Food Systems Interventions for Nutrition: Lessons from 6 Program Evaluations in Africa and South Asia

Although there is growing global momentum behind food systems strategies to improve planetary and human health-including nutrition-there is limited evidence of what types of food systems interventions work. Evaluating these types of interventions is challenging due to their complex and dynamic nature and lack of fit with standard evaluation methods. In this article, we draw on a portfolio of 6 evaluations of food systems interventions in Africa and South Asia that were intended to improve nutrition. We identify key methodological challenges and formulate recommendations to improve the quality of such studies. We highlight 5 challenges: a lack of evidence base to justify the intervention, the dynamic and multifaceted nature of the interventions, addressing attribution, collecting or accessing accurate and timely data, and defining and measuring appropriate outcomes. In addition to more specific guidance, we identify 6 cross-cutting recommendations, including a need to use multiple and diverse methods and flexible designs. We also note that these evaluation challenges present opportunities to develop new methods and highlight several specific needs in this space.

Using evidence-based co-design to develop a hybrid delivered exercise intervention that aims to increase confidence to exercise in people with haemophilia

INTRODUCTION

Due to advances in treatments, people with haemophilia (PWH) are living longer. They are not as active as the general population due to joint damage and lack confidence to be active due to concerns about further bleeds and pain. There is a need to facilitate healthy aging through promotion of physical activity (PA) and exercise. Changing patient beliefs and increasing physical literacy and confidence to move are thought to be key to helping PWH become more active.

AIM

This paper describes the development of an exercise and behaviour change intervention to improve confidence to exercise in PWH.

METHODS

The 4-stage Medical Research Council framework for complex intervention development was used.

RESULTS

Stakeholders included 17 PWH and 7 physiotherapists working in haemophilia. Seven online focus group meetings were held. The final intervention is a hybrid 12-week physiotherapist led progressive exercise programme. Classes are 45 min including Pilates, High intensity interval training and balance elements, together with discussion sessions focusing on PA recommendations, the types and benefits of different exercise styles and the effects of PA, together with the effects of aging for PWH. The COM-B model of behaviour change was used to develop the intervention.

CONCLUSION

Co-design helps to produce an intervention that understands the stakeholders needs. Through this process the intervention developed to incorporate not only increasing PA but also confidence to exercise. The use of behaviour change theory identified the behaviour techniques included in the intervention and aims to increase physical literacy in this population.

Overcoming Common Anxieties in Knowledge Translation: Advice for Scholarly Issue Advocates

Policy Points Faced with urgent threats to human health and well-being such as climate change, calls among the academic community are getting louder to contribute more effectively to the implementation of the evidence generated by our research into public policy. As interest in knowledge translation (KT) surges, so have a number of anxieties about the field's shortcomings. Our paper is motivated by a call in the literature to render useful advice for those beginning in KT on how to advance impact at a policy level. By integrating knowledge from fields such as political science, moral psychology, and marketing, we suggest that thinking and acting like marketers, lobbyists, movements, and political scientists would help us advance on the quest to bridge the chasm between evidence and policy.

Using theory of change to plan for the implementation of a psychological intervention addressing alcohol use disorder and psychological distress in Uganda

In conflict-affected settings, prevalence of alcohol use disorders (AUDs) can be high. However, limited practical information exists on AUD management in low-income settings. Using a theory of change (ToC) approach, we aimed to identify pathways influencing the implementation and maintenance of a new transdiagnostic psychological intervention ("CHANGE"), targeting both psychological distress and AUDs in humanitarian settings. Three half-day workshops in Uganda engaged 41 stakeholders to develop a ToC map. ToC is a participatory program theory approach aiming to create a visual representation of how and why an intervention leads to specific outcomes. Additionally, five semi-structured interviews were conducted to explore experiences of stakeholders that participated in the ToC workshops. Two necessary pathways influencing the implementation and maintenance of CHANGE were identified: policy impact, and mental health service delivery. Barriers identified included policy gaps, limited recognition of social determinants and the need for integrated follow-up care. Interviewed participants valued ToC's participatory approach and expressed concerns about its adaptability in continuously changing contexts (e.g., humanitarian settings). Our study underscores ToC's value in delineating context-specific outcomes and identifies areas requiring further attention. It emphasizes the importance of early planning and stakeholder engagement for sustainable implementation of psychological interventions in humanitarian settings.

Implementing the QUALI-DEC project in Argentina, Burkina Faso, Thailand and Viet Nam: a process delineation and theory-driven process evaluation protocol

The project 'Quality Decision-making by women and providers' (QUALI-DEC) combines four non-clinical interventions to promote informed decision-making surrounding mode of birth, improve women's birth experiences, and reduce caesarean sections among low-risk women. QUALI-DEC is currently being implemented in 32 healthcare facilities across Argentina, Burkina Faso, Thailand, and Viet Nam. In this paper, we detail implementation processes and the planned process evaluation, which aims to assess how and for whom QUALI-DEC worked, the mechanisms of change and their interactions with context and setting; adaptations to intervention and implementation strategies, feasibility of scaling-up, and cost-effectiveness of the intervention. We developed a project theory of change illustrating how QUALI-DEC might lead to impact. The theory of change, together with on the ground observations of implementation processes, guided the process evaluation strategy including what research questions and perspectives to prioritise. Main data sources will include: 1) regular monitoring visits in healthcare facilities, 2) quantitative process and output indicators, 3) a before and after cross-sectional survey among post-partum women, 4) qualitative interviews with all opinion leaders, and 5) qualitative interviews with postpartum women and health workers in two healthcare facilities per country, as part of a case study approach. We foresee that the QUALI-DEC process evaluation will generate valuable information that will improve interpretation of the effectiveness evaluation. At the policy level, we anticipate that important lessons and methodological insights will be drawn, with application to other settings and stakeholders looking to implement complex interventions aiming to improve maternal and newborn health and wellbeing.Trial registration: ISRCTN67214403.

Developing a Theory of Change for a Digital Youth Mental Health Service (Moderated Online Social Therapy): Mixed Methods Knowledge Synthesis Study

BACKGROUND

Common challenges in the youth mental health system include low access, poor uptake, poor adherence, and limited overall effectiveness. Digital technologies offer promise, yet challenges in real-world integration and uptake persist. Moderated Online Social Therapy (MOST) aims to overcome these problems by integrating a comprehensive digital platform into existing youth mental health services. Theory of change (ToC) frameworks can help articulate how and why complex interventions work and what conditions are required for success.

OBJECTIVE

The objective of this study is to create a ToC for MOST to explain how it works, why it works, who benefits and how, and what conditions are required for its success.

METHODS

We used a multimethod approach to construct a ToC for MOST. The synthesis aimed to assess the real-world impact of MOST, a digital platform designed to enhance face-to-face youth mental health services, and to guide its iterative refinement. Data were gathered from 2 completed and 4 ongoing randomized controlled trials, 11 pilot studies, and over 1000 co-design sessions using MOST. Additionally, published qualitative findings from diverse clinical contexts and a review of related digital mental health literature were included. The study culminated in an updated ToC framework informed by expert feedback. The final ToC was produced in both narrative and table form and captured components common in program logic and ToC frameworks.

RESULTS

The MOST ToC captured several assumptions about digital mental health adoption, including factors such as the readiness of young people and service providers to embrace digital platforms. External considerations included high service demand and a potential lack of infrastructure to support integration. Young people and service providers face several challenges and pain points MOST seeks to address, such as limited accessibility, high demand, poor engagement, and a lack of personalized support. Self-determination theory, transdiagnostic psychological treatment approaches, and evidence-based implementation theories and their associated mechanisms are drawn upon to frame the intervention components that make up the platform. Platform usage data are captured and linked to short-, medium-, and long-term intended outcomes, such as reductions in mental health symptoms, improvements in functioning and quality of life, reductions in hospital visits, and reduced overall mental health care costs.

CONCLUSIONS

The MOST ToC serves as a strategic framework for refining MOST over time. The creation of the ToC helped guide the development of therapeutic content personalization, user engagement enhancement, and clinician adoption through specialized implementation frameworks. While powerful, the ToC approach has its limitations, such as a lack of standardized methodology and the amount of resourcing required for its development. Nonetheless, it provides an invaluable roadmap for iterative development, evaluation, and scaling of MOST and offers a replicable model for other digital health interventions aiming for targeted, evidence-based impact.

Co-design of dementia prevention program for Aboriginal Australians (DAMPAA)

INTRODUCTION

Dementia is highly prevalent in older Aboriginal Australians, with several modifiable risk factors. Currently, there is limited evidence on how to prevent cognitive decline in Aboriginal Australians.

METHODS

Based on our Theory of Change (ToC) framework, we co-developed the Dementia risk management and prevention program for Aboriginal Australians (DAMPAA) aged over 45 years in partnership with Aboriginal community-controlled organizations (ACCOs) and Elders. Qualitative data were collected through ACCO staff workshops, Elders yarning, and governance groups to inform the protocol. Additionally, we conducted a small pilot study.

RESULTS

Expected DAMPAA ToC outcomes are: (1) improved daily function, (2) better cardiovascular risk management, (3) falls reduction, (4) improved quality of life, and (5) reduced cognitive decline. Attendance enablers are social interaction, environment, exercise type/level, and logistics.

DISCUSSION

Findings suggest that ToC is an effective collaborative approach for co-designing Aboriginal health programs.

Developing a compassionate community: a Canadian conceptual model for community capacity development

The purpose of this article is to share a Canadian model called Developing a Compassionate Community (DCC) in which aging, dying, caregiving, and grieving are everyone's responsibility. The model provides a research-informed practice guide for people who choose to adopt a community capacity development approach to developing a compassioante community. Based on 30 years of Canadian research by the author in rural, urban, First Nations communities, and long-term care homes, the DCC model offers a practice theory and practical tool. The model incorporates the principles of community capacity development which are as follows: change is incremental and in phases, but nonlinear and dynamic; the change process takes time; development is essentially about developing people; development builds on existing resources (assets); development cannot be imposed from the outside; and development is ongoing (never-ending). Community capacity development starts with citizens who want to make positive changes in their lives and their community. They become empowered by gaining the knowledge, skills, and resources they need. The community mobilizes around finding solutions rather than discussing problems. Passion propels their action and commitment drives the process. The strategy for change is engaging, empowering, and educating community members to act on their own behalf. It requires mobilizing networks of families, friends, and neighbors across the community, wherever people live, work, or play. Community networks are encouraged to prepare for later life, and for giving and getting help among themselves. This Canadian model offers communities one approach to developing a compassionate community and is a resource for implementing a public health approach to end-of-life care in Canada. The model is also available to be evaluated for its applicability beyond Canada and is designed to be adapted to new contexts if desired.

How the Gus Schumacher Produce Prescription Program Works: An Adaptation of a Nutrition Incentive Theory of Change

The United States Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) supports nutrition incentive (NI) and produce prescription programs (PPRs). PPRs allow healthcare providers to "prescribe" fruits and vegetables (FVs) to patients experiencing low income and/or chronic disease(s) and who screen positive for food insecurity. We developed a Theory of Change (TOC) that summarizes how and why PPRs work, identifies what the programs hope to achieve, and elucidates the causal pathways necessary to achieve their goals. We created the PPR TOC through an iterative, participatory process that adapted our previously developed GusNIP NI TOC. The participatory process involved food and nutrition security experts, healthcare providers, PPR implementors, and PPR evaluators reviewing the existing NI TOC and suggesting modifications to accurately reflect PPRs. The resulting TOC describes the mechanisms, assumptions, rationale, and underpinnings that lead to successful and equitable outcomes. Modifications of the NI TOC centered around equity and focused on inclusion of healthcare as an additional partner and the importance of health and healthcare utilization as outcomes. The TOC describes how the GusNIP PPR program reaches its goals. This understanding will be useful for PPR developers, implementers, funders, and evaluators for describing the pathways, assumptions, and foundations of successful PPRs.

Evaluating the design of the Integrated Care for Older People: a theory of change approach

Introduction

Given the progressive aging of the population, there is an urgent need at the health system level to implement effective models to care for older people (OP). Healthy aging is imperative to reach the Sustainable Development Goals. The World Health Organization (WHO) developed the Integrated Care for Older People (ICOPE) strategy to address this challenge. Implementing ICOPE requires its adaption to a specific context. We propose a pathway for such adaptation through an evaluation of the design of ICOPE; thus, we aim to describe the Theory of Change (ToC) of ICOPE and evaluate it for its implementation in Mexico City.

Methods

Based on the WHO and published literature documentation, we drafted an initial ToC for ICOPE. Then, we validated the ToC with experts in ICOPE, after which we evaluated and refined it by discussing the causal pathway, intervention required to activate it, rationale, and assumptions in consecutive workshops with 91 stakeholders and healthcare workers, using the nominal group technique to reach a consensus.

Results

The resulting ToC has the potential to contribute to healthy aging by three expected impacts: (1) prevention, reversal, or delaying of the decline of intrinsic capacity (IC) in OP; (2) improvement of the quality of life of OP; and (3) increase of disability-free life expectancy. The ICOPE causal pathway had ten preconditions, including the availability of resources, identifying at-risk individuals, available treatments, and evaluating results.

Discussion

We adapted ICOPE to a specific implementation context by evaluating its ToC in a participatory process that allows us to identify challenges and address them, at least in terms of the guidelines to operate the strategy. As ICOPE is an approach for a primary healthcare system, its adoption in a community healthcare program is promising and feasible. Evaluation as a tool could contribute to the design of effective interventions. The evaluation of the design of ICOPE for its implementation contributes to the strength of its potential to improve care for OP. This design for implementing ICOPE has the potential to be applied to similar contexts, for example, in other lower-middle-income countries.

Multi-sectoral action to promote psychological wellbeing: Theorising the role of place-based policy

ISSUES ADDRESSED

Several national governments are showing interest in policies to promote wellbeing. One common strategy is to devise systems to measure indictors of wellbeing, presuming that governments act on what they measure. This article will argue instead that formation of multisectoral policies to promote psychological wellbeing requires a different kind of theoretical and evidentiary basis.

METHODS

The article integrates ideas from literature on wellbeing, health in all policies, political science, mental health promotion, and social determinants of health to make a case for place-based policy as the central feature of multi-sectoral policy for psychological wellbeing.

RESULTS AND DISCUSSION

I argue that the required theoretical foundation for policy action on psychological wellbeing lies with understanding certain basic functions of human social psychology including the role of stress arousal. I then draw on policy theory to propose three steps to translate this theoretical understanding of psychological wellbeing into practicable, multi-sectoral policies. Step one is concerned with adopting a thoroughly revised conception of psychological wellbeing as a policy problem. Step two involves uptake of a theory of change in policy, grounded on recognition of essential social conditions required to promote psychological wellbeing. Proceeding from these, I will argue that a necessary (but not sufficient) third step is to implement place-based strategies involving government-community partnerships, to generate essential conditions for psychological wellbeing on a universal basis. Finally, I examine implications of the proposed approach for current theory and practice in mental health promotion policy.

CONCLUSIONS

Place-based policy is foundational for effective multi-sectoral policy to promote psychological wellbeing. SO WHAT?: Governments aiming to promote psychological wellbeing should position place-based policy at the centre of their strategies.

Towards a Dignified Death: A New Approach to Care for People Using Substances Who Are at, or Near, the End of Their Lives

There are no effective intervention studies for people using substances who are at, or near, the end of their lives. The needs of this group of people have been consistently overlooked even within the literature that identifies marginalised groups of people in need of greater recognition in palliative and end-of-life care. The aims of the project were to: (i) determine what a new, co-produced, model of care should look like for people using substances needing palliative and end-of-life care, and (ii) establish whether the new model had the potential to improve people's access to, and experience of, end-of-life care. This paper presents the development of the new approach to care. It was developed using participatory action research principles over a course of online workshops during the COVID-19 pandemic lockdown period in the UK. A theory of change that aims to inform future policy and practice development is presented. While the ambition of the research was stunted by the pandemic, the process of its development and dissemination of the model and its resources has continued. Response from participants highlighted the importance of this work, however, in this new field of policy and practice, preparatory work that engages a wide range of stakeholders is crucial to its success. This relationship building and topic engagement are major parts of implementation before more substantial and sustainable development goals can be met.

A Researcher-Practitioner Collaboration to Enable Replication of an Evidence-Based Financial Education and Coaching Program That Improves Health in Low-Income Single Mothers

Financial strain is a social determinant of health (SDOH). Although public financial education helps individuals improve financial well-being, specifics are lacking on how and why effective programs work, potentially limiting their successful replication in other practice settings. In this study, researchers and practitioners cocreated the core components and theory of change of a novel financial education and coaching program, which a randomized controlled trial found was effective in significantly improving participants' financial and health-related behaviors. A Cocreating Knowledge Translation Framework within a case study design was used at a university-affiliated nonprofit in Omaha, Nebraska, from August to December 2020. Twelve practitioner and alumni participants were purposefully sampled. An administrative records review, semi-structured interviews (n =3), survey (n = 10), and facilitated backward mapping session (n = 5) were conducted. Transcripts were coded to identify themes. Thirty-one core components were identified within program principles, design, tools, activities, and expectations of participants and coaches. Ten theory of change outcomes described participants' pathway to change. Interventions occurred at individual, relationship, and community levels from initial engagement, through behavioral changes, to improved health-related quality of life. Activities and indicators were mapped to each outcome. The program's intersecting and reinforcing design was key to enabling participants' outcomes. Its theory of change described how and why the model improved financial and health behaviors. Findings suggest that other SDOH-focused organizations may benefit from researcher-practitioner collaboration to investigate their interventions' core components and theories of change. This may enable replication, promoting downstream health benefits in new community settings.

A guide to qualitative attribution methods for evaluation in conservation

Knowledge of what conservation interventions improve biodiversity outcomes, and in which circumstances, is imperative. Experimental and quasi-experimental methods are increasingly used to establish causal inference and build the evidence base on the effectiveness of interventions, but their ability to provide insight into how and under what conditions an intervention should be implemented to improve biodiversity outcomes faces limitations. A suite of attribution methods that leverage qualitative methods for causal inference is available but underutilized in conversation impact evaluation. This article provides a guide to 5 such qualitative attribution methods: contribution analysis, process tracing, realist evaluation, qualitative comparative analysis, and most significant change. It defines and introduces each method and then illustrates how they could be applied through a case study of community conservancies in Namibia. This guide provides examples of how qualitative attribution methods can advance knowledge of what works, in which contexts, and why in biodiversity conservation.

Improving service provision through change management

The change agent role of the family physician is often a daunting task with very little guidance on how to approach change leadership in the current fellowship curriculum. This continuing medical education resource will utilise the theory of change and provide some guidance to taking on this task in the workplace. The approach can be used in healthcare, the community, academia, and research projects. The resource will outline a systematic approach to developing a logic-based strategy for outcomes. The process will be unpacked, the evaluation method outlined, and strategies for ensuring the sustainability of the changing culture will be discussed.

Improving child health service interventions through a Theory of Change: A scoping review

Background

The objective of this scoping review was to map how child health service interventions develop, utilise, and refine theories of change. A Theory of Change (ToC) is a tool for designing, implementing, and evaluating interventions that is being increasingly used by child health practitioners who are aiming to enact change in health services.

Methods

A published protocol guided this scoping review. Relevant publications were identified through selected electronic databases and grey literature via a search strategy. The main inclusion criteria were any child health service intervention globally that described their ToC or ToC development process. These were applied by two independent reviewers. Data relevant to the research sub-questions were extracted, charted and discussed.

Findings

38 studies were included in the analysis. This scoping review highlights the disparate and inconsistent use, and reporting of ToCs in the child health service intervention literature.

Conclusion

A ToC may be a helpful tool to enact change in a child health service but careful consideration must be undertaken by the child health service regarding how to maximise the benefits of doing a ToC, and how to accurately report it.

Theory of change and strategic priorities of the world federation of haemophilia

The World Federation of Haemophilia (WFH) is a global network of national member organizations (NMOs) that advocate, collectively and individually, to improve lives of people with inherited bleeding disorders. The WFH vision of "Treatment for All" speaks to a future in which all people with an inherited bleeding disorder will have access to care, regardless of their gender or where they live. Over the last several years, initiatives including the WFH Humanitarian Aid program, the World Bleeding Disorders Registry, and Guidelines for the Management of Haemophilia and von Willebrand disease have significantly changed how the WFH and its partners work to improve and sustain care for people with bleeding disorders. Following an extensive consultation that included over 200 stakeholders from 70 countries, a Theory of Change was developed, and strategic priorities identified, to clearly define the WFH's intended impact and point of accountability to its stakeholders, and to determine how and through who those goals will be achieved. Both should help the WFH better support its NMOs and healthcare providers around the world in their efforts to improve access to diagnosis and care, as new therapies revolutionize the treatment landscape and the fallout of the global pandemic continues to challenge the ways in which we work and connect. Global collaboration of all stakeholders, based on their resources, objectives and skills, will be required to achieve these goals and to ensure more people have reliable access to safe treatment and care, regardless of their bleeding disorder, gender, or where they live.

Love Shouldn't Hurt - E le Sauā le Alofa: Co-designing a theory of change for preventing violence against women in Samoa

Despite the widespread adoption of Theories of Change (ToC) for programme evaluation, the process of collaboratively developing these theories is rarely outlined or critical analysed, limiting broader methodological discussions on co-production. We developed a ToC as part of E le Sauā le Alofa ('Love Shouldn't Hurt') - a participatory peer-research study to prevent violence against women (VAW) in Samoa. The ToC was developed in four phases: (1) semi-structured interviews with village representatives (n = 20); (2) peer-led semi-structured interviews with community members (n = 60), (3) community conversations with 10 villages (n = 217) to discuss causal mechanisms for preventing VAW, and (4) finalising the ToC pathways. Several challenges were identified, including conflicting understandings of VAW as a problem; the linearity of the ToC framework in contrast to intersecting realities of people's lived experiences; the importance of emotional engagements, and theory development as a contradictory and incomplete process. The process also raised opportunities including a deeper exploration of local meaning-making, iterative engagement with local mechanisms of violence prevention, and clear evidence of ownership by communities in developing a uniquely Samoan intervention to prevent VAW. This study highlights a clear need for ToCs to be complemented by indigenous frameworks and methodologies in post-colonial settings such as Samoa.

Development of a Psychological Intervention to Improve Depressive Symptoms and Enhance Adherence to Antiretroviral Therapy among Adolescents and Young People Living with HIV in Dar es Salaam Tanzania

Background: Interventions that simultaneously target depression and antiretroviral therapy (ART) medication adherence are recommended for improving HIV treatment outcomes and quality of life for adolescents living with HIV. However, evidence is scarce on culturally feasible and acceptable interventions that can be implemented for HIV-positive adolescents in Tanzania. We, therefore, developed a manualized brief psychological intervention that utilizes evidence-based strategies to address depression and ART adherence in adolescents living with HIV in Tanzania. Methods: We used the Theory of Change Enhanced Medical Research Council framework (TOCMRC) for developing complex interventions in health care to develop the intervention in five phases. First, the literature was reviewed to identify potential intervention components. Second, we conducted a situational analysis using qualitative interviews with adolescents living with HIV, health care providers, and caregivers. Third, we conducted a mental health expert workshop; and fourth, theory of change workshops with representatives from the Ministry of Health, mental health professionals, HIV implementing partners, adolescents, and healthcare providers. Lastly, we synthesized results to finalize the intervention and a theory of change map showing the causal pathway for how we expect the developed intervention to achieve its impact. Results: Adolescents living with HIV in Tanzania experience several unmet mental health needs ranging from overwhelming depressive symptoms to not feeling understood by healthcare providers who lack mental health knowledge. Participants perceived psychological intervention that utilizes a task-shifting approach to be acceptable and beneficial to addressing those problems. The novel components of the NITUE intervention included incorporating evidence-based intervention components, namely, cognitive-behavioral therapy, motivational interviewing, and problem solving. In addition, caregiver inclusion in the treatment was essential to ensure access to care, compliance, and improved outcomes. Conclusions: A culturally appropriate brief psychological intervention that utilizes a task-shifting approach to address depression and medication adherence for adolescents living with HIV in Dar es Salaam, Tanzania, was developed. The intervention will be piloted for appropriateness, feasibility, and acceptability and will provide material for a future trial to determine its effectiveness.

Developing an Evidence and Theory Based Multimodal Integrative Intervention for the Management of Renal Cachexia: A Theory of Change

In this study, we aimed to develop a theoretical framework for a multimodal, integrative, exercise, anti-inflammatory and dietary counselling (MMIEAD) intervention for patients with renal cachexia with reference to how this addresses the underlying causal pathways for renal cachexia, the outcomes anticipated, and how these will be evaluated. We used a Theory of Change (ToC) approach to guide six steps. Step 1 included inputs from a workshop to obtain key stakeholder views on the potential development of a multimodal intervention for renal cachexia. Step 2 included the findings of a mixed-methods study with Health Care Practitioners (HCPs) caring for individuals with End Stage Kidney Disease (ESKD) and cachexia. Step 3 included the results from our systematic literature review on multimodal interventions for cachexia management. In step 4, we used the body of our research team's cachexia research and wider relevant research to gather evidence on the specific components of the multimodal intervention with reference to how this addresses the underlying causal pathways for renal cachexia. In steps 5 and 6 we developed and refined the ToC map in consultation with the core research team and key stakeholders which illustrates how the intervention components of MMIEAD interact to achieve the intended long-term outcomes and anticipated impact. The results of this study provide a theoretical framework for the forthcoming MMIEAD intervention for those with renal cachexia and in subsequent phases will be used to determine whether this intervention is effective. To the best of our knowledge no other multimodal intervention trials for cachexia management have reported a ToC. Therefore, this research may provide a useful framework and contribute to the ongoing development of interventions for cachexia management.

Exploring the design of a sport for employability program: A case study

Rates of young people who are neither in employment, education, or training (NEET) are fairly high in the European Union. Correspondingly, there has been a growing tendency to regard sport as a suitable tool to develop soft skills and raise NEETs' level of employability. However, if and how such sport for employability (SfE) programs are able to realize these major claims has been called into question. The purpose of the present study was, therefore, to explore how an actual SfE initiative constructs and delivers its program. In addition, the article assessed whether the investigated program operates in line with researchers' recent calls for theory-based approaches. Guided by a case study approach set up within an initiative located in Flanders, data were gathered through 12 semi-structured interviews with 8 program providers. Results, analyzed using thematic analysis, indicated that the program was characterized by an absence of well-defined desired outcomes, imprecision as to how the program should contribute to these outcomes, and consequently minimal attention to the follow-up of participants' progress. As such, these findings and the accompanying challenges point to the absence of a theory-based approach. Several possible sources for the lack of a systematic approach are discussed.

Building trusting relationships to support implementation: A proposed theoretical model

This paper presents a theory of change that articulates (a) proposed strategies for building trust among implementation stakeholders and (b) the theoretical linkages between trusting relationships and implementation outcomes. The theory of change describes how trusting relationships cultivate increases in motivation, capability, and opportunity for supporting implementation among implementation stakeholders, with implications for commitment and resilience for sustained implementation, and ultimately, positive implementation outcomes. Recommendations related to the measurement of key constructs in the theory of change are provided. The paper highlights how the development of a testable causal model on trusting relationships and implementation outcomes can provide a bridge between implementation research and implementation practice.

Indigenous and Non-Indigenous Theories of Wellbeing and Their Suitability for Wellbeing Policy

A growing interest among governments in policies to promote wellbeing has the potential to revive a social view of health promotion. However, success may depend on the way governments define wellbeing and conceptualize ways to promote it. We analyze theories of wellbeing to discern twelve types of wellbeing theory and assess the suitability of each type of theory as a basis for effective wellbeing policies. We used Durie's methodology of working at the interface between knowledge systems and Indigenous dialogic methods of yarning and deep listening. We analyzed selected literature on non-Indigenous theories and Indigenous theories from Australia, New Zealand, Canada and the United States to develop a typology of wellbeing theories. We applied political science perspectives on theories of change in public policy to assess the suitability of each type of theory to inform wellbeing policies. We found that some theory types define wellbeing purely as a property of individuals, whilst others define it in terms of social or environmental conditions. Each approach has weaknesses regarding the theory of change in wellbeing policy. Indigenous relational theories transcend an 'individual or environment' dichotomy, providing for pluralistic approaches to health promotion. A broad theoretic approach to wellbeing policy, encompassing individual, social, equity-based and environmental perspectives, is recommended.

Typifying conservation practitioners' views on the role of education

Education is an established tool to enhance human-environment relationships, despite the lack of empirical evidence to support its use. We used theories of change to unpack assumptions about the role of education in conservation. We interviewed practitioners from 15 conservation organizations in Madagascar to typify implicit pathways of change and assess whether emerging pathways echo theoretical advances. Five pathways were drivers of change: increasing knowledge, changing emotional connection and changing traditional cultural practices, fostering leaders, diversifying outcomes, and influencing community and society. These pathways reflect existing sociopsychological theories on learning and behavioral change. Most interviewees' organizations had a predominant pathway that was often combined with elements from other pathways. Most pathways lacked culturally grounded approaches. Our research reveals assumptions about the role of education in conservation and indicates that organizations had different ideas of how change happens. The diversity of practices reflects the complexity of factors that influence behavior. Whether this diversity is driven by local sociocultural context, interaction with other conservation approaches, or contingencies remains unclear. Yet, typifying the pathways of change and reflecting on them is the first step towards comprehensive evaluation of when and which pathways and interactions to promote.

Enabling older people with mental health needs to engage with community social care: A scoping review to inform a theory of change

Despite apparent need, many older people with cognitive impairment and/or mental health needs do not fully engage with social care. This can manifest in different ways, including passive or aggressive attempts to avoid or repel care workers. However, little is known about how to support such individuals in their own homes and deliver effective care. Against this background, we undertook a scoping review with a view to developing a preliminary theory of change suggesting how care might be modified to engage this client group. The most recent search was conducted on 21/04/21. Papers were included if they (i) focused on older people (65+) living at home with social care needs and (ii) described difficulties/problems with the provision/receipt of social care associated with individuals' mental health needs. Twenty-six citations were identified through electronic database searches and reference screening, and the results were charted according to key theory of change concepts (long-term outcomes, preconditions, interventions, rationale and assumptions). All the included papers were related to people with dementia. Four subgroups of papers were identified. The first highlights those external conditions that make it more likely an intervention will be successful; the second describes specific interventions to engage older people who by virtue of their mental health needs have not engaged with social care; the third explores what services can be done to increase service uptake by older people with mental health needs and their caregivers more generally; and the fourth details theoretical approaches to explaining the behaviour of people with dementia. Each provides information that could be used to inform care delivery and the development of interventions to improve engagement with health and social care for these individuals. The study concludes that different framing of engagement difficulties, such as that offered through positioning theory, may assist in future service design.

How Does the Gus Schumacher Nutrition Incentive Program Work? A Theory of Change

Increased fruit and vegetable (FV) intake is associated with decreased risk of nutrition-related chronic diseases. Sociodemographic disparities in FV intake indicate the need for strategies that promote equitable access to FVs. The United States Department of Agriculture’s Gus Schumacher Nutrition Incentive Program (GusNIP) supports state and local programs that offer nutrition incentives (NIs) that subsidize purchase of FVs for people participating in the Supplemental Nutrition Assistance Program (SNAP). While a growing body of research indicates NIs are effective, the pathways through which GusNIP achieves its results have not been adequately described. We used an equity-focused, participatory process to develop a retrospective Theory of Change (TOC) to address this gap. We reviewed key program documents; conducted a targeted NI literature review; and engaged GusNIP partners, practitioners, and participants through interviews, workshops, and focus groups in TOC development. The resulting TOC describes how GusNIP achieves its long-term outcomes of increased participant FV purchases and intake and food security and community economic benefits. GusNIP provides NIs and promotes their use, helps local food retailers develop the capacity to sell FVs and accept NIs in accessible and welcoming venues, and supports local farmers to supply FVs to food retailers. The TOC is a framework for understanding how GusNIP works and a tool for improving and expanding the program.

Using theory of change in child health service interventions: a scoping review protocol

Background: The objective of this scoping review is to map the evidence of how child health service interventions use their theory of change. A theory of change is a hypothesis of how and why an intervention is intended to bring about change. It can be used as a program design, implementation, and evaluation tool. This scoping review will provide an overview of the evidence base for, and identify the way in which, theories of change in child health service interventions are defined, rationalised, developed, presented, and refined. Methods: The inclusion criteria for this scoping review is any child health service intervention globally, that describes their theory of change or theory of change development process. Relevant exclusions include: logic models or logic frameworks that do not meet this review's definition of theory of change, systematic reviews, behavioural change interventions that target patient's behaviour, school-based interventions, and maternal health interventions not related to child health outcomes. This scoping review will follow the Joanna Briggs Institute Reviewer's manual. Relevant publications will be first searched on selected electronic databases and grey literature. A search strategy will be developed. The search will be limited to articles written in the English language. Results of the search will be curated using Endnote and duplicates removed. Results will be imported to Rayyan. The inclusion criteria will be applied during the process of title and abstract screening, by two independent reviewers and disagreements resolved by a third independent reviewer. Full-texts will have the inclusion criteria applied via the same reviewer process. Data relevant to the research sub-questions will be extracted, analysed, charted and discussed. Ethics and dissemination: Ethical approval is not required for this review as we will make use of already published data. We aim to publish the findings of our review in a peer-reviewed journal.

Unpacking the Theory Behind One Health Food Safety Programs: A Vietnam Case Study

Many One Health programs are inherently complex, characterized by multiple perspectives from multiple sectors, delivery across various scales, and a focus on complex problems at the convergence of people, animals, and the environment. This complexity makes them difficult to conceptualize, requiring frameworks to organize the different program components. Evaluation frameworks that unpack the sequence of events linking program activities to outcomes (e.g., Theory of Change) and track outcomes (e.g., Outcome Mapping) show promise in supporting the development of One Health programs. While widely used in international development and health contexts, there has been little reflection on the use of Theory of Change and Outcome Mapping within One Health efforts. This paper reflects on the process of applying these frameworks to conceptualize a One Health food safety program in Vietnam. We find Theory of Change fostered the characterization of a change pathway toward safer pork, while Outcome Mapping kept us informed of where along the change pathway we were. One Health programs considering evaluation frameworks should adopt elements that make sense to them, be intentional about co-designing the evaluation, and view evaluation as a process, not a product.

Mapping the movement for climate change and health in England: a descriptive review and theory of change analysis

Aims:

There are a growing number of organisations working to address the connections between climate change and health. This article introduces the concept of ‘theories of change’ – the methodology by which organisations or movements hope to bring about social change – and applies it to the current climate change and health movement in England. Through movement mapping, the article describes and offers reflections on the climate change and health ecosystems in England.

Methods:

Organisations working on climate change and health in England were identified and publicly available information was collated to map movement characteristics, target stakeholders and methodologies deployed, using an inductive, iterative approach.

Results:

A total of 98 organisations working on health and climate change (and/or sustainability) were initially identified, of which 70 met the inclusion criteria. Most organisations target two or more stakeholders, with healthcare workers, management structures, and government being most commonly cited. Methodological approaches identified include Formal education programmes; Awareness-raising; Purchasing-procurement power; Advocacy; Financial; Media-messaging; Networking; Knowledge generation; and Policy making, of which education, awareness-raising, and advocacy are most commonly used.

Conclusion:

There is a tendency for climate change and health organisations in England to focus on individual level and sectoral change over system change. More could be made of the potential for the healthcare professions’ voice and messaging for the wider climate movement. Given the rapid boom of climate change and health organisations in recent years, a mind-set shift that recognises different players as part of a cohesive ecosystem with better coordination and collaboration may reduce unnecessary work, and facilitate more cohesive outcomes.

Guidance for the Reporting of an Intervention's Theory

BACKGROUND

Interventions in clinical trials should be clearly and completely described to inform their evaluation in replication studies and implementation in clinical practice. Guidelines were developed to standardize the reporting of interventions, but failed to provide guidance on reporting of the theory of interventions. Further, space constraints imposed by many research journals often limit the comprehensive description of both the theoretical and operational aspects of interventions.

PURPOSE

To address these gaps, we propose that the theory of interventions be published in separate conceptual papers that would provide an in-depth description of the health problem targeted by an intervention, the components comprising an intervention, the causal mechanism responsible for an intervention's impact on the outcomes, and the conditions necessary for the proper implementation and the effectiveness of an intervention.

IMPLICATIONS

Such papers would assist in the critical appraisal of the adequacy, implementation, and evaluation of interventions. A description of the theory of interventions clarifies to health professionals what the interventions are about, who is likely to benefit from the interventions, how the interventions work and under what context.

Dynamical Properties and Conceptual Interpretation of Latent Change Score Models

Latent Change Score models (LCS) are a popular tool for the study of dynamics in longitudinal research. They represent processes in which the short-term dynamics have direct and indirect consequences on the long-term behavior of the system. However, this dual interpretation of the model parameters is usually overlooked in the literature, and researchers often find it difficult to see the connection between parameters and specific patterns of change. The goal of this paper is to provide a comprehensive examination of the meaning and interpretation of the parameters in LCS models. Importantly, we focus on their relation to the shape of the trajectories and explain how different specifications of the LCS model involve particular assumptions about the mechanisms of change. On a supplementary website, we present an interactive Shiny App that allows users to explore different sets of parameter values and examine their effects on the predicted trajectories. We also include fully explained code to estimate some of the most relevant specifications of the LCS model with the R-packages lavaan and OpenMx.

One Health Evaluation: A Case Study at the University of Bologna

The level of One Health (OH), or “One Health-ness,” of health interventions has been defined as the capacity to operate according to six dimensions concerning OH operations and OH infrastructures, respectively (thinking, planning, and working; and information sharing, reciprocal learning, and systemic organization). Although health initiatives and research increasingly claim their orientation toward OH, such a capacity is rarely assessed. The objective of this study is to evaluate the One Health-ness of the academic team of the University of Bologna (UNIBO Team) working in the “ELEPHANT” project (Empowering universities' Learning and rEsearch caPacities in the one Health Approach for the maNagement of animals at the wildlife, livestock and human interface in SouTh Africa). This project involves universities, six from South Africa and two from Europe, and aims at embedding OH in research and learning to enable the control of diseases at the human, animal, and environmental interface, and to emphasize the interests of local African communities with wildlife conservation. The methodology adopts the NEOH method, developed in 2018 by the EU-COST Action, “Network for the Evaluation of One Health.” The approach is based on questionnaires delivered to participants, which focus on the six OH dimensions, and then translate answers into quantitative metrics through the OH Index (OHI) and the OH Ratio (OHR). The following two evaluation levels are foreseen: the whole project and the single partner institutions. The evaluations are carried on in parallel, with preliminary, mid-term, and final assessments, to monitor the efficacy of the project actions. The preliminary evaluation of the UNIBO Team resulted in the OHI of 0.23 and the OHR of 1.69 which indicate a low degree of OH-ness and an imbalance between OH operation and OH infrastructure. The UNIBO case study will be the baseline for the evaluation of the other partner institutions involved in the ELEPHANT project. This type of evaluation can support the implementation of OH practices inside a project and underpin the strategies that allow to achieving more effective results. Any improvement in the OH-ness of each single academic team can be also considered as a result of the ELEPHANT project, thus showing its multiplier effect in the context.

Beyond the project: Building a strategic theory of change to address dementia care, treatment and support gaps across seven middle-income countries

Evidence from middle-income countries indicates high and increasing prevalence of dementia and need for services. However, there has been little investment in care, treatment or support for people living with dementia and their carers. The Strengthening Responses to Dementia in Developing Countries (STRiDE) project aims to build both research capacity and evidence on dementia care and services in Brazil, Indonesia, India, Jamaica, Kenya, Mexico and South Africa. This article presents the Theory of Change (ToC) approach we used to co-design our research project and to develop a strategic direction for dementia care, treatment and support, with stakeholders. ToC makes explicit the process underlying how a programme will achieve its impact. We developed ToCs in each country and across the STRiDE project with researchers, practitioners, people living with dementia, carers and policymakers at different levels of government. This involved (1) an initial ToC workshop with all project partners (43 participants); (2) ToC workshops in each STRiDE country (22-49 participants in each); (3) comparison between country-specific and overall project ToCs; (4) review of ToCs in light of WHO dementia guidelines and action plan and (5) a final review. Our experiences suggest ToC is an effective way to generate a shared vision for dementia care, treatment and support among diverse stakeholders. However, the project contribution should be clearly delineated and use additional strategies to ensure appropriate participation from people living with dementia and their carers in the ToC process.

Fostering Cultures of Sustainability in a Multi-Unit Office Building: A Theory of Change

Psychological approaches to fostering sustainability are heavily focused on individual behaviors and often insufficiently address the physical and social contexts individuals are embedded in. This limits the ability to create meaningful, long-lasting change, as many of day-to-day behaviors are social practices embedded in broader cultural norms and systems. This is particularly true in the work context, where organizational cultures heavily condition both the actions of individual employees and the collective actions of organizations. Thus, we argue cultures, not behaviors, must become the focus of sustainability change efforts. In this paper, we present a theory of change aimed at fostering strong organizational cultures of sustainability (COS) within a high-performance multi-tenant office building. Our theory takes a systems perspective that incorporates the social and physical aspects of the work environment, and views culture change as a co-creative exercise involving engagement of multiple stakeholders. The paper concludes with implications for practice and research.

Implementation and Evaluation of a Social Media-Based Communication Strategy to Enhance Employee Engagement: Experiences From a Children's Hospital, Pakistan

Social media can complement organizational communication strategy which is integral to employee engagement. However, successful case studies which can allow replication are limited. The objective of the study is to describe the design, implementation, and evaluation of a social media-based communication strategy in a tertiary care hospital in Pakistan. The leadership of the pediatric service line developed an intervention plan to engage the employees with the newly reframed vision to improve patient and family experience. An online communication platform—Facebook page—was created for all employees of the pediatric service line. The strategy to influence employees was based on Cialdini's six principles of persuasion. Implementation of the strategy between October 2017 and December 2019 was evaluated for reach, discussion themes, and outcomes using the framework by Murdough (2009). Quantitative indicators included total posts, mean comments, and reactions per post. Posts were qualitatively analyzed with an emergent approach for insights into the discussion. The analysis revealed a total of 9,085 posts, with mean reactions per post of 8.4, mean comments of 7.2, and active viewership by 90% members on average. In terms of post types, photos were the highest (4,779), while videos were the lowest (1,163). Qualitative analysis indicated 54% of the posts were of the theme “inspirational and thought provoking,” while the greatest engagement was generated on the theme “challenges and solution.” The authors conclude that the strategy was successfully implemented to maintain active membership, engage employees in meaningful conversations, and have them express intent to execute quality improvement projects.

Development and Implementation of Liposomal Encapsulated Micronutrient Fortified Body Oil Intervention for Infant Massage: An Innovative Concept to Prevent Micronutrient Deficiencies in Children

Indian communities have the ancient cultural practice of gentle oil massage for infants which has been shown to play a beneficial role in neuro-motor development. The concept of incorporating nanosized liposomes of micronutrients (i.e., iron, folate, vitamin B12, and vitamin D) in the body oil leverages this practice for transdermal supplementation of essential micro-nutrients. This paper describes the experience of developing an intervention in the form of body oil containing nanosized liposomes of iron and micro-nutrients built on the social context of infant oil massage using a theory of change approach. The process of development of the intervention has been covered into stages such as design, decide and implement. The design phase describes how the idea of nanosized liposomal encapsulated micronutrient fortified (LMF) body oil was conceptualized and how its feasibility was assessed through initial formative work in the community. The decide phase describes steps involved while scaling up technology from laboratory to community level. The implementation phase describes processes while implementing the intervention of LMF oil in a community-based randomized controlled study. Overall, the theory of change approach helps to outline the various intermediate steps and challenges while translating novel technologies for transdermal nutrient fortification to community level. In our experience, adaptation in the technology for large scale up, formative work and pilot testing of innovation at community level were important processes that helped in shaping the innovation. Meticulous mapping of these processes and experiences can be a useful guide for translating similar innovations.

Generating Evidence From Contextual Clinical Research in Low- to Middle Income Countries: A Roadmap Based on Theory of Change

Along with inadequate access to high-quality care, competing health priorities, fragile health systems, and conflicts, there is an associated delay in evidence generation and research from LMICs. Lack of basic epidemiologic understanding of the disease burden in these regions poses a significant knowledge gap as solutions can only be developed and sustained if the scope of the problem is accurately defined. Congenital heart disease (CHD), for example, is the most common birth defect in children. The prevalence of CHD from 1990 to 2017 has progressively increased by 18.7% and more than 90% of children with CHD are born in Low and Middle-Income Countries (LMICs). If diagnosed and managed in a timely manner, as in high-income countries (HICs), most children lead a healthy life and achieve adulthood. However, children with CHD in LMICs have limited care available with subsequent impact on survival. The large disparity in global health research focus on this complex disease makes it a solid paradigm to shape the debate. Despite many challenges, an essential aspect of improving research in LMICs is the realization and ownership of the problem around paucity of local evidence by patients, health care providers, academic centers, and governments in these countries. We have created a theory of change model to address these challenges at a micro- (individual patient or physician or institutions delivering health care) and a macro- (government and health ministries) level, presenting suggested solutions for these complex problems. All stakeholders in the society, from government bodies, health ministries, and systems, to frontline healthcare workers and patients, need to be invested in addressing the local health problems and significantly increase data to define and improve the gaps in care in LMICs. Moreover, interventions can be designed for a more collaborative and effective HIC-LMIC and LMIC-LMIC partnership to increase resources, capacity building, and representation for long-term productivity.

Towards a Program Theory for Family-Focused Practice in Adult Mental Health Care Settings: An International Interview Study With Program Leaders

Objectives: In several high-income countries, family-focused practice programs have been introduced in adult mental health care settings to identify and support children whose parents live with mental health problems. Whilst their common goal is to reduce the impact of parental mental illness on children, the mechanisms by which they improve outcomes in different systems and settings are less well known. This kind of knowledge can importantly contribute to ensuring that practice programs achieve pre-defined impacts. Methods: The aim of this study was to develop knowledge about relationships between contextual factors, mechanisms and impact that could inform a program theory for developing, implementing, and evaluating family-focused practice. Principles of a realist evaluation approach and complex system thinking were used to conceptualize the design of semi-structured in-depth interviews with individuals who led the implementation of programs. Seventeen individuals from eight countries participated in the study. Results: Interviewees provided rich accounts of the components that programs should include, contextual factors in which they operated, as well as the behavior changes in practitioners that programs needed to achieve. Together with information from the literature, we developed an initial program theory, which illustrates the interconnectedness between changes that need to co-occur in practitioners, parents, and children, many of which related to a more open communication about parental mental health problems. Stigma, risk-focused and fragmented health systems, and a lack of management commitment were the root causes explaining, for example, why conversations about parents' mental illness did not take place, or not in a way that they could help children. Enabling practitioners to focus on parents' strengths was assumed to trigger changes in knowledge, emotions and behaviors in parents that would subsequently benefit children, by reducing feelings of guilt and improving self-esteem. Conclusion: To our knowledge, this is the first research, which synthesizes knowledge about how family-focused practice programs works in a way that it can inform the design, implementation, and evaluation of programs. Stakeholder, who fund, design, implement or evaluate programs should start co-developing and using program theories like the one presented in this paper to strengthen the design and delivery of family-focused practice.

Development of a quality improvement package for reducing sight-threatening retinopathy of prematurity

Purpose:

With improving survival of preterm neonates, retinopathy of prematurity (ROP) is emerging as a major cause of childhood blindness. Incidence of sight-threatening ROP can be reduced by improving the quality of care provided to preterm neonates.

Methods:

This before-and-after study was designed to develop a need-based intervention package to improve knowledge, skills, and practices of those providing care for preterm neonates, and to evaluate the effectiveness of this package when combined with point-of-care quality improvement (POCQI) in improving survival of preterm neonates without sight-threatening ROP. The study had a formative component to assess baseline knowledge, skills, practices and attitudes, and to assess the needs of the healthcare staff to improve the care of preterm neonates. It was conducted in four special care neonatal units (SCNU) in the state of Madhya Pradesh in India.

Results:

A theory of change was developed to guide the development of study tools including needs assessment and educational package development. The educational package thus developed has been tested at the study sites in combination with POCQI projects driven by local teams of healthcare providers. The effectiveness of the interventions has been evaluated by collection of individual-level data on neonates admitted at the study sites.

Conclusion:

A multidimensional educational package integrated with system changes in the form of quality improvement (QI) endeavours driven by local context and needs were developed and evaluated in the project.

Towards the Development of an Intervention to Address Social Determinants of Non-Communicable Disease in Kerala, India: A Mixed Methods Study

In India, cardiovascular disease (CVD), with hypertension as its foremost risk factor, has the highest prevalence rate of non-communicable diseases (NCDs) and a rising mortality. Previous research has found a clustering of behavioural and social risks pertaining to NCDs, though the latter are infrequently addressed in public health interventions in India. This paper reaches toward the development of a social intervention to address social determinants of NCD relating to hypertension and diabetes. We used Theory of Change (ToC) as a theoretical approach to programme design. Mixed methods were used, including qualitative interviews with community members (n = 20), Accredited Social Health Activists (n = 6) and health professionals (n = 8), and a stakeholder workshop (n = 5 participants). The recruitment of participants from one local area in Kerala enabled us to map service provision and gain a holistic understanding of how to utilise the existing workforce to target social risk factors. The findings suggest that social interventions need to focus on ensuring health behaviour information reaches all parts of the community, and that those with more social risk factors are identified and supported to engage with treatment. Further research is required to test the resulting intervention model.

Identifying pathways for large-scale implementation of a school-based mental health programme in the Eastern Mediterranean Region: a theory-driven approach

Globally there is a substantial burden of mental health problems among children and adolescents. Task-shifting/task-sharing mental health services to non-specialists, e.g. teachers in school settings, provide a unique opportunity for the implementation of mental health interventions at scale in low- and middle-income countries (LMICs). There is scant information to guide the large-scale implementation of school-based mental health programme in LMICs. This article describes pathways for large-scale implementation of a School Mental Health Program (SMHP) in the Eastern Mediterranean Region (EMR). A collaborative learning group (CLG) comprising stakeholders involved in implementing the SMHP including policymakers, programme managers and researchers from EMR countries was established. Participants in the CLG applied the theory of change (ToC) methodology to identify sets of preconditions, assumptions and hypothesized pathways for improving the mental health outcomes of school-aged children in public schools through implementation of the SMHP. The proposed pathways were then validated through multiple regional and national ToC workshops held between January 2017 and September 2019, as the SMHP was being rolled out in three EMR countries: Egypt, Pakistan and Iran. Preconditions, strategies and programmatic/contextual adaptations that apply across these three countries were drawn from qualitative narrative summaries of programme implementation processes and facilitated discussions during biannual CLG meetings. The ToC for large-scale implementation of the SMHP in the EMR suggests that identifying national champions, formulating dedicated cross-sectoral (including the health and education sector) implementation teams, sustained policy advocacy and stakeholders engagement across multiple levels, and effective co-ordination among education and health systems especially at the local level are among the critical factors for large-scale programme implementation. The pathways described in this paper are useful for facilitating effective implementation of the SMHP at scale and provide a theory-based framework for evaluating the SMHP and similar programmes in the EMR and other LMICs.

Mechanisms and impacts of an incentive-based conservation program with evidence from a randomized control trial

Conservation science needs more high-quality impact evaluations, especially ones that explore mechanisms of success or failure. Randomized control trials (RCTs) provide particularly robust evidence of the effectiveness of interventions (although they have been criticized as reductionist and unable to provide insights into mechanisms), but there have been few such experiments investigating conservation at the landscape scale. We explored the impact of Watershared, an incentive-based conservation program in the Bolivian Andes, with one of the few RCTs of landscape-scale conservation in existence. There is strong interest in such incentive-based conservation approaches as some argue they can avoid negative social impacts sometimes associated with protected areas. We focused on social and environmental outcomes based on responses from a household survey in 129 communities randomly allocated to control or treatment (conducted both at the baseline in 2010 and repeated in 2015-2016). We controlled for incomplete program uptake by combining standard RCT analysis with matching methods and investigated mechanisms by exploring intermediate and ultimate outcomes according to the underlying theory of change. Previous analyses, focused on single biophysical outcomes, showed that over its first 5 years Watershared did not slow deforestation or improve water quality at the landscape scale. We found that Watershared influenced some outcomes measured using the survey, but the effects were complex, and some were unexpected. We thus demonstrated how RCTs can provide insights into the pathways of impact, as well as whether an intervention has impact. This paper, one of the first registered reports in conservation science, demonstrates how preregistration can help make complex research designs more transparent, avoid cherry picking, and reduce publication bias.

Tailoring Process and Impact Evaluation of a "Cash-Plus" Program: The Value of Using a Participatory Program Impact Pathway Analysis

BACKGROUND

Evaluations are often limited to affirming what impact health and nutrition interventions have, without providing enough insights into "how/why" impacts are achieved.

OBJECTIVES

This article describes how a Program Impact Pathway (PIP) analysis was used to tailor theory-driven impact and process evaluation of a "Cash-Plus" program combining unconditional cash transfers with behavior change communication (BCC) activities, which was implemented to improve children's growth in Togo.

METHODS

A theoretical PIP diagram was developed using existing literature, program documentation, and interviews with the program's stakeholders at the central level. Next, the PIP diagram was refined through 2 regional participatory workshops, 6 mo after the program began. Workshop participants were multilevel field implementers and were asked to 1) discuss their vision of the program's objectives; 2) describe the "inputs-process-outputs-outcomes-impacts" flow; 3) reflect on modifiers that may arise along the PIP; and 4) report bottlenecks in the program's conception or implementation and suggest corrective actions. The PIP was used to determine research questions that should be investigated during impact or process evaluation and guided the choice of data collection methods and tools.

RESULTS

The PIP analysis identified 3 impact pathways, all based on the synergy between cash and raised women's knowledge. Along these pathways, the motivation and workload of frontline workers, along with issues in cash flow, were identified as factors that may affect the delivery of activities, whereas women's control over resources, time availability, support from relatives, and the presence of markets and health and school services were recognized as factors that may influence the uptake of activities. Improved communication between stakeholders and increased involvement of husbands were suggested for better impact achievement.

CONCLUSIONS

The participatory PIP analysis helped implementers and evaluators to share a common vision of the program's objective and logic, encouraged communication across sectors, and facilitated course-adjustments of the program.

A framework for evaluating the impact of the IUCN Red List of threatened species

The International Union for Conservation of Nature (IUCN) Red List of Threatened Species, a species extinction risk assessment tool, has been guiding conservation efforts for over 5 decades. It is widely assumed to have been instrumental in preventing species from moving closer to extinction and driving recoveries. However, the impact of the IUCN Red List in guiding conservation has not been evaluated. We conducted, transcribed, and coded interviews with experts who use the IUCN Red List across a range of sectors to understand how the list is used in conservation. We developed a theory of change to illustrate how and why change is expected to occur along causal pathways contributing to the long-term goal of the IUCN Red List and an evaluation framework with indicators for measuring the impact of the IUCN Red List in generating scientific knowledge, raising awareness among stakeholders, designating priority conservation sites, allocating funding and resources, influencing development of legislation and policy, and guiding targeted conservation action (key themes). Red-list assessments were the primary input leading to outputs (scientific knowledge, raised awareness), outcomes (better informed priority setting, access to funding and resource availability, improved legislation and policy), and impact (implemented conservation action leading to positive change) that have resulted in achievement of IUCN Red List goals. To explore feasibility of attributing the difference made by the IUCN Red List across themes, we studied increased scientific knowledge, raised awareness, access to funding and resource allocation, and increased conservation activity. The feasibility exploration showed increased scientific knowledge over time identified through positive trends in publications referring to the IUCN Red List in the literature; raised awareness of the list following high IUCN activity identified by peaks in online search activity; an increased proportion of conservation funding bodies requesting IUCN Red List status in the application process; and, based on interviews with Amphibian Specialist Group members, red-list assessments were essential in connecting relevant stakeholders and ensuring conservation action. Although we identified the IUCN Red List as a vital tool in global conservation efforts, it was challenging to measure specific impacts because of its ubiquitous nature. We are the first to identify the influence of the IUCN Red List on conservation.

A protocol for evaluating a multi-level implementation theory to scale-up obstetric triage in referral hospitals in Ghana

BACKGROUND

Ghana significantly reduced maternal and newborn mortality between 1990 and 2015, largely through efforts focused on improving access to care. Yet achieving further progress requires improving the quality and timeliness of care. Beginning in 2013, Ghana Health Service and Kybele, a US-based non-governmental organization, developed an innovative obstetric triage system to help midwives assess, diagnosis, and determine appropriate care plans more quickly and accurately. In 2019, efforts began to scale this successful intervention into six additional hospitals. This protocol describes the theory-based implementation approach guiding scale-up and presents the proposed mixed-methods evaluation plan.

METHODS

An implementation theory was developed to describe how complementary implementation strategies would be bundled into a multi-level implementation approach. Drawing on the Interactive Systems Framework and Evidenced Based System for Implementation Support, the proposed implementation approach is designed to help individual facilities develop implementation capacity and also build a learning network across facilities to support the implementation of evidence-based interventions. A convergent design mixed methods approach will be used to evaluate implementation with relevant data drawn from tailored assessments, routinely collected process and quality monitoring data, textual analysis of relevant documents and WhatsApp group messages, and key informant interviews. Implementation outcomes of interest are acceptability, adoption, and sustainability.

DISCUSSION

The past decade has seen a rapid growth in the development of frameworks, models, and theories of implementation, yet there remains little guidance on how to use these to operationalize implementation practice. This study proposes one method for using implementation theory, paired with other kinds of mid-level and program theory, to guide the replication and evaluation of a clinical intervention in a complex, real-world setting. The results of this study should help to provide evidence of how implementation theory can be used to help close the "know-do" gap. Every woman and every newborn deserves a safe and positive birth experience. Yet in many parts of the world, this goal is often more aspiration than reality. In 2006, Kybele, a US-based non-governmental organization, began working with the Ghanaian government to improve the quality of obstetric and newborn care in a large hospital in Greater Accra. One successful program was the development of a triage system that would help midwives rapidly assess pregnant women to determine who needed what kind of care and develop risk-based care plans. The program was then replicated in another large hospital in the Greater Accra region, where a systematic theory to inform triage implementation was developed. This paper describes the extension of this approach to scale-up the triage program implementation in six additional hospitals. The scale-up is guided by a multi-level theory that extends the facility level theory to include cross-facility learning networks and oversight by the health system. We explain the process of theory development to implement interventions and demonstrate how these require the combination of local contextual knowledge with evidence from the implementation science literature. We also describe our approach for evaluating the theory to assess its effectiveness in achieving key implementation outcomes. This paper provides an example of how to use implementation theories to guide the development and evaluation of complex programs in real-world settings.

Expanding choice through online contraception: a theory of change to inform service development and evaluation

BACKGROUND

This study presents the theory of change underpinning an intervention to provide online contraceptive care in an inner London area with high rates of unplanned pregnancy. It aims to suggest attributes of an effective service and to identify key questions for its evaluation.

METHODS

Thematic analysis of an online sexual and reproductive health programme funding application and 21 semi-structured interviews with a purposive sample of stakeholders selected to provide expertise in contraception and online health.

RESULTS

A theory of change model summarised the positive processes of change which could be initiated through increased access to contraceptive supplies, online information and remote interaction and support. Stakeholders predicted that perceptions of convenience and anonymity of online access would vary across the target population. They stressed the importance of trusting service-users' capabilities for autonomous contraceptive decision-making, but expressed concerns that online access could be detrimental for those requiring more complex care. Concerns were alleviated by the prospect of responsive support through text messaging and phone calls, and when the online service was positioned as part of a broader system of provision including physical services.

CONCLUSIONS

This study has revealed priority areas for the ongoing development of an online contraception service and pertinent evaluation questions. Evaluative research should test assumptions within the theory of change model, exploring the characteristics and circumstances of those preferring online access over existing services and the value of convenience, anonymity, autonomous access and responsive support in executing effective contraceptive choices within a new landscape of contraceptive delivery.

Contribution of the Alive & Thrive-UNICEF advocacy efforts to improve infant and young child feeding policies in Southeast Asia

Evaluating the impact of advocacy for policy change presents many challenges. Recent advances in the field of evaluation, such as contribution analysis (CA), offer guidance on how to make credible claims regarding such impact. The purposes of this article are (a) to detail the application of CA to assess the contribution of an advocacy initiative to improve infant and young child feeding policies and (b) to present the emergent theory of change and contribution story of how progress was achieved. An evaluation applying developmental evaluation and CA was conducted on the Alive & Thrive (A&T)-UNICEF initiative in seven Southeast Asian countries to document the extent to which policy objectives were achieved and identify key drivers of policy change. A contribution story was developed based on these experiences. The advocacy approach, which involved a four-part process, contributed directly to (a) set the agenda of various actors and (b) create a strategic group; and indirectly to (a) set and maintain the issue on the agenda at all stages of the policy cycle, (b) support the government to carry out a set of critical tasks, and (c) extend commitment. All of this helped to achieve progress towards policy change. External influences were at play. The flexibility of A&T allowed key actors to utilize the positive external influences and address some of the negative ones through developing responsive strategies mitigating their effects. The emerging contribution story supports that A&T-UNICEF initiative contributed to the progress achieved in the participating countries.

An illustration of how responsive feedback in a social marketing tobacco control intervention in Ghana enabled managers to make decisions that increased intervention effectiveness

This report illustrates how a feedback loop, set up to provide data and insights to a donor and designers/implementers of a social marketing tobacco prevention intervention in Ghana, helped adapt the original design of the intervention to one that was more suited to the social and media contexts of Ghana. The designers/implementers had previously, successfully implemented a tobacco control intervention with adolescents in Botswana. This experience had informed the initial intervention design in Ghana. As the feedback generated by evaluators started demonstrating just how different the Ghanaian social and media contexts were from the Botswanan one, implementers started making changes to their selection of channels, resulting in a design which was quite different from the original one. The close involvement of the donor in this process enabled implementers to make rapid changes to the design of the intervention. This illustration adds to a small but growing literature establishing the importance of feedback loops to improve the design and implementation of development interventions.

A Model of Mental Health Care Involving Trained Lay Health Workers for Treatment of Major Mental Disorders Among Youth in a Conflict-Ridden, Low-Middle Income Environment: Part I Adaptation and Implementation

OBJECTIVES

In low- and middle-income countries (LMIC), major mental disorders often remain untreated because of barriers related to access and resources. In rural areas and in conflict-ridden regions, the problem can be exacerbated by increased rates of mental illness and by reduced access to care. This paper describes a project designed to provide mental health services for major mental disorders among youth using a low-cost model in a rural district of the troubled Kashmir valley.

METHODS

We describe the geographic and political context, the guiding principles and adaptation of the service model (through partnership with a voluntary organization and use of technology), and the implementation of the model using Theory of Change framework. The core of the intervention was to train a pool of lay health workers (LHWs) to provide mental health services to young (aged 14-30 years) people with major mental disorders in their own communities, supported by clinical professionals.

RESULTS

Despite political turmoil and major floods, 40 (male and female) LHWs were trained. The LHWs efficiently engaged in case identification, basic interventions, and data collection on outcomes. Several different stakeholders were engaged in activities relevant to the objectives of the project; however, the use of technologies was moderated by several challenges, including access to internet services and patient preference for personal contact.

CONCLUSIONS

This service model is applicable in an environment where protracted political and armed conflict, low resources, and geographical isolation make exclusive reliance on scarce professional services impractical.