Lesotho is one of the poorest countries in the world with high levels of food insecurity and malnutrition. The aim was to evaluate the impact of a nutrition education intervention informed by self-efficacy and locus of control theories among women in Lesotho.A randomized pre-test-post-test design was adopted to implement a systematically designed nutrition education intervention in women from Maseru and Berea districts in Lesotho. Women from selected villages were randomly assigned to comparison and intervention groups. Baseline and post assessments were conducted before, and 6 months after the intervention. Nutrition-related self-efficacy and locus of control were assessed using a semi-structured knowledge, attitudes, beliefs, and practices (KABP) questionnaire.n = 105) and intervention groups (n = 154) were interviewed. Self-efficacy beliefs that improved significantly in the intervention group but not in the comparison group included increased confidence that they could eat a healthy diet every day [95% CI for the percentage difference ]; an improved ability to secure several healthy foods in the home; increased confidence in engaging in physical activity [95% CI ]; reducing the amount of salt they used in food [95% CI ]; and compiling a budget for food purchases [95% CI ]. Regarding locus of control, the belief in a personal capacity to take charge of one's health through the production and consumption of healthy food improved in the intervention group [95% CI ] but not in the comparison group [95% CI ]. At follow-up, a significantly larger percentage of participants in the intervention group also believed that they could take control of their health and that they could prevent some illnesses by the food they eat.At baseline, 444 women aged 19–60 years were included. After the intervention, 259 women in the comparison (A nutrition education intervention that is systematically planned and framed on selected theories of health behavior improved nutrition-related beliefs in self-efficacy and locus of control. Supporting food and nutrition security is undoubtedly the first and foremost strategy to ensure access to safe, acceptable and adequate sources of food . HoweverLesotho is a small mountainous country with a population of 2.2 million people. It is considered to be one of the world's least developed and poorest countries, with half of the population living in poverty and many exposed to high levels of food insecurity –7. The u.evious studies in Lesotho have shown that Basotho women lack nutrition-related knowledge and that their dietary intake is largely inadequate. As a result, their nutritional status is challenged and they present with high levels of malnutrition, including both undernutrition, overnutrition, and micro-nutrient deficiencies –10. AlthTheories of health behavior have popularly been used in health education and promotion interventions –14. ThesSelf-efficacy, derived from Bandura's Social Cognitive Theory , 15 has Locus of control is the personal control that people feel toward health. It is either internal or external. An internal locus of control means that a person believes that they can influence their health, while external locus of control means that an individual believes that their health is in the hands of others . IndividThe bases for using self-efficacy and locus of control as framework theories for the current nutrition education intervention was largely influenced by the assertion that for an individual to change their dietary and other health behaviors, they need the motivation to want to change. The most effective method of raising motivation to change is restoring self-esteem and self-efficacy and developing an internal locus of control .Given the above, the present study aimed to determine the impact of a nutrition education intervention, framed on improving self-efficacy and internal locus of control, on the nutrition-related behavior of Basotho women. To our knowledge, no systematically designed nutrition education intervention programmes that are relevant to the unique situation of women in Lesotho have previously been implemented.The research team designed a nutrition education intervention based on identified needs of women in Lesotho. An in-depth literature review was conducted to identify knowledge, beliefs, attitudes, and practices that promote or hinder desirable nutrition actions in resource-limited settings. The South African Food-Based Dietary Guidelines (SAFBDG) and selected theories of health behavior—in this case, self-efficacy and locus of control—were used as a framework for the intervention. Although it is acknowledged that environmental mediators and barriers play an important role in health behaviors , the current intervention was intended to address person-related barriers and mediators that could be addressed within the resource-limited environment that the women live. Based on this, culturally appropriate intervention goals and content were developed to respond to the identified needs by creating awareness, cultivating self-efficacy and internal locus of control, and providing information to increase knowledge.The intervention was compiled in accordance with health psychology and health promotion guidelines of theories of health behavior and had the following characteristics: It was systematically designed as it followed steps and sequence and used strategies that included questioning and brainstorming . It builThe current study adopted a randomized pre-test post-test design. Two out of 10 districts, Maseru and Berea, were included in the study because both their urban and rural areas are fairly accessible. Urban and rural areas were defined according to the Lands Surveys and Physical Planning (LSPP) boundaries in Lesotho . RandomiAll women in the age group 19–60 years who signed informed consent were eligible to participate. The choice of women in this age group was made with the knowledge that in Lesotho, women are homemakers and decide what is to be eaten in the family. The following categories of women were excluded from the study: domestic workers that lived in the homes of women participating in the study, pupils/students, acutely ill and disabled women, and pregnant and lactating women. These groups have unique characteristics that need special considerations that were beyond the scope of this study.Ethics approval was obtained from the Health Sciences Research Ethics Committee of the University of the Free State and the Ministry of Health in Lesotho. Baseline and follow-up assessments were carried out during 2013 at baseline and 6 months after the intervention.pitsos , where information related to the project was disseminated. Women were invited to participate in the study, after which arrangements for data collection and implementing the nutrition education intervention were made.After a random selection of villages to be included in the study, the researcher arranged information sessions with the community leaders/counselors to sensitize them to the intended project and obtain approval. The community leaders were asked to call Five research assistants  were recruited and trained to conduct the interviews. The pilot study was completed among 26 volunteers in an area other than Maseru and Berea, and thus these women were not included in the main study. The pilot study served to determine if questions were understood clearly and the time that it would take to complete an interview.Volunteers assembled at the agreed venues on the set dates and times arranged for baseline measurements and interviews. After the participants had signed consent, the researcher and field workers completed the questionnaires in a structured interview with each participant. Nutrition-related self-efficacy and locus of control were assessed using a semi-structured knowledge, attitudes, beliefs, and practices (KABP) questionnaire designed by the research team. To assess self-efficacy and locus of control, participants' responses to specific statements were categorized in terms of whether they believed in their own capability to produce and eat a healthy diet; and whether they had an internal or external locus of control regarding food.To assure validity, the questionnaire was based on an in-depth literature review and compiled in accordance with the standard methods suggested by health psychology and health promotion experts and followed the suggested guidelines of theories of health behavior , 12, 16.The nutrition education intervention was presented after completion of the baseline survey. Ten 2-day participatory workshops were presented in intervention groups . One worBox 1Self-awareness/self-assessment of vulnerability/threat:Describe own nutrition and related lifestyle behaviors;Describe perceptions of personal vulnerability;Describe perceptions of personal threat.Barriers:Identify barriers to achieving a balanced diet ;Identify barriers to physical activity ;Devise ways of dealing with barriers.Personal control/social norms and cultures:Express feelings of personal power/control over barriers;Express whether they believed that their health was in the hands of chance/fate/luck/witchcraft  or whether they believed that their health was in their own hands ;Identify social norms and cultures that promote or inhibit the performance of recommended action .Thoughts and feelings:Express thoughts and feelings regarding intended nutritional changes by reporting how the changes are going to affect them personally;Predict how their families are going to react to the new changes and how this is going to affect them personally;Propose ways to deal with the reactions, both personally and otherwise.Self-efficacy/goal setting/intention to act:Describe confidence in achieving a balanced diet every day/week;Demonstrate the ability to compile a budget for food;Describe intended changes to food production, purchases, and preparation.Knowledge:Use food pictures to demonstrate which foods are included under the different FBDGs;Identify foods that are considered to be healthy and less healthy.After completion of the interviews, women were served a light meal of sandwiches with tea and fruit.The initial and follow-up assessments were described by frequencies and percentages for categorical data and medians and ranges for numerical data, calculated per group. The change from initial to post assessment was calculated per group and compared by means of 95% confidence intervals.At baseline a total of 444 participants (204 in the comparison (C) group and 240 in the intervention (I) group) were included in the study. At follow-up, 105 comparison and 154 intervention participants were interviewed.The median age of participants was 43 years (range 19–60 years), with 65% of participants in the control group and 52% of those in the intervention group living in a rural area. Only about half of participants had completed primary school education  and were in a traditional marriage . Fifty-five percent of participants in the control group and 46% in the intervention group were unemployed. Few participants were employed , self-employed , engaged in subsistence farming , or had a part-time/piece job . Although the majority of participants owned a house , very few had a bathroom in the house , and fewer still had access to their own water tap , with the predominant access to water being a communal tap . Few participants had access to electricity  and many used a pit latrine system . Most had a kitchen/place for cooking  where some used open fire  as fuel for cooking . In most households, only one member of the family was employed .At baseline, 30% of participants in both the comparison and intervention groups indicated that they were confident that they could eat a healthy diet every day . After the intervention, a statistically significant improvement was seen in the intervention group, but not in the comparison group [95% CI for the percentage difference ].To determine whether or not participants had access to the food to enable them to eat a healthy diet every day, they were asked if they had the following foods in their house: breakfast cereal, rice, maize-meal (ground maize), samp, vegetables, fruits, meat, legumes, milk, eggs, and bread flour .At baseline the majority of participants indicated that they had maize-meal ; vegetables ; and dried beans  in their houses. After the intervention, availability of bread flour improved significantly from 57.9 to 90.3% in the intervention group [95% CI ] but not in the comparison group.At baseline, about 40% of participants in both the comparison and intervention groups reported having milk in the house. After the intervention, availability of milk remained more or less the same in the comparison group [95% CI ] but improved significantly to 75% in the intervention group [95% CI ].Other significant improvements in the availability of foods that were seen in the intervention group included fruits [95% CI ]; breakfast cereal [95% CI ]; and rice [95% CI ].To further establish self-efficacy, participants were asked to indicate their confidence in performing certain actions related to eating and other lifestyle factors .At baseline, almost all items except growing vegetables  were reported by < 40% of participants. After the intervention, improvements were observed in all items in the intervention group. These included removing fat from meat before cooking [C = 95% CI ]; engaging in physical activity for 30 min or longer at least three times a week [95% CI ]; reducing the amount of salt in food [95% CI ]; and compiling a list of foods to purchase every month [95% CI ] and every week .To assess whether participants had an internal or external locus of control regarding food, they were asked to indicate whether or not they agreed with several statements informed by the theory .At baseline, the majority of participants indicated that they believed that illness and health were caused by luck, fate or chance , while most indicated that they did not believe that illness and health were caused by witchcraft . More than half believed they could take control of their health , while more than 70% reported that they could prevent some illnesses by the food they ate .After the intervention, the belief that illness and health were not caused by luck, fate or chance improved significantly in the intervention group [95% CI ]. In the intervention groups, significant improvements were also observed in the belief that illness and health were not caused by witchcraft [95% CI ]; that they could prevent some illnesses by the food they ate [95% CI ].The Basotho women included in the current study were characterized by low levels of education and unemployment. The lack of amenities such as own sanitation, running water and electricity are evidence of the poverty that is endemic to Lesotho. The widespread limited food availability and access in Lesotho  have negIn terms of self-efficacy, the intervention was successful in improving the confidence of women to eat a healthy diet every day. Before the intervention, hardly 40% indicated that they had confidence in their ability to do so. The nutrition education delivered to the intervention group thus seemed to reaffirm the women's confidence in the foods that they should eat. In framing this intervention on a social cognition model, the study was consistent with other studies that determined the effectiveness of dietary interventions to promote healthy eating using psychological based interventions , 23.Before the intervention, almost all women reported that they had maize-meal in their homes, while about 90% had vegetables (more than 80% grew vegetables in their gardens), leaving little room for improvement due to the nutrition education intervention. On the other hand, improvements were seen in the availability of dried beans, milk, fruits, breakfast cereal, and rice. These improvements are evidence that the nutrition education intervention improved self-efficacy in making healthy food choices. For any health behavior to be performed effectively, individuals must believe in their competency to successfully perform the behaviors in question  and mustAlthough most participants in the current study grew and ate vegetables, most studies report a low intake of vegetables. Nutrition education interventions to improve fruit and vegetable consumption report varying levels of effectiveness, despite most people knowing that fruit and vegetable consumption is positively associated with health benefits . In the At baseline, < 40% of all women had self-efficacy in removing fat from meat before cooking; in engaging in physical activity for 30 min or longer at least three times a week; and in reducing the amount of salt they used in food. After the intervention, women in the intervention group's self-efficacy to perform health-promoting behaviors relating to food in all these items improved significantly. Similarly, high self-efficacy was found to predict an intention to choose and consume low fat and low sodium foods among North American students .Before the intervention, very few women in the current study compiled a budget or planned food purchases in advance. After the intervention, women in the intervention group were no longer purchasing food every day, indicating that they had learned to plan food purchases. In contrast, the comparison group was not enabled to change this behavior. Improvements in the ability to shop using a list indicate growth in self-efficacy about the importance of budgeting, planning and making healthy food choices.Generally having high self-efficacy reduces stress levels  and motiAn improved perception of personal control as defined by an internal locus of control is predictive of health protective behavior . Eating Shehu and Mokgwathi found that internal locus of control was predictive of internal resilience and its relationship with physical education among adolescents in Botswana . InternaWe acknowledge that the inclusion of two areas that were relatively accessible to the research team may introduce a bias in terms of the representation of women in Lesotho. Although there is a general view that poverty is worse in rural areas, the African Food Security Urban Network (AFSUN) reports that the urban poor in Maseru may be the most food insecure in the country . The womThe findings of our study confirm that a nutrition education intervention that is systematically planned and framed on selected theories of health behavior improved aspects of nutrition-related beliefs in self-efficacy and locus of control. Improved self-efficacy was evidenced by increased confidence in the foods that they should eat and an improved ability to secure healthy foods in the home. The intervention was also able to increase the women's beliefs in their own ability to make decisions about food , empowering them to eat a healthy diet despite their limited resources.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Health Sciences Research Ethics Committee of the University of the Free State. The patients/participants provided their written informed consent to participate in this study.CW and MR: study conception, design, and draft manuscript preparation. MR: data collection and implementation of intervention. MN: statistical analysis. All authors approved the final version of the manuscript.


Accessed 03 Oct 2021) shows that more than 80% of job interviews are conducted remotely, particularly in large companies. However, for some reason, an interviewee might attempt to deceive an interviewer or feel difficult to tell the truth. Although the ability of interviewers to detect deception among interviewees is significant for their company or organization, it still strongly depends on their individual experience and cannot be automated. To address this issue, in this study, we propose a machine learning approach to aid in detecting whether a person is attempting to deceive the interlocutor by associating the features of their facial expressions with those of their pulse rate. We also constructed a more realistic dataset for the task of deception detection by asking subjects not to respond artificially, but rather to improvise natural responses using a web camera and wearable device (smartwatch). The results of an experimental evaluation of the proposed approach with 10-fold cross-validation using random forests classifier show that the accuracy and the F1 value were in the range between 0.75 and 0.8 for each subject, and the highest values were 0.87 and 0.88, respectively. Through the analysis of the importance of the features the trained models, we revealed the crucial features of each subject during deception, which differed among the subjects.Given the ongoing COVID-19 pandemic, remote interviews have become an increasingly popular approach in many fields. For example, a survey by the HR Research Institute (PCR Institute in Survey on hiring activities for graduates of 2021 and 2022.  With the recent trends of digital transformation and the ongoing COVID-19 pandemic, remote (or online) interviews and relevant applications have become increasingly popular. These provide more opportunities to talk among participants who may be geographically dispersed. Typical application fields of them include commercial/enterprise communications, medical services, education, law enforcement and national security. For example, according to a survey of 240 companies conducted by the HR Research Institute  to analyze the relationship between the subjects’ psychological profiles and the results of the interviewing experiment, as a further study.Finally, we must note the limitation of this study. In order to obtain statistically rigorous results using our approach, we essentially need several thousands of recorded videos and richer sensor data with the help of a huge number of subjects, who might have different cultural backgrounds and neurodivergent statuses, but it was difficult for us. Hence, we restricted our attention to providing some case-study style analysis with the help of few subjects based on the range of our proposed method in the present literature.Our approach and results might be helpful for interviewers who might have an interest in using an automatic deception detection system in real interviews, where, as we noted in our introduction, they need to be careful with ethical issues and local laws when using such an application.


Following preventive behaviors is a key measure to protect people from infectious diseases. Protection motivation theory (PMT) suggests that perceived risk motivates individuals to take protective measures. The COVID-19 pandemic has posed unprecedented stress to the public, and changes in perceived risk may be more pronounced among college students than among other groups due to the related campus lockdown. With 1,119 college students recruited as research subjects, a quantitative research was conducted in Wuhan, China, to deduce the relationship between the perceived risk and preventive behavior of college students, as well as between the mediation effect of individual affect and the moderating effect of physical exercise. The results showed that the preventive behavior of college students was significantly affected by perceived risk, and both positive affect and negative affect played a mediating role between perceived risk and preventive behavior. Specifically, positive affect aided the relationship between perceived risk and preventive behavior, negative affect was detrimental to their relationship, and the mediation effect of positive affect is significantly higher than that of negative affect. Furthermore, physical exercise played a moderating role in the mediation effects of positive affect and negative affect. Therefore, appropriate measures should be taken to strengthen Chinese college students' perceived risk and provide them with corresponding guidance. The importance of physical exercise should also be emphasized to help college students with low perceived risk reduce negative affect, increase positive affect, and promote their preventive behavior. In 2022, the pandemic situation became more pressing because of its continuing mutation, shorter incubation period, and higher rates of asymptomatic infection. With the beginning of a new semester, some colleges and universities in China had to adopt a 1- to 3-month campus lockdown policy in response to the local outbreak of the COVID-19 pandemic, and college students had to take some actions to cope with this situation accordingly. The importance of preventive behavior , excluding 0. It indicates that NA plays a significant role in the association between PR and PB, and this indirect effect accounts for 26.2% of the total effect. The association between PR and PB via the mediator (PA) is 0.152, with a confidence interval of , excluding 0. It indicates that PA also plays a significant role in the association between PR and PB, and this indirect effect accounts for 49.5% of the total effect. Hypothesis 4 is confirmed. The confidence interval for the difference in the association between PR and PB via the mediator (NA and PA) is , indicating that the mediation effect of PA is significantly higher than that of NA.t = −3.779, p < 0.001), indicating that PE has a significant negative moderating effect between NA and PB; the interaction terms of PA and PE has a significant positive effect on PB , indicating that PE has a significant positive moderating effect between PA and PB. In model 9, the interaction terms of PR and PE has a significant negative effect on NA , indicating that PE has a significant negative moderating effect between PR and NA. In model 10, the interaction terms of PR and PE has a significant positive effect on PA , indicating that PE has a significant positive moderating effect between PR and PA.A bootstrap method was used to further confirm the presence of mediating effects whose low and high values were calculated based on the mean ± 1 standard deviation. The results of the mediated moderation effect are demonstrated in Based on the PMT, this study constructed a moderated mediation model with PA and NA as the mediating variables and with physical exercise as moderating variable, and the influence of college students' PR on PB was discussed.Our results support the notion that PR is positively associated with PB . CollegeThe results could indicate that higher levels of PR cause lower NA and higher PA. The relationship between PR and NA in this study is partly different from the previous studies , 79, whiThe results could indicate that college students' PA was positively associated with PB and NA was negatively associated with PB. This is consistent with the proposition of positive psychology , 47 thatThe results about mediating effect showed that PA and NA partially mediated the relationship between PR and PB among college students, and the value of the indirect effect of PA is greater than that of NA. This finding provides more evidence for emerging research. It reveals the differential influences of PA/NA on PB related to PR . That isThe results of the moderating effect showed that PE moderated not only the first half of the mediated effect pathway but also the second half of the mediated effect pathway. Specifically, the mediating effect of PA and NA between PR and PB was significantly enhanced in college students with high levels of PE. This may be because people who participate more in physical exercise may be more inclined to pursue a healthy lifestyle, are more likely to perceive risks, feel more able to adhere to preventive behavior, have a more positive impact, and actively participate in preventive behavior. Some facts proved that, through higher levels of risk information perceived from the COVID-19 pandemic, and college students might be able to generate higher levels of PAs and lower levels of NAs with the help of PE during the campus lockdown, which then led to active PBs. This confirmed the role of PE on mental health . PE can In the context of ongoing campus lockdown due to the COVID-19 pandemic, this study mainly determined the relationship between college students' PR and PB, revealed the potential mediating role of PA and NA on the relationship between PR and PB among college students, and discussed the potential moderating role of PE in the aforementioned mediating role. We built a model which is composed of five hypotheses and partly verified them with 1,119 valid responses. The results showed that PR is not only directly and significantly associated with PB but also influences PB through PA and NA, and the effect of PA is greater than that of NA. Furthermore, PE moderates the mediating role of PA and NA between PR and PB in college students. These findings contribute to illuminating how PA/NA mediates college student's PR and PB and how PE participates in the relationship mentioned earlier.College students' PR is positively associated with PB, but measures to increase college students' PR should not be limited to adopting campus lockdowns in all respects. The experience of Wuhan provides an excellent example of public crisis events, and adopting more flexible measures in lockdown is effective for enduring the existence of the COVID-19 pandemic; the important intermediary mechanism of PA/NA in this study requires college administrators to take the obligation to help college students establish a correct concept of affects management and provide a convenient channel for help on this basis of preventing them from missing the opportunity of psychological intervention when encountering emergent public crisis. The effect of PE is confirmed in this study. Based on the important function of PE on PR and PB, college administrators should provide more sports venues and prolong the timing of availablity, and hold sports games of different scales to encourage college students to take more PE to give full play the role of PE and enhance college students' PB in the COVID-19 pandemic.First, the utilization of cross-section data in this article cannot guarantee the evaluation of causal relationships among variables, which would inevitably result in inaccurate research conclusions. Future research is suggested to adopt a longitudinal research method which is necessary to substantiate the findings from the present study and further improve the validity of the conclusion. Second, in terms of the respondents, college students in Wuhan are a typical representative group on the topic of COVID-19; thus, this study is not generalizable to other populations than students. Third, due to the limitation in the range of variable selection, social management factors such as public opinion and government authority are excluded, which can be further studied.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study of human participants in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.LZ: conceptualization, manuscript writing, and revision. XC: data analysis, revision, and proofreading. ZL: translation and proofreading. All the authors participated in the article and approved the submitted version.


The authors describe a successful strategy of task-shifting child immunization activities to CHWs in insecure areas of Burkina Faso to improve vaccine coverage. As part of Burkina Faso's national health system resilience plan, a task-shifting strategy was piloted in 1 district using community health workers (CHWs) to provide child immunization services to hard-to-reach populations in areas affected by terrorist attacks.Vaccine coverage improved for all antigens administered.Essential factors of the strategy's success included capacity-building of CHWs, adequate planning to ensure a vaccine supply, communication activities to increase community awareness and demand, and routine data collection and monitoring.After the experience in the Sahel region, the strategy was scaled up in the whole Sahel region and integrated into national guidelines.National immunization guidelines should be adapted and used by governments and implementing partners to strengthen the credibility of a task-shifting strategy.Task-shifting strategies must take into account the CHWs' training, supervision, and remuneration, as well as additional financial costs that CHWs incur in performing their duties.We call on health system managers to build strong community health systems so countries or regions are better prepared to withstand crises and shocks. Faced with the frequent disruptions to the health care system and provision of immunization services caused by terrorist attacks that began in 2015, the Sahel region in Burkina Faso initiated resilience strategies, including the task-shifting of immunization activities to community health workers (CHWs). This strategy was designed to involve more CHWs in the vaccination delivery process and ultimately to improve the performance of the health care system.The task-shifting strategy began as a pilot in Djibo health district in 2019 and then extended to all 4 districts of the Sahel region. CHWs included both personnel recruited through the Ministry of Health and Public Hygiene processes at the national level and other community members who support the operation of health facilities. They were trained on standardized immunization modules and provided with vaccines by functional health facilities teams. Implementation initiated with the administration of oral antigens by CHWs. Subsequently, their service delivery was expanded to include injectable vaccines in the context of the worsening terrorist attacks and the urgent need to protect the health of local populations affected by the security and humanitarian crisis.The intervention was evaluated through an internal programmatic review conducted as a descriptive cross-sectional study implemented from August 1 to October 28, 2022, in the Sahel region, including a survey in Dori health district. CHWs involved in implementing the strategy were considered for interviews. Performance indicators for all antigens have shown an upward trend since the strategy's inception in 2019.The task-shifting of immunization activities to CHWs has been implemented successfully in a region seriously affected by terrorism-related insecurity. It holds the promise of maintaining or even improving performance if institutionalized and scaled up while improving the monitoring of adverse events following immunization by the CHWs. Improving maternal and child health is a key objective of health care systems worldwide. To achieve this, a number of public health interventions are being implemented to reduce the burden of childhood morbidity and mortality, which has previously been relatively high in sub-Saharan Africa.,Vaccines also reduce disability.However, since the beginning of terrorist attacks by armed groups in 2015, the health care system has been frequently disrupted, including the provision of immunization services. In 2021, the Sahel region had an estimated population of 1,526,160.,The health care system is structured around 3 levels. At the peripheral level, the first point of contact with health services is the health facility.Yet, vaccines are essential for the prevention and control of many communicable diseases, making them a pillar of global health security.,Various initiatives have been launched as part of Burkina Faso's 2019 health system resilience strategy, including the development of vaccination strategies in insecure areas.The development of vaccination strategies in insecure areas is part of Burkina Faso's health system resilience strategy.In this article, we describe the task-shifting strategy designed and implemented in the Sahel region of Burkina Faso in terms of content, implementation process, and results achieved.After the health facilities performance analysis, the Sahel regional health directorate team designed the strategy in collaboration with the health district management teams. However, before this, consultations were held with national bodies, including the national directorate in charge of prevention through vaccinations and international partners, such as the country office of the World Health Organization. The strategy planning required prioritization of health facilities based on financial resources available for CHW training and the feasibility of CHWs to commute commuting for the distribution of supplies and vaccination in villages. As part of the development of the implementation plan, the Sahel Regional Health Department team estimated the target area to be covered. It then estimated the number of doses of vaccine needed and the budget required. To mobilize the financial resources needed for the training courses, the team held meetings with its partners and identified government resources at the district level that could be used. The main stages of implementation are shown in Assessment of the recurrence and risk of terrorist attacks by attempting to count and map them by health care facility.Assessment of the vaccination performance of health facilities using measles-rubella (MR) vaccination coverage over the last 2 years (2017 and 2018).The selection of health facilities for implementation was a 2-step process .AssessmThis process led to the selection of the first health facilities (n=27) in Djibo health district based on MR1 and MR2 vaccination coverage in 2017 and 2018.,The strategy relied on CHWs living in the intervention zones, who were recruited and incentivized (US$34/month) by the Ministry of Health in 2016.To ensure sustainability, vaccine supply was designed to use the health system operations with adaptations. CHWs obtained supplies from the nearest health facilities. To do this, health facilities had to provide CHWs with vaccine carriers . These are then transported to the point of service delivery by cart, motorcycle, or bus. CHWs living in places where health facilities are not functional could use the refrigerators of these health facilities with the support of district immunization focal points for maintenance. In the absence of functioning refrigerators, CHWs traveled between the villages and the nearest functional health facility and received their supplies in vaccine carriers according to their needs at vaccination sites. The planning of vaccination sessions and the supplying of vaccines were done according to a schedule defined by health facility teams, and CHWs' health facilities were responsible for rationing the doses to limit wastage. The rest of the supply chain, from the regional vaccine store to districts, remained unchanged.Communication was an important dimension in the implementation of the strategy. It was addressed through direct engagement with the various communities, advocacy with local authorities, home visits, and the use of town criers to convey messages, where possible, during mass campaigns .Communication was an important dimension in the implementation of the strategy and was used to address the population's doubts and prevent poor acceptance of vaccination.These communication activities aimed to address the population's doubts and prevent poor acceptance of vaccination by the community, particularly regarding the administration of injectable products by CHWs. The CHWs used educational talks and home visits to raise community awareness. Emphasis was placed on CHWs' ability to communicate the benefits of immunization as outlined in the child health promotion leaflets. Vaccination calendar posters were also distributed to CHWs.Communication about scheduled vaccination sessions was made door-to-door by the CHWs on the eve of the activity to get parents involved. The tools used were those recommended by Burkina Faso's Expanded Programme on Immunization, based on the WHO guideCHWs were required to ensure proper cleaning before and after vaccination sessions by collecting biomedical waste produced during the session. CHWs were trained according to the national vaccination guide,Activities were conducted under the coordination and supervision of the health facility teams. When a health facility was closed, responsibility for coordination fell to the nearest health facility, assisted by the district immunization focal point. The standard health information system data collection forms were reproduced and used.The aim of this evaluation was to assess the functionality of immunization service delivery by CHWs after 2 years of implementation. More specifically, we sought to identify lessons that could improve and strengthen this task-shifting strategy for immunization services in such a complex and changing environment.In our evaluation, we sought to identify lessons that could improve and strengthen the task-shifting strategy in this complex and changing environment.Evaluation Practices and Methods in Africa.We carried out a process evaluation based on the requirements described by Ridde in Our evaluation focused on the implementation process. To gain a broad understanding of the lessons learned from this vaccination task-shifting strategy, we opted to carry out a mixed-method evaluation combining quantitative and qualitative methodologies. We used data generated by health services for activities between 2016 and 2022  extracted from DHIS2 and data from other sources at the level of the Sahel regional health directorate. Primary data collection  took place between August 1 and October 28, 2022, in the Sahel region of Burkina Faso.Our evaluation focused on children aged 0–59 months, conventional health workers, and CHWs in the evaluation area.Quantitative data were collected from CHWs according to geographical distribution and whether they were involved in the implementation of the strategy in Dori health district, where the regional health directorate is headquartered. This convenience sampling of respondents (CHWs) was essentially driven by security reasons and the availability of financial resources to collect data. The selected health facilities were Lamdamol, Selbo, Gotougou, Katchirga, and Sampelga—all rural facilities in Dori health district—with a sample of 31 CHWs.Qualitative data was collected remotely by telephone, involving 28 CHWs implementing vaccination activities in the Dori, Gorom Gorom, and Sebba health districts. The region's fourth health district, Djibo, was deprived of a functioning telephone network for its rural health facilities due to the sabotage of telecommunication equipment by armed groups and was therefore not included in this evaluation. In addition, an exhaustive list of children aged 0–59 months vaccinated between 2017 and 2021 and recorded in the DHIS2 database was used.Demographic characteristics: occupation, place of residence, level of education, distance between the village and the health facility site, length of service, etc.Operations: training, effectiveness of interventions, existence of financial support, nature of district support, community support, availability of equipment, type of antigen administered, supply method, etc.Vaccine coverage: bacille Calmette-Guérin, oral polio vaccine 1 and oral polio vaccine 3, Penta1 and Penta3, MR1 and MR2, and meningococcal A coverage rates.Both quantitative and qualitative data collection techniques were used for data collection. For the quantitative component, we designed a document review grid that enabled us to capture data extracted from the national data management portal (DHIS2).Quantitative data were then entered into Excel and analyzed using Excel and SPSS 22. Qualitative data from CHW interviews were recorded and transcribed into MS Word in French, the language used by these CHWs, and analyzed after verbatim coding using MAXQDA software.We obtained administrative authorization from the Ministry of Health. Before the start of data collection, we also obtained administrative authorization from the Sahel Regional Health Department, district medical officers, and municipalities. Data were stored on electronic media accessible only to the restricted evaluation team and protected by an access code. As this work was considered to be an evidence-based program evaluation, it was not submitted to the national ethics committee for further review.The quantitative survey included 31 CHWs in Dori health district who consented to participate. As shown in The qualitative interview by telephone reached 32 CHWs working in villages and linked to 24 health facilities. The average median age of participants was 31.32 years .The administration of injectable vaccines by CHWs began in December 2019, with the supervision of 40 CHWs trained initially in the town of Djibo and providing vaccinations in areas where internally displaced persons gathered. The strategy was subsequently extended to other districts. By the end of 2021, the region had 332 CHWs trained in the strategy and regularly providing vaccination in their localities.The task-shifting to CHWs enabled 6,223 children to be vaccinated, including 180 in their first contact with vaccination services, according to data from the statistics office of the Sahel regional health directorate. The resulting data, available in DHIS2, show that the strategy has improved vaccine coverage performance in the Sahel region . OverallData indicate that the strategy has improved vaccine coverage in the Sahel region, reversing a downward trend before the implementation period.The emergence of COVID-19 led to a number of restrictive measures that had an impact on vaccination services. The use of CHWs enabled vaccination to continue with smaller numbers of people, often door-to-door, and to comply with the social distancing measures recommended at the height of the pandemic.The reports and results obtained indicate that the application of biomedical waste management guidelines has been effective from the outset. The survey of the Dori district showed that 64.5% of the CHWs surveyed (n=31) stated that they bring their vaccine waste to the health facilities for incineration. According to the same survey, some CHWs bury and burn their waste.In the implementation of this activity, the majority of CHWs were recruited by the government of Burkina Faso, which provides them with a monthly incentive of US$34. A few were volunteers at the health facilities, usually members of management committees or helpers managing the medicine store.However, a number of additional costs were reported in the implementation of daily activities linked to the distance traveled  and meanThe main difficulties identified during interviews with CHWs related to issues such as the unavailability of a suitable means of transport, such as motorcycles, or related logistical challenges. The CHWs that did not have a motorcycle or bicycle made every effort to carry out their activities either by borrowing a means of transport, using vehicles from which to reach village markets when available, or using carts.I walk 7 km to get to the vaccination site. I don't have a motorcycle and the nurse joins me with the vaccines. —CHWThe health facility motorcycle is very old, it needs a lot of repairs: they say it's up to the Town Hall to reimburse me or do it, but so far nothing concrete. —CHWI miss my program (or I arrive late because I'm on foot), because I don't have a motorcycle. —CHWRespondents also mentioned a lack of means to finance the cost of the fuel needed for these transports.Yes, there's a problem: I have my own motorcycle, but sometimes I walk to vaccinate because there's no fuel or money for fuel. —CHW[I] take a motorcycle cab at a cost of 500 FCFA to be paid in 2 installments in order to collect the vaccine or to work at the vaccination site every Thursday (vaccination day). No one has ever given me anything. —CHWThese expenses are incurred despite their criticism of the amount of monthly allowance provided by the government.I receive 20,000 FCFA, which is not enough for fathers of families, and it takes a long time to come, you have to credit all the time, and it doesn't look good: they don't even trust us anymore. —CHWThe incentives  haven't arrived for 10 months; it demotivates us, and we're forced to look elsewhere, including the gold mines in Côte d'Ivoire. —CHWFinally, our analyses allowed us to perceive the presence of risk and fear in the comments of these community members.We take a lot of risks, to save the children. —CHWAnother CHW reported the presence of armed men in his area of operation.I've already come across them 4 times. Thank God, I've only been bothered once. People say I'm crazy, but I'm not. It's a sacrifice; my work as a CHW. —CHW,The task-shifting strategy was initially inspired by the security context and then became critical in the resumption of immunization services after the interruption caused by COVID-19.The implementation of the task-shifting strategy has made it possible to maintain health protection even amid the closure of health facilities or an upsurge in terrorist attacks.,The task-shifting strategy makes it possible to fill major gaps in the health workforce that existed before the COVID-19 pandemic. The World Health Organization estimates the health workforce at 18 million health workers worldwide.,,Task-shifting vaccination services is an appropriate way to move toward better population access to primary health care.Our findings lead us to recommend the implementation of this strategy in areas facing a security crisis or other major crises and to argue for greater involvement of CHWs in health programs and disease management. Burkina Faso has used CHWs in task-shifting for the management of childhood illnesses such as malaria, diarrhea, and pneumonia.,,This strategy was of vital importance during the implementation of the COVID-19 immunization roll-out plan in the Sahel region that required substantial effort to overcome reluctance and generate community support, similar to previous experiences with other vaccines, such as the polio vaccine.The strategy contributes to strengthening equity in immunization by facilitating coverage of the Sahel region, which faces a security crisis involving many internally displaced persons. It has enabled the maintenance of vaccination services despite the risks faced by communities, which would probably not have been borne by health facility teams. Increasing the availability of resources for the strategy's effective and sustainable implementation, including the strengthening of a cold chain more adapted to the context , could improve vaccine safety.Interviews with CHWs suggest that the application of selection criteria and refresher training to keep current with directives were essential to the success of the strategy. These CHWs have a generally satisfactory level of education, according to the Dori district survey. The profile of CHWs complies with the national guidelines governing their recruitment in Burkina Faso.,,Generally, supervision is proving to be a major success factor in initiatives to involve CHWs in service provision. It has been crucial in the integration of community activities during the involvement of adolescents in the provision of adolescent-friendly reproductive health services in Zambia.The interviews conducted enabled us to note additional financial needs, with a suggestion to increase the amount of financial incentives given by the government to CHWs and to set up a clear mechanism at the health district level to support the cost of fuel that some CHWs are required to bear on their own. CHWs recruited by the Burkina Faso government receive a monthly allowance of around US$34, which is far from enough to cover their related expenses. These related expenses could be borne by direct allocations to CHWs as part of the financing of outreach immunization services. The continuity of the strategy is reassuring, given the government's commitment, in particular, with a state budget line to cover CHWs' monthly allowances and the inclusion of community strategies in the strategic orientations of the national health development plan. However, despite this commitment, material resources should be mobilized through various Ministry of Health projects to facilitate implementation of the strategy by health establishments. The continuation of activities requires better support for the mobility of CHWs . Implementation of the strategy is highly dependent on travel and logistics, and some CHWS have indicated the use of their own motorcycles for service activities.The continuation of activities requires better support for the mobility of CHWs, as implementation of the strategy is highly dependent on travel and logistics.The system must also provide more resources to improve the quality of strategy implementation. Indeed, some CHWs had to walk long distances despite the many trips, which could lead to exhaustion and abandonment of the work, yet the strategy calls for the use of small quantities to avoid deteriorating vaccine quality. Activities continued relatively smoothly in localities where solar refrigerators were available, regardless of the functionality of the health facility. In situations where the cold chain was not available, CHWs traveled back and forth to obtain stocks of vaccines and supplies needed for vaccination sessions in their localities. There is a lack of equipment for transporting and storing vaccines. This has led us to recommend the provision of more durable means (refrigerators and vaccine carriers) for solar-powered vaccine storage at the community level.According to the survey results in the Dori health district, CHWs are making an effort to bring biomedical waste back to health facilities and manage it with incinerators or, in the worst case, burn and bury it. However, our evaluation has revealed a number of difficulties faced by stakeholders in transporting waste to health facilities—the main practice of community workers in vaccine waste management. These difficulties are essentially logistical, namely the lack of financial resources and motorcycles for transporting waste to health facilities for destruction. Vaccine waste management could also be disrupted by shortages of supplies, in particular garbage cans for sharp items such as needles, and difficulties in transporting vaccine waste.Data were collected using tools from the national health information system. We are able to trace and integrate data into aggregate health data. However, we note that the reporting of adverse events following immunization must be strengthened, given the very low reporting rate since the beginning of the strategy. Monitoring and evaluation with dissemination of reports are essential in this context to document the safety of injectable vaccine administration by CHWs, which could reassure communities and other public health actors who may still have concerns. The provision of immunization services is an international priority and an essential component of children's right to be considered in emergencies.Increase the financial motivation of CHWs in the Sahel region and other insecure areas who implement community-based interventions, including immunization.Provide health facility teams and CHWs with financial resources for refresher training and supervision.Strengthen the cold chain with adequate material and energy autonomy for CHW activities in the Sahel region.Provide CHWs with interactive training tools such as audiovisual firmware, audio messages, and pocket memos on immunization for self-training and distance coaching.Strengthen the availability of resources for surveillance of adverse events following immunization at the community level.Provide health facilities with resources for waste management .Strengthen the integration of services at the community level for the delivery of a broader package of services by CHWs.Considering the results of this evaluation, we propose the following recommendations.This evaluation has its limitations, as it did not take into account the overall cost of the strategy in its design, and its inclusion in future evaluations will undoubtedly reinforce the strategy's sustainability. Also, future studies could assess beneficiary satisfaction and use an analytical study design to investigate all factors associated with improved immunization coverage.Task-shifting of immunization services is being implemented in the Sahel region of Burkina Faso with encouraging results. Analyses of the results obtained between 2017 and 2021 show the positive influence of task-shifting in immunization. This strategy is now institutionally anchored with its adoption in many health system resilience tools, such as vaccination guidelines in security-compromised areas. Task-shifting holds the promise of enabling the continuity of primary health care, including immunization, when conventional health workers can no longer operate due to insecurity. The successful and sustainable implementation of the task-shifting strategy will require a reliable supply of vaccines and related supplies and adequate funding to pay for CHWs and their activities. Finally, periodic evaluations of the strategy will be necessary for ongoing learning, adjustments, and improvements.


The high cost of health care for people with behavioral health (BH) conditions or intellectual and developmental disabilities (IDD) in the United States led one state to implement the Provider-led Arkansas Shared Savings Entity (PASSE) program. PASSE is a managed care model that puts provider-led organizations at risk for the highest need people with BH conditions or IDD in Medicaid, a public health insurance program for low-income residents. Drawing on key informant interviews and payment models across the United States, we describe the PASSE program, how it compares with state Medicaid programs for similar populations, and prospects for the program. Key informants cited several PASSE features as promising mechanisms to improve beneficiary outcomes: expanded care coordination, service flexibility, incentives for community investments, accountability for cost and quality across physical health, behavioral health, and long-term care, quality target accountability, fostered competition, and provider ownership. Informants worry that PASSE features will be insufficient to catalyze changes in provider behavior. Efforts may be targeted to control costs primarily through service reductions with uncertain effects on quality of care. PASSE hinges on improved care coordination and increased efforts to address social determinants of health. Success or failure in these areas will likely determine whether PASSE leads to improved outcomes for two of the most costly and vulnerable populations. Each state operates a Medicaid program, which is jointly funded by the state and the federal government. Medicaid consumes an ever-growing share of state budgets, crowding out other state spending obligations like education and infrastructure. From 1988 to 2014, the percent of state funds devoted to Medicaid rose from 8.7 percent to 19.3 percent By design, Medicaid covers people with disabilities and those with low income and resources. The poverty rate of people with disabilities is more than twice that of people without disabilities Arkansas follows the national trend in devoting a disproportionate share of Medicaid spending – 31 percent, or $2 billion in 2017 - to the 14 percent  of beneficiaries with BH conditions or IDD Through the provision of care coordination and the alignment of provider incentives, the Provider-led Arkansas Shared Savings Entity (PASSE) program aims to integrate physical, behavioral, and long-term care for high-need Medicaid beneficiaries with BH conditions or IDD. PASSE beneficiaries have high functional needs due to the severity and complexity of their disabilities, and reside in a high poverty, predominately rural state, making PASSE accountable for the care for one of the most vulnerable populations in the country. Our goals are to describe PASSE, detail how its principal features compare to other state Medicaid programs for people with BH conditions or IDD, discuss its development, and provide key stakeholder views of the prospects for the program.1.1The Medicaid Accountable Care Organization Learning Collaborative suggests state Medicaid agencies address a set of key questions when designing their accountable care programs 1.1.1Arkansas recognized that ~ 28,000 of the ~ 150,000 beneficiaries with IDD or BH conditions accounted for $1.1 billion annually, or half of the spending for this group. To capture the beneficiaries in this ‘tail of the spending distribution’ without using historical spending directly, the state defined the mandatory population as beneficiaries with IDD or BH conditions with the highest levels of functional need. To our knowledge, no other state has designed a risk- or value-based Medicaid model around only the most complex BH or IDD beneficiaries. To identify the subset of beneficiaries with the highest needs, the state contracted with an independent organization to conduct a functional assessment of all BH and IDD beneficiaries. The assessment categorized beneficiaries into one of three tiers see . Benefic1.1.2Each PASSE is accountable for the physical, behavioral, and long-term care of its attributed population; only a few services and settings, such as non-emergency medical transportation and skilled nursing facilities, are excluded. In accordance with the 2016 Medicaid managed care regulations 1.1.3Each PASSE is required to provide statewide coverage. Initial attribution of Tier II or III beneficiaries to a PASSE was based on the prior relationship between the beneficiary and his or her chief provider, and was designed to favor relationships with BH or IDD providers. Beneficiaries could select a different PASSE ninety days after this initial assignment, and at the beginning of each year thereafter. As of December 2018, approximately 46,000 individuals were assessed as Tier II or III and were enrolled in the PASSE program; most  were eligible due to a BH condition. Of the beneficiaries with IDD, about 60 percent  were enrolled in the existing DD Medicaid waiver, about 30 percent  were on the waiting list for the waiver, and about 10 percent (~750) resided in privately owned institutions 1.1.4shared savings in the program name, the PASSEs will retain any savings generated or absorb any losses sustained within a certain threshold, and will share in the savings or losses beyond that threshold , diagnostic eligibility category , Medicare eligibility , tier level, and region of the state (north or south) hreshold  [22].TabAs a managed care entity, each PASSE will pay an annual 2.5 percent premium tax. The state plans to use the premium taxes for two purposes: (1) to increase enrollment by reducing the IDD waiver waiting list, and (2) to incentivize improved beneficiary outcomes through payment of financial rewards to the PASSEs. PASSEs will be monitored on measures of access , satisfaction (PASSEs are required to administer beneficiary satisfaction surveys and report the results to DHS), process , and utilization  commonly used in outsourced Medicaid programs 1.1.5An IDD provider, a BH provider, a hospital, a physician, and a pharmacist together must own at least 51 percent of each PASSE, and partner with an organization experienced in insurance administration. PASSEs are required to recruit statewide networks of diverse provider types, and may negotiate a variety of payment agreements , which are expected to promote cost reduction and quality improvement. DHS allows and encourages providers who are not equity owners in a PASSE to join the network of each PASSE and to enter into alternative payment arrangements with one or more PASSEs. PASSEs must determine how to assess the quality of network providers as well as which metrics will factor into shared savings or incentive payments to providers with whom PASSEs have entered into alternative payment agreements.1.2Among state Medicaid programs in general, there is considerable variation in eligibility criteria, coverage policy, payment rates, and other structural elements. Except for covering only the highest need beneficiaries, PASSE shares several features in common with other state Medicaid programs for people with BH conditions or IDD. To better understand the array of programs for these two populations, we conducted a review of Medicaid state agency websites, managed care and accountable care contracts, approved waivers, program evaluations, and other publicly available sources. We first identified the programs in which an entity other than the state Medicaid agency is accountable for the physical, behavioral, and long-term quality and cost of care of its attributed population. For each of these programs, we outline the degree of similarity to PASSE, namely (1) beneficiary attribution (2) payment, and (3) leadership.Other than PASSE, 29 programs in twenty-six states shift accountability, for both the physical and behavioral health of the BH population to an entity other than the state Medicaid agency see . Like PAOnly Arizona, Iowa, Kansas, Maine, and Vermont like Arkansas have shifted accountability for the physical health, behavioral health, and long-term services and supports for their IDD populations see . Like ArWhile not equivalent in design, Arkansas and other states with recently implemented managed care models for people with complex needsmeta-analysis of PACE evaluations suggested the program was associated with fewer inpatient hospitalizations and a lower mortality rate, but at the cost of increased Medicaid spending, primarily due to higher rates of institutionalization Three programs for beneficiaries dually eligible for Medicare and Medicaid also aim to integrate acute and long-term care for a vulnerable and costly population. The Program of All-Inclusive Care for the Elderly (PACE) began in the 1980 s as a demonstration, and was permanently authorized in 1997. Through a single three-way contract between the Centers for Medicare and Medicaid Services (CMS), the state Medicaid agency, and the operating organization, PACE uses capitation payments to serve individuals age fifty-five and over, primarily dually eligible beneficiaries, who are eligible for nursing facility care. A 2The success of the PASSE program rests largely with the provider-led organizations, and beneficiaries and other providers of the program. Their experience as PASSE is implemented, and their perspective on the potential benefits and concerns with PASSE may influence their behavior and thus the outcomes of this innovative health care and social service model. To understand any implementation challenges and prospects for the program from the perspective of stakeholders prior to full implementation, key informants from several relevant sectors were interviewed in the fall of 2017, before the monthly care coordination payments began.Requests for interviews were sent to associations representing IDD and BH providers, associations representing IDD and BH beneficiaries, the Arkansas Hospital Association, the Arkansas Pharmacy Association, and representatives of the five PASSEs that submitted letters of intent to join the program The interview consisted of a 12-question instrument  that addThirteen requests for interviews were sent; ten interviews were completed. An in-person interview was not feasible for one informant; two informants did not respond to the request for an interview. Interviews were conducted in person and lasted no more than one hour. Representatives from all five prospective PASSEs completed interviews. Four of the seven informants representing the PASSEs also represented BH or pharmacy associations. The remaining three informants represented the state hospital association, beneficiaries with IDD, and children and families.33.1PASSE implementation proceeded rapidly, with twenty-three months from legislative passage to full implementation; see Once tier level was determined and a beneficiary was attributed to a PASSE, DHS provided the PASSE with three years of claims history for the beneficiary. Shortly thereafter, on February 1, 2018, PASSEs began to receive monthly payments in return for providing care coordination for attributed beneficiaries. PASSEs were to use this time, during which claims continued to be reimbursed fee-for-service, to analyze the claims history of attributed beneficiaries and gain experience providing care coordination without being at-risk for all Medicaid services. Several informants reported problems with the accuracy and timeliness of data provided by DHS, potentially limiting the usefulness of the lead time.By April 1, 2018, PASSEs had to demonstrate an adequate, statewide referral network of BH providers, IDD providers, hospitals, physicians, and pharmacists. Network adequacy is defined for each provider type by a maximum distance from each beneficiary in an urban or rural area and by a maximum ratio of providers to beneficiaries. DHS officials and stakeholders reported that PASSEs struggled to develop their contracted networks, particularly with non-BH or IDD providers. In part due to the rapid implementation timeline, providers around the state remained unaware of the program. In addition to the limited time for implementation, informants pointed to inadequate provider and beneficiary outreach, education, and training on the new model. As program implementation approached, DHS increased education through town hall meetings, webinars, and training materials, and published a provider manual Within the short implementation timeline, DHS issued little guidance related to PASSE operations. PASSEs have had relative freedom to select their business partners, develop provider networks, and establish care coordination processes. Five letters of intent were submitted by prospective PASSEs. As implementation proceeded and the PASSE owners learned what it would take to succeed in the program, not all remained in operation. One informant noted the feeling of “flying the plane while we are building it.” DHS had anticipated that two or three PASSEs would have sufficiently large networks, resources, and number of beneficiaries to be financially viable. Indeed, four of the five progressed to beneficiary attribution, and three are currently in operation and have begun to accept full risk for all Medicaid services. The limited guidance and communication from DHS were a frustration for many informants interviewed and may also have contributed to the decline in the number of PASSEs.DHS executed a series of waivers, waiver amendments, and state plan amendments to implement PASSE 3.2Overall, informants described the potential for the design elements of PASSE to stimulate changes in provider and beneficiary behavior. Following is a critical appraisal of the program based on potential benefits and concerns articulated by the key informants and summarized in 3.2.1One of the benefits mentioned most often by key informants and echoed in the literature is that PASSEs will have the opportunity to improve beneficiary outcomes by fostering coordinated, integrated care, a model that has shown clear benefits for individuals with BH conditions The expanded definition of care coordination, the flexibility to provide services not covered by the state Medicaid fee-for-service program and the incentive to make community investments also foster coordinated care by widening the scope of accountability for the lives of beneficiaries. About three quarters of the key informants felt that with the increased flexibility and accountability for physical, behavioral, and long-term care providers would begin to work together to address the needs of the whole person, versus, as one informant stated, “What can I bill?” DHS staff report that the program has already seen some benefits of improved coordination, for example in greater scrutiny of institutional placement of children in foster care and in efforts to expedite behavioral health treatment for offenders involved in state juvenile and adult judicial systems. Several other states have begun to formally recognize the influence of social determinants of health on spending and outcomes by including requirements to address determinants like employment, criminal justice, and child care in their Medicaid contracts Several key informants representing PASSEs and provider associations cited PASSE accountability for meeting quality targets as a promising mechanism to improve beneficiary outcomes. One informant expressed confidence that the accountability would “bring quality to Medicaid like in the private industry.” Pay-for-performance models in health care have shown inconsistent associations with quality measures, with positive changes mostly in process and intermediate outcome measures All key informants representing provider associations or beneficiaries expressed their preference for provider ownership of the PASSEs instead of a traditional managed care organization, while noting that a provider-led model is “a difficult way to do it.” The requirement for PASSEs to be provider-owned draws upon evidence suggesting a benefit of provider leadership of organizations seeking to manage and change the behavior of provider groups. Among organizations managing provider groups, those with provider leadership have been associated with greater diffusion of innovation within the provider groups Most key informants cited the capitation payment structure as the primary mechanism for achieving the cost savings called for by the Governor. They expected DHS would set the capitation payments at a level that achieved most of the required savings off the top. Informants representing PASSEs or provider associations pointed to the opportunity to earn shared savings as the secondary mechanism for cost savings. Profit maximization is intended to incentivize the PASSEs to reduce costs to a point that maximizes shared savings while achieving sufficient quality to, at a minimum, comply with contract requirements and to attract an adequate number of members to stay in business, and at best earn all available quality incentive payments. Informants expressed hope that it would be through care coordination, service flexibility, and provider leadership that PASSEs achieved the spending reductions necessary to earn shared savings.3.2.2One of the planned benefits of PASSE was the considerable lead time PASSEs had to examine the claims history of their beneficiaries prior to bearing full risk for all services. PASSEs were to use the time between attribution and full-risk capitation payments to gain a more complete understanding of their risk pool and to begin to deliver intensive care coordination to prevent future costly care . Despite DHS training, to date it appears PASSEs are continuing to operate much the same as providers have in the past by, for example, simply checking in with beneficiaries once a month to assess satisfaction with services. PASSEs are required to report any alternative payment arrangements with providers, but none have been reported to date.PASSEs may be anticipating that little to no change in practice will be required. Included in this assumption is that most Tier I beneficiaries will join the program when able and select the PASSE to which their current long-term care provider belongs, allowing providers to maintain the same patient population. Two key informants representing PASSEs and provider associations expressed concern that limiting required enrollment to Tier II and Tier III beneficiaries may hinder the ability of a PASSE to manage risk. If Tier I beneficiaries remain in traditional Medicaid, the dual system may threaten both the sustainability of PASSE and the quality of care for beneficiaries, as the same pool of providers must follow requirements for two programs . The PASSEs may view this scenario as untenable and therefore unlikely to occur and continue with business as usual. However, the lack of evolution in provider practices may portend that the key care coordination component of PASSE will not fulfill the quality-enhancing and cost containment potential envisioned. The present period of transition to full risk and graduated network adequacy requirements, and the upcoming start of voluntary Tier I enrollment will reveal more about if and how the approach to services will change.Almost all key informants had concerns that there would be stinting on care due to the shift from fee-for-service to capitated payment. Under the former structure, providers profit from increasing spending, while under the latter the accountable organization profits from reduced provider spending, which can risk deterioration in health and quality of life. Most evaluations to date indicate greater negative than positive quality of care effects of Medicaid MCOs for people with BH conditions or IDD The considerable evidence of negative impacts of managed care for people with BH conditions or IDD raises questions of how PASSE beneficiaries will fare. Already a vulnerable group because of the complexity of their disabilities, PASSE beneficiaries face the added challenge of living in a high poverty, predominately rural state, perhaps rendering their well-being more sensitive to changes in the quality of Medicaid services than beneficiaries in other states. If the blend of provider and risk management leadership in the PASSEs does not lead to sufficient cost savings in short order, key informants worried that the state may modify the program to resemble a traditional MCO, with one informant noting “providers are scared to death” of managed care. Regardless of the model, some key informants representing provider associations cited the additional administrative burden of having to interact with different managed care policies and procedures, billing systems, etc.4Arkansas has blended promising elements of previous and current U.S. payment reform models in designing PASSE. Accountability for acute, behavioral and long-term services and for the coordination of non-Medicaid services, quality targets tied to payment, statewide competition for members, and the capitation payments with the opportunity to share in savings all portend positive quality of care outcomes and an absence of spending increases, if not spending decreases. However, the undesirable cost and quality outcomes of previous managed care arrangements for people with BH conditions or IDD, and the risk ambiguity presented by the dual payment systems for these populations suggest that quality improvements and spending reductions are far from certain.The success of PASSE will be challenging to quantify. PASSE administrators must establish protocols for monitoring quality of care and beneficiary outcomes and are striving to select measures that are meaningful to beneficiaries and can identify improvements or deteriorations in quality of life. Researchers, policymakers and others have identified a lack of consensus about how to assess the quality of care delivered to people with chronic conditions, and have called the gap in a meaningful evaluation strategy a “significant limitation” to monitoring the impact of Medicaid for beneficiaries with disabilities 5We are aware of several limitations of the paper. First, since PASSE is new, we are not able to present outcomes of the program. The purpose of the present study is to describe how PASSE fits within the context of Medicaid programs for beneficiaries with complex needs, and to understand the prospects for the program from the perspective of the individuals and organizations responsible for making it work. Rigorous evaluation with appropriate methods and measures of access, process, satisfaction, and outcomes will be an important next step to understand the mechanisms and effect of this type of systems change. Second, the key informants interviewed offered a particular perspective. A different set of informants may have seen different prospects for the program. The informants were chosen based on their knowledge of PASSE, their involvement in the development of PASSE, and their prominent role in determining the success of PASSE. Third, in the environmental scan of state Medicaid programs for beneficiaries with BH conditions or IDD, we may have missed relevant programs in the review of public documents and webpages.6PASSE architects have drawn from the promising elements of previous payment reforms to create a unique model of care for Medicaid beneficiaries with BH conditions or IDD. Holding each PASSE accountable for the physical, behavioral, and long-term care needs of attributed beneficiaries, directing attention to social determinants of health, requiring PASSEs to be provider-owned and include an entity with risk management experience in the ownership structure, requiring statewide coverage for each PASSE, and establishing shared savings and pay-for-performance incentives are all features anticipated to bring down costs and improve quality of care for beneficiaries. Conversely, there are concerns that shifting to a managed care structure and focusing only on beneficiaries with the most complex needs may have a negative effect on beneficiary outcomes. Will providers continue with business as usual, or will PASSE succeed in aligning the incentives to reduce spending, improve outcomes, and maximize profit? As Arkansas continues to roll out the PASSE program, other payers such as CMS, other states, commercial insurance companies, and other countries will be keen to see whether payment reform for the most vulnerable and expensive beneficiaries can achieve improvements in costs or quality.The research reported herein was performed pursuant to a grant from the U.S. Social Security Administration (SSA) funded as part of the Disability Research Consortium. The opinions and conclusions expressed are solely those of the author(s) and do not represent the opinions or policy of SSA or any agency of the Federal Government. Neither the United States Government nor any agency thereof, nor any of their employees, makes any warranty, expressed or implied, or assumes any legal liability or responsibility for the accuracy, completeness, or usefulness of the contents of this report. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not necessarily constitute or imply endorsement, recommendation or favoring by the United States Government or any agency thereof. Additionally, the third author was funded by a Robert Wood Johnson Foundation Health Policy Fellowship.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.