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Evidence from several countries in sub-Saharan Africa suggests that the integration of family planning (FP) with childhood immunization services can help reduce the unmet need for FP among postpartum women without undermining the uptake of immunizations. However, the quality and responsiveness of FP services that are integrated with childhood immunizations remain understudied. A qualitative study was conducted in two districts of Malawi, which examined the factors influencing the responsiveness of FP services that were integrated with childhood immunizations in monthly public outreach clinics. Semi-structured interviews with clients (n = 23) and FP providers (n = 10) and a clinic audit were carried out in six clinics. Hardware (material) and software (relational) factors influencing service responsiveness were identified through thematic and framework analyses of interview transcripts, and clinic characteristics were summarized from the audit data to contextualize the qualitative findings. Overall, 13 factors were found to influence service responsiveness in terms of the ease of access, choice of provider, environment, service continuity, confidentiality, communication, dignity and FP counselling afforded to clients. Among these factors, hardware deficiencies, including the absence of a dedicated building for the provision of FP services and the lack of FP commodities in clinics, were perceived to negatively affect service responsiveness. Crucially, the providers’ use of their agency to alter the delivery of services was found to mitigate the negative effects of some hardware deficits on the ease of access, choice of provider, environment and confidentiality experienced by clients. This study contributes to an emerging recognition that providers can offset the effect of hardware deficiencies when services are integrated if they are afforded sufficient flexibility to make independent decisions. Consideration of software elements in the design and delivery of FP services that are integrated with childhood immunizations is therefore critical to optimize the responsiveness of these services.

Generalisability is typically only briefly mentioned in discussion sections of evaluation articles, which are unhelpful in judging whether an intervention could be implemented elsewhere, with similar effects. Several tools to assess generalisability exist, but they are difficult to operationalise and are rarely used. We believe a different approach is needed. Instead of focusing on similarities (or more likely, differences) in generic population and setting characteristics, generalisability assessments should focus on understanding an intervention’s mechanism of action - why or how an intervention was effective. We believe changes are needed to four types of research. First, outcome evaluations should draw on programme theory. Second, process evaluations should aim to understand interventions’ mechanism of action, rather than simply ‘what happened’. Third, small scoping studies should be conducted in new settings, to explore how to enact identified mechanisms. Finally, innovative synthesis methods are required, in order to identify mechanisms of action where there is a lack of existing process evaluations.

Background Over two-thirds of Africans have no access to eye care services. To increase access, the World Health Organization (WHO) recommends integrating eye care into primary health care, and the WHO Africa region recently developed a package for primary eye care. However, there are limited data on the capacities needed for delivery, to guide policymakers and implementers on the feasibility of integration. The overall purpose of this study was to assess the technical capacity of the health system at primary level to deliver the WHO primary eye care package. Findings with respect to service delivery, equipment and health management information systems (HMIS) are presented in this paper. Methods This was a mixed-methods, cross sectional feasibility study in Anambra State, Nigeria. Methods included a desk review of relevant Nigerian policies; a survey of 48 primary health facilities in six districts randomly selected using two stage sampling, and semi-structured interviews with six supervisors and nine purposively selected facility heads. Quantitative study tools included observational checklists and questionnaires. Survey data were analysed descriptively using STATA V.15.1 (Statcorp, Texas). Differences between health centres and health posts were analysed using the z-test statistic. Interview data were analysed using thematic analysis assisted by Open Code Software V.4.02. Results There are enabling national health policies for eye care, but no policy specifically for primary eye care. 85% of facilities had no medication for eye conditions and one in eight had no vitamin A in stock. Eyecare was available in Conclusion A policy for primary eye care is needed which aligns with existing eye health policies. There are currently substantial capacity gaps in service delivery, equipment and data management which will need to be addressed if eye care is to be successfully integrated into primary care in Nigeria.

Background Postpartum women represent a considerable share of the global unmet need for modern contraceptives. Evidence suggests that the integration of family planning (FP) with childhood immunisation services could help reduce this unmet need by providing repeat opportunities for timely contact with FP services. However, little is known about the clients’ experiences of FP services that are integrated with childhood immunisations, despite being crucial to contraceptive uptake and repeat service utilisation. Methods The responsiveness of FP services that were integrated with childhood immunisations in Malawi was assessed using cross-sectional convergent mixed methods. Exit interviews with clients (n=146) and audits (n=15) were conducted in routine outreach clinics. Responsiveness scores across eight domains were determined according to the proportion of clients who rated each domain positively. Text summary analyses of qualitative data from cognitive interviewing probes were also conducted to explain responsiveness scores. Additionally, Spearman rank correlation and Pearson’s chi-squared test were used to identify correlations between domain ratings and to examine associations between domain ratings and client, service and clinic characteristics. Results Responsiveness scores varied across domains: dignity (97.9%); service continuity (90.9%); communication (88.7%); ease of access (77.2%); counselling (66.4%); confidentiality (62.0%); environment (53.9%) and choice of provider (28.4%). Despite some low performing domains, 98.6% of clients said they would recommend the clinic to a friend or family member interested in FP. The choice of provider, communication, confidentiality and counselling ratings were positively associated with clients’ exclusive use of one clinic for FP services. Also, the organisation of services in the clinics and the providers’ individual behaviours were found to be critical to service responsiveness. Conclusions This study establishes that in routine outreach clinics, FP services can be responsive when integrated with childhood immunisations, particularly in terms of the dignity and service continuity afforded to clients, though less so in terms of the choice of provider, environment, and confidentiality experienced. Additionally, it demonstrates the value of combining cognitive interviewing techniques with Likert questions to assess service responsiveness.

Background There has been a successful push towards parasitological diagnosis of malaria in Africa, mainly with rapid diagnostic tests (mRDTs), which has reduced over-prescribing of artemisinin-based combination therapies (ACT) to malaria test-negative patients. The effect on prescribing for test-positive patients has received much less attention. Malaria infection in endemic Africa is often most dangerous for young children and those in low-transmission settings. This study examined non-prescription of antimalarials for patients with malaria infection demonstrated by positive mRDT results, and in particular these groups who are most vulnerable to poor outcomes if antimalarials are not given. Methods Analysis of data from 562,762 patients in 8 studies co-designed as part of the ACT Consortium, conducted 2007–2013 in children and adults, in Cameroon, Ghana, Nigeria, Tanzania, and Uganda, in a variety of public and private health care sector settings, and across a range of malaria endemic zones. Results Of 106,039 patients with positive mRDT results (median age 6 years), 7426 (7.0%) were not prescribed an ACT antimalarial. The proportion of mRDT-positive patients not prescribed ACT ranged across sites from 1.3 to 37.1%. For patients under age 5 years, 3473/44,539 (7.8%) were not prescribed an ACT, compared with 3833/60,043 (6.4%) of those aged ≥ 5 years. The proportion of Conclusions In eight studies of mRDT implementation in five African countries, substantial proportions of patients testing mRDT-positive were not prescribed an ACT antimalarial, and many were not prescribed an antimalarial at all. Patients most vulnerable to serious outcomes, children Trial registration Reported in individual primary studies.

Qualitative comparative analysis (QCA) was originally developed as a tool for cross-national comparisons in macrosociology, but its use in evaluation and evidence synthesis of complex interventions is rapidly developing. QCA is theory-driven and relies on Boolean logic to identify pathways to an outcome (eg, is the intervention effective or not?). We use the example of two linked systematic reviews on weight management programs (WMPs) for adults-one focusing on user views (a "views synthesis") and one focusing on the effectiveness of WMPs incorporating dietary and physical activity-to demonstrate how a synthesis of user views can supply a working theory to structure a QCA. We discuss how a views synthesis is especially apt to supply this working theory because user views can (a) represent a "middle-range theory" of the intervention; (b) bring a participatory, democratic perspective; and (c) provide an idiographic understanding of how the intervention works that external taxonomies may not be able to furnish. We then discuss the practical role that the views synthesis played in our QCA examining pathways to effectiveness: (a) by suggesting specific intervention features and sharpening the focus on the most salient features to be examined, (b) by supporting interpretation of findings, and (c) by bounding data analysis to prevent data dredging.

National immunization technical advisory groups (NITAGs) develop immunization-related recommendations. Systematic reviews are recommended to be used in this process, but conducting them requires significant resources, which many NITAGs lack. Using existing systematic reviews could help address this problem. The Robert Koch Institute and collaborators set up the SYSVAC2 project to facilitate the retrieval of existing systematic reviews and offer guidance on using them. This will include an online registry of systematic reviews relevant to immunization policy and an online course on how to use existing reviews. This report describes an international expert workshop held in December 2019 to develop consensus on methods for using existing reviews and other relevant factors for the registry and course. Members from NITAGs representing different regions of the world presented their experiences of using systematic reviews and reflected on challenges inhibiting use. Three methodologists considered different aspects of using systematic reviews. Interactive sessions followed, where implications for SYSVAC2 were discussed. Participants supported having critical appraisal ratings, plain language summaries, keyword search, and data visualization functions in the registry. They suggested tailoring course content to different audiences and including overviews of reviews as a topic and examples of how NITAGs have used or could use existing reviews. Participants agreed that whether a review is out-of-date should be decided by those using the review rather than registry staff. The registry could help by highlighting the date of literature search or included primary studies. Participants recommended a visualization function to highlight overlap across reviews and guidance on handling challenges to using reviews, ideally, involving a practical element. No consensus was reached on which critical appraisal tool to use for reviews in the registry, but a majority of participants wanted registry staff to perform appraisals. Formative research is planned before the registry and online course are launched in 2020.

Background To increase access to eye care, the World Health Organization’s Africa Region recently launched a primary eye care (PEC) package for sub-Saharan Africa. To determine the technical feasibility of implementing this package, the capacity of health systems at primary level needs to be assessed, to identify capacity gaps that would need to be addressed to deliver effective and sustainable PEC. This study reports on the human resource and governance challenges for delivering PEC in Anambra State, Nigeria. Methods Design: This was a mixed methods feasibility study. A desk review of relevant Nigerian national health policy documents on both eye health and primary health care was conducted, and 48 primary health care facilities in Anambra state were surveyed. Data on human resource and governance in primary health facilities were collected using structured questionnaires and through observation with checklists. In-depth interviews were conducted with district supervisors and selected heads of facilities to explore the opportunities and challenges for the delivery of PEC in their facilities/districts. Data were analysed using the World Health Organization’s health system framework. Results A clear policy for PEC is lacking. Supervision was conducted at least quarterly in 54% of facilities and 56% of facilities did not use the standard clinical management guidelines. There were critical shortages of health workers with 82% of facilities working with less than 20% of the number recommended. Many facilities used volunteers and/or ad hoc workers to mitigate staff shortages. Conclusion Our study highlights the policy, governance and health workforce gaps that will need to be addressed to deliver PEC in Nigeria. Developing and implementing a specific policy for PEC is recommended. Implementation of existing national health policies may help address health workforce shortages at the primary health care level.

BackgroundTuberculosis (TB) control relies on early diagnosis and treatment. International guidelines recommend systematic TB screening at health facilities in high-burden settings, but implementation is challenging. To construct a TB diagnosis care cascade, we investigated screening guideline adherence and completion of TB testing steps in Blantyre, Malawi.MethodsA prospective cohort recruited adult (≥18) outpatients attending Bangwe acute-care primary clinic between 21/5/2018 and 6/9/2018. Entry interviews recording TB symptoms and demographic characteristics were linked to exit interviews by biometrics. Care cascades were constructed to estimate the proportion of patients progressing through each step of the diagnostic pathway. Multivariable logistic regression was used to investigate factors associated with being asked to submit sputum.ResultsOf 5,442 clinic attendances 2,397 (44%) had exit interviews. In clinically indicated participants (n=330) 203 (61.5%) were asked about cough, 39 (11.8%) were asked for sputum, 27 (8.2%) gave sputum and 1 (0.3%) received same-day results. Significant associations with request for sputum were: any TB symptom (aOR:3.20, 95%CI:2.02-5.06), increasing age (aOR:1.02, 95%CI:1.01-1.04 per year) and for HIV-negative participants only, a history of previous TB (aOR:3.37, 95%CI:1.45-7.81). Numbers requiring sputum survey (20/day) outnumbered diagnostic capacity (8-12/day).ConclusionPatients were lost at every stage of the TB care cascade, with same day sputum submission achieved in only 8.2% if clinically indicated. Infection control strategies should be implemented, with reporting on early steps of the TB care cascade formalised. High-throughput interventions, such as digital CXR, that can optimise same-day TB screening are urgently needed to meet WHO End TB goals.SummaryWhat is already known?WHO guidelines recommend systematic screening for Tuberculosis at health facilities in high-burden settings, but implementation is challenging.Care cascades have been widely used by HIV programmes to evaluate care delivery but have only recently been applied to TB care. Care cascades help to define the steps of the cascade most in need of interventionWhat are the new findings?In this study, only 8.2% of those clinically indicated to test for TB (as per national guidelines in Malawi) did so, with patients lost at every step of the diagnosis care cascade.Failure to request sputum by clinicians despite elicited symptoms led to the biggest single gap in the diagnosis care cascade, followed by not asking about symptoms.If all patients attending the clinic were screened for TB as per the guidelines, the current testing facilities would only be able to process up to two thirds of the required samples.What do the new findings imply?Interventions focusing on health worker behaviour may have the greatest potential for retaining presumptive TB patients within the diagnosis cascadeWe must formalise and strengthen reporting on the early steps in the TB care cascade: a requirement to report numbers of screened presumptive TB cases would allow greater focus on these critical steps.If identification of presumptive TB patients is subsequently improved a novel high-throughput approach to triage testing using new diagnostics will be required for LMICs to increase capacity.

Background Approximately 90% of the 253 million blind or visually impaired people worldwide live in low- and middle-income countries. Lack of access to eye care is why most people remain or become blind. The World Health Organization Regional Office for Africa (WHO-AFRO) recently launched a primary eye care (PEC) package for sub-Saharan Africa—the WHO-AFRO PEC package—for integration into the health system at the primary health care (PHC) level. This has the potential to increase access to eye care, but feasibility studies are needed to determine the extent to which the health system has the capacity to deliver the package in PHC facilities. Objective Our objective is to assess the technical feasibility of integrating the WHO-AFRO PEC package in PHC facilities in Nigeria. Methods This study has several components, which include (1) a literature review of PEC in sub-Saharan Africa, (2) a Delphi exercise to reach consensus among experts regarding the technical complexity of the WHO-AFRO PEC package and the capacities needed to deliver it in PHC facilities, (3) development of PEC technical capacity assessment tools, and (4) data collection, including facility surveys and semistructured interviews with PHC staff and their supervisors and village health workers to determine the capacities available to deliver PEC in PHC facilities. Analysis will identify opportunities and the capacity gaps that need to be addressed to deliver PEC. Results Consensus was reached among experts regarding the technical complexity of the WHO-AFRO PEC package and the capacities needed to deliver it as part of PHC. Quantitative tools (ie, structured questionnaires, in-depth interviews, and observation checklists) and topic guides based on agreed-upon technical capacities have been developed and relevant stakeholders have been identified. Surveys in 48 PHC facilities and interviews with health professionals and supervisors have been undertaken. Capacity gaps are being analyzed. Conclusions This study will determine the capacity of PHC centers to deliver the WHO-AFRO PEC package as an integral part of the health system in Nigeria, with identification of capacity gaps. Although capacity assessments have to be context specific, the tools and findings will assist policy makers and health planners in Nigeria and similar settings, who are considering implementing the package, in making informed choices. International Registered Report Identifier (IRRID) DERR1-10.2196/17263

Cyberbullying is associated with considerable negative mental and psychosocial consequences in children and young people, making it a serious public health concern. To review the highest level of available evidence, a systematic mapping review was conducted to identify systematic reviews that investigated the relationship between cyberbullying and mental and psychological outcomes in young people. Topic-relevant bibliographic databases and online resources were searched to identify reviews published since 2007. Data were extracted using a coding tool developed for this study. Methodological quality of included reviews was assessed using AMSTAR criteria. Nineteen systematic reviews satisfied the inclusion criteria and they reported a strong negative association between cyberbullying and mental health outcomes in young people. Meta-analysis was performed in 11 reviews and narrative synthesis in 8 reviews. Data were derived from predominantly cross-sectional studies and a clear causal relationship between cyberbullying and mental outcomes cannot be established. Two-third of the included reviews were classified to be of low or unclear quality, due to the lack of quality assessment of the primary studies included in individual reviews. This systematic map consolidates available evidence at review level and confirms the existing gaps in longitudinal and qualitative evidence synthesis. Closer examination of the moderating factors influencing cyberbullying behaviors in future research can advance our understanding and inform the development of tailored programs of intervention to mitigate the negative impact of this phenomenon.

This study aimed to identify critical features of successful lifestyle weight management interventions for overweight children (0-11years). Eleven qualitative UK-based studies examining children's, parents' and providers' perspectives and experiences of programmes were synthesised to identify components felt to be critical. Studies for this views synthesis were identified from existing reviews and an update of one review's search, which was run in December 2015. The identified components were then explored in a synthesis of intervention evaluations (five 'most effective' and 15 'least effective') conducted in western Europe, North America, Australia or New Zealand. The intervention evaluations were identified from existing reviews and an update of one review's search, which was run in March 2016. This evaluation synthesis was carried out using Qualitative Comparative Analysis. Three important mechanisms were present in all the most effective interventions but absent in all the least effective: 1/ showing families how to change: a) providing child physical activity sessions, b) delivering practical behaviour change strategy sessions, c) providing calorie intake advice; 2/ ensuring all the family are on board: a) delivering discussion/education sessions for both children and parents, b) delivering child-friendly sessions, c) aiming to change behaviours across the whole family; 3/ enabling social support for both parents and children by delivering both child group sessions and parent group sessions. To conclude, programmes should ensure the whole family is on board the programme, that parents and children can receive social support and are not just told what to change, but shown how.

Objectives Rwanda was the first country in Africa to introduce the human papillomavirus (HPV) vaccine. This was achieved through multi-year school-based campaigns. Our study evaluated the impact of the HPV vaccine introduction on the country's immunisation programme and health system. Methods Thirty key informants were interviewed at national and district levels, and in participating schools. Twenty-seven health facilities completed a questionnaire exploring the effects of the new vaccine introduction on six health system building blocks, as defined by the World Health Organization. Routine service activity data were collected during a 90-day period around the introduction. Results Routine vaccination activities were not disrupted during the delivery, likely due to a strong Expanded Program on Immunization, appropriate planning and a well-resourced operation. Opportunities were seized to co-deliver other interventions targeted at children and adolescents, such as health promotion. Collaboration with the Ministry of Education was strengthened at national level. Although there were some temporary increases in staff workload, no major negative effects were reported. Conclusion Despite its delivery through school-based campaigns, the HPV vaccine integrated well into the immunisation programme and health system. The introduction had no major negative effects. Some opportunities were seized to expand services and collaborations.

Introduction SYSVAC is an online bibliographic database of systematic reviews and systematic review protocols on vaccines and immunisation compiled by the London School of Hygiene & Tropical Medicine and hosted by the World Health Organization (WHO) through their National Immunization Technical Advisory Groups (NITAG) resource centre ( www.nitag-resource.org ). Here the development of the database and a bibliometric review of its content is presented, describing trends in the publication of policy-relevant systematic reviews on vaccines and immunisation from 2008 to 2016. Materials and methods Searches were conducted in seven scientific databases according to a standardized search protocol, initially in 2014 with the most recent update in January 2017. Abstracts and titles were screened according to specific inclusion criteria. All included publications were coded into relevant categories based on a standardized protocol and subsequently analysed to look at trends in time, topic, area of focus, population and geographic location. Results After screening for inclusion criteria, 1285 systematic reviews were included in the database. While in 2008 there were only 34 systematic reviews on a vaccine-related topic, this increased to 322 in 2016. The most frequent pathogens/diseases studied were influenza, human papillomavirus and pneumococcus. There were several areas of duplication and overlap. Discussion As more systematic reviews are published it becomes increasingly time-consuming for decision-makers to identify relevant information among the ever-increasing volume available. The risk of duplication also increases, particularly given the current lack of coordination of systematic reviews on vaccine-related questions, both in terms of their commissioning and their execution. The SYSVAC database offers an accessible catalogue of vaccine-relevant systematic reviews with, where possible access or a link to the full-text. Conclusions SYSVAC provides a freely searchable platform to identify existing vaccine-policy-relevant systematic reviews. Systematic reviews will need to be assessed adequately for each specific question and quality.

Background Extensive research effort shows that weight management programmes (WMPs) targeting both diet and exercise are broadly effective. However, the critical features of WMPs remain unclear. Objective To develop a deeper understanding of WMPs critical features, we undertook a systematic review of qualitative evidence. We sought to understand from a service‐user perspective how programmes are experienced, and may be effective, on the ground. Search strategy We identified qualitative studies from existing reviews and updated the searches of one review. Inclusion criteria We included UK studies capturing the views of adult WMP users. Data extraction and synthesis Thematic analysis was used inductively to code and synthesize the evidence. Main results Service users were emphatic that supportive relationships, with service providers or WMP peers, are the most critical aspect of WMPs. Supportive relationships were described as providing an extrinsic motivator or “hook” which helped to overcome barriers such as scepticism about dietary advice or a lack confidence to engage in physical activity. Discussion and conclusions The evidence revealed that service‐users’ understandings of the critical features of WMPs differ from the focus of health promotion guidance or descriptions of evaluated programmes which largely emphasize educational or goal setting aspects of WMPs. Existing programme guidance may not therefore fully address the needs of service users. The study illustrates that the perspectives of service users can reveal unanticipated intervention mechanisms or underemphasized critical features and underscores the value of a holistic understanding about “what happens” in complex psychosocial interventions such as WMPs.

Background Previous systematic reviews of weight management programmes (WMPs) have not been able to account for heterogeneity of effectiveness within programmes using top‐down behavioural change taxonomies. This could be due to overlapping causal pathways to effectiveness (or lack of effectiveness) in these complex interventions. Qualitative comparative analysis (QCA) can help identify these overlapping pathways. Methods Using trials of adult WMPs with dietary and physical activity components identified from a previous systematic review, we selected the 10 most and 10 least effective interventions by amount of weight loss at 12 months compared to minimal treatment. Using intervention components suggested by synthesis of studies of programme user views, we labelled interventions as to the presence of these components and, using qualitative comparative analysis, developed pathways of component combinations that created the conditions sufficient for interventions to be most effective and least effective. Results Informed by the synthesis of views studies, we constructed 3 truth tables relating to quality of the user‐provider relationship; perceived high need for guidance from providers; and quality of the relationship between peers in weight management programmes. We found effective interventions were characterized by opportunities to develop supportive relationships with providers or peers, directive provider‐led goal setting and components perceived to foster self‐regulation. Conclusions Although QCA is an inductive method, this innovative approach has enabled the identification of potentially critical aspects of WMPs, such as the nature of relationships within them, which were previously not considered to be as important as more concrete content such as dietary focus.

Since 2010, the World Health Organization has been recommending that all suspected cases of malaria be confirmed with parasite-based diagnosis before treatment. These guidelines represent a paradigm shift away from presumptive antimalarial treatment of fever. Malaria rapid diagnostic tests (mRDTs) are central to implementing this policy, intended to target artemisinin-based combination therapies (ACT) to patients with confirmed malaria and to improve management of patients with nonmalarial fevers. The ACT Consortium conducted ten linked studies, eight in sub-Saharan Africa and two in Afghanistan, to evaluate the impact of mRDT introduction on case management across settings that vary in malaria endemicity and healthcare provider type. This synthesis includes 562,368 outpatient encounters (study size range 2,400–432,513). mRDTs were associated with significantly lower ACT prescription (range 8–69% versus 20–100%). Prescribing did not always adhere to malaria test results; in several settings, ACTs were prescribed to more than 30% of test-negative patients or to fewer than 80% of test-positive patients. Either an antimalarial or an antibiotic was prescribed for more than 75% of patients across most settings; lower antimalarial prescription for malaria test-negative patients was partly offset by higher antibiotic prescription. Symptomatic management with antipyretics alone was prescribed for fewer than 25% of patients across all scenarios. In community health worker and private retailer settings, mRDTs increased referral of patients to other providers. This synthesis provides an overview of shifts in case management that may be expected with mRDT introduction and highlights areas of focus to improve design and implementation of future case management programs.

Since 2007, low and middle-income countries (LMICs) have gained experience delivering HPV vaccines through HPV vaccination pilots, demonstration projects and national programmes. This commentary summarises lessons from HPV vaccination experiences in 45 LMICs and what works for HPV vaccination introduction. Methods included a systematic literature review, unpublished document review, and key informant interviews. Data were extracted from 61 peer-reviewed articles, 11 conference abstracts, 188 technical reports, and 56 interviews, with quantitative data analysed descriptively and qualitative data analysed thematically. Key lessons are described under five themes of preparation, communications, delivery, coverage achievements, and sustainability. Lessons learnt were generally consistent across countries and projects and sufficient lessons have been learnt for countries to deliver HPV vaccine through phased national rollout rather than demonstration projects. However, challenges remain in securing the political will and financial resources necessary to implement successful national programmes.

Objectives\ud To examine the impact of use of rapid diagnostic tests for malaria on prescribing of antimicrobials, specifically antibiotics, for acute febrile illness in Africa and Asia. \ud Design\ud Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).\ud Setting\ud Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.\ud Participants\ud 522 480 children and adults with acute febrile illness.\ud Interventions\ud Rapid diagnostic tests for malaria.\ud Main outcome measures\ud Proportions of patients for whom an antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of antibiotics prescribed in different settings.\ud Results\ud Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups. Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more antibiotic prescriptions than patients with positive results for all the most commonly used classes: penicillins, trimethoprim-sulfamethoxazole (one exception), tetracyclines, and metronidazole.Conclusions Introduction of rapid diagnostic tests for malaria to reduce unnecessary use of antimalarials-a beneficial public health outcome-could drive up untargeted use of antibiotics. That 69% of patients were prescribed antibiotics when test results were negative probably represents overprescription.This included antibiotics from several classes, including those like metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of malaria testing might increase untargeted antibiotic use and must be examined. [Abstract copyright: Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.]

Rigorous evidence of "what works" to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This article presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach was used to draw out experiences and insights from multidisciplinary teams who undertook to design and evaluate these studies. Four steps appeared necessary for intervention design: (1) definition of scope, with reference to evaluation possibilities; (2) research to inform design, including evidence and theory reviews and empirical formative research; (3) intervention design, including consideration and selection of approaches and development of activities and materials; and (4) refining and finalizing the intervention, incorporating piloting and pretesting. Alongside these steps, projects produced theories, explicitly or implicitly, about (1) intended pathways of change and (2) how their intervention would be implemented.The work required to design interventions that meet and contribute to current standards of evidence should not be underestimated. Furthermore, the process should be recognized not only as technical but as the result of micro and macro social, political, and economic contexts, which should be acknowledged and documented in order to infer generalizability. Reporting of interventions should go beyond descriptions of final intervention components or techniques to encompass the development process. The role that evaluation possibilities play in intervention design should be brought to the fore in debates over health care improvement.

Demonstration projects or pilots of new public health interventions aim to build learning and capacity to inform country-wide implementation. Authors examined the value of HPV vaccination demonstration projects and initial national programmes in low-income and lower-middle-income countries, including potential drawbacks and how value for national scale-up might be increased. Data from a systematic review and key informant interviews, analyzed thematically, included 55 demonstration projects and 8 national programmes implemented between 2007-2015 (89 years' experience). Initial demonstration projects quickly provided consistent lessons. Value would increase if projects were designed to inform sustainable national scale-up. Well-designed projects can test multiple delivery strategies, implementation for challenging areas and populations, and integration with national systems. Introduction of vaccines or other health interventions, particularly those involving new target groups or delivery strategies, needs flexible funding approaches to address specific questions of scalability and sustainability, including learning lessons through phased national expansion.

Determining whether research findings from one setting are relevant to another is complex and poorly understood. This study aimed to explore the factors affecting whether research from other settings was perceived to be of potential use to those working in or researching maternal health in Ghana. Semi-structured interviews were conducted with 69 purposively sampled government decision-makers, researchers and other stakeholders working in maternal health in Ghana in 2008-09. The most influential factors affecting perceptions of applicability/transferability were the study's congruence with interviewees' previous experiences and beliefs. Interventions' adaptability was also considered crucial (and more important than remaining faithful to the original intervention). However, it was frequently considered a distinct stage in the research use process rather than a consideration of applicability/transferability. More attention was paid to the implementability of the intervention in the new setting, than to whether it would be as effective there. Interpretations of intervention descriptions and evaluation findings varied between interviewees, even when the same information was presented. This study is one of the first to explore perceptions of applicability/transferability of public health research among researchers and potential research users in a low-income setting. The findings suggest that existing frameworks of applicability/transferability do not reflect the factors considered to be most important in Ghana.

Objective: To review published frameworks that included criteria for the assessment of external validity, applicability and transferability in their assessment of health research. Methods: Five databases were searched for articles relating to the assessment of external validity or applicability and transferability in health research. A coding framework was developed inductively and used to assess which types of criteria were included in the frameworks. Results: Thirty-eight articles describing 25 frameworks were identified. Eleven focused solely on the assessment of applicability and transferability; 14 presented more general decision-making or evidence appraisal frameworks. The criteria were synthesized into four main categories: setting, intervention, outcomes and evidence. None of the frameworks covered all the criteria identified. A major limitation was the lack of empirical data used to develop many frameworks and the apparent lack of assessment of their perceived utility. Conclusion: A validated framework of applicability and transferability would help those aiming to encourage research use, as well as those conducting research. Greater understanding of applicability and transferability could help to encourage the appropriate use of research and the development of research that is more useful.

In recent years numerous new vaccines have been developed, offering potential reductions in the morbidity and mortality caused by a range of diseases. This has led to increased interest in decision-making about the adoption of new vaccines into national immunization programmes. This paper aims to systematically review the literature on national decision-making around the adoption of new vaccines. A thematic framework was developed inductively through analysis of the vaccine adoption decision-making frameworks included in the review. This thematic framework was then applied to the remaining studies included in the review. In total, 85 articles were included in the review: 39 articles describing examples of vaccine adoption decision-making, 26 presenting vaccine decision-making frameworks, 21 empirical articles of decision-making relating to vaccine adoption and 19 theoretical essays. An analysis of vaccine adoption decision-making frameworks identified nine broad categories of criteria: the importance of the health problem; vaccine characteristics; immunization programme considerations; acceptability; accessibility, equity and ethics; financial/economic issues; impact; alternative interventions and the decision-making process. The quality of the empirical studies was varied. Although some of the issues included in the frameworks were similar to those considered in the studies, there were also some notable differences. On the whole, the frameworks were more comprehensive than the studies, including a greater range of criteria. The existing literature provides a good foundation for further research into vaccine adoption decision-making. The current review, in pulling together what is already known and by identifying strengths, weaknesses and gaps in the existing evidence base, aims to encourage a more focused and rigorous approach to the topic in future. This could help to identify the most appropriate ways to develop vaccine adoption decision-making, so as to improve decisions and, ultimately, health outcomes.

Objectives To evaluate the effectiveness of pre-notification and pleading invitations in Web surveys by embedding a randomized controlled trial (RCT) in a Web-based survey. Study Design and Setting E-mail addresses of 569 authors of published maternal health research were randomized in a 2×2 factorial trial of a pre-notification vs. no pre-notification e-mail and a pleading vs. a non-pleading invitation e-mail. The primary outcome was completed response rate, and the secondary outcome was submitted response rate (which included complete and partial responses). Results Pleading invitations resulted in 5.0% more completed questionnaires, although this difference did not reach statistical significance [odds ratio (OR) 1.23; 95% confidence interval (CI): 0.86, 1.74; P =0.25]. Pre-notification did not increase the completion rate (OR 1.04; 95% CI 0.73, 1.48; P =0.83). Response was higher among authors who had published in 2006 or later (OR 2.07; 95% CI: 1.43, 2.98; P =0.001). There was some evidence that pre-notification was more effective in increasing submissions from authors with recent publications ( P =0.04). Conclusion The use of a "pleading" tone to e-mail invitations may increase response to a Web-based survey. Authors of recently published research are more likely to respond to a Web-based survey.

Objective This article reviews the evidence for the effectiveness of non-clinical interventions to reduce maternal mortality in low-income settings and identifies the gaps in the evidence base. Methods A systematic search was conducted to identify reviews and evaluations of non-clinical interventions to reduce maternal mortality in lower-income countries with high maternal mortality published between 1997 and 2008. Studies were reviewed to identify the topic focus, study design, and outcomes measured. Results There were 109 intervention evaluations and 30 reviews identified. Studies had been conducted in less than half of the countries and were generally poor quality. More studies focused on tertiary prevention (i.e., preventing death) rather than secondary prevention (i.e., preventing complications). More interventions sought to address quality of care than delays in seeking or accessing care. Conclusions While evidence partly reflects difficulties in evaluating complex public health interventions, more robust study designs are possible to evaluate interventions to reduce maternal mortality. In addition, better standardized outcome measures are needed. This overview identifies topic areas neglected by intervention research.

This paper aimed to identify the key elements that should be included in a fruit and vegetable‐promoting programme in British primary schools. Such a programme could be used in healthy schools schemes or “five‐a‐day” programmes. Five US school intervention studies were analysed to identify their most effective elements. Four of the five studies found that their intervention had a significant effect on fruit and vegetable consumption. All the studies were behaviourally focussed and used interactive teaching methods and were based on social cognitive theory. Targeting fruit and vegetable consumption appeared to be more effective than broader lifestyle/healthy eating interventions. All studies, except one, increased the availability of fruit and vegetables at school lunches but none increased their availability at snack times and breakfast. Three studies taught preparation skills. All included taste testing activities which aim to increase familiarity and so increase taste preferences. Four used role models to promote fruit and vegetables and two gave rewards for consumption. One study attempted to improve the sensory properties of fruit and vegetables at lunch through preparation techniques. Two studies included a community involvement component and four involved families in the intervention. Results from two of the studies showed that interventions must be maintained over time if effects are to be maintained. Greater effects were seen for fruit consumption than vegetable consumption except for one study which focussed specifically on vegetables.

© Policy Press 2015. This article explores the perceived value of public health research and the types of research considered useful in Ghana. Sixty-nine decision makers, researchers and stakeholders were interviewed. A broad range of research was highly valued. Two traits were important: an applied, relevant topic and quickly produced findings. Interviewees valued research which explored implementation issues or identified and increased understanding of health problems. Effectiveness research often lacked these traits and was not generally considered as important because it was implicitly assumed that as long as interventions (that were based on a good understanding of the situation) were implemented well, they would be effective.

OBJECTIVES: The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts.DESIGN: A comparative case study approach, analysing variation in outcomes across different settings.SETTING: Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case.PARTICIPANTS: 28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria.INTERVENTIONS: The interventions included different mRDT training packages, supervision, supplies and community sensitisation.OUTCOME MEASURES: Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider adherence to positive mRDTs (% Plasmodium falciparum positive prescribed/given Artemisinin Combination Treatment); (3) provider adherence to negative mRDTs (% P. falciparum negative not prescribed/given antimalarial).RESULTS: Outcomes varied widely across cases: 12-100% mRDT uptake; 44-98% adherence to positive mRDTs; 27-100% adherence to negative mRDTs. Providers appeared more motivated to perform well when mRDTs and intervention characteristics fitted with their own priorities. Goodness of fit of mRDTs with existing consultation and diagnostic practices appeared crucial to maximising the impact of mRDTs on care, as did prior familiarity with malaria testing; adequate human resources and supplies; possible alternative treatments for mRDT-negative patients; a more directive intervention approach and local preferences for ACTs.CONCLUSIONS: Basic training and resources are essential but insufficient to maximise the potential of mRDTs in many contexts. Programme design should respond to assessments of provider priorities, expectations and capacities. As mRDTs become established, the intensity of supporting interventions required seems likely to reduce.

Objective We aimed to explore the impacts of new vaccine introductions on immunization programmes and health systems in low- and middle-income countries. Methods We conducted case studies of seven vaccine introductions in six countries (Cameroon, PCV; Ethiopia, PCV; Guatemala, rotavirus; Kenya, PCV; Mali, Meningitis A; Mali, PCV; Rwanda, HPV). Interviews were conducted with 261 national, regional and district key informants and questionnaires were completed with staff from 196 health facilities. Routine data from districts and health facilities were gathered on vaccination and antenatal service use. Data collection and analysis were structured around the World Health Organisation health system building blocks. Findings The new vaccines were viewed positively and seemed to integrate well into existing health systems. The introductions were found to have had no impact on many elements within the building blocks framework. Despite many key informants and facility respondents perceiving that the new vaccine introductions had increased coverage of other vaccines, the routine data showed no change. Positive effects perceived included enhanced credibility of the immunisation programme and strengthened health workers’ skills through training. Negative effects reported included an increase in workload and stock outs of the new vaccine, which created a perception in the community that all vaccines were out of stock in a facility. Most effects were found within the vaccination programmes; very few were reported on the broader health systems. Effects were primarily reported to be temporary, around the time of introduction only. Conclusion Although the new vaccine introductions were viewed as intrinsically positive, on the whole there was no evidence that they had any major impact, positive or negative, on the broader health systems.

Background: Little is known about the process of assessing whether research conducted in one setting is applicable (i.e. implementable) and transferable (i.e. as effective) to another, despite its importance for health policy and practice. Applicability/transferability differs from external validity; the former focuses on potential utility in another specific setting, whilst the latter is more general. This study explored perceptions of applicability/transferability among maternal health researchers. Methods: Published maternal public health researchers in low- or middle-income countries were invited to complete an online questionnaire. They were shown four summaries of maternal public health intervention evaluations and asked which they felt were the most and least applicable/transferable to their own setting and why. Results: 283 valid questionnaires were received (41% response rate). Applicability/transferability decisions frequently depended on the pertinence of the problem addressed by the intervention or the intervention’s characteristics. Less common were comparison of the respondents’ setting with the study setting, or consideration of the study’s effectiveness. Conclusions: The factors affecting perceptions of applicability/transferability are broader than those associated with external validity. Improving the reporting of intervention characteristics and implementation is particularly important for applicability/transferability assessments and could increase the appropriate use of public health research in policy and practice.

(2003). Short Report: Good Enough to Eat? The Diet of Pregnant Teenagers. International Journal of Health Promotion and Education: Vol. 41, No. 2, pp. 59-61.

We conducted a systematic review of the published literature to examine the impact of new vaccine introduction on countries' immunization and broader health systems. Six publication databases were searched using 104 vaccine and health system-related search terms. The search yielded 15,795 unique articles dating from December 31, 1911 to September 29, 2010. Based on review of the title and abstract, 654 (4%) of these articles were found to be potentially relevant and were referred for full review. After full review, 130 articles were found to be relevant and included in the analysis. These articles represented vaccines introduced to protect against 10 different diseases (hepatitis A, hepatitis B, Haemophilus influenzae type b disease, human papilloma virus infection, influenza, Japanese encephalitis, meningococcal meningitis, Streptococcus pneumoniae disease, rotavirus diarrhea and typhoid), in various formulations and combinations. Most reviewed articles (97 [75%]) reported experiences in high-income countries. New vaccine introduction was most efficient when the vaccine was introduced into an existing delivery platform and when introduced in combination with a vaccine already in the routine childhood immunization schedule (i.e., as a combination vaccine). New vaccine introduction did not impact coverage of vaccines already included in the routine childhood immunization schedule. The need for increased cold chain capacity was frequently reported. New vaccines facilitated the introduction and widespread use of auto-disable syringes into the immunization and the broader health systems. The importance of training and education for health care workers and social mobilization was frequently noted. There was evidence in high-income countries that new vaccine introduction was associated with reduced health-care costs. Future evaluations of new vaccine introductions should include the systematic and objective assessment of the impacts on a country's immunization system and broader health system, especially in lower-income countries.

As more new and improved vaccines become available, decisions on which to adopt into routine programmes become more frequent and complex. This qualitative study aimed to explore processes of national decision-making around new vaccine adoption and to understand the factors affecting these decisions. Ninety-five key informant interviews were conducted in seven low- and middle-income countries: Bangladesh, Cameroon, Ethiopia, Guatemala, Kenya, Mali and South Africa. Framework analysis was used to explore issues both within and between countries. The underlying driver for adoption decisions in GAVI-eligible countries was the desire to seize GAVI windows of opportunity for funding. By contrast, in South Africa and Guatemala, non-GAVI-eligible countries, the decision-making process was more rooted in internal and political dynamics. Decisions to adopt new vaccines are, by nature, political. The main drivers influencing decisions were the availability of funding, political prioritization of vaccination or the vaccine-preventable disease and the burden of disease. Other factors, such as financial sustainability and feasibility of introduction, were not as influential. Although GAVI procedures have established more formality in decision-making, they did not always result in consideration of all relevant factors. As familiarity with GAVI procedures increased, questioning by decision-makers about whether a country should apply for funding appeared to have diminished. This is one of the first studies to empirically investigate national processes of new vaccine adoption decision-making using rigorous methods. Our findings show that previous decision-making frameworks (developed to guide or study national decision-making) bore little resemblance to real-life decisions, which were dominated by domestic politics. Understanding the realities of vaccine policy decision-making is critical for developing strategies to encourage improved evidence-informed decision-making about new vaccine adoptions. The potential for international initiatives to encourage evidence-informed decision-making should be realised, not assumed.

Semi-structured interviews in Ghana and England explored perceptions of the usefulness and use of foreign research (ie, beyond the original study country) compared to locally conducted research (ie, conducted in Ghana). There was a preference for locally conducted studies, although interviewees generally recognised the potential usefulness of foreign research. Various factors affected whether foreign research was considered useful or used; it was not used automatically or indiscriminately. Researchers should recognise the potential usefulness of their research beyond the original study country. Further work is needed to explore how to maximise the utility of foreign research, as a means of enabling evidence-informed decision making where locally conducted research is not available.

Background In research, diagrams are most commonly used in the analysis of data and visual presentation of results. However there has been a substantial growth in the use of diagrams in earlier stages of the research process to collect data. Despite this growth, guidance on this technique is often isolated within disciplines. Methods A multidisciplinary systematic review was performed, which included 13 traditional healthcare and non-health-focused indexes, non-indexed searches and contacting experts in the field. English-language articles that used diagrams as a data collection tool and reflected on the process were included in the review, with no restriction on publication date. Results The search identified 2690 documents, of which 80 were included in the final analysis. The choice to use diagrams for data collection is often determined by requirements of the research topic, such as the need to understand research subjects' knowledge or cognitive structure, to overcome cultural and linguistic differences, or to understand highly complex subject matter. How diagrams were used for data collection varied by the degrees of instruction for, and freedom in, diagram creation, the number of diagrams created or edited and the use of diagrams in conjunction with other data collection methods. Depending on how data collection is structured, a variety of options for qualitative and quantitative analysis are available to the researcher. The review identified a number of benefits to using diagrams in data collection, including the ease with which the method can be adapted to complement other data collection methods and its ability to focus discussion. However it is clear that the benefits and challenges of diagramming depend on the nature of its application and the type of diagrams used. Discussion/Conclusion The results of this multidisciplinary systematic review examine the application of diagrams in data collection and the methods for analyzing the unique datasets elicited. Three recommendations are presented. Firstly, the diagrammatic approach should be chosen based on the type of data needed. Secondly, appropriate instructions will depend on the approach chosen. And thirdly, the final results should present examples of original or recreated diagrams. This review also highlighted the need for a standardized terminology of the method and a supporting theoretical framework.

McCartney mentioned Aspinall and Watters’ report, which highlights poorer pregnancy outcomes among refugees.1 2 Let there be no doubt about what poorer means: asylum seekers and refugees are more likely than the general population to die during pregnancy or childbirth.3 Maternal health complications and neonatal deaths and …

Objective To evaluate the effectiveness of youth development in reducing teenage pregnancy, substance use, and other outcomes. Design Prospective matched comparison study. Setting 54 youth service sites in England. Participants Young people (n=2724) aged 13-15 years at baseline deemed by professionals as at risk of teenage pregnancy, substance misuse, or school exclusion or to be vulnerable. Intervention Intensive, multicomponent youth development programme including sex and drugs education (Young People’s Development Programme) versus standard youth provision. Main outcome measures Various, including pregnancy, weekly cannabis use, and monthly drunkenness at 18 months. Results Young women in the intervention group more commonly reported pregnancy than did those in the comparison group (16% v 6%; adjusted odds ratio 3.55, 95% confidence interval 1.32 to 9.50). Young women in the intervention group also more commonly reported early heterosexual experience (58% v 33%; adjusted odds ratio 2.53, 1.09 to 5.92) and expectation of teenage parenthood (34% v 24%; 1.61, 1.07 to 2.43). Conclusions No evidence was found that the intervention was effective in delaying heterosexual experience or reducing pregnancies, drunkenness, or cannabis use. Some results suggested an adverse effect. Although methodological limitations may at least partly explain these findings, any further implementation of such interventions in the UK should be only within randomised trials.

BACKGROUND: The WHO health systems Building Blocks framework has become ubiquitous in health systems research. However, it was not developed as a research instrument, but rather to facilitate investments of resources in health systems. In this paper, we reflect on the advantages and limitations of using the framework in applied research, as experienced in three empirical vaccine studies we have undertaken. DISCUSSION: We argue that while the Building Blocks framework is valuable because of its simplicity and ability to provide a common language for researchers, it is not suitable for analysing dynamic, complex and inter-linked systems impacts. In our three studies, we found that the mechanical segmentation of effects by the WHO building blocks, without recognition of their interactions, hindered the understanding of impacts on systems as a whole. Other important limitations were the artificial equal weight given to each building block and the challenge in capturing longer term effects and opportunity costs. Another criticism is not of the framework per se, but rather how it is typically used, with a focus on the six building blocks to the neglect of the dynamic process and outcome aspects of health systems.We believe the framework would be improved by making three amendments: integrating the missing "demand" component; incorporating an overarching, holistic health systems viewpoint and including scope for interactions between components. If researchers choose to use the Building Blocks framework, we recommend that it be adapted to the specific study question and context, with formative research and piloting conducted in order to inform this adaptation. SUMMARY: As with frameworks in general, the WHO Building Blocks framework is valuable because it creates a common language and shared understanding. However, for applied research, it falls short of what is needed to holistically evaluate the impact of specific interventions on health systems. We propose that if researchers use the framework, it should be adapted and made context-specific.