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Background Policymakers need research-informed guidance on leveraging national government funding to promote evidence-based practice (EBP) implementation, however empirical studies of policy financing strategies in implementation science remain limited. Major investments are already being made. Starting in 2012, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) funded state substance use service agencies to implement EBPs for youth substance use. We examined 19 states funded to implement the Adolescent Community Reinforcement Approach (A-CRA), an exemplar EBP selected by most states. Using the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework, we sought to explain state-level variation in A-CRA reach (defined as the proportion of A-CRA certified providers) and to identify policy implications for improving EBP financing strategies. Methods We conducted an explanatory sequential mixed-method (QUAN→QUAL) comparative case study, treating each state as a case. States were categorized as achieving high, medium, and low reach during their grant periods using A-CRA certification records and state demographic data. We then synthesized available data (i.e., interviews with 33 state agency administrators, grant administrative records, other documents describing A-CRA implementation) to summarize grant activities completed and their quality, and factors potentially influencing reach in each state. Finally, we compared and contrasted state cases to identify policy implications through pattern matching techniques. Results We characterized the 19 states’ reach levels as high ( n  = 7), medium ( n  = 5), and low ( n  = 7) and identified an average of 5 grant-related activities completed per state; the most common being A-CRA training to treatment organizations. Six states were case anomalies (e.g., low quantity and quality of activities, while achieving high reach). Most notably, we found that high-reach states had more specific, intentional, and explicit A-CRA implementation requirements for treatment organizations than did low- and medium-reach states. States were also more successful in achieving A-CRA reach when they reported proactively addressing implementation barriers (e.g., provider turnover, state leadership buy-in and support). Conclusions Our mixed-method comparative case study advances policy-focused implementation research related to EBP financing strategies, demonstrating how examination of large-scale real-world funding initiatives can produce generalizable lessons. Our findings have implications for how future funding initiatives can facilitate EBP delivery to maximize reach.

Economic incentives through health insurance may promote healthier behaviors. Little is known about health and economic impacts of incentivizing diet, a leading risk factor for diabetes and cardiovascular disease (CVD), through Medicare and Medicaid. A validated microsimulation model (CVD-PREDICT) estimated CVD and diabetes cases prevented, quality-adjusted life years (QALYs), health-related costs (formal healthcare, informal healthcare, and lost-productivity costs), and incremental cost-effectiveness ratios (ICERs) of two policy scenarios for adults within Medicare and Medicaid, compared to a base case of no new intervention: (1) 30% subsidy on fruits and vegetables (\"F&V incentive\") and (2) 30% subsidy on broader healthful foods including F&V, whole grains, nuts/seeds, seafood, and plant oils (\"healthy food incentive\"). Inputs included national demographic and dietary data from the National Health and Nutrition Examination Survey (NHANES) 2009-2014, policy effects and diet-disease effects from meta-analyses, and policy and health-related costs from established sources. Overall, 82 million adults (35-80 years old) were on Medicare and/or Medicaid. The mean (SD) age was 68.1 (11.4) years, 56.2% were female, and 25.5% were non-whites. Health and cost impacts were simulated over the lifetime of current Medicare and Medicaid participants (average simulated years = 18.3 years). The F&V incentive was estimated to prevent 1.93 million CVD events, gain 4.64 million QALYs, and save $39.7 billion in formal healthcare costs. For the healthy food incentive, corresponding gains were 3.28 million CVD and 0.12 million diabetes cases prevented, 8.40 million QALYs gained, and $100.2 billion in formal healthcare costs saved, respectively. From a healthcare perspective, both scenarios were cost-effective at 5 years and beyond, with lifetime ICERs of $18,184/QALY (F&V incentive) and $13,194/QALY (healthy food incentive). From a societal perspective including informal healthcare costs and lost productivity, respective ICERs were $14,576/QALY and $9,497/QALY. Results were robust in probabilistic sensitivity analyses and a range of one-way sensitivity and subgroup analyses, including by different durations of the intervention (5, 10, and 20 years and lifetime), food subsidy levels (20%, 50%), insurance groups (Medicare, Medicaid, and dual-eligible), and beneficiary characteristics within each insurance group (age, race/ethnicity, education, income, and Supplemental Nutrition Assistant Program [SNAP] status). Simulation studies such as this one provide quantitative estimates of benefits and uncertainty but cannot directly prove health and economic impacts. Economic incentives for healthier foods through Medicare and Medicaid could generate substantial health gains and be highly cost-effective.

Health service utilization serves as a vital indicator of healthcare access and equity. In Ethiopia, the fee waiver system is a key component of healthcare financing reforms designed to improve access to essential health services for economically disadvantaged populations. However, the evidence regarding health service utilization among fee waiver beneficiaries remains inconsistent. This systematic review and meta-analysis synthesize existing studies to provide comprehensive insight on health service utilization and associated factors among fee waiver beneficiaries in Ethiopia. A systematic search of peer-reviewed articles and gray literature was conducted up to February 2024, in databases such as PubMed/MEDLINE, African Journals Online (AJOL), Cumulative Index to Nursing & Allied Health Literature (CINAHL), Science Direct, Research4life, and Google Scholar. A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines. Data were extracted using Microsoft Excel and analyzed with STATA 17 software. The quality of studies was assessed using Joanna Briggs Institute (JBI) checklists. The pooled prevalence of health service utilization among fee waiver beneficiaries was estimated using random-effects meta-analysis. Subgroup analyses were performed based on study regions. Publication bias was evaluated with a DOI plot, the Luis Furuya Kanamori (LFK) index, and Egger's test, while heterogeneity was assessed using the I² statistic. The study analyzed seven primary studies comprising a total of 11,488 participants. All the included studies demonstrated a low risk of bias, and no significant evidence of publication bias was detected among them. The pooled prevalence of health service utilization was found to be 60.57% (95% CI: 58.11-63.04; I² = 54.2%, p = 0.041). A family size of fewer than five was negatively and significantly associated with health service utilization (OR = 0.69, 95% CI: 0.51-0.95; I² = 0.0%, p = 0.47). On the other hand, having chronic diseases was positively and significantly associated with health service utilization among fee waiver beneficiaries (OR = 4.85, 95% CI: 1.34-17.56; I² = 93.5%, p < 0.001). Residence showed no significant association (OR = 1.58; 95% CI: 0.03-71.49), with wide confidence intervals reflecting considerable uncertainty. The findings suggest that a significant number of beneficiaries accessed health services, indicating that the system is likely contributing to enhanced healthcare access for the target population. However, this also highlights the need for further efforts to ensure broader and more equitable utilization. The analysis reveals that health service utilization is negatively associated with a family size of fewer than five and positively associated with having chronic diseases. To improve the utilization rate among poor populations, policymakers in Ethiopia should implement integrated strategies that address these key factors and target barriers to healthcare access.

Background Community Health Centers (CHCs) are a vital part of the health safety net, providing high quality care to underserved communities with complex health and social needs. Yet, despite their crucial role, CHCs operate on slim financial margins, relying in part on grant funding streams. Little is known about the role that grant requirements have in directing the functioning of CHCs. Methods We conducted qualitative thematic analysis, based on 56 semi-structured interviews of CHC leadership and staff in New York City. Results Three overarching themes described ways that CHCs are hampered by the designs and requirements of grant funding: 1) narrowness of available funding, 2) lack of access to operational funding, and 3) inability to utilize available funding to address workforce needs. Conclusions Our analysis illuminates the tension between the weighty charge placed on CHCs as key pillars of the health safety net and the inflexible grant funding mechanisms available to sustain them. Restrictive funding limits CHCs’ capacity to deliver comprehensive care and meet community needs.

Background This study aims to explore the development status of the supply level of professional public health resources in Beijing Municipality, analyze the areal differences and spatial distribution characteristics of the supply level in 16 districts, and provide a scientific basis for promoting the balanced development of the supply level of professional public health resources in each district of Beijing Municipality. Methods Based on panel data from Statistical Yearbook of Health Work in Beijing Municipality and Health and Family Planning Work in Beijing Municipality from 2014 to 2022. Using the entropy method to measure the supply level of professional public health resources in Beijing, employing the Dagum Gini coefficient and Kernel density estimation method to analyze the spatial differentiation characteristics and dynamic evolution process of the supply level, and using heat maps to display the spatial distribution of the supply level in various districts of Beijing. Results The Dagum Gini coefficient of the supply level of professional public health resources in Beijing Municipality decreased continuously from 0.3419 in 2014 to 0.29736 in 2020, then gradually increased, showing a trend of initially decreasing and then increasing overall spatial differences. The spatial differences mainly stem from differences between areas. The kernel density curve shows that the supply level of professional public health resources in Beijing Municipality gradually increased, slightly decreased after 2021, and did not form a situation of two or multi-level differentiation. Conclusion From 2014 to 2022, the supply level of professional public health resources in Beijing Municipality showed an overall upward trend, but attention should be paid to the decline after 2021; spatial differences initially decreased and then increased, and the differences between areas is the main source of the overall difference in Beijing. Therefore, the Beijing Municipal Government should focus on narrowing the differences between areas, determine the allocation and management of public health resources based on the actual situation of core areas, promote coordinated development within and outside areas, and thus enhance the supply level of professional public health resources.

Background The World Trade Center (WTC) Health Program, a limited federal healthcare program, provides medical monitoring and treatment for WTC-related conditions to eligible Responders and Survivors of the 9/11 terrorist attacks. Free initial health evaluations (IHE) represent the first step towards the Program’s goal of providing equitable and timely member access to healthcare. This study aimed to evaluate equity in IHE utilization among Program members to inform the development of targeted interventions. Methods This surveillance study used administrative and surveillance data collected from January 2012 through February 2024. It included Program members newly enrolled during 2012–2022 who completed an IHE or were alive for ≥ 1 year after enrollment. We conducted descriptive and multivariable logistic regression analyses. Outcomes of interest included timely IHE utilization (proportion of members completing an IHE within 6 months of enrollment) and any IHE utilization (proportion completing an IHE by February 2024). Factors of interest included member type, sex, age, race/ethnicity, preferred language, and urban/rural residence. Results 27,379 Responders and 30,679 Survivors were included. Responders were 89% male, 70% 45–64 years old at enrollment and 76% non-Hispanic White. Survivors were 54% male, 54% 45–64 years old at enrollment and 57% non-Hispanic White. Timely IHE utilization remained stable (~ 65%) among Responders, while for Survivors, it increased from 16% among those enrolled in 2017 to 68% in 2021. Timely IHE utilization was lower for younger members (enrolled < 45 years old vs. ≥ 65 years old, adjusted odds ratio [aOR] = 0.71, p  < 0.001), rural residents, female Survivors (44% vs. 47% males, aOR = 0.87, p  < 0.001), and Survivors who preferred non-English languages (39% vs. 46% who preferred English, aOR = 0.70, p  < 0.001). Compared to non-Hispanic White members, non-Hispanic Black members had higher timely/any IHE utilization, while non-Hispanic Asian/Pacific Islander/Native Hawaiian and Hispanic Survivors had lower timely IHE utilization. Conclusions This study highlights Program achievements (e.g. increased timely IHE utilization among Survivors over time and higher timely/any IHE utilization among non-Hispanic Black members compared to non-Hispanic White members) and gaps in providing equitable IHE services to its members. The Program can develop tailored strategies to further improve equity in IHE utilization (e.g. working with providers to adopt/expand flexible IHE scheduling and increase non-English language capacity).

Catch-up human papillomavirus (HPV) vaccination is challenging in many low- and middle-income countries (LMICs). Pay-it-forward offers an individual a subsidized vaccine, then an opportunity to donate to help others access vaccinations. Our randomized control trial assessed the effectiveness of pay-it-forward in improving HPV vaccination among girls aged 15-18 years in China. This study was conducted from July 6, 2022, to June 9, 2023, in four community health centers (CHCs) in Chengdu, western China. Eligible participants were unvaccinated girls living in the service areas of CHCs. Participants were initially recruited via telephone and, after providing verbal consent, attended in-person visit where they were randomly assigned using the sealed envelope method to either the pay-it-forward arm (received a community subsidy of 47.7 USD covering the first vaccine and an opportunity to support others) or control arm (self-paid vaccination at the market price). Participants were unblinded only after the envelope was opened, while the CHC staff coordinators, physicians prescribing the vaccine, outcome assessors, and data analysts were blinded to the intervention allocation. The primary outcome was the first-dose HPV vaccination rate, verified against clinical records. Data were analyzed using the intention-to-treat approach. We identified 662 participants per phone invitation. A total of 321 participants showed up in the health centers and randomly assigned to the pay-it-forward arm (n = 161) or control arm (n = 160). Most caregivers were female (80.1%, 257/321). In the pay-it-forward arm, 55 of 161 (34.2%) girls received the HPV vaccine, compared with 28 of 160 (17.5%) girls in the control arm (adjusted proportion difference = 17.9%, (95% CI [8.7%, 27.0%]; P < 0.001). Among 55 girls in the pay-it-forward arm who received the vaccination, 37 (67.3%) wrote a postcard message, and 39 (70.9%) of their caregivers donated to support future girls. The financial cost per person vaccinated was $294 in the control arm and $230 in the pay-it-forward arm. The trial had several limitations, including a 54% clinic attendance rate (360 of 662 consented participants attended) and its conduct in a single western province of China. The pro-social pay-it-forward strategy was effective to increase catch-up HPV vaccination among teenage girls. This approach also enhanced vaccine confidence among participants. Pay-it-forward demonstrates promise as an effective intervention to improve vaccine uptake through community engagement. Chinese clinical trial registry ChiCTR2200055542 (https://www.chictr.org.cn/hvshowproject.html?id=183292&v=1.3).

Introduction To improve the multilevel older adult care service system in China, the central government has been allocating special lottery public welfare funds through a reward-subsidy mechanism for five consecutive years since 2016 to conduct a home and community-based older adult care service reform pilot. Methods Based on the gradual expansion of the pilot, this study uses CHARLS 2013–2018 micro data and the difference-in-differences method to empirically test the impact of the first batch (2016) and the second batch (2017) of pilots on older adults’ life satisfaction. And the dependent variable life satisfaction is measured by older adult’s answer and assignment value decreases from 5 to 1. Results The estimated results indicated that the pilots had a significant impact on older adults’ life satisfaction, with the probability of being very satisfied and extremely satisfied increasing by 0.020 ( p  < 0.05) and 0.008( p  < 0.05), respectively. Moreover, the effects of the pilot varied among different types of older people. Robustness tests confirmed the basic validity of the benchmark regression. Regarding mechanism analysis, the pilots enhanced older adults’ life satisfaction by reducing the demand for family care, improving the psychological state of older adults, and increasing their participation in social activities. Conclusions It is necessary to fully leverage the role of central financing concerning support, policy guidance, and performance evaluation. It is also important to summarise and share experiences from the pilots, clearly identify and fully recognise developmental challenges, and strive to solve them.

In the United States, patients with HIV face significant barriers to linkage to and retention in care which impede the necessary steps toward achieving the desired clinical outcome of viral suppression. Individual-level interventions, such as patient navigation, are evidence based, effective strategies for improving care engagement. In addition, use of surveillance and clinical data to identify patients who are not fully engaged in care may improve the effectiveness and cost-effectiveness of these programs. We employed a pre-post design to estimate the outcomes and costs, from the program perspective, of 5 state-level demonstration programs funded under the Health Resources and Services Administration's Special Projects of National Significance Program (HRSA/SPNS) Systems Linkages Initiative that employed existing surveillance and/or clinical data to identify individuals who had never entered HIV care, had fallen out of care, or were at risk of falling out of care and navigation strategies to engage patients in HIV care. Outcomes and costs were measured relative to standard of care during the first year of implementation of the interventions (2013 to 2014). We followed patients to estimate the number and proportion of additional patients linked, reengaged, retained, and virally suppressed by 12 months after enrollment in the interventions. We employed inverse probability weighting to adjust for differences in patient characteristics across programs, missing data, and loss to follow-up. We estimated the additional costs expended during the first year of each intervention and the cost per outcome of each intervention as the additional cost per HIV additional care continuum target achieved (cost per patient linked, reengaged, retained, and virally suppressed) 12 months after enrollment in each intervention. In this study, 3,443 patients were enrolled in Louisiana (LA), Massachusetts (MA), North Carolina (NC), Virginia (VA), and Wisconsin (WI) (147, 151, 2,491, 321, and 333, respectively). Patients were a mean of 40 years old, 75% male, and African American (69%) or Caucasian (22%). At baseline, 24% were newly diagnosed, 2% had never been in HIV care, 45% had fallen out of care, and 29% were at risk of falling out of care. All 5 interventions were associated with increases in the number and proportion of patients with viral suppression [percent increase: LA = 90.9%, 95% confidence interval (CI) = 88.4 to 93.4; MA = 78.1%, 95% CI = 72.4 to 83.8; NC = 47.5%, 95% CI = 45.2 to 49.8; VA = 54.6, 95% CI = 49.4 to 59.9; WI = 58.4, 95% CI = 53.4 to 63.4]. Overall, interventions cost an additional $4,415 (range = $3,746 to $5,619), $2,009 (range = $1,516 to $2,274), $920 (range = $627 to $941), $2,212 (range = $1,789 to $2,683), and $3,700 ($2,734 to $4,101), respectively per additional patient virally suppressed. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess patients against themselves at baseline and not against standard of care during the same time period. Patient navigation programs were associated with improvements in engagement of patients in HIV care and viral suppression. Cost per outcome was minimized in states that utilized surveillance data to identify individuals who were out of care and/or those that were able to identify a larger number of patients in need of improvement at baseline. These results have the potential to inform the targeting and design of future navigation-type interventions.

Background Persons with co-occurring disorders, both substance use and mental health problems (COP) may be encountered within various disciplinary systems and organisational levels of treatment. In western countries, the most common evidence-based housing programme for persons with complex, long-term needs due to severe mental illness and substance use is Housing First. The context of this study were the Nordic countries, granting universal access to treatment and free public services. The aim was to examine how multidisciplinary and integrated housing services are organised and coordinated for persons with COP. Methods We conducted a systematic search for literature in six databases (i.e. CINAHL, Ovid, SocINDEX, Web of Science, Scopus, and Social Services Abstracts), along with manual searches. After blinded review by two authors in Rayyan, the full texts of 75 articles were reviewed for inclusion, the quality of the selected research articles was completed according to checklists from the Joanna Briggs Institute. A thematic analysis of nine articles was completed according to a coding scheme. Results From the Nordic perspective, introduced as a model in this article, regions need to develop the organisation and the workforce skills of health and social services as an integrated whole, with special focus on defining responsibilities at different levels, maintaining and improving relationships within a multidisciplinary, integrated, comprehensive, and community-based system of care inclusive of housing services. Supporting the recovery of persons with COP means giving them a voice and having professionals skilled in COP aid them. Conclusions The approach of emphasizing primary care and multidisciplinary mental health is yet today a challenge even in high-income areas. The integration of services was not on an ideal level, even though the housing policies were rights-based. We identified societal responsibilities stemming from national policies. It is possible that functional integration does not take place in all regions. As the working methods were based on active relationship building to be able to help persons with COP, we interpreted this as a sign of clinical integration. The recommendations for the organisation and coordination of services for persons with COP include ensuring the right to a home, ensuring social integration and community involvement, combatting stigma, and systemising user involvement. There are research gaps in all Nordic countries and the research within housing for persons with COP is scarce. We call for using multi-dimensional research approaches. Clinical trial number Not applicable.