Conflict and fragmented public health emergency management system in Tigray region of Northern Ethiopia: A double burden to accommodate resilient and advanced public health emergency management. A commentary review for policy-makers and a call to action.

An estimated 2.5 million people have been internally and externally displaced in the Tigray region of northern Ethiopia in conflict and post-conflict settings. This induced a loss of access to basic and essential healthcare services. The situation was overwhelming, causing service inaccessibility, inadequate health facilities, unstable security to access the services, shortage of supplies and drugs, and medical equipment's in the region. The regional public health emergency management is one service delivery set up for the critically ill. It is characterized by weak emergency management capacities, poor coordination and integration. In addition, the system falls in to two independent sectors in the Tigray Health Bureau (THB), Tigray Health Research Institute (THRI). This leads to a fragmented system, an unclear leadership and governance role and a poor service delivery setup and tracking mechanism. The situation leads to resource duplication and poor business practice. Indeed, this type of service delivery setup secures personal and professional interest more than community interest. The situation exacerbated the occurrence of recurrent outbreaks in the region, with, for instance, zoonotic diseases (anthrax and rabies), acute watery diarrhoea, measles, malaria, yellow fever, and coronavirus disease 2019 (COVID-19) approaching to their level of epidemic. Moreover, they will spike as an epidemic in the future. All these circumstances made it evident that the system need reform to adhere with legal global, national, and regional frameworks, guidelines and proclamations. The system should have one service delivery set up at regional level. It must fall into regional public health institutes (PHIs) to adhere its service packages to the current advancements. Furthermore, integrated effort need from program implementers, relevant stakeholders and policy-makers should be committed and work together in the review and reform process.

The Dutch Citizen's Understanding and Perception of the Actors Involved in the Netherlands' COVID-19 Pandemic Response: A Focus Group Study During the First Pandemic Wave.

INTRODUCTION: The COVID-19 pandemic was a public health emergency (PHE) of unprecedented magnitude and impact. It provided the possibility to investigate the Dutch citizens' understanding and perception of the actors involved in the Dutch pandemic response as a PHE unfolded. METHODS: Three focus groups (FGs) were held with 16 Dutch citizens in June 2020. Citizens were recruited using the Dutch Health Care Consumer Panel. During the FGs, participants were asked to fill in a table with actors they thought were involved in the management of the COVID-19 pandemic. They also received information on actors involved in Dutch outbreak responses. Then, the actors named and omitted by the participants were discussed. RESULTS: An analysis of the FGs suggests that the Dutch citizens participating in the study were not fully aware of the scope of actors involved in the Dutch COVID-19 pandemic response. Some participants would have appreciated more information on the actors involved. This would help them have an informed opinion of the actors involved in the decision-making process, and accept non-pharmaceutical interventions implemented. Lastly, most participants recognised that they played a role in limiting the spread of the COVID-19 pandemic. Yet, very few spontaneously mentioned themselves as actors within the COVID-19 pandemic response. CONCLUSION: This study suggests that early in the COVID-19 pandemic, the Dutch citizens participating in this study's FG did not have a complete understanding of the scope of actors involved in the Dutch COVID-19 pandemic response, or the potential role of the citizen. Future research can build on these results to explore the citizen's perception of their role during PHEs of another origin, as well as other geographical and historical contexts. PATIENT OR PUBLIC CONTRIBUTION: The public participated in the focus groups and received a non-expert report summarising the outcomes of the focus groups.

The Mpox outbreak is a public health emergency of international concern: Implications for mental health and global preparedness.

BACKGROUND: The Mpox, a zoonotic viral disease that has historically affected Central and West Africa, has been declared a Public Health Emergency of International Concern by the World Health Organization. Rapid transmission and recent dissemination in Africa may imply significant challenges to global health, including mental health. METHODS: We reviewed the mental health implications of the Mpox outbreak according to the published literature. We also discussed the psychological effects of the global spreading of this infection and public health preparedness strategies. Key areas of intervention may include the epidemiological surveillance, vaccine development, and mental health strategies. COMMENTS: The Mpox outbreak calls for a robust global preparedness to address potential health emergencies. Strengthening epidemiological surveillance, ensuring equitable vaccine distribution, and building resilient public health infrastructure are crucial. Additionally, addressing mental health consequences may require immediate, intermediate, and long-term strategies, including telepsychiatry, stress management training, and the integration of mental health into primary care.

Development and psychometric testing of the nurses' core competencies for public health emergencies scale: A multicenter cross-sectional study.

BACKGROUND: The significance of addressing public health emergencies (PHEs) emphasizes the pivotal role of a skilled nursing workforce in effective preparedness and response. However, there's a lack of comprehensive assessments tailored to nurses' core competencies, serving as a standard for ongoing education in preparedness. OBJECTIVE: This study aimed to develop a psychometrically sound scale for identifying and measuring essential core competencies crucial for nurses during public health emergencies. DESIGN: A multicenter cross-sectional study was conducted. SETTINGS: Twelve tertiary hospitals in Shanghai. PARTICIPANTS: Affiliated nurses with prior experience and significant exposure to public health emergencies were recruited. METHODS: The study underwent development and validation in two stages, utilizing qualitative data analysis, a Delphi expert panel, and an empirical quantitative cross-sectional survey. The Nurses' Core Competencies for Public Health Emergencies (NCC-PHEs) scale and a demographic questionnaire were distributed between January 2023 and March 2023. Exploratory factor analysis, confirmatory factor analysis, Pearson correlations, and Cronbach's alpha analyses were employed to identify theoretical constructs, assess scale reliability, and establish validity. RESULTS: Analysis was conducted on valid data collected from 1481 nurses. Factor analysis identified 47 professional nursing competencies arranged within a four-factor high-order model: prevention competencies (9 items), preparation competencies (7 items), response competencies (comprising basic and advanced levels) (26 items), and recovery competencies (5 items). Structural equation modelling confirmed satisfactory factor loadings and a good model fit, validating construct integrity. The reliability of the total scale was confirmed. CONCLUSION: This study presents a valid scale that empirically measures nurses' core competencies crucial for preparedness and response during public health emergencies. The findings offer instrumental support for guiding the development of future courses and training programs in nursing research and practice.

Decision fatigue experience of front-line nurses in the context of public health emergency: an interpretative phenomenological analysis.

BACKGROUND: Decision fatigue is a new concept in the field of psychology and refers to a state of fatigue alongside impaired cognitive processing and emotional regulation ability. Previous studies have confirmed that nurses are prone to decision fatigue, and nurses who experience decision fatigue may implement nursing measures that are inconsistent with clinical evidence, thus affecting patients' benefits. COVID-19, as a large-scale global public health emergency, increased the workload and burden of nurses and aggravated decision fatigue. However, the factors leading to decision fatigue among nurses have not yet been identified. METHODS: This study is guided by interpretative phenomenology. During the epidemic period of COVID-19: From November 2022 to February 2023, a one-to-one, semi-structured in-depth interview was conducted among nurses with decision fatigue experience who were participating in front-line work in Jilin Province using homogenous sampling. The interview recordings and related data were transcribed into text within 24 h, and data analysis was assisted by NVivo 12.0 software. RESULTS: After a total of 14 front-line nurses were analyzed in this study, The thematic level reaches saturation, the findings present a persuasive and coherent narrative, and the study is terminated, and finally extracted and formed three core themes: "Cognition, influence and attitude of decision fatigue", "Approaching factors of decision fatigue" and "Avoidant factors of decision fatigue". CONCLUSION: This study confirmed that decision fatigue was widespread in the work of front-line nurses, affecting the physical and psychological health of nurses, the quality of nursing work, the degree of benefit of patients and the clinical outcome. However, nursing staff do not know enough about decision fatigue, so the popularization and research of decision fatigue should be strengthened. Improve the attention of medical institutions, nursing managers and nursing staff.Some suggestions are put forward for the intervention of decision fatigue through personnel, task, tool and technology, organization and environment.

Scientific uncertainty and the challenges of applying criminal law: Lessons from China's COVID-19 response.

This study addresses the complexities of applying criminal law during public health emergencies, particularly under the shadow of scientific uncertainty, and explores the challenge of balancing public health protection with individual rights. The primary aim is to dissect the application of criminal law in the context of the COVID-19 pandemic in China, focusing on the impact of scientific uncertainty on legal decision-making and the efficacy of criminal law interventions in public health crises. This study utilized a doctrinal method combined with case studies, integrating theoretical frameworks on risk and uncertainty with an analysis of China's legal responses to COVID-19. It involved assessing legislative and policy documents alongside judicial decisions, focusing on their alignment with evolving scientific understanding and public health strategies. The study reveals significant hurdles, including the limitations of empirical rules in judicial judgments, the emergence of technocratic bureaucracy, and the complexities surrounding risk mitigation and legal attribution under uncertain conditions. It highlights the inadequacy of traditional criminal law mechanisms to respond dynamically to the evolving landscape of public health emergencies. To address these challenges, the study recommends the development of temporary criminal legislation tailored to public health emergencies, the adoption of risk-based criminal law approaches, and the refinement of individualized risk assessment procedures. These measures aim to provide a more flexible and effective legal framework capable of safeguarding public health while ensuring the protection of individual liberties during crises.

Lessons Learned from the Launch and Implementation of the COVID-19 Contact Tracing Program in New York City: a Qualitative Study.

On June 1, 2020, NYC Health + Hospitals, in partnership with the NYC Department of Health and Mental Hygiene, other city agencies, and a large network of community partners, launched the New York City Test & Trace (T2) COVID-19 response program to identify and isolate cases, reduce transmission through contact tracing, and provide support to residents during isolation or quarantine periods. In this paper, we describe lessons learned with respect to planning and implementation of case notification and contact tracing. Our findings are based on extensive document review and analysis of 74 key informant interviews with T2 leadership and frontline staff, cases, and contacts conducted between January and September 2022. Interviews elicited respondent background, history of program development, program leadership and structure, goals of the program, program evolution, staffing, data systems, elements of community engagement, trust with community, program reach, timeliness, equity, general barriers and challenges, general facilitators and best practices, and recommendations/improvement for the program. Facilitators and barriers revealed in the interviews primarily revolved around hiring and managing staff, data and technology, and quality of interactions with the public. Based on these facilitators and barriers, we identify suggestions to support effective planning and response for future case notification and contact tracing programs, including recommendations for planning during latent periods, case management and data systems, and processes for outreach to cases and contacts.

Ethical Considerations in Infodemic Management: Systematic Scoping Review.

BACKGROUND: During health emergencies, effective infodemic management has become a paramount challenge. A new era marked by a rapidly changing information ecosystem, combined with the widespread dissemination of misinformation and disinformation, has magnified the complexity of the issue. For infodemic management measures to be effective, acceptable, and trustworthy, a robust framework of ethical considerations is needed. OBJECTIVE: This systematic scoping review aims to identify and analyze ethical considerations and procedural principles relevant to infodemic management, ultimately enhancing the effectiveness of these practices and increasing trust in stakeholders performing infodemic management practices with the goal of safeguarding public health. METHODS: The review involved a comprehensive examination of the literature related to ethical considerations in infodemic management from 2002 to 2022, drawing from publications in PubMed, Scopus, and Web of Science. Policy documents and relevant material were included in the search strategy. Papers were screened against inclusion and exclusion criteria, and core thematic areas were systematically identified and categorized following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We analyzed the literature to identify substantive ethical principles that were crucial for guiding actions in the realms of infodemic management and social listening, as well as related procedural ethical principles. In this review, we consider ethical principles that are extensively deliberated upon in the literature, such as equity, justice, or respect for autonomy. However, we acknowledge the existence and relevance of procedural practices, which we also consider as ethical principles or practices that, when implemented, enhance the efficacy of infodemic management while ensuring the respect of substantive ethical principles. RESULTS: Drawing from 103 publications, the review yielded several key findings related to ethical principles, approaches, and guidelines for practice in the context of infodemic management. Community engagement, empowerment through education, and inclusivity emerged as procedural principles and practices that enhance the quality and effectiveness of communication and social listening efforts, fostering trust, a key emerging theme and crucial ethical principle. The review also emphasized the significance of transparency, privacy, and cybersecurity in data collection. CONCLUSIONS: This review underscores the pivotal role of ethics in bolstering the efficacy of infodemic management. From the analyzed body of literature, it becomes evident that ethical considerations serve as essential instruments for cultivating trust and credibility while also facilitating the medium-term and long-term viability of infodemic management approaches.

A Mixed Methods Exploration of Young Women's Agency and Mental Health during COVID-19 in Low-Income Communities in Mumbai, India.

INTRODUCTION: Adolescent girls and young women (AGYW) in India face additional health inequities compared to their male peers, as gender norms constrain agency for prevention and self-care. The onset of the COVID-19 pandemic and associated lockdowns deepened health inequities and often worsened mental health, but the impacts on agency are unclear. This exploratory sequential mixed methods paper examined mental health and COVID-19 elements that exacerbated or mitigated adverse consequences for AGYW in low-income communities in Mumbai. METHODS: We conducted semi-structured interviews with AGYW (aged 15-25 years; N = 60) and adults (parents, healthcare providers, community-based organization representative; N = 30). We administered a structured survey to AGYW (N = 150) to assess health concerns, depression and anxiety symptoms (using the PHQ-8 and GAD-7 scales), and experiences during COVID-19. We analyzed qualitative data using the constant comparative approach in Atlas.ti, and quantitative data using R and SPSS. RESULTS: Qualitative data revealed that AGYW faced stressors and had limited agency during lockdowns due to limited access to education, financial insecurity, and community violence. Quantitative data indicated that limited agency in the context of COVID-19 was significantly associated with depression and anxiety. Financial resources to address COVID-19 created new employment and leadership opportunities for AGYW to become COVID educators and preschool teachers; participation in these opportunities was associated with less anxiety. DISCUSSION: Pandemic stress was difficult for low-income AGYW in Mumbai. Mitigating programs for COVID-19 control helped address acute needs and enable capabilities. Exploring similar themes among a broader population of youth can help design strategies and opportunities for young people in low-income communities during health emergencies.

Assessing self-reported public health emergency competencies for civil aviation personnel in China: a pilot study.

INTRODUCTION: COVID-19 has demonstrated the importance of competent staff with expertise in public health emergency preparedness and response in the civil aviation system. The civil aviation system is a critical sentinel and checkpoint to prevent imported cases and slow the spread of communicable diseases. Understanding the current competencies of staff to deal with public health emergencies will help government agencies develop targeted training and evidence-based policies to improve their public health preparedness and response capabilities. METHODS: This cross-sectional pilot study was conducted from November 2022 to October 2023, involving 118 staff members from various positions within China's civil aviation system. A 59-item questionnaire was translated and developed according to a competency profile. Data were collected using the self-report questionnaire to measure the workforce's self-perceptions of knowledge and skills associated with public health emergency proficiency, categorized into (1) general competency, (2) preparedness competency, (3) response competency, and (4) recovery competency. KMO & Bartlett test and Cronbach's α reliability analysis were used to test the reliability and validity of the questionnaire. Descriptive statistics, independent sample T-test, ANOVA, and linear regression models were performed to analyze the competencies. RESULTS: A total of 107 staff members from the aviation system were surveyed in this study. The KMO & Bartlett test, (KMO = 0.919, P < 0.001) and Cronbach's α coefficients (α = 0.985) for this questionnaire were acceptable. The results suggested that respondents scored a mean of 6.48 out of 9 for the single question. However, the staff needed to acquire more knowledge in investigating epidemic information (5.92) and case managing (5.91) in the response stage. Overall, males scored higher (409.05 ± 81.39) than females (367.99 ± 84.97), with scores in the medical department (445.67 ± 72.01) higher than management (387.00 ± 70.87) and general department (362.32 ± 86.93). Additionally, those with completely subjective evaluation (425.79 ± 88.10) scored higher than the general group (374.39 ± 79.91). To predict the total score, female medical workers were more likely to have lower scores (ß = -34.5, P = 0.041). Compared with those in the medical department, the management workers (ß = -65.54, P = 0.008) and general workers (ß = -78.06, P < 0.001) were associated with a lower total score. CONCLUSIONS: There was still a gap between the public health emergency competencies of the civil aviation system and the demand. Staff in China's civil aviation systems demonstrated overall competence in public health emergency preparedness and response. However, there was a need to enhance the accumulation of practical experience. Implementing effective training programs for public health emergencies was recommended to mitigate knowledge gaps. Meanwhile, regular training evaluations were also recommended to give comprehensive feedback on the value of the training programs.

The effects of the COVID-19 pandemic on urban and rural hospital profitability.

INTRODUCTION: There are long-standing differences in profitability between rural and urban hospitals. Prior to the COVID-19 Public Health Emergency (PHE), rural hospital profitability was decreasing, while urban hospital profitability was increasing. During the PHE, the Federal Government provided billions of dollars of support to hospitals. Given the prepandemic differences in trends in profitability, it is likely that the PHE funding had different effects on rural hospitals and urban hospitals. METHODS: This study uses 2015-2023 Medicare cost report data from acute-care hospitals to assess the impact of COVID-19 PHE funding on hospital profitability. We employ descriptive Kruskal-Wallis and chi-square tests and an interrupted time series analysis to evaluate the effect of PHE funding on operating margins for a stratified sample of rural prospective payment system (PPS), urban PPS, and critical access hospitals (CAHs). RESULTS: We found that the PHE funding was associated with significant increases in operating margins, with rural PPS hospitals experiencing similar increases compared to urban PPS hospitals, and CAHs surpassing both rural and urban PPS hospitals in their margin values. However, if PHE funding had not been provided, our evidence suggests operating margins for all hospitals in 2022-2023 would have been below prepandemic levels. DISCUSSION: This preliminary analysis portrays the importance of the PHE government funding in supporting hospitals during the pandemic, and shows declining profitability trends without the funds. Rural PPS hospitals fare the worst suggesting continued need for financial support if the trend continues.

The Declaration of the National Emergency in Child and Adolescent Mental Health: It Takes a Village.

Recognition of the high prevalence of children's mental health conditions and challenges to accessing needed care faced by children and their families have been long-standing concerns, emerging well before the onset of the COVID-19 pandemic. Global data examining the prevalence of at least one mental health and/or substance-use disorder for 2516 million people aged 5 to 24 years in 2019 found that at least 293 million people were affected by at least one mental health disorder and 31 million affected by a substance-use disorder.

Dentistry and Bioterrorism: A Legitimate Threat.

Bioterrorism involves the deliberate release of harmful biological agents, such as bacteria and viruses, aimed at causing mass casualties within a population. Often referred to as "poor man's nuclear weapons," chemical and biological weapons pose a significant threat due to their potential for mass destruction. Detecting and preventing bioterrorist attacks is challenging, making them one of the most feared scenarios. Dentistry plays a crucial role in responding to bioterrorism and other catastrophic events, leveraging its personnel and facilities effectively. This paper explores the signs and symptoms of biological agents used in mass destruction, as well as the oral and dental manifestations of both naturally occurring and bioengineered infectious agents. Furthermore, the article stresses the importance of countermeasures against bioterrorism, including deterrence, prevention, surveillance, medical management, and training. Emphasis is placed on implementing surveillance systems, bolstering medical readiness, and conducting training programs to effectively detect, assess, and respond to bioterrorism threats. Ultimately, the article underscores the critical role of dentists and healthcare professionals in collaborative efforts to mitigate the impacts of bioterrorism through proactive measures.

Mental Health Impact of Pandemics and Other Public Health Emergencies in Children.

Pediatric health care providers can provide universal support to children and families to mitigate potential risk factors to adjustment while fostering protective factors to promote resiliency in children and families. They can educate caregivers about ways to enhance recovery of their children by modifying expectations and addressing the special emotional and social needs of their children. Most public health emergencies evolve through stages across an extended time period, often taxing the personal resources of health care providers. This underscores the need for pediatric health care providers to integrate self-care strategies in their personal and professional practice routines.

Provincial Intra-Action Review of the COVID-19 Vaccination Programme: Opportunities to Improve Vaccine Response in North Kivu, Democratic Republic of Congo.

Background: Low levels of COVID-19 vaccination coverage in many countries prompted the use of rapid assessments to characterize barriers to vaccination and identify corrective measures. The World Health Organization recommended the use of intra-action reviews (IARs) to identify best practices, gaps, and lessons learned to make real-time improvements to the COVID-19 vaccination response. Objective: The Democratic Republic of the Congo (DRC) implemented a national IAR in July 2021 that was poorly attended by the provincial health level, where vaccination activities are planned and implemented. To bridge this gap, we proposed sub-national IARs focused on COVID-19 vaccine program implementation at the provincial level. Methods: Using the WHO methodology, we organized a four-day provincial IAR workshop and invited national, provincial and health zone Ministry of Health (MoH) representatives and private and non-governmental organizations involved in the provincial COVID-19 vaccination response. Participants were divided into six groups based on their expertise, affiliation, and role within the health system to assess and identify lessons learned, challenges and the solutions within each of the six technical areas: (1) coordination, planning and monitoring; (2) service delivery; (3) risk communication and community engagement; (4) adverse effects following immunization (AEFI); (5) logistics; (6) and data management, monitoring and evaluation. Results: The first provincial COVID-19 IAR was conducted in Goma, North Kivu, from January 19-22, 2022. A total of 56 participants came from provincial and health zone offices, and non-governmental organizations. Through work group discussions, they identified best practices, challenges, and lessons learned, and made recommendations to improve implementation of vaccination activities and reach coverage targets. Activities were proposed to operationalize recommendations and address challenges to improve the provincial response. Conclusion: This provincial IAR was a useful tool for reviewing progress and areas of improvement, while evaluating aspects of the COVID-19 vaccine rollout. It provided a means to share information with vaccination partners on areas of intervention, tailored to the local context.

Difference in Rumor Dissemination and Debunking Before and After the Relaxation of COVID-19 Prevention and Control Measures in China: Infodemiology Study.

BACKGROUND: The information epidemic emerged along with the COVID-19 pandemic. While controlling the spread of COVID-19, the secondary harm of epidemic rumors to social order cannot be ignored. OBJECTIVE: The objective of this paper was to understand the characteristics of rumor dissemination before and after the pandemic and the corresponding rumor management and debunking mechanisms. This study aimed to provide a theoretical basis and effective methods for relevant departments to establish a sound mechanism for managing network rumors related to public health emergencies such as COVID-19. METHODS: This study collected data sets of epidemic rumors before and after the relaxation of the epidemic prevention and control measures, focusing on large-scale network rumors. Starting from 3 dimensions of rumor content construction, rumor propagation, and rumor-refuting response, the epidemic rumors were subdivided into 7 categories, namely, involved subjects, communication content, emotional expression, communication channels, communication forms, rumor-refuting subjects, and verification sources. Based on this framework, content coding and statistical analysis of epidemic rumors were carried out. RESULTS: The study found that the rumor information was primarily directed at a clear target audience. The main themes of rumor dissemination were related to the public's immediate interests in the COVID-19 field, with significant differences in emotional expression and mostly negative emotions. Rumors mostly spread through social media interactions, community dissemination, and circle dissemination, with text content as the main form, but they lack factual evidence. The preferences of debunking subjects showed differences, and the frequent occurrence of rumors reflected the unsmooth channels of debunking. The χ2 test of data before and after the pandemic showed that the P value was less than .05, indicating that the difference in rumor content before and after the pandemic had statistical significance. CONCLUSIONS: This study's results showed that the themes of rumors during the pandemic are closely related to the immediate interests of the public, and the emotions of the public accelerate the spread of these rumors, which are mostly disseminated through social networks. Therefore, to more effectively prevent and control the spread of rumors during the pandemic and to enhance the capability to respond to public health crises, relevant authorities should strengthen communication with the public, conduct emotional risk assessments, and establish a joint mechanism for debunking rumors.

Evolutionary game analysis of multiple subjects in the management of major public health emergencies.

The frequent occurrence of major public health emergencies (MPHEs) significantly challenges national security, economic stability, social operation and the safety of people's lives and property worldwide. Consequently, enhancing the emergency management of MPHEs is critically urgent. This paper constructs a game model involving local government, social organisations, and the public for MPHE management, exploring strategy combinations and influencing factors across various scenarios. Several results were obtained. (1) Local government, social organisations, and the public each have positive and negative strategy choices based on cost-benefit analysis, leading to eight different strategy combinations. Furthermore, all three take positive strategies as the optimal way to achieve the game equilibrium. (2) The transformation of strategy combinations is primarily influenced by the cost-benefit gap and the strategic decisions of local government. (3) Altering a subject's initial strategy value doesn't change its final choice but impacts the time to achieve a stable strategy equilibrium. The severity of local government punishments on social organisations influences their strategic choices and the time to optimal strategy, whereas rewards to the public or social organisations only affect the time to achieve this strategy. The findings of this study can not only help improve the collaborative governance system of MPHEs but also provide scientific guidance on how governments can manage MPHEs.

Association of licensure and relationship requirement waivers with out-of-state tele-mental health care, 2019-2021.

During the COVID-19 public health emergency, states waived in-state licensure and pre-existing patient-physician relationship requirements to increase access to care. We exploit this state telehealth policy variation to estimate the association of in-state licensure requirement waivers and pre-existing patient-physician relationship requirement waivers with out-of-state tele-mental health care utilization of patients diagnosed with COVID-19. Using claims from January 2019 until December 2021 of 2 037 977 commercially insured individuals in 3 metropolitan statistical areas (MSAs) straddling Midwestern state borders, we found increased out-of-state telehealth utilization as a share of out-of-state mental health care by 0.1411 and 0.0575 visits per month or 1679.76% and 467.48% after licensure and relationship waivers, respectively. Within-MSA analyses illustrate an urban-rural digital divide in out-of-state utilization as a share of total or telehealth mental health care. Our findings indicate waivers primarily enhance access to care of established patients by enabling the transition of in-person out-of-state health care online. Interstate medical licensure compact participation may provide broader access to out-of-state tele-mental health care than emergency waivers.

How policymakers innovate around behavioral health: adoption of the New Mexico "No Behavioral Health Cost-Sharing" law.

State policymakers have long sought to improve access to mental health and substance use disorder (MH/SUD) treatment through insurance market reforms. Examining decisions made by innovative policymakers ("policy entrepreneurs") can inform the potential scope and limits of legislative reform. Beginning in 2022, New Mexico became the first state to eliminate cost-sharing for MH/SUD treatment in private insurance plans subject to state regulation. Based on key informant interviews (n = 30), this study recounts the law's passage and intended impact. Key facilitators to the law's passage included receptive leadership, legislative champions with medical and insurance backgrounds, the use of local research evidence, advocate testimony, support from health industry figures, the severity of MH/SUD, and increased attention to MH/SUD during the COVID-19 pandemic. Findings have important implications for states considering similar laws to improve access to MH/SUD treatment.