Policies for type 2 diabetes and non-communicable disease management during the COVID-19 pandemic in Kenya and Tanzania: a desk review and views of decision-makers.

BACKGROUND: The COVID-19 pandemic caused disruptions in care that adversely affected the management of non-communicable diseases (NCDs) globally. Countries have responded in various ways to support people with NCDs during the pandemic. This study aimed to identify policy gaps, if any, in the management of NCDs, particularly diabetes, during COVID-19 in Kenya and Tanzania to inform recommendations for priority actions for NCD management during any future similar crises. METHODS: We undertook a desk review of pre-existing and newly developed national frameworks, policy models and guidelines for addressing NCDs including type 2 diabetes. This was followed by 13 key informant interviews with stakeholders involved in NCD decision-making: six in Kenya and seven in Tanzania. Thematic analysis was used to analyse the documents. RESULTS: Seventeen guidance documents were identified (Kenya=10; Tanzania=7). These included pre-existing and/or updated policies/strategic plans, guidelines, a letter, a policy brief and a report. Neither country had comprehensive policies/guidelines to ensure continuity of NCD care before the COVID-19 pandemic. However, efforts were made to update pre-existing documents and several more were developed during the pandemic to guide NCD care. Some measures were put in place during the COVID-19 period to ensure continuity of care for patients with NCDs such as longer supply of medicines. Inadequate attention was given to monitoring and evaluation and implementation issues. CONCLUSION: Kenya and Tanzania developed and updated some policies/guidelines to include continuity of care in emergencies. However, there were gaps in the documents and between policy/guideline documents and practice. Health systems need to establish disaster preparedness plans that integrate attention to NCD care to enable them to better handle severe disruptions caused by emergencies such as pandemics. Such guidance needs to include contingency planning to enable adequate resources for NCD care and must also address evaluation of implementation effectiveness.

Fluctuations in barriers to medication treatment for opioid use disorder prescribing over the course of a one-year external facilitation intervention.

BACKGROUND: The Veterans Health Administration (VHA) is invested in expanding access to medication treatment for opioid use disorder (MOUD) to save lives. Access varies across VHA facilities and, thus, requires implementation strategies to promote system-wide adoption of MOUD. We conducted a 12-month study employing external facilitation that targeted MOUD treatment among low-adopting VHA facilities. In this study, we sought to evaluate the patterns of perceived barriers over 1 year of external implementation facilitation using the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. METHODS: We randomly selected eight VHA facilities from the bottom quartile of the proportion of Veterans with an OUD diagnosis receiving MOUD (< 21%). The 1-year external implementation intervention included developmental evaluation to tailor the facilitation, an on-site visit, and monthly facilitation calls. Facilitators recorded detailed notes for each call on a structured template. Qualitative data was analyzed by coding and mapping barriers to the constructs in the i-PARIHS framework (Innovation, Recipients, Context). We identified emerging themes within each construct by month. RESULTS: Barriers related to the Innovation, such as provider perception of the need for MOUD in their setting, were minimal throughout the 12-month study. Barriers related to Recipients were predominant and fluctuated over time. Recipient barriers were common during the initial months when providers did not have the training and waivers necessary to prescribe MOUD. Once additional providers (Recipients) were trained and waivered to prescribe MOUD, Recipient barriers dropped and then resurfaced as the facilities worked to expand MOUD prescribing to other clinics. Context barriers, such as restrictions on which clinics could prescribe MOUD and fragmented communication across clinics regarding the management of patients receiving MOUD, emerged more prominently in the middle of the study. CONCLUSIONS: VHA facilities participating in 12-month external facilitation interventions experienced fluctuations in barriers to MOUD prescribing with contextual barriers emerging after a facilitated reduction in recipient- level barriers. Adoption of MOUD prescribing in low-adopting VHA facilities requires continual reassessment, monitoring, and readjustment of implementation strategies over time to meet challenges. Although i-PARIHS was useful in categorizing most barriers, the lack of conceptual clarity was a concern for some constructs.

Emergency Department Utilization for Substance Use-Related Disorders and Assessment of Treatment Facilities in New York State, 2011-2013.

BACKGROUND: Annually, 1.8 million New York (NY) residents experience substance use disorders (SUDs). Even though emergency departments (EDs) continue to experience high numbers of SUD-related visits, only 15% receive treatment. OBJECTIVES: This study estimates hospital-based EDs rates for SUDs in the State of New York. Also, the geographic distribution of substance use treatment centers and EDs are mapped to correlate utilization with access to care. METHODS: The 2011-2013 Healthcare Cost and Utilization Project's NY State Emergency Department Database provided information on utilization of services in EDs, charges, diagnoses, and discharge, as well as patient demographic variables. All patients within NY who had visited the ED for SUDs comprised the study population. Geographic mapping of EDs and substance abuse treatment centers at the county-level is based on data from the National Emergency Department Inventory and National Survey of Substance Abuse Treatment Services, respectively. RESULTS: A total of 492,419 ED visits for SUDs were reported through 2011-2013. Despite NY's Medicaid expansion in 2012, ED visits increased in 2013. About $856 million was spent in treating SUDs in EDs, with average charge of $1,764 per visit. Conclusions/Importance: Alcohol and drug-induced mental disorders are increasingly prevalent in New York's EDs. There is a need to develop health policies and programs to improve access to care for SUDs in urban states.

Non-communicable disease prevention policy process in five African countries.

BACKGROUND: The increasing burden of non-communicable diseases (NCDs) in sub-Saharan Africa is causing further burden to the health care systems that are least equipped to deal with the challenge. Countries are developing policies to address major NCD risk factors including tobacco use, unhealthy diets, harmful alcohol consumption and physical inactivity. This paper describes NCD prevention policy development process in five African countries (Kenya, South Africa, Cameroon, Nigeria, Malawi), including the extent to which WHO "best buy" interventions for NCD prevention have been implemented. METHODS: The study applied a multiple case study design, with each country as a separate case study. Data were collected through document reviews and key informant interviews with national-level decision-makers in various sectors. Data were coded and analyzed thematically, guided by Walt and Gilson policy analysis framework that examines the context, content, processes and actors in policy development. RESULTS: Country-level policy process has been relatively slow and uneven. Policy process for tobacco has moved faster, especially in South Africa but was delayed in others. Alcohol policy process has been slow in Nigeria and Malawi. Existing tobacco and alcohol policies address the WHO "best buy" interventions to some extent. Food-security and nutrition policies exist in almost all the countries, but the "best buy" interventions for unhealthy diet have not received adequate attention in all countries except South Africa. Physical activity policies are not well developed in any study countries. All have recently developed NCD strategic plans consistent with WHO global NCD Action Plan but these policies have not been adequately implemented due to inadequate political commitment, inadequate resources and technical capacity as well as industry influence. CONCLUSION: NCD prevention policy process in many African countries has been influenced both by global and local factors. Countries have the will to develop NCD prevention policies but they face implementation gaps and need enhanced country-level commitment to support policy NCD prevention policy development for all risk factors and establish mechanisms to attain better policy outcomes while considering other local contextual factors that may influence policy implementation such as political support, resource allocation and availability of local data for monitoring impacts.

Influence of the WHO framework convention on tobacco control on tobacco legislation and policies in sub-Saharan Africa.

BACKGROUND: The World Health Organization's Framework Convention on Tobacco Control, enforced in 2005, was a watershed international treaty that stipulated requirements for signatories to govern the production, sale, distribution, advertisement, and taxation of tobacco to reduce its impact on health. This paper describes the timelines, context, key actors, and strategies in the development and implementation of the treaty and describes how six sub-Saharan countries responded to its call for action on tobacco control. METHODS: A multi-country policy review using case study design was conducted in Cameroon, Kenya, Nigeria, Malawi, South Africa, and Togo. All documents related to the WHO Framework Convention on Tobacco Control and individual country implementation of tobacco policies were reviewed, and key informant interviews related to the countries' development and implementation of tobacco policies were conducted. RESULTS: Multiple stakeholders, including academics and activists, led a concerted effort for more than 10 years to push the WHO treaty forward despite counter-marketing from the tobacco industry. Once the treaty was enacted, Cameroon, Kenya, Nigeria, Malawi, South Africa, and Togo responded in unique ways to implement tobacco policies, with differences associated with the country's socio-economic context, priorities of country leaders, industry presence, and choice of strategies. All the study countries except Malawi have acceded to and ratified the WHO tobacco treaty and implemented tobacco control policy. CONCLUSIONS: The WHO Framework Convention on Tobacco Control provided an unprecedented opportunity for global action against the public health effects of tobacco including non-communicable diseases. Reviewing how six sub-Saharan countries responded to the treaty to mobilize resources and implement tobacco control policies has provided insight for how to utilise international regulations and commitments to accelerate policy impact on the prevention of non-communicable diseases.

Assessment of the multi-sectoral approach to tobacco control policies in South Africa and Togo.

BACKGROUND: Tobacco use is the world's leading preventable cause of illness and death and the most important risk factor for non-communicable diseases (NCDs), particularly cardiovascular and chronic respiratory diseases (heart attack, stroke, congestive obstructive pulmonary disease, and lung cancer). Tobacco control is one of the World Health Organization's "best-buys" interventions to prevent NCDs. This study assessed the use of a multi-sectoral approach (MSA) in developing and implementing tobacco control policies in South Africa and Togo. METHODS: This two-country case study consisted of a document review of tobacco control policies and of key informant interviews (N = 56) about the content, context, stakeholders, and strategies employed throughout policy formulation and implementation in South Africa and Togo. To guide our analysis, we used the Comprehensive Framework for Multi-Sectoral Approach to Health Policy, which is built around four major constructs of context, content, stakeholders and strategies. RESULTS: The findings show that the formulation of tobacco control policies in both countries was driven locally by the political, historical, social and economic contexts, and globally by the adoption WHO Framework Convention on Tobacco Control (FCTC). In both countries, the health department led policy formulation and implementation. The stakeholders involved in South Africa were more diverse, proactive and dynamic than those in Togo, whereas the strategies employed were more straightforward in Togo than in South Africa. The extent of understanding and use of MSA in both countries consisted of an inter-sectoral action for health, whereby the health department strove to collaborate with other sectors within and outside the government. Consequently, information sharing was identified as the main outcome of the interactions between institutions and interest groups within and across three critical sectors of the state, namely the public (government), the private and the civil society. CONCLUSION: Tobacco control policies in South Africa and Togo were formulated and implemented from an inter-sectoral approach perspective, which relied heavily on information transfer between stakeholders and less on collaborative problem-solving approach. Incorporation of multiple stakeholders allowed both countries to formulate policies to meet FCTC goals for tobacco control and NCD reduction.

Recommendations for Writing Successful Grant Proposals: An Information Synthesis.

PURPOSE: To provide a detailed account of the nature and scope of recommendations for promoting faculty grant proposal success in academic medical settings. METHOD: The authors searched relevant scientific databases for articles related to techniques that promote faculty research proposal success, published from 2000 through June 1, 2012. They applied standard information synthesis procedures for sifting abstracts, scrutinizing full texts, and abstracting data. RESULTS: The search identified 1,130 abstracts, which the authors narrowed to 83 for in-depth review. Of these, 53 unique articles fit the inclusion criteria. From these articles, the authors extracted 10 recommendations for writing successful grant proposals: (1) research and identify appropriate funding opportunities; (2) use key proposal components to persuade reviewers of project significance and feasibility; (3) describe proposed activities and their significance persuasively, clearly, and concisely; (4) seek review and feedback from colleagues; (5) establish a study design that is simple, logical, feasible, and appropriate for the research questions; (6) develop a timeline for the proposal process; (7) select a novel, high-impact project; (8) conduct an exhaustive literature review; (9) ensure that budgets are reasonable; and (10) consider interdisciplinary collaborations. CONCLUSIONS: These findings highlight that further institution-level development and interventions to support faculty grant writing success are warranted. Future research should employ more rigorous evaluation methods to move the field toward a stronger evidence base for determining which specific faculty development activities help increase funding.

The effects of prior authorization policies on medicaid-enrolled children's use of antipsychotic medications: evidence from two mid-Atlantic states.

OBJECTIVE: The purpose of this study was to examine the impact of prior authorization policies on the receipt of antipsychotic medication for Medicaid-enrolled children. METHODS: Using de-identified administrative Medicaid data from two large, neighboring, mid-Atlantic states from November 2007 through June 2011, we identified subjects <18 years of age using antipsychotics, from the broader group of children and adolescents receiving behavioral health services or any psychotropic medication. Prior authorization for antipsychotics was required for children in State A <6 years of age from September 2008, and for children <13 years of age from August 2009. No such prior authorizations existed in State B during that period. Filled prescriptions were identified in the data using national drug codes. Using a triple-difference strategy (using differences among the states, time periods, and differences in antidepressant prescribing rates among states over the same time periods), we examined the effect of the prior authorization policy on the rate at which antipsychotic prescriptions were filled for Medicaid-enrolled children and adolescents. RESULTS: The impact of prior authorization policies on antipsychotic medication use varied by age: Among 6-12 year old children, the impact of the prior authorization policy on antipsychotic medication prescribing was a modest but statistically significant decrease of 0.47% after adjusting for other factors; there was no effect of the prior authorization among children 0-5 years. CONCLUSIONS: Prior authorization policies had a modest but statistically significant effect on antipsychotic use in 6-12 year old children, but had no impact in younger children. Future research is needed to understand the utilization and clinical effects of prior authorization and other policies and interventions designed to influence antipsychotic use in children.

Transitioning between systems of care: missed opportunities for engaging adults with serious mental illness and criminal justice involvement.

Individuals with serious mental illness are overrepresented in the criminal justice system and face difficulties accessing mental health services both during incarceration and upon re-entry into the community. This study examines how such individuals describe their experiences receiving care both during and after their time in custody and explores the perspectives of mental health service providers who treat this population upon re-entry. Semi-structured interviews were conducted with 43 individuals identified as having a history of serious mental illness and criminal justice involvement, as well as with 25 providers who have worked with this population. Clients noted the stress of transitioning to criminal justice settings, the uneven availability of services within jail and prison, and the significant challenges faced upon re-entry. Providers reported barriers to working with this population, including minimal coordination with the criminal justice system and challenging behaviors and attitudes on the part of both clients and providers. Findings identify potential target areas for improved care coordination as well as for additional provider education regarding the unique needs of this population.

Improving quality of care in substance abuse treatment using five key process improvement principles.

Process and quality improvement techniques have been successfully applied in health care arenas, but efforts to institute these strategies in alcohol and drug treatment are underdeveloped. The Network for the Improvement of Addiction Treatment (NIATx) teaches participating substance abuse treatment agencies to use process improvement strategies to increase client access to, and retention in, treatment. NIATx recommends five principles to promote organizational change: (1) understand and involve the customer, (2) fix key problems, (3) pick a powerful change leader, (4) get ideas from outside the organization, and (5) use rapid cycle testing. Using case studies, supplemented with cross-agency analyses of interview data, this paper profiles participating NIATx treatment agencies that illustrate successful applications of each principle. Results suggest that organizations can successfully integrate and apply the five principles as they develop and test change strategies, improving access and retention in treatment, and agencies' financial status. Upcoming changes requiring increased provision of behavioral health care will result in greater demand for services. Treatment organizations, already struggling to meet demand and client needs, will need strategies that improve the quality of care they provide without significantly increasing costs. The five NIATx principles have potential for helping agencies achieve these goals.

Substance abuse treatment programs' data management capacity: an exploratory study.

Despite treatment improvement and performance management imperatives, little research describes the data management capacity of substance abuse treatment programs, and useful metrics are not available to gauge capacity. This exploratory study evaluates clinical and administrative data management at eight substance abuse treatment programs in four US states to identify factors for developing an appropriate metric. Findings indicate that programs tend to manage data inefficiently and have few protocols guiding information management. Barriers to better data management included lack of integrated information technology (IT) systems; limited funding, time, and staff for developing and implementing IT-related changes; and divergent staff skills in and attitudes toward IT. This snapshot of substance abuse treatment programs' data management capabilities suggests a need for a metric to examine data management capability in these settings. Infusion of expertise, training, and funding are needed to improve substance abuse treatment programs' IT-related systems and data management processes.

Health disparities between women with and without disabilities: a review of the research.

As part of a women's health center project, we reviewed 16 years of research to examine health disparities between women with and without disabilities. We reviewed MEDLINE-indexed articles between 1990 and 2005 with data on women with and without physical, sensory, intellectual, developmental, or psychiatric disabilities. Our review found few articles examining health disparities in chronic disease, cancer, mental health and substance abuse, preventive screening, health-promoting behaviors, and health services utilization. Results reflect apparent health disparities between women with and without disabilities. Challenges for the field exist in standardizing disability definitions and determining a future course for health disparity research and policy.

Women's health policies associated with obesity, diabetes, high blood pressure, and smoking: a follow-up on the women's health report card.

This study sought to elucidate associations between state-level policies related to women's health and state prevalence of obesity, smoking, high blood pressure, and diabetes among women. Using data from national sources compiled for Making the Grade on Women's Health: A National and State-by-State Report Card, state policies on key women's health issues were evaluated on the degree to which policies adequately protected women's health. Blocked regressions assessed the policies associated with state outcomes. Antidiscrimination policies were prominent for high blood pressure, smoking, and obesity; models accounted for significant variance for all outcomes. State policies that support women may improve women's health.

Preparing to implement medication algorithms: staff perspectives and system infrastructure.

To assess the readiness of mental health facilities in Oregon to implement medication algorithms using the Medication Management Approaches in Psychiatry toolkit (MedMAP) developed by the Substance Abuse and Mental Health Services Administration (SAMHSA), researchers conducted interviews with 68 clinical and administrative employees of four inpatient and four outpatient mental health facilities in Oregon. Respondents had generally positive opinions about the algorithms, but they also expressed many concerns about logistics and implementation, chiefly related to medication selection and expected restrictions on choices for prescribing providers and patients. In implementing medication algorithms, it may be beneficial to assess staff perspectives as well as the capabilities of the program's infrastructure. The extent to which staff concerns, values, and needs are anticipated and promptly and responsively addressed is likely have a major influence on successful implementation.

Patterns of atypical antipsychotic subtherapeutic dosing among Oregon Medicaid patients.

OBJECTIVE: To examine a cohort of Medicaid patients with new prescriptions for atypical antipsychotic medication to determine the prevalence of subtherapeutic atypical antipsychotic medication use and to identify patient and prescribing provider characteristics associated with occurrence of subtherapeutic use. METHOD: This observational cohort study examined Medicaid administrative claims data for patients aged 20 to 64 years with a new prescription for an atypical antipsychotic medication (clozapine, olanzapine, quetiapine, risperidone, ziprasidone) between January 1, 2004, and December 31, 2004. Patient diagnostic information was identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes on submitted medical claims. Patient characteristics, prescribing provider characteristics, length of therapy, and dosing were examined. A logistic regression assessed the probability of subtherapeutic dosing. RESULTS: Among 830 individuals in our sample who began treatment with an atypical antipsychotic, only 15% had a documented diagnosis of schizophrenia, subtherapeutic dosing was common (up to 86% of patients taking quetiapine), and 40% continued less than 30 days with the index prescription. A logistic model indicated that a general practitioner as prescribing provider, length of therapy equal to or less than 30 days, and prescription of quetiapine were significantly associated with a subtherapeutic dose (p < .001, p = .028, and p < .001, respectively). CONCLUSIONS: These results suggest that there is extensive use of expensive atypical antipsychotic medications for off-label purposes such as sedation or for other practice patterns that should be explored further. Approaches that minimize off-label atypical antipsychotic use could be of considerable value to Medicaid programs. In addition, these findings support the need for the introduction or increased use of utilization monitoring and the implementation of medication practice guidelines as appropriate decision support for prescribing providers.

Process improvement needs in substance abuse treatment: admissions walk-through results.

Researchers have questioned whether the addiction treatment infrastructure will be able to deliver high-quality care to the large numbers of people in need. In this context, the Robert Wood Johnson Foundation and the Center for Substance Abuse Treatment created a nationwide network to improve access and retention in treatment. Applicant agencies described results of an admission process walk-through. This qualitative study used narrative text from 327 applications to the Robert Wood Johnson Foundation, focusing on admissions-related problems. We developed and applied a coding scheme and then extracted themes from code-derived text. Primary themes described problems reported during treatment admissions: poor staff engagement with clients; burdensome procedures and processes; difficulties with addressing the clients' complex lives and needs; and infrastructure problems. Subthemes elucidated specific process-related problems. Although the findings from our analyses are descriptive and exploratory, they suggest the value of walk-through exercises for program assessment and program-level factors that may affect treatment access and retention.

Addiction treatment agencies' use of data: a qualitative assessment.

Addiction treatment agencies typically do not prioritize data collection, management, and analysis, and these agencies may have barriers to integrating data in agency quality improvement. This article describes qualitative findings from an intervention designed to teach 23 addiction treatment agencies how to make data-driven decisions to improve client access to and retention in care. Agencies demonstrated success adopting process improvement and data-driven strategies to make improvements in care. Barriers to adding a process improvement and data-driven focus to care included a lack of a data-based decision making culture, lack of expertise and other resources, treatment system complexity, and resistance. Factors related to the successful adoption of process-focused data include agency leadership valuing data and providing resources, staff training on data collection and use, sharing of change results, and success in making data-driven decisions.

Relating health policy to women's health outcomes.

Individuals' social and economic circumstances, including socioeconomic status and medical care availability, are central to health outcomes, particularly for women. These factors are often mediated by governmental policies. This exploratory study found associations between women's health outcomes and state-level policies related to women's health. Outcomes were mortality rates for four leading causes of death for women in the US (heart disease, stroke, lung cancer, and breast cancer), infant mortality, and a mental health outcome variable. State policies on key women's health issues were evaluated on the degree to which they adequately protected women's health. Our regression models accounted for significant variance in mortality rates and substantial variance in the mental health outcome. Policies affecting access to care (Medicaid eligibility and efforts to expand Medicaid) and community (environmental health tracking and violence against women) were significantly associated with mortality outcomes. State health policies should be examined further for their relationship to health outcomes.

"Being in a funk": teens' efforts to understand their depressive experiences.

Although there is literature about adults' experiences of depression, little research has focused on teenagers' experiences. In this article, the authors describe how a sample of adolescents makes sense of depression and responds to a depression diagnosis. Twenty-two adolescents participated in in-depth individual or focus group interviews. Teens discussed their experiences with depression and getting health care for depression, and described a trajectory similar to that found among adults: a slow growth of distress, a time of being in a funk, and a time of consideration of whether they are depressed. Teens who received a diagnosis from a medical provider then sought to make sense of their depression. Teens understood a depression diagnosis as a helpful label, a chronic medical problem, or a significant part of their identity. Understanding the subjective experience of adolescents who are depressed might increase health care providers'empathy and improve their communication with teens.