Introduction Integration of management of tuberculosis (TB) and HIV with prevention and treatment of non-communicable diseases (NCDs) is a global priority. However, delivering the full spectrum of HIV/TB and NCD services is hindered by a lack of evidence regarding effective models and strategies for integrating NCDs and HIV/TB care services in varying contexts and across interventions. We conducted a scoping review to describe service delivery models and strategies used to facilitate integration of NCD care in HIV and/or TB care settings in low- and middle-income countries (LMICs).Methods We searched eight electronic databases for studies published from 2010 to 2025 that evaluated methods to integrate evidence-based screening and/or treatment of NCDs (diabetes, cervical cancer, hypertension and depression) and NCD risk factors (alcohol and tobacco use) in the context of HIV and/or TB care in LMICs. We applied a framework for categorising integration models ranging from coordination to full integration and used implementation science taxonomies to define implementation strategies and outcomes.Results 72 articles were included; 62.5% evaluated implementation of NCD interventions in HIV care settings, 31.9% in TB care and 5.6% in both. Less than a third (27.8%) reported a fully integrated service delivery model (shared systems and services). Commonly described implementation strategies included training (81.9%), evaluation strategies (43.1%), interactive assistance for providers (40.3%) and infrastructure change (eg, changing record systems) (37.5%).Conclusion Studies in LMICs are evaluating a range of strategies and service models for integrating NCD interventions into HIV and TB care in LMICs. This reflects differences in health system capacity and priorities. Greater alignment with WHO systems-integration models and implementation science frameworks could strengthen the evidence base and support progress towards global NCD goals through more consistent reporting of frameworks, integration strategies and implementation outcomes.

Previous research has demonstrated that sexual and reproductive health care providers never or rarely prescribe pre-exposure prophylaxis (PrEP) to cisgender women, despite their perception that HIV burden is high in this population. The present research was therefore designed to explore: (1) providers' PrEP knowledge and relevant experiences, (2) providers' willingness to prescribe PrEP to cisgender women, and (3) providers' perceived barriers to PrEP uptake among cisgender women at the systems/community level, clinician level, and patient level. We conducted semistructured individual interviews with 18 health care providers currently working in a clinical capacity with cisgender women, including Obstetrics/Gynecology (OB/GYN) (n = 10), Primary Care (n = 4), Infectious Disease (n = 2), and Other Specialty (n = 2) providers. Participants practiced in 12 states across the Northeast (n = 10), West Coast (n = 4), South (n = 3), and Midwest (n = 1) regions of the United States. Interviews were coded using inductive/deductive hybrid thematic analysis. Of the 18 health care providers interviewed, nearly all (n = 17) expressed willingness to prescribe PrEP. However, among those theoretically willing to prescribe PrEP, fewer than half (n = 8) had ever prescribed it. When asked open-ended questions about their attitudes and experiences, all providers identified barriers to prescribing PrEP to cisgender women. These barriers fell into four categories: (1) knowledge, messaging, and (mis)information; (2) stigma and/or fear of stigma; (3) characteristics of the medication itself; and (4) accessibility of health care services. We discuss the implications for developing interventions to address the identified implementation gap and increase PrEP access and uptake among cisgender women.

Background: Suicide is a leading cause of death in the United States, and state policies can be effective tools to prevent suicide. State legislators are increasingly active on social media, communicating about their legislative priorities and signaling information about their knowledge and attitudes about issues. Objective: This study aimed to characterize US state legislators' social media posts mentioning suicide on X (formerly Twitter) and explore differences in how Democrat and Republican legislators communicate about suicide. Methods: We used Quorum, a public affairs database, to identify all state legislator X posts mentioning suicide (N=1049) between December 1, 2023, and November 30, 2024. We developed a codebook and used content analysis to characterize posts and document the frequency of communication about suicide and themes related to causes, solutions, and consequences of suicide. We assessed concordance between the social media post language used and guidelines for reporting about suicide. We conducted univariate analysis and chi-square tests to assess differences in the content of posts between Democrat and Republican legislators. Differences in the frequency of posts about suicide were analyzed using 2-tailed t tests. Results: Of 1049 posts identified, 849 (80.9%) were included in the final sample. The annual suicide post rate per 10,000 posts was 13.2 (0.1% of all posts) among Democrats and 7.4 (0.1% of all posts) among Republicans (P=.09). Suicide related to a specific population was identified in 52.2% (443/849) of posts, with youth, veterans, firearm owners, and the LGBTQ+ (lesbian, gay, bisexual, transgender, queer, and more) population being identified most frequently. Causes of suicide were identified in 37.1% (315/849) of posts, with no significant difference between Democrats and Republicans. However, the types of causes identified varied, with Democrats more likely to identify lethal means (eg, firearms) as a cause of suicide than Republicans (115/573, 20.1% vs 20/172, 7.5%; P <.001). About two-thirds (558/849, 65.7%) of posts identified at least one solution to prevent suicide, with Democrats more likely to identify a solution than Republicans (443/573, 77.3% vs 114/268, 42.5%; P <.001). General awareness was the most frequent solution, while policy-specific solutions were present in only 23.3% (198/849) of posts. Collateral consequences of suicide were infrequently mentioned. Conclusions: This study found differences between Democrats and Republicans in their X posts about suicide and areas of misalignment with research evidence. When considered within the context of research on the epidemiology of suicide and evidence supporting suicide prevention policies, the study highlights the need to improve communication about suicide with state legislators and to encourage further collaboration with suicide prevention organizations and experts. Furthermore, given the differences observed, study findings suggest potential value in tailoring messages about suicide for legislators based on their political party.

The growing burden of non-communicable diseases (NCDs) among people living with HIV (PWH) in low- and middle-income countries (LMICs), threatens gains in life expectancy. Global organizations have called for integrating NCD management into existing HIV care systems, but it is unclear what actions countries are taking to accomplish this goal. To bridge this knowledge gap, we conducted a quantitative content analysis of HIV policy documents from the World Health Organization (WHO), the US President's Emergency Plan for AIDS Relief (PEPFAR) and 22 PEPFAR-sponsored LMICs to analyze mentions of: 1) screening and treatment of selected NCDs (hypertension, diabetes, cervical cancer, and depression) and/or two NCD risk factors (alcohol and tobacco use), and 2) health system-strengthening strategies when mentioned in relation to the selected NCDs and risk factors. We used the WHO's Building Blocks framework to identify these strategies. Screening and treatment for cervical cancer and mental health conditions were reported in the WHO and PEPFAR documents and in the majority of country documents. Strategies to strengthen service delivery (e.g., NCD care coordination across health facilities, establishing guidelines for integrated care) were frequently referenced across WHO, PEPFAR, and country-level documents. Far fewer documents mentioned strategies related to health information technology, medication access, and financing to support care integration. Although the WHO, PEPFAR and country-level documents illustrate a commitment to NCD-HIV health system integration, there was variation in which NCDs were being prioritized. Mentions of screening and treatment of NCD risk factors were rare, suggesting that tobacco and alcohol-related services may be comparatively under-resourced. Integrating NCD and HIV care requires sustained investments that align with local resources and attention to system-level enablers (e.g., improved information systems, stronger medicine supply chains) that support comprehensive care. Future research should focus on identifying the determinants of policy adoption, including factors that either drive or constrain integration of the full spectrum of NCD services within HIV care settings.

Abstract Background To promote high-quality behavioral health service delivery, federal agencies often invest in evidence-informed and evidence-based practice (EBP) implementation through discretionary (i.e., competitive) grants. However, gaps remain in understanding how federal grant mechanisms can lead to large-scale reach (i.e., the extent of EBP integration into service systems). To understand EBP reach through federal grant mechanisms and provide actionable data, we conducted a series of focus groups with relevant federal and state policy actors to gather their perspectives on how to improve federal grants to support EBP implementation. Methods This study was informed by ongoing research examining implementation outcomes (i.e., provider-level reach) from federal grants supporting the delivery of the Adolescent Community Reinforcement Approach (A-CRA), an EBP to address youth substance use. We conducted four focus groups, two with staff from state agencies who received federal A-CRA grants (n = 12) and two with U.S. federal agency officials responsible for behavioral health grant making (n = 12). We used the policy-adapted EPIS (Exploration, Preparation, Implementation, Sustainment) framework, conceptualizing grants as bridging factors between the outer policy context and inner service provision context. We used directed content analysis to characterize participant perspectives on contextual influences of EBP reach, and thematic analyses to identify how to improve federal grants for EBP implementation success (e.g., high levels of reach). We codified themes by EPIS domains and phases, and by policy actors. Results We identified three contextual influences in Bridging Factors, six in the Inner Contexts, nine in the Outer Contexts, and three in Innovation characteristics. We found seven themes about grant improvements spanning all EPIS phases; examples include strengthening collaboration between multilevel actors in the implementation process (specifically federal and state agencies and treatment organizations), and integrating EBPs into insurance billing practices (which also included insurance leadership as a key actor group). Conclusions To support large-scale EBP reach, federal funders may consider using implementation strategies that foster greater collaboration between policy actors from multiple sectors and organization levels. This work also demonstrates how implementation science frameworks can be used to study the influence of federal financing initiatives for EBPs in the area of youth behavioral health.

Youth mental health is a growing concern worldwide. Mental health education—which teaches youth about the signs and symptoms of poor mental health, help-seeking for themselves and peers, and mental health stigma—is a universal prevention strategy to address this crisis. This scoping review seeks to understand policies that mandate universal (i.e., tier one) mental health education in schools. It also summarizes extant evidence about the implementation outcomes of these policies (e.g., fidelity, acceptability, feasibility), as well as experiences of and recommendations for mental health education. 9,114 articles were reviewed by title and abstract, and 41 articles were included in this review. Results indicate that few tier one mental health education policies have been established, and that existing policies likely need to be modified regarding expectations for curriculum content, training, and funding. Results further indicate that implementation of tier one mental health education varies widely due to factors such as lack of training, inconsistent curricula, and lack of buy-in. The reporting on implementation factors was also found to vary widely. This review synthesizes the recommendations of numerous articles and outlines future directions for universal mental health education implementation and policy and finds that ongoing policy evaluation and implementation strategies may be required.

OBJECTIVE:To examine how healthcare personnel in Puerto Rico perceive the impact of successive disasters on the healthcare workforce. STUDY SETTING AND DESIGN:Qualitative in-depth semi-structured interviews were conducted with key informants from hospitals and Federally Qualified Health Centers (FQHCs) across Puerto Rico. Interviews were conducted via Zoom or in-person between 2023 and 2025. DATA SOURCES AND ANALYTIC SAMPLE:Thirty-one (31) key informants were interviewed. Deductive and inductive thematic content analyses were conducted using both a priori codes informed by the interview questions and emergent codes following data collection. Each transcript was coded by 2-3 coders using NVivo 14 software. Coding discrepancies were discussed until a consensus was reached. This study focuses on findings from two deductive codes that align with the study's research questions. PRINCIPAL FINDINGS:Repeated exposure to successive disasters in Puerto Rico contributed to a prolonged state of emotional distress among healthcare workers and staff, including feelings of stress, sadness, fear, and anxiety. These emotions contributed to burnout, staff attrition, and staff turnover. Recent healthcare graduates often lacked relevant clinical experience due to COVID-19 pandemic-related shifts to online education, which placed additional pressure on facilities to provide this essential training. CONCLUSIONS:Successive disasters led to prolonged emotional distress among the healthcare workforce, contributing to burnout, attrition, turnover, and reduced capacity to deliver high-quality care. The findings underscore the need for workforce policies that reduce disaster-related stressors and increase mental health support and clinical training opportunities for healthcare workers in Puerto Rico amid future disasters.

Importance The 988 Suicide & Crisis Lifeline (998 Lifeline) receives millions of contacts annually. Adequate staffing of 988 Lifeline centers may be important for timely, high-quality service, but little information exists on current staffing levels or difficulties. Objectives To describe 988 Lifeline center staffing and assess staffing-related difficulties. Design, Setting, and Participants In this cross-sectional study, a survey was fielded between May 6 and July 25, 2025, to all 206 centers in the 988 Lifeline network in the US and territories. Eligible respondents were individuals in leadership positions (eg, executive directors, vice presidents). Main Outcomes and Measures The survey measured staffing levels, shift coverage, modalities (telephone, text, and/or chat), operation of non-988 lines (eg, 211, local lines), proportions of paid and volunteer staff, remote and/or in-person work arrangements, and 4 domains of staffing difficulty: adequate staffing for the volume of contacts, acquiring funding to hire, recruiting staff, and retaining staff. Responses were linked with administrative data on location, presence of state 988 telecommunications fees, and subnetwork services (eg, national backup, Spanish language). Results Leaders at 159 of the 206 centers completed the survey (77% response rate), 71% (102 of 144) reported that their center was understaffed, and 89% (141 of 159) indicated difficulty acquiring resources to hire. Leaders at centers offering remote work reported greater difficulty in obtaining these resources compared with centers without remote work (94% [89 of 95] vs 81% [50 of 62]; odds ratio [OR], 3.40; 95% CI, 1.21-9.68; P = .02) but less difficulty recruiting staff (76% [72 of 95] vs 89% [55 of 62]; OR, 0.39; 95% CI, 0.14-0.98; P = .04). Respondents from centers with all paid staff reported greater difficulty recruiting compared with centers using at least some volunteers (86% [102 of 118] vs 66% [27 of 41]; OR, 3.28; 95% CI, 1.42-7.60; P = .006). Leaders at centers handling only 988 contacts reported less difficulty retaining staff than those also handling non-988 lines (63% [17 of 27] vs 83% [109 of 132]; OR, 0.36; 95% CI, 0.14-0.92; P = .03). Wide 95% CIs indicate uncertainty in the magnitude of these results. Conclusions and Relevance In this cross-sectional survey study of 988 Lifeline leaders, results suggested that most centers struggled to find resources to keep the center fully staffed. If staffing challenges persist, centers could face risks to staff well-being and service quality. Financing and operational strategies that support recruitment and retention will be critical to sustaining the quality and accessibility of 988 Lifeline centers.

Puerto Rico has endured multiple public health disasters over the past decade, including major hurricanes, earthquakes, and the COVID-19 pandemic, which have profoundly impacted its healthcare infrastructure and the mental and physical well-being of its residents. This study aims to identify temporal patterns in health-related search interests and explore associations with major public health disasters. This study utilizes Google Trends data from August 6, 2017, to October 22, 2022, to analyze public interest in three health-related categories: health care access, help-seeking behaviors, and mental and cognitive health during and following key disasters. Search activity showed no consistent pattern for health care access, yet searches related to help-seeking behaviors declined post- disasters, while mental health searches showed heterogeneous patterns, rising post-natural disasters but declining after COVID-19. These findings underscore the critical need for accessible and responsive mental health services in Puerto Rico, particularly post-disaster, and demonstrate the utility of digital surveillance tools like Google Trends for timely monitoring of population health concerns to inform resource allocation during crises.

Cisgender women account for approximately 20% of new HIV diagnoses in the U.S., yet of those indicated for pre-exposure prophylaxis (PrEP) uptake is only 10%. Cisgender women are amenable to PrEP; however, clinicians encounter individual and interpersonal barriers to prescriptions. This research examines clinicians' decision-making processes regarding PrEP provision for cisgender women. Semi-structured individual interviews were conducted with clinicians working with cisgender women in the U.S. to explore their decision-making processes for PrEP prescription and were presented with a vignette of a hypothetical patient. Clinicians were asked how they would assess their eligibility for PrEP and their clinical recommendations. Eighteen clinicians were interviewed. The majority reported at least some familiarity with PrEP. The majority were practicing clinicians trained as OB/GYNs, followed by Primary Care/Family/Internal Medicine. Clinicians frequently report their PrEP recommendations rely on the patient's overall risk and ability to use condoms. Clinicians' decision-making processes often follow a linear pathway through (1) the assessment of HIV risk, (2) STI testing, (3) condom counseling, and (4) PrEP counseling and provision. Despite medical guidelines recommending PrEP to all sexually active patients, clinicians rely on condoms as the primary prevention method and continue to assess the utility of PrEP through a risk-focused lens.

Objective : To understand how 988 Lifeline centers are connected to the broader crisis care continuum—including 911, mobile crisis response, and community-based services. Methods : The authors conducted a cross-sectional survey of 988 Lifeline centers in the U.S. between May and July 2025. A total of 159 centers (78%) completed the survey, which assessed transfer to/from 911, coordination with mobile crisis teams, capacity for referrals, and tracking dispositions and outcomes. Exploratory bivariate analyses were conducted to understand the factors associated with transfers to/from 911 and mobile crisis response team dispatch capability. Results : Approximately 45% of centers reported bidirectional interoperability with 911. Among the 153 centers with a mobile crisis response team in their service region, 61% could dispatch the team directly. Exploratory bivariate analysis indicated that centers had higher odds of interoperating with 911 when mobile crisis services were present throughout their jurisdiction (OR = 2.10 [1.06, 4.20]) and could schedule appointments on callers’ behalf (OR = 2.88 [1.39, 6.23]). Conclusions : Variation remains in centers’ ability to interoperate with 911 and dispatch mobile crisis teams. Centers with these capabilities were associated with having multiple referral, dispatch, and coordination capacities. Improving integration between 988 and other crisis services requires strengthened partnerships, sustainable funding, and investments in technology and data-sharing infrastructure.

This cross-sectional study examines differences in rates of sexual violence experienced among Native Hawaiian and Other Pacific Islander adolescents compared with adolescents from other racial and ethnic groups in Hawai‘i.

Background Dissemination initiatives have the potential to increase consumer knowledge of and engagement with evidence-based treatments (e.g., cognitive behavioral therapy [CBT]). Opinion leaders (OLs) have been used in public health campaigns, but have not been examined for the dissemination of mental health treatments. This study uses the Theory of Planned Behavior to test the dissemination strategy of involving an OL in an educational presentation to increase caregiver demand for CBT for youth anxiety.Method Participants (N = 262; 92% female; 69% White, 82% non-Hispanic) were caregivers who registered for a virtual presentation on youth anxiety treatment through their child's school. Schools within 1.5-hr drive of Philadelphia, PA were cluster-randomized (k = 25; two-arm prospective randomization) to the OL condition (presented by a clinical researcher and local caregiver OL; n = 119 participants) or the researcher-only condition (n = 143 participants). Presentations occurred from May 2021 to May 2022. Measures were completed pre- and post-presentation and at 3-month follow-up.Results Relative to the researcher co-presenter, participants rated the OL as significantly more relatable, familiar, similar, and understanding of their community, but less credible than the researcher co-presenter. In both conditions, there was a significant pre-post increase in participants' knowledge of, attitudes about, subjective norms related to, and intention of seeking CBT for youth anxiety, but not stigma. Presentation conditions did not differ in change on these measures, or on rates of seeking youth anxiety CBT at follow-up.Conclusions Although involvement of a caregiver OL did not increase caregiver demand for evidence-based treatment for youth anxiety, the outreach presentation was associated with increases in knowledge of, attitudes about, subjective norms related to, and intention to seek CBT for youth anxiety. Involving OLs in researcher-delivered dissemination efforts may not be necessary for all consumer audiences, but may be beneficial for engendering a sense of relatability, similarity, and connection with disseminators.

Recent policy initiatives such as the 988 Suicide and Crisis Lifeline aim to increase the use of crisis services. We conducted a probability survey of 5,006 US adults in 2023 and used latent class analysis to identify population segments that vary in crisis help-seeking preferences. We identified five segments: "Seek Help Nowhere," "Definitely Not 988, Yes Friends And Family-Distressed," "Seek Help Everywhere," "Seek Help Most Places, But Not Religious Network," and "Relatively Indifferent-Not Distressed." Having serious prior-thirty-day psychological distress was positively associated with membership in the Definitely Not 988 segment and was negatively associated with the Relatively Indifferent segment. Respondents who were not aware of the 988 Lifeline were more likely to be in the Seek Help Nowhere and Definitely Not 988 segments. Political party affiliation was associated with membership in all segments. Communication campaigns that encourage the use of crisis services and help seeking may consider tailoring messages for these different audience segments.

Policy Points Certified community behavioral health clinics (CCBHCs) commonly partner with emergency response systems in mobile crisis response through 911 referral arrangements, wherein behavioral health practitioner-only teams respond to 911 calls, and co-response partnerships, wherein a CCBHC clinician joins a police or emergency medical services team. Both the internal staff capacity of the CCBHC and external police capacity are associated with when CCBHCs partner with emergency response systems in mobile crisis response, although their effects differ by partnership: Co-response is more likely when CCBHCs have greater internal capacity, whereas 911 referral is more common in communities with lower police capacity. Stakeholders seeking to increase CCBHC-emergency response system partnerships may need to apply different strategies depending on the type of arrangement they aim to expand.ContextIndividuals with behavioral health disorders are more likely to experience substantial harm from a police encounter, prompting reforms to minimize encounters between police and people experiencing a behavioral health crisis. One strategy involves expanding partnerships between certified community behavioral health clinic (CCBHC) mobile crisis teams and emergency response systems, often through two models: 911 referral, wherein a CCBHC's behavioral health practitioner-only team responds to 911 calls, and co-response, wherein a CCBHC clinician joins a police or emergency medical services (EMS) team. We examine whether the internal capacity of the CCBHC and external police capacity influence when CCBHCs engage in these partnerships.MethodsUsing data from the only national survey of CCBHCs, this study applies multivariable logistic regression to assess whether CCBHC staff capacity and police capacity are associated with CCBHC-emergency response system partnerships in mobile crisis, controlling for organizational characteristics of the CCBHC and demographic and socioeconomic features of its service area.FindingsOne-third (33.0%, 95% confidence interval [CI], 26.0-40.0) of CCBHCs report a 911 referral partnership, and nearly half (48.5%, 95% CI 41.1-55.9) report a co-response arrangement. While police capacity is not significantly associated with co-response, a one standard deviation increase in police capacity corresponds to an 11.0-percentage-point (95% CI -19.5 to -2.5) decrease in the predicted probability of a 911 referral partnership. CCBHC capacity is not associated with 911 referral arrangements, but CCBHCs in the top tertile of CCBHC capacity are 19.2 (95% CI 4.3-34.2) percentage points more likely to report a co-response partnership.ConclusionsThe internal capacity of CCBHCs and external police capacity are associated with when CCBHCs partner with emergency response systems in mobile crisis. Because a robust behavioral health crisis system likely requires multiple response models with varying police involvement, stakeholders may need different strategies depending on the type of partnership they aim to expand.

Objective: Concerns about financing for the 988 Suicide and Crisis Lifeline have persisted since its launch. The authors aimed to assess perceptions of financing factors affecting 988's implementation among professionals involved with its operation. Methods: In May-August 2024, professionals (N=384) completed a web-based survey. Fifteen items were used to characterize perceptions of the extent to which financing factors had positively influenced 988's implementation and were considered important for its future. Results: All 15 items were rated significantly (p<0.001) lower in past positive influence than in future importance to 988's future. Only 10% of the respondents completely agreed that the 988 Lifeline had sufficient funding to meet its service demands, and 8% completely agreed that sufficient funding had been available for quality monitoring. Ratings were similar for respondents who were (vs. were not) very involved with 988's financial planning. Conclusions: The professionals surveyed perceived financing as a prominent concern likely to affect the 988 Lifeline's future success.

Objective: This study aimed to characterize the perceived priorities of state and county policy makers for youth mental health services and the factors that influence those priorities. Methods: Mental health agency officials (N=338; N=221 state officials, N=117 county officials) representing 49 states completed a Web-based survey in 2019-2020. On 5-point scales, respondents rated the extent to which 15 issues were priorities for their agency in providing youth mental health services and the extent to which nine factors influenced those priorities. Results: Suicide was identified as the highest priority (mean +/- SD rating=4.38 +/- 0.94), followed by adverse childhood experiences and childhood trauma and then increasing access to evidence-based treatments. Budget issues (mean=4.27 +/- 0.92) and state legislative priorities (mean=4.01 +/- 0.99) were perceived as having the greatest influence on setting priorities. Conclusions: These findings provide insights into youth mental health policy priorities and can be used to guide implementation and dissemination strategies for research and program development within state and county systems.