Bringing a health systems modelling approach to complex evaluations: multicountry applications in HIV, TB and malaria.

INTRODUCTION: Understanding how to deliver interventions more effectively is a growing emphasis in Global Health. Simultaneously, health system strengthening is a key component to improving delivery. As a result, it is challenging to evaluate programme implementation while reflecting real-world complexity. We present our experience in using a health systems modelling approach as part of a mixed-methods evaluation and describe applications of these models. METHODS: We developed a framework for how health systems translate financial inputs into health outcomes, with in-country and international experts. We collated available data to measure framework indicators and developed models for malaria in Democratic Republic of the Congo (DRC), and tuberculosis in Guatemala and Senegal using Bayesian structural equation modelling. We conducted several postmodelling analyses: measuring efficiency, assessing bottlenecks, understanding mediation, analysing the cascade of care and measuring subnational effectiveness. RESULTS: The DRC model indicated a strong relationship between shipment of commodities and utilisation thereof. In Guatemala, the strongest model coefficients were more evenly distributed. Results in Senegal varied most, but pathways related to community care had the strongest relationships. In DRC, we used model results to estimate the end-to-end cost of delivering commodities. In Guatemala, we used model results to identify potential bottlenecks and understand mediation. In Senegal, we used model results to identify potential weak links in the cascade of care, and explore subnationally. CONCLUSION: This study demonstrates a complementary modelling approach to traditional evaluation methods. Although these models have limitations, they can be applied in a variety of ways to gain greater insight into implementation and functioning of health service delivery.

"Se vale llorar y se vale reír": Latina Immigrants' Coping Strategies for Maintaining Mental Health in the Face of Immigration-Related Stressors.

Latina immigrant women in the U.S. are at increased risk for poor mental health status, due to socioeconomic- and immigration-related stressors. We sought to describe the mechanisms linking immigration-related stressors and mental health, including how the current social and political climate affects women's mental health status, and which coping strategies are used to maintain well-being. We conducted four focus groups with Latina immigrants (N = 58) recruited through local community-based organizations. We drew on the stages of migration framework to guide our study design and analysis. Focus group transcripts were analyzed to identify emergent themes across groups. On average, focus group participants were 35.5 years old and had lived in the U.S. for 12.5 years. Most were from Mexico. Participants reported immigration-related stressors including unsafe migration, worry about immigration enforcement, broken social ties, and limited access to health and social services. In the face of these stressors, they relied on transnational social networks and connections with other Latina immigrant women. Social ties with family in the U.S. also helped them alleviate social isolation and overcome barriers to social services. Those who were mothers expressed that their children were a source of encouragement and comfort with feelings of stress. Immigration policies that contribute to unsafe migration, worry about immigration enforcement, limited social ties, and limited access to social services were associated with increased stress among Latina immigrants who participated in the focus groups. These participants could benefit from increased access to mental health care and community-based programs that connect them to resources.