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BackgroundAdverse 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.MethodsThis 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.FindingsOf 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.InterpretationPrimary care represents a potentially strategic setting for addressing ACEs, but evidence on patient- and provider-related outcomes remains scarce.FundingThe California Department of Health Care Services and the Office of the California Surgeon General.

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.

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. Objectif Analyser l'allocation des ressources et les couts lies a la fourniture de services de prise en charge du virus de l'immunodeficience humaine (VIH) en Ouganda et en Republique-Unie de Tanzanie. Methodes Nous avons utilise un systeme de calcul des couts par activite pilote par le temps (TDABC), pour identifier les ressources consommees et les couts engendres par cinq services de prise en charge du VIH en Ouganda et en Republique-Unie de Tanzanie: le traitement antiretroviral (TAR); le depistage du VIH et les conseils en la matiere; la prevention de la transmission de la mere a l'enfant; la pratique volontaire de la circoncision masculine medicalisee; et enfin, la prophylaxie preexposition. Resultats Des equipes deployees dans chaque pays ont mene un calcul des couts par activite pilote par le temps aupres de 1119 adultes en Ouganda et 886 adultes en Republique-Unie de Tanzanie. En Ouganda, les couts de prestation des services etaient compris entre 8,18 dollars americains (USD) par visite de depistage du VIH et de conseils en la matiere, et 43,43 USD pour un TAR (sur les patients chez qui la charge virale a ete supprimee). En Republique-Unie de Tanzanie, ces couts variaient entre 3,67 USD par visite de depistage du VIH et de conseils en la matiere a 28,00 USD pour la pratique volontaire de la circoncision masculine medicalisee. Dans les deux pays, les consommables representaient le principal facteur de cout, avec plus de 60% des depenses. Les schemas de procedure ont montre que, dans les deux pays, l'enregistrement, la mesure des signes vitaux, la consultation et l'administration du traitement constituaient les etapes les plus frequentes chez les patients faisant l'objet d'un TAR. Conclusion Il est possible d'etablir un dispositif longitudinal rigoureux pour suivre les investissements realises dans les services de prise en charge du VIH, qui inclut des milliers de patients et de nombreux etablissements dans differents endroits fortement touches par le VIH. Limplication constante des partenaires de mise en oeuvre et la standardisation des formations et instruments de collecte des donnees se sont revelees essentielles a la reussite de ces demarches. Objetivo Analizar la asignacion de recursos y los costes asociados a la prestacion de servicios por el virus de la inmunodeficiencia humana (VIH) en Uganda y en la Republica Unida de Tanzania. Metodos Utilizamos los costes basados en el tiempo invertido por actividad, con el fin de determinar los recursos consumidos y los costes de la prestacion de cinco servicios por VIH en Uganda y en la Republica Unida de Tanzania: terapia antirretroviral (TAR); pruebas y asesoramiento sobre el VIH; prevencion de la transmision de madre a hijo; circuncision medica masculina de caracter voluntario y profilaxis previa a la exposicion. Resultados Los equipos fundados en el pais se encargaron de analizar los costes basados en el tiempo invertido por actividad con 1119 adultos en Uganda y 886 adultos en la Republica Unida de Tanzania. En Uganda, los costes por la prestacion de servicios oscilaron entre 8,18 dolares estadounidenses (USD) por visita destinada a pruebas y asesoramiento sobre VIH, y 43,43 USD por TAR (para clientes en los que se habia erradicado el VIH). En la Republica Unida de Tanzania, estos costes estuvieron comprendidos entre 3,67 USD por visita destinada a pruebas y asesoramiento sobre VIH, y 28,00 USD por circuncision medica masculina de caracter voluntario. En ambos paises, los consumibles fueron los principales generadores de costes, representando mas del 60% del gasto. Los mapas de procesos mostraron que en ambos paises el registro, la medicion de las constantes vitales, asi como las consultas y la dispensacion de medicacion fueron los pasos que mas se repitieron entre los clientes con TAR. Conclusion Implantar un sistema riguroso y longitudinal para realizar un seguimiento de las inversiones en servicios por VIH, lo que engloba a miles de clientes y numerosas instalaciones, es algo que se puede lograr en aquellos centros con una elevada incidencia de VIH. Quedo demostrado que el compromiso constante de los socios encargados de la implementacion, asi como la existencia de instrumentos estandarizados de formacion y de recopilacion de datos resultaban esenciales para el exito de estos ejercicios., Introduction Despite evolving epidemiological trends, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are still responsible for one of the largest disease burdens in sub-Saharan Africa. (1) In low-income [...]

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.

Despite a rise in the observed prevalence of autism spectrum disorder among children, few 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- and county-level characteristics in offering mental health care for children with autism spectrum disorder. This study utilized a secret shopper telephone survey to contact almost all outpatient mental health treatment facilities in the contiguous United States. We estimated multivariable regressions to examine county- and facility-level predictors of offering services for children with autism spectrum disorder. We found that 50.3% of 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. Only half of outpatient mental health treatment facilities offered care for children with autism spectrum disorder, and both rural and lower socioeconomic status counties were less likely to have a facility offering care for children with autism spectrum disorder.

All 50 US states have enacted mandates requiring insurers to cover autism-related services. We assessed whether and to what extent variation in generosity of state insurance mandates has been associated with rate of growth in the health workforce for children with autism spectrum disorder: including board-certified behavioral analysts, child psychiatrists, and pediatricians. Drawing data from the National Conference of State Legislatures and Area Health Resource Files, we evaluated eight mandate policy features, utilizing a fixed-effect longitudinal regression framework to examine their relationships with workforce growth during a 15-year period (2003-2017) over which 44 states enacted a mandate. Aspects of mandate generosity included ages covered, spending caps, and types of services covered. We found that mandate generosity was closely associated with the magnitude of increase in supply of board-certified behavioral analysts and--to a lesser extent--child psychiatrists. States with the most generous mandates would be expected to have 39% more board-certified behavioral analysts and 17% more child psychiatrists in 2017, compared to states with least generous mandates. We found no association between mandate generosity and supply of pediatricians. Collectively, our results suggest that the degree of generosity afforded by mandates may be as important as the passage of mandate legislation itself for encouraging workforce growth.

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]

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]

In early 2020, several global health institutions --including the Global Fund to Fight AIDS, Tuberculosis and Malaria, Joint United Nations Programme on HIV/AIDS (UNAIDS), United States Agency for International Development [...]

Objective To evaluate the implementation of a time-driven activity-based costing analysis at five community health facilities in Haiti. Methods Together with stakeholders, the project team decided that health-care providers should enter start and end times of the patient encounter in every fifth patient's medical dossier. We trained one data collector per facility, who manually entered the time recordings and patient characteristics in a database and submitted the data to a cloud-based data warehouse each week. We calculated the capacity cost per minute for each resource used. An automated web-based platform multiplied reported time with capacity cost rate and provided the information to health-facilities administrators. Findings Between March 2014 and June 2015, the project tracked the clinical services for 7162 outpatients. The cost of care for specific conditions varied widely across the five facilities, due to heterogeneity in staffing and resources. For example, the average cost of a first antenatal-care visit ranged from 6.87 United States dollars (US$) at a low-level facility to US$ 25.06 at a high-level facility. Within facilities, we observed similarly variation in costs, due to factors such as patient comorbidities, patient arrival time, stocking of supplies at facilities and type of visit. Conclusion Time-driven activity-based costing can be implemented in low-resource settings to guide resource allocation decisions. However, the extent to which this information will drive observable changes at patient, provider and institutional levels depends on several contextual factors, including budget constraints, management, policies and the political economy in which the health system is situated. Objectif Evaluer la realisation d'une analyse des couts par prestation et par duree dans cinq etablissements de soins communautaires en Haiti. Methodes En collaboration avec les parties prenantes, l'equipe du projet a decide que les prestataires de soins devraient indiquer I'heure de debut et de fin de la consultation dans le dossier medical d'un patient sur cinq. Nous avons forme un responsable du recueil des donnees par etablissement, qui a saisi manuellement les horaires ainsi que les caracteristiques des patients dans une base de donnees et a enregistre ces dernieres dans un entrepot de donnees en ligne chaque semaine. Nous avons calcule les couts de capacite par minute pour chaque ressource utilisee. Les durees indiquees ont ete multipliees par le cout de capacite unitaire a l'aide d'une plate-forme virtuelle automatisee, par laquelle ces informations ont ete transmises aux administrateurs des etablissements de soins. Resultats Entre mars 2014 et juin 2015, le projet a suivi les services cliniques dispenses a 7162 patients externes. Le cout des soins prodigues pour differentes affections etait tres variable entre les cinq etablissements, en raison de l'heterogeneite du personnel et des ressources. Par exemple, le cout moyen d'une premiere consultation prenatale allait de 6,87 dollars des Etats-Unis ($ US) dans un etablissement de premier nlveau a 25,06 $ US dans un etablissement de haut niveau. Au sein des etablissements, nous avons egalement observe des variations de couts, qui etaient dues a des facteurs tels que les comorbidites des patients, le moment d'arrivee des patients, les stocks de fournitures dans les etablissements et le type de consultation. Conclusion Il est possible de determiner les couts par prestation et par duree dans les structures a faibles ressources afin d'orienter les decisions concernant l'affectation des ressources. Cependant, la mesure dans laquelle ces Informations vont entrainer des changements observables au niveau des patients, des prestataires et des institutions depend de plusieurs facteurs contextueis, notamment des contraintes budgetalres, de la gestion, des politiques et de l'economie politique dans laquelle se trouve le systeme de sante. Objetivo Evaluar la implementacion de un analisis de gastos basado en el tiempo invertido por actividad en cinco centros sanitarios comunitarios en Haiti. Metodos Junto a las partes interesadas, el equipo del proyecto decidio que los profesionales sanitarios debian introducir los horarios del comienzo y el final de la consulta con el paciente en el dossier medico de uno de cada cinco pacientes. Formamos a un recopilador de datos por cada centro, que introdujo manualmente los registros de tiempo y las caracteristicas de los pacientes en una base de datos, los cuales enviaba a un almacen de datos en la nube cada semana. Calculamos el coste de capacidad por minuto para cada recurso utilizado. Una plataforma automatizada en linea multiplico el tiempo registrado por la tasa del coste de capacidad y proporciono la informacion a los administradores de los centros sanitarios. Resultados Entre marzo de 2014 y junio de 2015, el proyecto registro los servicios clinicos a 7162 pacientes. El coste de la atencion para condiciones especificas variaba considerablemente entre los cinco centros, debido a la heterogeneidad del personal y de los recursos. Por ejemplo, el coste medio de una primera consulta de atencion prenatal variaba de 6,87 USD en un centro de bajo nivel a 25,06 USD en un centro de alto nivel. En los centros, observamos una variacion similar en los costes, debido a factores como las comorbilidades de los pacientes, el tiempo de llegada del paciente, el almacenamiento de suministros en los centros y el tipo de consulta. Conclusion Los gastos basados en el tiempo invertido por actividad se pueden implementar en entornos con pocos recursos para orientar la toma de decisiones sobre asignacion de recursos. Sin embargo, la medida en que esta informacion generara cambios notables a nivel de los pacientes, profesionales e instituciones depende de varios factores contextuales, incluidas las limitaciones presupuestarias, la gestion, las politicas y la economia politica en que se encuentra el sistema de salud., Introduction Understanding the cost of health-care delivery is essential for guiding resource allocation decisions that have direct implications for patient care and health outcomes. (1) Optimizing resources available for patients [...]