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The ability to empathize with another person's inner experience is believed to be a central element of our social interactions. Previous research has focused on cognitive (e.g., theory of mind) and emotional (e.g., emotional contagion) empathy, and less on behavioral factors (i.e., the ability to respond empathically). Recent studies suggest that the Default Mode Network (DMN) mediates individual variability in distinct empathy-related behaviors. However, little is known about DMN activity during actual empathic responses, understood in this study as the ability to communicate our understanding of the others' experience back to them. This study used an empathy response paradigm with 28 participants (22-37 years old) to analyze the relationship between the quality of empathic responses to 14 empathy-eliciting vignettes and patterns of attenuation in the DMN. Overall, the results suggest that high levels of empathic response, are associated with sustained activation of the DMN when compared with lower levels of empathy. Our results demonstrate that the DMN becomes increasingly involved in empathy-related behavior, as our level of commitment to the other's experience increases. This study represents a first attempt to understand the relation between the capacity for responding in a supportive way to others' needs and the intra-individual variability of the pattern of the DMN attenuation. Here we underline the critical role that the DMN plays in high-level social cognitive processes and corroborate the DMN role in different psychiatric disorders associated with a lack of empathy.

Background: Healthcare systems in low-resource settings need simple, low-cost interventions to improve services and address gaps in care. Though routine data provide opportunities to guide these efforts, frontline healthcare workers (HCW) are rarely engaged in analyzing them for facility-level decision making. The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages HCW in use of facility-level data to promote systems-level thinking and quality improvement (QI) efforts within multi-step care cascades. SAIA was originally developed to address HIV care in resource-limited settings, but has since been adapted to a variety of clinical care systems including cervical cancer screening, mental health treatment, and hypertension management, among others; and across a variety of settings in sub-Saharan Africa and the United States. We aimed to extend the growing body of SAIA research by defining the core elements of SAIA using established specification approaches, and thus improve reproducibility, guide future adaptations and lay the groundwork to define its mechanism of action. Methods: Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA-researchers, implementing agents and stakeholders using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor’s recommendation for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects.Results: Based on this review and clarification of the operational definitions of the components of the SAIA, the four components of SAIA were mapped to 13 ERIC strategies. SAIA strategy meetings encompassed external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to three ERIC strategies; facilitating relay of clinical data to providers, use of audit and feedback of routine data with healthcare teams, and modelling and simulation of change. Process mapping tied to local needs assessment, local consensus discussions and assessment of readiness and identification of barriers and facilitators. Finally, continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change and purposefully re-examining the implementation process.Conclusions: Specifying the components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings.

Background: The Systems Analysis and Improvement Approach (SAIA) is an evidence-based package of systems engineering tools designed to improve patient flow through the prevention of mother-to-child transmission of HIV (PMTCT) cascade. SAIA is a potentially scalable model for maximizing benefits of universal antiretroviral therapy (ART) for mothers and their babies. SAIA-SCALE was a stepped wedge trial implemented in Manica province, Mozambique, to evaluate SAIA’s effectiveness when led by district health managers, rather than by study nurses. We present results of a qualitative assessment of implementation determinants of the SAIA-SCALE strategy during two intensive and one maintenance phases.Methods: We used an extended case study design that embedded the Consolidated Framework for Implementation Research (CFIR) to guide data collection, analysis, and interpretation. From March 2019 through April 2020, we conducted in-depth individual interviews (IDIs) and focus group discussions (FGDs) with district managers, health facility Maternal and Child Health (MCH) managers and frontline nurses at 21 health facilities and seven districts of Manica Province (Chimoio, Báruè, Gondola, Macate, Manica, Sussundenga, and Vanduzi).Results: We included 85 participants: 50 through IDIs and 35 from three FGDs. Most study participants were women (98%), frontline nurses (49.4%) and MCH health facility managers (32.5%). An identified facilitator of successful intervention implementation (regardless of intervention phase) was related to SAIA’s compatibility with organizational structures, processes, and priorities of Mozambique’s health system at the district and health facility levels. Identified barriers to successful implementation included (a) inadequate health facility and road infrastructure preventing mothers from accessing MCH/PMTCT services at study health facilities and preventing nurses from dedicating time to improving data quality and service provision, and (b) challenges in managing intervention funds.Conclusions: The SAIA-SCALE qualitative evaluation suggests that the scalability of SAIA for PMTCT is enhanced by its fit within organizational structures, processes, and priorities at the primary level of healthcare delivery and health system managers in Mozambique. Barriers to implementation that impact scalability of SAIA include district-level financial management capabilities and lack of infrastructure at the health facility level. SAIA cannot be successfully scaled-up to adequately address PMTCT needs without leveraging central level resources and priorities. Trial registration: ClinicalTrials.gov NCT03425136 (registered 02/06/2018).

This chapter presents insights about how NOS Inovação has reshaped their teams to get a more horizontal and holistic overview about their services (from development to operations) and how this change has positively impacted the development of new services targeting internet personalisation. Furthermore, this chapter also describes the NOS vision about Industry 5.0, where digital transition is a key enabler and presents a critical role in the future.

BACKGROUND Optimal delivery of prevention of mother to child transmission of HIV (PMTCT) programs is challenging, including in Mozambique. The Systems Analysis and Improvement Approach (SAIA) is a multi-component, systems engineering strategy that has demonstrated PMTCT cascade improvement in a previous cluster randomized trial. To facilitate scale-up and improve integration into routine management systems, the SAIA-SCALE trial (NCT03425136) evaluates delivery of SAIA to health facilities by maternal and child health district supervisors, with minimal external support. SAIA-SCALE uses the RE-AIM framework to evaluate essential ingredients for public health impact that are infrequently reported. In this article we report intervention reach, adoption, implementation, and maintenance.METHODS SAIA-SCALE is a stepped-wedge trial in 36 facilities covering all 12 districts of Manica province, central Mozambique, from 2018—2021. Each district received a one-year intensive phase with external research staff support and financial support, followed by a maintenance phase with only limited financial support. We used data from health management information systems and implementation tracking to assess reach, adoption, implementation, and maintenance of the SAIA strategy using descriptive statistics.RESULTS SAIA-SCALE reached 36 facilities covering over 146,000 institutional births and 206,000 first antenatal care visits during the study period. Mean scores on two organizational readiness predictors of adoption were 4.82/5 for change commitment and 4.78/5 for change efficacy. Program adoption was 100%—all 12 targeted districts attended initial training, and all targeted 36 facilities initiated the SAIA strategy. Intensive and maintenance phases comprised equal facility-months. Each facility received an average of 1.1 and 1.0 mentorship visits per month from district supervisors during the intensive and maintenance phases, respectively. Across all facilities, 429 workplans were developed during the intensive and 432 during the maintenance phase. Facility staff reported implementing 91.8% of intensive phase workplans, and 85.9% of maintenance phase workplans. Facilities reported adopting into routine practice 70% and 62% of micro-interventions tested during the intensive and maintenance phases, respectively.CONCLUSIONS Assessment of reach, adoption, implementation, and maintenance revealed the successful integration of a systems engineering strategy for PMTCT into routine healthcare management systems in Mozambique. R-AIM should more frequently be reported alongside effectiveness for a deeper understanding of sustained public health impact of HIV prevention programs.Trial registration:ClinicalTrials.gov NCT03425136 (registered 02/06/2018).

Background: The Systems Analysis and Improvement Approach (SAIA) is an evidence-based, multi-component implementation strategy that engages service providers in the use of routinely-available service data to optimize service delivery cascades and promote systems-level thinking. SAIA was originally developed to address bottlenecks in HIV care in low-and middle-income countries, but has since been adapted and applied to a variety of care systems including: cervical cancer screening, mental health treatment, hypertension management, family planning, and community-based naloxone distribution. These projects have been implemented across a variety of settings in sub-Saharan Africa and the United States. Given the diversity of implementation experience, our consortium aimed to define the core elements of SAIA, to improve reproducibility, guide future adaptations, and lay the groundwork to evaluate mechanisms of action. Methods: Specification of the SAIA strategy was undertaken over 12 months by an expert panel of SAIA researchers, implementing agents and stakeholders, using a three-round, modified nominal group technique approach to match core SAIA components to the Expert Recommendations for Implementing Change (ERIC) list of distinct implementation strategies. Core implementation strategies were then specified according to Proctor’s recommendation for specifying and reporting, followed by synthesis of data on related implementation outcomes linked to the SAIA strategy across projects.Results: The four components of the SAIA strategy: (1) SAIA strategy meetings; (2) cascade analysis; (3) process mapping; and (4) continuous quality improvement, mapped to 13 distinct ERIC strategies. The SAIA strategy meetings component mapped to external facilitation, organization of provider implementation meetings, and provision of ongoing consultation. Cascade analysis mapped to facilitating relay of clinical data to providers, use of audit and feedback, and modelling and simulation of change. Process mapping tied to local needs assessment, local consensus discussions, and assessment of readiness and identification of barriers and facilitators. Continuous quality improvement encompassed tailoring strategies, developing a formal implementation blueprint, cyclical tests of change and purposefully re-examining the implementation process.Conclusions: Formally specifying the core components of SAIA provides improved conceptual clarity to enhance reproducibility for other researchers and practitioners interested in applying the SAIA across novel settings. Furthermore, this work provides a structured framework to examine potential mechanisms of SAIA and its component implementation strategies.