COVID-19 government measures and their impact on mental health: a cross-sectional study of older primary care patients in Germany.

Background: With the outbreak of COVID-19, government measures including social distancing and restrictions of social contacts were imposed to slow the spread of the virus. Since older adults are at increased risk of severe disease, they were particularly affected by these restrictions. These may negatively affect mental health by loneliness and social isolation, which constitute risk factors for depressiveness. We aimed to analyse the impact of perceived restriction due to government measures on depressive symptoms and investigated stress as mediator in an at-risk-population in Germany. Methods: Data were collected in April 2020 from the population of the AgeWell.de-study, including individuals with a Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) score ≥9, using the depression subscale of the Brief Symptom Inventory (BSI-18) and the Perceived Stress Scale (PSS-4). Feeling restricted due to COVID-19 government measures was surveyed with a standardized questionnaire. Stepwise multivariate regressions using zero-inflated negative binomial models were applied to analyse depressive symptoms, followed by a general structural equation model to assess stress as mediator. Analysis were controlled for sociodemographic factors as well as social support. Results: We analysed data from 810 older adults (mean age = 69.9, SD = 5). Feeling restricted due to COVID-19 government measures was linked to increased depressiveness (b = 0.19; p < 0.001). The association was no longer significant when adding stress and covariates (b = 0.04; p = 0.43), while stress was linked to increased depressive symptoms (b = 0.22; p < 0.001). A final model confirms the assumption that the feeling of restriction is mediated by stress (total effect: b = 0.26; p < 0.001). Conclusion: We found evidence that feeling restricted due to COVID-19 government measures is associated with higher levels of depressive symptoms in older adults at increased risk for dementia. The association is mediated by perceived stress. Furthermore, social support was significantly associated with less depressive symptoms. Thus, it is of high relevance to consider possible adverse effects of government measures related to COVID-19 on mental health of older people.

Outcome measures from international older adult care home intervention research: a scoping review.

BACKGROUND: Care homes are increasingly important settings for intervention research to enhance evidence-informed care. For such research to demonstrate effectiveness, it is essential that measures are appropriate for the population, setting and practice contexts. OBJECTIVE: To identify care home intervention studies and describe the resident outcome measures used. DESIGN: Scoping review. METHODS: We reviewed international care home research published from 2015 to August 2022. We searched MEDLINE, EMBASE, CINAHL and ASSIA. We included any intervention study conducted in a care home, reporting resident outcomes. We extracted resident outcome measures, organised these using the domains of an adapted framework and described their use. RESULTS: From 7,330 records screened, we included 396 datasets reported in 436 publications. These included 12,167 care homes and 836,842 residents, with an average of 80 residents per study. The studies evaluated 859 unique resident outcomes 2,030 times using 732 outcome measures. Outcomes were evaluated between 1 and 112 times, with 75.1% of outcomes evaluated only once. Outcome measures were used 1-120 times, with 68.4% of measures used only once. Only 14 measures were used ≥20 times. Functional status, mood & behaviour and medications were the commonest outcome domains assessed. More than half of outcomes were assessed using scales, with a fifth using existing records or administrative data. CONCLUSIONS: There is significant heterogeneity in the choice and assessment of outcomes for intervention research in care homes. There is an urgent need to develop a consensus on useful and sensitive tools for care homes, working with residents, families and friends and staff.

Exploring preferences of older adults for dental services: A pilot multi-national discrete choice experiment.

OBJECTIVES: To pilot an exploration of older adults' future preferences using discrete choice experiments to understand who should provide dental examinations and treatment, where these services should be provided, and participants' willingness to pay and willingness to travel. BACKGROUND: The proportion of older adults in the general population is increasing and is recognised as a pressing public health challenge. MATERIALS AND METHODS: Older people aged 65 years and over were recruited into this study from the UK, Switzerland and Greece. Drawing on earlier stakeholder engagement, a set of choice experiments are developed to explore the future preferences of older people for dental examinations and dental treatment, as they anticipated losing their independence. These were presented to the participants using a range of platforms, because of the COVID pandemic. Data were analysed in STATA using a random-effects logit model. RESULTS: Two hundred and forty-six participants (median age 70 years) completed the pilot study. There was a strong preference across all countries for a dentist to undertake a dental examination (Greece: ß = 0.944, Switzerland: ß = 0.260, UK ß = 0.791), rather than a medical doctor (Greece: ß = -0.556, Switzerland: ß = -0.4690, UK: ß = -0.468). Participants in Switzerland and the UK preferred these examinations to be undertaken in a dental practice (Switzerland: ß = 0.220, UK: ß = 0.580) while participants in Greece preferred the dental examination to be undertaken in their homes (ß = 1.172). Greek participants preferred dental treatment to be undertaken by a specialist (ß = 0.365) in their home (ß = 0.862), while participants from the UK and Switzerland preferred to avoid any dental treatment at home (Switzerland: ß = -0.387; UK: ß = -0.444). Willingness to pay analyses highlighted that participants in Switzerland and the UK were willing to pay more to ensure the continuity of future service provision at a family dental practice (Switzerland: ß = 0.454, UK: ß = 0.695). CONCLUSION: Discrete choice experiments are valuable for exploring older people's preferences for dental service provision in different countries. Future larger studies should be conducted to further explore the potential of this approach, given the pressing need to design services that are fit for purpose for older people. Continuity of dental service provision is considered as important by most older people, as they anticipate losing their dependence.

Locked down by inequality: Older people and the COVID-19 pandemic.

This paper develops the argument that post-COVID-19 recovery strategies need to focus on building back fairer cities and communities, and that this requires a strong embedding of 'age-friendly' principles to support marginalised groups of older people, especially those living in deprived urban neighbourhoods, trapped in poor quality housing. It shows that older people living in such areas are likely to experience a 'double lockdown' as a result of restrictions imposed by social distancing combined with the intensification of social and spatial inequalities. This argument is presented as follows: first, the paper examines the disproportionate impact of COVID-19 on older people, highlighting how the pandemic is both creating new and reinforcing existing inequalities in ageing along the lines of gender, class, ethnicity, race, ability and sexuality. Second, the paper explores the role of spatial inequalities in the context of COVID-19, highlighting how the pandemic is having a disproportionate impact on deprived urban areas already affected by cuts to public services, the loss of social infrastructure and pressures on the voluntary sector. Finally, the paper examines how interrelated social inequalities at both the individual and spatial level are affecting the lives of older people living in deprived urban neighbourhoods during the pandemic. The paper concludes by developing six principles for 'age-friendly' community recovery planning aimed at maintaining and improving the quality of life and wellbeing of older residents in the post-pandemic city.

Older Adults Using Technology for Meaningful Activities During COVID-19: An Analysis Through the Lens of Self-Determination Theory

Restrictions during the COVID-19 pandemic significantly affected people's opportunities to engage in activities that are meaningful to their lives. In response to these constraints, many people, including older adults, turned to digital technologies as alternative ways to pursue meaningful activities. These technology-mediated activities, however, presented new challenges for older adults' everyday use of technology. In this paper, we investigate how older adults used digital technologies for meaningful activities during COVID-19 restrictions. We conducted in-depth interviews with 40 older adults and analyzed the interview data through the lens of self-determination theory (SDT). Our analysis shows that using digital technologies for meaningful activities can both support and undermine older people's three basic psychological needs for autonomy, competence, and relatedness. We argue that future technologies should be designed to empower older adults' content creation, engagement in personal interests, exploration of technology, effortful communication, and participation in beneficent activities. © 2023 ACM.

THE PREVALENCE AND INCIDENCE OF PSORIASIS AND PSORIATIC ARTHRITIS IN ENGLAND FROM 2009-2019: AN OBSERVATIONAL STUDY USING PRIMARY CARE DATA

BackgroundPsoriasis (PsO) and psoriatic arthritis (PsA) can greatly impact quality of life and result in substantial personal and societal costs. Complete and up to date data on the prevalence and incidence of these conditions and whether these change over time and vary by age is important for healthcare service planning so that specialist care and funding can be appropriately allocated.ObjectivesTo determine the prevalence and incidence of PsO and PsA in males and females from 2009-2019 across all age groups in England.MethodsWe used Clinical Practice Research Datalink AURUM, a primary care electronic health record database, including 20% of the English population. The codes used to identify patients with PsO and PsA were selected by rheumatologists and dermatologists and cross-checked with published code lists from other studies to ensure inclusion of all relevant codes. All included patients must have data for at least 1 year before their diagnosis. The annual incidence and point prevalence were calculated from 2009-2019 and stratified by age/sex. The study period ended in 2019 to avoid COVID-19 pandemic affecting results.ResultsThe prevalence of PsO and PsA in males and females increased annually, peaking in 2019 (PsO males 2.41% [95% confidence interval (CI) 2.40, 2.42];PsO females 2.60% [95% CI 2.59-2.61];PsA males 0.20% [95% CI 0.20-0.20];PsA females 0.21% [95% CI 0.21- 0.22]), as illustrated in Table 1. In 2019, the prevalence of PsO and PsA was highest in the over 65 years age group;PsO 4.25% [95% CI 4.22-4.28] and PsA 0.38% [95% CI 0.37-0.38]. The annual incidence (per 100,000 person years) of PsO has gradually decreased in males (from 168 (164-171) in 2009 to 148 (145-151) in 2019) but in females it has been stable with a slight annual decrease (from 180 (177-184) in 2009 to 173 (170-176) in 2019). The annual incidence for PsA has increased in both males and females (13 (12-14) in 2009 and 15 (14-16) in 2019 for males and 12 (11-13) in 2009 and 18 (17-19) in 2019 for females).ConclusionThe increasing prevalence of PsO and PsA highlights the importance of organising healthcare services to meet this need, particularly in the elderly population.ReferencesNIL.Table 1.Prevalence of PsO and PsA from 2009-2019 in EnglandYear20092010201120122013201420152016201720182019Population (n)1073383110910802110318501118036711343299112249341137842211657996119336261223432512420998PsO (n)216841229106239819250667259988268032276804286499295712304568311104PsO prevalence (%, 95%CI)-Male1.98 (1.96-1.99)2.06 (2.05- 2.07)2.13 (2.12-2.14)2.19 (2.18-2.20)2.24 (2.23- 2.25)2.33 (2.32- 2.34)2.37 (2.36- 2.38)2.39 (2.38- 2.40)2.40 (2.39- 2.41)2.40 (2.39- 2.42)2.41 (2.40- 2.42)-Female2.07 (2.05- 2.08)2.14 (2.13- 2.16)2.22 (2.21- 2.23)2.29 (2.28- 2.31)2.35 (2.33- 2.36)2.45 (2.43- 2.46)2.50 (2.49- 2.51)2.53 (2.52- 2.54)2.56 (2.54- 2.57)2.58 (2.56- 2.59)2.60 (2.59- 2.61)PsO incidence (100,000 person years)-Male168 (164-171)158 (155- 162)161 (158-165)153 (150-157)161 (157- 164)156 (153- 159)155 (152- 159)154 (151- 157)153 (150-156)150 (147-153)148 (145-151)-Female180 (177-184)176 (172-179)181 (177-184)171 (167-174)175 (171-178)176 (172-180)179 (176-183)178 (174-181)177 (174-181)174 (170-177)173 (170-176)PsA (n)1444515443164681752218545196182072021994232572451425683PsA prevalence (%, 95%CI)-Male0.14 (0.14- 0.14)0.15 (0.14- 0.15)0.15 (0.15- 0.16)0.16 (0.16- 0.16)0.17 (0.16- 0.17)0.18 (0.17- 0.18)0.18 (0.18- 0.19)0.19 (0.18- 0.19)0.19 (0.19- 0.20)0.20 (0.19- 0.20)0.20 (0.20- 0.20)-Female0.13 (0.13- 0.13)0.14 (0.13- 0.14)0.15 (0.14- 0.15)0.15 (0.15- 0.16)0.16 (0.16- 0.16)0.17 (0.17- 0.18)0.18 (0.18- 0.18)0.19 (0.19- 0.19)0.20 (0.19- 0.20)0.20 (0.20- 0.21)0.21 (0.21- 0.22)PsA incidence (100,000 person years)-Male13 (12- 14)12 (11- 13)13 (12- 14)12 (11- 13)13 (12-14)14 (13- 15)14 (13- 15)14 (13-15)1514-16)14(13- 15)15 (14-16)-Female12 (11- 13)13 (12- 14)13 (12- 14)14 (13-15)14 (13-15)15 (14-16)17 (16- 18)16 (15- 17)17 (16- 18)18 (17-19)18 (17-19)Acknowledgements:NIL.Disclosure of InterestsArani Vivekanantham: None declared, Edward Burn: None dec ared, Marta Pineda-Moncusí: None declared, Sara Khalid Grant/research support from: SK has received research grant funding from the UKRI and Alan Turing Institute outside this work. SK's research group has received grant support from Amgen and UCB Biopharma., Daniel Prieto-Alhambra Grant/research support from: DPA's department has received grant/s from Amgen, Chiesi-Taylor, Lilly, Janssen, Novartis, and UCB Biopharma. His research group has received consultancy fees from Astra Zeneca and UCB Biopharma. Amgen, Astellas, Janssen, Synapse Management Partners and UCB Biopharma have funded or supported training programmes organised by DPA's department., Laura Coates Speakers bureau: LC has been paid as a speaker for AbbVie, Amgen, Biogen, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, Medac, Novartis, Pfizer and UCB., Consultant of: LC has worked as a paid consultant for AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Gilead, Galapagos, Janssen, Novartis, Pfizer and UCB., Grant/research support from: LC has received grants/research support from AbbVie, Amgen, Celgene, Eli Lilly, Novartis and Pfizer.

Stakeholder Analysis: Medicare Diabetes Prevention Program Awareness and Implementation

Study Design: We conducted a qualitative stakeholder analysis project with suppliers of the MDPP and health care providers. Am J Manag Care. 2023;29(6):In Press _____ Takeaway Points More than 5 years after CMS enacted coverage of the CDC-approved Medicare Diabetes Prevention Program (MDPP) in 2018, little is known about why MDPP uptake is so limited. * Findings of our stakeholder analysis with program suppliers and health care providers reinforced existing evidence on insufficient reimbursement and low awareness of the program. * Newer insights include recommendations about lagged payments, ongoing virtual delivery, and formally diagnosing prediabetes among MDPP participants. * Our findings on barriers and facilitators can inform policy to refine the MDPP and research on the MDPP, particularly within the field of implementation science. _____ Population-level strategies to prevent type 2 diabetes are urgently needed for the more than 24 million older adults with prediabetes in the United States.1 Evidence-based lifestyle interventions can prevent diabetes onset, per evidence from the landmark Diabetes Prevention Program trial.2 Thus, the CDC launched the National Diabetes Prevention Program (NDPP) in 2010.3 Significant reductions in weight and medical spending were observed among Medicare beneficiaries who participated in the NDPP,4 prompting CMS to fully cover the Medicare Diabetes Prevention Program (MDPP) starting in 2018.5 Despite unprecedented Medicare coverage for a disease prevention program, MDPP uptake is limited. Regarding awareness, national guidelines recommend referral to lifestyle intervention for adults aged 40 to 70 years with prediabetes.9 Yet less than 5% of adults eligible for a NDPP reported receiving a referral,10 which may stem from limited awareness among health care providers.11 Thus, we conducted a qualitative stakeholder analysis to learn about regional awareness of, referral to, facilitators of, and barriers to the MDPP. The 8 interviewees included 5 program directors (3 from YMCAs, 1 from a private organization, and 1 from a hospital system) and 3 health care providers (2 family physicians and 1 dietitian).

Social insecurity and varieties of family resilience strategies during the COVID-19 pandemic

PurposeThis study is aimed at developing an understanding of the consequences of the pandemic on families' socioeconomic resilience, and the strategies adopted by the families in overcoming social vulnerabilities amid uncertainty.Design/methodology/approachThe materials for this study consist of semi-structured interviews with 21 families spread across the South Sumatra Province, Indonesia. Families in the study represent four different income levels, namely very high, high, middle and low, and who also work in the informal sector. Each family has at least 1 or more members who fall into the vulnerable category (children, the elderly, people with disabilities unemployed or having potential economic vulnerability).FindingsTwo main findings are outlined. Regardless of their socioeconomic status, many of the families analyzed adopted similar strategies to remain resilient. Among the strategies are classifying the urgency of purchasing consumer goods based on financial capacity rather than needs, leveraging digital economic opportunities as alternative sources of income, utilizing more extensive informal networks and going into debt. Another interesting finding shows that the pandemic, to some extent, has saved poor families from social insecurity. This is supported by evidence showing that social distancing measures during the pandemic have reduced the intensity of sociocultural activities, which require invited community members to contribute financially. The reduction of sociocultural activities in the community has provided more potential savings for the poor.Research limitations/implicationsIn this study, informants who provided information about their family conditions represent a major segment of the workforce and tend to be technologically savvy and younger, due to the use of Zoom as a platform for conducting interviews. Therefore, there may be a bias in the results. Another limitation is that since the interviewees were recommended by our social network in the fields, there is a risk of a distorted selection of participants.Originality/valueThis study offers insights that are critical in helping to analyze family patterns in developing countries in mitigating the risks and uncertainties caused by COVID-19. In addition, the literature on social policy and development could benefit from further research on COVID-19 as an alternative driver to identify mechanisms that could bring about change that would result in "security.” Critical questions and limitations of this study are presented at the end of the paper to be responded to as future research agenda.

Patient Recruitment Goes High-Tech

Clinical trial patient recruitment is arguably the most difficult aspect of pharmaceutical development, because it involves a variety of factors beyond study sponsors' control. The aggregation of data across 80 hospitals and 20 systems, for the purpose of understanding patients, doing feasibility studies, or engaging in decentralized recruitment, is the trend we're seeing." Nimita Limaye, PhD, is the vice president of research for the life sciences R&D strategy and technology division at the International Data Corporation (IDC), a market research and advisory firm specializing in the technology industry and headquartered in Boston, Mass. Limaye says the rise of social media-based patient recruitment has opened the door for sponsors and investigators to mine real-world data and to give patients a more central focus in research.

Spending behavior and stimulus transfer use in response to income shocks among older Americans: evidence from the COVID-19 pandemic

This study examines household behavioural responses to the pandemic-induced income shocks regarding their overall spending and spending out of 2020 CARES stimulus payments. Using data from the 2020 Health and Retirement Study COVID-19 project and restricting our sample to older adults (51 years old and above), we show that the negative income shocks experienced during the COVID-19 pandemic put downward pressure on household spending. Results also reveal that, relative to those who did not experience an income shock, stimulus recipients who experienced income losses were more likely to use the stimulus transfer to increase spending, pay off debt, or for other purposes rather than to save.

Social media interactions in Mexico about the SARS-CoV-2 vaccination plan

This chapter focuses on the concern about the implementation strategy of the Federal Government's Vaccination Plan. Both the public and private health professionals, as well as those persons who must leave their homes to earn their livelihood, have been the most affected by the Covid-19 pandemic. Therefore, the objective of this research was to study the interactions carried out on two social media, in order to analyze what people think about the way the Federal Government's Vaccination Plan has been implemented. A mixed methodology (quantitative) was used to carry out this analysis, in order to gather the data and carry out a numerical visualization with the aim of obtaining a general appraisal about the study object. Additionally, digital ethnography was used to observe the type of interaction carried out in the fora. The data was gathered during three episodes. The first episode included informants, who were asked to get the opinion of their groups about a discussion-generating question, which raised doubts about the vaccination strategy. The second episode consisted of following a person's post expressing his opinion about the senior citizens' first vaccination day. The aim of the third episode of this analysis was to study the first 150 comments that Internet users made on the walls of two prestigious Mexican research-professors: Lorenzo Meyer and Sergio Aguayo. © Springer Nature Switzerland AG 2023. All rights reserved.

Confinement with No Rights. Perceptions of Inmates' Relatives Regarding Measures for COVID-19 Control Implemented in Mexican Prisons

Based on a participatory study design, this article describes how a group of family members of people deprived of liberty (PDL) experienced the COVID-19 control measures implemented in Mexico's prisons. We conducted 28 in-depth interviews and analyzed them using ATLAS.ti. We found that the measures implemented in Mexican prisons to avoid the spread of COVID-19 focused mainly on suspension of visitation and PDL confinement. The isolation imposed on PDL impacted their living conditions, making them more vulnerable to contracting COVID-19 due to lack of access to essential services, food, and hygiene supplies. Visit restrictions and PDL isolation also impacted PDL relatives' health and socioeconomic conditions. Our findings indicate that the consequences of COVID-19 control actions in Mexican prisons differ according to the gender and jurisdiction of PDL. Women in federal prisons were more isolated, while those in local ones were more deprived of basic supplies. Imprisoned women's isolation has especially severe effects on the mental and physical health of their elderly parents and children. The results show how the measures adopted to control COVID-19 outbreaks in Mexican prisons have exacerbated the preexisting systemic violence experienced by PDL and their families and how they have failed to prevent the spread of COVID-19 in these settings. These findings provide support for the health-informed penal reform of Mexican prisons.

EUROPE'S ETERNAL STRUGGLE WITH SAFETY AND INNOVATION

Amid the heated COVID-driven controversies over vaccination that are ruffling Europe, a specialized European advisory group on ethics has just issued a cautious opinion on the use of gene editing-including a call for a global guarantee that heritable human genome editing is not prematurely clinically applied. The European Group on Ethics in Science and New Technologies (EGE) is tasked with advising the European Commission with "high quality, independent advice on all aspects of EU legislation and policies, where ethical, societal and fundamental rights issues intersect with the development of science and new technologies." With a view to promoting broad alignment, the group has asked the European Commission to engage in global discussions on regulation of this emerging field with the World Health Organization and the World Medical Association, covering universal adoption of standards on the ethical use of genome editing in human beings. [...]within Europe it wants to see the creation of a specifically European platform to exchange information and promote "a broad and open public debate" on the ethical and social implications of germline genome editing in human beings.

The COVID-19 Pandemic's Impact on UK Older People's Social Workers: A Mixed-Methods Study

In this article, we examined the impacts of the COVID-19 pandemic on the well-being, working conditions of social workers employed in UK older people's services and their intentions to leave the social work profession. Data came from a wider study of health and social care practitioners who completed online surveys at five different time points during the COVID-19 pandemic. The surveys contained both quantitative and qualitative questions. We analysed the responses of 426 social workers who worked in older people's services between May 2020 and July 2022 and found that: The well-being of older people's social workers declined as the pandemic progressed and remained low in comparison to UK population norms. Lower well-being scores were associated with greater intentions to leave the social work profession. In comparison to older people's social workers who were aged sixty plus years, those aged between twenty and forty years were more than seven times more likely to state their intentions to leave social work. Lastly, respondents voiced concerns over staffing levels and staff absences;feelings of being unsupported and isolated;increased pressures;and a blurring of home-work boundaries. The social work profession was heavily impacted by the COVID-19 pandemic. In this study, we examined the well-being, working conditions and intentions to leave the social work profession among a sample of UK older people's social workers. This was a cross-sectional mixed methods study analysing data from 426 social workers who worked in older people's services in the UK at five time points of the pandemic spanning 2020-2022. Data were collected using anonymous online surveys which included both quantitative and qualitative questions. The mental well-being of participants decreased as the pandemic progressed and this decline was associated with intentions to leave the profession. Thematic analysis of qualitative data revealed two major themes: Practice challenges and Staff well-being. The findings highlight the nature of stressors related to internal related practice demands, and external health and social care service stressors encountered during the COVID-19 pandemic and have implications for policy, practice and research in older people's social work.

"Trying to Find People to Fit the Tech…”: A Qualitative Exploration of the Lessons Learnt Introducing Artificial Intelligence-Based Technology into English Social Care

Digital technology is expected to improve care and address significant service pressures within the National Health Service and social care though evidence on how their implementation might be optimised is lacking. This study explores how one such example, home-based sensors with artificial intelligence capabilities, was implemented in English social care to identify changes in behaviour that indicate the onset of potentially more serious issues. Its focus was staff perspectives on decision-making processes and implementation, to inform recommendations for others exploring the potential of new and emerging technology. Qualitative data were collected from 18 semistructured interviews conducted across three sites delivering social care, with senior decision makers, operational leads, and care staff. We identified several issues with the selection process and implementation of AI-based technology in social care, including a lack of consensus around what success would look like, problems identifying and evaluating alternatives, and technical challenges to implementation, as well as obstacles to developing a longer-term, more preventative approach in a system experienced as focused on responding to acute needs. Ultimately, the research confirmed a number of recognised implementation challenges associated with training, resource, and acceptability to staff and patients. It added particular insights around the anxieties experienced by frontline staff and the cultural shift required of preventative interventions in a system geared to meeting acute crises. That many barriers are familiar suggests a particular need to focus on helping policymakers/local leaders avoid similar pitfalls in the future.