Implementation research: new imperatives and opportunities in global health

Challenges in Implementing Artificial Intelligence in Breast Cancer Screening Programs: Systematic Review and Framework for Safe Adoption

BACKGROUND

Artificial intelligence (AI) studies show promise in enhancing accuracy and efficiency in mammographic screening programs worldwide. However, its integration into clinical workflows faces several challenges, including unintended errors, the need for professional training, and ethical concerns. Notably, specific frameworks for AI imaging in breast cancer screening are still lacking.

OBJECTIVE

This study aims to identify the challenges associated with implementing AI in breast screening programs and to apply the Consolidated Framework for Implementation Research (CFIR) to discuss a practical governance framework for AI in this context.

METHODS

Three electronic databases (PubMed, Embase, and MEDLINE) were searched using combinations of the keywords "artificial intelligence," "regulation," "governance," "breast cancer," and "screening." Original studies evaluating AI in breast cancer detection or discussing challenges related to AI implementation in this setting were eligible for review. Findings were narratively synthesized and subsequently mapped directly onto the constructs within the CFIR.

RESULTS

A total of 1240 results were retrieved, with 20 original studies ultimately included in this systematic review. The majority (n=19) focused on AI-enhanced mammography, while 1 addressed AI-enhanced ultrasound for women with dense breasts. Most studies originated from the United States (n=5) and the United Kingdom (n=4), with publication years ranging from 2019 to 2023. The quality of papers was rated as moderate to high. The key challenges identified were reproducibility, evidentiary standards, technological concerns, trust issues, as well as ethical, legal, societal concerns, and postadoption uncertainty. By aligning these findings with the CFIR constructs, action plans targeting the main challenges were incorporated into the framework, facilitating a structured approach to addressing these issues.

CONCLUSIONS

This systematic review identifies key challenges in implementing AI in breast cancer screening, emphasizing the need for consistency, robust evidentiary standards, technological advancements, user trust, ethical frameworks, legal safeguards, and societal benefits. These findings can serve as a blueprint for policy makers, clinicians, and AI developers to collaboratively advance AI adoption in breast cancer screening.

TRIAL REGISTRATION

PROSPERO CRD42024553889; https://tinyurl.com/mu4nwcxt.

Social and health impacts of exoskeleton use on care workers

BackgroundIn many countries, the growing shortage of care workers versus the growing number of people needing care is causing concern. In this healthcare transformation, exoskeletons, a form of wearable robotics, have been introduced as a means to aid care workers in their physically demanding and ergonomically challenging work.ObjectiveThis study investigated the human impacts of exoskeleton use in care work. We followed a mixed-methods research approach, presenting a novel combination of qualitative and quantitative research.MethodsWe conducted a three-week trial of an exoskeleton with eight assistant nurses in a round-the-clock care home. Qualitative data consist of pre-interviews, post-interviews and user diaries. Quantitative data were collected via physiological measurements.ResultsSeveral types of social and health impacts of exoskeleton use were identified. The qualitative analysis revealed physical, mental, work practice and learning-related impacts. The exoskeleton was most useful in bed care activities. The physiological measurement results demonstrated a trend-like reduction in muscle activity throughout the workday and in different work tasks when using the exoskeleton. The exoskeleton did not have an impact on metabolic strain or perceived exertion but did increase perceived discomfort after the measured work shift when using the exoskeleton.ConclusionsBoth the qualitative and quantitative results suggest that there is potential for exoskeleton use in care work environments if sufficient attention is paid to its essential prerequisites. These include the care work and tasks in question, care workers' interests and competences, the environment, planning and organisation of the work, managerial practices and clients' health.

Examining barriers and facilitators of dental fear treatment adoption: A qualitative study of practicing dentists

Over fifteen percent of the global population experiences dental fear, and although evidence-based treatments exist, adoption of these treatments is almost non-existent. Informed by our prior research examining barriers to adopting face-to-face behavioral treatments in dental operatories, this study examined dentists' responses to three stepped-care Cognitive Behavioral Therapy for Dental Fear (CBT-DF) formats that use technology. All approaches offer an automated component as the first step (a mobile app) and either an in-person, virtual reality (VR), or video telehealth session as the second step. This study aims to understand which of these approaches would most likely be adopted by private practice dentists and why. Eight focus groups/solo interviews with a total of 13 private practice dentists were conducted with the aim to assess barriers and facilitators to implementing three stepped-care approaches of CBT-DF. The qualitative data obtained from these interviews was coded and analyzed according to Rogers' framework of innovation (relative advantage, compatibility, complexity, trialability, and observability). The results indicated that participants acknowledged the value of interventions to address dental fear, as they had personal experiences with fearful patients that impacted their practices. Participants responded positively to the automated component of treatment (the app) and were more wary of treatment options requiring office space and staff time (in-person VR and in-person mental health provider). The telehealth option received the most favorable response, although some doubts were expressed regarding relative efficacy and patient accountability. Thus, dissemination of an app-telehealth treatment model that allows dentists to serve as referral partners is promising, given dentists' incentives to decrease patient fear while avoiding opportunity cost (e.g., occupied chairs and staff time).

Medical preparedness for bioterrorism and chemical warfare: A public health integration review

Global public health faces a major danger from chemical and biological weapon-related terrorism which requires comprehensive emergency preparedness and response strategies. This review investigates present-day public health measures against bioterrorism by focusing on an all-hazards framework which unifies traditional and nontraditional threats. The review evaluates federal programs that boost state and local health systems through funding, distribution and team-based partnerships and technological innovation. The primary emergency response elements consist of identifying outbreaks early and improving surveillance together with using state-of-the-art diagnostic tools to detect biological and chemical agents. The review emphasizes the necessity of maintaining healthcare provider education alongside preparations of full medical readiness plans as well as strategic approaches for safeguarding defenseless groups. This paper investigates resource constraints and governmental agency coordination challenges during biowarfare emergencies. The review examines nucleic-acid-based diagnostic and sensor network innovations as vital components for real-time biological agent detection systems. The review emphasizes the vital role of community involvement together with psychological resistance training in addition to continued pathogen behavior study and protection research. The review demonstrates that successful bioterrorism risk reduction depends on advanced integrated protection strategies which combine state agency collaboration with state of the art monitoring techniques and strengthened public health systems.

How valuable is an implementation toolkit for midwives? An exploratory study

BACKGROUND

Incorporating evidence-based approaches in maternity care throughout the entire trajectory from pregnancy through to the postnatal phase is integral to good public health. Yet, despite developing theories, frameworks, and models to guide midwives' implementation efforts, implementing new evidence-based practices in midwifery practice settings remains challenging.

METHODS

An exploratory study design was used to conduct an initial assessment of the appeal and suitability of an implementation 'how to' Toolkit for Australian change-leader midwives. We aimed to determine the effectiveness of the intervention by evaluating midwives' experience of using the Toolkit, and report on the usability of the Toolkit in maternity care. We also sought to establish the degree to which the intervention could reach a broad cross-section of midwives, confirming the usability of the Toolkit across a range of public and private maternity services.

RESULTS

Twenty-four midwives participated in our study. Participants provided practical Toolkit evaluation data, contextual information related to Toolkit content, their understanding of what implementation in a healthcare context is, and factors that hindered midwives' implementation efforts in clinical settings. The importance of co-design research and involving end-users in product development were also highlighted as crucial factors underpinning the effectiveness of resources like ours, particularly those designed to support specialist disciplines and the implementation challenges experienced by health practitioners in clinical environments.

CONCLUSIONS

It is crucial to progress health care practitioners understanding of how to accelerate the implementation and sustainment of new evidence-based practices in clinical settings, including strategies to support organisational readiness, local barriers or challenges, and partnerships between researchers and end-users. Evaluation of our midwifery-specific implementation Toolkit indicates health professionals require tailored materials and information specific to their disciplines and clinical work environments; ideally, packaged in a centalised, open-access format. Future research is required to evaluate the mid-to-longterm impact of our Toolkit on implementation initiatives in midwifery contexts, and to establish the adaptability of our Toolkit in other settings, and with other disciplines.

The state of implementation science in major depressive disorder: A narrative review

Major depressive disorder (MDD) is one of the most prevalent and disabling mental disorders with high recurrence rate. There is often a gap between scientific evidence related to the effective and cost-effective treatment of depression and clinical practice. Implementation science is a field of inquiry that aims to advance the process of applying evidence-based interventions to real-world problems. Implementation research consists of two broad phases. The first phase seeks to identify the gaps that exist between evidence and practice and their impact on outcomes. The second phase, building on the first, evaluates the effectiveness of implementation strategies by examining various implementation indicators to support the adoption and scale up of interventions. Although implementation research can facilitate the uptake and adoption of evidence-based interventions, it is underused in depression research. In this narrative review, the authors will introduce the definition of implementation science and the state of implementation science in MDD in order to support more widespread use of implementation science for scaling up evidence-based interventions.

Factors Associated with Nonspecialist Quality of Delivery within a Family Strengthening Intervention in Rwanda: a Parallel Latent Growth Model

In task-shared, mental health, and psychosocial support interventions, monitoring the quality of delivery (fidelity and competence) of nonspecialist providers is critical. Quality of delivery is frequently reported in brief, summary statistics, and while both fidelity and competence scores tend to be high, rarely have factors associated with quality of delivery in low-resource, mental health, and psychosocial support interventions been examined using inferential statistics. Understanding both modifiable and non-modifiable predictors of quality of delivery is important for adapting training and supervision approaches throughout intervention delivery. In this study, we use a parallel process latent growth model to examine the association of non-modifiable, demographic characteristics of nonspecialists and changes in both fidelity and competence over time. We find that nonspecialist age is significantly associated with higher initial fidelity and competence scores and smaller improvements in fidelity and competence over time, although this finding is interpreted in the presence of ceiling effects. In addition, nonspecialists in a certain district were more likely to have higher initial fidelity and competence scores but also see smaller changes over time. Fidelity and competence were found to significantly co-vary. This study provides conceptual and measurement guidance regarding quality of delivery, suggesting that fidelity and competence are theoretically distinct and must be measured separately, but linked together under the umbrella of quality of delivery. This study also has implications for recruiting, training, and supporting nonspecialists delivering behavioral interventions, suggesting that future implementation teams can further contribute to research on how to better support high-quality training, supervision, and personal and professional growth among the growing nonspecialist workforce globally.

What is needed to address psychosocial hazards in road transport? Using implementation science to understand the gaps

Work-related psychosocial hazards have a significant influence on the development of musculoskeletal and mental health disorders (MSDs and MHDs). This study used behavioural change theory to guide understanding of barriers and enablers for leaders working in the Heavy Vehicle Road Transport industry, to address workplace psychosocial hazards. The findings will be used to inform design of a future intervention to support leaders to more effectively address these hazards. Principal results and major conclusions: A higher number of barriers than enablers were identified. The most prevalent barriers were inadequate knowledge and interpersonal skills, and environmental context and inadequate resources, and the most prevalent enabler was risk management. The findings extend previous evidence by providing more specific detail regarding requirements for addressing psychosocial hazards. Further, the findings identified there is a need to improve the capability, opportunity and motivation of leaders to enable them to more effectively address psychosocial hazards.

Prioritising and including children in intersectoral policymaking: uncovering Immunity to Change in Ghana

Despite strong commitments to improving children's well-being, nearly a third of Ghanaian children aged 36-59 months are not developmentally on track, with additional challenges due to the COVID-19 pandemic. Improvements in children's health and well-being rely on effective intersectoral policies, however, not enough is known about how to achieve this in practice, particularly in low- and middle-income countries. We report on a case study of participatory intersectoral policymaking for child health in Ghana in 2021, feeding into the national Early Childhood Care and Development Policy. We used systematic methods to analyse policy documents from 22 Ministries, Departments and Agencies; procedural outputs from national policy convenings; and children's inputs via a national competition, worksheets at a policy convening and video interviews. Data sources were analysed separately using content analysis for real-time application of findings into the policy process. Subsequently, data were re-analysed together, using an 'insider-outsider' approach, to provide a holistic view of the policy process. Beyond traditional child-centred policy areas (ie, health, education, youth and sports, social protection), most ministries lacked budgeted child-specific policies, partly because policymakers felt this was outside their mandate. Analysing children's inputs to the policy process showed they had substantive policy ideas on their health and well-being that were intersectoral in nature. While underlying social and cultural assumptions about children's place in society impeded their participation in policymaking, stakeholders nonetheless expressed their commitment to amplifying and institutionalising children's contributions. Our study adds evidence on how to operationalise intersectoral partnerships, including by mapping mandates, budgets and roles across different functions and levels of government, with the mobilising participation of civil society. We also report on new mechanisms for including children's perspectives in policymaking. Our findings have implications for child health policy and for other health initiatives that require effective intersectoral, participatory approaches.

Engaging stakeholders in Non-communicable diseases (NCDs) Implementation Research in low- and middle-income countries (LMICs): a scoping review protocol

INTRODUCTION

Non-communicable diseases (NCDs) present a significant health challenge globally, especially in low- and middle-income countries (LMICs). Effective Implementation Research (IR) is vital in addressing this challenge, with stakeholder engagement playing a crucial role. However, the landscape of stakeholder engagement in NCD IR within LMICs faces unique challenges, including resource constraints and power imbalances. Despite these challenges, stakeholder engagement offers substantial benefits, including improved research relevance and sustainability of interventions.

METHODS AND ANALYSIS

This scoping review aims to comprehensively describe the current practices of stakeholder engagement in NCD IR within LMICs. Employing a two-stage screening process and a thematic synthesis approach based on the International Association for Public Participation Spectrum of Public Participation, the review will analyse studies meeting predefined eligibility criteria. A rigorous search strategy will be implemented across identified electronic databases and grey literature sources, including published studies from 2011 to present. Data will be charted using a standardised form, and information regarding study characteristics, NCD focus, LMIC context, stakeholder engagement method and reported outcomes/findings will be collected. This scoping review will follow a standard protocol adhering to the methodological framework outlined by Arksey and O'Malley to comprehensively map existing evidence on stakeholder engagement in NCD IR within LMICs.

ETHICS AND DISSEMINATION

Ethical considerations involve respecting original authors, maintaining integrity and transparency, managing data ethically and disclosing conflicts of interest. Dissemination will occur through publication in peer-reviewed journals, conference presentations, open-access repositories, policy briefs, stakeholder engagement activities and social media platforms.

REGISTRATION

This scoping review protocol is registered on Open Science Framework, with the Digital Object Identifier 10.17605/OSF.IO/ACQ52, ensuring transparency and accountability in the research process.

An Analysis of National Institutes of Health-Funded Dissemination and Implementation Research in Low- and Middle-Income Countries

Implementation science can inform healthcare delivery to improve outcomes in resource-constrained settings through tailored strategies. The National Institutes of Health funds implementation science largely through its Dissemination and Implementation Research in Health program. We analyzed the program's grants with collaborators in low- and middle-income countries to understand trends and gaps in National Institutes of Health-funded global implementation science research. Query-View-Report was used to identify grants awarded between fiscal years 2013-2022 with at least one collaborating institution in a low- and middle-income country. Two coders reviewed the abstract and specific aims to determine the intervention being studied, setting, implementer, implementation outcomes, strategies, frameworks, and study design. From fiscal years 2013-2022, 81 grants had collaborating institutions across 25 low- and middle-income countries in five World Bank-defined regions, funded by 11 National Institutes of Health institutes and centers. Most grants focused on cancer (n = 12), other non-communicable diseases (n = 16), and tuberculosis (n = 12). Common implementation outcomes included costs (n = 43), fidelity (n = 38), maintenance (n = 36), and adoption (n = 35). Commonly studied implementation strategies included assess for readiness and identify barriers and facilitators (n = 18), revise professional roles (n = 17), and change service sites (n = 15). Frequently reported frameworks were RE-AIM (n = 30), CFIR (n = 22), and EPIS (n = 8). Most grants tested implementation strategies using experimental study designs (n = 52) in healthcare settings (n = 56). The National Institutes of Health funds a range of implementation science grants with collaborators in low- and middle-income countries. This analysis helps identify commonly utilized implementation outcomes, strategies, and frameworks and enables exploration of gaps and opportunities for further global research.

Strengthening policy engagement when scaling up interventions targeting non-communicable diseases: insights from a qualitative study across 20 countries

Policy engagement is an essential component of implementation research for scaling up interventions targeting non-communicable diseases (NCDs). It refers to the many ways that research team members, implementers and policymakers, who represent government decision-making, connect and interact to explore common interests. Well-conducted engagement activities foster co-production, local contextualization and assist in the successful translation of research evidence into policy and practice. We aimed to identify the challenges and facilitators to policy engagement during the early implementation phase of scale-up research studies. This qualitative study was focused on the research projects that were funded through the Global Alliance for Chronic Diseases in the 2019 round. Nineteen project teams opted to participate, with these studies implemented in 20 countries. Forty-three semi-structured stakeholder interviews, representing research, implementation and government were undertaken between August 2020 and July 2021. Transcripts were open-coded using thematic analysis to extract 63 codes which generated 15 themes reflecting both challenges and facilitators to undertaking policy engagement. Knowledge of the local government structures and trusting relationships provided the foundation for successful engagement and were strengthened by the research. Four cross-cutting concepts for engagement were identified and included: (1) the importance of understanding the policy landscape; (2) facilitating a network of suitable policy champions, (3) providing an environment for policy leaders to genuinely contribute to co-creation and (4) promoting two-way learning during researcher-policymaker engagement. We recommend undertaking formative policy analysis to gain a strategic understanding of the policy landscape and develop targeted engagement plans. Through engagement, researchers must facilitate cohesive vision and build a team of policy champions to advocate NCD research within their networks and spheres of influence. Ensuring equitable partnerships is essential for enabling local ownership and leadership. Further, engagement efforts must create a synergistic policymaker-researcher lens to promote the uptake of evidence into policy.

Why Collect and Use Race/Ethnicity Data? A Qualitative Case Study on the Perspectives of Mental Health Providers and Patients During COVID-19

CONTEXT

Calls to collect patients' race/ethnicity (RE) data as a measure to promote equitable health care among vulnerable patient groups are increasing. The COVID-19 pandemic has highlighted how a public health crisis disproportionately affects racialized patient groups. However, less is known about the uptake of RE data collection in the context of mental health care services.

METHODOLOGY

A qualitative case study used surveys with mental health patients (n = 47) and providers (n = 12), a retrospective chart review, and a focus group to explore healthcare providers' and patients' perspectives on collecting RE data in Canada.

RESULTS

The patient survey data and focus groups show that patients avoid providing identifying information due to perceived stigma and discrimination and a lack of trust. Providers did not feel comfortable asking patients about RE, leading to chart review data where RE information was not systematically collected.

CONCLUSIONS

The uptake and implementation of RE data collection in mental health care contexts require increased training and support, systematic implementation, and further evaluation and measurement of how the collection of RE data will be used to mitigate systemic racism and improve mental health outcomes.

Onsite training-mentoring intervention improves data quality: an implementation research

BACKGROUND

The quality of health data is not satisfactory in Low and Middle Income Countries (LMICs). Haramaya University, in collaboration with Ministry of Health and Regional Health Bureau, conducted an implementation research in selected public health facilities and administrative units. This research was aimed to test the onsite training-mentoring (OTM) intervention and adaptation of the implementation strategy to improve the routine health information system (RHIS) data quality in the context of public health sector.

METHODS

An interrupted time series design with an onsite training-mentoring intervention was used to improve data quality in public health sector of Jigjiga Woreda, eastern Ethiopia from July 2021 to June 2022. Both the pre and post intervention assessments data were collected by experienced and trained public health professionals using interviewer guided self-administered interview, record review and observation data collection techniques. Data were analyzed using descriptive, bivariate, and multivariate logistic models to identify predictors of data quality.

RESULTS

The overall data accuracy was increased from 88.12% before to 95.0% after intervention; and it was above 90% in all the facilities. The overall data content completeness was increased from 75.75% to 89.9%, though it varied among the facilities. The timeliness and report completeness were 100% in all the facilities. The odds of those health workers who had poor knowledge were less likely to ensure data quality (AOR = 0.39; 95%CI: 0.19, 0.83) than their counterparts.

CONCLUSIONS

The intervention was brought substantial changes of data quality in the study setting. Knowledge of the workers towards data quality is a crucial factor to ensure data quality in the sector. Thus, collective efforts is required to continue this tested intervention to ensure the quality of the routine health information system in the lower levels of the sector.

Updating the critical steps of the quality implementation framework: a protocol for an umbrella review of reviews

INTRODUCTION

Implementation science focuses on improving the dissemination, uptake and adoption of evidence into practice. Over the last decade, implementation science research has proliferated, particularly in healthcare and social science. The key synthesis of implementation frameworks conducted by Meyers and colleagues in 2012, and the resulting Quality Implementation Framework, has yet to be updated to incorporate this research. This protocol proposes an umbrella review of reviews (RORs) to synthesise the literature since 2012 on implementation science in the fields of healthcare and social science and provides recommendations for an updated Quality Implementation Framework.

METHODS AND ANALYSIS

This ROR will be conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Four academic databases (PubMed, Scopus, PsycINFO and Web of Science) will be used to identify peer-reviewed meta-analyses, systematic reviews and scoping reviews published in the English language since January 2012 and report on the development, application or update of one or more implementation frameworks in healthcare or social science contexts. Multiple reviewers will be involved in the screening of articles and extraction of data, and the quality of reviews will be assessed using the AMSTAR (A MeaSurement Tool to Assess systematic Reviews) 2. The outcome of interest is the content of implementation science frameworks reported in the included reviews. The content of these frameworks will be synthesised, aggregated and mapped to the four phases and 14 steps outlined in the original Quality Implementation Framework using both deductive and inductive analysis.

ETHICS AND DISSEMINATION

Ethics approval is not required as this ROR protocol and the resulting ROR do not involve primary data collection. The protocol as well as the ROR will be disseminated in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42023475994.

Recherche sur ou recherche de la mise en œuvre ?

La qualité de la mise en œuvre d'une intervention de promotion de la santé est essentielle pour garantir son adaptation au contexte et aux besoins des populations. Pourtant, elle est encore négligée dans les recherches. Alors qu'elle est entreprise depuis les années 1930 dans l'étude des politiques publiques, le domaine de la santé fait face à une prolifération de termes qui ne facilite pas son enseignement et son organisation. Ce commentaire montre qu'il n'existe pas de différence notoire entre la recherche sur la mise en œuvre (implementation science) et la recherche de mise en œuvre (implementation research). Plutôt qu'un débat sémantique, il est important de rendre cette analyse plus systématique avec des démarches scientifiques et interdisciplinaires. La recherche concernant la mise en œuvre d'une intervention de promotion de la santé doit chercher à comprendre comment rendre nos actions plus équitables et plus efficaces.

A Scoping Review of Implementation Science Studies in the Field of Traumatic Brain Injury: State of the Science and Future Directions

OBJECTIVE

Implementation research is essential to accelerating the public health benefits of innovations in health settings. However, the US National Academies of Sciences, Engineering, and Medicine 2022 report identified a lag in published implementation research applied to traumatic brain injury (TBI). Our objectives were to characterize implementation science studies published to date in TBI clinical care and rehabilitation and provide recommendations for future directions.

METHODS

A scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Articles published between 2011 and 2023 were identified (MEDLINE, PubMed, PsychInfo, and Web of Science), and included if the study focused on the TBI population, measured at least one Proctor (2011) implementation outcome and aligned with implementation research designs. Data were charted using an extraction template.

RESULTS

Of the 38 articles, 76% were published between 2018 and 2023. About 37% of articles were in the pre-implementation phase, and 57.9% were in the implementation phase. Over half of articles used a theory, model, or framework to guide the research. Fifteen studies were descriptive, 10 were qualitative, 7 were mixed methods, and 4 were randomized controlled trials. Most studies investigated implementation outcomes regarding national guidelines following TBI or TBI symptom management. Adoption (42.1%) and fidelity (42.1%) were the most commonly studied implementation outcomes, followed by feasibility (18.4%), acceptability (13.2%), and penetration (10.5%). Only 55% of studies used or tested the effectiveness of one or more implementation strategies, with training and education used most commonly, followed by data warehousing techniques.

CONCLUSIONS

Future research should prioritize the selection and investigation of implementation strategy effectiveness and mechanisms across contexts of care and use implementation research reporting standards to improve study rigor. Additionally, collaborative efforts between researchers, community partners, individuals with TBI, and their care partners could improve the equitable translation of innovations across service contexts.

How to leverage implementation research for equity in global health

Implementation research (IR) is important for addressing equity in global health. However, there is limited knowledge on how to operationalize IR for health equity, and pathways for improving health equity through IR in global health settings. This paper provides an overview of guidance and frameworks for thinking about health equity as part of IR while noting the gaps in how this guidance and frameworks apply to global health. It proposes an approach to guide implementation teams in the application of IR for achieving equity in global health considering these gaps. It describes key equity considerations for different aspects of IR (i.e., implementation contexts, strategies, outcomes, and research designs). These considerations can be applied prospectively and retrospectively, and at different stages of IR. The paper further describes causal pathways, intervention levers, and strategies for achieving health equity in global health settings through IR. Central to these pathways is the power asymmetries among different actors involved in IR in global health and how these contribute to health inequities. The paper suggests recommendations and strategies for shifting the balance of power among these actors while addressing the structural and systemic determinants of health inequities as part of IR. Explicit considerations for health equity as part of implementation research and practice are needed for the achievement of global health goals. Such explicit considerations should look back as much as possible, and entail defining and analyzing health inequities and intervening on the underlying causes and mechanisms of health inequities as part of IR on a routine basis.

Role and promise of health policy and systems research in integrating rehabilitation into the health systems

Despite recognized need and reasonable demand, health systems and rehabilitation communities keep working in silos, independently with minimal recognition to the issues of those who require rehabilitation services. Consolidated effort by health systems and rehabilitation parties, recognizing the value, power and promise of each other, is a need of the hour to address this growing issue of public health importance. In this paper, the importance and the need for integration of rehabilitation into health system is emphasized. The efforts being made to integrate rehabilitation into health systems and the potential challenges in integration of these efforts were discussed. Finally, the strategies and benefits of integrating rehabilitation in health systems worldwide is proposed. Health policy and systems research (HPSR) brings a number of assets that may assist in addressing the obstacles discussed above to universal coverage of rehabilitation. It seeks to understand and improve how societies organize themselves to achieve collective health goals; considers links between health systems and social determinants of health; and how different actors interact in policy and implementation processes. This multidisciplinary lens is essential for evidence and learning that might overcome the obstacles to the provision of rehabilitation services, including integration into health systems. Health systems around the world can no longer afford to ignore rehabilitation needs of their populations and the World Health Assembly (WHA) resolution marked a global call to this effect. Therefore, national governments and global health community must invest in setting a priority research agenda and promote the integration of rehabilitation into health systems. The context-specific, need-based and policy-relevant knowledge about this must be made available globally, especially in low- and middle-income countries. This could help integrate and implement rehabilitation in health systems of countries worldwide and also help achieve the targets of Rehabilitation 2030, universal health coverage and Sustainable Development Goals.

Innovate! Accelerate! Evaluate! Harnessing the RE-AIM framework to examine the global dissemination of parenting resources during COVID-19 to more than 210 million people

BACKGROUND

Parents were at the forefront of responding to the needs of children during the COVID-19 pandemic. This study used the RE-AIM framework to examine the Reach, Effectiveness, Adoption, Implementation, and Maintenance of a global inter-agency initiative that adapted evidence-based parenting programs to provide immediate support to parents.

METHODS

Data were collected via short surveys sent via email, online surveys, and analysis of social media metrics and Google Analytics. Retrospective surveys with 1,303 parents and caregivers in 11 countries examined impacts of the resources on child maltreatment, positive relationship building, parenting efficacy, and parenting stress.

RESULTS

The parenting resources were translated into over 135 languages and dialects; reached an estimated minimum 212.4 million people by June 2022; were adopted by 697 agencies, organizations, and individuals; and were included in 43 national government COVID-19 responses. Dissemination via social media had the highest reach (n = 144,202,170, 67.9%), followed by radio broadcasts (n = 32,298,525, 15.2%), text messages (n = 13,565,780, 6.4%), and caseworker phone calls or visits (n = 8,074,787, 3.8%). Retrospective surveys showed increased parental engagement and play, parenting self-efficacy, confidence in protecting children from sexual abuse, and capacity to cope with stress, as well as decreased physical and emotional abuse. Forty-four organizations who responded to follow-up surveys in April 2021 reported sustained use of the resources as part of existing services and other crisis responses.

CONCLUSION

This study highlights the importance of a) establishing an international collaboration to rapidly adapt and disseminate evidence-based content into easily accessible resources that are relevant to the needs of parents; b) creating open-source and agile delivery models that are responsive to local contexts and receptive to further adaptation; and c) using the best methods available to evaluate a rapidly deployed global emergency response in real-time. Further research is recommended to empirically establish the evidence of effectiveness and maintenance of these parenting innovations.

Non-alcoholic fatty liver disease (NAFLD) integration into India's NCD program - Obstacles and solutions for the implementation of guidelines at the national level

Individuals who have non-alcoholic fatty liver disease (NAFLD) are at high risk of metabolic comorbidities and can put a significant strain on healthcare systems. If not managed in a timely manner, NAFLD can lead to sustained healthcare costs, economic losses, and reduced health-related quality of life. In India, the Ministry of Health and Family Welfare recognized the need for a comprehensive approach to prevent NAFLD and integrated public health measures into the existing National Program for Prevention and Control of Non-Communicable Diseases (NP NCD). However, 3 years after the integration, there is no clear measure of the extent of implementation of this program, and the exact facilitators and barriers to implementing the program are yet to be determined. The next step toward providing comprehensive and effective healthcare services to those affected by NAFLD is the implementation of NAFLD guidelines under the NP NCD. The article emphasizes the importance of replacing old reporting formats with updated ones that incorporate NAFLD. It also highlights the need for healthcare personnel and community health workers to receive multiple trainings. While measuring waist circumference (WC) and identifying patients who need referral poses challenges, we can overcome them by updating the Non-Communicable Disease (NCD) application to include NAFLD, recording WC in registers, and using up-to-date reporting formats.

A qualitative study identifying implementation strategies using the i-PARIHS framework to increase access to pre-exposure prophylaxis at federally qualified health centers in Mississippi

BACKGROUND

Mississippi (MS) experiences disproportionally high rates of new HIV infections and limited availability of pre-exposure prophylaxis (PrEP). Federally Qualified Health Centers (FQHCs) are poised to increase access to PrEP. However, little is known about the implementation strategies needed to successfully integrate PrEP services into FQHCs in MS.

PURPOSE

The study had two objectives: identify barriers and facilitators to PrEP use and to develop tailored implementation strategies for FQHCs.

METHODS

Semi-structured interviews were conducted with 19 staff and 17 PrEP-eligible patients in MS FQHCs between April 2021 and March 2022. The interview was guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework which covered PrEP facilitators and barriers. Interviews were coded according to the i-PARIHS domains of context, innovation, and recipients, followed by thematic analysis of these codes. Identified implementation strategies were presented to 9 FQHC staff for feedback.

RESULTS

Data suggested that PrEP use at FQHCs is influenced by patient and clinic staff knowledge with higher levels of knowledge reflecting more PrEP use. Perceived side effects are the most significant barrier to PrEP use for patients, but participants also identified several other barriers including low HIV risk perception and untrained providers. Despite these barriers, patients also expressed a strong motivation to protect themselves, their partners, and their communities from HIV. Implementation strategies included education and provider training which were perceived as acceptable and appropriate.

CONCLUSIONS

Though patients are motivated to increase protection against HIV, multiple barriers threaten uptake of PrEP within FQHCs in MS. Educating patients and providers, as well as training providers, are promising implementation strategies to overcome these barriers.

Protocol for a mixed-methods study to explore implementation outcomes of the Phone-based Interventions under Nurse Guidance after Stroke (PINGS-II) across 10 hospitals in Ghana

BACKGROUND

Stroke survivors are at a substantially higher risk for adverse vascular events driven partly by poorly controlled vascular risk factors. Mobile health interventions supported by task shifting strategies have been feasible to test in small pilot trials in low-income settings to promote vascular risk reduction after stroke. However, real-world success and timely implementation of such interventions remain challenging, necessitating research to bridge the know-do gap and expedite improvements in stroke management. The Phone-based Interventions under Nurse Guidance after Stroke (PINGS-II) is a nurse-led mHealth intervention for blood pressure control among stroke survivors, currently being assessed for efficacy in a hybrid clinical trial across 10 hospitals in Ghana compared with usual care. This protocol aims to assess implementation outcomes such as feasibility, appropriateness, acceptability, fidelity, cost and implementation facilitators and barriers of the PINGS-II intervention.

METHODS AND ANALYSIS

This study uses descriptive mixed methods. Qualitative data to be collected include in-depth interviews and FGDs with patients who had a stroke on the PINGS-II intervention, as well as key informant interviews with medical doctors and health policy actors (implementation context, barriers and facilitators). Data will be analysed by thematic analysis. Quantitative data sources include structured questionnaires for clinicians (feasibility, acceptability and appropriateness), and patients who had a stroke (fidelity and costs). Analysis will include summary statistics like means, medians, proportions and exploratory tests of association including χ2 analysis.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Committee for Human Research Publication and Ethics at the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. Voluntary written informed consent will be obtained from all participants. All the rights of the participants and ethical principles guiding scientific research shall be adhered to. Findings from the study will be presented in scientific conferences and published in a peer-reviewed scientific journal. A dissemination meeting will be held with relevant agencies of the Ghana Ministry of Health, clinicians, patient group representatives, and non-governmental organisations.

A qualitative study exploring how vocational rehabilitation for people with multiple sclerosis can be integrated within existing healthcare services in the United Kingdom

BACKGROUND

To explore how a vocational rehabilitation (VR) intervention can be integrated within existing healthcare services for people with multiple sclerosis (MS) in the United Kingdom (UK) National Health Service (NHS).

METHODS

Data from 37 semi-structured interviews with 22 people with MS, eight employers, and seven healthcare professionals were analysed using a framework method informed by the Consolidated Framework for Implementation Research and an intervention logic model.

RESULTS

Four themes were identified relating to the structure of current NHS services, how to improve access to and awareness of VR services, the collaboration between internal and external networks, and the benefits of integrating VR within the NHS services. Participants identified several implementation barriers such as poor links with external organisations, staffing issues, and lack of funding. To overcome these barriers, participants suggested enablers such as technology (e.g., apps or online assessments) and collaboration with third-sector organisations to reduce the pressure on the NHS.

CONCLUSION

Significant organisational changes are required to ensure a successful implementation of a VR intervention within current NHS services. Despite this, the NHS was seen as a trustworthy organisation to offer support that can optimise the health and professional lives of people with MS.

Health worker perspectives on barriers and facilitators of tuberculosis investigation coverage among index case contacts in rural Southwestern Uganda: a qualitative study

BACKGROUND

In 2012, the World Health Organization recommended screening and investigation of contacts of index tuberculosis patients as a strategy to accelerate detection of tuberculosis (TB) cases. Nine years after the adoption of this recommendation, coverage of TB contact investigations in Uganda remains low. The objective of this study was to examine health care providers' perceptions of factors influencing coverage of TB contact investigations in three selected rural health facilities in Mbarara district, southwestern Uganda.

METHODS

This study identified provider opinions on the barriers and facilitators to implementation of TB contact investigation using the Consolidated Framework for Implementation Research. Using an exploratory qualitative study design, semi-structured interviews with 19 health workers involved in the TB program at district, health facility and community levels were conducted from April 2020 and July 2020. Analysis was conducted inductively using reflexive thematic analysis in six iterative steps: familiarizing with the data, creating initial codes, searching for themes, reviewing themes, developing theme definitions, and writing the report.

RESULTS

Nineteen health care workers participated in this study which translates to a 100% response rate. These included two district TB and leprosy supervisors, five nurses, five clinical officers, six village health team members and one laboratory technician. The three themes that emerged from the analysis were intervention-related, health system and contextual factors. Health system-related barriers included inadequate or delayed government funding for the TB program, shortage of human resources, insufficient personal protective equipment, and a stock-out of supplies such as Xpert MTB cartridges. Contextual barriers included steep terrain, poverty or low income, and the stigma associated with TB and COVID-19. Facilitators comprised increased knowledge and understanding of the intervention, performance review and on-the-job training of health workers.

CONCLUSIONS

This study found that most of the factors affecting TB contact investigations in this rural community were related to health system constraints such as inadequate or delayed funding and human resource shortages. This can be addressed by strengthening the foundational elements of the health system - health financing and human resources - to establish a comprehensive TB control program that will enable the efficient identification of missing TB patients.

Taking the Big Leap | understanding, accessing and improving behavioural science interventions

Applied behaviour science's focus on individual-level behaviours has led to overestimation of and reliance on biases and heuristics in understanding behaviour and behaviour change. Behaviour-change interventions experience difficulties such as effect sizes, validity, scale-up, and long-term sustainability. One such area where we need to re-examine underlying assumptions for behavioural interventions in Human Immunodeficiency Virus (HIV) and Tuberculosis (TB) prevention, which seek population-level benefits and sustained, measurable impact. This requires taking a "Big Leap." In our view, taking the big leap refers to using a behavioural science-informed approach to overcome the chasms due to misaligned assumptions, tunnel focus, and overweighting immediate benefits, which can limit the effectiveness and efficiency of public health programmes and interventions. Crossing these chasms means that decision-makers should develop a system of interventions, promote end-user agency, build choice infrastructure, embrace heterogeneity, recognise social and temporal dynamics, and champion sustainability. Taking the big leap toward a more holistic approach means that policymakers, programme planners, and funding bodies should "Ask" pertinent questions to evaluate interventions to ensure they are well informed and designed.

The Getting It right First Time (GIRFT) programme in urology; rationale and methodology

The Getting It Right First Time (GIRFT) programme is a quality improvement initiative covering the National Health Service in England. The programme aims to standardise clinical practices and improve patient and system level outcomes by utilising data-driven insights and clinically-led recommendations. There are GIRFT workstreams for every medical and surgical specialty, including urology. Defining features of the GIRFT methodology are that it is clinically led by experienced clinicians, data-driven, and specialty specific. Each specialty workstream conducts deep-dive visits to every hospital, analysing performance data and engaging with clinicians and management to identify and share improvement priorities. For urology, GIRFT has completed deep-dive visits and published reports outlining priority areas for development. Reports include recommendations pertaining to streamlining care pathways, reducing the acuity of care environments, enhancing emergency services, optimising utilisation of outpatient services, and workforce training and utilisation. The GIRFT academy provides guides for implementing best practices specific to priority areas of care. These include important disease pathways, and GIRFT-advocated innovations such as urology investigation units and urology area networks. GIRFT offers clinical transformation, cost reduction, equity in access to care, and leaner models of care that are often more environmentally sustainable. Evaluation efforts of the programme have focussed on assessing the adoption of GIRFT recommendations, understanding barriers to change, and modelling the climate impact of advocated practices.

Multimethods study to develop tools for competency-based assessments of implementation research training programmes in low and middle-income countries

INTRODUCTION

Methods and validated tools for evaluating the performance of competency-based implementation research (IR) training programmes in low-middle-income countries (LMICs) are lacking. In this study, we developed tools for assessing the performance of IR training programmes based on a framework of IR core competencies in LMICs.

METHODS

We developed self-assessment and objective-assessment tools drawing on the IR competency framework. We used exploratory factor analyses and a one-parameter logistic model to establish construct validity and internal consistency of the tools drawing on a survey conducted in 2020 with 166 trainees before and after an index IR course across five universities and LMICs under the Special Program for Research and Training in Tropical Diseases postgraduate IR training scheme. We conducted key informant interviews (KII) with 20 trainees and five trainers to reflect on the usefulness of the tools and framework for guiding IR training in LMICs.

RESULTS

Two 16-item tools for self-assessment of IR knowledge and self-efficacy and a 40-item objective assessment tool were developed. The factor loadings of items in the self-assessment tools were 0.65-0.87 with Cronbach's alpha (α) of 0.97, and 0.77-0.91 with α of 0.98 for the IR knowledge and self-efficacy tools, respectively. The distribution of item difficulty in the objective-assessment tool was consistent before and after the index IR course. Pearson correlation coefficient (r) between the self-assessed and objectively assessed IR knowledge before the index IR course was low, r=0.27 (p value: <0.01), with slight improvements after the index IR course, r=0.43 (p value: <0.01). All KII respondents reported the assessment tools and framework were valid for assessing IR competencies.

CONCLUSION

The IR competency framework and tools developed for assessing IR competencies and performance of IR training programmes in LMICs are reliable and valid. Self-assessment methods alone may not suffice to yield a valid assessment of performance in these settings.

[Evidence Register Green List Prevention: Analysis of the listed effectiveness-tested programmes]

BACKGROUND

In the areas of prevention and health promotion, there is a large number of measures for children and adolescents. One way of facilitating evidence-based action for those involved in these taks is by making available online evidence registers with customised, effectiveness-tested measures. The Green List Prevention is such a register and offers an overview of evidence-based programmes in Germany, currently with a focus on psychosocial health.

OBJECTIVE

The aims of this study were (a) to analyse the characteristics of the available and evaluated programmes on the psychosocial health of children and adolescents, (b) to identify priorities and underrepresented areas of the Green List Prevention and (c) to optimise the search functions of the register.

METHOD

The characteristic features were recorded on the basis of the existing upper categories of the register entries which were differentiated into subcategories in an inductive procedure by at least two persons. In addition, deductive categories were added for relevant aspects concerning content and implementation. The upper and lower categories formed were operationalized with characteristic values. All entries were analyzed by using a data sheet and were descriptively evaluated.

RESULTS

The 102 programmes listed (as of 2/2024) addressed not only the primary target group of children and youth, but also secondary target groups (mainly teachers and guardians). Social and life skills programmes as well as trainings for guardians represented a focus. Behavioral prevention programmes on the topics of violence (including bullying) (63.7%), addiction (46.1%) and/or mental health (35.3%) were frequently represented, whereas nutrition and/or physical activity (4.9%) were hardly represented. Most of the programmes (88.2%) could be assigned to the eligibility criteria of the statutory health insurers (§20a SGB V). Potentials digital implementation forms and further implementation aspects were identified.

CONCLUSION

The Green List Prevention bundles a large number of different measures and that there is potential for expansion. Processing knowledge about effective measures in a user-friendly manner can be optimised through expanded search functions, so that resource-conserving, evidence-based action can be facilitated.

Interviews with policymakers in Australian health policy: Understanding the process of policy development

OBJECTIVE

To determine the barriers and enablers oral health and chronic disease policymakers identify during policy development.

METHODS

Semi-structured interview questions were developed utilizing an interview guide and applying a knowledge mobilization framework. Reflective thematic analysis of the data was completed based on the research of Braun and Clarke encompassing a critical realist approach.

RESULTS

Twelve policymakers were interviewed. Policymakers reported barriers to accessing evidence including the sheer volume of information and a lack of: research summaries, comprehensive oral health data sets, open access articles, consistency of reporting, and time. They did find relationships with experts and intermediaries crucial at times to policy development. Co-creation of research was also a key enabler for policymakers.

CONCLUSIONS

This study highlights that policymakers find evidence crucial during the development of policy and often use it to advocate for policies. However, the links between poor oral health; and cardiovascular disease, diabetes, and cognitive impairment are not well recognized among chronic disease policymakers. It is important that oral health researchers and policymakers work to close this gap. The treatment of poor oral health is a global population health issue. It is imperative that evidence of these links is implemented into health policy for the treatment and prevention of chronic diseases and improved quality of life for individuals living with chronic diseases.

Challenges to the implementation of a multi-level intervention to reduce mistreatment of women during childbirth in Iran: a qualitative study using the Consolidated Framework for Implementation Research

BACKGROUND

Mistreatment during childbirth is a growing concern worldwide, especially in developing countries, such as Iran. In response, we launched a comprehensive implementation research (IR) project to reduce mistreatment during childbirth and enhance positive birth experiences in birth facilities. This study identified the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth using the Consolidated Framework for Implementation Research (CFIR).

METHODS

An exploratory qualitative study, involving 30 in-depth interviews, was conducted between July 2022 and February 2023. Participants included a purposive sample of key stakeholders at different levels of the health system (macro: Ministry of Health and Medical Education; meso: universities of medical sciences and health services; and micro: hospitals) with sufficient knowledge, direct experience, and/or collaboration in the implementation of the studied interventions. Interviews were transcribed verbatim and coded using directed qualitative content analysis (CFIR constructs) in MAXQDA 18.

RESULTS

The identified challenges were: (1) individual level (childbirth preparation classes: e.g., adaptability, design quality and packaging, cosmopolitanism; presence of birth companions: e.g., patient needs and resources, structural characteristics, culture); (2) healthcare provider level (integrating respectful maternity care into in-service training: e.g., relative priority, access to knowledge and information, reflecting and evaluating); (3) hospital level (evaluating the performance of maternity healthcare providers: e.g., executing, external policies and incentives); and (4) national health system level (implementation of pain relief during childbirth guidelines: e.g., networks and communications, patient needs and resources, executing, reflecting and evaluating).

CONCLUSIONS

This study provides a clear understanding of the challenges of implementing a multi-level intervention to reduce mistreatment of women during childbirth and highlights potential implications for policy makers and practitioners of maternal health programs. We encourage them to take the lessons learned from this study and revise their current programs and policies regarding the quality of maternity care by focusing on the identified challenges.

Michigan appropriateness guide for intravenous catheters in pediatrics - miniMAGIC-Brasil: translation into Brazilian portuguese

OBJECTIVE

To perform the translation and adaptation of the Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics (miniMAGIC) into Brazilian Portuguese.

METHODS

Methodological study performed in five recommended stages: initial translations; synthesis of the translations; back translations; assessment of the back translations; expert committee assessment. The expert committee was composed of three registered nurses and two doctors who had a Master's and/or PhD degree, and an expertise in intravenous therapy and pediatric and neonatal care. To assess the semantic, idiomatic, experiential and conceptual adequacy, a Likert scale was applied, in which 1, "not equivalent"; 2, "inequivalent"; 3, "cannot assess"; 4, "quite equivalent"; 5, "totally equivalent". The terms mostly analyzed as negative in equivalence and with a lower than 20 score were reviewed and submitted to a new assessment, with the Delphi Technique until consensus was obtained. The results were stored in electronic spreadsheets and treated with concordance index, with a minimum acceptable result of 0.80.

RESULTS

The content of all recommendations, named as miniMAGIC-Brasil, was validated by the expert committee after two stages of evaluation. All recommendations had an overall agreement index of 0.91.

CONCLUSIONS

The miniMAGIC-Brazil guide was validated in respect to the adequacy of the translation after two steps.

Challenges and Opportunities for Paving the Road to Global Health Equity Through Implementation Science

Implementation science focuses on enhancing the widespread uptake of evidence-based interventions into routine practice to improve population health. However, optimizing implementation science to promote health equity in domestic and global resource-limited settings requires considering historical and sociopolitical processes (e.g., colonization, structural racism) and centering in local sociocultural and indigenous cultures and values. This review weaves together principles of decolonization and antiracism to inform critical and reflexive perspectives on partnerships that incorporate a focus on implementation science, with the goal of making progress toward global health equity. From an implementation science perspective, wesynthesize examples of public health evidence-based interventions, strategies, and outcomes applied in global settings that are promising for health equity, alongside a critical examination of partnerships, context, and frameworks operationalized in these studies. We conclude with key future directions to optimize the application of implementation science with a justice orientation to promote global health equity.

Evaluation of the Ask-Inform-Manage-Encourage-Refer Intervention and Its Implementation Targeting the Provision of Mental Wellbeing Support Within the Audiology Setting

OBJECTIVES

The ask, inform, manage, encourage, refer (AIMER) program is a behavior change intervention designed to increase the frequency with which hearing healthcare clinicians (HHCs) ask about and provide information regarding mental wellbeing within adult audiology services. The objective of this study was to systematically evaluate the first iteration of the AIMER program to determine whether the intervention achieved the changes in HHC behaviors anticipated and to evaluate feasibility of implementing the AIMER program based on the implementation protocol.

DESIGN

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to guide this evaluation. Data were collected from October 2020 to February 2022 and included both quantitative and qualitative measures (i.e., observation reports, staff surveys, clinical diaries, clinical file audits, and interviews).

RESULTS

Comparison between pre- and post-implementation data showed that the AIMER intervention successfully increased: (i) HHC's skills and confidence for discussing mental wellbeing; (ii) how often HHCs ask about mental wellbeing within audiology consultations; (iii) how often HHCs provide personalized information and support regarding mental wellbeing within audiology consultations; and (iv) how often HHCs use mental wellbeing terms within clinical case notes and general practitioner reports. The factors affecting feasibility of implementing the AIMER program within the clinical setting could be classified into three major categories: (i) the AIMER program itself and its way of delivery to clinical staff; (ii) people working with the AIMER program; and (iii) contextual factors. Key recommendations to improve future implementation of the AIMER program were provided by the participants.

CONCLUSIONS

The AIMER program was shown to be effective at increasing the frequency with which HHCs ask about and provide information regarding mental wellbeing within routine audiological service delivery. Implementation of the AIMER program was feasible but leaves room for improvement. Use of the reach, effectiveness, adoption, implementation, and maintenance framework facilitated systematic evaluation of multiple indicators providing a broad evaluation of the AIMER program. Our analysis helps to better understand the optimal levels of training and facilitation and provides recommendations to improve future scale-up of the AIMER program. The findings of this study will be used to further adapt and improve the AIMER program and to enhance program implementation strategies before its further dissemination.

Assessing primary health care provider and organization readiness to address family violence in Alberta, Canada: development of a Delphi consensus readiness tool

BACKGROUND

Family violence, which includes intimate partner abuse, child abuse, and elder abuse, is a serious public health concern. Primary healthcare (PHC) offers a vital opportunity to identify and address family violence, yet barriers prevent the effective implementation of family violence interventions in PHC settings. The purpose of this study is to improve family violence identification and response in Alberta's PHC settings by exploring readiness factors.

METHODS

An integrated knowledge translation approach, combining implementation science and participatory action research, was employed to develop a readiness assessment tool for addressing family violence within PHC settings in Alberta. The research involved three phases: phase 1 involved a rapid evidence assessment, phase 2 engaged a panel of healthcare and family violence experts to explore readiness components in the Alberta context, and phase 3 utilized a 3-round Delphi consensus-building process to refine readiness indicators.

RESULTS

Phase 1 findings from a rapid evidence assessment highlighted five main models/tools for assessing readiness to implement family violence interventions in PHC settings. In phase 2, additional concepts were identified through exploration with healthcare and family violence expert panel members, resulting in a total of 16 concepts for assessing family violence readiness within the Alberta PHC context. The 3-round Delphi consensus-building process in Phase 3 involved nine panelists, who collectively agreed on the inclusion of all concepts and indicators, yielding a total of 60 items for the proposed readiness assessment tool for addressing family violence in PHC within Alberta.

CONCLUSION

The current study lays the groundwork for future family violence intervention programs, offering insights into key components that promote readiness for implementing comprehensive programs and supporting PHC organizations in effectively addressing family violence.

Female genital mutilation: trends, economic burden of delay and basis for public health interventions

BACKGROUND

The practice of female genital mutilation (FGM) is a health and social problem. Millions of girls and women have undergone FGM or will soon, and more information is needed to effectively reduce the practice. The aim of this research is to provide an overview of the FGM trendlines, the inequality of its prevalence, and the economic burden. The findings shed light on 30-year trends and the impact of the pandemic on planned efforts to reduce FGM which helps with public health interventions.

METHODS

Temporal trend analysis, and graphical analysis were used to assess the change and inequality over the last 30 years. We included 27 countries in which FGM is prevalent. We calculated the extra economic burden of delayed interventions to reduce FGM like COVID-19.

RESULTS

For the 27 countries analyzed for temporal trendlines, 13 countries showed no change over time while 14 had decreasing trends. Among the 14, nine countries, Uganda, Togo, Ghana, Benin, Kenya, Nigeria, Central African Republic, Chad, and Ethiopia had high year-decrease (CAGR - 1.01 and - 10.26) while five, Côte d'Ivoire, Egypt, Gambia, Djibouti, and Mali had low year-decrease (CAGR>-1 and < 0). Among these five are the highest FGM prevalence similar distribution regardless the wealth quintiles or residence. There is an economic burden of delay or non-decline of FGM that could be averted.

CONCLUSION

Findings indicate that some countries show a declining trend over time while others not. It can be observed that there is heterogeneity and homogeneity in the FGM prevalence within and between countries which may indicate inequality that deserves further investigation. There is considerable economic burden due to delays in the implementation of interventions to reduce or eliminate FGM. These insights can help in the preparation of public health interventions.

Reinforcing Feedbacks for Sustainable Implementation of Rural Drinking-Water Treatment Technology

Progress toward universal access to safe drinking water depends on rural water service delivery models that incorporate water safety management. Water supplies of all types have high rates of fecal contamination unless water safety risks are actively managed through water source protection, treatment, distribution, and storage. Recognizing the role of treatment within this broader risk-based framework, this study focuses on the implementation of passive chlorination and ultraviolet (UV) disinfection technologies in rural settings. These technologies can reduce the health risk from microbiological contaminants in drinking water; however, technology-focused treatment interventions have had limited sustainability in rural settings. This study examines the requirements for sustainable implementation of rural water treatment through qualitative content analysis of 26 key informant interviews, representing passive chlorination and UV disinfection projects in rural areas in South America, Africa, and Asia. The analysis is aligned with the RE-AIM framework and delivers insight into 18 principal enablers and barriers to rural water treatment sustainability. Analysis of the interrelationships among these factors identifies leverage points and encourages fit-for-purpose intervention design reinforced by collaboration between facilitating actors through hybrid service delivery models. Further work should prioritize health impact evidence, water quality reporting guidance, and technological capabilities that optimize trade-offs in fit-for-purpose treatment design.

Navigating the field of implementation science towards maturity: challenges and opportunities

BACKGROUND

The field of implementation science has significantly expanded in size and scope over the past two decades, although work related to understanding implementation processes have of course long preceded the more systematic efforts to improve integration of evidence-based interventions into practice settings. While this growth has had significant benefits to research, practice, and policy, there are some clear challenges that this period of adolescence has uncovered.

MAIN BODY

This invited commentary reflects on the development of implementation science, its rapid growth, and milestones in its establishment as a viable component of the biomedical research enterprise. The authors reflect on progress in research and training, and then unpack some of the consequences of rapid growth, as the field has grappled with the competing challenges of legitimacy among the research community set against the necessary integration and engagement with practice and policy partners. The article then enumerates a set of principles for the field's next developmental stage and espouses the aspirational goal of a "big tent" to support the next generation of impactful science.

CONCLUSION

For implementation science to expand its relevance and impact to practice and policy, researchers must not lose sight of the original purpose of the field-to support improvements in health and health care at scale, the importance of building a community of research and practice among key partners, and the balance of rigor, relevance, and societal benefit.

Data-driven decision-making for district health management: a cluster-randomised study in 24 districts of Ethiopia

BACKGROUND

Use of local data for health system planning and decision-making in maternal, newborn and child health services is limited in low-income and middle-income countries, despite decentralisation and advances in data gathering. An improved culture of data-sharing and collaborative planning is needed. The Data-Informed Platform for Health is a system-strengthening strategy which promotes structured decision-making by district health officials using local data. Here, we describe implementation including process evaluation at district level in Ethiopia, and evaluation through a cluster-randomised trial.

METHODS

We supported district health teams in 4-month cycles of data-driven decision-making by: (a) defining problems using a health system framework; (b) reviewing data; (c) considering possible solutions; (d) value-based prioritising; and (e) a consultative process to develop, commit to and follow up on action plans. 12 districts were randomly selected from 24 in the North Shewa zone of Ethiopia between October 2020 and June 2022. The remaining districts formed the trial's comparison arm. Outcomes included health information system performance and governance of data-driven decision-making. Analysis was conducted using difference-in-differences.

RESULTS

58 4-month cycles were implemented, four or five in each district. Each focused on a health service delivery challenge at district level. Administrators' practice of, and competence in, data-driven decision-making showed a net increase of 77% (95% CI: 40%, 114%) in the regularity of monthly reviews of service performance, and 48% (95% CI: 9%, 87%) in data-based feedback to health facilities. Statistically significant improvement was also found in administrators' use of information to appraise services. Qualitative findings also suggested that district health staff reported enhanced data use and collaborative decision-making.

CONCLUSIONS

This study generated robust evidence that 20 months' implementation of the Data-Informed Platform for Health strengthened health management through better data use and appraisal practices, systemised problem analysis to follow up on action points and improved stakeholder engagement.

TRIAL REGISTRATION NUMBER

NCT05310682.

Integrated Management of Childhood Illness implementation in Nepal: understanding strategies, context, and outcomes

BACKGROUND

Health system-delivered evidence-based interventions (EBIs) are important to reducing amenable under-5 mortality (U5M). Implementation research (IR) can reduce knowledge gaps and decrease lags between new knowledge and its implementation in real world settings. IR can also help understand contextual factors and strategies useful to adapting EBIs and their implementation to local settings. Nepal has been a leader in dropping U5M including through adopting EBIs such as integrated management of childhood illness (IMCI). We use IR to identify strategies used in Nepal's adaptation and implementation of IMCI.

METHODS

We conducted a mixed methods case study using an implementation research framework developed to understand how Nepal outperformed its peers between 2000-2015 in implementing health system-delivered EBIs known to reduce amenable U5M. We combined review of existing literature and data supplemented by 21 key informant interviews with policymakers and implementers, to understand implementation strategies and contextual factors that affected implementation outcomes. We extracted relevant results from the case study and used explanatory mixed methods to understand how and why Nepal had successes and challenges in adapting and implementing one EBI, IMCI.

RESULTS

Strategies chosen and adapted to meet Nepal's specific context included leveraging local research to inform national decision-makers, pilot testing, partner engagement, and building on and integrating with the existing community health system. These cross-cutting strategies benefited from facilitating factors included community health system and structure, culture of data use, and local research capacity. Geography was a critical barrier and while substantial drops in U5M were seen in both the highest and lowest wealth quintiles, with the wealth equity gap decreasing from 73 to 39 per 1,000 live births from 2001 to 2016, substantial geographic inequities remained.

CONCLUSIONS

Nepal's story shows that implementation strategies that are available across contexts were key to adopting and adapting IMCI and achieving outcomes including acceptability, effectiveness, and reach. The value of choosing strategies that leverage facilitating factors such as investments in community-based and facility-based approaches as well as addressing barriers such as geography are useful lessons for countries working to accelerate adaptation and implementation of strategies to implement EBIs to continue achieving child health targets.

Institutional capacity assessment in the lens of implementation research: Capacity of the local institutions in delivering WASH services at Cox's Bazar district, Bangladesh

BACKGROUND

The influx of Forcibly Displaced Myanmar Nationals (FDMNs) has left the Southwest coastal district of Cox's Bazar with one of the greatest contemporary humanitarian crises, stressing the existing water, sanitation, and hygiene (WASH) resources and services. This study aimed to assess the existing capacity of local institutions involved in delivering WASH services and identify relevant recommendations for intervention strategies.

METHODS

We used a qualitative approach, including interviews and capacity assessment workshops with institutions engaged in WASH service delivery. We conducted five key informant interviews (KII) with sub-district level officials of the Department of Public Health Engineering (DPHE), Directorate General of Health Services (DGHS), Directorate of Primary Education (DPE) and Bangladesh Rural Advancement Committee (BRAC) to have a general idea of WASH service mechanisms. Seven capacity assessment workshops were organized with the relevant district and sub-district level stakeholders from August 2019 to September 2019. These workshops followed three key areas: i) knowledge of policy, organizational strategy, guidelines, and framework; ii) institutional arrangements for service delivery such as planning, implementation, coordination, monitoring, and reporting; and iii) availability and management of human, financial and infrastructural resources. Data were categorized using thematic content analysis.

RESULTS

The majority of stakeholders lacked awareness of national WASH policies. Furthermore, the top-down planning approaches resulted in activities that were not context-specific, and lack of coordination between multiple institutions compromised the optimal WASH service delivery at the local level. Shortage of human resources in delivering sustainable WASH services, inadequate supervision, and inadequate evaluation of activities also required further improvement, as identified by WASH stakeholders.

CONCLUSION

Research evidence suggests that decision-makers, donors, and development partners should consider learning from the WASH implementers and stakeholders about their existing capacity, gaps, and opportunities before planning for any WASH intervention in any particular area.

Implementation and Evaluation of a mHealth-Based Community Health Worker Feedback Loop for Hispanics with and at Risk for Diabetes

BACKGROUND

Gaps in accessibility and communication hinder diabetes care in poor communities. Combining mobile health (mHealth) and community health workers (CHWs) into models to bridge these gaps has great potential but needs evaluation.

OBJECTIVE

To evaluate a mHealth-based, Participant-CHW-Clinician feedback loop in a real-world setting.

DESIGN

Quasi-experimental feasibility study with intervention and usual care (UC) groups.

PARTICIPANTS

A total of 134 participants (n = 67/group) who were all low-income, uninsured Hispanics with or at-risk for type 2 diabetes.

INTERVENTION

A 15-month study with a weekly to semimonthly mHealth Participant-CHW-Clinician feedback loop to identify participant issues and provide participants monthly diabetes education via YouTube.

MAIN MEASURES

We used pre-defined feasibility measures to evaluate our intervention: (a) implementation, the execution of feedback loops to identify and resolve participant issues, and (b) efficacy, intended effects of the program on clinical outcomes (baseline to 15-month HbA1c, systolic blood pressure (SBP), diastolic blood pressure (DBP), and weight changes) for each group and their subgroups (at-risk; with diabetes, including uncontrolled (HbA1c ≥ 7%)).

KEY RESULTS

CHWs identified 433 participant issues (mean = 6.5 ± 5.3) and resolved 91.9% of these. Most issues were related to supplies, 26.3% (n = 114); physical health, 23.1% (n = 100); and medication access, 20.8% (n = 90). Intervention participants significantly improved HbA1c (- 0.51%, p = 0.03); UC did not (- 0.10%, p = 0.76). UC DBP worsened (1.91 mmHg, p < 0.01). Subgroup analyses revealed HbA1c improvements for uncontrolled diabetes (intervention: - 1.59%, p < 0.01; controlled: - 0.72, p = 0.03). Several variables for UC at-risk participants worsened: HbA1c (0.25%, p < 0.01), SBP (4.05 mmHg, p < 0.01), DBP (3.21 mmHg, p = 0.01). There were no other significant changes for either group.

CONCLUSIONS

A novel mHealth-based, Participant-CHW-Clinician feedback loop was associated with improved HbA1c levels and identification and resolution of participant issues. UC individuals had several areas of clinical deterioration, particularly those at-risk for diabetes, which is concerning for progression to diabetes and disease-related complications.

CLINICAL TRIAL

NCT03394456, accessed at https://clinicaltrials.gov/ct2/show/NCT03394456.

Adolescent sexual and reproductive health and rights for ethnic minority girls in Vietnam

There has been significant progress in improved adolescent sexual and reproductive health and rights (ASRHR) for girls across low- to- middle-income countries (LMICs). However, progress has been uneven, and disparities persistent across and within countries. For example, Vietnam is one of only nine countries to have achieved the 2015 maternal mortality rate (MMR) target of the Millennium Development Goals (MDGs) as a nation, but for some sub-populations, progress has been much slower, and MMR is more than twice that the national average. Ensuring equity is a current focus of the Sustainable Development Goals (SDGs) agenda that seeks to Leave No One Behind. This paper explores some of these inequities and potential drivers for ethnic minority adolescent girls in Vietnam, with a specific focus on the Tay community, the largest ethnic minority group in Vietnam. This paper highlights the challenges to progress, including areas where there is still limited evidence about the range of socio-cultural factors that may determine sexual and reproductive health outcomes for Tay adolescent girls. In the era of the SDGs, Vietnam's national policy platforms and current aid architecture provide a solid basis on which to build research, policy and practice investments that improve the health of adolescent ethnic minority girls in Vietnam.

Culturally Adapting the World Health Organization Digital Intervention for Family Caregivers of People With Dementia (iSupport): Community-Based Participatory Approach

BACKGROUND

Informal caregivers of people with dementia are at high risk of developing mental and physical distress because of the intensity of the care provided. iSupport is an evidence-based digital program developed by the World Health Organization to provide education and support for the informal everyday care of people living with dementia.

OBJECTIVE

Our study aims to describe in detail the cultural adaptation process of iSupport in Switzerland. We specifically focused on the participatory strategies we used to design a culturally adapted, Swiss version of iSupport that informed the development of the desktop version, mobile app, and printed manual.

METHODS

We used a mixed methods design, with a community-based participatory approach. The adaptation of iSupport followed the World Health Organization adaptation guidelines and was developed in 4 phases: content translation, linguistic and cultural revision by the members of the community advisory board, validation with formal and informal caregivers, and refinement and final adaptation.

RESULTS

The findings from each phase showed and consolidated the adjustments needed for a culturally adapted, Swiss version of iSupport. We collected feedback and implemented changes related to the following areas: language register and expressions (eg, from "lesson" to "chapter" and from "suffering from" dementia to "affected by" dementia), resources (hyperlinks to local resources for dementia), contents (eg, from general nonfamiliar scenarios to local and verisimilar examples), graphics (eg, from generalized illustrations of objects to human illustrations), and extra features (eg, a glossary, a forum session, and a read-aloud option, as well as a navigation survey).

CONCLUSIONS

Our study provides evidence on how to culturally adapt a digital program for informal caregivers of people living with dementia. Our results suggest that adopting a community-based participatory approach and collecting lived experiences from the final users and stakeholders is crucial to meet local needs and to inform the further development, testing, and implementation of digital interventions in a specific cultural context.