r
ed
.D
a
t
ab
a
s
eandg
r
eyl
i
t
e
r
a
tu
r
e
s
e
a
r
ch
e
sw
e
r
ea
l
lcondu
c
t
edv
i
aon
l
in
em
e
ch
an
i
sm
s
.
In
c
lu
s
ionandEx
c
lu
s
ionC
r
i
t
e
r
iafo
rL
i
t
e
ra
tu
r
eCon
s
id
e
ra
t
ion
S
in
c
eth
er
e
s
e
a
r
chqu
e
s
t
ioni
squ
it
eb
ro
adw
i
thr
e
sp
e
c
ttoth
ew
ay
sinwh
i
chPCP
s
m
ayf
a
c
i
l
i
t
a
t
ead
ap
t
a
t
ionandw
e
l
lb
e
inginc
a
r
eg
iv
e
r
s
,m
anytyp
e
so
fa
r
t
i
c
l
e
sa
ro
s
eou
to
f
th
ein
i
t
i
a
ls
e
a
r
chandw
e
r
ein
i
t
i
a
l
lyin
c
lud
edinth
er
e
su
l
t
s
.Fo
rex
amp
l
e
,anyemp
i
r
i
c
a
l
s
tud
i
e
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a
tex
am
in
edin
t
e
rv
en
t
ion
sr
e
l
a
t
edtoICPWDw
e
r
ein
c
lud
ed
,a
sw
e
r
enon
exp
e
r
im
en
t
a
la
r
t
i
c
l
e
sp
e
r
t
a
in
ingtobu
rd
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i
skf
a
c
to
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sfo
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rd
en
,s
e
rv
i
c
eu
t
i
l
i
z
a
t
ion
,
r
e
l
a
t
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sh
ip
sb
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tw
e
enc
a
r
eg
iv
e
r
sandp
r
im
a
ryc
a
r
ep
rov
id
e
r
s
,andc
a
r
eg
iv
e
r
’
sexp
e
r
i
en
c
e
sin
th
econ
t
ex
to
fd
em
en
t
i
a
.Qu
a
l
i
t
a
t
iv
es
tud
i
e
sw
e
r
ea
l
soin
c
lud
edth
a
tex
am
in
edth
en
e
ed
so
r
exp
e
r
i
en
c
e
so
fc
a
r
eg
iv
e
r
sp
rov
id
ingc
a
r
efo
rind
iv
idu
a
l
sw
i
thd
em
en
t
i
a
,inth
ein
t
e
r
e
s
to
f
g
a
in
inganund
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r
s
t
and
ingo
fth
ec
a
r
eg
iv
ingjou
rn
eyinth
econ
t
ex
to
fd
em
en
t
i
a
.Th
ehop
ew
a
s

46

	
  

th
a
tth
ein
c
lu
s
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fqu
a
l
i
t
a
t
iv
ed
a
t
awou
ldaddd
ep
thtoth
eov
e
r
a
l
lr
ev
i
ewth
a
tex
am
in
ing
qu
an
t
i
t
a
t
iv
ed
a
t
aon
lywou
ldno
ta
f
fo
rd
.Fu
r
th
e
r
,th
eadd
i
t
iono
fqu
a
l
i
t
a
t
iv
es
tud
i
e
sp
rov
id
ed
in
s
igh
tin
totho
s
en
e
ed
sth
a
tPCP
sn
e
edtoadd
r
e
s
sino
rd
e
rtoe
f
f
e
c
t
iv
e
lyf
a
c
i
l
i
t
a
t
ead
ap
t
a
t
ion
andw
e
l
l
b
e
inginICPWD
.How
ev
e
r
,du
etoamy
r
i
ado
fl
i
t
e
r
a
tu
r
efounddu
r
ingth
es
e
a
r
ch
,
th
ein
c
lu
s
ionc
r
i
t
e
r
i
aw
e
r
esub
s
equ
en
t
lyn
a
r
row
edtoin
c
lud
eon
lyc
a
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eg
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e
rn
e
ed
s
,
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47

	
  
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48

r
ev
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in
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lp
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efoundtob
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lu
s
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sr
ev
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t
e
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a
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chs
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r
a
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.

49

	
  
Chap
t
e
r3
:F
ind
ing
s
Inth
i
sch
ap
t
e
r
,qu
a
l
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t
a
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i
l
lb
eexp
lo
r
edf
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s
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rd
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a
inan
und
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s
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and
ingo
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r
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c
e
sandn
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so
fICPWD
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ex
t
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eev
id
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r
t
a
in
ingto

p
r
im
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r
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s
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lb
eex
am
in
edino
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rtoh
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lptod
e
t
e
rm
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n
e
howe
f
f
e
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e
s
ein
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e
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sa
r
ea
timp
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r
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rICPWD
.
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in
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ly
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lp
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edtoinv
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r
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en
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r
ttoin
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rm
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in
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el
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r
er
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Th
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r
eg
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romth
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e
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rd
e
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igh
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ech
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e
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s
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sp
e
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t
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s
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t
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.
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av
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a
r
en
e
s
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e
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e
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i
en
c
e
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f
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e
r
en
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t
ag
e
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fd
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en
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i
am
ayh
e
lptop
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t
e
w
ay
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s
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r
tICPWD
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a
lv
in
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r
e
s
,andR
i
ch
a
rd
son(2005
)s
t
a
t
eth
a
t“
th
i
s
‘
in
s
id
e
r
’v
i
ewi
sab
l
etof
a
c
i
l
i
t
a
t
eemp
a
th
i
cund
e
r
s
t
and
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th
e
r
sandthu
sempow
e
ra
d
e
ep
e
rl
ev
e
lo
fp
a
t
i
en
t
c
en
t
r
edc
a
r
e
”(p
.9
)
.
Pu
l
l
ingou
to
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ed
r
iv
eway
:Th
eb
eg
inn
ingo
fth
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e
sinth
i
s
r
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e
s
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e
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s
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ro
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.

50

	
  

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r
a
lo
th
e
rr
e
a
son
s
,in
c
lud
ing
:al
a
cko
ft
r
a
in
ingind
em
en
t
i
ac
a
r
e
;al
a
cko
f
know
l
edg
eabou
tr
e
sou
r
c
e
sinwh
i
chtop
rov
id
eon
c
ead
i
agno
s
i
si
sm
ad
e
;symp
tom
sm
ay
no
tb
eno
t
i
c
eddu
r
ingo
f
f
i
c
ev
i
s
i
t
s
;andth
eym
ayno
tw
i
shtod
i
s
c
lo
s
ead
i
agno
s
i
sth
a
tw
i
l
l
c
au
s
ed
i
s
t
r
e
s
stot
h
e
i
rp
a
t
i
en
tand
/o
rin
fo
rm
a
lc
a
r
eg
iv
e
r(A
l
zh
e
im
e
rSo
c
i
e
tyo
fB
r
i
t
i
sh
Co
lumb
i
a
,2012
)
.
No
ton
lyisth
ed
i
agno
s
i
so
fd
em
en
t
i
aad
i
f
f
i
cu
l
ton
etoab
so
rbbu
ts
tudyp
a
r
t
i
c
ip
an
t
s
a
l
sod
e
s
c
r
ib
edc
au
s
e
so
fs
t
r
e
s
sa
r
i
s
ingf
roma
s
so
c
i
a
t
edf
in
an
c
i
a
l
,phy
s
i
c
a
l
,ande
mo
t
ion
a
l
f
a
c
to
r
s
.Th
eco
s
to
fm
ed
i
c
a
t
ion
s
,fo
rm
a
lsuppo
r
t
iv
es
e
rv
i
c
e
s
,andr
e
s
id
en
t
i
a
lc
a
r
ea
r
enow
th
ing
sth
a
tth
ec
a
r
eg
iv
e
rn
e
ed
stoth
inkabou
twh
en
,p
e
rh
ap
s
,th
i
sh
adno
tp
r
ev
iou
s
lyev
en
b
e
enp
a
r
to
fth
e
i
rthough
tp
ro
c
e
s
s
e
s
.Th
es
tudyp
a
r
t
i
c
ip
an
t
sd
e
s
c
r
ib
edun
c
e
r
t
a
in
tyandf
e
a
r
abou
twh
a
tth
efu
tu
r
eh
e
ldfo
rth
em
s
e
lv
e
sandth
ec
a
r
er
e
c
ip
i
en
t
.
As
en
s
eo
flon
e
l
in
e
s
sandl
a
cko
fsuppo
r
tf
romo
th
e
rf
am
i
lym
emb
e
r
sandPCP
sw
e
r
e
p
rom
in
en
tth
em
e
sinth
es
tudy
.Al
a
cko
fedu
c
a
t
ionp
rov
id
edtoth
ec
a
r
eg
iv
e
r
sbyPCP
sw
i
th
r
e
sp
e
c
ttoa
sp
e
c
t
so
fc
a
r
eg
iv
ing
,su
cha
sp
rov
id
ingp
e
r
son
a
lc
a
r
e
,w
a
sano
t
edf
ru
s
t
r
a
t
ion
.
On
ec
a
r
eg
iv
e
rs
t
a
t
edth
a
t“
th
eys
aynobodyc
anp
r
ep
a
r
eyoufo
ri
t
.W
e
l
l
,Ith
inkth
eyc
an
”
(T
e
e
l&C
a
r
son
,2003
,p
.49
)
.A
l
thoughc
a
r
eg
iv
e
r
sf
e
l
tal
a
cko
fsuppo
r
tf
romPCP
sinth
i
s

51

	
  

r
eg
a
rd
,mo
s
ts
tudyp
a
r
t
i
c
ip
an
t
sr
epo
r
t
edth
a
ta
t
t
end
ingsuppo
r
tg
roup
sh
e
lp
edtom
e
e
ttho
s
e
p
a
r
t
i
cu
l
a
rl
e
a
rn
ingn
e
ed
s
.No
tsu
rp
r
i
s
ing
ly
,wh
ena
sk
edwh
a
tth
eyw
an
t
edPCP
stoknow
ov
e
r
a
l
labou
tth
e
i
rexp
e
r
i
en
c
e
sa
sf
am
i
lyc
a
r
eg
iv
e
r
s
,th
es
tudyp
a
r
t
i
c
ip
an
t
scon
s
i
s
t
en
t
ly
r
epo
r
t
edth
e
i
rd
e
s
i
r
etof
e
e
lsuppo
r
t
edbyPCP
s
.Ov
e
r
a
l
l
,th
eexp
e
r
i
en
c
e
so
fth
eICPWDin
T
e
e
landC
a
r
son
’
s(2003
)s
tudysugg
e
s
tth
a
tPCP
sn
e
edtob
eaw
a
r
eo
fth
epo
t
en
t
i
a
ls
t
r
e
s
so
r
s
th
a
tICPWDm
ayf
a
c
edu
r
ingth
e
i
rc
a
r
eg
iv
ingjou
rn
eyandb
eop
entoh
e
a
r
ingabou
t
ICPWD
’
sexp
e
r
i
en
c
e
s
.
A
l
thoughth
ef
ind
ingth
a
tICPWDf
e
l
tth
a
tth
e
i
rl
e
a
rn
ingn
e
ed
sw
e
r
em
e
tth
rough
suppo
r
tg
roup
s
,r
a
th
e
rth
anth
roughth
e
i
rPCP
,w
a
scon
s
i
s
t
en
ta
c
ro
s
ss
tudyp
a
r
t
i
c
ip
an
t
s
,th
e
au
tho
r
ss
t
a
t
edth
a
tth
ep
a
r
t
i
c
ip
an
t
sw
e
r
er
e
c
ru
i
t
edth
roughsuppo
r
tg
roup
sandth
a
tth
i
s
p
a
r
t
i
cu
l
a
rf
ind
ingshou
ldth
e
r
e
fo
r
eb
ein
t
e
rp
r
e
t
edw
i
thc
au
t
ion
.Th
e
r
e
fo
r
e
,ano
t
ab
l
e
l
im
i
t
a
t
iono
fth
es
tudyw
a
sth
eund
e
r
r
ep
r
e
s
en
t
a
t
iono
fc
a
r
eg
iv
e
r
swhod
idno
ta
t
t
endsuppo
r
t
g
roup
s(T
e
e
l&C
a
r
son
,2003
)
.Ano
th
e
rl
im
i
t
a
t
iono
fth
es
tudyw
a
sth
ehomog
enou
ss
tudy
s
amp
l
ea
sa
l
lo
fth
es
tudyp
a
r
t
i
c
ip
an
t
sw
e
r
eC
au
c
a
s
i
anandth
em
a
jo
r
i
ty(
64%)w
e
r
ef
em
a
l
e
.
A
l
thoughth
i
sm
ayb
ear
ep
r
e
s
en
t
a
t
iv
es
amp
l
eo
fth
ec
a
r
eg
iv
ingpopu
l
a
t
ioninKan
s
a
s
,th
e
f
ind
ing
sm
ayno
tb
eg
en
e
r
a
l
i
z
ab
l
etomo
r
emu
l
t
i
cu
l
tu
r
a
lcommun
i
t
i
e
s
.
Inth
es
e
conds
tudy
,Ad
am
s(2006
)u
t
i
l
i
z
edaph
enom
eno
log
i
c
a
lapp
ro
a
chand
g
round
edth
eo
rym
e
thodo
logytoexp
lo
r
eth
eexp
e
r
i
en
c
e
so
fICPWDdu
r
ingth
ee
a
r
lys
t
ag
e
s
o
fd
em
en
t
i
aandhowth
eyad
ju
s
t
edtoth
en
ewc
a
r
eg
iv
ingro
l
e
.Tw
en
tyspou
s
eo
radu
l
tch
i
ld
ICPWDw
e
r
er
e
c
ru
i
t
edth
roughth
eUn
iv
e
r
s
i
ty M
emo
ryandAg
ingC
en
t
r
einC
l
ev
e
l
and
,
Oh
io
,USAandund
e
rw
en
tind
ep
thin
t
e
rv
i
ew
sl
a
s
t
ingon
ehou
re
a
ch
.S
ev
e
r
a
lth
em
e
sand
sub
th
em
e
sw
e
r
eev
id
en
tinth
es
tudyf
ind
ing
s
.Th
ef
i
r
s
tth
em
e
,‘
f
am
i
lym
emb
e
rt
a
sk
s
’
,
invo
lv
edth
ec
a
r
eg
iv
e
rt
ak
ingonn
ewro
l
e
sandt
a
sk
sth
a
tth
ec
a
r
er
e
c
ip
i
en
tcou
ldnolong
e
r

52

	
  

p
e
r
fo
rmands
t
rugg
l
ingw
i
thth
ed
e
c
i
s
iono
fhowmu
chtoa
l
lowth
en
ew
lyd
i
agno
s
edp
e
rson
todo
,su
cha
sp
ay
ingb
i
l
l
s
,m
an
ag
ingth
e
i
rownm
ed
i
c
a
t
ion
,o
rd
r
iv
ingac
a
r
.
Th
es
e
condth
em
einth
eAd
am
s(2006
)s
tudyinvo
lv
ed‘
ch
ang
e
sinth
er
e
l
a
t
ion
sh
ip
’
(p
ro
t
e
c
t
iv
en
e
s
sandcon
c
e
rn
,lo
s
so
fcon
f
id
an
t
)
.S
ev
e
r
a
lo
fth
es
tudyp
a
r
t
i
c
ip
an
t
sd
e
s
c
r
ib
e
d
howth
eyt
r
i
edtom
a
in
t
a
inin
t
im
a
cyanda
sp
e
c
t
so
fth
e
i
rr
e
l
a
t
ion
sh
ipth
a
tth
eyh
ada
lw
ay
s
v
a
lu
ed
,su
cha
shumou
r
;how
ev
e
r
,th
ec
a
r
eg
iv
e
r
sr
epo
r
t
edexp
e
r
i
en
c
ingf
e
e
l
ing
so
flo
s
sa
s
th
ec
a
r
er
e
c
ip
i
en
t
’
scogn
i
t
iond
e
t
e
r
io
r
a
t
ed
.
Th
eth
i
rdp
rom
in
en
tth
em
einth
i
ss
am
es
tudyadd
r
e
s
s
edn
eg
a
t
iv
eemo
t
ion
s
.Ad
am
s
(2006
)s
t
a
t
edth
a
t19ou
to
f20s
tudyp
a
r
t
i
c
ip
an
t
sr
epo
r
t
edh
av
ingexp
e
r
i
en
c
edn
eg
a
t
iv
e
imp
a
c
tf
romc
a
r
eg
iv
ing
.Th
ec
a
r
eg
iv
e
r
sexp
r
e
s
s
edf
e
e
l
ing
so
fang
e
r
,f
ru
s
t
r
a
t
ion
,and
imp
a
t
i
en
c
etow
a
rd
sth
ec
a
r
er
e
c
ip
i
en
tandsom
er
epo
r
t
edf
e
e
l
ing
so
fr
e
s
en
tm
en
t
.
Suppo
r
tf
romo
th
e
r
s(
in
fo
rm
a
landfo
rm
a
l
)w
a
sth
efou
r
thth
em
e
.C
a
r
eg
iv
e
r
svo
i
c
ed
f
e
e
l
ingso
c
i
a
l
lyi
so
l
a
t
eddu
etoth
ef
e
a
ro
fs
t
igm
ao
rbu
rd
en
ingo
th
e
r
s
.M
anyc
a
r
eg
iv
e
r
s
r
epo
r
t
edf
e
e
l
ingh
e
s
i
t
an
ttoa
c
c
e
s
sfo
rm
a
lsuppo
r
tdu
etof
e
e
l
ing
so
fgu
i
l
to
rf
e
e
l
ingth
a
tth
ey
w
e
r
et
ak
ingaw
ayth
ec
a
r
er
e
c
ip
i
en
t
’
sind
ep
end
en
c
e
.
Th
el
a
s
tth
em
efoundinth
es
tudyw
a
sth
a
to
f‘
though
t
so
fth
efu
tu
r
e
’
;i
tinvo
lv
ed
f
e
e
l
ing
so
fun
c
e
r
t
a
in
tym
ix
edw
i
thhop
eth
a
tth
ec
a
r
er
e
c
ip
i
en
twou
ldno
td
e
t
e
r
io
r
a
t
equ
i
ck
ly
(Ad
am
s
,2006
)
.
As
t
r
eng
tho
fth
i
ss
tudyw
a
sth
einvo
lv
em
en
to
fm
a
l
ec
a
r
eg
iv
e
r
sino
rd
e
rtog
a
inth
e
i
r
p
e
r
sp
e
c
t
iv
ea
sp
a
r
t
i
c
ip
an
t
sinmo
s
tc
a
r
eg
iv
ings
tud
i
e
sa
r
ep
r
edom
in
an
t
lyf
em
a
l
e
;how
ev
e
r
,
th
esm
a
l
l
,p
r
im
a
r
i
lyC
au
c
a
s
i
ans
amp
l
ea
l
lpu
l
l
edf
romas
ing
l
eg
eog
r
aph
i
c
a
la
r
e
am
ay
p
r
ev
en
tb
ro
ad
e
rg
en
e
r
a
l
i
z
ab
i
l
i
tyo
fth
ef
ind
ing
s
.

53

	
  

Onth
eroad
:Th
ejou
rn
eycon
t
inu
e
sth
roughth
em
idd
l
es
tag
e
s
.O
’Sh
aughn
e
s
sy
,
L
e
e
,andL
in
t
e
rn(2010
)condu
c
t
edaph
enom
eno
log
i
c
a
lqu
a
l
i
t
a
t
iv
es
tudytoinv
e
s
t
ig
a
t
eth
e
c
a
r
eg
iv
ingexp
e
r
i
en
c
e
sandp
e
r
c
e
iv
edm
e
an
ing
sth
a
tspou
s
ec
a
r
eg
iv
e
r
sg
av
etoth
e
s
e
exp
e
r
i
en
c
e
s
.Th
i
ss
tudycon
s
i
s
t
edo
fs
ev
enin
fo
rm
a
lspou
s
ec
a
r
eg
iv
e
r
s(
f
iv
ew
iv
e
sandtwo
hu
sb
and
s
,a
l
lov
e
rth
eag
eo
f59
)whow
e
r
ep
rov
id
ingc
a
r
efo
rap
e
r
soninth
em
id
s
t
ag
e
so
f
d
em
en
t
i
a
.Th
e
s
es
tudyp
a
r
t
i
c
ip
an
t
sw
e
r
er
e
c
ru
i
t
edf
romA
l
zh
e
im
e
r
’
sSo
c
i
e
t
i
e
sinth
eUn
i
t
ed
K
ingdom
.E
a
chp
a
r
t
i
c
ip
an
tw
a
sin
t
e
rv
i
ew
edind
ep
end
en
t
lyw
i
the
a
chin
t
e
rv
i
ewl
a
s
t
ing45to
75m
inu
t
e
s
.
Th
ef
ind
ing
so
fth
eO
’Sh
aughn
e
ssye
ta
l
.(2010
)s
tudyr
e
su
l
t
edinfou
rov
e
r
a
r
ch
ing
th
em
e
s
.Th
ef
i
r
s
tth
em
ew
a
sconn
e
c
t
edn
e
s
sands
ep
a
r
a
t
en
e
s
s
;spou
s
e
ss
t
a
t
edth
a
tth
eys
t
i
l
l
f
e
l
tconn
e
c
t
edtoth
ec
a
r
er
e
c
ip
i
en
tinsom
ew
ay
s
,y
e
tf
e
l
tacon
cu
r
r
en
ts
ep
a
r
a
t
ionf
romth
e
p
e
r
sona
sth
ed
em
en
t
i
ap
rog
r
e
s
s
ed
.Th
es
e
condth
em
ein
c
lud
edt
en
s
ionb
e
tw
e
enm
e
e
t
ingth
e
n
e
ed
so
fth
ec
a
r
er
e
c
ip
i
en
twh
i
l
es
t
i
l
lm
e
e
t
ingth
e
i
rownn
e
ed
s
.Th
ec
a
r
eg
iv
e
r
sinth
es
tudy
r
epo
r
t
edf
e
e
l
inggu
i
l
tyandov
e
rwh
e
lm
edw
i
thth
ec
a
r
eg
iv
ings
i
tu
a
t
ion
.On
ec
a
r
eg
iv
e
r
r
epo
r
t
edf
e
e
l
inga
si
fh
e
rn
e
ed
sw
e
r
en
ev
e
rm
e
t
,in
c
lud
ingth
er
equ
i
r
em
en
t
so
fh
e
rown
h
e
a
l
thcond
i
t
ion
s
.Th
eth
i
rdth
em
einvo
lv
edc
a
r
eg
iv
e
r
’
sun
c
e
r
t
a
in
tyabou
tth
efu
tu
r
ea
s
c
a
r
eg
iv
e
r
sr
epo
r
t
edo
s
c
i
l
l
a
t
ingb
e
tw
e
ena
c
c
ep
t
an
c
eabou
twh
a
tw
a
stocom
eandun
c
e
r
t
a
in
ty
abou
tth
efu
tu
r
e
.Th
efou
r
thth
em
einvo
lv
edan
e
edtom
a
in
t
a
incon
t
ro
linth
e
i
rl
iv
e
sand
imp
l
em
en
te
f
f
e
c
t
iv
ecop
ings
t
r
a
t
eg
i
e
s
.
L
i
l
lye
ta
l
.(2012
)condu
c
t
edaqu
a
l
i
t
a
t
iv
ed
e
s
c
r
ip
t
iv
es
tudyth
a
ttookp
l
a
c
einth
r
e
e
commun
i
t
i
e
sinth
eSou
th
e
rnIn
t
e
r
io
ro
fB
r
i
t
i
shCo
lumb
i
a
.Tw
en
tyth
r
e
eind
iv
idu
a
l
sw
e
r
e
r
e
c
ru
i
t
edfo
rth
es
tudy
,in
c
lud
ingICPWD
,p
e
e
rsuppo
r
tvo
lun
t
e
e
r
s
,andPCP
swhosuppo
r
t
ed
ICPWDa
sap
a
r
to
fth
e
i
rro
l
e(
so
c
i
a
lwo
rk
e
r
s
,fo
rex
amp
l
e
)
.Th
es
tudyp
a
r
t
i
c
ip
an
t
stookp
a
r
t

54

	
  

inth
r
e
efo
cu
sg
roup
s
.T
h
ep
a
r
t
i
c
ip
an
t
sw
e
r
ep
r
im
a
r
i
lywom
en(n=20
)ande
ld
e
r
ly
,l
iv
ingin
e
i
th
e
rsm
a
l
lu
rb
ana
r
e
a
s(21
)o
rru
r
a
la
r
e
a
s(n=2
)
.
An
a
ly
s
i
so
fth
ef
ind
ing
sr
e
su
l
t
edintwoth
em
e
s
:1
)ICPWDf
e
e
l
ingfo
rgo
t
t
en
,a
lon
e
andab
andon
ed
;and2
)h
e
a
l
thc
a
r
ep
rov
id
e
r
sh
av
ingun
r
e
a
l
i
s
t
i
cexp
e
c
t
a
t
ion
sfo
rc
a
r
eg
iv
e
r
s
e
l
f
c
a
r
e(L
i
l
lye
ta
l
.
,2012
)
.Th
eICPWDinth
eL
i
l
lye
ta
l
.(2012
)s
tudyr
epo
r
t
edth
a
t
,
a
l
thoughth
eyw
e
r
eaw
a
r
eo
fth
eb
en
e
f
i
t
so
fs
e
l
f
c
a
r
e
,m
anyfoundth
i
sch
a
l
l
eng
ingto
a
c
comp
l
i
sh
.Fu
r
th
e
r
,th
eICPWDr
epo
r
t
ed
ap
e
r
c
ep
t
ionth
a
tPCP
sexp
e
c
t
edth
emtob
eab
l
e
top
e
r
fo
rms
e
l
f
c
a
r
eandth
i
sp
l
a
c
edadd
i
t
ion
a
lb
u
rd
enandr
e
spon
s
ib
i
l
i
tyonth
eICPWDto
m
e
e
ttho
s
eexp
e
c
t
a
t
ion
s. W
i
thr
e
sp
e
c
ttof
e
e
l
ingfo
rgo
t
t
en
,ICPWDr
epo
r
t
edf
e
e
l
inga
si
f
th
eyw
e
r
eb
e
ingt
ak
enfo
rg
r
a
n
t
edbyth
ec
a
r
er
e
c
ip
i
en
t
,f
am
i
lym
emb
e
r
s
,PCP
s
,and
r
ep
r
e
s
en
t
a
t
iv
e
so
fth
eh
e
a
l
thc
a
r
esy
s
t
em
.S
ev
e
r
a
lICPWDf
e
l
ta
sthoughth
eyh
adtof
igh
tfo
r
r
e
cogn
i
t
iono
fth
e
i
rwo
rkandtoh
av
eth
e
i
rownsuppo
r
tn
e
ed
sm
e
t
.ICPWDexp
r
e
s
s
edan
e
ed
fo
rr
e
f
e
r
r
a
l
sandin
fo
rm
a
t
iona
roundd
em
en
t
i
aandav
a
i
l
ab
l
es
e
rv
i
c
e
s
,in
c
r
e
a
s
edoppo
r
tun
i
t
i
e
s
fo
rr
e
sp
i
t
e
,anda
s
s
i
s
t
an
c
edu
r
ingth
et
r
an
s
i
t
iono
fc
a
r
er
e
c
ip
i
en
t
stor
e
s
id
en
t
i
a
lc
a
r
e
.M
any
s
tudyp
a
r
t
i
c
ip
an
t
sr
epo
r
t
edth
a
tth
eICPWDw
a
i
t
edtoolongb
e
fo
r
er
equ
e
s
t
inga
s
s
i
s
t
an
c
e
f
romfo
rm
a
ls
e
rv
i
c
ep
rov
id
e
r
s
.L
i
l
lye
ta
l
.(2012
)s
t
a
t
edth
a
tth
i
sw
a
sno
tasu
rp
r
i
s
ingf
ind
ing
con
s
id
e
r
ingth
ep
e
r
c
e
iv
edexp
e
c
t
a
t
ion
so
fPCP
sr
e
l
a
t
edtoc
a
r
eg
iv
e
r
s
’r
e
spon
s
ib
i
l
i
tyand
ab
i
l
i
tyfo
rs
e
l
f
c
a
r
e
,a
sw
e
l
la
sth
el
im
i
t
edamoun
to
ffo
rm
a
lsupp
o
r
ts
e
rv
i
c
e
sa
c
tu
a
l
ly
av
a
i
l
ab
l
e
.
Th
eau
tho
r
sno
t
edth
a
ts
ev
e
r
a
lm
e
thodo
log
i
c
a
ll
im
i
t
a
t
ion
sex
i
s
t
ed
.F
i
r
s
t
,th
es
amp
l
e
s
i
z
ew
a
ssm
a
l
landhomog
enou
s
.Th
eexp
e
r
i
en
c
e
so
fm
enw
e
r
eno
tw
e
l
l
r
ep
r
e
s
en
t
edinth
e
s
amp
l
e
.Th
ee
thn
i
c
i
tyo
fth
ep
a
r
t
i
c
ip
an
t
sw
a
sno
tdo
cum
en
t
ed
.S
t
r
eng
th
so
fth
es
tudyno
t
ed
byth
eau
tho
r
sin
c
lud
edh
av
ingPCP
sandvo
lun
t
e
e
r
sinvo
lv
edinth
efo
cu
sg
roup
s
,wh
i
ch

55

	
  

add
edd
i
f
f
e
r
en
tp
e
r
sp
e
c
t
iv
e
sabou
tth
eexp
e
r
i
en
c
e
so
fICPWD
.How
ev
e
r
,th
i
sm
ayh
av
ea
l
so
a
c
t
eda
sal
im
i
t
a
t
iona
sth
ec
a
r
eg
iv
e
rr
e
spon
s
e
sm
ayh
av
eb
e
enin
f
lu
en
c
edbyth
ep
r
e
s
en
c
eo
f
PCP
s
.
G
a
lv
in
,Tod
r
e
s
,andR
i
ch
a
rd
son(2005
)p
e
r
fo
rm
edas
ing
l
ec
a
s
en
a
r
r
a
t
iv
es
tudyabou
t
on
ec
a
r
eg
iv
e
r
’
sexp
e
r
i
en
c
e
so
fp
rov
id
ingc
a
r
etoh
i
sw
i
f
ew
i
thd
em
en
t
i
a
.Th
eau
tho
r
scho
s
e
th
i
sn
a
r
r
a
t
iv
einqu
i
ryino
rd
e
rtop
rov
id
ead
ep
thandm
e
an
ingtoth
ecomp
l
exjou
rn
ey
ICPWDf
a
c
e
.P
r
in
c
ip
l
e
sth
a
ts
t
emm
edf
romh
e
rm
en
eu
t
i
cph
enom
eno
logyw
e
r
eu
s
edto
o
rg
an
i
z
eandan
a
ly
z
eth
ein
fo
rm
a
t
ionob
t
a
in
edth
roughth
es
ing
l
etwo
hou
rin
t
e
rv
i
eww
i
th
th
es
tudyp
a
r
t
i
c
ip
an
t(G
a
lv
ine
ta
l
.
,2005
)
.
Th
r
e
eth
em
e
sem
e
rg
edf
romth
i
sin
t
e
rv
i
ewr
eg
a
rd
ingth
ec
a
r
eg
iv
ingjou
rn
ey
.Th
e
f
i
r
s
tth
em
eth
a
tw
a
sd
i
s
cov
e
r
edw
a
sth
econ
c
ep
tth
a
t‘
som
e
th
ingi
sw
rong
’
.M
r
.M
.d
e
s
c
r
ib
ed
th
ec
r
i
s
i
sinvo
lv
edw
i
thm
emo
rylo
s
sinh
i
sw
i
f
edu
r
ingth
ee
a
r
lys
t
ag
el
e
ad
ingupto
d
i
agno
s
i
s
,th
eso
c
i
a
li
so
l
a
t
ion
,t
ry
ingtoe
s
t
ab
l
i
shan
ewr
e
l
a
t
ion
sh
ipw
i
th
inth
e
i
rex
i
s
t
ing
on
e
,andc
r
e
a
t
iv
e
lyad
ju
s
t
ing“
sh
a
r
edl
i
f
eth
a
ti
spo
s
s
ib
l
e
”a
sth
ed
em
en
t
i
ap
rog
r
e
s
s
ed
(G
a
lv
ine
ta
l
.
,2005
,p
.6
)
.
O
th
e
rsh
a
r
edexp
e
ri
en
c
e
sf
e
l
lund
e
rth
es
e
condth
em
eo
f‘
th
ech
a
l
l
eng
ingsh
a
r
ed
jou
rn
ey
:b
e
ingth
ec
a
r
e
r
’
,wh
i
chin
c
lud
edch
a
l
l
eng
e
sr
e
l
a
t
edtophy
s
i
c
a
lc
a
r
e
,m
ed
i
c
a
t
ion
m
an
ag
em
en
t
,r
e
spond
ingtos
id
ee
f
f
e
c
t
sf
romm
ed
i
c
a
t
ion
s
,andb
e
ingv
ig
i
l
an
ttono
t
i
c
ingand
a
c
t
inguponch
ang
e
sinh
i
sw
i
f
e
’
scond
i
t
ion
.Animpo
r
t
an
td
i
f
f
i
cu
l
tya
s
so
c
i
a
t
edw
i
th
c
a
r
eg
iv
ingth
a
tw
a
sr
epo
r
t
edby M
r
.M
.
,an
dw
a
ss
im
i
l
a
rtoth
ef
ind
ing
so
fL
i
l
lye
ta
l
.
’
s
(2012
)s
tudy
,w
a
sth
ech
a
l
l
eng
ea
s
so
c
i
a
t
edw
i
thac
a
r
eg
iv
e
r
’
ss
e
l
f
c
a
r
e
.Fo
rex
amp
l
e
,M
r
.M
.
foundth
a
ts
e
l
f
n
eg
l
e
c
to
c
cu
r
r
eda
tt
im
e
s
,andh
etu
rn
edtor
e
sp
i
t
ewh
enh
er
e
cogn
i
z
edth
i
s

56

	
  
o
c
cu
r
r
ing
.How
ev
e
r
,a
l
t
hough M
r
.M
.f
e
l
tr
e
l
i
e
fa
s
so
c
i
a
t
edw
i
thu
t
i
l
i
z
ingr
e
sp
i
t
e
,h
ea
l
so
d
e
s
c
r
ib
edexp
e
r
i
en
c
ingf
e
e
l
ing
so
fgu
i
l
twh
enh
ed
ids
e
ekou
tth
i
ss
e
rv
i
c
e
.
Th
ef
in
a
lth
em
einvo
lv
ed‘
cop
ingth
roughm
e
an
ingm
ak
ing
:advo
c
a
cy
’
.M
r
.M
.

d
i
s
cu
s
s
edth
eimpo
r
t
an
c
eo
fcon
t
inu
i
tyo
fc
a
r
e
,andh
av
ingtol
e
a
rnabou
td
i
f
f
e
r
en
tl
ev
e
l
so
f
fo
rm
a
lsuppo
r
tandwh
entoa
c
c
e
s
sth
em
,s
in
c
e“
su
chanin
t
eg
r
a
t
ed‘m
ap
’w
a
sno
tp
rov
id
ed
fo
rh
im
”(G
a
lv
ine
ta
l
.
,2005
,p
.7
)
.Fu
r
th
e
r
,M
r
.M
.d
e
s
c
r
ib
edhowt
ak
ingonth
ero
l
eo
f
advo
c
a
t
ew
a
sap
a
r
amoun
tw
ayfo
rh
imtom
ak
em
e
an
ingou
to
fth
e
i
rd
i
f
f
i
cu
l
tc
i
r
cum
s
t
an
c
e
s
.
Ano
t
ab
l
ew
e
akn
e
s
so
fth
eG
a
lv
ine
ta
l
.(2005
)s
tudyw
a
sth
a
ti
ton
lyin
c
lud
edth
e
l
e
a
rn
edexp
e
r
i
en
c
e
so
fon
ep
a
r
t
i
c
ip
an
t
.How
ev
e
r
,th
eth
em
e
sth
a
tem
e
rg
edf
romth
en
a
r
r
a
t
iv
e
w
e
r
es
im
i
l
a
rtom
anyo
th
e
rc
a
r
eg
iv
e
r
’
sexp
e
r
i
en
c
e
sandp
rov
id
edv
a
lu
ab
l
ein
s
igh
tin
toth
e
w
ay
sth
a
tth
e
s
eexp
e
r
i
en
c
e
sc
anh
e
lptod
r
iv
ec
l
in
i
c
a
lp
r
a
c
t
i
c
ed
ev
e
lopm
en
tand
imp
rov
em
en
t(G
a
lv
ine
ta
l
.
,2005
)
.Th
eth
em
e
sth
a
th
av
eem
e
rg
edinth
i
ss
tudya
r
e
con
s
i
s
t
en
tw
i
thth
eo
th
e
rqu
a
l
i
t
a
t
iv
es
tud
i
e
sth
a
th
av
eb
e
enr
ev
i
ew
edthu
sf
a
r
.
K
a
r
l
s
sone
ta
l
.(2015)p
e
r
fo
rm
edaqu
a
l
i
t
a
t
iv
es
tudyu
s
ingfo
cu
sg
roupm
e
thodo
logy
.
Inth
i
ss
tudy
,137ICPWDandth
e
i
rc
a
r
er
e
c
ip
i
en
t
sp
a
r
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ip
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t
edinfo
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sg
roupin
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e
rv
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ew
sin
e
igh
tEu
rop
e
ancoun
t
r
i
e
s
.Th
epu
rpo
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eo
fth
es
tudyw
a
stoinv
e
s
t
ig
a
t
eth
ev
i
ew
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e
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e
p
a
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ip
an
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eg
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rd
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e
r
p
ro
f
e
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s
ion
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lin
fo
rm
a
t
ion
,co
l
l
abo
r
a
t
ion
,andcommun
i
c
a
t
ion
th
roughth
ed
em
en
t
i
at
r
a
j
e
c
to
ry
.Pu
rpo
s
iv
es
amp
l
ingw
a
su
s
edino
rd
e
rtoc
ap
tu
r
ea
r
ep
r
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en
t
a
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iv
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a
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ro
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et
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en
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ind
ing
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efo
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sg
roup
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l
t
edinth
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ingth
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a
r
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en
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en
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r
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fo
rm
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in
to
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a
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ec
a
r
eg
iv
e
rs
t
a
t
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th
e
r
ei
sno

57

	
  

coo
rd
in
a
t
ion
!B
e
c
au
s
eth
a
ti
sno
tth
ero
l
eo
ftho
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ea
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e
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ldb
eon
ec
en
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r
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l
po
in
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e
r
eev
e
ryon
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ldb
eab
l
etogoandg
e
tin
fo
rm
a
t
ion…
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a
r
l
s
sone
ta
l
.
,2015
,p
.
1412
)
.
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eICPWDp
a
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ip
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edPCP
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ryknow
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es
tudyp
a
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ip
an
t
s
.
B
a
s
edonth
es
tudyf
ind
ing
s
,K
a
r
l
s
sone
ta
l
.(2015
)sugg
e
s
t
edth
eu
s
eo
fco
l
l
abo
r
a
t
iv
e
c
a
r
eo
rc
a
s
em
an
ag
em
en
tin
t
e
rv
en
t
ion
s
.How
ev
e
r
,s
tud
i
e
sbyConno
re
ta
l
.(2008
)andJ
an
s
en
e
ta
l
.(2011
)th
a
tex
am
in
edc
a
s
em
an
ag
em
en
tin
t
e
rv
en
t
ion
sd
emon
s
t
r
a
t
edth
a
tth
e
r
ei
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in
su
f
f
i
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en
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r
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eu
s
eo
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a
s
em
an
ag
em
en
ttoimp
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fo
rm
a
lc
a
r
eg
iv
e
r
w
e
l
lb
e
ing
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tudys
t
r
eng
th
sin
c
lud
edanad
equ
a
t
es
amp
l
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i
z
eandth
ein
c
lu
s
iono
fnum
e
rou
s
quo
t
a
t
ion
sth
a
temph
a
s
i
z
edth
em
e
an
ingo
fth
ec
a
r
eg
iv
e
r
s
’exp
e
r
i
en
c
e
s
.
J
enn
ing
se
ta
l
.(2015
)condu
c
t
edac
ro
s
s
s
e
c
t
ion
a
lob
s
e
rv
a
t
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lcoho
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inv
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s
t
ig
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t
eth
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i
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c
e
so
fICPWDo
fp
a
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r
edtoad
em
en
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ac
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r
ep
rog
r
am
(DCP
)
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eau
tho
r
ssough
ttod
e
t
e
rm
in
eth
er
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l
a
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sh
ipb
e
tw
e
enc
a
r
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t
r
a
in
,
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ep
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iv
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s
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e
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f
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rm
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etyp
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r
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r
r
ingPCP
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tudyp
a
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e
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een
ro
l
l
edinth
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s
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rn
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thth
ec
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ip
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t
a
lo
f307ICPWDw
e
r
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rv
ey
edov
e
ra

58

	
  
p
e
r
iodo
fon
ey
e
a
r
.Th
ec
a
r
eg
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r
sw
e
r
emo
s
t
lyf
em
a
l
e(67%
)ande
i
th
e
ranadu
l
tch
i
ld
(49%
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rspou
s
e(41%
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fth
ec
a
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er
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c
ip
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t
.
V
a
l
id
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edtoo
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e
r
eu
s
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a
su
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ec
a
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rou
t
com
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s
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ep
r
e
s
s
iv
esymp
tom
s

w
e
r
em
e
a
su
r
edu
s
ingth
en
in
ei
t
emP
a
t
i
en
tH
e
a
l
thQu
e
s
t
ionn
a
i
r
e(PHQ
9
)(K
ro
enk
e
,Sp
i
t
z
e
r
,
&W
i
l
l
i
am
s
,2001
)
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e13i
t
em Mod
i
f
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a
r
eg
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rS
t
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a
inInd
ex(MCS
I
)(Tho
rn
ton&
T
r
av
i
s(2003
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a
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e
a
su
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ec
a
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eg
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t
r
a
in
,andth
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rop
sy
ch
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en
to
ry
Qu
e
s
t
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a
i
r
e(NP
IQ
)(K
au
f
e
r
,Cumm
ing
s
,&K
e
t
ch
e
l
,2000
)w
a
su
s
edtom
e
a
su
r
eth
e
c
a
r
eg
iv
e
r
’
sl
ev
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lo
fd
i
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l
a
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rp
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fBPSDs
ev
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a
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t
.
An
in
ei
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eyw
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in
eth
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i
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sr
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cogn
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to
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ip
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emon
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igh
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f
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59

	
  

a
r
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smo
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a
rd
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t
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ac
a
r
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enn
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se
ta
l
.
,2015
)
.
B
a
s
edonth
es
tudyf
ind
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s
,J
enn
ing
se
ta
l
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c
lud
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a
tmo
r
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a
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s
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rex
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enn
ing
se
ta
l
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e
s
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a
tth
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ev
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an
td
emog
r
aph
i
c
s(mo
s
t
lyf
em
a
l
e
,C
au
c
a
s
i
an
,and
m
ed
i
c
a
l
lyin
su
r
ed
)
.
On
lyon
es
tudyex
am
in
edth
eexp
e
r
i
en
c
e
so
fe
thn
i
c
a
l
lyd
iv
e
r
s
eICPWD
.Inth
i
s
qu
a
l
i
t
a
t
iv
es
tudy
,Bough
twoode
ta
l
.(2011
)u
s
edamod
i
f
i
edg
round
edth
eo
ryapp
ro
a
chto
ex
am
in
eth
ep
e
r
c
ep
t
ion
sandexp
e
r
i
en
c
e
so
fCALDICPWD
.On
ehund
r
edandtw
en
tyon
e
f
am
i
lyICPWDw
e
r
er
e
c
ru
i
t
edf
romA
r
ab
i
c
sp
e
ak
ing
,Ch
in
e
s
e
sp
e
ak
ing
,I
t
a
l
i
an
sp
e
ak
ing
,
andSp
an
i
sh
sp
e
ak
ingcommun
i
t
i
e
sinAu
s
t
r
a
l
i
a
.Th
es
tudyp
a
r
t
i
c
ip
an
t
sw
e
r
ep
r
im
a
r
i
ly
f
em
a
l
e(n=88
)andadu
l
tch
i
ld
r
eno
fth
ec
a
r
er
e
c
ip
i
en
t(
n=93
)
.S
tudyd
a
t
aw
a
sob
t
a
in
ed
f
rom16fo
cu
sg
roup
s
,con
s
i
s
t
ingo
fapp
rox
im
a
t
e
lye
igh
tp
eop
l
ef
rome
a
chg
roup
.
Fou
rth
em
e
sem
e
rg
edf
romth
ed
a
t
a
,in
c
lud
ingc
a
r
eg
iv
ingdu
t
i
e
s
;f
am
i
lyr
e
l
a
t
ed
i
s
su
e
s
;emo
t
ion
a
landp
e
r
son
a
lcon
c
e
rn
s
;andd
em
en
t
i
a
r
e
l
a
t
edcon
c
e
rn
s
.ICPWDf
roma
l
l

60

	
  

CALDb
a
ckg
round
sw
e
r
einvo
lv
edw
i
thphy
s
i
c
a
landemo
t
ion
a
lc
a
r
e
,anda
s
s
i
s
t
an
c
ewh
en
v
i
s
i
t
ingPCP
s
.W
i
thr
e
sp
e
c
ttoc
a
r
eg
iv
ingdu
t
i
e
s
,on
lyth
eI
t
a
l
i
an
sp
e
ak
ingandSp
an
i
sh
sp
e
ak
ingc
a
r
eg
iv
e
r
sr
epo
r
t
eda
c
t
inga
sadvo
c
a
t
e
swh
i
l
eth
ec
a
r
er
e
c
ip
i
en
tw
a
sinth
eho
sp
i
t
a
l
.
M
anyo
fth
ec
a
r
eg
iv
e
r
sp
e
r
c
e
iv
edth
eho
sp
i
t
a
ls
t
a
f
ftob
eun
ab
l
etom
e
e
tth
en
e
ed
so
fth
ec
a
r
e
r
e
c
ip
i
en
t
,o
f
t
enl
e
ad
ingtoth
ec
a
r
eg
iv
e
rsp
end
inglongp
e
r
iod
so
ft
im
einth
eho
sp
i
t
a
lto
suppo
r
tth
ec
a
r
er
e
c
ip
i
en
t
.Th
ei
mpo
r
t
an
c
eandimp
l
i
c
a
t
ion
so
fen
cou
r
ag
ingICPWDto
p
rov
id
eb
a
ckg
roundp
a
t
i
en
tin
fo
rm
a
t
iontotho
s
eh
e
a
l
thc
a
r
ewo
rk
e
r
swhoa
r
eun
f
am
i
l
i
a
r
w
i
thth
ec
a
r
er
e
c
ip
i
en
tw
i
l
lb
ed
i
s
cu
s
s
edfu
r
th
e
rinth
efo
l
low
ingch
ap
t
e
r
.
Exp
e
c
t
edg
end
e
rro
l
e
sandf
am
i
lycon
f
l
i
c
tsw
e
r
ed
i
s
cu
s
s
edbySp
an
i
sh
sp
e
ak
ingand
I
t
a
l
i
an
sp
e
ak
ingc
a
r
eg
iv
e
r
s
.Fo
rex
amp
l
e
,th
ewom
enw
e
r
eexp
e
c
t
edtop
e
r
fo
rmsp
e
c
i
f
i
c
t
a
sk
s
,su
cha
sp
e
r
son
a
lc
a
r
efo
rth
ec
a
r
er
e
c
ip
i
en
t
,wh
i
chm
ayh
av
eb
e
enp
e
r
c
e
iv
edinth
e
cu
l
tu
r
ea
sin
app
rop
r
i
a
t
efo
rm
a
l
e
stod
o
.W
i
thr
eg
a
rd
stof
am
i
lycon
f
l
i
c
t
s
,twopo
t
en
t
i
a
l
r
e
a
son
sfo
rcon
f
l
i
c
tw
e
r
eb
rough
ttol
igh
tinth
es
tudy
.Th
ef
i
r
s
tcon
f
l
i
c
tr
e
l
a
t
edtor
e
fu
s
a
lo
f
f
am
i
lym
emb
e
r
stop
a
r
t
i
c
ip
a
t
einc
a
r
e
,andth
es
e
condw
a
sr
e
l
a
t
edtocon
f
l
i
c
tb
e
tw
e
enadu
l
t
ch
i
ld
r
enc
a
r
eg
i
v
e
r
sandth
e
i
rspou
s
e
sdu
etoth
ed
em
and
sinvo
lv
edinc
a
r
ep
rov
i
s
ionwh
i
ch
tookt
im
eaw
ayf
romth
ec
a
r
eg
iv
e
r
’
sf
am
i
ly
.W
i
thr
e
sp
e
c
ttoemo
t
ion
a
landp
e
r
son
a
l
con
c
e
rn
s
,a
l
lo
fth
es
tudyp
a
r
t
i
c
ip
an
t
sr
epo
r
t
edcon
c
e
rn
sr
e
l
a
t
edtog
r
i
e
fandlo
s
s
,l
a
cko
f
t
im
efo
rs
e
l
f
,anx
i
e
tyabou
tth
efu
tu
r
e
,andd
e
t
e
r
io
r
a
t
iono
fth
e
i
rh
e
a
l
th
.Und
e
rth
eth
em
eo
f
d
em
en
t
i
a
r
e
l
a
t
edcon
c
e
rn
s
,Ch
in
e
s
e
,I
t
a
l
i
an
,andSp
an
i
sh
sp
e
ak
ingp
a
r
t
i
c
ip
an
t
sno
t
edBPSD
a
sacon
c
e
rn
,wh
e
r
e
a
sA
r
ab
i
c
,I
t
a
l
i
an
,andSp
an
i
sh
sp
e
ak
ingp
a
r
t
i
c
ip
an
t
sr
ep
o
r
t
eds
a
f
e
ty
i
s
su
e
sandc
a
r
er
e
c
ip
i
en
t
scon
fu
s
ingf
am
i
lym
emb
e
r
sw
i
tho
th
e
rm
emb
e
r
so
fth
ef
am
i
lya
s
con
c
e
rn
s
.

61

	
  
Bough
twoode
ta
l
.(2011
)foundth
a
tf
am
i
l
i
smandcu
l
tu
r
a
lp
i
e
tyimp
a
c
t
edth
e
d
e
c
i
s
ion
sth
a
tCALDICPWDm
ad
e
.Th
e
s
et
r
a
i
t
sshou
ldb
econ
s
id
e
r
edbyPCP
swh
en

in
c
lud
ingICPWDind
em
en
t
i
ac
a
r
ep
l
ann
ing
.Add
i
t
ion
a
lcu
l
tu
r
a
lcon
s
id
e
r
a
t
ion
sfo
rPCP
s
in
c
lud
eth
epo
s
s
ib
i
l
i
tyo
fnum
e
rou
sin
fo
rm
a
lc
a
r
eg
iv
e
r
sb
e
inginvo
lv
edind
e
c
i
s
ionm
ak
ing
,
th
es
t
r
e
s
sth
a
tCALDICPWDm
ayexp
e
r
i
en
c
er
e
l
a
t
edtoth
epo
t
en
t
i
a
ln
e
edtot
r
an
s
l
a
t
e
m
ed
i
c
a
lin
fo
rm
a
t
iontoth
ec
a
r
er
e
c
ip
i
en
t
,andth
ee
th
i
c
sandch
a
l
l
eng
e
sa
s
so
c
i
a
t
edw
i
th
u
s
ingc
a
r
eg
iv
e
r
sa
st
r
an
s
l
a
to
r
s(Bough
twoode
ta
l
.
,2011
)
.Bough
twoode
ta
l
.(2011
)a
l
so
s
t
a
t
edth
a
tPCP
swhoin
t
e
r
a
c
tw
i
thICPWDf
romCALDcommun
i
t
i
e
smu
s
tr
e
f
l
e
c
tupon
th
e
s
ec
i
r
cum
s
t
an
c
e
sandcon
s
id
e
rpo
s
s
ib
l
ew
ay
sinwh
i
chtosuppo
r
tsu
chc
a
r
eg
iv
e
r
sdu
r
ing
p
r
im
a
ryc
a
r
ev
i
s
i
t
s
.
Th
ecomp
a
r
i
sono
ffou
rd
i
f
f
e
r
en
tcu
l
tu
r
a
lg
roup
s
,r
a
th
e
rth
anju
s
ton
eo
rtwo
,i
sa
no
t
ab
l
es
t
r
eng
tho
fth
es
tudy
.Th
i
sb
ro
ad
e
rp
i
c
tu
r
ep
rov
id
e
sPCP
sw
i
thab
e
t
t
e
r
und
e
r
s
t
and
ingo
fth
epo
t
en
t
i
a
ln
e
ed
so
fm
emb
e
r
so
fd
i
f
f
e
r
en
tCALDcommun
i
t
i
e
s
.
Twol
im
i
t
a
t
ion
so
fth
es
tudyw
e
r
eid
en
t
i
f
i
edbyth
er
e
s
e
a
r
ch
e
r
s
.Th
ef
i
r
s
tl
im
i
t
a
t
ion
w
a
sth
eex
c
lu
s
iono
fAng
lophon
ep
a
r
t
i
c
ip
an
t
sinwh
i
chtocomp
a
r
eexp
e
r
i
en
c
e
s
.Th
es
e
cond
l
im
i
t
a
t
ionw
a
sth
ein
c
lu
s
iono
fon
lyth
ed
i
r
e
c
tc
a
r
eg
iv
e
r
sinth
es
tudyr
a
th
e
rth
ano
th
e
rf
am
i
ly
m
emb
e
r
sa
sw
e
l
l
.I
twou
ldh
av
eb
e
env
a
lu
ab
l
etocomp
a
r
eth
ep
e
r
c
ep
t
ion
so
fo
th
e
rf
am
i
ly
m
emb
e
r
sw
i
ththo
s
eo
fth
ed
i
r
e
ctc
a
r
eg
iv
e
r
sr
eg
a
rd
ingf
am
i
lycon
f
l
i
c
tandd
e
c
i
s
ion
sabou
t
th
ec
a
r
er
e
c
ip
i
en
t
’
sc
a
r
e(Bough
twoode
ta
l
.
,2011
)
.Bough
twoode
ta
l
.(2011
)con
c
lud
edth
a
t
c
a
r
eg
iv
ingexp
e
r
i
en
c
e
sw
e
r
ed
e
ep
lyin
f
lu
en
c
edbycu
l
tu
r
e
,andth
a
tPCP
smu
s
tb
eaw
a
r
eo
f
cu
l
tu
r
a
lcon
t
ex
twh
enp
rov
id
ingc
a
r
etop
a
t
i
en
t
sw
i
thd
em
en
t
i
aandth
e
i
rin
fo
rm
a
lc
a
r
eg
iv
e
r
s
.
Twor
e
s
e
a
r
chs
tud
i
e
sin
c
lud
edinth
i
sr
ev
i
ewsough
ttoid
en
t
i
fyth
epo
s
i
t
iv
e
exp
e
r
i
en
c
e
so
fICPWDth
roughou
tth
ec
a
r
eg
iv
ingjou
rn
ey
.Inth
ef
i
r
s
ts
tudy
,Coh
en
,

62

	
  

Con
an
ton
i
a
,andV
e
rn
i
ch(2002
)d
e
s
c
r
ib
eth
eexp
e
r
i
en
c
e
so
f289ICPWDwhow
e
r
ep
a
r
to
fa
s
amp
l
eo
fc
a
r
eg
iv
e
r
sd
e
r
iv
edf
romth
eC
an
ad
i
anS
tudyo
fH
e
a
l
thandAg
e
ing(L
ind
s
ay
,
1994
)
.In
fo
rm
a
t
ionw
a
sco
l
l
e
c
t
edth
roughp
e
r
son
a
lin
t
e
rv
i
ew
sw
i
thth
ec
a
r
eg
iv
e
r
s
.Th
e
r
e
su
l
t
sd
emon
s
t
r
a
t
edth
a
tth
em
a
jo
r
i
tyo
fth
ec
a
r
eg
iv
e
r
sinth
es
tudyexp
e
r
i
en
c
eda
tl
e
a
s
ton
e
po
s
i
t
iv
ea
sp
e
c
to
fc
a
r
ingdu
r
ingth
e
i
rc
a
r
eg
iv
ingjou
rn
ey
.Twohund
r
edande
l
ev
en(73%
)
cou
ldf
indon
epo
s
i
t
iv
ea
sp
e
c
t
,wh
i
l
e6
.9%exp
r
e
s
s
edmo
r
eth
anon
e
.Sp
e
c
i
f
i
cpo
s
i
t
iv
e
f
ind
ing
sa
s
so
c
i
a
t
edw
i
thth
ec
a
r
eg
iv
ingro
l
ein
c
lud
edcomp
an
ion
sh
ip(22
.5%
)
,fu
l
f
i
l
lm
en
t
(21
.8%
)
,en
joym
en
t(12
.8%
)
,fu
l
f
i
l
lm
en
to
fas
en
s
eo
fdu
ty(10
.4%
)
,imp
rov
edQOL(7
.3%
)
,
andf
ind
ingas
en
s
eo
fm
e
an
ing(5
.9%
)
.U
s
ingNoon
anandT
enn
s
t
ed
t
’
s(1997
)con
c
ep
tu
a
l
mod
e
l
,Coh
ene
ta
l
.(2002
)u
s
edas
t
ag
eds
t
epw
i
s
emu
l
t
ip
l
er
eg
r
e
s
s
ionapp
ro
a
chwh
i
ch
in
co
rpo
r
a
t
edcon
t
ex
tu
a
lv
a
r
i
ab
l
e
s(d
emog
r
aph
i
c
s
)
,s
t
r
e
s
so
rv
a
r
i
ab
l
e
s(
c
a
r
er
e
c
ip
i
en
t
’
sADL
l
im
i
t
a
t
ion
s
)
,m
ed
i
a
to
rv
a
r
i
ab
l
e
s(
s
e
rv
i
c
e
su
s
ed
,andpo
s
i
t
iv
ea
sp
e
c
t
so
fc
a
r
ing
)
,andou
t
com
e
v
a
r
i
ab
l
e
s(bu
rd
en
,s
e
l
f
a
s
s
e
s
s
edh
e
a
l
thm
e
a
su
r
e
s
,andd
ep
r
e
s
s
ion
)
.B
a
s
edonth
es
tudy
f
ind
ing
s
,th
eau
tho
r
ssugg
e
s
tth
a
tc
l
in
i
c
i
an
sa
skabou
tpo
s
i
t
iv
ec
a
r
eg
iv
ingexp
e
r
i
en
c
e
sin
o
rd
e
rtob
e
t
t
e
rund
e
r
s
t
andth
ein
fo
rm
a
lc
a
r
eg
iv
e
rexp
e
r
i
e
n
c
eandp
rov
id
ea
s
s
i
s
t
an
c
etotho
s
e
whon
e
edi
t
.
P
e
a
co
cke
ta
l
.(2010
)p
e
r
fo
rm
edas
e
cond
a
ryan
a
ly
s
i
so
faC
an
ad
i
anm
ix
edm
e
thod
s
tudy(Fo
rb
e
se
ta
l
.
,2008
)ino
rd
e
rtog
a
ing
r
e
a
t
e
rin
s
igh
tin
toth
eov
e
r
a
l
lexp
e
r
i
en
c
e
so
f
ICPWD
.Th
eau
tho
r
su
s
edas
t
r
eng
t
hb
a
s
edp
e
r
sp
e
c
t
iv
e
,wh
i
cha
cknow
l
edg
e
sbo
thn
eg
a
t
iv
e
andpo
s
i
t
iv
eexp
e
r
i
en
c
e
s
,ino
rd
e
rtoan
a
ly
z
eth
ed
a
t
a(P
e
a
co
cke
ta
l
.
,2010
)
.ICPWDf
rom
bo
thru
r
a
landu
rb
ancommun
i
t
i
e
sinOn
t
a
r
io
,M
an
i
tob
a
,andS
a
sk
a
t
ch
ew
anw
e
r
er
e
c
ru
i
t
ed
f
romcommun
i
tysuppo
r
tp
r
og
r
am
s
,su
cha
sth
eA
l
zh
e
im
e
rSo
c
i
e
tysuppo
r
tg
roup
sfo
r
c
a
r
eg
iv
e
r
s
.Th
i
r
ty
s
ixICPWDp
a
r
t
i
c
ip
a
t
edinfo
cu
sg
roup
sandth
r
e
eund
e
rw
en
tind
iv
idu
a
l

63

	
  

in
t
e
rv
i
ew
s
.Th
eu
s
eo
fop
en
end
edin
t
e
rv
i
ewqu
e
s
t
ion
sw
a
sano
t
ab
l
es
t
r
eng
tho
fth
es
tudya
s
i
ta
l
low
edfo
ranou
tpou
r
ingo
fr
e
f
l
e
c
t
ionandf
e
e
l
ing
so
fth
eICPWD(P
e
a
co
cke
ta
l
.
,2010
)
.
Th
es
tudyf
ind
ing
sp
rodu
c
edf
iv
eth
em
e
s
:r
e
c
ip
ro
c
i
ty
;p
e
r
son
a
lg
row
th
;d
i
s
cov
e
ryo
f
inn
e
rs
t
r
eng
th
sbyconn
e
c
t
ingw
i
tho
th
e
r
s
;d
ev
e
lop
ingas
en
s
eo
fcomp
e
t
en
c
ea
sac
a
r
eg
iv
e
r
;
andanoppo
r
tun
i
tytobu
i
lds
t
rong
e
rr
e
l
a
t
ion
sh
ipw
i
thandacomm
i
tm
en
ttoth
ec
a
r
e
r
e
c
ip
i
en
t(P
e
a
co
cke
ta
l
.
,2010
)
.Fo
rex
amp
l
e
,inth
es
tudym
anyadu
l
tch
i
ld
r
enandhu
sb
and
s
vo
i
c
edf
e
e
l
ing
so
fr
e
c
ip
ro
c
i
ty
;how
ev
e
r
,w
iv
e
sd
idno
t
.Th
i
sm
ayb
eexp
l
a
in
edbyth
ef
a
c
t
th
a
tm
anywom
enm
aycon
s
id
e
rc
a
r
eg
iv
ingfo
raspou
s
etob
eju
s
tacon
t
inu
an
c
eo
fth
ero
l
e
th
eya
lw
ay
sh
e
ldw
i
th
inth
ef
am
i
lycon
t
ex
twh
e
r
e
a
s
,fo
radu
l
tch
i
ld
r
eno
rhu
sb
and
s,adu
l
t
c
a
r
eg
iv
ingm
ayb
eanen
t
i
r
e
lyn
ewexp
e
r
i
en
c
e
.
B
a
s
edonth
ef
ind
ing
so
fth
es
tudy
,P
e
a
co
cke
ta
l
.(2010
)po
s
i
tth
a
tPCP
sand
r
e
s
e
a
r
ch
e
r
sa
l
ik
eshou
ldno
ta
s
sum
eth
a
tICPWDa
r
eeng
ro
s
s
edinon
lyn
eg
a
t
iv
ec
a
r
eg
iv
ing
exp
e
r
i
en
c
e
s
.Id
en
t
i
fy
ingth
epo
s
i
t
iv
ea
sp
e
c
t
so
fth
ec
a
r
eg
iv
ingexp
e
r
i
en
c
ec
anh
e
lptobu
i
ld
po
s
i
t
iv
er
e
l
a
t
ion
s
h
ip
sb
e
tw
e
enbo
thPCP
sandICPWD
,andb
e
tw
e
enICPWDandr
e
c
ip
i
en
t
s
.
Fu
r
th
e
rmo
r
e
,fo
cu
s
ingonpo
s
i
t
iv
eexp
e
r
i
en
c
e
sm
ayen
cou
r
ag
eICPWDtov
i
ewch
a
l
l
eng
e
sa
s
oppo
r
tun
i
t
i
e
sr
a
th
e
rth
anob
s
t
a
c
l
e
s
.Animpo
r
t
an
tcon
s
id
e
r
a
t
ionno
t
edbyth
eau
tho
r
si
sth
e
n
e
edtoavo
idp
l
a
c
ingtoomu
chemph
a
s
i
sonpo
s
i
t
iv
ea
sp
e
c
t
so
fc
a
r
eg
iv
ing
,wh
i
chr
i
sk
s
pu
sh
ingth
eICPWDb
eyondth
e
i
rc
ap
ab
i
l
i
t
i
e
s
.
Ano
t
ab
l
el
im
i
t
a
t
iono
fth
es
tudyid
en
t
i
f
i
edbyth
eau
tho
r
si
sth
a
tmo
s
to
fth
es
tudy
p
a
r
t
i
c
ip
an
t
sw
e
r
eu
s
e
r
so
fcommun
i
tysuppo
r
t
i
v
es
e
rv
i
c
e
s
.W
e
l
l
suppo
r
t
edc
a
r
eg
iv
e
r
sm
ay
r
epo
r
tmo
r
epo
s
i
t
iv
ea
sp
e
c
t
so
fc
a
r
eg
iv
ingcomp
a
r
edtotho
s
ewhodono
tu
s
eth
e
s
es
e
rv
i
c
e
s
,
th
e
r
ebypo
t
en
t
i
a
l
lyin
f
lu
en
c
ingth
es
tudyr
e
su
l
t
s
.

64

	
  

R
ea
ch
ingth
eendo
fth
eroad
:N
ea
rth
eendo
fth
ejou
rn
ey
.On
lyon
ear
t
i
c
l
einth
e
r
ev
i
ewp
e
r
t
a
in
edtoICPWDexp
e
r
i
en
c
e
sdu
r
ingth
eends
t
ag
e
so
fd
em
en
t
i
a
.Asm
a
l
l
qu
a
l
i
t
a
t
iv
es
tudybySh
an
l
eye
ta
l
.(2011
)exp
lo
r
edth
eexp
e
r
i
en
c
e
so
f15spou
s
eo
radu
l
t
ch
i
ldICPWDth
roughin
d
ep
th
,s
em
is
t
ru
c
tu
r
edin
t
e
rv
i
ew
s
.F
iv
eth
em
e
se
m
e
rg
edf
romth
e
d
a
t
a
:ob
t
a
in
ingfo
rm
a
landin
fo
rm
a
lsuppo
r
tin
c
lud
ingr
e
sp
i
t
e
;h
av
ingtot
ru
s
to
th
e
r
sw
i
th
c
a
r
e
;m
an
ag
ingth
elon
e
l
in
e
s
so
fb
e
ingac
a
r
eg
iv
e
r
;w
i
tn
e
s
s
ingalov
edon
ef
ad
eaw
ay
;
an
t
i
c
ip
a
t
ingandexp
e
r
i
en
c
ingd
e
a
th
;andr
e
e
s
t
ab
l
i
sh
ingl
i
f
ea
f
t
e
rth
efun
e
r
a
l
.C
a
r
eg
iv
e
r
sin
th
es
tudyexp
r
e
s
s
edf
e
e
l
ing
so
fex
t
r
em
elon
e
l
in
e
s
sandth
en
e
edfo
remp
a
thy
,y
e
tm
anyd
id
no
texp
e
r
i
en
c
eth
i
sf
romfo
rm
a
lc
a
r
ep
rov
id
e
r
so
rf
am
i
ly
.Th
el
a
cko
femp
a
thyandsuppo
r
t
f
romPCP
scou
ldb
er
e
l
a
t
edtoth
ef
a
c
tth
a
td
em
en
t
i
ai
smo
s
to
f
t
enno
tv
i
ew
eda
sap
a
l
l
i
a
t
iv
e
d
i
agno
s
i
s
.PCP
sm
ayno
tr
e
cogn
i
z
eth
en
e
edfo
rp
a
l
l
i
a
t
iv
esuppo
r
tdu
etoth
el
eng
thyd
i
s
e
a
s
e
t
r
a
j
e
c
to
rys
e
eninp
a
t
i
en
t
sw
i
thd
em
en
t
i
a
.V
i
ew
ingd
em
en
t
i
aa
sap
a
l
l
i
a
t
iv
ed
i
agno
s
i
sf
rom
th
ein
i
t
i
a
ld
i
agno
s
i
sm
ayh
e
lpPCP
stob
e
t
t
e
rp
r
ep
a
r
eICPWDfo
rth
eendo
fth
ejou
rn
eyw
i
th
th
ec
a
r
er
e
c
ip
i
en
tandb
eyond
.
B
a
s
edonth
eexp
e
r
i
en
c
e
so
fICPWDinth
es
tudy
,Sh
an
l
eye
ta
l
.(2011
)s
t
r
e
s
s
edth
e
impo
r
t
an
c
eo
fp
rov
id
ingund
e
r
s
t
and
ing
,emp
a
thy
,ands
en
s
i
t
iv
i
tytoICPWD
,p
a
r
t
i
cu
l
a
r
ly
du
r
ingth
eends
t
ag
e
so
fd
em
en
t
i
a
.Add
i
t
ion
a
l
ly
,d
e
sp
i
t
eth
ef
a
c
tth
a
tPCP
smo
s
to
f
t
en
en
cou
r
ag
eind
iv
idu
a
l
stom
ak
eth
e
i
rownh
e
a
l
thc
a
r
ed
e
c
i
s
ion
s
,Sh
an
l
eye
ta
l
.(2011
)
sugg
e
s
t
eden
cou
r
ag
ingc
e
r
t
a
inc
a
r
eg
iv
e
r
stoa
c
c
e
s
ssuppo
r
t
iv
es
e
rv
i
c
e
si
fn
e
ed
ed
.
Ano
t
ab
l
el
im
i
t
a
t
iono
fth
i
ss
tudyi
sth
esm
a
l
ls
amp
l
es
i
z
e,wh
i
chl
im
i
t
s
g
en
e
r
a
l
i
z
ab
i
l
i
ty
.

65

	
  
In
fo
rma
lCa
r
eg
iv
e
rN
e
ed
sTh
roughou
tth
eCa
r
eg
iv
ingJou
rn
ey
D
e
sp
i
t
eongo
ingimp
rov
em
en
t
sw
i
thr
e
sp
e
c
ttoin
fo
rm
a
lc
a
r
eg
iv
e
rr
e
cogn
i
t
ionand
suppo
r
t
iv
eg
roup
s
,al
a
cko
fund
e
r
s
t
and
ingo
fin
fo
rm
a
lc
a
r
eg
iv
e
rn
e
ed
sandth
ew
ay
sin

wh
i
chPCP
sc
anad
equ
a
t
e
lym
e
e
ttho
s
en
e
ed
si
sev
id
en
c
edbyr
e
cu
r
r
en
tho
sp
i
t
a
ladm
i
s
s
ion
s
r
e
l
a
t
edtoc
a
r
eg
iv
e
rbu
rnou
tandr
ep
e
a
t
edc
a
r
eg
iv
e
rr
epo
r
t
so
fro
l
es
t
r
a
inandpoo
rcop
ing
.
Rob
in
sone
ta
l
.(2013
)con
cu
r
,s
t
a
t
ingth
a
t“
e
f
fo
r
t
stom
e
e
tc
a
r
eg
iv
e
r
s
’n
e
ed
sr
em
a
inp
i
e
c
e
m
e
a
linap
a
t
chwo
rkc
a
r
ed
e
l
iv
e
rysy
s
t
emth
a
th
a
simp
rov
edl
i
t
t
l
eov
e
rth
ep
a
s
ts
ev
e
r
a
l
d
e
c
ad
e
s
”(p
.502
)
.I
ti
simp
e
r
a
t
iv
eth
a
tPCP
send
e
avou
rtoid
en
t
i
fyth
e
s
en
e
ed
so
fin
fo
rm
a
l
c
a
r
eg
iv
e
r
sino
rd
e
rtop
rov
id
ecomp
r
eh
en
s
iv
e
,e
f
f
e
c
t
iv
e
,ho
l
i
s
t
i
c
,p
e
r
son
c
en
t
r
edc
a
r
e
.
Inam
ix
edm
e
thodexp
lo
r
a
to
r
ys
tudy
,S
t
i
r
l
inge
ta
l
.(2010
)comp
a
r
edm
e
a
su
r
e
so
f
c
a
r
eg
iv
e
rbu
rd
enw
i
thunm
e
tn
e
ed
sandsuppo
r
ts
e
rv
i
c
e
sr
e
c
e
iv
ed
.Tw
en
ty
fou
rICPWD
w
e
r
er
e
c
ru
i
t
edf
romth
eHob
a
r
tch
ap
t
e
ro
fth
eA
l
zh
e
im
e
r
’
sAu
s
t
r
a
l
i
aO
rg
an
i
z
a
t
ion
;20o
f
th
e
s
ec
a
r
eg
iv
e
r
scon
s
en
t
edtos
tudyp
a
r
t
i
c
ip
a
t
ion
.Th
ec
a
r
eg
iv
e
r
sinth
es
amp
l
ew
e
r
e
p
r
im
a
r
i
lyf
em
a
l
e(90%
)
,aspou
s
eo
fth
ec
a
r
er
e
c
ip
i
en
t(70%
)
,anda
l
lw
e
r
eov
e
r66y
e
a
r
so
f
ag
e
.Th
es
tudytookp
l
a
c
eov
e
r12w
e
ek
sands
tudyp
a
r
t
i
c
ip
an
t
scomp
l
e
t
eds
e
l
f
r
epo
r
t
ed
m
e
a
su
r
e
sdu
r
ingw
e
ekon
e
,fou
r
,e
igh
t
,and12th
a
ta
s
s
es
s
edbu
rd
enands
t
r
e
s
s(no
rm
a
t
iv
e
n
e
edm
e
a
su
r
e
s
)ands
e
rv
i
c
ew
an
t
s(
f
e
l
tn
e
edm
e
a
su
r
e
s
)
.Th
es
tudyp
a
r
t
i
c
ip
an
t
sa
l
sologg
ed
th
e
i
rs
e
rv
i
c
eu
s
ag
eov
e
rth
e12
w
e
ekp
e
r
iod(
exp
r
e
s
s
edn
e
edm
e
a
su
r
e
s
)andp
a
r
t
i
c
ip
a
t
edin
th
r
e
es
em
i
s
t
ru
c
tu
r
edin
t
e
rv
i
ew
sl
a
s
t
ingb
e
tw
e
en30and90m
inu
t
e
se
a
ch
.
Ob
j
e
c
t
iv
ec
a
r
eg
iv
e
rbu
rd
enw
a
sa
s
s
e
s
s
edbym
e
a
su
r
ingfun
c
t
ion
a
ld
ep
end
en
cyand
d
em
en
t
i
as
ev
e
r
i
tyo
fth
ec
a
r
er
e
c
ip
i
en
tu
s
ingth
eD
em
en
t
i
aR
a
t
ingS
c
a
l
e
2(DSR2
)(Mon
s
ch
e
ta
l
.
,1995
)andB
ay
e
rADLS
c
a
l
e(BALDS
)(H
indm
a
r
ch
,L
e
h
f
i
e
ld
,d
eJohgh
,&E
r
z
igk
e
i
t
,
1998
)
.Sub
j
e
c
t
iv
ec
a
r
eg
iv
e
rbu
rd
enw
a
sm
e
a
su
r
edu
s
ingth
eC
a
r
e
r
s
’Ch
e
ck
l
i
s
t(Hodg
son
,

66

	
  
H
igg
in
son
,&J
e
f
f
e
ry
s
,1998
)andG
en
e
r
a
lH
e
a
l
thQu
e
s
t
ionn
a
i
r
e(GHQ30
)(Go
ldb
e
rg&

W
i
l
l
i
am
s
,1988
)
.S
tudyr
e
su
l
t
sd
emon
s
t
r
a
t
edar
e
l
a
t
ion
shipb
e
tw
e
ens
t
r
e
s
sinth
eICPWD
andunm
e
ts
e
rv
i
c
en
e
ed
s(p=0
.05
)andin
fo
rm
a
t
ionn
e
ed
s(p=0
.01
)
.Ov
e
r
a
l
l
,th
es
tudy
f
ind
ing
ssugg
e
s
tth
a
twh
encon
s
id
e
r
ings
e
rv
i
c
en
e
ed
so
fICPWD
,h
av
inganund
e
r
s
t
and
ingo
f
f
e
l
tn
e
edm
ayb
emo
r
eu
s
e
fu
lth
a
tno
rm
a
t
iv
en
e
e
da
sf
e
l
tn
e
edh
a
sas
ign
i
f
i
c
an
tr
e
l
a
t
ion
sh
ip
w
i
thc
a
r
eg
iv
e
r
’
sm
en
t
a
lh
e
a
l
ths
t
a
tu
s
.
As
ign
i
f
i
c
an
tl
im
i
t
a
t
iono
fth
es
tudyw
a
sth
esm
a
l
ls
amp
l
es
i
z
e
.S
tud
i
e
sw
i
thl
a
rg
e
r
s
amp
l
es
i
z
e
sa
r
en
e
ed
edtosuppo
r
tth
ef
ind
ing
so
fth
i
ss
tudy
.Th
eau
tho
r
scon
c
lud
edt
h
a
t
g
a
in
inganund
e
r
s
t
and
ingo
fwh
a
ts
e
rv
i
c
e
sth
eICPWDw
an
ti
smo
r
eimpo
r
t
an
tth
an
m
e
a
su
r
ingp
e
r
c
e
iv
edl
ev
e
l
so
fbu
rd
enands
t
r
e
s
s
.F
e
l
tn
e
edm
aya
l
sob
ear
e
l
ev
an
t‘
r
edf
l
ag
’
o
fc
a
r
eg
iv
e
rbu
rnou
t
,ev
enw
i
thou
tth
econ
sp
i
cuou
s‘
r
edf
l
ag
s
’c
au
s
edbyd
e
c
l
in
einth
ec
a
r
e
r
e
c
ip
i
en
t(S
t
i
r
l
inge
ta
l
.
,2010
)
.Th
e
r
e
fo
r
e
,th
eau
tho
r
sr
e
comm
endmov
ingaw
ayf
rom
no
rm
a
t
iv
en
e
ed
sa
s
s
e
s
sm
en
tinc
l
in
i
c
a
lp
r
a
c
t
i
c
eandfo
cu
s
ingmo
r
eonvo
i
c
edn
e
ed
so
f
ICPWD
.
Inaqu
a
l
i
t
a
t
iv
es
tudybyL
eong
,M
ad
j
a
r
,andF
iv
e
a
sh(2001
)
,th
er
e
s
e
a
r
ch
e
r
s
id
en
t
i
f
i
eda
r
e
a
so
funm
e
tp
e
r
c
e
iv
edn
e
edo
fICPWDinanAu
s
t
r
a
l
i
ancommun
i
ty
.S
tudy
p
a
r
t
i
c
ip
an
t
s(n=94
)w
e
r
er
e
c
ru
i
t
edf
romcommun
i
tynu
r
s
ings
e
rv
i
c
e
sandlo
c
a
ld
em
en
t
i
a
suppo
r
tg
roupm
e
e
t
ing
s
.Ov
e
rtwoth
i
rd
so
fc
a
r
eg
iv
e
r
sw
e
r
ee
ld
e
r
lyandf
em
a
l
e
.Pu
rpo
s
iv
e
s
amp
l
ingw
a
su
s
edtoob
t
a
inav
a
r
i
eds
amp
l
eth
a
tin
c
lud
edc
a
r
eg
iv
e
r
sw
i
thd
i
f
f
e
r
en
t
b
a
ckg
round
sp
rov
id
ingc
a
r
etop
e
r
son
sind
i
f
f
e
r
en
ts
t
ag
e
so
fd
em
en
t
i
a
.Qu
a
l
i
t
a
t
iv
e
in
t
e
rv
i
ew
sandasu
rv
eyw
e
r
eu
s
edfo
rd
a
t
aco
l
l
e
c
t
ion
.Th
esu
rv
eycon
s
i
s
t
edo
ftwo
,f
iv
e
i
t
em
L
ik
e
r
ttyp
es
c
a
l
e
sfo
re
a
cho
fth
e42n
e
edi
t
em
sonth
el
i
s
t
.T
enc
a
r
eg
iv
e
r
sinth
es
tudya
l
so
p
a
r
t
i
c
ip
a
t
edins
em
i
s
t
ru
c
tu
r
edqu
a
l
i
t
a
t
iv
ein
t
e
rv
i
ew
s
.

67

	
  
S
ixunm
e
tn
e
ed
sw
e
r
eid
en
t
i
f
i
edbys
tudyp
a
r
t
i
c
ip
an
t
sin
c
lud
ing
:know
ingth
a
t
som
e
on
ew
i
l
lp
rov
id
ec
a
r
ewh
enth
eICPWDi
sun
ab
l
etodoso
;a24
hou
rt
e
l
ephon
e

in
fo
rm
a
t
ionl
in
e
;r
e
sp
i
t
e
;in
fo
rm
a
t
ionabou
tw
ay
stod
e
a
lw
i
ths
t
r
e
s
s
;t
im
efo
rphy
s
i
c
a
lr
e
s
t
;
andedu
c
a
t
ionabou
tw
ay
stod
e
a
lw
i
thf
e
e
l
ing
so
ff
e
e
l
ingt
r
app
ed(
ro
l
ec
ap
t
iv
i
ty
)
.In
r
e
spon
s
etoth
e
s
es
tudyf
ind
ing
s
,L
eonge
ta
l
.(2001
)r
e
comm
end
edth
a
tPCP
sho
ldf
am
i
ly
con
f
e
r
en
c
e
sw
i
thICPWDando
th
e
rf
am
i
lym
emb
e
r
so
rp
e
r
son
sinvo
lv
edw
i
thc
a
r
eo
fp
a
t
i
en
t
w
i
thd
em
en
t
i
aino
rd
e
rtoo
rg
an
i
z
er
e
sp
i
t
eandd
ev
e
lopana
l
t
e
rn
a
t
ep
l
ano
fc
a
r
ei
fth
e
p
r
im
a
ryICPWDi
st
empo
r
a
r
i
lyo
rp
e
rm
an
en
t
lyun
ab
l
etop
rov
id
ec
a
r
e
.L
eonge
ta
l
.(2001
)
a
l
sosugg
e
s
t
edt
ak
ingm
e
a
su
r
e
stor
a
i
s
epub
l
i
caw
a
r
en
e
s
sabou
td
em
en
t
i
aino
rd
e
rto
d
e
c
r
e
a
s
eso
c
i
a
li
so
l
a
t
iono
fICPWDandc
a
r
er
e
c
ip
i
en
t
s
.
Ro
s
ae
ta
l
.(2010
)condu
c
t
edam
ix
edm
e
thod
ss
tudyino
rd
e
rtod
e
t
e
rm
in
eth
eunm
e
t
n
e
ed
so
fICPWDwhow
e
r
ep
rov
id
ingc
a
r
efo
rind
iv
idu
a
l
sw
i
thmod
e
r
a
t
etos
ev
e
r
ed
em
en
t
i
a
.
On
ehund
r
edandtw
e
lv
eICPWDw
e
r
er
e
c
ru
i
t
edf
romam
emo
ryc
l
in
i
cinI
t
a
ly
.
Qu
e
s
t
ionn
a
i
r
e
sw
e
r
eu
s
edtoid
en
t
i
fyp
a
t
i
en
tn
e
ed
s
.C
a
r
eg
iv
e
r
’
sbu
rd
enw
a
sa
s
s
e
s
s
edu
s
ing
th
eC
a
r
eg
iv
e
rBu
rd
enInv
en
to
ry(CB
I
)(Nov
ak&Gu
e
s
t
,1989
)
.D
ep
r
e
s
s
ionandanx
i
e
tyw
e
r
e
ev
a
lu
a
t
edu
s
ingth
eC
en
t
r
efo
rEp
id
em
io
log
i
c
a
lS
tud
i
e
sD
ep
r
e
s
s
ionS
c
a
l
e(R
ad
lo
f
f
,1977
)
andS
t
a
t
e
T
r
a
itAnx
i
e
tyInv
en
to
ry(Sp
i
e
lb
e
rg
e
re
ta
l
.
,1980
)
,r
e
sp
e
c
t
iv
e
ly
.In
t
e
r
e
s
t
ing
ly
,Ro
s
a
e
ta
l
.(2010
)foundth
a
tth
ec
a
r
eg
iv
e
r
sd
idno
texp
r
e
s
sag
r
e
a
tn
e
edfo
remo
t
ion
a
land
p
sy
cho
log
i
c
a
lsuppo
r
t
;how
ev
e
r
,d
e
sp
i
t
eth
ef
a
c
tm
anyo
fth
ec
a
r
eg
iv
e
r
sh
adb
e
enp
rov
id
ing
c
a
r
efo
ras
ign
i
f
i
c
an
tamoun
to
ft
im
e
,th
eys
t
i
l
ld
emon
s
t
r
a
t
edas
ign
i
f
i
c
an
tn
e
edfo
rob
t
a
in
ing
d
i
agno
s
i
s(65%
)
,edu
c
a
t
ionabou
td
em
en
t
i
a(78%
)
,know
l
edg
eabou
tph
a
rm
a
co
log
i
c
a
l
t
r
e
a
tm
en
t(75%
)
,c
a
r
eg
iv
e
r
/
c
a
r
er
e
c
ip
i
en
tcommun
i
c
a
t
ion(83%
)
,andnon
ph
a
r
m
a
co
log
i
c
a
l
m
an
ag
em
en
to
fcogn
i
t
iv
e(77%
)andb
eh
av
iou
r
a
lp
rob
l
em
s(81%
)
.B
a
s
edonth
e
s
ef
ind
ing
s
,

68

	
  
Ro
s
ae
ta
l
.(2010
)sugg
e
s
t
edu
t
i
l
i
z
ingamu
l
t
id
i
s
c
ip
l
in
a
ryp
r
im
a
ryc
a
r
et
e
amwhoc
an
p
rov
id
eth
e
i
rexp
e
r
t
i
s
einadd
r
e
s
s
ingth
ed
i
f
f
e
r
en
ta
r
e
a
so
fn
e
ed
.
Ino
rd
e
rtoexp
lo
r
eexp
e
r
i
en
c
e
so
fp
a
t
i
en
t
sw
i
thd
em
en
t
i
aandth
e
i
rin
fo
rm
a
l

c
a
r
eg
iv
e
r
sinp
r
im
a
ryc
a
r
es
e
t
t
ing
s
,P
ro
roke
ta
l
.(2013
)p
e
r
fo
rm
edasy
s
t
em
a
t
i
cr
ev
i
ewand
e
thnog
r
aph
i
cm
e
t
a
syn
th
e
s
i
so
f46qu
a
l
i
t
a
t
iv
eandm
ix
edm
e
thods
tud
i
e
s
.F
iv
eth
em
e
s
r
e
l
a
t
edtoth
e
s
eexp
e
r
i
en
c
e
sw
e
r
eid
en
t
i
f
i
ed
.Th
ef
i
r
s
tid
en
t
i
f
i
edth
em
ew
a
s‘
s
e
ek
inga
d
i
agno
s
i
s
’
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es
e
condth
em
ew
a
s‘
a
c
c
e
s
s
ingsuppo
r
t
sands
e
rv
i
c
e
s
’
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eth
i
rdw
a
s
‘
add
r
e
s
s
ingin
fo
rm
a
t
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e
ed
s
’
.Th
efou
r
thw
a
s‘d
i
s
e
a
s
em
an
ag
em
en
t
’andth
ef
i
f
thth
em
e
w
a
s‘commun
i
c
a
t
ionanda
t
t
i
tud
e
s
’
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ro
roke
ta
l
.(2013
)d
ev
e
lop
edacon
c
ep
tu
a
lf
r
am
ewo
rk
th
a
td
e
s
c
r
ib
e
sth
ep
rog
r
e
s
s
iono
fICPWD
’
sexp
e
r
i
en
c
e
sinh
e
a
l
thc
a
r
eth
roughph
a
s
e
s
s
e
ek
ingund
e
r
s
t
and
ingandin
fo
rm
a
t
ion
,id
en
t
i
fy
ingth
ep
rob
l
em
,ro
l
et
r
an
s
i
t
ion
sfo
l
low
i
ng
d
i
agno
s
i
s
,andl
iv
ingw
i
thch
ang
e
.
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a
s
edonth
er
e
su
l
t
so
fth
er
ev
i
ew
,P
ro
roke
ta
l
.(2013
)con
c
lud
edth
a
t
,ov
e
r
a
l
l
,th
e
h
e
a
l
thc
a
r
eexp
e
r
i
en
c
efo
rICPWDi
ssub
s
t
and
a
rdandp
a
r
t
so
fc
a
r
eg
iv
e
r
s
’exp
e
r
i
en
c
e
scou
ld
b
eimp
rov
edupon
.Th
eau
tho
r
ss
t
a
t
eth
a
timp
l
em
en
t
ingc
e
r
t
a
inin
t
e
rv
en
t
ion
s
,su
cha
sth
eu
s
e
o
fc
a
r
em
an
ag
e
r
sandp
sy
cho
edu
c
a
t
ion
,m
ayb
en
e
f
i
tICPWD
.Th
eu
s
eo
fm
e
t
a
e
thno
logyto
an
a
ly
z
eth
el
i
t
e
r
a
tu
r
ei
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t
r
eng
thr
e
cogn
i
z
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eau
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r
s
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si
ta
l
low
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rsupp
l
em
en
t
a
ry
an
a
ly
s
i
sandth
ed
ev
e
l
opm
en
to
ff
r
am
ewo
rk
ssu
cha
sth
e“
con
c
ep
tu
a
lf
r
am
ewo
rkfo
rth
e
h
e
a
l
thc
a
r
eexp
e
r
i
en
c
eo
fp
eop
l
ew
i
thd
em
en
t
i
aandth
e
i
rc
a
r
eg
iv
e
r
s
”(P
ro
roke
ta
l
.
,2013
,p
.
E675
)
.
Th
eexp
e
r
i
en
c
e
so
fmyG
r
andm
aandAun
ta
r
er
e
f
l
e
c
t
edinm
anyo
fth
es
tudy
f
ind
ing
sd
i
s
cu
s
s
edthu
sf
a
rinth
i
sch
ap
t
e
r
.S
im
i
l
a
rtoICPWDinth
eBough
twoode
ta
l
.
(2011
)s
tudy
,myG
r
andm
aandAun
tbo
thsp
en
ts
ign
i
f
i
c
an
tamoun
t
so
ft
im
einth
eho
sp
i
t
a
l

69

	
  
wh
enmyG
r
andp
aw
a
sadm
i
t
t
ed
,a
sth
eyo
f
t
enf
e
l
tth
a
th
i
sn
e
ed
sw
e
r
eno
tb
e
ingm
e
t
.In

m
anyc
a
s
e
s
,h
i
sn
e
ed
sw
e
r
eno
tm
e
t
,b
e
c
au
s
es
t
a
f
fw
e
r
eno
tf
am
i
l
i
a
rw
i
thh
i
sh
i
s
to
ryo
rhow
toin
t
e
rp
r
e
th
i
sb
eh
av
iou
r
s
.Th
er
epo
r
t
edf
e
e
l
ingo
flon
e
l
in
e
s
sw
a
sc
e
r
t
a
in
lysh
a
r
edbymy
G
r
andm
aandAun
tw
i
tho
th
e
rICPWDinth
es
tud
i
e
s
.Th
ecommonandsh
a
r
edexp
e
r
i
en
c
e
s
o
fmyf
am
i
ly
’
sl
iv
edexp
e
r
i
en
c
eandICPWDinth
er
ev
i
ew
eds
tud
i
e
sd
emon
s
t
r
a
t
e
sth
a
tth
e
ch
a
l
l
eng
e
sandn
e
e
d
sr
epo
r
t
edinth
el
i
t
e
r
a
tu
r
ea
r
e
,inf
a
c
t
,ar
e
a
l
i
tyfo
rC
an
ad
i
anICPWD
.
Th
i
sr
e
a
l
i
tyemph
a
s
i
z
e
sth
en
e
edfo
rag
r
e
a
t
e
rund
e
r
s
t
and
ingo
fth
e
s
el
iv
edexp
e
r
i
en
c
e
sby
PCP
sino
rd
e
rtob
e
s
tsuppo
r
tICPWDinp
r
im
a
ryc
a
r
eu
s
ingap
e
r
sonc
en
t
r
edapp
ro
a
ch
.
In
fo
rma
lCa
r
eg
iv
e
rA
s
s
e
s
sm
en
t
O
fth
e30a
r
t
i
c
l
e
sandgu
id
e
l
in
e
sr
ev
i
ew
ed
,on
econ
s
en
su
sr
epo
r
tp
e
r
t
a
in
edto
c
a
r
eg
iv
e
ra
s
s
e
s
sm
en
t
.Th
eF
am
i
lyC
a
r
eg
iv
e
rA
l
l
i
an
c
e(2006
)a
s
c
e
r
t
a
in
edth
a
t“
e
s
t
ab
l
i
sh
ing
c
a
r
eg
iv
e
ra
s
s
e
s
sm
en
ta
sab
a
s
i
ccompon
en
to
fp
r
a
c
t
i
c
ea
c
ro
s
sc
a
r
es
e
t
t
ing
s
w
i
thfo
rm
a
l
r
e
cogn
i
t
iono
fc
a
r
eg
iv
ingf
am
i
l
i
e
sandth
ego
a
lo
fs
t
r
eng
th
en
ingth
em
c
a
l
l
sfo
ra
fund
am
en
t
a
lch
ang
eo
fth
ink
inginpo
l
i
cyan
dp
r
a
c
t
i
c
e
”(p
.1
)
.Ino
rd
e
rtoen
cou
r
ag
ec
a
r
e
p
rov
id
e
r
stoin
co
rpo
r
a
t
ea
s
s
e
s
sm
en
to
fin
fo
rm
a
lc
a
r
eg
iv
e
r
sin
top
r
a
c
t
i
c
eandn
a
r
rowth
e
r
e
s
e
a
r
ch
p
r
a
c
t
i
c
eg
ap
,th
eF
am
i
lyC
a
r
eg
iv
e
rA
l
l
i
an
c
e(2006
)d
ev
e
lop
edacon
s
en
su
sr
epo
r
t
onc
a
r
eg
iv
e
ra
s
s
e
s
sm
en
tb
a
s
edonexp
e
r
top
in
ion
so
fnum
e
rou
sh
e
a
l
thc
a
r
el
e
ad
e
r
s
.Th
e
r
epo
r
tp
rov
id
e
sbo
thp
r
in
c
ip
l
e
sandgu
id
e
l
in
e
sth
a
th
e
a
l
thc
a
r
ep
rov
id
e
r
sc
ana
s
s
im
i
l
a
t
ein
to
th
e
i
rp
r
a
c
t
i
c
e
.Inth
egu
id
e
l
in
e
s
,th
eF
am
i
lyC
a
r
eg
iv
e
rA
l
l
i
an
c
e(2006
)r
e
comm
end
s
a
s
s
e
s
s
inga
l
lid
en
t
i
f
i
edc
a
r
eg
iv
e
r
s
,con
s
id
e
r
ingp
a
t
i
en
t
sandc
a
r
eg
iv
e
r
sa
sdy
ad
s
,t
a
i
lo
r
ing
a
s
s
e
s
sm
en
tandin
t
e
rv
en
t
ion
stoth
ec
a
r
eg
iv
ingcon
t
ex
t
,andc
l
e
a
r
lycommun
i
c
a
t
ingth
e
r
e
a
son
sfo
ra
s
s
e
s
sm
en
ttoth
ec
a
r
eg
iv
e
r
.Fu
r
th
e
r
,i
ti
ssugg
e
s
t
edth
a
tag
lob
a
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e
s
sm
en
t
,

70

	
  

gu
id
edbyacon
c
ep
tu
a
lf
r
am
ewo
rk
,shou
ldb
ep
e
r
fo
rm
eda
tth
eb
eg
inn
ingo
fe
a
chc
a
r
eg
iv
ing
jou
rn
eyandwh
en
ev
e
rt
r
an
s
i
t
ion
so
c
cu
ra
sp
a
r
to
fth
ec
a
r
eg
iv
ingjou
rn
ey
.
Th
egu
id
e
l
in
e
sinth
er
epo
r
tw
e
r
eno
tg
r
ad
edfo
rqu
a
l
i
ty
.A
l
thoughsuppo
r
t
ing
l
i
t
e
r
a
tu
r
ew
a
su
s
edth
ro
ughou
tth
er
epo
r
t
,r
e
comm
end
a
t
ion
sinth
egu
id
e
l
in
e
sa
r
ein
fo
rm
ed
bycon
s
en
su
so
fop
in
ionandth
e
r
e
fo
r
eth
es
t
r
eng
tho
fth
er
e
comm
end
a
t
ion
si
sd
im
in
i
sh
ed
.
D
e
sp
i
t
eth
es
t
a
t
edl
im
i
t
a
t
ion
s
,th
er
epo
r
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ropo
s
e
ss
a
l
i
en
tp
r
in
c
ip
l
e
sandc
l
e
a
r
r
e
comm
end
a
t
ion
sth
a
tPCP
sc
anu
s
etoadd
r
e
s
sin
fo
rm
a
lc
a
r
eg
iv
e
rn
e
ed
sandgu
id
eth
e
s
e
l
e
c
t
iono
fsuppo
r
t
iv
ein
t
e
rv
en
t
ion
s
.
P
rov
id
ing‘Road
s
id
eA
s
s
i
s
tan
c
e
’
:HowE
f
f
e
c
t
iv
eA
r
eP
r
ima
ryCa
r
eBa
s
ed
In
t
e
rv
en
t
ion
s?
In
t
e
rv
en
t
ion
b
a
s
edr
e
s
e
a
r
chs
tud
i
e
scon
t
r
ibu
t
etoth
efound
a
t
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fev
id
en
c
e
b
a
s
ed
p
r
a
c
t
i
c
ebysub
s
t
an
t
i
a
t
ingth
ee
f
f
i
c
a
cyo
fsp
e
c
i
f
i
cin
t
e
rv
en
t
ion
s(G
rov
e
,Bu
rn
s
,&G
r
ey
,
2013
)
.S
id
an
iandB
r
ad
en(1998
)con
s
id
e
r
edin
t
e
rv
en
t
ion
stob
e“
t
r
e
a
tm
en
t
s
,th
e
r
ap
i
e
s
,
p
ro
c
edu
r
e
s
,o
ra
c
t
ion
simp
l
em
en
t
edbyh
e
a
l
thp
ro
f
e
s
s
ion
a
l
stoan
dw
i
thc
l
i
en
t
s
,ina
p
a
r
t
i
cu
l
a
rs
i
tu
a
t
ion
,tomov
eth
ec
l
i
en
t
s
’cond
i
t
iontow
a
rdd
e
s
i
r
edh
e
a
l
thou
t
com
e
sth
a
ta
r
e
b
en
e
f
i
c
i
a
ltoth
ec
l
i
en
t
s
”(p
.8
)
.P
r
im
a
ryc
a
r
e
b
a
s
edin
t
e
rv
en
t
ion
sfoundinth
el
i
t
e
r
a
tu
r
e
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im
eda
timp
rov
ingth
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e
a
l
tho
fin
fo
rm
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lc
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r
eg
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e
r
sa
r
ev
a
r
i
ed
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chin
t
e
rv
en
t
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sr
ang
e
f
romen
su
r
ingknow
l
edg
e
sh
a
r
ingb
e
tw
e
enth
ePCPandth
ec
l
i
en
tr
eg
a
rd
ingav
a
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l
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l
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commun
i
tyr
e
sou
r
c
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l
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iv
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t
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l
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ip
l
in
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l
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e
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s
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e
amandcommun
i
tys
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ep
a
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e
r
s
.
D
e
sp
i
t
eth
er
e
l
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t
iv
eabund
an
c
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fc
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r
eg
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en
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ac
a
r
el
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t
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a
tu
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a
i
l
ab
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ea
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e
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t
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ro
fs
tud
i
e
sp
e
r
t
a
in
ingsp
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f
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c
a
l
lytop
r
im
a
ryc
a
r
e
b
a
s
edin
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e
rv
en
t
ion
s
.
S
in
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so
f
t
enh
av
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t
a
c
tw
i
thICPWD
,ac
r
i
t
i
c
a
ls
t
epinan
sw
e
r
ingth
e

71

	
  

r
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s
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a
r
chqu
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t
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fth
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sl
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r
im
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abo
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c
t
i
t
ion
e
ro
rnu
r
s
ef
rom
th
ep
r
im
a
ryc
a
r
ec
l
in
i
c
.
Ano
t
ab
l
es
t
r
eng
tho
fth
es
tudyin
c
lud
edth
eu
s
eo
fv
a
l
id
a
t
eds
e
l
fr
epo
r
t
ed
qu
e
s
t
ionn
a
i
r
e
stoob
t
a
inou
t
com
ed
a
t
a
,wh
i
chenh
an
c
edth
econv
e
rg
en
tv
a
l
id
i
tyo
fth
es
tudy
.
Th
ev
a
l
id
a
t
edandr
ep
l
i
c
a
t
ed12i
t
emv
e
r
s
iono
fth
eG
en
e
r
a
lH
e
a
l
thQu
e
s
t
ionn
a
i
r
e(GHQ
12
)
(Mon
t
a
z
e
r
ie
ta
l
.
,2003
)w
a
su
s
edtom
e
a
su
r
eth
ec
a
r
eg
iv
e
r
’
sp
e
r
c
ep
t
ion
so
fth
e
i
rm
en
t
a
l

72

	
  
h
e
a
l
tha
sap
r
im
a
ryou
t
com
e
.S
e
cond
a
ryou
t
com
e
s(d
y
s
fun
c
t
ion
a
lthough
t
s
,QOL
,and

bu
rd
en
)w
e
r
em
e
a
su
r
edu
s
ingth
eDy
s
fun
c
t
ion
a
lThough
t
sabou
tC
a
r
eg
iv
ingQu
e
s
t
ionn
a
i
r
e
(Mono
to
r
io
,Lo
s
ad
a
,I
z
a
l
,& M
á
rqu
e
z
,2009
)
,Ru
i
zandB
a
c
a
’
s(1993
)Qu
e
s
t
ionn
a
i
r
e
,andth
e
Sho
r
tZ
a
r
i
tBu
rd
enIn
t
e
rv
i
ew(B
éd
a
rde
ta
l
.
,2001
)
,r
e
sp
e
c
t
iv
e
ly
.S
t
a
t
i
s
t
i
c
a
l
lys
ign
i
f
i
c
an
t
imp
rov
em
en
t
sw
e
r
efoundinr
e
l
a
t
iontody
s
fun
c
t
ion
a
lthough
t
sabou
tc
a
r
eg
iv
ing(p=.01
)
,
a
sw
e
l
la
sw
i
th
intwodom
a
in
so
fth
eGHQ
12
:cogn
i
t
ionandphy
s
io
log
i
c
a
l(p=.04
)and
g
en
e
r
a
lw
e
l
f
a
r
e(p=.01
)
.How
ev
e
r
,nos
ign
i
f
i
c
an
timp
rov
em
en
t
sw
e
r
ed
emon
s
t
r
a
t
edin
r
e
l
a
t
iontoQOLo
rbu
rd
en
.A
sar
e
su
l
to
fth
e
s
ef
ind
ing
s
,th
i
sin
t
e
rv
en
t
ionc
anno
tb
e
r
e
comm
end
edini
so
l
a
t
iontoimp
rov
eth
eg
en
e
r
a
lw
e
l
l
b
e
ingo
fin
fo
rm
a
lc
a
r
eg
iv
e
r
s
(Rod
r
igu
e
z
S
an
ch
e
ze
ta
l
.
,2012
)
.Anoth
e
rl
im
i
t
a
t
iono
fth
i
ss
tudyi
sth
eab
s
en
c
eo
ffo
l
low
upa
f
t
e
rth
es
tudy
’
scomp
l
e
t
iontod
e
t
e
rm
in
eanylong
t
e
rme
f
f
e
c
t
iv
en
e
s
so
fth
ein
t
e
rv
en
t
ion
.
AG
e
rm
anRCTby M
enne
ta
l
.(2012
)comp
a
r
edth
r
e
ecoun
s
e
l
l
ingandsuppo
r
t
in
t
e
rv
en
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ion
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fd
i
f
f
e
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en
tin
t
en
s
i
t
i
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ep
rov
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s
iono
fu
su
a
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e
rtod
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t
e
rm
in
e
wh
e
th
e
rth
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e
rv
en
t
ion
simp
a
c
t
edt
im
ingo
fnu
r
s
inghom
ep
l
a
c
em
en
to
fp
a
t
i
en
t
sw
i
th
d
em
en
t
i
a
.Th
i
sth
r
e
e
a
rmc
lu
s
t
e
r
RCTinvo
lv
edal
a
rg
es
amp
l
es
i
z
eo
f390ind
iv
idu
a
l
sw
i
th
d
em
en
t
i
aag
ed65y
e
a
r
so
ro
ld
e
ra
sw
e
l
la
sth
e
i
rin
fo
rm
a
lc
a
r
eg
iv
e
r
s
.Th
ein
t
e
rv
en
t
ion
in
c
lud
edth
et
r
a
in
ingo
ff
am
i
lyphy
s
i
c
i
an
sind
em
en
t
i
ac
a
r
eandth
e
i
rsub
s
equ
en
tin
o
f
f
i
c
e
coun
s
e
l
ingandr
e
f
e
r
r
a
l
stosuppo
r
tg
roup
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rc
a
r
eg
iv
e
r
s
.Th
elongt
e
rme
f
f
e
c
t
so
fth
e
in
t
e
rv
en
t
io
nw
e
r
ea
s
s
e
s
s
edov
e
rafou
r
y
e
a
rp
e
r
iod
,am
a
rk
eds
t
r
eng
tho
fth
es
tudy
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f
t
e
rtwo
y
e
a
r
s
,12%o
fth
ep
a
r
t
i
c
ip
an
tp
a
t
i
en
t
sh
adb
e
ent
r
an
s
f
e
r
r
edtor
e
s
id
en
t
i
a
lc
a
r
ewh
i
l
e66%s
t
i
l
l
l
iv
eda
thom
e
.Fou
ry
e
a
r
sl
a
t
e
r
,24%o
fth
ep
a
r
t
i
c
ip
an
tp
a
t
i
en
t
sh
adb
e
enin
s
t
i
tu
t
ion
a
l
i
z
edand
on
ly39%r
em
a
in
eda
thom
e(M
enne
ta
l
.
,2012
)
.Th
e
s
ef
ind
ing
ssuppo
r
te
a
r
l
i
e
rcon
t
en
t
ion
s
th
a
tth
ein
ab
i
l
i
tyo
fth
eICPWDtocon
t
inu
ec
a
r
ingfo
rth
ec
a
r
er
e
c
ip
i
en
ti
scong
ru
en
tw
i
th

73

	
  
th
ebu
rd
ena
s
so
c
i
a
t
edw
i
thth
ep
rog
r
e
s
s
iv
en
a
tu
r
eo
fd
e
m
en
t
i
asymp
tom
s
.

Ov
e
r
a
l
l
,M
enne
ta
l
.(2012
)foundnos
ign
i
f
i
c
an
td
i
f
f
e
r
en
c
e
sb
e
tw
e
enth
ein
t
e
rv
en
t
ion
andcon
t
ro
lg
roup
sr
eg
a
rd
ingth
et
im
ingo
fr
e
s
id
en
t
i
a
lc
a
r
ep
l
a
c
em
en
ta
ttwoandfou
ry
e
a
r
s
(p=0
.25andp=0
.71
,r
e
sp
e
c
t
iv
e
ly
)
.S
im
i
l
a
r
ly
,d
e
sp
i
t
ead
j
u
s
t
ingfo
rcon
found
ing
d
emog
r
aph
i
cv
a
r
i
ab
l
e
s
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e
cond
a
ryou
t
com
e
ssu
cha
scogn
i
t
iv
efun
c
t
ion
ingandADL
so
fth
e
p
a
t
i
en
t
s
,c
a
r
eg
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e
rbu
rd
en
,andQOL
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ign
i
f
i
c
an
td
i
f
f
e
r
en
c
e
sw
e
r
ed
emon
s
t
r
a
t
edb
e
tw
e
en
th
ein
t
e
rv
en
t
ionandcon
t
ro
lg
roup
sa
tth
etwoandfou
ry
e
a
rm
a
rk
s
.How
ev
e
r
,i
ti
simpo
r
t
an
t
tono
t
eth
a
tth
er
e
su
l
t
so
fth
i
ss
tudym
ayh
av
eb
e
enin
f
lu
en
c
edbys
ev
e
r
a
lcon
found
ing
va
r
i
ab
l
e
s
.Fo
rex
amp
l
e
,th
e
r
ew
e
r
eah
ighnumb
e
ro
fp
a
t
i
en
t
sinth
ee
a
r
lys
t
ag
e
so
fd
em
en
t
i
a
a
tth
eb
eg
inn
ingo
fth
es
tudy
,l
ik
e
lya
f
f
e
c
t
ingp
r
im
a
ryands
e
cond
a
ryou
t
com
e
ssu
cha
s
c
a
r
eg
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rbu
rd
enandIADLfun
c
t
ion
inga
sth
ec
a
r
er
e
c
ip
i
en
t
’
sn
e
edfo
ra
s
s
i
s
t
an
c
ei
sl
e
s
s
.
Fu
r
th
e
r
,incon
t
r
a
s
ttoo
th
e
rs
tud
i
e
sr
ev
i
ew
ed
,in
fo
rm
a
lc
a
r
eg
iv
e
rp
a
r
t
i
c
ip
an
t
sinth
i
ss
tudy
vo
lun
t
a
r
i
lycho
s
ewh
e
t
h
e
ro
rno
ttou
s
eth
esuppo
r
t
iv
ecompon
en
t
so
fth
ein
t
e
rv
en
t
ion
,su
ch
a
scoun
s
e
l
ingandsuppo
r
tg
roup
s
.A
l
low
ingth
es
tudyp
a
r
t
i
c
ip
an
t
stochoo
s
ewh
a
t
in
t
e
rv
en
t
ion
sth
eyr
equ
i
r
e
dmo
r
ea
c
cu
r
a
t
e
lym
i
r
ro
r
edr
e
a
l
i
s
t
i
cp
r
im
a
ryc
a
r
eand
t
r
an
s
f
e
r
ab
i
l
i
tytop
r
a
c
t
i
c
e
,thu
sp
rov
id
inge
l
ev
a
t
edex
t
e
rn
a
lv
a
l
id
i
tyo
fth
es
tudyf
ind
ing
s
(M
enne
ta
l
.
,2012
)
.
Du
r
ingth
ecomp
r
eh
en
s
iv
el
i
t
e
r
a
tu
r
es
e
a
r
ch
,on
lyon
esy
s
t
em
a
t
i
cr
ev
i
eww
a
sfound
th
a
tex
am
in
edp
r
im
a
ryc
a
r
e
b
a
s
edp
sy
cho
so
c
i
a
lin
t
e
rv
en
t
ion
ssp
e
c
i
f
i
c
a
l
ly
.Du
etoth
ed
e
a
r
th
o
fl
i
t
e
r
a
tu
r
ew
i
thr
eg
a
rdtop
r
im
a
ryc
a
r
e
b
a
s
edc
a
r
eg
iv
e
rin
t
e
rv
en
t
ion
s
,th
esy
s
t
em
a
t
i
cr
ev
i
ew
condu
c
t
edbyG
r
e
enwood
,P
e
lon
e
,andH
a
s
s
enk
amp(2016
)in
c
lud
edon
lyfou
rr
e
s
e
a
r
ch
s
tud
i
e
sth
a
tsyn
th
e
s
i
z
edev
id
en
c
efo
rth
eu
s
eo
fp
sy
cho
so
c
i
a
lin
t
e
rv
en
t
ion
sfo
rin
fo
rm
a
l
c
a
r
eg
iv
e
r
so
find
iv
idu
a
l
sw
i
the
i
th
e
rd
em
en
t
i
ao
rs
t
rok
eing
en
e
r
a
lp
r
a
c
t
i
c
e
.A
l
though

74

	
  

c
a
r
eg
iv
e
r
so
find
iv
idu
a
l
swhoh
adexp
e
r
i
en
c
edas
t
rok
ew
e
r
ein
c
lud
edinth
es
e
a
r
ch
,th
efou
r
s
tud
i
e
sth
a
tf
i
tth
ec
r
i
t
e
r
i
ao
fth
er
ev
i
ewinv
e
s
t
ig
a
t
edICPWDon
ly
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fth
e
s
es
tud
i
e
s
w
e
r
eRCT
s
.Th
eth
i
rds
tudyw
a
sanonequ
iv
a
l
en
tcon
t
ro
lg
roupt
r
i
a
landth
efou
r
thw
a
s
d
e
f
in
eda
san“un
con
t
ro
l
l
edb
e
fo
r
eanda
f
t
e
rs
tudy
”(G
r
e
en
woode
ta
l
.
,2016
)
.Th
eau
tho
r
s
u
s
edKm
e
t
,L
e
e
,andCook
’
s(2004
)qu
a
l
i
tya
s
s
e
s
sm
en
tc
r
i
t
e
r
i
atoa
s
s
e
s
sth
em
e
thodo
log
i
c
a
l
qu
a
l
i
tyandfoundth
a
ton
lytwoo
fth
es
tud
i
e
sw
e
r
er
a
t
eda
s“good
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,w
i
thas
co
r
eo
f85%o
r
mo
r
e(G
r
e
enwoode
ta
l
.
,2016
)
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tud
i
e
sinc
lud
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er
ev
i
ewm
e
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su
r
edc
a
r
eg
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rou
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e
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o
fd
ep
r
e
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iv
esymp
tom
s
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t
ion
a
landphy
s
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c
a
lh
e
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l
th
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a
r
eg
iv
ingch
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l
l
eng
e
s
,d
em
en
t
i
a
know
l
edg
e
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rd
en
,so
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i
a
lsuppo
r
t
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e
l
l
b
e
ing
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a
i
l
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l
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id
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c
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e
s
t
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a
t
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em
en
t
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t
iono
fp
sy
cho
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lin
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r
eg
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rw
e
l
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ingandm
en
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lh
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a
l
th
.How
ev
e
r
,c
au
t
ionw
a
ssugg
e
s
t
edbyth
eau
tho
r
s
con
s
id
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r
ingth
a
tth
er
e
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l
t
so
fth
es
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en
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,andc
a
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eg
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)
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tudyth
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emon
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a
t
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c
i
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l
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en
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e
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en
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,
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i
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edo
ff
iv
ew
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ek
lyedu
c
a
t
ions
e
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ion
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,e
a
chl
a
s
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ing30m
inu
t
e
s
.Th
er
e
s
e
a
r
ch
e
r
s
r
e
cogn
i
z
edth
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e
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i
en
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c
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an
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en
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i
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ll
im
i
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iono
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es
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iv
enth
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t
phy
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i
c
i
an
sh
adl
im
i
t
edt
r
a
in
ingind
em
en
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i
ac
a
r
e
.
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r
ingth
ef
i
r
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ts
e
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ion
,th
ephy
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i
c
i
anfo
cu
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edonc
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eg
iv
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ra
s
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e
s
sm
en
t
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e
fo
l
low
ingfou
rs
e
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s
ion
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encon
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i
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edo
fedu
c
a
t
iona
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td
em
en
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i
a
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tu
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eimp
l
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c
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ion
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th
ed
i
s
e
a
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e
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r
e
a
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en
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r
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ingonch
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av
iou
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rd
enw
a
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m
e
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su
r
edu
s
ingth
eZ
a
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i
tC
a
r
e
rBu
rd
enIn
t
e
rv
i
ew(B
éd
a
rde
ta
l
.
,2001
),d
i
s
t
r
e
s
su
s
ingth
e
SRQ20c
a
r
e
rp
sy
cho
log
i
c
a
ld
i
s
t
r
e
s
stoo
l(M
ar
i& W
i
l
l
i
am
s
,1985
)
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s
ingth
e
WHOQOLBREFtoo
l(Th
e WHOQOLG
roup
,1998
)
.BPSDandQOLw
e
r
em
e
a
su
r
edin

78

	
  

th
ep
e
r
sonw
i
thd
em
en
t
i
au
s
ingth
eNP
I
Q(K
au
f
e
re
ta
l
.
,2000
)andth
ed
em
en
t
i
asp
e
c
i
f
i
c
h
e
a
l
thr
e
l
a
t
edQOL(DEMQOL
,Sm
i
the
ta
l
.
,2005
)s
c
a
l
e
s
.Th
er
e
s
e
a
r
ch
e
r
sr
epo
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a
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i
c
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l
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ign
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f
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edu
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t
ioninc
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iv
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rd
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e
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a
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eg
iv
e
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th
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e
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en
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iong
roup
;how
ev
e
r
,i
tshou
ldb
eno
t
edth
a
tth
epo
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i
t
iv
ef
ind
ingw
i
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e
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e
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tto
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rd
enm
ayb
ear
e
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l
to
fatyp
eIe
r
ro
r(
f
a
l
s
epo
s
i
t
iv
er
e
su
l
t
)(G
av
r
i
lov
ae
ta
l
.
,2009
)
.Asa
l
l
o
th
e
rou
t
com
e
sd
idno
th
av
epo
s
i
t
iv
er
e
su
l
t
ss
in
c
eth
es
tudyw
a
s“no
ts
t
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t
i
s
t
i
c
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l
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e
r
edto
d
e
t
e
c
td
i
f
f
e
r
en
c
e
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i
ss
i
z
e
”(p
.352
)(
l
e
ad
ingtotyp
eI
Ie
r
ro
r
s
)
,y
e
tth
ebu
rd
enou
t
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e
w
a
spo
s
i
t
iv
ede
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i
t
es
ev
e
r
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ls
t
a
t
i
s
t
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c
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lcomp
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r
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h
er
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e
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ch
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e
l
tth
a
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etyp
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r
ro
r
m
ayh
av
eo
c
cu
r
r
ed(G
av
r
i
lov
ae
ta
l
.
,2009
)
.
Co
l
labo
ra
t
iv
eca
r
ein
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e
rv
en
t
ion
s
.Fou
rs
tud
i
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ev
i
ewinv
e
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ig
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edth
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a
c
to
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l
l
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a
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ion
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r
eg
iv
e
rou
t
com
e
s
.Inth
ef
i
r
s
ts
tudy
,B
a
s
se
t
a
l
.(2013
)imp
l
em
en
t
edaRCTth
a
tev
a
lu
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t
edth
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f
f
e
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iv
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rog
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amonimp
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e
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en
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l
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im
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rom

79

	
  

th
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ips
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e
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eg
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r
ts
e
rv
i
c
e
s
)(B
a
s
se
ta
l
.
,
2013
)
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ep
r
e
s
s
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sm
e
a
su
r
edu
s
ingth
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em
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cS
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i
e
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ep
r
e
s
s
ionS
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a
l
e(Kohou
t
e
ta
l
.
,1993
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i
l
ea
l
lo
th
e
rou
t
com
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sw
e
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r
edu
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l
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l
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andK
enyon
P
e
s
c
e(2009
)condu
c
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i
l
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an
f
romth
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ro
lg
roup
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r
t
in
skye
ta
l
.(2009
)a
l
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80

	
  
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a
l
l
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andom
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roup(n=69
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er
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en
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efoundb
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e
enth
eg
roup
sin

81

	
  
th
et
im
ingo
fnu
r
s
inghom
ep
l
a
c
em
en
t
,imp
rov
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en
to
fp
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t
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en
tcogn
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ion
,o
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s
.
How
ev
e
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,i
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eno
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et
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e
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einh
ib
i
to
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s
,

cogn
i
t
iv
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s
s
e
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sm
en
t
sw
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ep
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fo
rm
edov
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et
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l
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e(wh
i
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ayb
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f
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etof
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en
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s
)
,andth
eh
e
t
e
rog
en
eou
ss
amp
l
eh
admu
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ip
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id
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ch
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rm
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c
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lt
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e
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tm
en
tcho
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en(C
a
l
l
ah
ane
ta
l
.
,2006
)
.
As
ign
i
f
i
c
an
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ind
ingo
fth
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r
eg
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roupr
a
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’
sp
r
im
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edtoon
ly
55
.9%o
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su
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lc
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eg
roup(p=0
.002
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ev
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t18mon
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s
ixmon
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f
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in
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)
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im
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r
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su
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roup(p=0
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i
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s
t
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ip
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e
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eg
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ep
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ipw
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aych
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ea
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eg
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ev
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rd
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c
r
e
a
s
e
s
.
L
a
s
t
ly
,V
i
ck
r
eye
ta
l
.(2006
)ex
am
in
edth
ee
f
f
e
c
to
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em
en
t
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ac
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em
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igh
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andom
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roup
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edo
fac
a
r
em
an
ag
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id
ings
t
ru
c
tu
r
ed

82

	
  
a
s
s
e
s
sm
en
t
s
,d
ev
e
lop
ingc
a
r
ep
l
an
s
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e
f
e
r
r
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l
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in
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t
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tw
e
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l
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r
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egu
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rt
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l
ephon
eo
rin
hom
efo
l
lowupv
i
s
i
t
s
,andedu
c
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a
ls
em
in
a
r
s
.

C
a
r
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r
sf
romth
ein
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epo
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t
edin
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s
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roupa
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fh
e
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l
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ro
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roup
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sd
e
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l
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l
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e
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tl
i
t
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r
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ein
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end
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t
p
r
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c
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i
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e
r
sinth
e
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rd
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c
i
s
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ak
ingandtoenh
an
c
ep
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t
i
en
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a
r
e(Th
eN
a
t
ion
a
lA
c
ad
emyo
f
S
c
i
en
c
e
s
,2011
)
.Un
fo
r
tun
a
t
e
ly
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el
i
t
e
r
a
tu
r
es
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a
r
chfo
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a
i
l
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id
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l
in
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ssp
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i
f
i
ctoin
fo
rm
a
lc
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r
eg
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s
;how
ev
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r
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ac
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r
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i
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te
a
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t
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eg
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r
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s
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e
gu
id
e
l
in
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sa
r
esumm
a
r
i
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a
ly
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l
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lys
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c
em
anyo
fth
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w
e
r
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im
i
l
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randin
c
lud
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tha
s
s
e
s
sm
en
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l
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ad
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ty
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id
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es
t
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fth
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si
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ss
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ef
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sd
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lop
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thp
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r
t
i
cu
l
a
r

83

	
  
con
s
id
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r
a
t
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fth
ep
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im
a
ryc
a
r
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t
ex
t
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e
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l
sa
sn
e
c
e
s
s
a
ry
.U
t
i
l
i
z
a
t
iono
fapp
rop
r
i
a
t
e
commun
i
tys
e
rv
i
c
e
sfo
rth
ep
a
t
i
en
tw
i
thd
em
en
t
i
ai
sr
e
comm
end
ed
.
Th
eSp
an
i
shN
a
t
ion
a
lH
e
a
l
thS
e
rv
i
c
e(SNS
)pub
l
i
sh
edth
es
e
condgu
id
e
l
in
eonth
e
Comp
r
eh
en
s
iv
eC
a
r
eo
fP
eop
l
ew
i
thA
l
zh
e
im
e
r
’
sD
i
s
e
a
s
eandO
th
e
rD
em
en
t
i
a
sin2011
.Th
e
SNS(2011
)id
en
t
i
f
i
e
sana
f
f
i
l
i
a
t
edA
l
zh
e
im
e
r
’
sd
i
s
e
a
s
esuppo
r
to
rg
an
iz
a
t
iona
sav
a
lu
ab
l
e
r
e
sou
r
c
etowh
i
chPCP
sc
anconn
e
c
tc
a
r
eg
iv
e
r
sfo
rapp
rop
r
i
a
t
ecoun
s
e
l
ing
,edu
c
a
t
ion
,and
suppo
r
t
iv
es
e
rv
i
c
e
s
.Ar
e
comm
end
a
t
ioni
sm
ad
etoe
s
t
ab
l
i
sha“w
e
l
com
ep
rog
r
am
”fo
r
p
a
t
i
en
t
sw
i
thd
em
en
t
i
aandth
e
i
rc
a
r
eg
iv
e
r
s
,tob
eo
f
f
e
r
edbya
nin
t
e
rd
i
s
c
ip
l
in
a
ryp
r
im
a
ry
c
a
r
et
e
amina
s
so
c
i
a
t
ionw
i
thana
f
f
i
l
i
a
t
edsuppo
r
t
iv
ed
em
en
t
i
ao
rg
an
i
z
a
t
ion
.Du
r
ingth
eend
s
t
ag
eo
fd
em
en
t
i
a
,th
eSNS(2011
)sugg
e
s
t
sco
l
l
abo
r
a
t
ingw
i
thp
a
l
l
i
a
t
iv
ec
a
r
es
e
rv
i
c
e
sin
o
rd
e
rtop
rov
id
ec
a
r
eg
iv
e
r
sw
i
thg
r
i
e
fanden
do
fl
i
f
esuppo
r
t
iv
ein
t
e
rv
en
t
ion
s
.Th
e
s
e
r
e
comm
end
a
t
ion
sexp
l
i
c
i
t
lysuppo
r
tth
ef
a
c
i
l
i
t
a
t
iono
fad
ap
t
a
t
iondu
r
ingt
r
an
s
i
t
ion
sf
a
c
ed
th
roughou
tth
ec
a
r
eg
iv
ingjou
rn
ey
,ak
eys
t
r
eng
tho
fth
e
s
ep
a
r
t
i
cu
l
a
rgu
id
e
l
in
e
s
.
Th
eth
i
rdgu
id
e
l
in
ew
a
sw
r
i
t
t
enin2006byth
eS
co
t
t
i
shIn
t
e
r
co
l
l
eg
i
a
t
eGu
id
e
l
in
e
s
N
e
two
rk(S
IGN
)
.Inadd
i
t
iontoth
eon
er
e
comm
end
a
t
ionth
a
tedu
c
a
t
ionshou
ldb
ebo
th
p
a
t
i
en
t
-andc
a
r
eg
iv
e
r
c
en
t
r
ed
,S
IGN(2006
)o
f
f
e
r
sp
r
a
c
t
i
c
epo
in
t
sth
a
tw
e
r
eb
a
s
edonth
e

84

	
  

c
l
in
i
c
a
lexp
e
r
i
en
c
eo
fth
egu
id
e
l
in
es
t
e
e
r
ingcomm
i
t
t
e
e
.Th
r
e
ep
r
a
c
t
i
c
epo
in
t
sw
e
r
ep
rov
id
ed
,
in
c
lud
ingm
a
in
t
a
in
inge
f
f
e
c
t
iv
ecommun
i
c
a
t
ionw
i
thc
a
r
eg
iv
e
r
s
,o
f
f
e
r
ingin
fo
rm
a
t
ionto
c
a
r
eg
iv
e
r
sinadv
an
c
eo
fth
en
ex
ts
t
ag
eo
fth
ed
i
s
e
a
s
e
,ando
f
f
e
r
ingsuppo
r
tandin
t
e
rv
en
t
ion
s
th
roughou
tth
ec
a
r
eg
iv
ingjou
rn
ey
.A
l
thoughth
e
s
esugg
e
s
t
ion
sa
r
eop
in
ion
b
a
s
ed
,th
eydo
r
e
f
l
e
c
twh
a
th
a
sb
e
ensugg
e
s
t
edino
th
e
rl
i
t
e
r
a
tu
r
e(Ro
s
e&Lop
e
z
,2012
)
.Th
eu
t
i
l
i
z
a
t
iono
f
an
t
i
c
ip
a
to
rygu
id
an
c
einaf
a
i
r
lyp
r
ed
i
c
t
ab
l
ed
i
s
e
a
s
ep
ro
c
e
s
sm
ayd
emon
s
t
r
a
t
es
ign
i
f
i
c
an
t
b
en
e
f
i
ttoc
a
r
eg
iv
e
r
so
fd
em
en
t
i
ap
a
t
i
en
t
sinas
im
i
l
a
rf
a
sh
iontoth
eb
en
e
f
i
ti
tp
rov
id
e
sto
p
a
r
en
t
sth
roughth
e
i
rch
i
ld
r
en
’
sd
ev
e
lopm
en
t
.
Th
efou
r
thandf
in
a
lgu
id
e
l
in
er
ev
i
ew
edw
a
saco
l
l
abo
r
a
t
iv
ee
f
fo
r
tb
e
tw
e
enth
e
N
a
t
ion
a
lCo
l
l
abo
r
a
t
iv
eC
en
t
r
efo
rM
en
t
a
lH
e
a
l
thandth
eN
a
t
ion
a
lIn
s
t
i
tu
t
efo
rH
e
a
l
thand
C
l
in
i
c
a
lEx
c
e
l
l
en
c
e(N
ICE
)
.Th
i
sgu
id
e
l
in
ei
sen
t
i
t
l
ed
:D
em
en
t
i
a
:AN
ICE–SC
IEGu
id
e
l
in
e
onSuppo
r
t
ingP
eop
l
ew
i
thD
em
en
t
i
aandTh
e
i
rC
a
r
e
r
sinH
e
a
l
thandSo
c
i
a
lC
a
r
e(
N
ICE
,
2011
)
.On
es
e
c
t
ioninth
i
sgu
id
e
l
i
n
ep
e
r
t
a
in
stoth
eimp
l
em
en
t
a
t
iono
fc
a
r
eg
iv
e
r
in
t
e
rv
en
t
ion
ssp
e
c
i
f
i
c
a
l
ly
.R
e
comm
end
a
t
ion
sin
c
lud
ea
s
s
e
s
s
ingc
a
r
eg
iv
e
r
sth
roughou
tth
e
d
i
s
e
a
s
ep
ro
c
e
s
sandth
enth
roughou
tc
a
r
eg
iv
ingt
r
an
s
i
t
ion
s
,in
c
lud
ingr
e
s
id
en
t
i
a
lc
a
r
e
p
l
a
c
em
en
to
fth
ep
e
r
sonw
i
thd
em
en
t
i
a
.Ag
a
in
,th
ep
a
r
t
i
cu
l
a
rf
r
equ
en
cyo
fr
e
comm
end
ed
a
s
s
e
s
sm
en
ti
sno
tid
en
t
i
f
i
ed
.Th
ein
c
lu
s
iono
fv
a
r
iou
st
a
i
lo
r
edin
t
e
rv
en
t
ion
sinc
a
r
eg
iv
e
rc
a
r
e
p
l
an
si
sa
l
sor
e
comm
end
edinth
egu
id
e
l
in
e
,in
c
lud
ingar
e
comm
end
a
t
ionth
a
td
i
r
e
c
t
invo
lv
em
en
to
fth
ep
e
r
sonw
i
thd
em
en
t
i
ashou
ldb
econ
s
id
e
r
edwh
enid
en
t
i
fy
ingapp
rop
r
i
a
t
e
suppo
r
t
iv
ein
t
e
rv
en
t
ion
s
.Th
i
sr
e
comm
end
a
t
ioni
ssuppo
r
t
edbyth
eSNS(2011
)gu
id
e
l
in
e
,
wh
i
chs
t
a
t
e
sth
a
tmu
l
t
i
compon
en
tin
t
e
rv
en
t
ion
st
endtob
emo
s
te
f
f
e
c
t
iv
einsuppo
r
t
ingand
m
e
e
t
ingth
en
e
ed
so
fc
a
r
eg
iv
e
r
s
.A
sar
e
su
l
t
,th
eyr
e
comm
endimp
l
em
en
t
ingsk
i
l
l
st
r
a
in
ing
,
edu
c
a
t
ion
,andp
sy
cho
so
c
i
a
lsuppo
r
tw
i
th
inth
ec
a
r
eg
iv
e
rc
a
r
ep
l
an
.

85

	
  
Th
ea
s
s
e
s
sm
en
to
fth
el
ev
e
lo
fp
e
r
c
e
iv
edbu
rd
en
,andth
eimp
l
em
en
t
a
t
iono
f

app
rop
r
i
a
t
ein
t
e
rv
en
t
ion
s
,i
sr
e
co
mm
end
edintwogu
id
e
l
in
e
s(CMA
,1999
,SNS
,2011
)w
i
th
th
eSNSsugg
e
s
t
ingth
eu
s
eo
fv
a
l
id
a
t
eds
c
r
e
en
ingtoo
l
ssu
cha
sth
eZ
a
r
i
tBu
rd
ens
c
a
l
e
(B
éd
a
rde
ta
l
.
,2001
)toqu
an
t
i
fybu
rd
en
.Th
e
s
eCMA(1999
)andSNS(2011
)gu
id
e
l
in
e
sa
l
so
r
e
comm
endedu
c
a
t
ingth
ec
a
r
eg
iv
e
rabou
tm
an
i
f
e
s
t
a
t
ion
so
fd
em
en
t
i
aino
rd
e
rtob
e
t
t
e
r
p
r
ep
a
r
ec
a
r
eg
iv
e
r
sfo
rth
efu
tu
r
e
.A
l
lfou
ro
fth
egu
id
e
l
in
e
sr
e
comm
endt
a
i
lo
r
ingin
fo
rm
a
t
ion
andin
t
e
rv
en
t
ion
stoth
ep
e
r
c
e
iv
edn
e
ed
so
fc
a
r
eg
iv
e
r
s
.Inadd
i
t
ion
,th
r
e
egu
id
e
l
in
e
ss
t
a
t
eth
a
t
th
eid
en
t
i
f
i
c
a
t
iono
fm
en
t
a
lh
e
a
l
thi
s
su
e
sandsub
s
equ
en
tt
r
e
a
tm
en
tw
i
thp
sy
cho
th
e
r
apy
,
ph
a
rm
a
co
log
i
c
a
lth
e
r
apyo
rsp
e
c
i
a
l
i
s
tr
e
f
e
r
r
a
l
sshou
ldb
econ
s
id
e
r
ed(CMA
,1999
;N
ICE
,
2011
;SNS
,2011
)
.
Insumm
a
ry
,a
l
lfou
ro
fth
egu
id
e
l
in
e
sa
cknow
l
edg
eth
eimpo
r
t
an
c
eo
fr
e
cogn
i
z
ing
c
a
r
eg
iv
e
rn
e
ed
sa
longw
i
ththo
s
eth
ep
a
t
i
en
tw
i
thd
em
en
t
i
a
.Th
einh
e
r
en
tn
e
edfo
rad
equ
a
t
e
commun
i
c
a
t
ionb
e
tw
e
enPCP
sandc
a
r
eg
iv
e
r
si
ss
im
i
l
a
r
lyh
igh
l
igh
t
ed
.Th
eimp
l
em
en
t
a
t
ion
o
fc
a
r
eg
iv
e
rsuppo
r
tth
rougha
s
s
e
s
sm
en
t
,edu
c
a
t
ion
,andp
e
r
son
a
l
i
z
edin
t
e
rv
en
t
ion
si
s
r
e
comm
end
edina
l
lo
fth
egu
id
e
l
in
e
s
;how
ev
e
r
,th
et
im
inginwh
i
cha
s
s
e
s
sm
en
t
sand
in
t
e
rv
en
t
ion
sshou
ldb
eimp
l
em
en
t
edth
roughth
ec
a
r
eg
iv
ingjou
rn
eyi
sl
a
ck
ingina
l
lfou
r
gu
id
e
l
in
e
s
.Ino
rd
e
rtod
ev
e
lopcomp
r
eh
en
s
iv
e
,u
s
e
fu
l
,ande
f
f
e
c
t
iv
ec
l
in
i
c
a
lp
r
a
c
t
i
c
e
gu
id
e
l
in
e
ssp
e
c
i
f
i
ctoICPWD
,th
e
r
ei
sacomp
e
l
l
ingn
e
edfo
rth
eimp
l
em
en
t
a
t
ionand
pub
l
i
c
a
t
iono
ffu
r
th
e
remp
i
r
i
c
a
lc
a
r
eg
iv
ingr
e
s
e
a
r
chw
i
thex
c
e
l
l
en
tm
e
thodo
log
i
c
a
lqu
a
l
i
ty
.
Th
equ
a
l
i
t
a
t
iv
eandqu
an
t
i
t
a
t
iv
er
e
s
e
a
r
chh
a
sb
e
enr
e
v
i
ew
edandan
a
ly
z
edino
rd
e
rto
an
sw
e
rth
er
e
s
e
a
r
chqu
e
s
t
ion
.S
in
c
ePCP
sa
r
einap
r
im
epo
s
i
t
iontop
rov
id
esuppo
r
tto
in
fo
rm
a
lc
a
r
eg
iv
e
r
s
,ev
id
en
c
ew
a
sex
am
in
edth
a
tp
e
r
t
a
in
edtom
e
ch
an
i
sm
so
fsuppo
r
tth
a
t

	
  
c
anb
ep
rov
id
edw
i
th
inap
r
im
a
ryc
a
r
es
e
t
t
ing
.Thefo
l
low
ingch
ap
t
e
rw
i
l
ld
i
s
cu
s
sth
e
f
ind
ing
sind
e
t
a
i
l
.

86

87

	
  
Chap
t
e
r4:D
i
s
cu
s
s
ion

Th
en
eg
a
t
iv
ephy
s
i
c
a
l
,p
sy
cho
log
i
c
a
l
,f
in
an
c
i
a
l
,andso
c
i
a
le
f
f
e
c
t
sa
s
so
c
i
a
t
edw
i
th
in
fo
rm
a
lc
a
r
eg
iv
ingc
anb
e
com
eov
e
rwh
e
lm
ingfo
rICPWD
.L
i
l
lye
ta
l
.(2012
)s
t
a
t
edth
a
t
,a
s
th
eh
e
a
l
thc
a
r
esy
s
t
emg
r
e
a
t
lyd
ep
end
sonth
ec
r
i
t
i
c
a
lcon
t
r
ibu
t
ion
so
fICPWD
,anin
c
r
e
a
s
ed
fo
cu
sonth
e
s
ec
a
r
eg
iv
e
r
s
,andonc
a
r
eg
iv
e
rsuppo
r
tbyPCP
sandh
e
a
l
thsy
s
t
em
s
,n
e
ed
sto
o
c
cu
r
.Afo
cu
sonICPWDm
ays
an
c
t
ionsuppo
r
t
swh
i
chp
romo
t
ec
a
r
eg
iv
e
rw
e
l
lb
e
ing
“
r
a
th
e
rth
anr
e
so
r
t
ingtoco
s
t
lyp
a
t
i
en
tc
a
r
efo
rc
a
r
eg
iv
e
r
swhoh
av
er
e
a
ch
edth
epo
in
to
f
bu
rnou
tandc
a
r
er
e
c
ip
i
en
t
swhoh
av
eb
e
enin
s
t
i
tu
t
ion
a
l
i
z
ed
”(L
i
l
lye
ta
l
.
,2012
,p
.103
)
.In
o
rd
e
rtob
eab
l
etop
rov
id
eth
emo
s
tapp
rop
r
i
a
t
esuppo
r
tandin
t
e
rv
en
t
ion
stoICPWD
,PCP
s
n
e
edtomo
r
ec
l
e
a
r
lyund
e
r
s
t
andth
e
s
ec
a
r
eg
iv
e
r
s
’n
e
ed
s
.Inp
a
r
t
i
cu
l
a
r
,th
eyn
e
edtob
eaw
a
r
e
o
fwh
a
td
r
aw
sc
a
r
eg
iv
e
r
stop
rov
id
ec
a
r
e
,wh
a
tch
a
l
l
eng
e
sth
eym
ayf
a
c
e
,andwh
a
ts
e
rv
i
c
e
s
a
r
econ
s
id
e
r
edn
e
c
e
s
s
a
rywh
i
l
ec
a
r
ingfo
rap
e
r
sonw
i
thd
em
en
t
i
a
.Byid
en
t
i
fy
ingc
a
r
eg
iv
e
r
s
’
n
e
ed
sandexp
e
r
i
en
c
e
s
,r
e
l
ev
an
tande
f
f
e
c
t
iv
ein
t
e
rv
en
t
ion
sc
anb
ee
s
t
ab
l
i
sh
edtob
e
t
t
e
r
suppo
r
tth
em(K
a
r
l
s
sone
ta
l
.
,2015
;L
eonge
ta
l
.
,2001
)
.
D
i
s
cu
s
s
iono
fth
ef
ind
ing
sf
romCh
ap
t
e
rFou
rw
i
l
ls
e
rv
etoin
fo
rms
t
r
a
t
eg
i
e
sth
a
t
PCP
sc
animp
l
em
en
tw
i
th
inp
r
im
a
ryc
a
r
es
e
t
t
ingsino
rd
e
rtop
rov
id
esuppo
r
ttoICPWD
.
Th
ero
l
eo
fNP
ssp
e
c
i
f
i
c
a
l
lyw
i
l
lb
ed
i
s
cu
s
s
edw
i
thav
i
ewtoh
igh
l
igh
tth
eun
iqu
ero
l
eo
f
NP
sandth
econ
t
r
ibu
t
ion
sth
eyc
anm
ak
etoICPWD
,th
e
i
rc
a
r
er
e
c
ip
i
en
t
s
,andh
e
a
l
thc
a
r
e
sy
s
t
em
sa
l
ik
e(S
ang
s
t
e
r
Go
rm
l
ey
,2014
)
.R
e
comm
end
a
t
ion
sfo
rPCPp
r
a
c
t
i
c
e
,edu
c
a
t
ion
,
andr
e
s
e
a
r
ch
,w
i
thap
a
r
t
i
cu
l
a
rfo
cu
sonth
eNPro
l
e
,w
i
l
lb
ed
i
s
cu
s
s
eding
r
e
a
t
e
rd
e
t
a
i
lin
Ch
ap
t
e
rS
ix
.

88

	
  
N
e
ed
sandExp
e
r
i
en
c
e
so
fICPWD
: Mapp
ingth
eCa
r
eg
iv
ingJou
rn
ey

A
l
thoughth
es
tud
i
e
stookp
l
a
c
eind
i
f
f
e
r
en
ts
e
t
t
ing
sandfo
cu
s
edonth
ec
a
r
eg
iv
e
r
’
s
exp
e
r
i
en
c
e
sdu
r
ingd
i
f
f
e
r
en
ts
t
ag
e
so
fd
em
en
t
i
a
,s
ev
e
r
a
lr
e
cu
r
r
ingth
em
e
sandsub
th
em
e
s
w
e
r
eid
en
t
i
f
i
edinth
el
i
t
e
r
a
tu
r
e
.Twoo
fth
er
ev
i
ew
eds
tud
i
e
sfo
cu
s
edonpo
s
i
t
iv
ea
sp
e
c
t
so
f
c
a
r
eg
iv
ing
;how
ev
e
r
,th
em
a
jo
r
i
tyo
fth
el
i
t
e
r
a
tu
r
ed
i
s
cu
s
s
edn
eg
a
t
iv
eexp
e
r
i
en
c
e
sandunm
e
t
n
e
ed
s
,thu
sh
igh
l
ig
h
t
ingg
ap
sinc
a
r
eg
iv
e
rc
a
r
eandth
en
e
edtod
ev
e
lopinnov
a
t
iv
eand
e
f
f
e
c
t
iv
ein
t
e
rv
en
t
ion
sinp
r
im
a
ryc
a
r
es
e
t
t
ing
s(H
in
ton
,Ch
amb
e
r
s
,V
e
l
á
squ
e
z
,Gon
z
a
l
e
z
,&
H
a
an(2006
)
.Fou
rm
a
jo
rth
em
e
sands
ev
e
r
a
lsub
th
em
e
sem
e
rg
edf
romsyn
th
e
s
i
so
fth
e
l
i
t
e
r
a
tu
r
einth
i
sr
ev
i
ew
.Th
efou
rm
a
jo
rov
e
r
a
r
ch
ingth
em
e
sw
e
r
e
:th
eh
e
a
l
thsy
s
t
em
;f
am
i
ly
andcommun
i
ty
;r
e
l
a
t
ion
sh
ipw
i
thth
ec
a
r
er
e
c
ip
i
en
t
;andp
e
r
son
a
ljou
rn
ey
.Th
e
s
eth
em
e
s
w
e
r
ead
ap
t
edf
romth
em
e
sth
a
tem
e
rg
edf
romas
tudyby W
i
e
r
sm
a
,S
am
e
sh
im
a
,andDupu
i
s
(20
14
)
.
Th
eh
ea
l
thsy
s
t
em.Th
ef
i
r
s
tth
em
eadd
r
e
s
s
e
si
s
su
e
sth
a
tICPWDr
a
i
s
edinth
e
r
ev
i
ew
eds
tud
i
e
sr
eg
a
rd
ingd
i
agno
s
i
s
,edu
c
a
t
ion
,commun
i
c
a
t
ionb
e
tw
e
enPCP
sand
ICPWD
,t
r
an
s
i
t
ion
a
lc
a
r
e
,andsuppo
r
ts
e
rv
i
c
e
s
.
D
iagno
s
i
s
.AnICPWDinK
a
r
l
s
sone
ta
l
.
’
s(2015)s
tudys
t
a
t
edth
a
te
a
r
lyd
i
agno
s
i
si
s
th
emo
s
timpo
r
t
an
ta
sp
e
c
to
fth
ec
a
r
eg
iv
ingjou
rn
ey
. Wh
end
i
agno
s
i
si
sw
e
l
l
t
im
ed
,
t
r
e
a
tm
en
tc
anb
ecomm
en
c
edandsuppo
r
t
spu
tin
top
l
a
c
ee
a
r
lyinth
et
r
a
j
e
c
to
ry
,p
r
ep
a
r
ing
bo
thth
eICPWDandc
a
r
er
e
c
ip
i
en
tfo
rth
eup
com
ingjou
rn
ey
.AnICPWDinK
a
r
l
s
sone
t
a
l
.
’
s(2015
)s
tudys
im
i
l
a
r
lyno
t
edth
eimpo
r
t
an
c
eo
fane
a
r
lyd
i
agno
s
i
sandd
e
s
c
r
ib
edh
i
s
s
a
t
i
s
f
a
c
t
ionwh
enh
i
smo
th
e
rr
e
c
e
iv
edad
i
agno
s
i
sp
romp
t
ly
:“Sh
ego
td
i
agno
s
ed[d
em
en
t
i
a
]
v
e
ryqu
i
ck
ly...andth
enev
e
ry
th
i
ngh
app
en
edl
ik
eth
i
s(
sn
ap
sw
i
thh
i
sf
ing
e
r
s
)
.V
e
rysoon

89

	
  

th
eycon
t
a
c
t
edhom
e
c
a
r
e
.Hom
ec
a
r
ec
am
ein
.W
eh
adam
e
e
t
ing
,w
en
tth
roughh
e
rn
e
ed
s
.
Ev
e
ry
th
ingwo
rk
edp
e
r
f
e
c
t
...
”(p
.1413
)
.
Un
fo
r
tun
a
t
e
ly
,du
etod
en
i
a
lo
fth
esymp
tom
so
fd
em
en
t
i
a
,o
ranin
abi
l
i
tyto
r
e
cogn
i
z
etho
s
esymp
tom
s
,m
anyin
fo
rm
a
lc
a
r
eg
iv
e
r
sdono
ts
e
ekd
i
agno
s
i
sun
t
i
lac
r
i
s
i
s
s
i
tu
a
t
iono
c
cu
r
s
,i
.
e
.wh
enth
ed
eg
r
e
eo
fcogn
i
t
iv
eo
rfun
c
t
ion
a
limp
a
i
rm
en
to
fth
ec
a
r
e
r
e
c
ip
i
en
tc
annolong
e
rr
em
a
inigno
r
edo
ra
t
t
r
ibu
t
edtoinno
cuou
sc
au
s
e
s(Ad
am
s
,2006
;
G
a
lv
ine
ta
l
.
,2005
)
.M
anyICPWD whoh
adr
e
a
ch
edth
i
spo
in
tth
envo
i
c
edf
e
e
l
ing
so
f
f
ru
s
t
r
a
t
ion(P
ro
roke
ta
l
.
,2013
)andm
i
s
t
ru
s
t(T
e
e
l&C
a
r
son
,2003
)tow
a
rd
sth
e
i
rPCPd
u
e
toth
ep
ro
c
e
s
so
fob
t
a
in
ingad
i
agno
s
i
sfo
rth
ec
a
r
er
e
c
ip
i
en
t
.Th
e
s
ef
e
e
l
ing
sw
e
r
ea
s
so
c
i
a
t
ed
w
i
thth
ep
e
r
c
ep
t
ionth
a
tPCP
sw
e
r
er
e
lu
c
t
an
ttod
i
agno
s
ed
em
en
t
i
a
,c
au
s
ingth
eICPWDand
c
a
r
er
e
c
ip
i
en
ttos
e
e
,andr
e
l
ayth
e
i
rs
to
ryto
,num
e
rou
sPCP
sb
e
fo
r
ead
i
agno
s
i
sw
a
sm
ad
e
(T
e
e
l&C
a
r
son
,2003
)
.Fo
rp
a
t
i
en
t
sinru
r
a
lcommun
i
t
i
e
swhoh
av
ea
c
c
e
s
stol
im
i
t
edP
CP
s
andsp
e
c
i
a
l
i
s
t
s
,th
i
sc
anh
av
emu
l
t
ip
l
eadd
i
t
ion
a
limp
l
i
c
a
t
ion
sfo
rbo
thth
ep
a
t
i
en
tand
ICPWD
.Fo
rin
s
t
an
c
e
,th
eco
s
tandemo
t
ion
a
landphy
s
i
c
a
lch
a
l
l
eng
e
sa
s
so
c
i
a
t
edw
i
th
t
r
av
e
l
ingou
to
ftowntos
e
esp
e
c
i
a
l
i
s
t
sm
ayb
et
ax
ingonbo
thth
ec
a
r
er
e
c
ip
i
en
tandICPWD
.
Con
s
equ
en
t
ly,th
eimpo
r
t
an
c
eo
fw
e
l
l
t
im
edd
i
agno
s
i
sw
a
ss
t
r
e
s
s
edbyICPWDa
sc
r
i
t
i
c
a
l
s
in
c
ee
a
r
lyd
i
agno
s
i
sc
anl
e
adtomo
r
esu
c
c
e
s
s
fu
lt
r
an
s
i
t
ion
sfo
rbo
thth
eICPWDandth
e
c
a
r
er
e
c
ip
i
en
t(P
ro
roke
ta
l
.
,2013
)
.
P
rov
id
ingad
i
agno
s
i
so
fap
rog
r
e
s
s
iv
eandt
e
rm
in
a
ld
i
s
e
a
s
em
ayp
rov
ech
a
l
l
eng
ing
fo
ranyPCP
,e
sp
e
c
i
a
l
lya
si
timp
a
c
t
sno
ton
lyth
ep
a
t
i
en
tbu
ttho
s
ewhow
i
l
lin
ev
i
t
ab
ly
p
rov
id
ec
a
r
efo
rth
a
tp
e
r
son
.Th
e
con
s
id
e
r
ab
l
eimp
a
c
to
fad
em
en
t
i
ad
i
agno
s
i
si
sev
id
en
t
w
i
thK
e
l
so
’
s(2016
)s
t
a
t
em
en
t
:"
Wh
end
i
agno
s
inganA
l
zh
e
im
e
r
'
s
/d
em
en
t
i
ap
a
t
i
en
tyoua
r
e
notju
s
td
i
agno
s
ingth
eind
iv
idu
a
lw
i
thth
ed
i
s
e
a
s
e
;youa
r
einon
es
t
rok
e
,a
s
s
ign
inga

90

	
  

r
em
a
rk
ab
lych
a
l
l
eng
ingn
ewl
i
f
e
s
ty
l
etoa
tl
e
a
s
ton
em
emb
e
ro
faf
am
i
ly
”(p
a
r
a
.6
)
.L
e
a
ch
andH
i
ck
s(2013
)s
t
a
t
eth
a
tch
a
l
l
eng
e
sa
s
so
c
i
a
t
edw
i
thd
e
l
ay
edd
i
agno
s
i
sh
av
ea
r
i
s
enf
rom
s
ev
e
r
a
lf
a
c
to
r
s
,in
c
lud
ingin
f
lu
en
c
e
sf
romPCP
s(d
em
en
t
i
ac
a
r
et
r
a
in
ing
,a
t
t
i
tud
e
s
,and
con
f
id
en
c
eind
i
agno
s
ing
)
,th
ein
fo
rm
a
lc
a
r
eg
iv
e
r
sth
em
s
e
lv
e
s(d
i
f
f
e
r
ingcu
l
tu
r
a
lb
e
l
i
e
f
sand
poo
rr
e
cogn
i
t
iono
fth
em
an
i
f
e
s
t
a
t
ion
so
fd
em
en
t
i
a
)
,andth
es
t
r
u
c
tu
r
eo
fp
r
im
a
ryc
a
r
e
.Th
e
d
i
f
f
i
cu
l
tya
s
so
c
i
a
t
edw
i
thp
rov
id
ingsu
chad
ev
a
s
t
a
t
ingd
i
agno
s
i
sm
ayn
ev
e
rg
e
te
a
s
i
e
rfo
r
PCP
s
.How
ev
e
r
,edu
c
a
t
ionfo
rPCP
sr
eg
a
rd
ingd
em
en
t
i
ac
a
r
eandd
i
agno
s
i
s
,a
sw
e
l
la
s
pub
l
i
cedu
c
a
t
iona
roundsymp
tom
so
fd
em
en
t
i
a
,m
ayimp
rov
et
im
e
lyd
i
agno
s
i
s(T
e
e
l&
C
a
r
son
,2003
)
.
Edu
ca
t
ion.P
inqu
a
r
tandSö
r
en
s
en(2006
)s
t
a
t
eth
a
timp
rov
ingth
eedu
c
a
t
ion
p
rov
id
edtoICPWDabou
td
em
en
t
i
aandm
a
n
ag
ingsymp
tom
so
fd
em
en
t
i
aw
a
sfoundtob
e
e
f
f
e
c
t
iv
einimp
rov
ingw
e
l
l
b
e
ingandd
e
c
r
e
a
s
ingd
e
p
r
e
s
s
iv
esymp
tom
sandbu
rd
en
.ICPWD
l
i
s
t
ededu
c
a
t
iona
sth
emo
s
ts
ign
i
f
i
c
an
tunm
e
tn
e
edth
eyh
adth
roughou
tth
een
t
i
r
ec
a
r
eg
iv
ing
jou
rn
ey(H
in
tone
ta
l
.
,2006
;J
enn
ing
se
ta
l
.
,2015
;K
a
r
l
s
sone
ta
l
.
,2015
;L
eonge
ta
l
.
,2001
;
L
i
l
lye
ta
l
.
,2012
;P
ro
roke
ta
l
.
,2013
;T
e
e
l&C
a
r
son
,2003
)
.M
anyICPWDs
t
a
t
edth
a
tal
a
ck
o
fin
fo
rm
a
t
ionf
romPCP
sr
eg
a
rd
ingd
em
en
t
i
a
,b
eh
av
iou
rm
an
ag
em
en
t
,ph
a
rm
a
co
log
i
c
a
l
m
an
ag
em
en
t
,p
e
r
son
a
lc
a
r
e
,andav
a
i
l
ab
l
esuppo
r
t
iv
es
e
rv
i
c
e
sw
a
sacommonexp
e
r
i
en
c
e
;
som
ec
a
r
eg
iv
e
r
sev
enr
ep
o
r
t
edb
e
ingth
eon
e
swhoh
adtoin
i
t
i
a
t
ed
i
s
cu
s
s
ion
sw
i
thPCP
s
abou
tth
e
i
rcon
c
e
rn
sandabou
td
em
en
t
i
am
an
ag
em
en
t(P
ro
roke
ta
l
.
,2013
)
.
M
anyICPWDexp
e
c
tth
ePCPtoh
av
eexp
e
r
t
i
s
eabou
td
em
en
t
i
ac
a
r
eandcu
r
r
en
t
r
e
sou
r
c
e
s(
J
enn
ing
se
ta
l
.
,2015
;K
a
r
l
s
sone
ta
l
.
,2015
;P
ro
roke
ta
l
.
,2013
)
,y
e
to
f
t
en
p
e
r
c
e
iv
edth
ePCPtob
el
a
ck
ingknow
l
edg
eo
rf
e
l
tth
a
tin
fo
rm
a
t
ionp
rov
i
s
ionw
a
sno
tc
l
e
a
r
(P
ro
roke
ta
l
.
,2013
)
.Th
e
r
ei
sad
i
s
t
in
c
tpo
t
en
t
i
a
ltoc
lo
s
eth
i
sg
apbyen
su
r
ingth
a
tcu
r
r
en
t

91

	
  

andfu
tu
r
ePCP
sa
r
eed
u
c
a
t
edonth
e
s
ei
s
su
e
sandb
e
com
emo
r
ep
ro
f
i
c
i
en
ta
tedu
c
a
t
ingand
coun
s
e
l
ingICPWDabou
td
em
en
t
i
a
,c
a
r
eg
iv
ing
,andth
er
e
sou
r
c
e
sav
a
i
l
ab
l
etoICPWD
(H
in
tone
ta
l
.
,2006
)
.
Commun
i
ca
t
ionb
e
tw
e
enPCPandICPWD
.K
a
r
l
s
sone
ta
l
.(2015
)foundth
a
t
“
in
fo
rm
a
t
ion
,commun
i
c
a
t
ion
andco
l
l
abo
r
a
t
ionw
e
r
econ
s
id
e
r
edtob
ed
ep
end
en
ton
e
s
t
ab
l
i
sh
i
ngat
ru
s
t
ingr
e
l
a
t
ion
sh
ip[w
i
thPCP
s
]
”(p
.1413
)
.Ad
equ
a
t
ecommun
i
c
a
t
ion
b
e
tw
e
enICPWDandth
ec
a
r
er
e
c
ip
i
en
t
’
sPCPi
simpo
r
t
an
ta
ta
l
ls
t
ag
e
so
fth
ec
a
r
eg
iv
ing
jou
rn
ey
.Poo
rc
ommun
i
c
a
t
ionc
anl
e
adtoin
e
f
f
e
c
t
iv
er
e
l
a
t
ion
sh
ip
sb
e
tw
e
enPCP
sand
ICPWDandap
e
r
c
ep
t
iono
fin
ad
equ
a
t
ep
a
t
i
en
tc
a
r
e
.P
e
rh
ap
sth
emo
s
timpo
r
t
an
tf
ind
ingin
th
el
i
t
e
r
a
tu
r
ei
sth
ef
a
c
tth
a
tmo
s
tICPWDs
imp
lyw
an
ttof
e
e
lsuppo
r
t
edbyPCP
s
,f
e
e
lth
a
t
th
e
i
rh
a
rdwo
rkands
a
c
r
i
f
i
c
ei
sb
e
ingr
e
cogn
i
z
ed
,andp
e
r
c
e
iv
eth
a
tth
e
i
rf
e
e
l
ing
sandn
e
ed
s
a
r
eb
e
ingv
a
l
id
a
t
ed(L
i
l
lye
ta
l
.
,2012
,O
’Sh
aughn
e
s
sye
ta
l
.
,2010
;P
ro
roke
ta
l
.
,2013
;
Sh
an
l
eye
ta
l
.
,2010
)
.O
’Sh
aughn
e
s
sye
ta
l
.(2010
)s
t
a
t
edth
a
t
,inth
i
sr
e
sp
e
c
t,suppo
r
tg
roup
s
c
ans
e
rv
ea
sak
eysou
r
c
eo
fv
a
l
id
a
t
ionfo
rICPWDandc
ansupp
l
em
en
tth
ee
f
fo
r
t
so
fth
e
PCP
sinth
i
sr
eg
a
rd
.Wh
a
ti
smo
r
e
,ICPWDinth
eSh
an
l
ey(2011
)s
tudyf
e
l
tth
a
tsuppo
r
t
g
roup
sw
e
r
ep
a
r
amoun
ttom
e
e
t
ingth
e
i
rn
e
ed
s
.Suppo
r
tg
roup
sa
l
l
ow
edICPWDtocomp
a
r
e
th
e
i
rownexp
e
r
i
en
c
e
sw
i
tho
th
e
r
sandtog
a
th
e
rb
en
e
f
i
c
i
a
lin
fo
rm
a
t
ionf
romo
th
e
rICPWD
(
O
’Sh
aughn
e
s
sye
ta
l
.
,2010)
.Mo
s
to
fth
ep
a
r
t
i
c
ip
an
t
sinth
i
ss
tudyr
e
c
e
iv
edag
r
e
a
td
e
a
lo
f
a
s
s
i
s
t
an
c
ef
romaw
e
l
l
f
a
c
i
l
i
t
a
t
edsuppo
r
tg
roupandf
e
l
tth
a
tth
eg
roupw
a
son
eo
fth
emo
s
t
impo
r
t
an
tw
ay
sinwh
i
chth
e
i
rn
e
ed
sw
e
r
em
e
t
.
T
ran
s
i
t
iona
lca
r
e
.Ac
a
r
er
e
c
ip
i
en
t
’
ss
t
ayinana
cu
t
eo
rlongt
e
rmc
a
r
ef
a
c
i
l
i
tyc
an
c
au
s
ein
c
r
e
a
s
eds
t
r
e
s
sfo
rbo
thth
ec
a
r
er
e
c
ip
i
en
tandICPWD
.Th
en
e
edfo
radvo
c
a
cyfo
rth
e
c
a
r
er
e
c
ip
i
en
ti
scommon
.Th
eICPWDinK
a
r
l
s
sone
ta
l
.
’
s(2015
)s
tudyr
epo
r
t
edth
a
tm
any

92

	
  
ho
sp
i
t
a
ls
t
a
f
fs
t
rugg
l
edw
i
thd
em
en
t
i
ac
a
r
e
,l
e
av
ingICPWDf
ru
s
t
r
a
t
ed
.S
im
i
l
a
r
ly
,

Bough
twoode
ta
l
.(2011
)foundth
a
tm
anyCALDICPWDsp
en
tlonghou
r
sinth
eho
sp
i
t
a
l
tot
r
an
s
l
a
t
eandtoen
su
r
eth
e
i
rf
am
i
lym
emb
e
rr
e
c
e
iv
edad
equ
a
t
ec
a
r
e
.U
t
i
l
i
z
a
t
iono
fth
eTop
5S
t
r
a
t
egy(C
l
in
i
c
a
lEx
c
e
l
l
en
c
eComm
i
s
s
ion
,2014
)b
e
fo
r
eac
a
r
er
e
c
ip
i
en
ti
st
r
an
s
f
e
r
r
edtoa
f
a
c
i
l
i
tym
ayp
r
ev
en
tth
ef
ru
s
t
r
a
t
ionr
epo
r
t
edbyICPWDandc
r
e
a
t
eab
e
t
t
e
rexp
e
r
i
en
c
e
du
r
ingt
r
an
s
i
t
ion
sinc
a
r
e
.Th
eTop5S
t
r
a
t
egyp
romo
t
e
sr
e
cogn
i
t
ionanda
cknow
l
edg
em
en
t
o
fICPWD
’
sknow
l
edg
eandsk
i
l
l
sbyf
a
c
i
l
i
tys
t
a
f
fw
i
thr
e
sp
e
c
ttoth
ec
a
r
er
e
c
ip
i
en
tandc
a
r
e
p
rov
i
s
ionfo
rth
ec
a
r
er
e
c
ip
i
en
t(C
l
in
i
c
a
lEx
c
e
l
l
en
c
eComm
i
s
s
ion
,2014
;S
t
rudw
i
ck
,2009
)
.
S
e
eApp
end
ixCfo
ranex
amp
l
eo
fanad
ap
t
a
t
iono
fth
eTop5s
t
r
a
t
egy
.
Suppo
r
tS
e
r
v
i
c
e
s
.M
anyc
a
r
eg
iv
e
r
sh
av
er
epo
r
t
edas
ign
i
f
i
c
an
tn
e
edfo
rs
e
rv
i
c
e
r
e
f
e
r
r
a
l
s
,y
e
tth
eyo
f
t
ent
r
av
e
l
eddownalongp
a
thb
e
fo
r
eob
t
a
i
n
ingth
esuppo
r
tth
ey
r
equ
i
r
ed
.J
enn
ing
se
ta
l
.(2015
)s
t
a
t
edth
a
tbu
syPCP
so
f
t
ena
r
eno
taw
a
r
eo
fav
a
i
l
ab
l
e
suppo
r
ts
e
rv
i
c
e
sinth
e
i
rcommun
i
t
i
e
sno
rdoth
eya
lw
ay
sh
av
eth
et
im
etop
rov
id
ein
o
f
f
i
c
e
suppo
r
t
iv
ein
t
e
rv
en
t
ion
s
,su
cha
scoun
s
e
l
l
ingo
redu
c
a
t
ionp
rov
i
s
ion
.Fu
r
th
e
r
,th
el
i
t
e
r
a
tu
r
e
sugg
e
s
t
sth
a
tc
a
r
eov
e
r
a
l
linth
i
spopu
l
a
t
ionr
em
a
in
sf
r
agm
en
t
edandpoo
r
lycoo
rd
in
a
t
ed
(B
a
s
se
ta
l
.
,2013
)
.On
eICPWDr
epo
r
t
ed
,“m
anyt
im
e
syoun
e
edat
e
ame
f
fo
r
t
,bu
tth
e
r
ei
s
no
tth
econn
e
c
t
ionb
e
tw
e
enth
eso
c
i
a
lwo
rk
e
r
,th
eHom
eC
a
r
e
,th
edo
c
to
r
,th
ewh
a
t
ev
e
r
.
Th
e
r
e
’
sno
tsom
ebodyth
a
tc
anpu
ti
ta
l
ltog
e
th
e
rfo
rth
eind
iv
idu
a
l
”(Sh
an
l
eye
ta
l
.
,2011
,p
.
330
)
.
L
i
l
lye
ta
l
.(2012
)po
s
i
t
edth
a
tc
a
r
eg
iv
e
r
so
f
t
enon
lyr
e
c
e
iv
es
e
rv
i
c
e
son
c
eth
eya
r
e
onth
ev
e
rg
eo
fb
e
com
ingp
a
t
i
en
t
sth
em
s
e
lv
e
sb
e
c
au
s
eo
fth
es
t
r
e
s
sa
s
so
c
i
a
t
edw
i
than
un
suppo
r
t
edc
a
r
eg
iv
ingro
l
e
.Th
eimpo
r
t
an
c
eo
ft
a
i
lo
r
ingin
t
e
rv
en
t
ion
sands
e
rv
i
c
e
stoth
e
a
r
t
i
cu
l
a
t
edn
e
ed
so
fICPWDandth
ec
a
r
er
e
c
ip
i
en
t
’
sn
e
ed
sw
a
ss
t
r
e
s
s
ed(K
a
r
l
s
sone
ta
l
.
,

93

	
  

2015
;L
il
lye
ta
l
.
,2012
;S
t
i
r
l
inge
ta
l
.
,2010
)
. Mo
r
eov
e
r
,S
t
i
r
l
inge
ta
l
.(2010
)emph
a
s
i
z
ed
th
a
tfo
cu
s
ingonICPWD
’
sf
e
l
tn
e
edandp
e
r
c
e
iv
edn
e
edi
smu
chmo
r
ep
r
ed
i
c
t
iv
eo
fth
e
i
r
t
ru
en
e
edfo
rs
e
rv
i
c
e
sth
anno
rm
a
t
iv
en
e
ed
.No
rm
a
t
iv
en
e
edc
anb
ev
i
ew
eda
sp
a
t
e
rn
a
l
i
s
t
i
c
,
wh
e
r
ebyth
ePCPr
e
f
e
r
sth
eICPWDfo
rs
e
rv
i
c
e
sb
a
s
edonth
e
i
rop
in
iono
fth
ec
a
r
eg
iv
e
r
s
n
e
ed
.
R
e
sp
i
t
ew
a
sh
e
r
a
ld
eda
sth
emo
s
tv
a
lu
ab
l
efo
rm
a
ls
e
rv
i
c
efo
rm
anyICPWD
(K
a
r
l
s
sone
ta
l
.
,2015
;L
eonge
ta
l
.
,L
i
l
lye
ta
l
.
,2012
;Sh
an
l
eye
ta
l
.
,2011
)
;o
f
t
en
,th
e
suppo
r
tn
e
ed
edbyICPWDi
sno
tfo
ra
s
s
i
s
t
an
c
ew
i
thth
ec
a
r
er
e
c
ip
i
en
t
’
sADL
so
r
hou
s
ewo
rk
,bu
tr
a
th
e
rt
im
eaw
ayfo
ran
e
ed
edb
r
e
ako
rtoa
t
t
endtor
e
spon
s
ib
i
l
i
t
i
e
sou
t
s
id
e
th
ehom
e(Sh
an
l
eye
ta
l
.
,2011
)
.D
e
sp
i
t
eth
en
e
edfo
rr
e
sp
i
t
ec
a
r
e
,th
i
sr
e
sou
r
c
ei
ss
c
a
r
c
e
,
w
i
thICPWDo
f
t
enun
ab
l
etoa
c
c
e
s
si
tf
rome
i
th
e
rfo
rm
a
lo
rin
fo
rm
a
lsou
r
c
e
s(Sh
an
l
eye
ta
l
.
,
2011
)
.
Ino
rd
e
rtop
rov
id
emo
r
ee
f
f
e
c
t
iv
ep
e
r
son
c
en
t
r
edco
l
l
abo
r
a
t
iv
ec
a
r
e
,J
enn
ing
se
ta
l
.
(2015
)r
e
comm
endth
eimp
l
em
en
t
a
t
iono
fac
a
r
ed
e
l
i
v
e
rymod
e
lth
a
tin
c
lud
e
sa
comp
r
eh
en
s
iv
ec
a
r
ep
l
anfo
rth
ec
a
r
er
e
c
ip
i
en
t
,coun
s
e
l
ing
,edu
c
a
t
ion
,an
t
i
c
ip
a
to
rygu
id
an
c
e
,
co
l
l
abo
r
a
t
ionw
i
thcommun
i
tys
e
rv
i
c
e
s
,conn
e
c
t
iontor
e
sp
i
t
e
,24
hou
rsuppo
r
tem
e
rg
en
cy
suppo
r
t
,andh
e
lpw
i
thadv
an
c
edc
a
r
ep
l
ann
ing
.Anin
t
e
rd
i
s
c
ip
l
in
a
ryt
e
amo
rNP
/phy
s
i
c
i
an
t
e
amm
aysu
c
c
e
s
s
fu
l
lyimp
l
em
en
tth
i
sc
a
r
emod
e
lth
a
ti
sa
im
eda
tmo
r
ecomp
r
eh
en
s
iv
e
ly
m
e
e
t
ingth
en
e
ed
so
fbo
thICPWDandc
a
r
er
e
c
ip
i
en
t
s
.
Fam
i
lyandcommun
i
ty
.Th
i
sth
em
einvo
lv
edth
er
e
l
a
t
ion
sh
ip
sb
e
tw
e
enICPWD
ando
th
e
rf
am
i
lym
emb
e
r
sa
sw
e
l
la
sm
emb
e
r
so
fth
ecommun
i
ty
.Con
c
e
rn
sabou
td
i
s
c
lo
su
r
e
o
fd
i
agno
s
i
sdu
etos
t
igm
af
romf
am
i
ly
,f
r
i
end
s
,ando
th
e
rm
emb
e
r
so
fth
ecommun
i
tya
l
so
f
e
l
lund
e
rth
i
sth
em
e
.ICPWDinth
el
i
t
e
r
a
tu
r
er
epo
r
t
edan
e
edfo
rongo
ingsupp
o
r
tf
rom

94

	
  

f
am
i
lyandf
r
i
end
s(T
e
e
l&C
a
r
son
,2003
)
.Fo
rm
anyICPWD
,f
am
i
lyandf
r
i
end
sa
r
epo
s
i
t
iv
e
sou
r
c
e
so
fsuppo
r
t
.R
eg
r
e
t
t
ab
ly
,con
f
l
i
c
to
f
t
eno
c
cu
r
sb
e
tw
e
enICPWDando
th
e
rf
am
i
ly
m
emb
e
r
sa
sth
er
e
su
l
to
fth
es
t
r
e
s
so
fp
rog
r
e
s
s
ingd
em
en
t
i
a
,l
e
ad
ingtoanev
e
r
in
c
r
e
a
s
ing
l
a
cko
fou
t
s
id
esuppo
r
t(Bough
twood
,2011
)
.C
a
r
eg
iv
e
r
sinth
eBough
twoode
ta
l
.(2011
)
s
tudyfoundth
a
tcon
f
l
i
c
tm
aya
r
i
s
eb
e
tw
e
ens
ib
l
ing
sfo
rex
amp
l
e
,i
fon
er
e
fu
s
edtoa
s
s
i
s
t
w
i
thc
a
r
e
,o
rb
e
tw
e
enspou
s
e
si
fc
a
r
eg
iv
ingfo
rane
ld
e
r
lyp
a
r
en
tw
a
st
ak
ingt
im
eaw
ayf
rom
anadu
l
tch
i
ld
’
simm
ed
i
a
t
ef
am
i
ly
.Conv
e
r
s
e
ly
,i
fm
anyp
eop
l
ea
r
einvo
lv
edinp
rov
id
ing
c
a
r
etoth
es
am
eind
iv
idu
a
lw
i
thd
em
en
t
i
a
,con
f
l
i
c
tm
aya
r
i
s
eou
to
fa
t
t
emp
t
stom
ak
esh
a
r
ed
o
rcon
s
en
su
sd
e
c
i
s
ion
m
ak
ingar
e
a
l
i
ty(B
ough
twoode
ta
l
.
,2011
)
.
Du
etoth
ef
e
a
ro
fs
t
igm
ao
remb
a
r
r
a
s
sm
en
t
,ICPWDm
ayavo
idso
c
i
a
ls
i
tu
a
t
ion
s
,
th
e
r
ebyg
iv
ingr
i
s
etofu
r
th
e
rso
c
i
a
li
so
l
a
t
ion(P
ro
rok
,2013
)
.Fo
rin
s
t
an
c
e
,twoICPWDin
T
e
e
landC
a
r
son
’
s(2003
)s
tudyno
t
edan
e
edfo
rb
e
t
t
e
rpub
l
icaw
a
r
en
e
s
sabou
td
em
en
t
i
a
.
On
eICPWDs
t
a
t
ed
,“
som
anyt
im
e
swh
enItookmyhu
sb
andou
tinpub
l
i
c
,p
eop
l
ewou
ld
com
eov
e
randa
ckno
w
l
edg
em
eandt
a
lktom
eandto
t
a
l
lyigno
r
eh
im… Youc
an’
tju
s
t
to
t
a
l
lyigno
r
eth
emo
f
fth
ef
a
c
eo
fth
ee
a
r
th
!
”
.Ano
th
e
rp
a
r
t
i
c
ip
an
tno
t
ed
,“
mayb
ei
t
’
smy
im
ag
in
a
t
ion
,bu
twh
enI
’v
et
ak
enh
e
rou
t
,a
ro
undg
roup
so
fp
eop
l
e
,th
eyk
indo
fa
c
tl
ik
ei
t
’
s
acon
t
ag
i
ou
sd
i
s
e
a
s
e
”(T
e
e
l&C
a
r
son
,2003
,p
.51
)
.
F
ind
ing
sinth
el
i
t
e
r
a
tu
r
ed
emon
s
t
r
a
t
edth
a
tcu
l
tu
r
es
ign
i
f
i
c
an
t
lyimp
a
c
t
sth
e
c
a
r
eg
iv
ingexp
e
r
i
en
c
e
.Fo
rex
amp
l
e
,th
eno
t
iono
fs
t
igm
ac
ans
ign
i
f
i
c
an
t
lya
f
f
e
c
tCALD
ICPWD
.M
iy
aw
ak
i(2015
)foundth
a
tth
ed
i
agno
s
i
so
fd
em
en
t
i
ai
so
f
t
enno
td
i
s
c
lo
s
eddu
eto
s
t
igm
a
.S
t
igm
aw
a
sa
s
so
c
i
a
t
edw
i
thsh
am
einsom
eCh
in
e
s
eC
an
ad
i
anandCh
in
e
s
e
Am
e
r
i
c
anICPWD
,i
so
l
a
t
ingth
emf
romo
th
e
r
sinth
e
i
rcommun
i
tyandp
r
ev
en
t
ingth
emf
rom
s
e
ek
ingsuppo
r
t
iv
es
e
rv
i
c
e
s(M
iy
aw
ak
i
,2015
)
.W
i
thr
e
sp
e
c
ttoimp
l
i
c
a
t
ion
sfo
rPCP
s
,

95

	
  
In
c
r
e
a
s
edpub
l
i
caw
a
r
en
e
s
swou
lds
e
rv
etoadd
r
e
s
sno
ton
lys
t
igm
a
,bu
tth
ed
e
l
ay
ed
d
i
agno
s
i
si
s
su
eid
en
t
i
f
i
edandd
i
s
cu
s
s
edp
r
ev
iou
s
ly
.

Ino
rd
e
rfo
rPCP
stop
rov
id
esuppo
r
t
iv
ec
a
r
etoICPWDf
romCALDcommun
i
t
i
e
s
,
th
ecu
l
tu
r
a
lcon
t
ex
tandpo
t
en
t
i
a
ld
i
f
f
i
cu
l
t
i
e
st
h
eym
ayf
a
c
emu
s
tb
econ
s
id
e
r
edinth
e
p
r
a
c
t
i
c
es
e
t
t
ing(Bough
twoode
ta
l
.
,2011
;M
iy
aw
ak
i
,2015
)
.PCP
sc
anp
rov
id
ecu
l
tu
r
a
l
ly
s
en
s
i
t
iv
ec
a
r
ebyob
s
e
rv
ingth
eb
eh
av
iou
r
so
fICPWDinth
ehom
eo
rc
l
in
i
cs
e
t
t
ing
,and
exp
lo
r
ingwh
a
ta
sp
e
c
t
so
fc
a
r
eg
iv
ingi
sim
po
r
t
an
ttoth
em(L
ehm
an
,n
.d
.
)
.Mo
r
esp
e
c
i
f
i
c
a
l
ly
,
h
av
inganund
e
r
s
t
and
ingo
fcu
l
tu
r
a
ls
en
s
i
t
iv
i
tyi
sc
r
i
t
i
c
a
lwh
ent
e
a
ch
ingm
ino
r
i
tyin
fo
rm
a
l
c
a
r
eg
iv
e
r
sabou
tsk
i
l
l
stoimp
rov
eth
e
i
rw
e
l
l
b
e
ing(Coh
en&L
e
e
,2007
)
.Wh
i
l
ei
ti
s
e
s
s
en
t
i
a
ltor
e
cogn
i
z
eth
a
tno
ta
l
lCALDICPWDa
r
een
t
r
en
ch
edins
im
i
l
a
rcu
l
tu
r
a
lv
a
lu
e
s
,
“
know
l
edg
eo
fcommonp
a
t
t
e
rn
sandcu
s
tom
sp
rov
id
e
safound
a
t
ionfo
rsp
e
c
i
f
i
ca
s
s
e
s
sm
en
t
o
fth
ec
a
r
eg
iv
e
randc
a
r
er
e
c
e
iv
e
rexp
e
r
i
en
c
e
”(L
ehm
an
,n
.d
.
,p
.6
)
.
R
e
la
t
ion
sh
ipw
i
thth
eca
r
er
e
c
ip
i
ent
.M
anyo
fth
eICPWDinth
el
i
t
e
r
a
tu
r
e
d
e
s
c
r
ib
edth
e
i
rexp
e
r
i
en
c
e
so
fhowth
e
i
rr
e
l
a
t
ion
sh
ipw
i
thth
ec
a
r
er
e
c
ip
i
en
tch
ang
eda
sth
e
d
em
en
t
i
ap
rog
r
e
s
s
ed
.Th
ech
ang
ingro
l
eo
fth
ec
a
r
er
e
c
ip
i
en
tf
romspou
s
eo
rp
a
r
en
tto
d
ep
end
en
tw
a
sfoundtob
ev
e
ryd
i
f
f
i
cu
l
tfo
rbo
thth
ec
a
r
er
e
c
ip
i
en
t
sandICPWD
(O
’Sh
aughn
e
s
sye
ta
l
.
,2010
)
.ICPWDinBough
twoode
ta
l
.
’
s(2011
)s
tudyr
epo
r
t
ed
p
e
rp
e
tu
a
ld
i
f
f
i
cu
l
tytoa
c
c
ep
tth
i
sch
ang
edr
e
l
a
t
ion
sh
ip
.R
e
l
a
t
ion
sh
ip
sth
a
ton
c
econ
s
i
s
t
edo
f
lov
eandin
t
im
a
cyw
e
r
ed
e
s
c
r
ib
eda
so
f
t
envo
l
a
t
i
l
eandd
i
s
t
an
t(Bough
twoode
ta
l
.
,2011
)
.
Fo
rex
amp
l
e
,ac
a
r
eg
iv
e
rinO
’Sh
aughn
e
s
sye
ta
l
.
’
s(2010
)s
tudyr
epo
r
t
ed
,“
sh
e
’
sb
e
com
e
v
e
rys
e
l
fc
en
t
e
r
ed
,sh
en
ev
e
rw
a
sth
a
tso
r
to
fp
e
r
son …sh
ew
a
sv
e
ryou
tgo
inga
sIw
a
s
t
a
lk
ingtosom
eon
eth
a
tIh
av
eknownfo
raf
ewy
e
a
r
sandsh
ew
a
ssu
chabubb
lyp
e
r
son
,
sh
e
’
slo
s
tth
a
t...
”(p
.243
)
.Conv
e
r
s
e
ly
,som
eICPWDr
epo
r
t
edan
ew
lyd
e
f
in
edr
e
l
a
t
ion
sh
ip

96

	
  

th
a
tin
c
lud
edg
r
e
a
t
e
ra
f
f
e
c
t
ion
.On
eICPWDs
t
a
t
ed
,“
th
ankh
e
av
en
sth
a
tsh
e
’
sa
f
f
e
c
t
ion
a
t
e
tow
a
rd
sm
e
,th
a
t
’
swond
e
r
fu
lr
e
a
l
ly
.Sh
es
t
i
l
lshow
sm
ea
f
f
e
c
t
ionandth
el
i
t
t
l
es
igni
sth
a
t
sh
e
’
scom
eupandsh
e
’
l
lrubmya
rm
so
rrubmyb
a
ck
.Th
a
t
’
sh
e
ra
f
f
e
c
t
ions
ign…
”(O
’
Sh
aughn
e
s
sy
,2011
,p
.243
)
.Acommonandp
a
r
t
i
cu
l
a
r
lyadm
i
r
ab
l
ef
ind
inginth
el
i
t
e
r
a
tu
r
e
wa
sth
a
tm
anyICPWDend
e
avou
r
edtom
a
in
t
a
inth
ec
a
r
er
e
c
ip
i
en
t
’
sf
e
e
l
ingo
fs
e
l
f
wo
r
th
andh
app
in
e
s
s(Ad
am
s
,2006
;K
a
r
l
s
sone
ta
l
.
,2015
;O
’Sh
aughn
e
s
sye
ta
l
.
,2010
)
.
O
’Sh
aughn
e
s
sye
ta
l
.(2010
)s
t
a
t
eth
a
ten
cou
r
ag
ingICPWDtofo
cu
son‘wo
rk
ingtog
e
th
e
r
’
w
ithth
ec
a
r
er
e
c
ip
i
en
t
,e
sp
e
c
i
a
l
lydu
r
ingth
ee
a
r
lys
t
ag
e
so
fd
em
en
t
i
a
,c
and
e
c
r
e
a
s
es
t
r
e
s
s
andimp
rov
eth
ed
em
en
t
i
ajou
rn
eyfo
rbo
thinvo
lv
ed
.Th
i
ss
t
r
a
t
egyc
anb
esugg
e
s
t
edby
PCP
stoen
cou
r
ag
emo
r
epo
s
i
t
iv
ec
a
r
eg
iv
ingexp
e
r
i
en
c
e
s
.
P
e
r
sona
ljou
rn
ey
.A
sICPWDt
r
av
e
lth
ed
em
en
t
i
ajou
rn
eyw
i
thth
ec
a
r
er
e
c
ip
i
en
t
,
th
eyemb
a
rkuponth
e
i
rownp
e
r
son
a
ljou
rn
eya
sw
e
l
l
.ICPWDr
epo
r
t
edh
av
ingexp
e
r
i
en
c
ed
m
anyemo
t
ion
s
.Ev
eninth
ee
a
r
lys
t
ag
e
so
fth
ec
a
r
er
e
c
ip
i
en
t
’
sd
i
s
e
a
s
ep
ro
c
e
s
s
,ICPWDm
ay
exp
e
r
i
en
c
elon
e
l
in
e
s
sandso
c
i
a
li
so
l
a
t
ion(G
a
lv
ine
ta
l
.
,2005
;L
i
l
lye
ta
l
.
,2012
)
.F
r
i
end
s
andf
am
i
lym
emb
e
r
sm
ayb
eg
intoavo
idth
ec
a
r
er
e
c
ip
i
en
ton
c
em
emo
ryimp
a
i
rm
en
tand
unp
r
ed
i
c
t
ab
l
eb
eh
av
iou
r
sb
e
com
emo
r
eno
t
i
c
e
ab
l
e
.M
anyICPWDr
epo
r
t
edf
e
e
l
ing
so
f
un
c
e
r
t
a
in
tyinth
i
ss
t
ag
eo
fth
e
i
rjou
rn
eyinp
a
r
t
i
cu
l
a
r(L
i
l
lye
ta
l
.
,2012
;O
’Sh
aughn
e
s
sye
t
a
l
.
,2010
;P
ro
roke
ta
l
.
,2013
;T
e
e
l&C
a
r
son
,2003
)
.O
th
e
rn
eg
a
t
iv
eemo
t
ion
ssu
cha
sf
e
a
r
,
r
e
s
en
tm
en
t
,f
ru
s
t
r
a
t
ion
,gu
i
l
t
,g
r
i
e
f
,ang
e
r
,andimp
a
t
i
en
c
ew
e
r
ef
r
equ
en
t
lym
en
t
ion
edinth
e
l
i
t
e
r
a
tu
r
eands
ev
e
r
a
lICPWDs
t
a
t
edth
a
tth
eycommon
lyexp
e
r
i
en
c
edo
s
c
i
l
l
a
t
ingn
eg
a
t
iv
e
f
e
e
l
ing
sw
i
tha
c
c
ep
t
an
c
e(O
’Sh
aughn
e
s
sye
ta
l
.
,2010
)
.
Ev
e
ryjou
rn
eyw
i
l
lb
ed
i
f
f
e
r
en
tfo
re
a
chICPWD
;how
ev
e
r
,a
sno
t
edinth
el
i
t
e
r
a
tu
r
e
m
anyemo
t
ion
sandexpe
r
i
en
c
e
sa
r
esh
a
r
ed
.Th
einv
a
lu
ab
l
ero
l
eo
fsuppo
r
tg
roup
si
s

97

	
  

emph
a
s
i
z
edag
a
ina
sth
eyg
iv
eICPWDth
eoppo
r
tun
i
tytor
e
l
ayth
e
s
ef
e
e
l
ing
stoo
th
e
r
sth
a
t
c
anr
e
l
a
t
etoth
e
i
rexp
e
r
i
en
c
e
sandi
t
e
r
a
t
etoth
ec
a
r
eg
iv
e
rth
a
t
,a
l
thoughth
eya
r
e
exp
e
r
i
en
c
ingm
anyd
i
f
f
i
cu
l
t
i
e
s
,th
eya
r
eno
ta
lon
einth
e
i
rs
i
tu
a
t
ion
.
Ano
th
e
rc
r
i
t
i
c
a
limp
l
i
c
a
t
ionfo
rPCPp
r
a
c
t
i
c
ei
sb
e
ingcogn
i
z
an
tth
a
tICPWDm
ay
r
e
a
chapo
in
tinth
e
i
rjou
rn
eywh
enth
eya
r
enolong
e
rab
l
eo
rw
i
l
l
ingtop
rov
id
ec
a
r
etoth
e
c
a
r
er
e
c
ip
i
en
t
.Th
i
si
simpo
r
t
an
ta
s“…
suppo
r
t
ingc
a
r
eg
iv
e
r
sa
l
som
e
an
sr
e
sp
e
c
t
ing
c
a
r
eg
iv
e
r
s
’d
e
c
i
s
ion
s
.Suppo
r
ti
sal
a
rg
et
e
rmandm
e
an
sa
l
sosuppo
r
t
ingc
a
r
eg
iv
e
r
swho
don
’
tw
an
tto[b
ec
a
r
eg
iv
e
r
s
]anymo
r
e
”(Du
ch
a
rm
e
,2012
,p
a
r
a
.62
)
.P
rov
id
ingemo
t
ion
a
l
suppo
r
tandh
av
inganaw
a
r
en
e
s
so
fr
e
sou
r
c
e
sav
a
i
l
ab
l
etoh
e
lpICPWDandsh
a
r
ingth
ema
s
th
eyr
e
l
inqu
i
shth
ero
l
eo
fc
a
r
eg
iv
e
ri
sanimpo
r
t
an
timp
l
i
c
a
t
ionfo
rPCP
s
.
Po
s
i
t
i
v
ea
sp
e
c
t
so
fca
r
eg
i
v
ing
.Mu
cho
fth
el
i
t
e
r
a
tu
r
efo
cu
s
e
sonn
eg
a
t
iv
ea
sp
e
c
t
so
f
th
ec
a
r
eg
iv
ingro
l
e
;how
ev
e
r
,twos
tud
i
e
sex
am
in
edth
epo
s
i
t
iv
ea
sp
e
c
t
so
fc
a
r
eg
iv
ing
.Th
e
po
s
i
t
iv
ea
sp
e
c
t
so
fc
a
r
ingc
anb
econ
c
ep
tu
a
l
i
z
edu
s
ingNo
l
ane
ta
l
.
’
s(1996
)‘
s
a
t
i
s
f
a
c
t
ion
so
f
c
a
r
ing
’th
a
tadd
r
e
s
sth
edyn
am
i
cr
e
l
a
t
ion
sh
ipb
e
tw
e
enth
eICPWDandth
ec
a
r
er
e
c
ip
i
en
t
,
s
a
t
i
s
f
a
c
t
ionf
romin
t
e
rp
e
r
son
a
lv
i
ew
so
fc
a
r
eg
iv
ing
,ands
a
t
i
s
f
a
c
t
ionf
romp
romo
t
ingw
e
l
l
b
e
ingandp
ro
t
e
c
t
ingth
ec
a
r
er
e
c
ip
i
en
tf
romh
a
rm
.Th
el
a
t
t
e
rw
a
sd
emon
s
t
r
a
t
edbyICPWD
whos
t
r
iv
etom
a
in
t
a
inth
ec
a
r
er
e
c
ip
i
en
t
’
sh
app
in
e
s
sands
en
s
eo
fb
e
long
ing
,a
sd
i
s
cu
s
s
ed
p
r
ev
iou
s
ly
.Coh
ene
ta
l
.(2002
)foundth
a
tpo
s
i
t
iv
ef
e
e
l
ing
sa
s
so
c
i
a
t
edw
i
thc
a
r
eg
iv
ingw
e
r
e
inv
e
r
s
e
lys
ign
i
f
i
c
an
t
lyr
e
l
a
t
edton
eg
a
t
iv
ef
e
e
l
ing
so
fd
ep
r
e
s
s
ion
,s
e
l
f
r
a
t
edh
e
a
l
thand
bu
rd
en
,wh
e
r
e
a
sICPWDwhof
e
l
tpo
s
i
t
iv
eabou
tc
a
r
eg
iv
ingr
epo
r
t
edl
e
s
sn
eg
a
t
iv
ef
e
e
l
ing
s
.
Coh
ene
ta
l
.(2002
)sugg
e
s
tth
a
t
,byPCP
sa
sk
ingICPWDabou
twh
e
th
e
rth
eyf
e
e
l
po
s
i
t
iv
eabou
tc
e
r
t
a
ina
sp
e
c
t
so
fc
a
r
eg
iv
ing
,tho
s
ewhodono
tr
epo
r
tanypo
s
i
t
iv
ea
sp
e
c
t
s
r
e
l
a
t
edtoc
a
r
eg
iv
ingm
ayb
eid
en
t
i
f
i
eda
sa
tr
i
skfo
rd
ep
r
e
s
s
ion
.Conv
e
r
s
e
ly
,c
a
r
eg
iv
e
r
swho

98

	
  

f
e
e
lv
e
rypo
s
i
t
iv
eabou
tth
e
i
rro
l
em
ayr
e
fu
s
eano
f
f
e
ro
fsuppo
r
t
iv
es
e
rv
i
c
e
s
;th
eym
ayno
t
f
e
e
lth
a
to
th
e
r
sc
anp
rov
id
eth
es
am
el
ev
e
lo
fc
a
r
etot
h
ec
a
r
er
e
c
ip
i
en
tth
a
tth
eyth
em
s
e
lv
e
s
a
r
eab
l
etodo
.A
l
thoughno
ta
l
lICPWDn
e
edsuppo
r
t
iv
es
e
rv
i
c
e
sa
tth
et
im
eth
eya
r
e
o
f
f
e
r
ed
,r
e
fu
s
ingsu
chs
e
rv
i
c
e
sm
ayp
l
a
c
eth
ema
tr
i
skl
a
t
e
roninth
ejou
rn
eyi
fth
ey
sub
s
equ
en
t
lyb
e
com
ebu
rd
en
edandh
av
eno
tm
ad
etho
s
esuppo
r
t
iv
econ
t
a
c
t
s(Coh
ene
ta
l
.
,
2002
)
.Inadd
i
t
iontod
e
t
e
rm
in
ingr
i
skth
roughcon
s
id
e
r
a
t
iono
fpo
s
i
t
iv
ea
sp
e
c
t
so
f
c
a
r
eg
iv
ing
,fo
cu
s
ingonpo
s
i
t
iv
ec
a
r
ingexp
e
r
i
en
c
e
sm
ayh
e
lpICPWDtos
e
tth
e
i
rown
r
e
sou
r
c
e
sinmo
t
ionandfo
s
t
e
rbo
thp
e
r
son
a
lg
row
thandag
r
e
a
t
e
rs
en
s
eo
fm
e
an
ing
(P
e
a
co
cke
ta
l
.
,2010
)
.Fu
r
th
e
r
,en
cou
r
ag
ingICPWDtofo
cu
sonth
e
i
rs
t
r
eng
th
sm
ay
mo
t
iv
a
t
eth
ec
a
r
eg
iv
e
rtocon
t
inu
eonth
e
i
rjou
rn
ey
,thu
smo
s
tc
e
r
t
a
in
lyc
r
e
a
t
ingab
e
t
t
e
r
d
em
en
t
i
ajou
rn
eyfo
rth
ec
a
r
er
e
c
ip
i
en
t
.
“Road
s
id
eA
s
s
i
s
tan
c
e”
:Th
eE
f
f
e
c
t
iv
en
e
s
so
fSuppo
r
t
iv
eIn
t
e
rv
en
t
ion
s
Num
e
rou
ss
tud
i
e
sth
a
th
av
eex
am
in
edth
ee
f
f
e
c
t
so
fv
a
r
iou
sp
sy
cho
so
c
i
a
land
edu
c
a
t
ion
a
lin
t
e
rv
en
t
ion
sonou
t
com
e
so
fICPWDh
av
ed
emon
s
t
r
a
t
edin
con
s
i
s
t
en
t
imp
rov
em
en
t
sinc
a
r
eg
iv
e
rQOLo
rw
e
l
l
b
e
ingandon
lymod
e
r
a
t
ee
f
f
e
c
tinm
e
e
t
ingo
th
e
r
c
a
r
eg
iv
e
rou
t
com
e
s(B
rod
a
ty
,G
r
e
en
,&Ko
s
ch
e
r
a
,2003
;C
z
a
j
ae
ta
l
.
,2013
;Sör
en
s
en
,
P
inqu
a
r
t
,&Dub
e
r
s
t
e
in
,2002
;W
i
l
ze
ta
l
.
,2011
)
.G
r
e
enwoode
ta
l
.(2016
)foundth
a
t
p
sy
cho
so
c
i
a
lin
t
e
rv
en
t
ion
sm
ayimp
rov
eICPWD
’
sw
e
l
l
b
e
ingandd
e
c
r
e
a
s
el
ev
e
l
so
f
d
ep
r
e
s
s
ion
.
	
  
How
ev
e
r,du
etopoo
rm
e
thodo
log
i
c
a
lqu
a
l
i
tyo
rin
s
ign
i
f
i
c
an
tr
e
su
l
t
s
,mo
s
t
in
t
e
rv
en
t
ion
sa
r
eno
ta
c
tu
a
l
lyb
e
ingr
e
comm
end
edfo
rp
r
a
c
t
i
c
e
.ICPWDinK
a
r
l
s
sone
ta
l
.
’
s
(2015
)s
tudya
s
so
c
i
a
t
edin
o
f
f
i
c
ecoun
s
e
l
l
ingth
roughou
tth
ed
em
en
t
i
at
r
a
j
e
c
to
ryw
i
thgood
PCPp
r
a
c
t
i
c
e
.How
ev
e
r
,t
h
ep
sy
cho
so
c
i
a
lin
t
e
rv
en
t
ion
sinth
es
tud
i
e
sinth
i
sr
ev
i
ew
,
in
c
lud
ingcogn
i
t
iv
eb
eh
av
iou
r
a
ls
e
s
s
ion
s
,in
o
f
f
i
c
ecoun
s
e
l
ing
,andr
e
f
e
r
r
a
l
stosuppo
r
t
iv
e

99

	
  

s
e
rv
i
c
e
s
,d
emon
s
t
r
a
tednoimp
rov
em
en
tinICPWDQOLo
rind
e
c
r
e
a
s
ingbu
rd
en(M
enne
t
a
l
.
,2012
;Rod
r
igu
e
z
S
an
ch
e
ze
ta
l
.
,2012
)
.A
l
thoughc
a
r
eg
iv
e
r
swhor
e
c
e
iv
edcogn
i
t
iv
e
b
eh
av
iou
r
a
lth
e
r
apyr
epo
r
t
edimp
rov
em
en
t
sinth
e
i
rm
en
t
a
lh
e
a
l
thandg
en
e
r
a
lw
e
l
l
b
e
ingin
Rod
r
igu
e
zS
an
ch
e
ze
ta
l
.
’
ss
tudy(2012
)
,th
em
e
thodo
log
i
c
a
lqu
a
l
i
tyw
a
sl
a
ck
ing
.
Th
ef
ind
ing
so
fth
eedu
c
a
t
ion
a
lin
t
e
rv
en
t
ions
tud
i
e
sw
e
r
econ
t
r
ad
i
c
to
ryw
i
thr
e
sp
e
c
t
toth
ee
f
f
e
c
tonc
a
r
eg
iv
e
rbu
rd
en(Fo
r
t
in
skye
ta
l
.
,2014
;G
av
r
i
lov
ae
ta
l
.
,2009
)and
c
a
r
eg
iv
e
rd
ep
r
e
s
s
ion(Bu
rn
se
ta
l
.
,2003
;Fo
r
t
in
skye
ta
l
.
,2014
)
.A
l
thoughth
eBu
rn
se
ta
l
.
(2003
)s
tudyd
idno
td
emon
s
t
r
a
t
eanys
t
a
t
i
s
t
i
c
a
ls
ign
i
f
i
c
an
c
eb
e
tw
e
enou
t
com
e
sdu
eto
in
su
f
f
i
c
i
en
tpow
e
rf
romasm
a
l
ls
amp
l
es
i
z
e
,th
eau
tho
r
sa
rgu
e
dth
a
tth
es
t
ab
l
er
a
t
e
so
f
d
ep
r
e
s
s
ionw
e
r
ec
l
in
i
c
a
l
lys
ign
i
f
i
c
an
t
.Bu
rn
se
ta
l
.(2013
)s
t
a
t
edth
a
t“
i
tm
ayb
en
a
ïv
eto
th
inkth
a
tin
t
e
rv
en
t
ion
sw
i
l
le
l
im
in
a
t
eo
rm
a
rk
ed
lyd
e
c
r
e
a
s
ec
a
r
eg
iv
e
rs
t
r
e
s
so
rd
ep
r
e
s
s
ion
ov
e
rth
ecou
r
s
eo
fth
ei
l
ln
e
s
s
”(p
.553
)
.Thu
s
,inth
econ
t
ex
to
fan
eu
rod
eg
en
e
r
a
t
iv
ed
i
s
e
a
s
e
,
anin
t
e
rv
en
t
ionth
a
tm
a
in
t
a
in
sas
t
ab
l
el
ev
e
lo
fd
ep
r
e
s
s
iono
rs
t
r
e
s
sinICPWDm
ayinf
a
c
tb
e
con
s
id
e
r
edane
f
f
e
c
t
iv
ein
t
e
rv
en
t
ion(Bu
rn
se
ta
l
.
,2003
)
.
Th
et
r
an
s
f
e
r
ab
i
l
i
tyo
fth
ein
t
e
rv
en
t
ion
sb
e
tw
e
enr
e
s
e
a
r
chandp
r
a
c
t
i
c
ew
a
s
sp
e
c
i
f
i
c
a
l
lyqu
e
s
t
ion
edintwoo
fth
es
tud
i
e
s(Bu
rn
se
ta
l
.
,2003
;Rod
r
igu
e
z
S
an
ch
e
ze
ta
l
.
,
2012
)
.Insom
es
a
l
a
r
i
edNP
l
edp
r
im
a
ryc
a
r
ec
l
in
i
c
s
,acogn
i
t
iv
eb
eh
av
io
r
a
lth
e
r
apy
in
t
e
rv
en
t
ionm
ayb
ef
e
a
s
ib
l
eandimp
rov
eth
em
en
t
a
lh
e
a
l
tho
fICPWD
.R
eg
r
e
t
t
ab
ly
,th
e
im
p
l
em
en
t
a
t
iono
fmo
s
to
fth
e
s
ein
t
e
r
imsuppo
r
t
iv
ein
t
e
rv
en
t
ion
sin
to20
90m
inu
t
es
e
s
s
ion
s
inbu
sy
,f
e
e
fo
r
s
e
rv
i
c
ep
r
im
a
ryc
a
r
ec
l
in
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c
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s
tl
a
rg
e
lyb
ev
i
ew
eda
sun
r
e
a
l
i
s
t
i
c
.B
a
s
edon
th
ef
ind
ing
so
fth
el
i
t
e
r
a
tu
r
e
,i
th
a
sb
e
com
ec
l
e
a
rth
a
tth
eb
e
s
tsuppo
r
t
iv
es
t
r
a
t
eg
i
e
sfo
r
ICPWDa
r
ep
rov
id
edbyamu
l
t
id
i
s
c
ip
l
in
a
ryt
e
amth
a
tcon
t
inu
e
sth
roughou
ta
l
ls
t
ag
e
so
fth
e
d
em
en
t
i
ajou
rn
ey
.J
enn
ing
se
ta
l
.(2016
)ag
r
e
e
,s
t
a
t
ingth
a
t“
in
t
e
rv
en
t
ion
sth
a
t …p
rov
id
e

100

	
  
ongo
inga
s
s
i
s
t
an
c
ea
sth
ed
i
s
e
a
s
ep
rog
r
e
s
s
e
sh
av
eb
e
enmo
s
te
f
f
e
c
t
iv
e …bu
tbu
sy
phy
s
i
c
i
an
sh
av
en
e
i
th
e
rth
et
im
eno
r
,insom
ec
a
s
e
s
,th
esk
i
l
l
stoad
equ
a
t
e
lyimp
l
em
en
t

in
t
e
rv
en
t
ion
s…
”(p
.283
)
.How
ev
e
r
,c
e
r
t
a
ina
sp
e
c
t
so
fth
er
ev
i
ew
edin
t
e
rv
en
t
ion
scou
ldb
e
app
l
i
edtop
r
a
c
t
i
c
eino
rd
e
rtom
e
e
tth
en
e
ed
so
fICPWD
.Fo
rex
amp
l
e
,edu
c
a
t
ionabou
t
d
i
s
e
a
s
em
an
ag
em
en
t
,s
t
r
e
s
sm
an
ag
em
en
t
,andb
eh
av
iou
r
a
lm
an
ag
em
en
tcou
ldb
ep
rov
id
ed
byNP
sju
s
ta
sedu
c
a
t
ioni
sp
rov
id
edtop
a
t
i
en
t
sw
i
tho
th
e
rch
ron
i
cd
i
s
e
a
s
e
sdu
r
ingp
r
im
a
ry
c
a
r
ev
i
s
i
t
s(Bu
rn
se
ta
l
.
,2003
)
.Th
i
sv
i
ewi
ssuppo
r
t
edbyG
av
r
i
lov
ae
ta
l
.(2009
)whos
t
a
t
ed
th
a
tev
enun
comp
l
i
c
a
t
ed
,sho
r
tedu
c
a
t
ion
a
lin
t
e
rv
en
t
ion
sm
ayp
rov
ev
a
lu
ab
l
efo
rICPWD
.In
l
a
rg
e
rin
t
e
rd
i
s
c
ip
l
in
a
ryc
l
in
i
c
s
,o
th
e
rm
emb
e
r
so
fth
et
e
am
,su
cha
sR
eg
i
s
t
e
r
edNu
r
s
e
s
,m
ay
a
l
sob
eab
l
etop
rov
id
ep
a
t
i
en
t
sw
i
thmo
r
ed
e
t
a
i
l
ededu
c
a
t
ioni
fth
eNPi
swo
rk
ingw
i
th
in
sho
r
t
e
rappo
in
tm
en
tt
im
e
s
.
Th
eimp
l
em
en
t
a
t
iono
fco
l
l
abo
r
a
t
iv
ec
a
r
ein
t
e
rv
en
t
ion
sinp
r
im
a
ryc
a
r
ey
i
e
ld
edth
e
mo
s
tp
rom
i
s
ecomp
a
r
edtop
sy
cho
so
c
i
a
landedu
c
a
t
ion
a
lin
t
e
rv
en
t
ion
sa
lon
e(B
as
se
ta
l
,
2013
;V
i
ck
r
ey
,2006
)
.Du
etoth
ecomp
l
exn
a
tu
r
eo
fc
a
r
eg
iv
e
r
sn
e
ed
s
,th
i
si
sno
tp
a
r
t
i
cu
l
a
r
ly
su
rp
r
i
s
ing
.Th
ee
f
f
e
c
t
iv
en
e
s
so
fth
ePa
r
tn
e
r
sinDem
en
t
i
aCa
r
ein
t
e
rv
en
t
ioninth
eB
a
s
se
ta
l
.
(2013
)s
tudyinm
e
e
t
ingunm
e
tin
fo
rm
a
lc
a
r
eg
iv
e
rn
e
ed
,s
t
r
a
in
,andd
ep
r
e
s
s
ionm
ayb
e
r
e
l
a
t
edtoth
ef
a
c
tth
a
tth
ep
rog
r
amw
a
sd
ev
e
lop
edw
i
thav
i
ewtoadd
r
e
s
ssp
e
c
i
f
i
ci
s
su
e
sw
i
th
c
a
r
eth
a
tICPWDh
adexp
r
e
s
s
edp
r
io
rtod
ev
e
lopm
en
to
fth
ep
rog
r
am
.Th
e
s
ei
s
su
e
sm
i
r
ro
r
th
er
epo
r
t
edn
e
ed
so
fICPWDinth
es
tud
i
e
sinth
i
sr
ev
i
ew
,in
c
lud
ingl
a
cko
fr
e
cogn
i
t
iono
f
c
a
r
eg
iv
e
r
’
sf
e
e
l
ing
so
fi
so
l
a
t
ion
,l
a
cko
fedu
c
a
t
ionandr
e
sou
r
c
esh
a
r
ing
,f
r
agm
en
t
ed
,poo
r
ly
coo
rd
in
a
t
eds
e
rv
i
c
ep
rov
i
s
ion
,andth
el
a
cko
fcon
s
id
e
r
a
t
iono
fc
a
r
eg
iv
e
r
s
’n
e
ed
s(B
a
s
se
ta
l
.
,
2013
)
.Th
einv
a
lu
ab
leb
en
e
f
i
to
fth
eco
l
l
abo
r
a
t
ionb
e
tw
e
enh
e
a
l
ths
e
rv
i
c
e
sandad
em
en
t
i
a
fo
cu
s
edcommun
i
tyag
en
cyw
a
sev
id
en
tinth
es
tudybyB
a
s
se
ta
l
.(2013
)
.

101

	
  

Bo
tho
fth
eNPl
edin
t
e
rv
en
t
ion
sev
a
lu
a
t
edinth
el
i
t
e
r
a
tu
r
er
e
su
l
t
edinas
a
t
i
s
f
a
c
to
ry
ev
a
lu
a
t
iono
fth
ein
t
e
rv
en
t
ionbys
tudyp
a
r
t
i
c
ip
an
t
sr
e
l
a
t
edtoth
ed
ev
e
lopm
en
to
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s
i
t
iv
e
r
e
l
a
t
ion
sh
ip
sw
i
thth
eNP
swhoimp
l
em
en
t
edth
ein
t
e
rv
en
t
ion
s(C
a
l
l
ah
ane
ta
l
.
,2006
;
Fo
r
t
in
skye
ta
l
.
,2009
).Th
i
sm
ayb
eas
ign
i
f
i
c
an
tf
ind
ingini
t
s
e
l
f
,a
sth
ec
a
r
eg
iv
e
r
’
s
p
e
r
c
ep
t
iono
ft
h
er
e
l
a
t
ion
sh
ipw
i
thth
ePCPin
f
lu
en
c
e
sth
ep
e
r
c
ep
t
iono
fsuppo
r
t
.Th
i
s
d
emon
s
t
r
a
t
e
sth
eimpo
r
t
an
c
eo
fp
rov
id
ingsuppo
r
tth
roughth
ed
ev
e
lopm
en
tandfo
s
t
e
r
ingo
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th
e
r
ap
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t
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cr
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l
a
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ip
s
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fth
eICPWDcon
t
inu
e
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e
e
lsuppo
r
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edbyth
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i
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r
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e
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ip
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en
t
’
sPCP
,th
i
sm
ayb
emu
chmo
r
epow
e
r
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lth
anth
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e
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en
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ioni
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s
e
l
fa
timp
rov
ing
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ec
a
r
eg
iv
ingjou
rn
ey
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a
inth
et
r
an
s
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e
r
ab
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l
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tyo
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i
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e
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e
a
r
chtop
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a
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r
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sh
Co
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i
a(BC
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ayb
el
im
i
t
eda
sth
ero
l
eo
fth
eNP
sinth
e
s
es
tud
i
e
si
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e
ryd
i
f
f
e
r
en
ttoth
e
ro
l
eo
fmo
s
tNP
sinBC
,m
anyo
fwhomh
av
es
im
i
l
a
rro
l
e
stoF
am
i
lyPhy
s
i
c
i
an
s
.
C
l
in
i
ca
lP
ra
c
t
i
c
eGu
id
e
l
in
e
s
Tu
rn
e
r
,M
i
s
so
,H
a
r
r
i
s
,andG
r
e
en(2008
)s
t
a
t
edth
a
t,h
i
s
to
r
i
c
a
l
ly
,c
l
in
i
c
a
lp
r
a
c
t
i
c
e
gu
id
e
l
in
e
s“w
e
r
eo
f
t
end
ev
e
lop
edbycon
s
en
su
so
fag
roupo
fexp
e
r
tc
l
in
i
c
i
an
sw
i
thou
t
exp
l
i
c
i
tr
e
f
e
r
en
c
etor
e
s
e
a
r
chev
id
en
c
e
”(p
.2
)
.Tod
ay
,i
ti
sanexp
e
c
t
a
t
iono
fmo
s
tPCP
sth
a
t
c
l
in
i
c
a
lp
r
a
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i
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lb
ed
ev
e
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op
edb
a
s
edonh
ighqu
a
l
i
tyev
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en
c
e
.How
ev
e
r
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e
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e
comm
end
a
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sinth
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a
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e
rsuppo
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ts
e
c
t
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sind
em
en
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ac
a
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ec
l
in
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t
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e
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id
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l
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e
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i
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r
eno
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r
t
edbyth
i
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indo
fev
id
en
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e
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im
i
l
a
r
ly
,inaned
i
to
r
i
a
l
byCo
l
l
in
s&Sw
a
r
t
z(201
1
)
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l
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ec
l
in
i
c
a
lr
e
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end
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lysuppo
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l
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id
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102

	
  
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l
ly
,andin
t
e
rn
a
t
ion
a
l
lyi
sl
ik
e
ly
con
t
r
ibu
t
i
ngtoth
ein
con
s
i
s
t
en
tsuppo
r
tICPWDa
r
er
e
c
e
iv
inginp
r
im
a
ryc
a
r
ep
r
a
c
t
i
c
e
s
e
t
t
ing
s
.Th
eav
a
i
l
ab
i
l
i
tyo
facomp
r
eh
en
s
iv
eBC
b
a
s
edo
rn
a
t
ion
a
lgu
id
e
l
in
eou
t
l
in
ingth
e
b
e
s
tw
ay
stosuppo
r
tICPWDc
ou
ldb
en
e
f
i
tNPp
r
a
c
t
i
c
ea
si
twou
lda
l
lowNP
stoen
su
r
eth
a
t
th
eyw
e
r
ep
rov
id
ingcon
s
i
s
t
en
tev
id
en
c
e
b
a
s
edsuppo
r
t
iv
es
t
r
a
t
eg
i
e
sfo
rICPWD
.
Th
eRo
l
eo
fth
eNPandImp
l
i
ca
t
ion
sfo
rNPP
ra
c
t
i
c
e
Incondu
c
t
ingth
i
sin
t
eg
r
a
t
iv
el
i
t
e
r
a
tu
r
er
ev
i
ew
,no
t
ab
l
eg
ap
sinp
r
a
c
t
i
c
e
,r
e
s
e
a
r
ch
,
andpo
l
i
cyh
av
eem
e
rg
edth
a
tcou
lda
f
f
e
c
tth
ep
e
r
c
e
iv
edanda
c
tu
a
lsuppo
r
tth
a
tICPWD
r
e
c
e
iv
e
.Fu
r
th
e
rmo
r
e
,i
th
a
sb
e
com
ec
l
e
a
rth
roughsyn
th
e
s
i
so
fth
el
i
t
e
r
a
tu
r
eth
a
tth
ero
l
eo
f
th
eNPi
sb
en
e
f
i
c
i
a
linm
e
e
tingth
eexp
r
e
s
s
edn
e
ed
so
fICPWDandp
rov
id
inge
f
f
e
c
t
iv
e
suppo
r
tfo
rth
e
s
ec
a
r
eg
iv
e
r
s
.Ina“
s
t
rong
lyphy
s
i
c
i
an
c
en
t
r
i
c
”(Tho
rn
e
,2011
,p
a
r
a
.1
)
p
r
im
a
ryc
a
r
esy
s
t
emth
a
ti
scu
r
r
en
t
lys
t
rugg
l
ingtom
e
e
tth
en
e
ed
so
fICPWD
,NP
sc
an
p
rov
id
einnov
a
t
iv
eapp
ro
a
ch
e
stoc
a
r
eth
a
tno
ton
lyp
rov
id
emu
chn
e
ed
edsuppo
r
tto

103

	
  

ICPWD
,bu
tth
a
twou
lda
l
sowo
rkono
rg
an
i
z
a
t
ion
a
landsy
s
t
em
sl
ev
e
l
stoc
r
e
a
t
ech
ang
e
sfo
r
th
e
s
ec
a
r
eg
iv
e
r
s
,th
e
r
ebyn
a
r
row
ingth
eex
i
s
t
ingg
ap
sinh
e
a
l
thc
a
r
e
.
Th
ero
l
eo
fNP
sp
rov
id
e
saun
iqu
ep
e
r
sp
e
c
t
iv
ef
romwh
i
chtosu
c
c
e
s
s
fu
l
lygu
id
e
ICPWDth
roughth
e
i
rjou
rn
ey
s
.Inanin
t
e
rv
i
eww
i
thS
chw
a
r
t
z(2009
)
,S
t
r
ing
a
r
iMu
r
r
ay
s
t
a
t
edth
a
tth
eNPmod
e
lo
fc
a
r
ei
sp
a
t
i
en
t
,f
am
i
ly
,andcommun
i
tyfo
cu
s
edr
a
th
e
rth
anth
e
d
i
s
e
a
s
efo
cu
sth
a
tcomp
r
i
s
e
sth
em
ed
i
c
a
lmod
e
lo
fc
a
r
e
.A
sadv
an
c
edp
r
a
c
t
i
c
enu
r
s
e
s
,NP
s
b
r
ingaho
l
i
s
t
i
cp
e
r
sp
e
c
t
iv
e
;th
i
saugm
en
t
sth
e
i
rd
i
agno
s
t
i
cknow
l
edg
e
,c
l
in
i
c
a
lsk
i
l
l
s
,and
ab
i
l
i
tytoa
idind
ev
e
lop
ingh
igh
lyth
e
r
ap
eu
t
i
cin
t
e
rp
e
r
son
a
lr
e
l
a
t
ion
sh
ip
sw
i
thICPWDand
th
e
i
rc
a
r
er
e
c
ip
i
en
t
s
.NP
sc
anu
s
eth
e
i
rc
l
in
i
c
a
lknow
l
edg
eandsk
i
l
l
stoob
t
a
inatho
rough
h
i
s
to
ryo
fth
e
s
ec
l
i
en
t
swh
i
l
ea
l
soinqu
i
r
ingabou
tso
c
i
a
ld
e
t
e
rm
in
an
t
so
fh
e
a
l
thandth
e
f
am
i
lycon
t
ex
t
,comp
l
e
t
ingaphy
s
i
c
a
lex
am
,p
e
r
fo
rm
ingcogn
i
t
iv
ea
s
s
e
s
sm
en
t
s
,and
in
t
e
rp
r
e
t
ingl
abwo
rkando
th
e
rinv
e
s
t
ig
a
t
ion
storu
l
eou
tr
ev
e
r
s
ib
l
ec
au
s
e
so
fd
em
en
t
i
a
.
Onc
esu
chacomp
r
eh
en
s
iv
ea
s
s
e
s
sm
en
tandwo
rkuph
a
sb
e
encomp
l
e
t
ed
,th
eNPwou
ldb
e
ab
l
etop
rov
id
ead
i
agno
s
i
so
fd
em
en
t
i
a
,wh
e
r
eapp
rop
r
i
a
t
e
.
Th
eC
an
ad
i
anFound
a
t
ionfo
rH
e
a
l
th
c
a
r
eImp
rov
em
en
t(2010
)s
t
a
t
edth
a
tp
a
t
i
en
t
s
app
r
e
c
i
a
t
eth
ecommun
i
c
a
t
ions
ty
l
eo
fNP
sandth
eadd
i
t
ion
a
lt
im
eth
eysp
endw
i
thth
e
i
r
p
a
t
i
en
t
s
.Fu
r
th
e
r
,s
tud
i
e
sh
av
ed
emon
s
t
r
a
t
edth
a
tNP
st
endtoa
skmo
r
equ
e
s
t
ion
so
fp
a
t
i
en
t
s
ando
f
f
e
rmo
r
ein
fo
rm
a
t
ionandop
t
ion
sfo
rc
a
r
eth
anphy
s
i
c
i
an
s(C
an
ad
i
anFound
a
t
ionfo
r
H
e
a
l
th
c
a
r
eImp
rov
em
en
t
,2010
)
.AnICPWDsp
e
ak
ingw
i
thK
e
l
so(2015
)s
t
a
t
edth
a
t
,in
add
i
t
iontom
e
e
t
ingth
e
i
rm
ed
i
c
a
ln
e
ed
s
,th
eNPc
an“
add
r
e
s
sth
ep
sy
cho
so
c
i
a
ln
e
ed
sth
a
t
m
ayo
rm
ayno
tb
em
ed
i
c
a
l
lys
e
r
iou
sbu
ts
t
i
l
lacon
c
e
rn
”(p
a
r
a
.5
)
.Fo
rin
s
t
an
c
e
,NP
sc
anu
s
e
th
eth
em
e
sth
a
tem
e
rg
edinth
equ
a
l
i
t
a
t
iv
el
i
t
e
r
a
tu
r
einth
i
sr
ev
i
ewtoin
i
t
i
a
t
econv
e
r
s
a
t
ion
w
i
thICPWDr
eg
a
rd
ingi
s
su
e
sth
a
tth
eym
ayb
ef
a
c
ingandemo
t
ion
sth
a
tth
eym
ayb
e

104

	
  
f
e
e
l
ing
.M
anyICPWDm
ayno
tth
em
s
e
lv
e
sin
i
t
i
a
t
eth
i
sconv
e
r
s
a
t
ionw
i
thth
e
i
rPCP
;

th
e
r
e
fo
r
e
,m
en
t
ion
ingo
th
e
rICPWDexp
e
r
i
en
c
e
sc
ana
l
lowNP
stoa
s
s
e
s
swh
a
ti
s
su
e
sth
a
t
ICPWDm
ayb
eexp
e
r
i
en
c
ingandadd
r
e
s
sth
emth
roughin
o
f
f
i
c
ecoun
s
e
l
ingandsuppo
r
t
,a
s
w
e
l
la
so
f
f
e
r
ingr
e
sou
r
c
e
sth
a
tm
ayb
en
e
f
i
tth
ec
a
r
eg
iv
e
r
.Th
eNPc
ana
l
sowo
rkw
i
thth
e
p
a
t
i
en
tandf
am
i
lyinp
rov
id
ingan
t
i
c
ip
a
to
rygu
id
an
c
ea
sth
eywo
rkth
roughth
en
ew
d
i
agno
s
i
sandth
ech
ang
e
sth
a
tw
i
l
lcom
eov
e
rt
im
e
.
Th
esk
i
l
ls
e
to
fNP
si
so
fp
a
r
t
i
cu
l
a
rs
ign
i
f
i
c
an
c
ea
tth
et
im
eo
fd
i
agno
s
i
s
.D
i
agno
s
ing
ap
a
t
i
en
tw
i
thd
em
en
t
i
ac
anb
ev
e
ryd
i
f
f
i
cu
l
tfo
rPCP
s
.Fo
rth
ep
a
t
i
en
tandth
e
i
rf
am
i
ly
m
emb
e
r
s
,th
eimp
a
c
to
fr
e
c
e
iv
ingad
i
agno
s
i
so
fat
e
rm
in
a
l
,p
rog
r
e
s
s
iv
e
,n
eu
rod
eg
en
e
r
a
t
iv
e
d
i
s
e
a
s
eth
a
th
a
snohop
eo
facu
r
ec
anb
ed
ev
a
s
t
a
t
ing
.NP
sc
ano
f
f
e
rth
et
im
etop
rov
i
d
e
edu
c
a
t
ionandh
e
a
l
thp
romo
t
ions
t
r
a
t
eg
i
e
s
,add
r
e
s
scon
c
e
rn
sr
a
i
s
edbyICPWDo
rth
ec
a
r
e
r
e
c
ip
i
en
t
,p
rov
id
eemo
t
ion
a
lsuppo
r
t
,andconn
e
c
tf
am
i
l
i
e
stor
e
sou
r
c
e
sth
a
tth
eym
ayn
e
eda
t
th
i
sc
r
i
t
i
c
a
lt
im
einth
ed
em
en
t
i
ajou
rn
ey
;o
th
e
rPCP
sm
ayno
tb
es
im
i
l
a
r
lyab
l
etoo
f
f
e
rsu
ch
comp
r
eh
en
s
iv
eb
en
e
f
i
t
sdu
etoth
ecu
r
r
en
tf
e
e
fo
r
s
e
rv
i
c
emod
e
lth
a
tcu
r
r
en
t
lyex
i
s
t
sin
C
an
ad
a
.M
anyNP
swo
rk
inga
sm
emb
e
r
so
famu
l
t
id
i
s
c
ip
l
in
a
ryt
e
amwh
i
chw
i
l
ls
t
r
eng
th
en
th
ec
a
r
emod
e
lfo
rth
ep
a
t
i
en
tandf
am
i
lya
sth
eyjou
rn
eyth
roughth
ed
i
s
e
a
s
ep
r
og
r
e
s
s
iono
f
d
em
en
t
i
a
.
Eng
ag
em
en
tinco
l
l
abo
r
a
t
iv
ep
r
a
c
t
i
c
ei
sak
eycompon
en
to
fNPp
r
a
c
t
i
c
e(T
e
e
l&
C
a
r
son
,2003
).NP
sc
anu
s
eth
e
i
re
f
f
e
c
t
iv
ecommun
i
c
a
t
ionsk
i
l
l
stoco
l
l
abo
r
a
t
ew
i
th
m
emb
e
r
so
famu
l
t
id
i
s
c
ip
l
in
a
ryt
e
am
,sp
e
c
i
a
l
i
s
t
s
,commun
i
tyo
rg
an
i
z
a
t
ion
s
,a
sw
e
l
la
sth
e
ICPWDandc
a
r
er
e
c
ip
i
en
ttod
ev
e
lopc
a
r
ep
l
an
sfo
rth
ep
a
t
i
en
tw
i
thd
em
en
t
i
aandth
e
i
r
ICPWD
.Th
eNPm
ayp
a
r
t
i
c
ip
a
t
einco
l
l
abo
r
a
t
iv
et
e
amv
i
s
i
t
sandf
am
i
lym
e
e
t
ing
stosh
a
r
e
th
e
i
rknow
l
edg
ew
i
thth
et
e
amanda
idinp
rov
id
ingqu
a
l
i
typ
a
t
i
en
tc
a
r
e
.

105

	
  

Th
ecomp
a
s
s
ion
a
t
eandp
ro
f
e
s
s
ion
a
ln
a
tu
r
eo
fNP
sc
anl
endi
t
s
e
l
ftoasu
c
c
e
s
s
fu
l
p
a
l
l
i
a
t
iv
ec
a
r
eapp
ro
a
chs
t
a
r
t
inga
td
i
agno
s
i
sw
i
thadv
an
c
edc
a
r
ep
l
ann
ing
.C
lo
s
e
rtoth
eend
o
fth
ed
em
en
t
i
ajou
rn
eyNP
sc
ana
l
soco
l
l
abo
r
a
t
ew
i
thm
emb
e
r
so
fap
a
l
l
i
a
t
iv
ec
a
r
et
e
amto
p
rov
id
eICPWDandth
e
i
rc
a
r
er
e
c
ip
i
en
t
sw
i
thn
e
ed
edsuppo
r
ta
tth
a
tt
im
e
.
Ano
th
e
rinv
a
lu
ab
l
ea
sp
e
c
to
fNPp
r
a
c
t
i
c
ei
sth
eab
i
l
i
tytoo
f
f
e
rhom
ev
i
s
i
t
swh
e
r
eth
e
NPh
a
sth
eoppo
r
tun
i
tytoob
s
e
rv
eth
eho
m
eenv
i
ronm
en
to
fICPWDandc
a
r
er
e
c
ip
i
en
t
sand
d
ev
e
lopag
r
e
a
t
e
rund
e
r
s
t
and
ingo
fth
e
i
rs
i
tu
a
t
ion(Unw
in&T
a
tum
,2011
)
.Hom
ev
i
s
i
t
sa
r
e
animpo
r
t
an
tcompon
en
to
fd
em
en
t
i
ac
a
r
e
,a
sth
eym
ayd
e
c
r
e
a
s
eth
enumb
e
ro
fho
sp
i
t
a
l
adm
i
s
s
ion
sandt
r
an
s
f
e
r
stor
e
s
id
en
t
i
a
lc
a
r
ef
a
c
i
l
i
t
i
e
s(Unw
in&T
a
tum
,2011
)
.
NP
sa
l
soo
f
t
enwo
rkw
i
thvu
ln
e
r
ab
l
epopu
l
a
t
ion
swhoa
r
ea
th
ighr
i
sko
ff
a
l
l
ingin
to
th
e“d
i
agno
s
t
i
cg
ap
”(L
e
a
ch&H
i
ck
s
,2013
,p
.439
)
.N
ay
lo
re
ta
l
.(2013
)s
t
a
t
eth
a
tsu
ch
vu
ln
e
r
ab
l
epopu
l
a
t
ion
sc
anin
c
lud
e
:ind
iv
idu
a
l
sw
i
thou
taPCP
,m
a
rg
in
a
l
i
z
edpopu
l
a
t
ion
s
,
tho
s
ewhol
iv
ea
lon
e
,th
e“o
ld
e
s
to
ld
”ind
iv
idu
a
l
s
,andtho
s
einru
r
a
la
r
e
a
s
.NP
sm
ayb
eina
p
a
r
t
i
cu
l
a
r
lygoodpo
s
i
t
iontoid
en
t
i
fyanda
s
s
e
s
sth
e
s
eh
igh
r
i
skp
a
t
i
en
t
s
,con
s
equ
en
t
ly
p
romo
t
ingt
im
e
lyd
i
agno
s
i
sandth
ee
a
r
lyimp
l
em
en
t
a
t
iono
fsuppo
r
t
sfo
rp
a
t
i
en
t
sandth
e
i
r
ICPWD
.Fu
r
th
e
r
,NP
scon
s
id
e
ra
l
ld
e
t
e
rm
in
an
t
so
fh
e
a
l
thth
a
tm
ayimp
a
c
tth
eh
e
a
l
thand
w
e
l
lb
e
ingo
fICPWDa
sw
e
l
la
sc
a
r
eg
iv
e
rbu
rd
en
.Ov
e
r
a
l
l
,NP
sc
anp
l
ayak
eyro
l
ein
suppo
r
t
ingbo
thICPWDandth
ec
a
r
er
e
c
ip
i
en
tw
i
thd
em
en
t
i
a
.
Th
ein
c
lu
s
iono
fNPro
l
e
sinp
r
im
a
ryc
a
r
eo
f
f
e
r
soppo
r
tun
i
tyfo
rimp
rov
edp
a
t
i
en
t
andh
e
a
l
thc
a
r
esy
s
t
emou
t
com
e
s
,a
sNP
sno
ton
lyenh
an
c
ep
r
im
a
ryc
a
r
ep
r
a
c
t
i
c
ew
i
thth
e
i
r
un
iqu
esk
i
l
l
sandexp
e
r
i
en
c
e
,bu
tt
h
eya
l
socon
t
r
ibu
t
etoh
e
a
l
thc
a
r
eth
roughl
e
ad
e
r
sh
ipand
con
su
l
t
a
t
ion
.Th
e
s
eab
i
l
i
t
i
e
sa
l
lowNP
stoimp
rov
eav
a
i
l
ab
l
esuppo
r
tth
roughc
l
in
i
c
a
l

106

	
  

p
r
a
c
t
i
c
ea
sw
e
l
la
sth
roughth
ed
ev
e
lopm
en
to
fpo
l
i
c
i
e
sandcommun
i
tyando
rg
an
i
z
a
t
ion
a
l
c
ap
a
c
i
ty
bu
i
ld
ing(CNA
,2011
)
.
W
i
thth
eg
row
ingnumb
e
ro
fag
ingadu
l
t
sw
i
thd
em
en
t
i
a,andth
esub
s
equ
en
tnumb
e
r
o
fICPWDinC
an
ad
a
,th
eadv
e
r
s
eou
t
com
e
sth
a
tc
ano
c
cu
rr
e
l
a
t
edtoc
a
r
eg
iv
ingw
i
l
l
con
t
inu
etob
eacomp
e
l
l
ingp
rob
l
emth
a
tmu
s
tb
eadd
r
e
s
s
edinp
r
im
a
ryc
a
r
e
.I
ti
simp
e
r
a
t
iv
e
th
a
tICPWDa
r
ew
e
l
l
suppo
r
t
edino
rd
e
rtom
a
in
t
a
inth
eh
e
a
l
thandw
e
l
l
b
e
ingo
fbo
th
ICPWDandth
e
i
rc
a
r
er
e
c
ip
i
en
t
sth
roughth
een
t
i
r
ed
em
en
t
i
ajou
rn
ey
.Fo
rNP
s
,th
i
sm
e
an
s
u
s
ingaf
am
i
ly
c
en
t
r
ed
,co
l
l
abo
r
a
t
iv
e
,p
ro
a
c
t
iv
ep
r
im
a
ryc
a
r
eapp
ro
a
chtod
ev
e
lopand
imp
l
em
en
tinnov
a
t
iv
eande
f
f
e
c
t
iv
esuppo
r
t
iv
es
t
r
a
t
eg
i
e
s
.
Rob
in
sonVo
l
lm
anand M
a
r
t
inM
i
s
en
e
r(2005
)a
s
c
e
r
t
a
in
edth
a
ti
ti
se
s
s
en
t
i
a
lth
a
t
NP
seng
ag
ea
tmu
l
t
ip
l
esy
s
t
em
sl
ev
e
l
sino
rd
e
rtoadd
r
e
s
si
s
su
e
sth
a
ta
f
f
e
c
tp
a
t
i
en
t
sandth
e
i
r
f
am
i
l
i
e
s
.Th
ed
ev
e
lopm
en
to
famod
e
lo
rf
r
am
ewo
rkth
a
tou
t
l
in
e
ssuppo
r
t
iv
es
t
r
a
t
eg
i
e
sa
ta
l
l
l
ev
e
l
so
fin
f
lu
en
c
e
,and
du
r
inga
l
ls
t
ag
e
so
fd
em
en
t
i
a
,wou
ldh
e
lpNP
sando
th
e
rPCP
sto
p
rov
id
econ
s
i
s
t
en
t
,comp
r
eh
en
s
iv
e
,co
l
l
abo
r
a
t
iv
ec
a
r
etobo
thICPWDandth
e
i
rc
a
r
e
r
e
c
ip
i
en
t
s
.Th
ed
ev
e
lopm
en
to
fan
e
wmod
e
lo
fc
a
r
ei
saqu
a
l
i
tyex
amp
l
eo
fadv
an
c
em
en
t
andn
e
edfo
rNPro
l
e
sth
a
tex
t
endb
eyondc
l
in
i
c
a
lp
r
a
c
t
i
c
e(B
ry
an
t
Luko
s
iu
s
,D
iC
en
so
,
B
rown
e
,&P
in
e
l
l
i
,2004)
.D
ev
e
lop
ingandimp
l
em
en
t
ingn
ewin
t
e
rv
en
t
ion
sandam
od
e
lo
f
c
a
r
ewou
ldp
rov
id
eoppo
r
tun
i
t
i
e
sfo
rp
ro
f
e
s
s
ion
a
ld
ev
e
lopm
en
t
,co
l
l
abo
r
a
t
iv
ee
f
fo
r
t
s
b
e
tw
e
eno
th
e
rPCP
sandr
e
s
e
a
r
ch
e
r
s
,anda
l
lowNP
stod
emon
s
t
r
a
t
eth
e
i
rwo
rkinas
cho
l
a
r
ly
c
ap
a
c
i
ty(Co
rn
e
re
ta
l
.
,1995
,P
l
an
te
ta
l
.
,2000
)
.
Anad
ap
t
a
t
iono
ftheC
en
t
e
r
sfo
rD
i
s
e
a
s
eCon
t
ro
landP
r
ev
en
t
ion
’
s(CDC
,2015
)
so
c
i
a
le
co
log
i
c
a
lmod
e
l(
s
e
eF
igu
r
e3
)p
rov
id
e
sanex
amp
l
eo
famu
l
t
i
l
ev
e
l
,mu
l
t
i
d
i
s
c
ip
l
in
a
ryp
r
im
a
ryc
a
r
eapp
ro
a
chtoICPWDsuppo
r
t
.NP
sc
anu
s
esu
chamod
e
ltod
ev
e
lop

107

	
  

suppo
r
t
iv
es
t
r
a
t
eg
i
e
sa
ta
l
ll
ev
e
l
so
fin
f
lu
en
c
e
.U
s
ingaso
c
io
e
co
log
i
c
a
lmod
e
lsu
cha
sth
e
CDC
’
s(2015
)“o
f
f
e
r
sc
l
e
a
rimp
l
em
en
t
a
t
iongu
id
e
l
in
e
sfo
rm
ax
im
i
z
ingth
eh
e
a
l
th
,e
conom
i
c
,
andso
c
i
e
t
a
lb
en
e
f
i
t
s
”o
fin
t
e
rv
en
t
ion
sa
im
eda
th
e
a
l
thp
romo
t
ionandp
r
ev
en
t
ion(S
toko
l
s
,
1996
,p.295
)
.

Po
l
i
c
y
Commu
n
i
ty
O
r
g
a
n
i
z
a
t
io
n
a
l
R
e
l
a
t
io
n
a
l
In
fo
rm
a
l
C
a
r
eg
iv
e
r
(
s
)
/
p
a
t
i
en
tw
i
th
d
em
en
t
i
a

F
igu
r
e3.So
c
i
a
le
co
log
i
c
a
lmod
e
lfo
rp
r
im
a
ryc
a
r
eb
a
s
edsuppo
r
t
iv
es
t
r
a
t
eg
i
e
sfo
rICPWD
.
Ad
ap
t
edf
rom“So
c
i
a
lE
co
log
i
c
a
l Mod
e
l
”
,byTh
eC
en
t
e
r
sfo
rD
i
s
ea
s
eCon
t
ro
land
P
r
e
v
en
t
ion,2015
.Copy
r
igh
t2015byth
eP
rov
in
c
eo
fB
r
i
t
i
shCo
lumb
i
a
.
Ex
amp
l
e
so
fr
e
l
ev
an
tin
t
e
rv
en
t
ion
sa
ta
l
ll
ev
e
l
sin
c
lud
e
:
•
	
  In
fo
rma
lca
r
eg
i
v
e
r
/pa
t
i
en
tw
i
thd
em
en
t
ia
:In
c
r
e
a
s
ingknow
l
edg
eo
fd
em
en
t
i
a
,
c
a
r
eg
iv
e
rcomp
e
t
en
c
e
,sk
i
l
lbu
i
ld
ing
,s
t
r
e
s
sm
an
ag
em
en
t
,andcop
ingsk
i
l
l
sth
rough
edu
c
a
t
ionandr
e
f
e
r
r
a
l
scommun
i
typ
rog
r
am
s
,andp
rov
id
ingt
im
e
lyd
i
agno
s
i
sand
emo
t
ion
a
lsuppo
r
ta
td
i
agno
s
i
sandimm
ed
i
a
t
e
lya
f
t
e
rtop
r
ep
a
r
eICPWDfo
rth
e
jou
rn
eyah
e
ad
;

108

	
  
•
	
  R
e
la
t
iona
l:a
s
s
e
s
s
ingsuppo
r
tn
e
two
rk
s
,ho
ld
ingf
am
i
lym
e
e
t
ing
stod
e
t
e
rm
in
ea

f
am
i
lyr
e
sp
i
t
ep
l
an
,r
e
f
e
r
r
a
ltosuppo
r
tg
ro
up
sandsuppo
r
t
iv
ecommun
i
tys
e
rv
i
c
e
s
,
andbu
i
ld
ings
t
rongth
e
r
ap
eu
t
i
cr
e
l
a
t
ion
sh
ip
sw
i
thth
eICPWDandth
ec
a
r
er
e
c
ip
i
en
t
;
•
	
  O
rgan
i
za
t
iona
l:p
romo
t
ingaf
am
i
ly
c
en
t
r
edapp
ro
a
chinth
ewo
rkp
l
a
c
e
,en
su
r
ing
coo
rd
in
a
t
eds
e
rv
i
c
ep
rov
i
s
ion
,p
i
lo
t
ingICPWDa
s
s
e
s
sm
en
tfo
rm
so
rco
l
l
abo
r
a
t
iv
e
p
rog
r
am
sa
im
eda
timp
rov
ingou
t
com
e
sfo
rICPWD
;co
l
l
abo
r
a
t
ingw
i
tho
th
e
r
m
emb
e
r
so
fth
eh
e
a
l
thc
a
r
et
e
am
,andp
rov
id
ingo
th
e
rPCP
sw
i
thanupd
a
t
edr
e
sou
r
c
e
l
i
s
tfo
rsuppo
r
t
iv
es
e
rv
i
c
e
s
;
•
	
  Commun
i
t
y:r
a
i
s
ingpub
l
i
caw
a
r
en
e
s
so
fd
em
e
n
t
i
aandc
a
r
eg
iv
ingth
roughm
ed
i
a
c
amp
a
ign
so
rb
e
com
inginvo
lv
edinch
a
r
i
t
ab
l
eev
en
t
sa
im
eda
tr
a
i
s
ingaw
a
r
en
e
s
sand
fund
ingfo
rd
em
en
t
i
ac
a
r
eandr
e
s
e
a
r
ch
,o
rwo
rk
ingw
i
thcommun
i
ty
b
a
s
ed
o
rg
an
i
z
a
t
ion
stod
ev
e
lopsuppo
r
t
iv
es
t
r
a
t
eg
i
e
s
;
•
	
  Po
l
i
c
y:d
ev
e
lop
ingc
l
in
i
c
a
lp
r
a
c
t
i
c
egu
id
e
l
in
e
sa
im
eda
tICPWDsuppo
r
t
,d
ev
e
lop
ing
asho
r
tICPWDa
s
s
e
s
sm
en
tfo
rmth
a
tNP
sc
anu
s
einth
ep
r
a
c
t
i
c
es
e
t
t
ing
sfo
ra
l
l
ICPWD
;p
a
r
t
i
c
ip
a
t
inginh
e
a
l
thc
a
r
epo
l
i
cych
ang
e
sth
a
ten
cou
r
ag
eaf
am
i
ly
c
en
t
r
ed
app
ro
a
chtoc
a
r
e
;o
rd
ev
e
lop
i
ngo
fan
ewmod
e
lo
fc
a
r
ea
im
eda
tsuppo
r
t
ingICPWD
andth
ec
a
r
er
e
c
ip
i
en
t
.
An
a
ly
z
ingth
el
i
t
e
r
a
tu
r
eh
a
sp
rov
id
edinv
a
lu
ab
l
ein
s
igh
t
sfo
rNP
sin
toth
en
e
ed
s
andexp
e
r
i
en
c
e
so
fICPWD
.G
a
in
ingknow
l
edg
eabou
tth
e
i
rexp
e
r
i
en
c
e
sc
anin
fo
rmth
e
d
ev
e
lopm
en
to
fp
e
r
son
c
en
t
r
edandf
am
i
ly
c
en
t
r
eds
t
r
a
t
eg
i
e
s
,su
cha
swh
enandhowto
imp
l
em
en
tsuppo
r
t
iv
es
e
rv
i
c
e
sa
san
e
c
e
s
s
a
rys
t
eptom
e
e
t
ingth
eICPWD
’
sn
e
ed
sandto
p
rov
id
ingad
equ
a
t
esuppo
r
t(Dupu
i
s
,Epp
,&Sm
a
l
e
,2004
)
.How
ev
e
r
,d
i
r
e
c
t
iononwh
a
t
typ
eo
fin
fo
rm
a
t
i
onandin
t
e
rv
en
t
ion
sshou
ldb
ep
rov
id
eda
te
a
chs
t
ag
eo
fth
ed
em
en
t
i
a

109

	
  

jou
rn
eyi
sl
a
ck
ing
.Th
eS
IGNgu
id
e
l
in
e(2011
)ag
r
e
e
ss
t
a
t
ingth
a
t“
th
er
e
s
e
a
r
chl
i
t
e
r
a
tu
r
e
do
e
sno
tp
rov
id
eac
l
e
a
rcon
s
en
su
sr
eg
a
rd
ingth
etyp
eo
fin
fo
rm
a
t
ionp
eop
l
ew
i
th
d
em
en
t
i
aandth
e
i
rc
a
r
e
r
sn
e
eda
td
i
f
f
e
r
en
ts
t
ag
e
so
fth
e
i
rjou
rn
eyo
fc
a
r
e
”(p
.21
)
.In
add
i
t
ion
,wh
i
l
eNP
sa
r
er
equ
i
r
edtou
s
eev
id
en
c
eb
a
s
edgu
id
e
l
in
e
stop
romo
t
ecomp
e
t
en
t
,
qu
a
l
i
tyc
a
r
e(CNA
,2006
)
,nogu
id
e
l
in
e
sh
av
ey
e
tb
e
end
ev
e
lop
edtogu
id
ed
e
c
i
s
ion
m
ak
ingw
i
thr
eg
a
rd
stop
rov
id
ingsuppo
r
ttoICPWD
.A
tth
epo
l
i
cyl
ev
e
l
,NP
sc
an
p
a
r
t
i
c
ip
a
t
einth
ed
ev
e
lopm
en
to
fb
e
s
tp
r
a
c
t
i
c
egu
id
e
l
in
e
sandth
ed
ev
e
lopm
en
to
fa‘
ro
ad
m
ap
’th
a
tou
t
l
in
e
swh
a
tin
t
e
rv
en
t
ion
sshou
ldb
eimp
l
em
en
t
eda
tsp
e
c
i
f
i
ct
im
e
sdu
r
ingth
e
d
em
en
t
i
ajou
rn
ey
.Anex
amp
l
eo
fth
etyp
eo
f‘
ro
adm
ap
’th
a
tNP
scou
ldu
s
einp
r
a
c
t
i
c
e
b
a
s
edonth
ef
ind
ing
so
fth
i
sr
ev
i
ewi
sp
rov
id
edinApp
end
ixD
.
Ano
th
e
rimp
l
i
c
a
t
ionfo
rp
r
a
c
t
i
c
ea
tth
epo
l
i
cyl
ev
e
li
stoadvo
c
a
t
efo
rICPWDby
lobby
ingfo
rch
ang
e
.Dupu
i
s
,Epp
,&Sm
a
l
e(2004
)en
cou
r
ag
ePCP
stolobbytoch
ang
e
ex
i
s
t
ingpo
l
i
c
i
e
sw
i
thr
e
sp
e
c
ttogov
e
rnm
en
tfund
ingfo
rsuppo
r
t
iv
es
e
rv
i
c
e
s
,and
“
d
ev
e
lopinnov
a
t
iv
eapp
ro
a
ch
e
stoth
ep
rov
i
s
iono
fcommun
i
tysuppo
r
ts
e
rv
i
c
e
sth
a
ta
r
e
t
ru
lysu
s
t
a
in
ab
l
e
,f
l
ex
ib
l
e
,po
r
t
ab
l
e
,andr
e
spon
s
iv
etoind
iv
idu
a
lc
a
r
eg
iv
e
r
s
’n
e
ed
s
”(p
.
74
)
.Th
i
si
sanimpo
r
t
an
tcon
s
id
e
r
a
t
ionfo
rPCP
sa
sth
eF
am
i
lyC
a
r
eg
iv
e
r
s
’N
e
two
rk
So
c
i
e
ty(2010
)r
epo
r
t
edth
a
t77%o
fth
esuppo
r
t
iv
es
e
rv
i
c
e
sfo
rin
fo
rm
a
lc
a
r
eg
iv
e
r
sw
e
r
e
p
rov
id
edbynon
p
ro
f
i
to
rg
an
i
z
a
t
ion
swhor
e
lyonmon
eyf
romh
e
a
l
thau
tho
r
i
t
i
e
s
,g
r
an
t
s
,
o
rfund
r
a
i
s
ingtorunth
e
i
rp
rog
r
am
s
.M
anyp
rog
r
am
s
,su
cha
sth
eC
a
r
eg
iv
e
rA
s
so
c
i
a
t
ion
o
fBC
,a
r
efo
r
c
edtoc
e
a
s
erunn
ingdu
etol
a
cko
ffund
ing
.NP
sc
anlobbyfo
rch
ang
eby
sp
e
ak
ingtoth
e
i
rM
emb
e
ro
fP
a
r
l
i
am
en
td
i
r
e
c
t
lyo
rbyconn
e
c
t
ingw
i
tho
rg
an
i
z
a
t
ion
s
(
su
cha
sth
eC
an
ad
i
anNu
r
s
e
s
’A
s
so
c
i
a
t
ion
)toen
cou
r
ag
eo
th
e
r
sinth
ef
i
e
ldtojo
in

110

	
  

tog
e
th
e
randc
r
e
a
t
eas
t
rong
e
rvo
i
c
einwh
i
chtoch
amp
ionch
ang
efo
rICPWDinp
r
im
a
ry
c
a
r
es
e
t
t
ing
s
.
	
  
Th
ewo
rkdon
einth
i
sr
ev
i
ewh
a
si
l
lum
in
a
t
edth
eimpo
r
t
an
tro
l
eth
a
tNP
sc
anand
shou
ldp
l
ayinad
equ
a
t
e
lysuppo
r
t
ingICPWDandth
e
i
rc
a
r
er
e
c
ip
i
en
t
sinp
r
im
a
ryc
a
r
eand
th
enum
e
rou
simp
l
i
c
a
t
ion
sfo
rNP
s
.Th
eg
row
ingnumb
e
ro
fp
e
r
son
sw
i
thd
em
en
t
i
aandth
e
i
r
in
fo
rm
a
lc
a
r
eg
iv
e
r
s
,th
ed
ev
a
s
t
a
t
ingimp
a
c
to
fd
i
agno
s
i
sandd
i
s
e
a
s
em
an
i
f
e
s
t
a
t
ion
s
,andth
e
l
a
cko
fc
l
in
i
c
a
lp
r
a
c
t
i
c
egu
id
e
l
in
e
sandav
a
i
l
ab
l
ec
a
r
eg
iv
e
ra
s
s
e
s
sm
en
ttoo
l
s
,a
l
l
s
ign
i
f
i
c
an
t
ly
imp
a
c
tNPp
r
a
c
t
i
c
e
.M
anyoppo
r
tun
i
t
i
e
sex
i
s
tfo
rNP
stoo
f
f
e
rc
o
l
l
abo
r
a
t
iv
e
,coo
rd
in
a
t
ed
s
e
rv
i
c
ep
rov
i
s
ionth
a
tsuppo
r
t
sandm
e
e
t
sth
en
e
ed
so
fICPWDandth
e
i
rc
a
r
er
e
c
ip
i
en
t
s
.
Po
l
i
cyl
ev
e
ls
t
r
a
t
eg
i
e
sh
av
eb
e
end
i
s
cu
s
s
ed
.Fu
r
th
e
rs
t
r
a
t
eg
i
e
sth
a
tc
anb
eimp
l
em
en
t
eda
tth
e
ind
iv
idu
a
l
,r
e
l
a
t
ion
a
l
,o
rg
an
i
z
a
t
ion
a
l
,andcom
mun
i
tyl
ev
e
lw
i
l
lb
ed
i
s
cu
s
s
edinth
e
fo
l
low
ingch
ap
t
e
r
.

111

	
  
Chap
t
e
r5:R
e
comm
enda
t
ion
s
P
e
a
co
cke
ta
l
.(2010
)s
t
a
t
eth
a
tp
rog
r
e
s
sh
a
sb
e
enm
ad
etoimp
rov
esuppo
r
tto

ICPWD
;how
ev
e
r
,mo
r
eimp
rov
em
en
t
sa
r
en
e
ed
edinth
ea
r
e
ao
fc
l
in
i
c
a
lp
r
a
c
t
i
c
e
,r
e
s
e
a
r
ch
,
andh
e
a
l
thandso
c
i
a
lpo
l
i
c
i
e
s
.Aninnov
a
t
iv
eandp
ro
a
c
t
iv
eapp
ro
a
chbyPCP
sc
ana
s
s
i
s
t
I
CPWDtoad
ap
ttoth
ech
ang
ingro
l
e
sth
eyw
i
l
lexp
e
r
i
en
c
eth
roughou
tth
ec
a
r
eg
iv
ing
jou
rn
ey(No
l
an
,Ing
r
am
,& W
a
t
son
,2002
)
.G
a
in
ingund
e
r
s
t
and
ingo
fth
eexp
e
r
i
en
c
e
so
f
ICPWDp
rov
id
e
sth
efound
a
t
ioninwh
i
chto“m
apth
ed
em
en
t
i
ajou
rn
ey
”fo
rc
a
r
eg
iv
e
r
s
(
W
i
er
sm
a
,2014
)
.A
l
thoughco
l
l
abo
r
a
t
iv
ec
a
r
ein
t
e
rv
en
t
ion
sshowp
rom
i
s
ea
timp
rov
ingth
e
l
iv
edexp
e
r
i
en
c
e
so
fICPWD
,ov
e
r
a
l
l
,th
el
i
t
e
r
a
tu
r
einth
i
sr
ev
i
ewh
a
sd
emon
s
t
r
a
t
edth
a
t
comp
l
ex
,t
im
e
con
sum
ingp
r
im
a
ryc
a
r
e
b
a
s
edp
rog
r
am
sa
r
eno
tn
e
c
e
s
s
a
r
i
lyth
emo
s
t
e
f
f
e
c
t
iv
ea
timp
rov
ingc
a
r
eg
iv
e
rw
e
l
l
b
e
ing
.Add
i
t
ion
a
l
ly
,w
i
thr
e
sp
e
c
ttoc
a
r
eg
iv
e
r
a
s
s
e
s
sm
en
t
,noev
id
en
c
eh
a
sb
e
enfoundth
a
tsuppo
r
t
sth
eu
s
eo
fa
s
s
e
s
sm
en
ttoo
l
ssp
e
c
i
f
i
cto
th
eun
iqu
en
e
ed
so
fICPWD
.E
l
em
en
t
a
ry
,o
f
f
i
c
e
b
a
s
edin
t
e
rv
en
t
ion
sp
e
r
fo
rm
edbyPCP
s
m
ay,inf
a
c
t
,
p
rov
etob
emo
r
ee
f
f
e
c
t
iv
ea
te
f
f
e
c
t
iv
e
lysuppo
r
t
ingICPWD
.Inana
t
t
emp
tto
b
r
ingabou
tth
eimp
rov
em
en
t
sP
e
a
co
cke
ta
l
.(2010
)h
a
ssugg
e
s
t
ed
,th
i
sch
ap
t
e
rw
i
l
lou
t
l
in
e
imp
l
i
c
a
t
ion
sfo
rc
l
in
i
c
a
lp
r
a
c
t
i
c
efo
rPCP
s
,r
e
comm
end
a
t
ion
sfo
redu
c
a
t
ion
,and
r
e
comm
end
a
t
ion
sfo
rfu
tu
r
er
e
s
e
a
r
ch
.
R
e
comm
enda
t
ion
sfo
rC
l
in
i
ca
lP
ra
c
t
i
c
e
T
im
e
lyd
iagno
s
i
s.E
a
r
lyd
i
agno
s
i
sc
anh
e
lpbo
thICPWDandc
a
r
er
e
c
ip
i
en
t
sby
in
i
t
i
a
t
ingph
a
rm
a
co
th
e
r
apytot
r
e
a
td
em
en
t
i
a
,en
su
r
ingsuppo
r
t
sa
r
epu
tin
top
l
a
c
eb
e
fo
r
ea
c
r
i
s
i
ss
i
tu
a
t
iono
c
cu
r
s
,andad
equ
a
t
e
lyp
r
ep
a
r
ingth
eICPWDandth
ec
a
r
er
e
c
ip
i
en
tfo
rth
e
jou
rn
eyth
eya
r
eemb
a
rk
ingupon
.A
l
thoughs
c
r
e
en
ingfo
rcogn
i
t
iv
eimp
a
i
rm
en
tin
a
symp
tom
a
t
i
cp
a
t
i
en
t
si
sno
tr
e
comm
end
ed(Gu
id
e
l
in
e
sandP
ro
to
co
l
sComm
i
t
t
e
e
,2014
)
,

112

	
  
e
ld
e
r
lyp
a
t
i
en
t
sandc
a
r
eg
iv
e
r
sshou
ldb
een
cou
r
ag
edtoapp
ro
a
chth
ePCPi
fch
ang
e
sin
cogn
i
t
iono
rfun
c
t
ion
inga
r
eno
t
i
c
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e
rtobo
thcomm
en
c
et
e
s
t
ingandob
t
a
ina

d
i
agno
s
i
sinat
im
e
lym
ann
e
r
.I
faPCPsu
sp
e
c
t
sd
em
en
t
i
a
,cogn
i
t
iv
et
e
s
t
ingu
s
ingv
a
l
id
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t
ed
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l
ssu
cha
sth
eM
in
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en
t
a
lS
t
a
t
eEx
am(Ku
r
low
i
c
z& W
a
l
l
a
c
e
,1999
)o
rth
eMon
t
r
e
a
l
Cogn
i
t
iv
eA
s
s
e
s
sm
en
t(N
a
s
r
edd
in
e
,2016
)c
anb
ep
e
r
fo
rm
ed
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longw
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s
to
ry
,phy
s
i
c
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l
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am
,andd
i
agno
s
t
i
ct
e
s
t
ingtoru
l
eou
to
th
e
rc
au
s
e
so
fcogn
i
t
iv
eimp
a
i
rm
en
t(Gu
id
e
l
in
e
sand
P
ro
to
co
l
sComm
i
t
t
e
e
,2014
)
.
Th
eNPu
t
i
l
i
z
e
sh
i
so
rh
e
rc
l
in
i
c
a
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s
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i
a
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s
ta
s
impo
r
t
an
t
ly
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eh
i
so
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e
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tcommun
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c
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t
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en
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r
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e
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tknow
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l
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t
e
rp
r
ep
a
r
efo
rth
ed
e
a
tho
fth
e
i
rlov
edon
e
.A
s
d
em
en
t
i
ai
sp
rog
r
e
s
s
iv
eandin
cu
r
ab
l
e
,y
e
tm
ayp
rog
r
e
s
sov
e
rm
anyy
e
a
r
s
,th
equ
e
s
t
iono
f
wh
entop
rov
id
eendo
fl
i
f
ein
fo
rm
a
t
ionb
e
co
m
e
sch
a
l
l
eng
ingfo
rPCP
s
.Th
eSNS(2010
)
r
e
comm
end
edconn
e
c
t
ingth
eICPWDandc
a
r
er
e
c
ip
i
en
tw
i
thp
a
l
l
i
a
t
iv
ec
a
r
es
e
rv
i
c
e
sbu
t
do
e
sno
ta
c
tu
a
l
lysp
e
c
i
fywh
entos
t
a
r
tp
rov
id
ingend
o
f
l
i
f
ein
fo
rm
a
t
ion
.Coomb
se
ta
l
.

113

	
  

(2015
)s
t
a
t
eth
a
tm
any“
C
an
ad
i
anl
e
ad
e
r
sf
romnon
gov
e
rnm
en
t
a
lo
rg
an
i
z
a
t
ion
s
,nu
r
s
ingand
gov
e
rnm
en
t
a
ls
e
c
to
r
sa
r
er
e
comm
end
ingap
a
l
l
i
a
t
iv
eapp
ro
a
chb
eemb
edd
edin
top
r
im
a
ry
c
a
r
e
”(p
.3
)
.Ino
rd
e
rtob
e
s
tsuppo
r
tICPWD
,h
e
lp
ingth
emtop
r
ep
a
r
efo
rth
efu
tu
r
ei
s
e
s
s
en
t
i
a
l
.Th
e
r
e
fo
r
e
,i
ti
sr
e
com
m
end
edth
a
tp
a
l
l
i
a
t
iv
ec
a
r
ep
l
an
sandin
fo
rm
a
t
ionsh
a
r
ing
b
eg
ina
td
i
agno
s
i
s
.A
l
thoughi
tm
igh
ts
e
emto
oe
a
r
lytocomm
en
c
eap
a
l
l
i
a
t
iv
eapp
ro
a
cha
t
th
a
tt
im
e
,C
a
r
s
t
a
i
r
s(2010
)s
t
a
t
e
sth
a
tp
a
l
l
i
a
t
iv
ec
a
r
eid
e
a
l
lys
t
a
r
t
sa
td
i
agno
s
i
so
fach
ron
i
c
,
t
e
rm
in
a
lcond
i
t
ionandcon
t
inu
e
sun
t
i
ld
e
a
th
.I
tm
ays
e
emcoun
t
e
r
in
tu
i
t
iv
etocomm
en
c
e
p
a
l
l
i
a
t
iv
ec
a
r
ea
td
i
agno
s
i
sa
sm
anyind
iv
idu
a
l
sw
i
thd
em
en
t
i
aw
i
l
lcon
t
inu
etol
iv
efo
rm
any
y
e
a
r
s
;how
ev
e
r
,adv
an
c
edc
a
r
ep
l
ann
ingw
i
thr
e
sp
e
c
ttom
ed
i
c
a
l
,f
in
an
c
i
a
l
,andl
eg
a
l
d
e
c
i
s
ion
si
sb
e
s
ts
t
a
r
t
ede
a
r
lywh
i
l
eth
ec
a
r
er
e
c
ip
i
en
ti
ss
t
i
l
lab
l
etop
a
r
t
i
c
ip
a
t
eind
e
c
i
s
ion
m
ak
ing
.Coomb
se
ta
l
.(2015
)s
t
a
t
eth
a
tNP
sc
anp
romo
t
eth
i
sin
t
e
rp
ro
f
e
s
s
ion
a
lapp
ro
a
ch
th
roughth
e
i
rl
e
ad
e
r
sh
ipab
i
l
i
t
i
e
s
.
Suppo
r
tdu
r
ingo
f
f
i
c
evi
s
i
t
s
.InT
e
e
landC
a
r
son
’
s(2003
)s
tudy
,ICPWDp
rov
id
ed
ex
amp
l
e
so
fwh
a
tPCP
scou
lddotob
e
t
t
e
rd
emon
s
t
r
a
t
eev
id
en
c
eo
fsuppo
r
t
.Th
e
s
e
sugg
e
s
t
ion
sin
c
lud
eda
l
low
ingsu
f
f
i
c
i
en
tt
im
edu
r
ingo
f
f
i
c
ev
i
s
i
t
stosp
e
akw
i
t
hth
ec
a
r
eg
iv
e
r
a
lon
e
,l
i
s
t
en
ingtoth
ec
a
r
eg
iv
e
r
s
,anda
sk
ingqu
e
s
t
ion
sabou
tth
ec
a
r
eg
iv
ingexp
e
r
i
en
c
e
.On
e
c
a
r
eg
iv
e
rs
t
a
t
ed“
Ir
e
a
l
lyw
i
shth
ey[PCP
s
]wou
ldt
a
lktoth
ef
am
i
lys
ep
a
r
a
t
e
ly
.You
’
r
eno
t
g
e
t
t
ingt
im
etot
e
l
lwh
a
t
’
sh
app
en
ing
,bu
tyou
’
r
ea
l
sono
th
av
ingyou
rexp
e
r
i
en
c
e
sv
a
l
id
a
t
ed
byth
ep
ro
f
e
s
s
ion
a
l
”(T
e
e
l&C
a
r
son
,2003
,p
.51
)
.
Ad
e
lm
an
,Tm
anov
a
,D
e
lg
ado
,D
ion
,andL
a
ch
s(2014
)r
e
comm
endth
a
tPCP
sshou
ld
p
e
r
fo
rmmo
r
ec
a
r
eg
iv
e
ra
s
s
e
s
sm
en
t
sinp
r
a
c
t
i
c
e
.How
ev
e
r
,th
eau
tho
r
sr
e
cogn
i
z
eth
a
tth
e
comp
l
e
t
iono
facomp
r
eh
en
s
iv
ec
a
r
eg
iv
e
rn
e
ed
sa
s
s
e
s
sm
en
ti
sno
tn
e
c
e
s
s
a
r
i
lyf
e
a
s
ib
l
ein
mo
s
tp
r
im
a
ryc
a
r
es
e
t
t
ing
sdu
etot
im
econ
s
t
r
a
in
t
sandag
en
e
r
a
ll
a
cko
fr
e
sou
r
c
e
s
.In

114

	
  

add
i
t
ion
,i
fth
ec
a
r
eg
iv
e
ri
sno
tap
a
t
i
en
to
fth
ePCP
,th
el
a
cko
ff
in
an
c
i
a
lcomp
en
s
a
t
ionfo
r
th
ePCPandth
epo
s
s
ib
i
l
i
tyth
a
tcon
f
id
en
t
i
a
l
i
tyi
s
su
e
sm
aya
r
i
s
ec
ana
l
sob
eo
fcon
c
e
rn
.
How
ev
e
r
,th
ePCPshou
lda
l
lowenought
im
edu
r
ingth
eo
f
f
i
c
ev
i
s
i
ttoexp
lo
r
eth
e
c
a
r
eg
iv
e
r
’
sw
e
l
l
b
e
ing
,n
e
edfo
rsuppo
r
t
s
,andadd
r
e
s
sanyi
s
su
e
sth
a
tm
ayb
er
a
i
s
edbyth
e
in
fo
rm
a
lc
a
r
eg
iv
e
r(Ad
e
lm
ane
ta
l
.
,2014
)
.So
c
i
a
lsuppo
r
tc
anb
ea
s
s
e
s
s
edbya
sk
ingabou
t
th
eICPWD
’
ssuppo
r
tn
e
two
rko
fr
e
sou
r
c
e
s
,fun
c
t
ion
a
lsuppo
r
t
ssu
cha
shom
esuppo
r
t
,and
howth
eyp
e
r
c
e
iv
etho
s
esuppo
r
t
sav
a
i
l
ab
l
etoth
em
.I
fth
ec
a
r
eg
iv
e
ri
sno
tap
a
t
i
en
to
fth
e
PCP
,af
ews
imp
l
equ
e
s
t
ion
sc
anb
eu
s
edtoen
cou
r
ag
eth
ec
a
r
eg
iv
e
rtos
e
ekh
e
lpf
romth
e
i
r
ownPCPi
fsu
cha
s
s
i
s
t
an
c
ei
sn
e
ed
ed
:
•
	
  “Top
rov
id
eth
ev
e
ryb
e
s
tp
a
t
i
en
tc
a
r
e
,If
indIn
e
edtoa
l
sop
aya
t
t
en
t
iontomy
p
a
t
i
en
t
s
’c
a
r
eg
iv
e
r
s
.C
anyout
e
l
lm
eab
i
tabou
thowyoua
r
ef
e
e
l
ing
/do
ing
?
”
•
	
  “W
eknowth
a
tc
a
r
eg
iv
e
r
so
f
t
enn
eg
l
e
c
tth
e
i
rownh
e
a
l
th
. Wh
enw
a
sth
el
a
s
tt
im
eyou
s
awyou
rphy
s
i
c
i
an
?
”
•
	
  “Doyouh
av
eyou
rownphy
s
i
c
i
an
?I
ssh
eo
rh
eaw
a
r
eo
fyou
rc
a
r
eg
iv
ings
i
tu
a
t
ion
?
Wh
a
th
a
ssh
eo
rh
eadv
i
s
edabou
ti
t
?
”(Ad
e
lm
ane
ta
l
.
,2014
)
.
I
f
,how
ev
e
r
,th
ec
a
r
eg
iv
e
ri
sa
l
soap
a
t
i
en
to
fth
ePCPandth
ec
a
r
er
e
c
ip
i
en
tag
r
e
e
s
,
th
enanappo
in
tm
en
tfo
rth
ec
a
r
eg
iv
e
rcou
ldb
es
ch
edu
l
edimm
ed
i
a
t
e
lya
f
t
e
rth
a
to
fth
ec
a
r
e
r
e
c
ip
i
en
ttoad
d
r
e
s
scon
c
e
rn
sr
a
i
s
eddu
r
ingth
a
tf
i
r
s
tappo
in
tm
en
t
.Anad
j
a
c
en
tappo
in
tm
en
t
no
ton
lyp
r
ev
en
t
sv
a
lu
ab
l
et
im
eb
e
ingt
ak
enaw
ayf
romth
ec
a
r
er
e
c
ip
i
en
t
’
sv
i
s
i
t
,bu
ta
l
low
s
fo
rth
ec
a
r
eg
iv
e
r
’
scon
c
e
rn
stob
eadd
r
e
s
s
edimm
ed
i
a
t
e
ly
,th
e
r
ebyv
a
l
id
a
t
ingth
ec
a
r
eg
iv
e
r
’
s
exp
e
r
i
en
c
e
s
.Sep
a
r
a
t
ebu
tad
j
a
c
en
tappo
in
tm
en
t
sa
l
soa
l
lowfo
rth
esh
a
r
ingo
fin
fo
rm
a
t
ion
th
a
tm
igh
tno
to
th
e
rw
i
s
eh
av
eb
e
enm
en
t
ion
eddu
r
ingth
ec
a
r
er
e
c
ip
i
en
t
’
sappo
in
tm
en
t
,su
ch
a
sf
e
e
l
ing
so
fbu
rd
eno
ragg
r
e
s
s
ionbyth
ec
a
r
er
e
c
ip
i
en
t
.Inadd
i
t
i
on
,p
rov
id
ingad
j
a
c
en
t

115

	
  

appo
in
tm
en
t
sm
e
an
sth
a
tth
ec
a
r
eg
iv
e
rw
i
l
lno
th
av
etocon
t
endw
i
tho
rg
an
i
z
ingadd
i
t
ion
a
l
t
r
an
spo
r
t
a
t
ionr
equ
i
r
em
en
t
sno
rw
i
then
su
r
ingsup
e
rv
i
s
ionfo
rth
ec
a
r
er
e
c
ip
i
en
t
,th
e
r
eby
d
e
c
r
e
a
s
ings
t
r
e
s
sandbu
rd
en
.
I
fth
ec
a
r
er
e
c
ip
i
en
tp
r
e
s
en
tsa
lon
etoth
ec
l
in
i
c
,e
sp
e
c
i
a
l
lydu
r
ingth
ee
a
r
lys
t
ag
e
so
f
d
em
en
t
i
a
,t
h
ePCPc
anen
cou
r
ag
eh
eo
rsh
etoin
c
lud
eth
ein
fo
rm
a
lc
a
r
eg
iv
e
rinc
l
in
i
cv
i
s
i
t
s
,
ino
rd
e
rtod
ev
e
lops
t
rongp
a
r
tn
e
r
sh
ip
sandm
ak
esh
a
r
edd
e
c
i
s
ion
swh
i
l
eth
ec
a
r
er
e
c
ip
i
en
ti
s
s
t
i
l
lc
ap
ab
l
eo
fdo
ingso
.NP
sh
av
eth
eab
i
l
i
tytod
ev
e
lops
t
rongth
e
r
ap
eu
t
i
cr
e
l
a
t
ion
sh
ip
s
w
i
thth
ec
a
r
er
e
c
ip
i
en
tandth
e
i
rin
fo
rm
a
lc
a
r
eg
iv
e
randc
anf
a
c
i
l
i
t
a
t
eno
ton
lyth
esuppo
r
t
sy
s
t
em
sth
a
ta
r
er
equ
i
r
ed
,bu
ta
l
sop
rov
id
eth
eedu
c
a
t
ionandan
t
i
c
ip
a
to
rygu
id
an
c
efo
r
ind
iv
idu
a
l
swhoexp
e
r
i
en
c
eth
i
sjou
rn
ey
.
Th
eu
s
eo
fana
log
i
e
s
.Ju
s
ta
sth
i
sr
ev
i
ewu
s
edth
ejou
rn
eyan
a
logytogu
id
eth
e
r
e
ad
e
rth
roughth
ec
a
r
eg
iv
ingexp
e
r
i
en
c
e
,th
ePCPc
anu
s
e
l
ayan
a
log
i
e
stoa
s
s
i
s
tth
e
c
a
r
eg
iv
e
rtob
e
t
t
e
rund
e
r
s
t
andth
e
i
rexp
e
r
i
en
c
e
s(
andth
ecommon
a
l
i
tyo
ftho
s
eexp
e
r
i
en
c
e
s
)
.
Fo
rex
amp
l
e
,toexp
l
a
inth
eimpo
r
t
an
c
eo
fa
c
c
ep
t
ingsuppo
r
t
iv
es
e
rv
i
c
e
stoICPWD
,th
ePCP
m
ayu
s
eanan
a
logysu
cha
sth
efo
l
low
ing
:w
h
enap
e
r
soni
sonalongro
adt
r
ipandh
a
sb
e
en
d
r
iv
ingfo
rtoolong
,h
eo
rsh
eb
e
com
e
sf
a
t
igu
ed
. Wh
enth
ep
e
r
sonr
e
a
ch
e
sth
epo
in
to
f
exh
au
s
t
ion
,h
eo
rsh
en
e
ed
stor
e
s
to
rth
eym
ayf
a
l
la
s
l
e
epandb
e
com
einvo
lv
edinamo
to
r
v
eh
i
c
l
ea
c
c
id
en
t
.Th
es
am
eapp
l
i
e
stoc
a
r
eg
iv
e
r
sonth
e
i
rlongjou
rn
ey
.Th
eAu
s
t
r
a
l
i
an
gov
e
rnm
en
tag
en
cyT
r
an
spo
r
tfo
rN
ewSou
th W
a
l
e
s(2014
)
,adop
t
edth
es
log
an‘
s
top
,
r
ev
iv
e
,su
rv
iv
e
’tocomb
a
tmo
to
rv
eh
i
c
l
ea
c
c
id
en
t
sons
t
a
t
eh
ighw
ay
sr
e
l
a
t
edtod
r
iv
e
r
f
a
t
igu
e
.Th
eadc
amp
a
ign
sen
cou
r
ag
edd
r
iv
e
r
stos
topev
e
rytwohou
r
sa
ta“d
r
iv
e
rr
ev
iv
e
r
”
s
i
t
eand“
s
topfo
rab
i
s
cu
i
tandacupo
fBu
sh
e
l
l
st
e
ao
rco
f
f
e
e
”(T
r
an
spo
r
tN
ewSou
th W
a
l
e
s
,
2014
,p
a
r
a
.3
)
.Th
i
spub
l
i
cs
a
f
e
tyc
amp
a
ignc
anb
eu
s
eda
sam
e
t
apho
rtot
e
a
chc
a
r
eg
iv
e
r
s

116

	
  

abou
twh
e
r
eth
e
i
r‘d
r
iv
e
rr
ev
iv
e
r
’s
i
t
e
sm
igh
tr
e
s
id
eandwh
enandhowtoa
c
c
e
s
sth
em
.An
ex
amp
l
eo
fid
en
t
i
fy
inganda
c
c
e
s
s
ingsu
char
e
sou
r
c
em
ayinvo
lv
eth
ec
a
r
eg
iv
e
ra
sk
inga
r
e
l
a
t
iv
etos
t
ayw
i
thth
ec
a
r
er
e
c
ip
i
en
tfo
rtwohou
r
sev
e
ryF
r
id
aysoth
a
tth
ec
a
r
eg
iv
e
rc
an
m
e
e
tw
i
thaw
a
lk
ingg
roup
.Th
i
ssho
r
ttwohou
rb
r
e
ake
a
chw
e
ekm
ayb
ea
l
lth
ec
ar
eg
iv
e
r
n
e
ed
stor
ev
iv
eino
rd
e
rtosu
rv
iv
eth
ejou
rn
ey
.PCP
sc
anexp
l
a
intoc
a
r
eg
iv
e
r
sth
a
t
,a
tsom
e
po
in
tinth
ejou
rn
eyev
eni
fth
eya
r
es
topp
ingtor
ev
iv
e
,th
eym
ayr
e
a
chapo
in
to
fexh
au
s
t
ion
wh
eni
ti
sun
s
a
f
efo
rth
emandth
ec
a
r
er
e
c
ip
i
en
tinth
ec
ari
fth
eycon
t
inu
eonw
i
thou
th
e
lp
.
Th
eymu
s
tl
e
tsomeon
ee
l
s
eg
e
tb
eh
indth
ewh
e
e
landt
ak
eov
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rth
ed
r
iv
ing
,ev
eni
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lyfo
r
sho
r
tp
e
r
iod
so
ft
im
e
.Th
i
sm
ayb
einth
efo
rmo
fin
fo
rm
a
lc
a
r
esuppo
r
tf
romf
r
i
end
so
r
f
am
i
lym
emb
e
r
s
,o
rfo
rm
a
lsuppo
r
tsu
cha
shom
esuppo
r
to
rr
e
sp
i
t
e
.
U
s
ingsu
chanan
a
logym
ayh
e
lpth
ec
a
r
eg
iv
e
rtob
e
t
t
e
rund
e
r
s
t
andth
en
e
c
e
s
s
i
tyo
f
know
ingwh
entog
e
th
e
lpanda
c
c
e
s
s
ingth
eh
e
lpwh
eni
ti
sn
e
ed
ed
,e
sp
e
c
i
a
l
lyfo
rtho
s
eth
a
t
a
r
er
e
s
i
s
t
iv
etor
e
l
inqu
i
sh
ingc
a
r
eo
fth
ec
a
r
er
e
c
i
p
i
en
t
.Fu
r
th
e
r
,b
e
ingp
r
ep
a
r
ed
,know
ing
wh
e
r
eth
ed
r
iv
e
rr
ev
iv
e
rs
i
t
e
sa
r
eandh
av
ingth
esuppo
r
t
sa
r
r
ang
edinadv
an
c
eo
ff
a
t
igu
e
s
e
t
t
ingin
,w
i
l
lh
e
lptos
a
f
egu
a
rdev
e
ryon
eonth
ejou
rn
ey
.ICPWDc
anth
enb
et
augh
tabou
t
s
ign
sandsymp
tom
so
fs
t
r
e
s
s
,bu
rd
e
n
,f
a
t
igu
e
,andbu
rnou
tandh
e
a
l
thp
romo
t
ions
t
r
a
t
eg
i
e
s
top
r
ev
en
tth
e
s
eadv
e
r
s
eou
t
com
e
s
.
	
  
Imp
rov
ingexp
e
r
i
en
c
e
sdu
r
ingt
ran
s
i
t
iona
lca
r
e
.Mo
s
t
,i
fno
ta
l
l
,p
e
r
son
sw
i
th
d
em
en
t
i
aw
i
l
lev
en
tu
a
l
lyexp
e
r
i
en
c
et
im
einana
cu
t
ec
a
r
eo
rlong
t
e
rmc
a
r
es
e
t
t
ing
.M
any
c
a
r
eg
iv
e
r
sh
av
em
en
t
ion
edd
i
f
f
i
cu
l
t
i
e
sth
a
tth
eyen
coun
t
e
r
edwh
i
l
eth
e
i
rlov
edon
ew
a
sinth
e
ho
sp
i
t
a
l(Bough
twoode
ta
l
.
,2011
;T
e
e
l&C
a
r
son
,2003
)
.On
ec
a
r
eg
iv
e
rr
epo
r
t
edth
a
t
“ho
sp
i
t
a
lp
e
r
sonn
e
ls
e
emtoh
av
ev
e
ryl
i
t
t
l
eund
e
r
s
t
and
ingabou
tA
l
zh
e
im
e
r
’
sandhowth
e
d
i
s
e
a
s
ea
f
f
e
c
t
sp
eop
l
e
;th
eywou
ldt
r
e
a
th
e
rl
ik
esh
ew
a
satyp
i
c
a
lp
a
t
i
en
tw
i
thm
emo
ryand

117

	
  
cogn
i
t
ion
.Th
eyn
e
ededu
c
a
t
ionabou
thowtowo
rkw
i
thA
l
zh
e
im
e
r
’
sp
a
t
i
en
t
s
”(T
e
e
l&

C
a
r
son
,2003
,p
.52
)
.Sh
an
l
eye
ta
l
.(2011
)s
t
a
t
edth
a
t“
c
a
r
e
r
sn
e
edtof
e
e
lth
a
ts
t
a
f
fwholook
a
f
t
e
rth
e
i
rlov
edon
ea
r
eno
tju
s
tp
rov
id
ingm
in
im
a
lphy
s
i
c
a
lc
a
r
ebu
ta
r
em
ak
ingane
f
fo
r
tto
knowth
ep
e
r
sonanda
r
er
e
l
a
t
ingtoth
emonap
e
r
son
a
ll
ev
e
l
”(p
.335
)
.ICPWDshou
ldb
e
en
cou
r
ag
edtou
t
i
l
i
z
eth
eTop5s
t
r
a
t
eg
y(C
l
in
i
c
a
lEx
c
e
l
l
en
c
eComm
i
s
s
ion
,2016
)th
a
tw
a
s
m
en
t
ion
edinCh
ap
t
e
rOn
e
,andi
sshowninApp
end
ixC
,toa
l
l
ev
i
a
t
esom
eo
fs
t
r
e
s
sinvo
lv
ed
wh
enc
a
r
er
e
c
ip
i
en
tsa
r
eadm
i
t
t
edtoa
cu
t
eo
rlong
t
e
rmc
a
r
ef
a
c
i
l
i
t
i
e
s
.Th
eNPa
sPCPcou
ld
fo
rmu
l
a
t
eac
a
r
ep
l
anth
a
tc
anb
ec
a
r
r
i
edbyth
ep
a
t
i
en
tand
/o
rf
am
i
lym
emb
e
rtop
r
e
s
en
tto
ano
th
e
rc
a
r
es
e
t
t
ingino
rd
e
rtoop
t
im
i
z
ec
a
r
eou
t
com
e
s
.
Co
l
labo
ra
t
iv
eca
r
e.In
t
e
r
p
ro
f
e
s
s
ion
a
lco
l
l
abo
r
a
t
iv
ee
f
f
o
r
t
sa
r
eo
f
t
enr
equ
i
r
edto
m
e
e
tth
ecomp
l
exn
e
ed
so
fin
fo
rm
a
lc
a
r
eg
iv
e
r
s(S
chu
l
z& M
a
t
i
r
e
,2004
)
.B
a
s
edonth
e
f
ind
ing
sf
romth
el
i
t
e
r
a
tu
r
e
,aco
l
l
abo
r
a
t
iv
eapp
ro
a
chtoc
a
r
ei
sr
e
comm
end
ed
.Inp
r
im
a
ry
c
a
r
ec
en
t
r
e
sw
i
thanin
t
e
rd
i
s
c
ip
l
in
a
ryt
e
am
,NP
s
,So
c
i
a
l Wo
rk
e
r
sandR
eg
i
s
t
e
r
edNu
r
s
e
sm
ay
a
l
lp
l
ayimpo
r
t
an
tro
l
e
sinp
rov
id
in
gsuppo
r
tandedu
c
a
t
iontoICPWD
,a
sw
e
l
la
scomp
l
e
t
ing
comp
r
eh
en
s
iv
ein
fo
rm
a
lc
a
r
eg
iv
e
ra
s
s
e
s
sm
en
t
s(Ad
e
lm
an
,2014
)
.Ano
t
ab
l
eex
amp
l
eo
fth
i
s
typ
eo
fco
l
l
abo
r
a
t
iv
ec
a
r
ei
sth
ec
a
r
eg
iv
e
rsuppo
r
tp
rog
r
amrunbyanNP
,d
i
e
t
i
c
i
an
,so
c
i
a
l
wo
rk
e
r
,andr
eg
i
s
t
e
redp
sy
ch
i
a
t
r
i
cnu
r
s
ea
tL
ak
eh
e
adNP
L
edC
l
in
i
cinThund
e
rB
ay
,
On
t
a
r
io(L
ak
eh
e
adNu
r
s
eP
r
a
c
t
i
t
ion
e
rL
edC
l
in
i
c
,2010
)
.Th
i
sf
r
e
e,s
ix
w
e
eklong1
.5h
our
p
e
rw
e
ekp
rog
r
amp
rov
id
e
sin
fo
rm
a
lc
a
r
eg
iv
e
r
sw
i
thedu
c
a
t
ionandsk
i
l
l
stoh
e
lpth
em
th
roughth
e
i
rjou
r
n
ey
.Th
i
styp
eo
fp
rog
r
amno
ton
lyp
rov
id
e
sanex
c
e
l
l
en
tsou
r
c
eo
fsuppo
r
t
fo
rICPWDbu
ti
ta
l
sofo
s
t
e
r
spo
s
i
t
iv
ein
t
e
rp
ro
f
e
s
s
ion
a
lr
e
l
a
t
ion
sh
ip
s
.
In
t
e
r
ag
en
cyco
l
l
abo
r
a
t
ioni
sp
a
r
amoun
ttoe
f
f
e
c
t
iv
e
lysuppo
r
tICPWD
.PCP
sm
ay
r
e
f
e
rth
ec
a
r
er
e
c
ip
i
en
ttoh
om
esuppo
r
ts
e
rv
i
c
e
s
,r
e
f
e
rtoanadu
l
td
ayp
rog
r
am
,o
rconn
e
c
t

118

	
  
th
eICPWDtoth
eA
l
zh
e
im
e
rSo
c
i
e
tyo
fB
r
i
t
i
shCo
lumb
i
ao
ro
th
e
rlo
c
a
lch
ap
t
e
ro
fa
d
em
en
t
i
asuppo
r
tg
roup
.B
a
s
edonth
eov
e
rwh
e
lm
ing
lypo
s
i
t
iv
es
en
t
im
en
t
sth
a
tICPWD

h
av
esh
a
r
edinth
el
i
t
e
r
a
t
u
r
er
eg
a
rd
ingth
eb
en
e
f
i
to
fc
a
r
eg
iv
e
rsuppo
r
tg
roup
s
,r
e
f
e
r
r
a
ltoa
lo
c
a
lsuppo
r
tg
roupa
td
i
agno
s
i
si
sr
e
comm
end
ed
.Th
eNPa
lon
ei
sav
i
t
a
lsou
r
c
eo
fsuppo
r
t
fo
rICPWDinm
anyw
ay
s
,y
e
taco
l
l
abo
r
a
t
iv
ee
f
fo
r
ti
sv
e
ryo
f
t
enn
e
c
e
s
s
a
rytomo
r
e
comp
l
e
t
e
lym
ee
tth
en
e
ed
so
fICPWD
.
Fam
i
lyc
en
t
r
edapp
roa
chtoca
r
e
.Th
roughr
ev
i
ewo
fth
el
i
t
e
r
a
tu
r
e,i
tb
e
c
am
e
ev
id
en
tth
a
tap
e
r
sonandf
am
i
ly
c
en
t
r
edapp
ro
a
chshou
ldb
eimp
l
em
en
t
edinp
r
a
c
t
i
c
ea
s
“
p
e
r
son-andf
am
i
ly
c
en
t
r
edc
a
r
efo
cu
s
e
sonth
ewho
l
ep
e
r
sona
saun
iqu
eind
iv
idu
a
landno
t
ju
s
tonth
e
i
ri
l
ln
e
s
so
rd
i
s
e
a
s
e
”(R
eg
i
s
t
e
r
edNu
r
s
e
s
’A
s
so
c
i
a
t
iono
fOn
t
a
r
io[RNAO
]
,2015
,
p
.8
).Th
eC
an
ad
i
anpub
l
i
ch
e
a
l
thc
a
r
esy
s
t
emi
smov
ingtow
a
rd
saf
am
i
lyc
en
t
r
edapp
ro
a
ch
toc
a
r
er
a
th
e
rth
anfo
cu
s
ingonth
esy
s
t
emandPC
P
s(RNAO
,2015
)
.Inv
i
ew
ingth
eICPWD
th
roughth
i
sl
en
s
,PCP
sm
ayg
a
inb
e
t
t
e
rund
e
r
s
t
and
ingo
fth
ec
a
r
eg
iv
e
r
’
sowns
to
ry
,th
e
i
r
h
e
a
l
thc
a
r
eexp
e
r
i
en
c
e
s
,and
howth
eym
ayh
e
lpth
ep
e
r
sonw
i
thd
em
en
t
i
atom
a
in
t
a
inth
e
i
r
h
e
a
l
th(RNAO
,2015
)
.
Af
am
i
lyc
en
t
r
edapp
ro
a
cha
l
soen
su
r
e
sth
a
tICPWDa
r
er
e
cogn
i
z
ed
,a
cknow
l
edg
ed
andin
c
lud
edinth
ec
a
r
ep
l
ann
ingfo
rth
ep
e
r
sonw
i
thd
em
en
t
i
a
.Fu
r
th
e
r
,u
t
i
l
i
z
a
t
iono
fth
i
s
app
ro
a
chfo
s
t
e
r
spo
s
i
t
iv
er
e
l
a
t
ion
sh
ip
s
,r
e
sp
e
c
t
,andcu
l
tu
r
a
l
lycomp
e
t
en
tc
a
r
eth
a
ti
s
r
e
spon
s
iv
et
oth
en
e
ed
so
fbo
thth
eICPWDandc
a
r
er
e
c
ip
i
en
t(A
c
c
r
ed
i
t
a
t
ionC
an
ad
a
,2013
)
.
Ex
amp
l
e
so
faf
am
i
lyc
en
t
r
edapp
ro
a
chin
c
lud
e
:en
su
r
ingaf
am
i
lym
emb
e
ri
sw
i
thth
ec
a
r
e
r
e
c
ip
i
en
tdu
r
ingd
i
agno
s
i
sandappo
in
tm
en
t
sfo
l
low
ingd
i
agno
s
i
s
,a
s
s
e
s
s
ingth
ep
sy
cho
so
c
i
a
l
n
e
ed
so
fbo
thth
eICPWDandc
a
r
er
e
c
ip
i
en
ta
ta
l
lappo
in
tm
en
t
s
,ando
rg
an
i
z
ingf
am
i
ly
m
e
e
t
ing
stod
ev
e
lopc
a
r
ep
l
an
sth
a
tcon
s
id
e
rin
fo
rm
a
t
ionsh
a
r
edb
e
tw
e
enf
am
i
lym
emb
e
r
s

119

	
  
andm
emb
e
r
so
fth
eh
e
a
l
thc
a
r
et
e
am
.
Fam
i
ly m
e
e
t
ing
s.F
am
i
lym
e
e
t
ing
sa
r
er
e
com
m
end
edfo
rs
ev
e
r
a
lr
e
a
son
s
.F
i
r
s
t
,

th
e
s
em
e
e
t
ing
sembodyaf
am
i
ly
c
en
t
r
edapp
ro
a
chtoc
a
r
ea
sth
eyinvo
lv
ef
am
i
lyandf
r
i
end
s
whoa
r
ep
a
r
to
fth
el
iv
e
so
fth
eICPWDandc
a
r
er
e
c
ip
i
en
t
.F
am
i
lym
e
e
t
ing
sa
l
lowfo
r
sh
a
r
ingo
fin
fo
rm
a
t
ionth
a
tm
ayno
tb
esh
a
r
eddu
r
ingano
f
f
i
c
ev
i
s
i
t
.In
t
e
rd
i
s
c
i
p
l
in
a
ryf
am
i
ly
m
e
e
t
ing
sc
ancon
t
r
ibu
t
etoth
ed
ev
e
lopm
en
to
fe
f
f
e
c
t
iv
ec
a
r
ep
l
an
sth
a
tb
e
s
tm
e
e
tth
en
e
ed
s
o
fbo
thICPWDandc
a
r
er
e
c
ip
i
en
t
s
.Su
chm
e
e
t
ing
sm
aya
l
soh
e
lptoa
l
l
e
v
i
a
t
esom
ef
am
i
ly
con
f
l
i
c
ta
sth
eyg
iv
eth
eICPWDanoppo
r
tun
i
tytovo
i
c
eth
e
i
rn
e
edfo
rsuppo
r
tf
romtho
s
e
f
am
i
lyandf
r
i
end
swhoa
t
t
endth
em
e
e
t
ing
.Fu
r
th
e
r
,PCP
sc
anr
e
i
t
e
r
a
t
eth
en
e
edfo
rin
fo
rm
a
l
andfo
rm
a
lsuppo
r
tfo
rth
eICPWD
,th
ec
a
r
er
e
c
ip
i
en
t
,ando
th
e
rpo
t
en
t
i
a
lsuppo
r
tp
e
r
son
sa
t
t
h
em
e
e
t
ing
.O
f
t
en
,i
fs
u
char
equ
e
s
ti
sm
ad
ebyaPCPr
a
th
e
rth
anth
eICPWD
,o
th
e
r
sm
ay
b
emo
r
ein
c
l
in
edtoh
e
lp(Ad
e
lm
ane
ta
l
.
,2014
;B
a
rn
a
rd&Y
a
f
f
e
,2012
)
.F
am
i
lym
e
e
t
ing
s
c
ana
l
sop
rov
id
eth
eoppo
r
tun
i
tyfo
rar
e
sp
i
t
ep
l
antob
ed
ev
e
lop
edb
e
tw
e
enf
am
i
lyand
f
r
i
end
s
,a
sw
e
l
la
sanem
e
rg
en
cyr
e
sp
i
t
ep
l
ani
fth
ec
a
r
eg
iv
e
ri
sho
sp
i
t
a
l
i
z
ed
,fo
rex
amp
l
e
.
Th
e
r
ea
r
enor
e
comm
end
a
t
ion
sinth
el
i
t
e
r
a
tu
r
er
e
l
a
t
edtoth
et
im
ingo
ff
am
i
lym
e
e
t
ing
s
.I
ti
s
th
e
r
e
fo
r
eimpo
r
t
an
ttoa
s
s
e
s
sth
es
i
tu
a
t
ionando
f
f
e
rt
im
e
lyf
am
i
lym
e
e
t
ing
songo
inga
sth
e
n
e
ed
sch
ang
eov
e
rt
im
e
.
R
e
comm
enda
t
ion
sfo
rEdu
ca
t
ion
Edu
ca
t
ionfo
rICPWD
.C
a
r
eg
iv
inginth
econ
t
ex
to
fd
em
en
t
i
ai
sno
tap
r
ed
i
c
t
ab
l
e
jou
rn
ey(G
a
lv
in
,Tod
r
e
s
,&R
i
ch
a
rd
son
,2005
)
.C
e
r
t
a
inch
a
l
l
eng
e
sands
t
r
e
s
so
r
sc
anno
tev
e
r
b
een
t
i
r
e
lyp
r
ev
en
t
ed
;how
ev
e
r
,anim
po
r
t
an
ta
sp
e
c
to
fanyjou
rn
eyinvo
lv
e
san
t
i
c
ip
a
t
ingand
app
rop
r
i
a
t
e
lyp
l
ann
ingfo
rwh
a
tm
ayl
i
eah
e
ad
.Th
eov
e
r
a
l
lc
a
r
eg
iv
ingexp
e
r
i
en
c
e
so
f
ICPWDc
anb
econ
c
ep
tu
a
l
i
z
eda
smov
ingth
roughs
ev
e
r
a
lph
a
s
e
sa
sth
ed
em
en
t
i
a

120

	
  

p
rog
r
e
s
s
e
s
,e
a
chw
i
thp
a
r
t
i
cu
l
a
roppo
r
tun
i
t
i
e
sfo
re
f
f
e
c
t
iv
ein
t
e
rv
en
t
ionandsuppo
r
tbyPCP
s
(P
ro
roke
ta
l
.
,2013
)
.
An
t
i
c
ipa
to
r
ygu
idan
c
e
.P
r
ep
a
r
ingc
a
r
eg
iv
e
r
sth
roughedu
c
a
t
ionfo
re
a
chs
t
ag
eo
f
d
em
en
t
i
ac
anp
rov
id
eth
emw
i
thth
er
e
sou
r
c
e
sth
eyn
e
edtom
an
ag
etho
s
ei
s
su
e
sth
a
tw
i
l
l
in
ev
i
t
ab
lyo
c
cu
r
.Th
el
i
t
e
r
a
tu
r
ed
emon
s
t
r
a
t
e
sth
a
tICPWDn
e
edongo
ingin
fo
rm
a
t
ion
th
roughou
tth
ec
a
r
eg
iv
ingjou
rn
ey
,no
tju
s
ta
td
i
agno
s
i
s
.A
l
lPCP
sc
ane
f
f
e
c
t
iv
e
lyu
t
i
l
i
z
e
an
t
i
c
ip
a
to
rygu
id
an
c
etop
r
ep
a
r
eICPWDfo
rwh
a
tm
ayl
i
eah
e
adinth
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i
rjou
rn
eyandth
e
r
eby
m
ak
eth
ein
ev
i
t
ab
l
ech
a
l
l
eng
e
ss
e
eml
e
s
sin
su
rmoun
t
ab
l
e
.
An
t
i
c
ip
a
to
rygu
id
an
c
eshou
ldb
ep
rov
id
edtoa
l
lICPWD
,r
eg
a
rd
l
e
s
si
fth
eya
r
ea
p
a
t
i
en
to
fth
ePCPo
rno
t
.On
em
aycomp
a
r
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eo
f
f
i
c
ev
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s
i
to
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en
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i
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aand
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rin
fo
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r
eg
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en
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e
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ech
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ldwou
ldb
e
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comp
an
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edbyac
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r
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rwhom
ayno
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eap
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t
i
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to
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ePCP
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ec
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eg
iv
e
rm
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a
r
en
t
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r
andp
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rh
ap
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e
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a
r
en
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eg
a
rd
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s
so
fth
ec
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r
eg
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e
r
’
sb
a
ckg
round
,
th
ePCPwou
lda
skth
ec
a
r
eg
iv
e
rqu
e
s
t
ion
sabou
tpo
t
en
t
i
a
ls
a
f
e
tyh
a
z
a
rd
sinth
ehom
e
,
f
am
i
lydyn
am
i
c
s
,f
am
i
lycon
f
l
i
c
t
,s
t
r
e
s
s
,c
a
r
eg
iv
e
rf
a
t
igu
e
,s
l
e
ephyg
i
en
e
,andd
ep
r
e
s
s
ion
,
andwh
e
th
e
rth
ec
a
r
eg
iv
e
rh
adanycon
c
e
rn
sabou
tc
a
r
eo
fth
ech
i
ld(Rou
rk
e
,L
edu
c
,&
Rou
rk
e
,2014
)
.S
im
i
l
a
r
ly
,qu
e
s
t
ion
scou
ldb
ea
sk
edo
fth
eICPWDtoen
su
r
es
a
f
e
tyo
fth
e
c
a
r
er
e
c
ip
i
en
ta
sw
e
l
la
stoen
su
r
eth
eICPWDi
sapp
rop
r
i
a
t
e
lysuppo
r
t
ed
.Th
ech
a
l
l
eng
e
a
s
so
c
i
a
t
edw
i
thd
em
en
t
i
ai
sth
a
tind
iv
idu
a
l
smov
eth
roughth
es
t
ag
e
so
fd
em
en
t
i
aa
td
i
f
f
e
r
en
t
r
a
t
e
s
.Th
roughr
egu
l
a
rfo
l
low
upappo
in
tm
en
t
sandd
i
s
cu
s
s
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sw
i
thICPWD
,PCP
sm
ay
d
e
t
e
rm
in
ewh
enth
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a
t
i
en
tw
i
thd
em
en
t
i
ai
st
r
an
s
i
t
ion
ingth
roughs
t
ag
e
so
fd
em
en
t
i
aandb
e
ab
l
etop
rov
id
eth
eICPWDw
i
thapp
rop
r
i
a
t
ein
fo
rm
a
t
iona
tth
eb
e
s
tpo
s
s
ib
l
et
im
e
.En
su
r
ing
th
a
tr
e
sou
r
c
e
sa
r
ep
rov
id
edtoICPWDe
a
r
lyinth
ed
em
en
t
i
at
r
a
j
e
c
to
ry
,andth
ena
tr
egu
l
a
r

121

	
  

in
t
e
rv
a
l
sth
roughou
tth
ejou
rn
ey
,w
i
l
lh
e
lpICPWDtoad
equ
a
t
e
lyp
r
ep
a
r
efo
rth
efu
tu
r
eand
tof
e
e
lsuppo
r
t
eda
longth
ew
ay
.
Edu
ca
t
ionfo
rPCP
s.P
r
in
c
e
,L
iv
ing
s
ton
,andK
a
ton
a(2007
)r
em
indu
sth
a
t
sp
e
c
i
a
l
i
s
t
s
,su
cha
sn
eu
ro
log
i
s
t
s
,g
e
r
i
a
t
r
i
c
i
an
s
,andp
sy
ch
i
a
t
r
i
s
t
s
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r
ear
e
l
a
t
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e
lys
c
a
r
c
e
r
e
sou
r
c
e(p
a
r
t
i
cu
l
a
r
lyinru
r
a
landr
emo
t
ecommun
i
t
i
e
s
)whoa
r
emo
s
to
f
t
enun
ab
l
eto
p
rov
id
ef
ron
t
l
in
ed
em
en
t
i
ac
a
r
eandc
a
r
eg
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rsuppo
r
t
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e
r
e
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r
e
,PCP
sho
ldac
r
i
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r
r
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td
em
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e
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e
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en
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n
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rk
ingg
roup
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eNP
sinB
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i
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i
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r
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ap
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on
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ip
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e
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r
e
a
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einth
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c
a
r
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r
.On
ec
a
r
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rs
t
a
t
edth
a
t“Anyon
ewhoi
sa[p
ro
f
e
s
s
ion
a
l
]c
a
r
eg
iv
e
rough
ttoh
av
e
cu
r
r
en
tin
fo
rm
a
t
iononwh
a
ti
sh
app
en
inginth
ed
rugindu
s
t
ry
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ewp
i
l
l
s
,n
ewm
ed
i
c
a
t
ion
,
n
ewth
ing
sth
a
ta
r
ecom
ingou
t
b
e
c
au
s
eth
a
tk
indo
fl
i
f
t
syouupal
i
t
t
l
e
”(T
e
e
l&C
a
r
son
,
2003
,p
.52
)
.
Edu
ca
t
ionfo
rth
epub
l
i
c
.In
c
r
e
a
s
ingpub
l
i
caw
a
r
en
e
s
so
fth
epo
t
en
t
i
a
l
m
an
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f
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s
t
a
t
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so
fd
em
en
t
i
a
,a
sw
e
l
la
sth
ech
a
l
l
eng
e
sw
i
thwh
i
chICPWDm
aycon
t
end
,h
a
s

122

	
  

s
ev
e
r
a
limp
l
i
c
a
t
i
on
s
,in
c
lud
ing
d
e
c
r
e
a
s
ingth
es
t
igm
aa
t
t
a
ch
edtod
em
en
t
i
aandd
e
c
r
e
a
s
ing
f
e
e
l
ing
so
fso
c
i
a
li
so
l
a
t
ionfo
rICPWD
.K
eya
r
e
a
so
fl
a
cko
faw
a
r
en
e
s
sin
c
lud
er
i
skf
a
c
to
r
s
fo
rd
em
en
t
i
a
,p
a
thophy
s
io
logyo
fd
em
en
t
i
a
,l
iv
ingw
i
thd
em
en
t
i
a
,t
r
e
a
tm
en
t
s
,e
a
r
lyand
symp
tom
so
fd
em
en
t
i
a
,and
,v
e
ryimpo
r
t
an
t
ly
,w
h
entos
e
ekp
ro
f
e
s
s
ion
a
lh
e
lp(A
l
zh
e
im
e
r
’
s
So
c
i
e
ty
,2009
)
.T
e
e
landC
a
r
son(2003
)sugg
e
s
tth
a
tin
c
r
e
a
s
ingpub
l
i
caw
a
r
en
e
s
sh
a
sb
e
en
su
c
c
e
s
s
fu
l
lyconv
ey
eda
sam
e
an
stoimp
rov
eth
equ
a
l
i
tyo
fc
a
r
efo
rp
a
t
i
en
t
sw
i
th
d
ep
r
e
s
s
ion
;thu
s
,s
im
i
l
a
rapp
ro
a
ch
e
scou
ldb
eu
s
edtos
im
i
l
a
r
lyb
en
e
f
i
tICPWD
.S
ev
e
r
a
l
s
t
r
a
t
eg
i
e
scou
ldb
eimp
l
em
en
t
edino
rd
e
rtor
a
i
s
epub
l
i
caw
a
r
en
e
s
s
.Fo
rex
amp
l
e
,PCP
s
cou
ldho
ldcommun
i
tyedu
c
a
t
ions
e
s
s
ion
s
.Adc
amp
a
ign
scou
ldb
erunth
roughv
a
r
iou
styp
e
s
o
fm
ed
i
a
,in
c
lud
ingn
ew
sp
ap
e
r
s
,t
e
l
ev
i
s
ion
,andso
c
i
a
lm
ed
i
aon
l
in
es
i
t
e
s
.Ch
a
r
i
t
ab
l
eev
en
t
s
a
r
eano
th
e
rw
aytor
a
i
s
ebo
thaw
a
r
en
e
s
sandfund
ingtosuppo
r
tin
fo
rm
a
lc
a
r
eg
iv
e
r
sand
p
e
r
son
sw
i
thd
em
en
t
i
a
.
R
e
comm
enda
t
ion
sfo
rR
e
s
ea
r
ch
Th
el
a
cko
fh
ighqu
a
l
i
tyr
e
s
e
a
r
chandth
eab
s
en
c
eo
fgu
id
e
l
in
e
sp
e
r
t
a
in
ingtoICPWD
h
igh
l
igh
tth
eex
i
s
t
en
c
eo
fs
ign
i
f
i
c
an
tr
e
s
e
a
r
chandp
r
a
c
t
i
c
eg
ap
s
.Ov
e
rth
ep
a
s
ttw
en
tyy
e
a
r
s
,
as
ign
i
f
i
c
an
tamoun
to
fl
i
t
e
r
a
tu
r
eh
a
sb
e
enw
r
i
t
t
enabou
tin
fo
rm
a
lc
a
r
eg
iv
e
rbu
rd
enandth
e
ad
v
e
r
s
ee
f
f
e
c
t
sth
a
tc
a
r
eg
iv
ingc
anh
av
eonth
ein
fo
rm
a
lc
a
r
eg
iv
e
r
. Mo
r
er
e
c
en
t
ly
,qu
a
l
i
t
a
t
iv
e
r
e
s
e
a
r
chh
a
sexp
lo
r
edth
ec
a
r
eg
iv
ingexp
e
r
i
en
c
e
so
fICPWDandr
e
s
e
a
r
ch
e
r
sh
av
e
inv
e
s
t
ig
a
t
edth
ee
f
f
e
c
t
iv
en
e
s
so
fin
t
e
rv
en
t
ion
sbym
e
a
su
r
ingou
t
com
e
ssu
cha
sbu
rd
en
,
d
ep
r
e
s
s
ion
,andQOL
.Y
e
tth
equ
an
t
i
t
a
t
iv
el
i
t
e
r
a
tu
r
eh
a
sf
a
i
l
edtoev
a
lu
a
t
eag
lob
a
lm
e
a
su
r
e
o
fth
eov
e
r
a
l
lc
a
r
eg
iv
ingexp
e
r
i
en
c
e
.Th
eimp
l
em
en
t
a
t
iono
fm
ix
edm
e
thods
tud
i
e
sm
ayb
e
u
s
e
fu
lind
e
t
e
rm
in
inghowe
f
f
e
c
t
iv
efo
rm
a
lin
t
e
rv
en
t
ion
sa
c
tu
a
l
lya
r
ea
timp
rov
ingth
e
c
a
r
eg
iv
ingexp
e
r
i
en
c
efo
rICPWD
.Add
i
t
ion
a
l
ly
,long
i
tud
in
a
ls
tud
i
e
sexp
lo
r
ingth
e

123

	
  

exp
e
r
i
en
c
e
so
fICPWDov
e
rth
een
t
i
r
ed
em
en
t
i
ajou
rn
eywou
ldp
rov
id
ev
a
lu
ab
l
ein
fo
rm
a
t
ion
abou
tth
ech
ang
ingn
e
ed
sth
roughth
ed
i
s
e
a
s
et
r
a
j
e
c
to
rytoin
fo
rmth
et
im
ingo
fa
s
s
e
s
sm
en
t
andin
t
e
rv
en
t
ion
s
.
M
a
l
eICPWDandCALDICPWDa
r
eno
t
i
c
e
ab
lyund
e
rr
ep
r
e
s
en
t
edinc
a
r
eg
iv
ing
r
e
s
e
a
r
ch
.M
anyin
t
e
rv
en
t
ion
sh
av
et
a
rg
e
t
edp
r
im
a
r
i
lyf
em
a
l
e
,C
au
c
a
s
i
anpopu
l
a
t
ion
sf
rom
n
eu
ro
logyo
rm
emo
ryc
l
in
i
c
s
.I
ti
sd
i
f
f
i
cu
l
ttod
e
t
e
rm
i
n
ewh
e
th
e
ro
rno
tth
e
s
es
am
e
in
t
e
rv
en
t
ion
swou
ldb
ee
f
f
e
c
t
iv
efo
rm
ino
r
i
tyo
rm
a
l
eICPWD(Au
s
t
rome
ta
l
.
,2006
)
.
Fu
r
th
e
rr
e
s
e
a
r
chfo
cu
s
ingonth
e
s
eg
roup
si
sr
e
comm
end
edino
rd
e
rtog
a
inab
e
t
t
e
r
und
e
r
s
t
and
ingo
fg
end
e
randcu
l
tu
r
a
ld
i
f
f
e
r
en
c
e
sw
i
th
inth
ec
a
r
eg
iv
ingexp
e
r
i
en
c
e
.L
ik
ew
i
s
e
,
mo
r
ein
t
e
rv
en
t
ionr
e
s
e
a
r
chi
sn
e
ed
edw
i
thth
e
s
eg
roup
stod
e
t
e
rm
in
ewh
e
th
e
rou
t
com
e
s
d
i
f
f
e
rincomp
a
r
i
sontoth
ep
r
im
a
ryC
au
c
a
s
i
an
,e
ld
e
r
lyf
em
a
l
es
tudys
amp
l
e
s
.G
a
in
ingth
e
p
e
r
sp
e
c
t
iv
e
so
fm
a
l
ein
fo
rm
a
lc
a
r
eg
iv
e
r
si
so
fp
a
r
t
i
cu
l
a
rimpo
r
t
an
c
e
,s
in
c
ea
lmo
s
th
a
l
fo
f
C
an
ad
i
anc
a
r
eg
iv
e
r
sa
r
em
a
l
e(E
a
l
e
se
ta
l
.
,2015
)
.A
sC
an
ad
i
ans
tud
i
e
sonth
eexp
e
r
i
en
c
e
so
f
ICPWDi
sno
t
ab
lyl
a
ck
ing
,fu
r
th
e
rr
e
s
e
a
r
chi
sn
e
ed
edtod
ev
e
lopanin
d
ep
thund
e
r
s
t
and
ing
o
fth
e
s
eexp
e
r
i
en
c
e
sinaC
an
ad
i
ancon
t
ex
tinwh
i
chtoin
fo
rmpo
l
i
cyandp
r
a
c
t
i
c
e
.High
qu
a
l
i
tyqu
an
t
i
t
a
t
iv
er
e
s
e
a
r
chinv
e
s
t
ig
a
t
ingp
r
im
a
ryc
a
r
e
b
a
s
edin
t
e
rv
en
t
ion
si
sn
e
ed
edto
suppo
r
tev
id
en
c
e
b
a
s
edp
r
a
c
t
i
c
ea
sw
e
l
la
stod
ev
e
lopc
l
in
i
c
a
lp
r
a
c
t
i
c
egu
id
e
l
in
e
sth
a
ta
r
eno
t
b
a
s
edon
lyup
onmod
e
r
a
t
equ
a
l
i
tys
tud
i
e
sandexp
e
r
top
in
iono
fgu
id
e
l
in
ecomm
i
t
t
e
e
s
.
Fu
r
th
e
r
,mo
r
ein
fo
rm
a
lc
a
r
eg
iv
e
rr
e
s
e
a
r
chi
sd
e
sp
e
r
a
t
e
lyn
e
ed
edtoin
fo
rmth
ed
ev
e
lopm
en
t
o
fn
ewc
l
in
i
c
a
lp
r
a
c
t
i
c
egu
id
e
l
in
e
sth
a
ta
r
ea
im
eda
tr
e
comm
end
ingev
id
en
c
e
b
a
s
edp
r
a
c
t
i
c
e
.

124

	
  
Con
c
lu
s
ion

Th
eexp
e
r
i
en
c
e
so
fmyownf
am
i
lym
emb
e
r
sa
sICPWD
,a
sw
e
l
la
smyexp
e
r
i
en
c
e
s
a
saReg
i
s
t
e
r
edNu
r
s
ewhoh
a
sp
rov
id
edc
a
r
etoICPWDandc
a
r
er
e
c
ip
i
en
t
sinth
ea
cu
t
ec
a
r
e
s
e
t
t
ing
,l
edtoth
ed
ev
e
lopm
en
to
fth
er
e
s
e
a
r
chqu
e
s
t
ion
:howc
anPCP
sb
e
s
tsuppo
r
tICPWD
th
roughth
ed
em
en
t
i
ajou
rn
ey
?Th
i
squ
e
s
t
ionw
a
san
sw
e
r
edth
roughth
er
ev
i
ewo
f30a
r
t
i
c
l
e
s
in
c
lud
ing23qu
a
l
i
t
a
t
iv
e
,qu
an
t
i
t
a
t
iv
e
,o
rm
ix
edm
e
thod
ss
tud
i
e
s
,twosy
s
t
em
a
t
i
cr
ev
i
ew
s
,
on
er
epo
r
t
,andfou
rc
l
in
i
c
a
lp
r
a
c
t
i
c
egu
id
e
l
in
e
s
.R
ev
i
ewo
fth
el
i
t
e
r
a
tu
r
eh
a
sg
en
e
r
a
t
edsom
e
impo
r
t
an
tcon
t
r
ibu
t
ion
stow
a
rdund
e
r
s
t
and
ingth
el
iv
edexp
e
r
i
en
c
e
sandn
e
ed
so
fICP
WD
andh
a
sp
rov
id
edin
s
igh
tin
toth
ef
e
a
s
ib
i
l
i
tyande
f
f
e
c
t
iv
en
e
s
so
fsom
ep
r
im
a
ryc
a
r
e
b
a
s
ed
in
t
e
rv
en
t
ion
s
.Th
el
i
t
e
r
a
tu
r
er
ev
i
ewun
cov
e
r
edg
ap
sinev
id
en
c
e
b
a
s
edp
r
a
c
t
i
c
ew
i
thr
e
sp
e
c
t
toc
a
r
eg
iv
e
rsuppo
r
t
.
Th
er
e
s
e
a
r
chf
ind
ing
sh
av
ea
f
fo
rd
edin
s
igh
tin
toth
eun
iqu
ech
a
l
l
eng
e
s
,a
sw
e
l
la
s
po
s
i
t
iv
ea
sp
e
c
t
s
,o
fc
a
r
eg
iv
ingth
a
tICPWDexp
e
r
i
en
c
e
.A
l
thoughc
a
r
eg
iv
e
r
sh
av
ed
iv
e
r
s
e
b
a
ckg
round
sandind
iv
idu
a
ln
e
ed
s
,m
anysh
a
r
es
im
i
l
a
rexp
e
r
i
en
c
e
sth
roughou
tth
e
i
r
c
a
r
eg
iv
ingjou
rn
ey
.Inth
el
i
t
e
r
a
tu
r
eICPWDc
a
r
eg
iv
e
r
sd
e
s
c
r
ib
edf
e
e
l
ing
so
fun
c
e
r
t
a
in
ty
,
f
e
a
r
,andlon
e
l
in
e
s
s
.Th
eyd
e
s
c
r
ib
edd
i
f
f
i
cu
l
t
i
e
sw
i
thob
t
a
in
ingt
im
e
lyd
i
agno
s
i
sandw
i
th
ob
t
a
in
ingsu
f
f
i
c
i
en
tin
fo
rm
a
t
ionf
romPCP
sr
eg
a
rd
ingc
a
r
eg
iv
ingo
rd
em
en
t
i
a
.M
any
c
a
r
eg
iv
e
r
sexp
e
r
i
en
c
edf
am
i
lycon
f
l
i
c
ta
sw
e
l
la
sin
t
e
rp
e
r
son
a
lcon
f
l
i
c
ta
sth
eys
t
rugg
l
ew
i
th
ro
l
ech
ang
e
sandb
a
l
an
c
ingth
e
i
rownn
e
ed
sw
i
thth
en
e
ed
so
fth
ec
a
r
er
e
c
ip
i
en
t
.M
anya
l
so
exp
r
e
s
s
edd
i
f
f
i
cu
l
tyinob
t
a
in
ingbo
thin
fo
rm
a
landfo
rm
a
lsuppo
r
t
s
.D
ev
e
lop
ingan
und
e
r
s
t
and
ingo
fth
en
e
ed
sandexp
e
r
i
en
c
e
so
fICPWDa
f
fo
rd
safound
a
t
iononwh
i
chto
con
s
t
ru
c
te
f
f
e
c
t
iv
eandsuppo
r
t
iv
ein
t
e
rv
en
t
ion
sinp
r
im
a
ryc
a
r
es
e
t
t
ing
s
.

125

	
  
Ino
rd
e
rtod
i
s
cov
e
re
f
f
e
c
t
iv
ew
ay
stosuppo
r
tICPWD
,p
r
im
a
ryc
a
r
e
b
a
s
ed
in
t
e
rv
en
t
ion
sw
e
r
einv
e
s
t
ig
a
t
ed
.Su
rp
r
i
s
ing
ly
,th
ef
i
nd
ing
si
l
lu
s
t
r
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i
:10
.1046
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j
.1365
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.2003
.00419
.x
W
i
lk
s
,S
.E
.
,&C
room
,B
.(2008
)
.P
e
r
c
e
iv
eds
t
r
e
s
sandr
e
s
i
l
i
en
c
einA
l
zh
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im
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sd
i
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iv
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r
s
:T
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e
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a
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ionandm
ed
i
a
t
ionmod
e
l
so
fso
c
i
a
lsuppo
r
t
.Ag
ing&
M
en
ta
lH
ea
l
th
,12(3
)
,357
–
365
.do
i
:10
.1080
/13607860801933323
W
i
l
z
,G
.
,S
ch
inkö
th
e
,D
.
,&So
e
l
ln
e
r
,R
.(2011
)
.Go
a
la
t
t
a
inm
en
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r
e
a
tm
en
tcomp
l
i
an
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e
inacogn
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eh
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am
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w
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i
a
.G
e
roP
s
y
ch
,24(3
)
,115
125
.do
i
:10
.1024
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9647
/
a000043
W
in
t
e
r
,L
.
,&G
i
t
l
in
,L
.N
.(2006
)
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roup
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em
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,21
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)
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397
.
do
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:10
.1177
/1533317506291371
Y
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.
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ed
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s
so
c
ia
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ion
,287
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)
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i
:10
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.287
.16
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.J
.
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,P
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,&B
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ak
,L
.(2008
)
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am
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lyphy
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s
.Canad
ianFam
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ian
,54
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)
,1008
1015
.R
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r
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edf
romh
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tp
:
/
/www
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cb
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lm
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ih
.gov
/pm
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/
a
r
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l
e
s
/PMC2464807
/pd
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/0541008
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f

	
  

151

Z
a
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s
end
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.
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r
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en
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.
,&L
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t
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ch
,S
.A
.(1999
)
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)
,
355361
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152

	
  
App
end
ixA
Typ
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153

	
  
App
end
ixB
D
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ex
tpag
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.

	
  

154

S
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to
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equ
i
r
efu
l
la
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i
s
tan
c
ew
i
th su
cha
swa
l
k
ingo
rs
i
t
t
ing
,
a
l
lda
i
l
ya
c
t
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i
t
i
e
s
,ma
yha
v
e ma
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s
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l
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k
lo
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yand
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r
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ro
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p
s
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to
ra
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v
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ysu
ch wo
rd
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swa
l
k
ing
A
v
e
rag
edu
ra
t
ion
:2
.5y
r
s
(D
eL
eonandR
e
i
sb
e
rg
,1999
;D
em
en
t
i
aC
a
r
eC
en
t
r
a
l
,2013
; Mo
r
r
i
s
,1993
;R
e
i
sb
e
rg
,1982
;
S
c
l
an&R
e
i
sb
e
rg
,1992
)

155

	
  
App
end
ixC
Ex
amp
l
eo
fTop5S
t
r
a
t
egy
:G
r
andp
a
’
sB
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r
aphy

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i
f
efo
rn
e
a
r
ly63y
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a
r
s -Bunny
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au
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r
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i
ck(
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r
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augh
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r–
	
  
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and
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r
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a
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andd
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l
l
a
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inn
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.

156

	
  
App
end
ixD
A‘Ro
ad M
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157

	
  
	
  

	
  

	
  

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r
a
c
t
i
v
i
t
i
e
ssu
cha
s
hobb
i
e
sfo
ra
slong M
ed
i
ca
t
ionr
e
v
i
ew
a
spo
s
s
ib
l
e
En
su
r
eICPWDi
s
En
cou
rag
eh
ea
l
th
y l
in
k
edw
i
tha
l
i
f
e
s
t
y
l
echo
i
c
e
s
suppo
r
tg
roup
(d
i
e
t
/
e
x
e
r
c
i
s
e
/
s
t
r
e
s
s
	
  
manag
em
en
t
)
	
  
M
ed
i
ca
t
ionr
e
v
i
ew
Edu
ca
t
ion
:
d
em
en
t
ia
s
t
r
e
s
sandcop
ing
s
e
l
f
ca
r
e
/h
ea
l
th
d
r
i
v
ing

(E
l
i
z
z
,2015
)

Coun
s
e
l
l
ing
r
ega
r
d
ing
chang
ing
r
e
la
t
ion
sh
ip
s

	
  

158

	
  
App
end
ixE	
  

R
e
c
o
rd
sid
e
n
t
i
f
i
e
dth
rough
d
a
t
a
b
a
s
es
e
a
r
c
h
ing
(n=3
,603
)
	
  

A
dd
i
t
ion
a
lr
e
c
o
rd
sid
e
n
t
i
f
i
e
d
th
rougho
th
e
rs
ou
r
c
e
s(WW
W
e
b
,h
a
nds
e
a
r
c
h
)
(n=1
,766
)

E
l
ig
ib
i
l
i
ty

S
c
r
e
en
ing

R
e
c
o
rd
sa
f
t
e
rdup
l
i
c
a
t
e
sr
emov
e
d
(n=4
,557
)

R
e
c
o
rd
ss
c
r
e
e
n
e
d
(n=4
,557
)

R
e
c
o
rd
se
x
c
lud
e
d
(n=4
,2
45)

Fu
l
lt
e
x
ta
r
t
i
c
l
e
s
a
s
s
e
s
s
e
dfo
re
l
ig
ib
i
l
i
ty
(n=312
)

Fu
l
lt
e
x
ta
r
t
i
c
l
e
s
e
x
c
lud
e
d
,w
i
thr
e
a
s
on
s
(n=282
)

R
e
s
e
a
r
c
hs
tud
i
e
s
in
c
lud
e
dinr
e
v
i
ew
(n=25
)
In
c
lud
ed

	
  

Id
en
t
i
f
i
c
a
t
ion

L
i
t
e
r
a
tu
r
eS
e
a
r
chD
i
ag
r
am

G
u
id
e
l
in
e
sa
ndr
e
po
r
t
in
c
lud
e
dinr
e
v
i
ew
(n=5
)