Behavioral Health Care Providers Research Articles

Effectiveness of specialist involvement in case discussion conferences with primary healthcare providers on the management of type 2 diabetes patients: a study protocol for a cluster randomized controlled trial

BackgroundIn supporting primary healthcare in delivering high-quality care for individuals with type 2 diabetes mellitus (T2DM), previous research emphasized strategies to facilitate communication and collaboration between primary healthcare providers and hospitals. This study aims to evaluate the effectiveness of case discussion conferences between specialists from hospitals and primary healthcare providers in China on the optimization of diabetes management and the improvement of patient health outcomes.MethodsThis study will be a parallel cluster randomized controlled trial in which primary healthcare institutions in Shouguang city and Shangsi County will be randomly allocated to the intervention and control groups. The intervention will involve regular case discussion conferences where attendants will meet to discuss complex cases with patients diagnosed with type 2 diabetes mellitus, exchange experiences, and seek and provide expert advice. Family doctor teams from primary healthcare institutions and specialists from secondary or tertiary hospitals will engage in these conferences. Data will be collected at baseline and at the 6- and 12-month follow-ups. The primary clinical outcome measures will focus on the changes in the HbA1c and FBG levels of patients under management. The secondary outcomes will include other physiological indicators, such as blood pressure, BMI, and cholesterol. The evaluation will extend to changes in the capabilities and behaviors of primary healthcare providers. Furthermore, the feasibility and adherence of this intervention will be thoroughly assessed.DiscussionThis study is designed to generate robust evidence on the effectiveness of case discussion conferences, an interprofessional collaboration strategy, in enhancing diabetes care delivery in primary healthcare, with the ultimate goal of improving patient health outcomes.Trial registrationChinese Clinical Trial Registry ChiCTR2300078829. Registered on December 19, 2023. https://www.chictr.org.cn/showproj.html?proj=210293

Public and health care provider attitudes, understanding, and behaviors regarding emergency use authorizations: a scoping literature review

BackgroundUnder Sect. 564 of the Federal Food, Drug, and Cosmetic Act, when the US Department of Health and Human Services Secretary issues a declaration based on one of four types of determinations, FDA may authorize an unapproved product or unapproved uses of an approved product for emergency use. It is unclear how much the public and health care providers understand about emergency use authorizations and how that understanding influences perceptions or behavioral intentions. The current study aimed to explore consumer and health care provider perceptions of emergency use authorizations and how promotion of emergency use authorizations has been investigated in the literature.MethodsWe conducted a scoping review via PubMed, Embase, Web of Science, and CINAHL for original research published in English from January 1, 2012, through November 10, 2022. We conducted surveillance of the literature through March 2023.ResultsWe identified 13 studies reported in 14 publications that addressed public and health care provider attitudes, understanding, and behaviors with regard to products authorized under an emergency use authorization. We did not identify any articles describing research regarding the promotion of emergency use authorization products. Findings suggest gaps in understanding of emergency use authorizations, both for the public and health care providers. Findings also suggest the public and health care providers have concerns about safety or the lack of full FDA approval that may contribute to decreased willingness to receive treatments and vaccines under an emergency use authorization.ConclusionsFuture research should explore how emergency use authorizations have been promoted and how that promotion impacts public and health care provider perceptions.

Burnout among behavioral healthcare workers during the pandemic

ABSTRACT We present the findings of a statewide survey of behavioral healthcare providers based in New England conducted in November 2021. The study included a measure of COVID-19 stress and the Copenhagen Burnout Scale. The sample was mostly white, female and 45 years of age or older. Overall, the stresses causing the most concern were related to financial issues, the infection of loved ones, and concerns about social distancing and quarantining. We found elevated rates of stress appraisal among people of color. With respect to burnout, women had higher levels of burnout as did those in the youngest age groups in the sample. We found a strong association between COVID-19 stress appraisal and burnout, both at the zero-order level and in the OLS multiple regression model. Implications for the behavioral healthcare workplace are discussed.

Improving Pain Management for Marginalized Communities: Educating the Next Generation of Health Care Professionals

Inadequately managed pain has immense negative impacts on children, families, health care systems, and societies. Historically and presently, inadequately treated pain disproportionally affects marginalized communities. Deficiencies in pain education for health care providers are widely recognized as a leading contributor to poorly managed pain. Existing training for providers prioritizes physiological systems and pharmacological interventions for pain, despite decades of evidence supporting the biopsychosocial model and interdisciplinary treatment of pain. Moreover, education for health care providers rarely acknowledges the role of bias, prejudice, and systemic racism in perpetuating disparities in pain care. To address this gap, we sought to develop an innovative curriculum for health care teams to combat racial injustice related to pain management. This curriculum was developed and refined collaboratively with community partners representing diverse expertise, including lived experiences of pain, interdisciplinary pain management, cultural humility and authentic allyship, and curriculum development and evaluation. Four modules delivered across 1 to 2 hours were developed and pilot-tested extensively with multidisciplinary providers across a large pediatric health system. Learner feedback indicated high acceptability and informed iterative changes to the curriculum. Additional research is needed to examine impacts of the curriculum on health care provider knowledge and behavior (eg, clinical decision-making) and patient-reported outcomes as well as to test dissemination and implementation strategies. PerspectiveWe present the development and evaluation of a curriculum for health care professionals to combat racial injustice in pain management. By engaging diverse community partners, using design thinking, applying an antiracist lens, and designing for dissemination, we aim to equip the next generation of providers to deliver equitable pain care.

Impact of an Electronic Health Record-Based Interruptive Alert Among Patients With Headaches Seen in Primary Care: Cluster Randomized Controlled Trial.

Headaches, including migraines, are one of the most common causes of disability and account for nearly 20%-30% of referrals from primary care to neurology. In primary care, electronic health record-based alerts offer a mechanism to influence health care provider behaviors, manage neurology referrals, and optimize headache care. This project aimed to evaluate the impact of an electronic alert implemented in primary care on patients' overall headache management. We conducted a stratified cluster-randomized study across 38 primary care clinic sites between December 2021 to December 2022 at a large integrated health care delivery system in the United States. Clinics were stratified into 6 blocks based on region and patient-to-health care provider ratios and then 1:1 randomized within each block into either the control or intervention. Health care providers practicing at intervention clinics received an interruptive alert in the electronic health record. The primary end point was a change in headache burden, measured using the Headache Impact Test 6 scale, from baseline to 6 months. Secondary outcomes included changes in headache frequency and intensity, access to care, and resource use. We analyzed the difference-in-differences between the arms at follow-up at the individual patient level. We enrolled 203 adult patients with a confirmed headache diagnosis. At baseline, the average Headache Impact Test 6 scores in each arm were not significantly different (intervention: mean 63, SD 6.9; control: mean 61.8, SD 6.6; P=.21). We observed a significant reduction in the headache burden only in the intervention arm at follow-up (3.5 points; P=.009). The reduction in the headache burden was not statistically different between groups (difference-in-differences estimate -1.89, 95% CI -5 to 1.31; P=.25). Similarly, secondary outcomes were not significantly different between groups. Only 11.32% (303/2677) of alerts were acted upon. The use of an interruptive electronic alert did not significantly improve headache outcomes. Low use of alerts by health care providers prompts future alterations of the alert and exploration of alternative approaches.

“Nothing about Us without Us” Meets the “All Teach, All Learn” Model: Autistic Self-Advocates as Leaders and Collaborators in Project ECHO

Those with intellectual and developmental disabilities (I/DD), especially autism, represent an often misunderstood and underserved population. In order to address health disparities faced by those with I/DD in Washington state, the Extension for Community Healthcare Outcomes (Project ECHO) model was implemented to build capacity to serve these individuals and their families in their home communities. Through this year-long telementorship and learning community, expert teams lead clinics based on interdisciplinary case-based discussion and knowledge sharing with medical, behavioral, and mental healthcare providers. A cornerstone of these expert teams are autistic self-advocates, who provide insight into lived experience. In this paper, we will discuss how the inclusion of six autistic self-advocates across four different ECHO programs has allowed ECHO participants to broaden their horizons and gain new insight into supports for their I/DD clients across multiple aspects of care. In addition to the unique knowledge provided by self-advocates, their participation illustrates the potential for all people with I/DD to live rich and fulfilling lives. The initial implementation and on-going success of including lived experience within the ECHO model can be used as an example of how to create partnerships that meaningfully inform decisions and improve equitable outcomes in service provision.

Degree of primary care integration predicts job satisfaction and emotional exhaustion among rural medical and behavioral healthcare providers.

Minimal research on integrated primary care (IPC) or integrated behavioral health (IBH) has examined clinics in rural communities. The relationships between provider burnout, job satisfaction, and IBH/IPC practices remain understudied, particularly in rural settings. We employed an online survey of 147 medical and behavioral health care providers in primary care settings throughout Montana. Respondents self-identified as predominantly White/European American (89.4%) and female (76.7%). We tested whether degree of adherence to IBH/IPC practices concurrently predicted providers' reports of emotional exhaustion (EE), a dimension of burnout, and job satisfaction. Data were collected during the COVID-19 pandemic, in 2020. In multiple linear regression analyses, providers' reports of IBH/IPC practices significantly predicted EE (B = -0.036, p < .01) and job satisfaction (B = 0.123, p < .05), suggesting that higher levels of integration were linked to less EE and greater job satisfaction. Our findings contribute to the evidence base regarding the potential usefulness of IBH/IPC models. Specifically, because existing research links provider burnout and low job satisfaction with provider retention difficulties and diminished health, poor patient satisfaction and outcomes, and cost inefficiencies, our findings have potential to inform policy-level discussions regarding the use of IBH/IPC models in rural states like Montana. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

"I want to be healthy and move on": A qualitative study of barriers and facilitators to antiretroviral treatment adherence among young adult survivors with perinatal HIV in Thailand.

We know that HIV treatment outcome depends on antiretroviral treatment (ART) adherence. Young adults with perinatal HIV (YPHIV) who survived have endured various adherence challenges in their adolescent years. While some of them could maintain perfect adherence with sustainable virologic suppression, many experienced one or more episodes of virologic failure. We explored factors affecting ART adherence from real-life experiences of YPHIV. A qualitative study was conducted between June and November 2022. Twenty YPHIV aged 21-29 years with a history of virologic failure and resumed virologic suppression during adolescent years were invited to share their experiences through individual in-depth interviews. Audio records were transcribed verbatim and analyzed using deductive thematic analysis. We divided excerpts into two themes: barriers and facilitators to ART adherence. The socio-ecological model was used to frame subthemes at personal, societal, and healthcare system levels. Most barriers to adherence were concentrated at the personal level, including work/study-related conditions, personal entertainment, medication issues, mental health problems, thought, and belief. At the societal level, social activities and fear of HIV disclosure were frequently mentioned as barriers. Medical care cost was the only identified barrier at the healthcare system level. The facilitators to adherence at the personal level included perceiving health deterioration, being afraid of hospitalization and medical procedures, and wishing to be healthy and move on. At the same time, perceived family support and determination to complete family without HIV transmission were identified as facilitators at the societal level. Service behaviors of healthcare providers were mentioned as facilitators to adherence at the healthcare system level. From this study, most factors associated with non-adherence in adolescents were at the personal level, and the fear of HIV disclosure was critical at the societal level. The key facilitator to adherence was the determination to be healthy and have a promising future. Our findings reinforce the importance of establishing youth-friendly services in the existing HIV care setting. More time allocation for tailored individual counseling, using other novel approaches like mHealth, online media, and involvement of social support from different sectors might be beneficial to maximize adherence self-efficacy during the transitional period of YPHIV.

Association between depression severity, mental health recovery and dropout from behavioral health care treatment

BackgroundUnderstanding the relationship between depression severity, patient recovery, and treatment continuity may help optimize the delivery of behavioral health services. MethodsUsing Cox proportional hazards regression, this study measures the association between treatment dropout and baseline depression severity, as measured by the Patient Health Questionnaire (PHQ-9), and the association between treatment dropout and baseline recovery, as measured by the Recovery Assessment Scale (RAS). The study also explores heterogeneity by service line (general mental health, substance use disorder, and eating disorder), residential versus intermediate level of care setting, age groups (adolescent and adult), and dropout factors. The data include 14,689 patients treated at a multi-state behavioral health care provider, discharged between 2021 and 2022. Premature dropout from behavioral health care treatment for any cause, patient factors and administrative factors were used as separate outcomes. FindingsA unit increase in baseline PHQ-9 was associated with a 1.2% reduced treatment dropout risk (hazard ratio (HR): 0.988; 95% confidence interval [0.983–0.992]). A unit increase in baseline RAS score was associated with 0.5% increased dropout likelihood (HR: 1.005; 95% CI [1.004, 1.007]). Subgroup analyses show associations are driven by general mental health, adolescent, and intermediate level of care subgroups. Patients with higher baseline suicidality and lower willigness to ask for helphad a reduced risk of dropout. InterpretationPatients with greater depression severity and lower recovery scores at admission were more likely to stay in behavioral health treatment, especially among adolescents, patients with general mental health issues, and outpatients.

Looking Toward the Future of Integrated Care: History, Developments, and Opportunities

For almost five decades, the development and implementation of integrated care—the simultaneous combination of primary care with mental health and substance use care—has been a major challenge for the behavioral health care field. Integrated care is exceptionally important because many people with behavioral health conditions also have chronic physical health conditions. Early research findings in the mid-1980s showed that persons with mental illness are likely to develop chronic physical conditions earlier and more severely than other people. These findings precipitated efforts to understand this problem and to develop further appropriate integrated care solutions. Subsequently, the US Surgeon General made care integration a major focus of his landmark 1999 Report on Mental Health, as did the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Patient Protection and Affordable Care Act. However, it was not until 2014, and later, that integrated care actually began to be implemented more broadly. This article reviews these major developmental milestones, examines current activities, and explores likely developments over the next several years. Major current issues include the response to the COVID-19 pandemic, adjusting to its effects on the behavioral health care workforce, and the growing realization that behavioral health care must address the social determinants of life. Likely developments over the next several years will include devising ways to address our workforce crisis, developing effective community interventions, and implementing population health management strategies; implementing the CMS Innovation in Behavioral Health Model; improving reimbursement practices; and exploring the potential of AI for integrated care. Implications for future service organization and training of behavioral health care providers also are discussed. Granted the severity of the current workforce crisis in behavioral health care, urgent efforts are needed to advance the deployment of integrated care in the short-term future.

Care challenges and silver linings in HIV and behavioral health service delivery for individuals living with HIV and severe mental illness during the COVID-19 pandemic: a qualitative study

BackgroundThere has been a longstanding effort to integrate behavioral health and HIV care for people with comorbid HIV and behavioral health needs, including those with severe mental illness (SMI). As this population frequents both behavioral health and HIV care settings, they were likely to experience new obstacles to the quality and availability of care during the COVID-19 pandemic. This study aims to describe how clinics for HIV services or behavioral healthcare—as well as co-located sites providing both—sought to rapidly shift protocols to maintain a standard of patient care for people with comorbid HIV and SMI while adapting to the unprecedented circumstances of the pandemic.MethodsWe interviewed HIV and behavioral healthcare providers, clinic leaders, and support service agencies that served clients impacted by both HIV and SMI. Seventeen key informants across three settings (HIV care settings, behavioral health care settings, and integrated or co-located care settings) were interviewed in 2022. Interviews focused on changes in clinical services, protocols, and care provision strategies during and at the onset of the COVID-19 pandemic. Interviews were transcribed and coded using thematic analysis.ResultsCommonly endorsed themes included both positive and negative changes in care and care provision during the pandemic. Negative impacts of the pandemic included the loss of physical space, exacerbated mental health needs and disengagement in HIV care, patient barriers to telehealth and the digital divide, and increased healthcare workforce burnout. Positive changes included improved healthcare delivery and care engagement through telehealth, new opportunities to provide a wide range of social services, paradoxical increases in engagement in HIV care for certain patients, and broad institution of workforce wellness practices.ConclusionsThough COVID-19 presented several complex barriers to care for providers serving patients with comorbid HIV and SMI, the increased flexibility afforded by telehealth and a greater focus on collaborative approaches to patient care may benefit this patient population in the future. Additionally, the focus on workforce wellness may serve to increase retention and avoid burnout among providers. The strategies and lessons learned through adapting to COVID-19 may be invaluable moving forward as healthcare systems respond to future pandemics.

Perceptions and behaviors of healthcare providers towards rehabilitation support to children with severe malaria-related disability in Ethiopia: A qualitative descriptive study using the Theoretical Domains Framework.

Severe malaria often results in childhood disability. The prevalence of disability related to severe malaria is significant and is estimated to affect up to 53% of severe malaria survivors. In contrast, information is sparse about how healthcare providers in Africa think about or provide rehabilitation support in acute and post-acute phases respectively. Understanding the perceptions and behaviors of healthcare providers treating malaria could help inform malaria-related disability research, policy, and practice, aimed at the providers themselves. This study explored the perceptions and behaviors of healthcare providers towards rehabilitation for children with severe malaria-related disability. The Theoretical Domains Framework was used to describe the findings relative to wider literature on health provider behavior change. A qualitative descriptive approach was used to interview thirteen healthcare providers recruited purposively based on their clinical professions, roles, and settings. Data were analyzed using directed content analysis. We decided on the most prominent theoretical domains considering the frequency of specific perceptions and behaviors across the participants, the frequency of perceptions and behaviors in each domain, and evidence of strong perceptions and behaviors. Nine out of fourteen theoretical domains were identified. These domains were: Beliefs about consequences, environmental context and resources, goals, knowledge, skills, optimism, reinforcement, social influences, and social or professional role and identity. Healthcare providers' beliefs about their roles in screening for disability or referring to rehabilitation were less positive. The findings of this study suggest the need for interventions to support healthcare providers in acute phases (prevention and control of severe malaria) and post-acute phases (disability screening, referral, and rehabilitation care). Recommended interventions should focus on developing clinical guidelines, training clinicians, addressing institutional factors, and modifying external social influences such as socio-cultural factors.

Features and behaviours for weight loss in the Chilean cohort with obesity from the ACTION study.

In Latin America, obesity rates are among the highest in the world. Currently, people with obesity (PWO) receive suboptimal care due to several challenges and barriers. The international ACTION-IO study aimed to identify perceptions, attitudes and behaviours of PWO and healthcare providers (HCP), and to assess potential barriers to effective obesity care. The aim of this subanalysis of the Chilean cohort was to compare their characteristics, perceptions, attitudes and behaviours according to the percentage of weight loss (lower weight loss [LWL; ≤10%] or higher weight loss [HWL; >10%] of basal weight). The ACTION-IO survey was completed by 1000 Chilean PWO and 200 HCPs. Mean age of PWO was 38 years (range 18-75); 62% were female. The majority had class I obesity. HWL subgroup represented 17.2% of all Chilean subset. Specific characteristics of patients with HWL were identified (higher educational level, lower proportion of class III obesity, preference for consulting obesity specialists, considering conversations with HCP as very helpful). HWL patients reported higher rates of favourable outcomes following HCP advice and a higher probability of attending scheduled follow-up visits. Certain demographic and behavioural variables (educational level, consultation to obesity specialists, adherence to HCP advice, follow-up scheduled visits and becoming aware of the obesity state) may identify PWO with a higher probability of a greater weight loss.

A-I-D for Cascades: Designing a theory-informed intervention for addressing prescribing cascades in primary care

Abstract Introduction Prescribing cascades, which occur when a medication is used to treat the side effect of another medication, are important contributors to polypharmacy. There is an absence of studies that evaluate the implementation or impact of existing interventions to address prescribing cascades in practice. Aim To design theory-informed options for interventions to address prescribing cascades within interprofessional primary care teams. Methods The Behaviour Change Wheel (BCW) framework, and its eight steps, were applied to guide intervention development by the research team. Three target behaviours were drafted and prioritised for intervention development based on data collected as part of two qualitative studies exploring why and how cascades occur across practice settings.[1,2] A target behaviour was selected and the COM-B (capability, opportunity, motivation-behaviour) model was then applied to identify the relevant factors for interprofessional primary care teams. The BCW was used to determine the relevant intervention types and policy options for the behaviour. Next, corresponding behaviour change techniques (BCTs) were identified and intervention options drafted. Prioritisation of behaviours and intervention examples were guided by the APEASE criteria (Affordability, Practicability, Effectiveness/cost-effectiveness, Acceptability, Side-effects/safety, Equity). Results The three target behaviours involved supporting: 1) healthcare providers to ask about, investigate and manage cascades (often through deprescribing), 2) the public to ask about prescribing cascades, and 3) the public to share medication histories and experiences with healthcare providers. The team selected the healthcare provider behaviour, called A-I-D (ask, investigate, deprescribe), for intervention development. Psychological capability and physical opportunity were determined to be the most relevant COM-B components, corresponding to education, training, environmental restructuring, and enablement intervention types and the guidelines, communications and marketing, and service provision policy options within the BCW model. Ultimately, 10 intervention options comprised of BCTs were developed by the team, which are ready for further prioritisation by stakeholders. These can be grouped into three categories: provision of educational content or materials for use by clinicians, provision of consultation or training to support clinicians, and knowledge mobilisation strategies. Through the process, the team identified that development of a practice guidance tool, which assists healthcare providers to investigate and manage prescribing cascades, is needed to support further intervention development. Conclusion The BCW framework guided the design of intervention options that will support primary care clinicians practising in interprofessional teams to address prescribing cascades. A limitation of this work is that applying the BCW framework required several judgements by the team, comprised of scientists, pharmacists, and nurses but not a general practitioner physician. Many but not all have practised with primary care interprofessional teams. When identifying interventions for future consultation, it was determined that the development of a practice guidance tool (i.e., which assists with identifying, investigating, and managing prescribing cascades) underpinned all the proposed interventions for addressing prescribing cascades in practice. Further research is needed to determine what primary care clinicians will need in this practice guidance tool and how it will be used in practice, to support its development.

Patient and Health Care Professional Perspectives About Referral, Self-Reported Use, and Perceived Importance of Digital Mental Health App Attributes in a Diverse Integrated Health System: Cross-Sectional Survey Study.

Digital mental health applications (DMHAs) are emerging, novel solutions to address gaps in behavioral health care. Accordingly, Kaiser Permanente Mid-Atlantic States (KPMAS) integrated referrals for 6 unique DMHAs into clinical care in 2019. This study investigated patient and health care professional (HCP) experiences with DMHA referral; DMHA use; and perceived importance of engagement, functionality, design, and information attributes in real-world practice. Separate cross-sectional surveys were developed and tested for patients and HCPs. Surveys were administered to KPMAS participants through REDCap (Research Electronic Data Capture), and completed between March 2022 and June 2022. Samples included randomly selected patients who were previously referred to at least 1 DMHA between April 2021 and December 2021 and behavioral health and primary care providers who referred DMHAs between December 2019 and December 2021. Of the 119 patients e-mailed a survey link, 58 (48.7%) completed the survey and 44 (37%) confirmed receiving a DMHA referral. The mean age of the sample was 42.21 (SD 14.08) years (29/44, 66%); 73% (32/44) of the respondents were female, 73% (32/44) of the respondents had at least a 4-year college degree, 41% (18/44) of the respondents were Black or African American, and 39% (17/44) of the respondents were White. Moreover, 27% (12/44) of the respondents screened positive for anxiety symptoms, and 23% (10/44) of the respondents screened positive for depression. Overall, 61% (27/44) of the respondents reported DMHA use for ≤6 months since referral, 36% (16/44) reported use within the past 30 days, and 43% (19/44) of the respondents reported that DMHAs were very or extremely helpful for improving mental and emotional health. The most important patient-reported DMHA attributes by domain were being fun and interesting to use (engagement); ease in learning how to use (functionality); visual appeal (design); and having well-written, goal- and topic-relevant content (information). Of the 60 sampled HCPs, 12 (20%) completed the survey. Mean HCP respondent age was 46 (SD 7.75) years, and 92% (11/12) of the respondents were female. Mean number of years since completing training was 14.3 (SD 9.94) years (10/12, 83%). Of the 12 HCPs, 7 (58%) were physicians and 5 (42%) were nonphysicians. The most important HCP-reported DMHA attributes by domain were personalized settings and content (engagement); ease in learning how to use (functionality); arrangement and size of screen content (design); and having well-written, goal- and topic-relevant content (information). HCPs described "typical patients" referred to DMHAs based on perceived need, technical capability, and common medical conditions, and they provided guidance for successful use. Individual patient needs and preferences should match the most appropriate DMHA. With many DMHA choices, decision support systems are essential to assist patients and HCPs with selecting appropriate DMHAs to optimize uptake and sustained use.

The Role of Trust as a Driver of Private-Provider Participation in Disease Surveillance: Cross-Sectional Survey From Nigeria.

Recognition of the importance of valid, real-time knowledge of infectious disease risk has renewed scrutiny into private providers' intentions, motives, and obstacles to comply with an Integrated Disease Surveillance Response (IDSR) framework. Appreciation of how private providers' attitudes shape their tuberculosis (TB) notification behaviors can yield lessons for the surveillance of emerging pathogens, antibiotic stewardship, and other crucial public health functions. Reciprocal trust among actors and institutions is an understudied part of the "software" of surveillance. We aimed to assess the self-reported knowledge, motivation, barriers, and TB case notification behavior of private health care providers to public health authorities in Lagos, Nigeria. We measured the concordance between self-reported notification, TB cases found in facility records, and actual notifications received. A representative, stratified sample of 278 private health care workers was surveyed on TB notification attitudes, behavior, and perceptions of public health authorities using validated scales. Record reviews were conducted to identify the TB treatment provided and facility case counts were abstracted from the records. Self-reports were triangulated against actual notification behavior for 2016. The complex health system framework was used to identify potential predictors of notification behavior. Noncompliance with the legal obligations to notify infectious diseases was not attributable to a lack of knowledge. Private providers who were uncomfortable notifying TB cases via the IDSR system scored lower on the perceived benevolence subscale of trust. Health care workers who affirmed "always" notifying via IDSR monthly reported higher median trust in the state's public disease control capacity. Although self-reported notification behavior was predicted by age, gender, and positive interaction with public health bodies, the self-report numbers did not tally with actual TB notifications. Providers perceived both risks and benefits to recording and reporting TB cases. To improve private providers' public health behaviors, policy makers need to transcend instrumental and transactional approaches to surveillance to include building trust in public health, simplifying the task, and enhancing the link to improved health. Renewed attention to the "software" of health systems (eg, norms, values, and relationships) is vital to address pandemic threats. Surveys with private providers may overestimate their actual participation in public health surveillance.

Examining State Licensing Requirements for Select Master's-Level Behavioral Health Providers for Children.

The authors examined licensing requirements for select children's behavioral health care providers. Statutes and regulations as of October 2021 were reviewed for licensed clinical social workers, licensed professional counselors, and licensed marriage and family therapists for all 50 U.S. states and the District of Columbia. All jurisdictions had laws regarding postgraduate training and license portability. No jurisdiction included language about specialized postgraduate training related to serving children and families or cultural competence. Other policies that related to the structure, composition, and authority of licensing boards varied across states and licensure types. In their efforts to address barriers to licensure, expand the workforce, and ensure that children have access to high-quality and culturally responsive care, states could consider their statutes and regulations.

The Importance of Autonomy and Performance Goals in Perceived Workload Among Behavioral Health Providers.

The authors sought to assess workplace characteristics associated with perceived reasonable workload among behavioral health care providers in the Veterans Health Administration. The authors evaluated perceived reasonable workload and workplace characteristics from the 2019 All Employee Survey (AES; N=14,824) and 2019 Mental Health Provider Survey (MHPS; N=10,490) and facility-level staffing ratios from Mental Health Onboard Clinical Dashboard data. Nine AES and 15 MHPS workplace predictors of perceived reasonable workload, 11 AES and six MHPS demographic predictors, and facility-level staffing ratios were included in mixed-effects logistic regression models. In total, 8,874 (59.9%) AES respondents and 5,915 (56.4%) MHPS respondents reported having a reasonable workload. The characteristics most strongly associated with perceived reasonable workload were having attainable performance goals (average marginal effect [AME]=0.10) in the AES and ability to schedule patients as frequently as indicated (AME=0.09) in the MHPS. Other AES characteristics significantly associated with reasonable workload included having appropriate resources, support for personal life, skill building, performance recognition, concerns being addressed, and no supervisor favoritism. MHPS characteristics included not having collateral duties that reduce care time, staffing levels not affecting care, support staff taking over some responsibilities, having spirit of teamwork, primary care-mental health integration, participation in performance discussions, well-coordinated mental health care, effective veteran programs, working at the top of licensure, and feeling involved in improving access. Facility-level staffing ratios were not significantly associated with perceived reasonable workload. Leadership may consider focusing resources on initiatives that support behavioral health providers' autonomy to schedule patients as clinically indicated and develop attainable performance goals.

Development of an evidence-informed governance and stewardship framework for elderly healthcare in Iran: A qualitative study

BackgroundThe ageing population poses significant challenges to healthcare systems, necessitating the establishment of high-functioning, integrated frameworks for elderly healthcare. This study aimed to explore the key challenges associated with the stewardship of elderly care in Iran and to develop a holistic stewardship framework. MethodsFor this qualitative study, thirty semi-structured interviews were conducted with key Iranian healthcare stakeholders, utilizing purposive and snowball sampling during 2021–2022. Inductive open coding was utilized to generate new concepts related to key stewardship challenges. The World Health Organization's conceptual framework, outlining the three stewardship tasks, served as the basis for crafting a tailored framework for elderly healthcare stewardship in Iran. ResultsFourteen main challenges and 38 sub-challenges were identified for elderly healthcare stewardship in Iran, categorized according to the WHO framework's three stewardship tasks. Challenges related to WHO stewardship task 1, involving health policy formulation and vision definition, included challenges in vision definition, planning, policymaking, and intergovernmental institutional superiority. Challenges related to WHO stewardship task 2, delineating governance and stewardship through control and regulation, encompassed issues such as support for the elderly, system responsiveness, behavior of healthcare providers, organizational structure, and cross-sectoral leadership challenges. Challenges associated with WHO stewardship task 3, about the use of collective intelligence, explored stakeholder collaboration, information for decision-making, and challenges within the elderly information system, covering data documentation, reporting, analysis, accessibility, distribution, and circulation. Subsequently, a framework was developed, covering areas like defining the vision and direction of health policy, managing information systems, evidence-informed policymaking, and delivering elderly health services with a holistic approach. ConclusionThe present framework shows how a management information system, guided by evidenced-informed policymaking and the formulation of customized health policies, can facilitate the provision of elderly health services based on identified needs. It presents a governance and stewardship pathway that can be adopted by Iranian health policymakers and similar middle-income countries facing analogous challenges in ageing and aged care system stewardship, serving as a model for developing their own frameworks.

Managing Medications During “Sick Days” in Patients With Diabetes, Kidney, and Cardiovascular Conditions: A Theory-informed Approach to Intervention Design and Implementation

ObjectivesOur aim in this work was to 1) explore barriers and enablers to patient and health-care provider (HCP) behaviours related to sick-day medication guidance (SDMG), 2) identify theory-informed strategies to advise SDMG intervention design, and 3) obtain perspectives on an eHealth tool for this purpose. MethodsA qualitative descriptive study using qualitative conventional content analysis was undertaken. Interviews and focus groups were held with patients and HCPs from January 2021 to April 2022. Data were analyzed using the Behaviour Change Wheel and Theoretical Domains Framework to inform intervention design. ResultsForty-eight people (20 patients, 13 pharmacists, 12 family physicians, and 3 nurse practitioners) participated in this study. Three interventions were designed to address the identified barriers and enablers: 1) prescriptions provided by a community-based care provider, 2) pharmacists adding a label to at-risk medications, and 3) built-in prompts for prescribing and dispensing software. Most participants accepted the concept of an eHealth tool and identified pharmacists as the ideal point-of-care provider. Challenges for an eHealth tool were raised, including credibility, privacy of data, medical liability, clinician remuneration and workload impact, and equitable access to use of the tool. ConclusionsPatients and HCPs endorsed non-technology and eHealth innovations as strategies to aid in the delivery of SDMG. These findings can guide the design of future theory-informed SDMG interventions.