Identifying emerging hot spots of road traffic injury severity using spatiotemporal methods: longitudinal analyses on major roads in Ghana from 2005 to 2020.

BACKGROUND: Although road traffic injuries and deaths have decreased globally, there is substantial national and sub-national heterogeneity, particularly in low- and middle-income countries (LMICs). Ghana is one of few countries in Africa collecting comprehensive, spatially detailed data on motor vehicle collisions (MVCs). This data is a critical step towards improving roadway safety, as accurate and reliable information is essential for devising targeted countermeasures. METHODS: Here, we analyze 16 years of police-report data using emerging hot spot analysis in ArcGIS to identify hot spots with trends of increasing injury severity (a weighted composite measure of MVCs, minor injuries, severe injuries, and deaths), and counts of injuries, severe injuries, and deaths along major roads in urban and rural areas of Ghana. RESULTS: We find injury severity index sums and minor injury counts are significantly decreasing over time in Ghana while severe injury and death counts are not, indicating the latter should be the focus for road safety efforts. We identify new, consecutive, intensifying, and persistent hot spots on 2.65% of urban roads and 4.37% of rural roads. Hot spots are intensifying in terms of severity and frequency on major roads in rural areas. CONCLUSIONS: A few key road sections, particularly in rural areas, show elevated levels of road traffic injury severity, warranting targeted interventions. Our method for evaluating spatiotemporal trends in MVC, road traffic injuries, and deaths in a LMIC includes sufficient detail for replication and adaptation in other countries, which is useful for targeting countermeasures and tracking progress.

Methodology for adapting a co-created early childhood development intervention and implementation strategies for use by frontline workers in India and Guatemala: a systematic application of the FRAME-IS framework.

There is little evidence on optimizing the effectiveness and implementation of evidence-based early childhood development (ECD) interventions when task-shifted to frontline workers. In this Methods Forum paper, we describe our adaptation of the International Guide for Monitoring Child Development (GMCD) for task-shifting to frontline workers in Guatemala and India. In 2021-2022, implementers, trainers, frontline workers, caregivers, and international GMCD experts collaborated to adapt the GMCD for a task shifted implementation by frontline workers. We used an eight-step co-creating process: assembling a multidisciplinary team, training on the existing package, working groups to begin modifications, revision of draft modifications, tailoring of visual materials and language, train-the-trainers activities, pilot frontline worker trainings, final review and feedback. Preliminary effectiveness of adaptations was evaluated through narrative notes and group-based qualitative feedback following pilot trainings with 16 frontline workers in India and 6 in Guatemala. Final adaptations included: refining training techniques to match skill levels and learning styles of frontline workers; tailoring all visual materials to local languages and contexts; design of job aids for providing developmental support messages; modification of referral and triage processes for children in need of enhanced support and speciality referral; and creation of post-training support procedures. Feedback from pilot trainings included: (1) group consensus that training improved ECD skills and knowledge across multiple domains; and (2) feedback on ongoing needed adjustments to pacing, use of video-based vs. role-playing materials, and time allocated to small group work. We use the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) framework to document our adaptations. The co-creating approach we use, as well as systematic documentation of adaptation decisions will be of use to other community-based early childhood interventions and implementation strategies.

Main findings: The International Guide for Monitoring Child Development, an early childhood development support and monitoring tool, was successfully adapted for use by frontline workers in rural India and Guatemala.Added knowledge: Our Methods Forum paper uses a detailed framework to document the collaborative, co-creating process used and the adaptive decisions taken.Global health impact for policy and action: Evidence on how best to adapt and optimize early childhood interventions for frontline workers will be useful or scaling up support for children globally.

"We are pleading for the government to do more": Road user perspectives on the magnitude, contributing factors, and potential solutions to road traffic injuries and deaths in Ghana.

Road traffic collisions disproportionately impact Ghana and other low- and middle-income countries. This study explored road user perspectives regarding the magnitude, contributing factors, and potential solutions to road traffic collisions, injuries, and deaths. We designed a qualitative study of 24 in-depth interviews with 14 vulnerable road users (pedestrians, occupants of powered 2- and 3-wheelers, cyclists) and ten non-vulnerable road users in four high-risk areas in November 2022. We used a mixed deductive (direct content analysis) and inductive (interpretive phenomenological analysis) approach. In the direct content analysis, a priori categories based on Haddon's Matrix covered human, vehicle, socioeconomic environment, and physical environment factors influencing road traffic collisions, along with corresponding solutions. We used inductive analysis to identify emerging themes. Participants described frequent and distressing experiences with collisions, and most often reported contributing factors, implementation gaps, and potential solutions within the human (road user) level domain of Haddon's Matrix. Implementation challenges included sporadic enforcement, reliance on road users' adherence to safety laws, and the low quality of the existing infrastructure. Participants expressed that they felt neglected and ignored by road safety decision-makers. This research emphasizes the need for community input for successful road safety policies in Ghana and other low- and middle-income countries, calling for greater governmental support an action to address this public health crisis. We recommend the government collaborates with communities to adapt existing interventions including speed calming, footbridges, and police enforcement, and introduces new measures that meet local needs.

Laboratory Data Timeliness and Completeness Improves Following Implementation of an Electronic Laboratory Information System in Côte d'Ivoire: Quasi-Experimental Study on 21 Clinical Laboratories From 2014 to 2020.

BACKGROUND: The Ministry of Health in Côte d'Ivoire and the International Training and Education Center for Health at the University of Washington, funded by the United States President's Emergency Plan for AIDS Relief, have been collaborating to develop and implement the Open-Source Enterprise-Level Laboratory Information System (OpenELIS). The system is designed to improve HIV-related laboratory data management and strengthen quality management and capacity at clinical laboratories across the nation. OBJECTIVE: This evaluation aimed to quantify the effects of implementing OpenELIS on data quality for laboratory tests related to HIV care and treatment. METHODS: This evaluation used a quasi-experimental design to perform an interrupted time-series analysis to estimate the changes in the level and slope of 3 data quality indicators (timeliness, completeness, and validity) after OpenELIS implementation. We collected paper and electronic records on clusters of differentiation 4 (CD4) testing for 48 weeks before OpenELIS adoption until 72 weeks after. Data collection took place at 21 laboratories in 13 health regions that started using OpenELIS between 2014 and 2020. We analyzed the data at the laboratory level. We estimated odds ratios (ORs) by comparing the observed outcomes with modeled counterfactual ones when the laboratories did not adopt OpenELIS. RESULTS: There was an immediate 5-fold increase in timeliness (OR 5.27, 95% CI 4.33-6.41; P<.001) and an immediate 3.6-fold increase in completeness (OR 3.59, 95% CI 2.40-5.37; P<.001). These immediate improvements were observed starting after OpenELIS installation and then maintained until 72 weeks after OpenELIS adoption. The weekly improvement in the postimplementation trend of completeness was significant (OR 1.03, 95% CI 1.02-1.05; P<.001). The improvement in validity was not statistically significant (OR 1.34, 95% CI 0.69-2.60; P=.38), but validity did not fall below pre-OpenELIS levels. CONCLUSIONS: These results demonstrate the value of electronic laboratory information systems in improving laboratory data quality and supporting evidence-based decision-making in health care. These findings highlight the importance of OpenELIS in Côte d'Ivoire and the potential for adoption in other low- and middle-income countries with similar health systems.

Implementation outcomes of the integrated district evidence to action (IDEAs) program to reduce neonatal mortality in central Mozambique: an application of the RE-AIM evaluation framework.

BACKGROUND: Scarce evidence exists on audit and feedback implementation processes in low-resource health systems. The Integrated District Evidence to Action (IDEAs) is a multi-component audit and feedback strategy designed to improve the implementation of maternal and child guidelines in Mozambique. We report IDEAs implementation outcomes. METHODS: IDEAs was implemented in 154 health facilities across 12 districts in Manica and Sofala provinces between 2016 and 2020 and evaluated using a quasi-experimental design guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Reach is the proportion of pregnant women attending IDEAs facilities. Adoption is the proportion of facilities initiating audit and feedback meetings. Implementation is the fidelity to the strategy components, including readiness assessments, meetings (frequency, participation, action plan development), and targeted financial support and supervision. Maintenance is the sustainment at 12, 24, and 54 months. RESULTS: Across both provinces, 56% of facilities were exposed to IDEAs (target 57%). Sixty-nine and 73% of pregnant women attended those facilities' first and fourth antenatal consultations (target 70%). All facilities adopted the intervention. 99% of the expected meetings occurred with an average interval of 5.9 out of 6 months. Participation of maternal and child managers was high, with 3076 attending meetings, of which 64% were from the facility, 29% from the district, and 7% from the province level. 97% of expected action plans were created, and 41 specific problems were identified. "Weak diagnosis or management of obstetric complications" was identified as the main problem, and "actions to reinforce norms and protocols" was the dominant subcategory of micro-interventions selected. Fidelity to semiannual readiness assessments was low (52% of expected facilities), and in completing micro-interventions (17% were completed). Ninety-six and 95% of facilities sustained the intervention at 12 and 24 months, respectively, and 71% had completed nine cycles at 54 months. CONCLUSION: Maternal and child managers can lead audit and feedback processes in primary health care in Mozambique with high reach, adoption, and maintenance. The IDEAs strategy should be adapted to promote higher fidelity around implementing action plans and conducting readiness assessments. Adding effectiveness to these findings will help to inform strategy scale-up.

Strengthening integrated depression services within routine primary health care using the RE-AIM framework in South Africa.

Integration of mental health into routine primary health care (PHC) services in low-and middle-income countries is globally accepted to improve health outcomes of other conditions and narrow the mental health treatment gap. Yet implementation remains a challenge. The aim of this study was to identify implementation strategies that improve implementation outcomes of an evidence-based depression care collaborative implementation model integrated with routine PHC clinic services in South Africa. An iterative, quasi-experimental, observational implementation research design, incorporating the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework, was applied to evaluate implementation outcomes of a strengthened package of implementation strategies (stage two) compared with an initial evaluation of the model (stage one). The first stage package was implemented and evaluated in 10 PHC clinics and the second stage strengthened package in 19 PHC clinics (inclusive of the initial 10 clinics) in one resource-scarce district in the province of KwaZulu-Natal, South Africa. Diagnosed service users were more likely to be referred for counselling treatment in the second stage compared with stage one (OR 23.15, SE = 18.03, z = 4.04, 95%CI [5.03-106.49], p < .001). Training in and use of a validated, mandated mental health screening tool, including on-site educational outreach and technical support visits, was an important promoter of nurse-level diagnosis rates (OR 3.75, 95% CI [1.19, 11.80], p = 0.02). Nurses who perceived the integrated care model as acceptable were also more likely to successfully diagnose patients (OR 2.57, 95% CI [1.03-6.40], p = 0.043). Consistent availability of a clinic counsellor was associated with a greater probability of referral (OR 5.9, 95%CI [1.29-27.75], p = 0.022). Treatment uptake among referred service users remained a concern across both stages, with inconsistent co-located counselling services associated with poor uptake. The importance of implementation research for strengthening implementation strategies along the cascade of care for integrating depression care within routine PHC services is highlighted.

Development of novel composite data quality scores to evaluate facility-level data quality in electronic data in Kenya: a nationwide retrospective cohort study.

BACKGROUND: In this evaluation, we aim to strengthen Routine Health Information Systems (RHIS) through the digitization of data quality assessment (DQA) processes. We leverage electronic data from the Kenya Health Information System (KHIS) which is based on the District Health Information System version 2 (DHIS2) to perform DQAs at scale. We provide a systematic guide to developing composite data quality scores and use these scores to assess data quality in Kenya. METHODS: We evaluated 187 HIV care facilities with electronic medical records across Kenya. Using quarterly, longitudinal KHIS data from January 2011 to June 2018 (total N = 30 quarters), we extracted indicators encompassing general HIV services including services to prevent mother-to-child transmission (PMTCT). We assessed the accuracy (the extent to which data were correct and free of error) of these data using three data-driven composite scores: 1) completeness score; 2) consistency score; and 3) discrepancy score. Completeness refers to the presence of the appropriate amount of data. Consistency refers to uniformity of data across multiple indicators. Discrepancy (measured on a Z-scale) refers to the degree of alignment (or lack thereof) of data with rules that defined the possible valid values for the data. RESULTS: A total of 5,610 unique facility-quarters were extracted from KHIS. The mean completeness score was 61.1% [standard deviation (SD) = 27%]. The mean consistency score was 80% (SD = 16.4%). The mean discrepancy score was 0.07 (SD = 0.22). A strong and positive correlation was identified between the consistency score and discrepancy score (correlation coefficient = 0.77), whereas the correlation of either score with the completeness score was low with a correlation coefficient of -0.12 (with consistency score) and -0.36 (with discrepancy score). General HIV indicators were more complete, but less consistent, and less plausible than PMTCT indicators. CONCLUSION: We observed a lack of correlation between the completeness score and the other two scores. As such, for a holistic DQA, completeness assessment should be paired with the measurement of either consistency or discrepancy to reflect distinct dimensions of data quality. Given the complexity of the discrepancy score, we recommend the simpler consistency score, since they were highly correlated. Routine use of composite scores on KHIS data could enhance efficiencies in DQA at scale as digitization of health information expands and could be applied to other health sectors beyondHIV clinics.

Application of the Expert Recommendations for Implementing Change (ERIC) compilation of strategies to health intervention implementation in low- and middle-income countries: a systematic review.

BACKGROUND: The Expert Recommendations for Implementing Change (ERIC) project developed a compilation of implementation strategies that are intended to standardize reporting and evaluation. Little is known about the application of ERIC in low- and middle-income countries (LMICs). We systematically reviewed the literature on the use and specification of ERIC strategies for health intervention implementation in LMICs to identify gaps and inform future research. METHODS: We searched peer-reviewed articles published through March 2023 in any language that (1) were conducted in an LMIC and (2) cited seminal ERIC articles or (3) mentioned ERIC in the title or abstract. Two co-authors independently screened all titles, abstracts, and full-text articles, then abstracted study, intervention, and implementation strategy characteristics of included studies. RESULTS: The final sample included 60 studies describing research from all world regions, with over 30% published in the final year of our review period. Most studies took place in healthcare settings (n = 52, 86.7%), while 11 (18.2%) took place in community settings and four (6.7%) at the policy level. Across studies, 548 distinct implementation strategies were identified with a median of six strategies (range 1-46 strategies) included in each study. Most studies (n = 32, 53.3%) explicitly matched implementation strategies used for the ERIC compilation. Among those that did, 64 (87.3%) of the 73 ERIC strategies were represented. Many of the strategies not cited included those that target systems- or policy-level barriers. Nearly 85% of strategies included some component of strategy specification, though most only included specification of their action (75.2%), actor (57.3%), and action target (60.8%). A minority of studies employed randomized trials or high-quality quasi-experimental designs; only one study evaluated implementation strategy effectiveness. CONCLUSIONS: While ERIC use in LMICs is rapidly growing, its application has not been consistent nor commonly used to test strategy effectiveness. Research in LMICs must better specify strategies and evaluate their impact on outcomes. Moreover, strategies that are tested need to be better specified, so they may be compared across contexts. Finally, strategies targeting policy-, systems-, and community-level determinants should be further explored. TRIAL REGISTRATION: PROSPERO, CRD42021268374.

Higher rates of mental health screening of adolescents recorded after provider training using simulated patients in a Kenyan HIV clinic: results of a pilot study.

Background: Kenyan adolescent girls and young women (AGYW) experience a dual burden of HIV and common mental disorders (CMD). HIV clinics are a key entry point for AGYW in need of integrated CMD and HIV care; however, rates of screening and referral for CMDs are low. Our objective was to test an evidence-based provider training strategy, simulated patient encounters (SPEs), on CMD service delivery for AGYW in a Kenyan HIV clinic. Methods: This pilot study was conducted in a public HIV clinic in Thika, Kenya from January to November 2021. The simulated patient encounter (SPE) implementation strategy included case script development from prior qualitative work, patient actor training, and a three-day SPE training including four standardized mock clinical encounters followed by quantitative surveys assessing provider competencies for each encounter. We abstracted medical record data related to HIV and CMDs such as HIV status, reason for visit, CMD screening test performed, and counselling or referral information. We conducted an interrupted time series analysis using abstracted HIV and CMD screening rates from AGYW ages 16-25 years visiting the clinic 7 months before and 3 months after SPE training. We used generalized linear models to assess changes in CMD screening rates after training. Results: A total of 10 providers participated in the training. Competency ratings improved across four mock encounters (mean score from 8.1 to 13.7) between first and fourth encounters. We abstracted all medical records (n = 1,154) including from 888 (76%) AGYW seeking HIV treatment, 243 (21%) seeking prevention services, and 34 (3%) seeking other services. CMD screening rates increased immediately following training from 8 to 21% [relative risk (RR) = 2.57, 95% confidence interval (CI) = 1.34-4.90, p < 0.01]. The 3 months following the SPE training resulted in an 11% relative increase in CMD screening proportion compared to the 7 months pre-SPE (RR: 1.11, 95% CI: 1.04-1.17, p < 0.01). Finally, 1% of all pre-SPE screens resulted in referral versus 5% of post-SPE screens (p = 0.07). Conclusion: The SPE model is a promising implementation strategy for improving HIV provider competencies and CMD service delivery for adolescents in HIV clinics. Future research is needed to explore effects on adolescent clinical outcomes in larger trials.

Adapting a transdiagnostic digital mental health intervention for use among immigrant and refugee youth in Seattle: a human-centered design approach.

Digital mental health interventions show promise in addressing mental health needs, especially among youth and marginalized communities. This study adapted the World Health Organization -developed STARS (Sustainable Technology for Adolescents to Reduce Stress) digital mental health intervention for use among youth and young adults aged 14-25 from immigrant and refugee communities in Seattle, Washington. Human-centered design methods centered around qualitative semi-structured interviews were used to contextually and culturally adapt the intervention and prioritize the needs and preferences of the intended end user. Intervention prototypes were modified and then presented to the target groups in iterative cycles until saturation was achieved. Qualitative interviews occurred in three iterations of five participants each. Modifications were documented according to the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) implementation science framework. Modifications aligned with the FRAME process elements: (a) tailoring/refining, which included adapting language to less resemble digital phishing scams; (b) changes in packaging or materials, which included naming the chatbot and adopting a corresponding avatar; (c) adding/removing, which included changing existing emojis and adding additional media types including graphics interchange format images, pictures, and voice memos; (d) shortening/condensing, which included shortening the length of individual text sections as well as deleting redundant language; (e) lengthening/extending, which included allowing the user to choose to receive content catered to teenagers or to adults; and (f) loosening structure, including giving users options to skip parts of modules or to engage with additional material. The modified STARS intervention shows promise for engagement with immigrant and refugee youth in Seattle and can be examined for clinical effectiveness. Adaptations increased the relevance of content to the intended end user, expanded options for personalization and customization of the user experience, and utilized language that was age appropriate, engaging, and did not invoke feelings of stigma or distrust. Adaptations of digital mental health interventions should focus on modifications that maximize acceptability and appropriateness to intended audiences.

Digital mental health interventions like apps and online mental health tools show promise in addressing mental health needs. This study adapted the STARS (Sustainable Technology for Adolescents to Reduce Stress) digital mental health intervention for use among youth and young adults from immigrant and refugee communities in Seattle, Washington. In our study, we adapted the intervention in a way that prioritizes the preferences of the intended end user. Modifications occurred in cycles: each time modifications resulted in a new version, the version was presented to a group of participants for their feedback and further modifications. Modifications in the final version included adapting language to less resemble digital phishing scams; naming the chatbot and adopting a corresponding avatar; changing existing emojis and adding additional media types; shortening the length of individual text sections as well as deleting redundant language; allowing the user to choose content catered to teenagers or to adults; and giving users options to skip parts of modules or to engage with additional material. The modified STARS intervention shows promise for engagement with immigrant and refugee youth in Seattle and can be examined for clinical effectiveness.

Refining the Performance of Routine Information System Management (PRISM) framework for data use at the local level: An integrative review.

INTRODUCTION: Foundational to a well-functioning health system is a strong routine health information system (RHIS) that informs decisions and actions at all levels of the health system. In the context of decentralization across low- and middle-income countries, RHIS has the promise of supporting sub-national health staff to take data-informed actions to improve health system performance. However, there is wide variation in how "RHIS data use" is defined and measured in the literature, impeding the development and evaluation of interventions that effectively promote RHIS data use. METHODS: An integrative review methodology was used to: (1) synthesize the state of the literature on how RHIS data use in low- and middle-income countries is conceptualized and measured; (2) propose a refined RHIS data use framework and develop a common definition for RHIS data use; and (3) propose improved approaches to measure RHIS data use. Four electronic databases were searched for peer-reviewed articles published between 2009 and 2021 investigating RHIS data use. RESULTS: A total of 45 articles, including 24 articles measuring RHIS data use, met the inclusion criteria. Less than half of included articles (42%) explicitly defined RHIS data use. There were differences across the literature whether RHIS data tasks such as data analysis preceded or were a part of RHIS data use; there was broad consensus that data-informed decisions and actions were essential steps within the RHIS data use process. Based on the synthesis, the Performance of Routine Information System Management (PRISM) framework was refined to specify the steps of the RHIS data use process. CONCLUSION: Conceptualizing RHIS data use as a process that includes data-informed actions emphasizes the importance of actions in improving health system performance. Future studies and implementation strategies should be designed with consideration for the different support needs for each step of the RHIS data use process.

State Policy Removing the Personal Belief Exemption for Measles, Mumps, and Rubella (MMR) School Immunization Requirement, Washington State, 2014-2022.

Objectives. To assess the impact of Washington State's 2019 Engrossed House Bill (EHB) 1638-which removed measles, mumps, and rubella (MMR) personal belief exemptions-on MMR vaccine series completion and exemption rates in K-12 students. Methods. We used interrupted time-series analyses to examine changes in MMR vaccine series completion rates before and after EHB 1638 was passed and the χ2 test for differences in exemption rates. Results. EHB 1638 implementation was associated with a 5.4% relative increase in kindergarten MMR vaccine series completion rates (95% confidence interval = 3.8%, 7.1%; P ≤ .001), and results were similar with Oregon as a control state (no change observed in Oregon; P = .68). MMR exemptions overall decreased 41% (from 3.1% in 2018-2019 to 1.8% in 2019-2020; P ≤ .001), and religious exemptions increased 367% (from 0.3% to 1.4%; P ≤ .001). Conclusions. EHB 1638 was associated with an increase in MMR vaccine series completion rates and a decrease in any MMR exemption. However, effects were partially offset by an increase in religious exemption rates. Public Health Implications. Removal of personal belief exemptions for the MMR immunization requirement only may be an effective approach to increase MMR vaccine coverage rates statewide and among underimmunized communities. (Am J Public Health. 2023;113(7):795-804. https://doi.org/10.2105/AJPH.2023.307285).

Early effects of COVID-19 on maternal and child health service disruption in Mozambique.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Introduction: After the World Health Organization declared COVID-19 a pandemic, more than 184 million cases and 4 million deaths had been recorded worldwide by July 2021. These are likely to be underestimates and do not distinguish between direct and indirect deaths resulting from disruptions in health care services. The purpose of our research was to assess the early impact of COVID-19 in 2020 and early 2021 on maternal and child healthcare service delivery at the district level in Mozambique using routine health information system data, and estimate associated excess maternal and child deaths. Methods: Using data from Mozambique's routine health information system (SISMA, Sistema de Informação em Saúde para Monitoria e Avaliação), we conducted a time-series analysis to assess changes in nine selected indicators representing the continuum of maternal and child health care service provision in 159 districts in Mozambique. The dataset was extracted as counts of services provided from January 2017 to March 2021. Descriptive statistics were used for district comparisons, and district-specific time-series plots were produced. We used absolute differences or ratios for comparisons between observed data and modeled predictions as a measure of the magnitude of loss in service provision. Mortality estimates were performed using the Lives Saved Tool (LiST). Results: All maternal and child health care service indicators that we assessed demonstrated service delivery disruptions (below 10% of the expected counts), with the number of new users of family planing and malaria treatment with Coartem (number of children under five treated) experiencing the largest disruptions. Immediate losses were observed in April 2020 for all indicators, with the exception of treatment of malaria with Coartem. The number of excess deaths estimated in 2020 due to loss of health service delivery were 11,337 (12.8%) children under five, 5,705 (11.3%) neonates, and 387 (7.6%) mothers. Conclusion: Findings from our study support existing research showing the negative impact of COVID-19 on maternal and child health services utilization in sub-Saharan Africa. This study offers subnational and granular estimates of service loss that can be useful for health system recovery planning. To our knowledge, it is the first study on the early impacts of COVID-19 on maternal and child health care service utilization conducted in an African Portuguese-speaking country.

The Systems Analysis and Improvement Approach: specifying core components of an implementation strategy to optimize care cascades in public health.

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 providers 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 providers 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 USA. 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 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 recommendations 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 modeling and simulation of change. Process mapping matched 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.

Prevalence and associated factors of common mental disorders in primary care settings in Sofala Province, Mozambique.

BACKGROUND: In Mozambique, the prevalence of common mental illness in primary care is not well established. AIMS: This study aimed to assess the prevalence of, and associated factors for, common mental illness in patients accessing primary care services in three Ministry of Health clinics in Mozambique. METHOD: Adult patients were recruited from the waiting rooms of prenatal, postpartum and general out-patient consultations. A mental health professional administered a diagnostic interview to examine prevalence of major depressive disorder (MDD), generalised anxiety disorder (GAD), post-traumatic stress disorder (PTSD) and any substance misuse or dependence. Generalised linear mixed models were used to examine the odds of each disorder and sociodemographic associations. RESULTS: Of 502 patients interviewed, 74.1% were female (n = 372) and the average age was 27.8 years (s.d. = 7.4). Of all participants, 23.9% (n = 120) met diagnostic criteria for at least one common mental disorder; 8.6% were positive for MDD (n = 43), 13.3% were positive for GAD (n = 67), 4.8% were positive for PTSD (n = 24) and 4.0% were positive for any substance misuse or dependence (n = 20). Patients attending prenatal or postpartum consultations had significantly lower odds of any common mental disorder than patients attending out-patient primary care. Age was negatively associated with MDD, but positively associated with substance misuse or dependence. CONCLUSIONS: Over 20% of patients attending primary care in Mozambique may have common mental disorders. A specific focus on patients attending general out-patient visits, young people for depression, and older people and men for substance misuse/dependence would provide a targeted response to high-risk demographics.

Demonstration project of a lay counselor delivered trans-diagnostic mental health intervention for newly diagnosed HIV patients in Mozambique.

ABSTRACTCommon mental disorders (CMDs) are associated with poor HIV outcomes in low- and middle-income countries. The present study implemented a psychological therapy delivered in routine HIV care and examined its effects on HIV outcomes in Mozambique. The Common Elements Treatment Approach (CETA) was integrated into routine HIV care in Sofala, Mozambique for all newly-diagnosed HIV+ patients with CMD symptoms. HIV treatment initiation and retention were compared to overall facility averages (those enrolled in CETA + those not enrolled). Of 250 patients screened, 59% (n = 148 met the criteria for CETA enrollment, and 92.6 (n = 137) enrolled in CETA. After four CETA visits, CMD symptoms decreased >50% and suicidal ideation decreased 100%. Patients enrolling in CETA had an antiretroviral therapy initiation rate of 97.1%, one-month retention of 69.2%, and three-month retention of 82.4%. Patients in the comparison group had one-month retention of 66.0% and three-month retention of 68.0%. CETA may be a promising approach to reduce symptoms of CMDs and improve HIV care cascade outcomes in areas with high HIV prevalence.

Early effects of COVID-19 on maternal and child health service disruption in Mozambique

After the World Health Organization declared COVID-19 a pandemic, more than 184 million cases and 4 million deaths had been recorded worldwide by July 2021. These are likely to be underestimates and do not distinguish between direct and indirect deaths resulting from disruptions in health care services. The purpose of our research was to assess the early impact of COVID-19 in 2020 and early 2021 on maternal and child healthcare service delivery at the district level in Mozambique using routine health information system data, and estimate associated excess maternal and child deaths...

Using the RE-AIM framework to evaluate the implementation of scaling-up the Friendship Bench in Zimbabwe - a quantitative observational study.

BACKGROUND: This study aimed to evaluate the real-world implementation of the Friendship Bench (FB) - an evidence-based brief psychological intervention delivered by community health workers (CHWs) - three years after its implementation in three city health departments in Zimbabwe. Implementation sites were evaluated according to their current performance using the RE-AIM framework making this one of the first evaluations of a scaled-up evidence-based psychological intervention in sub-Saharan Africa (SSA). METHODS: Using the RE-AIM guide ( www.re-aim.org ), the authors designed quantitative indicators based on existing FB implementation data. Thirty-six primary health care clinics (PHC) in Harare (n=28), Chitungwiza (n=4) and Gweru (n=4) were included. Among these clinics 20 were large comprehensive health care centers, 7 medium (mostly maternal and child healthcare) and 9 small clinics (basic medical care and acting as referral clinic). Existing data from these clinics, added to additionally collected data through interviews and field observations were used to investigate and compare the performance of the FB across clinics. The focus was on the RE-AIM domains of Reach, Adoption, and Implementation. RESULTS: Small clinics achieved 34% reach, compared to large (15%) and medium clinics (9%). Adoption was high in all clinic types, ranging from 59% to 71%. Small clinics led the implementation domain with 53%, followed by medium sized clinics 43% and large clinics 40%. Small clinics performed better in all indicators and differences in performance between small and large clinics were significant. Program activity and data quality depends on ongoing support for delivering agents and buy-in from health authorities. CONCLUSION: The Friendship Bench program was implemented over three years transitioning from a research-based implementation program to one led locally. The Reach domain showed the largest gap across clinics where larger clinics performed poorly relative to smaller clinics and should be a target for future implementation improvements. Program data needs to be integrated into existing health information systems. Future studies should seek to optimize scale-up and sustainment strategies to maintain effective task-shared psychological interventions in SSA.

Toward 90-90-90 Goals for Global Mental Health.

This Viewpoint discusses the adoption of 90-90-90 goals for global mental health, specifically targeting neurologic and substance use disorders, to prioritize mental health quality improvement within existing health services and destigmatize these conditions to promote treatment.