Safeguarding Research Using Federal Health Insurance Data.

This Viewpoint discusses the importance of researcher access to federal health care data following a CMS decision to limit the use of physical data and proposes solutions to maintain access and security.

Access to perinatal doula services in Medicaid: a case analysis of 2 states.

Doula services support maternal and child health, but few Medicaid programs reimburse for them. Through qualitative interviews with key policy informants (n = 20), this study explored facilitators and barriers to Medicaid reimbursement through perceptions of doula-related policies in 2 states: Oregon, where doula care is reimbursed, and Massachusetts, where reimbursement is pending. Five themes characterize the inclusion of doula services in Medicaid. In Theme 1, stakeholders recognized an imperative to expand access to doula services. Subsequent themes represent complications in accomplishing that imperative. In Theme 2, perceptions that doula services were not valued by health care providers resulted in conflict between doulas and the health care system. In Theme 3, complex billing processes created friction and impeded reimbursement. In Theme 4, internal conflict presented barriers to policymaking. In Theme 5, structural fragmentation between state government and doula communities was prominent in Massachusetts, presenting tensions during policymaking. Informants reported on problems demanding resolution to establish equitable and robust doula care policies. Medicaid coverage of doula services requires ongoing collaboration with doulas, providers, and health care advocates.

Evaluating Success and Challenges of a Primary Care Youth Mental Health Programme Using Complexity, Implementation Science, and Appreciative Inquiry.

Background Using an innovative framework of complexity and implementation science, with underpinning core values of appreciative inquiry (CIS-A), this paper describes the evaluation of a pilot service in New Zealand aiming to deliver integrated psychological therapy services within primary care, to young people (aged 18-24) experiencing mild to moderate mental distress. Method Using mixed quantitative and qualitative methods and multiple data sources, there was a strong focus on local innovation and co-design with service users, young people and multiple care providers. Data is drawn from service users, stakeholders and providers of the service in three areas of the lower North Island of New Zealand.  Results The Piki pilot provided a significant and innovative enhancement of mental health care to this population. The service supported 5307 individuals with a range of therapy options, with the majority having between one and three therapy sessions. From 730 service users who completed a survey, 591 (81%) were 'very satisfied' with the service provided. The CIS-A framework was used successfully to provide rapid feedback and encourage adaptation to evolving issues. These included unexpected workload pressures, changes to therapy delivery, the integration of co-design and prioritising the needs of vulnerable groups. There was a successful incorporation of youth/service user input to co-design the programme, introduction of a peer-to-peer support service, and integration of a digital resource platform. The framework was also used to address challenges encountered and to support necessary adaptations in response to the COVID-19 pandemic.  Conclusions We describe the use of an embedded evaluation to support and inform the implementation of a novel and innovative youth mental health programme. Complexity and implementation science, underpinned by the core values of appreciative inquiry (CIS-A), were successfully utilised providing potential learning that can be applied locally, nationally and internationally. This study has a focus on youth mental health but the principles and utility of applying a complexity and implementation science approach have application in many different health care settings. The use of a framework such as CIS-A can support complex innovation and implementation and can be used to enable rapid course correction and turn 'hindsight to foresight'.

Extended Postpartum Medicaid In Colorado Associated With Increased Treatment For Perinatal Mood And Anxiety Disorders.

Perinatal mood and anxiety disorders (PMAD), a leading cause of perinatal morbidity and mortality, affect approximately one in seven births in the US. To understand whether extending pregnancy-related Medicaid eligibility from sixty days to twelve months may increase the use of mental health care among low-income postpartum people, we measured the effect of retaining Medicaid as a low-income adult on mental health treatment in the postpartum year, using a "fuzzy" regression discontinuity design and linked all-payer claims data, birth records, and income data from Colorado from the period 2014-19. Relative to enrolling in commercial insurance, retaining postpartum Medicaid enrollment was associated with a 20.5-percentage-point increase in any use of prescription medication or outpatient mental health treatment, a 16.0-percentage-point increase in any use of prescription medication only, and a 7.3-percentage-point increase in any use of outpatient mental health treatment only. Retaining postpartum Medicaid enrollment was also associated with $40.84 lower out-of-pocket spending per outpatient mental health care visit and $3.24 lower spending per prescription medication for anxiety or depression compared with switching to commercial insurance. Findings suggest that extending postpartum Medicaid eligibility may be associated with higher levels of PMAD treatment among the low-income postpartum population.

Equity and unmet need of non-communicable diseases services in Saudi Arabia using a National Household Survey (2019).

BACKGROUND: Saudi Arabia is implementing a comprehensive health system transformation in health services provision, governance, and financing. Given the high burden of non-communicable diseases (NCD), a key objective of the transformation is to integrate NCD prevention and treatment into primary care. The study objectives were to assess primary care service use for treatment of NCDs, to quantify existing inequities in preventive services utilization, and to identify regional and sociodemographic factors associated with these inequities. METHODS: Using the 2019 Kingdom of Saudi Arabia World Health Survey, multivariable logistic regression models were conducted to identify predictors of utilization of primary care services for NCD prevention and treatment, unmet need among those with a diagnosis of diabetes, hypertension, or dyslipidemia, and unmet need in breast and cervical cancer screening. RESULTS: Among those with an NCD diagnosis, living in a high-income household was associated with a lower probability of having an unmet need compared to those in low-income households. Furthermore, rural residents were less likely to have an unmet need compared to urban residents (OR 0.58, p=0.029). Individuals without a perceived need for healthcare within the last 12 months had three times the probability of unmet need in comparison to those with such a perceived need (p<0.001). Women in all regions had a lower probability of ever having a mammogram compared to women in the central regions around Riyadh. Women with an education above a secondary level had five times the odds of undergoing cervical cancer screening and three times the likelihood of ever having a mammogram (P=0.012, p=0.02) than other women. Compared to women in low-income households, those in middle (OR 1.99, P=0.026), upper middle (OR 3.47, p<0.001), or high-income households (OR 2.59, p<0.001) had a higher probability of having had cervical cancer screening. CONCLUSIONS: Inequities in NCD treatment and prevention services' utilization in Saudi Arabia are strongly associated with region of living, population density, wealth, income, education and perceived need for health care. More research is needed to better understand the extent of unmet primary care needs for NCD and how to address the underlying contributing factors to access inequities.

COVID-19 Medicaid Continuous Enrollment Provision Yielded Gains In Postpartum Continuity Of Coverage.

The Medicaid continuous enrollment provision mandated by the Families First Coronavirus Response Act of 2020 effectively prohibited the termination of enrollees from Medicaid during the COVID-19 public health emergency, including people enrolled in Medicaid during pregnancy. Using data from the Transformed Medicaid Statistical Information System, we found that the rate of continuous Medicaid enrollment during the twelve months postpartum increased from 59.3 percent for births during March-December 2018 to 90.7 percent for births during March-December 2020, when the public health emergency was in effect. This corresponds to approximately 430,000 fewer people losing Medicaid coverage after pregnancy and an average of more than 2.5 months of additional postpartum enrollment. These findings indicate that states that have extended or that plan to extend pregnancy-related Medicaid eligibility in the postpartum year are likely to experience significant gains in continuity of coverage.

A phase 1 study of regorafenib and sildenafil in adults with advanced solid tumors.

The purpose of this study is to establish the recommended phase 2 dose for regorafenib in combination with sildenafil for patients with advanced solid tumors. Secondary outcomes included identification of antitumor effects of regorafenib and sildenafil, toxicity of the combination, determination of PDE5 expression in tumor samples, and the impact of sildenafil on the pharmacokinetics of regorafenib. This study was a phase 1, open-label single-arm dose-escalation trial using a 3 + 3 design. Additional patients were enrolled at the maximum tolerated dose (MTD) until a total of 12 patients were treated at the MTD. A total of 29 patients were treated in this study. The median duration of treatment was 8 weeks. The recommended phase 2 doses determined in this study are regorafenib 160 mg daily with sildenafil 100 mg daily. The most common toxicities included palmar-plantar erythrodysesthesia syndrome (20 patients, 69%) and hypophosphatemia (18 patients, 62%). Two patients (7%) experienced grade 4 lipase increase. Objective responses were not observed; however, 14 patients (48%) had a period of stable disease during the study. Stable disease for up to 12 months was observed in patients with ovarian cancer as well as up to 20 months for a patient with cervical cancer. The combination of regorafenib and sildenafil at the recommended phase 2 dose is safe and generally well tolerated. Disease control in patients with gynecologic malignancies was especially encouraging. Further evaluation of the combination of regorafenib and sildenafil in gynecologic malignancies is warranted. Clinical Trial Registration Number: NCT02466802.

It takes it out of the textbook: Benefits of and barriers to expert by experience involvement in pre-registration mental health nursing education.

WHAT IS KNOWN ON THE SUBJECT?: Service user involvement in mental health nursing education is beneficial in terms of attitudinal change to reduce stigma, clinical skill development and enhancing understandings of recovery-oriented practice. Service users as experts by experience have not been embedded within pre-registration nursing programs. Consequently, they remain limited in number, ad hoc and frequently tokenistic. Nurse academics responsible for the design and delivery of pre-registration mental health nursing curricula have a potentially important role in facilitating expert by experience involvement in mental health nursing education. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: Nurse academics teaching mental health nursing have generally favourable views about the importance of expert by experience involvement. Nurse academics experience significant barriers in supporting the implementation of academic positions for experts by experience, particularly in obtaining funding. The experts by experience could contribute to mental health nursing education does not appear to be clearly understood by nurse academics. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health services aspire to adopt a recovery-oriented approach to practice. Involving experts by experience in mental health nursing education can facilitate increased understanding and appreciation of recovery-oriented practice. Nurse academics could play an important role in supporting the implementation of experts by experience positions in nursing academia. To do so, they require an understanding of the benefits of EBE involvement in academia and the barriers that can be encountered when attempting to facilitate the implementation of such positions. Experts by experience contribute unique expertise, essential to the development of quality mental health services. Conveying this expertise through the educating the future nursing workforce in mental health is essential. ABSTRACT: INTRODUCTION: Involving service users in mental health nursing education is ad hoc and minimal, despite growing evidence of its benefits. Insights and experiences of nurse academics teaching mental health to pre-registration students have been underrepresented in the research to date. AIM: To seek insights and experiences of nurse academics involved in designing and delivering pre-registration mental health nursing education in Australian universities regarding involving service users in mental health nursing education. METHODS: A descriptive qualitative study involving 19 nurse academics from 13 Australian universities, involved in pre-registration mental health nursing education. Data were analysed thematically. RESULTS: Participants reported minimal service user involvement. Most sought an increase and identified barriers. Data analysis resulted in five identified themes: (1) value-rich, (2) resource-poor, (3) imperfect processes, (4) 'part, but not all' and (5) unrecognised worth. CONCLUSIONS: Increasing meaningful involvement of service-users in mental health nursing education requires support and investment from multiple stakeholders. Nurse academics are crucial stakeholders in understanding the unique expertise service users bring. IMPLICATIONS FOR PRACTICE: Service users being central to all aspects of mental health services requires their active participation in the education of health professionals. Nurse academics have an important role in realising this goal.

Assembly of FAP93 at the proximal axoneme in Chlamydomonas cilia.

To identify proteins specific to the proximal ciliary axoneme, we used iTRAQ to compare short (~2 µm) and full-length (~11 µm) axonemes of Chlamydomonas. Known compoents of the proximal axoneme such as minor dynein heavy chains and LF5 kinase as well as the ciliary tip proteins FAP256 (CEP104) and EB1 were enriched in short axonemes whereas proteins present along the length of the axoneme were of similar abundance in both samples. The iTRAQ analysis revealed that FAP93, a protein of unknown function, and protein phosphatase 2A (PP2A) are enriched in the short axonemes. Consistently, immunoblots show enrichment of FAP93 and PP2A in short axonemes and immunofluorescence confirms the localization of FAP93 and enrichment of PP2A at the proximal axoneme. Ciliary regeneration reveals that FAP93 assembles continuously but more slowly than other axonemal structures and terminates at 1.03 µm in steady-state axonemes. The length of FAP93 assembly correlates with ciliary length, demonstrating ciliary length-dependent assembly of FAP93. Dikaryon rescue experiments show that FAP93 can assemble independently of IFT transport. In addition, FRAP analysis of GFP-tagged FAP93 demonstrates that FAP93 is stably anchored in axoneme. FAP93 may function as a scaffold for assembly of other specific proteins at the proximal axoneme.

The Wisdom of Hindsight: Allies Reflections on Their Role in Supporting the Implementation of Expert by Experience Positions in Academia.

Experts by experience involvement in mental health education has consistently demonstrated positive attitudinal outcomes including a greater appreciation for recovery-focused practice. Mental health academic allies have played a crucial role in supporting implementation of expert by experience academic positions. To date the inclusion of their views in research is limited. The aim of this study was to explore and present allies' reflections on their involvement in supporting expert by experience academic roles in relation to "hindsight" and "foresight." A qualitative descriptive design was used, involving in-depth semi-structured interviews with allies who had supported the implementation of academic roles for experts by experience. Participants described the wisdom of hindsight. Based on their own experiences they emphasised the importance of, laying the groundwork, facilitating a supportive environment, contributing to meaningful, credible, and sustainable roles, and vision for the future as key to successful implementation. They also described a vision for the expansion of expert by experience roles in mental health education in the future. Allies' reflections suggest the importance of preparation to facilitate a smooth as possible implementation process and enhance the likelihood of successful outcomes. The transition to recovery-focused mental health services requires the attitudes of health professionals to change. The potential of experts by experience to influence attitudinal change can be enhanced by understanding the experiences and reflections of academic allies.

Comparing approaches to identify live births using the Transformed Medicaid Statistical Information System.

OBJECTIVE: To evaluate the performance of different approaches for identifying live births using Transformed Medicaid Statistical Information System Analytic Files (TAF). DATA SOURCES: The primary data source for this study were TAF inpatient (IP), other services (OT), and demographic and eligibility files. These data contain administrative claims for Medicaid enrollees in all 50 states and the District of Columbia from January 1, 2018 to December 31, 2018. STUDY DESIGN: We compared five approaches for identifying live birth counts obtained from the TAF IP and OT data with the Centers for Disease Control and Prevention (CDC) Natality data-the gold standard for birth counts at the state level. DATA COLLECTION/EXTRACTION METHODS: The five approaches used varying combinations of diagnosis and procedure, revenue, and place of service codes to identify live births. Approaches 1 and 2 follow guidance developed by the Centers for Medicare and Medicaid Services (CMS). Approaches 3 and 4 build on the approaches developed by CMS by including all inpatient hospital claims in the OT file and excluding codes related to delivery services for infants, respectively. Approach 5 applied Approach 4 to only the IP file. PRINCIPAL FINDINGS: Approach 4, which included all inpatient hospital claims in the OT file and excluded codes related to infants to identify deliveries, achieved the best match of birth counts relative to CDC birth record data, identifying 1,656,794 live births-a national overcount of 3.6%. Approaches 1 and 3 resulted in larger overcounts of births (20.5% and 4.5%), while Approaches 2 and 5 resulted in undercounts of births (-3.4% and -6.8%). CONCLUSIONS: Including claims from both the IP and OT files, and excluding codes unrelated to the delivery episode and those specific to services rendered to infants improves accuracy of live birth identification in the TAF data.

'We only come from one perspective': Exploring experiences of allies supporting expert by experience leadership in mental health education.

INTRODUCTION: Academics from health professional backgrounds have a crucial role in supporting the implementation and sustainability of academic positions for experts by experience in mental health education. Perspectives and experiences of these academics have yet to be extensively explored. A deeper understanding will add to our understanding of this important role and provide guidance for academics with similar aspirations. AIM: The aim of the study was to explore the experiences of supporting academic positions for experts by experience in mental health education. METHODS: A qualitative exploratory design was utilised. In-depth interviews were conducted with academics who have actively supported academic positions for experts by experience. RESULTS: Allyship was a key theme identified. Participants described allyship as complex, time-consuming and rewarding, through three sub-themes: the tension of allyship, the impact of being an ally and interpersonal and relational issues with health professional academics. CONCLUSIONS: Allyship was influenced by the negative attitudes of many health professional academics, who do not appreciate the value of this work. IMPLICATIONS FOR PRACTICE: Allyship has a crucial role in enhancing experts by experience leadership in the education of health professionals. Understanding the experience of allyship will assist in further understanding and developing these important roles.

Access to Guideline Concordant Care for Node-Positive Non-Small Cell Lung Cancer in the United States.

BACKGROUND: This study sought to determine whether seeking care at multiple Commission on Cancer (CoC) hospitals is associated with different rates of receiving guideline-concordant care (GCC) among patients with non-small cell lung cancer (NSCLC). METHODS: The National Cancer Database was queried for the years 2004 to 2018 for patients with margin-negative pT1 to pT3 N1 to N2 M0 noncarcinoid NSCLC without neoadjuvant therapy. GCC was defined as chemotherapy for pN1 disease and as chemotherapy with or without radiation for pN2 disease. Patients who received care at >1 facility were examined separately. Factors previously associated with barriers to care were compared between groups. Kaplan-Meier analysis with log-rank tests analyzed 5-year overall survival (OS). Propensity score matching was performed to compare the effect sizes of race, insurance status, and income. RESULTS: In total 44,531 patients met inclusion criteria, 11,980 (26.9%) of whom sought care at >1 CoC institution. Among patients with pN1 disease, 5565 (76.7%) received GCC if they visited >1 facility vs 13,995 (68.5%) patients who sought care at 1 facility (P < .001). For patients with pN2 disease, 3991 (84.4%) received GCC if they visited >1 facility vs9369 (77.4%) patients receiving care at 1 facility (P < .001). Visiting >1 facility was associated with higher OS at 5 years (4784 [54.35%] vs 10,215 [45.62%]; P < .001). CONCLUSIONS: Visiting >1 CoC institution is associated with higher rates of GCC for individuals with pN1 to pN2 lung cancer. Patients who received care at >1 facility had higher OS at 5 years. Further study is warranted to identify factors associated with the ability of patients to seek care at multiple facilities.

A Phase II Basket Trial of Dual Anti-CTLA-4 and Anti-PD-1 Blockade in Rare Tumors (DART SWOG 1609 Cohort 47) in Patients with Gestational Trophoblastic Neoplasia.

PURPOSE: The efficacy of immune checkpoint blockade in gestational trophoblastic neoplasia (GTN) remains uncertain. We report the results of the GTN cohort of SWOG S1609 dual anti-CTLA-4 and anti-PD-1 blockade in rare tumors (DART). PATIENTS AND METHODS: This prospective, open-label phase II trial evaluated ipilimumab plus nivolumab across multiple rare tumor cohorts, including GTN. Eligible patients received nivolumab 240 mg, i.v. every 2 weeks and ipilimumab 1 mg/kg i.v. every 6 weeks. The primary endpoint was overall response rate [ORR; complete response (CR) + partial response (PR)] by quantitative serum beta human chorionic gonadotropin (ß-hCG); secondary endpoints included progression-free survival (PFS), overall survival (OS), and toxicity. RESULTS: Four patients with refractory GTN enrolled and received therapy. At 11 months of ongoing follow-up, 3 of 4 patients responded [ORR = 75% (CR, 25%, n = 1, tumor mutation burden = 1 mutation/megabase; PD-L1 tumor proportion score = 50%); PR, 50%, n = 2)]. Responders included malignant gestational trophoblastic neoplasm (n = 1, CR, PFS 11+ months) and choriocarcinoma (n = 2, both PRs, PFS 10+ and 6+ months). One patient with epithelioid trophoblastic tumor experienced disease progression. The 6-month PFS was 75% [95% confidence interval (CI), 43%-100%], and the median PFS was not reached (range, 35-339+ days); all 4 patients were alive at last follow-up. Two patients experienced grade 3 immune-related toxicity (arthralgia and colitis); there were no grade ≥4 events. CONCLUSIONS: Ipilimumab plus nivolumab demonstrated efficacy in chemotherapy-refractory GTN, an ultra-rare cancer affecting young women. Three of 4 patients achieved ongoing objective responses with a reasonable safety profile at 6-11+ months.

A community-based child health and parenting intervention to improve child HIV testing, health, and development in rural Lesotho (Early Morning Star): a cluster-randomised, controlled trial.

BACKGROUND: When caregivers live in remote settings characterised by extreme poverty, poor access to health services, and high rates of HIV/AIDS, their caregiving ability and children's development might be compromised. We aimed to test the effectiveness of a community-based child health and parenting intervention to improve child HIV testing, health, and development in rural Lesotho. METHODS: We implemented a matched cluster-randomised, controlled trial in the Mokhotlong district in northeastern Lesotho with 34 community clusters randomly assigned to intervention or wait-list control groups within a pair. Eligible clusters were villages with non-governmental organisation partner presence and an active preschool. Participants were caregiver-child dyads, where the child was 12-60 months old at baseline. The intervention consisted of eight group sessions delivered at informal preschools to all children in each village. Mobile health events were hosted for all intervention (n=17) and control (n=17) clusters, offering HIV testing and other health services to all community members. Primary outcomes were caregiver-reported child HIV testing, child language development, and child attention. Assessments were done at baseline, immediately post-intervention (3 months post-baseline), and 12 months post-intervention. We assessed child language by means of one caregiver-report measure (MacArthur-Bates Communicative Development Inventory [CDI]) and used two observational assessments of receptive language (the Mullen Scales of Early Learning receptive language subscale, and the Peabody Picture Vocabulary Test 4th edn). Child attention was assessed by means of the Early Childhood Vigilance Task. Assessors were masked to group assignment. Analysis was by intention to treat. This trial was registered with ISRCTN.com, ISRCTN16654287 and is completed. FINDINGS: Between Aug 8, 2015, and Dec 10, 2017, 1040 children (531 intervention; 509 control) and their caregivers were enrolled in 34 clusters (17 intervention; 17 control). Compared with controls, the intervention group reported significantly higher child HIV testing at the 12-month follow-up (relative risk [RR] 1·46, 95% CI 1·29 to 1·65, p<0·0001), but not immediately post-intervention. The intervention group showed significantly higher child receptive language on the caregiver report (CDI) at immediate (effect size 3·79, 95% CI 0·78 to 6·79, p=0·028) but not at 12-month follow-up (effect size 2·96, 95% CI -0·10 to 5·98, p=0·056). There were no significant group differences for the direct assessments of receptive language. Child expressive language and child attention did not differ significantly between groups. INTERPRETATION: Integrated child health and parenting interventions, delivered by trained and supervised lay health workers, can improve both child HIV testing and child development. FUNDING: United States Agency for International Development (USAID) and the President's Emergency Plan for AIDS Relief (PEPFAR).

Medicaid Reimbursement for Doula Care: Policy Considerations From a Scoping Review.

Evidence suggests that perinatal doula care can support maternal health and reduce racial inequities among low-income pregnant and postpartum people, prompting growing interest by state Medicaid agencies to reimburse for doula services. Emerging peer-reviewed and gray literature document factors facilitating or impeding that reimbursement. We conducted a scoping review of that literature (2012-2022) to distill key policy considerations for policymakers and advocates in the inclusion of doula care as a Medicaid-covered benefit. Fifty-three reports met the inclusion criteria. Most (53%) were published in 2021 or 2022. Their stated objectives were advocating for expanded access to doula care (17%), describing barriers to policy implementation, and/or offering recommendations to overcome the barriers (17%). A primary policy consideration among states was prioritizing partnership with doulas and doula advocates to inform robust and equitable policymaking to sustain the doula profession.

Using WhatsApp support groups to promote responsive caregiving, caregiver mental health and child development in the COVID-19 era: A randomised controlled trial of a fully digital parenting intervention.

Objective: Digital interventions hold important potential for supporting parents when face-to-face interventions are unavailable. We assessed the feasibility and effectiveness of a digital parenting intervention in Zambia and Tanzania. Methods: Using a randomised controlled trial, we evaluated the Sharing Stories digital parenting intervention for caregivers of children aged 9-32 months with access to a smartphone in their household. Caregivers were stratified based on child age and randomly assigned to the intervention or waitlist control arm. The intervention was delivered via facilitated WhatsApp groups over 6 weeks to promote caregiver wellbeing and responsive caregiving through shared reading activities. Primary outcomes were caregiver-reported responsive caregiving, child language and socio-emotional development. Secondary outcomes were caregiver mental health and parental stress. Masked assessors conducted assessments at baseline and immediate follow-up. Results: Between October 2020 and March 2021, we randomly assigned 494 caregiver-child dyads to the intervention (n = 248) or waitlist control (n = 246) arm. Caregivers in the intervention group reported more responsive caregiving (OR = 2.55, 95% CI: 1.15-5.66, p = 0.02), time reading or looking at books (ß = 0.45, p = 0.04) and telling stories (ß = 0.72, p = 0.002). Intervention caregivers reported significantly lower symptoms of depression (ß = -0.64, p = 0.05) and anxiety (ß = -0.65, p = 0.02). Child development and parental stress did not differ significantly between groups. Conclusions: Digital parenting interventions using WhatsApp can effectively promote responsive caregiving and caregiver mental health in low-resource settings, with great potential for scalability. Trial registration: ISRCTN database, ISRCTN77689525.

Georgia Pathways-Partial Medicaid Expansion With Work Requirements and Premiums.

This Viewpoint discusses the Georgia Pathways to Coverage program, which is the first state program that partially expands Medicaid eligibility to low-income adults with work requirements.