Contextual factors associated with diarrhea among under-five children in the Gambia: a multi-level analysis of population-based data.

BACKGROUND: Diarrhea poses a significant threat to the lives of children in The Gambia, accounting for approximately 9% of all deaths among children under the age of five. Addressing and reducing child mortality from diarrhea diseases is crucial for achieving the Sustainable Development Goal (SDG) 3, specifically target 3.2, which aims to eliminate preventable deaths in newborns and children under the age of five by 2030. Thus, this research aims to assess the prevalence and contextual factors associated with diarrhea among under-five children in The Gambia. METHODS: This research employed secondary data from the 2019/20 Gambia Demographic Health Survey (GDHS). The study initially involved 8,362 women aged between 15 and 49 years. Of these, 6,929 women with children under five were included in this analysis. Data were analyzed using STATA with cross-tabulation and model fitting. Multilevel logistic regression was applied to accommodate the hierarchical structure of the demographic health survey data. The model comparison parameters were BIC, AIC, deviance, and LLR. Variables with a p-value less than 0.05 were selected for multivariable analysis. The statistical significance of the factors was determined using an adjusted odds ratio with a 95% confidence interval (CI) and a p-value of less than 0.05. RESULTS: The prevalence of diarrhea in under-five children was 53.2% in males and 46.8% in females. In the final model, Kerewan (aOR = 0.58; 95% CI = 0.33-0.98) and Basse (aOR = 0.59; 95% CI = 0.35-0.98) have significantly lower odds of childhood diarrhea compared to Banjul, female children show slightly lower, yet significant, odds of diarrhea compared to males (aOR = 0.96; 95% CI = 0.86-0.98), deliveries at government health centers are associated with higher odds of childhood diarrhea compared to home births (aOR = 1.24; 95% CI = 1.01-1.52). Mothers with post-secondary education had significantly lower odds of having children with diarrhea than those without any education (aOR = 0.50; 95% CI = 0.26-0.99) after controlling for confounders. CONCLUSION: The study findings indicate that several factors significantly impact the risk of childhood diarrhea in The Gambia. These factors include region of residence, sex of the child, place of delivery, and education level of the mother. The study suggests that existing interventions aimed at improving child health outcomes in the country should take into consideration these influential factors. Addressing these modifiable factors can enhance the effectiveness of interventions and promote better health outcomes for children in Gambia.

Lessons learned from implementation of four HIV self-testing (HIVST) distribution models in Zambia: applying the Consolidated Framework for Implementation Research to understand impact of contextual factors on implementation.

BACKGROUND: Although Zambia has integrated HIV-self-testing (HIVST) into its Human Immunodeficiency Virus (HIV) regulatory frameworks, few best practices to optimize the use of HIV self-testing to increase testing coverage have been documented. We conducted a prospective case study to understand contextual factors guiding implementation of four HIVST distribution models to inform scale-up in Zambia. METHODS: We used the qualitative case study method to explore user and provider experiences with four HIVST distribution models (two secondary distribution models in Antenatal Care (ANC) and Antiretroviral Therapy (ART) clinics, community-led, and workplace) to understand factors influencing HIVST distribution. Participants were purposefully selected based on their participation in HIVST and on their ability to provide rich contextual experience of the distribution models. Data were collected using observations (n = 31), group discussions (n = 10), and in-depth interviews (n = 77). Data were analyzed using the thematic approach and aligned to the four Consolidated Framework for Implementation Research (CFIR) domains. RESULTS: Implementation of the four distribution models was influenced by an interplay of outer and inner setting factors. Inadequate compensation and incentives for distributors may have contributed to distributor attrition in the community-led and workplace HIVST models. Stockouts, experienced at the start of implementation in the secondary-distribution and community-led distribution models often disrupted distribution. The existence of policy and practices aided integration of HIVST in the workplace. External factors complimented internal factors for successful implementation. For instance, despite distributor attrition leading to excessive workload, distributors often multi-tasked to keep up with demand for kits, even though distribution points were geographically widespread in the workplace, and to a less extent in the community-led models. Use of existing communication platforms such as lunchtime and safety meetings to promote and distribute kits, peers to support distributors, reduction in trips by distributors to replenish stocks, increase in monetary incentives and reorganisation of stakeholder roles proved to be good adaptations. CONCLUSION: HIVST distribution was influenced by a combination of contextual factors in variable ways. Understanding how the factors interacted in real world settings informed adaptations to implementation devised to minimize disruptions to distribution.

Integrating context in the examination of pubertal timing effects on disordered eating among Black and Latinx girls.

Earlier pubertal onset has been associated with increased disordered eating symptoms in cisgender girls. Although this finding has been replicated across studies of disordered eating, most studies have focused on white samples. The lack of studies is surprising given that early pubertal timing may impact disordered eating risk in Black and Latinx girls differently due to trends of earlier pubertal onset in these groups and increased stressors related to interpersonal and structural racism and economic marginalization. Current methods of examining pubertal timing among Black and Latinx girls may also not fully capture their experience. Contextual factors (e.g., neighborhood and school racial/ethnic composition) may influence how minoritized girls both perceive and are affected by their pubertal timing. Moreover, factors such as ethnic-racial identity development and experiences of discrimination may be important mechanisms explaining the association between pubertal timing and disordered eating risk. This paper aims to provide a brief overview of studies examining pubertal timing and disordered eating risk among Black and Latinx girls in the US and to discuss recommendations for future research that integrate contextual factors in the examination of pubertal timing and its effects. PUBLIC SIGNIFICANCE: Early pubertal timing has been associated with increased risk of disordered eating symptoms among cisgender girls; however, studies have been limited due to the use of predominantly white samples. The article provides a brief overview of findings related to pubertal timing effects among Black and Latinx girls, discusses considerations for the measurement of pubertal timing, and highlights the need for inclusion of contextual factors in future research.

We know a lot about little and little about a lot: A contextualized scoping review on injury prevention in alpine ski racing.

BACKGROUND: Our goal was to summarize and contextualize the available literature on alpine ski racing injury epidemiology, injury etiology, injury prevention measures, injury prevention context, and implementation issues. MATERIALS AND METHODS: We searched four electronic databases using predetermined search terms. We included original studies that assessed injury, injury risk factors, and injury mechanisms, and assessed and reported the effect of an injury prevention measure in alpine ski racing. Two authors independently conducted title-abstract screening, and one performed the full-text review. For data synthesis and categorization, we used the Translating Research into the Injury Prevention Practice framework and a modified and adapted version of the Haddon matrix. RESULTS: Of the 157 included studies, most corresponded to injury epidemiology and etiology, whereas few studies encompassed injury prevention measure development, implementation and evaluation. Preventive interventions targeting equipment, rules and regulations, course design and snow preparation were the most prevalent in the literature. Furthermore, various contextual factors in the current literature have been found, including gender, competition level, countries and federations, and time periods within a season. CONCLUSIONS: We provided an in-depth and comprehensive overview of the current state-of-the-art in the alpine ski racing context. We know a lot about little and little about a lot across all the areas associated with injury prevention in such context. The limitations in the literature yield a road map for designing future injury prevention studies to address the key gaps identified. A more comprehensive context-driven approach throughout all stages of injury prevention would benefit the ultimate implementation of effective preventive strategies.

Climate change and infectious disease surveillance in Nepal: qualitative study exploring social, cultural, political and institutional factors influencing disease surveillance.

BACKGROUND: To explore the impacts of contextual issues encompassing social, cultural, political and institutional elements, on the operation of public health surveillance systems in Nepal concerning the monitoring of infectious diseases in the face of a changing climate. METHODS: Semi-structured interviews (n = 16) were conducted amongst key informants from the Department of Health Services, Health Information Management System, Department of Hydrology and Meteorology, World Health Organization, and experts working on infectious disease and climate change in Nepal, and data were analysed using thematic analysis technique. RESULTS: Analysis explicates how climate change is constructed as a contingent risk for infectious diseases transmission and public health systems, and treated less seriously than other 'salient' public health risks, having implications for how resources are allocated. Further, analysis suggests a weak alliance among different stakeholders, particularly policy makers and evidence generators, resulting in the continuation of traditional practices of infectious diseases surveillance without consideration of the impacts of climate change. CONCLUSIONS: We argue that along with strengthening systemic issues (epidemiological capacity, data quality and inter-sectoral collaboration), it is necessary to build a stronger political commitment to urgently address the influence of climate change as a present and exponential risk factor in the spread of infectious disease in Nepal.

Factors influencing clinician-educators' assessment practice in varied Southern contexts: a health behaviour theory perspective.

In many contexts, responsibility for exit-level assessment design and implementation in undergraduate medical programmes lies with individuals who convene clinical clerkships. Their assessment practice has significant consequences for students' learning and the patients and communities that graduates will serve. Interventions to enhance assessment must involve these assessors, yet little is known about factors influencing their assessment practice. The purpose of this study was to explore factors that influence assessment practice of clerkship convenors in three varied low-and-middle income contexts in the global South. Taking assessment practice as a behaviour, Health Behaviour Theory (HBT) was deployed as a theoretical framework to explore, describe and explain assessor behaviour. Thirty-one clinician-educators responsible for designing and implementing high-stakes clerkship assessment were interviewed in South Africa and Mexico. Interacting personal and contextual factors influencing clinician-educator assessment intention and action were identified. These included attitude, influenced by impact and response appraisal, and perceived self-efficacy; along with interpersonal, physical and organisational, and distal contextual factors. Personal competencies and conducive environments supported intention to action transition. While previous research has typically explored factors in isolation, the HBT framing enabled a systematic and coherent account of assessor behaviour. These findings add a particular contextual perspective to understanding assessment practice, yet also resonate with and extend existing work that predominantly emanates from high-income contexts in the global North. These findings provide a foundation for the planning of assessment change initiatives, such as targeted, multi-factorial faculty development.

Contextual determinants of multiple sexual partnerships amongst young people in South Africa: a multilevel analysis.

BACKGROUND: Risky sexual behaviour (RSB), particularly multiple sexual partnerships (MSP) continues to be a major public health concern and has been linked to the increasing STIs, including HIV/AIDS in many parts of sub-Saharan Africa (SSA), suggesting that there is an association between contextual factors and multiple sexual partnering. However, in South Africa, this association is not well established in recent literature. Hence, this study examined the contextual factors contributing to multiple sexual partnerships among young people in South Africa. MATERIALS AND METHODS: Data was extracted from the 2016 South Africa Demographics and Health Survey (2016 SADHS). A cross-sectional study of 3889 never-married young people. Descriptive and inferential statistics as well as multilevel logistic regression were used to analyse the data on never-married young people aged 15 to 24 years. RESULTS: The results indicated that at the individual level, young males (61.7%) were significantly more likely than their female counterparts (56.1%) to engage in multiple sexual partners, although, the difference was not as significant as expected. At the community level clustering, the likelihood of exposure to multiple sexual partnerships significantly increased among females (OR = 1.47; 95% CI: 1.25-1.73) but decreased among their male counterparts (OR = 0.73; 95% CI: 0.58-0.92), in particular, family disruption, residential instability, and ethnic diversity led young people to engage in multiple sexual partnerships. CONCLUSIONS: There is a need to intensify programmes aimed at considering appropriate policy options to reduce the prevalence of multiple sexual partnerships. Adopting the implications of these findings is essential for a developmental strategy towards achieving the sustainable development goal of ending STIs among young people in South Africa.

Using implementation research to understand lessons in reducing child mortality.

Under-5 mortality decreased significantly worldwide between 2000 and 2015, but there is still progress to be made, particularly in lower- and middle-income countries. This supplement shares the work over the last four years on a project to understand how six countries (Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal) were more successful in decreasing child mortality than many of their regional and economic peers. The use of implementation research across these countries identifies common implementation strategies and contextual factors that can facilitate or impede successful implementation of an evidence-based intervention and explores a common pathway to implementation. The work highlights how the use of implementation research to understand the "how" and the "why" behind countries' success provides important actionable knowledge and lessons to country-level decision-makers, donors, and implementers as we arrive at the midpoint of the Sustainable Development Goal era.

Cross-country analysis of contextual factors and implementation strategies in under-5 mortality reduction in six low- and middle-income countries 2000-2015.

BACKGROUND: The Exemplars in Under-5 Mortality (U5M) was a multiple cases study of how six low- and middle-income countries (LMICs), Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal, implemented health system-delivered evidence-based interventions (EBIs) to reduce U5M between 2000 and 2015 more effectively than others in their regions or with similar economic growth. Using implementation research, we conducted a cross-country analysis to compare decision-making pathways for how these countries chose, implemented, and adapted strategies for health system-delivered EBIs that mitigated or leveraged contextual factors to improve implementation outcomes in reducing amenable U5M. METHODS: The cross-country analysis was based on the hybrid mixed methods implementation research framework used to inform the country case studies. The framework included a common pathway of Exploration, Preparation, Implementation, Adaptation, and Sustainment (EPIAS). From the existing case studies, we extracted contextual factors which were barriers, facilitators, or determinants of strategic decisions; strategies to implement EBIs; and implementation outcomes including acceptability and coverage. We identified common factors and strategies shared by countries, and individual approaches used by countries reflecting differences in contextual factors and goals. RESULTS: We found the six countries implemented many of the same EBIs, often using similar strategies with adaptations to local context and disease burden. Common implementation strategies included use of data by decision-makers to identify problems and prioritize EBIs, determine implementation strategies and their adaptation, and measure outcomes; leveraging existing primary healthcare systems; and community and stakeholder engagement. We also found common facilitators included culture of donor and partner coordination and culture and capacity of data use, while common barriers included geography and culture and beliefs. We found evidence for achieving implementation outcomes in many countries and EBIs including acceptability, coverage, equity, and sustainability. DISCUSSION: We found all six countries used a common pathway to implementation with a number of strategies common across EBIs and countries which contributed to progress, either despite contextual barriers or by leveraging facilitators. The transferable knowledge from this cross-country study can be used by other countries to more effectively implement EBIs known to reduce amenable U5M and contribute to strengthening health system delivery now and in the future.

Social and economic determinants of drug overdose deaths: a systematic review of spatial relationships.

PURPOSE: To synthesize the available evidence on the extent to which area-level socioeconomic conditions are associated with drug overdose deaths in the United States. METHODS: We performed a systematic review (in MEDLINE, EMBASE, PsychINFO, Web of Science, EconLit) for papers published prior to July 2022. Eligible studies quantitatively estimated the association between an area-level measure of socioeconomic conditions and drug overdose deaths in the US, and were published in English. We assessed study quality using the Effective Public Health Practice Project Quality Assessment Tool. The protocol was preregistered at Prospero (CRD42019121317). RESULTS: We identified 28 studies that estimated area-level effects of socioeconomic conditions on drug overdose deaths in the US. Studies were scored as having moderate to serious risk of bias attributed to both confounding and in analysis. Socioeconomic conditions and drug overdose death rates were moderately associated, and this was a consistent finding across a large number of measures and differences in study designs (e.g., cross-sectional versus longitudinal), years of data analyzed, and primary unit of analysis (e.g., ZIP code, county, state). CONCLUSIONS: This review highlights the evidence for area-level socioeconomic conditions are an important factor underlying the geospatial distribution of drug overdose deaths in the US and the need to understand the mechanisms underlying these associations to inform future policy recommendations. The current evidence base suggests that, at least in the United States, employment, income, and poverty interventions may be effective targets for preventing drug overdose mortality rates.

Contextual Triggers and Tic Severity Across Life Periods: A Retrospective Analysis in Adults with Tic Disorders.

In tic disorders (TD), tic expression varies across the lifespan and as a function of contextual factors. This study explored connections between tic expression and contextual triggers across life periods in 74 adults (Mage = 23.2) with TDs. The Tic History and Coping Strategies form assessed retrospective self-reports of contextual antecedents, consequences, and tic severity during four life periods (middle school; 9th/10th grade; 11th/12th grade; college/work) and past month. Tics reportedly worsened during and after school in school-aged years and worsened in the evening during college/work years. Stress and anxiety were reported to consistently trigger tics across time. The impact of activities, places, and emotions did not differ across life periods. Attention-based consequences, most prevalent during middle school, were more common than escape- or avoidance-related consequences across all periods. Findings illuminate how contextual factors may influence tics across life periods and underscore the consistent impact of tic-triggering emotions and attention-related consequences.

Size of government and willingness-to-pay for environmental policy: Evidence from a cross-country survey.

Citizen support is an important precursor to climate change mitigation polices. Public opinion can shape public policy and vice versa. This paper uses the 2010 International Social Survey Programme (ISSP) Environment Module to investigate cross-national differences in support for climate policy. We introduce size of government, measured by government revenues as a share of GDP, as a new country-level factor. Our sample includes 31,511 responses from 33 countries. We use multilevel models to estimate the relationship between country-level factors and environmental policy support, conditional on a series of individual factors. Increasing the size of government by one standard deviation reduces support for environmental policy by 0.13 points on a 5-point scale. For comparison, a one standard deviation increase in GDP per capita leads to a 0.24 increase in support and a one standard deviation increase in air pollution leads to a 0.13 point increase. The implication for environmental policy is that high tax countries have an aversion to price and tax increases aimed at protecting the environment. We conclude that use of taxes for environmental policy must include clear expectations for how revenues will be recycled or how other taxes will be lowered if they are to gain widespread support.

School type and oral conditions associated with school performance and absenteeism in adolescents: A multilevel analysis.

BACKGROUND: Investigations assessing how oral health status affects school performance and attendance considering individual and community variables are lacking. AIM: To analyze the association of school contextual factors and oral conditions with school performance and absenteeism in early adolescence. DESIGN: This cross-sectional study was carried out with 593 12-year-old students from 20 schools in Passo Fundo, a southern city in Brazil. The caregivers provided sociodemographic information by means of a questionnaire. Oral health status was clinically examined for dental caries and gingival bleeding. Students answered the CPQ11-14 questionnaire to assess the oral health-related quality of life (OHRQoL). Information on contextual factors was obtained from the schools' administrators. "School performance" was measured by Portuguese and Mathematic tests' scores, and "school absenteeism" by the number of school days missed. Descriptive statistics was conducted, followed by unadjusted and adjusted multilevel linear regression. RESULTS: At the individual level, low OHRQoL was associated with lower school performance and higher absenteeism. At the contextual level, students from private schools had higher school performance and lower mean of school days missed. CONCLUSIONS: The type of school and OHRQoL were associated with school performance and attendance of adolescents.

Contextual factors for understanding the heterogeneity of outcomes of a policy of exemption from payment for care in Chad / Les facteurs contextuels pour comprendre l'hétérogénéité des résultats d'une politique d'exemption du paiement des soins au Tchad

Chad has one of the highest maternal and infant mortality rates in the world. Efforts to reduce these rates have led to the introduction of fee exemption and community involvement initiatives to further encourage the use of health services. Despite the introduction of these initiatives, inequalities in access to and use of health facilities persist. The aim of this study is to understand why and how the same action, implemented in a quasi-homogeneous way, produced contrasting results in different health centers. A multiple, contrasting case study was used to analyze the outcomes of pediatrics consultations and deliveries in four health centers in the Bénoye and Beinamar districts. Data were collected through individual interviews (n=26) and focus groups (n=22) with women beneficiaries, community health workers, and health care providers. The qualitative software QDA Miner was used to process the data. The study revealed that the organizational and managerial capacities of the providers and community actors would explain the heterogeneity of the results observed. Contextual factors such as the remoteness of services or the impassability and dangerousness of roads accentuated the disparities in the results observed. The results of this study show that human and contextual factors would explain the heterogeneity of the observed effects.

Le Tchad a l'un des taux de mortalité maternelle et infantile les plus élevés au monde. Les efforts visant à réduire ces taux ont conduit à la mise en place d'une politique d'exemption du paiement des soins, associée à l'implication des communautés pour encourager l'utilisation des services. Malgré l'introduction de cette initiative, des inégalités dans l'accès et l'utilisation des établissements de santé persistent. L'objectif de cette étude est de comprendre pourquoi et comment cette politique d'exemption, mise en œuvre de manière quasi homogène, a donné des résultats contrastés dans plusieurs centres de santé. Une étude de cas multiples contrastés a été utilisée pour analyser les résultats des consultations pédiatriques et des accouchements dans quatre centres de santé des districts de Bénoye et Beinamar. Les données ont été recueillies lors des entretiens individuels (n=26) et des groupes de discussion (n=22) auprès des femmes bénéficiaires, des agents de santé communautaire et des prestataires de soins. Le logiciel QDA Miner a été utilisé pour traiter les données. L'étude a révélé que les capacités organisationnelles et managériales des prestataires et des acteurs communautaires expliqueraient l'hétérogénéité des résultats observés. Des facteurs contextuels tels que l'éloignement des services ou l'impraticabilité et la dangerosité des routes ont accentué les disparités des résultats observés. Dans la mise en place des politiques de santé, il est important de tenir compte des facteurs humains et contextuels, car ils participent à l'explication de l'hétérogénéité des effets observés et renforcent la pertinence de ce type d'études.

Informing efforts beyond tailored promotional campaigns by understanding contextual factors shaping vaccine hesitancy among equity-deserving populations in Canada: an exploratory qualitative study.

BACKGROUND: Vaccine hesitancy exists on a continuum ranging between complete adherence and complete refusal due to doubts or concerns within a heterogeneous group of individuals. Despite widespread acknowledgement of the contextual factors influencing attitudes and beliefs shaping COVID-19 vaccine hesitancy, qualitative research with equity-deserving groups, accounting for unique lived experiences, remains a gap in the literature. We aim to identify and begin to understand and document the unique contextual factors shaping hesitancy by equity-deserving groups as it relates to relationships with government and health authorities. METHODS: Participants were recruited and interviewed between Aug-Dec 2021. Semi-structured interviews using a convergent interviewing technique were conducted with individuals from the general population, as well as individuals who identify as First Nations, Métis, or Inuit, members of the LGBT2SQ + community, low-income Canadians, Black Canadians, and newcomers. Interviews were audio recorded and transcribed by a team of researchers. Memos were written following interviews and used to complement the thematic analysis of the interview data. Themes are presented in the results section. RESULTS: The rationale for hesitancy among equity-deserving groups is consistent with literature documenting hesitancy in the general population. Contextual factors surrounding equity-deserving groups' attitudes and beliefs, however, are unique and relate to a history of oppression, discrimination, and genocide. We identified factors unique to subgroups; for example, religious or fatalistic beliefs among participant who identify as FNMI, fear associated with lack of testing and speed of vaccines' production among participants who identify as FNMI, Black, and LGBT2SQ + , distrust of the healthcare system for LGBT2SQ + and Black Canadians, and distrust of the government and opposition to vaccine mandates for participating who identify as LGBT2SQ + , low-income, FNMI, or Black Canadian. Newcomers stood out as very trusting of the government and accepting of COVID-19 vaccination. CONCLUSIONS: While our data on vaccine hesitancy largely mirror concerns reported in the vast body of literature citing rationale for COVID-19 hesitancy in high-income countries, the contextual factors identified in our work point to the need for wider systemic change. Our results may be used to support efforts, beyond tailored promotion campaigns, to support the confident acceptance of vaccines for COVID-19 and the acceptance of novel vaccines as future infectious diseases emerge.

Contextual factors of child behavioral health across developmental stages.

This study examines the relative influence of environmental contexts (family, school, neighborhood) on child behavioral health at ages 3, 5, 9, and 15 years. Path analysis was conducted on a sample of 4,898 urban children from a longitudinal dataset called the Fragile Families and Child Wellbeing Study. Child physical abuse, emotional abuse, maternal depression, substance use, neighborhood social cohesion, neighborhood poverty, school connectedness, and peer bullying had concurrent relationships with child behavior problems at one or more developmental stages. Early childhood abuse (age 3) and school age environmental contexts (age 9) had lasting effects on later behavior problems. Findings underscore the importance of both multilevel contextual factors and developmental timing in determining behavioral health outcomes in children.

Local contextual factors of child stunting found via shared values of stakeholder groups: an exploratory case study in Kaffrine, Senegal.

OBJECTIVE: This work aims to demonstrate an original approach to identify links between locally situated shared values and contextual factors of stunting. Stunting results from multi-factorial and multi-sectoral determinants, but interventions typically neglect locally situated lived experiences, which contributes to problematic designs that are not meaningful for those concerned and/or relatively ineffective. DESIGN: This case study investigates relevant contextual factors in two steps: by first facilitating local stakeholder groups (n 11) to crystallise their shared-values-in-action using a specialised method from sustainability studies (WeValue_InSitu (WVIS)). Secondly, participants (n 44) have focus group discussions (FGD) about everyday practices around child feeding/food systems, education and/or family life. Because the first step strongly grounds participants in local shared values, the FGD can reveal deep links between contextual factors and potential influences on stunting. SETTING: Kaffrine, Senegal, an 'Action Against Stunting Hub' site. December 2020. PARTICIPANTS: Eleven stakeholder groups of mothers, fathers, grandmothers, pre-school teachers, community health workers, farmers, market traders and public administrators. RESULTS: Local contextual factors of stunting were identified, including traditional beliefs concerning eating and growing practices; fathers as decision-makers; health worker trust; financial non-autonomy for women; insufficient water for preferred crops; merchants' non-access to quality produce; religious teachings and social structures affecting children's food environment. CONCLUSIONS: Local contextual factors were identified. Pre-knowledge of these could significantly improve effectiveness of intervention designs locally, with possible applicability at other sites. The WVIS approach proved efficient and useful for making tangible contextual factors and their potential links to stunting, via a lens of local shared values, showing general promise for intervention research.

From purists to pragmatists: a qualitative evaluation of how implementation processes and contexts shaped the uptake and methodological adaptations of a maternal and neonatal quality improvement programme in South Africa prior to, and during COVID-19.

BACKGROUND: Despite progress, maternal and neonatal mortality and still births remain high in South Africa. The South African National Department of Health implemented a quality improvement (QI) programme, called Mphatlalatsane, to reduce maternal and neonatal mortality and still births. It was implemented in 21 public health facilities, seven per participating province, between 2018 and 2022. METHODS: We conducted a qualitative process evaluation of the contextual and implementation process factors' influence on implementation uptake amongst the QI teams in 15 purposively selected facilities. Data collection included three interview rounds with the leaders and members of the QI teams in each facility; intermittent interviews with the QI advisors; programme documentation review; observation of programme management meetings; and keeping a fieldwork journal. All data were thematically analysed in Atlas.ti. Implementation uptake varied across the three provinces and between facilities within provinces. RESULTS: Between March and August 2020, the COVID-19 pandemic disrupted uptake in all provinces but affected QI teams in one province more severely than others, because they received limited pre-pandemic training. Better uptake among other sites was attributed to receiving more QI training pre-COVID-19, having an experienced QI advisor, and good teamwork. Uptake was more challenging amongst hospital teams which had more staff and more complicated MNH services, versus the primary healthcare facilities. We also attributed better uptake to greater district management support. A key factor shaping uptake was leaders' intrinsic motivation to apply QI methodology. We found that, across sites, organic adaptations to the QI methodology were made by teams, started during COVID-19. Teams did away with rapid testing of change ideas and keeping a paper trail of the steps followed. Though still using data to identify service problems, they used self-developed audit tools to record intervention effectiveness, and not the prescribed tools. CONCLUSIONS: Our study underscores the critical role of intrinsic motivation of team leaders, support from experienced technical QI advisors, and context-sensitive adaptations to maximise QI uptake when traditionally recognised QI steps cannot be followed.

Contextual factors influencing the roles of patent medicine vendors in the provision of injectable contraception services in Nigeria.

BACKGROUND: Patent medicine vendors (PMVs) play vital roles in the delivery of family planning services in Nigeria and other developing countries. There is a growing recognition of the need to integrate them into the formal health care system as a strategy to increase the contraceptive prevalence rate and achieve universal health coverage. Though promising, the success of this proposition is largely dependent on a critical analysis of the factors which influence their operations. This study was designed to identify the contextual factors influencing the provision of injectable contraceptive services by PMVs and the broader effects of their activities on the health system to inform similar interventions in Nigeria. METHODS: This was a qualitative study guided by the UK Medical Research Council's Framework for Complex Interventions. Twenty-seven in-depth interviews were conducted among officials of the association of PMVs, health workers, government regulatory officers and programme implementers who participated in a phased 3-year (2015-2018) intervention designed to enhance the capacity of PMVs to deliver injectable contraceptive services. The data were transcribed and analyzed thematically using NVIVO software. RESULTS: The contextual factors which had implications on the roles of PMVs were socio-cultural and religious, the failing Nigerian health system coupled with government regulatory policies. Other factors were interprofessional tensions and rivalry between the PMVs and some categories of health care workers and increasing donors' interest in exploring the potentials of PMVs for expanded healthcare service provision. According to the respondents, the PMVs bridged the Nigerian health system service delivery gaps serving as the first point of contact for injectable contraceptive services and this increased contraceptive uptake in the study sites. A negative effect of their operation is the tendency to exceed their service provision limits, which has spurred a planned tiered PMV accreditation system. CONCLUSIONS: This study has highlighted the contextual factors which define the roles and scope of practice of PMVs involved in injectable contraceptive service provision. Strategies and interventions aimed at expanding the healthcare delivery roles of PMVs must be encompassing to address the broader contextual factors which underpin their capacities and functions.

A Systematic Review of School-Based Suicide Prevention Interventions for Adolescents, and Intervention and Contextual Factors in Prevention.

Suicide is the fourth leading cause of death among adolescents, globally. Though post-primary, school-based suicide prevention (PSSP) has the potential to be a key strategy for preventing adolescent suicidal thoughts and behaviours (STBs), there are persisting challenges to translating PSSP research to practice. Intervention and contextual factors relevant to PSSP are likely key to both PSSP effectiveness and implementation. As such, this systematic review aimed to summarise the effectiveness of PSSP for adolescent STBs and highlight important intervention and contextual factors with respect to PSSP. PsycINFO, Medline, Education Source, ERIC, Web of Science, and the Cochrane Central Register of Controlled Trials were searched to identify randomised and non-randomised studies evaluating the effectiveness of interventions located in post-primary, school-based settings targeting adolescent STBs. PSSP effectiveness and intervention and contextual factors were synthesised narratively. Twenty-eight studies were retained, containing nearly 47,000 participants. Twelve out of twenty-nine trials comparing intervention and independent control comparators reported statistically significant reductions in STBs postintervention, and 5/7 trials comparing preintervention and postintervention scores demonstrated significant reductions in STBs over time. Reporting and analysis of intervention and contextual factors were lacking across studies, but PSSP effectiveness and intervention acceptability varied across type of school. Although school personnel commonly delivered PSSP interventions, their input and perspectives on PSSP interventions were lacking. Notably, adolescents had little involvement in designing, inputting on, delivering and sharing their perspectives on PSSP interventions. Twenty out of twenty-eight studies were rated as moderate/high risk of bias, with non-randomised trials demonstrating greater risks of bias and trial effectiveness, in comparison to cluster randomised trials. Future research should prioritise complete reporting and analysis of intervention and contextual factors with respect to PSSP, involving key stakeholders (including adolescents and school personnel) in PSSP, and investigating key stakeholders' perspectives on PSSP. Given the inverse associations between both study quality and study design with PSSP effectiveness, particular consideration to study quality and design in PSSP research is needed. Future practice should consider PSSP interventions with universal components and PSSP which supports and involves key stakeholders in engaging with PSSP.