Sarah Gimbel

Background: Heart disease is the leading cause of death in the United States with a disproportionate impact in rural America, and health worker shortages contribute to these disparities. Team‐based heart disease care models can help mitigate health worker shortages, but lack of role clarity and restrictive scope of practice laws can be a barrier to their implementation. Methods: To better understand the intersection of licensed scope of practice laws with rural heart disease care, we performed a legal epidemiology analysis to identify and describe licensed scope of practice laws for 9 health worker cadres in 13 state and federal jurisdictions for 8 heart disease services. Results: We found substantial ambiguity, variation, and some important gaps, which may undermine the predictability of regulatory and reimbursement environments and hinder implementation of innovative team‐based care models. Conclusions: Three policy opportunities to address the identified gaps include: (1) linking licensed scope of practice definitions to the scope of accredited training curricula, (2) shifting away from collaborative practice agreements to define licensed scope of practice, and (3) prohibiting insurance plans from conditioning reimbursement based solely on provider cadre.

Despite high coverage of facility-based maternal and child health (MCH) services in Mozambique, preventable maternal and neonatal deaths remain among the h

Objetivo: identificar los patrones de consumo de alcohol asociados a la adherencia al tratamiento antirretroviral (TARV) en pacientes con VIH. Material y métodos: Estudio transversal en una población de 4000 pacientes mayores de 18 años que recibieron TARV por la Estrategia Sanitaria Nacional de Prevención y Control de ITS- VIH/SIDA desde el 2004 en un hospital de Lima. El estudio se realizó entre setiembre 2017 y enero 2018. El tamaño muestral fue de 351 pacientes seleccionados aleatoriamente. Se evaluaron los patrones de consumo de alcohol usando prevalencia de consumo de alcohol alguna vez en la vida, en el último año, en los últimos seis meses, en el último mes y en los últimos siete días. El consumo de riesgo se evaluó con el AUDIT. La adherencia al TARV se evaluó con el Simplified Medication Adherence Questionnaire (SMAQ). Se calculó la razón de prevalencia (RP) y se compararon promedios. El estudio fue aprobado por el Comité de Ética del Hospital Nacional Cayetano Heredia y de la Universidad Peruana Cayetano Heredia. Resultados: El 74% de los pacientes evaluados fueron varones, con 38 años en promedio, el 25% presentó adherencia al TARV. Se encontró asociación entre adherencia al TARV y consumo de alcohol en los últimos seis meses (p = 0,017), así como con consumo de alcohol en el último mes (p = 0,011), con una razón de prevalencia de 1,158 (1,022<RP<1,312) y 1,167 (1,037<RP<1,312) respectivamente. Conclusión: Los patrones de consumo de alcohol en el último mes y en los últimos seis se asocian a una falta de adherencia al TARV.

RESUMO Objetivo Compreender os significados atribuídos pelas pessoas vivendo com HIV às inter-relações sociais nesta condição crônica. Métodos Pesquisa qualitativa, exploratória, guiada pela Grounded Theory e pelo Interacionismo Simbólico. Participaram 36 pessoas, dentre pacientes e profissionais, compondo quatro grupos amostrais. Aplicou-se a entrevista semiestruturada e a observação não participante. A análise procedeu-se em etapas: codificação aberta, codificação axial e integração. Resultados Destacaram-se estratégias para melhora do cuidado de si e do seguimento do tratamento com base na gestão compartilhada; o [...] RESUMO Objetivo Compreender os significados atribuídos pelas pessoas vivendo com HIV às inter-relações sociais nesta condição crônica. Métodos Pesquisa qualitativa, exploratória, guiada pela Grounded Theory e pelo Interacionismo Simbólico. Participaram 36 pessoas, dentre pacientes e profissionais, compondo quatro grupos amostrais. Aplicou-se a entrevista semiestruturada e a observação não participante. A análise procedeu-se em etapas: codificação aberta, codificação axial e integração. Resultados Destacaram-se estratégias para melhora do cuidado de si e do seguimento do tratamento com base na gestão compartilhada; o

Background: Between 2012–2022 opioid-related overdose deaths in the United States, including Washington State, have risen dramatically. Opioid use disorder (OUD) is a complex, chronic, and criminalized illness with biological, environmental, and social causes. One-fifth of people with OUD have recent criminal-legal system involvement; > 50% pass through WA jails annually. Medications for Opioid Use Disorder (MOUD) can effectively treat OUD. WA has prioritized improving access to MOUD, including for those in jails. As patients in jail settings are systematically marginalized due to incarceration, it is critical to foster connections to MOUD services upon release, an acknowledged period of high overdose risk. Currently, there is insufficient focus on developing strategies to foster linkages between jail-based MOUD and referral services. The Systems Analysis and Improvement Approach (SAIA), an evidence-based implementation strategy, may optimize complex care cascades like MOUD provision and improve linkages between jail- and community-based providers. SAIA bundles systems engineering tools into an iterative process to guide care teams to visualize cascade drop-offs and prioritize steps for improvement; identify modifiable organization-level bottlenecks; and propose, implement, and evaluate modifications to overall cascade performance. The SAIA-MOUD study aims to strengthen the quality and continuity of MOUD care across jail and referral clinics in King County, WA, and ultimately reduce recidivism and mortality. Methods: We will conduct a quasi-experimental evaluation of SAIA effectiveness on improving MOUD care cascade quality and continuity for patients receiving care in jail and exiting to referral clinics; examine determinants of SAIA-MOUD adoption, implementation, and sustainment; and determine SAIA-MOUD’s cost and cost-effectiveness. Clinic teams with study team support will deliver the SAIA-MOUD intervention at the jail-based MOUD program and three referral clinics over a two-year intensive phase, followed by a one-year sustainment phase where SAIA implementation will be led by King County Jail MOUD staff without study support to enable pragmatic evaluation of sustained implementation. Discussion: SAIA packages user-friendly systems engineering tools to guide decision-making by front-line care providers to identify low-cost, contextually appropriate health care improvement strategies. By integrating SAIA into MOUD care provision in jail and linked services, this pragmatic trial is designed to test a model for national scale-up. Trial registration: ClinicalTrials.gov NCT06593353 (registered 09/06/2024; https://register.clinicaltrials.gov/prs/beta/studies/S000EVJR00000029/recordSummary).

Introduction: Gaps in HIV RNA monitoring persist globally impeding the ability to determine clinical progress and outcomes. This study systematically evaluated provider (e.g., guideline non- adherence), system (e.g., laboratory error) and patient-based (e.g., refusal) drivers of missed viral load (VL) monitoring measurements among adults living with HIV in Kenya. Methods: Adults aged 18-65 years were followed across five health facilities in Kenya as part of a clinical trial ( NCT#02338739 ) where HIV RNA monitoring was done routinely. Instances of missed VL despite being indicated per Kenyan guidelines were identified. An algorithm for assessing root causes of missing HIV RNA was developed and generalized linear models estimated the risk ratios (RR) for patient-level characteristics associated with missed viral load. Results: Among 1,754 patients (66% female), the prevalence of missed viral load in year one and two was 24.4% and 29.4%, respectively. Drivers for missed viral load measurements included loss to follow up (51.5% in year one and 57.8% in year two), clinician non-adherence with guidelines (36.7% in year one and 32.2% in year two), unknown (10.3% in year one and 8.6% in year two), and requested but not collected (1.5% in year one and 1.3% in year two). Patients aged < 24 years (RR 2.27, 95% CI: 1.66-3.12), those with higher socioeconomic status (RR 1.47, 95% CI: 1.03- 1.91), receiving HIV treatment at a rural clinic (RR 1.22, 95% CI: 1.02-1.46) and with advanced HIV disease (RR 2.39, 95% CI: 1.52-3.73) were more likely to miss VL monitoring. Conclusions: Missed routine viral load monitoring remains high, primarily due to loss to follow- up, and may substantially alter suppression estimates. Sustainable approaches to keep people living with HIV engaged in care, alongside strengthening providers’ clinical practices and alignment with national guidelines, are necessary for optimizing viral monitoring and accurately assessing viral suppression within public health systems.

Malnutrition is a leading contributor to deaths in children, with six times higher risk for hospital mortality among wasted children compared to those who are well nourished. Although national guidelines for management of acute malnutrition have been available for decades, adherence to them remains suboptimal. In this exploratory mixed method study, health workers who provide care to children with severe acute malnutrition at Migori County Referral Hospital (MCRH) identified an important barrier to implementing care according to guidelines. Through a participatory co-design process, we identified the content and features they preferred in a toolkit to help address the challenges faced when a nutritionist is not available. The co-design process incorporated feedback from 24 pre-pilot surveys, 18 design sessions with health workers, and a consensus meeting with 6 health workers representing all cadres to refine the Team Approach to Malnutrition Services (TeAMS) Toolkit prior to piloting. The Toolkit included sections on (1) teamwork skills, (2) roles and responsibilities, (3) summarized information from the Integrated Management of Acute Malnutrition guideline, and (4) monitoring and documentation. The TeAMS Toolkit was then piloted for ten weeks and then the usability and feasibility of the toolkit and the perceived competence, teamwork attitudes, and role perceptions of health workers were assessed using quantitative surveys and qualitative interviews. Usability of the toolkit was scored as 77.4/100 on the System Usability Scale, which indicates good usability of the tool. This aligned with qualitative feedback that highlighted the benefits of having this easy reference, especially for feeding prescriptions. Pre/post surveys identified an increase in mean scores on five out of six measures of teamwork attitudes, including knowing your own role (3.74/5 to 4.26/5) and sharing information (3.79/5 to 4.42/5). Participants described a change from a perception that offering feeding was only for the nutritionist to one of ensuring that feeding was provided in good time by other team members in case a nutritionist was not available. In this pilot study, the co-designed TeAMS Toolkit supported multi-disciplinary care for children with SAM. Further refinement and alignment with updated guidelines will ready this resource for delivery at additional facilities. Keywords: Severe Acute Malnutrition, Teamwork, Co-design, Roles, Usability

Introduction Routine health information systems (RHISs) are an essential source of data to inform decisions and actions around health facility performance, but RHIS data use is often limited in low and middle-income country contexts. Determinants that influence RHIS data-informed decisions and actions are not well understood, and few studies have explored the relationship between RHIS data-informed decisions and actions. Methods This qualitative thematic analysis study explored the determinants and characteristics of successful RHIS data-informed actions at the health facility level in Mozambique and which determinants were influenced by the Integrated District Evidence to Action (IDEAs) strategy. Two rounds of qualitative data were collected in 2019 and 2020 through 27 in-depth interviews and 7 focus group discussions with provincial, district and health facility-level managers and frontline health workers who participated in the IDEAs enhanced audit and feedback strategy. The Performance of Routine Information System Management-Act framework guided the development of the data collection tools and thematic analysis. Results Key behavioural determinants of translating RHIS data into action included health worker understanding and awareness of health facility performance indicators coupled with health worker sense of ownership and responsibility to improve health facility performance. Supervision, on-the-job support and availability of financial and human resources were highlighted as essential organisational determinants in the development and implementation of action plans. The forum to regularly meet as a group to review, discuss and monitor health facility performance was emphasised as a critical determinant by study participants. Conclusion Future data-to-action interventions and research should consider contextually feasible ways to support health facility and district managers to hold regular meetings to review, discuss and monitor health facility performance as a way to promote translation of RHIS data to action.

What is Dissemination and Implementation Science? The field of Implementation Science studies how intentional actions promote the incorporation of evidence-based intervention into usual care, while Dissemination Science examines how to intentionally share information about evidence-based intervention. It is important to clarify that scientific research results are understood as effective interventions or innovations (e.g., practices, programs, policies, procedures, products, medications, etc.) that are evidence-based.() To implement and disseminate an intervention in usual care, one of the models of D&I proposes the [...] What is Dissemination and Implementation Science? The field of Implementation Science studies how intentional actions promote the incorporation of evidence-based intervention into usual care, while Dissemination Science examines how to intentionally share information about evidence-based intervention. It is important to clarify that scientific research results are understood as effective interventions or innovations (e.g., practices, programs, policies, procedures, products, medications, etc.) that are evidence-based.() To implement and disseminate an intervention in usual care, one of the models of D&I proposes the