Managed care updates of subscriber jail release to prompt community suicide prevention: clinical trial protocol.

BACKGROUND: Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail. METHODS: This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data. CONCLUSIONS: This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023.

Neighborhood Deprivation and Severe Maternal Morbidity in a Medicaid Population.

INTRODUCTION: Few studies have examined whether neighborhood deprivation is associated with severe maternal morbidity (SMM) in already socioeconomically disadvantaged populations. Little is known about to what extent neighborhood deprivation accounts for Black-White disparities in SMM. This study investigated these questions among a statewide Medicaid-insured population, a low-income population with heightened risk of SMM. METHODS: Data were from Michigan statewide linked birth records and Medicaid claims between 01/01/2016 and 12/31/2019, and were analyzed between 2022 and 2023. Neighborhood deprivation was measured with the Area Deprivation Index at census block group and categorized as low, medium, or high deprivation. Multilevel logistic models were used to examine the association between neighborhood deprivation and SMM. Fairlie nonlinear decomposition was conducted to quantify the contribution of neighborhood deprivation to SMM racial disparity. RESULTS: People in the most deprived neighborhoods had higher odds of SMM than those in the least deprived neighborhoods (aOR [95% CI]: 1.27 [1.15, 1.40]). Such association was observed in Black (aOR [95% CI]: 1.34 [1.07, 1.67]) and White (aOR [95% CI]: 1.26 [1.12, 1.42]) racial subgroups. Decomposition showed that of 57.5 (cases per 10,000) explained disparity in SMM, neighborhood deprivation accounted for 23.1 (cases per 10,000; 95% CI: 16.3, 30.0) or two-fifths (40.2%) of the Black-White disparity. Analysis on SMM excluding blood transfusion showed consistent but weaker results. CONCLUSIONS: Neighborhood deprivation may be used as an effective tool to identify at-risk individuals within a low-income population. Community-engaged interventions aiming at improving neighborhood conditions may be helpful to reduce both SMM prevalence and racial inequity in SMM.

Impact of County-level health infrastructure on participation in a reform effort to reduce the use of jail for individuals with mental health disorders.

BACKGROUND: The national Stepping Up Initiative has attracted over 500 counties interested in reducing the use of jail for individuals with mental health disorders. This paper identifies socioeconomic, criminal legal, and health care factors that predict the likelihood of counties joining Stepping Up. RESULTS: After performing variable selection, logistic regression models were performed on 3,141 U.S. counties. Counties designated as medically underserved and/or mental health staffing shortage areas were less likely to participate in this initiative. Logistic regression models showed that larger counties (populations over 250,000) with better health care infrastructure, more mental health providers per capita, higher percent of Medicaid funded drug treatment services, and at least one medical school, were more likely to join Stepping Up. These counties had lower per capita jail populations, higher concentration of police resources, and higher pretrial incarceration rate. CONCLUSIONS: County-level health care delivery factors are major contributors to a county's likelihood, or willingness, of engaging in Stepping Up reform efforts to reduce jail population with mental health disorders issues. Therefore, improving availability and accessibility of medical and behavioral health care in different communities, may facilitate efforts to address the unnecessary incarceration of individuals with mental health disorders.

Study protocol for the ROSE Scale-Up Study: Informing a decision about ROSE as universal postpartum depression prevention.

PURPOSE: To examine the effectiveness, cost-outcome, equity, scalability, and mechanisms of the Reach Out, Stay strong, Essentials for mothers of newborns (ROSE) postpartum depression prevention (PPD) program as universal versus selective or indicated prevention. BACKGROUND: The United States Preventive Services Task Force (USPSTF) currently recommends PPD prevention for pregnant people at risk of PPD (i.e., selective/indicated prevention). However, universal prevention may be more scalable, equitable, and cost-beneficial. DESIGN: Effectiveness of ROSE for preventing PPD among people at risk is known. To assess ROSE as universal prevention, we need to determine the effectiveness of ROSE among all pregnant people, including those screening negative for PPD risk. We will enroll 2320 pregnant people, assess them with commonly available PPD risk prediction tools, randomize everyone to ROSE or enhanced care as usual, and assess ROSE as universal, selective, and indicated prevention in terms of: (1) effectiveness (PPD prevention and functioning), (2) cost-benefit, (3) equity (PPD cases prevented by universal prevention that would not be prevented under selective/indicated for minority vs. non-Hispanic white people), (4) quantitative and qualitative measures of scalability (from 98 agencies previously implementing ROSE), (5) ROSE mechanisms across risk levels. We will integrate results to outline pros and cons of the three prevention approaches (i.e., universal, selective, indicated). CONCLUSION: This will be the first trial to assess universal vs. selective/indicated PPD prevention. Trial design illustrates a novel, efficient way to make these comparisons. This trial, the largest PPD prevention trial to date, will examine scalability, an understudied area of implementation science.

Implementation Preparation Costs of Virtual Reality Job Interview Training in Prisons: A Budget Impact Analysis.

Virtual Reality Job Interview Training (VR-JIT) has increased employment rates for returning citizens when added to a successful prison-based employment readiness program. However, implementation preparation cost-expenses prior to offering VR-JIT to intended recipients-is unknown. We estimated the cost of implementation preparation activities (e.g., organizing workflow) for two prisons to deliver VR-JIT. We conducted a budget impact analysis and enumerated the labor costs incurred during this important stage of implementation. Labor costs were approximately $8,847 per prison. Our sensitivity analysis estimated the labor costs to replicate this effort in a new prison to range from $2,877 to $4,306 per prison. Thus, VR-JIT may be an affordable tool for prison-based employment readiness programs to improve gainful employment.

Study protocol: The Maternal Health Multilevel Intervention for Racial Equity (Maternal Health MIRACLE) Project.

PURPOSE: To test the effectiveness and cost-effectiveness of a multilevel intervention for population-level African American (AA) severe maternal morbidity and mortality. BACKGROUND: Severe maternal morbidity and mortality in the U.S. disproportionately affect AA women. Inequities occur at many levels, including community, provider, and health system levels. DESIGN: Intervention. Throughout the two intervention counties, we will expand access to enhanced prenatal care services using telehealth and flexible scheduling (community level), provide actionable maternal health-focused anti-racism training (provider level), and implement equity-focused community care maternal safety bundles (health system level). Partnership. Interventions were developed/co-developed by intervention county partners, including AA women, enhanced prenatal care staff, and health providers. For equity, 46% of project direct cost dollars go to our partners. Most study investigators are female (75%) and/or AA (38%). Partners are overwhelmingly AA women. Sample, measures, analyses. We use a quasi-experimental difference-in-differences with propensity scores approach to compare pre (2016-2019) to post (2022-2025) changes in outcomes for Medicaid-insured women in intervention counties to similar women in the other Michigan, USA, counties. The sample includes all Medicaid-insured deliveries in Michigan during these years (n ~ 540,000), with women observed during pregnancy, at birth, and up to 1 year postpartum. Measures are taken from a linked dataset that includes Medicaid claims and vital records. CONCLUSION: This study is among the first to examine effects of any multilevel intervention on AA severe maternal morbidity and mortality. It features a rigorous quasi-experimental design, multilevel multi-partner county-wide interventions developed by community partners, and assessment of intervention effects using population-level data.

The relationship between community public health, behavioral health service accessibility, and mass incarceration.

BACKGROUND: The relationship between healthcare service accessibility in the community and incarceration is an important, yet not widely understood, phenomenon. Community behavioral health and the criminal legal systems are treated separately, which creates a competing demand to confront mass incarceration and expand available services. As a result, the relationship between behavioral health services, demographics and community factors, and incarceration rate has not been well addressed. Understanding potential drivers of incarceration, including access to community-based services, is necessary to reduce entry into the legal system and decrease recidivism. This study identifies county-level demographic, socioeconomic, healthcare services availability/accessibility, and criminal legal characteristics that predict per capita jail population across the U.S. More than 10 million individuals pass through U.S. jails each year, increasing the urgency of addressing this challenge. METHODS: The selection of variables for our model proceeded in stages. The study commenced by identifying potential descriptors and then using machine learning techniques to select non-collinear variables to predict county jail population per capita. Beta regression was then applied to nationally available data from all 3,141 U.S. counties to identify factors predicting county jail population size. Data sources include the Vera Institute's incarceration database, Robert Wood Johnson Foundation's County Health Rankings and Roadmaps, Uniform Crime Report, and the U.S. Census. RESULTS: Fewer per capita psychiatrists (z-score = -2.16; p = .031), lower percent of drug treatment paid by Medicaid (-3.66; p < .001), higher per capita healthcare costs (5.71; p < .001), higher number of physically unhealthy days in a month (8.6; p < .001), lower high school graduation rate (-4.05; p < .001), smaller county size (-2.66, p = .008; -2.71, p = .007; medium and large versus small counties, respectively), and more police officers per capita (8.74; p < .001) were associated with higher per capita jail population. Controlling for other factors, violent crime rate did not predict incarceration rate. CONCLUSIONS: Counties with smaller populations, larger percentages of individuals that did not graduate high school, that have more health-related issues, and provide fewer community treatment services are more likely to have higher jail population per capita. Increasing access to services, including mental health providers, and improving the affordability of drug treatment and healthcare may help reduce incarceration rates.

Developing and maintaining intergenerational relationships in an economically vulnerable community: findings from the Flint women's study.

Few studies describe how community disadvantage impacts intergenerational relationships. Using interviews with women and service providers (n = 100), we explored benefits and challenges of intergenerational relationships in Flint, Michigan, an economically vulnerable community. Women valued relationships that increased social connections and generativity; however, few community resources promoted such relationships. Intergenerational relationships were important for leaving a social legacy in lieu of a meaningful economic legacy. Some middle-aged women are overwhelmed by caregiving, balancing employment while caring for multiple generations. Women desired intergenerational activities that include children and younger adult women. Further, caregiving programs should attend to the needs of middle-aged caregivers.

Intersectionality, special populations, needs and suggestions: the Flint Women's study.

BACKGROUND: Equitable access to services that promote health and wellbeing is an important component of social justice. A community-engaged participatory qualitative study was conducted in Flint, Michigan, USA, to understand the needs of special populations (young women, perinatal women and new mothers, older women, women with disabilities, and LGBTQIA women) and elicit their ideas about solutions. METHODS: In-depth interviews (n = 100) were conducted. Participants were either women living in the Flint area, human service providers in the area, or both. A team of community and academic coders analyzed the data using an a priori framework. RESULTS: Participants identified needs of different groups of women and suggested ways to address them. Access to healthy food, reducing healthcare costs, and improving transportation, job opportunities and affordable quality housing were crosscutting themes across all groups of women. Mentoring support was said to protect vulnerable young women from the risk of human trafficking. Older women were said to gain a sense of purpose, build their social support and reduce their loneliness by engaging in mentoring younger women. Women with disabilities were reported to benefit from infrastructure accessibility and authentic inclusion in all areas of life. Providing help that considers their dignity, pride and self-worth were suggested. LGBTQIA women were reported to have housing needs due to discrimination; mostly turned down as renters and can be rejected from faith-based homeless shelters. LGBTQIA women would also benefit from increased sensitivity among healthcare providers. For all groups of women, streamlining access to social services and other resources, building social support networks and increasing awareness about existing resources were recommended. CONCLUSION: Efforts directed towards improving women's health and wellbeing should include perspectives and suggestions of diverse groups of women from the community. Acting on suggestions that emanate from the community's lived experiences may reduce inequalities in health and wellbeing.

The Church Challenge: A community-based multilevel cluster randomized controlled trial to improve blood pressure and wellness in African American churches in Flint, Michigan.

Chronic disease carries high morbidity and mortality in the United States, with large racial and ethnic disparities observed in chronic disease. Physical activity and healthy food are vital for chronic disease prevention yet challenging to access in economically distressed areas. Public health prevention efforts have become particularly prominent within faith-based organizations over the last three decades. This manuscript describes the protocol of the Church Challenge, a multilevel cluster-randomized controlled nutrition and physical activity trial across 24 churches to reduce blood pressure by 6 mmHg among 576 residents in Flint, MI. The Church Challenge was developed using community-based participatory approaches and is rooted in a church-based program developed by and for primarily African-American Flint church congregations. This three-level intervention addresses health at the community (level 3), church (level 2), and individual (level 1) to reduce blood pressure, reduce chronic disease risk, and promote health equity and wellbeing in Flint. Churches are randomized in a 1:1 ratio to a 16-week physical activity and nutrition program or a 4-session health and wellness workshop. Flint is not a unique community but has a history of traumatic community wide events; even now, the public health infrastructure continues to be a challenge and distract residents from focusing on their health. This trial is highly significant and innovative because it uses a combination of evidence-based practices simultaneously supporting health behavior change for individuals and their faith organizations, and evaluates multilevel efforts to sustain long-term health promotion activities in vulnerable communities like Flint.

Randomized cost-effectiveness trial of group interpersonal psychotherapy (IPT) for prisoners with major depression.

OBJECTIVE: This study tested the effectiveness and cost-effectiveness of interpersonal psychotherapy (IPT) for major depressive disorder (MDD) among prisoners. It is the first fully powered randomized trial of any treatment (pharmacological or psychosocial) targeting MDD among incarcerated individuals. METHOD: One hundred eighty-one male (n = 117) and female (n = 64) prisoners from prison facilities in 2 states were randomized to group IPT (delivered by master's-level and nonspecialist prison counselors) for MDD plus prison treatment as usual (TAU) or to TAU alone. Participants' average age was 39 (range = 20-61); 20% were African American and 19% were Hispanic. Outcomes assessed at posttreatment and 3-month follow-up included depressive symptoms (primary; assessed using the Hamilton Rating Scale for Depression), suicidality (assessed with the Beck Scale for Suicide Ideation and Beck Hopelessness Scale), in-prison functioning (i.e., enrollment in correctional programs; discipline reports; aggression/victimization; and social support), remission from MDD, and posttraumatic stress disorder symptoms. RESULTS: IPT reduced depressive symptoms, hopelessness, and posttraumatic stress disorder symptoms, and increased rates of MDD remission relative to prison TAU alone. Effects on hopelessness were particularly strong. Cost per patient was $2,054 including costs for IPT training and supervision or $575 without these costs. For providers running their second or subsequent IPT group, cost per additional week in remission from MDD (relative to TAU alone) was $524 ($148 excluding training and supervision costs, which would not be needed for established programs). CONCLUSIONS: IPT is effective and cost-effective and we recommend its use for MDD among prisoners. It is currently the only treatment for MDD evaluated among incarcerated individuals. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Protocol for the ROSE sustainment (ROSES) study, a sequential multiple assignment randomized trial to determine the minimum necessary intervention to maintain a postpartum depression prevention program in prenatal clinics serving low-income women.

BACKGROUND: More research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women. METHODS: All 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership. DISCUSSION: This study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03267563 . Registered June 14, 2018.

Phosphatidylethanol Levels Among Incarcerated Women: The Influence of Pre-incarceration Alcohol Consumption and Length of Abstinence.

BACKGROUND: Phosphatidylethanol (PEth) is a direct biomarker for alcohol that is formed shortly after alcohol use and may remain detectable in blood for weeks after alcohol consumption. There is little research on alcohol use factors that influence PEth elimination, especially among women. METHODS: Data were collected from 116 alcohol use-disordered women who were recently incarcerated. We used a 2-part model with logistic and linear components to examine whether alcohol consumption in the 2 weeks prior to incarceration and days since last alcoholic drink (operationalized as abstinence days prior to incarceration + days incarcerated) were associated with PEth detectability (>8 ng/ml) and level (ng/ml) in blood. RESULTS: Participants reported drinking an average of 10 drinks per day in the 2 weeks prior to incarceration. Days since last drink was negatively associated with PEth level (odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.93; 0.99) and being PEth detectable (OR = 0.96, 95% CI = 0.91; 0.99). Quantity of alcohol consumed prior to jail admission was associated with PEth detection (OR = 1.08; 95% CI = 1.03; 1.16), but not PEth level. CONCLUSIONS: Days since last alcoholic drink and drinks per day both influenced PEth detectability, but only days since last drink predicted PEth level among a large sample of women with alcohol use disorder in the criminal justice system.

Hazardously Drinking Jailed Women: Post-Release Perceived Needs and Risk of Reincarceration.

Women who drink hazardously face a high risk for re-arrest and reincarceration when they return to their communities after a jail stay. This study is the first to examine the associations between women's own reports of basic needs 1 month after jail release, and reincarceration (defined as spending at least one night in jail) during the next 5 months among unsentenced, female pretrial jail detainees who drink hazardously. Perceived needs for housing (adjusted odds ratio [AOR] = 3.63; p < .01), substance treatment services (AOR = 2.65; p < .01), assistance/benefits (AOR = 2.37; p < .05), and mental health counseling (AOR = 2.07; p < .05) at 1 month after jail release were associated with reincarceration during the next 5 months for the 165 hazardously drinking jailed women in this study. These findings demonstrate that self-reported needs during the high-risk period immediately following jail release are associated with heightened odds of reincarceration among hazardously drinking jailed women.

Study protocol: Hybrid Type I cost-effectiveness and implementation study of interpersonal psychotherapy (IPT) for men and women prisoners with major depression.

PURPOSE: This article describes the protocol for a Hybrid Type I cost-effectiveness and implementation study of interpersonal psychotherapy (IPT) for men and women prisoners with major depressive disorder (MDD). The goal is to promote uptake of evidence-based treatments in criminal justice settings by conducting a randomized effectiveness study that collects implementation data, including a full cost-effectiveness analysis. BACKGROUND: More than 2.3 million people are incarcerated in the United States on any given day. MDD is the most common severe mental illness among incarcerated individuals. Despite the prevalence and consequences of MDD among incarcerated populations, this study will be the first fully-powered randomized trial of any treatment for MDD in an incarcerated population. DESIGN: Given the politically charged nature of the justice system, advantageous health outcomes are often not enough to get an intervention implemented in prisons. To increase the policy impact of this trial, we sought advice from prison providers and administrators about outcomes that would be persuasive to policy-makers and defensible to the public. In this trial, effectiveness questions will be answered using a randomized clinical trial design comparing IPT plus prison treatment as usual (TAU) to TAU alone, with outcomes including depressive symptoms (primary), suicidality, and in prison functioning (enrollment and completion of correctional programs; disciplinary and incident reports; aggression/victimization; social support). Implementation outcomes will include cost-effectiveness; feasibility and acceptability of IPT to clients, providers, and administrators; prison provider intervention fidelity, attitudes, and competencies; and barriers and facilitators of implementation assessed through surveys, interviews, and process notes.

Provider Experiences with Prison Care and Aftercare for Women with Co-occurring Mental Health and Substance Use Disorders: Treatment, Resource, and Systems Integration Challenges.

Incarcerated women with co-occurring mental health and substance use disorders (COD) face complex psychosocial challenges at community reentry. This study used qualitative methods to evaluate the perspectives of 14 prison and aftercare providers about service delivery challenges and treatment needs of reentering women with COD. Providers viewed the needs of women prisoners with COD as distinct from those of women with substance use alone and from men with COD. Providers described optimal aftercare for women with COD as including contact with the same provider before and after release, access to services within 24-72 hours after release, assistance with managing multiple social service agencies, assistance with relationship issues, and long-term follow-up. Providers also described larger service system and societal issues, including systems integration and ways in which a lack of prison and community aftercare resources impacted quality of care and reentry outcomes. Practice and policy implications are provided.

Incarceration history relative to health, substance use, and violence in a sample of vulnerable South African women: implications for health services in criminal justice settings.

International research has suggested that women in the criminal justice system carry a higher burden of many illnesses than women in the community, especially mental health disorders, substance use disorders, sexually transmitted infections, and a history of violent victimization. Knowledge of these health disparities is often used to advocate for relevant screening and treatment services for women passing through criminal justice custody within US and European settings. However, almost all criminal justice health research has taken place in high-income countries, with little or no research taking place in other countries, especially in South Africa. This baseline analysis compares the health, substance use, and violent victimization of women who have ever been incarcerated to those who have not, in a cross-sectional sample of 720 young, vulnerable, substance-using women in Cape Town, South Africa. Results of univariate tests indicated that women who had ever been incarcerated had worse health, mental health, and sexually transmitted infection indicators and were more likely to report use of substances and to have been victims of physical and sexual assault than women who had never been incarcerated. Passing through the criminal justice system appears to be a marker for a variety of current and/or future health service needs among vulnerable South African women, suggesting that screening, prevention, and treatment referral efforts at the time of intersection with the criminal justice system may reduce health burden for these women.