Using policy codesign to achieve multi-sector alignment in adolescent behavioral health: a study protocol.

BACKGROUND: Policymaking is quickly gaining focus in the field of implementation science as a potential opportunity for aligning cross-sector systems and introducing incentives to promote population health, including substance use disorders (SUD) and their prevention in adolescents. Policymakers are seen as holding the necessary levers for realigning service infrastructure to more rapidly and effectively address adolescent behavioral health across the continuum of need (prevention through crisis care, mental health, and SUD) and in multiple locations (schools, primary care, community settings). The difficulty of aligning policy intent, policy design, and successful policy implementation is a well-known challenge in the broader public policy and public administration literature that also affects local behavioral health policymaking. This study will examine a blended approach of coproduction and codesign (i.e., Policy Codesign), iteratively developed over multiple years to address problems in policy formation that often lead to poor implementation outcomes. The current study evaluates this scalable approach using reproducible measures to grow the knowledge base in this field of study. METHODS: This is a single-arm, longitudinal, staggered implementation study to examine the acceptability and short-term impacts of Policy Codesign in resolving critical challenges in behavioral health policy formation. The aims are to (1) examine the acceptability, feasibility, and reach of Policy Codesign within two geographically distinct counties in Washington state, USA; (2) examine the impact of Policy Codesign on multisector policy development within these counties using social network analysis; and (3) assess the perceived replicability of Policy Codesign among leaders and other staff of policy-oriented state behavioral health intermediary organizations across the USA. DISCUSSION: This study will assess the feasibility of a specific approach to collaborative policy development, Policy Codesign, in two diverse regions. Results will inform a subsequent multi-state study measuring the impact and effectiveness of this approach for achieving multi-sector and evidence informed policy development in adolescent SUD prevention and treatment.

Acceptability and feasibility of policy implementation strategies for taxes earmarked for behavioral health services.

Background: This study's aims are to: (1) Compare the acceptability and feasibility of five types of implementation strategies that could be deployed to increase the reach of evidence-based practices (EBPs) with revenue from policies that earmark taxes for behavioral health services, and (2) Illustrate how definitions of implementation strategies and measures of acceptability and feasibility can be used in policy-focused implementation science research. Methods: Web-based surveys of public agency and community organization professionals involved with earmarked tax policy implementation were completed in 2022-2023 (N = 211, response rate = 24.9%). Respondents rated the acceptability and feasibility of five types of implementation strategies (dissemination, implementation process, integration, capacity-building, and scale-up). Aggregate acceptability and feasibility scores were calculated for each type of strategy (scoring range 4-20). Analyses of variance compared scores across strategies and between organizational actor types. Findings: For acceptability, capacity-building strategies had the highest rating (M = 16.3, SD = 3.0), significantly higher than each of the four other strategies, p ≤ . 004), and scale-up strategies had the lowest rating (M = 15.6). For feasibility, dissemination strategies had the highest rating (M = 15.3, significantly higher than three of the other strategies, p ≤ .002) and scale-up strategies had the lowest rating (M = 14.4). Conclusions: Capacity-building and dissemination strategies may be well-received and readily deployed by policy implementers to support EBPs implementation with revenue from taxes earmarked for behavioral health services. Adapting definitions of implementation strategies for policy-focused topics, and applying established measures of acceptability and feasibility to these strategies, demonstrates utility as an approach to advance research on policy-focused implementation strategies.

Measuring Variation in Infant Mortality and Deaths of Despair by U.S. Congressional Districts in Pennsylvania: A Methodological Case Study.

Many ecological studies examine health outcomes and disparities using administrative boundaries such as census tracts, counties, or states. These boundaries help us to understand the patterning of health by place along with impacts of policies implemented at these levels. However, additional geo-political units, or units with both geographic and political meaning, such as congressional districts, present further opportunities to connect research with public policy. We provide a step-by-step guide in how to conduct disparities-focused analysis at the congressional district level, and as an applied case study we use geocoded vital statistics data from 2010-2015 to examine levels and disparities of infant mortality (IM) and deaths of despair (DoD) in the 19 U.S. congressional districts of Pennsylvania for the 111th-112th (2009-2012) Congresses, and 18 districts for the 113th-114th (2013-2016) Congresses. We also provide recommendations for extending congressional district level analysis to other outcomes, states, and geopolitical boundaries such as state legislative districts. Increased surveillance of health outcomes at the congressional district level can help prompt policy action, advocacy, and hopefully, reduce rates and disparities in health.

Impact of U.S. Federal Loan Repayment Programs on the Behavioral Health Workforce: Scoping Review.

OBJECTIVE: Federal loan repayment programs (LRPs) are one strategy to address the shortage of behavioral health providers. This scoping review aimed to identify and characterize the federal LRPs' impact on the U.S. behavioral health workforce. METHODS: A scoping review was conducted in accordance with JBI (formerly known as the Joanna Briggs Institute) methodology for scoping reviews. The authors searched the Ovid MEDLINE, Web of Science, APA PsycInfo, EconLit, PAIS Index, and Embase databases, and gray literature was also reviewed. Two coders screened each article's abstract and full text and extracted study data. Findings were narratively synthesized and conceptually organized. RESULTS: The full-text screening identified 17 articles that met eligibility criteria. Of these, eight were peer-reviewed studies, and all but one evaluated the National Health Service Corps (NHSC) LRP. Findings were conceptually organized into five categories: descriptive studies of NHSC behavioral health needs and the NHSC workforce (k=4); providers' perceptions of, and experiences with, the NHSC (k=2); associations between NHSC funding and the number of NHSC behavioral health providers (k=4); NHSC behavioral health workforce productivity and capacity (k=3); and federal LRP recruitment and retention (k=4). CONCLUSIONS: The literature on federal LRPs and their impact on the behavioral health workforce is relatively limited. Although federal LRPs are an important and effective tool to address the behavioral health workforce shortage, additional federal policy strategies are needed to attract and retain behavioral health providers and to diversify the behavioral health workforce.

Methods and measures to evaluate the impact of participatory model building on public policymakers: a scoping review protocol.

INTRODUCTION: Public policymakers are increasingly engaged in participatory model building processes, such as group model building. Understanding the impacts of policymaker participation in these processes on policymakers is important given that their decisions often have significant influence on the dynamics of complex systems that affect health. Little is known about the extent to which the impacts of participatory model building on public policymakers have been evaluated or the methods and measures used to evaluate these impacts. METHODS AND ANALYSIS: A scoping review protocol was developed with the objectives of: (1) scoping studies that have evaluated the impacts of facilitated participatory model building processes on public policymakers who participated in these processes; and (2) describing methods and measures used to evaluate impacts and the main findings of these evaluations. The Joanna Briggs Institute's Population, Concept, Context framework was used to formulate the article identification process. Seven electronic databases-MEDLINE (Ovid), ProQuest Health and Medical, Scopus, Web of Science, Embase (Ovid), CINAHL Complete and PsycInfo-will be searched. Identified articles will be screened according to inclusion and exclusion criteria and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist for scoping reviews will be used and reported. A data extraction tool will collect information across three domains: study characteristics, methods and measures, and findings. The review will be conducted using Covidence, a systematic review data management platform. ETHICS AND DISSEMINATION: The scoping review produced will generate an overview of how public policymaker engagement in participatory model building processes has been evaluated. Findings will be disseminated through peer-reviewed publications and to communities of practice that convene policymakers in participatory model building processes. This review will not require ethics approval because it is not human subject research.

Revisiting the policy ecology framework for implementation of evidence-based practices in mental health settings.

BACKGROUND: Over the past three decades, policy actors and actions have been highly influential in supporting the implementation of evidence-based practices (EBPs) in mental health settings. An early examination of these actions resulted in the Policy Ecology Framework (PEF), which was originally developed as a tactical primer for state and local mental health regulators in the field of child mental health. However, the policy landscape for implementation has evolved significantly since the original PEF was published. An interrogation of the strategies originally proposed in the PEF is necessary to provide an updated menu of strategies to improve our understanding of the mechanisms of policy action and promote system improvement. OBJECTIVES: This paper builds upon the original PEF to address changes in the policy landscape for the implementation of mental health EBPs between 2009 and 2022. We review the current state of policy strategies that support the implementation of EBPs in mental health care and outline key areas for policy-oriented implementation research. Our review identifies policy strategies at federal, state, agency, and organizational levels, and highlights developments in the social context in which EBPs are implemented. Furthermore, our review is organized around some key changes that occurred across each PEF domain that span organizational, agency, political, and social contexts along with subdomains within each area. DISCUSSION: We present an updated menu of policy strategies to support the implementation of EBPs in mental health settings. This updated menu of strategies considers the broad range of conceptual developments and changes in the policy landscape. These developments have occurred across the organizational, agency, political, and social contexts and are important for policymakers to consider in the context of supporting the implementation of EBPs. The updated PEF expands and enhances the specification of policy levers currently available, and identifies policy targets that are underdeveloped (e.g., de-implementation and sustainment) but are becoming visible opportunities for policy to support system improvement. The updated PEF clarifies current policy efforts within the field of implementation science in health to conceptualize and better operationalize the role of policy in the implementation of EBPs.

Amplifying consumers as partners in dissemination and implementation science and practice.

Background: This Viewpoint argues for consumers (people with lived experience and their families) to be amplified as key partners in dissemination and implementation science and practice. Method: We contend that consumer opinion and consumer demand can be harnessed to influence practitioners and policymakers. Results: Amplifying consumers' voices can improve the fit of evidence-based interventions to the intended end user. We offer recommendations of frameworks to engage consumers in the dissemination and implementation of health interventions. We discuss the primary types of evidence consumers may rely upon, including testimonials and lived experience. Conclusions: Our intention is for this Viewpoint to continue the momentum in dissemination and implementation science and practice of engaging consumers in our work.

Dissemination and implementation science has insufficiently acknowledged the importance of consumers (people with lived experience and their families) as partners in implementation initiatives. In this viewpoint, we highlight the role consumer opinion can play in influencing practitioners' and policymakers' decisions to sustainably implement evidence-based practices. We encourage implementation researchers and practitioners to solicit and respond to consumer perspectives during their implementation efforts.

A Tale of Two Taxes: Implementation of Earmarked Taxes for Behavioral Health Services in California and Washington State.

OBJECTIVE: The authors sought to characterize perceptions of the impacts, attributes, and support for taxes earmarked for behavioral health services and to compare perceptions of the taxes among professionals in California and Washington, two states differing in earmarked tax designs. METHODS: Surveys were completed by 155 public agency and community organization professionals involved in tax implementation in California (N=87) and Washington State (N=68) during 2022-2023 (29% response rate). Respondents indicated their perceptions of the taxes' impacts, attributes, and support. Responses were summed as aggregate scores and were also analyzed as individual items. Bivariate analyses were used to compare responses of professionals in California versus Washington State. RESULTS: Earmarked taxes were generally regarded positively. Of the respondents, >80% strongly agreed that the taxes increased funding for services and were helpful, and only 10% strongly agreed that the taxes decreased behavioral health funding from other sources. Substantially more respondents in California than in Washington State strongly agreed that taxes' reporting requirements were complicated (45% vs. 5%, p<0.001) and that the taxes increased unjustified scrutiny of services or systems (33% vs. 2%, p<0.001). However, more respondents in California than in Washington State also strongly agreed that the taxes increased public awareness about behavioral health (56% vs. 15%, p<0.001) and decreased behavioral health stigma (47% vs. 14%, p<0.001). CONCLUSIONS: Perceptions of the strengths and weaknesses of taxes earmarked for behavioral health services may vary by design features of the tax. Such features include stigma-reduction initiatives and tax spending and reporting requirements.

Using audience segmentation to identify implementation strategies to improve PrEP uptake among at-risk cisgender women: a mixed-methods study protocol.

BACKGROUND: In the USA, 19% of new HIV infections occur among cisgender women (cis women); however, only 10% of eligible cis women have been prescribed pre-exposure prophylaxis (PrEP) for the prevention of HIV infection (an evidence-based intervention). A fundamental challenge for expanding HIV prevention to cis women is ensuring implementation strategies are tailored to the various healthcare settings in which cis women seek care and the heterogeneous providers nested within these settings. This project's specific aims are to (1) explore clinician-level characteristics and organizational climate factors that are related to variability in adoption of PrEP service delivery as an evidence-based intervention for cis women; (2) identify latent audience segments of women's health providers as the related to PrEP acceptability, adoption, and maintenance and analyze demographic correlates of these segments; and (3) identify audience segment-specific implementation strategies to facilitate the adoption of PrEP as an evidence-based intervention among at-risk cis women. METHODS: Using the i-PARIHS framework, this mixed-methods study examines three domains for guiding audience segmentation to facilitate PrEP implementation for cis women: innovation (degree of fit with existing practices, usability), recipient beliefs and knowledge and context factors (organizational culture, readiness for change), needs to determine appropriate facilitation methods. To achieve aim 1, qualitative interviews will be conducted with PrEP-eligible cis women, women's health providers, and other key stakeholders. Aim 2 will consist of a quantitative survey among 340 women's health providers. Latent class analysis will be used to facilitate audience segmentation. To achieve aim 3, a panel of 5-8 providers for each audience segment will meet and engage in iterative discussions guided by Fernandez's implementation mapping to identify (1) implementation outcomes and performance objectives, determinants, and change objectives and (2) determine and refine of implementation strategies for each audience segment. DISCUSSION: This exploratory mixed methods study will provide an empirical foundation to inform the development implementations strategies aimed at increasing PrEP delivery to cis women among heterogenous groups of providers.

Unintended consequences of disseminating behavioral health evidence to policymakers: Results from a survey-based experiment.

Background: Communication research demonstrates that messages often have unintended consequences, but this work has received limited attention in implementation science. This dissemination experiment sought to determine whether state-tailored policy briefs about the behavioral health consequences of adverse childhood experiences (ACEs), compared to national policy briefs on the topic, increased state legislators'/staffers' perceptions of the policy brief relevance and parental blame for the consequences of ACEs, and whether effects differed between Democrats and Republicans. Method: A preregistered, web-based survey experiment with U.S. state legislators/staffers was conducted in 2021 (n = 133). Respondents were randomized to view a policy brief about the behavioral health consequences of ACEs that included state-tailored data (intervention condition) or national data (control condition) and then answered survey questions. Dependent variables were perceived policy brief relevance and parental blame for the consequences of ACEs. Results: The mean policy brief relevance score was 4.1% higher in the intervention than in the control condition (p = .24), but the mean parental blame score was 16.5% higher (p = .02). When outcomes were dichotomized, 61.2% of respondents in the intervention condition rated parents as "very much to blame" for the consequences of ACEs compared to 37.1% in the control condition (p = .01). When the sample was stratified by political affiliation, the effect of the state-tailored policy brief on parental blame was larger in magnitude among Democrats and not significant among Republicans. The intervention policy brief increased the mean parental blame score by 22.8% among Democrats relative to the control policy brief (p = .007) and doubled the proportion rating parents as "very much to blame" (52.2% vs. 26.1%, p = .03). Conclusions: Despite limited statistical power, state-tailored policy briefs significantly increased state legislators'/staffers' perceptions of parental blame for the behavioral health consequences of ACEs, relative to a policy brief with national data. Unintended messaging effects warrant greater attention in dissemination research and practice.

Prior studies have tested the effects of dissemination strategies on policymakers' engagement with research evidence. However, little research has assessed the potential unintended consequences of disseminating evidence to policymakers. This knowledge gap is important because a large body of communication research has found that messages often have negative and unintended effects. This paper adds to the literature on disseminating evidence about behavioral health issues to policymakers. A web-based survey experiment was conducted in which U.S. state legislators/staffers were randomized to view a policy brief about adverse childhood experiences (ACEs) that was tailored to present data from their state (intervention condition) or a policy brief that presented national data and then completed a survey. Legislators/staffers who viewed the state-tailored policy brief perceived the brief as slightly more relevant, but also rated parents as being significantly more to blame for the behavioral health consequence of ACEs. The effect of the state-tailored policy brief on parental blame is an unintended messaging effect that signals cause for caution when disseminating evidence about ACEs to policymakers and other practice audiences. More broadly, the findings highlight a need to consider unintended messaging effects in dissemination research and practice.

Where do psychologists turn to inform clinical decisions? Audience segmentation to guide dissemination strategies.

Background: Audience segmentation is an analysis technique that can identify meaningful subgroups within a population to inform the tailoring of dissemination strategies. We have conducted an empirical clustering audience segmentation study of licensed psychologists using survey data about the sources of knowledge they report most often consulting to guide their clinical decision-making. We identify meaningful subgroups within the population and inform the tailoring of dissemination strategies for evidence-based practice (EBP) materials. Method: Data come from a 2018-2019 web-based survey of licensed psychologists who were members of the American Psychological Association (APA; N = 518, response rate = 29.8%). Ten dichotomous variables assessed sources that psychologists regularly consult to inform clinical decision-making (e.g., colleagues, academic literature, and practice guidelines). We used latent class analysis to identify segments of psychologists who turn to similar sources and named each segment based on the segment's most salient characteristics. Results: Four audience segments were identified: the No-guidelines (45% of psychologists), Research-driven (16%), Thirsty-for-knowledge (9%), and No-reviews (30%). The four segments differed not only in their preferred sources of knowledge, but also in the types of evidence-based posttraumatic stress disorder (PTSD) treatments they provide, their awareness and usage intention of the APA PTSD clinical practice guideline, and attitudes toward clinical practice guidelines. Conclusion: The results demonstrate that licensed psychologists are heterogeneous in terms of their knowledge-seeking behaviors and preferences for knowledge sources. The distinctive characteristics of these segments could guide the tailoring of dissemination materials and strategies to subsequently enhance the implementation of EBP among psychologists.

Audience segmentation is a dissemination strategy that categorizes a group of intended users or audience into meaningful subgroups based on their beliefs, behaviors, and/or other characteristics. Like many other scientific or medical fields, clinical psychology also struggles to use clinically tested psychological treatments (or EBPs) in everyday practice due to practical challenges. To help address such barriers, professional organizations like the American Psychological Association (APA) publish clinical practice guidelines that practitioners can use to learn more about EBPs. However, even these clinical practice guidelines are not often used, so this study employed the audience segmentation analysis to better understand psychologists' diverse attitudes, behaviors, and preferences regarding clinical practice guidelines and other clinical information sources. Our study found four distinct subgroups within approximately 600 APA-registered psychologists based on their preferred source of knowledge: the no-guidelines (45% of psychologists), research-driven (16%), thirsty-for-knowledge (9%), and no-reviews (30%). Each subgroup also varied in the types of evidence-based treatments they provide, as well as their awareness, willingness to use, and attitudes toward clinical practice guidelines. This result shows that licensed psychologists are not a uniform group and that dissemination strategies should be adjusted to each subgroup's characteristics to maximize the effort to increase the use of EBPs among psychologists.

Use, Potential Use, and Awareness of the 988 Suicide and Crisis Lifeline by Level of Psychological Distress.

This cross-sectional study assesses variations in use, potential use, and awareness of the 988 Suicide and Crisis Lifeline among people with varying levels of psychological distress.

Comparing organization-focused and state-focused financing strategies on provider-level reach of a youth substance use treatment model: a mixed-method study.

BACKGROUND: Financial barriers in substance use disorder service systems have limited the widespread adoption-i.e., provider-level reach-of evidence-based practices (EBPs) for youth substance use disorders. Reach is essential to maximizing the population-level impact of EBPs. One promising, but rarely studied, type of implementation strategy for overcoming barriers to EBP reach is financing strategies, which direct financial resources in various ways to support implementation. We evaluated financing strategies for the Adolescent Community Reinforcement Approach (A-CRA) EBP by comparing two US federal grant mechanisms, organization-focused and state-focused grants, on organization-level A-CRA reach outcomes. METHOD: A-CRA implementation took place through organization-focused and state-focused grantee cohorts from 2006 to 2021. We used a quasi-experimental, mixed-method design to compare reach between treatment organizations funded by organization-focused versus state-focused grants (164 organizations, 35 states). Using administrative training records, we calculated reach as the per-organization proportion of trained individuals who received certification in A-CRA clinical delivery and/or supervision by the end of grant funding. We tested differences in certification rate by grant type using multivariable linear regression models that controlled for key covariates (e.g., time), and tested threats to internal validity from our quasi-experimental design through a series of sensitivity analyses. We also drew on interviews and surveys collected from the treatment organizations and (when relevant) interviews with state administrators to identify factors that influenced reach. RESULTS: The overall certification rates were 27 percentage points lower in state-focused versus organization-focused grants (p = .01). Sensitivity analyses suggested these findings were not explained by confounding temporal trends nor by organizational or state characteristics. We did not identify significant quantitative moderators of reach outcomes, but qualitative findings suggested certain facilitating factors were more influential for organization-focused grants (e.g., strategic planning) and certain barrier factors were more impactful for state-focused grants (e.g., states finding it difficult to execute grant activities). DISCUSSION: As the first published comparison of EBP reach outcomes between financing strategies, our findings can help guide state and federal policy related to financing strategies for implementing EBPs that reduce youth substance use. Future work should explore contextual conditions under which different financing strategies can support the widespread implementation of EBPs for substance use disorder treatment.

State Legislator Social Media Posts About the 988 Suicide and Crisis Lifeline.

This cross-sectional study examines the volume and content of state legislator social media posts about the 988 National Suicide and Crisis Lifeline.

Who's "in the room where it happens"? A taxonomy and five-step methodology for identifying and characterizing policy actors.

BACKGROUND: Engaging policy actors in research design and execution is critical to increasing the practical relevance and real-world impact of policy-focused dissemination and implementation science. Identifying and selecting which policy actors to engage, particularly actors involved in "Big P" public policies such as laws, is distinct from traditional engaged research methods. This current study aimed to develop a transparent, structured method for iteratively identifying policy actors involved in key policy decisions-such as adopting evidence-based interventions at systems-scale-and to guide implementation study sampling and engagement approaches. A flexible policy actor taxonomy was developed to supplement existing methods and help identify policy developers, disseminators, implementers, enforcers, and influencers. METHODS: A five-step methodology for identifying policy actors to potentially engage in policy dissemination and implementation research was developed. Leveraging a recent federal policy as a case study-The Family First Prevention Services Act (FFPSA)-publicly available documentation (e.g., websites, reports) were searched, retrieved, and coded using content analysis to characterize the organizations and individual policy actors in the "room" during policy decisions. RESULTS: The five steps are as follows: (1) clarify the policy implementation phase(s) of interest, (2) identify relevant proverbial or actual policymaking "rooms," (3) identify and characterize organizations in the room, (4) identify and characterize policy actors in the "room," and (5) quantify (e.g., count actors across groups), summarize, and compare "rooms" to develop or select engagement approaches aligned with the "room" and actors. The use and outcomes of each step are exemplified through the FFPSA case study. CONCLUSIONS: The pragmatic and transparent policy actor identification steps presented here can guide researchers' methods for continuous sampling and successful policy actor engagement. Future work should explore the utility of the proposed methods for guiding selection and tailoring of engagement and implementation strategies (e.g., research-policy actor partnerships) to improve both "Big P" and "little p" (administrative guidelines, procedures) policymaking and implementation in global contexts.

Four very basic ways to think about policy in implementation science.

BACKGROUND: Policy is receiving increasing attention in the field of implementation science. However, there remains a lack of clear, concise guidance about how policy can be conceptualized in implementation science research. Building on Curran's article "Implementation science made too simple"-which defines "the thing" as the intervention, practice, or innovation in need of implementation support-we offer a typology of four very basic ways to conceptualize policy in implementation science research. We provide examples of studies that have conceptualized policy in these different ways and connect aspects of the typology to established frameworks in the field. The typology simplifies and refines related typologies in the field. Four very basic ways to think about policy in implementation science research. 1) Policy as something to adopt: an evidence-supported policy proposal is conceptualized as "the thing" and the goal of research is to understand how policymaking processes can be modified to increase adoption, and thus reach, of the evidence-supported policy. Policy-focused dissemination research is well-suited to achieve this goal. 2) Policy as something to implement: a policy, evidence-supported or not, is conceptualized as "the thing" and the goal of research is to generate knowledge about how policy rollout (or policy de-implementation) can be optimized to maximize benefits for population health and health equity. Policy-focused implementation research is well-suited to achieve this goal. 3) Policy as context to understand: an evidence-supported intervention is "the thing" and policies are conceptualized as a fixed determinant of implementation outcomes. The goal of research is to understand the mechanisms through which policies affect implementation of the evidence-supported intervention. 4) Policy as strategy to use: an evidence-supported intervention is "the thing" and policy is conceptualized as a strategy to affect implementation outcomes. The goal of research is to understand, and ideally test, how policy strategies affect implementation outcomes related to the evidence-supported intervention. CONCLUSION: Policy can be conceptualized in multiple, non-mutually exclusive ways in implementation science. Clear conceptualizations of these distinctions are important to advancing the field of policy-focused implementation science and promoting the integration of policy into the field more broadly.

County- and state-level immigration policies are associated with Supplemental Nutrition Assistance Program (SNAP) participation among Latino households.

The purpose of this study was to investigate the association between county- and state-level immigrant criminalizing and integrating policies and Latino household participation in the largest safety net program against food insecurity in the U.S., the Supplemental Nutrition Assistance Program (SNAP). Our outcome, county-level proportion of SNAP-participating Latino households, and county-level covariates were obtained from the American Community Survey 1-year county files (N = 675 counties) for 13 years (2007-2019). Our exposures were county-level presence of sanctuary policies and a state-level immigrant friendliness score, created based on 19 immigrant criminalizing and integrating state-level policies obtained from the Urban Institute's State Immigration Policies Resource. We classified every county in the sample as 1) sanctuary policy + immigrant friendly state, 2) sanctuary policy + immigrant unfriendly state, 3) no sanctuary policy + immigrant friendly state, and 4) no sanctuary policy + immigrant unfriendly state. Using multivariable generalized linear models that adjusted for poverty levels and other social composition characteristics of counties, we found that county-level SNAP participation among Latino households was 1.1 percentage-point higher in counties with sanctuary policies (B = 1.12, 95%CI = 0.26-1.98), compared to counties with no sanctuary policies, and 1.6 percentage-point higher in counties with sanctuary policies in immigrant friendly states (B = 1.59, 95%CI = 0.33-2.84), compared to counties with no sanctuary policy in immigrant unfriendly states. Local and state immigration policy, even when unrelated to SNAP eligibility, may influence SNAP participation among Latino households. Jurisdictions which lack sanctuary policies or have more criminalizing and less integrating policies should consider adopting targeted outreach strategies to increase SNAP enrollment among Latino households.

Implementation of the 988 Suicide & Crisis Lifeline: Estimating State-Level Increases in Call Demand Costs and Financing.

BACKGROUND: Per federal law, "988" became the new three-digit dialing code for the National Suicide & Crisis Lifeline on July 16, 2022 (previously reached by dialing "1-800-283-TALK"). AIMS OF THE STUDY: This study aimed to produce state-level estimates of: (i) annual increases in 988 Lifeline call volume following 988 implementation, (ii) the cost of these increases, and (iii) the extent to which state and federal funding earmarked for increases in 988 Lifeline call volume are sufficient to meet call demand. METHOD: A 50 state pre-post policy implementation design was used. State-level Lifeline call volume data were obtained. For each state, we calculated the absolute difference in number of Lifeline calls in the four-month periods between August-November 2021 (pre-988 implementation) and August-November 2022 (post-988 implementation), and also expressed this difference as percent change and rate per 100,000 population. The difference call volume was multiplied by a published estimate of the cost of a single 988 Lifeline call (USD 82), and then by multiplied by three to produce annual, 12-month state-level cost increase estimates. These figures were then divided by each state's population size to generate cost estimates per state resident. State-level information on the amount of state (FY 2023) and federal SAMHSA (FY 2022) funding earmarked for 988 Lifeline centers in response to 988 implementation were obtained from legal databases and government websites and expressed as dollars per state resident. State-level differences between per state resident estimates of increased cost and funding were calculated to assess the extent to which state and federal funding earmarked for increases in 988 Lifeline call volume were sufficient to meet call demand. RESULTS: 988 Lifeline call volume increased in all states post-988 implementation (within-state mean percent change = +32.8%, SD = +20.5%). The total estimated cost needed annually to accommodate increases in 988 Lifeline call volume nationally was approximately USD 46 million. The within-state mean estimate of additional cost per state resident was +USD 0.16 (SD = +USD 0.11). The additional annual cost per state resident exceeded USD 0.40 in three states, was between USD 0.40- USD 0.30 in three states, and between USD 0.30 - USD 0.20 in seven states. Twenty-two states earmarked FY 2023 appropriations for 988 Lifeline centers in response to 988 (within-state mean per state resident = USD 1.51, SD = USD 1.52) and 49 states received SAMHSA 988 capacity building grants (within-state mean per state resident = USD 0.36, SD = USD 0.39). State funding increases exceeded the estimated cost increases in about half of states. CONCLUSIONS: The Lifeline's transition to 988 increased 988 Lifeline call volume in all states, but the magnitude of the increase and associated cost was heterogenous across states. State funding earmarked for increases in 988 Lifeline center costs is sufficient in about half of states. Sustained federal funding, and/or increases in state funding, earmarked for 988 Lifeline centers is likely important to ensuring that 988 Lifeline centers have the capacity to meet call demand in the post-988 implementation environment.