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Background: Neuropsychiatric conditions comprise 14% of the global burden of disease and 30% of all noncommunicable disease. Despite the existence of cost-effective interventions, including administration of psychotropic medicines, the number of persons who remain untreated is as high as 85% in low- and middle-income countries (LAMICs). While access to psychotropic medicines varies substantially across countries, no studies to date have empirically investigated potential health systems factors underlying this issue. Methods and findings: This study uses a cross-sectional sample of 63 LAMICs and country regions to identify key health systems components associated with access to psychotropic medicines. Data from countries that completed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) were included in multiple regression analyses to investigate the role of five major mental health systems domains in shaping medicine availability and affordability. These domains are: mental health legislation, human rights implementations, mental health care financing, human resources, and the role of advocacy groups. Availability of psychotropic medicines was associated with features of all five mental health systems domains. Most notably, within the domain of mental health legislation, a comprehensive national mental health plan was associated with 15% greater availability; and in terms of advocacy groups, the participation of family-based organizations in the development of mental health legislation was associated with 17% greater availability. Only three measures were related with affordability of medicines to consumers: level of human resources, percentage of countries' health budget dedicated to mental health, and availability of mental health care in prisons. Controlling for country development, as measured by the Human Development Index, health systems features were associated with medicine availability but not affordability. Conclusions: Results suggest that strengthening particular facets of mental health systems might improve availability of psychotropic medicines and that overall country development is associated with affordability.

Background: Prevention of mother to child transmission (PMTCT) programmes have traditionally been narrow in scope, targeting biomedical interventions during the perinatal period, rather than considering HIV as a family disease. This limited focus restricts programmes' effectiveness, and the opportunity to broaden prevention measures has largely been overlooked. Although prevention of vertical transmission is crucial, consideration of the family environment can enhance PMTCT. Family-centred approaches to HIV prevention and care present an important direction for preventing paediatric infections while improving overall family health. This paper reviews available literature on PMTCT programmatic models that have taken a broader or family-centred approach. We describe findings and barriers to the delivery of family-centred PMTCT and identify a number of promising new directions that may achieve more holistic services for children and families. Methods: Literature on the effectiveness of family-centred PMTCT interventions available via PubMed, EMBASE and PsycINFO were searched from 1990 to the present. Four hundred and three abstracts were generated. These were narrowed to those describing or evaluating PMTCT models that target broader aspects of the family system before, during and/or after delivery of an infant at risk of acquiring HIV infection (N = 14). Results: The most common aspects of family-centred care incorporated by PMTCT studies and programme models included counselling, testing, and provision of antiretroviral treatment for infected pregnant women and their partners. Antiretroviral therapy was also commonly extended to other infected family members. Efforts to involve fathers in family-based PMTCT counselling, infant feeding counselling, and general decision making were less common, though promising. Also promising, but rare, were PMTCT programmes that use interventions to enrich family capacity and functioning; these include risk assessments for intimate partner violence, attention to mental health issues, and the integration of early childhood development services. Conclusions: Despite barriers, numerous opportunities exist to expand PMTCT services to address the health needs of the entire family. Our review of models utilizing these approaches indicates that family-centred prevention measures can be effectively integrated within programmes. However, additional research is needed in order to more thoroughly evaluate their impact on PMTCT, as well as on broader family health outcomes.

Background: Cannabis use and cannabis use disorder are more prevalent in U.S. states with medical marijuana laws (MMLs), as well as among individuals with elevated psychological distress. We investigated whether adults with moderate and serious psychological distress experienced greater levels of cannabis use and/or disorder in states with MMLs compared to states without MMLs.Methods: National Survey of Drug Use and Health data (2013-2017) were used to compare past-month cannabis use, daily cannabis use, and cannabis use disorder prevalence among adults with moderate and serious psychological distress in states with versus without MMLs. We executed pooled multivariable logistic regression analyses to test main effects of distress, MMLs and their interaction, after adjustment.Results: Compared to states without MMLs, states with MMLs had higher adjusted prevalence of past-month use (11.1 % vs. 6.8 %), daily use (4.0 % vs. 2.2 %), and disorder (1.7 % vs. 1.2 %). Adults with moderate and serious psychological distress had greater adjusted odds of any use (AORs of 1.72 and 2.22, respectively) and of disorder (AORs of 2.17 and 2.94, respectively), compared to those with no/mild distress. We did not find evidence of an interaction between MMLs and distress category for any outcome.Conclusions: Associations between elevated distress and cannabis use patterns are no greater in states with MML. However, cannabis use is more prevalent in MML states. Thus, higher base rates of cannabis use and disorder among adults with elevated distress are proportionally magnified in these states. [ABSTRACT FROM AUTHOR]

Background: Lesotho experienced high rates of maternal (566/100,000 live births) and under-five mortality (72.9/1000 live births). A 2013 national assessment found centralized healthcare management in Ministry of Health led to fragmented, ineffective district health team management. Launched in 2014 through collaboration between the Ministry of Health and Partners In Health, Lesotho's Primary Health Care Reform (LPHCR) aimed to improve service quality and quantity by decentralizing healthcare management to the district level. We conducted a qualitative study to explore health workers' perceptions regarding the effectiveness of LPHCR in enhancing the primary health care system. Methods: We conducted 21 semi-structured key informant interviews (KII) with healthcare workers and Ministry of Health officials purposively sampled from various levels of Lesotho's health system, including the central Ministry of Health, district health management teams, health centers, and community health worker programs in four pilot districts of the LPHCR initiative. The World Health Organization's health systems building blocks framework was used to guide data collection and analysis. Interviews assessed health care workers' perspectives on the impact of the LPHCR initiative on the six-health system building blocks: service delivery, health information systems, access to essential medicines, health workforce, financing, and leadership/governance. Data were analyzed using directed content analysis. Results: Participants described benefits of decentralization, including improved efficiency in service delivery, enhanced accountability and responsiveness, increased community participation, improved data availability, and better resource allocation. Participants highlighted how the reform resulted in more efficient procurement and distribution processes and increased recognition and status in part due to the empowerment of district health management teams. However, participants also identified limited decentralization of financial decision-making and encountered barriers to successful implementation, such as staff shortages, inadequate management of the village health worker program, and a lack of clear communication regarding autonomy in utilizing and mobilizing donor funds. Conclusion: Our study findings indicate that the implementation of decentralized primary health care management in Lesotho was associated a positive impact on health system building blocks related to primary health care. However, it is crucial to address the implementation challenges identified by healthcare workers to optimize the benefits of decentralized healthcare management. [ABSTRACT FROM AUTHOR]

Although health screenings offer timely detection of health conditions and enable early intervention, adoption is often poor. How might financial interventions create the necessary incentives and resources to improve screening in primary care settings? This systematic review aimed to answer this question. Peer-reviewed studies published between 2000 and 2023 were identified and categorized by the level of intervention (practice or individual) and type of intervention, specifically alternative payment models (APMs), fee-for-service (FFS), capitation, and capital investments. Outcomes included frequency of screening, performance/quality of care (e.g., patient satisfaction, health outcomes), and workflow changes (e.g., visit length, staffing). Of 51 included studies, a majority focused on practice-level interventions (n =32), used APMs (n =41) that involved payments for achieving key performance indicators (KPIs; n =31) and were of low or very low strength of evidence based on GRADE criteria (n =42). Studies often included screenings for cancer (n =32), diabetes care (n =18), and behavioral health (n =15). KPI payments to both practices and individual providers corresponded with increased screening rates, whereas capitation and provider-level FFS models yielded mixed results. A large majority of studies assessed changes in screening rates (n =48) with less focus on quality of care (n =11) or workflow changes (n =4). Financial mechanisms can enhance screening rates with evidence strongest for KPI payments to both practices and individual providers. Future research should explore the relationship between financial interventions and quality of care, in terms of both clinical processes and patient outcomes, as well as the role of these interventions in shaping care delivery. [ABSTRACT FROM AUTHOR]

Perinatal depression has been shown to have deleterious effects on maternal postpartum functioning as well as early child development. However, few studies have documented whether depression care helps to mitigate these effects. We examined the effects of the M-DEPTH (Maternal Depression Treatment in HIV) depression care model (including antidepressants and individual problem solving therapy) on maternal functioning and infant development in the first 6 months post-delivery in an ongoing cluster randomized controlled trial of 391 HIV-infected women with at least mild depressive symptoms enrolled across eight antenatal care clinics in Uganda. A subsample of 354 (177 in each of the intervention and control groups) had a live birth delivery and composed the analytic sample, of whom 69% had clinical depression at enrollment; 70% of women in the intervention group (including 96% of those with clinical depression) received depression treatment. Repeated-measures multivariable regression models found that the intervention group reported better infant care, lower parental burden, and greater perceived adequacy of parental support, compared to the control group. These findings suggest that depression care for pregnant women living with HIV is important not only for maternal mental health but also because it helps women to better manage parenting and care for their infant. [ABSTRACT FROM AUTHOR]

Objective: Parenting behaviors have been studied largely in isolation with regard to child development in cross-national contexts. We examine and compare the relative strength of association between physical discipline and deprivation with risk of children's socioemotional and cognitive developmental delay in a cross-national sample.Method: The sample was drawn from the UNICEF Multiple Indicator Cluster Survey. Analyses used observations with data on parental physical discipline, parenting behaviors associated with deprivation, and child developmental outcomes. The present analysis included 29,792 children aged 36-59 months across 17 countries. Using the Early Child Development Index, risk for cognitive or socioemotional developmental delay was indicated if a child could not accomplish 2 or more items within that specific subdomain. Overall risk for delay was indicated if a child was at risk in either subdomain. Associations among discipline, deprivation, and delay were assessed using multivariable logistic regression.Results: Five of the 7 exposures were associated with risk of overall developmental delay. Physical discipline (odds ratio [OR] = 1.49 [95% CI = 1.39, 1.59]; p < .001) had the largest association with risk for socioemotional delay. Not having books (OR = 1.62 [95% CI = 1.42, 1.84]; p < .001) and not counting with the child (OR = 1.47 [95% CI = 1.32, 1.64]; p < .001) had the largest associations with risk of cognitive delay.Conclusion: The exposures of physical discipline and deprivation measured here have distinct associations with risk of socioemotional and cognitive delay cross-nationally. Programmatic and clinical interventions should seek to act on adversities that are relevant to the targeted delay. [ABSTRACT FROM AUTHOR]

Introduction: Perinatal depression is common among women living with HIV, but depression care is limited in low-resource settings. We examined (1) characteristics of women receiving Problem Solving Therapy (PST) versus antidepressant therapy (ADT), (2) treatment response by modality, and (3) correlates of treatment response. Methods: This analysis used data from 191 Ugandan women in the intervention arm of a cluster randomized controlled trial of task-shifted, stepped-care depression treatment for pregnant women living with HIV (PWLWH). Treatment response was defined as scoring < 5 on the nine-item Patient Health Questionnaire (PHQ-9). Bivariate analysis and multivariable logistic regression were used to examine characteristics of women by treatment group and correlates of treatment response. Results: Of 134 participants with depression, 129 (96%) were treated: 84 (65%) received PST and 45 (35%) received ADT. Severe depression at treatment initiation was more common in those receiving ADT (28.9% versus 4.8%, Fischer's Exact Test < 0.001). Treatment response was higher for PST (70/84; 83.3%) than ADT (30/45; 66.7%; p =.03). ADT side effects were rare and minor; no infants had serious congenital defects. Of 22 participants (19%) who did not respond to treatment, only five received intensified management. Social support and interpersonal violence were associated with treatment response (adjusted odds ratio, [aOR] = 3.06, 95% CI = 1.08–8.66 and aOR = 0.64, 95% CI = 0.44–0.93). Discussion: Both depression treatment modalities yielded high response rates in Ugandan PWLWH; ADT was well-tolerated. Our results highlight a need to build capacity to implement the stepped-care protocol for non-responders and screen for social support and interpersonal violence. Significance: What is Already Known on this Subject?Prior research has demonstrated the feasibility and effectiveness of delivering collaborative care for depression in low-resource settings including Uganda. What this Study adds?Both Problem-Solving Therapy and antidepressant therapy yielded high treatment response rates among pregnant women living with HIV in Uganda who met criteria for depression, and antidepressant therapy was well tolerated. This study highlights a need to build capacity to implement the task-shifted stepped-care protocol for women whose depression does not respond to initial treatment, and to screen for social support and interpersonal violence. [ABSTRACT FROM AUTHOR]

Internalized stigma is common among individuals with sexually transmitted infections such as HIV and among those with mental health conditions such as major depressive disorder (MDD). As part of a cluster randomized trial, we investigated the prevalence and correlates of internalized stigma among adults living with comorbid HIV and MDD in rural Malawi (n = 339). We found heightened stigma toward HIV and mental illness among those in the cohort: more than half of respondents (54%) endorsed negative perceptions associated with each health condition. Internalized HIV-related stigma was higher among those with no education (p = 0.04), younger adults (p = 0.03), and those with less social support (p = 0.001). Mental illness-related stigma was elevated among those with no source of income (p = 0.001), and it was also strongly associated with HIV-related stigma (p < 0.001). Our findings highlight potential avenues for reducing internalized stigma associated with high-prevalence health conditions in Malawi. Trial registration: ClinicalTrials.gov identifier: NCT04777006. [ABSTRACT FROM AUTHOR]

Background: Perinatal depression is highly prevalent among women living with HIV and contributes to nonadherence to the PMTCT (prevention of mother-to-child transmission) care continuum. We examined correlates of elevated depressive symptoms and suicidality in this population. Method: Baseline data from 391 Ugandan women enrolled in a cluster randomized controlled trial of a depression care intervention were analyzed. Adult women with confirmed sero-positive HIV status were eligible if their gestation period was ≤ 32 weeks, and they had a Patient Health Questionnaire (PHQ-9) score ≥ 5. Correlates of elevated depressive symptoms (PHQ-9 > 9) and moderate-to-severe suicidal ideation (more than half of the days in the prior 2 weeks) were assessed using bivariate and multivariate logistic regression models, controlling for clustering within study sites by using a random effects specification (with study site as the random effect), as well as age and education. Results: The mean PHQ-9 score was 12.7 (SD = 5.1); 267 (68.3%) participants had elevated depressive symptoms, and 51 (13.0%) reported moderate-to-severe suicidality. In multiple logistic regression analysis, perceived provider stigma of childbearing [OR (95% CI) = 1.81 (1.16, 2.84)], greater use of negative problem-solving [OR (95% CI) = 1.09 (1.04, 1.15)], and lower general social support [OR (95% CI) = 0.50 (0.30, 0.82)] were correlated with elevated depression symptoms, while moderate-to-severe suicidal ideation was correlated with greater experience of physical interpersonal violence (IPV) and greater use of negative problem-solving. Conclusions: Programs aimed at improving provider support for the childbearing needs of persons living with HIV, supporting women who are experiencing IPV, and helping women to develop effective problem-solving skills and social supports may reduce symptoms of perinatal depression and help optimize PMTCT care outcomes. Trial Registration: Clinicaltrials.gov NCT03892915 (registered March 21, 2019). [ABSTRACT FROM AUTHOR]

Background: It is not clear what the most effective implementation strategies are for supporting the enactment and sustainment of depression care services in primary care settings. This type-II Hybrid Implementation-Effectiveness study will compare the effectiveness of three system-level strategies for implementing depression care programs at 36 community health stations (CHSs) across 2 provinces in Vietnam. Methods: In this cluster-randomized controlled trial, CHSs will be randomly assigned to one of three implementation conditions: (1) Usual Implementation (UI), which consists of training workshops and toolkits; (2) Enhanced Supervision (ES), which includes UI combined with bi-weekly/monthly supervision; and (3) Community-Engaged Learning Collaborative (CELC), which includes all components of ES, combined with bi-monthly province-wide learning collaborative meetings, during which cross-site learning and continuous quality improvement (QI) strategies are implemented to achieve better implementation outcomes. The primary outcome will be measured based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation quality, and Maintenance) using indicators on implementation, provider, and client factors. The secondary outcome examines factors associated with barriers and facilitators of quality implementation, while the tertiary outcome evaluates the incremental cost-effectiveness ratio of services provided in the ES and CELC conditions, relative to UI condition for depression care. A total of 1,296 clients receiving depression care at CHSs will be surveyed at baseline and 6-month follow-up to assess mental health and psychosocial outcomes (e.g., depression and anxiety severity, health function, quality of life). Additionally, 180 CHS staff and 180 non-CHS staff will complete pre- and post-training evaluation and surveys at baseline, 6, 12, and 24 months. Discussion: We hypothesize that the additional implementation supports will make mental health service implementation superior in the ES and CELC arms compared to the UI arm. The findings of this project could identify effective implementation models and assess the added value of specific QI strategies for implementing depression care in primary care settings in Vietnam, with implications and recommendations for other low- and middle-income settings. More importantly, this study will provide evidence for key stakeholders and policymakers to consider policies that disseminate, scale up, and advance quality mental health care in Vietnam. Trial registration: NCT04491045 on Clinicaltrials.gov. Registered July 29, 2020. [ABSTRACT FROM AUTHOR]

On July 16, 2022, the 988 mental health crisis hotline launched nationwide. In addition to preparing for an increase in call volume, many jurisdictions used the launch of 988 as an opportunity to examine their full continuum of emergency mental health care. Our goal was to understand the characteristics of jurisdictions' existing continuums of care, identify factors that distinguished jurisdictions that were more- versus less-prepared for 988, and explore perceived strengths and limitations of the planning process. We conducted 15 qualitative interviews with state and local mental health program directors representing 10 states based on their preparedness for the 988 rollout. Interviews focused on 988 call centers, mobile crisis response, and crisis stabilization, as well as strengths and limitations of the 988 planning process. Data were analyzed using rapid qualitative analysis, an approach designed to draw insights on evolving processes and extract actionable findings. Interviewees from jurisdictions that reported that they were more-prepared for the launch of 988 tended to have local 988 call centers and already had local access to mobile crisis teams and crisis stabilization units. Interviewees across jurisdictions described challenges to offering a robust continuum of crisis services, including workforce shortages and geographic constraints. Though jurisdictions acknowledged the importance of integrating peer support staff and serving diverse populations, many perceived room for growth in these areas. Though 988 has launched, efforts to bolster the existing continuum will continue and hinge on efforts to expand the behavioral health workforce, engage diverse partners, and collect relevant data. [ABSTRACT FROM AUTHOR]

Globally, an estimated five percent of adults have major depressive disorder. However, little is known about the relationship between these individuals' depressive symptoms and their household members' mental health and well-being. We aimed to investigate the prevalence and predictors of depressive symptoms among adult household members of patients living with major depressive disorder in Neno District, Malawi. As part of a cluster randomized controlled trial providing depression care to adults with major depressive disorder, we conducted surveys with patients' household members (n = 236) and inquired about their overall health, depressive symptoms, disability, and social support. We calculated prevalence rates of depressive disorder and conducted multivariable linear regression and multivariable logistic regression analyses to assess correlates of depressive symptom severity and predictors of having depressive disorder (PHQ-9), respectively, among household members. We observed that roughly one in five household members (19%) screened positive for a depressive disorder (PHQ-9 > 9). More than half of household members endorsed six or more of the nine symptoms, with 68% reporting feeling 'down, depressed, or hopeless' in the prior two weeks. Elevated depression symptom severity was associated with greater disability (β = 0.17, p < 0.001), less social support (β = −0.04, p = 0.016), and lower self-reported overall health (β = 0.54, p = 0.001). Having depressive disorder was also associated with greater disability (adjusted Odds Ratio [aOR] = 1.12, p = 0.001) and less social support (aOR = 0.97, p = 0.024). In the Malawian context, we find that depressive disorder and depression symptoms are shared attributes among household members. This has implications for both screening and treatment, and it suggests that mental health should be approached from the vantage point of the broader social ecology of the household and family unit. ClinicalTrials.gov (NCT04777006) - March 2, 2021. [ABSTRACT FROM AUTHOR]

Introduction: Innovative strategies are needed to disseminate HIV prevention messages across communities efficiently, as well as reduce HIV stigma while promoting HIV prevention. This randomized controlled trial will evaluate the efficacy of a social network-based group intervention, Game Changers, which trains persons living with HIV (PLWH) to encourage members of their social network to use HIV protective behaviors METHODS: PLWH in HIV care for at least 1 year will be randomly assigned to receive the 8-session group advocacy training intervention or no-intervention control group. Each enrolled PLWH (index participant) will be asked to recruit up to four social network members (alter participant). Assessments will be administered at baseline and months 6, 12, and 18 to both index and alter participants. The primary outcomes are HIV testing and condom use among alter participants; secondary outcomes are engagement in HIV prevention advocacy and internalized HIV stigma among index participants. Repeated-measures multivariable regression analyses will be conducted to compare outcomes between the intervention and control arms, in addition to a cost-effectiveness evaluation.Discussion: This social network-based approach to HIV prevention is particularly timely in the era of biomedical interventions, which require widespread penetration of effective HIV prevention and care messaging into communities. Positioning PLWH as central to the solution for controlling (vs. causing) the HIV epidemic has the potential to reduce HIV stigma and improve prevention outcomes at the individual and network levels.Trial Registration: ClinicalTrials.gov NIH Clinical Trial Registry NCT05098015. Registered on October 18, 2021. [ABSTRACT FROM AUTHOR]

A significant treatment gap exists for mental illnesses across the world, particularly in low- and middle-income countries (LMICs). Task-sharing, a potentially scalable strategy to bridge the treatment gap, has been shown to be feasible and effective for the treatment of a range of mental illnesses. However, there is a lack of research examining lay mental health workers' experiences in such task-sharing roles. The aim of our study was to understand the barriers and facilitators that lay health workers (LHWs) face in delivering mental healthcare. We conducted in-depth interviews with 32 lay mental health workers recruited through maximum variation sampling and 18 stakeholders leading mental health programs at a variety of non-governmental organisations across India. Interviews were semi-structured and data was analyzed using the thematic analysis approach. Results showed that LHWs perceived barriers and facilitators at three levels: individually (related to personal characteristics and family support, and in their daily work such as in relationship building and supervision), organizationally (for example, related to compensation), and societally (such as encountering gender discrimination and stigma). Each of these areas should be taken into consideration when planning and implementing task-sharing interventions for mental illnesses. As the first qualitative study to explore broad LHW experiences in mental healthcare delivery in a diverse set of programs from a LMIC, this study shows that LHW voices should be central to program design and decision-making for mental health interventions. [ABSTRACT FROM AUTHOR]

Background: HIV prevention advocacy empowers persons living with HIV (PLWH) to act as advocates and encourage members of their social networks to engage in protective behaviors such as HIV testing, condom use, and antiretroviral therapy (ART) adherence. We examined correlates of HIV prevention advocacy among PLWH in Uganda.A cross-sectional analysis was conducted with baseline data from 210 PLWH (70% female; mean age = 40 years) who enrolled in a trial of an HIV prevention advocacy training program in Kampala, Uganda. The baseline survey, which was completed prior to receipt of the intervention, included multiple measures of HIV prevention advocacy (general and specific to named social network members), as well as internalized HIV stigma, HIV disclosure, HIV knowledge, positive living (condom use; ART adherence), and self-efficacy for HIV prevention advocacy.Consistent with our hypotheses, HIV disclosure, HIV knowledge, consistent condom use, and HIV prevention advocacy self-efficacy were all positively correlated with at least one measure of HIV prevention advocacy, after controlling for the other constructs in multiple regression analysis. Internalized HIV stigma was positively correlated with advocacy in bivariate analysis only.These findings identify which characteristics of PLWH are associated with acting as change agents for others in their social network to engage in HIV protective behaviors.Method: HIV prevention advocacy empowers persons living with HIV (PLWH) to act as advocates and encourage members of their social networks to engage in protective behaviors such as HIV testing, condom use, and antiretroviral therapy (ART) adherence. We examined correlates of HIV prevention advocacy among PLWH in Uganda.A cross-sectional analysis was conducted with baseline data from 210 PLWH (70% female; mean age = 40 years) who enrolled in a trial of an HIV prevention advocacy training program in Kampala, Uganda. The baseline survey, which was completed prior to receipt of the intervention, included multiple measures of HIV prevention advocacy (general and specific to named social network members), as well as internalized HIV stigma, HIV disclosure, HIV knowledge, positive living (condom use; ART adherence), and self-efficacy for HIV prevention advocacy.Consistent with our hypotheses, HIV disclosure, HIV knowledge, consistent condom use, and HIV prevention advocacy self-efficacy were all positively correlated with at least one measure of HIV prevention advocacy, after controlling for the other constructs in multiple regression analysis. Internalized HIV stigma was positively correlated with advocacy in bivariate analysis only.These findings identify which characteristics of PLWH are associated with acting as change agents for others in their social network to engage in HIV protective behaviors.Results: HIV prevention advocacy empowers persons living with HIV (PLWH) to act as advocates and encourage members of their social networks to engage in protective behaviors such as HIV testing, condom use, and antiretroviral therapy (ART) adherence. We examined correlates of HIV prevention advocacy among PLWH in Uganda.A cross-sectional analysis was conducted with baseline data from 210 PLWH (70% female; mean age = 40 years) who enrolled in a trial of an HIV prevention advocacy training program in Kampala, Uganda. The baseline survey, which was completed prior to receipt of the intervention, included multiple measures of HIV prevention advocacy (general and specific to named social network members), as well as internalized HIV stigma, HIV disclosure, HIV knowledge, positive living (condom use; ART adherence), and self-efficacy for HIV prevention advocacy.Consistent with our hypotheses, HIV disclosure, HIV knowledge, consistent condom use, and HIV prevention advocacy self-efficacy were all positively correlated with at least one measure of HIV prevention advocacy, after controlling for the other constructs in multiple regression analysis. Internalized HIV stigma was positively correlated with advocacy in bivariate analysis only.These findings identify which characteristics of PLWH are associated with acting as change agents for others in their social network to engage in HIV protective behaviors.Conclusion: HIV prevention advocacy empowers persons living with HIV (PLWH) to act as advocates and encourage members of their social networks to engage in protective behaviors such as HIV testing, condom use, and antiretroviral therapy (ART) adherence. We examined correlates of HIV prevention advocacy among PLWH in Uganda.A cross-sectional analysis was conducted with baseline data from 210 PLWH (70% female; mean age = 40 years) who enrolled in a trial of an HIV prevention advocacy training program in Kampala, Uganda. The baseline survey, which was completed prior to receipt of the intervention, included multiple measures of HIV prevention advocacy (general and specific to named social network members), as well as internalized HIV stigma, HIV disclosure, HIV knowledge, positive living (condom use; ART adherence), and self-efficacy for HIV prevention advocacy.Consistent with our hypotheses, HIV disclosure, HIV knowledge, consistent condom use, and HIV prevention advocacy self-efficacy were all positively correlated with at least one measure of HIV prevention advocacy, after controlling for the other constructs in multiple regression analysis. Internalized HIV stigma was positively correlated with advocacy in bivariate analysis only.These findings identify which characteristics of PLWH are associated with acting as change agents for others in their social network to engage in HIV protective behaviors. [ABSTRACT FROM AUTHOR]

Objective: In high HIV-burden countries like Uganda, financing and resource allocation for HIV services have rapidly evolved. This study aimed to employ time-driven activity-based costing (TDABC) to examine the allocation of resources and associated costs for HIV care throughout the country., Design: A cross-sectional study., Setting: This study was conducted at 31 health facilities throughout Uganda: 16 level III health centres, 10 level IV health centres and 5 district hospitals., Participants: 1119 persons receiving HIV services in 2020., Methods: We conducted TDABC to quantify costs, resource consumption and duration of service provision associated with antiretroviral therapy, prevention of mother-to-child transmission, HIV counselling and testing (HCT), voluntary medical male circumcision (VMMC) and pre-exposure prophylaxis. We also quantified disparities in resource consumption according to client-level and facility-level characteristics to examine equity. Fixed-effects multivariable regression analyses were employed to inspect factors associated with service costs and provider-client interaction time., Results: The mean cost of services ranged from US$8.18 per visit for HCT to US$32.28 for VMMC. In terms of disparities, those in the Western region received more provider time during visits compared with other regions (35 more minutes, p<0.001); and those receiving care at private facilities received more provider time compared with public facilities (13 more minutes, p=0.02); and those at level IV health centres received more time compared with those at level III (12 more minutes, p=0.01). Absent consumables, services for older adults (US$2.28 higher, p=0.02), those with comorbidities (US$1.44 higher, p<0.001) and those living in the Western region (US$2.88 higher, p<0.001) were more expensive compared with younger adults, those without comorbidities and those in other regions, respectively. Inclusive of consumables, services were higher-cost for individuals in wealthier households (US$0.83 higher, p=0.03) and those visiting level IV health centres (US$3.41 higher, p=0.006) compared with level III., Conclusions: Costs and resources for HIV care vary widely throughout Uganda. This variation requires careful consideration: some sources of variation may be indicative of vertical and horizontal equity within the health system, while others may be suggestive of inequities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Perinatal depression affects one-third of pregnant women living with HIV (WLH). We examined patterns of treatment response to a novel stepped model of depression care among WLH with perinatal depression in Uganda., Methods: As part of the Maternal Depression Treatment in HIV (M-DEPTH) cluster randomised controlled trial, 191 women were enrolled across four antenatal care clinics assigned to provide stepped care including behavioural and antidepressant therapy (ADT), and another 200 across four clinics assigned to provide usual care. They were assessed for depression severity using the Patient Health Questionnaire (PHQ-9) at enrolment and multiple times over 12 months of follow-up. We used repeated measures latent class analysis (LCA) to identify discrete trajectories of depression symptoms, while multinomial regression analyses measured correlates of class membership., Results: The LCA identified three trajectories among those in the treatment group: mildly depressed individuals who improved (MiD-I) (n = 143, 75%), moderately depressed individuals who improved (MoD-I) (n = 33, 17%), and moderately depressed individuals who remained depressed (MoD-R) (n = 15, 8%). Membership in MiD-I was associated with lower levels of intimate partner violence at baseline (P = 0.04) and month 6 (P < 0.001), and less recent trauma exposure (P = 0.03) at baseline. At month 6, social support was lowest in MoD-R, while the degree of negative problem-solving orientation was highest (both P < 0.001) in this class. The LCA also identified three trajectories among those in the usual care comparison group: mildly depressed (MiD) (n = 62, 31%), moderately depressed (MoD) (n = 71, 35%), and seriously depressed (SiD) (n = 67, 34%), with each experiencing slight improvement. Recent traumas at baseline were highest in SiD (P < 0.001); this group also reported the lowest positive problem-solving orientation and highest negative problem-solving orientation (P < 0.001) at baseline., Conclusions: Depression symptom trajectories among women with perinatal depression are related to modifiable factors such as problem-solving orientation and interpersonal dynamics, with the latter including intimate partner violence and social support. Most treatment recipients were characterised by trajectories indicating recovery from depression., Registration: ClinicalTrials.Gov (NCT03892915)., Competing Interests: Disclosure of interest: The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests., (Copyright © 2024 by the Journal of Global Health. All rights reserved.)

The 988 Suicide and Crisis Lifeline-known more simply as 988-holds promise for significantly improving the mental health of Americans and accelerating the decriminalization of mental illness. However, the rapid transition to 988 has left many gaps as communities scramble to prepare-not the least of which includes determining how 988 will interface with local 911 response systems and law enforcement. 911 is often the default option for individuals experiencing mental health emergencies, despite the fact that 911 call centers have limited resources to address behavioral health crises. Since 988 launched in 2022, one key area of focus has been ways that jurisdictions approach 988/911 interoperability: the existence of formal protocols, procedures, or agreements that allow for the transfer of calls from 988 to 911 and vice versa. This study presents case studies from three jurisdictions that have established models of 988/911 interoperability. It provides details related to interoperability in each model, including the role of each agency, points of interagency communication, and decision points that can affect the way a call flows through the local system. It also identifies facilitators, barriers, and equity-related considerations of each jurisdiction's approach, as well as lessons learned from implementation. This study should be of interest to jurisdictions that are looking to implement 988/911 interoperability, including those that are spearheading local initiatives and those that are responding to state-level legislation. Its findings are relevant to 988 call centers, public safety answering points, mobile crisis units, law enforcement, and local and state decisionmakers., (Copyright © 2024 RAND Corporation.)

Introduction: Non-communicable diseases (NCDs) constitute approximately 74% of global mortality, with 77% of these deaths occurring in low-income and middle-income countries. Tanzania exemplifies this situation, as the percentage of total disability-adjusted life years attributed to NCDs has doubled over the past 30 years, from 18% to 36%. To mitigate the escalating burden of severe NCDs, the Tanzanian government, in collaboration with local and international partners, seeks to extend the integrated package of essential interventions for severe NCDs (PEN-Plus) to district-level facilities, thereby improving accessibility. This study aims to estimate the cost of initiating PEN-Plus for rheumatic heart disease, sickle cell disease and type 1 diabetes at Kondoa district hospital in Tanzania., Methods and Analysis: We will employ time-driven activity-based costing (TDABC) to quantify the capacity cost rates (CCR), and capital and recurrent costs associated with the implementation of PEN-Plus. Data on resource consumption will be collected through direct observations and interviews with nurses, the medical officer in charge and the heads of laboratory and pharmacy units/departments. Data on contact times for targeted NCDs will be collected by observing a sample of patients as they move through the care delivery pathway. Data cleaning and analysis will be done using Microsoft Excel., Ethics and Dissemination: Ethical approval to conduct the study has been waived by the Norwegian Regional Ethics Committee and was granted by the Tanzanian National Health Research Ethics Committee NIMR/HQ/R.8a/Vol.IX/4475. A written informed consent will be provided to the study participants. This protocol has been disseminated in the Bergen Centre for Ethics and Priority Setting International Symposium, Norway and the 11th Muhimbili University of Health and Allied Sciences Scientific Conference, Tanzania in 2023. The findings will be published in peer-reviewed journals for use by the academic community, researchers and health practitioners., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Telehealth utilization for mental health care remains much higher than it was before the COVID-19 pandemic; however, availability may vary across facilities, geographic areas, and by patients' demographic characteristics and mental health conditions., Objective: To quantify availability, wait times, and service features of telehealth for major depressive disorder, general anxiety disorder, and schizophrenia throughout the US, as well as facility-, client-, and county-level characteristics associated with telehealth availability., Design, Settings, and Participants: Cross-sectional analysis of a secret shopper survey of mental health treatment facilities (MHTFs) throughout all US states except Hawaii from December 2022 and March 2023. A nationally representative sample of 1938 facilities were contacted; 1404 (72%) responded and were included. Data analysis was performed from March to July 2023., Exposure: Health facility, client, and county characteristics., Main Outcome and Measures: Clinic-reported availability of telehealth services, availability of telehealth services (behavioral treatment, medication management, and diagnostic services), and number of days until first telehealth appointment. Multivariable logistic and linear regression analyses were conducted to assess whether facility-, client-, and county-level characteristics were associated with each outcome., Results: Of the 1221 facilities (87%) accepting new patients, 980 (80%) reported offering telehealth. Of these, 97% (937 facilities) reported availability of counseling services; 77% (726 facilities), medication management; and 69% (626 facilities) diagnostic services. Telehealth availability did not differ by clinical condition. Private for-profit (adjusted odds ratio [aOR], 1.75; 95% CI, 1.05-2.92) and private not-for-profit (aOR, 2.20; 95% CI, 1.42-3.39) facilities were more likely to offer telehealth than public facilities. Facilities located in metropolitan counties (compared with nonmetropolitan counties) were more likely to offer medication management services (aOR, 1.83; 95% CI, 1.11-3.00) but were less likely to offer diagnostic services (aOR, 0.67; 95% CI, 0.47-0.95). Median (range) wait time for first telehealth appointment was 14 (4-75) days. No differences were observed in availability of an appointment based on the perceived race, ethnicity, or sex of the prospective patient., Conclusions and Relevance: The findings of this cross-sectional study indicate that there were no differences in the availability of mental telehealth services based on the prospective patient's clinical condition, perceived race or ethnicity, or sex; however, differences were found at the facility-, county-, and state-level. These findings suggest widespread disparities in who has access to which telehealth services throughout the US.

Introduction: This qualitative research study explored the perspectives of adolescents, 12 to 19-years-old, and caregivers of children under 12-years-old on the acceptibility of adverse childhood experiences (ACEs) screenings in five pediatric clinics., Method: A constructivist grounded theory approach was utilized. One-on-one semistructured phone interviews were conducted with 44 adolescents and 95 caregivers of children less than 12 years old. Interviews were analyzed using thematic analysis., Results: Most participants reported feeling comfortable discussing ACEs with their providers. Some reported that screening helped build trust. Others expressed privacy concerns and did not receive information about the reason for screening. Adolescent patients shared conflicting feelings-of both comfort and discomfort. Caregivers attending to multiple children, foster parents, and monolingual Spanish speakers disclosed unique challenges to ACEs screening. We found no evidence of lasting adverse effects., Discussion: Participants generally found ACEs screenings acceptable. Some adolescents identified benefits from the experience. However, clinics planning to adopt routine ACEs screening should ensure clear messaging on why screening is occurring, anticipate and address privacy concerns, and adopt workflows to discuss screening results., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Adverse childhood experiences (ACEs) can have harmful, long-term health effects. Although primary care providers (PCPs) could help mitigate these effects, no studies have reviewed the impacts of ACE training, screening, and response in primary care., Methods: This systematic review searched four electronic databases (PubMed, Web of Science, APA PsycInfo, CINAHL) for peer-reviewed articles on ACE training, screening, and/or response in primary care published between Jan 1, 1998, and May 31, 2023. Searches were limited to primary research articles in the primary care setting that reported provider-related outcomes (knowledge, confidence, screening behavior, clinical care) and/or patient-related outcomes (satisfaction, referral engagement, health outcomes). Summary data were extracted from published reports., Findings: Of 6532 records, 58 met inclusion criteria. Fifty-two reported provider-related outcomes; 21 reported patient-related outcomes. 50 included pediatric populations, 12 included adults. A majority discussed screening interventions (n = 40). Equal numbers (n = 25) discussed training and clinical response interventions. Strength of evidence (SOE) was generally low, especially for adult studies. This was due to reliance on observational evidence, small samples, and self-report measures for heterogeneous outcomes. Exceptions with moderate SOE included the effect of training interventions on provider confidence/self-efficacy and the effect of screening interventions on screening uptake and patient satisfaction., Interpretation: Primary care represents a potentially strategic setting for addressing ACEs, but evidence on patient- and provider-related outcomes remains scarce., Funding: The California Department of Health Care Services and the Office of the California Surgeon General., Competing Interests: RKM, NQ, DL, GMS, and NKE declare funding support from the California Department of Health Care Services over the prior 36 months, including since the initial planning of work. AS declares funding support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development over the prior 36 months. RG declares funding support from UCLA-UCSF ACEs Aware and Family Resilience Network (UCAAN) over the prior 36 months, including since the initial planning of work, as well as consulting fees from UCAAN. RG also declares consulting fees from the Center for Youth Welnness and payment for expert testimony from Eglet Adams and Nevada State ACEs and Toxic Stress Abatement Plan. RG also declares participation in three data safety monitoring/advisee boards: for Pathways to Resilience Expert Advisory Committee–Aurrera Health, Expert Review Panel, Safe Spaces: Foundations of Trauma-Informed Practice for Educational and Care Settings–Office of the California Surgeon General, and National Early Relational Health Network. RG declares roles as the co-founder of the National Committee on Asthma and Toxic Stress and board membership of the Board Member, California American Professional Society on the Abuse of Children, as well as stock options in Stronger Brains Inc. KK declares support from California Department of Health Care Services and UCAAN since the initial planning of the work, as well as grants/contracts and consulting fees through Aurrera Health Group, Hillcrest Advisory, and the Population Health Innovation Lab in the prior 36 months., (© 2023 RAND Corporation.)

Objective: To evaluate resource allocation and costs associated with delivery of human immunodeficiency virus (HIV) services in Uganda and the United Republic of Tanzania., Methods: We used time-driven activity-based costing to determine the resources consumed and costs of providing five HIV services in Uganda and the United Republic of Tanzania: antiretroviral therapy (ART); HIV testing and counselling; prevention of mother-to-child transmission; voluntary male medical circumcision; and pre-exposure prophylaxis., Findings: Country-based teams undertook time-driven activity-based costing with 1119 adults in Uganda and 886 adults in the United Republic of Tanzania. In Uganda, service delivery costs ranged from 8.18 United States dollars (US$) per visit for HIV testing and counselling to US$ 43.43 for ART (for clients in whom HIV was suppressed). In the United Republic of Tanzania, these costs ranged from US$ 3.67 per visit for HIV testing and counselling to US$ 28.00 for voluntary male medical circumcision. In both countries, consumables were the main cost driver, accounting for more than 60% of expenditure. Process maps showed that in both countries, registration, measurement of vital signs, consultation and medication dispensing were the steps that occurred most frequently for ART clients., Conclusion: Establishing a rigorous, longitudinal system for tracking investments in HIV services that includes thousands of clients and numerous facilities is achievable in different settings with a high HIV burden. Consistent engagement of implementation partners and standardized training and data collection instruments proved essential for the success of these exercises., ((c) 2023 The authors; licensee World Health Organization.)

Using time-driven activity-based costing (TDABC), we examined resource allocation and costs for HIV services throughout Tanzania at patient and facility levels. This national, cross-sectional analysis of 22 health facilities quantified costs and resources associated with 886 patients receiving care for five HIV services: antiretroviral therapy, prevention of mother-to-child transmission, HIV testing and counseling, voluntary medical male circumcision, and pre-exposure prophylaxis. We also documented total provider-patient interaction time, the cost of services with and without inclusion of consumables, and conducted fixed-effects multivariable regression analyses to examine patient- and facility-level correlates of costs and provider-patient time. Findings showed that resources and costs for HIV care varied significantly throughout Tanzania, including as a function of patient- and facility-level characteristics. While some variation may be preferable (e.g., needier patients received more resources), other areas suggested a lack of equity (e.g., wealthier patients received more provider time) and presented opportunities to optimize care delivery protocols., (© 2023. The Author(s).)

Purpose: To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care., Methods: We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals., Results: Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening., Conclusions: Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources., (© 2023 Annals of Family Medicine, Inc.)

Perinatal depression has been shown to impede adherence to antiretroviral therapy (ART) and the prevention of mother-to-child transmission (PMTCT) care continuum; therefore, treating perinatal depression may result in increased viral suppression and PMTCT adherence. We examined the effects of the M-DEPTH (Maternal Depression Treatment in HIV) depression care model (including antidepressants and individual Problem Solving Therapy) on depression, maternal viral suppression and adherence to PMTCT care processes in an ongoing cluster-randomized controlled trial of 391 HIV-infected pregnant women (200 usual care; 191 intervention) with at least mild depressive symptoms enrolled across 8 antenatal care clinics in Uganda. At baseline, 68.3% had clinical depression and 41.7% had detectable HIV viral load. Adjusted repeated-measures multivariable regression models found that the intervention group was nearly 80% less likely to be clinically depressed [Adjusted OR (95% CI) 0.22 (0.05, 0.89)] at the 2-month post-pregnancy assessment, compared to the control group. However, the intervention and control groups did not differ meaningfully on maternal viral suppression, ART adherence, and other PMTCT care processes and outcomes. In this sample of women who were mostly virally suppressed and ART adherent at baseline, the depression care model had a strong effect on depression alleviation, but no downstream effects on viral suppression or other PMTCT care processes.Trial Registration NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov)., (© 2023. The Author(s).)

Background and Objective: The Ministry of Health of Lesotho and Partners In Health piloted the Lesotho National Primary Health Care Reform (LPHCR) from July 2014 to June 2017 to improve quality and quantity of service delivery and enhance health system management. This initiative included improvement of routine health information systems (RHISs) to map disease burden and reinforce data utilisation for clinical quality improvement., Methods and Analysis: The WHO Data Quality Assurance framework's core indicators were used to compare the completeness of health data before versus after the LPHCR in 60 health centres and 6 hospitals across four districts. To examine change in data completeness, we conducted an interrupted time series analysis using multivariable logistic mixed-effects regression. Additionally, we conducted 25 key informant interviews with healthcare workers (HCWs) at the different levels of Lesotho's health system, following a purposive sampling approach. Interviews were analysed using deductive coding based on the Performance of Routine Information System Management framework, which inspected organisational, technical and behavioural factors influencing RHIS processes and outputs associated with the LPHCR., Results: In multivariable analyses, trends in monthly data completion rate were higher after versus before the LPHCR for: documenting first antenatal care visit (adjusted OR (AOR): 1.24, 95% CI: 1.14 to 1.36) and institutional delivery (AOR: 1.19, 95% CI: 1.07 to 1.32). When discussing processes, HCWs highlighted the value of establishing clear roles and responsibilities in reporting under a new organisational structure, improved community programmes among district health management teams, and enhanced data sharing and monitoring by districts., Conclusion: The Ministry of Health had a strong data completion rate pre-LPHCR, which was sustained throughout the LPHCR despite increased service utilisation. The data completion rate was optimised through improved behavioural, technical and organisational factors introduced as part of the LPHCR., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Psychiatric and substance use disorder (SUD) treatment beds are essential infrastructure for meeting the needs of individuals with behavioral health conditions. However, not all psychiatric and SUD beds are alike: They represent infrastructure within different types of facilities. For psychiatric beds, these vary from acute psychiatric hospitals to community residential facilities. For SUD treatment beds, these vary from facilities offering short-term withdrawal management services to others offering longer duration residential detoxification services. Different settings also serve clients with different needs. For example, some clients have high-acuity, short-term needs; others have longer-term needs and may return for care on multiple occasions. California's Merced, San Joaquin, and Stanislaus Counties, like other counties throughout the United States, have sought to assess shortages in psychiatric and SUD treatment beds. In this study, the authors estimated psychiatric bed and residential SUD treatment capacity, need, and shortages for adults and children and adolescents at various levels of care: acute, subacute, and community residential services for psychiatric treatment and SUD treatment service categories defined by American Society of Addiction Medicine clinical guidelines. Drawing from various data sets, literature review findings, and facility survey responses, the authors computed the number of beds required-at each level of care-for adults and children and adolescents and identified hard-to-place populations. The authors draw from these findings to offer Merced, San Joaquin, and Stanislaus Counties recommendations to help ensure all their residents, especially nonambulatory individuals, have access to the behavioral health care that they need., (Copyright © 2023 RAND Corporation.)

Discharging individuals from jails and prisons who may be poorly equipped for independent living-such as those with a history of chronic health conditions, including serious mental illness-is likely to reinforce a pattern of homelessness and recidivism. Permanent supportive housing (PSH)-which combines a long-term housing subsidy with supportive services-has been proposed as a mechanism to intervene directly on this relationship between housing and health. In Los Angeles County, jail has become a default housing and services provider to unhoused individuals with serious mental health issues. In 2017, the county initiated the Just in Reach Pay for Success (JIR PFS) project, which provided PSH as an alternative to jail for individuals with a history of homelessness and chronic behavioral or physical health conditions. The authors of this study assessed whether the project led to changes in use of several county services, including justice, health, and homeless services. The authors examined changes in county service use, before and after incarceration, by JIR PFS participants and a comparison control group and found that use of jail services was significantly reduced after JIR PFS PSH placement, while the use of mental health and other services increased. The researchers assess that the net cost of the program is highly uncertain but that it may pay for itself in terms of reducing the use of other county services and therefore provide a cost-neutral means of addressing homelessness among individuals with chronic health conditions involved with the justice system in Los Angeles County., (Copyright © 2023 RAND Corporation.)

988, a national mental health emergency hotline number, went live throughout the United States in July 2022. 988 connects callers to the 988 Crisis & Suicide Lifeline, previously known as the National Suicide Prevention Lifeline. The transition to the three-digit number aimed to respond to a growing national mental health crisis and to expand access to crisis care. We examined preparedness throughout the U.S. for the transition to 988. In February and March 2022, we administered a national survey of state, regional, and county behavioral health program directors. Respondents (n = 180) represented jurisdictional coverage of 120 million Americans. We found that communities throughout the U.S. appeared ill-prepared for rollout of 988. Fewer than half of respondents reported their jurisdictions were 'somewhat' or 'very' prepared for 988 in terms of financing (29%), staffing (41%), infrastructure (41%), or service coordination (47%). Counties with higher representation of Hispanic/Latinx individuals were less likely to report being prepared for 988 in terms of staffing (OR: 0.62, 95 %CI: 0.45, 0.86) and infrastructure (OR: 0.68, 95 %CI: 0.48, 0.98). In terms of existing services, sixty percent of respondents reported a shortage of crisis beds and fewer than half reported availability of short-term crisis stabilization programs in their jurisdictions. Our study highlights components of local, regional, and state behavioral health systems in the U.S. that require greater investments to support 988 and mental health crisis care., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 RAND Corporation.)

Pain conditions are the leading cause of disability among active-duty service members. Given the significant implications for force readiness and service member well-being, the Military Health System (MHS) has made it a strategic priority to provide service members with the highest-quality treatment for pain conditions. RAND researchers assessed MHS outpatient care for acute and chronic pain, including opioid prescribing. The assessment involved developing a set of 14 quality measures designed to assess aspects of outpatient care for pain, including care associated with dental and ambulatory procedures, acute low back pain, chronic pain, opioid prescribing, and medication treatment for opioid use disorder. This research offers the most comprehensive examination to date of the quality and safety of pain care in the MHS and its alignment with evidence-based clinical practice guidelines. It identifies several areas of strength in pain care delivery, along with some areas for improvement, and provides recommendations to support the MHS in continuing to improve pain care for service members., (Copyright © 2022 RAND Corporation.)

Homelessness, which refers to the lack of a fixed, regular, and adequate nighttime residence, is a pervasive public health issue. This article presents results from an implementation and outcome study of an ongoing permanent supportive housing (PSH) program-including service utilization and associated costs review-operated by a large not-for-profit Medicaid and Medicare managed care plan serving more than 1 million members in the Inland Empire area of Southern California. This PSH program combines a long-term housing subsidy with intensive case management services for adult plan members experiencing homelessness who have one or more chronic physical or behavioral health conditions and represent high utilizers of inpatient health care. The aim of this research was to determine whether programmatic costs incurred by the health plan supporting the PSH program were partially or fully offset by decreased costs attributable to health care utilization within the health system. The evaluation used a quasi-experimental research design with an observational control group. The authors differentiated the program's effect during the transitional period-that is, after program enrollment and prior to housing placement-from its effect during the period after members were housed. In addition, the authors present participant flow through the key program milestones (e.g., referral, enrollment, housing placement, program exit) and describe health care utilization and associated costs for members who exited the program. Finally, they report the PSH programmatic expenditures relative to the changes in health care costs to provide an overall picture of the intervention's benefits and costs to the health plan., (Copyright © 2022 RAND Corporation.)

Psychiatric beds are essential infrastructure for meeting the needs of individuals with mental health conditions. However, not all psychiatric beds are alike: They represent infrastructure within different types of facilities, ranging from acute psychiatric hospitals to community residential facilities. These facilities, in turn, serve clients with different needs: some who have high-acuity, short-term needs and others who have chronic, longer-term needs and may return multiple times for care. California, much like many parts of the United States, is confronting a shortage of psychiatric beds. In this article, the authors estimated California's psychiatric bed capacity, need, and shortages for adults at each of three levels of care: acute, subacute, and community residential care. They used multiple methods for assessing bed capacity and need in order to overcome limitations to any single method of estimating the potential psychiatric bed shortfall. The authors identified statewide shortfalls in beds at all levels of inpatient and residential care. They also documented regional differences in the shortfall and identified special populations that contributed to bottlenecks in the continuum of inpatient and residential care in the state., (Copyright © 2022 RAND Corporation.)

Objective: To estimate the number and geographic distribution of children and adolescents in the United States who reside in counties with neither child and adolescent psychiatrists nor sufficient Internet broadband to support telepsychiatry services., Method: This analysis combined data from the Health Resources and Services Administration's Area Health Resource Files on child psychiatrist workforce with Federal Communications Commission information on broadband coverage to generate a composite of in-person and digital access to child psychiatric services throughout the United States. Using multivariable fixed-effects Poisson regression analysis, we estimated the number of children and adolescents (aged 5-19 years) without access to psychiatric services and examined disparities across counties in the United States., Results: We estimate that 6,035,402 children and adolescents in the United States (approximately 10%) have inadequate in-person and digital availability of child psychiatric services within their counties. Although this was true for only 3% of children and adolescents in urban counties, this applied to more than half (51%) in rural counties (adjusted odds ratio [AOR] = 2.71; 95% CI = 1.94, 3.78; p < .001). Likewise, only 3% of children and adolescents in high-income counties had insufficient digital and physical access, compared to more than 4 in 10 children and adolescents (41%) in low-income counties (AOR = 0.43; 95% CI = 0.30-0.61; p < .001). Counties with a higher density of Black and Hispanic residents had greater likelihood of service availability (p < 0.001), potentially a function of living in metropolitan communities., Conclusion: Although telehealth holds promise for promoting access to child and adolescent psychiatric services, large disparities in overall access to services persists in rural and low-income communities., (Copyright © 2021 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Over 700,000 children throughout the U.S. have received insurance coverage through welcome mat effects of Medicaid expansion, including children with autism spectrum disorder (ASD). Utilizing health workforce data from the Health Resources and Services Administration, we examined workforce growth (2008-2017) among three types of health providers for children with ASD as a result of Medicaid expansion: child psychiatrists, board-certified behavioral analysts (BCBAs) and pediatricians. We found that state Medicaid expansion was associated with a 9% increase in BCBAs per 100,000 children one year after enactment, a 5% increase in child psychiatrists, and was not associated with growth in pediatricians. Results indicate the importance of new policies that directly address a shortage of providers for children with ASD., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Lay Abstract: There has been a rise in the observed prevalence of autism spectrum disorder among children. Existing studies show the share of counties with a treatment facility that offers care for children with autism spectrum disorder. However, no estimates exist of the share of US outpatient mental health treatment facilities that provide services for children with autism spectrum disorder. We identified key facility-level characteristics in offering mental health care for children with autism spectrum disorder. We used a telephone survey to contact almost all outpatient mental health treatment facilities in the contiguous United States. We asked the facilities if they provided mental health care for children with autism spectrum disorder. We took the results of this survey and estimated multivariable regressions to examine county- and facility-level predictors of offering services. We found that over half (50.3%) of the 6156 outpatient facilities reported offering care for children with autism spectrum disorder. Non-metro counties, counties with a lower percentage of non-White residents, counties with a higher percentage of uninsured residents, and counties with a higher poverty rate had fewer outpatient mental health treatment facilities providing care for children with autism spectrum disorder. Facilities accepting Medicaid as a form of payment, offering telehealth, and private for-profit facilities were more likely to provide services for children with autism spectrum disorder. Because only half of outpatient mental health treatment facilities offer care for children with autism spectrum disorder, public health officials and policymakers should do more to ensure that this vulnerable population has access to mental health services.

Background: Malawi is a low-income country in sub-Saharan Africa that has limited resources to address a significant burden of disease-including HIV/AIDS. Additionally, depression is a leading cause of disability in the country but largely remains undiagnosed and untreated. The lack of cost-effective, scalable solutions is a fundamental barrier to expanding depression treatment. Against this backdrop, one major success has been the scale-up of a network of more than 700 HIV clinics, with over half a million patients enrolled in antiretroviral therapy (ART). As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes., Methods: We will evaluate a stepped model of depression care that combines group-based Problem Management Plus (group PM+) with antidepressant therapy (ADT) for 420 adults with moderate/severe depression in Neno District, Malawi, as measured by the Patient Health Questionnaire-9 (PHQ-9) and Mini-International Neuropsychiatric Interview (MINI). Roll-out will follow a stepped-wedge cluster randomized design in which 14 health facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g., HIV: viral load, ART adherence; diabetes: A1C levels, treatment adherence; hypertension: systolic blood pressure, treatment adherence) will be measured every 3 months through 12-month follow-up. We will also evaluate the model's cost-effectiveness, quantified as an incremental cost-effectiveness ratio (ICER) compared to baseline chronic care services in the absence of the intervention model., Discussion: This study will conduct a stepped-wedge cluster randomized trial to compare the effects of an evidence-based depression care model versus usual care on depression symptom remediation as well as physical health outcomes for chronic care conditions. If determined to be cost-effective, this study will provide a model for integrating depression care into HIV clinics in additional districts of Malawi and other low-resource settings with high HIV prevalence., Trial Registration: ClinicalTrials.gov NCT04777006 . Registered on 1 March, 2021., (© 2021. The Author(s).)

Lay Abstract: To improve access to health services for children with autism spectrum disorder, US states have passed laws requiring health insurers to cover autism-related care, commonly known as state insurance mandates. However, the features of mandates differ across states, with some state laws containing very generous provisions and others containing very restrictive provisions such as whether the mandates include children aged above 12 years, whether there is a limit on spending, and whether there are restrictions on the types of services covered. This study examined the relationship between generosity of mandates and growth in the health workforce between 2003 and 2017, a period during which 44 states passed mandates. We found that states that enacted more generous mandates experienced significantly more growth in board-certified behavioral analysts who provide behavioral therapy as well as more growth in child psychiatrists. We did not find differences in the growth of pediatricians, which is a less specialized segment of the workforce. Our findings were consistent across eight different mandate features and suggest that the content of legislation may be as important as whether or not legislation has been passed in terms of encouraging growth in the supply of services for children with autism spectrum disorder.

Background: Since coronavirus disease 2019 (COVID-19) has caused dramatic changes in everyday life, a major concern is whether patients have adequate access to mental health care despite shelter-in-place ordinances, school closures, and social distancing practices., Objectives: The aim was to examine the availability of telehealth services at outpatient mental health treatment facilities in the United States at the outset of the COVID-19 pandemic, and to identify facility-level characteristics and state-level policies associated with the availability., Research Design: Observational cross-sectional study., Subjects: All outpatient mental health treatment facilities (N=8860) listed in the Behavioral Health Treatment Services Locator of the Substance Abuse and Mental Health Services Administration on April 16, 2020., Measures: Primary outcome is whether an outpatient mental health treatment facility reported offering telehealth services., Results: Approximately 43% of outpatient mental health facilities in the United States reported telehealth availability at the outset of the pandemic. Facilities located in the United States South and nonmetropolitan counties were more likely to offer services, as were facilities with public sector ownership, those providing care for both children and adults, and those accepting Medicaid as a form of payment. Outpatient mental health treatment facilities located in states with state-wide shelter-in-place laws were less likely to offer telehealth, as well as facilities in counties with more COVID-19 cases per 10,000 population., Conclusions: At the onset of the COVID-19 pandemic, fewer than half of outpatient mental health treatment facilities were providing telehealth services. Our results suggest that additional policies to promote telehealth may be warranted to increase availability over the course of the COVID-19 pandemic., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Through the Comprehensive Primary Care (CPC) and Comprehensive Primary Care Plus (CPC+) programs, the Centers for Medicare & Medicaid Services (CMS) has encouraged primary care practices to invest in "comprehensive primary care" capabilities. Empirical evidence suggests these capabilities are under-reimbursed or not reimbursed under prevailing fee-for-service payment models. To help CMS design alternative payment models (APMs) that reimburse the costs of these capabilities, the authors developed a method for estimating related practice expenses. Fifty practices, sampled for diversity across CPC+ participation status, geographic region, rural status, size, and parent-organization affiliation, completed the study. Researchers developed a mixed-methods strategy, beginning with interviews of practice leaders to identify their capabilities and the types of costs incurred. This was followed by researcher-assisted completion of a workbook tailored to each practice, which gathered related labor and nonlabor costs. In a final interview, practice leaders reviewed cost estimates and made any needed corrections before approval. A main goal was to address a persistent question faced by CMS: When practices reported widely divergent costs for a given capability, was that divergence due to practices having different prices for the same capability or from their having substantially different capabilities? The cost estimation method developed in this project collected detailed data on practice capabilities and their costs. However, the small sample did not allow quantitative estimation of the contributions of service level and pricing to the variation in overall costs. This cost estimation method, deployed on a larger scale, could generate robust data to inform new payment models aimed at incentivizing and sustaining comprehensive primary care., (Copyright © 2020 RAND Corporation.)

Objective: A diversity of health professional disciplines provide services for children with autism spectrum disorder (ASD) in the United States. We conducted a systematic review examining the availability, distribution, and competencies of the US workforce for autism-related child health care services, and assess studies' strength of evidence., Method: We searched PubMed, PsychINFO, Embase, and Google Scholar from 2008 to 2018 for relevant US-based studies. Two investigators independently screened and evaluated studies against a set of prespecified inclusion criteria and evaluated strength of evidence (SOE) using a framework designed to integrate a mixed-methods research., Results: Of 754 records identified, 33 studies (24 quantitative, 6 qualitative, and 3 mixed-methods) were included. Strength of evidence associated was low-to-moderate, with only 8 studies (24%) satisfying criteria for strong SOE. Geographies and provider cadres varied considerably. The most common specialties studied were pediatricians (n = 13), occupational therapists (n = 12), speech therapists (n = 11), physical therapists (n = 10), and child psychiatrists (n = 8). Topical areas included the following: provider availability by service area and care delivery model; qualitative assessments of provider availability and competency; role of insurance mandates in increasing access to providers: and disparities in access. Across provider categories, we found that workforce availability for autism-related services was limited in terms of overall numbers, time available, and knowledgeability. The greatest unmet need was observed among minorities and in rural settings. Most studies were short term, were limited in scope, and used convenience samples., Conclusion: There is limited evidence to characterize the availability and distribution of the US workforce for autism-related child health care services. Existing evidence to date indicates significantly restricted availability., (Copyright © 2019 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Non-communicable diseases (NCDs) account for the five largest contributors to burden of disease in Mexico, with diabetes representing the greatest contributor. However, evidence supporting chronic disease programmes in Mexico is limited, especially in rural communities. Compañeros En Salud (CES) partnered with the Secretariat of Health of Chiapas, Mexico to implement a novel community-based NCD treatment programme. We describe the implementation of this programme and conducted a population-based, retrospective analysis, using a difference-in-differences regression approach to estimate the impact of the programme. Specifically, we examined changes in diabetes and hypertension control rates between 2014 and 2016, comparing CES intervention clinics (n = 9) to care-as-usual at non-CES clinics (n = 806), adjusting for differences in facility-level characteristics. In 2014, the percent of diabetes patients with this condition under control was 36.9% at non-CES facilities, compared with 41.3% at CES facilities (P > 0.05). For hypertension patients, these figures were 45.2% at non-CES facilities compared with 56.2% at CES facilities (P = 0.02). From 2014 to 2016, the percent of patients with diabetes under control declined by 9.2% at non-CES facilities, while improving by 11.3% at non-CES facilities where the Compañeros En Salud Programa de Enfermedades Crónicas intervention was implemented (P < 0.001). Among hypertension patients, those with the condition under control increased by 21.5% at non-CES facilities between 2014 and 2016, compared with 16.2% at CES facilities (P > 0.05). Introduction of the CES model of NCD care was associated with significantly greater improvements in diabetes management between 2014 and 2016, compared with care-as-usual. Hypertension control measures were already greater at CES facilities in 2014, a difference that was maintained through 2016. These findings highlight the successful implementation of a framework for providing NCD care in rural Mexico, where a rapidly increasing NCD disease burden exists.