Challenges to implementing planning processes in Brazilian health regions.

OBJECTIVE: To recognize elements that facilitated or hindered the PlanificaSUS implementation stages. METHODS: A multiple case study was carried out in four pre-selected health regions in Brazil-Belo Jardim (PE), Fronteira Oeste (RS), Sul-Mato-Grossense (MT) and Valença (BA) using systemic arterial hypertension and maternal and child care as tracer conditions. Participant observation (in regional interagency commissions) and in-depth interviews with key informants from state and municipal management and primary health care and specialized outpatient care service professionals within the project were carried out in these four regions. Analysis was built according to political, technical-operational, and contextual dimensions. RESULTS: The political dimension evinced that the regions found the project an opportunity to articulate states and municipalities and an important political bet to build networks and lines of care but that there remained much to be faced in the disputes related to building the Unified Health System (SUS). In the technical operational dimension, it is important to consider that primary health care stimulated a culture of local planning and favored traditional tools to organize and improve it, such as organizing registrations, agendas, and demands. However, centralized training and planning-inducing processes fail to always respond to local needs and can produce barriers to implementation. CONCLUSIONS: It is worth considering the central and regional role of state managers in the commitment related to the project and the effect of mobilizing primary health care and expanding its power. There remains much to be faced in the disputes at stake in bullring SUS.

An implementation strategy postmortem method developed in the VA rural Transitions Nurse Program to inform spread and scale-up.

BACKGROUND: High-quality implementation evaluations report on intervention fidelity and adaptations made, but a practical process for evaluating implementation strategies is needed. A retrospective method for evaluating implementation strategies is also required as prospective methods can be resource intensive. This study aimed to establish an implementation strategy postmortem method to identify the implementation strategies used, when, and their perceived importance. We used the rural Transitions Nurse Program (TNP) as a case study, a national care coordination intervention implemented at 11 hospitals over three years. METHODS: The postmortem used a retrospective, mixed method, phased approach. Implementation team and front-line staff characterized the implementation strategies used, their timing, frequency, ease of use, and their importance to implementation success. The Expert Recommendations for Implementing Change (ERIC) compilation, the Quality Enhancement Research Initiative phases, and Proctor and colleagues' guidance were used to operationalize the strategies. Survey data were analyzed descriptively, and qualitative data were analyzed using matrix content analysis. RESULTS: The postmortem method identified 45 of 73 ERIC strategies introduced, including 41 during pre-implementation, 37 during implementation, and 27 during sustainment. External facilitation, centralized technical assistance, and clinical supervision were ranked as the most important and frequently used strategies. Implementation strategies were more intensively applied in the beginning of the study and tapered over time. CONCLUSIONS: The postmortem method identified that more strategies were used in TNP than planned and identified the most important strategies from the perspective of the implementation team and front-line staff. The findings can inform other implementation studies as well as dissemination of the TNP intervention.

The Collaborative Service Design Playbook to plan, design, and implement sustainable health services for impact.

This paper sets out the Collaborative Service Design Playbook, to guide planning, design, and implementation of co-created health services. Successful health service development and implementation is best guided by theoretically informed approaches; however, organisations often lack design and implementation know-how and have difficulty applying it. This study seeks to improve health service design and potential for scale-up by proposing a tool to guide an end-to-end process, drawing together service design, co-design, and implementation science; and exploring the tool's feasibility to establish a sustainable service solution developed with participants and experts that is scalable and sustainable. The Collaborative Service Design Playbook phases include, (1) Define the opportunity and initiatives, (2) Design the concept and prototype, (3) Deliver to scale and evaluate; and (4) Optimise to transform and sustain. This paper has implications for health marketing through providing an end-to-end approach with phased guidance for health service development, implementation, and scale up.

Findings from an Organizational Context Survey to Inform the Implementation of a Collaborative Care Study for Co-occurring Disorders.

Primary care is an opportune setting to deliver treatments for co-occurring substance use and mental health disorders; however, treatment delivery can be challenging due multi-level implementation barriers. Documenting organizational context can provide insight into implementation barriers and the adaptation of new processes into usual care workflows. This study surveyed primary care and behavioral health staff from 13 clinics implementing a collaborative care intervention for opioid use disorders co-occurring with PTSD and/or depression as part of a multisite randomized controlled trial. A total of 323 completed an online survey for a 60% response rate. The Consolidated Framework for Implementation Research guided this assessment of multi-level factors that influence implementation. Most areas for improvement focused on inner setting (organizational level) constructs whereas individual-level constructs tended to be strengths. This work addresses a research gap regarding how organizational analyses can be used prior to implementation and provides practical implications for researchers and clinic leaders.

Guia de políticas de saúde: implementando sistemas de melhoria da qualidade na atenção primária em saúde / Health policy guide: implementing quality improvement systems in primary health care

O Guia de Políticas de Saúde - Implementando Sistemas de Melhoria da Qualidade na Atenção Primária em Saúde oferece orientações abrangentes para gestores que desejem criar e implementar Sistemas de Qualidade na Atenção Primária à Saúde (APS) e para sanitaristas, acadêmicos e organizações da área da saúde interessadas no tema. Neste guia, você vai encontrar: O DESAFIO: Promover o acesso e a qualidade da APS é fundamental para garantir um SUS mais igualitário, mas essa não é uma tarefa simples. Fatores como a diversidade do território brasileiro e questões de governança dos dados em Saúde são desafios que precisam ser considerados para garantir um melhor funcionamento da APS. Nesta seção, apresentamos esses e outros desafios e motivos que fazem da APS um modelo eficaz e custo-efetivo. O IEPS TESTOU: A 1ª edição do Guia de Políticas de Saúde foi elaborado a partir da experiência de construção do programa Recife Monitora, que integra o projeto Qualifica Atenção Básica, uma parceria do IEPS com a Prefeitura do Recife e que conta com o apoio da Umane. O programa foi iniciado em 2022 e apresentou resultados expressivos em seu primeiro ano de implementação. Nesta seção, apresentamos um relato de experiência com as lições aprendidas no primeiro ano do projeto e os referenciais teóricos que embasaram a construção dos sistemas avaliativos da qualidade da APS, informações que podem ser valiosas para a implementação de sistemas de qualidade em todo o país. CODIFICANDO A ESTRATÉGIA: Nesta seção, apresentamos elementos-chaves e um passo a passo detalhado para que as gestões municipais de todo o país possam implementar sistemas de melhoria da qualidade da APS. Também apresentamos alguns desafios que podem ser enfrentados, considerando as singularidades de cada território.

Reflection on the application of the Consolidated Framework for Implementation Research to a national policy to improve inclusion of people with disabilities.

People with disabilities face many barriers in the built environment impacting their mobility, health, and social participation. In the US, under the Americans with Disabilities Act (ADA), municipalities were required to develop and implement barrier-removal plans for pedestrian infrastructure, called ADA transition plans, but very few have done so. Many communities know they need a plan but do not know how to get it done because of a lack of understanding of the many different implementation considerations. Implementation science offers a useful approach for understanding complex policy implementation such as ADA plans. This paper provides a reflection on the adaptation of the Consolidated Framework for Implementation Research (CFIR) to evaluate the implementation of ADA transition planning. To apply the CFIR, we tailored the construct definitions and modified them to fit the specific context of the ADA transition planning process. We documented the constructs that were more challenging to apply, those that were not relevant, and those that were particularly useful. This paper can serve as a valuable example that other researchers can use when considering adapting the CFIR or other implementation frameworks for the evaluation of complex social policy beyond the ADA.

Healthy eating and active living policy, systems, and environmental changes in rural Louisiana: a contextual inquiry to inform implementation strategies.

BACKGROUND: Healthy eating and active living policy, systems, and environmental (PSE) changes are implemented across the United States through Cooperative Extension. However, translating multisector PSE changes to practice in community settings is challenging and there is a lack of knowledge about barriers and facilitators to PSE changes among state Extension systems using standardized frameworks. Therefore, a research-to-practice partnership effort aimed to identify Louisiana Cooperative Extension Service Family and Consumer Science (LFCS) practitioners' barriers and facilitators to implementing PSE changes in rural Louisiana communities. METHODS: A qualitative approach using the 2022 Consolidated Framework for Implementation Research (2022 CFIR) was used. Focus group discussions were conducted at five LFCS regional trainings between February and May 2022. All LFCS practitioners with any level of experience implementing healthy eating and active living PSE changes were eligible to participate, with emphasis on understanding efforts within more rural communities. Focus group discussions were audio-recorded and transcribed verbatim. Researchers analyzed qualitative data using the constant comparison method and 2022 CFIR domains and constructs including Inner Setting (LFCS organization), Outer Setting (rural Louisiana communities), Innovation (PSE changes), and Individuals (PSE change implementation actors/partners). RESULTS: Across the five regions, LFCS practitioners (n = 40) described more barriers (n = 210) than facilitators (n = 100); findings were often coded with multiple 2022 CFIR domains. Reported Inner Setting barriers were lack of formal or informal information sharing and lack of access to knowledge and information. Outer Setting barriers included sustaining and initiating community partnerships and local environmental or political conditions. Individual barriers included a lack of time and expertise, and Innovation barriers included the complex nature of rural PSE changes. Facilitators were mentioned at multiple levels and included community partner buy-in and practitioners' motivation to implement PSE changes. CONCLUSIONS: Implementation strategies are needed to build on organizational strengths and to overcome multi-level barriers to PSE change implementation among LFCS practitioners. The results from the in-depth contextual inquiry used could serve as a guide for future pragmatic assessment efforts among other state Extension systems or as a model for identifying barriers and facilitators and associated implementation strategies among other public health systems in the U.S. and abroad.

Designing an Efficient Implementation Process for Large Scale Adoption of Telehealth.

Telehealth may be one of the solutions to the increasing demand of healthcare. However, implementation of such systems is a considerable effort, and requires an efficient and systemized process for large scale adoption. This study provides a process for telehealth implementation. Although quantitative studies of implementation processes introduce significant challenges, the study provide initial indications of increasing effectiveness, specifically in time to deployment.

Application of the Expert Recommendations for Implementing Change (ERIC) compilation of strategies to health intervention implementation in low- and middle-income countries: a systematic review.

BACKGROUND: The Expert Recommendations for Implementing Change (ERIC) project developed a compilation of implementation strategies that are intended to standardize reporting and evaluation. Little is known about the application of ERIC in low- and middle-income countries (LMICs). We systematically reviewed the literature on the use and specification of ERIC strategies for health intervention implementation in LMICs to identify gaps and inform future research. METHODS: We searched peer-reviewed articles published through March 2023 in any language that (1) were conducted in an LMIC and (2) cited seminal ERIC articles or (3) mentioned ERIC in the title or abstract. Two co-authors independently screened all titles, abstracts, and full-text articles, then abstracted study, intervention, and implementation strategy characteristics of included studies. RESULTS: The final sample included 60 studies describing research from all world regions, with over 30% published in the final year of our review period. Most studies took place in healthcare settings (n = 52, 86.7%), while 11 (18.2%) took place in community settings and four (6.7%) at the policy level. Across studies, 548 distinct implementation strategies were identified with a median of six strategies (range 1-46 strategies) included in each study. Most studies (n = 32, 53.3%) explicitly matched implementation strategies used for the ERIC compilation. Among those that did, 64 (87.3%) of the 73 ERIC strategies were represented. Many of the strategies not cited included those that target systems- or policy-level barriers. Nearly 85% of strategies included some component of strategy specification, though most only included specification of their action (75.2%), actor (57.3%), and action target (60.8%). A minority of studies employed randomized trials or high-quality quasi-experimental designs; only one study evaluated implementation strategy effectiveness. CONCLUSIONS: While ERIC use in LMICs is rapidly growing, its application has not been consistent nor commonly used to test strategy effectiveness. Research in LMICs must better specify strategies and evaluate their impact on outcomes. Moreover, strategies that are tested need to be better specified, so they may be compared across contexts. Finally, strategies targeting policy-, systems-, and community-level determinants should be further explored. TRIAL REGISTRATION: PROSPERO, CRD42021268374.

iCHECK-DH: Guidelines and Checklist for the Reporting on Digital Health Implementations.

BACKGROUND: Implementation of digital health technologies has grown rapidly, but many remain limited to pilot studies due to challenges, such as a lack of evidence or barriers to implementation. Overcoming these challenges requires learning from previous implementations and systematically documenting implementation processes to better understand the real-world impact of a technology and identify effective strategies for future implementation. OBJECTIVE: A group of global experts, facilitated by the Geneva Digital Health Hub, developed the Guidelines and Checklist for the Reporting on Digital Health Implementations (iCHECK-DH, pronounced "I checked") to improve the completeness of reporting on digital health implementations. METHODS: A guideline development group was convened to define key considerations and criteria for reporting on digital health implementations. To ensure the practicality and effectiveness of the checklist, it was pilot-tested by applying it to several real-world digital health implementations, and adjustments were made based on the feedback received. The guiding principle for the development of iCHECK-DH was to identify the minimum set of information needed to comprehensively define a digital health implementation, to support the identification of key factors for success and failure, and to enable others to replicate it in different settings. RESULTS: The result was a 20-item checklist with detailed explanations and examples in this paper. The authors anticipate that widespread adoption will standardize the quality of reporting and, indirectly, improve implementation standards and best practices. CONCLUSIONS: Guidelines for reporting on digital health implementations are important to ensure the accuracy, completeness, and consistency of reported information. This allows for meaningful comparison and evaluation of results, transparency, and accountability and informs stakeholder decision-making. i-CHECK-DH facilitates standardization of the way information is collected and reported, improving systematic documentation and knowledge transfer that can lead to the development of more effective digital health interventions and better health outcomes.

Measurement Characteristics of the Wraparound Fidelity Index Short Form: Results from a Statewide Implementation.

Implementation fidelity has been an important issue in the service provision and associated outcomes of Wraparound, an intensive, individualized care planning process that uses a team-based approach to integrate youth into the community to minimize the need for intensive, institutional services. In response to the growing need to monitor fidelity to the Wraparound process, a variety of instruments have been created and tested. In this study, the authors present the results of several analyses designed to better understand the measurement characteristics of the Wraparound Fidelity Index Short Form (WFI-EZ), a multi-informant fidelity instrument. The results from our analysis of 1027 WFI-EZ responses indicate that the internal consistency of the instrument is very good, although the negatively worded items did not appear to function as well as positively worded items. Results from two confirmatory factor analyses were unable to validate the original domains identified by the instrument developers, but for certain outcomes the WFI-EZ demonstrated deseriable predictive validity. Preliminary evidence is also provided that WFI-EZ responses likely differ by respondent type. We conclude by discussing the implications of using the WFI-EZ in programming, policy, and practice considering the findings of our study.

Plan interinstitucional para la atención en salud en el marco de los XXIV Juegos Centroamericanos y del Caribe, San Salvador 2023 / Inter-institutional plan for health care in the framework of the XXIV Central American and Caribbean Games, San Salvador 2023

Los Juegos Centroamericanos y del Caribe son un evento multideportivo, que se realizan cada 4 años desde 1926 en diferentes países de la región que comprenden América Central y la cuenca del Mar Caribe. Es el evento multidisciplinario regional más antiguo del mundo, son coordinados por la Organización Centro Caribe Sports. Para el año 2023 se estima que la fecha de realización de estos juegos será del 23 de junio al 8 de julio, esperando una afluencia masiva de atletas y delegaciones extrajeras. El Ministerio de Salud, como ente rector del Sistema Nacional Integrado de Salud, emite el presente Plan interinstitucional para la atención en salud en el marco de los XXIV Juegos Centroamericanos y del Caribe, San Salvador 2023, en la vigilancia epidemiológica, prevención y atención de la salud en casos de emergencias. El plan contiene estrategias de atención en casos de emergencias médicas (traumas, fracturas, intoxicaciones alimentarias, reacciones alérgicas, atenciones de primeros auxilios, atenciones masivas de víctimas en casos de desastres naturales y accidentes de tránsito), entre otros. Además, incluye una breve descripción del acceso a los puntos de atención médica y zonas de evacuación asignadas en los diferentes escenarios deportivos

The Central American and Caribbean Games are a multi-sport event, held every 4 years since 1926 in different countries of the region comprising Central America and the Caribbean Sea basin. It is the oldest regional multidisciplinary event in the world, coordinated by the Centro Caribe Sports Organization. For 2023 it is estimated that the date of these games will be from 23 June to 8 July, expecting a massive influx of athletes and foreign delegations. The Ministry of Health, as the governing body of the Integrated National Health System, issues this inter-institutional plan for health care within the framework of the twenty-third Central American and Caribbean Games, San Salvador 2023, in epidemiological surveillance, prevention and health care in emergencies The plan contains strategies for dealing with medical emergencies (traumas, fractures, food poisoning, allergic reactions, first-aid care, mass care of victims in cases of natural disasters and traffic accidents), among others. In addition, it includes a brief description of access to health care points and designated evacuation areas in different sports arenas

On-the-Go Adaptation of Implementation Approaches and Strategies in Health: Emerging Perspectives and Research Opportunities.

In many cases, implementation approaches (composed of one or more strategies) may need to change over time to work optimally. We use a literature review to inform a mechanistic analysis of such on-the-go adaptations. We suggest that such adaptations of implementation strategies consist of three necessary steps. The first component is the initial effect of the implementation approach on intended implementation, service delivery, or clinical outcomes. Second, these initial effects must in turn be used to modify, alter, intensify, or otherwise change the implementation approach. Third, the modified approach itself has effects. Conceiving of adaptation as all three steps implies that a full understanding of adaptation involves (a) a sense of initial effects, (b) conceptualizing and documenting content and rationale for changes in approach (e.g., alteration, intensification), and (c) the effects of the changed approach (including how the latter effects depend on initial effects). Conceptualizing these steps can help researchers ask questions about adaptation (e.g., thresholds for change, dosing, potentiation, sequencing) to advance our understanding of implementation strategies.

Local public health projectification in practice: a qualitative study of facilitators and barriers to a public health plan implementation.

AIMS: To identify factors perceived by local government employees to affect the implementation of a municipal public health plan. METHODS: Qualitative individual interviews (n=13) were carried out. Participants were sampled from three districts in Oslo municipality, Norway, and asked about their experiences with an ongoing implementation of the Oslo Public Health Plan (2017-2020). The conceptual framework of public sector projectification - a growing reliance on project organisation of policies - informed the study. The consolidated framework for implementation research was used to aid data coding and subsequent thematic analysis. RESULTS: Implementation facilitators included factors perceived to support flexibility, including plan adaptability to the local setting, and factors perceived to enable structure and control during the implementation process, such as the articulation of specific goals and a shared understanding of public health work. Barriers were mainly related to complex aspects of the plan, such as the need to involve multiple stakeholders and levels of governance, and to tensions between the time-limited implementation process and the permanent organisational structures. CONCLUSIONS: This study has demonstrated how research-based methods can be used for the evaluation of a local community implementation process. It has identified implementation determinants using a predetermined taxonomy of operationally defined factors that are likely to influence implementation. However, while implementing a time-limited public health plan can be seen as 'taking action' in relation to multidimensional and complex problems, further research is needed to investigate whether plan implementation has a long-term impact on the surrounding organisation and, eventually, on public health outcomes.

Estratégias de fortalecimento de Saúde do Trabalhador e da Trabalhadora: a experiência de uma Unidade Básica de Saúde / Strategies to strengthen workers' health: the experience of a Basic Health Unit

A saúde do trabalhador é determinada pela forma de organização do processo de trabalho no contexto do modo de produção capitalista, processo que gera sucessivos desgastes, inclusive na área da saúde. Objetiva-se apresentar o processo de elaboração de propostas de enfrentamento do desgaste do trabalhador da Atenção Primária em Saúde, por meio de pesquisa de implementação e da pesquisa participante, com vistas às transformações dos processos de trabalho. Realizou-se sete oficinas emancipatórias para instrumentalização dos trabalhadores com vistas à implementação de estratégias de fortalecimento de saúde dessa população, validadas em diálogo deliberativo, com trabalhadores de uma unidade de saúde da família. O processo educativo foi analisado captando-se os desgastes dos trabalhadores e elencando suas causas sob sua própria óptica, as quais foram se complexificando ao longo do processo, em direção à compreensão das raízes dos desgastes. Foi elaborado documento norteador para apoiar a realização de oficinas, de forma a preparar os trabalhadores para processos de implementação, constituindo o produto apresentado ao programa de mestrado profissional ao qual a pesquisa se vincula. As oficinas se apresentaram como instrumento potente de transformação da compreensão sobre a saúde do trabalhador e as formas de enfrentamento dos desgastes que estes sofrem.

Can systematic implementation support improve programme fidelity by improving care providers' perceptions of implementation factors? A cluster randomized trial.

BACKGROUND: Investigations of implementation factors (e.g., collegial support and sense of coherence) are recommended to better understand and address inadequate implementation outcomes. Little is known about the relationship between implementation factors and outcomes, especially in later phases of an implementation effort. The aims of this study were to assess the association between implementation success (measured by programme fidelity) and care providers' perceptions of implementation factors during an implementation process and to investigate whether these perceptions are affected by systematic implementation support. METHODS: Using a cluster-randomized design, mental health clinics were drawn to receive implementation support for one (intervention) and not for another (control) of four evidence-based practices. Programme fidelity and care providers' perceptions (Implementation Process Assessment Tool questionnaire) were scored for both intervention and control groups at baseline, 6-, 12- and 18-months. Associations and group differences were tested by means of descriptive statistics (mean, standard deviation and confidence interval) and linear mixed effect analysis. RESULTS: Including 33 mental health centres or wards, we found care providers' perceptions of a set of implementation factors to be associated with fidelity but not at baseline. After 18 months of implementation effort, fidelity and care providers' perceptions were strongly correlated (B (95% CI) = .7 (.2, 1.1), p = .004). Care providers perceived implementation factors more positively when implementation support was provided than when it was not (t (140) = 2.22, p = .028). CONCLUSIONS: Implementation support can facilitate positive perceptions among care providers, which is associated with higher programme fidelity. To improve implementation success, we should pay more attention to how care providers constantly perceive implementation factors during all phases of the implementation effort. Further research is needed to investigate the validity of our findings in other settings and to improve our understanding of ongoing decision-making among care providers, i.e., the mechanisms of sustaining the high fidelity of recommended practices. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03271242 (registration date: 05.09.2017).

Meaningful patient and public involvement in digital health innovation, implementation and evaluation: A systematic review.

INTRODUCTION: The importance of meaningfully involving patients and the public in digital health innovation is widely acknowledged, but often poorly understood. This review, therefore, sought to explore how patients and the public are involved in digital health innovation and to identify factors that support and inhibit meaningful patient and public involvement (PPI) in digital health innovation, implementation and evaluation. METHODS: Searches were undertaken from 2010 to July 2020 in the electronic databases MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus and ACM Digital Library. Grey literature searches were also undertaken using the Patient Experience Library database and Google Scholar. RESULTS: Of the 10,540 articles identified, 433 were included. The majority of included articles were published in the United States, United Kingdom, Canada and Australia, with representation from 42 countries highlighting the international relevance of PPI in digital health. 112 topic areas where PPI had reportedly taken place were identified. Areas most often described included cancer (n = 50), mental health (n = 43), diabetes (n = 26) and long-term conditions (n = 19). Interestingly, over 133 terms were used to describe PPI; few were explicitly defined. Patients were often most involved in the final, passive stages of an innovation journey, for example, usability testing, where the ability to proactively influence change was severely limited. Common barriers to achieving meaningful PPI included data privacy and security concerns, not involving patients early enough and lack of trust. Suggested enablers were often designed to counteract such challenges. CONCLUSIONS: PPI is largely viewed as valuable and essential in digital health innovation, but rarely practised. Several barriers exist for both innovators and patients, which currently limits the quality, frequency and duration of PPI in digital health innovation, although improvements have been made in the past decade. Some reported barriers and enablers such as the importance of data privacy and security appear to be unique to PPI in digital innovation. Greater efforts should be made to support innovators and patients to become meaningfully involved in digital health innovations from the outset, given its reported benefits and impacts. Stakeholder consensus on the principles that underpin meaningful PPI in digital health innovation would be helpful in providing evidence-based guidance on how to achieve this. PATIENT OR PUBLIC CONTRIBUTION: This review has received extensive patient and public contributions with a representative from the Patient Experience Library involved throughout the review's conception, from design (including suggested revisions to the search strategy) through to article production and dissemination. Other areas of patient and public contributor involvement include contributing to the inductive thematic analysis process, refining the thematic framework and finalizing theme wording, helping to ensure relevance, value and meaning from a patient perspective. Findings from this review have also been presented to a variety of stakeholders including patients, patient advocates and clinicians through a series of focus groups and webinars. Given their extensive involvement, the representative from the Patient Experience Library is rightly included as an author of this review.

Breast cancer screening in sub-Saharan Africa: a systematic review and ethical appraisal.

BACKGROUND: The aim of this systematic review was to evaluate the evidence and clinical outcomes of screening interventions and implementation trials in sub-Saharan Africa (SSA) and also appraise some ethical issues related to screening in the region through quantitative and qualitative narrative synthesis of the literature. METHODS: We searched Pubmed, OvidMEDLINE, Embase, and Web of Science to identify studies published on breast cancer screening interventions and outcomes in SSA. Descriptive statistics were used to summarize the frequency and proportions of extracted variables, and narrative syntheses was used to evaluate the clinical outcomes of the different screening modalities. The mixed methods appraisal tool was used to assess the quality of studies included in the review. RESULTS: Fifteen studies were included, which consisted of 72,572 women in ten countries in SSA. 63% (8/15) of the included publications evaluated Clinical Breast Examination (CBE), 47% (7/15) evaluated mammography and 7% (1/15) evaluated ultrasound screening. The cancer detection rate was < 1/1000 to 3.3/1000 and 3.3/100 to 56/1000 for CBE and mammography screening respectively. There was a lot of heterogeneity in CBE methods, target age for screening and no clear documentation of screening interval. Cost-effective analyses showed that CBE screening linked to comprehensive cancer care is most cost effective. There was limited discussion of the ethics of screening, including the possible harms of screening in the absence of linkage to care. The gap between conducting good screening program and the appropriate follow-up with diagnosis and treatment remains one of the major challenges of screening in SSA. DISCUSSION: There is insufficient real-world data to support the systematic implementation of national breast cancer screening in SSA. Further research is needed to answer important questions about screening, and national and international partnerships are needed to ensure that appropriate diagnostic and treatment modalities are available to patients who screen positive.

Removing the societal and legal impediments to the HIV response: An evidence-based framework for 2025 and beyond.

Societal and legal impediments inhibit quality HIV prevention, care, treatment and support services and need to be removed. The political declaration adopted by UN member countries at the high-level meeting on HIV and AIDS in June 2021, included new societal enabler global targets for achievement by 2025 that will address this gap. Our paper describes how and why UNAIDS arrived at the societal enabler targets adopted. We conducted a scoping review and led a participatory process between January 2019 and June 2020 to develop an evidence-based framework for action, propose global societal enabler targets, and identify indicators for monitoring progress. A re-envisioned framework called the '3 S's of the HIV response: Society, Systems and Services' was defined. In the framework, societal enablers enhance the effectiveness of HIV programmes by removing impediments to service availability, access and uptake at the societal level, while service and system enablers improve efficiencies in and expand the reach of HIV services and systems. Investments in societal enabling approaches that remove legal barriers, shift harmful social and gender norms, reduce inequalities and improve institutional and community structures are needed to progressively realize four overarching societal enablers, the first three of which fall within the purview of the HIV sector: (i) societies with supportive legal environments and access to justice, (ii) gender equal societies, (iii) societies free from stigma and discrimination, and (iv) co-action across development sectors to reduce exclusion and poverty. Three top-line and 15 detailed targets were recommended for monitoring progress towards their achievement. The clear articulation of societal enablers in the re-envisioned framework should have a substantial impact on improving the effectiveness of core HIV programmes if implemented. Together with the new global targets, the framework will also galvanize advocacy to scale up societal enabling approaches with proven impact on HIV outcomes.