Comparative effectiveness of implementation strategies for Accelerating Cervical Cancer Elimination through the integration of Screen-and-treat Services (ACCESS study): protocol for a cluster randomized hybrid type III trial in Nigeria.

BACKGROUND: Despite the increased risk of cervical cancer (CC) among women living with HIV (WLHIV), CC screening and treatment (CCST) rates remain low in Africa. The integration of CCST services into established HIV programs in Africa can improve CC prevention and control. However, the paucity of evidence on effective implementation strategies (IS) has limited the success of integration in many countries. In this study, we seek to identify effective IS to enhance the integration of CCST services into existing HIV programs in Nigeria. METHODS: Our proposed study has formative and experimental activities across the four phases of the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Through an implementation mapping conducted with stakeholders in the exploration phase, we identified a core package of IS (Core) and an enhanced package of IS (Core+) mostly selected from the Expert Recommendations for Implementing Change. In the preparation phase, we refined and tailored the Core and Core+ IS with the implementation resource teams for local appropriateness. In the implementation phase, we will conduct a cluster-randomized hybrid type III trial to assess the comparative effectiveness of Core versus Core+. HIV comprehensive treatment sites (k = 12) will be matched by region and randomized to Core or Core+ in the ratio of 1:1 stratified by region. In the sustainment phase, we will assess the sustainment of CCST at each site. The study outcomes will be assessed using RE-AIM: reach (screening rate), adoption (uptake of IS by study sites), IS fidelity (degree to which the IS occurred according to protocol), clinical intervention fidelity (delivery of CC screening, onsite treatment, and referral according to protocol), clinical effectiveness (posttreatment screen negative), and sustainment (continued integrated CCST service delivery). Additionally, we will descriptively explore potential mechanisms, including organizational readiness, implementation climate, CCST self-efficacy, and implementation intentions. DISCUSSION: The assessment of IS to increase CCST rates is consistent with the global plan of eliminating CC as a public health threat by 2030. Our study will identify a set of evidence-based IS for low-income settings to integrate evidence-based CCST interventions into routine HIV care in order to improve the health and life expectancy of WLHIV. TRIAL REGISTRATION: Prospectively registered on November 7, 2023, at ClinicalTrials.gov no. NCT06128304. https://classic. CLINICALTRIALS: gov/ct2/show/study/NCT06128304.

Implementation of state health insurance benefit mandates for cancer-related fertility preservation: following policy through a complex system.

BACKGROUND: A myriad of federal, state, and organizational policies are designed to improve access to evidence-based healthcare, but the impact of these policies likely varies due to contextual determinants of, reinterpretations of, and poor compliance with policy requirements throughout implementation. Strategies enhancing implementation and compliance with policy intent can improve population health. Critically assessing the multi-level environments where health policies and their related health services are implemented is essential to designing effective policy-level implementation strategies. California passed a 2019 health insurance benefit mandate requiring coverage of fertility preservation services for individuals at risk of infertility due to medical treatments, in order to improve access to services that are otherwise cost prohibitive. Our objective was to document and understand the multi-level environment, relationships, and activities involved in using state benefit mandates to facilitate patient access to fertility preservation services. METHODS: We conducted a mixed-methods study and used the policy-optimized exploration, preparation, implementation, and sustainment (EPIS) framework to analyze the implementation of California's fertility preservation benefit mandate (SB 600) at and between the state insurance regulator, insurer, and clinic levels. RESULTS: Seventeen publicly available fertility preservation benefit mandate-relevant documents were reviewed. Interviews were conducted with four insurers; 25 financial, administrative, and provider participants from 16 oncology and fertility clinics; three fertility pharmaceutical representatives; and two patient advocates. The mandate and insurance regulator guidance represented two "Big P" (system level) policies that gave rise to a host of "little p" (organizational) policies by and between the regulator, insurers, clinics, and patients. Many little p policies were bridging factors to support implementation across levels and fertility preservation service access. Characterizing the mandate's functions (i.e., policy goals) and forms (i.e., ways that policies were enacted) led to identification of (1) intended and unintended implementation, service, and patient outcomes, (2) implementation processes by level and EPIS phase, (3) actor-delineated key processes and heterogeneity among them, and (4) inner and outer context determinants that drove adaptations. CONCLUSIONS: Following the midstream and downstream implementation of a state health insurance benefit mandate, data generated will enable development of policy-level implementation strategies, evaluation of determinants and important outcomes of effective implementation, and design of future mandates to improve fit and fidelity.

Implementation of state health insurance benefit mandates for cancer-related fertility preservation: Following policy through a complex system.

Background: A myriad of federal, state, and organizational policies are designed to improve access to evidence-based healthcare, but the impact of these policies likely varies due to contextual determinants, re-interpretations of and poor compliance with policy requirements throughout implementation. Strategies enhancing implementation and compliance with policy intent can improve population health. Critically assessing the multi-level environments where health policies and their related health services are implemented is essential to designing effective policy-level implementation strategies. California passed a 2019 health insurance benefit mandate requiring coverage of fertility preservation (FP) services for individuals at risk of infertility due to medical treatments to improve access to services that are otherwise cost-prohibitive. Our objective was to document and understand multi-level environment, relationships, and activities involved in using state benefit mandates to facilitate patient access to FP services. Methods: We conducted a mixed-methods study and used the policy-optimized Exploration, Preparation, Implementation, Sustainment (EPIS) framework to analyze implementation of California's fertility preservation benefit mandate (SB 600) at and between the state insurance regulator, insurer and clinic levels. Results: Seventeen publicly available FP benefit mandate-relevant documents were reviewed, and four insurers, 25 financial, administrative and provider participants from 16 oncology and fertility clinics, three fertility pharmaceutical representatives, and two patient advocates were interviewed. The mandate and insurance regulator guidance represented two "Big P" (system level) policies that gave rise to a host of "little p" (organizational) policies by and between the regulator, insurers, clinics, and patients. Many little p policies were bridging factors to support implementation across levels and FP service access. Characterizing the mandate's functions (i.e., policy goals) and forms (i.e., ways that policies were enacted) led to identification of (1) intended and unintended implementation, service, and patient outcomes; (2) implementation processes by level, EPIS phase; (3) actor-delineated key processes and heterogeneity among them; and (4) inner and outer context determinants that drove adaptations. Conclusions: Following the mid- and down-stream implementation of a state health insurance benefit mandate, data generated will enable development of policy level implementation strategies, evaluation of determinants and important outcomes of effective implementation, and design of future mandates to improve fit and fidelity.

Rapid implementation mapping to identify implementation determinants and strategies for cervical cancer control in Nigeria.

Background: Cervical cancer constitutes a huge burden among women in Nigeria, particularly HIV-infected women. However, the provision and uptake of cervical cancer screening and treatment is limited in Nigeria. Understanding implementation determinants is essential for the effective translation of such evidence-based interventions into practice, particularly in low-resource settings. COVID-19 pandemic necessitated online collaboration making implementation mapping challenging in some ways, while providing streamlining opportunities. In this study, we describe the use of a virtual online approach for implementation mapping (steps 1-3) to identify implementation determinants, mechanisms, and strategies to implement evidence-based cervical cancer screening and treatment in existing HIV infrastructure in Nigeria. Methods: This study used a mixed methods study design with a virtual modified nominal group technique (NGT) process aligning with Implementation Mapping steps 1-3. Eleven stakeholders (six program staff and five healthcare providers and administrators) participated in a virtual NGT process which occurred in two phases. The first phase utilized online surveys, and the second phase utilized an NGT and implementation mapping process. The Exploration, Preparation, Implementation and Sustainment (EPIS) framework was used to elicit discussion around determinants and strategies from the outer context (i.e., country and regions), inner organizational context of existing HIV infrastructure, bridging factors that relate to bi-directional influences, and the health innovation to be implemented (in this case cervical cancer screening and treatment). During the NGT, the group ranked implementation barriers and voted on implementation strategies using Mentimeter. Results: Eighteen determinants to integrating cervical cancer screening and treatment into existing comprehensive HIV programs were related to human resources capacity, access to cervical cancer services, logistics management, clinic, and client-related factors. The top 3 determinants included gaps in human resources capacity, poor access to cervical cancer services, and lack of demand for services resulting from lack of awareness about the disease and servicesA set of six core implementation strategies and two enhanced implementation strategies were identified. Conclusions: Rapid Implementation Mapping is a feasible and acceptable approach for identifying and articulating implementation determinants, mechanisms, and strategies for complex healthcare interventions in LMICs.

Using Implementation Mapping to develop protocols supporting the implementation of a state policy on screening children for Adverse Childhood Experiences in a system of health centers in inland Southern California.

Adverse Childhood Experiences (ACEs) are defined as traumatic events occurring before age 18, such as maltreatment, life-threatening accidents, harsh migration experiences, or violence. Screening for ACEs includes asking questions about an individual's early exposure to these types of events. ACEs screenings have potential value in identifying children exposed to chronic and significant stress that produces elevated cortisol levels (i.e., toxic stress), and its associated physical and mental health conditions, such as heart disease, diabetes, depression, asthma, ADHD, anxiety, and substance dependence. However, ACEs screenings are seldom used in primary care settings. The Surgeon General of California has addressed this care gap by introducing ACEs Aware, an ACEs screening fee-for-service healthcare policy signed into law by Gov. Gavin Newsom. Since January 2020, Medi-Cal, California's Medicaid health care program, has reimbursed primary care providers for using the Pediatric ACEs and Related Life-events Screener (PEARLS) tool to screen children and adults for ACEs during wellness visits. To achieve the goals set by the ACEs Aware state policy, it is essential to develop and test implementation strategies that are informed by the values, priorities, and resources of clinical settings, healthcare professionals, and end-users. To address this need, we partnered with a system of federally qualified health centers in Southern California on a pilot study to facilitate the implementation of ACEs screenings in five community-based clinics. The health centers had broad ideas for an implementation strategy, as well as best practices to improve adoption of screenings, such as focusing on staff training to improve clinic workflow. This knowledge was incorporated into the development of an implementation strategy template, used at the outset of this study. We used the Exploration, Preparation, Implementation and Sustainment (EPIS) framework to guide the study and inform a participatory planning process called Implementation Mapping. In this paper, we describe how Implementation Mapping was used to engage diverse stakeholders and guide them through a systematic process that resulted in the development of the implementation strategy. We also detail how the EPIS framework informed each Implementation Mapping Task and provide recommendations for developing implementation strategies using EPIS and Implementation Mapping in health-care settings.

Mental health screening in pediatric primary care for children with autism.

LAY ABSTRACT: Children with autism experience high rates of co-occurring mental health conditions like challenging behaviors and anxiety. However, these co-occurring mental health needs are often not identified when they first become problematic. Pediatricians and their care staff are in a good position to identify mental health needs early and support families to connect to needed services. This study describes a project focused on mental health screening for children with autism in pediatric primary care clinics. Over half of eligible patients were screened using the Pediatric Symptom Checklist-17. Many children with autism had clinically elevated scores, suggesting the need for mental health assessment or services. In particular, children with positive screens had clinical elevations on the challenging behavior and attention subscales of the Pediatric Symptom Checklist-17. This finding is consistent with typical trends in co-occurring challenging behavior presentations in children with autism. Mental health screening in primary care is feasible and offers a promising opportunity to identify co-occurring mental health needs for children with autism early. Screening rates varied between clinics, suggesting tailored to improve routine screening in pediatric primary care for children with autism.

Prevalence of HIV/STIs and correlates with municipal characteristics among female sex workers in 13 Mexican cities / Prevalencia de VIH/ITS y correlaciones con carácterísticas municipales entre trabajadoras sexuales en 13 ciudades mexicanas

Abstract: Objective: To identify correlates of HIV/STI prevalence among 13 cities with varying sizes of female sex worker (FSW) populations and municipal characteristics in Mexico. Materials and methods: FSWs underwent interviews and testing for HIV, syphilis, gonorrhea and chlamydia. Logistic regression explored variations in HIV/STI prevalence. Results: Among FSWs (n=1 092), prevalence across 13 sites was: HIV: 0.4% (range: 0%-1.4%): syphilis: 7.8% (range: 0%-17.2%); chlamydia: 15.3% (range: 5.7%-32.2%); gonorrhea: 2.9% (range 0%-13.8%), and any HIV/STI: 23% (range: 9.9%-46%). Municipalities with high human development scores and a lower municipal marginalization index had higher odds of combined HIV/STI prevalence. After controlling for site-specific variability in municipal characteristics, greater risk of HIV/STIs was associated with lower education, having a spouse diagnosed or treated for an STI, unaffordability of condoms, and having non-Mexican clients. Conclusions: Prevalence of HIV/STIs varies across Mexican municipalities indicating the need for surveillance to identify hotspots for targeted resource allocation.

Resumen: Objetivo: Identificar correlaciones de la prevalencia de VIH / ITS entre 13 ciudades con diferentes tamaños de población de trabajadoras sexuales y características municipales en México. Material y métodos: Las trabajadoras sexuales fueron entrevistadas y recibieron pruebas de VIH, sífilis, gonorrea y clamidia. La regresión logística exploró las variaciones en la prevalencia del VIH/ITS. Resultados: Entre las trabajadoras sexuales (n = 1 092), la prevalencia en 13 sitios fue: VIH: 0.4% (rango: 0-1.4%): sífilis: 7.8% (rango: 0-17.2%); clamidia: 15.3% (rango: 5.7-32.2%); gonorrea: 2.9% (rango 0-13.8%) y cualquier VIH/ITS: 23% (rango: 9.9-46%). Los municipios con altos puntajes de desarrollo humano y menor índice de marginación municipal tuvieron una mayor probabilidad de prevalencia combinada de VIH/ITS. Después de controlar la variabilidad específica del sitio en las características municipales, el mayor riesgo de VIH / ITS se asoció con menor educación, tener un cónyuge diagnosticado o tratado para una ITS, imposibilidad de conseguir condones y tener clientes no mexicanos. Conclusiones: La prevalencia de VIH/ITS varía entre los municipios mexicanos, lo que indica la necesidad de una vigilancia para identificar hotspots para la asignación selectiva.

Depression is Associated with Increased Risk for Metabolic Syndrome in Latinos with Type 2 Diabetes.

OBJECTIVE: Latino adults are 66% more likely to have diabetes relative to non-Latino white adults. Prior research identifies depression as a significant risk factor for metabolic syndrome (MetS), but research examining this among Latinos is lacking. This study sought to examine the links between depression and MetS and clinically significant elevations in cardiovascular disease risk markers of MetS in a sample of community-dwelling older Latinos with type 2 diabetes. METHODS: Participants were 332 community-dwelling older (≥60 years) Latinos with type 2 diabetes who completed the nine-item Patient Health Questionnaire and received a health checkup assessing body mass index (BMI), triglyceride and high-density lipoprotein (HDL) cholesterol levels, and blood pressure. Logistic regression analysis compared MetS rates of those meeting criteria for depression with those who did not. Secondary analyses examined the associations between depression and individual MetS components. All analyses controlled for demographic (e.g., income, age) and other potential MetS risk factors (e.g., smoking status, physical activity, alcohol level consumption). RESULTS: Depression was significantly associated with an increased risk of MetS (OR: 5.79; 95% CI: 1.32-25.42) and clinically significant elevations in triglycerides (OR: 2.71; 95% CI: 1.15-6.42) and reduced (HDL) cholesterol (OR: 2.46; 95% CI: 1.11-5.45). A significant association was not observed between depression and either BMI or hypertension. CONCLUSION: Depression is significantly linked to MetS, and most notably dyslipidemia, in older Latinos with diabetes. Causation, however, cannot be inferred from these analyses given the cross-sectional nature of the study. Future research should prospectively examine the directionality of this effect.

Prevalence and Correlates of Hazardous Drinking among Female Sex Workers in 13 Mexican Cities.

AIMS: To describe the prevalence and correlates of hazardous drinking among female sex workers (FSWs) at 13 sites throughout Mexico. METHODS: FSWs (N = 1089) who were enrolled in a brief sexual risk reduction intervention (Mujer Segura) were queried about their sexual risk and substance use practices and their work contexts. Participants were classified as hazardous or non-hazardous drinkers based on the Alcohol Use Disorders test (AUDIT-C). Logistic regression models were used to examine individual, contextual, and community-level factors as correlates of hazardous drinking. RESULTS: Ninety-two percent of participants reported alcohol consumption in the past month. Among drinkers (N = 1001), 83% met AUDIT-C criteria for hazardous drinking. Factors that were independently associated with hazardous drinking included: drug use in the past month (adjusted odds ratio (AOR) = 3.31; 95% CI 1.29-8.45), being a cigarette smoker (AOR = 1.71; 95% CI 1.13-2.58), being a barmaid or dance hostess (AOR = 3.40; 95% CI 1.95-5.91), alcohol use before or during sex with clients (AOR = 7.78; 95% CI 4.84-12.52), and working in a city with a higher marginalization index (AOR = 1.07; 95% CI 1.04-1.11). CONCLUSIONS: Findings support the high prioritization by public health authorities of alcohol prevention and treatment programs for FSWs.

Smoking behavior of US youths: a comparison between child welfare system and community populations.

OBJECTIVES: We compared rates of smoking for 2 groups of youths aged 12 to 14 years: those involved in the child welfare system (CW) and their counterparts in the community population. We then investigated factors associated with smoking for each group. METHODS: We drew data from 2 national-level US sources: the National Survey of Child and Adolescent Well-Being and the National Longitudinal Study of Adolescent Health. We estimated logistic regression models for 3 binary outcome measures of smoking behavior: lifetime, current, and regular smoking. RESULTS: CW-involved youths had significantly higher rates of lifetime smoking (43% vs 32%) and current smoking (23% vs 18%) than did youths in the community population. For CW-involved youths, delinquency and smoking were strongly linked. Among youths in the community population, multiple factors, including youth demographics and emotional and behavioral health, affected smoking behavior. CONCLUSIONS: Smoking prevalence was notably higher among CW-involved youths than among the community population. In light of the persistent public health impact of smoking, more attention should be focused on identification of risk factors for prevention and early intervention efforts among the CW-involved population.

Measuring adolescent smoking cessation strategies: instrument development and initial validation.

A majority of adolescent smokers attempt cessation and report intentions to quit, yet little is known regarding the teen cessation process. To advance inquiry into the adolescent smoking cessation process the present report describes the development and initial evaluation of the Ways of Quitting questionnaire (WOQ), a measure designed to assess adolescent smoking cessation strategies. All participants were recruited from four public high schools in metropolitan San Diego, California. Items and questionnaire wording and format were developed based on responses from 36 adolescent participants in six focus groups. The resulting questionnaire included 28 cessation strategies. Descriptive and psychometric analyses were conducted for 88 adolescents who had previously attempted smoking cessation. For each WOQ item, respondents indicated whether they had used a given strategy and, if used, how helpful it was. The most frequently reported cessation methods included avoidance, reduction, and distraction strategies. These, along with social support strategies, received the highest helpfulness ratings. Formal intervention approaches were the least frequently used strategies. Formal methods also were rated as least helpful. Initial validation analyses on a subsample of participants revealed that use of more social support and smoking reduction strategies was significantly associated with length of abstinence following a cessation attempt. The present findings thus provide initial support for the utility and criterion validity of this newly developed measure.