Intervention Scalability Assessment Tool: A decision support tool for health policy makers and implementers

Codesign is the zeitgeist of our time, but what do we mean by this? A scoping review of the concept of codesign in collaborative research with young people

BACKGROUND

Codesign is increasingly valued in health research as a way to actively include stakeholders in the research process, particularly for groups that have been historically excluded, such as young people. Despite its popularity, codesign is often inconsistently defined in literature. This creates challenges for applying it consistently across research projects and for evaluating its effectiveness. To address this definitional ambiguity, we conducted a scoping review to examine and clarify the concept of codesign in research with young people in the health and social sciences.

METHODS

This scoping review drew on methodological guidance from JBI. Searches were conducted in Proquest, Scopus, Informit and Science Direct for relevant peer-reviewed publications for the period of January 2003-August 2023. Publications were included if they used the term codesign and/or related participatory research methods with young people aged 15-24 years. Screening, full-text review and data extraction were completed by two independent reviewers. Qualitative synthesis was used to identify definitions.

RESULTS

The search yielded 1334 publications, with 49 meeting the inclusion criteria. Publications varied with respect to the age range of included young people and focused on a variety of populations, including young people with mental ill-health or with disabilities, First Nations youth and young people involved with specific services or programs. In analysing the way codesign was described, we found considerable variation, with most studies using multiple terms to refer to their methods. Common terms included coproduction (n = 21), coresearch (n = 15), participatory research (n = 10), codesign (n = 9) and participatory action research (n = 7).

CONCLUSIONS

Many different terms were used to describe codesign research with young people. Codesign was used and operationalized in a myriad of ways and overlapped with methods taken in other participatory approaches. This overlap may reflect the so-called blending of approaches in practice, highlighting the need to tailor different collaborative approaches to specific research projects, processes and participants. Ultimately, the ambiguity and overlap of terms describing collaborative methods such as codesign may matter less than the need for researchers to be transparent about their methods, their understanding of the terms and approaches they are using in research and their justification for undertaking collaborative research.

The sustainability of health interventions implemented in Africa: an updated systematic review on evidence and future research perspectives

BACKGROUND

Sustaining evidence-based interventions in resource-limited settings is critical to optimizing gains in health outcomes. In 2015, we published a review of the sustainability of health interventions in African countries, highlighting gaps in the measurement and conceptualization of sustainability in the region. This review updates and expands upon the original review to account for developments in the past decade and recommendations for promoting sustainability.

METHODS

First, we searched five databases (PubMed, SCOPUS, Web of Science, Global Health, and Cumulated Index to Nursing and Allied Health Literature (CINAHL)) for studies published between 2015 and 2022. We repeated the search in 2023 and 2024. The review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies were included if they reported on the sustainability of health interventions implemented in African countries. Study findings were summarized using descriptive statistics and narrative synthesis, and sustainability strategies were categorized based on the Expert Recommendations for Implementing Change (ERIC) strategies.

RESULTS

Thirty-four publications with 22 distinct interventions were included in the review. Twelve African countries were represented in this review, with Nigeria (n = 6) having the most representation of available studies examining sustainability. Compared to the 2016 review, a similar proportion of studies clearly defined sustainability (52% in the current review versus 51% in the 2015 review). Eight unique strategies to foster sustainability emerged, namely: a) multi-sectorial partnership and developing stakeholder relationships, b) tailoring strategies to enhance program fit and integration, c) active stakeholder engagement and collaboration, d) capacity building through training, e) accessing new funding, f) adaptation, g) co-creation of intervention and implementation strategies and h) providing infrastructural support. The most prevalent facilitators of sustainability were related to micro-level factors (e.g., intervention fit and community engagement). In contrast, salient barriers were related to structural-level factors (e.g., limited financial resources).

CONCLUSIONS

This review highlights some progress in the published reports on the sustainability of evidence-based intervention in Africa. The review emphasizes the importance of innovation in strategies to foster funding determinants for sustainable interventions. In addition, it underscores the need for developing contextually relevant sustainability frameworks that emphasize these salient determinants of sustainability in the region.

Situation analysis of evidence-informed health decision-making in Lao PDR: the case of health technology assessment

Background

There is increasing interest in using evidence to inform policy in Lao PDR, which is in the process of establishing a unit for Health Technology Assessment (HTA). This situation analysis aims to explore the current landscape of evidence generation and translation into policy decisions in Lao PDR using the case of HTA.

Methods

A mixed methods approach was applied. Self-administered questionnaires and semi-structured interviews were conducted with different stakeholder groups. Data were analysed thematically and summarised in tabular form.

Findings

There were 212 responses to the survey and 38 stakeholders were interviewed between March and September 2021. The health policy decision process in Lao PDR is based on consultation meetings, influenced by external experts and/or companies, without consistent use of evidence. There remains a lack of human resource and infrastructure for health evidence to inform policy. Two-thirds of the respondents to the survey strongly agreed that HTA helps in efficient allocation of health resources and improving quality of healthcare. Half of the respondents perceived that HTA can impact the government budget and transparency, which was consistent with findings from the qualitative data. Use of economic considerations was limited in Lao PDR. HTA was seen to apply to policy areas, notably for reimbursement. Only a few organisations can supply health evidence and HTA output, and more training and multi-disciplinary collaboration is needed to conduct and produce HTA and other health evidence to inform policy in Lao PDR. Funding for HTA remains a concern.

Interpretation

Improvement of the health policy decision process is urgently needed in Lao PDR. Limited capacity to conduct HTA as well as institutional considerations need to be addressed. Recent efforts towards this end through the establishment of a unit focused on HTA, capacity building activities and international collaborations are promising to establish evidence-informed priority setting for health policy and can also benefit from regional efforts in this direction. This type of approach to assess the situation for evidence use will be beneficial for other countries embarking on this path.

Funding

Wellcome Trust, the United Kingdom Department of Health and Social Care (DHSC), and the Ministry of Public Health, Thailand.

A cluster randomized stepped wedge implementation trial of scale-up approaches to ending pregnancy-related and -associated morbidity and mortality disparities in 12 Michigan counties: rationale and study protocol

BACKGROUND

Hospital-focused maternal health safety and quality guidelines have been found to reduce pregnancy-related and -associated morbidity and mortality (PRAMM). Unfortunately, quality of obstetric care can improve without affecting disparities. This project is the first controlled implementation trial to test approaches to implementing safety guidelines that: (1) target PRAMM disparities; and (2) focus on community care (care provided outside hospitals in outpatient and other community settings, and coordination among care settings), where most deaths occur. It is also one of the first to test scale-up or sustainment implementation approaches to addressing maternal morbidity and mortality disparities.

METHODS

This project, one of three in the federally funded Multilevel Interventions for Raci.a.l Equity (MIRACLE) Maternal Health Research Center of Excellence, will develop and evaluate an implementation approach for scaling up bundled equity-focused maternal health safety guidelines in community care settings county-wide. The scale-up approach will be co-developed with partners, and then tested using a cluster randomized stepped-wedge trial of 12 Michigan counties with a total population of nearly 6 million. Randomization occurs at the county level; birthing people and providers are clustered within counties. PRAMM outcomes (individual level; primary) will be extracted from a pre-existing statewide linked dataset that includes Medicaid claims and vital records data. The sample will include all Medicaid insured individuals in the 12 counties observed during pregnancy, at birth, and up to 1 year postpartum during the project period (~ 151,920 births, including ~ 49,110 births to Black and/or Hispanic mothers). Implementation outcomes (provider level) will be collected using annual provider (n = 600) surveys and will include scale-up (penetration, reach, control for delivery, and intervention effectiveness at scale) and sustainment (maintenance of fidelity to core elements, health benefits, and capacity to deliver core elements over time) of bundles and cost-effectiveness of implementation approaches.

DISCUSSION

This implementation trial will be the first to evaluate an implementation approach to scaling community health equity-focused maternal safety guidelines, addressing an understudied aspect of implementation science (i.e., scale-up). The study will also provide information about implementation cost-effectiveness needed to drive policy decisions.

TRIAL REGISTRATION

The study was prospectively registered on Clinicaltrials.gov (NCT06541951) on August 6, 2024. The first participant has not yet been recruited. The url for the trial registration is: https://clinicaltrials.gov/study/NCT06541951?locStr=Flint,%20MI&country=United%20States&state=Michigan&city=Flint&rank=1 .

Readiness for scale up following effectiveness-implementation trial: results of scalability assessment of the Community Partnership Program for diabetes self-management for older adults with multiple chronic conditions

BACKGROUND

Implementation research should assess the feasibility of scale up to bridge the evidence-practice gap for integrated care programs in the prevention and management of chronic conditions. Scalability assessment is the first critical step of scale up to determine the potential suitability of a promising health program to be adopted into routine practice and the fit of the program within local contexts. The Community Partnership Program (CPP), an integrated care intervention for older adults with diabetes and multiple chronic conditions, was designed at the outset with scale up in mind, and evaluated in an implementation-effectiveness randomized controlled trial across three Canadian provinces. The final phase of this program of research was to assess scalability and determine the critical factors and next steps for the development of a scale up plan.

METHODS

Multiple methods were used to assess the scalability of the CPP including collection and analysis of publicly available documents, synthesis of qualitative and quantitative evidence from studies of the CPP, semi-structured interviews with key informants, feedback and recommendations arising from working group meetings and knowledge exchange workshops to discuss and rate the scalability of the program. Data collection and analysis was informed by the Intervention Scalability Assessment Tool (ISAT); developed to support practitioners and policy makers in conducting systematic assessments of the suitability of health interventions for population scale-up in high-income countries.

RESULTS

Overall, the CPP received high scalability ratings from participants. A phased, horizontal implementation and scale up process was recommended, facilitating local adaptations, on-going program evaluation, and accumulation of evidence. Challenges to scale up were identified, including the need for further evidence of program effectiveness in other diverse settings and populations, and designated funding and adequate health human resources.

CONCLUSIONS

Participants agreed the CPP meets the needs of many older adults with diabetes and multiple chronic conditions; however, they suggested further tailoring of the program to support different ethnocultural groups and targeting the CPP to older adults with higher needs. The scalability assessment process was a practical method to generate concrete strategies to facilitate the uptake of the CPP into practice.

TRIAL REGISTRATION

Clinical Trials.gov Identifier NCT03664583. Registration date: September 10, 2018.

The FIT FIRST 10 dose-response study: evaluation of implementation outcomes

Introduction

Increasing physical activity (PA) levels among children is critical to mitigate health risks associated with physical inactivity. Schools have been highlighted as ideal setting for promoting PA. However, existing school-based PA programs often face implementation challenges. The FIT FIRST 10 (FF10) multi-sport program has been introduced in Denmark, aiming to increase PA and to enhance children's health, fitness, and well-being. This study evaluates the implementation of the FF10 program for 2nd and 3rd graders.

Materials and methods

The FF10 program was implemented in a 20-week cluster randomized controlled trial across 27 schools. Schools were assigned to a control arm or intervention arms receiving either 3 (full dose) or 1.5 (half dose) FF10 40-min lessons weekly. Teachers received a one-day training session, comprehensive manuals, and necessary equipment. Data were collected from teachers via logbooks documenting implementation fidelity, and an online questionnaire assessing program acceptability, appropriateness, and feasibility, and teachers' capability, opportunity, and motivation for implementing the FF10 program.

Results

A total of 18 intervention schools with 36 classes participated in this study. Program fidelity was high in both intervention groups (2.8 and 2.0 session/week for full and half-dose, respectively). Confidence intervals indicated no differences between the two intervention groups for any outcomes. Teachers (n = 32) in both groups rated FF10 moderately acceptable, appropriate, and feasible (3.5-4.0 out of a potential maximum of 5). Both groups exhibited moderate physical and psychological capabilities (3.5-4.0) and high social opportunities (>4.0), but poor motivation scores (<3.5), particularly regarding the perceived benefits and automatization in delivering the FF10 program.

Conclusion

The FF10 program was almost delivered as intended, but time constraints, limited facilities, and modest teacher motivation might have hindered implementation. Reducing the program's dosage did not improve implementation outcomes, emphasizing the need for ongoing support to boost teacher motivation and integration of the program into school timetables.

The Role and Influence of Federally Established Health Policy Advisory Bodies in Canada

Since the passage of the Canada Health Act (1985), there have been many advisory bodies established by successive federal governments, each tasked with providing advice and making recommendations about where and how to improve the health system. Our analysis of interviews with advisory board members and implementers (e.g., ministry of health leaders, staff and consultants) addresses why participants perceived their advice and recommendations were generally not implemented and informal strategy groups used to facilitate implementation. We recommend that future health system advisory bodies focus on coalition building during policy development, integrate implementation plans into policy recommendations and evaluate the impact of policy recommendations.

An approach to Hemequity: Identifying the barriers and facilitators of iron deficiency reduction strategies in low- to middle-income countries

Approximately 1.92 billion people worldwide are anaemic, and iron deficiency is the most common cause. Iron deficiency anaemia (IDA) disproportionately affects women of reproductive age and remains under-addressed in low- to middle-income countries (LMICs). The primary objective of our scoping review is to evaluate the barriers and facilitators to IDA management in LMICs by using an intersectionality-enhanced implementation science lens adapted from the consolidated framework for implementation research and the theoretical domains framework. A total of 53 studies were identified. Contextual barriers included the deprioritization of IDA risk, unequal gender norms and stigma from the HIV/AIDS epidemic. Regional poverty, conflict and natural disasters led to supply chain barriers. Individual-level facilitators included partner support and antenatal care access while barriers included forgetfulness and having medical comorbidities. Successful interventions also utilized education initiatives to empower women in community decision-making. Moreover, community mobilization and the degree of community ownership determined the sustainability of IDA reduction strategies. IDA is not only a medical problem, but one that is rooted in the sociocultural and political context. Future approaches must recognize the resilience of LMIC communities and acknowledge the importance of knowledge translation rooted in community ownership and empowerment.

Overcoming the threat of anti-bias interventions: Combining self-report and psychophysiological measures to capture the process of change

Anti-bias interventions do not always have the intended results and can even backfire. In light of research on the psychology of morality, we examined whether confronting people with evidence of their own (group's) bias causes a (psychophysiological) threat response, and how to overcome this. We focused on an intervention addressing gender bias in teacher evaluations. After assessing their own teaching evaluations, we presented student research participants (N = 101; 71.3% female), in Part 1 of the intervention, with evidence of bias displayed in such teaching evaluations. This evidence either did (self-implied condition) or did not (self not-implied condition) include participants' own ostensibly biased evaluations. In Part 2 of the intervention, we asked participants to reflect on the issue of gender bias, and compared the impact of two experimental instructions. In the promotion condition, instructions referred to emphasizing how the university could try to achieve the ideal of promoting fair and just evaluations of teachers. In the prevention condition, instructions referred to highlighting the university's obligation to prevent unfair and unjust teacher evaluations. While participants verbally reflected on the intervention, during both phases (in Part 1 and Part 2) we measured their psychophysiological responses using indices of cardiovascular 'threat vs. challenge'. Then, we used self-report measures to examine participants' explicit responses to the different parts of the intervention. Results revealed that implicating the self in the occurrence of bias (Part 1) raises a psychophysiological threat response. However, emphasizing the future ideal of promoting fair evaluations of teachers (rather than the obligation of preventing biased evaluations; Part 2) resulted in a psychophysiological challenge response and increased perceived coping abilities to combat such bias. The implications of these findings are discussed.

A Scoping Review of Intimate Partner Violence Research in Canada

Intimate partner violence (IPV) is at epidemic levels across low-, middle-, and high-income countries, including Canada, where recent lifetime prevalence indicated that over 40% of women had IPV experiences. In response to this, Canada's federal government has made investments toward IPV prevention and response. We conducted a scoping review of English and French literature identified through searches of multiple databases and specific journals to assess the current state of IPV research in Canada. A total of 267 articles met inclusion criteria of being peer-reviewed research primarily about IPV in either French or English published from 2020 to 2022 with at least one Canadian-affiliated author. Almost a third of studies described services for survivors but did not evaluate service effectiveness. We noted a significant gap in research on the IPV experiences of gender and/or sexual minorities. Canada's federal social science research funding agency was the most common funder, with the two federal government departments with specific IPV funding initiatives in place cited as funding less than 6% of included studies. In general, there remains an overfocus on IPV epidemiology and on descriptions of service use, and not enough research examining the effectiveness and implementation of interventions, especially grounded in theoretical, gendered, and trauma- and violence-informed frameworks. Funders and researchers are encouraged to consider moving resources from ongoing description of well-established factors to assessment and implementation of evidence-informed interventions, and, crucially, primary prevention of IPV and all forms of gender-based violence.

Development of the Whole Day Matters Toolkit for Primary Care: a consensus-building study to mobilize national public health guidelines in practice

INTRODUCTION

Strategic knowledge mobilization efforts are needed to enhance uptake and use of the Canadian 24-Hour Movement Guidelines (24HMG), which describe optimal amounts of physical activity, sedentary behaviour and sleep each day for overall health. The Whole Day Matters Toolkit for Primary Care is an evidence-informed resource to help primary care providers (PCPs) disseminate the 24HMGs. The purpose of this study was to describe gaining consensus on toolkit components through iterative revisions to improve its utility in preparation for the September 2022 launch, and to summarize early dissemination efforts.

METHODS

A multidisciplinary expert working group planned three modified Delphi surveys to assess PCPs' level of agreement with toolkit components on 7-point Likert scales with follow-up prompts for ratings of 4 or less. Consensus was defined a priori as a mean of 6 or higher out of 7 and 60% or more of PCPs selecting at least "somewhat agree." Items on which consensus was reached were removed from subsequent surveys unless they were revised.

RESULTS

Twenty PCPs completed surveys 1 and 2; 15 completed survey 3. Consensus was reached on 5% (4/83), 17% (14/83) and 55% (38/69) of the items in surveys 1, 2 and 3, respectively. The number of qualitative comments decreased from 26 to 19 to 12, further indicating increasing consensus.

CONCLUSION

Items on which consensus was not gained may reflect differences in provider characteristics or settings. A coproduced dissemination strategy was enacted. Toolkit reach was evaluated at launch and 4 months later.

Assessing the scalability of health system interventions in Africa: protocol for a Delphi study

BACKGROUND

There is widespread enthusiasm for scaling interventions to strengthen health systems. However, little is known about the scalability of such interventions in Africa. In this study, we seek to assess the scalability of interventions for improving the functionality of health systems in Africa, as a key to large-scale implementation strategy of interventions with potential for impact.

METHODS

The study will deploy a multi-pronged approach, grounded in an integrated knowledge translation (iKT) approach. First, a multidisciplinary steering committee will be established, involving key female and male stakeholders in all stages of our study from its inception and as equal members of the research team for overseeing the project. Second, as part of the RAND/University of California, Los Angeles (UCLA) Appropriateness Method, evidence from a published systematic review will be used to develop the African Scalability Assessment Framework (AFROSAF), a series of multiple attributes for assessing the ability to scale a health system intervention in Africa. Third, the content of the AFROSAF will be validated using Delphi survey (within a deliberative dialogue) following the Lavis' framework for knowledge transfer and a conceptual framework developed by Boyko et al. a multi-stakeholder consensus exercise with experts from Africa will be convened. The Likert scaled scalability attributes developed will be rated and descriptive statistics and hierarchical cluster analysis will be used to synthesize the data. Finally, document analyses will be conducted to rate to which extent each intervention has data that meet criteria responding to the essential components of scalability using the AFROSAF. We will conduct an analysis to score and rank each intervention for scalability.

DISCUSSION

This project proposes an approach aiming to catalyse the scale of interventions for effective functionality of health systems in Africa. The process will yield a scalability assessment tool for Africa and inventory scalable interventions. The findings will help African countries and policymakers understand the parameters to use and assess health system interventions for scaling.

Effectiveness of Telemedicine in Inflammatory Bowel Disease in Russia: TIGE-Rus (Telemonitoring for IBD Goodness Examination in Russia) Study Protocol of a Randomized Controlled Trial

Background: Inflammatory bowel diseases (IBD), associated with a significant burden on patients' lives, are becoming increasingly common. Patients with IBD need continuous treatment and lifelong monitoring, which could be achieved by telemonitoring. Telemonitoring has been shown to be effective in improving outcomes for patients with IBD, and can provide a more convenient and accessible way for patients to receive care. However, the certainty of evidence remains low. This article outlines the methodology of a randomized control study that aims to assess the efficacy of telemonitoring compared to face-to-face follow-up for patients with IBD in Russia, hypothesizing that the implementation of telemonitoring will lead to improvement in clinical, social, and organizational areas. Methods: The TIGE-Rus study is a randomized controlled trial. The study consists of three stages, including selection of patients and random assignment into two groups with a ratio of 1:1, follow-up care using telemonitoring or face-to-face appointments, and evaluation and comparison of follow-up efficacy in both groups. In the first stage, all patients will undergo laboratory tests and instrumental examinations, and fill out questionnaires to measure disease activity, quality of life, medication adherence, psychological well-being, and satisfaction with medical care. In the second stage, the control group will receive standard care while the telemonitoring group will have access to a web platform where they can report their clinical activity, fill out questionnaires, and have online consultations with gastroenterologists. The gastroenterologists will also make monthly phone calls to each patient in the telemonitoring group to monitor their progress. In the third stage of the study, both the telemonitoring group and the control group will be re-hospitalized after six months of monitoring. IBD activity will be evaluated through laboratory and instrumental examinations. Additionally, all the participants will complete questionnaires to assess the disease activity, medication adherence, quality of life, psychological well-being, and satisfaction with medical care in both groups. Conclusions: The trial will explore whether telemonitoring is effective in improving clinical, social, and organizational aspects in the management of patients with IBD in the setting of the Russian healthcare system.

Scale-up of Global Child and Youth Mental Health Services: A Scoping Review

Numerous influential policy and scientific bodies are calling for more rapid advances in the scale-up of child and youth mental health services (CYMHS). A number of CYMHS innovations hold promise for advancing scale-up but little is known about how real-world efforts are progressing. We conducted a scoping review to identify promising approaches to CYMHS scale-up across the globe. Searches were completed in six databases (Academic Search Complete, CINAHL, MEDLINE, PsychInfo, PubMed, and Web of Science). Article selection and synthesis were conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist. A second search focused on low-and-middle-income countries (LMIC) was conducted based on the Cochrane Library recommended search filters of the World Bank listed LMIC countries. Authors used a double coding strategy during the title/abstract and full-text review. Twenty-eight articles meeting the eligibility criteria were identified that described 22 initiatives (in 11 different countries). Our review found the majority of published scale-up studies in CYMHS were not informed by scale-up frameworks in design or reporting. The methods and outcomes used in the identified articles were highly variable and limited our ability to draw conclusions about comparative effectiveness although promising approaches emerged. Successes and failures identified in our review largely reflect consensus in the broader literature regarding the need for strategies to better navigate the complexities of system and policy implementation while ensuring CYMHS interventions fit local contexts.

Views and Uses of Sepsis Digital Alerts in National Health Service Trusts in England: Qualitative Study With Health Care Professionals

BACKGROUND

Sepsis is a common cause of serious illness and death. Sepsis management remains challenging and suboptimal. To support rapid sepsis diagnosis and treatment, screening tools have been embedded into hospital digital systems to appear as digital alerts. The implementation of digital alerts to improve the management of sepsis and deterioration is a complex intervention that has to fit with team workflow and the views and practices of hospital staff. Despite the importance of human decision-making and behavior in optimal implementation, there are limited qualitative studies that explore the views and experiences of health care professionals regarding digital alerts as sepsis or deterioration computerized clinician decision support systems (CCDSSs).

OBJECTIVE

This study aims to explore the views and experiences of health care professionals on the use of sepsis or deterioration CCDSSs and to identify barriers and facilitators to their implementation and use in National Health Service (NHS) hospitals.

METHODS

We conducted a qualitative, multisite study with unstructured observations and semistructured interviews with health care professionals from emergency departments, outreach teams, and intensive or acute units in 3 NHS hospital trusts in England. Data from both interviews and observations were analyzed together inductively using thematic analysis.

RESULTS

A total of 22 health care professionals were interviewed, and 12 observation sessions were undertaken. A total of four themes regarding digital alerts were identified: (1) support decision-making as nested in electronic health records, but never substitute professionals' knowledge and experience; (2) remind to take action according to the context, such as the hospital unit and the job role; (3) improve the alerts and their introduction, by making them more accessible, easy to use, not intrusive, more accurate, as well as integrated across the whole health care system; and (4) contextual factors affecting views and use of alerts in the NHS trusts. Digital alerts are more optimally used in general hospital units with a lower senior decision maker:patient ratio and by health care professionals with experience of a similar technology. Better use of the alerts was associated with quality improvement initiatives and continuous sepsis training. The trusts' features, such as the presence of a 24/7 emergency outreach team, good technological resources, and staffing and teamwork, favored a more optimal use.

CONCLUSIONS

Trust implementation of sepsis or deterioration CCDSSs requires support on multiple levels and at all phases of the intervention, starting from a prego-live analysis addressing organizational needs and readiness. Advancements toward minimally disruptive and smart digital alerts as sepsis or deterioration CCDSSs, which are more accurate and specific but at the same time scalable and accessible, require policy changes and investments in multidisciplinary research.

Making health inequality analysis accessible: WHO tools and resources using Microsoft Excel

Addressing health inequity is a central component of the Sustainable Development Goals and a priority of the World Health Organization (WHO). WHO supports countries in strengthening their health information systems in order to better collect, analyze and report health inequality data. Improving information and research about health inequality is crucial to identify and address the inequalities that lead to poorer health outcomes. Building analytical capacities of individuals, particularly in low-resource areas, empowers them to build a stronger evidence-base, leading to more informed policy and programme decision-making. However, health inequality analysis requires a unique set of skills and knowledge. This paper describes three resources developed by WHO to support the analysis of inequality data by non-statistical users using Microsoft Excel, a widely used and accessible software programme. The resources include a practical eLearning course, which trains learners in the preparation and reporting of disaggregated data using Excel, an Excel workbook that takes users step-by-step through the calculation of 21 summary measures of health inequality, and a workbook that automatically calculates these measures with the user's disaggregated dataset. The utility of the resources is demonstrated through an empirical example.

Co-producing and co-assessing a new service solution for enhancing health and social care integration: a participatory research protocol

BACKGROUND

This paper describes a study protocol for co-producing and co-assessing a new sustainable and scalable service solution that enhances health and social integration by involving providers and volunteers delivering services for elderly people in the province of Cremona (Italy), where the elderly population will reach 27% in 2023.

METHODS

This upcoming study involves mixed-method participatory research and is structured in three study phases and related objectives. First, it will co-produce a new, accessible and sustainable service solution using an iterative design and management method, Plan-Do-Check-Act by involving professionals and volunteers of a heterogeneous group of health, social and third sector organizations located in the city of Cremona (Italy). Second, the study protocol will co-assess the outcomes of the new service solution using a mixed-method approach for measuring the outcomes on: professionals and volunteers (micro level) and their health, social and third sector organizations (meso level). Third, this study will co-investigate the scalability of the new solution promoting health and social integration in other similar urban areas of the Province of Cremona via the Intervention Scalability Assessment Tool (macro level). The data will be collected through the analysis of official documents, websites, policies and participatory workshops.

DISCUSSION

This protocol proposes an innovative intervention, a novel participatory approach, and an unexplored scalability assessment tool in the context of health and social care integration. This study aims to support professionals from health and social care service providers and volunteers from third-sector organizations to collaborate and integrate each other's resources. In doing so, the participatory approach will facilitate the co-creation of an effective response to the need of health and social integration, and the development of trustful relationships between health and social care service providers. Moreover, the adoption of Plan-Do-Check-Act and Intervention Scalability Assessment Tool will ensure the quality, scalability and sustainability of the new service solution in other settings.

The pathway to delivering injectable CAB for HIV prevention: strategies from global PrEP leaders leveraging an adapted version of the Intervention Scalability Assessment Tool (ISAT)

BACKGROUND

Longer-acting cabotegravir (CAB) is a novel, safe, and efficacious pre-exposure prophylaxis (PrEP) for HIV prevention. As we near a time for CAB scale-up, the experience of global leaders in PrEP research and implementation can be leveraged to identify optimal strategies for scaling and integrating CAB into existing PrEP infrastructure worldwide.

METHODS

We recruited leaders of HIV prevention clinical trials and large PrEP programs through a combination of purposive and snowball sampling for participation in individual interviews. We conducted interviews using a semi-structured guide that compared CAB to oral PrEP and sought perspectives on barriers and strategies for CAB scale-up. Interviews were conducted virtually, audio recorded, and transcribed. We used thematic analysis, grounded in an adapted version of the Intervention Scalability Assessment Tool (ISAT), to identify critical elements for optimizing delivery of CAB.

RESULTS

From October 2021 to April 2022, we interviewed 30 participants with extensive experience in PrEP research, care, and programming. Participants worked in all seven WHO regions and reported a median of 20 years working in HIV and 10 years in PrEP. Participants agreed that CAB was efficacious and discrete, therefore having the potential to address current concerns about oral PrEP adherence and stigma. Participants indicated direct and indirect costs for provider training, expansion of existing medical infrastructure, and the current medication cost of CAB as major concerns for roll out. The true cost to the end-user and health system were unknown. There were some conflicting strategies on how to best address product targeting, presentation of efficacy, and timing of product availability with scale-up. Some thought that targeting CAB for the general population could normalize PrEP and decrease stigma, while others thought that prioritizing key populations could optimize impact by targeting those with highest risk. Overall, participants emphasized that to ensure successful CAB scale-up, communities and stakeholders must be involved at every stage of planning and implementation.

CONCLUSIONS

Our evaluation found that although there is a clear and urgent need for additional HIV PrEP options beyond daily oral PrEP, CAB scale-up must be thoughtful, flexible, and based in lessons learned from oral PrEP rollout.

Call to Action: Screening and Addressing Caregiver Mental Health Needs within all Pediatric Medical Subspecialty Settings as Standard of Care

Objective

The objective of this topical review is to provide rationale for the development of standards of care to address the mental health needs of caregivers of youth with chronic and acute conditions.

Methods

In this topical review, we describe the relationship between pediatric medical conditions and caregiver mental health, the state of available screening and intervention options, standards of care in medicine, existing caregiver mental health standards in pediatric subspecialty populations, and exemplar caregiver mental health programs that were developed in response to standards. Finally, we will describe our rationale for this standard of care, provide a call to action, and describe anticipated challenges in developing and implementing such standards. The content of this topical review was guided by expert knowledge, literature review, and communication with members of the American Psychological Association (APA) Division 54 through listserv communication. This review did not involve human subjects research and thus did not require IRB approval, informed consent, or assent.

Results

Standards of Care to address caregiver mental health in pediatrics is one approach to reduce gaps between caregivers' needs and access to treatment. Standards that address caregiver mental health exist for a subset of pediatric medical subspecialty populations but are non-existent across most pediatric populations.

Conclusions

Multidisciplinary collaboration, with broad stakeholder input, could result in the writing of Standards of Care to lead to program development that addresses mental health for caregivers of children with a range of chronic and acute conditions.

Identification of key factors affecting the future of knowledge translation in Iranian health policy-making

BACKGROUND

Production, publication, and effective of academic research in health policy-making are tools to strengthen interactions between policy-makers, the scientific community, and the public. The purpose of this study was to identify the key factors of knowledge translation in the policy-making of the health system in Iran using the structural analysis method.

MATERIALS AND METHODS

This future study was conducted using the foresight structural analysis method for a 10-year horizon in Iran from 2022 to 2031. Initially, 183 factors were identified by literature review and interviews with experts. In the next step, factors were reduced to 34 factors based on the research team's opinions by merging similar items and removing fewer related items. Then, 34 factors were sent to the experts through an online questionnaire. Nineteen factors were identified with importance and uncertainty above the average. Then, the average degree of cross-impact of the selected factors in the matrix was scored by 11 experts in a focus group meeting, ranged from 3 (strong) to 1 (weak). The cross-impact of these factors was analyzed using MICMAC software.

RESULTS

Five factors, including "policy-making method," "role and function of universities," "specialized services of knowledge brokering," "international conflicts," and "policy-makers' trust in university researches," were identified as key factors due to their high influence and effectiveness.

CONCLUSION

The results of this study will help the research managers of the universities to be more informed and, therefore, more successful in their planning for more efficient utilization of the knowledge and evidence from academic research by knowing the factors influencing the translation of knowledge.

Process Evaluation of a Scaled-Up School-Based Physical Activity Program for Adolescents: Physical Activity 4 Everyone

BACKGROUND

Physical Activity 4 Everyone (PA4E1) is a whole-school physical activity program, with demonstrated efficacy (2012-2014). PA4E1 was adapted (scaled-up) and tested in a scale-up trial (2017-2020). This process evaluation study of the scale-up trial had 2 aims. First, to describe the acceptability, appropriateness, and feasibility of PA4E1 in the scale-up trial, from the perspective of school staff involved in the program management and delivery. Second, to generate themes that may explain school staff assessments of acceptability, appropriateness, and feasibility.

METHODS

Data were collected at various time points throughout the 2-year implementation phase. Online surveys were collected from In-School Champions, Head Physical Education teachers, Principals, and Physical Education teachers (quantitative data). Focus groups and interviews were conducted with In-School Champions, Principals, and Physical Education teachers (qualitative data). Existing published data on website engagement, adaptations, modifications, and the scale-up trial primary outcome (implementation of physical activity practices) were triangulated with the quantitative and qualitative during analysis, to generate themes.

RESULTS

School staff delivering PA4E1 reported it was highly acceptable, appropriate, and feasible. Seven themes were generated relating to acceptability, appropriateness, and feasibility. The themes related to how the program was funded, the delivery modes of implementation support, the identification of easy-wins, the recruitment of the right in-school champion, facilitating principal buy-in, mitigating the impact of school staff turnover, and engaging the whole school.

CONCLUSIONS

Recommendations are made to inform future adaptations for PA4E1 and potentially school-based physical activity programs more generally. The findings may inform future scalability assessments of the suitability of programs for scale-up.

Replicability, adaptability and long-term impact of the 'Healthy Youngsters, Healthy Dads' program in Newcastle, Australia

'Healthy Youngsters, Healthy Dads' (HYHD) targets fathers to improve the health of their preschool-aged children. In a previous randomized trial, fathers and children experienced meaningful improvements in physical activity and eating behaviours. The next phase is to test the replicability and adaptability of HYHD when delivered in the community by trained facilitators. Fathers/father-figures and children aged 3-5 years were recruited from Newcastle, Australia into a 9-week, non-randomized trial with assessments at baseline, 10 weeks, and 12 months. The primary outcome was achievement of pre-registered targets for recruitment (≥ 96 dyads), attendance (≥ 70%), compliance (completing ≥ 70% of home-based tasks), fidelity (≥ 80% of content delivered as intended) and program satisfaction (≥ 4/5). Secondary outcomes included physical activity, nutrition, screen time and parenting measures. Process targets were surpassed for recruitment (140 fathers, 141 children), attendance (79% for fathers-only workshops, 81% for father-child sessions), compliance (80% of home-tasks completed), fidelity (99% for education, ≥ 97% for practical) and program satisfaction (4.8/5). Mixed effects regression models revealed significant effects in fathers for moderate-to-vigorous physical activity, co-physical activity, dietary intake and parenting practises, which were maintained at 12 months. Significant effects were also established for screen time at 10 weeks only. For children, significant effects were observed for screen time and dietary intake at 10 weeks, while effects on energy-dense, nutrient-poor foods and healthy, nutrient-dense core food intake were maintained at 12 months. Findings demonstrate the replicability and adaptability of HYHD when delivered in the community by local trained facilitators. Further investigation into how to optimally scale-up HYHD is warranted.

Learning Health System to rapidly improve the implementation of a school physical activity policy

BACKGROUND

Learning Health Systems (LHS) - characterised by cycles of evidence generation and application - are increasingly recognised for their potential to improve public health interventions and optimise health impacts; however there is little evidence of their application in the context of public health practice. Here, we describe how an Australian public health unit applied a LHS approach to successfully improve a model of support for implementation of a school-based physical activity policy.

METHODS

This body of work was undertaken in the context of a strong research-practice partnership. Core LHS capabilities included: i) partnerships and stakeholder engagement; ii) workforce development and learning health communities; iii) multi-disciplinary scientific expertise; iv) practice data collection and management system; v) evidence surveillance and synthesis; and vi) governance and organisational processes of decision making. Three cycles of data generation and application were used. Within each cycle, randomised controlled trials conducted in NSW primary schools were used to generate data on the support model's effectiveness for improving schools' implementation of a government physical activity policy, its delivery costs, and process measures such as adoption and acceptability. Each type of data were analysed independently, synthesised, and then presented to a multi-disciplinary team of researchers and practitioners, in consult with stakeholders, leading to collaborative decisions for incremental improvements to the support model.

RESULTS

Cycle 1 tested the first version of the support model (composed of five implementation strategies targeting identified barriers of policy implementation) and showed the model's feasibility and efficacy for improving schools' policy implementation. Data-informed changes were made to enhance impact, including the addition of three implementation strategies to address outstanding barriers. Cycle 2 (now, testing a package of eight implementation strategies) established the model's effectiveness and cost-effectiveness for improving school's policy implementation. Data-informed changes were made to reduce delivery costs, specifically adapting the costliest strategies to reduce in-person contact from external support personnel. Cycle 3 showed that the adaptations minimised the relative cost of delivery without adversely impacting on the effect.

CONCLUSIONS

Through this process, we identified an effective, cost-effective, acceptable and scalable policy implementation support model for service delivery. This provides important information to inform or support LHS approaches for other agencies seeking to optimise the health impact of evidence-based interventions.

The economic evaluation of a housing maintenance project to improve the health of Aboriginal housing tenants in NSW: A scoping literature review and protocol for an economic analysis

Considerable evidence exists regarding the role housing plays in the determination of health and well-being outcomes. Despite the scale of health concerns arising from housing considerations, there are very few economic analyses of housing programs that seek to improve health outcomes by addressing the physical infrastructure of the living environment. The NSW Housing for Health (HfH) program is an environmental health initiative funded and administered by NSW Health, that addresses health-related hardware in residential accommodation to ensure the home environment supports healthy living practices to ultimately improve health outcomes for residents. This study reviews the economic methods that have been applied to comparable programs and identifies relevant costs and benefits that should be addressed. Founded on the requirement from decision makers, and the insights from the review, the paper outlines a protocol for a cost-benefit analysis that accounts for the disparate health, social, economic and intangible benefits generated from the HfH program and the resources utilised to realise these outcomes.

Primary health care response to noncommunicable diseases: an assessment of Wellness Clinics in Ghana

BACKGROUND

Globally, there is a significant unmet need for the rapidly growing burden of Non-Communicable Diseases (NCDs). Ghana has adopted and implemented Wellness Clinics (WC) nationwide to respond to the rising burden of NCDs. Regrettably, very little is known about WCs, including their structure and the services they offer. This study explores the concept of WC, their structure, position within the hospital environment, and services from the perspectives of healthcare providers and clients.

METHODS

An exploratory qualitative study was conducted with health professionals (n = 12) and clients (n = 26) of Wellness Clinics in two district hospitals and one regional hospital in a deprived region of Ghana where NCDs are rising. Using the WHO-PEN approach, an interview guide was purposely designed for this study. The data were analysed thematically using Atlas.ti.

RESULTS

All three Wellness Clinics were sub-units under the outpatient department. The WC was created by the facilities to respond to the increase in NCDs and to meet annual performance review requirements. The Wellness Clinics provided NCD diagnosis, counselling, and treatment services to approximately 300 clients per week at the facility level. Only one of the WCs provided NCD prevention services at the community level. Integrated NCD care was also provided at the WC, despite the health system and individual-level challenges reported by the health workers and clients.

CONCLUSION

The implementation of the Wellness Clinic demonstrates the government's commitment to addressing the increasing burden of NCDs in Ghana through the primary health system. To maximise the impact of the wellness clinics, we recommend developing best practices, providing logistics, and addressing health insurance challenges.

From Chaos to Rationality: A Contingent Meta-Model for Evidence-Informed Health Policymaking in Diverse Contexts

Background

Evidence-informed policymaking is a complex process that requires adapting to diverse contexts characterized by varying degrees of certainty and agreement. Existing models and frameworks often lack clear guidance for dealing with such contexts. This study aimed to develop a novel contingency model to guide the context-specific use of evidence in health policymaking.

Methods

The study conducted a meta-ethnographic synthesis of 15 existing models and frameworks on evidence-informed policymaking, integrating key factors and concepts influencing the use of evidence in policy decisions. The study also adapted the Stacey Matrix, a tool for understanding the complexity of decision-making, into a quantitative scoring system to assess the levels of certainty and agreement in a given policy context.

Results

The study proposed a contingency model that delineates seven modes of decision-making based on the dimensions of certainty and agreement, ranging from rational to molasses-slow collective. For each mode, the model suggests configuring four aspects: team composition, policy idea generation, problem analysis, and consensus building. The model also highlights the multifaceted influences of evidence, interests, values, and beliefs on policy decisions.

Conclusion

The contingency model offers researchers and policymakers a flexible framework for aligning policymaking processes with available evidence. The model also underscores the importance of context-specific approaches to evidence-informed policymaking. The model could enhance evidence-informed policymaking capacity, improving health outcomes and system performance. Further research should validate and extend the model empirically across diverse contexts.

Developing a hope-focused intervention to prevent mental health problems and improve social outcomes for young women who are not in education, employment, or training (NEET): A qualitative co-design study in deprived coastal communities in South-East England

Young women who are not in education, employment, or training (NEET) experience poorer health and social outcomes compared to non-NEET young women and to NEET young men, especially in deprived areas with intersecting inequalities. The evidence on effective public health approaches is scarce. Interventions that target hope, which NEET young women notably lack, offer a promising theory-driven and intuitive means to prevent mental health problems and improve social outcomes. Hope can be defined as a goal-focused mindset comprising self-agency (motivation and self-belief) and pathways (identifying routes to achieving goals). Hope is implicated in a variety of evidence-based psychosocial interventions for young people, but is not directly targeted by existing prevention programmes for NEET populations. The current study used a phased qualitative research design and participatory methods to model a hope-focused intervention for NEET young women. Phase 1 investigated population needs and intervention parameters through semi-structured interviews with 28 key informants living or working in disadvantaged coastal communities in South-East England. The sample comprised eight NEET young women, four family members, and 16 practitioners from relevant support organisations. Phase 2 refined intervention parameters and outcomes through co-design sessions with four NEET young women, followed by a theory of change workshop with 10 practitioners. The resulting intervention model is articulated as a mentor-supported, in-person psychosocial intervention that builds hope by enhancing positive sense of self and time spent in meaningful activities, before explicitly teaching the skills needed to identify, set, and pursue personally meaningful goals.

Research outcomes informing the selection of public health interventions and strategies to implement them: A cross-sectional survey of Australian policy-maker and practitioner preferences

BACKGROUND

A key role of public health policy-makers and practitioners is to ensure beneficial interventions are implemented effectively enough to yield improvements in public health. The use of evidence to guide public health decision-making to achieve this is recommended. However, few studies have examined the relative value, as reported by policy-makers and practitioners, of different broad research outcomes (that is, measures of cost, acceptability, and effectiveness). To guide the conduct of research and better inform public health policy and practice, this study aimed at describing the research outcomes that Australian policy-makers and practitioners consider important for their decision-making when selecting: (a) public health interventions; (b) strategies to support their implementation; and (c) to assess the differences in research outcome preferences between policy-makers and practitioners.

METHOD

An online value-weighting survey was conducted with Australian public health policy-makers and practitioners working in the field of non-communicable disease prevention. Participants were presented with a list of research outcomes and were asked to select up to five they considered most critical to their decision-making. They then allocated 100 points across these - allocating more points to outcomes perceived as more important. Outcome lists were derived from a review and consolidation of evaluation and outcome frameworks in the fields of public health knowledge translation and implementation. We used descriptive statistics to report relative preferences overall and for policy-makers and practitioners separately.

RESULTS

Of the 186 participants; 90 primarily identified as policy-makers and 96 as public health prevention practitioners. Overall, research outcomes of effectiveness, equity, feasibility, and sustainability were identified as the four most important outcomes when considering either interventions or strategies to implement them. Scores were similar for most outcomes between policy-makers and practitioners.

CONCLUSION

For Australian policy-makers and practitioners working in the field of non-communicable disease prevention, outcomes related to effectiveness, equity, feasibility, and sustainability appear particularly important to their decisions about the interventions they select and the strategies they employ to implement them. The findings suggest researchers should seek to meet these information needs and prioritize the inclusion of such outcomes in their research and dissemination activities. The extent to which these outcomes are critical to informing the decision of policy-makers and practitioners working in other jurisdictions or contexts warrants further investigation.

Developing and refining the COVID-19 to Routine Immunization Information System Transferability Assessment (CRIISTA) tool: a decision support tool to leverage COVID-19 immunization information system investments for routine immunization

To achieve the Immunization Agenda 2030 vaccine equity vision of a world where everyone everywhere benefits from vaccines, it is essential to invest in immunization information systems that can support the identification, reach and monitoring of zero-dose and under-immunized children. The rapid nature of COVID-19 vaccine introduction led to the investment of new systems to collect, manage and use immunization data. While many digital health assessment tools exist, there is an absence of tools to support decision-makers to systematically assess the suitability of transferring an immunization information system from one health context to another. To address this gap, the COVID-19 to Routine Immunization Information System Transferability Assessment tool was developed, informed by literature review, expert consultation and usability testing. The tool is organized into five thematic areas: context, functionality, technology, users and resources. Each thematic area has questions about the COVID-19 immunization information system, the current and desired state of the routine immunization information system and the gaps between them. Suitability scores are then calculated to assess whether a COVID-19 immunization information system is suitable for routine immunization so governments can leverage these investments to strengthen routine immunization programs and the broader health information ecosystem. Abrégé Pour réaliser la vision du Programme pour la vaccination à l'horizon 2030 concernant l'équité vaccinale d'un monde où tout le monde, partout, bénéficie des vaccins, il est essentiel d'investir dans des systèmes d'information sur la vaccination capables d'appuyer l'identification, l'accès et le suivi des enfants zéro dose et insuffisamment vaccinés. La nature rapide de l'introduction du vaccin contre la COVID-19 a entraîné l'investissement dans de nouveaux systèmes de collecte, de gestion et d'utilisation des données sur la vaccination. Bien que de nombreux outils numériques d'évaluation de la santé existent, on ne dispose d'aucun outil pour aider les décideurs à évaluer systématiquement la pertinence du transfert d'un système d'information sur la vaccination d'un contexte de santé à un autre. Pour combler cette lacune, l'outil d'évaluation de la transférabilité de la COVID-19 au système d'information sur la vaccination de routine a été élaboré, éclairé par un examen documentaire, des consultations d'experts et des tests bêta. Cet outil s'articule autour de cinq domaines thématiques: contexte, fonctionnalité, technologie, utilisateurs et ressources. Chaque domaine thématique comprend des questions sur le système d'information sur la vaccination contre la COVID-19, l'état actuel et souhaité du système d'information sur la vaccination de routine et les écarts entre eux. Les scores de pertinence sont ensuite calculés pour évaluer si un système d'information sur la vaccination contre la COVID-19 convient à la vaccination de routine afin que les pouvoirs publics puissent tirer parti de ces investissements pour renforcer les programmes de vaccination de routine et l'écosystème de l'information sur la santé dans son ensemble. Resumen Para lograr la visión de la Agenda de Inmunización 2030 de un mundo donde todas las personas de todas partes se beneficien de las vacunas, es esencial invertir en sistemas de información sobre vacunación que puedan apoyar la identificación, el alcance y el monitoreo de niños con dosis cero y subvacunados. La rápida introducción de la vacuna COVID-19 condujo a la inversión en nuevos sistemas para recopilar, administrar y utilizar datos sobre vacunación. Si bien existen muchas herramientas digitales de evaluación de la salud, faltan instrumentos para ayudar a los responsables de la toma de decisiones a evaluar sistemáticamente la idoneidad de transferir un sistema de información sobre vacunación de un contexto sanitario a otro. Para corregir esta deficiencia, se creó el Marco de evaluación de la transferibilidad del sistema de información sobre la vacunación contra la COVID-19 a la vacunación sistemática (CRIISTA), sobre la base de la revisión de literatura, consultas a expertos y pruebas beta. El Marco está organizado en cinco áreas temáticas: contexto, funcionalidad, tecnología, usuarios y recursos. Cada área temática contiene preguntas referidas al sistema de información sobre la vacunación contra la COVID-19, el estado actual del sistema de información sobre la vacunación sistemática y su estado deseado, y las brechas entre ellos. Seguidamente, se calculan las puntuaciones de idoneidad para evaluar si un sistema de información sobre la vacunación contra la COVID-19 es adecuado para la vacunación sistemática, de modo que los Gobiernos puedan aprovechar estas inversiones para fortalecer los programas de vacunación sistemática y el sistema más amplio de información sanitaria.

Private groundwater contamination and risk management: A comparative scoping review of similarities, drivers and challenges across two socio-economically developed regions

Consolidation of multi-domain risk management research is essential for strategies facilitating the concerted government (educational) and population-level (behavioural) actions required to reduce microbial private groundwater contamination. However, few studies to date have synthesised this literature or sought to ascertain the causal generality and extent of supply contamination and preventive responses. In light of the Republic of Ireland (ROI) and Ontario's high reliance and research focus on private wells and consequent utility for empirical comparison, a scoping review of pertinent literature (1990-2022) from both regions was undertaken. The SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) method was employed to inform literature searches, with Scopus and Web of Science selected as primary databases for article identification. The review identified 65 relevant articles (Ontario = 34, ROI = 31), with those investigating well user actions (n = 22) and groundwater quality (n = 28) the most frequent. A markedly higher pooled proportion of private supplies in the ROI exhibited microbial contamination (38.3 % vs. 4.1 %), despite interregional similarities in contamination drivers (e.g., weather, physical supply characteristics). While Ontarian well users demonstrated higher rates of historical (≥ 1) and annual well testing (90.6 % vs. 71.1 %; 39.1 % vs. 8.6 %) and higher rates of historical well treatment (42.3 % vs. 24.3 %), interregional levels of general supply knowledge were analogous (70.7 % vs. 71.0 %). Financial cost, organoleptic properties and residence on property during supply construction emerged as predictors of cognition and behaviour in both regions. Review findings suggest broad interregional similarities in drivers of supply contamination and individual-level risk mitigation, indicating that divergence in contamination rates may be attributable to policy discrepancies - particularly well testing incentivisation. The paucity of identified intervention-oriented studies further highlights the importance of renewed research and policy agendas for improved, targeted well user outreach and incentivised, convenience-based services promoting routine supply maintenance.

Gender and non-communicable diseases in Mexico: a political mapping and stakeholder analysis

BACKGROUND

Mexico and other low- and middle-income countries (LMICs) present a growing burden of non-communicable diseases (NCDs), with gender-differentiated risk factors and access to prevention, diagnosis and care. However, the political agenda in LMICs as it relates to health and gender is primarily focused on sexual and reproductive health rights and preventing violence against women. This research article analyses public policies related to gender and NCDs, identifying political challenges in the current response to women's health needs, and opportunities to promote interventions that recognize the role of gender in NCDs and NCD care in Mexico.

METHODS

We carried out a political mapping and stakeholder analysis during July-October of 2022, based on structured desk research and interviews with eighteen key stakeholders related to healthcare, gender and NCDs in Mexico. We used the PolicyMaker V5 software to identify obstacles and opportunities to promote interventions that recognize the role of gender in NCDs and NCD care, from the perspective of the political stakeholders interviewed.

RESULTS

We found as a political obstacle that policies and stakeholders addressing NCDs do not take a gender perspective, while policies and stakeholders addressing gender equality do not adequately consider NCDs. The gendered social and economic aspects of the NCD burden are not widely understood, and the multi-sectoral approach needed to address these aspects is lacking. Economic obstacles show that budget cuts exacerbated by the pandemic are a significant obstacle to social protection mechanisms to support those caring for people living with NCDs.

CONCLUSIONS

Moving towards an effective, equity-promoting health and social protection system requires the government to adopt an intersectoral, gender-based approach to the prevention and control of NCDs and the burden of NCD care. Despite significant resource constraints, policy innovation may be possible given the willingness among some stakeholders to collaborate, particularly in the labour and legal sectors. However, care will be needed to ensure the implementation of new policies has a positive impact on both gender equity and health outcomes. Research on successful approaches in other contexts can help to identify relevant learnings for Mexico.

Co-design personal sleep health technology for and with university students

University students often experience sleep disturbances and disorders. Personal digital technologies present a great opportunity for sleep health promotion targeting this population. However, studies that engage university students in designing and implementing digital sleep health technologies are scarce. This study sought to understand how we could build digital sleep health technologies that meet the needs of university students through a co-design process. We conducted three co-design workshops with 51 university students to identify design opportunities and to generate features for sleep health apps through workshop activities. The generated ideas were organized using the stage-based model of self-tracking so that our findings could be well-situated within the context of personal health informatics. Our findings contribute new design opportunities for sleep health technologies targeting university students along the dimensions of sleep environment optimization, online community, gamification, generative AI, materializing sleep with learning, and personalization.

A rapid review of the scalability of interventions targeting obesity prevention in infants

ISSUE ADDRESSED

Obesity in children is one of the most significant public health issues globally. Given the high prevalence of overweight and obesity in children, there is a need to identify effective obesity prevention efforts that can be delivered at scale to improve child health. We aimed to (i) identify obesity prevention interventions targeted at children aged 0-2 that have been scaled-up, and their relative efficacy compared to their pre-scale trial, (ii) describe adaptations made, and the extent to which factors related to scalability have been reported.

METHODS

We conducted a rapid review of pre-scale randomised controlled trials targeting nutrition, physical activity and obesity prevention in infants, and calculated the relative effect size for relevant outcomes in the corresponding scaled up trial. We documented adaptations made to the pre-scale trial for scale up, and explored how different components of scalability had been reported according to the Intervention Scalability Assessment Tool.

RESULTS

Of the 14 identified pre-scale trials, only one formal evaluation of the scale-up trial was identified. For body mass index, <10% of the effect was retained, however for nutrition and behavioural outcomes, the proportion of effect retained varied from -11.1% to 144%. Significant adaptations to modality were made in the scaled up trial primarily to reduce cost and increase reach of the intervention. Reporting of scalability components varied across the 14 trials, with only one trial reporting information for all assessed components.

CONCLUSIONS

The majority of effective interventions targeting obesity prevention in infants have not been evaluated in a scaled up form. The magnitude of effect retained for the single trial that was scaled up was variable. In general, reporting of components of scalability was sub-optimal. SO WHAT?: The findings suggest that there is substantial need for the development and rigorous evaluation of obesity prevention interventions in children aged 0-2 which are amenable for scale.

Expanding access to fracture liaison services in Australia for people with minimal trauma fractures: a system dynamics modelling study

OBJECTIVES

To project how many minimal trauma fractures could be averted in Australia by expanding the number and changing the operational characteristics of fracture liaison services (FLS).

STUDY DESIGN

System dynamics modelling.

SETTING, PARTICIPANTS

People aged 50 years or more who present to hospitals with minimal trauma fractures, Australia, 2020-31.

MAIN OUTCOME MEASURES

Numbers of all minimal trauma fractures and of hip fractures averted by increasing the FLS number (from 29 to 58 or 100), patient screening rate (from 30% to 60%), and capacity for accepting new patients (from 40 to 80 per service per month), and reducing the proportion of eligible patients who do not attend FLS (from 30% to 15%); cost per fracture averted.

RESULTS

Our model projected a total of 2 441 320 minimal trauma fractures (258 680 hip fractures; 2 182 640 non-hip fractures) in people aged 50 years or older during 2020-31, including 1 211 646 second or later fractures. Increasing the FLS number to 100 averted a projected 5405 fractures (0.22%; $39 510 per fracture averted); doubling FLS capacity averted a projected 3674 fractures (0.15%; $35 835 per fracture averted). Our model projected that neither doubling the screening rate nor reducing by half the proportion of eligible patients who did not attend FLS alone would reduce the number of fractures. Increasing the FLS number to 100, the screening rate to 60%, and capacity to 80 new patients per service per month would together avert a projected 13 672 fractures (0.56%) at a cost of $42 828 per fracture averted.

CONCLUSION

Our modelling indicates that increasing the number of hospital-based FLS and changing key operational characteristics would achieve only moderate reductions in the number of minimal trauma fractures among people aged 50 years or more, and the cost would be relatively high. Alternatives to specialist-led, hospital-based FLS should be explored.

Aligning organisational priorities and implementation science for cancer research

BACKGROUND

The challenge of implementing evidence into routine clinical practice is well recognised and implementation science offers theories, models and frameworks to promote investigation into delivery of evidence-based care. Embedding implementation researchers into health systems is a novel approach to ensuring research is situated in day-to-day practice dilemmas. To optimise the value of embedded implementation researchers and resources, the aim of this study was to investigate stakeholders' views on opportunities for implementation science research in a cancer setting that holds potential to impact on care. The research objectives were to: 1) Establish stakeholder and theory informed organisation-level implementation science priorities and 2) Identify and prioritise a test case pilot implementation research project.

METHODS

We undertook a qualitative study using semi-structured interviews. Participants held either a formal leadership role, were research active or a consumer advocate and affiliated with either a specialist cancer hospital or a cancer alliance of ten hospitals. Interview data were summarised and shared with participants prior to undertaking both thematic analysis, to identify priority areas for implementation research, and content analysis, to identify potential pilot implementation research projects. The selected pilot Implementation research project was prioritised using a synthesis of an organisational and implementation prioritisation framework - the organisational priority setting framework and APEASE framework.

RESULTS

Thirty-one people participated between August 2022 and February 2023. Four themes were identified: 1) Integration of services to address organisational priorities e.g., tackling fragmented services; 2) Application of digital health interventions e.g., identifying the potential benefits of digital health interventions; 3) Identification of potential for implementation research, including deimplementation i.e., discontinuing ineffective or low value care and; 4) Focusing on direct patient engagement e.g., wider consumer awareness of the challenges in delivering cancer care. Six potential pilot implementation research projects were identified and the EMBED project, to support clinicians to refer appropriate patients with cancer for genetic testing, was selected using the synthesised prioritisation framework.

CONCLUSIONS

Using a theory informed and structured approach the alignment between strategic organisational priorities and implementation research priorities can be identified. As a result, the implementation research focus can be placed on activities with the highest potential impact.

The Digital Therapeutics Real-World Evidence Framework: An Approach for Guiding Evidence-Based Digital Therapeutics Design, Development, Testing, and Monitoring

Digital therapeutics (DTx) are a promising way to provide safe, effective, accessible, sustainable, scalable, and equitable approaches to advance individual and population health. However, developing and deploying DTx is inherently complex in that DTx includes multiple interacting components, such as tools to support activities like medication adherence, health behavior goal-setting or self-monitoring, and algorithms that adapt the provision of these according to individual needs that may change over time. While myriad frameworks exist for different phases of DTx development, no single framework exists to guide evidence production for DTx across its full life cycle, from initial DTx development to long-term use. To fill this gap, we propose the DTx real-world evidence (RWE) framework as a pragmatic, iterative, milestone-driven approach for developing DTx. The DTx RWE framework is derived from the 4-phase development model used for behavioral interventions, but it includes key adaptations that are specific to the unique characteristics of DTx. To ensure the highest level of fidelity to the needs of users, the framework also incorporates real-world data (RWD) across the entire life cycle of DTx development and use. The DTx RWE framework is intended for any group interested in developing and deploying DTx in real-world contexts, including those in industry, health care, public health, and academia. Moreover, entities that fund research that supports the development of DTx and agencies that regulate DTx might find the DTx RWE framework useful as they endeavor to improve how DTxcan advance individual and population health.

Assessing the scalability of evidence-based healthy eating and physical activity interventions in early childhood education and care: A cross-sectional study of end-user perspectives

OBJECTIVES

To describe early childhood education and care (ECEC) services: i) perceptions regarding the scalability of healthy eating and physical activity interventions; and ii) associations between scalability and service characteristics.

METHODS

A cross-sectional survey was conducted with a randomly selected sample of ECEC services across Australia. The scalability of 12 healthy eating and physical activity interventions was assessed using items based on the Intervention Scalability Assessment Tool. Higher scores represented higher perceived scalability.

RESULTS

From 453 participants, the highest scoring healthy eating and physical activity interventions were 'providing healthy eating education and activities for children' (M43.05) (out of 50) and 'providing sufficient opportunities for child physical activity' (M41.43). The lowest scoring was 'providing families with lunchbox guidelines' (M38.99) and 'engaging families in activities to increase child physical activity' (M38.36). Services located in rural areas, compared to urban areas, scored the overall scalability of both healthy eating and physical activity interventions significantly lower.

CONCLUSIONS

Perceptions regarding the scalability of healthy eating and physical activity interventions in the ECEC setting vary according to service characteristics.

IMPLICATIONS FOR PUBLIC HEALTH

Findings identify where government investment and implementation efforts may be prioritised to facilitate scale-up. An investigation into the barriers and support required for lower-scoring interventions is warranted.

State of the Science of Scale-Up of Cancer Prevention and Early Detection Interventions in Low- and Middle-Income Countries: A Scoping Review

PURPOSE

Cancer deaths in low- and middle-income countries (LMICs) will nearly double by 2040. Available evidence-based interventions (EBIs) for cancer prevention and early detection can reduce cancer-related mortality, yet there is a lack of evidence on effectively scaling these EBIs in LMIC settings.

METHODS

We conducted a scoping review to identify published literature from six databases between 2012 and 2022 that described efforts for scaling cancer prevention and early detection EBIs in LMICs. Included studies met one of two definitions of scale-up: (1) deliberate efforts to increase the impact of effective intervention to benefit more people or (2) an intervention shown to be efficacious on a small scale expanded under real-world conditions to reach a greater proportion of eligible population. Study characteristics, including EBIs, implementation strategies, and outcomes used, were summarized using frameworks from the field of implementation science.

RESULTS

This search yielded 3,076 abstracts, with 24 studies eligible for inclusion. Included studies focused on a number of cancer sites including cervical (67%), breast (13%), breast and cervical (13%), liver (4%), and colon (4%). Commonly reported scale-up strategies included developing stakeholder inter-relationships, training and education, and changing infrastructure. Barriers to scale-up were reported at individual, health facility, and community levels. Few studies reported applying conceptual frameworks to guide strategy selection and evaluation.

CONCLUSION

Although there were relatively few published reports, this scoping review offers insight into the approaches used by LMICs to scale up cancer EBIs, including common strategies and barriers. More importantly, it illustrates the urgent need to fill gaps in research to guide best practices for bringing the implementation of cancer EBIs to scale in LMICs.

A randomized controlled trial of Promoting Physical Activity in Regional and Remote Cancer Survivors (PPARCS)

BACKGROUND

Physical activity (PA) is important for cancer survivors. Trials of remotely delivered interventions are needed to assist in reaching under-served non-metropolitan cancer survivors. The objective of this study was to ascertain whether wearable technology, coupled with health coaching was effective in increasing PA in breast and colorectal cancer survivors living in regional and remote areas in Australia.

METHODS

Cancer survivors from 5 states were randomized to intervention and control arms. Intervention participants were given a Fitbit Charge 2TM and received up to 6 telephone health coaching sessions. Control participants received PA print materials. Accelerometer assessments at baseline and 12 weeks measured moderate-to-vigorous PA (MVPA), light PA, and sedentary behavior.

RESULTS

Eighty-seven participants were recruited (age = 63 ± 11 years; 74 (85%) female). There was a significant net improvement in MVPA of 49.8 min/week, favoring the intervention group (95% confidence interval (95%CI): 13.6-86.1, p = 0.007). There was also a net increase in MVPA bouts of 39.5 min/week (95%CI: 11.9-67.1, p = 0.005), favoring the intervention group. Both groups improved light PA and sedentary behavior, but there were no between-group differences.

CONCLUSION

This is the first study to demonstrate that, when compared to standard practice (i.e., PA education), a wearable technology intervention coupled with distance-based health coaching, improves MVPA in non-metropolitan cancer survivors. The results display promise for the use of scalable interventions using smart wearable technology in conjunction with phone-based health coaching to foster increased PA in geographically disadvantaged cancer survivors.

A conceptualisation of scale-up and sustainability of social innovations in global health: a narrative review and integrative framework for action

BACKGROUND

The scale-up and sustainability of social innovations for health have received increased interest in global health research in recent years; however, these ambiguous concepts are poorly defined and insufficiently theorised and studied. Researchers, policymakers, and practitioners lack conceptual clarity and integrated frameworks for the scale-up and sustainability of global health innovations. Often, the frameworks developed are conceived in a linear and deterministic or consequentialist vision of the diffusion of innovations. This approach limits the consideration of complexity in scaling up and sustaining innovations.

OBJECTIVE

By using a systems theory lens and conducting a narrative review, this manuscript aims to produce an evidence-based integrative conceptual framework for the scale-up and sustainability of global health innovations.

METHOD

We conducted a hermeneutic narrative review to synthetise different definitions of scale-up and sustainability to model an integrative definition of these concepts for global health. We have summarised the literature on the determinants that influence the conditions for innovation success or failure while noting the interconnections between internal and external innovation environments.

RESULTS

The internal innovation environment includes innovation characteristics (effectiveness and testability, monitoring and evaluation systems, simplification processes, resource requirements) and organisational characteristics (leadership and governance, organisational change, and organisational viability). The external innovation environment refers to receptive and transformative environments; the values, cultures, norms, and practices of individuals, communities, organisations, and systems; and other contextual characteristics relevant to innovation development.

CONCLUSION

From these syntheses, we proposed an interconnected framework for action to better guide innovation researchers, practitioners, and policymakers in incorporating complexity and systemic interactions between internal and external innovation environments in global health.

Multi-country collaborative citizen science projects to co-design cardiovascular disease prevention strategies and advocacy: findings from Ethiopia, Malawi, Rwanda, and South Africa

BACKGROUND

Cardiovascular diseases (CVD) were responsible for 20.5 million annual deaths globally in 2021, with a disproportionally high burden in sub-Saharan Africa (SSA). There is growing evidence of the use of citizen science and co-design approaches in developing interventions in different fields, but less so in the context of CVD prevention interventions in SSA. This paper reports on the collaborative multi-country project that employed citizen science and a co-design approach to (i) explore CVD risk perceptions, (ii) develop tailored prevention strategies, and (iii) support advocacy in different low-income settings in SSA.

METHODS

This is a participatory citizen science study with a co-design component. Data was collected from 205 participants aged 18 to 75 years in rural and urban communities in Malawi, Ethiopia and Rwanda, and urban South Africa. Fifty-one trained citizen scientists used a mobile app-based (EpiCollect) semi-structured survey questionnaire to collect data on CVD risk perceptions from participants purposively selected from two communities per country. Data collected per community included 100-150 photographs and 150-240 voice recordings on CVD risk perceptions, communication and health-seeking intentions. Thematic and comparative analysis were undertaken with the citizen scientists and the results were used to support citizen scientists-led stakeholder advocacy workshops. Findings are presented using bubble graphs based on weighted proportions of key risk factors indicated.

RESULTS

Nearly three in every five of the participants interviewed reported having a relative with CVD. The main perceived causes of CVD in all communities were substance use, food-related factors, and litter, followed by physical inactivity, emotional factors, poverty, crime, and violence. The perceived positive factors for cardiovascular health were nutrition, physical activity, green space, and clean/peaceful communities. Multi-level stakeholders (45-84 persons/country) including key decision makers participated in advocacy workshops and supported the identification and prioritization of community-specific CVD prevention strategies and implementation actions. Citizen science-informed CVD risk screening and referral to care interventions were piloted in six communities in three countries with about 4795 adults screened and those at risk referred for care. Health sector stakeholders indicated their support for utilising a citizen-engaged approach in national NCDs prevention programmes. The citizen scientists were excited by the opportunity to lead research and advocacy.

CONCLUSION

The collaborative engagement, participatory learning, and co-designing activities enhanced active engagement between citizen scientists, researchers, and stakeholders. This, in turn, provided context-specific insights on CVD prevention in the different SSA settings.

Challenges for research uptake for health policymaking and practice in low- and middle-income countries: a scoping review

BACKGROUND

An estimated 85% of research resources are wasted worldwide, while there is growing demand for context-based evidence-informed health policymaking. In low- and middle-income countries (LMICs), research uptake for health policymaking and practice is even lower, while little is known about the barriers to the translation of health evidence to policy and local implementation. We aimed to compile the current evidence on barriers to uptake of research in health policy and practice in LMICs using scoping review.

METHODS

The scoping review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses-extension for Scoping Reviews (PRISMA-ScR) and the Arksey and O'Malley framework. Both published evidence and grey literature on research uptake were systematically searched from major databases (PubMed, Cochrane Library, CINAHL (EBSCO), Global Health (Ovid)) and direct Google Scholar. Literature exploring barriers to uptake of research evidence in health policy and practice in LMICs were included and their key findings were synthesized using thematic areas to address the review question.

RESULTS

A total of 4291 publications were retrieved in the initial search, of which 142 were included meeting the eligibility criteria. Overall, research uptake for policymaking and practice in LMICs was very low. The challenges to research uptake were related to lack of understanding of the local contexts, low political priority, poor stakeholder engagement and partnership, resource and capacity constraints, low system response for accountability and lack of communication and dissemination platforms.

CONCLUSION

Important barriers to research uptake, mainly limited contextual understanding and low participation of key stakeholders and ownership, have been identified. Understanding the local research and policy context and participatory evidence production and dissemination may promote research uptake for policy and practice. Institutions that bridge the chasm between knowledge formation, evidence synthesis and translation may play critical role in the translation process.

Assessing the scalability of healthy eating interventions within the early childhood education and care setting: secondary analysis of a Cochrane systematic review

OBJECTIVE

Early childhood education and care (ECEC) is a recommended setting for the delivery of health eating interventions 'at scale' (i.e. to large numbers of childcare services) to improve child public health nutrition. Appraisal of the 'scalability' (suitability for delivery at scale) of interventions is recommended to guide public health decision-making. This study describes the extent to which factors required to assess scalability are reported among ECEC-based healthy eating interventions.

DESIGN

Studies from a recent Cochrane systematic review assessing the effectiveness of healthy eating interventions delivered in ECEC for improving child dietary intake were included. The reporting of factors of scalability was assessed against domains outlined within the Intervention Scalability Assessment Tool (ISAT). The tool recommends decision makers consider the problem, the intervention, strategic and political context, effectiveness, costs, fidelity and adaptation, reach and acceptability, delivery setting and workforce, implementation infrastructure and sustainability. Data were extracted by one reviewer and checked by a second reviewer.

SETTING

ECEC.

PARTICIPANTS

Children 6 months to 6 years.

RESULTS

Of thirty-eight included studies, none reported all factors within the ISAT. All studies reported the problem, the intervention, effectiveness and the delivery workforce and setting. The lowest reported domains were intervention costs (13 % of studies) and sustainability (16 % of studies).

CONCLUSIONS

Findings indicate there is a lack of reporting of some key factors of scalability for ECEC-based healthy eating interventions. Future studies should measure and report such factors to support policy and practice decision makers when selecting interventions to be scaled-up.

Managed care updates of subscriber jail release to prompt community suicide prevention: clinical trial protocol

BACKGROUND

Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail.

METHODS

This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data.

CONCLUSIONS

This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023.

Test, evidence, transition projects in Scotland: developing the evidence needed for transition of effective interventions in cancer care from innovation into mainstream practice

BACKGROUND

A robust evidence base is required to assist healthcare commissioners and providers in selecting effective and sustainable approaches to improve cancer diagnosis and treatment. Such evidence can be difficult to build, given the fast-paced and highly pressured nature of healthcare delivery, the absence of incentives, and the presence of barriers in conducting pragmatic yet robust research evaluations. Cancer Research UK (CRUK) has played an active part in building the evidence base through its funding of programmes to identify, evaluate and scale-up innovative approaches across the UK. The aim of this paper is to describe and explain the research design and intended approach and activities for two cancer services improvement projects in Scotland funded by CRUK.

METHODS

A hybrid effectiveness-implementation study design will assess both the efficiency of the new pathways and their implementation strategies, with the aim of generating knowledge for scale-up. A range of implementation, service and clinical outcomes will be assessed as determined by the projects' Theories of Change (ToCs). A naturalistic case study approach will enable in-depth exploration of context and process, and the collection and synthesis of data from multiple sources including routine datasets, patient and staff surveys, in-depth interviews and observational and other data. The evaluations are informed throughout by a patient/public representatives' group, and by small group discussions with volunteer cancer patients.

DISCUSSION

Our approach has been designed to provide a holistic understanding of how (well) the improvement projects work (in relation to their anticipated outcomes), and how they interact with their wider contexts. The evaluations will help identify barriers, facilitators, and unanticipated consequences that can impact scalability, sustainability and spread. By opting for a pragmatic, participatory evaluation research design, we hope to inform strategies for scaling up successful innovations while addressing challenges in a targeted manner.

Peer support interventions in maternal and child healthcare delivery in sub-Saharan Africa: protocol for a realist review

BACKGROUND

Peer support has been proposed as a promising policy intervention for addressing adverse maternal and child healthcare (MCH) outcomes in sub-Saharan Africa (SSA). Existing reviews on peer support largely draw on evidence from high-income countries or focus on single services like breastfeeding, nutrition or postnatal care. In contrast, this review aims to provide a comprehensive overview of the empirical literature on peer support interventions across various MCH services in sub-Saharan Africa. Specifically, we aim to understand how, why, for whom, and in what circumstances different forms of MCH peer support interventions contribute to improving healthcare outcomes in sub-Saharan Africa.

METHODS

This review follows five iterative steps for undertaking realist reviews (1) defining the review scope; (2) developing initial programme theories; (3) searching for evidence; (4) selecting and appraising evidence; and (5) extracting, analysing and synthesising evidence. Four databases-Cochrane Library, PubMed, CINAHL, and EMBASE-were repeatedly searched between March and June 2021. From a large volume of records retrieved from the database and citation search, 61 papers have been selected for review. We will conduct a second search of the same database covering June 2021 to the present before the final extraction and synthesis. The final list of selected papers will be imported into NVivo 12 software and organised, extracted, analysed and synthesised iteratively to examine and illustrate the causal links between contexts, mechanisms and outcomes of MCH peer support interventions in SSA. We have drawn on the existing literature on peer support in healthcare generally to develop initial programme theories. We will then use the empirical literature on MCH peer support interventions in SSA, inputs from a stakeholders' workshop in Ghana and a conference presentation to refine the initial programme theory.

DISCUSSION

The review will develop an explicit theory of peer support intervention in healthcare delivery and provide insights for developing evidence-informed policy on the intervention. Drawing lessons from the different national contexts and diverse areas of MCH in SSA, the review will provide an analytically generalizable programme theory that can guide intervention design and implementation. While focusing on MCH peer support interventions in SSA, the review contributes to evolving conversations on the use of theory for health policy planning and complex intervention design and implementation globally.

TRIAL REGISTRATION

PROSPERO registration ID: CRD42023427751 .

Managed Care Updates of Subscriber Jail Release to Prompt Community Suicide Prevention: Clinical Trial Protocol

Background

Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail.

Methods

This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data.

Conclusions

This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk.

Trial Registration

The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023, https://beta.clinicaltrials.gov/study/NCT05579600?cond=Suicide&term=Managed%20Care&rank=1.

Evaluating the scaling up of an effective implementation intervention (PACE) to increase the delivery of a mandatory physical activity policy in primary schools

BACKGROUND

Physically Active Children in Education (PACE) is an effective implementation intervention for increasing the number of minutes classroom teachers schedule physical activity each week. To date, evaluations of PACE have included a smaller number of schools from only one region in New South Wales Australia. If PACE is to have population-wide benefits we must be able to deliver this support to a larger number of schools across multiple regions. This study aimed to evaluate the scale-up of PACE.

METHODS

An uncontrolled before and after study, with 100 schools from three regions was conducted. Participating schools received PACE for approximately 12 months. We assessed the following outcomes: delivery of the evidence-based intervention (EBI) (i.e. minutes of physical activity scheduled by classroom teachers per week); delivery of the implementation strategies (i.e. reach, dose delivered, adherence and indicators of sustainability); and key determinants of implementation (i.e. acceptability of strategies and cost). Data were collected via project officer records, and principal and teacher surveys. Linear mixed models were used to assess EBI delivery by evaluating the difference in the mean minutes teachers scheduled physical activity per week from baseline to follow-up. Descriptive data were used to assess delivery of the implementation strategies and their perceived acceptability (i.e. PACE). A prospective, trial-based economic evaluation was used to assess cost.

RESULTS

Delivery of the EBI was successful: teachers increas their average minutes of total physical activity scheduled across the school week by 26.8 min (95% CI: 21.2, 32.4, p < 0.001) after receiving PACE. Indicators for delivery of implementation strategies were high: 90% of consenting schools received all strategies and components (reach); 100% of strategies were delivered by the provider (dose); >50% of schools adhered to the majority of strategies (11 of the 14 components); and acceptability was > 50% agreement for all strategies. The incremental cost per additional minute of physical activity scheduled per week was $27 per school (Uncertainty Interval $24, $31).

CONCLUSIONS

PACE can be successfully delivered across multiple regions and to a large number of schools. Given the ongoing and scalable benefits of PACE, it is important that we continue to extend and improve this program while considering ways to reduce the associated cost.

Data-driven sudden cardiac arrest research in Europe: Experts' perspectives on ethical challenges and governance strategies

Background

Observational studies using large-scale databases and biobanks help improve prevention and treatment of sudden cardiac arrest (SCA) but the lack of guidance on data protection issues in this setting may harm patients' rights and the research enterprise itself. This qualitative study explored the ethical aspects of observational SCA research, as well as solutions.

Methods

European experts in SCA research, medical ethics and health law reflected on this topic through semi-structured interviews (N = 29) and a virtual roundtable conference (N = 18). The ESCAPE-NET project served as a discussion case. Findings were coded and thematically analysed.

Results

The first theme concerned the potential benefits and harms (at individual and group level) of observational data-based SCA studies and included the following sub-themes: societal value, scientific validity, data privacy, disclosure of genetic findings, stigma and discrimination, and medicalisation of sudden death. The second theme involved governance through 'privacy by design', 'privacy by policy' and associated regulation and oversight. Sub-themes were: de-identification of data, informed consent (broad and deferred), ethics review, and harmonisation.

Conclusions

Researchers and scientific societies should be aware that ethico-legal issues may arise during data-driven studies in SCA and other emergencies. These can be mitigated by combining technical data protection safeguards with appropriate informed consent policies and proportional ethics oversight. To ensure responsible conduct of data research in emergency medicine, we recommend the establishment of 'codes of conduct' which should be developed in interdisciplinary groups and together with patient representatives.

Study protocol for the ROSE Scale-Up Study: Informing a decision about ROSE as universal postpartum depression prevention

PURPOSE

To examine the effectiveness, cost-outcome, equity, scalability, and mechanisms of the Reach Out, Stay strong, Essentials for mothers of newborns (ROSE) postpartum depression prevention (PPD) program as universal versus selective or indicated prevention.

BACKGROUND

The United States Preventive Services Task Force (USPSTF) currently recommends PPD prevention for pregnant people at risk of PPD (i.e., selective/indicated prevention). However, universal prevention may be more scalable, equitable, and cost-beneficial.

DESIGN

Effectiveness of ROSE for preventing PPD among people at risk is known. To assess ROSE as universal prevention, we need to determine the effectiveness of ROSE among all pregnant people, including those screening negative for PPD risk. We will enroll 2320 pregnant people, assess them with commonly available PPD risk prediction tools, randomize everyone to ROSE or enhanced care as usual, and assess ROSE as universal, selective, and indicated prevention in terms of: (1) effectiveness (PPD prevention and functioning), (2) cost-benefit, (3) equity (PPD cases prevented by universal prevention that would not be prevented under selective/indicated for minority vs. non-Hispanic white people), (4) quantitative and qualitative measures of scalability (from 98 agencies previously implementing ROSE), (5) ROSE mechanisms across risk levels. We will integrate results to outline pros and cons of the three prevention approaches (i.e., universal, selective, indicated).

CONCLUSION

This will be the first trial to assess universal vs. selective/indicated PPD prevention. Trial design illustrates a novel, efficient way to make these comparisons. This trial, the largest PPD prevention trial to date, will examine scalability, an understudied area of implementation science.