The organizational social context of mental health services and clinician attitudes toward evidence-based practice: a United States national study

ABSTRACT: BACKGROUND: Evidence-based practices have not been routinely adopted in community mental health organizations despite the support of scientific evidence and in some cases even legislative or regulatory action. We examined the association of clinician attitudes toward evidence-based practice with organizational culture, climate, and other characteristics in a nationally representative sample of mental health organizations in the United States. METHODS: In-person, group-administered surveys were conducted with a sample of 1,112 mental health service providers in a nationwide sample of 100 mental health service institutions in 26 states in the United States. The study examines these associations with a two-level Hierarchical Linear Modeling (HLM) analysis of responses to the Evidence-Based Practice Attitude Scale (EBPAS) at the individual clinician level as a function of the Organizational Social Context (OSC) measure at the organizational level, controlling for other organization and clinician characteristics. RESULTS: We found that more proficient organizational cultures and more engaged and less stressful organizational climates were associated with positive clinician attitudes toward adopting evidence-based practice. CONCLUSIONS: The findings suggest that organizational intervention strategies for improving the organizational social context of mental health services may contribute to the success of evidence-based practice dissemination and implementation efforts by influencing clinician attitudes.     

The organizational social context of mental health services and clinician attitudes toward evidence-based practice: a United States national study

Background

Collaborative-care management is an evidence-based practice for improving depression outcomes in primary care. The Department of Veterans Affairs (VA) has mandated the implementation of collaborative-care management in its satellite clinics, known as Community Based Outpatient Clinics (CBOCs). However, the organizational characteristics of CBOCs present added challenges to implementation. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI) as a strategy to facilitate the adoption of collaborative-care management in CBOCs.

Methods

This nonrandomized, small-scale, multisite evaluation of EBQI was conducted at three VA Medical Centers and 11 of their affiliated CBOCs. The Plan phase of the EBQI process involved the localized tailoring of the collaborative-care management program to each CBOC. Researchers ensured that the adaptations were evidence based. Clinical and administrative staff were responsible for adapting the collaborative-care management program for local needs, priorities, preferences and resources. Plan-Do-Study-Act cycles were used to refine the program over time. The evaluation was based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) Framework and used data from multiple sources: administrative records, web-based decision-support systems, surveys, and key-informant interviews.

Results

Adoption: 69.0% (58/84) of primary care providers referred patients to the program. Reach: 9.0% (298/3,296) of primary care patients diagnosed with depression who were not already receiving specialty care were enrolled in the program. Fidelity: During baseline care manager encounters, education/activation was provided to 100% (298/298) of patients, barriers were assessed and addressed for 100% (298/298) of patients, and depression severity was monitored for 100% (298/298) of patients. Less than half (42.5%, 681/1603) of follow-up encounters during the acute stage were completed within the timeframe specified. During the acute phase of treatment for all trials, the Patient Health Questionnaire (PHQ9) symptom-monitoring tool was used at 100% (681/681) of completed follow-up encounters, and self-management goals were discussed during 15.3% (104/681) of completed follow-up encounters. During the acute phase of treatment for pharmacotherapy and combination trials, medication adherence was assessed at 99.1% (575/580) of completed follow-up encounters, and side effects were assessed at 92.4% (536/580) of completed follow-up encounters. During the acute phase of treatment for psychotherapy and combination trials, counseling session adherence was assessed at 83.3% (239/287) of completed follow-up encounters. Effectiveness: 18.8% (56/298) of enrolled patients remitted (symptom free) and another 22.1% (66/298) responded to treatment (50% reduction in symptom severity). Maintenance: 91.9% (10/11) of the CBOCs chose to sustain the program after research funds were withdrawn.

Conclusions

Provider adoption was good, although reach into the target population was relatively low. Fidelity and maintenance were excellent, and clinical outcomes were comparable to those in randomized controlled trials. Despite the organizational barriers, these findings suggest that EBQI is an effective facilitation strategy for CBOCs.

Trial registration

Clinical trial # NCT00317018.     

Firm-level perspectives on public sector engagement with private healthcare providers: survey evidence from Ghana and Kenya

Background

Health systems in Sub-Saharan Africa (SSA) are in urgent need of improvement. The private health sector is a major provider of care in the region and it will remain a significant actor in the future. Any efforts by SSA governments to improve health systems performance therefore has to account for the private health sector. Regional and international actors increasingly recognize importance of effectively engaging with the private health sector, and initiatives to improve engagement are underway in several countries. However, there is little systematic analysis of private health providers'' view and experience with engagement.

Methodology/Principal Findings

In this study we surveyed private health facilities in Kenya and Ghana to understand the extent to which and how governments interact and engage with these facilities. The results suggest that government engagement with private health facilities is quite limited. The primary focus of this engagement is “command-and-control” type regulations to improve the quality of care. There is little attention paid to building the capacity of health care businesses through either technical or financial assistance. The vast majority of these facilities also receive no government assistance in meeting public health and social goals. Finally, government engagement with private pharmacies is often neglected and clinics receive a disproportionate share of government assistance.

Conclusions/Significance

Overall, our findings suggest that there may be considerable untapped potential for greater engagement with private health facilities—particularly pharmacies. Improving engagement will likely help governments with limited resources to better take advantage of the private sector capacity to meet access and equity objectives and to accelerate the achievement of the Millennium Development Goals.     

The implementation of organizational LCA to internally manage the environmental impacts of a broad product portfolio: an example for a cosmetics,fragrances, and toiletry provider

Purpose

This paper presents the implementation of O-LCA by a Brazilian cosmetics manufacturer. The case study was developed within the framework of the road testing of the “Guidance on organizational LCA” of the UNEP/SETAC Life Cycle Initiative. The aim is to illustrate methodological choices and implementation challenges encountered by the company, i.e., related to the broad product portfolio. The study demonstrates that O-LCA allows quantifying and managing environmental impacts throughout global supply chains and for every individual product.

Methods

O-LCA provides the methodological framework for applying LCA to organizations, and a set of application options based on the structure and experience of organizations. The reporting organization is NATURA Brazil in 2013. The 2600 products in the portfolio are modeled in this first exercise of the company through the bestsellers at each of its ten product category groups. A hybrid approach is considered for data collection: top-down approach for modeling corporate activities and bottom-up approach for upstream and downstream life cycle phases. The data sources are NATURA’s recordings, data gathered from suppliers, estimates from mass and energy balances, and life cycle inventory databases. The approach to acquire direct data or use life cycle databases depends on the representativeness of each raw material or packaging.

Results and discussion

The results show that major impacts could be detected during use phase that demands water and energy to use rinse-off products (the use phase of NATURA’s products contributed over 41% to most impact categories), and in the supply chain, and generated during the obtaining of plant origin ingredients and materials for packaging. Overall, the whole NATURA had in 2013 a potential impact on climate change of 1.4 million tonnes of CO₂ eq, a natural land transformation of 1.3 million m², and a fossil depletion of 0.23 million tonnes of oil eq, among other impacts. Apart from the results at the organizational level, individual results for product bestsellers were calculated and are presented here.

Conclusions

The study confirmed the applicability of the O-LCA model at NATURA, addressed operational issues related to broad product portfolios, considering several dimensions such as data quality and availability, LCA software, and data management. Despite NATURA’s existing practices and previous knowledge in modeling environmental impacts of products and corporate activities, managing the large amount of data involved prove being a complex task. The company identified gaps and opportunities able to guide future method implementation and LCA-based management.

     

The malaria testing and treatment landscape in Kenya: results from a nationally representative survey among the public and private sector in 2016

Background

Since 2004, Kenya’s national malaria treatment guidelines have stipulated artemisinin-based combination therapy (ACT) as first-line treatment for uncomplicated malaria, and since 2014, confirmatory diagnosis of malaria in all cases before treatment has been recommended. A number of strategies to support national guidelines have been implemented in the public and private sectors in recent years. A nationally-representative malaria outlet survey, implemented across four epidemiological zones, was conducted between June and August 2016 to provide practical evidence to inform strategies and policies in Kenya towards achieving national malaria control goals.

Results

A total of 17,852 outlets were screened and 2271 outlets were eligible and interviewed. 78.3% of all screened public health facilities stocked both malaria diagnostic testing and quality-assured ACT (QAACT). Sulfadoxine–pyrimethamine (SP) for intermittent preventive treatment in pregnancy was available in 70% of public health facilities in endemic areas where it is recommended for treatment. SP was rarely found in the public sector outside of the endemic areas (< 0.5%). The anti-malaria stocking private sector had lower levels of QAACT (46.7%) and malaria blood testing (20.8%) availability but accounted for majority of anti-malarial distribution (70.6% of the national market share). More than 40% of anti-malarials were distributed by unregistered pharmacies (37.3%) and general retailers (7.1%). QAACT accounted for 58.2% of the total anti-malarial market share, while market share for non-QAACT was 15.8% and for SP, 24.8%. In endemic areas, 74.9% of anti-malarials distributed were QAACT. Elsewhere, QAACT market share was 49.4% in the endemic-prone areas, 33.2% in seasonal-transmission areas and 37.9% in low-risk areas.

Conclusion

Although public sector availability of QAACT and malaria diagnosis is relatively high, there is a gap in availability of both testing and treatment that must be addressed. The private sector in Kenya, where the majority of anti-malarials are distributed, is also critical for achieving universal coverage with appropriate malaria case management. There is need for a renewed commitment and effective strategies to ensure access to affordable QAACT and confirmatory testing in the private sector, and should consider how to address malaria case management among informal providers responsible for a substantial proportion of the anti-malarial market share.

     

The signaller's dilemma: a cost-benefit analysis of public and private communication

Background

Understanding the diversity of animal signals requires knowledge of factors which may influence the different stages of communication, from the production of a signal by the sender up to the detection, identification and final decision-making in the receiver. Yet, many studies on signalling systems focus exclusively on the sender, and often ignore the receiver side and the ecological conditions under which signals evolve.

Methodology/Principal Findings

We study a neotropical katydid which uses airborne sound for long distance communication, but also an alternative form of private signalling through substrate vibration. We quantified the strength of predation by bats which eavesdrop on the airborne sound signal, by analysing insect remains at roosts of a bat family. Males do not arbitrarily use one or the other channel for communication, but spend more time with private signalling under full moon conditions, when the nocturnal rainforest favours predation by visually hunting predators. Measurements of metabolic CO₂-production rate indicate that the energy necessary for signalling increases 3-fold in full moon nights when private signalling is favoured. The background noise level for the airborne sound channel can amount to 70 dB SPL, whereas it is low in the vibration channel in the low frequency range of the vibration signal. The active space of the airborne sound signal varies between 22 and 35 meters, contrasting with about 4 meters with the vibration signal transmitted on the insect''s favourite roost plant. Signal perception was studied using neurophysiological methods under outdoor conditions, which is more reliable for the private mode of communication.

Conclusions/Significance

Our results demonstrate the complex effects of ecological conditions, such as predation, nocturnal ambient light levels, and masking noise levels on the performance of receivers in detecting mating signals, and that the net advantage or disadvantage of a mode of communication strongly depends on these conditions.     

Number and type of guideline implementation tools varies by guideline,clinical condition,country of origin,and type of developer organization: content analysis of guidelines

Background

Guideline implementation tools (GI tools) can improve clinician behavior and patient outcomes. Analyses of guidelines published before 2010 found that many did not offer GI tools. Since 2010 standards, frameworks and instructions for GI tools have emerged. This study analyzed the number and types of GI tools offered by guidelines published in 2010 or later.

Methods

Content analysis and a published GI tool framework were used to categorize GI tools by condition, country, and type of organization. English-language guidelines on arthritis, asthma, colorectal cancer, depression, diabetes, heart failure, and stroke management were identified in the National Guideline Clearinghouse. Screening and data extraction were in triplicate. Findings were reported with summary statistics.

Results

Eighty-five (67.5%) of 126 eligible guidelines published between 2010 and 2017 offered one or more of a total of 464 GI tools. The mean number of GI tools per guideline was 5.5 (median 4.0, range 1 to 28) and increased over time. The majority of GI tools were for clinicians (239, 51.5%), few were for patients (113, 24.4%), and fewer still were to support implementation (66, 14.3%) or evaluation (46, 9.9%). Most clinician GI tools were guideline summaries (116, 48.5%), and most patient GI tools were condition-specific information (92, 81.4%). Government agencies (patient 23.5%, clinician 28.9%, implementation 24.1%, evaluation 23.5%) and developers in the UK (patient 18.5%, clinician 25.2%, implementation 27.2%, evaluation 29.1%) were more likely to generate guidelines that offered all four types of GI tools. Professional societies were more likely to generate guidelines that included clinician GI tools.

Conclusions

Many guidelines do not include any GI tools, or a variety of GI tools for different stakeholders that may be more likely to prompt guideline uptake (point-of-care forms or checklists for clinicians, decision-making or self-management tools for patients, implementation and evaluation tools for managers and policy-makers). While this may vary by country and type of organization, and suggests that developers could improve the range of GI tools they develop, further research is needed to identify determinants and potential solutions. Research is also needed to examine the cost-effectiveness of various types of GI tools so that developers know where to direct their efforts and scarce resources.

     

Labour market participation after breast cancer for employees from the private and public sectors: Educational and sector gradients in the effect of cancer

For employees who get cancer and survive, the probability of returning to work may depend on their ability to work, potential earnings losses if they do not return to work, qualifications and job type, but also on characteristics of the pre-cancer workplace. This paper focuses on differences between public and private sector employees in the effect of breast cancer on the probability of being out of the labour force three years after the diagnosis. We use propensity score weighting methods and a large longitudinal Danish administrative dataset which allows us to control for a wide range of important baseline characteristics such as education, sector of employment, labour market status, income, health, and demographics. We find that the educational gradient in the effect of cancer is significant in the public sector, where the estimated effects are 11.5 and 3.8 percentage points, respectively, for the low- and high-educated. The corresponding estimates for the private sector are 6.2 and 3.2 percentage points and here the educational gradient is only marginally significant. We discuss possible mechanisms behind the large sector gradient for the low-educated.     

The impact of provider flexibility and capacity allocation on the performance of primary care practices

The two important but often conflicting metrics for any primary care practice are: (1) Timely Access and (2) Patient-physician Continuity. Timely access focuses on the ability of a patient to get access to a physician (or provider, in general) as soon as possible. Patient–physician continuity refers to building a strong or permanent relationship between a patient and a specific physician by maximizing patient visits to that physician. In the past decade, a new paradigm called advanced access or open access has been adopted by practices nationwide to encourage physicians to “do today’s work today.” However, most clinics still reserve pre-scheduled slots for long lead-time appointments due to patient preference and clinical necessities. Therefore, an important problem for clinics is how to optimally manage and allocate limited physician capacities as much as possible to meet the two types of demand—pre-scheduled (non-urgent) and open access (urgent, as perceived by the patient)—while simultaneously maximizing timely access and patient–physician continuity. In this study we adapt ideas of manufacturing process flexibility to capacity management in a primary care practice. Flexibility refers to the ability of a primary care physician to see patients of other physicians. We develop generalizable analytical algorithms for capacity allocation for an individual physician and a two physician practice. For multi-physician practices, we use a two-stage stochastic integer programming approach to investigate the value of flexibility. We find that flexibility has the greatest benefit when system workload is balanced, when the physicians have unequal workloads, and when the number of physicians in the practice increases. We also find that partial flexibility, which restricts the number of physicians a patient sees and thereby promotes continuity, simultaneously succeeds in providing high levels of timely access.     

The impact of future summer temperature on public health in Barcelona and Catalonia,Spain

Several epidemiological studies have reported associations between increases in summer temperatures and risks of premature mortality. The quantitative implications of predicted future increases in summer temperature, however, have not been extensively characterized. We have quantified these effects for the four main cities in Catalonia, Spain (Barcelona, Tarragona, Lleida, Girona). We first used case-crossover analysis to estimate the association between temperature and mortality for each of these cities for the period 1983 to 2006. These exposure–response (ER) functions were then combined with local measures of current and projected changes in population, mortality and temperature for the years 2025 and 2050. Predicted daily mean temperatures were based on the A1B greenhouse gas emission, “business-as-usual” scenario simulations derived from the ENSEMBLES project. Several different ER functions were examined and significant associations between temperature and mortality were observed for all four cities. For these four cities, the age-specific piecewise linear model predicts 520 (95%CI  340, 720) additional annual deaths attributable to the change in temperature in 2025 relative to the average from the baseline period of 1960–1990. For 2050, the estimate increases to 1,610 deaths per year during the warm season. For Catalonia as a whole, the point estimates for those two years are 720 and 2,330 deaths per year, respectively, or about 2 and 3% of the warm season. In comparing these predicted impacts with current causes of mortality, they clearly represent significant burdens to public health in Catalonia.     

Falling giants and the rise of gene editing: ethics,private interests and the public good

This paper considers the tensions created in genomic research by public and private for-profit ideals. Our intent is to strengthen the public good at a time when doing science is strongly motivated by market possibilities and opportunities. Focusing on the emergence of gene editing, and in particular CRISPR, we consider how commercialisation encourages hype and hope—a sense that only promise and idealism can achieve progress. At this rate, genomic research reinforces structures that promote, above all else, private interests, but that may attenuate conditions for the public good of science. In the first part, we situate genomics using the aphorism that ‘on the shoulders of giants we see farther’; these giants are infrastructures and research cultures rather than individual ‘heroes’ of science. In this respect, private initiatives are not the only pivot for successful discovery, and indeed, fascination in those could impinge upon the fundamental role of public-supported discovery. To redress these circumstances, we define the extent to which progress presupposes research strategies that are for the public good. In the second part, we use a ‘falling giant’ narrative to illustrate the risks of over-indulging for-profit initiatives. We therefore offer a counterpoint to commercialised science, using three identifiable ‘giants’—scientists, publics and cultures—to illustrate how the public good contributes to genomic discovery.