The costs of Suaahara II, a complex scaled-up multisectoral nutrition programme in Nepal.

Limited evidence exists on the costs of scaled-up multisectoral nutrition programmes. Such evidence is crucial to assess intervention value and affordability. Evidence is also lacking on the opportunity costs of implementers and participants engaging in community-level interventions. We help to fill this gap by estimating the full financial and economic costs of the United States Agency for International Development-funded Suaahara II (SII) programme, a scaled-up multisectoral nutrition programme in Nepal (2016-2023). We applied a standardized mixed methods costing approach to estimate total and unit costs over a 3.7-year implementation period. Financial expenditure data from national and subnational levels were combined with economic cost estimates assessed using in-depth interviews and focus group discussions with staff, volunteers, community members, and government partners in four representative districts. The average annual total cost was US$908,948 per district, with economic costs accounting for 47% of the costs. The annual unit cost was US$132 per programme participant (mother in the 1000-day period between conception and a child's second birthday) reached. Annual costs ranged from US$152 (mountains) to US$118 (plains) per programme participant. Personnel (63%) were the largest input cost driver, followed by supplies (11%). Community events (29%) and household counselling visits (17%) were the largest activity cost drivers. Volunteer cadres contributed significant time to the programme, with female community health volunteers spending a substantial amount of time (27 h per month) on SII activities. Multisectoral nutrition programmes can be costly, especially when taking into consideration volunteer and participant opportunity costs. This study provides much-needed evidence of the costs of scaled-up multisectoral nutrition programmes for future comparison against benefits.

Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA.

BACKGROUND: In many countries including the USA, the UK and Canada, the impact of COVID-19 on people of colour has been disproportionately high but examination of disparities in patients presenting to ED has been limited. We assessed racial and ethnic differences in COVID-19 positivity and outcomes in patients presenting to EDs in the USA, and the effect of the phase of the pandemic on these outcomes. METHODS: This is a retrospective cohort study of adult patients tested for COVID-19 during, or 14 days prior to, the index ED visit in 2020. Data were obtained from the National Registry of Suspected COVID-19 in Emergency Care network which has data from 155 EDs across 27 US states. Hierarchical models were used to account for clustering by hospital. The outcomes included COVID-19 diagnosis, hospitalisation at index visit, subsequent hospitalisation within 30 days and 30-day mortality. We further stratified the analysis by time period (early phase: March-June 2020; late phase: July-September 2020). RESULTS: Of the 26 111 adult patients, 38% were non-Hispanic White (NHW), 29% Black, 20% Hispanic/Latino, 3% Asian and 10% all others; half were female. The median age was 56 years (IQR 40-69), and 53% were diagnosed with COVID-19; of those, 59% were hospitalised at index visit. Of those discharged from ED, 47% had a subsequent hospitalisation in 30 days. Hispanic/Latino patients had twice (adjusted OR (aOR) 2.3; 95% CI 1.8 to 3.0) the odds of COVID-19 diagnosis than NHW patients, after adjusting for age, sex and comorbidities. Black, Asian and other minority groups also had higher odds of being diagnosed (compared with NHW patients). On stratification, this association was observed in both phases for Hispanic/Latino patients. Hispanic/Latino patients had lower odds of hospitalisation at index visit, but when stratified, this effect was only observed in early phase. Subsequent hospitalisation was more likely in Asian patients (aOR 3.1; 95% CI 1.1 to 8.7) in comparison with NHW patients. Subsequent ED visit was more likely in Blacks and Hispanic/Latino patients in late phase. CONCLUSION: We found significant differences in ED outcomes that are not explained by comorbidity burden. The gap decreased but persisted during the later phase in 2020.

Risk of motor vehicle collision associated with cannabis and alcohol use among patients presenting for emergency care.

BACKGROUND: The objective of this study was to examine the relationship between cannabis and alcohol use and occurrence of motor vehicle collision (MVC) among patients in the emergency department (ED). METHODS: This was a cross-sectional study of visits to EDs in Denver, CO, Portland, OR, and Sacramento, CA by drivers who were involved in MVCs and presented with injuries (cases) and non-injured drivers (controls) who presented for medical care. We obtained blood samples and measured delta-9-THC and its metabolites. Alcohol levels were determined by breathalyzer or samples taken in the course of clinical care. Participants completed a research-assistant-administered interview consisting of questions about drug and alcohol use prior to their visit, context of use, and past-year drug and alcohol use. Multiple logistic regression was used to estimate the association between MVC and cannabis/alcohol use, adjusted for demographic characteristics. We then stratified participants based on levels of cannabis use and calculated the odds of MVC across these levels, first using self-report and then using blood levels for delta-9-THC in separate models. We conducted a case-crossover analysis, using 7-day look-back data to allow each participant to serve as their own control. Sensitivity analyses examined the influence of usual use patterns and driving in a closed (car, truck, van) versus open (motorcycle, motorbike, all-terrain vehicle) vehicle. RESULTS: Cannabis alone was not associated with higher odds of MVC, while acute alcohol use alone, and combined use of alcohol and cannabis were both independently associated with higher odds of MVC. Stratifying by level of self-reported or measured cannabis use, higher levels were not associated with higher odds for MVC, with or without co-use of alcohol; in fact, high self-reported acute cannabis use was associated with lower odds of MVC (odds ratio [OR] 0.18, 95% confidence interval [CI] 0.05-0.65). In the case-crossover analysis, alcohol use alone or in combination with cannabis was associated with higher odds of MVC, while cannabis use alone was again associated with decreased odds of MVC. CONCLUSIONS: Alcohol use alone or in conjunction with cannabis was consistently associated with higer odds for MVC. However, the relationship between measured levels of cannabis and MVC was not as clear. Emphasis on actual driving behaviors and clinical signs of intoxication to determine driving under the influence has the strongest rationale.

Non-linear associations between meteorological factors, ambient air pollutants and major mosquito-borne diseases in Thailand.

BACKGROUND: Transmission intensity for mosquito-borne diseases are highly heterogenous and multi-factorial. Understanding risk factors associated to disease transmission allow the optimization of vector control. This study sets out to understand and compare the combined anthropogenic and environmental risk factors of four major mosquito-borne diseases, dengue, malaria, chikungunya and Japanese encephalitis in Thailand. METHODS: An integrated analysis of mosquito-borne diseases, meteorological and ambient air pollutants of 76 provinces of Thailand was conducted over 2003-2021. We explored the use of generalized linear models and generalized additive models to consider both linear and non-linear associations between meteorological factors, ambient air pollutants and mosquito-borne disease incidence. Different assumptions on spatio-temporal dependence and nonlinearity were considered through province-specific and panel models, as well as different spline functions. Disease-specific model evidence was assessed to select best-fit models for epidemiological inference downstream. RESULTS: Analyses indicated several findings which can be generally applied to all diseases explored: (1) higher AH above mean values was positively associated with disease case counts (2) higher total precipitation above mean values was positively associated with disease case counts (3) extremely high temperatures were negatively associated with disease case counts (4) higher SO2 and PM2.5 surface concentrations were negatively associated with disease case counts. However, the relationships between disease and RH, non-extreme temperatures and CO surface concentration were more mixed, with directions of associations changing across the different diseases considered. CONCLUSIONS: This study found protective and enhancing effects of meteorological and ambient air pollutant factors on mosquito-borne diseases burdens in Thailand. Further studies should employ these factors to understand and predict risk factors associated with mosquito-borne disease transmission.

Family MUAC supported by a two-way SMS platform for identifying children with wasting: the Mama Aweza randomised controlled trial.

Background: Effective methods of preventing and identifying childhood wasting are required to achieve global child health goals. Family mid-upper arm circumference (MUAC) programs train caregivers to screen their child for wasting with MUAC tapes. We assessed the effectiveness of a two-way short message service (SMS) platform (referred to as the Maternally Administered Malnutrition Monitoring System [MAMMS]) in western Kenya. Methods: In this individual-level randomised controlled trial in two rural countries in western Kenya, children (aged 5-12 months) were randomly allocated (1:1) to receive either standard care (SOC) or MAMMS. Randomisation method was permuted-block randomisation with a block size of 10. Eligible participants were children attending maternal child health clinics in the two counties whom had a MUAC between 12.5 and 14.0 cm. The MAMMS group received two MUAC tapes and weekly SMS reminders to screen their child's MUAC. The SOC group received routine community health volunteer services and additional quarterly visits from the study team. The primary analysis used a cox proportional hazards model to compare SOC and MAMMS time-to-diagnosis of wasting (MUAC <12.5 cm) confirmed by a health professional during 6-months follow-up. Secondary outcomes were days from enrolment to treatment initiation among children with wasting, proportion of all children with wasting who were identified by the two approaches (treatment coverage), mean MUAC at treatment initiation, and duration of wasting treatment. This trial was registered on ClinicalTrials.gov, NCT03967015. Findings: Between August 1, 2019 and January 31, 2022, 1200 children were enrolled, among whom the incidence of confirmed wasting was 37% lower in the MAMMS group (hazard ratio: 0.63, 95% CI: 0.42-0.94, p = 0.022). Among children with wasting, the median number of days-to-diagnosis was similar between study groups (MAMMS: 63 days [interquartile range (IQR): 23-92], SOC: 58 days [IQR: 22-94]). Treatment coverage in the MAMMS group was 83.3% (95% CI: 39.9-100.0) while coverage in the SOC group was 55.6% (95% CI: 22.3-88.9%, p = 0.300). Treatment duration and mean MUAC at treatment initiation were similar between groups. Interpretation: Family MUAC supported by SMS was associated with a 37% reduction in wasting among young children. Empowering caregivers to monitor their child's nutritional status at home may prevent a substantial proportion of moderate wasting. Funding: Thrasher Research Foundation and Pamela and Evan Fowler.

Density forecasting of conjunctivitis burden using high-dimensional environmental time series data.

As one of the most common eye conditions being presented at clinics, acute conjunctivitis puts substantial strain on primary health resources. To reduce this public health burden, it is important to forecast and provide forward guidance to policymakers by estimating conjunctivitis trends, taking into account factors which influence transmission. Using a high-dimensional set of ambient air pollution and meteorological data, this study describes new approaches to point and probabilistic forecasting of conjunctivitis burden which can be readily translated to other infectious diseases. Over the period of 2012 - 2022, we show that simple models without environmental data provided better point forecasts but the more complex models which optimized predictive accuracy and combined multiple predictors demonstrated superior density forecast performance. These results were shown to be consistent over periods with and without structural breaks in transmission. Furthermore, ecological analysis using post-selection inference showed that increases in SO2, O3 surface concentration and total precipitation were associated to increased conjunctivitis attendance. The methods proposed can provide rich and informative forward guidance for outbreak preparedness and help guide healthcare resource planning in both stable periods of transmission and periods where structural breaks in data occur.

Association between ambient air pollutants and upper respiratory tract infection and pneumonia disease burden in Thailand from 2000 to 2022: a high frequency ecological analysis.

BACKGROUND: A pertinent risk factor of upper respiratory tract infections (URTIs) and pneumonia is the exposure to major ambient air pollutants, with short term exposures to different air pollutants being shown to exacerbate several respiratory conditions. METHODS: Here, using disease surveillance data comprising of reported disease case counts at the province level, high frequency ambient air pollutant and climate data in Thailand, we delineated the association between ambient air pollution and URTI/Pneumonia burden in Thailand from 2000 - 2022. We developed mixed-data sampling methods and estimation strategies to account for the high frequency nature of ambient air pollutant concentration data. This was used to evaluate the effects past concentrations of fine particulate matter (PM2.5), sulphur dioxide (SO2), and carbon monoxide (CO) and the number of disease case count, after controlling for the confounding meteorological and disease factors. RESULTS: Across provinces, we found that past increases in CO, SO2, and PM2.5 concentration were associated to changes in URTI and pneumonia case counts, but the direction of their association mixed. The contributive burden of past ambient air pollutants on contemporaneous disease burden was also found to be larger than meteorological factors, and comparable to that of disease related factors. CONCLUSIONS: By developing a novel statistical methodology, we prevented subjective variable selection and discretization bias to detect associations, and provided a robust estimate on the effect of ambient air pollutants on URTI and pneumonia burden over a large spatial scale.

Observational study of organisational responses of 17 US hospitals over the first year of the COVID-19 pandemic.

OBJECTIVES: The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic. DESIGN, SETTING AND PARTICIPANTS: This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021. OUTCOMES AND ANALYSIS: We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts. RESULTS: We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity. CONCLUSIONS: Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones.

Geographical Variations In Emergency Department Visits For Mental Health Conditions For Medicaid Beneficiaries.

Despite Medicaid's importance as a payer and source of coverage for mental health care, relatively little is known about how prevalence, access, and quality might vary among Medicaid beneficiaries. This study used national Medicaid data from 2018 to assess regional variations in emergency department (ED) visits for mental health conditions, a measure that may reflect unmet needs for behavioral health care. We found substantial variations, with rates in the region with the highest visit rates eight times higher than those in the region with the lowest rates. Many regions with high rates of ED visits for mental health conditions also had high rates of outpatient mental health use. Regional patterns differed substantially, with some regions exhibiting high rates of ED visits related to anxiety but low rates for schizophrenia and vice versa. The presence of large variations in ED visits for mental health conditions, with substantial differences in the composition across regions, suggests a need for context-specific solutions, including assessments of the ways in which mental health benefits are structured at the state Medicaid agency level and of differences in provider accessibility and an understanding of the types of mental illness underlying high rates of use.

Correction: The Story of #GetMePPE and GetUsPPE.org to Mobilize Health Care Response to COVID-19 : Rapidly Deploying Digital Tools for Better Health Care.

[This corrects the article DOI: 10.2196/20469.].

A cross-sectional survey exploring clinician perceptions of a novel Medicaid back pain policy.

OBJECTIVES: Oregon Medicaid (Oregon Health Plan, or OHP) implemented an innovative policy in 2016 that increased coverage of evidence-based non-pharmacologic therapies (NPT, including physical therapy, massage, chiropractic, and acupuncture) while restricting opioids, epidural steroid injections, and surgeries. The objective of this study was to compare the perspectives of clinicians who see back pain patients and can prescribe pharmacologic therapies and/or refer to NPTs and clinicians who directly provide NPT therapies affected by the policy. METHODS: A cross-sectional online survey was administered to Oregon prescribing clinicians and NPT clinicians between December 2019 and February 2020. The survey was completed by 107 prescribing clinicians and 83 NPT clinicians. RESULTS: Prescribing clinicians and NPT clinicians had only moderate levels of familiarity with core elements of the policy. Prescribing clinicians had higher levels of frustration caring for OHP patients with back pain than NPT clinicians (83 vs. 34%, p<0.001) and were less confident in their ability to provide effective care (73 vs. 85%, p = .025). Eighty-six percent of prescribing clinicians and 83% of NPT clinicians thought active NPT treatments were effective; 74 and 70% thought passive NPT treatments were effective. Forty percent of prescribing clinicians and 25% of NPT clinicians (p<0.001) thought medically-light therapies were effective, while 29% of prescribing clinicians and 10% of NPT clinicians thought medically-intensive treatments were effective (p=0.001). Prescribing clinicians thought increased access to NPTs improved outcomes, while opinions were less consistent on the impact of restricting opioid prescribing. CONCLUSIONS: Prescribing clinicians and NPT clinicians had varying perspectives of a Medicaid coverage policy to increase evidence-based back pain care. Understanding these perspectives is important for contextualizing policy effectiveness.

The economic costs of a multisectoral nutrition programme implemented through a credit platform in Bangladesh.

Bangladesh struggles with undernutrition in women and young children. Nutrition-sensitive agriculture programmes can help address rural undernutrition. However, questions remain on the costs of multisectoral programmes. This study estimates the economic costs of the Targeting and Re-aligning Agriculture to Improve Nutrition (TRAIN) programme, which integrated nutrition behaviour change and agricultural extension with a credit platform to support women's income generation. We used the Strengthening Economic Evaluation for Multisectoral Strategies for Nutrition (SEEMS-Nutrition) approach. The approach aligns costs with a multisectoral nutrition typology, identifying inputs and costs along programme impact pathways. We measure and allocate costs for activities and inputs, combining expenditures and micro-costing. Quantitative and qualitative data were collected retrospectively from implementers and beneficiaries. Expenditure data and economic costs were combined to calculate incremental economic costs. The intervention was designed around a randomised control trial. Incremental costs are presented by treatment arm. The total incremental cost was $795,040.34 for a 3.5-year period. The annual incremental costs per household were US$65.37 (Arm 2), USD$114.15 (Arm 3) and $157.11 (Arm 4). Total costs were led by nutrition counselling (37%), agriculture extension (12%), supervision (12%), training (12%), monitoring and evaluation (9%) and community events (5%). Total input costs were led by personnel (68%), travel (12%) and supplies (7%). This study presents the total incremental costs of an agriculture-nutrition intervention implemented through a microcredit platform. Costs per household compare favourably with similar interventions. Our results illustrate the value of a standardised costing approach for comparison with other multisectoral nutrition interventions.

Clinician Perspectives on Referring Medicaid Back Pain Patients to Integrative and Complementary Medicine: A Qualitative Study.

Objective: To increase understanding of referral processes from primary care to integrative and complementary medicine (ICM) under an Oregon Medicaid policy that restricted opioids and expanded access to ICM for back pain patients. Methods: Four asynchronous online focus groups with 48 medical clinicians were conducted. Themes were constructed using thematic analysis. Results: Three themes were constructed related to the clinician's experience: (1) high patient receptivity to ICM, (2) difficulty finding ICM providers who accept Medicaid beneficiaries, and (3) uncertainty of the effectiveness of ICM among clinicians. Conclusions: Findings suggest that health systems expanding access to ICM for Medicaid beneficiaries may benefit from establishing and supporting linkages between clinicians and ICM providers, especially in rural areas.

Perinatal depression and its impact on infant outcomes and maternal-nurse SMS communication in a cohort of Kenyan women.

BACKGROUND: Perinatal depression is broadly defined as depressive symptoms during pregnancy or within the 12 months following delivery, affecting approximately 20-25% of pregnant and postpartum women in low- and middle-income countries. The wide accessibility of mobile phones allows mobile health (mHealth) interventions to be considered a solution to identify perinatal depression and provide appropriate referrals for treatment. This study, nested in a larger SMS communication project, examined the prevalence and correlates of perinatal depression, determined the association between antenatal depression and infant morbidity and mortality, and compared SMS communication patterns between women with and without perinatal depression. METHODS: This was a prospective longitudinal cohort study of pregnant women seeking antenatal services at two public sector health clinics in Kenya. SMS messages were sent to participants with educational content related to their pregnancy and infant health and two-way SMS communication occurred with a nurse. Sociodemographic and obstetric characteristics, SMS messaging behaviors, infant health status, and depressive symptoms were assessed by a standardized questionnaire administered at enrollment (30-36 weeks gestation) and follow-up (14 weeks postpartum). Generalized estimating equation (GEE) with Poisson link was used to evaluate correlates of perinatal depressive symptoms, infant outcomes, and frequency of SMS messaging. RESULTS: Of the 572 women with complete follow-up information, 188 (32.9%) screened positive for elevated depressive symptoms (≥10 by EPDS scale) at some time point during pregnancy or postpartum. The strongest predictors of any depressive symptoms included interpersonal abuse during pregnancy, fewer years of schooling, and maternal unemployment. Antenatal depressive symptoms were associated with an increased risk of infant illness or hospitalization (RR = 1.12, 95% CI: 1.11, 1.13). Women with antenatal or persistent perinatal depressive symptoms sent fewer SMS messages during the study period than their counterparts without depression. CONCLUSIONS: Prevalence of elevated perinatal depressive symptoms was high in this cohort of Kenyan women. Our findings highlight the importance of screening perinatal women for experiences of symptoms of depression as well as abuse. Differences in messaging frequency between women with vs. without depressive symptoms presents an opportunity to provide more tailored support for those perinatal depression.

Increased identification of cannabis use among drivers involved in motor vehicle collisions using an expanded cannabis inventory.

OBJECTIVES: The objectives of this study were to implement and examine the potential capture rate of a novel instrument, the Expanded Cannabis Inventory, in a population of emergency department (ED) patients presenting after motor vehicle collisions (MVC). METHODS: Study participants who presented to the ED after MVC were recruited from three hospitals in cannabis-legal states (Denver, CO; Portland, OR; and Sacramento, CA). Research assistants (RAs) administered the Expanded Cannabis Inventory, which includes a wide variety of products that have become readily available in states where cannabis is legal, in addition to assessments related to patient demographic characteristics, general health, cannabis attitudes, and dependency measures. RAs also obtained blood samples for delta-9-THC and metabolites. RESULTS: Among 692 participants who provided responses to questions about cannabis use, 292 (42%) reported past-year use. Seventy-eight (27%) of those identified as using cannabis were only captured due to items in the expanded instrument. These patients were more likely to be White and were more likely to perceive daily use to be of high risk. Fewer had Cannabis Use Disorder Inventory Test (CUDIT) scores consistent with hazardous cannabis use. However, more of the patients only captured by the expanded instrument had high measured blood levels of delta-9-THC on samples obtained in the ED. CONCLUSIONS: Changing cannabis use patterns must be reflected in our measurements for clinical practice, research, and surveillance. Instruments that are the current standard in clinical practice capture limited data and may no longer perform well enough to identify a complete cohort or to provide insight into the health behaviors of patients.