Mapping Online Community Spaces Through Online Focus Group Discussions Among Gay, Bisexual, and Other Men Who Have Sex With Men in Guangdong, China: Implications for Human Immunodeficiency Virus/Sexually Transmitted Disease Prevention Services.

BACKGROUND: Chinese gay, bisexual, and other men who have sex with men (GBMSM) face discrimination in many facility-based health services, thus increasing the importance of online engagement. The purpose of this study was to examine online GBMSM community spaces and implications for HIV/sexually transmitted disease prevention services. METHODS: We conducted a total of 6 online focus group discussions with Chinese GBMSM from Guangdong province on the chat-based platform WeChat in 2021. Focus group discussions were asynchronous, and participants were able to provide and map out online spaces that they had participated in and share their perspectives on online engagement. Data were analyzed through framework analysis. RESULTS: Overall, 48 participants participated. Most were mainly sexually attracted to men (n = 43; 90.0%) and never participated in in-person LGBTQ-related events (n = 29; 60.4%). Participants articulated a typology of online spaces along the axes of whether such spaces were Chinese platforms (vs. non-Chinese) or whether they were GBMSM-specific (vs. non-GBMSM-specific). Participants articulated several advantages of online spaces, including greater anonymity, opportunities for community building, sharing of sexual health information, and being able to meet other GBMSM more efficiently. Drawbacks included the lack of personal connection, lack of safety measures for youth, encountering deception and the use of fake profile pictures, and needing a virtual proxy network to access some websites. Participants provided suggestions to further improve their experiences of online spaces. CONCLUSIONS: Although broad-based, GBMSM-specific messaging can be implemented in Chinese, GBMSM-specific spaces, sexual health messaging may also reach niche GBMSM communities in a variety of non-GBMSM spaces.

Quality improvement in public-private partnerships in low- and middle-income countries: a systematic review.

BACKGROUND: Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs. METHODS: We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author. RESULTS: We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change. CONCLUSIONS: Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.

Using the consolidated framework for implementation research to identify recruitment barriers and targeted strategies for a shared decision-making randomized clinical trial in pediatric sickle cell disease.

BACKGROUND/AIMS: Recruitment is often a barrier in clinical trials that include minoritized populations, such as individuals with sickle cell disease. In the United States, the majority of people with sickle cell disease identify as Black or African American. In sickle cell disease, 57% of the United States trials that ended early did so due to low enrollment. Thus, there is a need for interventions that improve trial enrollment in this population. After lower-than-expected recruitment during the first 6 months of the Engaging Parents of Children with Sickle Cell Anemia and their Providers in Shared-Decision-Making for Hydroxyurea trial, a multi-site study for young children with sickle cell disease, we collected data to understand barriers and used the Consolidated Framework for Implementation Research to categorize them and guide the development of targeted strategies. METHODS: Study staff used screening logs and coordinator and principal investigator calls to identify recruitment barriers that were then mapped onto Consolidated Framework for Implementation Research constructs. Targeted strategies were implemented during Months 7-13. Recruitment and enrollment data were summarized before (Months 1-6) and during the implementation period (Months 7-13). RESULTS: During the first 13 months, 60 caregivers (M = 30.65 years; SD = 6.35) enrolled in the trial. Most caregivers primarily self-identified as female (n = 54, 95%) and African American or Black (n = 51, 90%). Recruitment barriers mapped onto three Consolidated Framework for Implementation Research constructs: (1) Process barriers (i.e. no identified "site champion" and poor recruitment planning at several sites); (2) Inner setting barriers (i.e. limited communication, low relative study priority at several sites); and (3) Outer setting barriers (i.e. poor patient attendance at clinic appointments). Targeted strategies to improve recruitment included (1) principal investigator site visits and retraining on recruitment procedures to address process barriers; (2) increased frequency of communication through all coordinator, site principal investigator, and individual site calls to address inner setting barriers; and (3) development and implementation of no-show procedures for clinic appointments to address outer setting barriers. After implementation of the recruitment strategies, the number of caregivers identified for pre-screening increased from 54 to 164, and enrollment more than tripled from 14 to 46 caregiver participants. CONCLUSION: Consolidated Framework for Implementation Research constructs guided the development of targeted strategies that increased enrollment. This reflective process reframes recruitment challenges as the responsibility of the research team rather than characterizing minoritized populations as "difficult" or "hard to reach." Future trials including patients with sickle cell disease and minoritized populations may benefit from this approach.

Pay-it-forward gonorrhea and chlamydia testing among men who have sex with men and male STD patients in China: the PIONEER pragmatic, cluster randomized controlled trial protocol.

BACKGROUND: Gonorrhea and chlamydia are the most common sexually transmitted diseases (STDs) among men who have sex with men (MSM) in China. Previous studies have shown pay-it-forward (PIF) interventions to be associated with a substantial increase in gonorrhea and chlamydia test uptake compared to standard-of-care. We propose a 'pay-it-forward' gonorrhea and chlamydia testing randomized controlled trial (PIONEER). The trial would evaluate the effectiveness of two pay-it-forward strategies in promoting testing uptake compared to the standard of care (in which men pay for their tests out-of-pocket) among MSM and male STD patients in China. METHODS: PIONEER will be a three-armed, pragmatic cluster randomized controlled trial (RCT), conducted across 12 clinics (six MSM-led and six public STD clinics) to compare the effectiveness of three implementation strategies. Each facility will be randomized to a standard pay-it-forward intervention of gonorrhea/ chlamydia testing with minimal encouragement for testing, a community-engaged pay-it-forward arm, or a control arm where men pay for their tests out-of-pockets. The primary outcome will be dual gonorrhea/chlamydia test uptake. Secondary outcomes will include syphilis testing, amount donated in pay-it-forward, number of positive gonorrhea and chlamydia tests, and measures of antimicrobial resistance. A sequential transformative mixed methods design will be used to evaluate the implementation process in type 2 effectiveness-implementation hybrid design. Data sources will include survey on acceptability, and feelings and attitudes towards the interventions among participants; testing and treatment uptake data from clinic records, WeChat records, and qualitative data to gain insights into men's perceptions and attitudes towards the pay-it-forward, mechanisms driving uptake, and donating behaviors. Implementers and organizers will be interviewed about fidelity and adherence to protocol, sustainability of pay-it-forward intervention, and barriers and facilitators of implementing the intervention. DISCUSSION: PIONEER will substantially increase gonorrhea/chlamydia testing among MSM in China, providing an innovative and new financial mechanism to sustain STD screening among sexual minorities in low- and middle-income countries. This study will answer compelling scientific questions about how best to implement pay-it-forward and the individual and organizational characteristics that moderate it. TRIAL REGISTRATION: The study with identification number NCT05723263 has been registered on clinicaltrials.gov/.

Determinants of health workers intention to use malaria rapid diagnostic test in Kintampo North Municipality, Ghana - a cross-sectional study.

BACKGROUND: Resistance to antimalarial drugs resulting from overuse of the medication remains a threat to malaria control and elimination in endemic settings including Ghana. Reliance on clinical signs alone results in patients being diagnosed with malaria falsely. The World Health Organization and local guidelines recommend test-based diagnosis with malaria rapid diagnostic test (mRDT) or microscopy before prescription of antimalarial drugs. Despite the scale-up of mRDT through the procurement of mRDT kits and training of health workers on mRDT-led diagnosis of malaria, its use remains low with about 85% health workers reporting satisfaction with the presumptive diagnosis. METHODS: A quantitative cross-sectional study was conducted to investigate the determinants of intention to use mRDT among health workers in Kintampo North Municipality, Ghana. A total of 110 health workers were surveyed from February to April 2017. Intention to use mRDT was measured as the primary outcome with a 5-item scale questionnaire based on the Technology Acceptance Model (TAM). We then tested its association with hypothesized determinants: coherence, cognitive participation, collective action, and reflexive action informed by the Normalization Process Theory (NPT) as well as health workers' background characteristics using linear regression modeling. RESULTS: The mean intention to use mRDT score was 82% (SD: 12.6). The regression model showed health workers intention to use mRDT was positively associated with coherence (ß = 0.40, 95% CI 0.16-0.65) and cognitive participation (ß = 0.36, 95% CI 0.15-0.58). Intention to use mRDT score was 6.85 units higher among health workers with three or more years of experience compared to those with less than 3 years of experience (ß = 6.85 95% CI 0.59-13.12). However, intention to use mRDT score was inversely related to reflexive monitoring and collective action but not significant. CONCLUSION: The study identified that intention to use mRDT was positively influenced by health workers having a proper understanding of the aims and expected benefits (coherence) of the intervention and the availability of experienced staff and intervention champions (cognitive participation) to promote mRDT use among health workers.

Building health system capacity to improve maternal and newborn care: a pilot leadership program for frontline staff at a tertiary hospital in Ghana.

BACKGROUND: Frontline healthcare workers are critical to meeting the maternal, newborn and child health Sustainable Development Goals in low- and middle-income countries. The World Health Organization has identified leadership development as integral to achieving successful health outcomes, but few programs exist for frontline healthcare workers in low-resource settings. METHODS: An 18-month pilot leadership development program was designed and implemented at Greater Accra Regional Hospital, a tertiary care facility in Ghana. A multi-modal training approach was utilized to include individual coaching, participatory discussions, role plays, and didactic sessions on leadership styles, emotional intelligence, communication, accountability and compassionate care. RESULTS: A cross-section of 140 staff from 8 distinct hospital wards and 19 ranks were involved in various components of the leadership program from January 2014 to June 2015. At baseline, the primary leadership challenges and goals of the staff included: interpersonal communication, institutional logistics, compliance, efficiency and staff attitudes. Thirteen participants developed a total of 17 leadership projects to apply their training, many of which focused on improving challenges in organizational culture and systems through bettering leadership skills and interpersonal communication. The staff highly valued the program and found it beneficial to their work. CONCLUSIONS: Self-selected individual leadership projects mirrored areas of concern found in the needs assessment, indicating that the program was successful in achieving its goals. The on-site nature of the program was cost-effective and led to maximum staff participation despite clinical responsibilities. A longstanding relationship between the design team and the local hospital staff allowed for an exploration of approaches, many of which were new to the local context. Further research is needed on adapting the program to other settings in Ghana and integrating it into broader systems strengthening interventions. This pilot program was well received and warrants further adaptation and scale up.

Implementation process and quality of a primary health care system improvement initiative in a decentralized context: A retrospective appraisal using the quality implementation framework.

BACKGROUND: Effective implementation processes are essential in achieving desired outcomes of health initiatives. Whereas many approaches to implementation may seem straightforward, careful advanced planning, multiple stakeholder involvements, and addressing other contextual constraints needed for quality implementation are complex. Consequently, there have been recent calls for more theory-informed implementation science in health systems strengthening. This study applies the quality implementation framework (QIF) developed by Meyers, Durlak, and Wandersman to identify and explain observed implementation gaps in a primary health care system improvement intervention in Nigeria. METHODS: We conducted a retrospective process appraisal by analyzing contents of 39 policy document and 15 key informant interviews. Using the QIF, we assessed challenges in the implementation processes and quality of an improvement model across the tiers of Nigeria's decentralized health system. RESULTS: Significant process gaps were identified that may have affected subnational implementation quality. Key challenges observed include inadequate stakeholder engagements and poor fidelity to planned implementation processes. Although needs and fit assessments, organizational capacity building, and development of implementation plans at national level were relatively well carried out, these were not effective in ensuring quality and sustainability at the subnational level. CONCLUSIONS: Implementing initiatives between levels of governance is more complex than within a tier. Adequate preintervention planning, understanding, and engaging the various interests across the governance spectrum are key to improving quality.

Measuring and Understanding Depression in Women in Kisoro, Uganda.

Depression is highly prevalent and the cause of considerable suffering for peoples across the globe. Case finding for depression is challenging because individuals often do not recognize the symptoms in themselves or may resist the diagnosis as a result of cultural stigma. Screening instruments, to be accurate, must be valid in the particular setting in which they are being applied, and diagnosis in primary care settings, is further made challenging because patients often present with a wide variety of somatic symptoms that could be medical. 115 women were screened for depression in this study in one community in Uganda, and 87 were found to be depressed using the SRQ-20. The cognitive impairment and decreased energy sub-scales of the SRQ-20 seemed to best differentiate for depression. We then interviewed the 87 women and found that, overwhelmingly, their complaints were somatic, and that their expectation for treatment was to receive medical tests and medications. Caregivers in primary care clinics in Uganda should know that in the reporting of their somatic symptoms patients may be trying to communicate more about themselves than just the state of their physical health; and that feelings of uselessness or of hopelessness when expressed by a patient should lead them to suspect severe mental illness since these symptoms were not found to be characteristic of the milder depression that is highly prevalent in Ugandan women.

Implementation science in low-resource settings: using the interactive systems framework to improve hand hygiene in a tertiary hospital in Ghana.

QUALITY ISSUE: Low-resource clinical settings often face obstacles that challenge the implementation of recommended evidence-based practices (EBPs). Implementation science approaches are useful in identifying barriers and developing strategies to address them. INITIAL ASSESSMENT: Ridge Regional Hospital (RRH), a tertiary referral hospital in Accra, Ghana experienced a spike in rates of neonatal sepsis and launched a quality improvement (QI) initiative that identified poor adherence to hand hygiene in the neonatal intensive care unit as a potential source of infections. CHOICE OF SOLUTION: A multi-modal change package of World Health Organization-recommended solutions was created to address this issue. IMPLEMENTATION: To ensure that the outputs of the QI effort were adopted within the organization, leaders at RRH and Kybele, Inc. used an implementation science framework called the 'Interactive Systems Framework for Dissemination and Implementation' (ISF) to create a package of locally acceptable implementation strategies. The ISF has never been used before to guide implementation in low-resource settings. EVALUATION: Hand hygiene compliance rose from 67% to 92% overall, including a 36% increase during the night shifts-a group of healthcare workers with typically very low levels of compliance. LESSONS LEARNED: The drastic improvement in adherence to hand hygiene suggests the potential value of the joint use of QI and implementation science to promote the creation and application of contextually appropriate EBPs in low-resource settings. Our results also suggest that using an implementation framework such as the ISF could rapidly increase the uptake of other evidence-based interventions in low-resource settings.

Research versus practice in quality improvement? Understanding how we can bridge the gap.

The gap between implementers and researchers of quality improvement (QI) has hampered the degree and speed of change needed to reduce avoidable suffering and harm in health care. Underlying causes of this gap include differences in goals and incentives, preferred methodologies, level and types of evidence prioritized and targeted audiences. The Salzburg Global Seminar on 'Better Health Care: How do we learn about improvement?' brought together researchers, policy makers, funders, implementers, evaluators from low-, middle- and high-income countries to explore how to increase the impact of QI. In this paper, we describe some of the reasons for this gap and offer suggestions to better bridge the chasm between researchers and implementers. Effectively bridging this gap can increase the generalizability of QI interventions, accelerate the spread of effective approaches while also strengthening the local work of implementers. Increasing the effectiveness of research and work in the field will support the knowledge translation needed to achieve quality Universal Health Coverage and the Sustainable Development Goals.

Unpacking the black box of improvement.

During the Salzburg Global Seminar Session 565-'Better Health Care: How do we learn about improvement?', participants discussed the need to unpack the 'black box' of improvement. The 'black box' refers to the fact that when quality improvement interventions are described or evaluated, there is a tendency to assume a simple, linear path between the intervention and the outcomes it yields. It is also assumed that it is enough to evaluate the results without understanding the process of by which the improvement took place. However, quality improvement interventions are complex, nonlinear and evolve in response to local settings. To accurately assess the effectiveness of quality improvement and disseminate the learning, there must be a greater understanding of the complexity of quality improvement work. To remain consistent with the language used in Salzburg, we refer to this as 'unpacking the black box' of improvement. To illustrate the complexity of improvement, this article introduces four quality improvement case studies. In unpacking the black box, we present and demonstrate how Cynefin framework from complexity theory can be used to categorize and evaluate quality improvement interventions. Many quality improvement projects are implemented in complex contexts, necessitating an approach defined as 'probe-sense-respond'. In this approach, teams experiment, learn and adapt their changes to their local setting. Quality improvement professionals intuitively use the probe-sense-respond approach in their work but document and evaluate their projects using language for 'simple' or 'complicated' contexts, rather than the 'complex' contexts in which they work. As a result, evaluations tend to ask 'How can we attribute outcomes to the intervention?', rather than 'What were the adaptations that took place?'. By unpacking the black box of improvement, improvers can more accurately document and describe their interventions, allowing evaluators to ask the right questions and more adequately evaluate quality improvement interventions.

Participatory capacity building for improving quality of childcare centers in Thailand.

INTRODUCTION: Childcare centers (CCCs) with good quality standards can be effective in reducing the risk of diseases being easily spread from person to person. The aim of the present study's program, adapted from a method used by the United Nations Development Program, was to increase the capacity of local administrators(s) and heads of CCCs to improve quality standards. METHODS: This study was quasi-experimental, with a one group pretest-post-test design. In this study the authors describe the effects and impacts of the program in Chonburi Province in eastern Thailand. Six LAs and 48 CCC heads were trained regarding (1) knowledge of the Thai Department of Health quality standards, (2) implementation and assurance and (3) program evaluation. The program consisted of three sequential participatory workshops. Effects at the center level were increased overall knowledge of quality standards of CCCs (QCCC), and developed skills of improvement plans. The impact at the center level was CCCs achieving the QCCC. At the child level it was the reduction in the period prevalence of three diseases and two symptoms. RESULTS: The significant (p<0.05) effects and impacts at the center level were increased overall knowledge of QCCC in LAs and CCC heads and increased overall managerial skills of CCC heads. At the child level, the period prevalence of chickenpox and diarrhea symptom were reduced. CONCLUSION: Participatory capacity building is an appropriate way to enhance the managerial skills of LAs and heads of CCCs for improving quality of CCCs to meet the local authority and the Ministry of Public Health quality standards.

Using Value Stream Mapping to improve quality of care in low-resource facility settings.

QUALITY PROBLEM OR ISSUE: Jacaranda Health (JH) is a Kenya-based organization that attempts to provide affordable, high-quality maternal and newborn healthcare through a chain of private health facilities in Nairobi. INITIAL ASSESSMENT: JH needed to adopted quality improvement as an organization-wide strategy to optimize effectiveness and efficiency. CHOICE OF SOLUTION: Value Stream Mapping, a Lean Management tool, was used to engage staff in prioritizing opportunities to improve clinical outcomes and patient-centered quality of care. IMPLEMENTATION: Implementation was accomplished through a five-step process: (i) leadership engagement and commitment; (ii) staff training; (iii) team formation; (iv) process walkthrough; and (v) construction and validation. EVALUATION: The Value Stream Map allowed the organization to come together and develop an end-to-end view of the process of care at JH and to select improvement opportunities for the entire system. LESSONS LEARNED: The Value Stream Map is a simple visual tool that allows organizations to engage staff at all levels to gain commitment around quality improvement efforts.

Development and piloting of a plan for integrating mental health in primary care in Sehore district, Madhya Pradesh, India.

BACKGROUND: The large treatment gap for mental disorders in India underlines the need for integration of mental health in primary care. AIMS: To operationalise the delivery of the World Health Organization Mental Health Gap Action Plan interventions for priority mental disorders and to design an integrated mental healthcare plan (MHCP) comprising packages of care for primary healthcare in one district. METHOD: Mixed methods were used including theory of change workshops, qualitative research to develop the MHCP and piloting of specific packages of care in a single facility. RESULTS: The MHCP comprises three enabling packages: programme management, capacity building and community mobilisation; and four service delivery packages: awareness for mental disorders, identification, treatment and recovery. Challenges were encountered in training primary care workers to improve identification and treatment. CONCLUSIONS: There are a number of challenges to integrating mental health into primary care, which can be addressed through the injection of new resources and collaborative care models.

Global health partnerships: building multi-national collaborations to achieve lasting improvements in maternal and neonatal health.

BACKGROUND: In response to health care challenges worldwide, extensive funding has been channeled to the world's most vulnerable health systems. Funding alone is not sufficient to address the complex issues and challenges plaguing these health systems. To see lasting improvement in maternal and infant health outcomes in the developing world, a global commitment to the sharing of knowledge and resources through international partnerships is critical. But partnerships that merely introduce western medical techniques and protocols to low resource settings, without heeding the local contexts, are misguided and unsustainable. Forming partnerships with mutual respect, shared vision, and collaborative effort is needed to ensure that all parties, irrespective of whether they belong to resource rich or resource poor settings, learn from each other so that meaningful and sustained system strengthening can take place. METHODS: In this paper, we describe the partnership building model of an international NGO, Kybele, which is committed to achieving childbirth safety through sustained partnerships in low resource settings. The Kybele model adapts generic stages of successful partnerships documented in the literature to four principles relevant to Kybele's work. A multiple-case study approach is used to demonstrate how the model is applied in different country settings. RESULTS: The four principle of Kybele's partnership model are robust drivers of successful partnerships in diverse country settings. CONCLUSIONS: Much has been written about the need for multi-country partnerships to achieve sustainable outcomes in global health, but few papers in the literature describe how this has been achieved in practice. A strong champion, support and engagement of stakeholders, co-creation of solutions with partners, and involvement of partners in the delivery of solutions are all requirements for successful and sustained partnerships.

Transforming Maternal and Neonatal Outcomes in Tertiary Hospitals in Ghana: An Integrated Approach for Systems Change.

OBJECTIVE: In Ghana, regional referral facilities by design receive a disproportionate number of high-risk obstetric and neonatal cases and therefore have mortality rates higher than the national average. High volumes and case complexity result in these facilities experiencing unique clinical, operational, and leadership challenges. In order to improve outcomes in these settings, an integrated approach to strengthen the overall system is needed. METHODS: Clinical skills strengthening, quality improvement training, and leadership skill building have all been used to improve maternal and neonatal outcomes with some degree of success. We present here a customized model tailored to the particular context of tertiary referral hospitals that develops these three skills simultaneously, so that the complex interaction between clinical conditions, resource constraints, and organizational issues that affect the lives of mothers and babies can be considered together. This model uses local data to identify the drivers of poor maternal and neonatal outcomes and creates an integrated training package to focus on approaches to addressing these drivers. Based on this training, quality improvement projects are introduced to change the appropriate clinical or operational processes, or to strengthen organizational leadership. RESULTS: In testing in one of the largest referral hospitals in Ghana, the model has been well received and has improved performance in several cross-cutting areas affecting the quality of maternal and neonatal care, such as triage, patient flow, and NICU hand hygiene. CONCLUSION: An integrated approach to systems strengthening in referral hospitals holds much promise for improving outcomes for mothers with high-risk pregnancies and babies in Ghana and in other low-resource settings.

Objectif : Au Ghana, les établissements de recours régionaux reçoivent, de par leur nature, un nombre disproportionné de cas obstétricaux et néonataux exposés à des risques élevés; par conséquent, ces établissements comptent des taux de mortalité plus élevés que la moyenne nationale. Les volumes élevés et la complexité des cas font en sorte que ces établissements ont à faire face à des défis cliniques, opérationnels et de direction particuliers. Dans de telles situations, l'amélioration des issues nécessite la mise en œuvre d'une approche intégrée visant à renforcer le système dans sa globalité. Méthodes : Le renforcement des compétences cliniques, la formation en amélioration de la qualité et la consolidation des compétences propres au leadership sont des outils qui ont tous été utilisés, avec un certain succès, pour améliorer les issues maternelles et néonatales. Nous présentons ici un modèle, ayant été adapté au contexte particulier des hôpitaux de recours tertiaires, qui favorise la mise en œuvre simultanée de ces trois outils, de façon à ce que l'interaction complexe entre les conditions cliniques, les contraintes en matière de ressources et les facteurs organisationnels qui affectent la vie des mères et des enfants puisse être envisagée dans son ensemble. Ce modèle utilise des données locales pour identifier les éléments associés à l'obtention de piètres issues maternelles et néonatales, pour ensuite créer un programme intégré de formation axé sur des approches permettant d'aborder ces éléments. En fonction de ce programme de formation, des projets d'amélioration de la qualité sont mis en œuvre pour modifier les processus cliniques ou opérationnels appropriés, ou pour renforcer le leadership organisationnel. Résultats : Dans le cadre de sa mise à l'essai au sein de l'un des plus importants hôpitaux de recours du Ghana, ce modèle a été bien reçu et a permis une amélioration du rendement dans plusieurs domaines transsectoriels affectant la qualité des soins maternels et néonataux, comme le triage, le roulement des patientes et l'hygiène des mains en UNSI. Conclusion : La mise en œuvre d'une approche intégrée envers le renforcement des systèmes au sein des hôpitaux de recours s'avère fort prometteuse pour l'amélioration des issues chez les mères connaissant des grossesses exposées à des risques élevés et les nouveau-nés du Ghana et d'autres milieux ne disposant que de faibles ressources.

Challenges for Transformation: A Situational Analysis of Mental Health Care Services in Sehore District, Madhya Pradesh.

The proportion of individuals with mental disorders receiving evidence based treatments in India is very small. In order to address this huge treatment gap, programme for improving mental health care is being implemented in Sehore district of Madhya Pradesh, India. The aim of this study was to complete the situational analysis consisting of two parts; document review of Sehore district mental health programme followed by a qualitative study. The findings suggest that there are major health system challenges in developing and implementing the mental health care plan to be delivered through primary health care system in Sehore district.

ESSENCE: An Implementation Research Program to Scale Up Depression Care in Rural Communities.

BACKGROUND: Task sharing may involve training nonspecialist health workers (NSHWs) to deliver brief mental health interventions. This approach is promising for reducing the global mental health treatment gap. However, capacity is limited for training large cadres of frontline workers in low- and middle-income countries, hindering uptake of these interventions at scale. METHODS: The ESSENCE (enabling translation of science to service to enhance depression care) project in Madhya Pradesh, India, aims to address these challenges through two sequential randomized controlled trials. First, a training trial will evaluate the effectiveness and cost-effectiveness of digital training, compared with conventional face-to-face training, in achieving clinical competency of NSHWs in delivering an intervention for depression. This initial trial will be followed by an implementation trial aimed at evaluating the effectiveness of a remote enhanced implementation support, compared with routine implementation support, in addressing barriers to delivery of depression care in primary care facilities. RESULTS: This project involved developing and pilot testing a scalable smartphone-based program for training NSHWs to deliver a brief psychological intervention for depression screening. This initial research guided a randomized trial of a digital training approach with NSHWs to evaluate the effectiveness of this approach. This trial will be followed by a cluster-randomized trial to evaluate the effectiveness of remote implementation support in ensuring efficient delivery of depression care in primary care facilities. NEXT STEPS: Findings from these trials may inform sustainable training and implementation support models to integrate depression care into primary care for scale-up in resource-constrained settings.

Recent Progress in Neonatal Global Health Quality Improvement.

Quality improvement methodologies, coupled with basic neonatal resuscitation and essential newborn care training, have been shown to be critical ingredients in improving neonatal mortality. Innovative methodologies, such as virtual training and telementoring, can enable the mentorship and supportive supervision that are essential to the continued work of improvement and health systems strengthening that must be done after a single training event. Empowering local champions, building effective data collection systems, and developing frameworks for audits and debriefs are among the strategies that will create effective and high-quality health care systems.

Implementation matters: assessing the effectiveness and sustainment of an obstetric triage program at a high-volume facility in Ghana.

BACKGROUND: Maternal mortality remains stubbornly high in Ghana. Current national efforts are focused on improving the quality of care offered in health facilities. Obstetric triage is one intervention that has been proposed to improve the timeliness and appropriateness of care, two key elements of quality. In this study, we describe and evaluate a theory-based implementation approach to introduce obstetric triage into Tema General Hospital, a high-volume maternity hospital in Greater Accra, that blends concepts from implementation science and quality improvement. This implementation project was a first attempt to scale this intervention into a new facility, following initial development in the Greater Accra Regional Hospital (formerly Ridge Hospital) in Accra. METHODS: This was a retrospective mixed-methods evaluation of two stages of implementation: active implementation and sustainment. We triangulated monitoring data captured during active implementation with clinical outcome data (timeliness of first assessment, accuracy of diagnosis, and appropriateness of care plan) from direct observation or patient obstetric triage assessment forms at baseline, at the completion of the active implementation stage, and following a 12-month "washout" period with no contact between hospital staff and the purveyor organization. Finally, we assessed embeddedness of the new triage procedures using the NoMad, a quantitative assessment of constructs from normalization process theory (NPT). RESULTS: Patient waiting time decreased substantially during the study. At baseline, the median arrival-to-assessment waiting time was 70.5 min (IQR: 30.0-443.0 min). Waiting time decreased to 6.0 min (IQR: 3.0-15.0 min) following active implementation and to 5.0 min (IQR: 2.0-10.0 min) during the sustainment period. Accuracy of diagnosis was high at the end of active implementation (75.7% correct) and improved during the sustainment period (to 77.9%). The appropriateness of care plans also improved during the sustainment period (from 66.0 to 78.9%). Per NoMad data, hospital staff generally perceive obstetric triage to be well integrated into the facility. CONCLUSIONS: This theory-based implementation approach proved to be successful in introducing a novel obstetric triage concept to a busy high-volume hospital, despite resource constraints and a short implementation window. Results proved long-lasting, suggesting this approach has high potential for engendering sustainability in other facilities as well. Our approach will be useful to other initiatives that aim to utilize program data to create and test implementation theories.