Cochrane update: Predicting sustainability of intervention effects in public health evidence: identifying key elements to provide guidance

Sustainability of an outcome measure in outpatient stroke rehabilitation: A realist evaluation

RATIONALE

Only half of newly implemented evidence-based practices are sustained. Though poor sustainment can lead to negative consequences for clinical teams, organizations and patients, the causal explanations of sustainment are largely unknown.

AIMS AND OBJECTIVES

We aimed to ascertain how (mechanisms) and in what circumstances (context) a newly implemented outcome measure in rehabilitation was sustained or not (outcome).

METHODOLOGY

Informed by an integrated knowledge translation approach, we conducted a realist evaluation using a mixed method, embedded single case study design with data collection up to 18 months following the implementation of the Mayo-Portland Adaptability Inventory - version 4 (MPAI-4), a rehabilitation outcome measure. Quantitative data (survey and patient charts) was analysed using descriptive statistics, then integrated with qualitative data (interviews with 10 key informants) and analysed using inductive and deductive retroduction. We integrated the data to develop a case description and ultimately, to refine the programme theory to better understand the sustainability of the MPAI-4.

RESULTS

We linked context, mechanisms and outcomes, and also emphasized sustainability strategies in 18 explanations of how sustainability works. These explanations provide evidence for four overarching patterns: (1) implementation and sustainability phases are interconnected, (2) outcomes build on each other recursively, with patient benefits as the keystone outcome, (3) sustainment is achieved to varying levels across different sustainability outcomes [e.g., high level (e.g., rate of MPAI-4 scoring: 77.7%) to low level (e.g., rate of MPAI-4 application to clinical decision-making: 3.7%)] and (4) the work of sustaining the MPAI-4 is shared amongst different stakeholders.

CONCLUSION

Implementation teams can draw from this programme theory to improve the sustainment of outcomes measures while researchers could continue to refine the theory. Continued investigation of sustainability, including diverse and continuous sustainability outcomes, is needed to understand how to maintain improvements in quality of care and patient outcomes.

Collaborative sustainability planning for an outcome measure in outpatient stroke rehabilitation: A qualitative description study

RATIONALE

Evidence suggests that sustainability planning and the use of a collaborative approach to planning result in better sustainability outcomes and more relevant knowledge. Yet, both approaches appear to be underutilized. A detailed description of collaborative sustainability planning may encourage the use of these two impactful strategies.

AIMS AND OBJECTIVES

To explore the collaborative sustainability planning process for a single outcome measure in three rehabilitation sites.

METHODOLOGY

Within the Mayo-Portland Adaptability Inventory-version 4 (MPAI-4) implementation project, we conducted a qualitative description study. We used data from 12 core sustainability planning meetings and 108 follow-up meetings that included a total of 31 clinical and research team participants. Sustainability planning was informed by an MPAI-4-specific implementation guide, and by the results from a realist review of the sustainability of rehabilitation practices and the Clinical Sustainability Assessment Tool. We analyzed qualitative data using thematic content analysis.

RESULTS

Three themes describe the collaborative sustainability planning process: (1) "collaboration as a driver for sustainability" which captures the active collaboration underpinning sustainability planning; (2) "co-creation of a sustainability plan to achieve shared objectives" which captures the identified barriers and facilitators, and selected sustainability strategies linked to one of six collaboratively identified shared objectives; and (3) "the iterative nature of sustainability planning" which captures the necessity of an agile and responsive sustainability planning process.

CONCLUSION

Identified strategies may be useful to support (collaborative) sustainment. Future research could investigate the effect of collaborative sustainability planning on sustainability objectives, and the relationship between these objectives.

Sustaining health obesity prevention programs: Lessons from real-world population settings

Current understanding of what sustains public health programs is derived primarily from evaluations of programs delivered for only a few years. To improve program planning and knowledge on program sustainment, we examined real-world population programs that have been delivered for >2 years. Our focus was physical activity and nutrition programs for obesity prevention. We identified programs through published literature and searched through publicly available information on the theoretical factors determining sustainment. We reviewed 90 programs and explored intervention characteristics, provider, delivery and process level factors, and the outer environment influences. Programs were sustained on average 15 years and more frequently characterised as behavioural change skills programs targeting children, funded by non-government organisations and delivered by community organisations. Most programs had undergone some modification (n = 55). Differences between programs were observed across key factors: Programs sustained 15+ years were mainly behaviour skills programs (n = 21); and characterised by interactive designs (i.e., face-to-face or digital) over static innovations (i.e., print material) compared with those sustained <15 years (p = 0.024). While government funding supported many of the programs (n = 45;), those sustained 15+ years were more likely to have been commercially funded (p = 0.044); and were less likely to have current community involvement (p = 0.013). Differences in ownership and funding were also observed across countries. While multiple factors may influence program sustainment, longer delivered programs where distinguished by their program characteristics and outer contextual factors, suggesting such factors may have an important role in sustaining programs in the longer-term.

Sustainability of integrated hypertension and diabetes with HIV care for people living with HIV at primary health care in South Ethiopia: implication for integration

BACKGROUND

People living with human immunodeficiency virus (PLWH) have an increased risk of developing noncommunicable diseases (NCDs) compared with people without HIV. The multimorbidity of NCDs and HIV increases the need for integrated care. However, there is a paucity of evidence on the implementation of integrated sustained hypertension and diabetes with HIV care to address the multiple chronic care needs of PLWH in Ethiopia.

OBJECTIVE

This study aimed to determine the sustainability of integrated hypertension and diabetes within HIV care for PLWH in primary healthcare (PHC) in southern Ethiopia.

METHODS

The National Health Service Institute for Innovation and Improvement Sustainability Model (NHS- SM) self-assessment tool was used to assess sustainability. HIV care and NCD team members from five PHC facilities in South Ethiopia were included. Participants completed the self-administered NHS-SM assessment tool independently.

RESULT

The overall mean sustainability was 43.74 (95% CI: 42.15-45.33). All facilities had an overall sustainability score of less than 55. The perceived benefit beyond helping the patient, the likelihood of adaptability, and perceived alignment with the organizational goal were identified as potential factors promoting sustainability. The perceived lack of an effective system to monitor progress, staff behavior, inadequate staff involvement and training, inadequate senior leadership support and clinical leadership engagement, and infrastructure limitations could negatively affect sustainability.

CONCLUSIONS

Integrating hypertension and diabetes with HIV care sustainably at PHC requires staff involvement and training, staff behavior change communication, ensuring PHC management and clinical leadership (doctors and senior clinicians) engagement, and addressing infrastructure limitations.

Challenges and successes in the sustainment of Dutch community-level smoking cessation interventions for residents with a low socioeconomic position

BACKGROUND

When health promotion interventions are implemented, the gains are often short-lived, as interventions are seldom successfully sustained. The current study explores how and under what conditions community-level smoking cessation interventions for people with a lower socioeconomic position can be sustained, drawing upon interventions delivered in Dutch neighbourhoods with a predominantly low socioeconomic position.

METHODS

We conducted 15 semi-structured interviews with key stakeholders from three Dutch community-level smoking cessation interventions implemented at least three years prior. The topic guide was developed based on the Determinants of Innovation framework and transcripts were analysed thematically.

RESULTS

We identified several factors that promote the sustainment of smoking cessation community-level interventions: 1) structural, long-term funding through the commitment of health insurers and policy makers; 2) continued stakeholder enthusiasm and involvement; 3) training and time for professionals to discuss smoking cessation, thereby also increasing the visibility of the intervention for professionals and residents; 4) integrating the intervention with existing initiatives and adapting it to be compatible with current working practices of executive staff; and 5) planning for sustainment as a team from the outset.

CONCLUSIONS

The current study highlights challenges and successes in intervention sustainment for people with a lower socioeconomic position. Lack of structural funding was one of the most challenging aspects for intervention sustainment in which health insurers and policy makers can play an important role. Planning for sustainment from the outset would enable intervention coordinators to consider the abovementioned factors early on. This need not be done alone but can best be discussed within a team of stakeholders.

Child and adolescent mental health services in a devolved healthcare system: a qualitative exploration of sustainable practices

BACKGROUND

The transference of research evidence into routine healthcare practice remains poorly understood. This includes understanding the prerequisites of longer-term viability. The present study investigated the sustainable practices of GM i-THRIVE, a programme which reconceptualizes mental health services for children and young people (CYP) in Greater Manchester, United Kingdom. We aimed to establish whether a sustainable future was likely, and to identify areas of focus to improve that likelihood.

METHODS

The NHS Sustainability Model, typically completed as a questionnaire measure, was converted into interview questions. The responses of nine professionals, from a variety of roles across the CYP mental health workforce, were explored using inductive thematic framework analysis. Selected participants completed the original questionnaire.

RESULTS

Five themes (communication; support; barriers to implementation; past, present, and future: the implementation journey; and the nuances of GM i-THRIVE) and 21 subthemes formed the final thematic framework. Relationships with senior leaders and with colleagues across the workforce were seen as important. Leaders' roles in providing meaning and fit were emphasized. Whilst training delivered the programme's aims well, monitoring its dissemination was challenging. Widespread issues with dedicating sufficient time to implementation were raised. The flexibility of the programme, which can be applied in multiple ways, was discussed positively. This flexibility links to the idea of GM i-THRIVE as a mindset change, and the uniqueness of this style of intervention was discussed. To varying degrees, themes were supported by responses to the quantitative measure, although several limitations to the use of the questionnaire were discovered. Consequently, they were used to infer conclusions to a lesser degree than originally intended.

CONCLUSIONS

Professionals involved with GM i-THRIVE reported many elements that indicate a positive future for the programme. However, they suggested that more attention should be given to embedding the core concepts of the model at the current stage of implementation. Limitations relating to its use within our study are discussed, but we conclude that the NHS Sustainability Model is a suitable way of guiding qualitative implementation research. It is especially valuable for localized interventions. The constraints of our small sample size on transferability are considered.

Predictors of champion behaviors in an evidence-based parenting program: A structural equation modeling approach

The importance of champions in the implementation of evidence-based public health programs has been well established. Champions perform a range of behaviors which can have significant influence on the adoption and sustainability of interventions. This study investigates champion behaviors in parenting practitioners with the aim to provide insight into the range and extent that practitioners engage in champion behaviors and to examine predictors of practitioners' champion behaviors using structural equation modeling. Data were collected during a large international implementation survey of 1606 practitioners trained to deliver an evidence-based parenting program, the triple P-Positive Parenting Program. We developed a 13-item Champion Behaviors Scale which was administered alongside other measures of predictors of implementation outcomes. Perceived usefulness of the program was the most important facilitator of both public and personal champion behaviors. Certain desirable features of the program tended to not only be positively associated with the perceived usefulness of the program, but also had a unique impact on practitioners' personal champion behaviors. Higher positions within organizations were linked with more public champion behaviors. Although organizational support was found to be unrelated to champion behaviors in the structural model, it facilitated other predictors of champion behaviors.

Conditions and strategies influencing sustainability of a community-based exercise program incorporating a healthcare-community partnership for people with balance and mobility limitations in Canada: A collective case study of the Together in Movement and Exercise (TIME™) program

Background

Community-based exercise programs delivered through healthcare-community partnerships (CBEP-HCPs) are beneficial to individuals with balance and mobility limitations. For the community to benefit, however, these programs must be sustained over time.

Purpose

To identify conditions influencing the sustainability of CBEP-HCPs for people with balance and mobility limitations and strategies used to promote sustainability based on experiences of program providers, exercise participants, and caregivers.

Methods

Using a qualitative collective case study design, we invited stakeholders (program providers, exercise participants, and caregivers) from sites that had been running a CBEP-HCP for people with balance and mobility limitations for ≥4 years; and sites where the CBEP-HCP had been discontinued, to participate. We used two sustainability models to inform development of interview guides and data analysis. Qualitative data from each site were integrated using a narrative approach to foster deeper understanding of within-organization experiences.

Results

Twenty-nine individuals from 4 sustained and 4 discontinued sites in Ontario (n = 6) and British Columbia (n = 2), Canada, participated. Sites with sustained programs were characterized by conditions such as need for the program in the community, presence of secure funding or cost recovery mechanisms, presence of community partners, availability of experienced and motivated instructors, and the capacity to allocate resources towards program marketing and participant recruitment. For sites where programs discontinued, diminished participation and/or enrollment and an inability to allocate sufficient financial, human, and logistical resources towards the program affected program continuity. Participants from discontinued sites also identified issues such as staff with low motivation and limited experience, and presence of competing programs within the organization or the community. Staff associated the absence of referral pathways, insufficient community awareness of the program, and the inability to recover program cost due to poor participation, with program discontinuation.

Conclusion

Sustainability of CBEP-HCPs for people with balance and mobility limitations is influenced by conditions that exist during program implementation and delivery, including the need for the program in the community, and organization and community capacity to bear the program's financial and resource requirements. Complex interactions among these factors, in addition to strategies employed by program staff to promote sustainability, influence program sustainability.

Sustainable Partnerships to Ensure Quality in Psychological Support (EQUIP) for Adolescents

Ensuring that sustainable and effective mental health services are available for children and adolescents is a growing priority for national governments. However, little guidance exists on how to support service implementation. In Kenya, partnerships were formed among regional government, nongovernmental organizations, and universities to implement Ensuring Quality in Psychological Support (EQUIP)-Nairobi, a pilot project to train and supervise nonspecialists delivering psychological support to adolescents. Lessons were learned about integrating psychological services into existing health services by using the EQUIP platform to assess competencies, engaging partners for supervision and quality improvement, and involving youth stakeholders. The partnerships facilitated a rapid transition to remote services during the COVID-19 pandemic. The EQUIP-Nairobi project results offer lessons for partnerships in other low-resource settings.

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.

Understanding How Newly Implemented Rehabilitation Best Practices Are Sustained: A Realist Review

OBJECTIVE

We conducted a realist review to understand how (mechanism) and in what circumstances (context) evidence-based practices are sustained in rehabilitation (outcome).

DATA SOURCES

MEDLINE, Embase, reference lists, and targeted websites.

STUDY SELECTION

Two independent reviewers calibrated study selection; then 1 reviewer screened all titles and abstracts, while the second reviewer screened a random 20%. We repeated this process for full texts. We included 115 documents representing 61 implementation projects (8.9% of identified documents). Included documents described implementation projects in which physical therapists, occupational therapists, and/or speech-language pathologists were the target users of an evidence-based practice.

DATA EXTRACTION

Two reviewers repeated the independent process described in study selection to extract basic study and sustainability characteristics as well as context, mechanism, outcome, and strategy text.

DATA SYNTHESIS

Using basic numerical analyses, we found that only 54% of evidence-based practices in rehabilitation are sustained. Furthermore, while authors who reported sustainability planning sustained the practice 94% of the time, sustainability planning in rehabilitation is rare (only reported 26% of the time). Extracted text was synthesized using the realist technique of inductive and deductive retroduction in which context, mechanism, outcome, and strategy text are combined into narrative explanations of how sustainability works. To inform these explanations, we applied normalization process theory and the theory of planned behavior. Collectively, the 52 identified narratives provide evidence for 3 patterns: (1) implementation and sustainability phases are interconnected, (2) continued use of the evidence-based practice can be interpreted as the ultimate sustainability outcome, and (3) intermediate sustainability outcomes (ie, fit/alignment, financial support, benefits, expertise) can become contextual features influencing other sustainability outcomes.

CONCLUSIONS

Implementation teams can use the narrative explanations generated in this review to optimize sustainability planning. This can sustain practice changes and improve quality of care and patient outcomes. Future research should seek to iteratively refine the proposed narrative explanations.

Accelerating integration of tobacco use treatment in the context of lung cancer screening: Relevance and application of implementation science to achieving policy and practice

Based on the findings from the National Lung Screening Trial, the U.S. Preventive Services Task Force recommends annual low dose computed tomography (LDCT) lung cancer screening (LCS) among high-risk adults. Approximately 54% of individuals seeking LCS report current cigarette smoking. Effective smoking cessation interventions, offered at the time of LCS, enhances the health benefits of screening that are attributable to reductions in lung cancer overall and tobacco-related mortality. Considering these data, the Centers for Medicare & Medicaid Services' (CMS) 2015 decision to cover LCS with LDCT required that radiology imaging facilities make tobacco cessation interventions available for people who smoke. In February 2022, CMS reversed their 2015 coverage requirement for delivering tobacco use treatment at the time of LDCT; CMS retained the requirement for counseling during the shared decision-making visit prior to the exam. The policy change does not diminish the importance of offering high-quality tobacco cessation services in conjunction with routine LDCT for LCS. However, LCS programs face a range of barriers to implementing tobacco use treatment in their settings. As a result, implementation has lagged. Closing the "evidence to practice" gap is the focus of implementation science, a field that offers a set of rigorous methods and a systematic approach to identifying and overcoming contextual barriers to implementing evidence-based guidelines in a range of clinical settings. In this paper, we describe how implementation science frameworks and methods can be used to help guide LCS programs in their efforts to integrate tobacco use treatment and discuss policy changes needed to further facilitate the delivery of TUT as an essential component of the LCS process.

Application of a sustainability framework to enhance Australian food literacy programs in remote Western Australian communities

ISSUE ADDRESSED

Food literacy programs aim to build individuals' knowledge, skills and self-efficacy to adopt healthy food choices conducive to reducing the risk of chronic diseases, such as obesity. Foodbank WA's (FBWA) Healthy Food for All^® nutrition programs have supported the improvement of food literacy knowledge and skills among vulnerable people living in the Pilbara.

METHODS

A Sustainability Framework containing ten sustainability factors was overlaid with social ecological model (SEM) levels of influence to form a matrix. The use of this matrix facilitated sustainability strategy appraisal within three food literacy programs delivered in remote WA.

RESULTS

Programs included multiple sustainability strategies across levels of influence; all programs addressed all ten sustainability factors at community and organisational SEM levels of influence. Few sustainability strategies were employed at the public policy level of influence. No program employed formal governance structures to guide program direction, such as steering groups; however, school and parent program staff developed Memoranda of Understanding to ensure the continuation of program delivery between the FBWA teams' regional visits.

CONCLUSIONS

This study has showcased the comprehensive assessment of food literacy program sustainability across levels of influence and identified gaps for improvement by FBWA teams. SO WHAT?: The sustainability of food literacy programs aiming to increase knowledge and skills could be enhanced by conducting a similar analysis, during program planning or at program review. Using the matrix provides the opportunity to focus resources to address sustainability; supporting health promotion practitioners to transform the impacts of short-term food literacy interventions into long-term sustained outcomes.

HOBSCOTCH Your Way to Improved Cognition for Patients With Epilepsy

Effectiveness of a Self-Management Program to Improve Cognition and Quality of Life in Epilepsy: A Pragmatic, Randomized, Multicenter Trial

Streltzov NA, Schmidt SS, Schommer LM, Zhao W, Tosteson TD, Mazanec MT, Kiriakopoulos ET, Chu F, Henninger HL, Nagle K, Roth RM, Jobst B. Neurology. 2022;98(21):e2174-e2184. doi:10.1212/WNL.0000000000200346

Background and Objectives:

We conducted a multisite, pragmatic replication trial at 4 New England epilepsy centers to determine the effectiveness of Home-Based Self-Management and Cognitive Training Changes Lives (HOBSCOTCH) in a real-world setting and to assess feasibility of a virtual intervention.

Methods:

HOBSCOTCH is an 8-session intervention addressing cognitive impairment and quality of life (QoL) for people with epilepsy (PWE). Participants were recruited from epilepsy centers in 4 states and block-randomized into the following groups: in-person HOBSCOTCH (H-IP), virtual HOBSCOTCH (H-V), and waitlist control. Outcome measures were assessed for all groups at baseline, 3 months, and 6 months; intervention groups received long-term follow-up at 9 and 12 months.

Results:

A total of 108 participants were recruited, of whom 85 were included in this analysis (age at baseline 47.5 ± 11.5 years; 68% female). Participants completing the in-person intervention (H-IP) had a 12.4-point improvement in QoL score compared with controls (p < 0.001). Pairwise comparisons found a 6.2-point treatment effect for subjective cognition in the H-IP group (p < 0.001). There were no meaningful group differences in objective cognition or health care utilization at any time points and the treatment effect for QoL diminished by 6 months. The virtual intervention demonstrated feasibility but did not significantly improve outcomes compared with controls. Within-group analysis found improvements in QoL for both H-V and H-IP

Discussion:

This study replicated the effectiveness of the HOBSCOTCH program in improving QoL for PWE. The study was conducted prior to the COVID-19 pandemic, but the distance-delivered intervention may be particularly well-suited for the current environment. Future research will explore modifications designed to improve the efficacy of H-V and the sustainability of HOBSCOTCH’s treatment effect.

An Alpha, Beta and Gamma Approach to Evaluating Occupational Health Organizational Interventions: Learning from the Measurement of Work-Family Conflict Change

Given the rapid growth of intervention research in the occupational health sciences and related fields (e.g. work-family), we propose that occupational health scientists adopt an “alpha, beta, gamma” change approach when evaluating intervention efficacy. Interventions can affect absolute change in constructs directly (alpha change), changes in the scales used to assess change (beta change) or redefinitions of the construct itself (gamma change). Researchers should consider the extent to which they expect their intervention to affect each type of change and select evaluation approaches accordingly. We illustrate this approach using change data from groups of IT professionals and health care workers participating in the STAR intervention, designed by the Work Family Health Network. STAR was created to effect change in employee work-family conflict via supervisor family-supportive behaviors and schedule control. We hypothesize that it will affect change via all three change approaches—gamma, beta, and alpha. Using assessment techniques from measurement equivalence approaches, we find results consistent with some gamma and beta change in the IT company due to the intervention; our results suggest that not accounting for such change could affect the evaluation of alpha change. We demonstrate that using a tripartite model of change can help researchers more clearly specify intervention change targets and processes. This will enable the assessment of change in a way that has stronger fidelity between the theories used and the outcomes of interest. Our research has implications for how to assess change using a broader change framework, which employs measurement equivalence approaches in order to advance the design and deployment of more effective interventions in occupational settings.

Realist evaluation of the impact of the research translation process on health system sustainability: a study protocol

INTRODUCTION

Sustainability at a system level relates to the capacity of the system to be able to service the ongoing health needs of the population. It is a multifaceted concept encompassing both the affordability and efficiency of a system and the system's ability to adapt and change.To address issues that currently threaten health system sustainability, healthcare leaders, policy makers, clinicians and researchers are searching for solutions to ensure the delivery of safe, value-based care into the future. The timely translation of research evidence into sustainable interventions that can be adopted into the health system is one way of bolstering the sustainability of the system as a whole. We present a protocol for the realist evaluation of a research translation funding programme to understand how the research translation process contributes to health system sustainability and value-based healthcare.

METHODS AND ANALYSIS

Underpinned by the realist evaluation framework, we will: (1) Develop the Initial Program Theory (IPT) of the research translation process; (2) Test the program theory through case study analysis; and (3) Refine and consolidate the theory through stakeholder consultation. The evaluation uses a case example of a research translation programme, chosen for its representation of a microcosm of the broader health system and the heterogeneity of service improvement activities taking place within it. Across the three phases, analysis of data from documents about the research translation program and interviews and focus groups with stakeholders and program users will draw on the context (C), mechanism (M), outcome (O) formula that is core to realist evaluation. In addition, system dynamic methods will capture the feedback loops and complex relationships among the IPT and context-mechanism-outcome configurations. This approach to evaluation of a research translation funding programme may be adapted to similar programmes operating in other settings.

ETHICS AND DISSEMINATION

Curtin University Human Research Ethics Committee, Western Australia, approved this study (approval number: HRE2020-0464). Results will be published in scientific journals, and communicated to respondents and relevant partners.

Effectiveness of a Self-Management Program to Improve Cognition and Quality of Life in Epilepsy: A Pragmatic, Randomized, Multicenter Trial

BACKGROUND AND OBJECTIVES

We conducted a multisite, pragmatic replication trial at 4 New England epilepsy centers to determine the effectiveness of Home-Based Self-Management and Cognitive Training Changes Lives (HOBSCOTCH) in a real-world setting and to assess feasibility of a virtual intervention.

METHODS

HOBSCOTCH is an 8-session intervention addressing cognitive impairment and quality of life (QoL) for people with epilepsy (PWE). Participants were recruited from epilepsy centers in 4 states and block-randomized into the following groups: in-person HOBSCOTCH (H-IP), virtual HOBSCOTCH (H-V), and waitlist control. Outcome measures were assessed for all groups at baseline, 3 months, and 6 months; intervention groups received long-term follow-up at 9 and 12 months.

RESULTS

A total of 108 participants were recruited, of whom 85 were included in this analysis (age at baseline 47.5 ± 11.5 years; 68% female). Participants completing the in-person intervention (H-IP) had a 12.4-point improvement in QoL score compared with controls (p < 0.001). Pairwise comparisons found a 6.2-point treatment effect for subjective cognition in the H-IP group (p < 0.001). There were no meaningful group differences in objective cognition or health care utilization at any time points and the treatment effect for QoL diminished by 6 months. The virtual intervention demonstrated feasibility but did not significantly improve outcomes compared with controls. Within-group analysis found improvements in QoL for both H-V and H-IP.

DISCUSSION

This study replicated the effectiveness of the HOBSCOTCH program in improving QoL for PWE. The study was conducted prior to the COVID-19 pandemic, but the distance-delivered intervention may be particularly well-suited for the current environment. Future research will explore modifications designed to improve the efficacy of H-V and the sustainability of HOBSCOTCH's treatment effect.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov (NCT02394509).

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that in-person HOBSCOTCH delivery improved subjective measures of cognition in persons with epilepsy.

Understanding the sustainment of population health programmes from a whole-of-system approach

BACKGROUND

Population health prevention programmes are needed to reduce the prevalence of chronic diseases. Nevertheless, sustaining programmes at a population level is challenging. Population health is highly influenced by social, economic and political environments and is vulnerable to these system-level changes. The aim of this research was to examine the factors and mechanisms contributing to the sustainment of population prevention programmes taking a systems thinking approach.

METHODS

We conducted a qualitative study through interviews with population health experts working within Australian government and non-government agencies experienced in sustaining public health programs at the local, state or national level (n = 13). We used a deductive thematic approach, grounded in systems thinking to analyse data.

RESULTS

We identified four key barriers affecting program sustainment: 1) short term political and funding cycles; 2) competing interests; 3) silo thinking within health service delivery; and 4) the fit of a program to population needs. To overcome these barriers various approaches have centred on the importance of long-range planning and resourcing, flexible program design and management, leadership and partnerships, evidence generation, and system support structures.

CONCLUSION

This study provides key insights for overcoming challenges to the sustainment of population health programmes amidst complex system-wide changes.

Universal Screening in Positive School Mental Health Using the ASEBA Methodology for Teachers: A Pilot Epidemiological Study

School-based detection and intervention are critical components in ensuring positive mental health in children, with teachers playing an essential role in assessing students’ well-being. The current research aims to be a pilot epidemiological study on positive school mental health in Malaga, Spain, using the Achenbach System of Empirically Based Assessment (ASEBA). Data were collected in the COVID-19 pre-pandemic setting, using the Caregiver-Teacher Report Form (C-TRF) and the Teacher Report Form (TRF) in a sample of 420 children, who were between 5 and 8 years old at the time of the data collection. In 5-year-old children, the DSM-oriented scale with the highest clinical prevalence corresponds to attention deficit and hyperactivity problems (1.13%). In this same sub-sample, clinical levels of externalizing problems (4.52%) were non-significantly more common than internalizing conditions (1.69%). As for children between 6 and 8 years old, the DSM-oriented scale with the highest prevalence of clinical scores corresponds to anxiety problems (4.12%) and conduct problems (2.88%). Clinical levels of externalizing problems (9.47%) were non-significantly more prevalent than internalizing problems (6.58%). The results present 95% confidence intervals prevalence data in the general population and sex-differentiated descriptive statistics. The results are discussed according to their implication for school mental health.

Implementation of a Care Manager Organization and Its Association with Health Care Contacts and Psychotherapy: A Register-Based Study of Real-Life Outcomes at Primary Health Care Centers in Sweden

Background

A care manager organization, based on a collaborative care model, was implemented in the primary health care service in Region Västra Götaland, Sweden, to improve the care of persons with common mental disorders (CMDs). We aimed to investigate the association between the care manager organization and number of health care contacts, and the extent of psychotherapy among female and male patients with CMD compared to primary health care centers (PHCCs) offering usual care, in the introductory year of implementation with one year follow-up.

Methods

This register-based study included all PHCCs in the region, which were analyzed in two groups depending on their care manager status. The study periods were 2015.09.01–2016.08.31 (first year) and 2016.09.01–2017.08.31 (second year). Data on health care contacts and psychotherapy per PHCC were obtained from a health care register. The mean number and proportion of visits to different health care professionals, and the proportion of patients with short-term versus long-term psychotherapy were measured. A linear mixed-effects model for cross-sectional and longitudinal analysis was implemented as well as a generalized linear regression model for possible interaction effects of PHCC characteristic on care manager status and outcomes.

Results

PHCCs with a care manager organization had more nurse contacts (p = 0.001 for both year 1 and year 2) compared to PHCCs with usual care. PHCCs with usual care had a significantly lower proportion of visits to psychotherapists and a higher proportion of both female and male patients receiving short-term psychotherapy (1–5 sessions vs ≥6) over time and compared to PHCCs with a care manager organization.

Conclusion

With a care manager organization, nurse contacts increased at the PHCCs. However, this did not negatively influence the visits to a general practitioner and to psychotherapists. This evaluation showed that the care manager organization at PHCC level implies higher accessibility and sustainability of care for up to two years after implementation.

Ensuring sustainability of polio immunization in health system transition: lessons from the polio eradication initiative in Indonesia

BACKGROUND

Sustaining an effective evidence-based health intervention will maximize its impact on public health. Political and governmental reforms impacted on immunization program sustainability both positively and negatively. This study aims to explore the sustainability of polio immunization in a decentralized health system taking lessons learned from a polio eradication initiative in Indonesia.

METHODS

We collected qualitative data through in-depth interviews with 27 key informants from various backgrounds at district, provincial, and national levels, consisting of frontline workers, managers, and Non-government Organizations (NGOs). We conducted thematic analysis and triangulated using document reviews. We also conducted member checking and peer debriefing to ensure trustworthiness.

RESULTS

Competing priority was identified as the significant challenge to sustain government commitment for polio immunization and AFP surveillance during the transition toward a decentralized health system. Variation of local government capacities has also affected immunization delivery and commitment at the sub-national level government. The government reform has led to a more democratic society, facilitating vaccine rejection and hesitancy. The multi-sector partnership played a significant role in maintaining polio immunization coverage. Strong and continuous advocacy and campaign were essential to raising awareness of the community and policymakers to keep polio in the agenda and to maintain the high polio immunization coverage.

CONCLUSION

Competing priority was the major factor affecting high polio immunization coverage during the decentralization transition. Strong advocacy is needed at every level, from district to national level, to keep polio immunization prioritized.

A tale of 'politics and stars aligning': analysing the sustainability of scaled up digital tools for front-line health workers in India

INTRODUCTION

India has become a lighthouse for large-scale digital innovation in the health sector, particularly for front-line health workers (FLHWs). However, among scaled digital health solutions, ensuring sustainability remains elusive. This study explores the factors underpinning scale-up of digital health solutions for FLHWs in India, and the potential implications of these factors for sustainability.

METHODS

We assessed five FLHW digital tools scaled at the national and/or state level in India. We conducted in-depth interviews with implementers, technology and technical partners (n=11); senior government stakeholders (n=5); funders (n=1) and evaluators/academics (n=3). Emergent themes were grouped according to a broader framework that considered the (1) digital solution; (2) actors; (3) processes and (4) context.

RESULTS

The scale-up of digital solutions was facilitated by their perceived value, bounded adaptability, support from government champions, cultivation of networks, sustained leadership and formative research to support fit with the context and population. However, once scaled, embedding digital health solutions into the fabric of the health system was hampered by challenges related to transitioning management and ownership to government partners; overcoming government procurement hurdles; and establishing committed funding streams in government budgets. Strong data governance, continued engagement with FLHWs and building a robust evidence base, while identified in the literature as critical for sustainability, did not feature strongly among respondents. Sustainability may be less elusive once there is more consensus around the roles played between national and state government actors, implementing and technical partners and donors.

CONCLUSION

The use of digital tools by FLHWs offers much promise for improving service delivery and health outcomes in India. However, the pathway to sustainability is bespoke to each programme and should be planned from the outset by investing in people, relationships and service delivery adjustments to navigate the challenges involved given the dynamic nature of digital tools in complex health systems.

School-based interventions to prevent anxiety, depression and conduct disorder in children and young people: a systematic review and network meta-analysis

Background

Schools in the UK increasingly have to respond to anxiety, depression and conduct disorder as key causes of morbidity in children and young people.

Objective

The objective was to assess the comparative effectiveness of educational setting-based interventions for the prevention of anxiety, depression and conduct disorder in children and young people.

Design

This study comprised a systematic review, a network meta-analysis and an economic evaluation.

Data sources

The databases MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), PsycInfo® (American Psychological Association, Washington, DC, USA) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to 4 April 2018, and the NHS Economic Evaluation Database (NHS EED) was searched on 22 May 2019 for economic evaluations. No language or date filters were applied.

Main outcomes

The main outcomes were post-intervention self-reported anxiety, depression or conduct disorder symptoms.

Review methods

Randomised/quasi-randomised trials of universal or targeted interventions for the prevention of anxiety, depression or conduct disorder in children and young people aged 4–18 years were included. Screening was conducted independently by two reviewers. Data extraction was conducted by one reviewer and checked by a second. Intervention- and component-level network meta-analyses were conducted in OpenBUGS. A review of the economic literature and a cost–consequence analysis were conducted.

Results

A total of 142 studies were included in the review, and 109 contributed to the network meta-analysis. Of the 109 studies, 57 were rated as having an unclear risk of bias for random sequence generation and allocation concealment. Heterogeneity was moderate. In universal secondary school settings, mindfulness/relaxation interventions [standardised mean difference (SMD) –0.65, 95% credible interval (CrI) –1.14 to –0.19] and cognitive–behavioural interventions (SMD –0.15, 95% CrI –0.34 to 0.04) may be effective for anxiety. Cognitive–behavioural interventions incorporating a psychoeducation component may be effective (SMD –0.30, 95% CrI –0.59 to –0.01) at preventing anxiety immediately post intervention. There was evidence that exercise was effective in preventing anxiety in targeted secondary school settings (SMD –0.47, 95% CrI –0.86 to –0.09). There was weak evidence that cognitive–behavioural interventions may prevent anxiety in universal (SMD –0.07, 95% CrI –0.23 to 0.05) and targeted (SMD –0.38, 95% CrI –0.84 to 0.07) primary school settings. There was weak evidence that cognitive–behavioural (SMD –0.04, 95% CrI –0.16 to 0.07) and cognitive–behavioural + interpersonal therapy (SMD –0.18, 95% CrI –0.46 to 0.08) may be effective in preventing depression in universal secondary school settings. Third-wave (SMD –0.35, 95% CrI –0.70 to 0.00) and cognitive–behavioural interventions (SMD –0.11, 95% CrI –0.28 to 0.05) incorporating a psychoeducation component may be effective at preventing depression immediately post intervention. There was no evidence of intervention effectiveness in targeted secondary, targeted primary or universal primary school settings post intervention. The results for university settings were unreliable because of inconsistency in the network meta-analysis. A narrative summary was reported for five conduct disorder prevention studies, all in primary school settings. None reported the primary outcome at the primary post-intervention time point. The economic evidence review reported heterogeneous findings from six studies. Taking the perspective of a single school budget and based on cognitive–behavioural therapy intervention costs in universal secondary school settings, the cost–consequence analysis estimated an intervention cost of £43 per student.

Limitations

The emphasis on disorder-specific prevention excluded broader mental health interventions and restricted the number of eligible conduct disorder prevention studies. Restricting the study to interventions delivered in the educational setting may have limited the number of eligible university-level interventions.

Conclusions

There was weak evidence of the effectiveness of school-based, disorder-specific prevention interventions, although effects were modest and the evidence not robust. Cognitive–behavioural therapy-based interventions may be more effective if they include a psychoeducation component.

Future work

Future trials for prevention of anxiety and depression should evaluate cognitive–behavioural interventions with and without a psychoeducation component, and include mindfulness/relaxation or exercise comparators, with sufficient follow-up. Cost implications must be adequately measured.

Study registration

This study is registered as PROSPERO CRD42016048184.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Rethinking sustainability in childhood obesity prevention interventions: learning from South Australia's Obesity Prevention and Lifestyle (OPAL) Programme

Increases in childhood obesity have occurred across a relatively short time-period, yet childhood obesity prevention is a longer-term game. Programmes have only identified population-level changes after 12 years of on-the-ground activity [Romon et al.]. Community stakeholders can impact the success of public health interventions [Ganter et al.; Lee et al.] and they have been identified as a critical success factor for programme sustainability [Schell et al.]. Qualitative research with stakeholders (n = 59) provides their insights and understandings of the sustainability of OPAL, a South Australian childhood obesity prevention programme. Stakeholders identified activities that they thought contributed to improved sustainability of action such as embedding obesity prevention into organizational policy and plans; and installation of infrastructure within communities to modify physical environments. In contrast, there was little appetite for sustaining OPAL or other formulations of a childhood obesity prevention programme. This research has implications for planning and implementation of community-based childhood obesity prevention initiatives when considering the balance of the portfolio of activities for implementation.

Program sustainability post PEPFAR direct service support in the Western Cape, South Africa

BACKGROUND

Public health practitioners have little guidance around how to plan for the sustainability of donor sponsored programs after the donor withdraws. The literature is broad and provides no consensus on a definition of sustainability. This study used a mixed-methods methodology to assess program sustainability factors to inform donor-funded programs.

METHODS

This study examined 61 health facilities in the Western Cape, South Africa, supported by four PEPFAR-funded non-governmental organizations from 2007 to 2012. Retention in care (RIC) was used to determine health facility performance. Sustainability was measured by comparing RIC during PEPFAR direct service (20072012), to RIC in the post PEPFAR period (2013 to 2015). Forty-three semi-structured in-depth interviews were conducted with key informants. The qualitative data were used to examine how predictor variables were operationalized at a health facility and NGO level.

RESULTS

Our qualitative results suggest the following lessons for the sustainability of future programs: Sufficient and stable resources (i.e., financial, human resources, technical expertise, equipment, physical space)Investment in organizations that understand the local context and have strong relationships with local government.Strong leadership at a health facility levelJoint planning/coordination and formalized skill transferLocal positive perceived value of the programPartnerships.

CONCLUSION

Sustainability is complex, context dependent, and is reliant on various processes and outcomes. This study suggests additional health facility and community level staff should be employed in the health system to ensure RIC sustainability. Sustainability requires joint donor coordination with experienced local organizations with strong managers before during and after program implementation. If the program is as large as the South African HIV effort some dedicated additional resources in the long term would be required.

Improving HPV Vaccination Rates: A Stepped-Wedge Randomized Trial

OBJECTIVES

To evaluate the effectiveness of a stepped-wedge randomized trial of Development of Systems and Education for Human Papillomavirus Vaccination (DOSE HPV), a multilevel intervention.

METHODS

DOSE HPV is a 7-session program that includes interprofessional provider education, communication training, data feedback, and tailored systems change. Five primary care pediatric and/or family medicine practices completed interventions between 2016 and 2018; all chose to initiate vaccination at ages 9 to 10. We compared vaccination rates in the preintervention, intervention, and postintervention periods among 9- to 17-year-olds using random-effects generalized linear regression models appropriate for stepped-wedge design, accounting for calendar time and clustering of patients by providers and clinic. Outcomes included (1) the likelihood that eligible patients would receive vaccination during clinic visits; (2) the likelihood that adolescents would complete the series by age 13; and (3) the cumulative effect on population-level vaccine initiation and completion rates. Postintervention periods ranged from 6 to 18 months.

RESULTS

In the intervention and postintervention periods, the adjusted likelihood of vaccination at an eligible visit increased by >10 percentage points for ages 9 to 10 and 11 to 12, and completion of the vaccine series by age 13 increased by 4 percentage points (P < .001 for all comparisons). Population-level vaccine initiation coverage increased from 75% (preintervention) to 84% (intervention) to 90% (postintervention), and completion increased from 60% (preintervention) to 63% (intervention) to 69% (postintervention).

CONCLUSIONS

Multilevel interventions that include provider education, data feedback, tailored systems changes, and early initiation of the human papillomavirus vaccine series may improve vaccine series initiation and completion beyond the conclusion of the intervention period.

Sustainable by design: a systematic review of factors for health promotion program sustainability

Background

Sustaining health promotion programs (HPP) is critical to maintain their intended health benefits, community capacity, and to optimize resources and investment. However, not all programs are sustained beyond their initial implementation period. This is partly due to uncertainty regarding sustainability: lack of a clear definition; infrequent use of a sustainability framework; and lack of understanding of the factors that influence sustainability. The aim of this systematic review is to identify barriers and facilitators that promote or inhibit the sustainability of HPP, particularly those that can be considered in program planning.

Methods

Two search strategies were used: 1) electronic database searching; and 2) grey literature searching. Inclusion criteria included papers published since 1998, in English, focusing on the sustainability of HPP that explicitly used a sustainability framework and specifically reported on facilitators and barriers to sustainability. Exclusion criteria included papers that addressed environmental, system or sector sustainability. Quality assessment was conducted on all included papers and a quality assessment tool was developed for grey literature. Data analysis included a thematic analysis, using an a priori framework to initially code barriers and facilitators, which were then grouped into factors for HPP sustainability. Factors were then analyzed for frequency, importance, and relevance, and categorized into one of three tiers.

Results

Sixteen papers were included in this review. Eleven definitions of sustainability and 13 sustainability frameworks were used. A total of 83 barriers and 191 facilitators were identified and categorized into 14 factors: nine from the a priori framework, and five additional ones based on the results of our analysis. Tier 1 factors were the most important for sustainability with organizational capacity scoring the highest; tier 3, the least important.

Conclusion

This review provides clarity regarding existing definitions of sustainability and sustainability frameworks. It identifies fourteen factors that influence program sustainability, which practitioners can consider when planning, developing and implementing HPP. In addition, it is important for practitioners to clearly articulate program elements that should be sustained, define sustainability as it relates to the context of their program, select a sustainability framework to guide their work, and consider these factors for sustainability.

Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart

BACKGROUND

Oshikhandass is a rural village in northern Pakistan where a 1989-1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality. Intensive surveillance, active community health education and child health interventions were delivered in 1989-1996; here we assess improvements in under-5 mortality, diarrhea, and pneumonia over this period and 15 years later.

METHODS

Two prospective open-cohort studies in Oshikhandass from 1989 to 1996 (Study 1) and 2011-2014 (Study 2) enrolled all children under age 60 months. Study staff trained using WHO guidelines, conducted weekly household surveillance and promoted knowledge on causes and management of diarrhea and pneumonia. Information about household characteristics and socioeconomic status was collected. Hurdle models were constructed to examine putative risk factors for diarrhea and pneumonia.

RESULTS

Against a backdrop of considerable change in the socioeconomic status of the community, under-5 mortality, which declined over the course of Study 1 (from 114.3 to 79.5 deaths/1000 live births (LB) between 1989 and 1996), exceeded Sustainable Development Goal 3 by Study 2 (19.8 deaths/ 1000 LB). Reductions in diarrhea prevalence (20.3 to 2.2 days/ Child Year [CY]), incidence (2.1 to 0.5 episodes/ CY), and number of bloody diarrhea episodes (18.6 to 5.2%) seen during Study 1, were sustained in Study 2. Pneumonia incidence was 0.5 episodes /CY in Study 1 and 0.2/CY in Study 2; only 5% of episodes were categorized as severe or very severe in both studies. While no individual factors predicted a statistically significant difference in diarrhea or pneumonia episodes, the combined effect of water, toilet and housing materials was associated with a significant decrease in diarrhea; higher household income was the most protective factor for pneumonia in Study 1.

CONCLUSIONS

We report a 4-fold decrease in overall childhood mortality, and a 2-fold decrease in childhood morbidity from diarrhea and pneumonia in a remote rural village in Pakistan between 1989 and 2014. We conclude that significant, sustainable improvements in child health may be achieved through improved socioeconomic status and promoting interactions between locally engaged health workers and the community, but that continued efforts are needed to improve health worker training, supervision, and the rational use of medications.

TRIAL REGISTRATION

Not Applicable.

Evaluating the sustainability of differentiated service delivery interventions for stable ART clients in sub-Saharan Africa: a systematic review protocol

INTRODUCTION

In 2015, WHO recommended immediate treatment for people living with HIV (PLHIV). As a result, the number of PLHIV needing antiretroviral therapy (ART) in sub-Saharan Africa (SSA) doubled from 12 million to over 25 million. This put a strain on already weak health systems and inspired the exploration of innovative service delivery models-differentiated service delivery (DSD). In DSD, services are tailored according to client clinical type and offer much-needed improvement in efficiency. The potential of achieving good outcomes for both clients and the health system plus the promise of sustainability motivates DSD promotion especially in low-income and middle-income countries. This review aims to evaluate the sustainability of DSD interventions.

METHODS AND ANALYSIS

We will systematically review peer-reviewed English literature published between 2000 and 2019 identified by searching PubMed and EMBASE databases. Main inclusion criteria comprise studies describing DSD interventions conducted in SSA focused on stable adult ART clients, whether described alone or compared with clinic-based service delivery. Quality of included studies will be assessed employing the Down and Black's and Joanne Briggs Institute checklists for quantitative and qualitative studies, respectively. We will apply a comprehensive sustainability framework including 40 individual constructs to evaluate, score and rank each intervention for sustainability. Narrative and quantitative synthesis will be conducted as appropriate.

ETHICS AND DISSEMINATION

No ethical approval is required for this study as it is a review of published or publicly available data. Review results will be published in a peer-reviewed journal and presented at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42019120891.

Advancing successful implementation of task-shifted mental health care in low-resource settings (BASIC): protocol for a stepped wedge cluster randomized trial

BACKGROUND

The mental health treatment gap-the difference between those with mental health need and those who receive treatment-is high in low- and middle-income countries. Task-shifting has been used to address the shortage of mental health professionals, with a growing body of research demonstrating the effectiveness of mental health interventions delivered through task-shifting. However, very little research has focused on how to embed, support, and sustain task-shifting in government-funded systems with potential for scale up. The goal of the Building and Sustaining Interventions for Children (BASIC) study is to examine implementation policies and practices that predict adoption, fidelity, and sustainment of a mental health intervention in the education sector via teacher delivery and the health sector via community health volunteer delivery.

METHODS

BASIC is a Hybrid Type II Implementation-Effectiveness trial. The study design is a stepped wedge, cluster randomized trial involving 7 sequences of 40 schools and 40 communities surrounding the schools. Enrollment consists of 120 teachers, 120 community health volunteers, up to 80 site leaders, and up to 1280 youth and one of their primary guardians. The evidence-based mental health intervention is a locally adapted version of Trauma-focused Cognitive Behavioral Therapy, called Pamoja Tunaweza. Lay counselors are trained and supervised in Pamoja Tunaweza by local trainers who are experienced in delivering the intervention and who participated in a Train-the-Trainer model of skills transfer. After the first sequence completes implementation, in-depth interviews are conducted with initial implementing sites' counselors and leaders. Findings are used to inform delivery of implementation facilitation for subsequent sequences' sites. We use a mixed methods approach including qualitative comparative analysis to identify necessary and sufficient implementation policies and practices that predict 3 implementation outcomes of interest: adoption, fidelity, and sustainment. We also examine child mental health outcomes and cost of the intervention in both the education and health sectors.

DISCUSSION

The BASIC study will provide knowledge about how implementation of task-shifted mental health care can be supported in government systems that already serve children and adolescents. Knowledge about implementation policies and practices from BASIC can advance the science of implementation in low-resource contexts.

TRIAL REGISTRATION

Trial Registration: ClinicalTrials.gov Identifier: NCT03243396. Registered 9th August 2017, https://clinicaltrials.gov/ct2/show/NCT03243396.

End-Users and Caregivers' Involvement in Health Interventional Research Carried Out in Geriatric Facilities: A Systematic Review

Public involvement (PI) is of great interest. However, little is known about this topic in the design, development, and/or implementation of health interventions in geriatric facilities. This study aimed to provide a critical overview of the involvement of caregivers and end-users in interventions in these facilities, based on Rifkin’s analytical framework. This systematic review, supplemented by a questionnaire to the corresponding authors, covered non-drug intervention reports targeting nurses, doctors, residents, and their relatives. Articles were published in Pubmed, Medline, Scopus, and Cinahl, from January 2016 to April 2018. Ninety-seven articles were included. The review shows a low level or partial PI in geriatric facilities where it exists. These results are further supported by the authors’ responses to the questionnaire. PI remains uncommon in geriatric institutions and consists of a consumerist model, suggesting the need for improved practices. More efforts are needed to experiment with recommendations to meet the challenges of PI and enhance the public ownership of interventions. The protocol was registered on Prospero under the number CRD42018098504.

The effect of introducing a free breakfast club on eating habits among students at vocational schools

Background

Unhealthy eating habits are a major problem among adolescents. The objective of the study was to assess the effect of a free breakfast club intervention on dietary habits among students at vocational schools.

Methods

The study included students (n = 318) from four vocational schools in Denmark. Food frequency questionnaires were used to measure eating habits at baseline, first, and second follow-up, after 7 and 14 weeks respectively, in a clustered randomized controlled intervention of four months. The effect of the intervention was evaluated through self-reported frequencies of breakfast intake, intake of whole grain products for breakfast and intake of unhealthy snacking in the morning. The outcome measures were daily breakfast intake (yes/no), daily intake of whole grain for breakfast (yes/no), and unhealthy snacking on school day mornings (yes/no).

Results

The proportion of students who had breakfast every school day increased significantly in the intervention schools from baseline to the first follow-up compared to the control group (OR: 3.77; P = 0.0149). The effect was attenuated at the second follow-up. The intake of whole grain products for breakfast increased significantly more among students in intervention schools compared to students in control schools both at first (OR: 4.13; P = 0.0079) and second follow-up (OR: 3.27; P = 0.0317). No significant change in unhealthy snacking was found.

Conclusion

Provision of free breakfast at vocational schools can improve the dietary quality of breakfast and decrease breakfast skipping. However, the sustainability of the intervention is a critical issue that needs to be further studied and addressed.

Trial registration

ISRCTN11265280. Registered 20 November 2018 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6701-9) contains supplementary material, which is available to authorized users.

Cost-effectiveness of community-based childhood obesity prevention interventions in Australia

OBJECTIVES

The objective of this study is to examine, from a limited societal perspective, the cost-effectiveness of community-based obesity prevention interventions (CBIs)-defined as a programme of community-level strategies to promote healthy eating and physical activity for Australian children (aged 5-18 years).

METHODS

The effectiveness of CBIs was determined by undertaking a literature review and meta-analysis. Commonly implemented strategies to increase physical activity and improve nutrition were costed (in 2010 Australian dollars) to determine the average cost of a generic programme. A multiple cohort Markov model that simulates diseases associated with overweight and obesity was used to estimate the health benefits, measured as health-adjusted life years (HALYs) and healthcare-related cost offsets from diseases averted due to exposure to the intervention. Health and cost outcomes were estimated over the lifetime of the target population. Monte-Carlo simulation was used to assess second-order uncertainty of input parameters to estimate mean incremental cost-effectiveness ratios (ICER) with 95% uncertainty intervals (UIs). Scenario analyses tested variations in programme intensity, target population, and duration of effect.

RESULTS

The meta-analysis revealed a small but significant difference in BMI z-score (mean difference of - 0.07 (95% UI: - 0.13 to - 0.01)) favouring the CBI community compared with the control. The estimated net cost of implementing CBIs across all local government areas (LGAs) in Australia was AUD426M (95% UI: AUD3M to AUD823M) over 3 years. This resulted in 51,792 HALYs gained (95% UI: 6816 to 96,972) over the lifetime of the cohort. The mean ICER was AUD8155 per HALY gained (95% UI: AUD237 to AUD81,021), with a 95% probability of being cost-effective at a willingness to pay threshold of AUD50,000 per HALY.

CONCLUSIONS

CBIs are cost-effective obesity prevention initiatives; however, implementation across Australia will be (relatively) expensive when compared with current investments in preventive health.

The "Som la Pera" intervention: sustainability capacity evaluation of a peer-led social-marketing intervention to encourage healthy lifestyles among adolescents

Sustainability capacity, always considered a challenge, is the ability to maintain effective long-term intervention in a community. The aim of the study was to improve the sustainability capacity of effective "Som la Pera," a school-based, peer-led, social-marketing intervention that encourages healthy diet and physical activity, in low socioeconomic adolescents from Spain. The sustainability capacity was analyzed by a "programme sustainability assessment tool (PSAT)" comprising eight domains: political support, funding stability, partnerships, organizational capacity, programme evaluation, programme adaptation, communications, and strategic planning. Each domain was evaluated from 1 (no or to a small extent) to 7 points (to a great extent). The final score for sustainability capacity was the mean of the eight domain scores. The PSAT was assessed by nine professionals (researchers, staff members, and stakeholders) at two periods during intervention implementation: end of the first year (January 2015) and end of the second year (September 2015). At the end of the first year, strategic planning (4.43 ± 1.98) and funding stability (4.38 ± 1) were considered deficient domains, and at the end of the second year, these domains had improved by 1.67 points (p =.043) and 0.59 points (p = .159), respectively. The funding stability increase was not significant because only one of the five specific items, "policies implemented to ensure sustained funding," improved by 1.08 points (p = .036). The sustainability capacity final score was 5.93 ± 1.13. The sustainability capacity assessment during the intervention allows its improvement before the programme expires, ensuring the long-term implementation of the "Som la Pera" intervention programme to encourage healthy lifestyles in adolescents.

Changes in Sedentary and Active Lifestyle, Diet Quality and Body Composition Nine Months after an Education Program in Polish Students Aged 11⁻12 Years: Report from the ABC of Healthy Eating Study

The sustainability of education focused on improving the dietary and lifestyle behaviours of teenagers has not been extensively studied. The aim of this study was to determine the sustainability of diet-related and lifestyle-related school-based education on sedentary and active lifestyle, diet quality and body composition of Polish pre-teenagers in a medium-term follow-up study. An education-based intervention study was carried out on 464 students aged 11⁻12 years (educated/control group: 319/145). Anthropometric measurements were taken and body mass index (BMI) and waist-to-height ratios (WHtR) were calculated, both at the baseline and after nine months. Dietary data from a short-form food frequency questionnaire (SF-FFQ4PolishChildren) were collected. Two measures of lifestyle (screen time, physical activity) and two diet quality scores (pro-healthy, pHDI, and non-healthy, nHDI) were established. After nine months, in the educated group (vs. control) a significantly higher increase was found in nutrition knowledge score (mean difference of the change: 1.8 points) with a significantly higher decrease in physical activity (mean difference of the change: -0.20 points), nHDI (-2.3% points), the z-WHtR (-0.18 SD), and the z-waist circumference (-0.13 SD). Logistic regression modelling with an adjustment for confounders revealed that after nine months in the educated group (referent: control), the chance of adherence to a nutrition knowledge score of at least the median was over 2 times higher, and that of the nHDI category of at least the median was significantly lower (by 35%). In conclusion, diet-related and lifestyle-related school-based education from an almost one-year perspective can reduce central adiposity in pre-teenagers, despite a decrease in physical activity and the tendency to increase screen time. Central adiposity reduction can be attributed to the improvement of nutrition knowledge in pre-teenagers subjected to the provided education and to stopping the increase in unhealthy dietary habits.

Beginning with high value care in mind: A scoping review and toolkit to support the content, delivery, measurement, and sustainment of high value care

OBJECTIVE

To create a shared vision for the content, delivery, measurement, and sustainment of patient-centered high value care.

METHODS

We performed a scoping review and translated findings into toolkit for system leaders. For our scoping review, we searched Medline, 2005-November 2015, for literature on patient-centered care (PCC) and its relationship to a high value care change model. We supplemented searches with key author, Google Scholar, and key website searches. One author reviewed all titles, abstracts, and articles for inclusion; another reviewed a random 20%. To develop our toolkit, we translated evidence into simple, actionable briefs on key topics and added resources. We then iteratively circulated briefs and the overall toolkit to potential users, making updates as needed.

RESULTS

In our scoping review, we found multiple interventions and measures to support the components of PCC and our change model. We found little on the overall effects of PCC or how PCC creates value. Potential users reported our toolkit was simple, understandable, thorough, timely, and likely to be globally useful.

CONCLUSIONS

Considerable evidence supports patient-centered high value care and a toolkit garnered enthusiasm.

PRACTICE IMPLICATIONS

The toolkit is ready for use, but needs comparison to other approaches.

The role of psychological science in efforts to improve cardiovascular medication adherence

Poor adherence to cardiovascular disease medications carries significant psychological, physical, and economic costs, including failure to achieve therapeutic goals, high rates of hospitalization and health care costs, and incidence of death. Despite much effort to design and evaluate adherence interventions, rates of adherence to cardiovascular-related medications have remained relatively stagnant. We identify two major reasons for this: First, interventions have not addressed the time-varying reasons for nonadherence, and 2nd, interventions have not explicitly targeted the self-regulatory processes involved in adherence behavior. Inclusion of basic and applied psychological science in intervention development may improve the efficacy and effectiveness of behavioral interventions to improve adherence. In this article, we use a taxonomy of time-based phases of adherence-including initiation, implementation, and discontinuation-as context within which to review illustrative studies of barriers to adherence, interventions to improve adherence, and self-regulatory processes involved in adherence. Finally, we suggest a framework to translate basic psychological science regarding self-regulation into multicomponent interventions that can address multiple and time-varying barriers to nonadherence across the three adherence phases. The field of psychology is essential to improving medication adherence and associated health outcomes, and concrete steps need to be taken to implement this knowledge in future interventions. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Improving the sustainability of hospital-based interventions: a study protocol for a systematic review

INTRODUCTION

Sustaining effective interventions in hospital environments is essential to improving health outcomes, and reducing research waste. Current evidence suggests many interventions are not sustained beyond their initial delivery. The reason for this failure remains unclear. Increasingly research is employing theoretical frameworks and models to identify critical factors that influence the implementation of interventions. However, little is known about the value of these frameworks on sustainability. The aim of this review is to examine the evidence regarding the use of theoretical frameworks to maximise effective intervention sustainability in hospital-based settings in order to better understand their role in supporting long-term intervention use.

METHODS AND ANALYSIS

Systematic review. We will systematically search the following databases: Medline, AMED, CINAHL, Embase and Cochrane Library (CENTRAL, CDSR, DARE, HTA). We will also hand search relevant journals and will check the bibliographies of all included studies. Language and date limitations will be applied. We will include empirical studies that have used a theoretical framework (or model) and have explicitly reported the sustainability of an intervention (or programme). One reviewer will remove obviously irrelevant titles. The remaining abstracts and full-text articles will be screened by two independent reviewers to determine their eligibility for inclusion. Disagreements will be resolved by discussion, and may involve a third reviewer if required. Key study characteristics will be extracted (study design, population demographics, setting, evidence of sustained change, use of theoretical frameworks and any barriers or facilitators data reported) by one reviewer and cross-checked by another reviewer. Descriptive data will be tabulated within evidence tables, and key findings will be brought together within a narrative synthesis.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as no primary data will be collected. Dissemination of results will be through peer-reviewed journal publications, presentation at an international conference and social media.

PROSPERO REGISTRATION NUMBER

CRD42017081992.

Promoção da saúde na Atenção Primária à Saúde: sistematização de desafios e estratégias intersetoriais

RESUMO Foi realizada revisão da literatura com o intuito de sistematizar o conhecimento produzido no campo da promoção da saúde com ênfase nos desafios e estratégias para implementação da intersetorialidade. As bases de dados consultadas foram Lilacs, SciELO, Web of Science e Science Direct; e identificadas publicações referentes ao período compreendido entre 2006 e 2017. O corpus contou com 28 artigos, sendo analisados os aspectos relacionados com os resultados dos estudos. Verificou-se que eles têm destacado a discussão de fragilidades contextuais relacionadas com aspectos gerenciais e operacionais das intervenções para promoção da saúde, assim como com estratégias adotadas para fomentar a implementação e gestão de ações intersetoriais. Conclui-se que são necessários investimentos em estudos de caso que permitam analisar intervenções concretas direcionadas à promoção da saúde, agregar novas explicações e estabelecer coerência com a complexidade dos distintos contextos no âmbito da Atenção Primária à Saúde.

Outcomes of an electronic social network intervention with neuro-oncology patient family caregivers

INTRODUCTION

Informal family caregivers (FCG) are an integral and crucial human component in the cancer care continuum. However, research and interventions to help alleviate documented anxiety and burden on this group is lacking. To address the absence of effective interventions, we developed the electronic Support Network Assessment Program (eSNAP) which aims to automate the capture and visualization of social support, an important target for overall FCG support. This study seeks to describe the preliminary efficacy and outcomes of the eSNAP intervention.

METHODS

Forty FCGs were enrolled into a longitudinal, two-group randomized design to compare the eSNAP intervention in caregivers of patients with primary brain tumors against controls who did not receive the intervention. Participants were followed for six weeks with questionnaires to assess demographics, caregiver burden, anxiety, depression, and social support. Questionnaires given at baseline (T1) and then 3-weeks (T2), and 6-weeks (T3) post baseline questionnaire.

RESULTS

FCGs reported high caregiver burden and distress at baseline, with burden remaining stable over the course of the study. The intervention group was significantly less depressed, but anxiety remained stable across groups.

CONCLUSIONS

With the lessons learned and feedback obtained from FCGs, this study is the first step to developing an effective social support intervention to support FCGs and healthcare providers in improving cancer care.

A description of health care system factors in the implementation of universal weight management services for children with overweight or obesity: case studies from Queensland and New South Wales, Australia

Background

The prevalence of childhood obesity poses an urgent global challenge. The World Health Organization (WHO) Commission on Ending Childhood Obesity recommends the provision of appropriate family-based, lifestyle weight management services through universal health care to support families of children with overweight or obesity; however, there are few examples of their implementation ‘at scale’. The purpose of this research was to compare and contrast the impact of system and organisational factors on the implementation of childhood obesity management services within two Australian States (New South Wales and Queensland) to comprehensively describe their influence on the achievement of the WHO recommendation.

Methods

Purposeful stratified sampling was used to select health service study sites (n = 16) representative of program implementation (none, discontinued, repeated) and geographic location within each State. Within each health service site, staff involved in program delivery, co-ordination and management roles participated (n = 39). An additional 11 staff involved in implementation at State level also participated. The Consolidated Framework for Implementation Research (CFIR) was used to develop interview scripts. Telephone interviews were recorded and transcribed. Transcripts were thematically coded and scored according to CFIR constructs and rating rules to identify enablers and barriers to implementation according to sample characteristics.

Results

New South Wales achieved ongoing implementation; Queensland did not. Enablers included a quality evidence-based program, State government recognition of the urgency of the health issue and a commitment to address it, formally appointed and funded internal implementation leaders, strong communication and reporting at all levels. Barriers included the complexity of the health issue, in particular a lack of clear roles and responsibilities for local health service delivery, inadequate ongoing funding and challenges in meeting the diverse needs of families.

Conclusions

This research is an important progression of the evidence base in relation to the translation of childhood obesity management trials into routine health service delivery. Understanding enablers and barriers to program implementation ‘at scale’ is imperative to inform future planning and investment by Australia and WHO member states to meet their commitment to deliver childhood weight management services as part of universal health coverage.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0801-2) contains supplementary material, which is available to authorized users.

Understanding the dynamics of sustainable change: A 20-year case study of integrated health and social care

BACKGROUND

Change initiatives face many challenges, and only a few lead to long-term sustainability. One area in which the challenge of achieving long-term sustainability is particularly noticeable is integrated health and social care. Service integration is crucial for a wide range of patients including people with complex mental health and social care needs. However, previous research has focused on the initiation, resistance and implementation of change, while longitudinal studies remain sparse. The objective of this study was therefore to gain insight into the dynamics of sustainable changes in integrated health and social care through an analysis of local actions that were triggered by a national policy.

METHODS

A retrospective and qualitative case-study research design was used, and data from the model organisation's steering-committee minutes covering 1995-2015 were gathered and analysed. The analysis generated a narrative case description, which was mirrored to the key elements of the Dynamic Sustainability Framework (DSF).

RESULTS

The development of inter-sectoral cooperation was characterized by a participatory approach in which a shared structure was created to support cooperation and on-going quality improvement and learning based on the needs of the service user. A key management principle was cooperation, not only on all organisational levels, but also with service users, stakeholder associations and other partner organisations. It was shown that all these parts were interrelated and collectively contributed to the creation of a structure and a culture which supported the development of a dynamic sustainable health and social care.

CONCLUSION

This study provides valuable insights into the dynamics of organizational sustainability and understanding of key managerial actions taken to establish, develop and support integration of health and social care for people with complex mental health needs. The service user involvement and regular reviews of service users' needs were essential in order to tailor services to the needs. Another major finding was the importance of continuously adapting the content of the change to suit its context. Hence, continuous refinement of the change content was found to be more important than designing the change at the pre-implementation stage.

Examination of sustainability indicators for fall prevention strategies in three states

With 1-in-4 older adults suffering a fall each year, fall prevention efforts have emerged as a public health priority. Multi-level, evidence-based fall prevention programs have been promoted by the CDC and other government agencies. To ensure participants and communities receive programs' intended benefits, organizations must repeatedly deliver the programs over time and plan for program sustainability as part of 'scaling up' the initiative. The State Falls Prevention Project (SFPP) began in 2011 when the CDC provided 5 years of funding to State Departments of Health in Colorado, New York, and Oregon to simultaneously implement four fall prevention strategies: 1) Tai Chi: Moving for Better Balance; 2) Stepping On; 3) Otago Exercise Program; and 4) STEADI (STopping Elderly Accidents, Deaths, and Injuries) toolkit. Surveys were performed to examine systems change and perceptions about sustainability across states. The purposes of this study were to: 1) examine how funding influenced the capacity for program implementation and sustainability within the SFPP; and 2) assess reported Program Sustainability Assessment Tool (PSAT) scores to learn about how best to sustain fall preventing efforts after funding ends. Data showed that more organizations offered evidence-based fall prevention programs in participants' service areas with funding, and the importance of programming implementation, evaluation, and reporting efforts were likely to diminish once funding concluded. Participants' reported PSAT scores about perceived sustainability capacity did not directly align with previously reported perceptions about PSAT domain importance or modifiability. Findings suggest the importance of grantees to identify potential barriers and enablers influencing program sustainability during the planning phase of the programs.

Sustaining obesity prevention in communities: a systematic narrative synthesis review

Obesity is a global problem for which sustainable solutions are yet to be realized. Community-based interventions have improved obesity-related behaviours and obesity in the short term. Few papers have explored how to make the interventions and their intended outcomes sustainable. The aim of this paper is to identify factors that contribute to the sustainability of community-based obesity prevention interventions and their intended outcomes. A systematic narrative synthesis review was conducted of published community-based obesity prevention interventions to identify factors contributing to intervention sustainability. Data extracted were included study authors' perspectives of intervention success and sustainability. Eighty-one papers met the inclusion criteria, and from these we identified ten factors that contribute to sustainability: resourcing, leadership, workforce development, community engagement, partnerships, policy, communications, adaptability, evaluation and governance. This review of community-based obesity prevention interventions gives rise to optimism that sustainable change is possible. We propose a framework to help practitioners build sustainability into their interventions and report on them so that others can also benefit.

World Cafés Create Healthier Communities for Rural, Older Adults Living With Diabetes

Our global population is aging at an accelerated pace. While the average life expectancy has seen dramatic increases, chronic disease and disability have also increased, with rural America tending to be older, sicker, and poorer. This article examines the implementation and outcomes associated with the community engagement method of the world café that was instrumental in developing a “culture of health” aimed to reduce diabetes-related inequalities for older adults in rural counties of Kentucky. Older residents and the organizations that serve them participated in world cafés, which resulted in collective action due to the wisdom and capacity that evolve from the core element of the method, conversational sharing via multiple small group interactions. Four world cafés were held to explore the desires of the communities related to healthy eating, exercise, smoking cessation, and diabetes care. The world cafés brought a diverse group of community residents and governmental and business leaders to discuss topics that matter to their community, leading to the development of a strategic plan and a scorecard and, ultimately, community empowerment.

Participant and Public Involvement in Refining a Peer-Volunteering Active Aging Intervention: Project ACE (Active, Connected, Engaged)

Background

Evidence for the health benefits of a physically active lifestyle among older adults is strong, yet only a small proportion of older people meet physical activity recommendations. A synthesis of evidence identified "best bet" approaches, and this study sought guidance from end-user representatives and stakeholders to refine one of these, a peer-volunteering active aging intervention.

Methods

Focus groups with 28 older adults and four professional volunteer managers were conducted. Semi-structured interviews were conducted with 9 older volunteers. Framework analysis was used to gauge participants' views on the ACE intervention.

Results

Motives for engaging in community groups and activities were almost entirely social. Barriers to participation were lack of someone to attend with, lack of confidence, fear of exclusion or "cliquiness" in established groups, bad weather, transport issues, inaccessibility of activities, ambivalence, and older adults being "set in their ways". Motives for volunteering included "something to do," avoiding loneliness, the need to feel needed, enjoyment, and altruism. Challenges included negative events between volunteer and recipient of volunteering support, childcare commitments, and high volunteering workload.

Conclusion

Peer-volunteering approaches have great potential for promotion of active aging. The systematic multistakeholder approach adopted in this study led to important refinements of the original ACE intervention. The findings provide guidance for active aging community initiatives highlighting the importance of effective recruitment strategies and of tackling major barriers including lack of motivation, confidence, and readiness to change; transport issues; security concerns and cost; activity availability; and lack of social support.

SALTO - Study Protocol and Rationale of a Community-Oriented Obesity Prevention Program in the Kindergarten

BACKGROUND

The prevalence of early childhood overweight and obesity in Austria has reached average European levels of 20% in boys and 18% in girls. The rationale and study protocol of SALTO, Salzburg Together against Obesity will be presented, which is aimed to assist adults in increasing the rate of 4- to 6-year-old children with a healthy body weight.

METHODS

A controlled longitudinal sequential study design consisting of 14 intervention (IK) and 8 control (CK) kindergarten was used to investigate the effect of actions tailored for teachers and parents on BMI among 4- to 6-year-old children. The study launched in November 2014 was approved by the ethics committee of the University of Salzburg.

RESULTS

681 children, 181 parents (119 mothers, 62 fathers) and 30 teachers were investigated until October 2016. Preliminary analyses revealed that more boys (19%) and fathers (60% IK, 43% CK) were overweight and obese than girls (16%) and mothers (19% IK, 20% CK).

CONCLUSION

The challenges faced by the SALTO staff in the implementation of health-promoting actions in the kindergarten are manifold. The Community-Oriented Core Setting (COCS) intervention approach will show whether the actions will reduce the percentage of obesity and be sustainable in the long term.

An Interdisciplinary Approach to Implementing a Best Practice Guideline in Public Health

This article describes how one Ontario Public Health Unit implemented a best practice guideline throughout the organization and across disciplines to achieve best practice outcomes in the delivery of client-centered care. Integration of evidence-informed practice presents challenges for both implementation and sustainability. Applying a best practice guideline in the public health setting can add to the challenge. To address this, a variety of interventions were applied: building an interdisciplinary team, adapting a Registered Nurses' Association of Ontario Best Practice Guideline to reflect public health practice for nursing and other disciplines, developing a working definition of "client," engaging staff in knowledge translation, developing policy to support practice change, and incorporating client-centered care principles into daily practice. Outcomes indicate that nursing best practice guidelines, specific to client-centered care, can be successfully adapted and applied in public health practice. Considerations include the varied definitions of a "client," the various roles of public health professionals, and engagement of both internal and external clients. Moreover, interdisciplinary staff can apply the principles of client-centered care when working with clients and when engaging in education-, practice-, and policy-level initiatives to support evidence-informed practice.

Advancing understanding of the sustainability of lay health advisor (LHA) programs for African-American women in community settings

Lay health advisor (LHA) programs have made strong contributions towards the elimination of health disparities and are increasingly being implemented to promote health and prevent disease. Developed in collaboration with African-American survivors, the National Witness Project (NWP) is an evidence-based, community-led LHA program that improves cancer screening among African-American women. NWP has been successfully disseminated, replicated, and implemented nationally in over 40 sites in 22 states in diverse community settings, reaching over 15,000 women annually. We sought to advance understanding of barriers and facilitators to the long-term implementation and sustainability of LHA programs in community settings from the viewpoint of the LHAs, as well as the broader impact of the program on African-American communities and LHAs. In the context of a mixed-methods study, in-depth telephone interviews were conducted among 76 African-American LHAs at eight NWP sites at baseline and 12-18 months later, between 2010 and 2013. Qualitative data provides insight into inner and outer contextual factors (e.g., community partnerships, site leadership, funding), implementation processes (e.g., training), as well as characteristics of the intervention (e.g., perceived need and fit in African-American community) and LHAs (e.g., motivations, burnout) that are perceived to impact the continued implementation and sustainability of NWP. Factors at the contextual levels and related to motivations of LHAs are critical to the sustainability of LHA programs. We discuss how findings are used to inform (1) the development of the LHA Sustainability Framework and (2) strategies to support the continued implementation and sustainability of evidence-based LHA interventions in community settings.