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BACKGROUND: Inadequate and inequitable access to quality behavioral health services and high costs within the mental health systems are long-standing problems. System-level (e.g., fee-for-service payment model, lack of a universal payor) and individual factors (e.g., lack of knowledge of existing resources) contribute to difficulties in accessing resources and services. Patients are underserved in County behavioral health systems in the United States. Orange Countys (California) Behavioral Health System Transformation project sought to improve access by addressing two parts of their system: developing a template for value-based contracts that promote payor-agnostic care (Part 1); developing a digital platform to support resource navigation (Part 2). Our aim was to evaluate facilitators of and barriers to each of these system changes. METHODS: We collected interview data from County or health care agency leaders, contracted partners, and community stakeholders. Themes were informed by the Consolidated Framework for Implementation Research. RESULTS: Five themes were identified related to behavioral health system transformation, including 1) aligning goals and values, 2) addressing fit, 3) fostering engagement and partnership, 4) being aware of implementation contexts, and 5) promoting communication. A lack of fit into incentive structures and changing state guidelines and priorities were barriers to contract development. Involving diverse communities to inform design and content facilitated the process of developing digital tools. CONCLUSIONS: The study highlights the multifaceted factors that help facilitate or hinder behavioral health system transformation, such as the need for addressing systematic and process behaviors, leveraging the knowledge of leadership and community stakeholders, fostering collaboration, and adapting to implementation contexts.

In the spring of 2020, schools of all sectors across all nations were forced to close their doors as COVID-19 rippled through communities. Drawing upon the concept of liminality, which refers to a stage, state, or period of transition (Soderlund & Borg, 2017), this study investigated the intersections of the experience of liminality during the pandemic and functioning for Catholic school leaders. Interviews with urban school leaders were analyzed to understand key characteristics of liminality as experienced by school leaders within organizations. Findings indicate that school leaders responded to the liminal experience by sharpening the focus of work, which simultaneously complexified the traditional roles of individual and organization. These findings have significant potential in illuminating a path forward during liminal times for educators of all sectors. This paper provides an opportunity to interpret the impact of the pandemic across all sectors of education, with a primary analysis on Catholic schools.

Peer support specialists (peers) who have the lived experience of, and are in recovery from, mental health challenges are increasingly being integrated into mental health care as a reimbursable service across the US. This study describes the ways peers were integrated into Help@Hand, a multi-site innovation project that engaged peers throughout efforts to develop and offer digital mental health interventions across counties/cities (sites) in California. Using a mixed methods design, we collected quantitative data via quarterly online surveys, and qualitative data via semi-annual semi-structured phone interviews with key informants from Help@Hand sites. Quantitative data were summarized as descriptive findings and qualitative data from interviews were analyzed using rapid qualitative analysis methods. In the final analytic phase, interview quotes were used to illustrate the complex realities underlying quantitative responses. 117 quarterly surveys and 46 semi-annual interviews were completed by key informants from 14 sites between September 2020 and January 2023. Peers were integrated across diverse activities for support and implementation of digital mental health interventions, including development of training and educational materials (78.6% of sites), community outreach (64.3%), technology testing (85.7%), technology piloting (90.9%), digital literacy training (71.4%), device distribution (63.6%), technical assistance (72.7%), and cross-site collaboration (66.7%). Peer-engaged activities shifted over time, reflecting project phases. Peer-provided digital literacy training and technology-related support were key ingredients for project implementations. This study indicates the wide range of ways peers can be integrated into digital mental health intervention implementations. Considering contextual readiness for peer integration may enhance their engagement into programmatic activities.

BACKGROUND: People with disabilities face many health, economic and social disparities. Loneliness is recognized as a significant issue for this group however, its impact on students with disabilities (SWDs) remains a critically underexplored area of research. Importantly, as higher education continues its transition to the digital space, the potential to entrench social isolation and loneliness within this population has not been examined. This research seeks to explore the associations between SWDs, loneliness, online learning, and academic outcomes in a national survey of university students. METHODS: Using the National College Health Assessment from Spring 2022, this study compared multiple outcomes between different groups of SWDs and students without disabilities. Two ordinal regression models were used to estimate associations between loneliness, disability type and learning mode (online vs. in-person), as well as cumulative grade average (CGA) with disability type. RESULTS: All disability types included within this study were positively associated with increased odds of loneliness for those engaged in online learning compared to students without disabilities. Interactions indicate a significant effect of in-person learning compared with online learning for deaf or hard of hearing students, and those with multiple disabilities. Several disability groups reported decreased odds of higher CGA compared to students without disabilities. CONCLUSION: Loneliness is a significant issue for all SWD groups reported in this study. The impact of disability on academic outcomes is reported herein; however, its impact on medium-to-long term outcomes for these individuals remains unknown. To address inequities in higher education for SWDs, universities must invest more resources to holistically support these students.

BACKGROUND: Technology-enabled services (TESs) have the potential to increase access to mental healthcare. However, little research has focused on how TESs can be integrated into publicly funded service settings. As part of the state-wide Help@Hand project, Marin County conducted a pilot implementation of myStrength, a digital cognitive behavioral therapy platform, to explore its potential to reduce loneliness among isolated older adults. We evaluated the pilot impact using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. METHOD: A single-site 6-month pilot implementation recruited English (n = 15) and Spanish-speaking (n = 15) isolated older adults who received a digital literacy course followed by 8 weeks of myStrength access and human support. We evaluated factors related to reach, effectiveness, adoption, and implementation using the perspectives of users and County staff. Descriptive statistics were used to examine reach, adoption, and implementation. Nonparametric tests, including Friedman and Wilcoxon signed-rank, were used to examine effectiveness. RESULTS: Reach: Compared to overall county demographics, platform users were majority female (93.1% vs. 50.5%), ethnoracialized (62.1% vs. 24.2%), and of lower socioeconomic status (Mdn = $35,000 vs. $131,008). Effectiveness: Users reported a significant (z = -2.62, p

With funding from the National Institutes of Health's Community Engagement Alliance, starting in fall 2020, 11 academic medical centers and 75 community partners came together as the California Alliance Against COVID-19 to address COVID-19 inequities in California. Using data from focus groups, statewide meetings, and a statewide partner survey, we describe how promotoras and community health workers (P/CHWs; n = 540) helped to promote access to COVID-19 information, testing, and vaccination. We highlight opportunities to promote health equity among other public health collaborators with a P/CHW model. (Am J Public Health. 2024;114(S1):S45-S49. https://doi.org/10.2105/AJPH.2023.307471).

Abstract Introduction The study aimed to compare postoperative pain between alcohol-assisted and transepithelial photorefractive keratectomy in patients who received the novel analgesic preoperative nepafenac treatment 2 days preoperatively and 3 days postoperatively. Pain, stinging, tearing, light sensitivity, and stress levels were evaluated. Methods The study included a retrospective analysis of 55 patients divided into two groups: bilateral alcohol-assisted photorefractive keratectomy (aa-PRK) and transepithelial photorefractive keratectomy (transepithelial-PRK). Nepafenac was administered for pain control for all patients, with patients receiving four drops for 2 days before the surgery and 3 days postoperatively per clinical instructions. Patients completed questionnaires on the day of the surgery and for the first 5 days postoperatively. Statistical analysis was performed using XLSTAT (version 2023.1.2). t-Test was used to analyze and compare pain and symptom levels and Fisher’s exact test for categorical data. p-Values less than 0.05 were considered statistically significant. Results The study examined 55 patients (49% female) with a mean age of 25.11 ± 6.81 years who had undergone bilateral surface refractive surgery to correct myopic errors. The mean baseline standard error (SE) was −3.16 ± 2.20 D. Among these patients, 27 patients underwent aa-PRK and 28 patients underwent transepithelial-PRK. Higher levels of pain were significant in the aa-PRK group (p = 0.003). However, there was no significant difference between the groups in the average levels of stinging, tearing, or light sensation. Additionally, stress levels decreased over time in both groups, with levels becoming almost equal after 5 days, and there was no significant difference in the average stress levels between the two groups. Conclusions The study found that patients who underwent the transepithelial-PRK procedure had significantly lower pain levels compared with those who underwent aa-PRK after being treated with nepafenac per protocol. However, there was no significant difference between the two groups in terms of stinging, tearing, light sensation, and stress levels.

BACKGROUND: Diabetes-related multi-morbidity and cultural factors place Latinas with diabetes at increased risk for stress, which can threaten illness management. Families provide an ideal focus for interventions that seek to strengthen interpersonal resources for illness management and, in the process, to reduce stress. The current study sought to examine whether participating in a dyadic intervention was associated with reduced perceived stress and, furthermore, whether this association was mediated by persuasion and pressure, two forms of health-related social control. METHOD: Latina mothers with diabetes and their at-risk adult daughters participated in either (1) a dyadic intervention that encouraged constructive collaboration to improve health behaviors and reduce stress, or (2) a usual-care minimal control condition. Actor-partner interdependence model analysis was used to estimate the effect of the intervention on dyads perceived stress, and mother-daughter ratings of health-related social control as potential mediators. RESULTS: Results revealed that participating in the intervention was associated with significantly reduced perceived stress for daughters, but not for mothers (β =  - 3.00, p = 0.02; β =  - 0.57, p = 0.67, respectively). Analyses also indicated that the association between the intervention and perceived stress was mediated by persuasion, such that mothers who experienced more health-related persuasion exhibited significantly less post-intervention perceived stress (indirect effect =  - 1.52, 95% CI = [- 3.12, - 0.39]). Pressure exerted by others, however, did not evidence a mediating mechanism for either mothers or daughters. CONCLUSION: These findings buttress existing research suggesting that persuasion, or others attempts to increase participants healthy behaviors in an uncritical way, may be a driving force in reducing perceived stress levels.

Single-cell technologies have become essential to driving discovery in both basic and translational investigative dermatology. Despite the multitude of available datasets, a central reference atlas of normal human skin, which can serve as a reference resource for skin cell types, cell states, and their molecular signatures, is still lacking. For any such atlas to receive broad acceptance, participation by many investigators during atlas construction is an essential prerequisite. As part of the Human Cell Atlas project, we have assembled a Skin Biological Network to build a consensus Human Skin Cell Atlas and outline a roadmap toward that goal. We define the drivers of skin diversity to be considered when selecting sequencing datasets for the atlas and list practical hurdles during skin sampling that can result in data gaps and impede comprehensive representation and technical considerations for tissue processing and computational analysis, the accounting for which should minimize biases in cell type enrichments and exclusions and decrease batch effects. By outlining our goals for Atlas 1.0, we discuss how it will uncover new aspects of skin biology.

Abstract. Objectives:. To develop and validate a prediction model for a deep surgical site infection (SSI) after fixation of a tibial plateau or pilon fracture. Design:. Pooled data from 2 randomized trials (VANCO and OXYGEN). Setting:. Fifty-two US trauma centers. Patients:. In total, 1847 adult patients with operatively treated tibial plateau or pilon fractures who met criteria for a high risk of infection. Intervention:. We considered 13 baseline patient characteristics and developed and externally validated prediction models using 3 approaches (logistic regression, stepwise elimination, and machine learning). Main Outcomes and Measures:. The primary prediction model outcome was a deep SSI requiring operative debridement within 182 days of definitive fixation. Our primary prognostic performance metric for evaluating the models was area under the receiver operating characteristic curve (AUC) with clinical utility set at 0.7. Results:. Deep SSI occurred in 75 VANCO patients (8%) and in 56 OXYGEN patients (6%). The machine learning model for VANCO (AUC = 0.65) and stepwise elimination model for OXYGEN (AUC = 0.62) had the highest internal validation AUCs. However, none of the external validation AUCs exceeded 0.64 (range, 0.58 to 0.64). Conclusions:. The predictive models did not reach the prespecified clinical utility threshold. Our models' inability to distinguish high-risk from low-risk patients is likely due to strict eligibility criteria and, therefore, homogeneous patient populations.

Background Technology-enabled services (TESs) have the potential to increase access to mental healthcare. However, little research has focused on how TESs can be integrated into publicly funded service settings. As part of the state-wide Help@Hand project, Marin County conducted a pilot implementation of myStrength, a digital cognitive behavioral therapy platform, to explore its potential to reduce loneliness among isolated older adults. We evaluated the pilot impact using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Method A single-site 6-month pilot implementation recruited English ( n = 15) and Spanish-speaking ( n = 15) isolated older adults who received a digital literacy course followed by 8 weeks of myStrength access and human support. We evaluated factors related to reach, effectiveness, adoption, and implementation using the perspectives of users and County staff. Descriptive statistics were used to examine reach, adoption, and implementation. Nonparametric tests, including Friedman and Wilcoxon signed-rank, were used to examine effectiveness. Results Reach: Compared to overall county demographics, platform users were majority female (93.1% vs. 50.5%), ethnoracialized (62.1% vs. 24.2%), and of lower socioeconomic status ( Mdn = $35,000 vs. $131,008). Effectiveness: Users reported a significant ( z = −2.62, p

BackgroundPeople with disabilities face many health, economic and social disparities. Loneliness is recognized as a significant issue for this group however, its impact on students with disabilities (SWDs) remains a critically underexplored area of research. Importantly, as higher education continues its transition to the digital space, the potential to entrench social isolation and loneliness within this population has not been examined. This research seeks to explore the associations between SWDs, loneliness, online learning, and academic outcomes in a national survey of university students.MethodsUsing the National College Health Assessment from Spring 2022, this study compared multiple outcomes between different groups of SWDs and students without disabilities. Two ordinal regression models were used to estimate associations between loneliness, disability type and learning mode (online vs. in-person), as well as cumulative grade average (CGA) with disability type.ResultsAll disability types included within this study were positively associated with increased odds of loneliness for those engaged in online learning compared to students without disabilities. Interactions indicate a significant effect of in-person learning compared with online learning for deaf or hard of hearing students, and those with multiple disabilities. Several disability groups reported decreased odds of higher CGA compared to students without disabilities.ConclusionLoneliness is a significant issue for all SWD groups reported in this study. The impact of disability on academic outcomes is reported herein; however, its impact on medium-to-long term outcomes for these individuals remains unknown. To address inequities in higher education for SWDs, universities must invest more resources to holistically support these students.

BackgroundDigital mental health interventions (DMHIs) represent a promising solution to address the growing unmet mental health needs and increase access to care. Integrating DMHIs into clinical and community settings is challenging and complex. Frameworks that explore a wide range of factors, such as the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, can be useful for examining multilevel factors related to DMHI implementation efforts.ObjectiveThis paper aimed to identify the barriers to, facilitators of, and best practice recommendations for implementing DMHIs across similar organizational settings, according to the EPIS domains of inner context, outer context, innovation factors, and bridging factors.MethodsThis study stems from a large state-funded project in which 6 county behavioral health departments in California explored the use of DMHIs as part of county mental health services. Our team conducted interviews with clinical staff, peer support specialists, county leaders, project leaders, and clinic leaders using a semistructured interview guide. The development of the semistructured interview guide was informed by expert input regarding relevant inner context, outer context, innovation factors, and bridging factors in the exploration, preparation, and implementation phases of the EPIS framework. We followed a recursive 6-step process to conduct qualitative analyses using inductive and deductive components guided by the EPIS framework.ResultsOn the basis of 69 interviews, we identified 3 main themes that aligned with the EPIS framework: readiness of individuals, readiness of innovations, and readiness of organizations and systems. Individual-level readiness referred to the extent to which clients had the necessary technological tools (eg, smartphones) and knowledge (digital literacy) to support the DMHI. Innovation-level readiness pertained to the accessibility, usefulness, safety, and fit of the DMHI. Organization- and system-level readiness concerned the extent to which providers and leadership collectively held positive views about DMHIs as well as the extent to which infrastructure (eg, staffing and payment model) was appropriate.ConclusionsThe successful implementation of DMHIs requires readiness at the individual, innovation, and organization and system levels. To improve individual-level readiness, we recommend equitable device distribution and digital literacy training. To improve innovation readiness, we recommend making DMHIs easier to use and introduce, clinically useful, and safe and adapting them to fit into the existing client needs and clinical workflow. To improve organization- and system-level readiness, we recommend supporting providers and local behavioral health departments with adequate technology and training and exploring potential system transformations (eg, integrated care model). Conceptualizing DMHIs as services allows the consideration of both the innovation characteristics of DMHIs (eg, efficacy, safety, and clinical usefulness) and the ecosystem around DMHIs, such as individual and organizational characteristics (inner context), purveyors and intermediaries (bridging factor), client characteristics (outer context), as well as the fit between the innovation and implementation settings (innovation factor).

Abstract Background Inadequate and inequitable access to quality behavioral health services and high costs within the mental health systems are long-standing problems. System-level (e.g., fee-for-service payment model, lack of a universal payor) and individual factors (e.g., lack of knowledge of existing resources) contribute to difficulties in accessing resources and services. Patients are underserved in County behavioral health systems in the United States. Orange County’s (California) Behavioral Health System Transformation project sought to improve access by addressing two parts of their system: developing a template for value-based contracts that promote payor-agnostic care (Part 1); developing a digital platform to support resource navigation (Part 2). Our aim was to evaluate facilitators of and barriers to each of these system changes. Methods We collected interview data from County or health care agency leaders, contracted partners, and community stakeholders. Themes were informed by the Consolidated Framework for Implementation Research. Results Five themes were identified related to behavioral health system transformation, including 1) aligning goals and values, 2) addressing fit, 3) fostering engagement and partnership, 4) being aware of implementation contexts, and 5) promoting communication. A lack of fit into incentive structures and changing state guidelines and priorities were barriers to contract development. Involving diverse communities to inform design and content facilitated the process of developing digital tools. Conclusions The study highlights the multifaceted factors that help facilitate or hinder behavioral health system transformation, such as the need for addressing systematic and process behaviors, leveraging the knowledge of leadership and community stakeholders, fostering collaboration, and adapting to implementation contexts.