scholarly journals Scaling up Malaria Elimination Management and Leadership: A pilot in three provinces in Zimbabwe, 2016 -2018

2020 ◽  
Author(s):  
Amanda Marr Chung ◽  
Peter Case ◽  
Jonathan Gosling ◽  
Roland Gosling ◽  
Munashe Madinga ◽  
...  
Keyword(s):  
Quality Improvement ◽  
San Francisco ◽  
Organization Development ◽  
Program Effectiveness ◽  
Health Workers ◽  
Focal Point ◽  
Scale Up ◽  
Health Staff ◽  
Sphere Of Influence ◽  
Operational Issues

Abstract BackgroundFocus for improved malaria program performance is often placed on the technical challenges, while operational issues are neglected. Many of the operational challenges that inhibit malaria program effectiveness can be addressed by improving communication and coordination, increasing accountability, maintaining motivation, providing adequate training and supervision, and removing bureaucratic silos. MethodsIn collaboration with the Zimbabwe Ministry of Health and Child Care (MoHCC), University of California San Francisco (UCSF), University of West of England (UWE), Clinton Health Access Initiative (CHAI) Zimbabwe, and organization development consultants from South Africa and Zimbabwe, a program of work was piloted in Zimbabwe starting with one malaria eliminating province, Matabeleland South in 2016-2017, and scaled up to include two other provinces, Matabeleland North and Midlands, in 2017-2018. The intervention included participatory, organization development and quality improvement methods.ResultsWorkshop participants in Matabeleland South reported an improvement in data management, with the development of a data collection tool, the initiation of data reporting from district to province on a weekly basis, and the establishment of a data focal point in each district. In Matabeleland North, motivation among nurses improved as they gained confidence in case management from training, and overall staff morale was impacted positively. There was also an improvement in data quality and the frequency in which data was shared via weekly bulletins. In Midlands, the poorly performing district was motivated to improve, and both participating districts became more goal-oriented. They also became more focused on monitoring their data regularly and learned how to develop indicators to measure the process improvement changes they were making. Participants from all provinces reported having a better appreciation of the value of communication, teamwork, planning, continuous monitoring of data, and adjustment of work plans and gained skills in listening, communicating, facilitating discussions, and making presentations. Participation in the intervention changed the mindset of malaria program staff, increasing ownership and accountability, and empowering them to identify and solve problems, make decisions, and act within their sphere of influence, elevating challenges when appropriate. ConclusionsThis pilot demonstrates that a participatory, organization development and quality improvement approach has broad ranging effects, including inter alia: improving local delivery of interventions, tailoring strategies to target specific populations, finding efficiencies in the system that could not be found using the traditional top-down approach, and improving motivation and communication between different cadres of health workers. Scale-up of this simple model can be achieved and benefits sustained over time if the process is imbedded into the program with the training of health staff who can serve as management improvement coaches. Methods to improve operational performance that are scalable at the district level are urgently needed: a participatory, organization development and quality improvement approach is a possible tactic that can significantly contribute to the achievement of global malaria eradication goals.

scholarly journals Scaling up Malaria Elimination Management and Leadership: A pilot in three provinces in Zimbabwe, 2016 -2018

2020 ◽  
Author(s):  
Amanda Marr Chung ◽  
Peter Case ◽  
Jonathan Gosling ◽  
Roland Gosling ◽  
Munashe Madinga ◽  
...  
Keyword(s):  
Quality Improvement ◽  
San Francisco ◽  
Organization Development ◽  
Program Effectiveness ◽  
Health Workers ◽  
Focal Point ◽  
Scale Up ◽  
Team Work ◽  
Health Staff ◽  
Sphere Of Influence

Abstract Background Focus for improved malaria program performance is often placed on the technical challenges, while operational issues are neglected. Many of the operational challenges that inhibit malaria program effectiveness can be addressed by improving communication and coordination, increasing accountability, maintaining motivation, providing adequate training and supervision, and removing bureaucratic silos.Methods In collaboration with the Zimbabwe Ministry of Health and Child Care (MoHCC), University of California San Francisco (UCSF), University of West of England (UWE), Clinton Health Access Initiative (CHAI) Zimbabwe, and organization development consultants from South Africa and Zimbabwe, a program of work was piloted in Zimbabwe starting with one malaria eliminating province, Matabeleland South in 2016-2017, and scaled up to include two other provinces, Matabeleland North and Midlands, in 2017-2018. The intervention included participatory, organization development and quality improvement methods.Results Workshop participants in Matabeleland South reported an improvement in data management, with the development of a data collection tool, the initiation of data reporting from district to province on a weekly basis, and the establishment of a data focal point in each district. In Matabeleland North, motivation among nurses improved as they gained confidence in case management from training, and overall staff morale was impacted positively. There was also an improvement in data quality and the frequency in which data was shared via weekly bulletins. In Midlands, the poorly performing district was motivated to improve, and both participating districts became more goal-oriented. They also became more focused on monitoring their data regularly and learned how to develop indicators to measure the process improvement changes they were making. Participants from all provinces reported having a better appreciation of the value of communication, team work, planning, continuous monitoring of data, and adjustment of work plans and gained skills in listening, communicating, facilitating discussions, and making presentations. Participation in the intervention changed the mindset of malaria program staff, increasing ownership and accountability, and empowering them to identify and solve problems, make decisions, and act within their sphere of influence, elevating challenges when appropriate.Conclusions This pilot demonstrates that a participatory, organization development and quality improvement approach has broad ranging effects, including inter alia : improving local delivery of interventions, tailoring strategies to target specific populations, finding efficiencies in the system that could not be found using the traditional top-down approach, and improving motivation and communication between different cadres of health workers. Scale-up of this simple model can be achieved and benefits sustained over time if the process is imbedded into the program with the training of health staff who can serve as management improvement coaches. Methods to improve operational performance that are scalable at the district level are urgently needed: a participatory, organization development and quality improvement approach is a possible tactic that can significantly contribute to the achievement of global malaria eradication goals.

scholarly journals Scaling up Malaria Elimination Management and Leadership: A pilot in three provinces in Zimbabwe, 2016 -2018

2020 ◽  
Author(s):  
Amanda Marr Chung ◽  
Peter Case ◽  
Jonathan Gosling ◽  
Roland Gosling ◽  
Munashe Madinga ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Organization Development ◽  
Health Workers ◽  
Scale Up ◽  
Health Staff ◽  
Malaria Programme ◽  
Training And Supervision ◽  
Communication And Coordination ◽  
Sphere Of Influence ◽  
Operational Issues

Abstract Background Focus for improved malaria programme performance is often placed on the technical challenges, while operational issues are neglected. Many of the operational challenges that inhibit malaria programme effectiveness can be addressed by improving communication and coordination, increasing accountability, maintaining motivation, providing adequate training and supervision, and removing bureaucratic silos. Methods A programme of work was piloted in Zimbabwe with one malaria eliminating province, Matabeleland South in 2016-2017, and scaled up to include two other provinces, Matabeleland North and Midlands, in 2017-2018. The intervention included participatory, organization development and quality improvement methods. Results Workshop participants in Matabeleland South reported an improvement in data management. In Matabeleland North, motivation among nurses improved as they gained confidence in case management from training, and overall staff morale improved. There was also an improvement in data quality and data sharing. In Midlands, the poorly performing district was motivated to improve, and both participating districts became more goal-oriented. They also became more focused on monitoring their data regularly. Participants from all provinces reported having gained skills in listening, communicating, facilitating discussions, and making presentations. Participation in the intervention changed the mindset of malaria programme staff, increasing ownership and accountability, and empowering them to identify and solve problems, make decisions, and act within their sphere of influence, elevating challenges when appropriate. Conclusions This pilot demonstrates that a participatory, organization development and quality improvement approach has broad ranging effects, including improving local delivery of interventions, tailoring strategies to target specific populations, finding efficiencies in the system that could not be found using the traditional top-down approach, and improving motivation and communication between different cadres of health workers. Scale-up of this simple model can be achieved and benefits sustained over time if the process is imbedded into the programme with the training of health staff who can serve as management improvement coaches. Methods to improve operational performance that are scalable at the district level are urgently needed: this approach is a possible tactic that can significantly contribute to the achievement of global malaria eradication goals.

scholarly journals Digital Health Innovations, Tools, and Resources to Support Helping Babies Survive Programs

PEDIATRICS ◽  
2020 ◽  
Vol 146 (Supplement_2) ◽  
pp. S165-S182
Author(s):  
Sherri L. Bucher ◽  
Peter Cardellichio ◽  
Naomi Muinga ◽  
Jackie K. Patterson ◽  
Anu Thukral ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Nursing Education ◽  
Data Collection ◽  
Health Workers ◽  
Digital Health ◽  
Scale Up ◽  
Newborn Care ◽  
Training Data ◽  
Dissemination And Implementation ◽  
Health Innovations

The Helping Babies Survive (HBS) initiative features a suite of evidence-based curricula and simulation-based training programs designed to provide health workers in low- and middle-income countries (LMICs) with the knowledge, skills, and competencies to prevent, recognize, and manage leading causes of newborn morbidity and mortality. Global scale-up of HBS initiatives has been rapid. As HBS initiatives rolled out across LMIC settings, numerous bottlenecks, gaps, and barriers to the effective, consistent dissemination and implementation of the programs, across both the pre- and in-service continuums, emerged. Within the first decade of expansive scale-up of HBS programs, mobile phone ownership and access to cellular networks have also concomitantly surged in LMICs. In this article, we describe a number of HBS digital health innovations and resources that have been developed from 2010 to 2020 to support education and training, data collection for monitoring and evaluation, clinical decision support, and quality improvement. Helping Babies Survive partners and stakeholders can potentially integrate the described digital tools with HBS dissemination and implementation efforts in a myriad of ways to support low-dose high-frequency skills practice, in-person refresher courses, continuing medical and nursing education, on-the-job training, or peer-to-peer learning, and strengthen data collection for key newborn care and quality improvement indicators and outcomes. Thoughtful integration of purpose-built digital health tools, innovations, and resources may assist HBS practitioners to more effectively disseminate and implement newborn care programs in LMICs, and facilitate progress toward the achievement of Sustainable Development Goal health goals, targets, and objectives.

scholarly journals A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda

2019 ◽  
Vol 3 ◽  
pp. 1481
Author(s):  
Christine Kim ◽  
Ramadhan Kirunda ◽  
Frederick Mubiru ◽  
Nilufar Rakhmanova ◽  
Leigh Wynne
Keyword(s):  
Quality Improvement ◽  
Family Planning ◽  
Process Evaluation ◽  
Health Workers ◽  
Scale Up ◽  
Data Interpretation ◽  
Quality Improvement Collaborative ◽  
Community Based ◽  
Village Health Team ◽  
Facility Level

Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention.Methods:We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions.Results:The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled.Conclusions:A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.

scholarly journals A process evaluation of the quality improvement collaborative for a community-based family planning learning site in Uganda

2019 ◽  
Vol 3 ◽  
pp. 1481
Author(s):  
Christine Kim ◽  
Ramadhan Kirunda ◽  
Frederick Mubiru ◽  
Nilufar Rakhmanova ◽  
Leigh Wynne
Keyword(s):  
Quality Improvement ◽  
Family Planning ◽  
Process Evaluation ◽  
Health Workers ◽  
Scale Up ◽  
Data Interpretation ◽  
Quality Improvement Collaborative ◽  
Community Based ◽  
Village Health Team ◽  
Facility Level

Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention.Methods:We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions.Results:The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled.Conclusions:A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.

scholarly journals Coassessment framework to identify person-centred unmet needs in stroke rehabilitation: a case report in Norway

2020 ◽  
Vol 7 (1) ◽  
pp. 148-156
Author(s):  
Kari Jorunn Kværner ◽  
Linn Nathalie Støme ◽  
Jonathan Romm ◽  
Karianne Rygh ◽  
Frida Almquist ◽  
...  
Keyword(s):  
Cognitive Impairment ◽  
Stroke Rehabilitation ◽  
Unmet Needs ◽  
Health Workers ◽  
University Hospital ◽  
Health Staff ◽  
Hospital Workers ◽  
Next Of Kin ◽  
Patient Journey ◽  
Health Value

ObjectiveTo describe unmet needs and values in stroke rehabilitation using the Health Value Framework and the associated coassessment tool Health Value Spider, a framework designed to identify and prioritise unmet needs based on health technology assessment (HTA).SettingThe study took place at Oslo University Hospital, Norway, from February to April 2019. Participants in three consecutive workshops were recruited from Sunnaas Rehabilitation Hospital, Oslo Municipality, Hospital Procurement Trust and Oslo University Hospital. Twenty-four hospital workers (medical and allied health staff and administrative staff) participated in workshop 1 and 29 patients, user representatives and hospital workers in workshop 2. Twenty-one patients and hospital workers participated in workshop 3.InterventionsStakeholder analysis and scenario building was performed in a coassessment setting where unmet needs were identified applying the Health Value Framework. Two of the authors are also the developers of the Health Value Framework (KJK and LNS).ResultsIn the two first workshops where health workers, patients and next of kin perspectives were elicited, three needs were identified: patient insecurity in patient journey transitions, lack of stroke rehabilitation expertise in primary care and invisible patient problems, such as fatigue and cognitive impairment. In workshop 3, 12 opportunity areas were identified. Four opportunity areas were selected by the stakeholders based on a prioritisation process: early discovery of cognitive impairment, rehabilitation continuity, empowered patients and next of kin and remote monitoring and digital touchpoints.ConclusionHealth Value Spider successfully identified and prioritised unmet needs and described associated values.

scholarly journals Adaptation of a quality improvement approach to implement eScreening in VHA healthcare settings: innovative use of the Lean Six Sigma Rapid Process Improvement Workshop

2021 ◽  
Vol 2 (1) ◽  
Author(s):  
James O. E. Pittman ◽  
Borsika Rabin ◽  
Erin Almklov ◽  
Niloofar Afari ◽  
Elizabeth Floto ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Survey Data ◽  
Implementation Strategy ◽  
Scale Up ◽  
Implementation Process ◽  
Interview Data ◽  
Self Report ◽  
Veterans Health ◽  
Health Administration ◽  
Health Technologies

Abstract Background The Veterans Health Administration (VHA) developed a comprehensive mobile screening technology (eScreening) that provides customized and automated self-report health screening via mobile tablet for veterans seen in VHA settings. There is agreement about the value of health technology, but limited knowledge of how best to broadly implement and scale up health technologies. Quality improvement (QI) methods may offer solutions to overcome barriers related to broad scale implementation of technology in health systems. We aimed to develop a process guide for eScreening implementation in VHA clinics to automate self-report screening of mental health symptoms and psychosocial challenges. Methods This was a two-phase, mixed methods implementation project building on an adapted quality improvement method. In phase one, we adapted and conducted an RPIW to develop a generalizable process guide for eScreening implementation (eScreening Playbook). In phase two, we integrated the eScreening Playbook and RPIW with additional strategies of training and facilitation to create a multicomponent implementation strategy (MCIS) for eScreening. We then piloted the MCIS in two VHA sites. Quantitative eScreening pre-implementation survey data and qualitative implementation process “mini interviews” were collected from individuals at each of the two sites who participated in the implementation process. Survey data were characterized using descriptive statistics, and interview data were independently coded using a rapid qualitative analytic approach. Results Pilot data showed overall satisfaction and usefulness of our MCIS approach and identified some challenges, solutions, and potential adaptations across sites. Both sites used the components of the MCIS, but site 2 elected not to include the RPIW. Survey data revealed positive responses related to eScreening from staff at both sites. Interview data exposed implementation challenges related to the technology, support, and education at both sites. Workflow and staffing resource challenges were only reported by site 2. Conclusions Our use of RPIW and other QI methods to both develop a playbook and an implementation strategy for eScreening has created a testable implementation process to employ automated, patient-facing assessment. The efficient collection and communication of patient information have the potential to greatly improve access to and quality of healthcare.

scholarly journals A Qualitative Study Exploring the Experiences and Perspectives of Australian Aboriginal Women on Oral Health during Pregnancy

2021 ◽  
Vol 18 (15) ◽  
pp. 8061
Author(s):  
Ariana Kong ◽  
Michelle Dickson ◽  
Lucie Ramjan ◽  
Mariana S. Sousa ◽  
Joanne Goulding ◽  
...  
Keyword(s):  
Oral Health ◽  
Health Care Providers ◽  
Torres Strait Islander ◽  
Health Workers ◽  
Healthcare Providers ◽  
Aboriginal Health ◽  
Health Staff ◽  
Care Providers ◽  
Aboriginal Women ◽  
Torres Strait

The aim of this study was to explore whether oral health was an important consideration for Aboriginal and Torres Strait Islander women during pregnancy, whether oral health could be promoted by Aboriginal health staff, and strategies that would be appropriate to use in a new model of care. A qualitative descriptive methodology underpinned the study. All participants in this study identified as Aboriginal, with no Torres Strait Islander participants, and were from New South Wales, Australia. The interviews were analysed using inductive thematic analysis. From the data, two themes were constructed. The first theme identified that oral health was not always the first priority for participants as poor accessibility alongside other competing commitments were challenges to accessing oral health services. The second theme highlighted how relationships with personal networks and healthcare providers were essential and could be used to support maternal oral health during pregnancy. Effective strategies to promote oral health during pregnancy for Aboriginal and Torres Strait Islander women should involve key stakeholders and health care providers, like Aboriginal Health Workers, to facilitate culturally safe support and tailored oral health advice.

scholarly journals Physical Therapist–Established Intensive Care Unit Early Mobilization Program: Quality Improvement Project for Critical Care at the University of California San Francisco Medical Center

2013 ◽  
Vol 93 (7) ◽  
pp. 975-985 ◽  
Author(s):  
Heidi J. Engel ◽  
Shintaro Tatebe ◽  
Philip B. Alonzo ◽  
Rebecca L. Mustille ◽  
Monica J. Rivera
Keyword(s):  
Quality Improvement ◽  
Physical Therapy ◽  
San Francisco ◽  
Physical Therapist ◽  
Medical Center ◽  
Early Mobilization ◽  
Quality Improvement Project ◽  
Improvement Project ◽  
Icu Admission ◽  
Number Of Patients

Background Long-term weakness and disability are common after an intensive care unit (ICU) stay. Usual care in the ICU prevents most patients from receiving preventative early mobilization. Objective The study objective was to describe a quality improvement project established by a physical therapist at the University of California San Francisco Medical Center from 2009 to 2011. The goal of the program was to reduce patients' ICU length of stay by increasing the number of patients in the ICU receiving physical therapy and decreasing the time from ICU admission to physical therapy initiation. Design This study was a 9-month retrospective analysis of a quality improvement project. Methods An interprofessional ICU Early Mobilization Group established and promoted guidelines for mobilizing patients in the ICU. A physical therapist was dedicated to a 16-bed medical-surgical ICU to provide physical therapy to selected patients within 48 hours of ICU admission. Patients receiving early physical therapy intervention in the ICU in 2010 were compared with patients receiving physical therapy under usual care practice in the same ICU in 2009. Results From 2009 to 2010, the number of patients receiving physical therapy in the ICU increased from 179 to 294. The median times (interquartile ranges) from ICU admission to physical therapy evaluation were 3 days (9 days) in 2009 and 1 day (2 days) in 2010. The ICU length of stay decreased by 2 days, on average, and the percentage of ambulatory patients discharged to home increased from 55% to 77%. Limitations This study relied upon the retrospective analysis of data from 6 collectors, and the intervention lacked physical therapy coverage for 7 days per week. Conclusions The improvements in outcomes demonstrated the value and feasibility of a physical therapist–led early mobilization program.

scholarly journals Extent, Type and Reasons for Adaptation and Modification When Scaling-Up an Effective Physical Activity Program: Physical Activity 4 Everyone (PA4E1)

2021 ◽  
Author(s):  
Matthew Mclaughlin ◽  
Elizabeth Campbell ◽  
Rachel Sutherland ◽  
Tom McKenzie ◽  
Lynda Davies ◽  
...  
Keyword(s):  
Physical Activity ◽  
Program Effectiveness ◽  
Negative Impact ◽  
Positive Impact ◽  
Scale Up ◽  
Evaluation Methods ◽  
Physical Activity Program ◽  
Implementation Support ◽  
Support Strategies ◽  
Activity Program

Abstract Background Few studies have described the extent, type and reasons for making changes to a program prior to and during its delivery using a consistent taxonomy. Physical Activity 4 Everyone (PA4E1) is a secondary school physical activity program that was scaled-up for delivery to a greater number of schools. We aimed to describe the extent, type and reasons for changes to the PA4E1 program (the evidence-based physical activity practices, implementation support strategies and evaluation methods) made before its delivery at scale (adaptations) and during its delivery in a scale-up trial (modifications). Methods The Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) was used to describe adaptations (planned and made prior to the scale-up trial) and modifications (made during the conduct of the trial). A list of adaptations was generated from a comparison of the efficacy and scale-up trials via published PA4E1 protocols, trial registrations and information provided by trial investigators. Monthly trial team meetings tracked and coded modifications in ‘real-time’ during the conduct of the scale-up trial. The extent, type and reasons for both adaptations and modifications were summarized descriptively. Results In total, 20 adaptations and 20 modifications were identified, these were to physical activity practices (n = 8; n = 3), implementation support strategies (n = 6; n = 16) and evaluation methods (n = 6, n = 1), respectively. Few adaptations were ‘fidelity inconsistent’ (n = 2), made ‘unsystematically’ (n = 1) and proposed to have a ‘negative’ impact on the effectiveness of the program (n = 1). Reasons for the adaptations varied. Of the 20 modifications, all were ‘fidelity consistent’ and the majority were made ‘proactively’ (n = 12), though most were ‘unsystematic’ (n = 18). Fifteen of the modifications were thought to have a ‘positive’ impact on program effectiveness. The most common decision-maker in the modification process was the ‘program manager’ (n = 17). The main reason for modification was the ‘available resources’ (n = 14) of the PA4E1 Implementation Team. For both adaptations and modifications respectively, the most common goal was to ‘improve fit with recipients’ (n = 8; n = 7). Conclusions A considerable number of adaptations and modifications were made for scale-up that could have important impacts on intervention effects and are important to the interpretation of trial findings. Trial Registration Australia New Zealand Clinical Trial Registry: ACTRN12617000681358

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