An examination of mental health policy implementation efforts and the intermediaries that support them in New Zealand, Canada and Sweden: a comparative case study.

Introduction: The implementation of evidence-informed policies and practices across systems is a complex, multifaceted endeavor, often requiring the mobilization of multiple organizations from a range of contexts. In order to facilitate this process, policy makers, innovation developers and service deliverers are increasingly calling upon intermediaries to support implementation, yet relatively little is known about precisely how they contribute to implementation. This study examines the role of intermediaries supporting the implementation of evidence-informed policies and practices in the mental health and addictions systems of New Zealand, Ontario, Canada and Sweden. Methods: Using a comparative case study methodology and taking an integrated knowledge translation approach, we drew from established explanatory frameworks and implementation theory to address three questions: (1) Why were the intermediaries established? (2) How are intermediaries structured and what strategies do they use in systems to support the implementation of policy directions? and (3) What explains the lack of use of particular strategies? Data collection included three site visits, 49 key informant interviews and document analysis. Results: In each jurisdiction, a unique set of problems (e.g., negative events involving people with mental illness), policies (e.g., feedback on effectiveness of existing policies) and political events (e.g., changes in government) were coupled by a policy entrepreneur to bring intermediaries onto the decision agenda. While intermediaries varied greatly in their structure and characteristics, both the strategies they used and the strategies they didn't use were surprisingly similar. Specifically it was notable that none of the intermediaries used strategies that directly targeted the public, nor used audit and feedback. This emerged as the principle policy puzzle. Our analysis identified five reasons for these strategies not being employed: (1) their need to build/maintain healthy relationships with policy actors; (2) their need to build/maintain healthy relationships with service delivery system actors; (3) role differentiation with other system actors; (4) perceived lack of "fit" with the role of policy intermediaries; and (5) resource limitations that preclude intensive distributed (program-level) work. Conclusion: Policy makers and implementers must consider capacity to support implementation, and our study identifies how intermediaries can be developed and harnessed to support the implementation process.

Enhancing the delivery of comprehensive care for people living with HIV in Canada: insights from citizen panels and a national stakeholder dialogue.

BACKGROUND: People living with human immunodeficiency virus (HIV) are living longer with health-related disability associated with ageing, including complex conditions. However, health systems in Canada have not adapted to meet these comprehensive care needs. METHODS: We convened three citizen panels and a national stakeholder dialogue. The panels were informed by a plain-language citizen brief that outlined data and evidence about the challenge/problem, elements of an approach for addressing it and implementation considerations. The national dialogue was informed by a more detailed version of the same brief that included a thematic analysis of the findings from the panels. RESULTS: The 31 citizen panel participants emphasized the need for more prevention, testing and social supports, increased public education to address stigma and access to more timely data to inform system changes. The 21 system leaders emphasized the need to enhance person-centred care and for implementing learning and improvement across provinces, territories and Indigenous communities. Citizens and system leaders highlighted that policy actions need to acknowledge that HIV remains unique among conditions faced by Canadians. CONCLUSIONS: Action will require a national learning collaborative to support spread and scale of successful prevention, care and support initiatives. Such a collaborative should be grounded in a rapid-learning and improvement approach that is anchored on the needs, perspectives and aspirations of people living with HIV; driven by timely data and evidence; supported by appropriate decision supports and aligned governance, financial and delivery arrangements; and enabled with a culture of and competencies for rapid learning and improvement.

Framing Physical Literacy for Adults Through a Rehabilitation Lens: An Expert Consensus Study.

Research indicates a positive relationship between physical literacy and healthy aging; however, there is no consensus on the components required to become a physically literate adult. The objective of this study was to understand how physical literacy for adults with chronic conditions is characterized from the perspective of healthcare professionals. Physiotherapy leaders and physical literacy researchers within North America were invited to an online consensus panel and presented with questions related to physical literacy and rehabilitation. A nominal group technique was used for idea generation, clarification, and ranking. Confidence and safety with movements, motivation and commitment to physical activity, the ability to self-monitor changes in function, and understanding the benefits of physical activity were key components when defining physical literacy. There is a need to reconceptualize physical literacy to include the rehabilitation needs of adults living with chronic conditions, and to design programs that promote physical literacy to enhance function and mobility.

Access to novel drugs and therapeutics for children and youth: Eliciting citizens' values to inform public funding decisions.

INTRODUCTION: The unique evidentiary, economic and ethical challenges associated with health technology assessment (HTA) of precision therapies limit access to novel drugs and therapeutics for children and youth, for whom such challenges are amplified. We elicited citizens' perspectives about values-based criteria relevant to the assessment of paediatric precision therapies to inform the development of a child-tailored HTA framework. METHODS: We held four citizen panels virtually in May-June 2021, informed by a plain-language citizen brief summarizing global and local evidence about the challenges, policy and programmatic options and implementation strategies related to enhancing access to precision therapies for Canadian children and youth. Panellists were recruited through a nationally representative database, medical/patient networks and social media. We inductively coded and thematically analysed panel transcripts to generate themes and identify priority values. RESULTS: The perspectives of panellists (n = 45) coalesced into four overlapping themes, with attendant subthemes, relevant to a child-tailored HTA framework: (1) Childhood Distinctions: vulnerability, 'fair innings', future potential, family impacts; (2) Voice: agency of children and youth; lived versus no lived experience; (3) One versus Many: disease severity, rarity, equity, unmet need and (4) Health System Governance: funding, implementation inequities, effectiveness and safety. Participants broadly agreed that childhood distinctions, particularly family impacts, justify child-tailored HTA. Dissent arose over whose voice should inform HTA and how such perspectives are best incorporated. CONCLUSIONS: Citizens can offer unique insights into criteria relevant to the development or revision of HTA frameworks to capture holistic, societally responsive dimensions of value attached to unique contexts or populations, including children. Balancing the hopes and expectations of patients and caregivers for access to expensive but potential life-altering therapies against the opportunity costs borne by encompassing health systems is a fundamental challenge that will require rigorous methods to elicit, weigh and reconcile varied views. PATIENT OR PUBLIC CONTRIBUTION: A patient advocate served on the steering committee of this study and co-authored this article. Key informants for the Citizen Brief included patient advocates and caregivers; a separate patient advocate reviewed the Brief before dissemination. Qualitative and quantitative data were collected from the general public and caregivers of children, with written consent.

Web-Based System Navigation Database to Support Equitable Access to Assistive Technology: Usability Testing Study.

BACKGROUND: Assistive technology (AT) can contribute to how individuals participate and engage in everyday activities, such as communication and mobility, and facilitates access to the services they require. Navigating Canada's AT system has been described as fragmented and complex, presenting barriers for individuals who require AT, caregivers, and health service providers. AccessATCanada was developed as a centralized web-based resource to help support access to AT by providing information about the existing jurisdictional funding programs and services. OBJECTIVE: This study aimed to evaluate the usability of AccessATCanada by gathering feedback about its features, functionality, and areas of strength and opportunity from potential end users. METHODS: A usability testing study using a think-aloud approach and semistructured interviews was conducted to measure the effectiveness and efficiency of and user satisfaction with AccessATCanada and to identify issues with the interface during end-user interaction. A qualitative thematic analysis was used to generate insights into and core themes about user experiences. User feedback was used to inform subsequent updates of the database with the goal of enhancing website friendliness and functionality before its official launch. RESULTS: A total of 10 participants (6 consumers, 1 caregiver, and 3 providers) participated in the usability testing study. The usability performance and scores tended to improve between the 2 testing cycles. Most participants were able to successfully complete all the tasks independently. The efficiency scores tended to improve as the users continued to engage with the interface. The website received an overall System Usability Score of 62.22, which was ranked as "OK/fair to good." The users provided an overall positive evaluation of the beta version of the web-based resource tested over 2 cycles and helped to identify areas for improvement. They commented on the functionality and added value of the website, discovery of new programs and resources, and design aesthetics. Most usability issues were reported as minor challenges related to presentation, functionality, and language, and feedback was adopted into later iterations of the website. CONCLUSIONS: This study provides reflections on the value of usability testing and elements that are key to the creation of user-centered resources, such as the inclusion of participants with various abilities and considerations regarding website design and accessibility in an increasingly web-based world. AccessATCanada is now part of a growing global response to expand the reach of AT programs and services, improve the equity of access to AT, and reduce the complexity of navigating AT systems.

Facilitators, barriers and strategies for health-system guidance implementation: a critical interpretive synthesis protocol.

BACKGROUND: As systematically developed statements regarding possible courses of action, health system guidance (HSG) can assist with making decisions about addressing problems or achieving goals in health systems. However, there are conceptual and methodological challenges in HSG implementation due to the complexity of health-system policy-making, the diversity of available evidence and vast differences in contexts. To address these gaps, we aim to develop a theoretical framework for supporting HSG implementation as part of a broader effort to promote evidence-informed policy-making in health systems. METHODS: To develop a theoretical framework about facilitators, barriers and strategies for HSG implementation, we will apply a critical interpretive synthesis (CIS) approach to synthesize the findings from a range of relevant literature. We will search 11 electronic databases and seven organizational websites to identify relevant published and grey literature. We will check the references of included studies and contact experts to identify additional eligible papers. Finally, we will conduct purposively sampling of the literature to fill any identified conceptual gaps. We will use relevance and five quality criteria to assess included papers. A standardized form will be developed for extracting information. We will use an interpretive analytic approach to synthesize the findings, including a constant comparative method throughout the analysis. Two independent reviewers will conduct the literature screening and relevance assessment, and disagreements will be resolved through discussion. The principal investigator will conduct data extraction and synthesis, and a second reviewer will check the sample of extracted data for consistency and accuracy. DISCUSSION: A new theoretical framework about facilitators, barriers and strategies for HSG implementation will be developed using a CIS approach. The HSG implementation framework could be widely used for supporting the implementation of HSG covering varied topics and in different contexts (including low-, middle- and high-income countries). In later work, we will develop a tool for supporting HSG implementation based on the theoretical framework. Registration PROSPERO CRD42020214072. Date of Registration: 14 December 2020.

The impact of OHIP+ pharmacare on use and costs of public drug plans among children and youth in Ontario: a time-series analysis.

BACKGROUND: In 2018, Ontario implemented a pharmacare program (Ontario Health Insurance Plan Plus [OHIP+]) to provide children and youth younger than 25 years with full coverage for prescription medications in the provincial formulary. We aimed to assess the use of public drug plans and costs of publicly covered prescriptions before and after the program's implementation and modification. METHODS: We conducted a population-based, interrupted time-series analysis using data on prescription drug claims, from the Canadian Institute for Health Information's National Prescription Drug Utilization Information System, for people younger than 25 years from January 2016 to October 2019 in Ontario, using British Columbia as the control. We assessed changes in the level and trend of publicly covered prescriptions and expenditures after the introduction of OHIP+ in January 2018 and after program modifications in April 2019. We also assessed plan use and expenditures for publicly covered prescriptions for diabetes and asthma. RESULTS: Publicly covered prescriptions in Ontario increased by 290%, from 756 per 1000 people before OHIP+ to 2952 per 1000 (p < 0.001) after its implementation. After program modification, prescriptions decreased by 52% to 1421 per 1000 (p < 0.001). Similarly, total public drug expenditures increased by 254%, from $379 million in 2017 to $839 million in 2018, then reduced by 49% to $204 million in 2019. Monthly public plan expenditures increased by $115.94 (95% confidence interval [CI] $100.93 to $130.94) post-OHIP+ implementation and decreased by $99.97 (95% CI -$119.79 to -$80.15) per person per month after April 2019. INTERPRETATION: Adopting OHIP+ increased use of public drug plans and expenditures for publicly funded prescription medicines, and the program modification was associated with decreases in both outcomes. This study's findings can inform the national pharmacare debate; future research should investigate associations with health outcomes.

It is time for a national strategy on equitable access to assistive technology in Canada.

The time has come to develop and implement a Canadian strategy on equitable access to Assistive Technology (AT). AT use has significant health, social, and economic benefits for people with disabilities and older people, and benefits society by assisting to mitigate the most prominent health and social challenges of our time. Our research with citizens (with/without experiences of disabilities or AT use) and system leaders across Canada determined that access is variable and inequitable, with unmet needs, restricted funding, and inefficiencies. Collaboratively, we devised a blueprint, comprising a policy vision, three priority issues to address, principles to underpin policy actions, and short- and long-term priorities, from which to build a strategy. We hope the blueprint sparks action among citizens and health leaders, especially those working across governments, sectors, and communities to promote leadership and create a cross-jurisdictional coalition to elaborate on a national strategy and action plans for moving forward.

Enhancing the use of technology in the long-term care sector in Canada: Insights from citizen panels and a national stakeholder dialogue.

Enhancing the use of technology in long-term care has been identified as a key part of broader efforts to strengthen the sector in the wake of the COVID-19 pandemic. To inform such efforts, we convened a series of citizen panels, followed by a national stakeholder dialogue with system leaders focused on reimagining the long-term care sector using technology. Key actions prioritized through the deliberations convened included: developing an innovation roadmap/agenda (including national standards and guidelines); using co-design approaches for the strengthening the long-term care sector and for technological innovation; identifying and coordinating existing innovation projects to support scale and spread; enabling rapid-learning and improvement cycles to support the development, evaluation, and implementation of new technologies; and using funding models that enable the flexibility needed for such rapid-learning cycles.

Integrating citizen engagement into evidence-informed health policy-making in eastern Europe and central Asia: scoping study and future research priorities.

BACKGROUND: The perspectives of citizens are an important and often overlooked source of evidence for informing health policy. Despite growing encouragement for its adoption, little is known regarding how citizen engagement may be integrated into evidence-informed health policy-making in low- and middle-income counties (LMICs) and newly democratic states (NDSs). We aimed to identify the factors and variables affecting the potential integration of citizen engagement into evidence-informed health policy-making in LMICs and NDSs and understand whether its implementation may require a different approach outside of high-income western democracies. Further, we assessed the context-specific considerations for the practical implementation of citizen engagement in one focus region-eastern Europe and central Asia. METHODS: First, adopting a scoping review methodology, we conducted and updated searches of six electronic databases, as well as a comprehensive grey literature search, on citizen engagement in LMICs and NDSs, published before December 2019. We extracted insights about the approaches to citizen engagement, as well as implementation considerations (facilitators and barriers) and additional political factors, in developing an analysis framework. Second, we undertook exploratory methods to identify relevant literature on the socio-political environment of the focus region, before subjecting these sources to the same analysis framework. RESULTS: Our searches identified 479 unique sources, of which 28 were adjudged to be relevant. The effective integration of citizen engagement within policy-making processes in LMICs and NDSs was found to be predominantly dependent upon the willingness and capacity of citizens and policy-makers. In the focus region, the implementation of citizen engagement within evidence-informed health policy-making is constrained by a lack of mutual trust between citizens and policy-makers. This is exacerbated by inadequate incentives and capacity for either side to engage. CONCLUSIONS: This research found no reason why citizen engagement could not adopt the same form in LMICs and NDSs as it does in high-income western democracies. However, it is recognized that certain political contexts may require additional support in developing and implementing citizen engagement, such as through trialling mechanisms at subnational scales. While specifically outlining the potential for citizen engagement, this study highlights the need for further research on its practical implementation.

Policymaker and stakeholder perspectives on access to assistive technologies in Canada: challenges and proposed solutions for enhancing equitable access.

PURPOSE: Unmet needs for assistive technologies (ATs) exist and the need for ATs is growing owing to demographic changes worldwide. Little comprehensive research has examined equity of access to ATs in Canada. Our study elucidates perspectives of policymakers and stakeholders on challenges and solutions for enhancing equitable access to ATs to advance policy discussions. METHODS: We conducted a qualitative interview study with a purposive sample of policymakers and stakeholders. Stakeholders were from non-profit organisations; private insurance companies; ageing or technology industries; and advocacy, consumer, and support groups. We used thematic analysis to develop themes that summarised and facilitated data interpretation. RESULTS: We conducted 24 interviews involving 32 participants. We present three themes: (1) User experiences, detailing challenges experienced by AT system users; (2) System characteristics: Challenges and solutions, outlining governance, financial, and delivery arrangements that create challenges for accessing AT, as well as participants' proposed solutions; and (3) Shifts in models and principles, for approaches that may foster equitable access to ATs. We consolidate results into a set of valued qualities of a system that can enhance equitable AT access, and relate results to relevant national and international activities. CONCLUSIONS: This is the most comprehensive study of Canadian policymaker and stakeholder views on AT access to date. Identified challenges and solutions point to opportunities for policy action and to support work to create a national vision for AT access that strengthens the potential for ATs to enable daily activity participation, independence, and societal inclusion of seniors and people with disabilities.IMPLICATIONS FOR REHABILITATIONAT use supports daily activity participation, independence, and societal inclusion of seniors and people with disabilities.There is an urgent need to ensure that those who need ATs have access to them, considering the benefits of their use, current unmet needs for ATs, and the anticipated demand for ATs because of the ageing population and increased prevalence of chronic disease and disability.A comprehensive understanding of policymakers' and stakeholders' perspectives on challenges and potential solutions for enhancing equitable access to ATs is critical to support development of evidence- and values-informed policies.Understanding challenges and solutions identified by diverse policymakers and stakeholders can lead to national and local opportunities for policy action and support work to create a national vision for enhancing equitable access to AT.

Examining and Contextualizing Approaches to Establish Policy Support Organizations - A Critical Interpretive Synthesis.

BACKGROUND: In response to worldwide calls for the need to support evidence-informed policy-making (EIPM), more countries are increasingly interested in enhancing their efforts to use research to inform policy-making. In order to inform the efforts of those asked to lead the support of EIPM, our aim is to develop a conceptual framework to guide the process of establishing a policy support organization (PSO). METHODS: We conducted a critical interpretive synthesis (CIS). We conducted a two steps literature review. In the second step, we systematically searched OVID EMBASE, PsychInfo, HealthStar, CINAHL, Web of Science, Social Science Abstract, Health Systems Evidence, and ProQuest Dissertations and Theses Global databases for documents reporting the establishment of PSOs and the contextual factors influencing the process of establishing these organizations. We assessed the eligibility of the retrieved articles and synthesized the findings iteratively. RESULTS: We included 52 documents in the synthesis. Our findings suggest that a PSO establishment process has four interconnected stages: awareness, development, assessment, and maturation. The process of establishing a PSO is iterative and influenced by political, research and health systems contextual factors, which determine the availability of the resources and the trust between researchers and policy-makers. The contextual factors have an impact on each other, and the challenges that arise from one factor can be mitigated by other factors. CONCLUSION: For those interested in establishing a PSO, our framework provides a road map for identifying the most appropriate starting point and the factors that might influence the establishment process. Leaders of such PSOs can use our findings to expand or refine their scope of work. Given that this framework focuses only on PSOs in the health sector, an important next step for research would be to include other sectors from social systems and identify any additional insight that can enhance our framework.

Examining and Contextualizing Approaches to Establish Policy Support Organizations - A Mixed Method Study.

BACKGROUND: There has been an increase in the number of policy support organizations (PSOs) that have been created to foster the systematic use of evidence in health system policymaking. Our aim was to identify approaches for establishing a PSO or similar entities by soliciting insights from those with practical experience with developing and operationalizing PSOs in real-world contexts. METHODS: We used a sequential mixed method approached. We first conducted a survey to identify the views and experiences of those who were directly involved in the establishment of PSOs that have been developed and implemented across a variety of political-, health- and research-system contexts. The survey findings were then used to develop a purposive sample of PSO leaders and refine an interview guide for interviews with them. RESULTS: We received 19 completed surveys from leaders of PSOs in countries across the WHO regions and that operate in different settings (eg, as independent organization or within a university or government department) and conducted interviews with 15 senior managers from nine PSOs. Our findings provide in-depth insights about approaches and strategies across four stages for establishing a PSO, which include: (i) building awareness for the PSO; (ii) developing the PSO; (iii) assessing the PSO to identify potential areas for enhancement; and (iv) supporting maturation to build sustainability in the long-term. Our findings provide rich insights about the process of establishing a PSO from leaders who have undertaken the process. CONCLUSION: While all PSOs share the same objective in supporting evidence-informed policy-making (EIPM), there is no single approach that can be considered to be the most successful in establishing a PSO, and each country should identify the approach based on its context.

Paper 3: Selecting rapid review methods for complex questions related to health policy and system issues.

Approaches for rapid reviews that focus on streamlining systematic review methods are not always suitable for exploring complex policy questions, as developing and testing theories to explain these complexities requires configuring diverse qualitative, quantitative, and mixed methods studies. Our objective was therefore to provide a guide to selecting approaches for rapidly (i.e., within days to months) addressing complex questions related to health policy and system issues.We provide a two-stage, transdisciplinary collaborative process to select a rapid review approach to address complex policy questions, which consists of scoping the breadth and depth of the literature and then selecting an optimal approach to synthesis. The first stage (scoping the literature) begins with a discussion with the stakeholders requesting evidence to identify and refine the question for the review, which is then used to conduct preliminary searches and conceptually map the documents identified. In the second stage (selection of an optimal approach), further stakeholder consultation is required to refine and tailor the question and approach to identifying relevant documents to include. The approach to synthesizing the included documents is then guided by the final question, the breadth and depth of the literature, and the time available and can include a static or evolving conceptual framework to code and analyze a range of evidence. For areas already covered extensively by existing systematic reviews, the focus can be on summarizing and integrating the review findings, resynthesizing the primary studies, or updating the search and reanalyzing one or more of the systematic reviews.The choice of approaches for conducting rapid reviews is intertwined with decisions about how to manage projects, the amount of work to be done, and the knowledge already available, and our guide offers support to help make these strategic decisions.

Scoping reviews: reinforcing and advancing the methodology and application.

Scoping reviews are an increasingly common approach to evidence synthesis with a growing suite of methodological guidance and resources to assist review authors with their planning, conduct and reporting. The latest guidance for scoping reviews includes the JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews. This paper provides readers with a brief update regarding ongoing work to enhance and improve the conduct and reporting of scoping reviews as well as information regarding the future steps in scoping review methods development. The purpose of this paper is to provide readers with a concise source of information regarding the difference between scoping reviews and other review types, the reasons for undertaking scoping reviews, and an update on methodological guidance for the conduct and reporting of scoping reviews.Despite available guidance, some publications use the term 'scoping review' without clear consideration of available reporting and methodological tools. Selection of the most appropriate review type for the stated research objectives or questions, standardised use of methodological approaches and terminology in scoping reviews, clarity and consistency of reporting and ensuring that the reporting and presentation of the results clearly addresses the review's objective(s) and question(s) are critical components for improving the rigour of scoping reviews.Rigourous, high-quality scoping reviews should clearly follow up to date methodological guidance and reporting criteria. Stakeholder engagement is one area where further work could occur to enhance integration of consultation with the results of evidence syntheses and to support effective knowledge translation. Scoping review methodology is evolving as a policy and decision-making tool. Ensuring the integrity of scoping reviews by adherence to up-to-date reporting standards is integral to supporting well-informed decision-making.

Understanding the implementation of evidence-informed policies and practices from a policy perspective: a critical interpretive synthesis.

BACKGROUND: The fields of implementation science and knowledge translation have evolved somewhat independently from the field of policy implementation research, despite calls for better integration. As a result, implementation theory and empirical work do not often reflect the implementation experience from a policy lens nor benefit from the scholarship in all three fields. This means policymakers, researchers, and practitioners may find it challenging to draw from theory that adequately reflects their implementation efforts. METHODS: We developed an integrated theoretical framework of the implementation process from a policy perspective by combining findings from these fields using the critical interpretive synthesis method. We began with the compass question: How is policy currently described in implementation theory and processes and what aspects of policy are important for implementation success? We then searched 12 databases as well as gray literature and supplemented these documents with other sources to fill conceptual gaps. Using a grounded and interpretive approach to analysis, we built the framework constructs, drawing largely from the theoretical literature and then tested and refined the framework using empirical literature. RESULTS: A total of 11,434 documents were retrieved and assessed for eligibility and 35 additional documents were identified through other sources. Eighty-six unique documents were ultimately included in the analysis. Our findings indicate that policy is described as (1) the context, (2) a focusing lens, (3) the innovation itself, (4) a lever of influence, (5) an enabler/facilitator or barrier, or (6) an outcome. Policy actors were also identified as important participants or leaders of implementation. Our analysis led to the development of a two-part conceptual framework, including process and determinant components. CONCLUSIONS: This framework begins to bridge the divide between disciplines and provides a new perspective about implementation processes at the systems level. It offers researchers, policymakers, and implementers a new way of thinking about implementation that better integrates policy considerations and can be used for planning or evaluating implementation efforts.

Option B+ Program for the Prevention of Vertical Transmission of HIV: A Case Study in Johannesburg, South Africa.

Background: South Africa's National Department of Health adopted WHO's 2013 consolidated guidelines on ARVs for HIV treatment and prevention in 2015, including changes for Prevention from Mother-to-Child Transmission (PMTCT) through Option B+, aimed to reduce the HIV prevalence rate amongst women by placing them on lifelong treatment, irrespective of their CD4 count. As a result, these guidelines were implemented for the PMTCT program at Rahima Moosa Hospital. Little is known about the impact of these guidelines on the work of healthcare workers (HCWs) and no research had focused on how these changes have affected adherence for the patients. Objectives: The purpose of this research project was (1) to explore the impact of the Option B+ PMTCT program on the work of healthcare professionals, and (2) to understand pregnant HIV-positive women views and experiences with ART for life, as a way to better manage the Option B+ PMTCT program. Design: Qualitative semi-structured interviews with a phenomenological approach was used. Setting: Data collection at the antenatal/postnatal clinics/wards, OBGYN and Department of Pediatrics at RMMCH in Johannesburg. Method: A qualitative study design is used with a phenomenological approach. The methodology used semi-structured interviews with healthcare professionals and patients. The thematic analysis was used within an Accessibility Framework to guide the identification of domains that emerged from all transcribed data. A convenience sample in the antenatal clinic, postnatal clinic, antenatal ward, OBGYN, and Department of Pediatrics and Child Health at RMMCH. The study is situated in Johannesburg, South Africa. Results: The findings demonstrated that work has become difficult to manage for all healthcare professionals because of (1) the need for strengthening indicators for tracking to decrease loss to follow-up (LTFU); (2) inconsistency in delivery of counseling and support services and the need for communication across clinical departments; and (3) the lack of compassion and understanding by service providers. The difficult healthcare environment has affected overall views and experiences of pregnant HIV-positive women going on ART for life. All patient participants (n = 55) responded that they chose to take the fixed-dose combination (FDC) for life to protect the health of the baby and felt ART for life can be stopped after giving birth, unaware of the long-term benefits to the mother. Conclusion: The Option B+ program emphasized a need for the provision of continuous counseling and support services for women with same day initiation of ART. There is a need for better internal communication and collaboration amongst HCWs across all units of RMMCH for attainment in treatment outcomes. HCWs communication to patients is essential in helping patients build trust in service delivery, decreasing the LTFU and promoting adherence. The ability to understand functions of the work environment in which a PMTCT program operates in is essential in addressing policy implementation and program issues for ease of adaptability of Option B+ programming on a larger scale across all units of RMMCH. Implications for future research include the need to address changes within the healthcare system at both clinical and management levels. It is crucial to incorporate the perspective of patients in policy implementation; uptake and adherence are key indicators in informing whether the Option B+ PMTCT program is being adapted into state hospitals effectively. There needs to be extensive research on how to strengthen indicators for long term scalability and sustainability of the program. Future evaluations need to address how interdisciplinary collaboration within healthcare facilities improves the management and understanding of Option B+ program.

A framework for explaining the role of values in health policy decision-making in Latin America: a critical interpretive synthesis.

BACKGROUND: Although values underpin the goals pursued in health systems, including how health systems benefit the population, it is often not clear how values are incorporated into policy decision-making about health systems. The challenge is to encompass social/citizen values, health system goals, and financial realities and to incorporate them into the policy-making process. This is a challenge for all health systems and of particular importance for Latin American (LA) countries. Our objective was to understand how and under what conditions societal values inform decisions about health system financing in LA countries. METHODS: A critical interpretive synthesis approach was utilised for this work. We searched 17 databases in December 2016 to identify articles written in English, Spanish or Portuguese that focus on values that inform the policy process for health system financing in LA countries at the macro and meso levels. Two reviewers independently screened records and assessed them for inclusion. One researcher conceptually mapped the included articles, created structured summaries of key findings from each, and selected a purposive sample of articles to thematically synthesise the results across the domains of agenda-setting/prioritisation, policy development and implementation. RESULTS: We identified 5925 references, included 199 papers, and synthesised 68 papers. We identified 116 values and developed a framework to explain how values have been used to inform policy decisions about financing in LA countries. This framework has four categories - (1) goal-related values (i.e. guiding principles of the health system); (2) technical values (those incorporated into the instruments adopted by policy-makers to ensure a sustainable and efficient health system); (3) governance values (those applied in the policy process to ensure a transparent and accountable process of decision-making); and (4) situational values (a broad category of values that represent competing strategies to make decisions in the health systems, their influence varying according to the four factors). CONCLUSIONS: It is an effort to consolidate and explain how different social values are considered and how they support policy decision-making about health system financing. This can help policy-makers to explicitly incorporate values into the policy process and understand how values are supporting the achievement of policy goals in health system financing. TRIAL REGISTRATION: The protocol was registered with PROSPERO, ID=CRD42017057049 .

A critical interpretive synthesis of the roles of midwives in health systems.

BACKGROUND: Midwives' roles in sexual and reproductive health and rights continues to evolve. Understanding the profession's role and how midwives can be integrated into health systems is essential in creating evidence-informed policies. Our objective was to develop a theoretical framework of how political system factors and health systems arrangements influence the roles of midwives within the health system. METHODS: A critical interpretive synthesis was used to develop the theoretical framework. A range of electronic bibliographic databases (CINAHL, EMBASE, Global Health database, HealthSTAR, Health Systems Evidence, MEDLINE and Web of Science) was searched through to 14 May 2020 as were policy and health systems-related and midwifery organisation websites. A coding structure was created to guide the data extraction. RESULTS: A total of 4533 unique documents were retrieved through electronic searches, of which 4132 were excluded using explicit criteria, leaving 401 potentially relevant records, in addition to the 29 records that were purposively sampled through grey literature. A total of 100 documents were included in the critical interpretive synthesis. The resulting theoretical framework identified the range of political and health system components that can work together to facilitate the integration of midwifery into health systems or act as barriers that restrict the roles of the profession. CONCLUSIONS: Any changes to the roles of midwives in health systems need to take into account the political system where decisions about their integration will be made as well as the nature of the health system in which they are being integrated. The theoretical framework, which can be thought of as a heuristic, identifies the core contextual factors that governments can use to best leverage their position when working to improve sexual and reproductive health and rights.

Understanding the Role of Values in Health Policy Decision-Making From the Perspective of Policy-Makers and Stakeholders: A Multiple-Case Embedded Study in Chile and Colombia.

BACKGROUND: Chile and Colombia are examples of Latin American countries with health systems shaped by similar values. Recently, both countries have crafted policies to regulate the participation of private for-profit insurance companies in their health systems, but through very different mechanisms. This study asks: what values are important in the decision-making processes that crafted these policies? And how and why are they used? METHODS: An embedded multiple-case study design was carried out for 2 specific decisions in each country: (1) in Chile, the development of the Universal Plan of Explicit Entitlements -AUGE/GES - and mandating universal coverage of treatments for high-cost diseases; and (2) in Colombia, the declaration of health as a fundamental right and a mechanism to explicitly exclude technologies that cannot be publicly funded. We interviewed key informants involved in one or more of the decisions and/or in the policy analysis and development process that contributed to the eventual decision. The data analysis involved a constant comparative approach and thematic analysis for each case study. RESULTS: From the 40 individuals who were invited, 28 key informants participated. A tension between 2 important values was identified for each decision (eg, solidarity vs. individualism for the AUGE/GES plan in Chile; human dignity vs. sustainability for the declaration of the right to health in Colombia). Policy-makers used values in the decisionmaking process to frame problems in meaningful ways, to guide policy development, as a pragmatic instrument to make decisions, and as a way to legitimize decisions. In Chile, values such as individualism and free choice were incorporated in decision-making because attaining private health insurance was seen as an indicator of improved personal economic status. In Colombia, human dignity was incorporated as the core value because the Constitutional Court asserted its importance in its use of judicial activism as a check on the power of the executive and legislative branches. CONCLUSION: There is an opportunity to open further exploration of the role of values in different health decisions, political sectors besides health, and even other jurisdictions.