Implementation science protocol for a participatory, theory-informed implementation research programme in the context of health system strengthening in sub-Saharan Africa (ASSET-ImplementER)

OBJECTIVES

ASSET (Health System Strengthening in sub-Saharan Africa) is a health system strengthening (HSS) programme involving eight work-packages (ie, a research study that addresses a specific need for HSS) that aims to develop solutions that support high-quality care. Here we present the protocol for the implementation science (IS) theme within ASSET (ASSET-ImplmentER) that aims to understand what HSS interventions work, for whom and how, and how IS methodologies can be adapted to improve the HSS interventions within resource-poor contexts.

SETTINGS

Publicly funded health facilities in rural and urban areas in in Ethiopia, South Africa, Sierra Leone, and Zimbabwe.

PARTICIPANTS

Research staff including principal investigators, coinvestigators, field staff, PhD students, and research assistants.

INTERVENTIONS

Work-packages use a mixed-methods effectiveness-effectiveness hybrid designs. At the end of the pre-implementation phase, a workshop is held whereby the IS theme, jointly with ASSET work-packages apply IS determinant frameworks to research findings to identify factors that influence the effectiveness of delivering evidence-informed care. Determinants are used to select a set of HSS interventions for further evaluation, where work-packages also theorise selective mechanisms.In the piloting and rolling implementation phase, work-packages pilot the HSS interventions. An iterative process then begins involving evaluation, reflection and adaptation. Throughout this phase, IS determinant frameworks are applied to monitor and identify barriers/enablers to implementation. Selective mechanisms of action are also investigated. Implementation outcomes are evaluated using qualitative and quantitative methods. The psychometric properties of outcome measures including acceptability, appropriateness and feasibility are also evaluated. In a final workshop, work-packages come together, to reflect and explore the utility of the selected IS methods and provide suggestions for future use.Structured templates are used to organise and analyse common and heterogeneous patterns across work-packages. Qualitative data are analysed using thematic analysis and quantitative data are analysed using means and proportions.

CONCLUSIONS

We use a novel combination of IS methods at a programmatic level to facilitate comparisons of determinants and mechanisms that influence the effectiveness of HSS interventions in achieving implementation outcomes across different contexts. The study also contributes conceptual development and clarification at the underdeveloped interface of IS, HSS and global health.The ASSET-ImplementER theme is considered minimal risk as we only interview researchers involved in the different work-packages. To this effect we have received approval from King's College London Ethics Committee for research that is considered minimal risk (Reference number: MRA-20/21-21772).

Determination of hydroxyl radical production in aqueous solutions irradiated to clinically significant doses

Decarboxylation of 14C-carboxylbenzoic acid in aqueous solutions after low-dose irradiation has been used to determine the relative magnitude of oxidation reactions and estimate the hydroxyl radicals produced. The G CO2 values determined from these measurements of 0.4 to 1.0 mM solutions of benzoic acid after x-ray doses of 1000 rads ranged from 0.72 to 0.77, in excellent agreement with values reported by authors using much higher doses of radiation. Superoxide dismutase and catalase, known scavengers of superoxide and hydrogen peroxide, respectively, did not show impairment of the oxidation of benzoic acid. On the other hand, biologically significant concentrations of phenol and mannitol appear to impair the radiation-induced oxidation of benzoic acid, indicating that the process is secondary to a reaction with OH . . We found that serum and glucose, common cell media contents, are potent OH . scavengers. These observations indicate that the oxidation of benzoic acid can be as a reliable method to estimate OH . with radiation doses of clinically significant magnitudes. In addition, these results suggest that the radiation induced by OH . in cell systems can be significantly modified by the type of buffer used.

Dosimetry disparities resulting from two accepted methods of calibration of cobalt-60 teletherapy machines

The primary concern of all involved in the management of radiotherapeutic patients is that the tumor dose delivered to each and every patient in one institution is identical to that delivered anywhere else. Despite the advocacy 1,2,3,4 for the calibration of high energy photon beams at 5 cm depth or beyond in a water phantom to reduce the effect of electron "contamination" from collimators, filters, applicators, etc., the "in-air" method of calibration is still in vogue in many institutions in the United States and elsewhere. The introduction of S.I. units in radiology is likely to create ambiguity in proper conversion factors from exposure to absorbed dose which can be avoided if field instruments are calibrated in terms of absorbed dose in water under specified conditions. The present study shows that the estimated error can be as much as 7% low when the "in-air" method of calibration is used instead of measurements in a large water phantom at 5 cm depth for cobalt-60 photon beams and hence recommends that the procedure for "in-air" calibration for high energy photon beam should be discontinued.

An analysis of the dosimetry for mantle field therapy using 4 MV X-rays and its routine application

There are several different methods in vogue at present in determining patient midplane doses in the "mantle" treatment for Hodgkin's disease and malignant lymphomas. A method of determining midplane doses in individual cases using thermoluminescent dosimetry is presented. It shows excellent agreement with the midplane doses measured in an Alderson-Rando phantom treated as a hypothetical "mantle" patient.

A study of dose distribution patterns from cobalt-60 and Varian Clinac-4 beams

Dose distribution patterns of 4 MV x-rays from a Varian Clinac 4 linear accelerator are compared with those from a 60Co teletherapy machine. Field flatteners of lead and depleted uranium were used. Dose distribution maps display the off-axis high dose or "horns" with lead filters and circular dose distribution patterns. The uranium field flattener clearly "clipped the horns" and eliminated circular dose distribution patterns with larger fields.