ASHA-Led Community-Based Groups to Support Control of Hypertension in Rural India Are Feasible and Potentially Scalable

Background: To improve the control of hypertension in low- and middle-income countries, we trialed a community-based group program co-designed with local policy makers to fit within the framework of India's health system. Trained accredited social health activists (ASHAs), delivered the program, in three economically and developmentally diverse settings in rural India. We evaluated the program's implementation and scalability.Methods: Our mixed methods process evaluation was guided by the United Kingdom Medical Research Council guidelines for complex interventions. Meeting attendance reports, as well as blood pressure and weight measures of attendees and adherence to meeting content and use of meeting tools were used to evaluate the implementation process. Thematic analysis of separate focus group discussions with participants and ASHAs as well as meeting reports and participant evaluation were used to investigate the mechanisms of impact.Results: Fifteen ASHAs led 32 community-based groups in three rural settings in the states of Kerala and Andhra Pradesh, Southern India. Overall, the fidelity of intervention delivery was high. Six meetings were delivered over a 3-month period to each of the intervention groups. The mean number of meetings attended by participants at each site varied significantly, with participants in Rishi Valley attending fewer meetings [mean (SD) = 2.83 (1.68)] than participants in West Godavari (Tukeys test, p = 0.009) and Trivandrum (Tukeys test, p < 0.001) and participants in West Godavari [mean (SD) = 3.48 (1.72)] attending significantly fewer meetings than participants in Trivandrum [mean (SD) = 4.29 (1.76), Tukeys test, p < 0.001]. Culturally appropriate intervention resources and the training of ASHAs, and supportive supervision of them during the program were critical enablers to program implementation. Although highly motivated during the implementation of the program ASHA reported historical issues with timely remuneration and lack of supportive supervision.Conclusions: Culturally appropriate community-based group programs run by trained and supported ASHAs are a successful and potentially scalable model for improving the control of hypertension in rural India. However, consideration of issues related to unreliable/insufficient remuneration for ASHAs, supportive supervision and their formal role in the wider health workforce in India will be important to address in future program scale up.Trial Registration: Clinical Trial Registry of India [CTRI/2016/02/006678, Registered prospectively].

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Assessing scalability of an intervention: why, how and who?

Health Policy and Planning ◽

10.1093/heapol/czz068 ◽

2019 ◽

Vol 34 (7) ◽

pp. 544-552 ◽

Cited By ~ 5

Author(s):

Karen Zamboni ◽

Joanna Schellenberg ◽

Claudia Hanson ◽

Ana Pilar Betran ◽

Alexandre Dumont

Keyword(s):

Early Stage ◽

Scale Up ◽

Complex Interventions ◽

Scaling Up ◽

Outcome Evaluation ◽

Assessment Tools ◽

Assessment Process ◽

Optimal Timing ◽

Middle Income ◽

Rigorous Research

Abstract Public health interventions should be designed with scale in mind, and researchers and implementers must plan for scale-up at an early stage. Yet, there is limited awareness among researchers of the critical value of considering scalability and relatively limited empirical evidence on assessing scalability, despite emerging methodological guidance. We aimed to integrate scalability considerations in the design of a study to evaluate a multi-component intervention to reduce unnecessary caesarean sections in low- and middle-income countries. First, we reviewed and synthesized existing scale up frameworks to identify relevant dimensions and available scalability assessment tools. Based on these, we defined our scalability assessment process and adapted existing tools for our study. Here, we document our experience and the methodological challenges we encountered in integrating a scalability assessment in our study protocol. These include: achieving consensus on the purpose of a scalability assessment; and identifying the optimal timing of such an assessment, moving away from the concept of a one-off assessment at the start of a project. We also encountered tensions between the need to establish the proof of principle, and the need to design an innovation that would be fit-for-scale. Particularly for complex interventions, scaling up may warrant rigorous research to determine an efficient and effective scaling-up strategy. We call for researchers to better incorporate scalability considerations in pragmatic trials through greater integration of impact and process evaluation, more stringent definition and measurement of scale-up objectives and outcome evaluation plans that allow for comparison of effects at different stages of scale-up.

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PrEP in Primary Care; Health Care Worker Adaptations to PrEP Delivery in Eswatini

10.21203/rs.3.rs-73560/v1 ◽

2020 ◽

Author(s):

Kate Barnighausen ◽

Sarah Dalglish ◽

Sindy Matse ◽

Allison Hughey ◽

Anita Hettema ◽

...

Keyword(s):

Primary Care ◽

Public Sector ◽

Southern Africa ◽

Program Implementation ◽

Real World ◽

Scale Up ◽

Community Based ◽

Sexually Transmitted ◽

Primary Care Clinics ◽

Fast Tracking

Abstract BackgroundImplementation evidence for pre-exposure prophylaxis (PrEP) for the general population in primary-care clinics in Southern Africa is limited. Perspective from those providing PrEP in ‘real world’ settings is needed to better inform future programming, policy, and scale up. MethodsFrom September 2017 to January 2019 we conducted 54 semi-structured in-depth interviews with purposively selected healthcare workers (HCWs) from six public sector, nurse-led, primary-care clinics in Eswatini. Data from observational notes, daily debriefing sessions and interview transcripts were analyzed using Nvivo 12 following the tenets of Grounded Theory. We present our results within six domains of a modified Consolidated Framework for Implementation (CFIR). ResultsHCWs said that they adapted implementation guidelines in order to inform more people of PrEP. HCWs said that clinic and community based PrEP education and promotion was essential for demand creation, uptake and continued PrEP use. Clinic modifications included conducting PrEP risk assessments during existing TB screening services, and targeting PrEP counselling for pregnant women and clients with sexually transmitted infections. HCWs described streamlining the PrEP initiation process by fast-tracking at-risk clients for initiation and pill collection. HCW said they emphasised PrEP as being for ‘everyone’ to avoid stigma. ConclusionsIntegration of PrEP delivery into existing screening and treatment services may help reach those most vulnerable to HIV infection, avoid time-consuming referrals, and prevent loss of clients between different components of the care continuum. PrEP education and promotion should be both clinic and community based to ensure potential clients have enough information before reaching the clinic, prevent PrEP-associated stigma and assist in family and partner understanding of PrEP use. HCWs providing PrEP in public-sector clinics have first-hand knowledge of implementation in ‘real world’ settings in a field where policy and program implementation is largely undefined. Integrating their feedback into future programming and policy may support effective PrEP delivery in Eswatini and other high prevalence settings in Southern Africa.

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The applicability of trials of complex mental health interventions

10.1093/med/9780199680467.003.0002 ◽

2015 ◽

Cited By ~ 1

Author(s):

Lara Fairall ◽

Merrick Zwarenstein ◽

Graham Thornicroft

Keyword(s):

Mental Health ◽

Global Mental Health ◽

Scale Up ◽

Complex Interventions ◽

Real Life ◽

Implementation Process ◽

Potential Contribution ◽

Plos Medicine ◽

Mental Health Interventions ◽

Development Evaluation

The evidence on what interventions are currently known to be effective in mental health is summarized in the 2009 PLoS Medicine series on packages of care for mental, neurological, and substance-use disorders in LAMIC and the WHO mhGAP guidelines published in 2010. But far less is known about how best to deliver and scale-up these interventions in real-life settings. How to translate this evidence into practice, in ways that are culturally appropriate and sensitive has been identified as the key research priority in global mental health. This chapter discusses the potential contribution of trials to the genesis of interventions that are both effective and highly applicable to real-world settings by considering two frameworks : the development–evaluation–implementation process proposed by the Medical Research Council (MRC) in Britain in their 2000 and 2008 guidance on developing and evaluating complex interventions and the PRagmatic Explanatory Continuum Indicator Summary (PRECIS) tool.

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Implementation Science in Nutrition: Concepts and Frameworks for an Emerging Field of Science and Practice

Current Developments in Nutrition ◽

10.1093/cdn/nzy080 ◽

2018 ◽

Vol 3 (3) ◽

Cited By ~ 13

Author(s):

Alison Tumilowicz ◽

Marie T Ruel ◽

Gretel Pelto ◽

David Pelletier ◽

Eva C Monterrosa ◽

...

Keyword(s):

Implementation Science ◽

Program Implementation ◽

Implementation Research ◽

Scale Up ◽

Implementation Process ◽

Implementation Quality ◽

Wide Range ◽

Intervention Policy ◽

Culture Of Inquiry ◽

National Governments

AbstractMalnutrition in all its forms has risen on global and national agendas in recent years because of the recognition of its magnitude and its consequences for a wide range of human, social, and economic outcomes. Although the WHO, national governments, and other organizations have endorsed targets and identified appropriate policies, programs, and interventions, a major challenge lies in implementing these with the scale and quality needed to achieve population impact. This paper presents an approach to implementation science in nutrition (ISN) that builds upon concepts developed in other policy domains and addresses critical gaps in linking knowledge to effective action. ISN is defined here as an interdisciplinary body of theory, knowledge, frameworks, tools, and approaches whose purpose is to strengthen implementation quality and impact. It includes a wide range of methods and approaches to identify and address implementation bottlenecks; means to identify, evaluate, and scale up implementation innovations; and strategies to enhance the utilization of existing knowledge, tools, and frameworks based on the evolving science of implementation. The ISN framework recognizes that quality implementation requires alignment across 5 domains: the intervention, policy, or innovation being implemented; the implementing organization(s); the enabling environment of policies and stakeholders; the individuals, households, and communities of interest; and the strategies and decision processes used at various stages of the implementation process. The success of aligning these domains through implementation research requires a culture of inquiry, evaluation, learning, and response among program implementers; an action-oriented mission among the research partners; continuity of funding for implementation research; and resolving inherent tensions between program implementation and research. The Society for Implementation Science in Nutrition is a recently established membership society to advance the science and practice of nutrition implementation at various scales and in varied contexts.

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Menstrual product choice and uptake among young women in Zimbabwe: a pilot study

Pilot and Feasibility Studies ◽

10.1186/s40814-020-00728-5 ◽

2020 ◽

Vol 6 (1) ◽

Author(s):

Mandikudza Tembo ◽

Jenny Renju ◽

Helen A. Weiss ◽

Ethel Dauya ◽

Tsitsi Bandason ◽

...

Keyword(s):

Young Women ◽

Scale Up ◽

Cluster Randomized Trial ◽

Sociocultural Factors ◽

Product Choice ◽

Community Based ◽

Middle Income ◽

Intervention Delivery ◽

Younger Women ◽

Link Type

Abstract Background Menstrual health and hygiene (MHH) is a human rights issue; yet, it remains a challenge for many, especially in low- and middle-income countries (LMICs). MHH includes the socio-political, psychosocial, and environmental factors that impact women’s menstrual experiences. High proportions of girls and women in LMICs have inadequate MHH due to limited access to menstrual knowledge, products, and stigma reinforcing harmful myths and taboos. The aim of this pilot was to inform the design of an MHH sub-study and the implementation and scale-up of an MHH intervention incorporated into a community-based cluster-randomized trial of integrated sexual and reproductive health (SRH) services for youth in Zimbabwe. The objectives were to investigate (1) uptake of a novel MHH intervention, (2) menstrual product preference, and (3) the factors that informed uptake and product choice among young women. Methods Female participants aged 16–24 years old attending the community-based SRH services between April and July 2019 were offered the MHH intervention, which included either a menstrual cup or reusable pads, analgesia, and MHH education. Descriptive statistics were used to quantitatively assess uptake and product choice. Focus group discussions and in-depth interviews with participants and the intervention team were used to investigate the factors that influenced uptake and product choice. Results Of the 1732 eligible participants, 1414 (81.6%) took up the MHH intervention at first visit. Uptake differed by age group with 84.6% of younger women (16–19 years old) compared to 79.0% of older women (20–24 years old) taking up the intervention. There was higher uptake of reusable pads (88.0%) than menstrual cups (12.0%). Qualitative data highlighted that internal factors, such as intervention delivery, influenced uptake. Participants noted the importance of access to free menstrual products, analgesics, and MHH education in a youth-friendly environment. External factors such as sociocultural factors informed product choice. Barriers to cup uptake included fears that the cup would compromise young women’s virginity. Conclusions Pilot findings were used to improve the MHH intervention design and implementation as follows: (1) cup ambassadors to improve cup promotion, sensitization, and uptake; (2) use of smaller softer cups; and (3) education for community members including caregivers and partners. Trial registration Registry: Clinicaltrials.gov Registration Number: NCT03719521 Registration Date: 25 October 2018

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Using social networks to scale up and sustain community-based programmes to improve physical activity and diet in low-income and middle-income countries: a scoping review protocol

BMJ Open ◽

10.1136/bmjopen-2021-053586 ◽

2021 ◽

Vol 11 (9) ◽

pp. e053586

Author(s):

Nina Abrahams ◽

Estelle V Lambert ◽

Frederick Marais ◽

Zoi Toumpakari ◽

Charlie Foster

Keyword(s):

Physical Activity ◽

Social Networks ◽

Scoping Review ◽

Low Income ◽

Scale Up ◽

Community Based ◽

Middle Income ◽

Middle Income Countries ◽

Review Protocol

IntroductionThe World Health Organisation endorses community-based programmes as a cost-effective, feasible and a ‘best buy’ in the prevention and management of non-communicable diseases (NCDs). These programmes are particularly successful when the community actively participates in its design, implementation and evaluation. However, they may be only useful insofar as they can be scaled up and sustained in some meaningful way. Social network research may serve as an important tool for determining the underlying mechanisms that contribute to this process. The aim of this planned scoping review is to map and collate literature on the role of social networks in scaling-up and sustaining community-based physical activity and diet programmes in low-income and middle-income countries.Methods and analysisThis scoping review protocol has been planned around the Arksey and O'Malley framework and its enhancement. Inclusion criteria are peer-reviewed articles and grey literature exploring the role of social networks in the scale-up and/or sustainability of NCD prevention community-based programmes in adult populations. Studies must have been published since 2000, in English, and be based in a low-income or middle-income country. The following databases will be used for this review: PubMed, Cochrane, Scopus, Web of Science, CINAHL, SocIndex, the International Bibliography of the Social Sciences, Google and Google Scholar. Books, conference abstracts and research focused only on children will be excluded. Two reviewers will independently select and extract eligible studies. Included publications will be thematically analysed using the Framework Approach.Ethics and disseminationEthical approval will not be sought for this review as no individual-level data or human participants will be involved. This protocol is registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/KG7TX). The findings from the review will be published in an accredited journal. The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews checklist will be used to support transparency and guide translation of the review.

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Mobilizing a COVID-19 Contact Tracing Workforce at Warp Speed: A Framework for Successful Program Implementation

American Journal of Tropical Medicine and Hygiene ◽

10.4269/ajtmh.20-1665 ◽

2021 ◽

Author(s):

Jessica Celentano ◽

Darpun Sachdev ◽

Mivic Hirose ◽

Alexandra Ernst ◽

Michael Reid

Keyword(s):

Performance Management ◽

San Francisco ◽

Program Implementation ◽

Scale Up ◽

Rapid Expansion ◽

Contact Tracing ◽

Community Based ◽

Effective Performance ◽

Inclusive Approach ◽

The City

To effectively control the spread of COVID-19, it is essential that all jurisdictions have the capacity to rapidly contact trace all close contacts of each and every case. We describe the early experience in the City and County of San Francisco, where contact tracing capability was rapidly expanded to respond to COVID-19. Important prerequisites to scale up included rapid expansion of the COVID-19 contact tracing workforce, a comprehensive training and onboarding program, and the institution of effective performance management metrics. The San Francisco model for contact tracing, including focusing on rigorous training, recruiting, and partnering with community-based organizations from diverse, affected communities, is an inclusive approach relevant to other jurisdictions and settings.

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Sustainable support solutions for community-based rehabilitation workers in refugee camps: piloting telehealth acceptability and implementation

Globalization and Health ◽

10.1186/s12992-020-00614-y ◽

2020 ◽

Vol 16 (1) ◽

Author(s):

Bria Mitchell-Gillespie ◽

Hiba Hashim ◽

Megan Griffin ◽

Rawan AlHeresh

Keyword(s):

Focus Groups ◽

Speech Therapy ◽

Cultural Beliefs ◽

Scale Up ◽

Community Based ◽

Quality Health Care ◽

Middle Income ◽

Training Support ◽

Sustainable Implementation ◽

Community Based Rehabilitation

Abstract Background The lack of training and education of Community-Based Rehabilitation (CBR) workers poses one of the most significant barriers to receiving effective occupational, physical and speech therapy for individuals with disabilities in Low-to-Middle Income Countries (LMIC), especially in countries with significant refugee populations. The aim of this study was to successfully implement a telehealth support system for CBR workers, evaluate the feasibility and acceptability of this intervention’s implementation among CBR workers in the CBR setting, and further identify strategies to address the deficit of skilled rehabilitation workers in LMIC through technological intervention. Methods This pilot study included CBR workers and CBR managers to inform feasibility, acceptability, and sustainable implementation. The RE-AIM and Dynamic Sustainability Framework were incorporated to guide procedural design, survey development, data collection, data evaluation, and increase success of telehealth implementation. CBR workers participate in trainings, telehealth sessions, surveys and focus groups to inform feasibility and acceptability. CBR Managers participated in focus groups to inform feasibility and sustainable implementation. NVIVO 12 Software was utilized to develop themes from CBR worker and CBR manager responses. Results Findings from this study demonstrate the need for additional training support for CBR workers in CBR settings throughout the entire treatment process. The telehealth system demonstrated successful short-term implementation across several domains of feasibility. Telehealth utilization was also proven acceptable, appropriate and necessary. Cultural beliefs, CBR worker training, and CBR Center infrastructure pose the most significant barriers to implementation of telehealth technologies in CBR Centers. CBR workers and managers confirmed the demand for future telehealth-based support systems, strengthening effort towards sustainability and scale-up. Conclusions Telehealth can be utilized to support CBR workers that serve vulnerable and marginalized populations, and in turn improve the global health status among refugee populations by reducing inequitable access to quality health care. The results support the need for further research to rigorously evaluate effectiveness of telehealth interventions to support CBR workers.

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Emergent Change in a Mexican Midwifery Center Organization Amidst the COVID-19 Crisis

Frontiers in Sociology ◽

10.3389/fsoc.2021.611321 ◽

2021 ◽

Vol 6 ◽

Author(s):

Cristina Alonso ◽

Akane Sugimoto Storey ◽

Ilse Fajardo ◽

Hannah S. Borboleta

Keyword(s):

Maternity Care ◽

Qualitative Interviews ◽

Culturally Appropriate ◽

Community Based ◽

Middle Income ◽

Health Crisis ◽

Middle Income Countries ◽

International Evidence ◽

Governmental Support ◽

Emergent Change

Luna Maya is a Mexican NGO that operates two full-scope midwifery centers in Mexico City and Chiapas, Mexico, providing woman-centered, culturally appropriate midwifery model maternity care on a sliding cost scale. The COVID-19 health crisis has made it necessary for Luna Maya to quickly incorporate safety protocols for out-of-hospital maternity care. Yet many of the emerging guidelines on maternity care have focused on high-income and hospital settings; there are no specific guidelines for such care in out-of-hospital settings in low- and middle-income countries. Thus we have had to create our own, based on best available and emerging evidence. In this article, we describe the guidelines and protocols we have created in response to COVID-19, the international evidence and recommendations on which we base them, and precisely how we carry them out in practice. We also present and analyze the results of qualitative interviews we conducted for this article with eight of our midwives and eight of our midwifery clients. These interviews reveal the tremendous stresses both midwives and pregnant and birthing women are experiencing as a result of the pandemic, their creative adaptations, and the structural flaws, deficiencies, and inequities of the Mexican healthcare system. The article also addresses Luna Maya’s ongoing challenges in continuing to provide care completely outside of governmental support and in difficult economic times, and demonstrates the extreme need for improvements in the Mexican system of maternity care and for full integration of community-based midwives and out-of-hospital birth.

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