The preparation phase in the multiphase optimization strategy (MOST): a systematic review and introduction of a reporting checklist

Investigating the Relation of Political Orientation and Vaccination Outcomes: Identifying the Roles of Political Ideology, Party Affiliation, and Vaccine Hesitancy

Popular press and academic articles alike suggest that political orientation is a primary determinant of vaccination willingness, vaccination, and vaccine word-of-mouth (i.e., sharing of information regarding vaccines). In the current article, we test the validity of these suggestions, and we also assess the differential roles of political ideology (e.g., liberal-conservative) and party affiliation (e.g., Democrat-Republican) as well as the mediating effect of vaccine hesitancy's dimensions. To do so, we perform a four-wave survey study with 223 participants that completed all waves. Our results support that political orientation indeed relates to our outcomes of interest. Our results also show that political ideology has a more pronounced effect than party affiliation, and the vaccine hesitancy dimensions of Health Risks and Healthy mediate many of these relations. From these results, we suggest many directions for future research and practice, including the integration of political discourse theories in studies on political orientations and vaccination.

Using the Preparation Phase of the Multiphase Optimization Strategy to Design an Antiextremism Program in Bahrain: Formative and Pilot Research

BACKGROUND

Extremism continues to raise concerns about conflict and violent attacks that can lead to deaths, injuries, trauma, and stress. Adolescents are especially vulnerable to radicalization by extremists. Given its location in a region that often experiences extremism, Bahrain developed 4 peaceful coexistence lessons and 4 antiextremism lessons to be implemented as part of their Drug Abuse Resistance Education (D.A.R.E.) program.

OBJECTIVE

The aim of this study is to report the results of the preparation phase of the multiphase optimization strategy (MOST) to develop a peaceful coexistence program and an antiextremism program implemented by D.A.R.E. officers in Bahrain.

METHODS

We developed conceptual models for the peaceful coexistence and antiextremism programs, indicating which mediators each lesson should target, the proximal outcomes that should be shaped by these mediators, and the distal and ultimate outcomes that the intervention should change. We recruited 20 middle schools to pilot test our research protocol, survey measures, and the existing intervention lessons. A total of 854 seventh and ninth grade students completed a pretest survey, 4 peaceful coexistence intervention lessons, and an immediate posttest survey; and a total of 495 ninth grade students completed the pretest survey, 4 antiextremism lessons, and an immediate posttest survey. A series of 3-level models, nesting students within classrooms within schools, tested mean differences from pretest to posttest.

RESULTS

Pilot test results indicated that most measures had adequate reliability and provided promising evidence that the existing lessons could change some of the targeted mediators and proximal outcomes. Specifically, students who completed the peaceful coexistence lessons reported significant changes in 5 targeted mediating variables (eg, injunctive norms about intolerance, P<.001) and 3 proximal outcomes [eg, social skills empathy (P=.008); tolerance beliefs (P=.041)]. Students who completed the antiextremism lessons reported significant changes in 3 targeted mediators [eg, self-efficacy to use resistance skills themselves (P<.001)], and 1 proximal outcome (ie, social skills empathy, P<.001).

CONCLUSIONS

An effective antiextremism program has the potential to protect youth from radicalization and increase peaceful coexistence. We used the preparation phase of MOST to (1) develop a conceptual model, (2) identify the 4 lessons in each program as the components we will evaluate in the optimization phase of MOST, (3) pilot test the existing lessons, our newly developed measures, and research protocol, and (4) determine that our optimization objective will be all effective components. We will use these results to revise the existing lessons and conduct optimization trials to evaluate the efficacy of the individual lessons.

Intervention Optimization: A Paradigm Shift and Its Potential Implications for Clinical Psychology

To build a coherent knowledge base about what psychological intervention strategies work, develop interventions that have positive societal impact, and maintain and increase this impact over time, it is necessary to replace the classical treatment package research paradigm. The multiphase optimization strategy (MOST) is an alternative paradigm that integrates ideas from behavioral science, engineering, implementation science, economics, and decision science. MOST enables optimization of interventions to strategically balance effectiveness, affordability, scalability, and efficiency. In this review we provide an overview of MOST, discuss several experimental designs that can be used in intervention optimization, consider how the investigator can use experimental results to select components for inclusion in the optimized intervention, discuss the application of MOST in implementation science, and list future issues in this rapidly evolving field. We highlight the feasibility of adopting this new research paradigm as well as its potential to hasten the progress of psychological intervention science.

Optimization of implementation strategies using the Multiphase Optimization STratgey (MOST) framework: Practical guidance using the factorial design

The Multiphase Optimization STrategy (MOST) is a framework that uses three phases-preparation, optimization, and evaluation-to develop multicomponent interventions that achieve intervention EASE by strategically balancing Effectiveness, Affordability, Scalability, and Efficiency. In implementation science, optimization of the intervention requires focus on the implementation strategies-things that we do to deliver the intervention-and implementation outcomes. MOST has been primarily used to optimize the components of the intervention related to behavioral or health outcomes. However, innovative opportunities to optimize discrete (i.e. single strategy) and multifaceted (i.e. multiple strategies) implementation strategies exist and can be done independently, or in conjunction with, intervention optimization. This article details four scenarios where the MOST framework and the factorial design can be used in the optimization of implementation strategies: (i) the development of new multifaceted implementation strategies; (ii) evaluating interactions between program components and a discrete or multifaceted implementation strategies; (iii) evaluating the independent effects of several discrete strategies that have been previously evaluated as a multifaceted implementation strategy; and (iv) modification of a discrete or multifaceted implementation strategy for the local context. We supply hypothetical school-based physical activity examples to illustrate these four scenarios, and we provide hypothetical data that can help readers make informed decisions derived from their trial data. This manuscript offers a blueprint for implementation scientists such that not only is the field using MOST to optimize the effectiveness of an intervention on a behavioral or health outcome, but also that the implementation of that intervention is optimized.

Using Multiphase Optimization Strategy and Human-Centered Design to Create an Integrated Model of Palliative Care Skills in Home-Based Physical Therapy for Advanced Heart Failure

Background: Many older adults with advanced heart failure receive home health rehabilitation after hospitalization. Yet, integration of palliative care skills into rehabilitation is limited. Objective: Describe using the Multiphase Optimization Strategy (MOST) framework with human-centered design principles to engage clinical partners in the Preparation phase of palliative physical therapy intervention development. Design: We convened a home-based physical therapy advisory team (four clinicians, three clinical leaders) to identify physical therapist needs and preferences for incorporating palliative care skills in rehabilitation and design an intervention prototype. Results: Between 2022 and 2023, we held five advisory team meetings. Initial feedback on palliative care skill preferences and training needs directly informed refinement of our conceptual model and skills in the intervention prototype. Later feedback focused on reviewing and revising intervention content, delivery strategy, and training considerations. Conclusion: Incorporating human-centered design principles within the MOST provided a useful framework to partner with clinical colleagues in intervention design.

Evaluation of a long day care intervention targeting the mealtime environment and curriculum to increase children's vegetable intake: a cluster randomised controlled trial using the multiphase optimisation strategy framework

OBJECTIVE

To determine the reach, adoption, implementation and effectiveness of an intervention to increase children's vegetable intake in long day care (LDC).

DESIGN

A 12-week pragmatic cluster randomised controlled trial, informed by the multiphase optimisation strategy (MOST), targeting the mealtime environment and curriculum. Children's vegetable intake and variety was measured at follow-up using a modified Short Food Survey for early childhood education and care and analysed using a two-part mixed model for non-vegetable and vegetable consumers. Outcome measures were based on the RE-AIM framework.

SETTING

Australian LDC centres.

PARTICIPANTS

Thirty-nine centres, 120 educators and 719 children at follow-up.

RESULTS

There was no difference between intervention and waitlist control groups in the likelihood of consuming any vegetables when compared with non-vegetable consumers for intake (OR = 0·70, (95 % CI 0·34-1·43), P = 0·32) or variety (OR = 0·73 (95 % CI 0·40-1·32), P = 0·29). Among vegetable consumers (n 652), there was no difference between groups in vegetable variety (exp(b): 1·07 (95 % CI:0·88-1·32, P = 0·49) or vegetable intake (exp(b): 1·06 (95 % CI: 0·78, 1·43)), P = 0·71) with an average of 1·51 (95 % CI 1·20-1·82) and 1·40 (95 % CI 1·08-1·72) serves of vegetables per day in the intervention and control group, respectively. Intervention educators reported higher skills for promoting vegetables at mealtimes, and knowledge and skills for teaching the curriculum, than control (all P < 0·001). Intervention fidelity was moderate (n 16/20 and n 15/16 centres used the Mealtime environment and Curriculum, respectively) with good acceptability among educators. The intervention reached 307/8556 centres nationally and was adopted by 22 % eligible centres.

CONCLUSIONS

The pragmatic self-delivered online intervention positively impacted educator's knowledge and skills and was considered acceptable and feasible. Intervention adaptations, using the MOST cyclic approach, could improve intervention impact on children' vegetable intake.

Determining the Right Levels of Health Coaching and Heart Rate Variability Biofeedback in a Workplace Behavior Change Intervention: Multiphase Optimization Strategy Preparation Study

BACKGROUND

Work-related stress is associated with poor job performance and negative health outcomes. Changing health behaviors through corporate wellness programs can improve physical and mental health and help employees manage stress. This project sought to pilot the potential addition of brief coaching and biofeedback to an 8-week web-based self-help program to improve employee stress using the multiphase optimization strategy.

OBJECTIVE

This study aims to determine which candidate components will be tested in a later optimization phase and at what dose they will be tested, examine the feasibility and acceptability of delivering the different components, investigate whether the outcomes can be feasibly measured, and review evidence to build a conceptual model before the optimization phase.

METHODS

The study was positioned within the preparation phase of the multiphase optimization strategy. It is a 2×2×2×2 design with 4 components: 2 types of health coaching and 2 types of biofeedback. All components were tested by turning them on or off. A total of 16 adult office workers (mean age 40, SD 14.3 years; n=15 women) completed an 8-week self-paced web-based stress management and health behavior change program and were randomly assigned to 1 of the 16 conditions, created from a combination of the 4 candidate components. Assessments included web analytics, surveys, and interviews regarding program recommendations, likes, and dislikes.

RESULTS

Findings from the interviews provided suggestions to improve the intervention (eg, separating wellness from stress content) and trial conduct (eg, streamlining the onboarding process). On average, participants logged into the wellness program 83 times (range 36-291), with 75% (12/16) participant retention and 67% (8/12) survey completion. There were no reported problems with coaching or obtaining data from interviews or apps. The interview findings suggested potential mediators to include and assess in a future conceptual model.

CONCLUSIONS

The results provided areas to improve the intervention content and trial methods. Instead of progressing to the next scheduled large-scale optimization phase, our plan to iterate through a second preparation phase after making changes to the protocol, apps, and corporate coaching partner.

Development of an initiatives package to increase children's vegetable intake in long day care centres using the Multiphase Optimisation Strategy (MOST) randomised factorial experiment

OBJECTIVE

To inform a package of initiatives to increase children's vegetable intake while in long day care (LDC) by evaluating the independent and combined effects of three initiatives targeting food provision, the mealtime environment and the curriculum.

DESIGN

Using the Multiphase Optimisation Strategy (MOST) framework, a 12-week, eight-condition (n 7 intervention, n 1 control) randomised factorial experiment was conducted. Children's dietary intake data were measured pre- and post-initiative implementation using the weighed plate waste method (1× meal and 2× between-meal snacks). Vegetable intake (g/d) was calculated from vegetable provision and waste. The optimal combination of initiatives was determined using a linear mixed-effects model comparing between-group vegetable intake at follow-up, while considering initiative fidelity and acceptability.

SETTING

LDC centres in metropolitan Adelaide, South Australia.

PARTICIPANTS

32 centres, 276 staff and 1039 children aged 2-5 years.

RESULTS

There were no statistically significant differences between any of the intervention groups and the control group for vegetable intake (all P > 0·05). The curriculum with mealtime environment group consumed 26·7 g more vegetables/child/day than control (ratio of geometric mean 3·29 (95 % CI 0·96, 11·27), P = 0·06). Completion rates for the curriculum (> 93 %) and mealtime environment (61 %) initiatives were high, and acceptability was good (4/5 would recommend), compared with the food provision initiative (0-50 % completed the menu assessment, 3/5 would recommend).

CONCLUSION

A programme targeting the curriculum and mealtime environment in LDC may be useful to increase children's vegetable intake. Determining the effectiveness of this optimised package in a randomised controlled trial is required, as per the evaluation phase of the MOST framework.

Mobile Health (mHealth) Interventions to Increase Cancer Screening Rates in Hispanic/Latinx Populations: A Scoping Review

Hispanic/Latinx persons have disproportionately lower breast, cervical, and colorectal cancer screening rates than non-Hispanic White (NHW) persons. This low participation in cancer screening results in late-stage cancer diagnosis among Hispanic persons compared to NHW persons. Mobile health (mHealth) interventions effectively improve cancer screening rates in the general population; however, few reviews about mHealth interventions are tailored to Hispanic populations. This is important to investigate given that Hispanic persons differ from NHW persons with regard to culture, language, and health care utilization. Therefore, in this study, we investigated: (a) What types of mHealth interventions have been undertaken to increase cancer screening rates among Hispanic persons in the United States? (b) How effective have these interventions been? and (c) What features of these interventions help increase cancer screening rates? Searches conducted during December 2020 identified 10 articles published between January 2017 and December 2020 that met our inclusion criteria. The review revealed that mHealth interventions mainly provided education about cancer and cancer screening using videos, PowerPoint slides, and interactive multimedia. mHealth interventions that effectively improved screening behavior were mainly for easy-to-screen cancers like skin and cervical cancer. Finally, reviewed studies did not provide details on how cultural adaptations were made, and it is unclear what specific features of mHealth interventions increase cancer screening rates among Hispanic persons. Future research should identify and evaluate the effects of different components of culturally tailored interventions on cancer screening. Public health practitioners and health care providers should tailor mHealth approaches to their clients or patients and practice environment.

Development and acceptability of behavioral interventions promoting mothers' brushing of pre-school children's teeth: The preparation phase of the multi-phase optimization strategy framework

BACKGROUND

Early childhood caries can be prevented through regular parental-supported toothbrushing, indicating the importance of behavior modification interventions targeting parents. Mobile oral health (m-oral health) interventions are gaining increased popularity although their production is not always based on solid theoretical frameworks and evidence about the efficacy of individual intervention components is not available. The Multiphase Optimization Strategy (MOST) offers a framework to develop complex m-oral health interventions and assessing the efficacy of individual components.

AIM

This study describes the development and assesses the acceptability of 3 intervention components using MOST to promote mothers' brushing of their preschool children's teeth.

METHODS

The Theory of Planned Behavior guided the development of 3 components: motivational interviewing (MI), storytelling videos (STVs), and oral health promotion messages (OHPMs). A researcher received training to conduct MI. Twenty-four OHPMs were developed, and 14 STVs scripts were developed based on the "And, But, Therefore" framework. A feasibility pilot study was conducted to determine the optimization objective and assess mothers' preferences regarding the frequency and timing of receiving the intervention components. The mothers participated in a semi-structured interview to assess the acceptability of the components using 7 open-ended questions based on the framework of acceptability and thematic analysis was used to analyze the qualitative data. The mothers also responded to questions assessing the perceived and experienced acceptability of the components using close-ended questions. Descriptive statistics were presented as means and standard deviations for continuous variables and median and interquartile range for categorical variables.

RESULTS

Sixteen mothers were included. The mothers expressed positive affective attitude towards the interventions. They felt the components served as "good reminders" to brush their children's teeth. However, "time" was a burden for the mothers. 80% of the mothers preferred receiving the OHPMs and STVs once per week, from 8 pm to 2 am (50%), and 60% indicated they can set 15-30 min to receiving the interventions.

CONCLUSION

The 3 components were acceptable to the mothers. The OHPMs and STVs will be sent to the mothers once per week, between 8 pm to 2 am. The MI and follow-up phone calls will be limited to 15 min.

Suubi + Adherence4Youth: a study protocol to optimize the Suubi Intervention for Adherence to HIV treatment for youth living with HIV in Uganda

BACKGROUND

Suubi is an evidenced based multi-component intervention that targets psychosocial and economic hardships to improve ART adherence, viral suppression, mental health, family financial stability, and family cohesion for adolescents living with HIV (ALHIV) in Uganda. Suubi was originally tested as a combined package of four components: 1) Financial Literacy Training; 2) incentivized matched Youth Savings Accounts with income-generating activities; 3) a manualized and visual-based intervention for ART adherence and stigma reduction; and 4) engagement with HIV treatment-experienced role models. However, it is unknown if each component in Suubi had a positive effect, how the components interacted, or if fewer components could have produced equivalent effects. Hence, the overall goal of this new study is to identify the most impactful and sustainable economic and psychosocial components across 48 health clinics in Uganda.

METHODS

A total of 576 ALHIV (aged 11-17 years at enrollment) will be recruited from 48 clinics and each clinic will be randomized to one of 16 study conditions. Each condition represents every possible combination of the 4 components noted above. Assessments will be conducted at baseline, 12, 24, 36 and 48- months post-intervention initiation. Using the multi-phase optimization strategy (MOST), we will identify the optimal combination of components and associated costs for viral suppression, as well as test key mediators and moderators of the component-viral suppression relationship.

DISCUSSION

The study is a shift in the paradigm of research to use new thinking to build/un-pack highly efficacious interventions that lead to new scientific knowledge in terms of understanding what drives an intervention's success and how to iterate on them in ways that are more efficient, affordable and scalable. The study advances intervention science for HIV care outcomes globally.

TRIAL REGISTRATION

This project was registered at clinicaltrials.gov (NCT05600621) on October, 31, 2022. https://clinicaltrials.gov/ct2/show/NCT05600621.

A factorial experiment grounded in the multiphase optimization strategy to promote viral suppression among people who inject drugs on the Texas-Mexico border: a study protocol

BACKGROUND

People who inject drugs living with HIV (PWIDLH) suffer the lowest rates of HIV viral suppression due to episodic injection drug use and poor mental health coupled with poor retention in HIV care. Approximately 44% of PWIDLH along the US-Mexico border are retained in care and only 24% are virally suppressed. This underserved region faces a potential explosion of transmission of HIV due to highly prevalent injection drug use. This protocol describes an optimization trial to promote sustained viral suppression among Spanish-speaking Latinx PWIDLH.

METHODS

The multiphase optimization strategy (MOST) is an engineering-inspired framework for designing and building optimized interventions and guides this intervention. The primary aim is to conduct a 24 factorial experiment in which participants are randomized to one of 16 intervention conditions, with each condition comprising a different combination of four behavioral intervention components. The components are peer support for methadone uptake and persistence; behavioral activation therapy for depression; Life-Steps medication adherence counseling; and patient navigation for HIV care. Participants will complete a baseline survey, undergo intervention, and then return for 3-,6-,9-, and 12-month follow-up assessments. The primary outcome is sustained viral suppression, defined as viral loads of < 40 copies per mL at 6-,9-, and 12-month follow-up assessments. Results will yield effect sizes for each component and each additive and interactive combination of components. The research team and partners will make decisions about what constitutes the optimized multi-component intervention by judging the observed effect sizes, interactions, and statistical significance against real-world implementation constraints. The secondary aims are to test mediators and moderators of the component-to-outcome relationship at the 6-month follow-up assessment.

DISCUSSION

We are testing well-studied and available intervention components to support PWIDLH to reduce drug use and improve their mental health and engagement in HIV care. The intervention design will allow for a better understanding of how these components work in combination and can be optimized for the setting.

TRIAL REGISTRATION

This project was registered at clinicaltrials.gov (NCT05377463) on May 17th, 2022.

Components of smartphone cognitive-behavioural therapy for subthreshold depression among 1093 university students: a factorial trial

BACKGROUND

Internet-based cognitive-behavioural therapy (iCBT) is effective for subthreshold depression. However, which skills provided in iCBT packages are more effective than others is unclear. Such knowledge can inform construction of more effective and efficient iCBT programmes.

OBJECTIVE

To examine the efficacy of five components of iCBT for subthreshold depression.

METHODS

We conducted an factorial trial using a smartphone app, randomly allocating presence or absence of five iCBT skills including self-monitoring, behavioural activation (BA), cognitive restructuring (CR), assertiveness training (AT) and problem-solving. Participants were university students with subthreshold depression. The primary outcome was the change on the Patient Health Questionnaire-9 (PHQ-9) from baseline to week 8. Secondary outcomes included changes in CBT skills.

FINDINGS

We randomised a total of 1093 participants. In all groups, participants had a significant PHQ-9 reduction from baseline to week 8. Depression reduction was not significantly different between presence or absence of any component, with corresponding standardised mean differences (negative values indicate specific efficacy in favour of the component) ranging between -0.04 (95% CI -0.16 to 0.08) for BA and 0.06 (95% CI -0.06 to 0.18) for AT. Specific CBT skill improvements were noted for CR and AT but not for the others.

CONCLUSIONS

There was significant reduction in depression for all participants regardless of the presence and absence of the examined iCBT components.

CLINICAL IMPLICATION

We cannot yet make evidence-based recommendations for specific iCBT components. We suggest that future iCBT optimisation research should scrutinise the amount and structure of components to examine.

TRIAL REGISTRATION NUMBER

UMINCTR-000031307.

Developing mHealth Interventions with Implementation in Mind: Application of the Multiphase Optimization Strategy (MOST) Preparation Phase to Diabetes Prevention Programming (Preprint)

With thousands of mobile health (mHealth) solutions on the market, patients and health care providers struggle to identify which solution to use and prescribe. The lack of evidence-based mHealth solutions may be because of limited research on intervention development and the continued use of traditional research methods for mHealth evaluation. The Multiphase Optimization Strategy (MOST) is a framework that aids in developing interventions that produce the best-expected outcomes (ie, effectiveness), given constraints imposed on affordability, scalability, and efficiency (also known as achieving intervention EASE). The preparation phase of the MOST highlights the importance of formative intervention development—a stage often overlooked and rarely published. The aim of the preparation phase of the MOST is to identify candidate intervention components, create a conceptual model, and define the optimization objective. Although the MOST sets these 3 targets, no guidance is provided on how to conduct quality research within the preparation phase and what specific steps can be taken to identify potential intervention components, develop the conceptual model, and achieve intervention EASE with the implementation context in mind. To advance the applicability of the MOST within the field of implementation science, this study provides an account of the methods used to develop an mHealth intervention using the MOST. Specifically, we provide an example of how to achieve the goals of the preparation phase by outlining the formative development of an mHealth-prompting intervention within a diabetes prevention program. In addition, recommendations are proposed for future researchers to consider when conducting formative research on mHealth interventions with implementation in mind. Given its considerable reach, mHealth has the potential to positively affect public health by decreasing implementation costs and improving accessibility. The MOST is well-suited for the efficient development and optimization of mHealth interventions. By using an implementation-focused lens and outlining the steps in developing an mHealth intervention using the preparation phase of the MOST, this study may guide future intervention developers toward maximizing the impact of mHealth outside academia.

Human-centered design methods to achieve preparation phase goals in the multiphase optimization strategy framework

Background

The public health impact of behavioral and biobehavioral interventions to prevent and treat mental health and substance use problems hinges on developing methods to strategically maximize their effectiveness, affordability, scalability, and efficiency.

Methods

The multiphase optimization strategy (MOST) is an innovative, principled framework that guides the development of multicomponent interventions. Each phase of MOST (Preparation, Optimization, Evaluation) has explicit goals and a range of appropriate research methods to achieve them. Methods for attaining Optimization and Evaluation phase goals are well-developed. However, methods used in the Preparation phase are often highly researcher-specific, and concrete ways to achieve Preparation phase goals are a priority area for further development.

Results

We propose that the discover, design, build, and test (DDBT) framework provides a theory-driven and methods-rich roadmap for achieving the goals of the Preparation phase of MOST, including specifying the conceptual model, identifying and testing candidate intervention components, and defining the optimization objective. The DDBT framework capitalizes on strategies from the field of human-centered design and implementation science to drive its data collection methods.

Conclusions

MOST and DDBT share many conceptual features, including an explicit focus on implementation determinants, being iterative and flexible, and designing interventions for the greatest public health impact. The proposed synthesized DDBT/MOST approach integrates DDBT into the Preparation phase of MOST thereby providing a framework for rigorous and efficient intervention development research to bolster the success of intervention optimization.

Plain Language Summary

1. What is already known about the topic? Optimizing behavioral interventions to balance effectiveness with affordability, scalability, and efficiency requires a significant investment in intervention development.2. What does this paper add? This paper provides a structured approach to integrating human-centered design principles into the Preparation phase of the multiphase optimization strategy (MOST).3. What are the implications for practice, research, or policy? The proposed synthesized model provides a framework for rigorous and efficient intervention development research in the Preparation phase of MOST that will ensure the success of intervention optimization and contribute to improving public health impact of mental health and substance use interventions.