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

Best practices for implementing a technology-based intervention protocol: Participant and researcher considerations

Technology-based interventions present a promising approach to support health and wellness for older adults with a range of cognitive abilities. Technology can enhance access to interventions and support scaling of programs to reach more people. However, the use of technology for intervention delivery requires particular attention to users' needs and preferences and ensuring the materials are adaptable and supportive of a diverse range of technology proficiency levels. We share best practices based on lessons learned from the deployment of a randomized controlled trial (RCT) wherein we delivered an 8-week social engagement intervention through a video technology platform called OneClick for older adults with varying cognitive abilities. We developed a set of best practices and guidelines informed by the lessons learned through this RCT implementation. Technology-based interventions require attention to the application (e.g., video calls), system requirements (e.g., system memory, broadband internet), training (e.g., adaptability based on user competency), and support (e.g., handouts, live contact). These best practices relate to user needs; training design; personnel responsibility; structuring delivery and content; and evaluating success. These research-based best practices can guide the design, development, and implementation of technology-based interventions to support older adults with varying cognitive abilities.

Systematic review and meta-analysis examining the effects of midwife care on cesarean birth

BACKGROUND

The increasing number of unnecessary cesarean births is a cause for concern and may be addressed by increasing access to midwifery care. The objective of this review was to assess the effect of midwifery care on the likelihood of cesarean births.

METHODS

We searched five databases from the beginning of records through May 2020. We included observational studies that reported odds ratios or data allowing the calculation of odds ratios of cesarean birth for births with and without midwife involvement in care or presence at the institution. Standard inverse-variance random-effects meta-analysis was used to generate overall odds ratios (ORs).

RESULTS

We observed a significantly lower likelihood of cesarean birth in midwife-led care, midwife-attended births, among those who received instruction pre-birth from midwives, and within institutions with a midwifery presence.

CONCLUSIONS

Care from midwives reduces the likelihood of cesarean birth in all the analyses, perhaps due to their greater preference and skill for physiologic births. Increased use of midwives in maternal care can reduce cesarean births and should be further researched and implemented broadly, potentially as the default modality in maternal care.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR PUBLIC HEALTH

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

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

OBJECTIVE

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

DESIGN

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

SETTING

ECEC.

PARTICIPANTS

Children 6 months to 6 years.

RESULTS

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

CONCLUSIONS

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

An intervention mapping adaptation framework to develop a self-help intervention for athletes with eating disorder symptoms

OBJECTIVE

This research forum describes the use of the intervention mapping for adaptation (IMA) framework to develop and evaluate a novel intervention for athletes with mild eating disorder (ED) symptoms.

METHODS

The six IMA steps were followed. In step 1 (needs assessment), we conducted a systematic review of athlete ED interventions and held interviews/focus groups with athletes and sports professionals to inform intervention format and delivery. In step 2 (intervention search), needs assessment information guided the search for an evidence-based intervention suitable for adaptation to athletes. In steps 3 and 4 (intervention development), the identified intervention was adapted and feedback sought from athletes and sport professionals. In steps 5 and 6 (implementation and evaluation), a feasibility study was conducted with athletes (n = 35; females: n = 27; Mage  = 27.1).

RESULTS

The review highlighted poor evidence for the acceptability and relative efficacy of existing interventions, which were all delivered face-to-face in groups. Interview/focus group data suggested a need for more accessible intervention formats (e.g., self-help). One non-athlete self-help intervention was determined suitable for adaptation to athletes, and adaptations were made. Initial feedback suggested the adapted intervention was relevant within sport settings. The feasibility study revealed that the intervention (MOPED-A: Motivational and Psycho-Educational Self-Help Programme for Athletes with Mild Eating Disorder Symptoms) can be feasibly implemented, is acceptable to athletes and shows potential for reducing ED symptoms.

DISCUSSION

IMA is a useful framework for developing participant-centered and evidence-based interventions. The findings and approach taken provide a framework for other researchers and clinicians in developing similar interventions in the ED domain.

PUBLIC SIGNIFICANCE

The novel self-help intervention described in this article was developed using intervention mapping and provides promise as a tool for reducing eating disorder symptoms in athletes. We describe how adopting and systematically following a health intervention development approach, such as intervention mapping, can ensure that eating disorder interventions are participant-centered, contextually relevant, and evidence-based, which in turn could help to maximize their reach and effectiveness.

Enhancing the appropriateness of eyecare delivery: the iCaretrack approach

Optometrists play an integral role in primary eyecare services, including prevention, diagnosis, and management of acute and chronic eye conditions. Therefore, it remains essential that the care they provide be timely and appropriate to ensure the best patient outcomes and optimal utilisation of resources. However, optometrists continuously face many challenges that can affect their ability to provide appropriate care (i.e., the care in line with evidence-based clinical practice guidelines). To address any resulting evidence-to-practice gaps, programs are needed that support and enable optometrists to adopt and utilise the best evidence in clinical practice. Implementation science is a field of research that can be applied to improving the adoption and maintenance of evidence-based practices in routine care, through systematic development and application of strategies or interventions to address barriers to evidence-based practice. This paper demonstrates an approach using implementation science to enhance optometric eyecare delivery. A brief overview of the methods used to identify existing gaps in appropriate eyecare delivery is presented. An outline of the process used to understand the behavioural barriers responsible for such gaps follows, involving theoretical models and frameworks. The resulting development of an online program for optometrists to enhance their capability, motivation, and opportunity to provide evidence-based eyecare is described, using the Behaviour Change Model and co-design methods. The importance of and methods used in evaluating such programs are also discussed. Finally, reflections on the experience and key learnings from the project are shared. While the paper focuses on experiences in improving glaucoma and diabetic eyecare in the Australian optometry context, this approach can be adapted to other conditions and contexts.

Low-Value Surgical Procedures in Low- and Middle-Income Countries: A Systematic Scoping Review

Importance

Overuse of surgical procedures is increasing around the world and harms both individuals and health care systems by using resources that could otherwise be allocated to addressing the underuse of effective health care interventions. In low- and middle-income countries (LMICs), there is some limited country-specific evidence showing that overuse of surgical procedures is increasing, at least for certain procedures.

Objectives

To assess factors associated with, extent and consequences of, and potential solutions for low-value surgical procedures in LMICs.

Evidence Review

We searched 4 electronic databases (PubMed, Embase, PsycINFO, and Global Index Medicus) for studies published from database inception until April 27, 2022, with no restrictions on date or language. A combination of MeSH terms and free-text words about the overuse of surgical procedures was used. Studies examining the problem of overuse of surgical procedures in LMICs were included and categorized by major focus: the extent of overuse, associated factors, consequences, and solutions.

Findings

Of 4276 unique records identified, 133 studies across 63 countries were included, reporting on more than 9.1 million surgical procedures (median per study, 894 [IQR, 97-4259]) and with more than 11.4 million participants (median per study, 989 [IQR, 257-6857]). Fourteen studies (10.5%) were multinational. Of the 119 studies (89.5%) originating from single countries, 69 (58.0%) were from upper-middle-income countries and 30 (25.2%) were from East Asia and the Pacific. Of the 42 studies (31.6%) reporting extent of overuse of surgical procedures, most (36 [85.7%]) reported on unnecessary cesarean delivery, with estimated rates in LMICs ranging from 12% to 81%. Evidence on other surgical procedures was limited and included abdominal and percutaneous cardiovascular surgical procedures. Consequences of low-value surgical procedures included harms and costs, such as an estimated US $3.29 billion annual cost of unnecessary cesarean deliveries in China. Associated factors included private financing, and solutions included social media campaigns and multifaceted interventions such as audits, feedback, and reminders.

Conclusions and Relevance

This systematic review found growing evidence of overuse of surgical procedures in LMICs, which may generate significant harm and waste of limited resources; the majority of studies reporting overuse were about unnecessary cesarean delivery. Therefore, a better understanding of the problems in other surgical procedures and a robust evaluation of solutions are needed.

Reducing stigma impacting children and adolescents in low- and middle-income countries: The development of a common multi-component stigma reduction intervention

INTRODUCTION

Stigmatisation impedes health and quality of life. Evidence regarding stigma reduction interventions is, albeit growing, limited. There is a gap in the availability and evidence of interventions for reducing stigma among children and adolescents, especially in low- and middle-income countries. This paper describes the process that led to a stigma reduction intervention impacting children and adolescents in low- and middle-income countries, following previously conducted formative research.

METHODS

In this study, we conducted (i) online stakeholder consultations (FGD) (n = 43), including a survey assessing intervention acceptability, appropriateness, feasibility and scalability (n = 16); and (ii) preliminary field-testing of intervention content online and in a refugee settlement in Uganda.

FINDINGS

Stakeholder consultation showed the initial version of STRETCH (Stigma Reduction to Trigger Change for Children), albeit positively received, required adaptations. We made adjustments to i) take into account implementation duration, intervention flexibility and intersectionality; (ii) strengthen the involvement of individuals, including adolescents/youth, with lived stigma experience; (iii) target people close to individuals with lived stigma experience; and (iv) address feasibility and sustainability concerns. Preliminary field-testing simplified STRETCH while adding a community outreach component and revisiting the intervention setup, to ensure STRETCH can also be applied from a modular perspective.

CONCLUSION

We conducted a process to develop a child-focused multi-component stigma reduction intervention, with intended applicability across stigmas and settings. This paper provides an overview of the intervention development process, generating intervention-specific learnings with generic value. STRETCH aims to reduce stigmatisation at the implementing organisation, create community-wide reflection and stigma reduction demand, and reduce stigmatisation among various target groups.

Interventions addressing family violence and mental illness or substance use in low- and middle-income countries: A systematic review

Most family violence research has been conducted in high-income countries, although family violence rates are higher in low- and middle-income countries (LMICs), and outcomes more severe. Given the strong associations of family violence with substance use and mental illness, the aim of this systematic review was to examine interventions that targeted familial violence and at least one other condition of substance use or mental illness to determine effective treatments in LMICs. We conducted a systematic review of interventions that addressed family violence and mental illness or substance use. A committee of three researchers independently screened titles and abstracts and conducted full-text eligibility assessments. Two researchers conducted a risk of bias assessment. Data were extracted using a structured spreadsheet and narratively synthesized. Our search identified 29 articles produced from 19 studies conducted in 13 LMICs. Most (n = 15) studies randomized to study condition. Lack of blinding was the most common threat. The external validity of studies was generally poor. Fourteen studies had a primary intervention target of family violence, mental health, substance use, economic improvement, or HIV. None of the studies showed improvements in all intervention areas. Child maltreatment was less likely to be addressed than intimate partner violence (IPV). Targeted interventions for substance and mental health mostly improved primary outcomes, although they were less effective in reducing IPV. Evidence-based treatments must be rigorously evaluated before innovations in implementation can occur. Interventions overwhelmingly addressed IPV victimization and should consider how to work with couples and include men and children.

Changing maternal, infant and young child nutrition practices through social and behaviour change interventions implemented at scale: Lessons learned from Alive & Thrive

Alive & Thrive (A&T) is an initiative designed to advance the implementation of maternal, infant and young child nutrition (MIYCN) social and behaviour change (SBC) at a large scale. The aims of this research were to: (1) describe A&T's SBC implementation processes and their impact based on a review of programme documents and peer-reviewed publications and (2) gather lessons learned from key informant interviews (N = 23) with A&T staff and stakeholders in Bangladesh, Burkina Faso, Ethiopia, India, Nigeria and Vietnam. A&T's SBC approach used interpersonal communication, community mobilization and mass media to address knowledge gaps, strengthen self-efficacy and shift social norms. The initiative used data for design and evaluation and facilitated scale and sustainability through close collaboration with governments and other stakeholders. A&T's approach increased exclusive breastfeeding, minimum meal frequency of children and use of iron and folic acid tablets by pregnant women, but had mixed impacts on early initiation of breastfeeding and maternal and child dietary diversity. Multiple SBC channels and frequent contacts strengthened the impact of SBC on MIYCN practices. Lessons learned included: using existing large-scale platforms for interpersonal communication, improving counselling skills of health workers, delivering timely tailored messages, engaging key influencers to take specific actions, using research to address underlying behavioural concerns and maximize mass media reach and frequency, using simple memorable messages and employing additional channels to reach low media coverage areas. A&T developed and implemented at-scale MIYCN SBC in multiple countries, providing lessons learned about intervention strategies, engagement of influencers and mass media campaign development, which governments and other implementers can adapt and replicate.

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

PURPOSE

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

BACKGROUND

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

DESIGN

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

CONCLUSION

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

Evidence on Scaling in Health and Social Care: An Umbrella Review

Policy Points More rigorous methodologies and systematic approaches should be encouraged in the science of scaling. This will help researchers better determine the effectiveness of scaling, guide stakeholders in the scaling process, and ultimately increase the impacts of health innovations. The practice and the science of scaling need to expand worldwide to address complex health conditions such as noncommunicable and chronic diseases. Although most of the scaling experiences described in the literature are occurring in the Global South, most of the authors publishing on it are based in the Global North. As the science of scaling spreads across the world with the aim of reducing health inequities, it is also essential to address the power imbalance in how we do scaling research globally.

CONTEXT

Scaling of effective innovations in health and social care is essential to increase their impact. We aimed to synthesize the evidence base on scaling and identify current knowledge gaps.

METHODS

We conducted an umbrella review according to the Joanna Briggs Institute Reviewers' Manual. We included any type of review that 1) focused on scaling, 2) covered health or social care, and 3) presented a methods section. We searched MEDLINE (Ovid), Embase, PsycINFO (Ovid), CINAHL (EBSCO), Web of Science, The Cochrane Library, Sociological Abstracts (ProQuest), Academic Search Premier (EBSCO), and ProQuest Dissertations & Theses Global from their inception to August 6, 2020. We searched the gray literature using, e.g., Google and WHO-ExpandNet. We assessed methodological quality with AMSTAR2. Paired reviewers independently selected and extracted eligible reviews and assessed study quality. A narrative synthesis was performed.

FINDINGS

Of 24,269 records, 137 unique reviews were included. The quality of the 58 systematic reviews was critically low (n = 42). The most frequent review type was systematic review (n = 58). Most reported on scaling in low- and middle-income countries (n = 59), whereas most first authors were from high-income countries (n = 114). Most reviews concerned infectious diseases (n = 36) or maternal-child health (n = 28). They mainly focused on interventions (n = 37), barriers and facilitators (n = 29), frameworks (n = 24), scalability (n = 24), and costs (n = 14). The WHO/ExpandNet scaling definition was the definition most frequently used (n = 26). Domains most reported as influencing scaling success were building scaling infrastructure (e.g., creating new service sites) and human resources (e.g., training community health care providers).

CONCLUSIONS

The evidence base on scaling is evolving rapidly as reflected by publication trends, the range of focus areas, and diversity of scaling definitions. Our study highlights knowledge gaps around methodology and research infrastructures to facilitate equitable North-South research relationships. Common efforts are needed to ensure scaling expands the impacts of health and social innovations to broader populations.

Scalability of mobile technology interventions in the prevention and management of HIV among adolescents in low-income and middle-income countries: protocol for a systematic review

INTRODUCTION

The rate of new infections with HIV remains high among adolescents globally. Adolescents in low-income and middle-income countries (LMICs), who are least likely to have access to quality healthcare, have the highest proportion of those living with HIV. Mobile technology has played an important role in providing access to information and services among adolescents in recent years. This review aims to synthesise and summarise information that will be useful in the planning, designing and implementing of future mHealth strategies.

METHODS AND ANALYSIS

Interventional studies, reported in English, on the prevention and management of HIV among adolescents that used mobile technology in LMICs will be included. MEDLINE (via PubMed), Embase, Web of Science, CINAHL, Clinicaltrials.gov, WHO International Clinical Trials Registry Platform (ICTRP), and the Cochrane Library are the information sources that have been identified as relevant to the area of study. These sources will be searched from inception to March 2023. The risk of bias will be assessed using the Cochrane Risk of Bias tool. The scalability of each study will be assessed using the Intervention Scalability Assessment Tool. Two independent reviewers will conduct the selection of studies, data extraction, and assessment of the risk of bias and scalability. A narrative synthesis of all the included studies will be done.

ETHICS AND DISSEMINATION

Ethical approval was not necessary for this study. This is a systematic review of publicly available information and therefore ethical approval was not deemed necessary. The results of this review will be published in a peer reviewed journal.

TRIAL REGISTRATION

This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42022362130.

Scalability of mobile technology interventions in the prevention and management of HIV among adolescents in low- and middle-income countries: protocol for a systematic review

Introduction

The rate of new infection of HIV is still high among adolescents globally. Adolescents in low and middle-income countries (LMICs) who are least likely to have access to quality healthcare have the highest proportion of those living with HIV. Mobile technology has played an important role in providing access to information and services among adolescents within the region in recent years. This review aims to synthesise and summarise information that will be useful in planning, designing, and implementing future mHealth strategies within the region.

Methods and Analysis

Interventional studies on the prevention and management of HIV among adolescents that used mobile technology in LMICs will be included. MEDLINE (via PubMed), EMBASE, Web of Science, CINAHL, and the Cochrane Library are the information sources that have been identified as relevant to the area of study. These sources will be searched from inception to March 2023. The risk of bias will be assessed using the Cochrane Risk of Bias tool. The scalability of each study will be assessed using the Intervention Scalability Assessment Tool (ISAT). Two independent reviewers will conduct the selection of studies, data extraction, assessment of the risk of bias, and scalability. A narrative synthesis of all the included studies will be provided through a table.

Ethics and dissemination

An ethical approval was not necessary for this study. This is a systematic review of publicly available information and therefore ethical approval was not deemed necessary. The results of this review will be published in a peer reviewed journal and dataset will be presented in the main manuscript.

Strengths and limitations

We believe that the likelihood of missing any published article will be low because of the information sources we are considering.The scalability tool (ISAT) has not been used in any systematic review before.The evidence provided in this review will be limited to low-middle-income countries.The exclusion of studies not published in English is a limitation for this review.

From Pre-Implementation to Institutionalization: Lessons From Sustaining a Perinatal Audit Program in South Africa

INTRODUCTION

Maternal and perinatal death surveillance and response (MPDSR), or related forms of maternal and perinatal death audits, can strengthen health systems. We explore the history of initiating, scaling up, and institutionalizing a national perinatal audit program in South Africa.

METHODS

Data collection involved 56 individual interviews, a systematic document review, administration of a semistructured questionnaire, and 10 nonparticipant observations of meetings related to the perinatal audit program. Fieldwork and data collection in the subdistricts occurred from September 2019 to March 2020. Data analysis included thematic content analysis and application of a tool to measure subdistrict-level implementation. This study expands on case study research applied to 5 Western Cape subdistricts with long histories of implementation.

RESULTS

Although established in the early 1990s, the perinatal audit program was not integrated into national policy and guidelines until 2012 but was then excluded from policy in 2021. A network of national and subnational structures that benefited from a continuity of actors evolved and interacted to support uptake and implementation. Intentional efforts to demonstrate impact and enable local adaptation allowed for more ownership and buy-in. Implementation requires continuous efforts. Even in 5 subdistricts with long histories of practice, we found operational gaps, such as incomplete meeting minutes, signaling a need for strengthening. Nevertheless, the tool used to measure implementation may require revisions, particularly in settings with institutionalized practice.

CONCLUSION

This article provides lessons on how to initiate, expand, and strengthen perinatal audit. Despite a long history of implementation, the perinatal audit program in South Africa cannot be assumed to be indefinitely sustainable or final in its current form. To monitor uptake and sustainability of MPDSR, including perinatal audit, we need research approaches that allow exploration of context, local adaptation, and underlying issues that support sustainability, such as relationships, leadership, and trust.

Practical Strategies for Improving Sustainability and Scale-up of Noncommunicable Disease-related Public Health Interventions: Lessons from the Better Health Program in Southeast Asia

Introduction

The Better Health Program has been addressing key health system issues in the prevention and control of noncommunicable diseases (NCDs) in Malaysia, Thailand, Vietnam, and the Philippines. As the program comes to an end, the sustainability and scaling-up of issues have assumed importance.

Objectives

The objective is to assess how well sustainability and scale-up strategies have been integrated into the design and implementation of a 3-year multicountry technical program; to explore enablers and barriers of sustainability and scaling up; and to identify practical strategies that can improve sustainability and scale-up of Better Health Program interventions.

Methods

We applied a staged approach to explore barriers and enablers and to identify practical strategies to improve sustainability and scale-up of four NCD interventions: community-based obesity prevention, front-of-pack labeling, local learning networks (LLNs), and NCD surveillance. We extracted evidence from peer-reviewed literature and local documents. We also conducted in-depth interviews with the implementation teams and key stakeholders. We conducted a thematic synthesis of the resulting information to identify practical strategies that improve sustainability and scale-up of the four interventions.

Results

Strong engagement of stakeholders at higher levels of the health system was identified as the main enabler, while limited funding and commitment from local governments were identified as a key barrier to sustainability and scale-up. Strengthening the social and institutional anchors of community health volunteers, enhancing evidence-based advocacy for front-of-pack labeling, trailblazing the LLN innovation, and securing the commitment of local governments in the implementation of NCD surveillance were among the key strategies for improving sustainability and scale-up of Better Health Program interventions in Malaysia, Thailand, Philippines, and Vietnam, respectively.

Conclusions

This study identified practical strategies for improving sustainability and scale-up of NCD-related interventions. Implementation of the strategies that had high priority and feasibility will improve the sustainability of critical elements of the program in the respective countries.

Effect of salt reduction interventions in lowering blood pressure: A comprehensive systematic review and meta-analysis of controlled clinical trials

BACKGROUND

Excessive salt intake results in hypertension (HTN), which is a major risk factor for cardiovascular disease (CVD). This review and meta-analysis aimed to evaluate the effect of salt reduction interventions on systolic blood pressure (SBP) and diastolic blood pressure (DBP).

METHODS

Studies were identified via systematic searches of the databases, including PubMed, Embase, Scopus, and Web of Science. All the studies examining the effectiveness of salt reduction interventions on blood pressure (BP), regardless of age, sex, and HTN status, were included in the systematic review, and eligible studies were used in the meta-analysis. A random-effect model was applied for quantitative data synthesis.

RESULTS

A total of 50 trials extracted from 40 articles (21 trials on nutrition education,10 on self-help materials,17 on salt substitutes, and 2 on food reformulation) were included in the systematic review. The pooled results of 44 eligible trials showed that salt substitution and nutrition education interventions had significant effects on both SBP (WMD: -7.44 mmHg, P<0.001 and WMD: -2.75 mmHg, P<0.001, respectively), and DBP (WMD: -3.77 mmHg, P<0.001 and WMD: -2.11 mmHg, P<0.001, respectively). Furthermore, using self-help materials led to a significant reduction in SBP among subjects aged 25-60 years (WMD: -2.60 mmHg, P = 0.008); it also decreased both SBP and DBP among those who were hypertensive (WMD: -3.87 mmHg, P = 0.003 and WMD: -2.91 mmHg, P<0.001, respectively).

CONCLUSION

Our results supported that salt substitution and nutrition education are effective nutrition strategies to lower BP. It seems that multi-component approaches could be more effective in improving BP status. However, further trials are required.

Tensions and Paradoxes of Scaling Up: A Critical Reflection on Physical Activity Promotion

Achieving system-level, sustainable 'scale-up' of interventions is the epitome of successful translation of evidence-based approaches in population health. In physical activity promotion, few evidence-based interventions reach implementation at scale or become embedded within systems for sustainable health impact. This is despite the vast published literature describing efficacy studies of small-scale physical activity interventions. Research into physical activity scale-up (through case-study analysis; evaluations of scale-up processes in implementation trials; and mapping the processes, strategies, and principles for scale-up) has identified barriers and facilitators to intervention expansion. Many interventions are implemented at scale by governments but have not been evaluated or have unpublished evaluation information. Further, few public health interventions have evaluations that reveal the costs and benefits of scaled-up implementation. This lack of economic information introduces an additional element of risk for decision makers when deciding which physical activity interventions should be supported with scarce funding resources. Decision-makers face many other challenges when scaling interventions which do not relate to formal research trials of scale-up; Methods: To explore these issues, a multidisciplinary two-day workshop involving experts in physical activity scale-up was convened by the University of Newcastle, Australia, and the University of Ottawa, Canada (February 2019); Results: In this paper we discuss some of the scale-up tensions (challenges and conflicts) and paradoxes (things that are contrary to expectations) that emerged from this workshop in the context of the current literature and our own experiences in this field. We frame scale-up tensions according to epistemology, methodology, time, and partnerships; and paradoxes as 'reach without scale', 'planned serendipity' and 'simple complexity'. We reflect on the implications of these scale-up tensions and paradoxes, providing considerations for future scale-up research and practice moving forward; Conclusions: In this paper, we delve deeper into stakeholders' assumptions, processes and expectations of scaling up, and challenge in what ways as stakeholders, we all contribute to desired or undesired outcomes. Through a lens of 'tensions' and 'paradoxes', we make an original contribution to the scale-up literature that might influence current perspectives of scaling-up, provide future approaches for physical activity promotion, and contribute to understanding of dynamic of research-practice partnerships.

Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness

BACKGROUND

Globally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high-income countries, implementing them in low/middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking. We aimed to identify all perioperative safety and QI interventions applied at scale in LMICs and evaluate their implementation mechanisms using implementation theory.

METHODS

Systematic scoping review of perioperative QI interventions in LMICs from 1960 to 2020. Studies were identified through Medline, EMBASE and Google Scholar. Data were extracted in two phases: (1) abstract review to identify the range of QI interventions; (2) studies describing scale-up (three or more sites), had full texts retrieved and analysed for; implementation strategies and scale-up frameworks used; and implementation outcomes reported.

RESULTS

We screened 45 128 articles, identifying 137 studies describing perioperative QI interventions across 47 countries. Only 31 of 137 (23%) articles reported scale-up with the most common intervention being the WHO Surgical Safety Checklist. The most common implementation strategies were training and educating stakeholders, developing stakeholder relationships, and using evaluative and iterative strategies. Reporting of implementation mechanisms was generally poor; and although the components of scale-up frameworks were reported, relevant frameworks were rarely referenced.

CONCLUSION

Many studies report implementation of QI interventions, but few report successful scale-up from single to multiple-site implementation. Greater use of implementation science methodology may help determine what works, where and why, thereby aiding more widespread scale-up and dissemination of perioperative QI interventions.

Progress towards achieving child survival goals in Kenya after devolution: Geospatial analysis with scenario-based projections, 2015-2025

Subnational projections of under-5 mortality (U5M) have increasingly become an essential planning tool to support Sustainable Development Goals (SDGs) agenda and strategies for improving child survival. To support child health policy, planning, and tracking child development goals in Kenya, we projected U5M at units of health decision making. County-specific annual U5M were estimated using a multivariable Bayesian space-time hierarchical model based on intervention coverage from four alternate intervention scale-up scenarios assuming 1) the highest subnational intervention coverage in 2014, 2) projected coverage based on the fastest county-specific rate of change observed in the period between 2003-2014 for each intervention, 3) the projected national coverage based on 2003-2014 trends and 4) the country-specific targets of intervention coverage relative to business as usual (BAU) scenario. We compared the percentage change in U5M based on the four scale-up scenarios relative to BAU and examined the likelihood of reaching SDG 3.2 target of at least 25 deaths/1,000 livebirths by 2022 and 2025. Projections based on 10 factors assuming BAU, showed marginal reductions in U5M across counties with all the counties except Mandera county not achieving the SDG 3.2 target by 2025. Further, substantial reductions in U5M would be achieved based on the various intervention scale-up scenarios, with 63.8% (30), 74.5% (35), 46.8% (22) and 61.7% (29) counties achieving SDG target for scenarios 1,2,3 and 4 respectively by 2025. Scenario 2 yielded the highest reductions of U5M with individual scale-up of access to improved water, recommended treatment of fever and accelerated HIV prevalence reduction showing considerable impact on U5M reduction (≥ 20%) relative to BAU. Our results indicate that sustaining an ambitious intervention scale-up strategy matching the fastest rate observed between 2003-2014 would substantially reduce U5M in Kenya. However, despite this ambitious scale-up scenario, 25% (12 of 47) of the Kenya's counties would still not achieve SDG 3.2 target by 2025.

The need for a complex systems approach in rural health research

On a global scale, many major rural health issues have persisted for decades despite the introduction of new health interventions and public health policies. Although research efforts have generated valuable new knowledge about the aetiology of health, disease and health inequities in rural communities, rural health systems remain to be some of the most deprived and challenged in both the developing and developed world. While the reasons for this are many, a significant factor contributing to the current state of play is the pressing need for methodological innovation and relevant scientific approaches that have the capacity to support the translation of novel solutions into 'real world' rural contexts. Fortunately, complex systems approaches, which have seen an increase in popularity in the wider public health literature, could provide answers to some of the most resilient rural health problems in recent times. The purpose of this article is to promote the value and utility of a complex systems approach in rural health research. We explain the benefits of a complex systems approach and provide a background to the complexity sciences, including the main characteristics of complex systems. Two popular computational methods are described. The next step for rural health research involves exploring how a complex systems approach can help with the identification and evaluation of new and existing solutions to policy-resistant rural health issues. This includes generating awareness around the analytical trade-offs that occur between the use of traditional scientific methods and complex systems approaches.

From laboratory to community: Three examples of moving evidence-based physical activity into practice in Canada

Physical activity (PA) is important for enhancing and sustaining people's health and well-being. Although a number of efficacious PA interventions have been developed, few have been translated from research into practice. Consequently, the knowledge-to-practice gap continues to grow, leaving many individuals unable to access evidence-based PA opportunities. This gap may be particularly relevant for those who grapple with poor health due to intrapersonal, interpersonal, cultural and system-level barriers that limit their access to evidence-based PA opportunities. Implementation efforts designed to bring research into real-world settings may bridge the knowledge-to-practice gap. Yet, cultivating quality partnerships and ensuring effectiveness, methodological rigour and scalability in real-world settings can be difficult. Furthermore, researchers seldom publish examples of how they addressed these challenges and translated their evidence-based PA opportunities into practice. Herein, we describe three cases of successful PA implementation among diverse populations: (a) individuals affected by cancer, (b) adults living with prediabetes, and (c) children from under-resourced communities. Commonalities across cases include guiding theories and frameworks, the strategies to facilitate and maintain partnerships, and scalability and sustainability plans. Practical tips and recommendations are provided to spur research and translation efforts that consider implementation from the outset, ultimately ensuring that people receive the benefits PA can confer.

Assessing the scalability of a health management-strengthening intervention at the district level: a qualitative study in Ghana, Malawi and Uganda

Background

The scale-up of successfully tested public health interventions is critical to achieving universal health coverage. To ensure optimal use of resources, assessment of the scalability of an intervention is recognized as a crucial step in the scale-up process. This study assessed the scalability of a tested health management-strengthening intervention (MSI) at the district level in Ghana, Malawi and Uganda.

Methods

Qualitative interviews were conducted with intervention users (district health management teams, DHMTs) and implementers of the scale-up of the intervention (national-level actors) in Ghana, Malawi and Uganda, before and 1 year after the scale-up had started. To assess the scalability of the intervention, the CORRECT criteria from WHO/ExpandNet were used during analysis.

Results

The MSI was seen as credible, as regional- and national-level Ministry of Health officials were championing the intervention. While documented evidence on intervention effectiveness was limited, district- and national-level stakeholders seemed to be convinced of the value of the intervention. This was based on its observed positive results regarding management competencies, teamwork and specific aspects of health workforce performance and service delivery. The perceived need for strengthening of management capacity and service delivery showed the relevance of the intervention, and relative advantages of the intervention were its participatory and sustainable nature. Turnover within the DHMTs and limited (initial) management capacity were factors complicating implementation. The intervention was not contested and was seen as compatible with (policy) priorities at the national level.

Conclusion

We conclude that the MSI is scalable. However, to enhance its scalability, certain aspects should be adapted to better fit the context in which the intervention is being scaled up. Greater involvement of regional and national actors alongside improved documentation of results of the intervention can facilitate scale-up. Continuous assessment of the scalability of the intervention with all stakeholders involved is necessary, as context, stakeholders and priorities may change. Therefore, adaptations of the intervention might be required. The assessment of scalability, preferably as part of the monitoring of a scale-up strategy, enables critical reflections on next steps to make the intervention more scalable and the scale-up more successful.

Exploring the economics of public health intervention scale-up: a case study of the Supporting Healthy Image, Nutrition and Exercise (SHINE) cluster randomised controlled trial

Background

The costs and benefits of an intervention within the intervention testing phase may differ from those experienced when that intervention is implemented and delivered at scale. Yet limited empirical work has been undertaken to explore how economic constructs related to implementation and scale-up might have an impact on intervention cost. The aim of this study was to explore the potential economic impacts of implementation and scale-up on a healthy weight and body image intervention tested in a Type II translational research trial.

Methods

The Supporting Healthy Image, Nutrition and Exercise (SHINE) study is a cluster randomised controlled trial, aiming to deliver universal education about healthy nutrition, physical activity and wellbeing behaviours to adolescents in Australian secondary schools. Data on the cost of the intervention were collected alongside the trial using standard micro-costing techniques. Semi-structured interviews were conducted with key intervention stakeholders to explore the potential economic impacts of implementation and scale-up. Thematic content analysis was undertaken by two authors.

Results

Fifteen intervention group schools participated in the 8-week online intervention targeting students in 2019 (99 Grade 7 classes; 2,240 students). Booster sessions were delivered during one class session in Grades 8 and 9, in 2020 and 2021 respectively. Time costs of intervention delivery and co-ordination comprised the majority (90%) of intervention cost as per the trial, along with costs associated with travel for intervention training and equipment. Themes related to the benefit of the intervention emerged from interviews with six intervention stakeholders, including the potential for economies of scale afforded by online delivery. Contextual themes that may have an impact on intervention implementation and scale included acceptability across all school sectors, availability and reliability of IT infrastructure for intervention delivery and variations in population characteristics. A number of key alterations to the intervention program emerged as important in supporting and sustaining intervention scale-up. In addition, significant implementation costs were identified if the intervention was to be successfully implemented at scale.

Conclusions

The findings from this study provide important information relevant to decisions on progression to a Type III implementation trial, including budget allocation, and will inform modelled economic evaluation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13754-0.

Scalability of an ACT-Based strategy for improving well-being in health care providers: A mix-method and preliminary evaluation of efficacy

The burden of the COVID-19 pandemic has been mainly carried by health care providers. Technology-Mediated Interventions (TMI) seem to be a feasible alternative to increase access to behavioral health resources in this population. However, scaling-up treatments into TMI requires developing user-friendly, accepted, and accessible formats. A two-stage study was conducted to assess scalability of an Acceptance and Commitment Therapy (ACT) based strategy (named FACE COVID) delivered using technology. First, a mix-method design connected qualitative and quantitative data from health providers and ACT experts by which changes were performed to enhance scalability. Second, a pretest-posttest study was conducted to preliminary evaluate the efficacy of FACE COVID intervention on well-being, psychological distress, and psychological flexibility. Results showed a positive impact on well-being, but not distress and psychological flexibility. While this intervention has promising results, changes in dose intensity, social support, and mental health literacy could improve retention as well as increase opportunities to target distress and psychological flexibility in future studies.

Exploring the sustainability of perinatal audit in four district hospitals in the Western Cape, South Africa: a multiple case study approach

Introduction

Maternal and perinatal death surveillance and response (MPDSR) is an intervention process that uses a continuous cycle of identification, notification and review of deaths to determine avoidable causes followed by actions to improve health services and prevent future deaths. This study set out to understand how and why a perinatal audit programme, a form of MPDSR, has sustained practice in South Africa from the perspectives of those engaged in implementation.

Methods

A multiple case study design was carried out in four rural subdistricts of the Western Cape with over 10 years of implementing the programme. Data were collected from October 2019 to March 2020 through non-participant observation of seven meetings and key informant interviews with 41 purposively selected health providers and managers. Thematic analysis was conducted inductively and deductively adapting the extended normalisation process theory to examine the capability, contribution, potential and capacity of the users to implement MPDSR.

Results

The perinatal audit programme has sustained practice due to integration of activities into routine tasks (capability), clear value-add (contribution), individual and collective commitment (potential), and an enabling environment to implement (capacity). The complex interplay of actors, their relationships and context revealed the underlying individual-level and organisational-level factors that support sustainability, such as trust, credibility, facilitation and hierarchies. Local adaption and the broad social and structural resources were required for sustainability.

Conclusion

This study applied theory to explore factors that promote sustained practice of perinatal audit from the perspectives of the users. Efforts to promote and sustain MPDSR will benefit from overall good health governance, specific skill development, embedded activities, and valuing social processes related to implementation. More research using health policy and system approaches, including use of implementation theory, will further advance our understanding on how to support sustained MPDSR practice in other settings.

Scalability of effective adherence interventions for patients using cardiovascular disease medication - a realist synthesis inspired systematic review

Upscaling of medication adherence interventions to routine care is still challenging. This realist theory inspired review aimed to assess which intervention aspects are potentially important for the scalability of effective cardiovascular disease (CVD) medication adherence interventions and how they are reported in effectiveness studies. A total of 4097 articles from four databases were screened of which ultimately 31 studies were included. Relevant information on scalability was extracted using a theoretic framework based on the scalability assessment tool used in the QUALIDEC study for the following domains; (i) innovation, (ii) implementers and patients, (iii) adopting organizations and health system and (iv) socio-political context. Extracted articles were analysed for themes and chains of inference, which were grouped based on commonality and source of evidence to form new hypotheses. Six different domains relevant for scalability of adherence interventions were identified: 1) Complexity of the intervention 2) training; 3) customization of the intervention; 4) drivers of the intervention; 5) technical interventions 6) stakeholder involvement. These six domains might be useful for the development of more scalable interventions by bridging the gap between research and practice. Data relevant for scalability is not well reported on in effectiveness trials for CVD medication adherence interventions and only limited data on scalability has been published in additional papers. We believe the adoption and reach of effective CVD medication adherence interventions will improve with increased awareness for the necessity of scalability in all phases of intervention development.

Scaling Up Improved Inpatient Treatment of Severe Malnutrition: Key Factors and Experiences From South Africa, Bolivia, Malawi, and Ghana

We report lessons learned in 4 countries from scaling up the implementation of World Health Organization guidelines on inpatient management of severe acute malnutrition within routine health services. We provide evidence that implementation is achievable at scale within different contexts and health systems.

Severe acute malnutrition (SAM) can have high mortality, especially in very ill children treated in the hospital. Many medical and nursing schools do not adequately, if at all, teach how to manage children with SAM. There is a dearth of experienced practitioners and trainers to serve as exemplars of good practice or participate in capacity development. We consider 4 country studies of scaling up implementation of WHO guidelines for improving the inpatient management of SAM within under-resourced public sector health services in South Africa, Bolivia, Malawi, and Ghana. Drawing on implementation reports, qualitative and quantitative data from our research, prospective and retrospective data collection, self-reflection, and our shared experiences, we review our capacity-building approaches for improving quality of care, implementation effectiveness, and lessons learned. These country studies provide important evidence that improved inpatient management of SAM is scalable in routine health services and scalability is achievable within different contexts and health systems. Effectiveness in reducing inpatient SAM deaths appears to be retained at scale.

The country studies show evidence of impact on mortality early in the implementation and scaling-up process. However, it took many years to build workforce capacity, establish monitoring and mentoring procedures, and institutionalize the guidelines within health systems. Key features for success included collaborations to build capacity and undertake operational research and advocacy for guideline adoption; specialist teams to mentor and build confidence and competency through supportive supervision; and political commitment and administrative policies for sustainability. For frontline staff to be confident in their ability to deliver appropriate care competently, an enabling environment and supportive policies and processes are needed at all levels of the health system.

What matters for the scalability of prejudice reduction programs and interventions? A Delphi study

Background

In many countries, policy makers and practitioners turn to prejudice reduction programs and interventions to tackle prejudice in the community. However, successfully addressing prejudice requires an effective intervention that can scale to match the broad span of the problem. The scalability assessment frameworks from health sciences have varying emphasis on four categories—intervention, delivery, costs, and context. For example, the high-level factors in the two Milat et al. scalability assessments are weighted towards details of the intervention (Milae et al. in Health Promot Int 28(3):285–981, 2013; Health Res Policy Syst 2:1–17, 2020). Investigation into scalability, specific to prejudice reduction, is necessary to understand how scalability frameworks apply in a different discipline.

Methods

Using a Delphi approach—a structured method to obtain consensus from experts (Milae et al. Health Promot Int 28(3):285–981, 2013; Linstone and Turoff in The Delphi method—techniques and applications, Addison-Wesley, 1975; de Meyrick in Health Educ 103(1):7–16, 2003)—to bring together 16 prejudice reduction experts from multiple sectors including NGOs, private, government and academia, we developed a scalability assessment framework of criteria that are important for the successful scaling of prejudice interventions. We then applied that framework to exemplars of prejudice reduction interventions published in the academic literature.

Results

For prejudice reduction interventions, contextual factors are key considerations for successful scaling. Commonly used prejudice reduction intervention approaches like contact, whether face-to-face or online, can have limited scalability.

Conclusions

To reduce prejudice there needs to be consideration of scalability. This paper presents a first-of-its-kind framework for assessing scalability for prejudice reduction interventions. Applying the empirically developed framework to actual interventions demonstrated that for interventions to be effective and scalable, a greater focus on approaches beyond face-to-face contact is required.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study

INTRODUCTION

There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions.

METHODS AND ANALYSIS

We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks.

ETHICS AND DISSEMINATION

The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Protocol for the Let's Grow randomised controlled trial: examining efficacy, cost-effectiveness and scalability of a m-Health intervention for movement behaviours in toddlers

INTRODUCTION

Despite being an important period for the development of movement behaviours (physical activity, sedentary behaviour and sleep), few interventions commencing prior to preschool have been trialled. The primary aim of this trial is to assess the 12-month efficacy of the Let's Grow mHealth intervention, designed to improve the composition of movement behaviours in children from 2 years of age. Let's Grow is novel in considering composition of movement behaviours as the primary outcome, using non-linear dynamical approaches for intervention delivery, and incorporating planning for real-world implementation and scale-up from its inception.

METHODS AND ANALYSIS

A randomised controlled trial will test the effects of the 12-month parental support mHealth intervention, Let's Grow, compared with a control group that will receive usual care plus electronic newsletters on unrelated topics for cohort retention. Let's Grow will be delivered via a purpose-designed mobile web application with linked SMS notifications. Intervention content includes general and movement-behaviour specific parenting advice and incorporates established behaviour change techniques. Intervention adherence will be monitored by app usage data. Data will be collected from participants using 24-hour monitoring of movement behaviours and parent report at baseline (T₀), mid-intervention (T₁; 6 months post baseline), at intervention conclusion (T₂; 12 months post baseline) and 1-year post intervention (T₃; 2 years post baseline). The trial aims to recruit 1100 families from across Australia during 2021. In addition to assessment of efficacy, an economic evaluation and prospective scalability evaluation will be conducted.

ETHICS AND DISSEMINATION

The study was approved by the Deakin University Human Ethics Committee (2020-077). Study findings will be disseminated through publication in peer-reviewed journals, presentation at scientific and professional conferences, and via social and traditional media.

TRIAL REGISTRATION NUMBER

ACTRN12620001280998; U1111-1252-0599.

Tools for assessing the scalability of innovations in health: a systematic review

BACKGROUND

The last decade has seen growing interest in scaling up of innovations to strengthen healthcare systems. However, the lack of appropriate methods for determining their potential for scale-up is an unfortunate global handicap. Thus, we aimed to review tools proposed for assessing the scalability of innovations in health.

METHODS

We conducted a systematic review following the COSMIN methodology. We included any empirical research which aimed to investigate the creation, validation or interpretability of a scalability assessment tool in health. We searched Embase, MEDLINE, CINAHL, Web of Science, PsycINFO, Cochrane Library and ERIC from their inception to 20 March 2019. We also searched relevant websites, screened the reference lists of relevant reports and consulted experts in the field. Two reviewers independently selected and extracted eligible reports and assessed the methodological quality of tools. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics.

RESULTS

We identified 31 reports describing 21 tools. Types of tools included criteria (47.6%), scales (33.3%) and checklists (19.0%). Most tools were published from 2010 onwards (90.5%), in open-access sources (85.7%) and funded by governmental or nongovernmental organizations (76.2%). All tools were in English; four were translated into French or Spanish (19.0%). Tool creation involved single (23.8%) or multiple (19.0%) types of stakeholders, or stakeholder involvement was not reported (57.1%). No studies reported involving patients or the public, or reported the sex of tool creators. Tools were created for use in high-income countries (28.6%), low- or middle-income countries (19.0%), or both (9.5%), or for transferring innovations from low- or middle-income countries to high-income countries (4.8%). Healthcare levels included public or population health (47.6%), primary healthcare (33.3%) and home care (4.8%). Most tools provided limited information on content validity (85.7%), and none reported on other measurement properties. The methodological quality of tools was deemed inadequate (61.9%) or doubtful (38.1%).

CONCLUSIONS

We inventoried tools for assessing the scalability of innovations in health. Existing tools are as yet of limited utility for assessing scalability in health. More work needs to be done to establish key psychometric properties of these tools. Trial registration We registered this review with PROSPERO (identifier: CRD42019107095).

Assessing the scalability of an integrated falls prevention service for community-dwelling older people: a mixed methods study

Background

There is growing acknowledgement of the need for a phased approach to scaling up health interventions, beginning with an assessment of ‘scalability’, that is, the capacity of an individual intervention to be scaled up. This study aims to assess the scalability of a multi-component integrated falls prevention service for community-dwelling older people and to examine the applicability of the Intervention Scalability Assessment Tool (ISAT). The ISAT consists of 10 domains for consideration when determining the scalability of an intervention, and each domain comprises a series of questions aimed at examining readiness for scale-up.

Methods

Multiple methods were used sequentially as recommended by the ISAT: a review of policy documents, results from a service evaluation and falls-related literature; one-to-one interviews (n = 11) with key stakeholders involved in management and oversight of the service; and a follow-up online questionnaire (n = 10) with stakeholders to rate scalability and provide further feedback on reasons for their scores.

Results

Three of the ISAT domains were rated highly by the participants. Analysis of the qualitative feedback and documents indicated that the issue of falls prevention among older people was of sufficient priority to warrant scale-up of the service and that the service aligned with national health policy priorities. Some participants also noted that benefits of the service could potentially outweigh costs through reduced hospital admissions and serious injuries such as hip fracture. The remaining domains received a moderate score from participants, however, indicating considerable barriers to scale-up. In the qualitative feedback, barriers identified included the perceived need for more healthcare staff to deliver components of the service, for additional infrastructure such as adequate room space, and for an integrated electronic patient management system linking primary and secondary care and to prevent duplication of services.

Conclusions

Plans to scale up the service are currently under review given the practical barriers that need to be addressed. The ISAT provides a systematic and structured framework for examining the scalability of this multi-component falls prevention intervention, although the iterative nature of the process and detailed and technical nature of its questions require considerable time and knowledge of the service to complete.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02717-6.

Unfolding and characterizing the barriers and facilitators of scaling-up evidence-based interventions from the stakeholders' perspective: a concept mapping approach

INTRODUCTION AND AIMS

Much attention has been paid to scaling-up evidence-based interventions (EBIs) in previous implementation science studies. However, there is limited research on how stakeholders perceive factors of the scaling-up of EBIs. This study aimed to identify the barriers and facilitators of scaling-up the nurse-led evidence-based practice of post-stroke dysphagia identification and management (EBP-PSDIM) from the stakeholders' perspective, and to assess their importance and feasibility.

METHODS

This study was conducted using concept mapping. Through purposive sampling, 18 stakeholders were recruited for brainstorming in which they responded to the focus prompt. Here, statements regarding perceived barriers and facilitators to EBI scaling-up were elicited and then sorted by similarity before being rated based on the importance and feasibility. Cluster analysis, multidimensional scaling, and descriptive statistics were utilized to analyze the data.

RESULTS

Ultimately, 61 statements perceived to influence the scaling-up were grouped into four primary clusters, that is, community-related factors, resource team-related factors, evidence-based practice program-related factors, and scaling-up strategy-related factors. The 'perceived needs of the community' was rated as the most important and feasible factor to address, whereas 'costs/resource mobilization' was rated as the least important and feasible one.

CONCLUSION

From the stakeholders' perspective, factors involved in the EBP-PSDIM program scaling-up were initially validated as being multidimensional and conceptually distinct; The importance and feasibility ratings of the barriers and facilitators could be used to help decision-makers to prioritize the most appropriate factors to be considered when developing implementation strategies.

A systematic review of adaptations and effectiveness of scaled-up nutrition interventions

Context

Public health nutrition interventions shown to be effective under optimal research conditions need to be scaled up and implemented in real-world settings.

Objectives

The primary aim for this review was to assess the effectiveness of scaled-up public health nutrition interventions with proven efficacy, as examined in a randomized controlled trial. Secondary objectives were to: 1) determine if the effect size of scaled-up interventions were comparable to the prescale effect, and; 2) identify any adaptations made during the scale-up process.

Data sources

Six electronic databases were searched and field experts contacted.

Study selection

An intervention was considered scaled up if it was delivered on a larger scale than a preceding randomized controlled trial (“prescale”) in which a significant intervention effect (P ≤ 0.05) was reported on a measure of nutrition.

Data extraction

Two reviewers independently performed screening and data extraction. Effect size differences between prescale and scaled-up interventions were quantified. Adaptations to scale-up studies were coded according to the Adaptome model.

Results

Ten scaled-up nutrition interventions were identified. The effect size difference between prescale trials and scaled-up studies ranged from –32.2% to 222% (median, 50%). All studies made adaptations between prescale to scaled-up interventions.

Conclusion

The effects of nutrition interventions implemented at scale typically were half that achieved in prior efficacy trials. Identifying effective scale-up strategies and methods to support retainment of the original prescale effect size is urgently needed to inform public health policy.

Systematic Review Registration

PROSPERO registration no.CRD42020149267.

Action leveraging evidence to reduce perinatal mortality and morbidity (ALERT): study protocol for a stepped-wedge cluster-randomised trial in Benin, Malawi, Tanzania and Uganda

Background

Insufficient reductions in maternal and neonatal deaths and stillbirths in the past decade are a deterrence to achieving the Sustainable Development Goal 3. The majority of deaths occur during the intrapartum and immediate postnatal period. Overcoming the knowledge-do-gap to ensure implementation of known evidence-based interventions during this period has the potential to avert at least 2.5 million deaths in mothers and their offspring annually. This paper describes a study protocol for implementing and evaluating a multi-faceted health care system intervention to strengthen the implementation of evidence-based interventions and responsive care during this crucial period.

Methods

This is a cluster randomised stepped-wedge trial with a nested realist process evaluation across 16 hospitals in Benin, Malawi, Tanzania and Uganda. The ALERT intervention will include four main components: i) end-user participation through narratives of women, families and midwifery providers to ensure co-design of the intervention; ii) competency-based training; iii) quality improvement supported by data from a clinical perinatal e-registry and iv) empowerment and leadership mentoring of maternity unit leaders complemented by district based bi-annual coordination and accountability meetings. The trial’s primary outcome is in-facility perinatal (stillbirths and early neonatal) mortality, in which we expect a 25% reduction. A perinatal e-registry will be implemented to monitor the trial. Our nested realist process evaluation will help to understand what works, for whom, and under which conditions. We will apply a gender lens to explore constraints to the provision of evidence-based care by health workers providing maternity services. An economic evaluation will assess the scalability and cost-effectiveness of ALERT intervention.

Discussion

There is evidence that each of the ALERT intervention components improves health providers’ practices and has modest to moderate effects. We aim to test if the innovative packaging, including addressing specific health systems constraints in these settings, will have a synergistic effect and produce more considerable perinatal mortality reductions.

Trial registration

Pan African Clinical Trial Registry (www.pactr.org): PACTR202006793783148. Registered on 17th June 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07155-z.

Training Coaches in Community Agencies to Support Parents of Children with Suspected Autism: Outcomes, Facilitators, and Barriers

This study evaluated the fidelity and effectiveness of a parent coach training program for toddlers at risk for autism spectrum disorder and identified factors required for successful training implementation under real-world conditions. Training addressed four tiers of clinical competence and was delivered to early intervention providers across 23 partner agencies in a large Canadian province. Results indicated that mean trainee fidelity scores were within the range reported in previous community-based training studies but there was considerable variability across trainees. Implementation facilitators included agency learning climate, leadership support, and trainee readiness for change. Implementation barriers included time/caseload demands and challenges related to technology learning and infrastructure. Results have implications for parent coach training in community settings.

Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors

Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.

Mechanisms of scaling up: combining a realist perspective and systems analysis to understand successfully scaled interventions

Background

Sustainable shifts in population behaviours require system-level implementation and embeddedness of large-scale health interventions. This paper aims to understand how different contexts of scaling up interventions affect mechanisms to produce intended and unintended scale up outcomes.

Methods

A mixed method study combining a realist perspective and systems analysis (causal loop diagrams) of scaled-up physical activity and/or nutrition interventions implemented at a state/national level in Australia (2010–18). The study involved four distinct phases: Phase 1 expert consultation, database and grey literature searches to identify scaled-up interventions; Phase 2 generating initial Context-Mechanism-Outcome configurations (CMOs) from the WHO ExpandNet framework for scaling up; Phase 3 testing and refining CMOs via online surveys and realist interviews with academics, government and non-government organisations (NGOs) involved in scale up of selected interventions (Phase 1); and Phase 4 generating cross-case mid-range theories represented in systems models of scaling up; validated by member checking. Descriptive statistics were reported for online survey data and realist analysis for interview data.

Results

Seven interventions were analysed, targeting nutrition (n = 1), physical activity (n = 1), or a combination (n = 5). Twenty-six participants completed surveys; 19 completed interviews. Sixty-three CMO pathways underpinned successful scale up, reflecting 36 scale up contexts, 8 key outcomes; linked via 53 commonly occurring mechanisms. All five WHO framework domains were represented in the systems models. Most CMO pathways included ‘intervention attributes’ and led to outcomes ‘community sustainability/embeddedness’ and ‘stakeholder buy-in/perceived value’. Irrespective of interventions being scaled in similar contexts (e.g., having political favourability); mechanisms still led to both intended and unintended scale up outcomes (e.g., increased or reduced sustainability).

Conclusion

This paper provides the first evidence for mechanisms underpinning outcomes required for successful scale up of state or nationally delivered interventions. Our findings challenge current prerequisites for effective scaling suggesting other conditions may be necessary. Future scale up approaches that plan for complexity and encourage iterative adaptation throughout, may enhance scale up outcomes. Current linear, context-to-outcome depictions of scale up oversimplify what is a clearly a complex interaction between perceptions, worldviews and goals of those involved. Mechanisms identified in this study could potentially be leveraged during future scale up efforts, to positively influence intervention scalability and sustainability.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01103-0.

Physical activity is good for older adults-but is programme implementation being overlooked? A systematic review of intervention studies that reported frameworks or measures of implementation

OBJECTIVE

To examine older adult physical activity (PA) intervention studies that evaluated implementation and/or scale-up. Research question 1: What implementation and/or scale-up indicators (specific, observable and measurable characteristics that show the progress of implementation) were reported? Research question 2: What implementation and/or scale-up frameworks were reported? Research question 3: Did studies evaluate the relationship between implementation or scale-up of the intervention and individual level health/behaviour outcomes? If yes, how?

DESIGN

Systematic review.

DATA SOURCES

Publications from electronic databases and hand searches (2000 to December 2019).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Any PA intervention studies with community-dwelling older adult participants (mean age ≥60 years). Required indicators: (a) Must report amount of PA as an outcome, with validated self-report or objective measures, and (b) Must have reported at least one implementation or scale-up framework and/or one implementation or scale-up indicator.

RESULTS

137 studies were included for research question 1, 11 for question 2 and 22 for question 3. 137 studies reported an implementation indicator: 14 unique indicators. None were specified as indicators for scale-up evaluation. 11 studies were guided by an implementation or scale-up framework. 22 studies described a relationship between an implementation indicator and an individual-level health outcome.

CONCLUSION

There is need for implementation research that extends beyond analysis at the individual level, includes clearly defined indicators and provides a guiding framework to support PA initiatives in older adults. Such implementation studies should evaluate factors in the broader context (eg,political, environmental) that influence scale-up.

PROSPERO REGISTRATION

CRD42018091839.

Assessing the scalability of innovations in primary care: a cross-sectional study

BACKGROUND

Canadian health funding currently prioritizes scaling up for evidence-based primary care innovations, but not all teams prepare for scaling up. We explored scalability assessment among primary care innovators in the province of Quebec to evaluate their preparedness for scaling up.

METHODS

We performed a cross-sectional survey from Feb. 18 to Mar. 18, 2019. Eligible participants were 33 innovation teams selected for the 2019 Quebec College of Family Physicians' Symposium on Innovations. We conducted a Web-based survey in 2 sections: innovation characteristics and the Innovation Scalability Self-administered Questionnaire. The latter includes 16 criteria (scalability components) grouped into 5 dimensions: theory (1 criterion), impact (6 criteria), coverage (4 criteria), setting (3 criteria) and cost (2 criteria). We classified innovation types using the International Classification of Health Interventions. We performed a descriptive analysis using frequency counts and percentages.

RESULTS

Out of 33 teams, 24 participated (72.7%), with 1 innovation each. The types of innovation were management (15/24), prevention (8/24) and therapeutic (1/24). Most management innovations focused on patient navigation (9/15). In order of frequency, teams had assessed theory (79.2%) and impact (79.2%) criteria, followed by cost (77.1%), setting (59.7%) and coverage (54.2%). Most innovations (16/24) had assessed 10 criteria or more, including 10 management innovations, 5 prevention innovations and 1 therapeutic innovation. Implementation fidelity was the least assessed criterion (6/24).

INTERPRETATION

The scalability assessments of a primary care innovation varied according to its type. Management innovations, which were the most prevalent and assessed the most scalability components, appear to be most prepared for primary care scale-up in Canada.

Implementation and evaluation of nonclinical interventions for appropriate use of cesarean section in low- and middle-income countries: protocol for a multisite hybrid effectiveness-implementation type III trial

Background

While cesarean sections (CSs) are a life-saving intervention, an increasing number are performed without medical reasons in low- and middle-income countries (LMICs). Unnecessary CS diverts scarce resources and thereby reduces access to healthcare for women in need. Argentina, Burkina Faso, Thailand, and Vietnam are committed to reducing unnecessary CS, but many individual and organizational factors in healthcare facilities obstruct this aim. Nonclinical interventions can overcome these barriers by helping providers improve their practices and supporting women’s decision-making regarding childbirth. Existing evidence has shown only a modest effect of single interventions on reducing CS rates, arguably because of the failure to design multifaceted interventions effectively tailored to the context. The aim of this study is to design, adapt, and test a multifaceted intervention for the appropriate use of CS in Argentina, Burkina Faso, Thailand, and Vietnam.

Methods

We designed an intervention (QUALIty DECision-making—QUALI-DEC) with four components: (1) opinion leaders at heathcare facilities to improve adherence to best practices among clinicians, (2) CS audits and feedback to help providers identify potentially avoidable CS, (3) a decision analysis tool to help women make an informed decision on the mode of birth, and (4) companionship to support women during labor. QUALI-DEC will be implemented and evaluated in 32 hospitals (8 sites per country) using a pragmatic hybrid effectiveness-implementation design to test our implementation strategy, and information regarding its impact on relevant maternal and perinatal outcomes will be gathered. The implementation strategy will involve the participation of women, healthcare professionals, and organizations and account for the local environment, needs, resources, and social factors in each country.

Discussion

There is urgent need for interventions and implementation strategies to optimize the use of CS while improving health outcomes and satisfaction in LMICs. This can only be achieved by engaging all stakeholders involved in the decision-making process surrounding birth and addressing their needs and concerns. The study will generate robust evidence about the effectiveness and the impact of this multifaceted intervention. It will also assess the acceptability and scalability of the intervention and the capacity for empowerment among women and providers alike.

Trial registration

ISRCTN67214403

A Mixed Methods Evaluation of a Digital Intervention to Improve Sedentary Behaviour Across Multiple Workplace Settings

BACKGROUND

Prolonged sedentary behaviour (SB) is associated with risk of chronic diseases. Digital interventions in SB require mixed method evaluations to understand potential for impact in real-world settings. In this study, the RE-AIM QuEST evaluation framework will be used to understand the potential of a digital health promotion application which targets reducing and breaking up SB across multiple workplace settings.

METHODS

Four companies and 80 employees were recruited to use a digital application. Questionnaires were used to measure SB, and additional health and work-related outcomes at baseline, one month, three month and six month follow-up. Qualitative data was collected through focus groups with employees and interviews with stakeholders. Questionnaire data was analysed using Wilcoxon Sign Rank tests and qualitative data was thematically analysed.

RESULTS

The digital application significantly increased standing time at one month for the total group and transitions per hour in one of the companies. Facilitators and barriers were identified across RE-AIM.

CONCLUSIONS

Addressing the barriers which have been identified, while maintaining the positive attributes will be critical to producing an effective digital application which also has the potential for impact in the real world.

Should We Scale-Up? A Mixed Methods Process Evaluation of an Intervention Targeting Sedentary Office Workers Using the RE-AIM QuEST Framework

Background: Interventions targeting a reduction in sedentary behaviour in office workers need to be scaled-up to have impact. In this study, the RE-AIM QuEST framework was used to evaluate the potential for further implementation and scale-up of a consultation based workplace intervention which targeted both the reduction, and breaking up of sitting time. Methods: To evaluate the Springfield College sedentary behaviour intervention across multiple RE-AIM QuEST indicators; intervention participant, non-participant (employees who did not participate) and key informant (consultation delivery team; members of the research team and stakeholders in workplace health promotion) data were collected using interviews, focus groups and questionnaires. Questionnaires were summarized using descriptive statistics and interviews and focus groups were transcribed verbatim, and thematically analysed. Results: Barriers to scale-up were: participant burden of activity monitoring; lack of management support; influence of policy; flexibility (scheduling/locations); time and cost. Facilitators to scale up were: visible leadership; social and cultural changes in the workplace; high acceptability; existing health and wellbeing programmes; culture and philosophy of the participating college. Conclusions: There is potential for scale-up, however adaptations will need to be made to address the barriers to scale-up. Future interventions in office workers should evaluate for scalability during the pilot phases of research.

Optimising the use of caesarean section: a generic formative research protocol for implementation preparation

Background

Caesarean section rates are rising across all geographical regions. Very high rates for some groups of women co-occur with very low rates for others. Both extremes are associated with short and longer term harms. This is a major public health concern. Making the most effective use of caesarean section is a critical component of good quality, sustainable maternity care. In 2018, the World Health Organization published evidence-based recommendations on non-clinical interventions to reduce unnecessary caesarean section. The guideline identified critical research gaps and called for formative research to be conducted ahead of any interventional research to define locally relevant determinants of caesarean birth and factors that may affect implementation of multifaceted optimisation strategies. This generic formative research protocol is designed as a guide for contextual assessment and understanding for anyone planning to take action to optimise the use of caesarean section.

Methods

This formative protocol has three main components: (1) document review; (2) readiness assessment; and (3) primary qualitative research with women, healthcare providers and administrators. The document review and readiness assessment include tools for local mapping of policies, protocols, practices and organisation of care to describe and assess the service context ahead of implementation. The qualitative research is organized according to twelve identified interventions that may optimise use of caesarean section. Each intervention is designed as a “module” and includes a description of the intervention, supporting evidence, theory of change, and in-depth interview/focus group discussion guides. All study instruments are included in this protocol.

Discussion

This generic protocol is designed to underpin the formative stage of implementation research relating to optimal use of caesarean section. We encourage researchers, policy-makers and ministries of health to adapt and adopt this design to their context, and share their findings as a catalyst for rapid uptake of what works.