Use of concept mapping to inform a participatory engagement approach for implementation of evidence-based HPV vaccination strategies in safety-net clinics.

BACKGROUND: Multiple evidence-based strategies (EBS) for promoting HPV vaccination exist. However, adolescent HPV vaccination rates remain below target levels in communities at high risk for HPV-associated cancers and served by safety-net clinics. Participatory engaged approaches are needed to leverage the expertise of community and clinical partners in selecting EBS relevant to their local context. We engaged concept mapping as a method to inform the adoption and adaptation of EBS that seeks to empower implementation partners to prioritize, select, and ultimately implement context-relevant EBS for HPV vaccination. METHODS: Using 38 EBS statements generated from qualitative interviews and national HPV vaccine advocacy sources, we conducted a modified concept mapping activity with partners internal to safety-net clinics and external community members in two study sites of a larger implementation study (Greater Los Angeles and New Jersey), to sort EBS into clusters and rate each EBS by importance and feasibility for increasing HPV vaccination within safety-net clinics. Concept mapping findings (EBS statement ratings, ladder graphs and go-zones) were shared with leaders from a large federally qualified health center (FQHC) system (focusing on three clinic sites), to select and implement EBS over 12 months. RESULTS: Concept mapping participants (n=23) sorted and rated statements, resulting in an eight-cluster solution: 1) Community education and outreach; 2) Advocacy and policy; 3) Data access/quality improvement monitoring; 4) Provider tracking/audit and feedback; 5) Provider recommendation/communication; 6) Expanding vaccine access; 7) Reducing missed opportunities; and 8) Nurse/staff workflow and training. The FQHC partner then selected to intervene on eight of 17 EBS statements in the "go-zone" for action, with three from "reducing missed opportunities," two from "nurse/staff workflow and training," and one each from "provider tracking/audit and feedback," "provider recommendation/communication," and "expanding vaccine access," which the research team addressed through the implementation of three multi-level intervention strategies (e.g., physician communication training, staff training and workflow assessment, audit and feedback of clinic processes). CONCLUSIONS: Concept mapping provided a powerful participatory approach to identify multilevel EBS for HPV vaccination relevant to the local safety-net clinic context, particularly when several strategies exist, and prioritization is necessary. This study demonstrates how a clinic system benefited directly from the ratings and prioritization of EBS by multilevel clinic and community partners within the broader safety-net clinic context to identify and adapt prioritized solutions needed to advance HPV vaccine equity.

A Qualitative Investigation of the Experiences of Women with Perinatal Depression and Anxiety during the COVID-19 Pandemic.

OBJECTIVES: The COVID-19 pandemic has had significant impacts on maternal mental health. We explored the lived experiences of women with perinatal depression and anxiety to elucidate their perceptions of how the pandemic influenced their mental health and access to care. METHODS: We conducted a qualitative descriptive study using semi-structured interviews. From March to October 2021, purposive sampling was used to recruit a socio-demographically diverse sample of women with self-reported perinatal depression or anxiety who were pregnant or within one year postpartum between March 2020 and October 2021. Interviews were conducted remotely and thematically analyzed. RESULTS: Fourteen women were interviewed. Three major themes arose. Theme 1, Negative impacts of COVID-19 on symptoms of depression and anxiety, described how the pandemic magnified underlying symptoms of depression and anxiety, increased social isolation, generated anxiety due to fears of COVID-19 infection, and caused economic stress. In theme 2, Negative impacts of COVID-19 on access to and quality of health care, women described stressful and isolating delivery experiences, negative psychological impact of partners not being able to participate in their perinatal health care, interruptions and barriers to mental health treatment, and challenges in using telehealth services for mental health care. Theme 3, Positive impacts of COVID-19 on mental health, identified advantages of increased telehealth access and ability to work and study from home. CONCLUSIONS FOR PRACTICE: The COVID-19 pandemic negatively affected women with perinatal depression and anxiety by magnifying underlying symptoms, increasing stress and social isolation, and disrupting access to mental health care. Findings provide support for policies and interventions to prevent and address social isolation, as well as optimization of telehealth services to prevent and address gaps in perinatal mental health treatment.

On legal guardianship: An exploratory assessment of knowledge, attitudes and practices of resident physicians.

BACKGROUND: Clinicians encounter patients under legal guardianship. We aimed to assess the knowledge, attitudes and practices (KAP) on legal guardianship in residents. METHODS: A KAP pilot survey about legal guardianship was developed by an interdisciplinary medicine-law-public health team and was distributed via institutional email to internal medicine, psychiatry, and neurology residents in a single academic institution. RESULTS: Of the 172 invited residents, 105 (61%) responded and 102 surveys were included in the final analysis. Most respondents (58% women; internal medicine 73%, neurology 15%, psychiatry 12%) had attended 42 medical schools from 16 countries and had heard about guardianship (88%), but only 23% reported having received training on guardianship during medical school or residency. The vast majority (97%) understood the intended benefit of guardianship, but only 22.5% reported knowing that guardianship removed an individual's decision-making rights. Nearly half (47%) of respondents reported never having asked for documentation to prove that an individual was a patient's guardian, and only 15% expected to see a court order as proof of guardianship status. CONCLUSIONS: Although most residents intuitively understood the intended benefit of guardianship, they did not understand its full implications for clinical practice. Training interventions are warranted.

Maximizing the impact of reach out and read literacy promotion:anticipatory guidance and modeling.

BACKGROUND: Reach Out and Read (ROR) is a multi-component pediatric literacy promotion intervention. However, few studies link ROR components to outcomes. We examine associations between receipt of (1) multiple ROR components and (2) clinician modeling, a potential best practice, with enhanced home literacy environments (EHLEs) among Latino families. METHODS: We conducted secondary analyses of cross-sectional enrollment data from a randomized clinical trial at three urban community health centers between November 2020 and June 2023. Latino parents with infants 6-<9 months old were surveyed about ROR component receipt (children's book, anticipatory guidance, modeling) and EHLE (StimQ2- Infant Read Scale). We used mixed models with clinician as a random effect, adjusting for covariates. RESULTS: 440 Latino parent-infant dyads were included. With no components as the reference category, receipt of 1 component was not associated with EHLE. Receipt of 2 components (standardized beta = 0.27; 95%CI: 0.12-0.42) and 3 components (standardized beta = 0.33; 95% CI: 0.19-0.47) were associated with EHLE. In separate analyses, modeling was associated with EHLE (standardized beta = 0.16; 95%CI: 0.06-0.26). CONCLUSION: Findings support modeling as a core ROR component. Programs seeking to enhance equity by promoting EHLE should utilize such strategies as anticipatory guidance and clinician modeling in addition to book distribution. IMPACT: Reach Out and Read, a multi-component literacy promotion intervention, leverages primary care to promote equity in children's early language experiences. However, few studies link Reach Out and Read components to outcomes. Among Latino parent-infant dyads, we found that implementation of two and three components, compared to none, was associated with enhanced home literacy environments, following a dose response pattern. Parent report of clinician modeling was associated with enhanced home literacy environments. Literacy promotion programs seeking to enhance equity by promoting enhanced home literacy environments should utilize strategies in addition to book distribution, including anticipatory guidance and modeling, to maximize impact.

The role of perinatal psychiatry access programs in advancing mental health equity.

This editorial presents: 1) a review of Perinatal Psychiatry Access Programs as an integrated care model with potential for promoting perinatal mental health equity; and 2) a summary of how the model has been and can be further adapted to help achieve perinatal mental health equity in geographically diverse settings. Within the editorial, we highlight Access Programs as a promising model for promoting perinatal mental health equity. This editorial is supported by original descriptive data on the Lifeline for Moms National Network of Perinatal Psychiatric Access Programs. Descriptive data is additionally provided on three statewide Access Programs. The Access Program model, and the accompanying Network of Access Programs, is a multi-level approach demonstrating promise in reducing perinatal mental health inequities. Access Programs demonstrate potential to implement interventions to address well-documented inequities in perinatal mental healthcare access at the patient-, clinician-, practice-, community-, and policy-levels. For Access Programs to leverage their potential to advance perinatal mental health equity, systematic efforts are needed that include partnership with impacted communities and implementation teams.

Reach Out and Read Implementation: A Scoping Review.

BACKGROUND: Reach Out and Read (ROR) is an evidence-based literacy promotion intervention that leverages the near-universal access to children of primary care practices to promote optimal child development. While several studies document ROR's effectiveness, its implementation remains understudied. OBJECTIVE: This scoping review examines the existing literature to better understand ROR implementation. DATA SOURCES: PubMed, ERIC, Web of Science, Academic Search Premier, ProQuest Education Database, and CINAHL. STUDY SELECTION: We included peer-reviewed English-language papers focusing on ROR in an ambulatory setting in North America. DATA EXTRACTION: Extracted variables were informed by the Template for Intervention Description and Replication checklist and included publication year, title, author(s), clinic location, study design, study aim, ROR implementation, modifications, implementation assessment, barriers, facilitators, and outcomes. RESULTS: Seventy-one papers were included, of which 43 were research articles. We identified substantial variation in ROR implementation including differences in components delivered. A considerable number of research articles did not assess ROR implementation. The most common barriers to ROR implementation were at the system level (ie, financing and inadequate time). Modifications and enhancements to ROR are emerging; most address barriers at the clinician and family level. LIMITATIONS: This review was limited to published English language papers focusing on ROR. CONCLUSIONS: ROR implementation varies across studies, and many did not assess implementation. Consistent reporting and assessment of ROR implementation could create opportunities to better understand the mechanisms underlying ROR's effects and inform other early childhood interventions that seek to promote optimal development at the population level.

A Mixed-Methods Investigation Examining Site-Level Variation in Reach Out and Read Implementation.

OBJECTIVE: Reach Out and Read (ROR) is an evidence-based early childhood intervention that has been implemented at scale, yet description of ROR implementation is inconsistent. This study engages implementation science to examine ROR delivery and site-level variation. METHODS: As part of an ongoing clinical trial, we conducted a mixed-methods study in 3 community health centers (CHCs) that serve low-income Latino families. We integrated quantitative parent survey data, qualitative data from monthly key informant interviews with ROR site leaders over 1 year, and in-depth interviews with 18 additional clinicians. At enrollment, parents reported whether they received a children's book, guidance on reading, and modeling from clinicians. We analyzed quantitative data using descriptive statistics, and qualitative data iteratively engaging emergent and a priori codes drawn from the Template for Intervention Description and Replication Checklist. RESULTS: Three hundred Latino parents (mean age: 31; 75% ≤HS education) completed surveys. The mean child age was 8 months. Overall, most parents reported receiving a book (84%) and guidance (73%), but fewer experienced modeling (23%). Components parents received varied across CHCs. Two themes emerged to explain the variation observed: 1) differences in the perceived purpose of shared reading and book delivery aligned with variation in implementation, and 2) site-level barriers affected what components were implemented. CONCLUSION: Because of substantive variation in ROR implementation across sites, systematic descriptions using established frameworks and corresponding measurement to characterize ROR implementation may enhance our understanding of mechanisms underlying ROR's effects, which clinicians and policymakers can use to maximize ROR's impact.

The Role of Formal Policy to Promote Informed Consent of Psychotropic Medications for Youth in Child Welfare Custody: A National Examination.

Active participation of youth and surrogate decision-makers in providing informed consent and assent for mental health treatment is critical. However, the procedural elements of an informed consent process, particularly for youth in child welfare custody, are not well defined. Given calls for psychotropic medication oversight for youth in child welfare custody, this study proposes a taxonomy for the procedural elements of informed consent policies based upon formal and informal child welfare policies and then examines whether enacted state formal policies across the United States endorsed these elements. A sequential multi-method study design included: (1) semi-structured interviews with key informants (n = 58) primarily from state child welfare agencies to identify a taxonomy of procedural elements for informed consent of psychotropic medications and then (2) a legislative review of the 50 states and D.C. to characterize whether formal policies endorsed each procedural element through February 2022. Key informants reported five procedural elements in policy, including how to: (1) gather social and medical history, (2) prescribe the medication, (3) authorize its use through consent and youth assent, (4) notify relevant stakeholders, and (5) routinely review the consenting decision. Twenty-three states endorsed relevant legislation; however, only two states specified all five procedural elements. Additionally, the content of a procedural element, when included, varied substantively across policies. Further research and expert consensus are needed to set best practices and guide policymakers in setting policies to advance transparency and accountability for informed consent of mental health treatment among youth in child welfare custody.

Delays in autism diagnosis for U.S. Spanish-speaking families: The contribution of appointment availability.

Promoting equity in health services requires an understanding of the mechanisms that produce disparities. Utilizing a sequential, mixed-methods, explanatory study design, we analyzed child-, family-, and organizational-level factors and their association with wait times for an ASD diagnostic evaluation among 353 families scheduled for English and Spanish language appointments (27% Spanish language). A subset of parents and caregivers participated in English and Spanish language focus groups to provide their perspectives on the diagnostic process. Spanish language was associated with greater completion of, and time to evaluations than English language. The only variable found to mediate associations with time-to-evaluation was appointment availability - an organizational factor. Qualitative results elucidate potential explanations for greater Spanish language evaluation completion (e.g., fewer community-based diagnostic options). Results serve as a case study to support the utility and importance of analyzing the influence of organizational-level factors on delays and disparities for childhood health and mental health services. We discuss our findings in relation to strategies that can be widely applied to support equitable services access for childhood diagnostic and intervention services.

Perspectives on addressing bipolar disorder in the obstetric setting.

OBJECTIVE: Perinatal Psychiatry Access Programs have emerged to help obstetric professionals meet the needs of perinatal individuals with mental health conditions, including bipolar disorder (BD). We elucidate obstetric professionals' perspectives on barriers and facilitators to managing BD in perinatal patients, and how Access Programs may affect these processes. METHODS: We conducted three focus groups with obstetric professionals, two with- and one without-exposure to an Access Program, the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms. Focus groups discussed experiences, barriers, facilitators, and solutions to caring for perinatal individuals with BD. Qualitative data were coded and analyzed by two independent coders; emergent themes were examined across exposure groups. RESULTS: Thirty-one obstetric professionals (7 without-exposure, 24 with-exposure) participated. Identified themes included: (1) gaps in perinatal BD education; (2) challenges in patient assessment; (3) MCPAP for Moms as a facilitator for addressing BD; and (4) importance of continued outreach and destigmaization to increase care collaboration. CONCLUSIONS: Barriers to obstetric professionals accessing adequate mental healthcare for their patients with BD abound. With psychiatric supports in place, it is possible to build obstetric professionals' capacity to address BD. Perinatal Psychiatry Access Programs can facilitate obstetric professionals bridging these gaps in mental health care.

Deserving but not entitled: The social construction of autism spectrum disorder in federal policy.

Public policies play an influential role in shaping public opinion about health conditions, who is affected by them, and potential pathways for identification and intervention. This study draws upon a social constructionist perspective of policy design and disability to examine how autism spectrum disorder (ASD) has been framed in United States federal legislation. Qualitative content analysis of autism legislation passed between 1973 and 2019 indicates that policies reinforced ASD as a largely medicalized, neurobiological condition of childhood; this was reflected in both the policy aims, sources of knowledge and groups prioritized to address ASD; and the symbolic or material resources committed (or not committed) by enacted federal legislation to specific constituencies. Policy aims of early ASD legislation were symbolic in nature, focusing predominantly on framing children with ASD as a group worthy of public recognition. More recent legislation, in contrast, conferred material resources - albeit in targeted ways. Funding for surveillance and medical research on causation, early detection, treatment, and health professional training were prioritized with little attention to either service delivery needs of individuals with ASD and their families, supports over the lifecourse, or the social factors influencing ASD.

A national survey on adaptations by perinatal psychiatry access programs to promote perinatal mental healthcare equity.

OBJECTIVE: Perinatal Psychiatry Access Programs ("Access Programs") are system-level interventions that aim to build the capacity of perinatal healthcare professionals to address mental health, and thereby improve access to perinatal mental healthcare. Access Programs are widely implemented and positioned to promote health equity in perinatal mental healthcare, but little is known about the adaptations being made to the model in response to calls to promote health equity. METHODS: One respondent from each of the 14 Access Programs (n = 14) completed an online survey that queried on adaptations made to promote perinatal mental healthcare equity. RESULTS: Twelve of the 14 Access Program team members (86%) indicated implementation of at least one new equity initiative. The average number of initiatives that a single Access Program implemented was 3.5 (range 0-10). Two Access Programs (14%) implemented 8.5 initiatives (range: 7-10), indicating that a small cohort is leading promotion of equity among Access Programs. CONCLUSION: Efforts to further expand the capacity and services of Access Programs to address perinatal mental healthcare inequities are needed. These adaptations may provide a robust opportunity for implementation initiatives to promote health equity through a system-level intervention.

Mapping mental health inequalities: The intersecting effects of gender, race, class, and ethnicity on ADHD diagnosis.

While the effects of social stratification by gender, race, class, and ethnicity on health inequalities are well-documented, our understanding of the intersecting consequences of these social dimensions on diagnosis remains limited. This is particularly the case in studies of mental health, where "paradoxical" patterns of stratification have been identified. Using a Bayesian multi-level random-effects Poisson model and a nationally representative random sample of 138,009 households from the National Survey of Children's Health, this study updates and extends the literature on mental health inequalities through an intersectional investigation of one of the most commonly diagnosed psychiatric conditions of childhood/adolescence: attention-deficit hyperactivity disorder (ADHD). Findings indicate that gender, race, class, and ethnicity combine in mutually constitutive ways to explain between-group variation in ADHD diagnosis. Observed effects underscore the importance and feasibility of an intersectional, multi-level modelling approach and data mapping technique to advance our understanding of social subgroups more/less likely to be diagnosed with mental health conditions.

Effectiveness of Screening in Early Intervention Settings to Improve Diagnosis of Autism and Reduce Health Disparities.

IMPORTANCE: The American Academy of Pediatrics recommends referring children at elevated risk of autism spectrum disorder (ASD) for Part C early intervention (EI) services, but notes that EI services often fail to provide ASD screening. OBJECTIVE: To evaluate the hypothesis that a multistage screening protocol for ASD implemented in 3 EI settings will increase autism detection, especially among Spanish-speaking families. DESIGN, SETTING, AND PARTICIPANTS: Difference-in-differences analyses with propensity score weighting of a quasi-experimental design using administrative data on 3 implementation EI agencies and 9 comparison EI agencies from 2012 to 2018 provided by the Massachusetts Department of Public Health. Eligible children were aged 14 to 36 months, enrolled in EI, had no prior ASD diagnosis or medical condition precluding participation, and had parents who spoke English or Spanish. The final analytic sample included 33 326 unique patients assessed across 150 200 person-quarters. EXPOSURES: Multistage ASD assessment protocol including ASD screening questionnaires, observational screener, and diagnostic evaluation. MAIN OUTCOMES AND MEASURES: Increased incidence of ASD diagnoses as documented in Department of Public Health records and reductions in language-associated health care disparities. RESULTS: Implementation of screening at 3 EI sites was associated with a significant increase in the rate of ASD diagnoses (incidence rate ratios [IRR], 1.6; 95% CI, 1.3-2.1; P < .001), representing an additional 8.1 diagnoses per 1000 children per quarter. Among Spanish-speaking families, screening was also associated with a significant increase in the rate of ASD diagnoses (IRR, 2.6; 95% CI, 1.6-4.3; P < .001), representing 15.4 additional diagnoses per 1000 children per quarter-a larger increase than for non-Spanish-speaking families (interaction IRR, 1.8; 95% CI, 1.0-3.1; P = .005). Exploratory analyses revealed that screening was associated with a larger increase in the rate of ASD diagnoses among boys (IRR, 1.8; 95% CI, 1.4-2.3; P < .001) than among girls (IRR, 1.1; 95% CI, 0.6-1.7; P = .84). CONCLUSIONS AND RELEVANCE: In this study, associations between increased rates of ASD diagnoses and reductions in disparities for Spanish-speaking households support the effectiveness of multistage screening in EI. This study provides a comprehensive evaluation of ASD screening in EI settings as well as a rigorous evaluation of ASD screening in any setting with a no-screening comparison condition. Given that the intervention included multiple components, mechanisms of action warrant further research, as do disparities by child sex.

A Taxonomy of Reported Harms in Pediatric Autism Spectrum Disorder Screening: Provider and Parent Perspectives.

The U.S. Preventive Services Task Force (USPSTF) report on screening for Autism Spectrum Disorder (ASD) highlighted the need for research that examines the harms potentially associated with screening so as to assess the overall net benefit of universal screening. In response, this study engages qualitative, semi-structured interviews to generate a taxonomy outlining potential harms reported by parents and providers (pediatricians and Early Intervention providers) with experience in screening young children for ASD. Potential harms emerged including: physical, psychological, social, logistical/financial, opportunity cost, attrition, and exacerbation of non-targeted disparities. Respondents reported harms being experienced by the toddlers, parents, and providers. The harms reported highlight opportunities for providers to offer resources that mitigate the potential for these unintended consequences.

Rapid-cycle systems modeling to support evidence-informed decision-making during system-wide implementation.

BACKGROUND: To "model and simulate change" is an accepted strategy to support implementation at scale. Much like a power analysis can inform decisions about study design, simulation models offer an analytic strategy to synthesize evidence that informs decisions regarding implementation of evidence-based interventions. However, simulation modeling is under-utilized in implementation science. To realize the potential of simulation modeling as an implementation strategy, additional methods are required to assist stakeholders to use models to examine underlying assumptions, consider alternative strategies, and anticipate downstream consequences of implementation. To this end, we propose Rapid-cycle Systems Modeling (RCSM)-a form of group modeling designed to promote engagement with evidence to support implementation. To demonstrate its utility, we provide an illustrative case study with mid-level administrators developing system-wide interventions that aim to identify and treat trauma among children entering foster care. METHODS: RCSM is an iterative method that includes three steps per cycle: (1) identify and prioritize stakeholder questions, (2) develop or refine a simulation model, and (3) engage in dialogue regarding model relevance, insights, and utility for implementation. For the case study, 31 key informants were engaged in step 1, a prior simulation model was adapted for step 2, and six member-checking group interviews (n = 16) were conducted for step 3. RESULTS: Step 1 engaged qualitative methods to identify and prioritize stakeholder questions, specifically identifying a set of inter-related decisions to promote implementing trauma-informed screening. In step 2, the research team created a presentation to communicate key findings from the simulation model that addressed decisions about programmatic reach, optimal screening thresholds to balance demand for treatment with supply, capacity to start-up and sustain screening, and availability of downstream capacity to provide treatment for those with indicated need. In step 3, member-checking group interviews with stakeholders documented the relevance of the model results to implementation decisions, insight regarding opportunities to improve system performance, and potential to inform conversations regarding anticipated implications of implementation choices. CONCLUSIONS: By embedding simulation modeling in a process of stakeholder engagement, RCSM offers guidance to realize the potential of modeling not only as an analytic strategy, but also as an implementation strategy.

The Effect of Medical Home on Shared Decision-Making for Caregivers of Children with Emotional, Developmental, or Behavioral Health Conditions.

INTRODUCTION: Known as the "pinnacle of patient-centered care," shared decision-making (SDM) is the process that enables and encourages the health care provider, the patient, and/or their caregiver (parent or guardian) to participate collaboratively in medical decisions. Prior research indicates that children with emotional, developmental, or behavioral health conditions (EDB) are less likely to attain SDM than children with other special health care needs (SHCNs). This study investigates whether the presence of a medical home reduces disparities in SDM among children with EDB when compared to children with other SHCNs and the general pediatric population. METHODS: Using the 2016 National Survey of Children's Health, we conducted weighted descriptive statistics to investigate the prevalence of medical home and SDM for children with (1) EDB, (2) other SHCNs, and (3) no SHCNs. We then employed a nested multivariate logistic regression model to examine whether the presence of a medical home reduced the disparity between children with EDB and their counterparts. RESULTS: Nationally, 21% of children with EDB (n = 647,274), 14.0% of children with other SHCNs (n = 1,086,068), and 13% of children with no SHCNs (n = 883,969) did not attain caregiver-reported SDM in medical care. In each of the health condition groups, the presence of a medical home significantly improved the odds of SDM (p < 0.001). Presence of a medical home also reduced the disparities observed in caregiver-reported SDM among children with EDB as compared to those with other SHCNs and no SHCNs. DISCUSSION: Ongoing investment in medical homes may reduce disparities in SDM experienced by children with EDB.

Fall 2020 COVID-19 Needs Assessment among New Jersey Secondary School Educational Professionals.

Secondary or high school (HS) educational professionals expressed concerns about dealing with environmental and occupational health and safety protocols due to COVID-19. Concerns related to fall 2020 school re-opening and getting back into in-person teaching-whether full-time, part-time or some other approved hybrid model-plus ongoing uncertainty with how the state and federal government will be handling matters about mandates for virtual learning, rapid testing, vaccine distribution, etc. These concerns were related to both their experience as educational professionals and genuine interest in personal and student well-being. This study was a cross-sectional online survey in early fall from mid-September-early October 2020. Of a possible maximum participation of 740 New Jersey (NJ) supervisory-level HS teachers and administrators (e.g., department chairs, district and school principals), 100 confirmed unique respondents (13.5%) consented and completed the survey. Of 100 experienced (mean 18 years teaching) participants, 70% responded to the gender identity question (overall, 61% female, 39% male; by NJ region, gender ratios were similar). There were statistically significant differences (using Fischer's exact test) between NJ regions regarding provision of online counseling and support services for teachers (p < 0.001); for resources and equipment for teachers to mediate online learning (p = 0.02); for assistive video technology tools (p = 0.03) and accessibility to structured online learning and professional development (p = 0.002); concerning learning aids to engage students in online instruction, online counseling, and support services for students and their families (p = 0.006); appropriate protocol is clean and disinfect areas used by a person with COVID-19 (p = 0.002); and, immediately separate staff and students who screen positive for COVID-19 (p = 0.03). There were few statistical differences by gender. This study reported what participants wanted regarding the development of future policies then implemented as reopening practices. Data can inform recommendations in NJ and elsewhere at federal, state, and local levels. Data provide new insights and valuable information to inform the consideration of acceptability of various policy measures among HS education professionals.

The decision sampling framework: a methodological approach to investigate evidence use in policy and programmatic innovation.

BACKGROUND: Calls have been made for greater application of the decision sciences to investigate and improve use of research evidence in mental health policy and practice. This article proposes a novel method, "decision sampling," to improve the study of decision-making and research evidence use in policy and programmatic innovation. An illustrative case study applies the decision sampling framework to investigate the decisions made by mid-level administrators when developing system-wide interventions to identify and treat the trauma of children entering foster care. METHODS: Decision sampling grounds qualitative inquiry in decision analysis to elicit information about the decision-making process. Our case study engaged mid-level managers in public sector agencies (n = 32) from 12 states, anchoring responses on a recent index decision regarding universal trauma screening for children entering foster care. Qualitative semi-structured interviews inquired on questions aligned with key components of decision analysis, systematically collecting information on the index decisions, choices considered, information synthesized, expertise accessed, and ultimately the values expressed when selecting among available alternatives. RESULTS: Findings resulted in identification of a case-specific decision set, gaps in available evidence across the decision set, and an understanding of the values that guided decision-making. Specifically, respondents described 14 inter-related decision points summarized in five domains for adoption of universal trauma screening protocols, including (1) reach of the screening protocol, (2) content of the screening tool, (3) threshold for referral, (4) resources for screening startup and sustainment, and (5) system capacity to respond to identified needs. Respondents engaged a continuum of information that ranged from anecdote to research evidence, synthesizing multiple types of knowledge with their expertise. Policy, clinical, and delivery system experts were consulted to help address gaps in available information, prioritize specific information, and assess "fit to context." The role of values was revealed as participants evaluated potential trade-offs and selected among policy alternatives. CONCLUSIONS: The decision sampling framework is a novel methodological approach to investigate the decision-making process and ultimately aims to inform the development of future dissemination and implementation strategies by identifying the evidence gaps and values expressed by the decision-makers, themselves.

A best-worst scaling experiment to identify patient-centered claims-based outcomes for evaluation of pediatric antipsychotic monitoring programs.

OBJECTIVE: This article employs a best-worst scaling (BWS) experiment to identify the claims-based outcomes that matter most to patients and other relevant parties when evaluating pediatric antipsychotic monitoring programs in the United States. DATA SOURCES: Patients and relevant parties, with pediatric antipsychotic oversight and treatment experience, completed a BWS experiment, including policymakers (n = 31), foster care alumni (n = 28), caseworkers (n = 23), prescribing clinicians (n = 32), and caregivers (n = 18). STUDY DESIGN: Respondents received surveys with a scenario on antipsychotic monitoring programs and ranked 11 candidate claims-based outcomes as most and least important for program evaluation. DATA ANALYSIS: Stratified by respondent group, best-worst scores were calculated to identify the relative importance of the claims-based outcomes. A conditional logit examined whether candidate outcomes for safety, quality, and unintended consequences were preferred over reduction in antipsychotic treatment, the outcome used most often to evaluate antipsychotic monitoring programs. PRINCIPAL FINDINGS: Safety indicators (eg, antipsychotic co-pharmacy, cross-class polypharmacy, higher than recommended doses) ranked among the top three candidate outcomes across respondent groups and were an important complement to antipsychotic treatment reduction. Foster care alumni prioritized "antipsychotic treatment reduction" and "increased psychosocial treatment." Caseworkers, prescribers, and caregivers prioritized "increased follow-up after treatment initiation." Potential unintended consequences of an antipsychotic monitoring program ranked lowest, including increased use of other psychotropic medication classes (as a substitute), increased psychiatric hospital stays, and increased emergency room utilization. Results of the conditional logit model found only caregivers significantly preferred other indicators over antipsychotic treatment reduction, preferring improvements in follow-up care (5.78) and psychosocial treatment (4.53) and reduction in prescriptions of higher than recommended doses (3.64). CONCLUSIONS: The BWS experiment supported rank ordering of candidate claims-based outcomes demonstrating the opportunity for future studies to align outcomes used in antipsychotic monitoring program evaluations with community preferences, specifically by diversifying metrics to include safety and quality indicators.