scholarly journals Lessons from implementation research on community management of Possible Serious Bacterial Infection (PSBI) in young infants (0-59 days), when the referral is not feasible in Palwal district of Haryana, India

PLoS ONE ◽  
2021 ◽  
Vol 16 (7) ◽  
pp. e0252700
Author(s):  
Rupak Mukhopadhyay ◽  
Narendra Kumar Arora ◽  
Pradeep Kumar Sharma ◽  
Suresh Dalpath ◽  
Priya Limbu ◽  
...  
Keyword(s):  
Bacterial Infection ◽  
Implementation Research ◽  
Implementation Strategies ◽  
Technical Support ◽  
Health Centers ◽  
World Health ◽  
Policy Dialogue ◽  
Live Births ◽  
Young Infants ◽  
Oral Amoxicillin

Background Neonatal sepsis is a major cause of death in India, which needs hospital management but many families cannot access hospitals. The World Health Organization and the Government of India developed a guideline to manage possible serious bacterial infection (PSBI) when a referral is not feasible. We implemented this guideline to achieve high coverage of treatment of PSBI with low mortality. Methodology The implementation research study was conducted in over 50 villages of Palwal district, Haryana during August 2017-March 2019 and covered a population of 199143. Policy dialogue with central, state and district health authorities was held before initiation of the study. A baseline assessment of the barriers in the implementation of the PSBI intervention was conducted. The intervention was implemented in the program setting. The research team collected data throughout and also co-participated in the implementation of the intervention for the first six months to identify bottlenecks in the health system and at the community level. RE-AIM framework was utilized to document implementation strategies of PSBI management guideline. Implementation strategies by the district technical support unit (TSU) included: (i) empower mothers and families through social mobilization to improve care-seeking of sick young infants 0–59 days of age, (ii) build capacity through training and build confidence through technical support of health staff at primary health centers (PHC), community health centers (CHC) and sub-centers to manage young infants with PSBI signs and (iii) improve performance of accredited social health activists (ASHAs). Findings A total of 370 young infants with signs of PSBI were identified and managed in 5270 live births. Treatment coverage was 70% assuming that 10% of live births would have PSBI within the first two months of life. Mothers identified 87.6% (324/370) of PSBI cases. PHCs and CHCs became functional and managed 150 (40%) sick young infants with PSBI. Twenty four young infants (7-59days) who had only fast breathing were treated with oral amoxicillin without a referral. Referral to a hospital was refused by 126 (84%); 119 had clinical severe infection (CSI), one 0–6 days old had fast breathing and six had critical illness (CI). Of 119 CSI cases managed on outpatient injection gentamicin and oral amoxicillin, 116 (96.7%) recovered, 55 (45.8%) received all seven gentamicin injections and only one died. All 7–59 day old infants with fast breathing recovered, 23 on outpatient oral amoxicillin treatment; and 19 (79%) received all doses. Of 65 infants managed at either district or tertiary hospital, two (3.1%) died, rest recovered. Private providers managed 155 (41.9%) PSBI cases, all except one recovered, but sub-classification and treatment were unknown. Sub-centers could not be activated to manage PSBI. Conclusion The study demonstrated resolution of implementation bottlenecks with existing resources, activated PHCs and CHCs to manage CSI and fast breathers (7–59 day old) on an outpatient basis with low mortality when a referral was not feasible. TSU was instrumental in these achievements. We established the effectiveness of oral amoxicillin alone in 7–59 days old fast breathers and recommend a review of the current national policy.

scholarly journals Innovative approach for potential scale-up to jump-start simplified management of sick young infants with possible serious bacterial infection when a referral is not feasible: Findings from implementation research

PLoS ONE ◽  
2021 ◽  
Vol 16 (2) ◽  
pp. e0244192
Author(s):  
Abadi Leul ◽  
Tadele Hailu ◽  
Loko Abraham ◽  
Alemayehu Bayray ◽  
Wondwossen Terefe ◽  
...  
Keyword(s):  
Critical Illness ◽  
Bacterial Infection ◽  
Implementation Research ◽  
Severe Infection ◽  
World Health ◽  
Policy Dialogue ◽  
Health Post ◽  
Live Births ◽  
Young Infants ◽  
Oral Amoxicillin

Background Neonatal bacterial infections are a common cause of death, which can be managed well with inpatient treatment. Unfortunately, many families in low resource settings do not accept referral to a hospital. The World Health Organization (WHO) developed a guideline for management of young infants up to 2 months of age with possible serious bacterial infection (PSBI) when referral is not feasible. Government of Ethiopia with WHO evaluated the feasibility of implementing this guideline to increase coverage of treatment. Objective The objective of this study was to implement a simplified antibiotic regimen (2 days gentamicin injection and 7 days oral amoxicillin) for management of sick young infants with PSBI in a programme setting when referral was not feasible to identify at least 80% of PSBI cases, achieve an overall adequate treatment coverage of at least 80% and document the challenges and opportunities for implementation at the community level in two districts in Tigray, Ethiopia. Methods Using implementation research, we applied the PSBI guideline in a programme setting from January 2016 to August 2017 in Raya Alamata and Raya Azebo Woredas (districts) in Southern Tigray, Ethiopia with a population of 260884. Policy dialogue was held with decision-makers, programme implementers and stakeholders at federal, regional and district levels, and a Technical Support Unit (TSU) was established. Health Extension Workers (HEWs) working at the health posts and supervisors working at the health centres were trained in WHO guideline to manage sick young infants when referral was not feasible. Communities were sensitized towards appropriate home care. Results We identified 854 young infants with any sign of PSBI in the study population of 7857 live births. The expected live births during the study period were 9821. Assuming 10% of neonates will have any sign of PSBI within the first 2 months of life (n = 982), the coverage of appropriate treatment of PSBI cases in our study area was 87% (854/982). Of the 854 sick young infants, 333 (39%) were taken directly to a hospital and 521 (61%) were identified by HEW at health posts. Of the 521 young infants, 27 (5.2%) had signs of critical illness, 181 (34.7%) had signs of clinical severe infection, whereas 313 (60.1%) young infants 7–59 days of age had only fast breathing pneumonia. All young infants with critical illness accepted referral to a hospital, while 117/181 (64.6%) infants with clinical severe infection accepted referral. Families of 64 (35.3%) infants with clinical severe infection refused referral and were treated at the health post with injectable gentamicin for 2 days plus oral amoxicillin for 7 days. All 64 completed recommended gentamicin doses and 63/64 (98%) completed recommended amoxicillin doses. Of 313 young infants, 7–59 days with pneumonia who were treated by the HEWs without referral with oral amoxicillin for 7 days, 310 (99%) received all 14 doses. No deaths were reported among those treated on an outpatient basis at health posts. But 35/477 (7%) deaths occurred among young infants treated at hospital. Conclusions When referral is not feasible, young infants with PSBI can be managed appropriately at health posts by HEWs in the existing health system in Ethiopia with high coverage, low treatment failure and a low case fatality rate. Moreover, fast breathing pneumonia in infants 7–59 days of age can be successfully treated at the health post without referral. Relatively higher mortality in sick young infants at the referral level health facilities warrants further investigation.

scholarly journals Implementation research on management of sick young infants with possible serious bacterial infection when referral is not possible in Jimma Zone, Ethiopia: Challenges and solutions

PLoS ONE ◽  
2021 ◽  
Vol 16 (8) ◽  
pp. e0255210
Author(s):  
Melkamu Berhane ◽  
Tsinuel Girma ◽  
Workneh Tesfaye ◽  
Nega Jibat ◽  
Mulumebet Abera ◽  
...  
Keyword(s):  
Health Care ◽  
Critical Illness ◽  
Bacterial Infection ◽  
Implementation Research ◽  
Health Centre ◽  
Outpatient Basis ◽  
Health Post ◽  
Young Infants ◽  
Oral Amoxicillin ◽  
Jimma Zone

Introduction Of 2.5 million newborn deaths each year, serious neonatal infections are a leading cause of neonatal death for which inpatient treatment is recommended. However, manysick newborns in sub-Saharan Africa and south Asia do not have access to inpatientcare. A World Health Organization (WHO) guideline recommends simplified antibiotic treatment atan outpatient level for young infants up to two months of age with possible serious bacterial infection (PSBI), when referral is not feasible.We implemented this guidelinein Ethiopia to increase coverage of treatment and to learn about potential facilitating factors and barriers for implementation. Methods We conducted implementation research in two districts (Tiro Afata and Gera) in Jimma Zone, Ethiopia, to learn about the feasibility of implementing the WHO PSBI guideline within a programme setting using the existing health care structure. We conducted orientation meetings and policy dialogue with key stakeholders and trained health extension workers and health centre staff to identify and manage sick young infants with PSBI signs at a primary health care unit. We established a Technical Support Unit (TSU) to facilitate programme learning, built health workers’ capacity and provided support for quality control, monitoring and data collection.We sensitized the community to appropriate care-seeking and supported the health care system in implementation. The research team collected data using structured case recording forms. Results From September 2016 to August 2017, 6185 live births and 601 sick young infants 0–59 days of age with signs of PSBI were identified. Assuming that 25% of births were missed (total births 7731) and 10% of births had an episode of PSBI in the first two months of life, the coverage of appropriate treatment for PSBI was 77.7% (601/773). Of 601 infants with PSBI, fast breathing only (pneumonia) was recorded in 432 (71.9%) infants 7–59 days of age; signs of clinical severe infection (CSI) in 155 (25.8%) and critical illnessin 14 (2.3%). Of the 432 pneumonia cases who received oral amoxicillin treatment without referral, 419 (97.0%) were successfully treated without any deaths. Of 169 sick young infants with either CSI or critical illness, only 110 were referred to a hospital; 83 did not accept referral advice and received outpatient injectable gentamicin plus oral amoxicillin treatment either at a health post or health centre. Additionally, 59 infants who should have been referred, but were not received injectable gentamicin plus oral amoxicillin outpatient treatment. Of infants with CSI, 129 (82.2%) were successfully treated as outpatients, while two died (1.3%). Of 14 infants with critical illness, the caregivers of five accepted referral to a hospital, and nine were treated with simplified antibiotics on an outpatient basis. Two of 14 (14.3%) infants with critical illness died within 14 days of initial presentation. Conclusion In settings where referral to a hospital is not feasible, young infants with PSBI can be treated on an outpatient basis at either a health post or health centre, which can contribute to saving many lives. Scaling-up will require health system strengthening including community mobilization. Registration Trial is registered on Australian New Zealand Clinical Trials registry (ANZCTR) ACTRN12617001373369.

scholarly journals German Translation and Pre-testing of Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementation Change (ERIC)

2021 ◽  
Author(s):  
Verena Regauer ◽  
Eva Seckler ◽  
Craig Campbell ◽  
Amanda Phillips ◽  
Thomas Rotter ◽  
...  
Keyword(s):  
Implementation Research ◽  
English Language ◽  
Mother Tongue ◽  
Implementation Strategies ◽  
World Health ◽  
Evidence Based ◽  
Final Version ◽  
Forward Translation ◽  
German Speaking ◽  
Expert Recommendations

Abstract Background: Implementation frameworks may support local implementation strategies with a sound theoretical foundation. The Consolidated Framework for Implementation Research (CFIR) facilitates identification of contextual barriers and facilitators, and the Expert Recommendations for Implementation Change (ERIC) allows selecting adequate implementation strategies. Both instruments are already used in German-speaking countries; however, no standardised and validated translation is available thus far. The aim of this study was to translate the CFIR and ERIC framework into German, in order to increase the use of these frameworks and the adherence to evidence-based implementation efforts in German-speaking countries.Methods: The translation of the original versions of the CFIR and ERIC framework was guided by the World Health Organisation’s recommendations for the process of translating and adapting both conceptual frameworks. Accordingly, a four-step process was employed: First, forward translation from English into German was conducted by a research team of German native speakers with fluent knowledge of the English language. Second, a bilingual expert panel comprising one researcher with German as his mother tongue and expert command of the English language and one English language expert and university teacher reviewed the translation and discussed inconsistencies with the initial translators. Third, back-translation into English was conducted by an English native speaking researcher. The final version was pre-tested with 12 German researchers and clinicians who were involved in implementation projects using cognitive interviews.Results: The translation and review process revealed some inconsistencies between the original version and the German translations. All issues could be solved by discussion. Central aspects of the items were confirmed in 60% to 70% of the items, and modifications were proposed in 30% of the items. Finally, we revised one CFIR-item heading after pre-testing. The final version was given consent by all involved parties.Conclusions: Now, two validated and tested implementation frameworks to guide implementation efforts are available in the German language and can be used to improve adherence to and use of evidence-based implementation strategies into practice.

scholarly journals Management of possible serious bacterial infection in young infants where referral is not possible in the context of existing health system structure in Ibadan, South-west Nigeria

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0248720
Author(s):  
Adejumoke Idowu Ayede ◽  
Oluwakemi Oluwafunmi Ashubu ◽  
Kayode Raphael Fowobaje ◽  
Samira Aboubaker ◽  
Yasir Bin Nisar ◽  
...  
Keyword(s):  
Health Care ◽  
Critical Illness ◽  
Health System ◽  
Severe Pneumonia ◽  
Severe Infection ◽  
Technical Support ◽  
High Coverage ◽  
Young Infants ◽  
Oral Amoxicillin ◽  
Primary Health

Introduction Neonatal infections contribute substantially to infant mortality in Nigeria and globally. Management requires hospitalization, which is not accessible to many in low resource settings. World Health Organization developed a guideline to manage possible serious bacterial infection (PSBI) in young infants up to two months of age when a referral is not feasible. We evaluated the feasibility of implementing this guideline to achieve high coverage of treatment. Methods This implementation research was conducted in out-patient settings of eight primary health care centres (PHC) in Lagelu Local Government Area (LGA) of Ibadan, Oyo State, Nigeria. We conducted policy dialogue with the Federal and State officials to adopt the WHO guideline within the existing programme setting and held orientation and sensitization meetings with communities. We established a Technical Support Unit (TSU), built the capacity of health care providers, supervised and mentored them, monitored the quality of services and collected data for management and outcomes of sick young infants with PSBI signs. The Primary Health Care Directorate of the state ministry and the local government led the implementation and provided technical support. The enablers and barriers to implementation were documented. Results From 1 April 2016 to 31 July 2017 we identified 5278 live births and of these, 1214 had a sign of PSBI. Assuming 30% of births were missed due to temporary migration to maternal homes for delivery care and approximately 45% cases came from outside the catchment area due to free availability of medicines, the treatment coverage was 97.3% (668 cases/6861 expected births) with an expected 10% PSBI prevalence within the first 2 months of life. Of 1214 infants with PSBI, 392 (32%) infants 7–59 days had only fast breathing (pneumonia), 338 (27.8%) infants 0–6 days had only fast breathing (severe pneumonia), 462 (38%) presented with signs of clinical severe infection (CSI) and 22 (1.8%) with signs of critical illness. All but two, 7–59 days old infants with pneumonia were treated with oral amoxicillin without a referral; 80% (312/390) adhered to full treatment; 97.7% (381/390) were cured, and no deaths were reported. Referral to the hospital was not accepted by 87.7% (721/822) families of infants presenting with signs of PSBI needing hospitalization (critical illness 5/22; clinical severe infection; 399/462 and severe pneumonia 317/338). They were treated on an outpatient basis with two days of injectable gentamicin and seven days of oral amoxicillin. Among these 81% (584/721) completed treatment; 97% (700/721) were cured, and three deaths were reported (two with critical illness and one with clinical severe infection). We identified health system gaps including lack of staff motivation and work strikes, medicines stockouts, sub-optimal home visits that affected implementation. Conclusions When a referral is not feasible, outpatient treatment for young infants with signs of PSBI is possible within existing programme structures in Nigeria with high coverage and low case fatality. To scale up this intervention successfully, government commitment is needed to strengthen the health system, motivate and train health workers, provide necessary commodities, establish technical support for implementation and strengthen linkages with communities. Registration Trial is registered on Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001373369.

scholarly journals Identification and management of young infants with possible serious bacterial infection where referral was not feasible in rural Lucknow district of Uttar Pradesh, India: An implementation research

PLoS ONE ◽  
2020 ◽  
Vol 15 (6) ◽  
pp. e0234212
Author(s):  
Shally Awasthi ◽  
Naveen Kesarwani ◽  
Raj Kumar Verma ◽  
Girdhar Gopal Agarwal ◽  
Luxmi Shanker Tewari ◽  
...  
Keyword(s):  
Bacterial Infection ◽  
Implementation Research ◽  
Uttar Pradesh ◽  
Young Infants

scholarly journals Management of possible serious bacterial infection in young infants closer to home when referral is not feasible: Lessons from implementation research in Himachal Pradesh, India

PLoS ONE ◽  
2020 ◽  
Vol 15 (12) ◽  
pp. e0243724
Author(s):  
Nidhi Goyal ◽  
Temsunaro Rongsen-Chandola ◽  
Mangla Sood ◽  
Bireshwar Sinha ◽  
Amit Kumar ◽  
...  
Keyword(s):  
Bacterial Infection ◽  
Implementation Research ◽  
Case Fatality Rate ◽  
Case Fatality ◽  
Severe Pneumonia ◽  
Himachal Pradesh ◽  
Care Seeking ◽  
Fatality Rate ◽  
Young Infants ◽  
Facilitators And Barriers

Background Government of India and the World Health Organization have guidelines for outpatient management of young infants 0–59 days with signs of Possible Serious Bacterial Infection (PSBI), when referral is not feasible. Implementation research was conducted to identify facilitators and barriers to operationalizing these guidelines. Methods Himachal Pradesh government implemented the guidelines in program settings supported by Centre for Health Research and Development, Society for Applied Studies. The strategy included community sensitization, skill enhancement of Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANMs) and Medical Officers (MOs) to identify PSBI and treat when referral was not feasible. The research team collected information on facilitators and barriers. A technical support unit provided training and oversight. Findings Among 1997 live births from June 2017 to January 2019, we identified 160 cases of PSBI in young infants resulting in a coverage of 80%, assuming an incidence of 10%. Of these,29(18.1%) had signs of critical illness (CI), 92 (57.5%) had clinical severe infection (CSI), 5 (3.1%)had severe pneumonia (only fast breathing in young infants 0–6 days), while 34 (21%) had pneumonia (only fast breathing in young infants 7–59 days). Hospital referral was accepted by 48/160 (30%), whereas 112/160 (70%) were treated with the simplified treatment regimens at primary level facilities. Of the 29 infants with CI, 18 (62%) accepted referral; 26 (90%) recovered while 3 (10%) who had accepted referral, died. Of the 92 infants who had CSI, 86 (93%) recovered, 65 (71%) received simplified treatment and one infant who had accepted referral, died. All the five infants who had severe pneumonia, recovered; 3 (60%) had received simplified treatment. Of the 34 pneumonia cases, 33 received simplified treatment of which 5 (15%) failed treatment; two out of these 5 died. Overall, 6/160 infants died (case-fatality-rate 3.4%); 2 in the simplified treatment (case-fatality-rate 1.8%) and 4 in the hospital group (case-fatality-rate 8.3%). Delayed identification and care-seeking by families and health system weaknesses like manpower gaps and interrupted supplies were challenges in implementation. Conclusions Implementation of the guidelines in program settings is possible and acceptable. Scaling up would require creating community awareness, early identification and appropriate care-seeking, strengthening ASHA home-visitation program, building skills and confidence of MOs and ANMs, uninterrupted supplies and a dependable referral system.

scholarly journals FAKTOR – FAKTOR YANG BERHUBUNGAN DENGAN STATUS GIZI IBU HAMIL DI PUSKESMAS SIDOREJO KOTA LUBUKLINGGAU

2018 ◽  
Vol 9 (1) ◽  
pp. 56-62
Author(s):  
Zuraidah Zuraidah
Keyword(s):  
Nutritional Status ◽  
Pregnant Women ◽  
The Body ◽  
Health Centers ◽  
World Health ◽  
Survey Method ◽  
Chi Square ◽  
Cross Sectional ◽  
Important Indicator ◽  
Live Births

The nutritional status of pregnant women is one of the indicators to measure thenutritional status of the community. If the input of nutrition for pregnant women of thefood is not balanced with the needs of the body, there will be a deficiency of nutrients.Maternal Mortality become one important indicator in determining the degree of publichealth. According to the World Health Organization (WHO) in 2005 in developed countriesthe maternal mortality rate ranged from 5-10 per 100,000 live births, while in countriesemerging range between 750-1000 per 100,000 live births (Winkjosastro, 2005). Thepurpose of this study to determine the factors-factors related to the nutritional status ofpregnant women. The independent variables of this study are education, income andknowledge while the dependent variable is the nutritional status of pregnant women. Thisresearch uses a survey method with cross sectional analytic. The population in this studywere all pregnant women at health centers Sidorejo Lubuklinggau is numbered 40 pregnantwomen. The sample used is total sam-pling. Collecting data by distributing questionnairesto the respondents. The survey results revealed that respondents with low education,there are 23 (57.5%), lower income as many as 30 (75%), and respondents who haveenough knowledge-less 27 (67.5%), and respondents malnutrition status as 22 (55%). Aftertesting the chi square statistic diketahahui these three variables have a significant associationwith the nutritional status of pregnant women. Expected for health centers to providehealth education on nutrition in pregnant women, and also provide nutritious supplementaryfeeding program for pregnant women

scholarly journals Management of fast breathing pneumonia in young infants aged 7 to 59 days by community level health workers: protocol for a multi-centre cluster randomized controlled trial

2020 ◽  
Vol 7 (2) ◽  
pp. 83 ◽  
Author(s):  
Yasir Bin Nisar
Keyword(s):  
Health Workers ◽  
Controlled Trial ◽  
Community Level ◽  
World Health ◽  
Community Case Management ◽  
Open Label ◽  
Integrated Community Case Management ◽  
Young Infants ◽  
Oral Amoxicillin ◽  
Cluster Randomized

<p class="abstract"><strong>Background:</strong> WHO does not recommend community-level health workers (CLHWs) using integrated community case management (iCCM) to treat 7-59 days old infants with fast breathing with oral amoxicillin, whereas World Health Organization (WHO) integrated management of childhood illness (IMCI) recommends it. We want to collect evidence to help harmonization of both protocols.</p><p class="abstract"><strong>Methods:</strong> A cluster, randomized, open-label trial will be conducted in Africa and Asia (Ethiopia, Malawi, Bangladesh and India) using a common protocol with the same study design, inclusion criteria, intervention, comparison, and outcomes to contribute to the overall sample size. This trial will also identify hypoxaemia in young infants with fast breathing. CLHWs will assess infants for fast breathing, which will be confirmed by a study supervisor. Enrolled infants in the intervention clusters will be treated with oral amoxicillin, whereas in the control clusters they will be managed as per existing iCCM protocol. An independent outcome assessor will assess all enrolled infants on days 6 and 14 of enrolment for the study outcomes in both intervention and control clusters. Primary outcome will be clinical treatment failure by day 6. This trial will obtain approval from the WHO and site institutional ethics committees.</p><p class="abstract"><strong>Conclusions: </strong>If the research shows that CLHWs can effectively and safely treat fast breathing pneumonia in 7-59 days old young infants, it will increase access to pneumonia treatment substantially for infants living in communities with poor access to health facilities. Additionally, this evidence will contribute towards the review of the current iCCM protocol and its harmonization with IMCI protocol.</p><p class="abstract"><strong>Trial Registration:</strong> The trial is registered at AZNCTR International Trial Registry as ACTRN12617000857303.</p>

Adaptation in Dissemination and Implementation Science

2017 ◽  
Author(s):  
Ana A. Baumann ◽  
Leopoldo J. Cabassa ◽  
Shannon Wiltsey Stirman
Keyword(s):  
Implementation Science ◽  
Implementation Research ◽  
Implementation Strategies ◽  
Dissemination And Implementation ◽  
Research And Practice ◽  
Implementation Outcomes ◽  
Dissemination And Implementation Science ◽  
Dissemination And Implementation Research

This chapter focuses on adaptations in the context of dissemination and implementation research and practice. Consistent with the existing literature, the authors recommend that adaptations be proactively and iteratively determined, strongly informed by a variety of stakeholders, and that efforts be made to carefully describe and document the nature of the adaptations and evaluate their impact on desired service, health, and implementation outcomes. While this chapter focuses on adaptations to interventions and the context of practice, the authors also note that adaptations may need to be made to implementation strategies. Following the call by Proctor and colleagues for further precision in defining and operationalizing implementation strategies, and based on evidence that scholars are not necessarily reporting what and how they are adapting the interventions, scholars are urged to define and evaluate the adaptations they are making not only to the interventions and context of practice but also to the implementation strategies.

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