Applying the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to Safe Surgery 2020 Implementation in Tanzania's Lake Zone.

BACKGROUND: Access to safe, high-quality surgical care in sub-Saharan Africa is a critical gap. Interventions to improve surgical quality have been developed, but research on their implementation is still at a nascent stage. We retrospectively applied the Exploration, Preparation, Implementation, Sustainment framework to characterize the implementation of Safe Surgery 2020, a multicomponent intervention to improve surgical quality. METHODS: We used a longitudinal, qualitative research design to examine Safe Surgery 2020 in 10 health facilities in Tanzania's Lake Zone. We used documentation analysis with confirmatory key informant interviews (n = 6) to describe the exploration and preparation phases. We conducted interviews with health facility leaders and surgical team members at 1, 6, and 12 months (n = 101) post initiation to characterize the implementation phase. Data were analyzed using the constant comparison method. RESULTS: In the exploration phase, research, expert consultation, and scoping activities revealed the need for a multicomponent intervention to improve surgical quality. In the preparation phase, onsite visits identified priorities and barriers to implementation to adapt the intervention components and curriculum. In the active implementation phase, 4 themes related to the inner organizational context-vision for safe surgery, existing surgical practices, leadership support, and resilience-and 3 themes related to the intervention-innovation-value fit, holistic approach, and buy-in-facilitated or hindered implementation. Interviewees perceived improvements in teamwork and communication and intra- and inter-facility learning, and their need to deliver safe surgery evolved during the implementation period. CONCLUSIONS: Examining implementation through the exploration, preparation, implementation, and sustainment phases offers insights into the implementation of interventions to improve surgical quality and promote sustainability.

Scaling-Up Stage 4 Pediatric Obesity Clinics: Identifying Barriers and Future Directions Using Implementation Science.

Nearly one-fifth of the pediatric population in the United States has obesity. Comprehensive behavioral interventions, with at least 26 contact hours, are the recommended treatment for pediatric obesity; however, there are various barriers to implementing treatment. This Perspective applies the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to address barriers to implementing multidisciplinary pediatric weight management clinics and identify potential solutions and areas for additional research. Lack of insurance coverage and reimbursement, high operating costs, and limited access to stage 4 care clinics with sufficient capacity were among the main barriers identified. Clinicians, researchers, and patient advocates are encouraged to facilitate conversations with insurance companies and hospital and clinic administrators, increase telehealth adoption, request training to improve competency and self-efficacy discussing and implementing obesity care, and advocate for more stage 4 clinics.

Practice Facilitation in Integrated Behavioral Health and Primary Care Settings: a Scoping Review.

Little is known about the contributions of practice facilitators in settings aiming to deliver integrated behavioral health and primary care. This scoping review identifies peer-reviewed articles that describe efforts to deliver integrated behavioral health care with the support of practice facilitators. Five databases were systematically searched to identify empirical and conceptual papers. Fourteen articles met the following inclusion criteria: (1) empirical studies evaluating the effectiveness of practice facilitation (n = 4), (2) study protocols that will test the effectiveness of practice facilitation (n = 2), (3) studies that included practice facilitators as part of a larger intervention without evaluating their effectiveness (n = 5), and (4) conceptual manuscripts endorsing practice facilitation for integrated care (n = 3). Practice facilitators can potentially support health systems in delivering integrated behavioral health care, but future research is needed to understand their necessary qualifications, the effectiveness of practice facilitation these efforts, and what study outcomes are appropriate for evaluating whether practice facilitation has been effective.

The experiences of using polio outbreak simulation exercises to strengthen national outbreaks preparedness and response plans in sub-Saharan Africa.

INTRODUCTION: globally, by 2020 the paralytic poliomyelitis disease burden decreased to over 99% of the reported cases in 1988 when resolution 41.8 was endorsed by the World Health Assembly (WHA) for global polio eradication. It is clearly understood that, if there is Wild Poliovirus (WPV) and circulating Vaccines Derived Poliovirus (cVDPV) in the world, no country is safe from polio outbreaks. All countries remain at high risk of re-importation depending on the level of the containment of the types vaccine withdrawn, the laboratory poliovirus isolates, and the population immunity induced by the vaccination program. In this regard, countries to have polio outbreak preparedness and response plans, and conducting the polio outbreak simulation exercises for these plans remain important. METHODS: we conducted a cross-section qualitative study to review to 8 countries conducted polio outbreak simulation exercises in the East and Southern Africa from 2016 to 2018. The findings were categorized into 5 outbreak response thematic areas analyzed qualitatively and summarized them on their strengths and weaknesses. RESULTS: we found out that, most countries have the overall technical capacities and expertise to deal with outbreaks to a certain extent. Nevertheless, we noted that the national polio outbreak preparedness and response plans were not comprehensive enough to provide proper guidance in responding to outbreaks. The guidelines were inadequately aligned with the WHO POSOPs, and IHR 2005. Additionally, most participants who participated in the simulation exercises were less familiar with their preparedness and response plans, the WHO POSOPs, and therefore reported to be sensitized. CONCLUSION: we also realized that, in all countries where the polio simulation exercise conducted, their national polio outbreak preparedness and response plan was revised to be improved in line with the WHO POSOPs and IHR 2005. we, therefore, recommend the polio outbreak simulation exercises to be done in every country with an interval of 3-5 years.

An implementation science approach for developing and implementing a dietitian-led model of care for gestational diabetes: a pre-post study.

BACKGROUND: There is strong evidence that women with gestational diabetes mellitus (GDM) who receive a minimum of three appointments with a dietitian may require medication less often. The aim of this study was to evaluate the impact of a dietitian-led model of care on clinical outcomes and to understand the utility of the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework as a prospective tool for implementation. METHODS: This was a pre-post intervention study measuring outcomes before-and-after changing a gestational diabetes (GDM) model of care and included women with GDM managed at a large, regional hospital in Queensland, Australia. The i-PARIHS framework was used to develop, implement and evaluate a dietitian-led model of care which increased dietetic input for women with GDM to a minimum of one initial education and two review appointments. The outcomes were adherence to the schedule of appointments, clinician perspective of the implementation process, pharmacotherapy use, gestational age at commencement of pharmacotherapy and birth weight. Pre- and post- comparisons of outcomes were made using t-tests and chi-squared tests. RESULTS: Adherence to the dietetic schedule of appointments was significantly increased from 29 to 82% (p < 0.001) but pharmacotherapy use also increased by 10% (p = 0.10). There were significantly more women in the post-intervention group who were diagnosed with GDM prior to 24 weeks gestation, a strong independent predictor of pharmacotherapy use. Infant birthweight remained unchanged. The i-PARIHS framework was used as a diagnostic tool and checklist in the model of care development phase; a facilitation tool during the implementation phase; and during the evaluation phase was used as a reflection tool to identify how the i-PARIHS constructs and their interactions that may have impacted on clinical outcomes. CONCLUSIONS: The i-PARIHS framework was found to be useful in the development, implementation and evaluation of a dietitian-led model of care which saw almost 90% of women with GDM meet the minimum schedule of dietetic appointments.

Integrating the "best" evidence into nursing of venous thromboembolism in ICU patients using the i-PARIHS framework.

OBJECTIVES: To explore how to integrate the "best" practice into nursing of venous thromboembolism (VTE) based on the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework. METHODS: A mixed-methods design was used. A steering group for clinical evidence implementation (EI) was established to conduct pre-implementation baseline surveys, a thorough analysis of the evidence, and an analysis of the survey results. The hindering and enabling factors associated with the clinical implementation of the evidence were analysed based on the three core elements of i-PARIHS, to formulate the clinical implementation plan for VTE nursing evidence. On-site expert reviews and focus group interviews were used to evaluate the feasibility of the draft plan, make adjustments, and finalize the evidence-based practice plan, which was then put into practice and evaluated. RESULTS: A new nursing process, a health education manual and a nursing quality checklist on VTE has been established and proved to be appropriate through the implementation. Compliance with evidence related to VTE nursing increased significantly in the two units, with better compliance in unit B than unit A. The knowledge, attitude and behaviour scores for VTE nursing increased substantially in both nurses and patients. CONCLUSION: The EI programme of incorporating the "best" evidence on VTE nursing into clinical practice using the i-PARIHS framework demonstrated feasibility, appropriateness and effectiveness and could serve as a reference.

The Diverse Implementation of Geriatrics-Orthopedics Comanagement Programs in the United States.

BACKGROUND: Many health systems are establishing geriatrics-orthopedics (Geri-Ortho) comanagement programs; however, there is paucity of published information on existing programs' variations in clinical operations, structure, and reported implementation challenges and perceived successes. OBJECTIVE: Our objective was to obtain detailed information about the variety of existing Geri-Ortho comanagement programs in the United States. DESIGN/PARTICPANTS: We conducted a cross-sectional survey of 44 existing Geri-Ortho comanagement programs, with 23 (52%) of programs responding. MEASUREMENT: Quantitative questions were used to assess operational, staffing, and financial structures; and qualitative questions were used to identify reported challenges and perceived successes of implementation. RESULTS: Programs self-identified as urban (n = 23), academic (n = 20), or nonprofit (n = 22) and as having a level I trauma center (n = 17). Most programs (n = 18) were funded fully by the institution. Fourteen programs used geriatricians, and nine used medicine/hospitalists as the supporting clinical service, whereas approximately half (n = 11) used these services in a true comanagement model. Six universal themes were identified as necessary for program implementation. The most commonly described successes perceived by all respondents were improvements in clinical outcomes and better interdisciplinary relationships. Reported challenges included difficulty in interdisciplinary geriatrics education, difficulty in adherence to protocols, and lack of funding for staffing. CONCLUSIONS: There are diverse types of Geri-Ortho comanagement programs in the United States, although universal elements exist. Many had similar challenges in implementation, and further studies are needed to determine which implementation elements are critical to clinical and financial outcomes. J Am Geriatr Soc 68:1714-1719, 2020.

Implementation of Hip Fracture Co-Management Program (AGS CoCare: Ortho®) in a Large Health System.

OBJECTIVES: Acute hip fracture is common and leads to significant morbidity and mortality. Co-management programs, such as American Geriatric Society (AGS) CoCare: Ortho®, that optimize perioperative care of older adults, have demonstrated improved outcomes. Yet there is substantial variation in hip fracture care nationally. Our objective was to describe the implementation of AGS CoCare: Ortho® across a large integrated health system. DESIGN: Program implementation of four phases. SETTING: Large integrated health system. PARTICIPANTS: One tertiary and three community hospitals. MEASUREMENTS: The first two phases were communication and system-level planning. The communication phase consisted of getting health system leadership buy-in, creating an interdisciplinary steering committee, and building a business model. The planning phase consisted of choosing process and outcome measures, ensuring accurate and timely data collection, and creating standardized order sets and physician documentation. RESULTS: The second two phases were hospital-level planning and implementation. The planning phase consisted of identifying sites and developing the co-management structure. The implementation phase consisted of identifying and engaging frontline staff, rolling out the program, optimizing workflow, and educating providers. CONCLUSION: The program was implemented at four diverse sites. Major lessons learned included the need for an engaged steering committee to oversee the program; the importance of standardizing order sets and documentation; the utilization of hospitalists as co-managers; the benefit of developing and actively using a data dashboard; the challenge of ensuring wide uptake of education modules; and the need to take proactive steps to improve multidisciplinary communication. J Am Geriatr Soc 68:1706-1713, 2020.

Reduction of antimicrobial resistant pneumococci seven years after introduction of pneumococcal vaccine in Iceland.

BACKGROUND: Penicillin non-susceptible (PNSP) and multi-resistant pneumococci have been prevalent in Iceland since early nineties, mainly causing problems in treatment of acute otitis media. The 10-valent protein conjugated pneumococcal vaccine (PHiD-CV) was introduced into the childhood vaccination program in 2011. The aim of the study was to investigate the changes in antimicrobial susceptibility and serotype distribution of penicillin non-susceptible pneumococci (PNSP) in Iceland 2011-2017. METHODS AND FINDINGS: All pneumococcal isolates identified at the Landspítali University Hospital in 2011-2017, excluding isolates from the nasopharynx and throat were studied. Susceptibility testing was done according to the EUCAST guidelines using disk diffusion with chloramphenicol, erythromycin, clindamycin, tetracycline, trimethoprim/sulfamethoxazole and oxacillin for PNSP screening. Penicillin and ceftriaxone minimum inhibitory concentrations (MIC) were measured for oxacillin resistant isolates using the E-test. Serotyping was done using latex agglutination and/or multiplex PCR. The total number of pneumococcal isolates that met the study criteria was 1,706, of which 516 (30.2%) were PNSP, and declining with time. PNSP isolates of PHiD-CV vaccine serotypes (VT) were 362/516 (70.2%) declining with time, 132/143 (92.3%) in 2011 and 17/54 (31.5%) in 2017. PNSP were most commonly of serotype 19F, 317/516 isolates declining with time, 124/143 in 2011 and 15/54 in 2017. Their number decreased in all age groups, but mainly in the youngest children. PNSP isolates of non PHiD-CV vaccine serotypes (NVT) were 154/516, increasing with time, 11/14, in 2011 and 37/54 in 2017. The most common emerging NVTs in 2011 and 2017 were 6C, 1/143 and 10/54 respectively. CONCLUSIONS: PNSP of VTs have virtually disappeared from children with pneumococcal diseases after the initiation of pneumococcal vaccination in Iceland and a clear herd effect was observed. This was mainly driven by a decrease of PNSP isolates belonging to a serotype 19F multi-resistant lineage. However, emerging multi-resistant NVT isolates are of concern.

A Case Study of Implementing Grant-Funded Integrated Care in a Community Mental Health Center.

The US government funds integrated care demonstration projects to decrease health disparities for individuals with serious mental illness. Drawing on the Exploration Preparation Implementation Sustainability (EPIS) implementation framework, this case study of a community mental health clinic describes implementation barriers and sustainability challenges with grant-funded integrated care. Findings demonstrate that integrated care practices evolve during implementation and the following factors influenced sustainability: workforce rigidity, intervention clarity, policy and funding congruence between the agency and state/federal regulations, on-going support and training in practice application, and professional institutions. Implementation strategies for primary care integration within CMHCs include creating a flexible workforce, shared definition of integrated care, policy and funding congruence, and on-going support and training.

Cascade Analysis: An Adaptable Implementation Strategy Across HIV and Non-HIV Delivery Platforms.

BACKGROUND: Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement. METHODS: The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV. RESULTS: CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW. DISCUSSION: CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.

Implementing Risk Stratification in Primary Care: Challenges and Strategies.

INTRODUCTION: Primary care risk stratification (RS) has been shown to help practices better understand their patient populations' needs and may improve health outcomes and reduce expenditures by targeting and tailoring care to high-need patients. This study aims to understand key considerations practices faced and practice experiences as they began to implement RS models. METHODS: We conducted semistructured interviews about experiences in RS with 34 stakeholders from 15 primary care practices in Oregon and Colorado and qualitatively analyzed the data. RESULTS: Three decisions were important in shaping practices' experiences with RS: choosing established versus self-created algorithms or heuristics, clinical intuition, or a combination; selecting mechanisms for assigning risk scores; determining how to integrate RS approaches into care delivery. Practices using clinical intuition found stratification time-consuming and difficult to incorporate into existing workflows, but trusted risk scores more than those using algorithms. Trust in risk scores was influenced by data extraction capabilities; practices often lacked sufficient data to calculate their perceived optimal risk score. Displaying the scores to the care team was a major issue. Finally, obtaining buy-in from care team members was challenging, requiring repeated cycles of improvement and workflow integration. DISCUSSION: Practices used iterative approaches to RS implementation. As a result, procedural and algorithmic changes were introduced and were influenced by practices' health IT, staffing, and resource capacities. Practices were most successful when able to make iterative changes to their approaches, incorporated both automation and human process in RS, educated staff on the importance of RS, and had readily accessible risk scores.

Developing the Network Pain Rehabilitation Limburg: a feasibility study protocol.

INTRODUCTION: Patients having chronic musculoskeletal pain (CMP) face challenges as mismatches often exist between the complexity of patient's pain problem and the rehabilitation treatment offered. This can result in less efficient care for the patient and increased medical shopping. The Network Pain Rehabilitation Limburg (NPRL), a transmural integrated healthcare network, will be designed to improve daily care for patients with CMP. NPRL focusses on improving patient's level of functioning despite pain by stimulating a biopsychosocial approach given by all involved healthcare professionals. A feasibility study will be performed which will give insight into the barriers and facilitators, perceived value, acceptability and implementation strategies for NPRL. METHODS AND ANALYSIS: This study has a three-phase iterative and incremental design, based on key principles of a user-centred design. Mixed methods will be used in which healthcare professionals and patients involved in NPRL will participate. In phase 1, NPRL will be developed and healthcare professionals educated. Phase 2 focusses on the implementation and phase 3 on the transferability of NPRL. In addition, preliminary data on patient's work status, general health and participation level will be collected. The qualitative results of each phase will be analysed following the Consolidated Framework for Implementation Research (CFIR) and will be used to refine NPRL in daily practise. ETHICS AND DISSEMINATION: Informed consent will be obtained from all participants. The results of this feasibility study will form the basis for refinement of NPRL and planning of a large-scale process and effect evaluation of the Quadruple Aim outcomes. Dissemination will include publications and presentations at national and international conferences. Ethical approval for this study was granted by the Medical Ethics Committee Z, the Netherlands, METC 17 N-133.

An organisational participatory research study of the feasibility of the behaviour change wheel to support clinical teams implementing new models of care.

BACKGROUND: Health and social care organisations globally are moving towards prevention-focussed community-based, integrated care. The success of this depends on professionals changing practice behaviours. This study explored the feasibility of applying a behavioural science approach to help staff teams from health organisations overcome psychological barriers to change and implement new models of care. METHODS: An Organisational Participatory Research study was conducted with health organisations from North West England, health psychologists and health workforce education commissioners. The Behaviour Change Wheel (BCW) was applied with teams of professionals seeking help to overcome barriers to practice change. A mixed-methods data collection strategy was planned, including qualitative stakeholder interview and focus groups to explore feasibility factors and quantitative pre-post questionnaires and audits measuring team practice and psychological change barriers. Qualitative data were analysed with thematic analysis; pre-post quantitative data were limited and thus analysed descriptively. RESULTS: Four clinical teams from paediatrics, midwifery, heart failure and older adult mental health specialties in four organisations enrolled, seeking help to move care to the community, deliver preventative healthcare tasks, or become more integrated. Eighty-one managers, medical doctors, nurses, physiotherapists, midwives and other professionals contributed data. Three teams successfully designed a BCW intervention; two implemented and evaluated this. Five feasibility themes emerged from the thematic analysis of qualitative data. Optimising the BCW in an organisational change context meant 1) qualitative over quantitative data collection, 2) making behavioural science attractive, 3) co-development and a behavioural focus, 4) effective ongoing communication and 5) support from engaged leaders. Pre-post quantitative data collected suggested some positive changes in staff practice behaviours and psychological determinants following the intervention. CONCLUSIONS: Behavioural science approaches such as the BCW can be optimised to support teams within health and social care organisations implementing complex new models of care. The efficacy of this approach should now be trialled.

Waiting for common-law solutions for the most vulnerable populations' healthcare access.

BACKGROUND: The state of populations' health is linked to their access to quality healthcare. Best achieving this primary condition - a health, social and humanitarian condition - is an ongoing public policy objective. Although significant effort goes into this, do public policies sufficiently take into account the state of health of the most vulnerable populations? In France, reducing the non-take-up (NTU) of healthcare is a priority in current national health insurance policy. Under the local plans to tackle non-take-up, lack of understanding and exit from the system (PLANIR), national health insurance is currently rolling out a regional and partnership-based intervention framework in order to prevent NTU of healthcare by welfare clients. This social investment is unprecedented, yet the impact of the framework on the most vulnerable populations still seems to be limited. METHOD: The study of this example is based on monitoring of the framework's general implementation. This task was entrusted to the research team co-founded by the author, ODENORE (Observatory for the Non-take-up of Social Rights and Public Services). It is organized in four parts: quantitative monitoring of the detection and addressing of non-take-up situations (n=160,000 questionnaires); analysis of the results through qualitative interviews with beneficiaries and individuals who rejected the framework (n=365 interviews); analysis of the framework's implementation, using qualitative interviews and participant observations at the services in charge of the framework's implementation (n=18 collective interviews across three sites), and an analysis of the partnership through collective interviews with all the actors in the areas involved in the framework (three sites). RESULTS: The analysis shows that the integration of the most vulnerable populations' state of health into a common-law framework for intervention is hindered by three limitations: the framework's neutrality regarding public decisions and non-decisions that exacerbate social and regional health inequalities; its organizational design, which does not take into account the need for long-term medical-psycho-social care; and the absence of regulation capable of bringing together and coordinating the actors working towards healthcare access locally but with different populations. CONCLUSION: The difficulties of integrating the most vulnerable populations into a common-law framework such as the one proposed by the national health insurance do not seem insurmountable-provided, that is, that the regulatory authority (the regional health agencies) are willing and able to make it a strategic organizational objective at local level.

A conceptual framework and metrics for evaluating multicomponent interventions to increase colorectal cancer screening within an organized screening program.

BACKGROUND: Multicomponent, evidence-based interventions are viewed increasingly as essential for increasing the use of colorectal cancer (CRC) screening to meet national targets. Multicomponent interventions involve complex care pathways and interactions across multiple levels, including the individual, health system, and community. METHODS: The authors developed a framework and identified metrics and data elements to evaluate the implementation processes, effectiveness, and cost effectiveness of multicomponent interventions used in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program. RESULTS: Process measures to evaluate the implementation of interventions to increase community and patient demand for CRC screening, increase patient access, and increase provider delivery of services are presented. In addition, performance measures are identified to assess implementation processes along the continuum of care for screening, diagnosis, and treatment. Series of intermediate and long-term outcome and cost measures also are presented to evaluate the impact of the interventions. CONCLUSIONS: Understanding the effectiveness of multicomponent, evidence-based interventions and identifying successful approaches that can be replicated in other settings are essential to increase screening and reduce CRC burden. The use of common framework, data elements, and evaluation methods will allow the performance of comparative assessments of the interventions implemented across CRCCP sites to identify best practices for increasing colorectal screening, particularly among underserved populations, to reduce disparities in CRC incidence and mortality.

The everyday practice of supporting health system development: learning from how an externally-led intervention was implemented in Mozambique.

Health system strengthening (HSS) has often been undertaken by global health actors working through vertical programmes. However, experience has shown the challenges of this approach, and the need to recognize health systems as open complex adaptive systems-which in turn has implications for the design and implementation approach of more 'horizontal' HSS interventions. From 2009 to 2016, the Doris Duke Charitable Foundation supported the African Health Initiative, establishing Population Health Implementation and Training partnerships in five African countries (Ghana, Mozambique, Rwanda, Tanzania and Zambia). Each partnership was designed as a large-scale, long-term, complex health system strengthening intervention, at a primary care or district level-and in each country the intervention was adapted to suit that specific health systems context. In Mozambique, the Population Health Implementation and Training partnership sought to strengthen integrated health systems management at district and provincial levels (through a variety of capacity-development intervention activities, including in-service training and mentoring); to improve the quality of routine data and develop appropriate tools to facilitate decision-making for provincial and district managers; and to build capacity to design and conduct innovative operations research in order to guide integration and system-strengthening efforts. The success of this intervention, as assessed by outcome measures, has been reported elsewhere. In this paper, the implementation practice of this horizontal HSS intervention is assessed, focusing on the key features of how implementation occurred and the implementation approach. A case study focusing on HSS implementation practice was conducted by external researchers from 2014 to 2017. The importance of an accompanying implementation research approach is emphasized-especially for HSS interventions where the 'complex adaptive system' (complex and constantly changing context) forces constant adaptations to the intervention design and approach.

Evaluation of the impact of the ARC program on national nursing and midwifery regulations, leadership, and organizational capacity in East, Central, and Southern Africa.

BACKGROUND: The African Health Professions Regulatory Collaborative (ARC) was launched in 2011 to support countries in East, Central, and Southern Africa to safely and sustainably expand HIV service delivery by nurses and midwives. While the World Health Organization recommended nurse initiated and managed antiretroviral therapy, many countries in this region had not updated their national regulations to ensure nurses and midwives were authorized and trained to provide essential HIV services. For four years, ARC awarded annual grants, convened regional meetings, and provided technical assistance to country teams of nursing and midwifery leaders to improve national regulations related to safe HIV service delivery. We examined the impact of the program on national regulations and the leadership and organizational capacity of country teams. METHODS: Data was collected to quantify the level of participation in ARC by each country (number of grants received, number of regional meetings attended, and amount of technical assistance received). The level of participation was analyzed according to two primary outcome measures: 1) changes in national regulations and 2) improvements in leadership and organizational capacity of country teams. Changes in national regulations were defined as advancement of one "stage" on a capability maturity model; nursing and midwifery leadership and organizational capacity was measured by a group survey at the end of the program. RESULTS: Seventeen countries participated in ARC between 2012 and 2016. Thirty-three grants were awarded; the majority addressed continuing professional development (20; 61%) and scopes of practice (6; 18%). Fourteen countries (representing approximately two-thirds of grants) progressed at least one stage on the capability maturity model. There were significant increases in all five domains of leadership and organizational capacity (p < 0.01). The number of grants (Kendall's tau = 0.56, p = 0.02), duration of technical assistance (Kendall's tau = 0.50, p = 0.03), and number of learning sessions attended (Kendall's tau = 0.46, p = 0.04) were significantly associated with improvements in in-country collaboration between nursing and midwifery organizations. CONCLUSIONS: The ARC program improved national nursing regulations in participating countries and increased reported leadership, organizational capacity, and collaboration among national nursing and midwifery organizations. These changes help ensure national policies and professional regulations underpin nurse initiated and managed treatment for people living with HIV.

[Temporary approval for intranasal naloxone: Setting up in a French addiction center]. / Pratique de l'ATU de cohorte de la naloxone intranasale (Nalscue®) : mise en place dans un CSAPA parisien.

Intranasal naloxone aims at preventing opioid overdose related deaths in active drug users. In France, it has been available since July 2016 through a temporary approval which requires a hospital-based pharmacy and a nominative registration of each patient. We present the characteristics of the first patients who could receive this prescription in our hospital-based addiction center and how they used naloxone during follow-up. Results favor a larger dispensing of naloxone. Patients' as well as peers' and families' education is needed.