Interventions In Community Settings Research Articles

Costs and cost-effectiveness of treatment setting for children with wasting, oedema and growth failure/faltering: A systematic review.

This systematic review aimed to address the existing evidence gaps, and guide policy decisions on the settings within which to treat infants <12 months of age with growth faltering/failure, and infants and children aged <60 months with moderate wasting or severe wasting and/or bilateral pitting oedema. Twelve electronic databases were searched for studies published before 10 December 2021. The searches yielded 16,709 records from which 31 studies were eligible and included in the review. Three studies were judged as low quality, whilst 14 were moderate and the remaining 14 were high quality. We identified very few cost and cost-effectiveness analyses for most of the models of care with the certainty of evidence being judged at very low or low. However, there were 17 cost and 6 cost-effectiveness analyses for the initiation of treatment in outpatient settings for severe wasting and/or bilateral pitting oedema in infants and children <60 months of age. From this evidence, the costs appear lowest for initiating treatment in community settings, followed by initiating treatment in community and transferring to outpatient settings, initiating treatment in outpatients then transferring to community settings, initiating treatment in outpatient settings, and lastly initiating treatment in inpatient settings. In addition, the evidence suggested that initiation of treatment in outpatient settings is highly cost-effective when compared to doing nothing or no programme implementation scenarios, using country-specific WHO GDP per capita thresholds. The incremental cost-effectiveness ratios ranged from $20 to $145 per DALY averted from a provider perspective, and $68 to $161 per DALY averted from a societal perspective. However, the certainty of the evidence was judged as moderate because of comparisons to do nothing/ no programme scenarios which potentially limits the applicability of the evidence in real-world settings. There is therefore a need for evidence that compare the different available alternatives.

Comprehensive cancer-related resources for adolescents and young adults (AYAs) treated in the community setting: 2022 Landscape survey results.

151 Background: Availability of guideline-endorsed, cancer-related resources for adolescents and young adults (AYAs: aged 15–39) with cancer is unknown. AYAs often receive treatment in community settings. We describe the current landscape of comprehensive cancer care resources for AYAs treated in community settings. Methods: NCI Community Oncology Research Program (NCORP) practice groups completed the Landscape Assessment in 2022 to describe available infrastructure, resources, and research capacity. Practice groups were included in this analysis if ≥10% of their annual cancer cases were within the AYA age range, or at least 50 AYA cancer cases are treated annually. We described the proportion of practices serving AYA patients with access to fertility preservation, mental health services, genetic testing and counseling, nutritional counseling, distress monitoring (psychosocial and financial), palliative care, and survivorship programs. Results: Of 271 responding practice groups, 77 (28%) met criteria for treating AYAs, whereas 102 (38%) did not meet criteria. The remaining 92 (34%) could not be classified due to missing data. Among the 77 practices treating AYAs, fertility preservation was available at 51% (oocyte cryopreservation) and 58% (sperm banking) of practices. While nutritional support and genetic testing were widely available (99% and 100% respectively), only 49% of practices treating AYAs offered survivorship programs (Table 1). Conclusions: Many AYAs receiving treatment in community settings lack access to key resources for cancer care, including fertility preservation and survivorship services. Future research should seek to identify barriers and facilitators to offering comprehensive resources in NCORP practices that serve AYAs and to advance understanding of AYA uptake of available resources.[Table: see text]

Mapping priorities in Swedish suicide prevention policy: What, how and who are prioritized. A qualitative document study

BackgroundSuicide is a serious public health problem. All 194 member states of the World Health Organization have signed the Comprehensive Mental Health action plan 2013–2030 which tasks governments with implementing evidence-based interventions in community settings to prevent suicide at all stages of life. This study aims to map the priorities in suicide prevention policy in community-settings in Sweden, one of the World Health Organization's member states. MethodA document study, using data from suicide prevention policy documents in the 21 counties in Sweden. Data was analyzed using qualitative content analysis. ResultsSuicide prevention interventions at the universal, selective and indicated prevention levels were prioritized. Most of the suicide prevention interventions intended to be implemented at each prevention level was evidence-based. Most of the suicide prevention interventions at all prevention levels did not prioritize any specific age group, however when age groups were targeted there were some emphases on children and adolescents. ConclusionThere is a need to improve suicide prevention interventions prioritizing age-groups who have high suicide rates. As educational interventions that encourage young people to develop their ability to face life challenges related to adolescence are found to be appropriate suicide prevention interventions, so too could educational interventions aimed at other age-groups be developed, to enable them to develop their ability to face life challenges related to their age.

Growth of community-based immunotherapy treatment in the Veterans Health Administration.

The MISSION and CHOICE Acts expanded the Veterans Health Administration's (VA) capacity to purchase immunotherapy services for VA patients from community-based providers. Our objective was to identify predictors of community-based immunotherapy treatment, and assess differences in cost and utilization across community treatment settings METHODS: We examined claims for 21,257 patients who started immunotherapy treatment between 2015 and 2020. We assessed growth in VA community-based immunotherapy care, predictors of community-based immunotherapy treatment using multivariable logistic regression based on patients' sociodemographic and clinical characteristics. We compared utilization and costs among those who received community-based immunotherapy services in hospital outpatient departments (HOPDs) versus physician office settings (POs). The proportion of community-based immunotherapy in the VA increased from 5.3% in 2015 to 32.1% in 2020, with total annual costs of immunotherapy growing from $6.1 million to $187 million. Older, married, and rural patients and those with more comorbidities were more likely than younger, single, or urban patients to be treated in the community. Black patients were more likely to be treated in the VA. Respiratory Cancer was the most common cancer type in both settings. Among community immunotherapy patients, we observed no meaningful differences in the number of units administered, the unit drug costs, or the cost per immunotherapy visit between POs and HOPDs. Drug costs did not differ widely across HOPDs and POs among VA patients who receive community-based immunotherapy.

Intramuscular vs Intravenous SARS-CoV-2 Neutralizing Antibody Sotrovimab for Treatment of COVID-19 (COMET-TAIL): A Randomized Noninferiority Clinical Trial.

Convenient administration of coronavirus disease 2019 (COVID-19) treatment in community settings is desirable. Sotrovimab is a pan-sarbecovirus dual-action monoclonal antibody formulated for intravenous (IV) or intramuscular (IM) administration for early treatment of mild/moderate COVID-19. This multicenter phase 3 study based on a randomized open-label design tested the noninferiority of IM to IV administration according to an absolute noninferiority margin of 3.5%. From June to August 2021, patients aged ≥12 years with COVID-19, who were neither hospitalized nor receiving supplemental oxygen but were at high risk for progression, were randomized 1:1:1 to receive sotrovimab as a single 500-mg IV infusion or a 500- or 250-mg IM injection. The primary composite endpoint was progression to (1) all-cause hospitalization for >24 hours for acute management of illness or (2) all-cause death through day 29. Sotrovimab 500 mg IM was noninferior to 500 mg IV: 10 (2.7%) of 376 participants vs 5 (1.3%) of 378 met the primary endpoint, respectively (absolute adjusted risk difference, 1.06%; 95% CI, -1.15% to 3.26%). The 95% CI upper limit was lower than the prespecified noninferiority margin of 3.5%. The 250-mg IM group was discontinued early because of the greater proportion of hospitalizations vs the 500-mg groups. Serious adverse events occurred in <1% to 2% of participants across groups. Four participants experienced serious disease-related events and died (500 mg IM, 2/393, <1%; 250 mg IM, 2/195, 1%). Sotrovimab 500-mg IM injection was well tolerated and noninferior to IV administration. IM administration could expand outpatient treatment access for COVID-19. ClinicalTrials.gov: NCT04913675.

Remote Intensive Intervention for Young Children on the Autism Spectrum During COVID-19: the Experience of Caregivers and Service Providers

ObjectivesCommunity-based early autism intervention programs in Geneva, Switzerland, converted their in-person services to a telehealth format during the COVID-19 home confinement period. The current study was aimed at measuring the engagement and satisfaction of service providers and caregivers as they experienced telehealth services for the first time and at monitoring child progress.MethodsForty-five families from diverse backgrounds and their 45 service providers had daily videoconferencing sessions of primarily parent-mediated intervention. Satisfaction questionnaires were completed at three time points over a 2-month period. Session frequency and program participation were recorded. Caregiver and service provider’s answers were compared. Results were also analyzed by family annual income. Child progress was monitored using the Early Start Denver Model Curriculum Checklist.ResultsCaregivers and service providers maintained high levels of participation and satisfaction throughout the telehealth service period and appreciated how the telehealth format allowed them to meet more frequently. Lower-income families tended to be more unanimously positive about the services when compared with mid- and high-income families. We found significant group differences in service providers’ and caregivers’ perceptions of each other’s comfort level with the remote sessions. Child progress followed a pattern of continued significant improvement across most developmental domains during the telehealth service period.ConclusionsThese findings underscore the potential of telehealth as a promising and appreciated approach for delivering intensive early autism interventions in community settings. Further research is needed to determine optimal session frequency for remote parent-mediated intervention and to determine ways to make telehealth services more accessible for low-income families.

Associations between rumination, depression, and distress tolerance during CBT treatment for depression in a tertiary care setting

BackgroundRumination is strongly associated with depressive symptom severity and course. However, changes in rumination during outpatient cognitive behavioral therapy (CBT), and their links to baseline features such as distress tolerance and clinical outcomes, have received limited attention. Methods278 outpatients with depression received group or individual CBT. Measures of rumination, distress tolerance, and depression symptom severity were assessed at baseline and periodically during treatment. Mixed effect and regression-based models evaluated changes over time, and associations between rumination, distress tolerance and depression severity. ResultsDepression and rumination decreased throughout acute treatment. Rumination reduction was concurrently associated with depressive symptom reduction. Lower levels of rumination at each time point prospectively predicted lower depressive symptoms at the next time point. Distress tolerance measured at baseline was positively associated with depression symptom severity; the indirect effect on post-treatment depression symptoms via rumination measured mid-treatment was nonsignificant when rumination at baseline was accounted for. Changes in and associations between depression and rumination were replicated in sensitivity analyses; although changes in depression and rumination were smaller in magnitude in patients receiving treatment during COVID-19. LimitationsAdditional assessment points would permit a more nuanced assessment of the role rumination may play in mediating the associations between distress tolerance and depression severity. Additional investigation of treatments in community settings may also further our understanding of variability in rumination during depression treatment. ConclusionsThe current study provides unique real-world support for variability in rumination as a key indicator of change over the course of CBT for depression.

AppReminders – a pilot feasibility randomized controlled trial of a memory aid app for people with acquired brain injury

ABSTRACT Mobile phone reminding apps can be used by people with acquired brain injury (ABI) to compensate for memory impairments. This pilot feasibility trial aimed to establish the feasibility of a randomized controlled trial comparing reminder apps in an ABI community treatment setting. Adults with ABI and memory difficulty who completed the three-week baseline were randomized (n = 29) and allocated to Google Calendar or ApplTree app. Those who attended an intervention session (n = 21) watched a 30-minute video tutorial of the app then completed reminder setting assignments to ensure they could use the app. Guidance was given if needed from a clinician or researcher. Those who passed the app assignments (n = 19) completed a three-week follow up. Recruitment was lower than target (n = 50), retention rate was 65.5%, adherence rate was 73.7%. Qualitative feedback highlighted issues that may impact usability of reminding apps introduced within community brain injury rehabilitation. Feasibility results indicate a full trial would require 72 participants to demonstrate the minimally clinically important efficacy difference between apps, should a difference exist. Most participants (19 of 21) given an app could learn to use it with the short tutorial. Design features implemented in ApplTree have potential to improve the uptake and utility of reminding apps.

Outcome trajectories in a county mental health clinic before and after telemental health: a retrospective COVID-19 cohort study.

Telemental health (TMH) care has received increased attention, most recently due to the COVID-19 pandemic. Many treatment settings and clinicians were forced to rapidly shift to TMH modalities, including clinicians with limited exposure to and possibly negative attitudes toward alternative treatment delivery formats. With the shift to new modalities, effectiveness research is necessary to understand if patients are receiving the same quality of care as before the pandemic and their receipt of mostly in person services. This study compared the naturalistic treatment outcome trajectories for a cohort of patients who received in-person services prior to the pandemic and a distinct cohort of patients who received TMH services after the onset of the pandemic, in a community mental health setting with limited exposure to TMH prior to the COVID-19 pandemic. We adopted a retrospective cohort design to examine treatment modality as a between-group moderator of symptom change trajectory on the self-report Patient Health Questionnaire (PHQ-9) in a sample of N = 958 patients in the Northeast United States. Treatment durations differed in the naturalistic treatment setting and we examined patient-reported outcomes up to a maximum of one year. Statistically significant average decreases in symptom severity were found over the course of up to one year of treatment, yet the average outcome trajectory was not significantly different between two modality cohorts (in person delivery before the pandemic versus TMH delivery after pandemic onset). These findings suggest that even in a setting with limited exposure to or training in TMH, the average outcome trajectory for patients who received TMH was statistically similar to the outcome trajectory for patients in an earlier cohort who received in-person services prior to the pandemic onset. Overall, the results appear to support continued use of TMH services in community treatment settings.

Effectiveness of interventions to address different types of vulnerabilities in community-dwelling older adults: An umbrella review.

Frailty, social isolation, loneliness, and poverty may render older adults vulnerable to social or health stressors. It is imperative to identify effective interventions to address them especially in the context of COVID-19 pandemic. To identify effective community-based interventions to address frailty, social isolation, loneliness, and poverty among community-dwelling older adults. Umbrella review. We systematically searched PubMed, Ovid MEDLINE, Embase, Cochrane CENTRAL, EBM-Reviews, CINAHL via EBSCO, and APA PsycInfo via Ovid from January 2009 to December 2022. We included systematic reviews or quantitative reviews of non-pharmacologic interventions targeting community-dwelling older adults. Two review authors independently screened the titles and abstracts, performed data extraction and appraised the methodological quality of the reviews. We used a narrative synthesis approach to summarize and interpret the findings. We assessed the methodological quality of the studies using AMSTAR 2.0 tool. We identified 27 reviews incorporating 372 unique primary studies that met our inclusion criteria. Ten of the reviews included studies conducted in low-middle-income countries. Twelve reviews (46%, 12/26) included interventions that addressed frailty. Seventeen reviews (65%, 17/26) included interventions that addressed either social isolation or loneliness. Eighteen reviews included studies with single component interventions, while 23 reviews included studies with multi-component interventions. Interventions including protein supplementation combined with physical activity may improve outcomes including frailty status, grip strength, and body weight. Physical activity alone or in combination with diet may prevent frailty. Additionally, physical activity may improve social functioning and interventions using digital technologies may decrease social isolation and loneliness. We did not find any review of interventions addressing poverty among older adults. We also noted that few reviews addressed multiple vulnerabilities within the same study, specifically addressed vulnerability among ethnic and sexual minority groups, or examined interventions that engaged communities and adapted programs to local needs. Evidence from reviews support diets, physical activity, and digital technologies to improve frailty, social isolation or loneliness. However, interventions examined were primarily conducted under optimal conditions. There is a need for further interventions in community settings and conducted under real world settings in older adults living with multiple vulnerabilities.

PD15-05 LONG-TERM RATES OF BIOCHEMICAL RECURRENCE AFTER PRIMARY EXTERNAL BEAM RADIATION THERAPY FOR PROSTATE CANCER

You have accessJournal of UrologyCME1 Apr 2023PD15-05 LONG-TERM RATES OF BIOCHEMICAL RECURRENCE AFTER PRIMARY EXTERNAL BEAM RADIATION THERAPY FOR PROSTATE CANCER Domenique Escobar, Lufan Wang, Jasmin Banton, Janet Cowan, Samuel Washington, Osama Mohamad, Mani Menon, and Peter Carroll Domenique EscobarDomenique Escobar More articles by this author , Lufan WangLufan Wang More articles by this author , Jasmin BantonJasmin Banton More articles by this author , Janet CowanJanet Cowan More articles by this author , Samuel WashingtonSamuel Washington More articles by this author , Osama MohamadOsama Mohamad More articles by this author , Mani MenonMani Menon More articles by this author , and Peter CarrollPeter Carroll More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003262.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radiation therapy is a common form of treatment for men with prostate cancer. Biochemical recurrence (BCR) is defined according to the ASTRO Phoenix definition of PSA nadir +2. We sought to characterize long term rates of biochemical recurrence in a large, well-characterized and well-followed cohort of men treated with primary external beam radiation therapy (EBRT). METHODS: Patients were enrolled in CaPSURE, a national registry of men diagnosed with prostate cancer, from 1995 - 2017 with clinically localized prostate cancer (cN0M0/X, PSA≤50) and treated with primary EBRT. Cancer risk was defined by NCCN criteria. Cox proportional hazards regressions were used to assess associations between patient characteristics and BCR was defined by PSA nadir +2. RESULTS: 1193 patients were included. Mean age at diagnosis was 70 (SD 6.82), median PSA at diagnosis was 7.5 and mean number of follow up PSA tests was 5. Overall rates of BCR were 17.4% at 5 years and 39.4% at 10 years. NCCN clinical risk was significantly associated with rates of BCR with high-risk patients having the highest rates of recurrence, followed by intermediate- and low-risk groups (61.5%, 36.4% and 28.5% respectively at 10 years, log-rank p<0.01). NCCN high vs low clinical risk was significantly associated with likelihood of BCR (HR 4.8, CI 2.5–9.2). Rates of salvage treatment were 16% at 5 years and 19% at 10 years and these were also significantly associated with NCCN high vs low clinical risk (HR 3.7, CI 2.3–6) and concurrent ADT (HR 1.83, CI 1.2–2.7). Overall rates of bone metastases were 2.6% at 5 years and 4% at 10 years. Overall prostate cancer specific mortality was 3% at 5 years and 7% at 10 years. CONCLUSIONS: In this analysis, rates of BCR were fairly high and consistent with published RTOG studies, but rates of salvage treatment were relatively low in comparison, indicating that not all patients who recur need, are offered or want treatment. The limitations of this analysis include incomplete information on radiation dose and field size. The strengths of this analysis include the size of the cohort and the length of follow-up. Furthermore, as this cohort largely represents treatment in community settings, the results may be broadly applicable. Source of Funding: UCSF Goldberg-Benioff Program in Translational Cancer Biology © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e420 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Domenique Escobar More articles by this author Lufan Wang More articles by this author Jasmin Banton More articles by this author Janet Cowan More articles by this author Samuel Washington More articles by this author Osama Mohamad More articles by this author Mani Menon More articles by this author Peter Carroll More articles by this author Expand All Advertisement PDF downloadLoading ...

Long-term rates of biochemical recurrence after primary external beam radiation therapy (EBRT) for prostate cancer.

393 Background: Radiation therapy is a common form of treatment for men with prostate cancer. Biochemical recurrence (BCR) is most commonly defined using the Phoenix definition of PSA nadir + 2. We sought to characterize long term rates of biochemical recurrence in a large, well-characterized and well-followed cohort of men treated with primary EBRT. Methods: Patients enrolled in CaPSURE, a national registry of men diagnosed with prostate cancer, from 1995 - 2017 with clinically localized prostate cancer (cN0M0/X, PSA&lt;=50) treated with primary EBRT were included. Cancer risk was defined by NCCN criteria. Cox proportional hazards regressions were used to assess associations between patient characteristics and BCR as defined by PSA nadir + 2. Results: 1193 patients were included. Mean age at diagnosis was 70 (SD 6.82), median PSA at diagnosis was 7.6 and mean number of follow up PSA tests was 5. Overall rates of BCR were 17.4% at 5 years and 39.4% at 10 years. Rates of BCR were significantly associated with NCCN risk with high-risk patients having the highest rates of recurrence, followed by intermediate- and low-risk groups (61.5%, 36.4% and 28.5% respectively at 10 years). NCCN high vs low clinical risk was significantly associated with likelihood of BCR (HR 4.8, CI 2.5 – 9.2). Rates of salvage treatment, usually ADT, were 16% at 5 years and 19% at 10 years and these were also significantly associated with NCCN high vs low clinical risk (HR 3.7, CI 2.3 – 6) and concurrent ADT (HR 1.83, CI 1.2 – 2.7). Overall rates of bone metastases were 2.6% at 5 years and 4% at 10 years. Overall prostate cancer specific mortality was 3% at 5 years and 7% at 10 years. Conclusions: In this analysis, rates of BCR were fairly high and consistent with published RTOG studies, but rates of salvage treatment were relatively low in comparison, indicating that not all patients who recur need, are offered or want treatment. The limitations of this analysis include incomplete information on radiation dose and field size. The strengths of this analysis include the size of the cohort and the length of follow-up. Furthermore, as this cohort largely represents treatment in community settings, the results may be broadly applicable.

Driving the Chimeric Antigen Receptor: The Road Ahead for Cell Therapy

Driving the Chimeric Antigen Receptor: The Road Ahead for Cell Therapy

Use of an Interactive Obesity Treatment Approach in Individuals With Severe Mental Illness: Feasibility, Acceptability, and Proposed Engagement Criteria.

Digital and mobile health interventions are increasingly being used to support healthy lifestyle change, including in certain high-risk populations such as those with severe mental illnesses (SMIs). Life expectancy in this population lags 15 years behind counterparts in the general population, primarily due to obesity-related health conditions. We tested the feasibility and usability of a 12-week interactive obesity treatment approach (iOTA) to adults with chronic SMIs (depression, bipolar disorder and schizophrenia spectrum disorder) receiving treatment in community settings. The iOTA incorporates short message service (SMS) text messages to supplement monthly in-person health coaching. Factors hypothesized to be associated with weight change were illness severity and treatment engagement. Severe psychiatric symptoms were defined as baseline Clinical Global Impression severity score of >5. Criterion engagement was defined as a text messaging response rate >80% during the first 4 weeks of treatment. Disordered eating, assessed with the Loss of Control Over Eating Scores, was also evaluated. Participants provided qualitative data, further informing assessment of intervention feasibility, usability, and acceptability. A total of 26 participants were enrolled. The mean age was 48.5 (SD 15.67) years; 40% (10/26) were Black and 60% (15/26) female. Participants with lower symptom severity and adequate engagement demonstrated significantly decreased weight (F1,16=22.54, P<.001). Conversely, high symptom severity and lower text message response rates were associated with trend-level increases in weight (F1,7=4.33, P=.08). Loss-of-control eating was not observed to impact treatment outcome. Participants voiced preference for combination of live health coaching and text messaging, expressing desire for personalized message content. These results demonstrate the feasibility of delivering an adapted iOTA to SMI patients receiving care in community settings and suggest testable criteria for defining sufficient treatment engagement and psychiatric symptom severity, two factors known to impact weight loss outcomes. These important findings suggest specific adaptations may be needed for optimal treatment outcomes in individuals with SMI.

Weight restoration in adolescent anorexia: parents’ goal-directed processes

BackgroundParent-led weight restoration is a key intervention of family-based treatment, an empirically supported treatment for adolescent anorexia. Successful outcomes in family-based treatment depend almost entirely on parental action, yet current understandings of this intervention are primarily informed by professional theory and expert perspectives. Comparatively little is known about parents’ goals and actions while implementing the treatment, despite goal-directed action being an explicit framework of family-based treatment. This study seeks to investigate parents’ involvement in weight restoration from the perspective of the goal-directed actions they construct and engage in themselves and with others. This study focuses on the phenomenon of parent-led weight restoration as a project and addresses the following research question: “How do parents participate in the weight restoration of their adolescent as the adolescent recovers from anorexia nervosa?”.MethodThis multicase study used the action project method and conceptual framework of contextual action theory to examine four cases of five parents engaged in actions to help their adolescent regain weight and recover from anorexia. Data were collected using multi-part interviews and analyzed according to the action project method and the multicase approach.ResultsParents’ weight restoration projects were identified and grouped based on three common a themes. The primary theme, progressing toward health and well-being, was supported by three key processes: maintaining a holistic focus, trusting, and monitoring progress. Two secondary themes captured actions that were integral to the parents’ projects, but with less prominence. Secondary themes were creating capacity, which was supported by three processes (managing emotions to maintain a helpful focus, personal work, and resourcing time and finances), and coordinating and negotiating partnerships. The socio-cultural valuing of the thin ideal emerged as a unique process salient in one case. This study presents a goal-directed and contextual perspective on how parents translated the principles of family-based treatment into their daily lives. It joins a small but growing body of work concerned with generating new understandings and frameworks for practitioners and researchers to enhance the effectiveness of family-based treatment in community settings.

Community Initiated Care: A blue-print for the practical realization of contextual behavioral science

There is a vast unmet need for mental health care and support in the United States and globally. Although expanding specialty services is needed, this is neither sufficient nor necessary to comprehensively address the current and future demand. Traditional models of care which have focused on mental disorders, while useful for many, remain out of reach, unaffordable, and not timely for helping the vast majority of individuals in need of mental health support. There is a growing movement of community-based networks and organizations which aim to fill this need by harnessing existing community resources to promote mental health and prevent mental and substance use disorders. This paper describes our effort to derive a blue-print for an approach, which we call “Community Initiated Care (CIC)”, building on these real-world experiences and the growing science on lay person delivered brief psychosocial interventions in community settings. CIC serves as a back-bone for training lay persons to support the mental health and well-being of others in their communities. CIC is envisioned as an equitable, efficient, safe, and timely form of contextualized support to promote mental health and prevent self-harm, mental health and substance use problems. CIC is not intended to replace clinical interventions; instead, we envisage the supportive encounter to use a person-centered approach to bolster existing positive coping skills, promote positive social engagement, reduce risk of future mental health problems, and encourage other forms of help seeking when appropriate. This article explores how our thinking is aligned with and responsive to the strategies and tactics of the Contextual Behavioral Science Task Force to promote programs that are multi-dimensional, process-based, prosocial, practical, and multi-level. Development, implementation, and evaluation of CIC will not only advance contextual behavioral science but also move society forward to more equitable mental health and well-being.

Music-based interventions in community settings: Navigating the tension between rigor and ecological validity.

Empirical research of community-based music interventions has advanced to investigate the individual, social, and educational implications of arts-for-wellbeing practices. Here, we present the motivations, aims, hypotheses, and implications of this complex field of inquiry. We describe examples of recent large-scale investigations to reflect on the major methodological challenges. Community-based music interventions strike a balance between the empirical rigor of clinical trials and the demands of ecological validity. We argue that this balance should be viewed as an asset rather than a mere pragmatic compromise. We also offer some perspectives on best-practice models for effectively engaging in this type of work.

Heroin pipe distribution to reduce high-risk drug consumption behaviors among people who use heroin: a pilot quasi-experimental study

BackgroundHeroin pipe distribution may encourage people who use heroin (PWUH) to transition from injecting to smoking heroin, reducing harms associated with injection drug use. A syringe services program (SSP) in Seattle, Washington, led by people who use drugs developed a heroin pipe distribution program.MethodsWe conducted a pretest–posttest quasi-experimental study to evaluate the impact of heroin pipe distribution on drug consumption behaviors among PWUH between March and December 2019. SSP clients were surveyed during three weeklong timepoints before and four weeklong timepoints after heroin pipe distribution. Primary outcomes were change in proportion of SSP clients who exclusively injected heroin, exclusively smoked heroin, and both injected and smoked heroin in the past seven days comparing the pre- and post-intervention periods.ResultsAcross the seven observation timepoints, 694 unique respondents completed 957 surveys. Multiple responses from a single respondent in a given period were collapsed, resulting in 360 pre-intervention and 430 post-intervention records. Heroin use was reported in over half of pre-intervention (56%, 201/360) and post-intervention records (58%, 251/430). Compared to pre-intervention behaviors, the proportion of respondents who exclusively injected heroin was lower after the start of heroin pipe distribution (32%, 80/251 vs 43%, 86/201, p = 0.02), while the proportion of respondents who both injected and smoked heroin was higher (45%, 113/251 vs 36%, 72/201, p = 0.048). Just under half (44%, 110/251) of respondents who used heroin during the post-intervention period used a heroin pipe obtained from the SSP, of which 34% (37/110) reported heroin pipe distribution had reduced their heroin injection frequency. Self-reported hospitalization for a pulmonary cause was not associated with using a heroin pipe.ConclusionsThe proportion of SSP clients who exclusively injected heroin was lower after implementation of heroin pipe distribution. Randomized studies with longer follow-up are needed to investigate whether heroin pipe distribution reduces heroin injection and improves health outcomes associated with drug use. Limited intervention exposure, loss to follow-up, and pipe availability from other sources pose methodological challenges to evaluations of route transition interventions in community settings. This pilot highlights the potential for organizations led by people who use drugs to develop, implement, and evaluate novel public health programming.

The incidence rate of planned and emergency physical health hospital admissions in people diagnosed with severe mental illness: a cohort study.

People with severe mental illness (SMI) have more physical health conditions than the general population, resulting in higher rates of hospitalisations and mortality. In this study, we aimed to determine the rate of emergency and planned physical health hospitalisations in those with SMI, compared to matched comparators, and to investigate how these rates differ by SMI diagnosis. We used Clinical Practice Research DataLink Gold and Aurum databases to identify 20,668 patients in England diagnosed with SMI between January 2000 and March 2016, with linked hospital records in Hospital Episode Statistics. Patients were matched with up to four patients without SMI. Primary outcomes were emergency and planned physical health admissions. Avoidable (ambulatory care sensitive) admissions and emergency admissions for accidents, injuries and substance misuse were secondary outcomes. We performed negative binomial regression, adjusted for clinical and demographic variables, stratified by SMI diagnosis. Emergency physical health (aIRR:2.33; 95% CI 2.22-2.46) and avoidable (aIRR:2.88; 95% CI 2.60-3.19) admissions were higher in patients with SMI than comparators. Emergency admission rates did not differ by SMI diagnosis. Planned physical health admissions were lower in schizophrenia (aIRR:0.80; 95% CI 0.72-0.90) and higher in bipolar disorder (aIRR:1.33; 95% CI 1.24-1.43). Accident, injury and substance misuse emergency admissions were particularly high in the year after SMI diagnosis (aIRR: 6.18; 95% CI 5.46-6.98). We found twice the incidence of emergency physical health admissions in patients with SMI compared to those without SMI. Avoidable admissions were particularly elevated, suggesting interventions in community settings could reduce hospitalisations. Importantly, we found underutilisation of planned inpatient care in patients with schizophrenia. Interventions are required to ensure appropriate healthcare use, and optimal diagnosis and treatment of physical health conditions in people with SMI, to reduce the mortality gap due to physical illness.

Promoting positive parenting and mental wellbeing in Hong Kong Chinese parents: A pilot cluster randomised controlled trial.

Effective and brief positive parenting interventions could be adopted widely, but evidence is limited. We aimed to evaluate the effectiveness of a positive parenting programme in Hong Kong Chinese parents. We conducted a pilot cluster randomised controlled trial in 2017 in 144 Hong Kong Chinese parents (84.7% women, mean age 42.5 [SD 5.87] years) of school-age children (mean age 10.9 [2.8] years) in 4 family service centres (clusters). The intervention included two 2-hour interactive talks (4 hours in total). The contents covered skills of giving praise, showing appreciation and playing enjoyable family games. The control group was offered the intervention after all the data were collected. Praise, appreciation and enjoyment related behaviours were measured as primary outcomes at baseline, 1 month and 3 months. The secondary outcomes were subjective happiness, wellbeing, personal health and happiness, family health, family happiness and harmony, and family relationship. After the completion of all assessments, five focus group discussions with the parents and four individual in-depth interviews with community service providers were conducted to explore their experiences. Compared with the control group (n = 69), the intervention group (n = 75) showed greater positive changes in appreciation and enjoyment at 3 months with small effect sizes (d = 0.42 and 0.32, respectively), and greater improvements in the secondary outcomes at 3 months with small effect sizes (d: 0.29-0.48). In the focus groups, the parents reported more praise to their children, better temper control, more focus on their children's strengths and better family relationships. According to the service providers, most of the parents enjoyed the activities. The brief intervention in community settings with the engagement of community service providers has shown preliminary effectiveness in promoting positive parenting and mental wellbeing of Hong Kong Chinese parents. The authors confirm that all ongoing and related trials for this intervention are registered. The study reported in this manuscript is registered as clinical trial at clinicaltrials.gov: NCT03282071. https://clinicaltrials.gov/ct2/show/NCT03282071.