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Corporate Financing
Launched October 2014 Updated January 2015 13 lectures
Prof. Raghavendra Rau
University of Cambridge, UK
Traditionally, the typical demander of financing is a corporation, either a large publicly listed firm or a small or medium enterprise (SME). The corporations typically issue contracts, promising either a fixed series of payments and a final face value with priority over other financiers (debt), or the residual value after... read moredebt-holders have been paid off (equity). Intermediate forms of financing (private or bank debt or preferred shares) have alternative specifications of the amount to be repaid and the degree of control rights granted. The suppliers of finance are largely households. Standard financing models have involved a financial intermediary such as a bank bringing together suppliers and demanders of finance.
Most of the research questions in these areas have focused on portfolio allocation decisions (for households and individual investors), and the financing decision for the firm (largely extensions of capital structure theory and information asymmetries). Roles played by the financial intermediaries in this process involve reducing information asymmetries (by playing monitoring or certification roles), aggregating loan assets to reduce risk to investors (by asset securitization processes) and offering insurance (either by securitization or by offering derivative insurance and other innovative financial products).
In the first part of this lecture series, we examine the traditional financing patterns employed by firms – the initial financing decision, the choice to go public, and the choice between debt and equity. We examine the role played by financial institutions in facilitating this process.
In the past few years however, especially in the wake of the financial crisis, some of these roles have been shown to have weaknesses. For example, asset securitization involves aggregating loans to reduce risk. However, since the loans are not held on the financial intermediary's books, there is little incentive for the intermediary to monitor the loans. Loans were granted to borrowers who had little ability to repay because the lending agents had flawed incentives to issue as many loans as they could. Rating agencies, in turn, were under pressure to issue favorable ratings to borrowers. Buyers of the asset-backed securities felt little need to monitor the loans since they had been rated extremely highly by rating agencies. Overall, the lack of monitoring and the rise of information asymmetry helped worsen the financial crisis.
Over the past few years, an increasing number of borrowers and lenders have been interacting directly using new financial models. These models use alternative approaches to solving the central problem of information asymmetry in borrowing and lending. In the second part of the series, we examine these new financing models. Five examples are listed below.
MICROFINANCE INSTITUTIONS
Microcredit or microfinance institutions (MFIs) serve individual borrowers (or very small enterprises). Traditionally banks do not provide financial services to clients with no formal title to assets or with very little cash income (on the order of €2 per day). There are two reasons for this lack of service. First, the banks incur significant fixed transactions costs to manage these accounts – managing a hundred tiny transactions is extremely expensive, far more so than making one large loan to a wealthier borrower. Second, since the borrowers have little in the way of marketable assets, banks cannot secure loans with collateral.
The emerging field of microfinance deals with making a profit when lending to these types of borrowers. The solution to the monitoring problem was to monitor groups of borrowers who in turn were given incentives to monitor each other. Group lending with joint liability promotes initial screening of clients, and monitoring to verify client health and reduce ex post moral hazard. It reduces the information asymmetry problem in selection, monitoring and auditing. While the traditional view of typical microfinance clients is that they are located in countries associated with the bottom of the pyramid loan market, it is important to note that a substantial proportion of microfinance assets are located in developed countries as well. However, the numbers are considerably larger. For example, the EU defines microcredit as a loan of less than €25,000. In the US, it is defined as the extension of credit up to $35,000 while in Canada, microfinance loans are restricted to a maximum of $25,000.
Group lending is not a solution in developed countries since the unemployed micro-entrepreneurs may be located in towns far away from each other. In addition, the level of literacy, including financial literacy, is much higher than in developing countries. There are additional issues as well. Developed countries usually maintain welfare systems that provide unemployment benefits. Fears of losing these benefits have the potential to create poverty traps that inhibit people from starting their own firms. Existing larger banks and regulators have convergent interests – banks attempt to protect their markets and regulators attempt to protect small savings through regulation. As a result, in many developed countries, only banks are allowed to take micro-savings while existing insurance companies provide micro-insurance. In developed countries, pure MFIs typically provide only microcredit, in contrast with those operating in developing countries where microfinance includes many products.
While microfinance has proven to be a factor in reducing poverty levels across countries in Asia, the magnitude of this significance has been debated in the literature. For examples, studies have found that micro-investments yield high returns, but these exhibit declining returns to scale. Microfinance has also created a number of other problems. For example, investors in microfinance institutions prefer high growth rates, profits and the potential for scale. Many MFIs respond by stripping their operations down to one or two products and growing as fast as possible. They also operate in easier to reach areas to minimize costs and increase profits. Consequently, there is a high degree of competition among micro-finance organizations in the same area, all with incentives to loan officers tied to disbursements and collections. Since in many cases, the MFIs' financial systems do not keep pace with growth and since in most low-income countries, there is no centralized credit scoring agency, borrowers can obtain loans from several providers at the same time or take out one loan to repay another from a different MFI. Finally, joint liability does not help when there is a large-scale natural disaster that affects all individuals in a particular area. These disasters are particularly common in developing countries where the level of infrastructure spending is low.
Peer-to-peer (P2P) lending is another increasingly important financing model. Most peer-to-peer loans are unsecured loans obtained from a collection of individuals without the participation of a bank. The key development facilitating the growth of P2P lending has been the Internet. Borrowers post a request for funds and explain why they needed the money. An intermediary such as Zopa and RateSetter in the UK, Auxmoney in Germany, Society One in Australia or Prosper, and Lending Club in the US aggregates loan requests, runs credit checks, monitors and collects monthly payments and collects a commission for its services. How do these systems solve the information asymmetry problem? How do peer-to-peer lending networks work without financial intermediaries to certify the quality of the business opportunity?
Research has shown that lenders incorporate both hard and soft data while deciding their funding decisions. For example, personal characteristics of applicants (including photographs of attractive founders) have a significant impact on the terms of the loans extended. Network effects (the number of friends listed for each borrower) also influence the demand for investment opportunities. Effective lending networks provide both types of data. To illustrate this process, consider the approach taken by Prosper.com. Users join Prosper.com by providing an email address, which is verified by the website. To protect privacy, the true identity of borrowers and lenders is never publicly revealed on the website. All users are identified with user names that are chosen when signing up. This would appear to make it more difficult to verify the borrower's credit quality.
However, Prosper.com collects a set of hard data on each potential borrower. To engage in a transaction, users must provide additional verification. Borrowers must reside in the United States, have a valid social security number, a valid bank account number, a minimum FICO credit score, and a valid driver's license and address. The details are verified by Prosper.com, which also extracts a credit report from Experian, a major U.S. credit reporting agency. Prosper.com lenders are also subject to verification of the social security number, driver's license number, and bank account number.
Beyond the credit score and other hard data, Prosper.com also aggregates soft information. Any Prosper.com member with a verified email account can also create or join a friendship network. To form friendships, the inviting member fills out the friend's email address and a short message on Prosper.com. Prosper.com then generates an email message with a link that the recipient can click to establish a friendship. Although Prosper.com users are normally identified by user IDs (e.g., "banker234"), members on either end of a friendship tie know the real person behind the ID. Thus, friends can link user IDs of a borrower who defaults to the actual identities of the defaulter, potentially imposing social stigma costs on borrowers with friends. The important point is that a member's friend information is highly visible on the members' profile pages. Friendship data are prominently displayed in a listing. Indeed, it is one of the most prominent pieces of information outside the credit information and listing data about the borrower. Lin, Prabhala and Viswanathan (2013) show that friendship ties act as a strong signal of credit quality. Borrowers with friends, especially those that are likely to be credible signals of quality, are significantly less likely to default.
Crowdfunding is a third alternative financing method. Unlike P2P lending, charity sites, or investment sites, crowdsourcing is a form of micro-patronage. Patronage is an ancient concept. An artist approaches a rich patron to secure funding for an art project. The patron receives little financial reward for the project, but does obtain social or other benefits from being a patron of the arts. Crowdfunding aggregates micro-patrons, each of who would not be willing to finance a whole project, to finance a small fraction of many different projects.
The format for the earliest formal organization, Kickstarter, started in 2009, illustrates how crowd funding works. Kickstarter is a site where creative people attempt to obtain start-up money to get their projects off the ground. Projects might involve music, film, art, design, food, publishing and technology. For example, an artist might seek to record a CD, produce a short film or develop a new watch. The artist describes the project with a video, a description and a target dollar amount. Kickstarter lists the project for free. If donors pledge enough money to meet the target by the deadline set, then the artist gets the money for the project. Kickstarter charges 5%, and Amazon.com's credit card service charges another 3-5%. If however, not enough money is raised by the deadline, the project is cancelled, the donors are not liable for any cash, and Kickstarter takes nothing.
The important difference between the classic crowdsourcing model and P2P lending is that these are not investments. The donor's pledge will never return any financial gain, even if the play, movie or gadget becomes a huge hit. In some cases, the artist promises a memento of the donor's financial involvement — a T-shirt or a CD, for example, or a chance to preorder the item being developed — but nothing else tangible. The donor's pledges are also not tax-deductible, marking the difference between crowdsourcing and traditional charity sites.
As in the case of P2P lending, crowdsourcing platforms are proliferating. In April 2013, the passage of the JOBS act made it legal for businesses and startups to give equity to investors who will get an actual financial return instead of a T-shirt or CD. This has caused a boom in crowdfunding platforms with over 450 platforms listed in 2013. The increasing proliferation of business models has led to a blurring between the classic crowdfunding model and the P2P model, with many of the same problems being observed in each area.
Beyond the information asymmetry issues associated with P2P sites, social pressures are particularly strong for classic crowdfunding sites where the donors receive little for their funds except social benefits of being patrons. In some cases, founders have been unable to keep up with investor demand generated through this process. Mollick (2013) finds that the vast majority of crowdfunded efforts appear to attempt to deliver promised goods, but most projects are delayed.
Moving from individuals and very small businesses, the next set of financing models considers small and medium enterprises. After the financial crisis in 2008, banks in both Europe and the US considerably reduced lending capacity. SMEs are usually tied to bank financing because of information asymmetry in credit analysis. Because of the drop in lending capacity, SMEs are trying to reduce this reliance. Specifically, in several countries across Europe, notably in Germany, Italy, and the UK, borrowers are issuing listed and unlisted corporate micro-bonds directly to customers and local retail investors, bypassing banks completely. This is the 'Self-Issued Bond' (SIB) market. The German and Italian markets are considerably larger than the UK market: several hundred German issuers have issued SIBs in Germany while only a handful of them have done the same in the UK.
The UK market started with large firms such as Royal Bank of Scotland, Tesco Bank, and National Grid issuing bonds in multiple tranches. But over time, the market has attracted a more diverse range of mid-market companies such as interdealer broker ICAP and specialist lender Intermediate Capital Group. A significant proportion of these bonds are listed - the Order Book for Retail Bonds (Orb) platform was launched on the London Stock Exchange in February 2010 and about £2.5bn has now been raised from retail investors looking for higher-yielding investments.
Islamic finance is a final form of alternative financing model. Interest-bearing loans (Riba) and speculative trading are both banned under Islamic financing. Islamic laws prohibit Muslims from paying or receiving interest, taking out mortgages, carrying balances on credit cards, or investing in any fixed income securities. However, many Islamic finance contracts can also be seen as variants of traditional financing contracts in the West. For example, depositors in Islamic banks are classified as shareholders who earn dividends when the bank makes a profit and lose a portion of their savings when the bank posts a loss. Islamic law allows partnership finance (mudaraba) and profit and loss sharing (musharka). A mudaraba contract is an agreement where an investor (Islamic bank) entrusts capital to an agent for a project. Profits are based on a pre-arranged and agreed-on ratio. This is akin to a limited partnership where one party contributes the capital while the other runs the business. The profit is distributed based on a negotiated percentage of ownership. Similarly, musharaka is similar to a joint venture where the Islamic bank and client both provide capital and manage the project. Profits are shared in pre-agreed ratios but losses are split in proportion to equity participation.
In practice, Islamic banking diverges from the ideal version. All deposits (including investments) are typically explicitly or implicitly guaranteed. The Profit-Loss-Sharing principle is never strictly applied. In some cases, the bank guarantees the expected rate of return on deposits. In others, the financing is carried out by mark-up leasing and lease purchase transactions related to trade financing. Examples of these kinds of arrangements include declining balance co-ownership financing arrangements that involve financing for home purchases that does not involve the payment of interest.
The purpose of this series of talks is to systematically examine changing patterns in corporate financing from the traditional debt vs. equity choices to more innovative types of financing. As noted, the series will be split into two parts.
Part A:
Traditional forms of corporate financing will be discussed. These include the choice between debt and equity as driven by interactions between taxes, financial distress costs (Tradeoff theory) and asymmetric information (pecking order).
Part B:
New models of finance will be discussed. These include models of microfinance, crowd-sourcing, financing for small and medium enterprises and Islamic finance.
Play All talks in this series
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Part A: Traditional forms of corporate financing (10 Lectures)
Traditional theories of capital structure: trade-off vers... Traditional theories of capital structure: trade-off versus pecking order
Prof. Vidhan K. Goyal
Hong Kong University of Science and Technology, Hong Kong
Venture capital 1 Venture capital 1
Prof. Thomas J. Chemmanur
Boston College, USA
Security Design 1 Security Design 1
Prof. Tom Noe
Initial public offerings 1 Initial public offerings 1
Prof. John Cooney
Raising funds in the secondary markets a brief review of ... Raising funds in the secondary markets a brief review of the academic research related to Seasoned Equity Offers (SEOs)
Prof. Ajai Singh
Lehigh University, USA
Part B: Innovations in corporate financing policy (3 Lectures)
Peer-to-Peer (P2P) lending Peer-to-Peer (P2P) lending
Prof. Laura Gonzalez
Fordham University, USA
Equity crowdfunding and prosperity Equity crowdfunding and prosperity
Prof. Douglas Cumming
York University, Canada
Islamic banking and finance Islamic banking and finance
Prof. Philip Molyneux
Bangor University, UK


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Case Studies Illustrating Challenges to Research Translation
Implementation Science at the Research Design Level: RE–AIMing Translational Research
Implementation Science: Managing Practitioner Uptake
Dissemination and Engagement of Policymakers
Research Article | March 2013
Dissemination: Bringing Translational Research to Completion
Florence Clark; Daniel J. Park; Janice P. Burke
Florence Clark, PhD, OTR/L, FAOTA, is Professor and Associate Dean and Chair, Division of Occupational Science and Occupational Therapy, School of Dentistry, University of Southern California, 1540 Alcazar Street, CHP-133, Los Angeles, CA 90089; fclark@usc.edu
Daniel J. Park, OTD, OTR/L, is Assistant Professor of Clinical Occupational Therapy, Division of Occupational Science and Occupational Therapy, School of Dentistry, University of Southern California, Los Angeles
Janice P. Burke, PhD, OTR/L, FAOTA, is Dean, Jefferson School of Health Professions, and Professor and Chair, Department of Occupational Therapy, Thomas Jefferson University, Philadelphia
Evidence-Based Practice / Geriatrics/Productive Aging / Sensory Integration and Processing / Special Issue on the Accelerating Clinical Trials and Outcomes Research (ACTOR) Conference
American Journal of Occupational Therapy, March/April 2013, Vol. 67, 185-193. doi:10.5014/ajot.2013.006148
Florence Clark, Daniel J. Park, Janice P. Burke; Dissemination: Bringing Translational Research to Completion. Am J Occup Ther 2013;67(2):185-193. doi: 10.5014/ajot.2013.006148.
© 2019 American Occupational Therapy Association
Despite the availability of innovative health care research, a gap exists between research-generated knowledge and the utilization of that knowledge in real-world practice settings. This article examines the transition from research to implementation in the context of the dissemination of A. Jean Ayres' sensory integration procedures and of the challenges currently facing the University of Southern California Well Elderly Studies research team. Drawing from the emerging field of implementation science, this article discusses how researchers can develop an implementation plan to more easily translate evidence into practice. Such plans should address the intervention's reach (i.e., its capacity to penetrate into the intended target population), the settings for which it is applicable, the leaders who will encourage practitioner uptake, stakeholder groups, and challenges to dissemination. By taking action to ensure the more effective dissemination of research-generated knowledge, researchers can increase the likelihood that their interventions will lead to improvements in practice and more effective care for consumers.
Efficacious occupational therapy interventions exist across a broad spectrum of practice areas, and innovations in cutting-edge treatment approaches are continually being generated through research endeavors. However, too few of these interventions are actually implemented in the real world (Katz, 2010; Kitson et al., 2008). Occupational therapy researchers take for granted that implementation naturally flows from effective intervention trials, but this is not the case. Research suggests that less than half of evidence-based health care practices are ever implemented and that a 20-yr gap exists between research-generated knowledge and the utilization of that knowledge in health or mental health service delivery (Brekke, Ell, & Palinkas, 2007; Glasgow & Emmons, 2007). This gap between the demonstration of efficacious interventions and their implementation in practice manifests itself in patient care. Indeed, 30%–45% of patients receiving a wide range of professional programs and services currently do not receive care that is based on scientific evidence, and 20%–25% receive care that is not needed or is potentially harmful (Grol, 2008; Grol & Grimshaw, 2003).
In this article, we discuss the contributions of a newly emerging science—implementation science—and its implications for occupational therapy. Dedicated to uncovering systematic methods through which efficacious interventions can be validly and efficiently infused into practice, implementation science has challenged the assumption that this process happens automatically. We describe the actions occupational scientists and occupational therapy practitioners can take to maximize the likelihood of real-world implementation of evidence-based occupational therapy and of dissemination to consumers, policymakers, and the media. We start by presenting two contrasting case studies drawn from the profession's history to illustrate the successes and challenges that occupational therapists have faced in implementing efficacious interventions in the real world.
A. Jean Ayres and Sensory Integration Procedures
Today, we know A. Jean Ayres as a towering pioneer in the development of the sensory integration approach to treatment and as one of the first occupational therapists to conduct a systematic research program that resulted in the provision of preliminary intervention efficacy data. Looking back on the record of her achievements, we marvel at her vision, tenacity, scientific mind, and overall productivity. Clearly, occupational therapy owes her an enormous debt. But what is not well known is the strong resistance that her work initially encountered within the occupational therapy profession and the many barriers that she overcame in her efforts to ensure that sensory integration procedures would be widely adopted (Arluke, 1991). Today, not only are these procedures frequently incorporated as a component of occupational therapy service provision, but they are also firmly planted in many state-of-the-art comprehensive educational programs for children with neurodevelopmental disorders (Greenspan & Wieder, 2009; Mesibov, Shea, & Schopler, 2004; Prizant, Wetherby, Rubin, & Laurent, 2003; Rogers & Dawson, 2009; Schopler, 1997).
The first author (Florence Clark) met Ayres in 1974 while still a novice practitioner. Ayres had agreed to consult with Clark and her colleagues on a research project they were implementing on the effects of sensory integration procedures compared with operant methods in producing developmental gains in adults with intellectual disabilities (Clark, Miller, Thomas, Kucherawy, & Azen, 1978). Unaware at the time that Ayres' work was controversial within the occupational therapy community, Clark completed this early study without worries of disapprobation.
In the late 1960s, Ayres had encountered fierce resistance from occupational therapy practitioners and was "excluded from, rather than embraced by, the community of therapists" (Peters, 2011, p. 256). In discussing the work of her colleague, Lela Llorens recalled that when Ayres
was at what I would call the height of her game in terms of sensory integration, teaching, and trying to teach the rest of the profession, she was greeted with real hostility. . . . She met with a lot of hostility from people who didn't want to believe what she was saying. (as quoted in Peters, 2011, p. 256)
Why did this happen? Was the resistance Ayres experienced typical of what occurs during the gap between research generation and real-world implementation? Was the field unable and unprepared to incorporate new ideas and new evidence? Were therapists resistant to shifting their thinking about their practice, about nervous system plasticity, and about the potential of children with neurodevelopmental disorders to benefit from therapist-led interactions in sensory-rich environments? Did Ayres' research and the therapeutic approach that flowed from it present a threat to the status quo?
Ayres persisted in her efforts to ensure that this scientifically grounded intervention would be implemented in educational curricula and practice. Seeking academic legitimization, in 1976 she accepted an adjunct appointment as a faculty member in the occupational therapy department at the University of Southern California (USC) and gained approval to teach a course, Advanced Sensory Integration Practice, using a combination of seminars and intense practice mentoring in a privately owned clinic (the Ayres Clinic). Coincidentally, Clark had just accepted a full-time faculty position at USC responsible for teaching sensory integration content and was one of four students enrolled in the first session of the Advanced Sensory Integration Practice course.
Thirty-six years later, reflecting on that time, Clark now realizes that the most important takeaway was not improving clinical skills, as she had anticipated, but rather witnessing firsthand how science-driven practice is created and successfully implemented in the real world. She came to fully appreciate the ways in which the basic animal studies on neuroplasticity and environmental enrichment to which Ayres had previously been exposed during her postdoctoral studies at the University of California, Los Angeles Brain Research Institute informed sensory integration theory. Ayres posited that, much in the same way that increases in dendritic arborization in rats had been shown to result from interaction in enriched environment studies, similar changes in neural architectures could be achieved in children if they were presented with appropriate sensory input and challenges. Implementation of this idea required Ayres to invent much of the equipment that is now in widespread use in settings providing sensory integration therapy, including customized platform and bolster swings, ramps, and scooter boards. Today, one is struck by the resemblance of the typical sensory integration clinic to the enriched environments used in the animal model studies that informed Ayres' research (Figure 1).
Examples of (A) an enriched environment animal study and (B) a modern-day sensory integration clinic.
Note. Photographs courtesy of Wendy Sternberg. Photo credits: (A) Matthew Stein, 2009. (B) Erna Blanche, n.d.
Full Size | Slide (.ppt)
Before joining the USC faculty, Ayres had already embarked on a multifaceted implementation strategy. She had lectured on her work throughout the nation and had trained a cadre of therapists, who were providing continuing education programs on the therapeutic approach and would later offer a certification process to ensure valid use of the related battery of standardized tests Ayres had developed. This critical mass of transformational leaders, in combination with the strengths Ayres herself brought to the implementation process, was vital for gaining traction for the widespread incorporation of the sensory integration approach into pediatric occupational therapy. In part because of its adoption and the demonstration that it appeared efficacious for a subset of children with learning disabilities, the practice of pediatric occupational therapy surged. In the 1970s, 11% of all occupational therapists were working in pediatric practice; this percentage is now 32.2%, and 85% of practitioners working in a school setting report use of sensory integration as a component of their practice (American Occupational Therapy Association, 2010).
This case study is a shining example of how, despite significant headwinds and barriers to research translation, evidence-based interventions can successfully be adopted in practice and, concomitantly, can increase the demand for services. At the conclusion of her illustrious career, Ayres had published more than 50 articles and books, developed more than 10 standardized tests for differentiating types of sensory integration difficulties, specified a wide range of therapeutic procedures specifically tailored to be responsive to particular kinds of problems with sensory integration, and invented a wide range of therapeutic equipment, much of which is now commercially available.
USC Well Elderly Studies
A second, but contrasting, illustration of the challenges faced in translating evidence-based interventions into practice involves the USC Well Elderly Studies, two large-scale randomized controlled trials funded by the National Institutes of Health (R01 AG11810; 1 R01 AG021108–01A2) on which Clark served as principal investigator. These studies, involving a combined total of 800 participants, demonstrated the efficacy and cost-effectiveness of a preventive occupational therapy intervention (now called Lifestyle Redesign®) for improving the health and quality of life of independently living older adults. The overarching aim of the intervention is to enable older adults living independently to develop and implement sustainable, health-promoting routines in their everyday lives (Clark et al., 1997). In the first Well Elderly Study, the results showed that the Lifestyle Redesign intervention produced significant benefits across health, function, and quality of life domains, including vitality, general health, physical functioning, social functioning, and general mental health, and that 90% of gains were retained after 6 mo. The second Well Elderly Study replicated the previous results in a larger, more ethnically diverse population (Clark et al., 2012) and investigated the mechanisms that account for the intervention's positive effects. Both studies demonstrated the intervention to be cost-effective.
Interestingly, the Well Elderly Studies have had a greater impact internationally on policy and practice than in the United States. For instance, a modified version of the Lifestyle Redesign intervention customized for older people in the United Kingdom was recommended for promotion of mental well-being by the U.K. National Health Service's National Institute for Health and Clinical Excellence (2008) . The intervention has also been adapted for use by Norwegian researchers to develop a manualized Lifestyle Redesign program for stroke survivors (Lund, Michelet, Kjeken, Wyller, & Sveen, 2012).
Fifteen years have passed since publication of the findings of the first Well Elderly Study, and more than 15 related publications have described aspects or findings of the combined Well Elderly Studies, but the intervention approach has not been widely adopted in practice in the United States. Why? Several key explanations are plausible. First, and perhaps most significant, prevention services of this kind for independently living adults are not funded by the Centers for Medicare and Medicaid Services. Second, relatively few occupational therapists are employed in community-based settings where older adults reside. Third, the investigators, unlike Ayres, have not carried out a well-thought-out dissemination and implementation plan involving certification and continuing education. Despite the mismatch between the focus of the intervention, on one hand, and the contexts in which therapists are typically employed and the reimbursement coverage appropriated in public policy, on the other, a carefully conceived implementation plan for clinical adoption could potentially lead to overcoming such barriers.
The experience just described with respect to the USC Well Elderly Studies is not unique. The set of challenges that various professions have encountered in addressing this very problem has resulted in the emergence of a new field—implementation science. Broadly defined, implementation science "is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services and care" (Eccles & Mittman, 2006, Implementation Science section, para. 2). Disciplines such as nursing, medicine, and social work have generated knowledge and developed implementation models that can help bridge the gap between science and practice.
Figure 2 presents a two-phase research translation model developed by Brekke et al. (2007) after the implementation of social work mental health interventions. Phase 1 covers the progression from laboratory knowledge to clinical intervention trials through efficacy and effectiveness research, ideally resulting in strong research support for an intervention constituting best practice. Efficacy trials investigate whether an intervention produces a positive effect under ideal test conditions, whereas effectiveness trials investigate whether it produces similar results under real-world conditions among a more diverse population (Flay, 1986; Glasgow, Lichtenstein, & Marcus, 2003).
Brekke, Ell, and Palinkas' (2007) research translation model.
Note. From "Translational Science at the National Institute of Mental Health: Can Social Work Take Its Rightful Place?" by J. Brekke, K. Ell, & L. Palinkas, 2007, Research on Social Work Practice, 17, 123–133. http://dx.doi.org/10.1177/1049731506293693. Copyright © 2007 by SAGE Publications. Used with permission.
Phase 1 is similar to that completed by the USC Well Elderly Studies investigative team. Going beyond this, Figure 2 depicts Phase 2 as entailing a two-prong progression. One pathway corresponds to dissemination of research findings through strategies such as journal publications and outreach to media sources. The Well Elderly Studies investigative team completed these steps. However, the second pathway concerns implementation and transportation of interventions from the clinical trial sites into single usual-care sites and eventually into a larger, more diverse pool of population groups. In contrast to the course followed by Ayres, to date the Well Elderly Studies investigative team has not yet traversed this pathway.
As implementation science has developed and matured, there is widespread recognition that implementation of evidence-based practices is even more complicated than as depicted in Figure 2, requiring whole-system change at the research design, practitioner, and institution levels (Burke & Gitlin, 2012). Because of the multiple considerations that influence this change process, efficacy and effectiveness researchers need to take this complexity into account as they conceptualize and develop interventions and systematically study their outcomes. To that end, implementation science has brought to the forefront the understanding that it is not enough for an intervention to work: to have an impact, it must also have reach (Glasgow et al., 2003), defined as the capacity to be broadly applicable. Applicability, in turn, is maximized when interventions have the following characteristics:
They are seen by practitioners as having the potential to apply to large numbers of people.
They are not overly rigid but rather are easily customizable to the specific needs of local settings.
They can be replicated at a reasonable cost.
They do not require highly specialized training to consistently administer. (Glasgow et al., 2003)
In contrast, interventions that are viewed as too intensive, demanding too much time or effort, and not adequately packaged or manualized have been found to be less likely to be implemented (Glasgow & Emmons, 2007). To expedite the implementation process, interventions should be designed to possess real-world practicality and to be readily transferable to a wide range of practice settings. Taking these considerations into account, Russell Glasgow, a renowned behavioral scientist, developed the reach–effectiveness–adoption–implementation–maintenance (RE–AIM) framework as a heuristic for guiding researchers at the outset of their research programs in thinking through the entire progression of translational intervention trials so that implementation is more likely (Figure 3).
Recommendations for RE–AIMing translational research.
Note. From "Translating Research to Practice: Lessons Learned, Areas for Improvement, and Future Directions," by R. E. Glasgow, 2003, Diabetes Care, 26, p. 2452. Copyright © 2003 by the American Diabetes Association. Adapted with permission.
The first element of RE–AIM, reach, refers to the penetration of an intervention into its targeted audience (Glasgow, 2003). To maximize reach, researchers are encouraged to design interventions to be as broadly applicable as possible. Interventions that on the surface appear to be applicable to a narrow group of people are less likely to be implemented. In the case of Lifestyle Redesign, the intervention, although broadly applicable to independently living older adults, was not readily so for the rehabilitation population with whom occupational therapists typically work, making implementation complicated.
The second element of RE–AIM, effectiveness, refers to measurable change in important health outcomes, which optimally include an intervention's impact on quality of life. Research that demonstrates that an intervention influences such factors as disability, function, and health care costs and other economic measures maximizes the likelihood of its being perceived as relevant to real-world concerns. For example, the adoption of sensory integration procedures as a component of pediatric occupational therapy was, in part, contingent on demonstrating that the intervention went beyond minimizing "symptoms" and improved academic abilities in children with learning disabilities (Ayres, 1972).
The RE–AIM framework's third element, adoption, refers to the participation rate among clinical settings (e.g., clinics, organizations). To promote adoption, interventions should be developed that are feasible, replicable, and easily tailored to the particular needs of different settings, as previously discussed.
The fourth element, implementation, is defined narrowly in the RE–AIM model as the ability of the intervention to be delivered with consistency and fidelity. In designing intervention research, researchers need to specify methods for evaluating and ensuring intervention fidelity, such as manualizing the intervention and creating tools for assessing fidelity. Unfortunately, in the early implementation of sensory integration procedures, tools were not available to assess the degree to which practice implementation across settings was consistent and in keeping with the intervention's theoretically driven guidelines (i.e., fidelity). As a result, approaches have varied across settings in important ways. A well-designed fidelity measure has recently been published (Parham et al., 2011), however, and its use is likely to ensure greater consistency and fidelity in the application of sensory integration procedures.
Finally, maintenance, the fifth element of RE–AIM, is defined broadly both as program sustainability and as the long-term effects of the intervention. Sustainable interventions with evidence for long-term retention of therapeutic gains have a greater likelihood of implementation and follow-through. Thus, in the research design phase, researchers should carefully formulate plans for long-term follow-up studies and strategies to sustain the program.
Researchers can easily use the RE–AIM framework in the planning of a research program to evaluate the efficacy and effectiveness of occupational therapy interventions that, if demonstrated to be beneficial, will have a high likelihood of being readily implemented in practice. The many elements of an intervention's applicability—its measurable impact on health, quality of life, and economic outcomes; its ease in being consistently delivered in real-world settings; its feasibility; and its long-term sustainability—are determining factors in the ultimate translation of the research and thus are elements that researchers should pay attention to early on in the process of delineating the various steps in a long-term research program.
The whole-system change typically required for wide-scale implementation of efficacious occupational therapy interventions may also necessitate transformation at the practitioner and institutional levels. Altering practice patterns, mindsets, and beliefs at the practitioner level and culture at the institutional level is admittedly a challenging task. The concepts discussed in the paragraphs that follow offer promising launch points.
Practitioner Level: Mindlines
If occupational therapy practitioners are to consistently implement evidence-based practice in the therapy they provide, it is essential that their mindlines—that is, the ways they think during practice—be identified to facilitate change. In an impressive ethnography of clinical decision making, Gabbay and Le May (2011) defined mindlines as clinicians' internalized guidelines for treatment that, in turn, are translated into the treatment choices they make. Ultimately, practitioners determine the extent to which evidence-based interventions are actually used in practice. Each clinician's mindline is shaped by myriad factors, including experiential knowledge from practice; textbook knowledge; "grazing" of professional and commercial literature; conversations with colleagues; experiences with patients; and social, economic, and organizational demands. A clinician's mindline continually evolves as he or she takes in new information, and ideally, new evidence-based interventions are incorporated into his or her treatment repertoire through a process called mindline expansion.
How do mindlines change, expand, and incorporate new information? According to Gabbay and Le May (2011), mindlines expand through a process of knowledge integration in which explicit knowledge that is gathered from research and other external sources, such as the media, is transformed into tacit knowledge and then externalized into actions and clinical decisions (e.g., clinicians' treatment plans). This transformation process is largely one of internalization and socialization and thus is highly influenced by a practitioner's colleagues and work setting. Practically speaking, then, transformational leaders within the workplace have the ability to powerfully influence the mindline expansion of their fellow practitioners. This is what happened at the setting where Clark was employed in 1974. The sensory integration effectiveness study was launched because one charismatic and respected clinician had attended several of Ayres' lectures given in the context of continuing education. She influenced Clark and her fellow practitioners (1978) to attend sensory integration continuing education programs, to give this approach a salient place in their mindlines, and ultimately to implement their study.
Transformational leaders work with their colleagues to expand their mindlines rather than simply try to impose their beliefs about practice on them. These leaders encourage opportunities at work to critically appraise evidence, facilitate dialogue on how to incorporate new findings into the specific practice contexts they see every day, and urge their fellow practitioners to take relevant courses. Not only do they obtain the latest evidence on best practice from well-vetted sources, but they also are trusted and respected by their peers. Finally, they work with others so that together they can set the workplace standard for implementation. Through these practices, transformational leaders can facilitate ongoing expansion in the mindlines of others and concomitant alterations in best practice approaches in particular clinical settings.
Institutional Level: Promoting Action on Research Implementation in Health Services
The underlying assumption of the Promoting Action on Research Implementation in Health Services (PARiHS) framework is that successful implementation of evidence-based practice is a function of the interplay among three core elements: evidence, context, and facilitation (Kitson, Harvey, & McCormack, 1998). In this way, the PARiHS framework succinctly brings together the ideas previously presented in this article; however, the process of research translation is depicted on an institutional scale.
We have already described how the first element, evidence, which is obtained from the research literature, interacts with clinical experience, patient experience, and local context-specific information to shape a clinician's mindline. To this, the PARiHS framework adds the second component, context, emphasizing the critical importance of an organization's context on the extent to which evidence-based interventions are implemented at a particular setting or in a service delivery system.
Context encompasses an organization's culture, mandated protocols, leadership structure, and evaluation mechanisms, all of which support or hinder the likelihood of an evidence-based practice being adopted. For example, an organization's culture dictates whether continuing education is encouraged or whether practitioners are likely to regularly read cutting-edge rehabilitation journals and discuss their content with colleagues. Leadership structures determine whether clearly defined roles exist among colleagues and whether teamwork to implement new evidence-based practices can be effective. Evaluation mechanisms enable tracking of progress in the use of and corresponding outcomes of innovative interventions. These features of the context render it a powerful determinant of the degree to which implementation is successful in particular settings.
The third core element highlighted in the PARiHS framework is facilitation, defined as the support provided to enable change in attitudes, habits, skills, ways of thinking, and work (Kitson et al., 2008). Viewed as the active force that promotes change, facilitation is set into motion by people who possess the qualities of transformational leaders. Facilitation methods may vary in approach and support style over time; for example, early on they may be more directive, but later they may be less so and may take on an enabling and empowering role (Harvey et al., 2002). When facilitation methods are extremely effective, facilitators are able to draw out the inherent potential of others and concomitantly pursue their own change process in ways that are personally meaningful and relevant.
In the PARiHS framework, the interaction between these three core elements—evidence, context, and facilitation—is seen as determining how successful implementation of an evidence-based intervention will be. As illustrated in Figure 4, the optimal situation for translation of evidence into practice occurs when sound evidence works together with broad reach, a strong context, and skillful facilitation. Research programs with the aim of demonstrating the efficacy of a novel intervention need to address variations that are likely across multiple settings. To anticipate these differences at the outset, it is helpful to envision the populations to whom and settings in which the intervention will apply, anticipate the challenges the context may impose, conceptualize how the facilitation process can be expedited, and provisionally identify who will assume the roles of transformational leaders.
Role of facilitation in outcomes.
Note. From "Enabling the Implementation of Evidence Based Practice: A Conceptual Framework," by A. Kitson, G. Harvey, & B. McCormack, 1998, Quality in Health Care, 7, 153, http://dx.doi.org/10.1136/qshc.7.3.149. Copyright © 1998 by BMJ Publishing Group Ltd. Adapted with permission.
The research translation models previously discussed add to an understanding of the implementation of efficacious interventions by drawing attention to research design, practitioner, and institutional considerations. The final element required for successful implementation is to proactively communicate the results of the research to consumers and policymakers.
First, the importance of engaging stakeholders in the research process cannot be overstated. Stakeholders—the people who have an invested interest in the intervention or the population for which it is designed—may be community members, advocacy groups, patients, businesses, policymakers, or community-based organizations and can serve as valuable resources during both the trial and dissemination phases. Generally speaking, researchers should engage stakeholders at the very beginning stages of the research program. They may invite stakeholders to give input by serving on a community advisory committee or participating in a town hall forum (Katz, 2006). Stakeholders who see the importance of the proposed research can then aid in recruiting participants, identifying partners for collaboration, recognizing potential pitfalls, and ensuring real-world relevance. Moreover, alterations made in the design of the research program that are responsive to their input are likely to facilitate the probability that the intervention will be implementable in the future should it prove effective. Beyond this, stakeholders can be enormously helpful in raising the public profile of the intervention through word-of-mouth dissemination.
Second, it is important to communicate the benefits of an efficacious intervention directly to consumers in language that they can easily understand. Potential recipients of an efficacious intervention for stroke survivors, for example, will probably not be interested in the soundness of the statistical analysis but will want to know how the intervention will improve their lives. They will probably want to ascertain the extent to which the intervention has been shown to be responsive to practical concerns, such as whether it has beneficial effects on independence or disability or whether it decreases out-of-pocket health care expenditures. Forming partnerships with consumer interest and advocacy groups can help researchers identify outcome measures that matter to consumers and build linkages to networks of potential intervention recipients.
Third, researchers need to become savvy in using the media to disseminate study findings. The formulation of a coherent media strategy counteracts sporadic, fragmented, or limited media dissemination. Katz (2006) suggested calling reporters directly in addition to sending press releases to newspapers and television media outlets and providing contact information for people not directly involved with the study who can articulate what is compelling about the work to the public.
Fourth, researchers need to reach out to legislators and policymakers, recognizing that these people are under enormous time pressures and do not typically read rehabilitation or occupational therapy peer-reviewed journals. The best approach to alerting them to study findings is to contact them oneself and try to arrange a meeting either with the policymaker or his or her staff. For such meetings, one should bring copies of publications along with a one-page summary that clearly identifies which groups support the intervention and why. As with communication to consumers, it is important to succinctly tailor one's message to the interests and priorities of this audience. How cost-effective is the intervention? What will the effect be on communitywide health outcomes? What portion of the policymaker's constituents will benefit from this intervention?
In this article, we have illustrated that demonstrating the effectiveness or even the cost-effectiveness of an intervention does not guarantee its implementation in clinical practice. The process of doing clinical trials research has two phases: (1) developing and demonstrating the beneficial outcomes of an intervention and (2) implementing it in the real world so that it becomes incorporated as a best practice. When Phase 2 of the clinical trials research process—adoption of best practices in the community—is carefully planned, the likelihood that the intervention will actually improve practice and service delivery to consumers is increased. Scientists developing a clinical trials research program should incorporate an implementation plan at the outset of their research program that addresses concerns such as the following:
The reach of the intervention
The kinds of settings for which it is applicable
Who its transformational leaders will be
What groups constitute its stakeholders
What challenges will emerge to its infusion into the mindlines of occupational therapy practitioners.
We acknowledge Alison Cogan, Charlotte Deng, Monique Wolkoff, Vivian Tang, and Katherine Thompson for their valuable contribution to the production of this article. They performed the initial review of the implementation science literature that informed our early conceptualization of its relevance to occupational science and occupational therapy and greatly assisted with the development of the Advancing Clinical Trials and Outcomes Research (ACTOR) slide presentation that served as the foundation of this article. Finally, they contributed their technical expertise and computer skills in formatting the article and figures to American Psychological Association style specifications. An earlier version of this article was presented at the ACTOR Conference, Fairfax, VA, December 2011.
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redpajama_set_name: RedPajamaCommonCrawl


The Forever invitation suite isn't just referring to the 'forever' kind of love you and your guests will be celebrating on your big day; it's also referring to the party that your guests will remember - forever. With gold and black accents and a decorative ribbon that solidifies the bride and groom tying the knot, this boldly contemporary invite is the perfect complement to any wedding. Corresponding response and reception cards available while personalizing for an additional charge.


text:
A film which focuses on people, people's values and human beings placed in situations challenging expected behaviour and emotional response. The dilemma for the execution team is similar to that faced by the military staff entrusted to do as they're told and trained to do at the start of the film War Games, though in that case, presented with an air of 'boy's adventure'. Not here.
This is a much more gritty drama which tells the tale of the actions of a drone flying over Africa being controlled by a USA remote pilot, very well played by Breaking Bad's Jessie, Aaron Paul, the top military brass in London represented by the late Alan Rickman and the Colonel on the ground devotedly committed to the mission's goal, played by Helen Mirren.
It explores how the chain of command and decision making happens between governments, ministers, military personnel and politicians when human life is at stake for different cultures seeking different ideals whilst avoiding post-incident blame through investigation and enquiry. It highlights the difficulties faced by everyone in deciding how to choose between the worse of two undesirable outcomes and does so excellently with edge-of-the-seat tension and suspense.
It's beautifully directed by Gavin Hood with excellent photography and a haunting score throughout in what, for much of the time, are claustrophobic scenes.
Now, I'm not in any way qualified to know if any of it's accurate or based on what really does, can or would happen, nor stand in judgement about the issues involved about terrorism and how to right the world's wrongs, but it certainly made for a tight-knit engaging thriller with excellent performances. The time spent watching it just flies - and I'm finding that more and more difficult to say with films these days.
Recommended, certainly.


BCB Cricket Operations Chairman Akram Khan said on Wednesday the the family of the national cricketers can stay with them during the World Cup in England and Wales.
The cricket's biggest extravaganza will be going on from May 30-July 14 this year. Board Cricket Control for India (BCCI) however allowed the family of the cricketers and support staffs for first two week after the beginning of the World Cup.
But Bangladesh didn't give such sort of restriction, Akram said here today.
"During our time, our family was not allowed to stay with us in such long tournament because the team management was strict in this matter," Akram said.
"But we didn't set such rules. Last time in 2015 World Cup in Australia-New Zealand, players were allowed to take their family with them. There is no problem in it," he added.
Bangladesh will leave the country for Ireland to play a Tri-nation series in the first week of May after which they will go to England straightway.
There will be special camp for Bangladesh to cope with the condition of England. Considering a hectic schedule, some cricketers reportedly wanted to spend time with the family, skipping the special camp.
Akram said BCB will consider if the players seek some time-off to spend with the family.
"I heard cricketers talked about this issue (time off). But they didn't apply anything officially. We also know the tour in Ireland and World Cup is very long. In between they want four days off. It's good to spend time with the family. I hope BCB definitely will consider the matter," Akram informed.
The World Cup team of Bangladesh is expected to be announced on April 18. The camp for the World Cup will begin on April 22 at the Sher-e-Bangla National Cricket Stadium.


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Designated Survivor Season 3 Episode 9 Recap
designated survivor Netflix Recap tv news TV Recap
By Tiffany Gustanski
In the previous episode of Netflix's Designated Survivor, Marlowe identified Brunton as the person who tried to commission the virus. In Designated Survivor Season 3 Episode 9, the question of Moss's involvement was at the forefront while Carrie decided it was time.
Voter Suppression
Kirkman couldn't be involved with Brunton's arrest as it would seem like a political move. However, Harper met with the FBI director, Vargas, to remind him that it would be on him if there was a related terrorist attack before the election. The FBI finally arrested Brunton, and Moss played down his relationship with him for the press.
Eli and the CIA determined the true purpose of the virus. Though minorities would get the flu, they eventually got better. However, it would eventually cause them to become sterile. The effect would be a long-term way to suppress minority votes.
Harper went to Detwiler's office to gloat about his removal from the FlagKind board. While there, the FBI arrested Detwiler. Brunton had pointed the finger at him as his funder. Lorraine leaked a video of Moss, next to Brunton, pointing out that soon white people would be a minority, which would tip the political scales towards liberals. Because of this, Kirkman told the press he believed Moss was involved. However, Emily and Dontae uncovered that Lorraine used Pegasus to spy on Moss. Emily heard a call where it was clear that Moss hadn't known about the virus.
In Her Arms
Emily didn't go with the campaign to Texas. Instead, Carrie had decided that she could no longer wait. Emily mixed the drugs in orange juice, and Carrie drank it all. She lied in Emily's arms. When Carrie became unconscious, Emily called an ambulance. The doctor asked if Carrie had a DNR, and Emily heartbreakingly admitted that she did. Her mother was gone.
Acting Like a Politician
The Kirkman campaign was headed to New York, and Sasha would introduce him. Unfortunately, now that Moss's campaign was in trouble, Texas was up for grabs. Instead of Manhattan, they would go to Houston. Lorraine convinced Kirkman that it would hurt their campaign to have Sasha introduce him in Texas. Kirkman broke the news to Sasha, and she and Penny were hurt. He apologized to them and reminded himself that he didn't get into politics to act like a politician.
Keeping Up Appearances
Isabel told Seth that Aaron had slept with Emily. She reluctantly went with Aaron to a campaign trip in Florida. Her parents were flying in from Puerto Rico, and Isabel hadn't told them that they had broken up. Aaron asked for a second chance.
Seth met Stephanie's mother, Riya. She confessed that she chose Seth's sperm because he went to Harvard. Stephanie was applying but needed more to pad her application. She asked Seth to pull some strings to help her land a White House internship. After speaking with Stephanie, Seth encouraged her to apply. She had connections.
What did you think of this episode of Designated Survivor? Let us know in the comment section below!


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