Publications by authors named "Grace Ryan"

34 Publications

Lay-delivered talk therapies for adults affected by humanitarian crises in low- and middle-income countries.

Confl Health 2021 Apr 23;15(1):30. Epub 2021 Apr 23.

Department of Mental Health, Johns Hopkins University, Baltimore, MD, USA.

Background: Published by the World Health Organization (WHO) and United Nations High Commissioner for Refugees (UNHCR) in 2015, the mental health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG) recommends brief versions of structured psychological interventions for people experiencing symptoms of common mental disorders (CMDs). mhGAP-HIG acknowledges a growing body of evidence suggesting these interventions can be delivered by lay workers to people affected by humanitarian crises in low- and middle-income countries (LMICs). However, there has not yet been a systematic review and synthesis of this evidence. This paper reports the results of a systematic review of qualitative, quantitative, and mixed-methods studies assessing the implementation and/or effectiveness of talk therapies for CMDs when provided by lay workers in LMICs to adults who have survived or are currently living in humanitarian situations.

Methods: Seven electronic databases were searched: MEDLINE, Embase, PsycINFO, PsycEXTRA, Global Health, Cochrane Library, and ClinicalTrials.gov . We also hand-searched the contents pages of three academic journals, reference lists of 30 systematic reviews, and online resource directories of two mental health networks. A preliminary list of included studies was circulated to topical experts for review, and all included studies were backward and forward searched. All titles, abstracts, and full-texts were independently double-screened. Quality appraisal and data extraction were carried out by a single reviewer and checked by a second reviewer, using standardised tools. Any disagreements were discussed and referred to a third reviewer as needed.

Results: We identified 23 unique studies and carried out a narrative synthesis of patient and implementation outcome data. Every evaluation of the effectiveness of lay-delivered talk therapies for adults affected by humanitarian crises in LMICs showed some treatment effect for at least one CMD, and often multiple CMDs. Implementation research generally found these interventions to be acceptable, appropriate and feasible to implement, with good fidelity to manualised therapies.

Conclusion: Although results are promising, particularly for individually-delivered talk therapies based on cognitive behavioural therapy techniques, there is a high degree of heterogeneity in this literature. We make several recommendations on how to improve the quality and generalisability of research on this topic, to facilitate further evidence synthesis.

Trial Registration: PROSPERO registration number: CRD42017058287 .
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http://dx.doi.org/10.1186/s13031-021-00363-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062937PMC
April 2021

Barriers and drivers to stakeholder engagement in global mental health projects.

Int J Ment Health Syst 2021 Apr 3;15(1):30. Epub 2021 Apr 3.

Centre for Global Mental Health, Department of Population Health, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK.

Background: Engagement with diverse stakeholders, including policy makers, care providers and service users and communities, is essential for successful implementation of global mental health interventions. Despite being a fundamental factor in the implementation process, evidence about challenges and drivers to stakeholder engagement is limited in the global mental health literature.

Methods: We conducted semi-structured qualitative interviews with 29 recipients of Grand Challenges Canada Global Mental Health funding to assess barriers and drivers to global mental health implementation across a portfolio of projects. We used framework analysis to identify key themes related to implementation barriers and drivers. This paper reports on barriers and drivers to stakeholder engagement, with results related to capacity development and service delivery reported elsewhere in this journal.

Results: Barriers and drivers to stakeholder engagement were identified across four themes: (1) Contextual Considerations, (2) Resources, (3) Participation, Uptake and Empowerment, and (4) Stigma. While complex contextual challenges create barriers, mechanisms such as formative research can facilitate a deeper contextual understanding that supports effective implementation planning. Limited financial and human resources and competing priorities can lead to substantial challenges. Investing in and leveraging existing local resources and expertise can help to mitigate these barriers. The challenge of achieving active participation from stakeholders and diverging expectations about the nature of participation were identified as barriers, while providing opportunities for meaningful participation and empowerment acted as drivers. Stigma at the institutional, community and individual level was also identified as a substantial barrier to engagement.

Conclusion: The findings of this study are relevant to implementers in global mental health. They also have implications for global mental health funding agencies and policy organizations, who can support improved stakeholder engagement by investing in high-quality formative research, supporting capacity building for policy engagement, investing in longer-term funding schemes to support sustainable partnerships and scale-up, thus fostering successful engagement and supporting effective implementation of global mental health innovations.
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http://dx.doi.org/10.1186/s13033-021-00458-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019163PMC
April 2021

A Mixed-Methods Examination of Factors Related to HPV Vaccination Promotion in Private Dental Settings, Iowa, 2019.

Prev Chronic Dis 2021 Mar 25;18:E26. Epub 2021 Mar 25.

College of Public Health, University of Iowa, Iowa City, Iowa.

Introduction: Human papillomavirus (HPV)-associated oropharyngeal cancer rates are rising, particularly in males, although rates of other HPV-related cancers are decreasing. Although the HPV vaccine is safe and effective, vaccination rates remain below the Healthy People 2030 goal of 80% coverage. Engaging dental providers, who have experience with patient education and oropharyngeal cancer, may prove useful in efforts to increase vaccination rates. Our research explores dental providers' (dentists, dental hygienists) willingness to participate in continuing education about HPV, educate parents of adolescents, recommend the vaccine for adolescents, and refer parents to medical providers.

Methods: We used a mixed-methods approach and conducted a survey with dental hygienists and semistructured interviews with dental providers. We produced frequencies and descriptive statistics for all variables and used regression modeling to explore factors related to willingness to promote the HPV vaccine. We used a deductive approach to code interview transcripts.

Results: Regression models using survey data (n = 470) showed that after controlling for demographic and practice-level characteristics, higher levels of willingness were associated with thinking that parents would act on a recommendation and thinking that engaging in HPV promotion is within the scope of practice. Interview data reflected willingness of dental providers to work on HPV vaccination, but revealed barriers (eg, time, knowledge) that need to be addressed.

Discussion: Overall, dental providers expressed a willingness to participate in HPV vaccine promotion, and future efforts should focus on addressing barriers to doing so. Engaging dental providers in HPV vaccine recommendation and referral can help prevent future HPV-related cancers.
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http://dx.doi.org/10.5888/pcd18.200553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021145PMC
March 2021

Mental Health and Community-Based Rehabilitation: A Qualitative Description of the Experiences and Perspectives of Service Users and Carers in Bangladesh.

Community Ment Health J 2021 Mar 8. Epub 2021 Mar 8.

Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK.

Since 2016, Promotion of Human Rights of Persons with Disabilities in Bangladesh (PHRPB) has been working to include people with psychosocial disabilities in their community-based inclusive development work, and to increase access to formal mental health care. Field visits were carried out to PHRPBD catchment areas in Dhaka and Chittagong for a case study on the integration of mental health into community-based rehabilitation (CBR). This paper synthesizes the results of twenty-five semi-structured interviews carried out as part of the case study. Participants included people with psychosocial disabilities, intellectual disabilities, epilepsy or other cognitive impairments and their carers as needed. Interviews were audio-recorded, transcribed and translated from Bangla to English, then hand-coded for content analysis. Results were organized into five overarching categories: (1) explanatory models, (2) help-seeking behaviors, (3) impact of services, (4) challenges and barriers to improving mental health, (5) recommendations of users and carers. Respondents either had no explanation for why service users had become unwell or attributed it to physically and/or emotionally traumatic events or supernatural causes. Before attending PHRPBD's mental health services, most had visited formal or informal health care providers, often with disappointing results. Despite positive feedback on PHRPBD's services, participants identified ongoing challenges. Stigma, discrimination and human rights abuses persist and are compounded by issues of gender inequality. Participants also identified barriers and made recommendations specific to the program itself, mainly regarding accessibility (e.g., cost, distance, frequency). This study adds to the limited body of qualitative research on mental health in Bangladesh, reinforcing previous findings on explanatory models and health-seeking behaviors while providing new insights into the impact of a CBR program in this context. Feedback of service users and carers suggests that CBR may indeed be a useful approach to increase access to services in Bangladesh for people with psychosocial or intellectual disabilities, epilepsy or other cognitive impairments. However, this program is not without its limitations, some of which are the product of broader issues within the mental health system and others of the social and cultural context. More research is needed to formally evaluate this and other CBR programs in the Global South.
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http://dx.doi.org/10.1007/s10597-021-00790-0DOI Listing
March 2021

Barriers and drivers to service delivery in global mental health projects.

Int J Ment Health Syst 2021 Jan 24;15(1):14. Epub 2021 Jan 24.

Department of Psychiatry, Faculty of Medicine, University of British Columbia, 2255 Westbrook Mall, Vancouver, BC, V6T 2A1, Canada.

Background: Research in global mental health (GMH) has previously documented how contextual factors like political instability, poverty and poorly-funded health infrastructure continue to compromise effective and equitable mental health service delivery. There is a need to develop more feasible and evidence-based solutions through implementation research. This paper, one in a series pertaining to implementation in GMH projects worldwide, focuses on implementation factors influencing mental health service delivery.

Methods: This is a qualitative study carried out as part of a Theory of Change-driven evaluation of Grand Challenges Canada's (GCC's) Global Mental Health portfolio. Purposive sampling was used to recruit twenty-nine GCC grantees for interviews. A semi-structured interview schedule was used to guide the interviews which were recorded and subsequently transcribed. Transcripts were double-coded and analyzed in NVivo 11 using framework analysis. This paper reports results related to detection and treatment of mental illness, mental health promotion and prevention of mental illness.

Results: Key barriers included: lack of appropriate human resources and expertise for service delivery; lack of culturally appropriate screening tools and interventions; and difficulties integrating services with the existing mental health system. Formative research was a key driver facilitating the cultural adaptation of mental health detection, treatment, promotion and preventative approaches. Recruiting local providers and utilizing mHealth for improving screening, monitoring and data management were also found to be successful approaches in reducing workforce burden, improving sustainability, mental health literacy, participant engagement and uptake.

Conclusions: The study identifies a number of key barriers to and drivers of successful service delivery from the perspective of grantees implementing GMH projects. Findings highlight several opportunities to mitigate common challenges, providing recommendations for strengthening systems- and project-level approaches for delivering mental health services. Further, more inclusive research is required to inform guidance around service delivery for successful implementation, better utilization of funding and improving mental health outcomes among vulnerable populations in low-resource settings.
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http://dx.doi.org/10.1186/s13033-020-00427-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7827991PMC
January 2021

Prevalence of depression and its correlates among public university students in Bangladesh.

J Affect Disord 2021 03 28;282:689-694. Epub 2020 Dec 28.

School of Health & Life Sciences, Department of Public Health, North South University, Dhaka, Bangladesh.

This study aims to assess the prevalence of depression among public university students in Bangladesh, with a larger and more diverse sample than those included in previous studies. A cross-sectional study was conducted between April and September, 2018 at two public universities in Bangladesh. Data was collected on socio-demographic characteristics, lifestyle factors, history of depression, and symptoms of depression (9-item Patient Health Questionnaire). Multivariable logistic regression was applied to explore the independent relationships between depression and student characteristics. A total of 400 students participated in the survey. Mean age of the students was 22 (SD: 2.2) years. The prevalence of depression was 47.3% and higher in female than male students (50.7% vs. 43.6%). Results of the multivariate analysis showed that the odds were approximately 4.6 times higher for students who spent more than 6 hours per day on social media (OR:4.69, 95% CI: 1.94-11.30); more than 2 times higher among the students who had personal history of depression (OR: 3.51, 95% CI: 2.221-5.59). Male gender and having a smoking habit were both correlated with depressive symptoms (OR: 1.90; 95% CI:1.05-3.41) compared to the female students (OR:1.5; 95% CI:0.51-4.3). Nearly half of the students met the criteria for moderate to severe depression. Poor academic performance, use of social media and history of depression were the main factors associated with depressive symptoms. Given the high prevalence of depression in this student population, it is imperative to develop psychosocial interventions to better support students during this critical phase of life .
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http://dx.doi.org/10.1016/j.jad.2020.12.137DOI Listing
March 2021

Influences on HPV vaccination across levels of the social ecological model: perspectives from state level stakeholders.

Hum Vaccin Immunother 2021 Apr 17;17(4):1006-1013. Epub 2020 Dec 17.

Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA, USA.

Nationally, human papillomavirus (HPV) vaccination rates fall short of the Healthy People 2020 goal of 80% completion. Although strategies to increase these rates exist, low rates persist. We used concept mapping with state-level stakeholders to better understand barriers and facilitators to HPV vaccination. Concept mapping is a participatory research process in which respondents brainstorm ideas to a prompt and then sort ideas into piles. We present results of the brainstorming phase. We recruited participants identified by researchers' professional connections (n = 134) via e-mail invitations from five states (Iowa, South Dakota, Minnesota, Oregon, and Washington) working in adolescent health, sexual health, cancer prevention and control, or immunization. Using Concept Systems' online software we solicited participants' beliefs about what factors have the greatest influence on HPV vaccination rates in their states. From the original sample 58.2% (n = 78) of participants completed the brainstorming activity and generated 372 statements, our team removed duplicates and edited statements for clarity, which resulted in 172 statements. We coded statements using the Social Ecological Model (SEM) to understand at what level factors affecting HPV vaccination are occurring. There were 53 statements at the individual level, 22 at the interpersonal level, 21 in community, 51 in organizational, and 25 in policy. Our results suggest that a tiered approach, utilizing multi-level interventions instead of focusing on only one level may have the most benefit. Moreover, the policy-level influences identified by participants may be difficult to modify, thus efforts should focus on implementing evidence-based interventions to have the most meaningful impact.
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http://dx.doi.org/10.1080/21645515.2020.1839290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8018391PMC
April 2021

Barriers and drivers to capacity-building in global mental health projects.

Int J Ment Health Syst 2020 Dec 3;14(1):89. Epub 2020 Dec 3.

Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.

Background: The global shortage of mental health workers is a significant barrier to the implementation and scale-up of mental health services. Partially as a result of this shortage, approximately 85% of people with mental, neurological and substance-use disorders in low- and middle-income countries do not receive care. Consequently, developing and implementing scalable solutions for mental health capacity-building has been identified as a priority in global mental health. There remains limited evidence to inform best practices for capacity building in global mental health. As one in a series of four papers on factors affecting the implementation of mental health projects in low- and middle-income countries, this paper reflects on the experiences of global mental health grantees funded by Grand Challenges Canada, focusing on the barriers to and drivers of capacity-building.

Methods: Between June 2014 and May 2017, current or former Grand Challenges Canada Global Mental Health grantees were recruited using purposive sampling. N = 29 grantees participated in semi-structured qualitative interviews, representing projects in Central America and the Caribbean (n = 4), South America (n = 1), West Africa (n = 4), East Africa (n = 6), South Asia (n = 11) and Southeast Asia (n = 3). Based on the results of a quantitative analysis of project outcomes using a portfolio-level Theory of Change framework, six key themes were identified as important to implementation success. As part of a larger multi-method study, this paper utilized a framework analysis to explore the themes related to capacity-building.

Results: Study participants described barriers and facilitators to capacity building within three broad themes: (1) training, (2) supervision, and (3) quality assurance. Running throughout these thematic areas were the crosscutting themes of contextual understanding, human resources, and sustainability. Additionally, participants described approaches and mechanisms for successful capacity building.

Conclusions: This study demonstrates the importance of capacity building to global mental health research and implementation, its relationship to stakeholder engagement and service delivery, and the implications for funders, implementers, and researchers alike. Investment in formative research, contextual understanding, stakeholder engagement, policy influence, and integration into existing systems of education and service delivery is crucial for the success of capacity building efforts.
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http://dx.doi.org/10.1186/s13033-020-00420-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7712613PMC
December 2020

Implementation and outcome evaluation of a team nutrition intervention: increasing knowledge, attitudes, and preferences.

Health Educ Res 2021 Mar;36(1):75-86

Public Policy Center, 310 S. Grand Ave, Iowa City, IA 52242, USA.

Low-income, rural children are at a greater risk for poor dietary intake. Schools offer a venue to deliver appropriate interventions. Our aim was to evaluate the implementation and effectiveness of Healthy Schools, Healthy Students (HSHS). We conducted a mixed-methods evaluation using a cluster-randomized trial design with 20 schools in a rural, Midwestern state. HSHS included education sessions, cafeteria coaching and taste testing. We interviewed implementers (n = 13) and nutrition educators (n = 8), conducted six focus groups with cafeteria coaches, and surveyed fourth graders (n = 1057) about their nutrition knowledge, attitudes toward and preferences for fruits and vegetables (F&V), F&V consumption and MyPlate awareness. We used multi-level linear models to estimate the intervention effect and qualitative data were coded. There were very few challenges to implementation. HSHS participation was positively associated with knowledge, attitudes toward F&V, preferences for vegetables from the taste tests, MyPlate awareness and vegetable consumption. HSHS was viewed as beneficial and easy to deliver, suggesting this type of intervention could be widely implemented. Improving knowledge and attitudes through nutrition education and preferences through taste testing have the potential to improve dietary intake among rural students. Low-cost nutrition interventions can be successfully implemented in rural elementary schools with positive outcomes.
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http://dx.doi.org/10.1093/her/cyaa036DOI Listing
March 2021

Communicating a Complicated Medicaid Waiver Program to Enrollees in Iowa: How Federally Qualified Health Centers Support Medicaid Members.

J Ambul Care Manage 2021 Jan/Mar;44(1):12-20

Department of Community and Behavioral Health, University of Iowa College of Public Health, Iowa City (Dr Askelson, Mr Brady, and Ms Ryan); University of Iowa Public Policy Center, Iowa City (Drs Askelson, Momany, and Damiano, Mr Brady, and Mss Ryan and McInroy); and Department of Family Medicine, University of North Carolina School of Family Medicine, Chapel Hill (Dr Wright).

Iowa expanded Medicaid eligibility with a waiver including a personal responsibility component. Early program evaluation revealed low compliance and awareness among members. There is little research on leveraging existing contact points in the health care system to effectively communicate with Medicaid enrollees. We interviewed outreach and enrollment staff at Federally Qualified Health Centers (FQHCs) to explore their work. We show that FQHCs use several strategies to enroll individuals in appropriate programs and support them in understanding and navigating their health insurance coverage. With increasingly complex Medicaid programs, this support will be more widely needed to prevent hardship and loss of coverage.
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http://dx.doi.org/10.1097/JAC.0000000000000359DOI Listing
November 2020

Depression and experience of incarceration in North Central Nigeria: a situation analysis at Makurdi medium security prison.

Int J Ment Health Syst 2020 27;14:76. Epub 2020 Oct 27.

CBM Global and Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK.

Background: Human rights watchdogs have described conditions in Nigerian correctional facilities and detention centers as damaging to the physical and mental health of inmates. While the prevalence of mental disorders is high, access to appropriate healthcare is grossly inadequate. Understanding the current state of prison inmates' mental health and well-being is an essential first step to addressing this important issue. This study aims to document the mental health and experiences of incarceration of inmates of the largest medium security prison in Nigeria's Benue State.

Methods: A cross-sectional survey and descriptive analysis was carried out with a random sample of 381 prison inmates of Benue State Makurdi Medium Security Prison. Survey tools included: (1) a structured questionnaire on participants' experiences in prison, and (2) the Patient Health Questionnaire (PHQ-9), a screening tool for depression.

Results: Most participants were young men (95.5%, mean age 27.95) and had completed secondary school (63.5%). While prison authorities had identified only 27 participants as having a mental disorder, 144 (37.8%) screened positive for depression. Twenty six had received professional counseling while in prison. Of the six participants who were already taking a psychotropic medication at the time of imprisonment, four received medication after being imprisoned. Approximately half, (52%) of participants were dissatisfied with prison health care.

Conclusions: Despite the high prevalence of depression among prison inmates, few cases are detected and treated. Prison staff may not recognize depression as a mental disorder, and the mental health care available is generally poor. Inadequate mental health and social care not only affects prison inmates' well-being, but may also impact recidivism and health outcomes upon release. Prison inmates should be screened routinely for depression and other less-commonly recognized mental health conditions, and appropriate treatment made available.
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http://dx.doi.org/10.1186/s13033-020-00408-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592553PMC
October 2020

Challenges to peer support in low- and middle-income countries during COVID-19.

Global Health 2020 09 25;16(1):90. Epub 2020 Sep 25.

Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.

Background: A recent editorial urged those working in global mental health to "change the conversation" on coronavirus disease (Covid-19) by putting more focus on the needs of people with severe mental health conditions. UPSIDES (Using Peer Support In Developing Empowering mental health Services) is a six-country consortium carrying out implementation research on peer support for people with severe mental health conditions in high- (Germany, Israel), lower middle- (India) and low-income (Tanzania, Uganda) settings. This commentary briefly outlines some of the key challenges faced by UPSIDES sites in low- and middle-income countries as a result of Covid-19, sharing early lessons that may also apply to other services seeking to address the needs of people with severe mental health conditions in similar contexts.

Challenges And Lessons Learned: The key take-away from experiences in India, Tanzania and Uganda is that inequalities in terms of access to mobile technologies, as well as to secure employment and benefits, put peer support workers in particularly vulnerable situations precisely when they and their peers are also at their most isolated. Establishing more resilient peer support services requires attention to the already precarious situation of people with severe mental health conditions in low-resource settings, even before a crisis like Covid-19 occurs. While it is essential to maintain contact with peer support workers and peers to whatever extent is possible remotely, alternatives to face-to-face delivery of psychosocial interventions are not always straightforward to implement and can make it more difficult to observe individuals' reactions, talk about emotional issues and offer appropriate support.

Conclusions: In environments where mental health care was already heavily medicalized and mostly limited to medications issued by psychiatric institutions, Covid-19 threatens burgeoning efforts to pursue a more holistic and person-centered model of care for people with severe mental health conditions. As countries emerge from lockdown, those working in global mental health will need to redouble their efforts not only to make up for lost time and help individuals cope with the added stressors of Covid-19 in their communities, but also to regain lost ground in mental health care reform and in broader conversations about mental health in low-resource settings.
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http://dx.doi.org/10.1186/s12992-020-00622-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7517058PMC
September 2020

Implementation outcomes of cognitive behavioural therapy delivered by non-specialists for common mental disorders and substance-use disorders in low- and middle-income countries: a systematic review.

Int J Ment Health Syst 2020 29;14:40. Epub 2020 May 29.

Department of Psychology, University of Maryland, College Park, MD USA.

Due to severe shortages of specialist mental health personnel in low- and middle-income countries (LMICs), psychological therapies are increasingly being delivered by non-specialist health workers (NSHWs). Previous reviews have investigated the effectiveness of NSHW-delivered psychological therapies, including cognitive behavioural therapy (CBT), in LMIC settings. This systematic review aims to synthesise findings on the implementation outcomes of NSHW-delivered CBT interventions addressing common mental disorders and substance-use disorders in LMICs. Four databases were searched, yielding 3211 records, 18 of which met all inclusion criteria. We extracted and synthesised qualitative and quantitative data across eight implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration and sustainability. Findings suggest that delivery of CBT-based interventions by NSHWs can be acceptable, appropriate and feasible in LMIC settings. However, more research is needed to better evaluate these and other under-reported implementation outcomes.
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http://dx.doi.org/10.1186/s13033-020-00372-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7260765PMC
May 2020

Middle School Students' Perceptions of the Lunchroom: Implications for Future Interventions.

J Sch Nurs 2020 May 27:1059840520928504. Epub 2020 May 27.

Iowa Department of Education, Des Moines, IA, USA.

The National School Lunch Program provides nutritious and inexpensive lunches, but low participation and food waste are challenges in many schools. Interventions aim to improve participation in the program, but little is known about how students' perceptions affect their participation. This study explored how middle school students in a rural state perceive school food service staff, food served, and lunchroom atmosphere. An online survey was administered to middle school students at six schools participating in a larger lunchroom intervention. Mean perception scores were calculated for all measures. Multilevel logistic regression was used to examine the relationship between perceptions and consumption. Overall perceptions of staff, food, and atmosphere were positive, and students classified as school lunch eaters had more positive perceptions in all three areas than noneaters. Interventions to increase participation in school lunch programs and promote consumption of healthy food items should address multiple factors that contribute to school lunch participation.
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http://dx.doi.org/10.1177/1059840520928504DOI Listing
May 2020

What Do Parents Think About School Meals? An Exploratory Study of Rural Middle School Parents' Perceptions.

J Sch Nurs 2020 May 18:1059840520924718. Epub 2020 May 18.

Iowa Department of Education, Des Moines, IA, USA.

Interventions targeting school meals have been used to combat obesity in rural youth. Parents play a powerful role in childhood nutrition; however, we know little about parents' perceptions of school meal programs. This study aimed to understand parents' perceptions of school meal programs. Surveys were administered to middle school parents ( = 576) at six schools in a rural state. We conducted univariate and multivariate analyses to measure parents' overall perceptions of the school meals program and to identify differences in perceptions by their children's participation in the Free and Reduced Price School Meals (F&RM) program. Parents had largely negative views of school meals but agreed that they met students' needs. Results of the multivariate analysis revealed differences in perceptions by participation in F&RM including the relative importance of meal components. Including parents in meal-related experiences and decision making could improve their perceptions and increase children's participation in school lunch programs.
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http://dx.doi.org/10.1177/1059840520924718DOI Listing
May 2020

Peer support for people with severe mental illness versus usual care in high-, middle- and low-income countries: study protocol for a pragmatic, multicentre, randomised controlled trial (UPSIDES-RCT).

Trials 2020 May 1;21(1):371. Epub 2020 May 1.

Department of Psychiatry and Psychotherapy II, Ulm University, Ulm, Germany.

Background: Peer support is an established intervention involving a person recovering from mental illness supporting others with mental illness. Peer support is an under-used resource in global mental health. Building upon comprehensive formative research, this study will rigorously evaluate the impact of peer support at multiple levels, including service user outcomes (psychosocial and clinical), peer support worker outcomes (work role and empowerment), service outcomes (cost-effectiveness and return on investment), and implementation outcomes (adoption, sustainability and organisational change).

Methods: UPSIDES-RCT is a pragmatic, parallel-group, multicentre, randomised controlled trial assessing the effectiveness of using peer support in developing empowering mental health services (UPSIDES) at four measurement points over 1 year (baseline, 4-, 8- and 12-month follow-up), with embedded process evaluation and cost-effectiveness analysis. Research will take place in a range of high-, middle- and low-income countries (Germany, UK, Israel, India, Uganda and Tanzania). The primary outcome is social inclusion of service users with severe mental illness (N = 558; N = 93 per site) at 8-month follow-up, measured with the Social Inclusion Scale. Secondary outcomes include empowerment (using the Empowerment Scale), hope (using the HOPE scale), recovery (using Stages of Recovery) and health and social functioning (using the Health of the Nations Outcome Scales). Mixed-methods process evaluation will investigate mediators and moderators of effect and the implementation experiences of four UPSIDES stakeholder groups (service users, peer support workers, mental health workers and policy makers). A cost-effectiveness analysis examining cost-utility and health budget impact will estimate the value for money of UPSIDES peer support.

Discussion: The UPSIDES-RCT will explore the essential components necessary to create a peer support model in mental health care, while providing the evidence required to sustain and eventually scale-up the intervention in different cultural, organisational and resource settings. By actively involving and empowering service users, UPSIDES will move mental health systems toward a recovery orientation, emphasising user-centredness, community participation and the realisation of mental health as a human right.

Trial Registration: ISRCTN, ISRCTN26008944. Registered on 30 October 2019.
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http://dx.doi.org/10.1186/s13063-020-4177-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195705PMC
May 2020

Exploring Opportunities to Leverage Pharmacists in Rural Areas to Promote Administration of Human Papillomavirus Vaccine.

Prev Chronic Dis 2020 03 12;17:E23. Epub 2020 Mar 12.

Iowa Cancer Consortium, Coralville, Iowa.

Rural pharmacists have been identified as potential partners, along with health care providers, schools, and public health agencies, in administering and promoting the human papillomavirus (HPV) vaccine. We sought to understand the role of pharmacists in this work. We interviewed 11 pharmacists working at independently owned pharmacies in Iowa to explore their perspectives on HPV vaccine administration and promotion. Most pharmacists agreed that HPV vaccination was within their professional scope. They identified factors that facilitate vaccine administration (eg, accessibility of pharmacies). They also reported personal barriers (eg, lack of information, concerns about safety) and organizational barriers (eg, time and staff capacity). Future work should focus on alleviating barriers and building on strengths to improve vaccination rates and ultimately prevent HPV-related cancers.
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http://dx.doi.org/10.5888/pcd17.190351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7085911PMC
March 2020

Perspectives on Implementation: Challenges and Successes of a Program Designed to Support Expectant and Parenting Community College Students in Rural, Midwestern State.

Matern Child Health J 2020 Sep;24(Suppl 2):152-162

Bureau of Family Health, Iowa Department of Public Health, 321 E 12th St, 6th Floor, Des Moines, IA, 50319, USA.

Objectives: Expectant and parenting students (EPS) at community colleges are an underserved and often under-resourced group. In a rural, Midwestern state, the department of public health was awarded the Pregnancy Assistance Fund (PAF) grant to assist this population. This paper outlines the results of the implementation evaluation and offers suggestions for programs and evaluators working with this population in the community college setting.

Methods: We conducted a multicomponent evaluation utilizing quantitative and qualitative methods. Evaluation activities included tracking activities/services, surveys and interviews with participants, and interviews with community college staff implementing grant activities. The research team calculated frequencies for quantitative data and coded qualitative data for themes.

Results: Data from the community colleges and students' self-reports revealed that EPS most commonly received concrete support from the program, often in the form of stipends or gift cards. Students reported that concrete support was beneficial and helped to relieve financial stress during the semester. Students' major barriers to participation were lack of knowledge about the program and busy schedules that prevented them from accessing PAF services. Staff reported that difficulty identifying EPS and the short one-year project period were major implementation challenges.

Conclusions For Practice: We recommend that community colleges work to identify EPS, use fellow EPS to recruit program participants, and implement programming that works with the students' schedules.
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http://dx.doi.org/10.1007/s10995-020-02879-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7497370PMC
September 2020

Typology of modifications to peer support work for adults with mental health problems: systematic review.

Br J Psychiatry 2020 06;216(6):301-307

Researcher, Butabika National Referral Hospital, Uganda.

Background: Peer support work roles are being implemented internationally, and increasingly in lower-resource settings. However, there is no framework to inform what types of modifications are needed to address local contextual and cultural aspects.

Aims: To conduct a systematic review identifying a typology of modifications to peer support work for adults with mental health problems.

Method: We systematically reviewed the peer support literature following PRISMA guidelines for systematic reviews (registered on PROSPERO (International Prospective Register of Systematic Reviews) on 24 July 2018: CRD42018094832). All study designs were eligible and studies were selected according to the stated eligibility criteria and analysed with standardised critical appraisal tools. A narrative synthesis was conducted to identify types of, and rationales for modifications.

Results: A total of 15 300 unique studies were identified, from which 39 studies were included with only one from a low-resource setting. Six types of modifications were identified: role expectations; initial training; type of contact; role extension; workplace support for peer support workers; and recruitment. Five rationales for modifications were identified: to provide best possible peer support; to best meet service user needs; to meet organisational needs, to maximise role clarity; and to address socioeconomic issues.

Conclusions: Peer support work is modified in both pre-planned and unplanned ways when implemented. Considering each identified modification as a candidate change will lead to a more systematic consideration of whether and how to modify peer support in different settings. Future evaluative research of modifiable versus non-modifiable components of peer support work is needed to understand the modifications needed for implementation among different mental health systems and cultural settings.
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http://dx.doi.org/10.1192/bjp.2019.264DOI Listing
June 2020

Intersectoral cooperation to increase HPV vaccine coverage: an innovative collaboration between Managed Care Organizations and state-level stakeholders.

Hum Vaccin Immunother 2020 06 6;16(6):1385-1391. Epub 2019 Dec 6.

American Cancer Society , Des Moines, IA, USA.

In order to reduce disparities in human papillomavirus (HPV) vaccine coverage, intersectoral approaches are needed to reach vulnerable populations, including Medicaid enrollees. This manuscript describes a collaboration between Medicaid Managed Care Organizations (MCOs), the American Cancer Society, and a state health department in a Midwestern state to address HPV vaccination. Qualitative interviews (n = 11) were conducted via telephone with key stakeholders from the three participating organizations using an interview guide designed to capture the process of developing the partnership and implementing the HPV-focused project. Interviews were transcribed and coded using thematic analysis. Interviewees described motivation to participate, including shared goals, and facilitators, like pooled resources. They cited barriers, such as time and legal challenges. Overall, interviewees reported that they believed this project is replicable. Conducting this project revealed the importance of shared vision, effective communication, and the complementary resources and experiences contributed by each organization. Valuable lessons were learned about reaching the Medicaid population and groundwork was laid for future efforts to serve vulnerable populations and reduce health disparities. This work has significant implications for other organizations seeking to partner with large nonprofits, state health departments, MCOs, or others, and the lessons learned from this project could be translated to other groups working to improve vaccination rates in their communities.
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http://dx.doi.org/10.1080/21645515.2019.1694814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482769PMC
June 2020

Peer support for frequent users of inpatient mental health care in Uganda: protocol of a quasi-experimental study.

BMC Psychiatry 2019 11 29;19(1):374. Epub 2019 Nov 29.

Butabika National Referral Hospital, Kampala, Uganda.

Background: Reducing readmissions among frequent users of psychiatric inpatient care could result in substantial cost savings to under-resourced mental health systems. Studies from high-income countries indicate that formal peer support can be an effective intervention for the reduction of readmissions among frequent users. Although in recent years formal peer support programmes have been established in mental health services in a few low- and middle-income countries (LMICs), they have not been rigorously evaluated.

Methods: This protocol describes a quasi-experimental difference-in-differences study conducted as part of a broader evaluation of the Brain Gain II peer support programme based at Butabika National Referral Hospital in Kampala, Uganda. The primary objective is to investigate whether frequent users of psychiatric inpatient care who have access to a peer support worker (PSW+) experience a greater reduction in rehospitalisation rates and number of days spent in hospital compared to those who do not have access to a peer support worker (PSW-). Frequent users, defined as adults diagnosed with either a mental disorder or epilepsy who have had three or more inpatient stays at Butabika over the previous 24 months, are referred to Brain Gain II by hospital staff on five inpatient wards. Frequent users who normally reside in a district where peer support workers currently operate (Kampala, Jinja, Wakiso and Mukono) are eligible for formal peer support and enter the PSW+ group. Participants in the PSW+ group are expected to receive at least one inpatient visit by a trained peer support worker before hospital discharge and three to six additional visits after discharge. Frequent users from other districts enter the PSW- group and receive standard care. Participants' admissions data are extracted from hospital records at point of referral and six months following referral.

Discussion: To the best of our knowledge, this will be the first quasi-experimental study of formal peer support in a LMIC and the first to assess change in readmissions, an outcome of particular relevance to policy-makers seeking cost-effective alternatives to institutionalised mental health care.
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http://dx.doi.org/10.1186/s12888-019-2360-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6883561PMC
November 2019

A systematic review of influences on implementation of peer support work for adults with mental health problems.

Soc Psychiatry Psychiatr Epidemiol 2020 Mar 8;55(3):285-293. Epub 2019 Jun 8.

School of Health Sciences, Institute of Mental Health, University of Nottingham, Triumph Road, Nottingham, NG7 2TU, UK.

Purpose: The evidence base for peer support work in mental health is established, yet implementation remains a challenge. The aim of this systematic review was to identify influences which facilitate or are barriers to implementation of mental health peer support work.

Methods: Data sources comprised online databases (n = 11), journal table of contents (n = 2), conference proceedings (n = 18), peer support websites (n = 2), expert consultation (n = 38) and forward and backward citation tracking. Publications were included if they reported on implementation facilitators or barriers for formal face-to-face peer support work with adults with a mental health problem, and were available in English, French, German, Hebrew, Luganda, Spanish or Swahili. Data were analysed using narrative synthesis. A six-site international survey [Germany (2 sites), India, Israel, Tanzania, Uganda] using a measure based on the strongest influences was conducted. The review protocol was pre-registered (Prospero: CRD42018094838).

Results: The search strategy identified 5813 publications, of which 53 were included. Fourteen implementation influences were identified, notably organisational culture (reported by 53% of papers), training (42%) and role definition (40%). Ratings on a measure using these influences demonstrated preliminary evidence for the convergent and discriminant validity of the identified influences.

Conclusion: The identified influences provide a guide to implementation of peer support. For services developing a peer support service, organisational culture including role support (training, role clarity, resourcing and access to a peer network) and staff attitudes need to be considered. The identified influences provide a theory base to prepare research sites for implementing peer support worker interventions.
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http://dx.doi.org/10.1007/s00127-019-01739-1DOI Listing
March 2020

Implementation Challenges and Opportunities Related to HPV Vaccination Quality Improvement in Primary Care Clinics in a Rural State.

J Community Health 2019 08;44(4):790-795

Bureau of Immunization and Tuberculosis, Iowa Department of Public Health, Des Moines, Iowa, USA.

Efforts to understand low human papillomavirus vaccine coverage led us to explore quality improvement (QI) decision-making programs and processes to increase vaccine uptake. These QI programs often include interventions recommended by the AFIX (Assessment Feedback Incentives eXchange) Program that supports Vaccines for Children (VFC) clinics. However, little is known about decision-making around intervention selection or extent of implementation. In collaboration with the state public health department in the rural Midwestern, investigators developed a survey to explore vaccine-related QI in VFC clinics. The survey was distributed via email to all VFC clinics (n = 605); results presented are from the primary care clinics (n = 115). Respondents (VFC liaisons) reported decisions about vaccine QI were made by multiple actors within their own clinics (45.1%), by a clinic manager in charge of multiple clinics (33.0%) and/or at a centralized administrative office (35.2%). Additionally, the majority of respondents considered external actors, like insurance companies (52.7%) or Medicaid/Medicare (50.5%), important to the decision-making process. Most commonly implemented interventions focused on provider knowledge and patient education. Least commonly implemented interventions required systematic changes, such as reminder/recall and follow-up after missed appointments. This preliminary research indicates there are multiple points of decision-making within clinics and health care systems, and therefore change agents at all points need to be involved. The most commonly implemented interventions focus on providers and patients, with an emphasis on education. Interventions requiring system-level changes and use of electronic health records are less common and more attention should be directed towards such interventions.
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http://dx.doi.org/10.1007/s10900-019-00676-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6934039PMC
August 2019

Using Peer Support in Developing Empowering Mental Health Services (UPSIDES): Background, Rationale and Methodology.

Ann Glob Health 2019 04 5;85(1). Epub 2019 Apr 5.

School of Health Sciences, Institute of Mental Health, University of Nottingham, UK.

Background: Peers are people with lived experience of mental illness. Peer support is an established intervention in which peers offer support to others with mental illness. A large proportion of people living with severe mental illness receive no care. The care gap is largest in low- and middle-income countries, with detrimental effects on individuals and societies. The global shortage of human resources for mental health is an important driver of the care gap. Peers are an under-used resource in global mental health.

Objectives: To describe rationale and methodology of an international multicentre study which will scale-up peer support for people with severe mental illness in high-, middle-, and low-income countries through mixed-methods implementation research.

Methods: UPSIDES is an international community of research and practice for peer support, including peer support workers, mental health researchers, and other relevant stakeholders in eight study sites across six countries in Europe, Africa, and Asia. During the first two years of UPSIDES, a series of qualitative studies and systematic reviews will explore stakeholders' perceptions and the current state of peer support at each site. Findings will be incorporated into a conceptual framework to guide the development of a culturally appropriate peer support intervention to be piloted across all study sites. All intervention and study materials will be translated according to internationally recognised guidelines.Expected Impact: UPSIDES: will leverage the unique expertise of people with lived experience of mental illness to strengthen mental health systems in high-, middle- and low-income countries. UPSIDES will actively involve and empower service users and embed patient-centeredness, recovery orientation, human rights approaches, and community participation into services. The focus on capacity-building of peers may prove particularly valuable in low-resource settings in which shortages of human capital are most severe.
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http://dx.doi.org/10.5334/aogh.2435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6634474PMC
April 2019

Service user involvement in global mental health: what have we learned from recent research in low and middle-income countries?

Curr Opin Psychiatry 2019 07;32(4):355-360

Occupational Therapy Department, Butabika National Referral Hospital, Kampala.

Purpose Of Review: The Lancet Commission on global mental health and sustainable development claims the field of global mental health is undergoing a 'transformational shift' toward an ethic of 'nothing about us without us'. Yet a systematic review published in 2016 identified few examples of meaningful participation by service users in mental health systems strengthening in low and middle-income countries (LMICs). To investigate whether this is still the case, we conducted a rapid review of primary research published between June 2017 and December 2018.

Recent Findings: We identified 10 studies reporting on user involvement in LMICs, including three in mental health policy and planning, three in mental health services or capacity-building and three in treatment decision-making. An additional study was identified as having involved users in data collection, although this was unclear from the original text. Included studies were mostly qualitative and conducted as part of a situation analysis, pilot study, or other formative research. Few reported the results of efforts to improve involvement, suggesting this shift remains at an early stage.

Summary: Although the number of studies published on user involvement is rapidly increasing, the potentially 'transformational' effects of this shift in global mental health are not yet being felt by most users in LMICs.
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http://dx.doi.org/10.1097/YCO.0000000000000506DOI Listing
July 2019

Actively Involving Middle School Students in the Implementation of a Pilot of a Behavioral Economics-Based Lunchroom Intervention in Rural Schools.

Health Promot Pract 2019 09 16;20(5):675-683. Epub 2018 Oct 16.

3 Iowa Department of Education, Des Moines, IA, USA.

School-based interventions can play an important role in improving childhood and adolescent nutrition and preventing obesity. Schools offer a unique opportunity to implement policy, systems, and environmental interventions targeting healthy eating behaviors. An intervention was piloted in six middle schools featuring behavioral economics-based changes to the lunchroom, communication training, and communicate cues for food service staff. The pilot study employed a multicomponent evaluation with students and food service directors and staff including a lunchroom assessment, online surveys, production records, and interviews. Five schools increased their scores on the lunchroom assessment tool, and four schools increased the number of servings produced of healthy food items. Interviews with food service directors indicated the interventions was feasible and well received. School-based policy, systems, and environmental interventions targeting healthy eating behaviors may play a role in preventing obesity in children and adolescents.
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http://dx.doi.org/10.1177/1524839918807717DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7248680PMC
September 2019

Theory of change for the delivery of talking therapies by lay workers to survivors of humanitarian crises in low-income and middle-income countries: protocol of a systematic review.

BMJ Open 2018 02 17;8(2):e018193. Epub 2018 Feb 17.

Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.

Introduction: There is a severe shortage of specialist mental healthcare providers in low-income and middle-income countries (LMICs) affected by humanitarian crises. In these settings, talking therapies may be delivered by non-specialists, including lay workers with no tertiary education or formal certification in mental health. This systematic review will synthesise the literature on the implementation and effectiveness of talking therapies delivered by lay workers in LMICs affected by humanitarian crises, in order to develop a Theory of Change (ToC).

Methods And Analysis: Qualitative, quantitative and mixed-methods studies assessing the implementation or effectiveness of lay-delivered talking therapies for common mental disorders provided to adult survivors of humanitarian crises in LMICs will be eligible for inclusion. Studies set in high-income countries will be excluded. No restrictions will be applied to language or year of publication. Unpublished studies will be excluded. Seven electronic databases will be searched: MEDLINE, Embase, PsycINFO, PsycEXTRA, Global Health, Cochrane Library and ClinicalTrials.gov. Contents pages of three peer-reviewed journals will be hand-searched. Sources of grey literature will include resource directories of two online mental health networks (MHPSS.net and MHInnovation.net) and expert consultation. Forward and backward citation searches of included studies will be performed. Two reviewers will independently screen studies for inclusion, extract data and assess study quality. A narrative synthesis will be conducted, following established guidelines. A ToC map will be amended iteratively to take into account the review results and guide the synthesis.

Ethics And Dissemination: Findings will be presented in a manuscript for publication in a peer-reviewed journal and disseminated through a coordinated communications strategy targeting knowledge generators, enablers and users.

Prospero Registration Number: CRD42017058287.
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http://dx.doi.org/10.1136/bmjopen-2017-018193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855449PMC
February 2018

Increasing appropriate conversation skills using a behavioral skills training package for adults with intellectual disability and autism spectrum disorder.

J Intellect Disabil 2019 Dec 1;23(4):567-580. Epub 2018 Jan 1.

National University of Ireland, Ireland.

The current research evaluates the effectiveness of a behavioral skills training (BST) package used to increase appropriate conversation interactions for six adults with autism spectrum disorder (ASD). Deficits in the area of social skills can become a significant feature for individuals with disabilities and in particular for those with ASD. A multiple probe design across participant dyads was employed to examine the effects of the intervention on conversation interactions. The BST package was delivered in small group instruction and included (i) instructions about having a conversation, (ii) modeling a conversation, (iii) practicing a conversation, and (iv) feedback on performance during each session. Results indicated that BST was effective for increasing appropriate conversation interactions for all six participants, and maintenance was evident 4 weeks post intervention. The findings were discussed in relation to the importance of social interactions and communication amongst this population.
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http://dx.doi.org/10.1177/1744629517750744DOI Listing
December 2019

Discontinuing contact precautions for multidrug-resistant organisms: A systematic literature review and meta-analysis.

Am J Infect Control 2018 03 12;46(3):333-340. Epub 2017 Oct 12.

Office of Clinical Quality, Safety and Performance Improvement, University of Iowa Hospitals and Clinics, Iowa City, IA; Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Division of Medical Microbiology, Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA.

Background: Several single-center studies have suggested that eliminating contact precautions (CPs) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) control in nonoutbreak settings has no impact on infection rates. We performed a systematic literature review and meta-analysis on the impact of discontinuing contact precautions in the acute care setting.

Methods: We searched PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Embase through December 2016 for studies evaluating discontinuation of contact precautions for multidrug-resistant organisms. We used random-effect models to obtain pooled risk ratio estimates. Heterogeneity was evaluated with I estimation and the Cochran Q statistic. Pooled risk ratios for MRSA and VRE were assessed separately.

Results: Fourteen studies met inclusion criteria and were included in the final review. Six studies discontinued CPs for both MRSA and VRE, 3 for MRSA only, 2 for VRE only, 2 for extended-spectrum β-lactamase-producing Escherichia coli, and 1 for Clostridium difficile infection. When study results were pooled, there was a trend toward reduction of MRSA infection after discontinuing CPs (pooled risk ratio, 0.84; 95% confidence interval, 0.70-1.02; P = .07) and a statistically significant reduction in VRE infection (pooled risk ratio, 0.82; 95% confidence interval, 0.72-0.94; P = .005).

Conclusions: Discontinuation of CPs for MRSA and VRE has not been associated with increased infection rates.
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http://dx.doi.org/10.1016/j.ajic.2017.08.031DOI Listing
March 2018