A microcosting approach for planning and implementing community-based mental health prevention program: what does it cost?

BACKGROUND: Estimating program costs when planning community-based mental health programs can be burdensome. Our aim was to retrospectively document the cost for the first year of planning and implementing Healthy Minds Healthy Communities (HMHC), a mental health promotion and prevention multi-level intervention initiative. This Program is among the first to use the Community Initiated Care (CIC) model in the US and is aimed at building community resilience and the capacity for communities to provide mental health support, particularly among those disproportionately impacted by COVID-19. Our objective is to share our methods for costing a program targeting 10 zip codes that are ethnically and linguistically diverse and provide an example for estimating the cost of a mental health prevention and promotion programs consisting of multiple evidence-based interventions. METHODS: We used a semi-structured interview process to collect cost data through the first year of program planning, start-up and initial implementation from key staff. We calculated costs for each activity, grouped them by major project categories, and identified the cost drivers of each category. We further validated cost estimates through extensive literature review. The cost analysis was done from the provider's perspective, which included the implementing agency and its community partners. We delineated costs that were in-kind contributions to the program by other agency, and community partners. Sensitivity analyses were conducted to estimate uncertainty around parameters. RESULTS: For the first year of the development and implementation of the program, (funded through program and in-kind) is estimated at $1,382,669 (2022 US$). The costs for the three main activity domains for this project are: project management $135,822, community engagement $364,216 and design and execution $756,934. Overall, the cost drivers for the first year of this intervention were: hiring and onboarding staff, in-person community building/learning sessions, communications and marketing, and intervention delivery. CONCLUSION: Implementation of community-based mental health promotion and prevention programs, when utilizing a participatory approach, requires a significant amount of upfront investment in program planning and development. A large proportion of this investment tends to be human capital input. Developing partnerships is a successful strategy for defraying costs.

Clinical outcomes of a large-scale, partnership-based regional food prescription program: results of a quasi-experimental study.

BACKGROUND: Food prescription programs are gaining interest from funders, policy makers, and healthcare payers as a way to provide value-based care. A small body of research suggests that such programs effectively impact health outcomes; however, the quality of existing studies is variable, and most studies use small samples. This study attempts to address these gaps by utilizing a quasi-experimental design with non-equivalent controls, to evaluate clinical outcomes among participants enrolled in a food prescription program implemented at scale. METHODS: We completed a secondary analysis of participant enrollment and utilization data collected between May 2018 and March 2021, by the Houston Food Bank as part of its multi-institution food prescription program. Enrollment data was obtained from 16 health care partners and redemption data from across 40 food pantries in Houston, Texas. Our objective was to assess if program participation impacted multiple cardio-metabolic markers. Exposure was defined as any visit to a food pantry after receipt of prescription. Linear and logistic regression models were used to estimate change in outcomes by exposure status and number of food pantry visits. RESULTS: Exposed patients experienced a -0.28% (p = 0.007) greater change in HbA1c than unexposed patients, over six months. Differences across exposure categories were seen with systolic blood pressure (-3.2, p < 0.001) and diastolic blood pressure (-2.5, p = 0.028), over four months. The odds of any decline in HbA1c (OR = 1.06 per visit, p < 0.001) and clinically meaningful decline in HbA1c (OR = 1.04 per visit, p = 0.007) showed a linear association with visit frequency. CONCLUSIONS: Our study of a large food prescription program involving multiple health care and food pantry sites provides robust evidence of a modest decline in HbA1c levels among participants. These results confirm that food prescription programs can continue to be effective at scale, and portend well for institutionalization of such programs.

Effects of Large-Scale Municipal Safe Routes to School Infrastructure on Student Active Travel and Physical Activity: Design, Methods, and Baseline Data of the Safe Travel Environment Evaluation in Texas Schools (STREETS) Natural Experiment.

Past evaluations of Safe Routes to School (SRTS) programs have been relatively small in scope and have lacked objective measurements of physical activity. A 2016 Mobility Bond in Austin, Texas, USA, allocated USD 27.5 million for infrastructure changes to facilitate active commuting to schools (ACS). The Safe TRavel Environment Evaluation in Texas Schools (STREETS) study aims to determine the health effects of these infrastructure changes. The purpose of this paper is to describe the STREETS study design, methods, and selected baseline results. The STREETS study is comprised of two designs: (1) a serial cross-sectional design to assess changes in ACS prevalence, and (2) a quasi-experimental, prospective cohort to examine changes in physical activity. Differences between study arms (Austin SRTS and comparison) were assessed for school demographics, ACS, and school programs. At baseline, 14.3% of school trips were made by ACS, with non-significant differences between study arms. Only 26% of schools implemented ACS-related programs. Some significant differences across SRTS and comparison schools were identified for several school- and neighborhood-level characteristics. Substantial changes are needed across area schools and neighborhoods to promote optimum ACS. STREETS study longitudinal findings will be critical for informing optimal future implementations of SRTS programs.

Local Marketing of a National Texting-Based Smoking Cessation Program: Is It Cost Effective?

Tailored texting interventions for smoking cessation are increasingly popular given the ubiquitousness of smart phones. Because high development costs and limited expertise may pose substantial barriers to designing and implementing these programs at the local level, utilization of existing programs at the national level is a promising strategy. In 2011, Austin Public Health focused on promoting smoking cessation among Austin/Travis County residents. Their strategy involved marketing and linking their citizens to a federally-funded, evidence-based smoking cessation program via texting. The target audience was low income, 18-24 year olds. Their marketing strategies included radio ads, digital ads, social media ads, and direct outreach at events in Austin, Texas. During the period between April 2016 and July 2017, 1,022 people signed up for the program. The quit rate was comparable to other texting programs which were tailored at the local level, and the program was cost-effective, costing $12,704.56 per life-year added, averting $99.38 per person in medical costs, discounted at 3%.

Lay health supporters aided by a mobile phone messaging system to improve care of villagers with schizophrenia in Liuyang, China: protocol for a randomised control trial.

INTRODUCTION: Schizophrenia is a severe, chronic and disabling mental illness. Non-adherence to medication and relapse may lead to poorer patient function. This randomised controlled study, under the acronym LEAN (Lay health supporter, e-platform, award, and iNtegration), is designed to improve medication adherence and high relapse among people with schizophrenia in resource poor settings. METHODS/ANALYSIS: The community-based LEAN has four parts: (1) Lay health supporters (LHSs), mostly family members who will help supervise patient medication, monitor relapse and side effects, and facilitate access to care, (2) an E-platform to support two-way mobile text and voice messaging to remind patients to take medication; and alert LHSs when patients are non-adherent, (3) an Award system to motivate patients and strengthen LHS support, and (4) iNtegration of the efforts of patients and LHSs with those of village doctors, township mental health administrators and psychiatrists via the e-platform. A random sample of 258 villagers with schizophrenia will be drawn from the schizophrenic '686' Program registry for the 9 Xiang dialect towns of the Liuyang municipality in China. The sample will be further randomised into a control group and a treatment group of equal sizes, and each group will be followed for 6 months after launch of the intervention. The primary outcome will be medication adherence as measured by pill counts and supplemented by pharmacy records. Other outcomes include symptoms and level of function. Outcomes will be assessed primarily when patients present for medication refill visits scheduled every 2 months over the 6-month follow-up period. Data from the study will be analysed using analysis of covariance for the programme effect and an intent-to-treat approach. ETHICS AND DISSEMINATION: University of Washington: 49464 G; Central South University: CTXY-150002-6. Results will be published in peer-reviewed journals with deidentified data made available on FigShare. TRIAL REGISTRATION NUMBER: ChiCTR-ICR-15006053; Pre-results.

Mexican Immigrant Health: Health Insurance Coverage Implications.

A key facet of the Patient Protection and Affordable Care Act (PPACA) is the expansion of health insurance coverage. However, even with the PPACA, an estimated 11.2 million undocumented immigrants will remain uncovered. The majority of the remaining uncovered immigrant population is of Mexican origin. We assess the long-term benefits and short-term costs of providing coverage to male migrants from Mexico, employing data from the 2007-2011 Mexican Migration Project (MMP) and the 2009 Medical Expenditures Panel (MEPS) survey. Our results show that health status prior to migration, age at time of interview, emigrating from Central Mexico, and use of health services in the U.S. all predict declines in health at a significant level. We also find that having spent more than 10 cumulative years in the U.S. has borderline significance in predicting health decline (p=.052). Estimated coverage costs for health insurance for largely undocumented immigrants increase over time, but remain lower than those of comparable U.S.-born individuals. We conclude with several policy implications.

Village doctor-assisted case management of rural patients with schizophrenia: protocol for a cluster randomized control trial.

BACKGROUND: Strict compliance with prescribed medication is the key to reducing relapses in schizophrenia. As villagers in China lack regular access to psychiatrists to supervise compliance, we propose to train village 'doctors' (i.e., villagers with basic medical training and currently operating in villages across China delivering basic clinical and preventive care) to manage rural patients with schizophrenia with respect to compliance and monitoring symptoms. We hypothesize that with the necessary training and proper oversight, village doctors can significantly improve drug compliance of villagers with schizophrenia. METHODS/DESIGN: We will conduct a cluster randomized controlled trial in 40 villages in Liuyang, Hunan Province, China, home to approximately 400 patients with schizophrenia. Half of the villages will be randomized into the treatment group (village doctor, or VD model) wherein village doctors who have received training in a schizophrenia case management protocol will manage case records, supervise drug taking, educate patients and families on schizophrenia and its treatment, and monitor patients for signs of relapse in order to arrange prompt referral. The other 20 villages will be assigned to the control group (case as usual, or CAU model) wherein patients will be visited by psychiatrists every two months and receive free antipsychotic medications under an on-going government program, Project 686. These control patients will receive no other management or follow up from health workers. A baseline survey will be conducted before the intervention to gather data on patient's socio-economic status, drug compliance history, and clinical and health outcome measures. Data will be re-collected 6 and 12 months into the intervention. A difference-in-difference regression model will be used to detect the program effect on drug compliance and other outcome measures. A cost-effectiveness analysis will also be conducted to compare the value of the VD model to that of the CAU group. DISCUSSION/IMPLICATIONS: Lack of specialists is a common problem in resource-scarce areas in China and other developing countries. The results of this experiment will provide high level evidence on the role of health workers with relatively limited medical training in managing severe psychiatric disease and other chronic conditions in developing countries. TRIAL REGISTRATION: ChiCTR-TRC-13003263.

The price of access: capitalization of neighborhood contextual factors.

BACKGROUND: Studies of neighborhood context on health behavior have not considered that the health benefits of context may be 'capitalized' into, or included in, higher housing values. This study examines the associations of better neighborhood context with neighborhood housing values. METHODS: We use the third wave of Add Health (2000-2001) to estimate the association of neighborhood contextual variables and housing values first across then within income types. This is a census block group-level analysis. RESULTS: We find that neighborhood context, especially access to fruit and vegetable outlets, is capitalized into, or associated with, higher housing values. Fast food and convenience store access are associated with lower housing values. Capitalization differs by income quartile of the neighborhood. Even those in the poorest neighborhoods value access to fresh fruits and vegetables, and those in the wealthier neighborhoods value activity resources. All neighborhood incomes types place negative value on fast food access and convenience store access. CONCLUSIONS: Access to health-related contextual attributes is capitalized into higher housing prices. Access to fresh fruits and vegetables is valued in neighborhoods of all income levels. Modeling these associations by neighborhood income levels helps explain the mixed results in the literature on the built environment in terms of linking health outcomes to access.

Cigarette quitlines, taxes, and other tobacco control policies: a state-level analysis.

This paper estimates monthly quitline calls using panel data at the state level from January 2005 to June 2010. Calls to state quitline numbers (or 1-800-QUITNOW) were measured per million adult smokers in each state. The policies considered include excise taxes, workplace and public smoking bans, and a Peter Jennings television-based program warning of the health risks of smoking. We found that people anticipating increases in prices begin attempting to quit by calling quitlines. Finally, the Peter Jennings media campaign was highly correlated with quitline calls.

Do Mexican immigrants substitute health care in Mexico for health insurance in the United States? The role of distance.

Although language and culture are important contributors to uninsurance among immigrants, one important contributor may have been overlooked - the ability of immigrants to return to their home country for health care. This paper examines the extent to which uninsurance (private insurance and Medicaid) is related to the ability of immigrants to return to Mexico for health care, as measured by spatial proximity. The data for this study are from the Mexican Migration Project. After controlling for household income, acculturation and demographic characteristics, arc distance to the place of origin plays a role in explaining uninsurance rates. Distance within Mexico is quite important, indicating that immigrants from the South of Mexico are more likely to seek care in their communities of origin (hometowns).

The cost-effectiveness of a school-based overweight program.

BACKGROUND: This study assesses the net benefit and the cost-effectiveness of the Coordinated Approach to Child Health (CATCH) intervention program, using parameter estimates from the El Paso trial. There were two standard economic measures used. First, from a societal perspective on costs, cost-effectiveness ratios (CER) were estimated, revealing the intervention costs per quality-adjusted life years (QALYs) saved. QALY weights were estimated using National Health Interview Survey (NHIS) data. Second, the net benefit (NB) of CATCH was estimated, which compared the present value of averted future costs with the cost of the CATCH intervention. Using National Health and Nutrition Examination Survey I (NHANES) and NHANES follow-up data, we predicted the number of adult obesity cases avoided for ages 40-64 with a lifetime obesity progression model. RESULTS: The results show that CATCH is cost-effective and net beneficial. The CER was US$900 (US$903 using Hispanic parameters) and the NB was US$68,125 (US$43,239 using Hispanic parameters), all in 2004 dollars. This is much lower than the benchmark for CER of US$30,000 and higher than the NB of US$0. Both were robust to sensitivity analyses. CONCLUSION: Childhood school-based programs such as CATCH are beneficial investments. Both NB and CER declined when Hispanic parameters were included, primarily due to the lower wages earned by Hispanics. However, both NB and CER for Hispanics were well within standard cost-effectiveness and net benefit thresholds.

Differences in food consumption and meal patterns in Texas school children by grade.

INTRODUCTION: Having information about dietary patterns at different ages and stages in children's physical development is important in developing nutritional interventions. The purpose of this study was to examine differences in food choices between 4th-, 8th-, and 11th-grade students. The results provide information that can be used to tailor behavioral-based nutritional programs for children. METHODS: We determined food consumption patterns using validated data from the School Physical Activity and Nutrition survey; the survey is used as part of a surveillance program of public school students conducted by the University of Texas Health Science Center at Houston in partnership with the Texas Department of State Health Services. The sample included a total of 15,173 children in grades 4 (6235), 8 (5362), and 11 (3576). Multistage probability sampling weights were used. Odds ratios were computed controlling for sex, body mass index, and race and ethnicity, and cross-sectional patterns were determined using multivariate logistic regression. RESULTS: Children in grades 8 and 11 were more likely to consume hamburger and other meats, cheese, breads, buns, and rolls, and sweet rolls compared with 4th-grade students. In contrast, 4th-grade students were more likely to consume peanuts or peanut butter, yogurt, cereal, fruit, and milk compared with 8th- and 11th-grade students. Eighth- and eleventh-grade students were more likely to consume snacks than 4th-grade students. CONCLUSION: Using cross-sectional data to assess differences in dietary intake and meal patterns by grade can provide readily accessible information to develop a needs assessment or intervention materials for children and adolescents. Different intervention development approaches are necessary among children in different grades.