Pandemics, economic freedom, and institutional trade-offs.

We argue that institutions are bundles that involve trade-offs in the government's ability to provide public goods that affect public health. We hypothesize that the institutions underlying economic freedom affect the mix of diseases by reducing diseases of poverty relative to diseases of commerce (those associated with free movement of people, such as smallpox or COVID-19). We focus on smallpox and typhoid fever in the late nineteenth century and early twentieth century in order to build on recent work that make arguments similar to ours, especially the framework Werner Troesken sets forth in The Pox of Liberty. Our evidence shows that economic freedom, in multiple periods of time and settings prior to the eradication of smallpox in the second half of the twentieth century, reduced typhoid mortality but had no effect on smallpox deaths. The implication for COVID-19 is that the trade-off between fighting the pandemic and preserving economic freedom may not be too severe in the short run. However, in the long run, the wealth benefits from economic freedom are likely to be crucial in reducing vulnerability to diseases of commerce primarily from their impact on comorbidities (such as diabetes and heart disease). Thus, economic freedom is on balance good for public health, which suggests that it, while requiring trade-offs, might be the best institutional bundle for dealing with pandemics. Supplementary Information: The online version contains supplementary material available at 10.1007/s10657-021-09704-7.

Lifestyle and mental health disruptions during COVID-19.

Using a longitudinal dataset linking biometric and survey data from several cohorts of young adults before and during the COVID-19 pandemic ([Formula: see text]), we document large disruptions to physical activity, sleep, time use, and mental health. At the onset of the pandemic, average steps decline from 10,000 to 4,600 steps per day, sleep increases by 25 to 30 min per night, time spent socializing declines by over half to less than 30 min, and screen time more than doubles to over 5 h per day. Over the course of the pandemic from March to July 2020 the proportion of participants at risk for clinical depression ranges from 46% to 61%, up to a 90% increase in depression rates compared to the same population just prior to the pandemic. Our analyses suggest that disruption to physical activity is a leading risk factor for depression during the pandemic. However, restoration of those habits through a short-term intervention does not meaningfully improve mental well-being.

Impact of a Web-Based Electronic Health Record on Behavioral Health Service Delivery for Children and Adolescents: Randomized Controlled Trial.

BACKGROUND: Electronic health records (EHRs) have been widely proposed as a mechanism for improving health care quality. However, rigorous research on the impact of EHR systems on behavioral health service delivery is scant, especially for children and adolescents. OBJECTIVE: The current study evaluated the usability of an EHR developed to support the implementation of the Wraparound care coordination model for children and youth with complex behavioral health needs, and impact of the EHR on service processes, fidelity, and proximal outcomes. METHODS: Thirty-four Wraparound facilitators working in two programs in two states were randomized to either use the new EHR (19/34, 56%) or to continue to implement Wraparound services as usual (SAU) using paper-based documentation (15/34, 44%). Key functions of the EHR included standard fields such as youth and family information, diagnoses, assessment data, and progress notes. In addition, there was the maintenance of a coordinated plan of care, progress measurement on strategies and services, communication among team members, and reporting on services, expenditures, and outcomes. All children and youth referred to services for eight months (N=211) were eligible for the study. After excluding those who were ineligible (69/211, 33%) and who declined to participate (59/211, 28%), a total of 83/211 (39%) children and youth were enrolled in the study with 49/211 (23%) in the EHR condition and 34/211 (16%) in the SAU condition. Facilitators serving these youth and families and their supervisors completed measures of EHR usability and appropriateness, supervision processes and activities, work satisfaction, and use of and attitudes toward standardized assessments. Data from facilitators were collected by web survey and, where necessary, by phone interviews. Parents and caregivers completed measures via phone interviews. Related to fidelity and quality of behavioral health care, including Wraparound team climate, working alliance with providers, fidelity to the Wraparound model, and satisfaction with services. RESULTS: EHR-assigned facilitators from both sites demonstrated the robust use of the system. Facilitators in the EHR group reported spending significantly more time reviewing client progress (P=.03) in supervision, and less time overall sending reminders to youth/families (P=.04). A trend toward less time on administrative tasks (P=.098) in supervision was also found. Facilitators in both groups reported significantly increased use of measurement-based care strategies overall, which may reflect cross-group contamination (given that randomization of staff to the EHR occurred within agencies and supervisors supervised both types of staff). Although not significant at P<.05, there was a trend (P=.10) toward caregivers in the EHR group reporting poorer shared agreement on tasks on the measure of working alliance with providers. No other significant between-group differences were found. CONCLUSIONS: Results support the proposal that use of EHR systems can promote the use of client progress data and promote efficiency; however, there was little evidence of any impact (positive or negative) on overall service quality, fidelity, or client satisfaction. The field of children's behavioral health services would benefit from additional research on EHR systems using designs that include larger sample sizes and longer follow-up periods. TRIAL REGISTRATION: ClinicalTrials.gov NCT02421874; https://clinicaltrials.gov/ct2/show/NCT02421874 (Archived by WebCite at http://www.webcitation.org/6yyGPJ3NA).

Translating E-Mental Health Into Practice: What Are the Barriers and Enablers to E-Mental Health Implementation by Aboriginal and Torres Strait Islander Health Professionals?

BACKGROUND: With increasing evidence for the effectiveness of e-mental health interventions for enhancing mental health and well-being, a growing challenge is how to translate promising research findings into service delivery contexts. A 2012 e-mental health initiative by the Australian Federal Government (eMHPrac) has sought to address the issue through several strategies, one of which has been to train different health professional workforces in e-mental health (e-MH). OBJECTIVE: The aim of the study was to report on the barriers and enablers of e-MH uptake in a cohort of predominantly Aboriginal and Torres Strait Islander health professionals (21 Indigenous, 5 non-Indigenous) who occupied mainly support or case management roles within their organizations. METHODS: A 3- or 2-day e-MH training program was followed by up to 5 consultation sessions (mean 2.4 sessions) provided by the 2 trainers. The trainer-consultants provided written reports on each of the 30 consultation sessions for 7 consultation groups. They were also interviewed as part of the study. The written reports and interview data were thematically analyzed by 2 members of the research team. RESULTS: Uptake of e-MH among the consultation group was moderate (22%-30% of participants). There were significant organizational barriers to uptake resulting from procedural and administrative problems, demanding workloads, prohibitive policies, and a lack of fit between the organizational culture and the introduction of new technologies. Personal barriers included participant beliefs about the applicability of e-MH to certain populations, and workers' lack of confidence and skills. However, enthusiastic managers and tech-savvy champions could provide a counter-balance as organizational enablers of e-MH; and the consultation sessions themselves appear to have enhanced skills and confidence, shifted attitudes to new technologies, and seeded a perception that e-MH could be a valuable health education resource. CONCLUSIONS: A conclusion from the program was that it was important to match e-MH training and resources to work roles. In the latter stages of the consultation sessions, the Aboriginal and Torres Strait Islander health professionals responded very positively to YouTube video clips and apps with a health education dimension. Therapy-oriented apps and programs may fit less well within the scope of practice of some workforces, including this one. We suggest that researchers broaden their focus and definitions of e-MH and give rather more weight to e-MH's health education possibilities. Developing criteria for evaluating apps and YouTube videos may empower a rather greater section of health workforce to use e-MH with their clients.

Applying User Input to the Design and Testing of an Electronic Behavioral Health Information System for Wraparound Care Coordination.

Health information technology (HIT) and care coordination for individuals with complex needs are high priorities for quality improvement in health care. However, there is little empirical guidance about how best to design electronic health record systems and related technologies to facilitate implementation of care coordination models in behavioral health, or how best to apply user input to the design and testing process. In this paper, we describe an iterative development process that incorporated user/stakeholder perspectives at multiple points and resulted in an electronic behavioral health information system (EBHIS) specific to the wraparound care coordination model for youth with serious emotional and behavioral disorders. First, we review foundational HIT research on how EBHIS can enhance efficiency and outcomes of wraparound that was used to inform development. After describing the rationale for and functions of a prototype EBHIS for wraparound, we describe methods and results for a series of six small studies that informed system development across four phases of effort-predevelopment, development, initial user testing, and commercialization-and discuss how these results informed system design and refinement. Finally, we present next steps, challenges to dissemination, and guidance for others aiming to develop specialized behavioral health HIT. The research team's experiences reinforce the opportunity presented by EBHIS to improve care coordination for populations with complex needs, while also pointing to a litany of barriers and challenges to be overcome to implement such technologies.