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Migration is one of the defining issues of the 21st century. Better data is required to improve understanding about how and why people are moving, target interventions and support evidence-based migration policy. Big data, defined as large, complex data from diverse sources, is regularly proposed as a solution to help address current gaps in knowledge. The authors participated in a workshop held in London, UK, in July 2019, that brought together experts from the United Nations (UN), humanitarian non-governmental organisations (NGOs), policy and academia to develop a better understanding of how big data could be used for migration research and policy. We identified six key areas regarding the application of big data in migration research and policy: accessing and utilising data; integrating data sources and knowledge; understanding environmental drivers of migration; improving healthcare access for migrant populations; ethical and security concerns around the use of big data; and addressing political narratives. We advocate the need for careful consideration of the challenges faced by the use of big data, as well as increased cross-disciplinary collaborations to advance the use of big data in migration research whilst safeguarding vulnerable migrant communities.

BACKGROUND Lock To Live (L2L) is a novel web-based decision aid to help people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during virtual and in-person contact with healthcare providers. OBJECTIVE The goal of this project was to support implementation and evaluation of L2L during routine primary care and mental health specialty virtual and in-person encounters. METHODS The L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA), a large regional nonprofit healthcare system. Three dimensions from the RE-AIM model, including Reach, Adoption and Implementation, were selected to inform and evaluate implementation of L2L at KPWA 1/1/2020-12/31/2021. Electronic health record (EHR) data was used to purposefully recruit adult patients, including firearm owners and patients reporting suicidality, to participate in semi-structured interviews. Interview themes were used to facilitate L2L implementation and inform subsequent semi-structured interviews with providers responsible for suicide risk mitigation. Audio-recorded interviews were conducted virtually, transcribed, and coded using a rapid qualitative inquiry approach. Descriptive analysis of EHR data summarized L2L reach and adoption among patients identified at high risk of suicide. RESULTS Initial implementation consisted of updates to the safety planning EHR templates for providers to add a URL and QR code referencing L2L. Recommendations about introducing L2L were subsequently derived from thematic analysis of semi-structured interviews with patients (N=36), which included: 1) “have an open conversation,” 2) “validate their situation,” 3) “share what to expect,” 4) “make it accessible and memorable,” and 5) “walk through the tool.” Providers interviews (N=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the two-year observation period, 2739 patients reported prior month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27%) who also received L2L. Over four six-month increments of the observation period, adoption of L2L increased substantially-- from 2% to 29% among primary care providers and CONCLUSIONS Understanding the value of L2L from users’ perspectives was essential for facilitating implementation and increasing patient reach and provider adoption. Incorporating L2L into the existing system-level EHR-based safety plan template reduced the effort to use L2L and was likely the most impactful implementation strategy. As rising suicide rates galvanize the urgency of prevention, findings from this project, including L2L implementation tools and strategies, will support firearm suicide prevention practices in healthcare nationwide.

Copyright © The Authors 2022. Background and aim: Malawi’s agricultural economy relies on the yearly rains to support crop growth and national food availability. Climate change threatens food security, and risks undermining development initiatives for agriculture and population health. The study aim was to identify and quantify key relationships between climate, crop production and food security indicators, and identify areas for future data collection and research. Methods: Based on a conceptual model of the relationships between climate change, crop yields, food security and other contextual determinants (socioeconomic, demographic variables) we informed a set of multiple linear and logistic regression models for a number of system compartments. Models examined intra- and inter-district variability and quantified the impacts of various predictors upon metrics of crop yields, and food security across 32 districts in Malawi. Crop yields were examined using total mass produced, whilst food security was explored using proxies for both food availability and utility: self-reported hunger, number of meals consumed and childhood anthropometric measurements. Results: Climate-related variables of maximum monthly rainfall, soil moisture and Palmer Drought Severity Index (PDSI) showed only a modest impact upon crop production and almost no association with indicators of food security, in any district. Relationships with both crop production and food security were strongest for sociodemographic predictors including gender and migration status of the household head, household wealth and farm size. Being female or being a migrant demonstrated a strong negative relationship with both crop production and food insecurity. Conclusions: The impacts of climate upon Malawian smallholder farmers are complex. Quantifying the relationships are also dependent upon the metric of choice used to describe food security. Data paucity is a key limitation and better data is required to improve understanding and granularity of the impacts of climate change.

ImportanceUnhealthy alcohol use is common and affects morbidity and mortality but is often neglected in medical settings, despite guidelines for both prevention and treatment.ObjectiveTo test an implementation intervention to increase (1) population-based alcohol-related prevention with brief interventions and (2) treatment of alcohol use disorder (AUD) in primary care implemented with a broader program of behavioral health integration.Design, Setting, and ParticipantsThe Sustained Patient-Centered Alcohol-Related Care (SPARC) trial was a stepped-wedge cluster randomized implementation trial, including 22 primary care practices in an integrated health system in Washington state. Participants consisted of all adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018. Data were analyzed from August 2018 to March 2021.InterventionsThe implementation intervention included 3 strategies: practice facilitation; electronic health record decision support; and performance feedback. Practices were randomly assigned launch dates, which placed them in 1 of 7 waves and defined the start of the practice’s intervention period.Main Outcomes and MeasuresCoprimary outcomes for prevention and AUD treatment were (1) the proportion of patients who had unhealthy alcohol use and brief intervention documented in the electronic health record (brief intervention) for prevention and (2) the proportion of patients who had newly diagnosed AUD and engaged in AUD treatment (AUD treatment engagement). Analyses compared monthly rates of primary and intermediate outcomes (eg, screening, diagnosis, treatment initiation) among all patients who visited primary care during usual care and intervention periods using mixed-effects regression.ResultsA total of 333 596 patients visited primary care (mean [SD] age, 48 [18] years; 193 583 [58%] female; 234 764 [70%] White individuals). The proportion with brief intervention was higher during SPARC intervention than usual care periods (57 vs 11 per 10 000 patients per month; P P = .30). The intervention increased intermediate outcomes: screening (83.2% vs 20.8%; P P = .003), and treatment initiation (7.8 vs 6.2 per 10 000; P = .04).Conclusions and RelevanceIn this stepped-wedge cluster randomized implementation trial, the SPARC intervention resulted in modest increases in prevention (brief intervention) but not AUD treatment engagement in primary care, despite important increases in screening, new diagnoses, and treatment initiation.Trial RegistrationClinicalTrials.gov Identifier: NCT02675777

ImportanceUS residents report broad access to firearms, which are the most common means of suicide death in the US. Standardized firearm access questions during routine health care encounters are uncommon despite potential benefits for suicide prevention.ObjectiveTo explore patient and clinician experiences with a standard question about firearm access on a self-administered mental health questionnaire routinely used prior to primary care and mental health specialty encounters.Design, Setting, and ParticipantsQualitative semistructured interviews were conducted from November 18, 2019, to October 8, 2020, at Kaiser Permanente Washington, a large integrated care delivery system and insurance provider. Electronic health record data identified adult patients with a documented mental health diagnosis who had received a standard question about firearm access (“Do you have access to guns? yes/no”) within the prior 2 weeks. A stratified sampling distribution selected 30% who answered “yes,” 30% who answered “no,” and 40% who left the question blank. Two groups of clinicians responsible for safety planning with patients at risk of suicide were also sampled: (1) licensed clinical social workers (LICSWs) in primary and urgent care settings and (2) consulting nurses (RNs).Main Outcomes and MeasuresParticipants completed semistructured telephone interviews, which were recorded and transcribed. Directive (deductive) and conventional (inductive) content analyses were used to apply knowledge from prior research and describe new information. Thematic analysis was used to organize key content, and triangulation was used to describe the intersections between patient and clinician perspectives.ResultsThirty-six patients were interviewed (of 76 sampled; mean [SD] age, 47.3 [17.9] years; 19 [53%] were male; 27 [75%] were White; 3 [8%] were Black; and 1 [3%] was Latinx or Hispanic. Sixteen participants had reported firearm access and 15 had reported thoughts of self-harm on the questionnaire used for sampling. Thirty clinicians were interviewed (of 51 sampled) (mean [SD] age, 44.3 [12.1] years; 24 [80%] were female; 18 [60%] were White; 5 [17%] were Asian or Pacific Islander; and 4 [13%] were Latinx or Hispanic) including 25 LICSWs and 5 RNs. Key organizing themes included perceived value of standardized questions about firearm access, challenges of asking and answering, and considerations for practice improvement. Clinician interview themes largely converged and/or complemented patient interviews.Conclusions and RelevanceIn this qualitative study using semistructured interviews with patients and clinicians, a standardized question about firearm access was found to encourage dialogue about firearm access. Respondents underscored the importance of nonjudgmental acknowledgment of patients’ reasons for firearm access as key to patient-centered practice improvement.

This cross-sectional study evaluates whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and examines sociodemographic and clinical associations of reported access., Key Points Question Did patients respond to a standard question about firearm access on a mental health questionnaire, and, if so, how did they respond? Findings In this cross-sectional study of 128 802 patients receiving care for mental health and substance use, 83% of primary care patients answered a standard question about firearm access and 21% reported access. In mental health clinics, 92% of patients answered the question and 15% reported access. Meaning In this study, most patients reported firearm access on standard questionnaires; this screening practice may improve efforts to identify and engage patients at risk of suicide in discussions about securing firearms., Importance Firearms are the most common method of suicide, one of the “diseases of despair” driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown. Objective To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access. Design, Setting, and Participants Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system. Main Outcomes and Measures Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021. Results Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access. Conclusions and Relevance In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

OBJECTIVE: To describe the cost of using evidence‐based implementation strategies for sustained behavioral health integration (BHI) involving population‐based screening, assessment, and identification at 25 primary care sites of Kaiser Permanente Washington (2015‐2018). DATA SOURCES/STUDY SETTING: Project records, surveys, Bureau of Labor Statistics compensation data. STUDY DESIGN: Labor and nonlabor costs incurred by three implementation strategies: practice coaching, electronic health records clinical decision support, and performance feedback. DATA COLLECTION/EXTRACTION METHODS: Personnel time spent on these strategies was estimated for five broad roles: (a) project leaders and administrative support, (b) practice coaches, (c) clinical decision support programmers, (d) performance metric programmers, and (e) primary care local implementation team members. PRINCIPAL FINDING: Implementation involved 286 persons, 18 131 person‐hours, costing $1 587 139 or $5 per primary care visit with screening or $38 per primary care visit identifying depression, suicidal thoughts and/or alcohol or substance use disorders, in a single year. The majority of person‐hours was devoted to project leadership (35%) and practice coaches (34%), and 36% of costs were for the first three sites. CONCLUSIONS: When spread across patients screened in a single year, BHI implementation costs were well within the range for commonly used diagnostic assessments in primary care (eg, laboratory tests). This suggests that implementation costs alone should not be a substantial barrier to population‐based BHI.

Copyright © 2020 by the authors. Both climate change and migration present key concerns for global health progress. Despite this, a transparent method for identifying and understanding the relationship between climate change, migration and other contextual factors remains a knowledge gap. Existing conceptual models are useful in understanding the complexities of climate migration, but provide varying degrees of applicability to quantitative studies, resulting in non-homogenous transferability of knowledge in this important area. This paper attempts to provide a critical review of climate migration literature, as well as presenting a new conceptual model for the identification of the drivers of migration in the context of climate change. It focuses on the interactions and the dynamics of drivers over time, space and society. Through systematic, pan-disciplinary and homogenous application of theory to different geographical contexts, we aim to improve understanding of the impacts of climate change on migration. A brief case study of Malawi is provided to demonstrate how this global conceptual model can be applied into local contextual scenarios. In doing so, we hope to provide insights that help in the more homogenous applications of conceptual frameworks for this area and more generally.

Cyathostomins are the most common parasites of adult horses worldwide. Currently, the three classes of anthelmintics used to treat cyathostomin infections includes benzimidazoles, pyrimidines and macrocyclic lactones. However, due to widespread overuse, cyathostomins have developed varying degrees of resistance to all classes of anthelmintics. Fecal egg count reduction tests (FECRT) are currently used to determine the presence of anthelmintic resistance (AR), while egg reappearance periods (ERP) are used to investigate early macrocyclic lactone resistance. The objective of this study was to investigate the prevalence of cyathostomin pyrantel pamoate and ivermectin resistance, and to determine ERP at Prince Edward Island (PEI), Canada horse farms. In addition, fecal cultures and larval identification were performed to evaluate the prevalence of small and large strongyle egg shedding in PEI. Fecal egg counts (FEC) were performed on 270 horses on 14 horse farms across PEI. Horses with≥ 200 eggs per gram (EPG) met the inclusion criteria and were enrolled in the study (n = 101). The median (range) horses per farm was 7.5 (4–11) and 6.0 (4–8) for pyrantel pamoate and ivermectin groups, respectively. Horses were initially treated with 6.6 mg/kg of pyrantel pamoate orally (n = 101). Fecal egg counts were conducted every two weeks for 8 weeks post treatment. Once individual FEC were ≥ 200 EPG, horses were dewormed with 0.2 mg/kg of ivermectin orally (n = 80), and FEC were performed every 2–3 weeks for seven weeks. In this study the ERP was defined as the week the mean FECR were 10% below the initial mean two-week post treatment FECR. Fecal egg count reduction tests and ERP were used to evaluate the efficacy of each anthelmintic. Fecal culture was performed to confirm the shedding of cyathostomin eggs. Fecal egg count reduction tests detected pyrantel pamoate resistance on 5/14 farms. No signs of ivermectin AR were detected, while reappearance of eggs occurred at 4–6 weeks and 7–9 weeks for pyrantel pamoate and ivermectin, respectively. Fecal culture detected large strongyles on 5/14 farms, which accounted for 0.3% of strongyle type eggs cultured. The prevalence of Strongylus vulgaris among individual horses in this study was 2.8% and was detected on 2/14 farms. These findings will allow us to educate owners and veterinarians on appropriate anthelmintic protocols in PEI and can be used as a baseline for continued monitoring of ERP and anthelmintic resistance in this region.

To report the results of a questionnaire-based interventional study to evaluate the effects of strabismus surgery on private self-consciousness, public self-consciousness, and social anxiety using a validated self-consciousness survey instrument.Patients who underwent strabismus surgery completed a demographics and a self-consciousness scale form both pre- and postoperatively. The total and subscale (private self-consciousness, public self-consciousness, and social anxiety) summative scores were compared using the Wilcoxon signed-rank test, with statistically significant relationships defined as P 0.05. Total and subscale summative scores were analyzed as such and by strabismus type, years of education, and marital status.Overall improvement was found postoperatively in total scores (P = 0.012), public self-consciousness scores (P = 0.009), and social anxiety scores (P = 0.028). Although improvement was noted for the private self-consciousness subscale (P = 0.188), it did not reach statistical significance. Subdivided according to strabismic and demographic subgroups, significant improvement was only noted in esotropic patients, college graduates, married/living partner/widowed patients, and separated/divorced patients.This study suggests that beyond functional and cosmetic improvements, strabismus surgery can result in improved public self-consciousness and social anxiety, with greatest effect noted in esotropic, college graduates, and nonsingle patients.

Background Currently, there is limited evidence to guide intervention and service delivery coordination for youth who suffer a concussion and subsequently experience persistent post-concussive symptoms (PCS) (Lumba-Brown et al. JAMA Pediatr 172(11):e182853, 2018; Lumba-Brown A et al. JAMA Pediatr 172(11):e182847, 2018). We have developed a collaborative care intervention with embedded cognitive-behavioral therapy, care management, and stepped-up psychotropic medication consultation to address persistent PCS and related psychological comorbidities. The CARE4PCS-II study was designed to assess whether adolescents with persistent symptoms after sports-related concussion will demonstrate better outcomes when receiving this collaborative care intervention compared to a usual care (control) condition. Methods/design This investigation is a randomized comparative effectiveness trial to receive intervention (collaborative care) or control (usual care). Two hundred sports-injured male and female adolescents aged 11–18 years with three or more post-concussive symptoms that persist for at least 1 month but less than 9 months after injury will be recruited and randomized into the study. The trial focuses on the effects of the intervention on post-concussive, depressive, and anxiety symptoms measured 3, 6, and 12 months after baseline. Discussion The CARE4PCS II study is a large comparative effectiveness trial targeting symptomatic improvements in sports injured adolescents after concussion. The study is unique in its adaptation of the collaborative care model to a broad spectrum of primary care, sports medicine, and school settings. The investigation incorporates novel elements such as the delivery of CBT through HIPAA complaint video conferenceing technology and has excellent widespread dissemination potential should effectiveness be demonstrated. Trial registration ClinicalTrials.gov, NCT03034720. Registered on January 27, 2017.

Background Experts recommend that alcohol-related care be integrated into primary care (PC) to improve prevention and treatment of unhealthy alcohol use. However, few healthcare systems offer such integrated care. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington (KPWA) partnered to design a high-quality program of evidence-based care for unhealthy alcohol use: the Sustained Patient-centered Alcohol-related Care (SPARC) program. SPARC implements systems of clinical care designed to increase both prevention and treatment of unhealthy alcohol use. This clinical care for unhealthy alcohol use was implemented using three strategies: electronic health record (EHR) decision support, performance monitoring and feedback, and front-line support from external practice coaches with expertise in alcohol-related care (“SPARC implementation intervention” hereafter). The purpose of this report is to describe the protocol of the SPARC trial, a pragmatic, cluster-randomized, stepped-wedge implementation trial to evaluate whether the SPARC implementation intervention increased alcohol screening and brief alcohol counseling (so-called brief interventions), and diagnosis and treatment of alcohol use disorders (AUDs) in 22 KPWA PC clinics. Methods/Design The SPARC trial sample includes all adult patients who had a visit to any of the 22 primary care sites in the trial during the study period (January 1, 2015–July 31, 2018). The 22 sites were randomized to implement the SPARC program on different dates (in seven waves, approximately every 4 months). Primary outcomes are the proportion of patients with PC visits who (1) screen positive for unhealthy alcohol use and have documented brief interventions and (2) have a newly recognized AUD and subsequently initiate and engage in alcohol-related care. Main analyses compare the rates of these primary outcomes in the pre- and post-implementation periods, following recommended approaches for analyzing stepped-wedge trials. Qualitative analyses assess barriers and facilitators to implementation and required adaptations of implementation strategies. Discussion The SPARC trial is the first study to our knowledge to use an experimental design to test whether practice coaches with expertise in alcohol-related care, along with EHR clinical decision support and performance monitoring and feedback to sites, increase both preventive care—alcohol screening and brief intervention—as well as diagnosis and treatment of AUDs. Trial registration The trial is registered at ClinicalTrials.Gov: NCT02675777. Registered February 5, 2016, https://clinicaltrials.gov/ct2/show/NCT02675777. Electronic supplementary material The online version of this article (10.1186/s13012-018-0795-9) contains supplementary material, which is available to authorized users.

Background/aim Climate change can both directly and indirectly drive human migration. Despite this, strong understanding of the system of determinants of migration and their interactions, remains a knowledge gap resulting in large uncertainties and ill-informed interventions. Objectives To create a new conceptual model for the identification of drivers of migration in the context of climate change. Methods A critical analysis of existing theoretical and quantitative literature was performed in order to synthesise a new conceptual model for identifying the migration determinants system. Results Quantitative studies fail to homogenously apply a theoretical model for the drivers of migration and the variety of migration outcomes that occur. This in turn results in a poor evidence-base for interventions in areas where this is critical, including public health, land planning and immigration policies. Existing theoretical models are insufficiently transferable and fail to capture the full range of migration determinants. A new migration typology and conceptual model of migration is constructed based on an upstream, holistic approach to migration. The model overcomes current shortcomings by capturing temporality and driver dynamics as well as being a plastic model that may be transferred into any context. Conclusion From the homogenous application of such a conceptual framework, quantitative models may also be able to more accurately quantify the extent to which contemporary and future climate change influences migration. Such models are therefore informative tools for decision-making concerning strategies for migration policy and public health planning.

Alcohol use is a major cause of disability and death worldwide. To improve prevention and treatment addressing unhealthy alcohol use, experts recommend that alcohol-related care be integrated into primary care (PC). However, few healthcare systems do so. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington partnered to design a high-quality Program of Sustained Patient-centered Alcohol-related Care (SPARC). Here, we describe the SPARC pilot implementation, evaluate its effectiveness within three large pilot sites, and describe the qualitative findings on barriers and facilitators. Across the three sites (N = 74,225 PC patients), alcohol screening increased from 8.9% of patients pre-implementation to 62% post-implementation (p < 0.0001), with a corresponding increase in assessment for alcohol use disorders (AUD) from 1.2 to 75 patients per 10,000 seen (p < 0.0001). Increases were sustained over a year later, with screening at 84.5% and an assessment rate of 81 patients per 10,000 seen across all sites. In addition, there was a 50% increase in the number of new AUD diagnoses (p = 0.0002), and a non-statistically significant 54% increase in treatment within 14 days of new diagnoses (p = 0.083). The pilot informed an ongoing stepped-wedge trial in the remaining 22 PC sites.

This article critically reviews research studies on the identification and treatment of children's mental health problems by primary care providers. Using a valid and reliable instrument to guide the review, the investigators examined the methods and findings of all 13 studies published on the topic from 1979 to 1994. Overall, primary care providers appeared to underidentify mental health problems among children and adolescents, especially those whose emotional impairments were not overtly severe. Large proportions of youngsters identified as having mental health problems did not receive needed treatment.