Cost analysis for initiating an integrated package of essential non-communicable disease interventions (PEN-Plus) in Kondoa District Hospital, Tanzania: a time-driven activity-based costing (TDABC) study protocol.

INTRODUCTION: Non-communicable diseases (NCDs) constitute approximately 74% of global mortality, with 77% of these deaths occurring in low-income and middle-income countries. Tanzania exemplifies this situation, as the percentage of total disability-adjusted life years attributed to NCDs has doubled over the past 30 years, from 18% to 36%. To mitigate the escalating burden of severe NCDs, the Tanzanian government, in collaboration with local and international partners, seeks to extend the integrated package of essential interventions for severe NCDs (PEN-Plus) to district-level facilities, thereby improving accessibility. This study aims to estimate the cost of initiating PEN-Plus for rheumatic heart disease, sickle cell disease and type 1 diabetes at Kondoa district hospital in Tanzania. METHODS AND ANALYSIS: We will employ time-driven activity-based costing (TDABC) to quantify the capacity cost rates (CCR), and capital and recurrent costs associated with the implementation of PEN-Plus. Data on resource consumption will be collected through direct observations and interviews with nurses, the medical officer in charge and the heads of laboratory and pharmacy units/departments. Data on contact times for targeted NCDs will be collected by observing a sample of patients as they move through the care delivery pathway. Data cleaning and analysis will be done using Microsoft Excel. ETHICS AND DISSEMINATION: Ethical approval to conduct the study has been waived by the Norwegian Regional Ethics Committee and was granted by the Tanzanian National Health Research Ethics Committee NIMR/HQ/R.8a/Vol.IX/4475. A written informed consent will be provided to the study participants. This protocol has been disseminated in the Bergen Centre for Ethics and Priority Setting International Symposium, Norway and the 11th Muhimbili University of Health and Allied Sciences Scientific Conference, Tanzania in 2023. The findings will be published in peer-reviewed journals for use by the academic community, researchers and health practitioners.

Correlates of HIV Prevention Advocacy by Persons Living with HIV in Kampala, Uganda: A Cross-sectional Evaluation of a Conceptual Model.

BACKGROUND: HIV prevention advocacy empowers persons living with HIV (PLWH) to act as advocates and encourage members of their social networks to engage in protective behaviors such as HIV testing, condom use, and antiretroviral therapy (ART) adherence. We examined correlates of HIV prevention advocacy among PLWH in Uganda. METHOD: A cross-sectional analysis was conducted with baseline data from 210 PLWH (70% female; mean age = 40 years) who enrolled in a trial of an HIV prevention advocacy training program in Kampala, Uganda. The baseline survey, which was completed prior to receipt of the intervention, included multiple measures of HIV prevention advocacy (general and specific to named social network members), as well as internalized HIV stigma, HIV disclosure, HIV knowledge, positive living (condom use; ART adherence), and self-efficacy for HIV prevention advocacy. RESULTS: Consistent with our hypotheses, HIV disclosure, HIV knowledge, consistent condom use, and HIV prevention advocacy self-efficacy were all positively correlated with at least one measure of HIV prevention advocacy, after controlling for the other constructs in multiple regression analysis. Internalized HIV stigma was positively correlated with advocacy in bivariate analysis only. CONCLUSION: These findings identify which characteristics of PLWH are associated with acting as change agents for others in their social network to engage in HIV protective behaviors.

Financial Interventions to Improve Screening in Primary Care: A Systematic Review.

INTRODUCTION: Although health screenings offer timely detection of health conditions and enable early intervention, adoption is often poor. How might financial interventions create the necessary incentives and resources to improve screening in primary care settings? This systematic review aimed to answer this question. METHODS: Peer-reviewed studies published between 2000 and 2023 were identified and categorized by the level of intervention (practice or individual) and type of intervention, specifically alternative payment models (APMs), fee-for-service (FFS), capitation, and capital investments. Outcomes included frequency of screening, performance/quality of care (e.g., patient satisfaction, health outcomes), and workflow changes (e.g., visit length, staffing). RESULTS: Of 51 included studies, a majority focused on practice-level interventions (n=32), used APMs (n=41) that involved payments for achieving key performance indicators (KPIs; n=31) and were of low or very low strength of evidence based on GRADE criteria (n=42). Studies often included screenings for cancer (n=32), diabetes care (n=18), and behavioral health (n=15). KPI payments to both practices and individual providers corresponded with increased screening rates, whereas capitation and provider-level FFS models yielded mixed results. A large majority of studies assessed changes in screening rates (n=48) with less focus on quality of care (n=11) or workflow changes (n=4). DISCUSSION: Financial mechanisms can enhance screening rates with evidence strongest for KPI payments to both practices and individual providers. Future research should explore the relationship between financial interventions and quality of care, in terms of both clinical processes and patient outcomes, as well as the role of these interventions in shaping care delivery.

Availability of Mental Telehealth Services in the US.

Importance: Telehealth utilization for mental health care remains much higher than it was before the COVID-19 pandemic; however, availability may vary across facilities, geographic areas, and by patients' demographic characteristics and mental health conditions. Objective: To quantify availability, wait times, and service features of telehealth for major depressive disorder, general anxiety disorder, and schizophrenia throughout the US, as well as facility-, client-, and county-level characteristics associated with telehealth availability. Design, Settings, and Participants: Cross-sectional analysis of a secret shopper survey of mental health treatment facilities (MHTFs) throughout all US states except Hawaii from December 2022 and March 2023. A nationally representative sample of 1938 facilities were contacted; 1404 (72%) responded and were included. Data analysis was performed from March to July 2023. Exposure: Health facility, client, and county characteristics. Main Outcome and Measures: Clinic-reported availability of telehealth services, availability of telehealth services (behavioral treatment, medication management, and diagnostic services), and number of days until first telehealth appointment. Multivariable logistic and linear regression analyses were conducted to assess whether facility-, client-, and county-level characteristics were associated with each outcome. Results: Of the 1221 facilities (87%) accepting new patients, 980 (80%) reported offering telehealth. Of these, 97% (937 facilities) reported availability of counseling services; 77% (726 facilities), medication management; and 69% (626 facilities) diagnostic services. Telehealth availability did not differ by clinical condition. Private for-profit (adjusted odds ratio [aOR], 1.75; 95% CI, 1.05-2.92) and private not-for-profit (aOR, 2.20; 95% CI, 1.42-3.39) facilities were more likely to offer telehealth than public facilities. Facilities located in metropolitan counties (compared with nonmetropolitan counties) were more likely to offer medication management services (aOR, 1.83; 95% CI, 1.11-3.00) but were less likely to offer diagnostic services (aOR, 0.67; 95% CI, 0.47-0.95). Median (range) wait time for first telehealth appointment was 14 (4-75) days. No differences were observed in availability of an appointment based on the perceived race, ethnicity, or sex of the prospective patient. Conclusions and Relevance: The findings of this cross-sectional study indicate that there were no differences in the availability of mental telehealth services based on the prospective patient's clinical condition, perceived race or ethnicity, or sex; however, differences were found at the facility-, county-, and state-level. These findings suggest widespread disparities in who has access to which telehealth services throughout the US.

The effect of adverse childhood experience training, screening, and response in primary care: a systematic review.

Background: Adverse childhood experiences (ACEs) can have harmful, long-term health effects. Although primary care providers (PCPs) could help mitigate these effects, no studies have reviewed the impacts of ACE training, screening, and response in primary care. Methods: This systematic review searched four electronic databases (PubMed, Web of Science, APA PsycInfo, CINAHL) for peer-reviewed articles on ACE training, screening, and/or response in primary care published between Jan 1, 1998, and May 31, 2023. Searches were limited to primary research articles in the primary care setting that reported provider-related outcomes (knowledge, confidence, screening behavior, clinical care) and/or patient-related outcomes (satisfaction, referral engagement, health outcomes). Summary data were extracted from published reports. Findings: Of 6532 records, 58 met inclusion criteria. Fifty-two reported provider-related outcomes; 21 reported patient-related outcomes. 50 included pediatric populations, 12 included adults. A majority discussed screening interventions (n = 40). Equal numbers (n = 25) discussed training and clinical response interventions. Strength of evidence (SOE) was generally low, especially for adult studies. This was due to reliance on observational evidence, small samples, and self-report measures for heterogeneous outcomes. Exceptions with moderate SOE included the effect of training interventions on provider confidence/self-efficacy and the effect of screening interventions on screening uptake and patient satisfaction. Interpretation: Primary care represents a potentially strategic setting for addressing ACEs, but evidence on patient- and provider-related outcomes remains scarce. Funding: The California Department of Health Care Services and the Office of the California Surgeon General.

Utilization and Spending on Mental Health Services Among Children and Youths With Commercial Insurance.

This cross-sectional study examines telehealth, in-person, and overall pediatric mental health service utilization and spending rates from January 2019 through August 2022 among a US pediatric population with commercial insurance.

Clinician and Staff Perspectives on Implementing Adverse Childhood Experience (ACE) Screening in Los Angeles County Pediatric Clinics.

PURPOSE: To understand clinician and clinical staff perspectives on the implementation of routine Adverse Childhood Experience (ACE) screening in pediatric primary care. METHODS: We conducted a qualitative evaluation in 5 clinics in Los Angeles County, California, using 2 rounds of focus group discussions: during an early phase of the initiative, and 7 months later. In the first round, we conducted 14 focus group discussions with 67 participants. In the second round, we conducted 12 focus group discussions with 58 participants. Participants comprised clinic staff involved in ACE screening, including frontline staff that administer the screening, medical clinicians that use screening to counsel patients and make referrals, and psychosocial support staff who may receive referrals. RESULTS: Themes were grouped into 3 categories: (1) screening acceptability and perceived utility, (2) implementation and quality improvement, and (3) effects of screening on patients and clinicians. Regarding screening acceptability and perceived utility, clinicians generally considered ACE screening to be acceptable and useful. In terms of implementation and quality improvement, significant barriers included: insufficient time for screening and response, insufficient training, and lack of clarity about referral networks and resources that could be offered to patients. Lastly, regarding effects of screening, clinicians expressed that ACE screening helped elicit important patient information and build trust with patients. Further, no adverse events were reported from screening. CONCLUSIONS: Clinic staff felt ACE screening was feasible, acceptable, and beneficial within pediatric care settings to improve trauma-informed care and that ACE screening could be strengthened by addressing time constraints and limited referral resources.

Costing of HIV services, Uganda and United Republic of Tanzania.

Objective: To evaluate resource allocation and costs associated with delivery of human immunodeficiency virus (HIV) services in Uganda and the United Republic of Tanzania. Methods: We used time-driven activity-based costing to determine the resources consumed and costs of providing five HIV services in Uganda and the United Republic of Tanzania: antiretroviral therapy (ART); HIV testing and counselling; prevention of mother-to-child transmission; voluntary male medical circumcision; and pre-exposure prophylaxis. Findings: Country-based teams undertook time-driven activity-based costing with 1119 adults in Uganda and 886 adults in the United Republic of Tanzania. In Uganda, service delivery costs ranged from 8.18 United States dollars (US$) per visit for HIV testing and counselling to US$ 43.43 for ART (for clients in whom HIV was suppressed). In the United Republic of Tanzania, these costs ranged from US$ 3.67 per visit for HIV testing and counselling to US$ 28.00 for voluntary male medical circumcision. In both countries, consumables were the main cost driver, accounting for more than 60% of expenditure. Process maps showed that in both countries, registration, measurement of vital signs, consultation and medication dispensing were the steps that occurred most frequently for ART clients. Conclusion: Establishing a rigorous, longitudinal system for tracking investments in HIV services that includes thousands of clients and numerous facilities is achievable in different settings with a high HIV burden. Consistent engagement of implementation partners and standardized training and data collection instruments proved essential for the success of these exercises.

Mental Health Outcomes Among Patients Living in US Counties Lacking Broadband Access and Psychiatrists.

This cross-sectional study identifies the prevalence of counties without psychiatrists and broadband coverage, describes their sociodemographic characteristics, and quantifies their mental health outcomes.

Telehealth and In-Person Mental Health Service Utilization and Spending, 2019 to 2022.

This cohort study assesses trends in monthly telehealth vs in-person utilization and spending rates for mental health services among commercially insured US adults before and during the COVID-19 pandemic.

Patient and Caregiver Perspectives on Implementation of ACE Screening in Pediatric Care Settings: A Qualitative Evaluation.

INTRODUCTION: This qualitative research study explored the perspectives of adolescents, 12 to 19-years-old, and caregivers of children under 12-years-old on the acceptibility of adverse childhood experiences (ACEs) screenings in five pediatric clinics. METHOD: A constructivist grounded theory approach was utilized. One-on-one semistructured phone interviews were conducted with 44 adolescents and 95 caregivers of children less than 12 years old. Interviews were analyzed using thematic analysis. RESULTS: Most participants reported feeling comfortable discussing ACEs with their providers. Some reported that screening helped build trust. Others expressed privacy concerns and did not receive information about the reason for screening. Adolescent patients shared conflicting feelings-of both comfort and discomfort. Caregivers attending to multiple children, foster parents, and monolingual Spanish speakers disclosed unique challenges to ACEs screening. We found no evidence of lasting adverse effects. DISCUSSION: Participants generally found ACEs screenings acceptable. Some adolescents identified benefits from the experience. However, clinics planning to adopt routine ACEs screening should ensure clear messaging on why screening is occurring, anticipate and address privacy concerns, and adopt workflows to discuss screening results.

Depressive disorder at the household level: prevalence and correlates of depressive symptoms among household members.

BACKGROUND: Globally, an estimated five percent of adults have major depressive disorder. However, little is known about the relationship between these individuals' depressive symptoms and their household members' mental health and well-being. OBJECTIVES: We aimed to investigate the prevalence and predictors of depressive symptoms among adult household members of patients living with major depressive disorder in Neno District, Malawi. METHODS: As part of a cluster randomized controlled trial providing depression care to adults with major depressive disorder, we conducted surveys with patients' household members (n = 236) and inquired about their overall health, depressive symptoms, disability, and social support. We calculated prevalence rates of depressive disorder and conducted multivariable linear regression and multivariable logistic regression analyses to assess correlates of depressive symptom severity and predictors of having depressive disorder (PHQ-9), respectively, among household members. RESULTS: We observed that roughly one in five household members (19%) screened positive for a depressive disorder (PHQ-9 > 9). More than half of household members endorsed six or more of the nine symptoms, with 68% reporting feeling 'down, depressed, or hopeless' in the prior two weeks. Elevated depression symptom severity was associated with greater disability (ß = 0.17, p < 0.001), less social support (ß = -0.04, p = 0.016), and lower self-reported overall health (ß = 0.54, p = 0.001). Having depressive disorder was also associated with greater disability (adjusted Odds Ratio [aOR] = 1.12, p = 0.001) and less social support (aOR = 0.97, p = 0.024). CONCLUSIONS: In the Malawian context, we find that depressive disorder and depression symptoms are shared attributes among household members. This has implications for both screening and treatment, and it suggests that mental health should be approached from the vantage point of the broader social ecology of the household and family unit. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04777006) - March 2, 2021.

Study protocol for type II hybrid implementation-effectiveness trial of strategies for depression care task-sharing in community health stations in Vietnam: DEP Project.

BACKGROUND: It is not clear what the most effective implementation strategies are for supporting the enactment and sustainment of depression care services in primary care settings. This type-II Hybrid Implementation-Effectiveness study will compare the effectiveness of three system-level strategies for implementing depression care programs at 36 community health stations (CHSs) across 2 provinces in Vietnam. METHODS: In this cluster-randomized controlled trial, CHSs will be randomly assigned to one of three implementation conditions: (1) Usual Implementation (UI), which consists of training workshops and toolkits; (2) Enhanced Supervision (ES), which includes UI combined with bi-weekly/monthly supervision; and (3) Community-Engaged Learning Collaborative (CELC), which includes all components of ES, combined with bi-monthly province-wide learning collaborative meetings, during which cross-site learning and continuous quality improvement (QI) strategies are implemented to achieve better implementation outcomes. The primary outcome will be measured based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation quality, and Maintenance) using indicators on implementation, provider, and client factors. The secondary outcome examines factors associated with barriers and facilitators of quality implementation, while the tertiary outcome evaluates the incremental cost-effectiveness ratio of services provided in the ES and CELC conditions, relative to UI condition for depression care. A total of 1,296 clients receiving depression care at CHSs will be surveyed at baseline and 6-month follow-up to assess mental health and psychosocial outcomes (e.g., depression and anxiety severity, health function, quality of life). Additionally, 180 CHS staff and 180 non-CHS staff will complete pre- and post-training evaluation and surveys at baseline, 6, 12, and 24 months. DISCUSSION: We hypothesize that the additional implementation supports will make mental health service implementation superior in the ES and CELC arms compared to the UI arm. The findings of this project could identify effective implementation models and assess the added value of specific QI strategies for implementing depression care in primary care settings in Vietnam, with implications and recommendations for other low- and middle-income settings. More importantly, this study will provide evidence for key stakeholders and policymakers to consider policies that disseminate, scale up, and advance quality mental health care in Vietnam. TRIAL REGISTRATION: NCT04491045 on Clinicaltrials.gov. Registered July 29, 2020.

Expansion of Telehealth Availability for Mental Health Care After State-Level Policy Changes From 2019 to 2022.

Importance: Although telehealth services expanded rapidly during the COVID-19 pandemic, the association between state policies and telehealth availability has been insufficiently characterized. Objective: To investigate the associations between 4 state policies and telehealth availability at outpatient mental health treatment facilities throughout the US. Design, Setting, and Participants: This cohort study measured whether mental health treatment facilities offered telehealth services each quarter from April 2019 through September 2022. The sample comprised facilities with outpatient services that were not part of the US Department of Veterans Affairs system. Four state policies were identified from 4 different sources. Data were analyzed in January 2023. Exposures: For each quarter, implementation of the following policies was indexed by state: (1) payment parity for telehealth services among private insurers; (2) authorization of audio-only telehealth services for Medicaid and Children's Health Insurance Program (CHIP) beneficiaries; (3) participation in the Interstate Medical Licensure Compact (IMLC), permitting psychiatrists to provide telehealth services across state lines; and (4) participation in the Psychology Interjurisdictional Compact (PSYPACT), permitting clinical psychologists to provide telehealth services across state lines. Main Outcome and Measures: The primary outcome was the probability of a mental health treatment facility offering telehealth services in each quarter for each study year (2019-2022). Information on the facilities was obtained from the Mental Health and Addiction Treatment Tracking Repository based on the Substance Abuse and Mental Health Services Administration Behavioral Health Treatment Service Locator. Separate multivariable fixed-effects regression models were used to estimate the difference in the probability of offering telehealth services after vs before policy implementation, adjusting for characteristics of the facility and county in which the facility was located. Results: A total of 12 828 mental health treatment facilities were included. Overall, 88.1% of facilities offered telehealth services in September 2022 compared with 39.4% of facilities in April 2019. All 4 policies were associated with increased odds of telehealth availability: payment parity for telehealth services (adjusted odds ratio [AOR], 1.11; 95% CI, 1.03-1.19), reimbursement for audio-only telehealth services (AOR, 1.73; 95% CI, 1.64-1.81), IMLC participation (AOR, 1.40, 95% CI, 1.24-1.59), and PSYPACT participation (AOR, 1.21, 95% CI, 1.12-1.31). Facilities that accepted Medicaid as a form of payment had lower odds of offering telehealth services (AOR, 0.75; 95% CI, 0.65-0.86) over the study period, as did facilities in counties with a higher proportion (>20%) of Black residents (AOR, 0.58; 95% CI, 0.50-0.68). Facilities in rural counties had higher odds of offering telehealth services (AOR, 1.67; 95% CI, 1.48-1.88). Conclusion and Relevance: Results of this study suggest that 4 state policies that were introduced during the COVID-19 pandemic were associated with marked expansion of telehealth availability for mental health care at mental health treatment facilities throughout the US. Despite these policies, telehealth services were less likely to be offered in counties with a greater proportion of Black residents and in facilities that accepted Medicaid and CHIP.

Treatment of Perinatal Depression and Correlates of Treatment Response Among Pregnant Women Living with HIV in Uganda.

INTRODUCTION: Perinatal depression is common among women living with HIV, but depression care is limited in low-resource settings. We examined (1) characteristics of women receiving Problem Solving Therapy (PST) versus antidepressant therapy (ADT), (2) treatment response by modality, and (3) correlates of treatment response. METHODS: This analysis used data from 191 Ugandan women in the intervention arm of a cluster randomized controlled trial of task-shifted, stepped-care depression treatment for pregnant women living with HIV (PWLWH). Treatment response was defined as scoring < 5 on the nine-item Patient Health Questionnaire (PHQ-9). Bivariate analysis and multivariable logistic regression were used to examine characteristics of women by treatment group and correlates of treatment response. RESULTS: Of 134 participants with depression, 129 (96%) were treated: 84 (65%) received PST and 45 (35%) received ADT. Severe depression at treatment initiation was more common in those receiving ADT (28.9% versus 4.8%, Fischer's Exact Test < 0.001). Treatment response was higher for PST (70/84; 83.3%) than ADT (30/45; 66.7%; p = .03). ADT side effects were rare and minor; no infants had serious congenital defects. Of 22 participants (19%) who did not respond to treatment, only five received intensified management. Social support and interpersonal violence were associated with treatment response (adjusted odds ratio, [aOR] = 3.06, 95% CI = 1.08-8.66 and aOR = 0.64, 95% CI = 0.44-0.93). DISCUSSION: Both depression treatment modalities yielded high response rates in Ugandan PWLWH; ADT was well-tolerated. Our results highlight a need to build capacity to implement the stepped-care protocol for non-responders and screen for social support and interpersonal violence.

National Evaluation of HIV Service Resource Allocation in Tanzania.

Using time-driven activity-based costing (TDABC), we examined resource allocation and costs for HIV services throughout Tanzania at patient and facility levels. This national, cross-sectional analysis of 22 health facilities quantified costs and resources associated with 886 patients receiving care for five HIV services: antiretroviral therapy, prevention of mother-to-child transmission, HIV testing and counseling, voluntary medical male circumcision, and pre-exposure prophylaxis. We also documented total provider-patient interaction time, the cost of services with and without inclusion of consumables, and conducted fixed-effects multivariable regression analyses to examine patient- and facility-level correlates of costs and provider-patient time. Findings showed that resources and costs for HIV care varied significantly throughout Tanzania, including as a function of patient- and facility-level characteristics. While some variation may be preferable (e.g., needier patients received more resources), other areas suggested a lack of equity (e.g., wealthier patients received more provider time) and presented opportunities to optimize care delivery protocols.

Psychiatric and Substance Use Disorder Bed Capacity, Need, and Shortage Estimates in California: Merced, San Joaquin, and Stanislaus Counties.

Psychiatric and substance use disorder (SUD) treatment beds are essential infrastructure for meeting the needs of individuals with behavioral health conditions. However, not all psychiatric and SUD beds are alike: They represent infrastructure within different types of facilities. For psychiatric beds, these vary from acute psychiatric hospitals to community residential facilities. For SUD treatment beds, these vary from facilities offering short-term withdrawal management services to others offering longer duration residential detoxification services. Different settings also serve clients with different needs. For example, some clients have high-acuity, short-term needs; others have longer-term needs and may return for care on multiple occasions. California's Merced, San Joaquin, and Stanislaus Counties, like other counties throughout the United States, have sought to assess shortages in psychiatric and SUD treatment beds. In this study, the authors estimated psychiatric bed and residential SUD treatment capacity, need, and shortages for adults and children and adolescents at various levels of care: acute, subacute, and community residential services for psychiatric treatment and SUD treatment service categories defined by American Society of Addiction Medicine clinical guidelines. Drawing from various data sets, literature review findings, and facility survey responses, the authors computed the number of beds required-at each level of care-for adults and children and adolescents and identified hard-to-place populations. The authors draw from these findings to offer Merced, San Joaquin, and Stanislaus Counties recommendations to help ensure all their residents, especially nonambulatory individuals, have access to the behavioral health care that they need.

Just in Reach Pay for Success: Impact Evaluation and Cost Analysis of a Permanent Supportive Housing Program.

Discharging individuals from jails and prisons who may be poorly equipped for independent living-such as those with a history of chronic health conditions, including serious mental illness-is likely to reinforce a pattern of homelessness and recidivism. Permanent supportive housing (PSH)-which combines a long-term housing subsidy with supportive services-has been proposed as a mechanism to intervene directly on this relationship between housing and health. In Los Angeles County, jail has become a default housing and services provider to unhoused individuals with serious mental health issues. In 2017, the county initiated the Just in Reach Pay for Success (JIR PFS) project, which provided PSH as an alternative to jail for individuals with a history of homelessness and chronic behavioral or physical health conditions. The authors of this study assessed whether the project led to changes in use of several county services, including justice, health, and homeless services. The authors examined changes in county service use, before and after incarceration, by JIR PFS participants and a comparison control group and found that use of jail services was significantly reduced after JIR PFS PSH placement, while the use of mental health and other services increased. The researchers assess that the net cost of the program is highly uncertain but that it may pay for itself in terms of reducing the use of other county services and therefore provide a cost-neutral means of addressing homelessness among individuals with chronic health conditions involved with the justice system in Los Angeles County.

Effects of primary healthcare reform on routine health information systems (RHISs): a mixed-methods study in Lesotho.

BACKGROUND AND OBJECTIVE: The Ministry of Health of Lesotho and Partners In Health piloted the Lesotho National Primary Health Care Reform (LPHCR) from July 2014 to June 2017 to improve quality and quantity of service delivery and enhance health system management. This initiative included improvement of routine health information systems (RHISs) to map disease burden and reinforce data utilisation for clinical quality improvement. METHODS AND ANALYSIS: The WHO Data Quality Assurance framework's core indicators were used to compare the completeness of health data before versus after the LPHCR in 60 health centres and 6 hospitals across four districts. To examine change in data completeness, we conducted an interrupted time series analysis using multivariable logistic mixed-effects regression. Additionally, we conducted 25 key informant interviews with healthcare workers (HCWs) at the different levels of Lesotho's health system, following a purposive sampling approach. Interviews were analysed using deductive coding based on the Performance of Routine Information System Management framework, which inspected organisational, technical and behavioural factors influencing RHIS processes and outputs associated with the LPHCR. RESULTS: In multivariable analyses, trends in monthly data completion rate were higher after versus before the LPHCR for: documenting first antenatal care visit (adjusted OR (AOR): 1.24, 95% CI: 1.14 to 1.36) and institutional delivery (AOR: 1.19, 95% CI: 1.07 to 1.32). When discussing processes, HCWs highlighted the value of establishing clear roles and responsibilities in reporting under a new organisational structure, improved community programmes among district health management teams, and enhanced data sharing and monitoring by districts. CONCLUSION: The Ministry of Health had a strong data completion rate pre-LPHCR, which was sustained throughout the LPHCR despite increased service utilisation. The data completion rate was optimised through improved behavioural, technical and organisational factors introduced as part of the LPHCR.