Two decades of research capacity strengthening and reciprocal learning on sexual and reproductive health in East Africa - a point of (no) return.

As the world is facing challenges such as pandemics, climate change, conflicts, and changing political landscapes, the need to secure access to safe and high-quality abortion care is more urgent than ever. On 27th of June 2023, the Swedish government decided to cut funding resources available for developmental research, which has played a fundamental role in the advancement of sexual and reproductive health and rights (SRHR) globally, including abortion care. Withdrawal of this funding not only threatens the fulfilment of the United Nations sustainable development goals (SDGS) - target 3.7 on ensuring universal access to SRHR and target 5 on gender equality - but also jeopardises two decades of research capacity strengthening. In this article, we describe how the partnerships that we have built over the course of two decades have amounted to numerous publications, doctoral graduates, and important advancements within the field of SRHR in East Africa and beyond.

Main findings: The two-decade long collaboration between Sweden and East Africa, funded by the Swedish government, has resulted in important partnerships, research findings, and advancements within sexual and reproductive health and rights in East Africa.Added knowledge: The Swedish government is now cutting funding for development research, which jeopardises the progress made so far.Global health impact for policy and action: Governments need to prioritise women's sexual and reproductive health and rights.

Technical Assistance for Systemic Change: Lessons Learned From a National Technical Assistance Center.

Despite the millions of dollars awarded annually by the United States Department of Education to build implementation capacity through technical assistance (TA), data on TA effectiveness are severely lacking. Foundational to the operationalization and consistent research on TA effectiveness is the development and use of standardized TA core competencies, practices, and structures. Despite advances toward a consistent definition of TA, a gap still exists in understanding how these competencies are used within an operationalized set of TA practices to produce targeted outcomes at both individual and organizational levels to facilitate implementation of evidence-based practices. The current article describes key insights derived from the evaluation of an operationalized set of TA practices used by a nationally funded TA center, the State Implementation & Scaling Up of Evidence Based Practices (SISEP) Center. The TA provided by the Center supports the uptake of evidence-based practices in K-12 education for students with disabilities. Lessons learned include: (1) the need to understand the complexities and dependencies of operationalizing TA both longitudinally and at multiple levels of the system (state, regional, local); (2) the relative importance of building general and innovation-specific capacity for implementation success; (3) the value of using a co-design and participatory approach for effective TA delivery; (4) the need to develop TA providers' educational and implementation fluency across areas and levels of the system receiving TA; and (5) the need to ensure coordination and alignment of TA providers from different centers. Gaining an understanding into optimal TA practices will not only provide clarity of definition fundamental to TA research, but it will also inform the conceptual framing and practice of TA.

Supporting Implementation Through Online Learning Communities: Lessons Learned From a National Training and Technical Assistance Network.

Recent implementation science frameworks highlight the role of training and technical assistance (TTA) in building workforce capacity to implement evidence-based practices (EBPs). However, evaluation of TTA is limited. We describe three case examples that highlight TTA by three regional centers in the national Mental Health Technology Transfer Center (MHTTC) network. Each MHTTC formed Learning Communities (LCs) to facilitate connections among behavioral health professionals with the goals of sharing implementation strategies, discussing best-practices, and developing problem solving techniques. Data on outcomes were collected through a combination of self-report surveys and qualitative interviews. LC participants reported strong connectedness, gains in knowledge and skills, improvements in implementation capacity, and intentions to advocate for organizational and systems-level change. Furthermore, across the case examples, we identified LC characteristics that are associated with participant perceptions of outcomes, including tailoring LC content to workforce needs, providing culturally relevant information, engaging leaders, forming connections among participants and trainers, and challenging participants' current workplace practices. These findings are interpreted through the lens of the Interactive Systems Framework, which focuses on how TTA, such as LCs, can facilitate connections between the theoretical and empirical foundations of interventions and the practices of implementing interventions in real-world settings to advance workforce capacity.

Addressing Traumatizing Environments: A Case Study of the Showing up for Black Power, Liberation, and Healing Initiative.

Effectively combating HIV will require southern HIV Service Organizations (SHSOs) to support Black staff while they navigate traumas related to structural racism driving the epidemic. HIV organizational capacity-building research lacks effective community-led approaches to anti-racist organizational change centered on Black people's experiences. This participatory case study examines "Showing Up for Black Power, Liberation and Healing," an organizational capacity-building initiative that leads to individual and organizational change, developed and implemented by the SUSTAIN, an intermediary purveyor organization (IPO). Evaluation data include participant observation notes and in-depth, open-ended evaluation reports analyzed using interpretive phenomenological analysis. The intervention consisted of a two-part shared learning collaborative. Qualitative impact themes highlighted: 1) the power of defining and valuing Black-centered spaces to address trauma; 2) reframing self-care from an individualistic responsibility to an institutionally supported, communal means of healing; and 3) the role of the intervention in spurring organizational changes related to dismantling White supremacy work culture in SHSOs.

The POWER of LEARNing and LEADing Together: Shared Learning Communities.

Southern community-based organizations often lack adequate resources to implement high-quality, culturally appropriate HIV programs and services. Shared learning communities (SLCs) combine in-depth training, tailored coaching, and peer-to-peer learning to strengthen HIV programs and services. This paper describes five SLCs, participant characteristics, and their capacity-building components.

Operationalizing Equity-centered Implementation Through Person-centered Care Capacity-building with HIV Service Organizations: The SUSTAIN Approach.

Capacity-building in trauma-informed care and harm reduction approaches with Southern HIV service organizations must be implemented in ways that foster trust and spur organizational change. Using an equity-centered implementation science framework, this study examines implementation strategies of the SUSTAIN COMPASS Coordinating Center's person-centered care (PCC) capacity-building interventions. METHODS: Fifty-eight (58) in-depth qualitative interviews with staff (N=116) who received PCC capacity-building were analyzed using modified grounded theory. RESULTS: Analysis identified four factors of equity-centered implementation that facilitated PCC capacity-building implementation. 1) Innovation factors: SUSTAIN models PCC approaches when implementing PCC capacity-building. 2) Inner factors: SUSTAIN employs PCC approaches. 3) Outer factors: SUSTAIN highlights socio-political factors that may influence PCC implementation. 4) Bridging factors: SUSTAIN facilitates partnerships to promote PCC learning and sustainability. CONCLUSION: SUSTAIN PCC capacity-building advances health equity through operationalizing personcentered care in capacity-building implementation.

Expansion of Reconstructive Surgical Capacity in Vietnam: Experience from the ReSurge Global Training Program.

BACKGROUND: Building local surgical capacity in low-income and middle-income countries is critical to addressing the unmet global surgical need. Visiting educator programs can be utilized to train local surgeons, but the quantitative impact on surgical capacity has not yet been fully described. The authors' objective was to evaluate the effectiveness of training utilizing a visiting educator program on local reconstructive surgical capacity in Vietnam. METHODS: A reconstructive surgery visiting educator program was implemented in Vietnam. Topics of training were based on needs defined by local surgeons, including those specializing in hand surgery, microsurgery, and craniofacial surgery. A retrospective analysis of annual case numbers corresponding to covered topics between the years 2014 and 2019 at each hospital was conducted to determine reconstructive surgical volume and procedures per surgeon over time. Direct costs, indirect costs, and value of volunteer services for each trip were calculated. RESULTS: Over the course of 5 years, 12 visiting educator trips were conducted across three hospitals in Vietnam. Local surgeons subsequently independently performed a total of 2018 operations corresponding to topics covered during visiting educator trips, or a mean of 136 operations annually per surgeon. Within several years, the hospitals experienced an 81.5 percent increase in surgical volume for these reconstructive clinical conditions, and annual case volume continues to increase over time. Total costs were $191,290, for a mean cost per trip of $15,941. CONCLUSIONS: Surgical capacity can be successfully expanded by utilizing targeted visiting educator trips to train local reconstructive surgeons. Local providers ultimately independently perform an increased volume of complex procedures and provide further training to others.

Ranking the relative importance of COVID-19 vaccination strategies in Canada: a priority-setting exercise.

BACKGROUND: When vaccine supplies are anticipated to be limited, necessitating the vaccination of certain groups earlier than others, the assessment of values and preferences of stakeholders is an important component of an ethically sound vaccine prioritization framework. The objective of this study was to conduct a priority-setting exercise to establish an expert stakeholder perspective on the relative importance of COVID-19 vaccination strategies in Canada. METHODS: The priority-setting exercise included a survey of stakeholders that was conducted from July 22 to Aug. 14, 2020. Stakeholders included clinical and public health expert groups, provincial and territorial committees and national Indigenous groups, patient and community advocacy representatives and experts, health professional associations and federal government departments. Survey results were analyzed to identify trends. RESULTS: Of 155 stakeholders contacted, 76 surveys were received for a participation rate of 49%. During a period of anticipated initial vaccine scarcity for all pandemic scenarios, stakeholders generally considered the most important vaccination strategy to be protecting those who are most vulnerable to severe illness and death from COVID-19. This was followed in importance by strategies to protect health care capacity, minimize transmission of SARS-CoV-2 and protect critical infrastructure. INTERPRETATION: This priority-setting exercise established that there is general alignment in the values and preferences across stakeholder groups: the most important vaccination strategy at the time of limited initial vaccine availability is to protect those who are most vulnerable. The findings of this priority-setting exercise provided a timely expert perspective to guide early public health planning for COVID-19 vaccines.

"Do Their Own Thing": Radical Health Care and the Fair Haven Community Health Center.

Radical health reform movements of the 1960s inspired two widely adopted alternative health care models in the United States: free clinics and community health centers. These groundbreaking institutions attempted to realize bold ideals but faced financial, bureaucratic, and political obstacles. This article examines the history of Fair Haven Community Health Care (FHCHC) in New Haven, Connecticut, an organization that spanned both models and typified innovative aspects of each while resisting the forces that tempered many of its contemporaries' progressive practices. Motivated by a tradition of independence and struggling to address medical neglect in their neighborhood, FHCHC leaders chose not to affiliate with the local academic hospital, a decision that led many disaffected community members to embrace the clinic. The FHCHC also prioritized grant funding over fee-for-service revenue, thus retaining freedom to implement creative programs. Furthermore, the center functioned in an egalitarian manner, enthusiastically employing nurse practitioners and whole-staff meetings, and was largely able to avoid the conflicts that strained other community-controlled organizations. The FHCHC proved unusual among free clinics and health centers and demonstrated strategies similar institutions might employ to overcome common challenges. (Am J Public Health. 2021;111(10): 1806-1814. https://doi.org/10.2105/AJPH.2021.306417).

Capacity Building for Primary Stroke Prevention Teams in Children Living With Sickle Cell Anemia in Africa.

BACKGROUND: Nigeria has the highest proportion of children with sickle cell anemia (SCA) globally; an estimated 150,000 infants with SCA are born annually. Primary stroke prevention in children with SCA must include Nigeria. We describe capacity-building strategies in conjunction with two National Institutes of Health-funded primary stroke prevention trials (a feasibility trial and phase III randomized controlled trial) with initial hydroxyurea treatment for children with SCA and abnormal transcranial Doppler (TCD) velocities in Nigeria. We anticipated challenges to conducting clinical trials in a low-resource setting with a local team that had not previously been involved in clinical research and sought a sustainable strategy for primary stroke prevention. METHODS: This is a descriptive, prospective study of challenges, solutions, and research teams in two trials that enrolled a total of 679 children with SCA. RESULTS: As part of the capacity-building component of the trials, over eight years, 23 research personnel (physicians, nurses, research coordinators, a statistician, and a pharmacist) completed a one-month research governance and ethics training program at Vanderbilt University Medical Center, USA. A lead research coordinator for each site completed the Society of Clinical Research Professionals certification. TCD machines were donated; radiologists and nonradiologists were trained and certified to perform TCD. A scalable E-prescription was implemented to track hydroxyurea treatment. We worked with regional government officials to support ongoing TCD-based screening and funding for hydroxyurea for children with SCA at a high risk of stroke. CONCLUSIONS: Our trials and capacity building demonstrate a sustainable strategy to initiate and maintain pediatric SCA primary stroke prevention programs in Africa.

Building an advocacy model to improve the dementia-capability of health plans in California.

BACKGROUND: Given the high and growing prevalence of Alzheimer's disease and related dementias, and the intensity of this population's care needs, it is imperative that healthcare systems increase their capacity to effectively serve people living with dementia (PLwD). The Dementia Cal MediConnect (Dementia CMC) project proposes an advocacy model that may foster dementia-capable systems change. METHODS: The Dementia CMC project was a 5-year partnership (2013-2018) between local Alzheimer's organizations and 10 managed care health plans (HPs) in California's duals demonstration. It used an advocacy model with the following steps: (1) Identify dementia-capable best practices to set as systems change indicators; (2) Identify and leverage public policies in support of systems change indicators; (3) Identify and engage champions; (4) Develop and advocate for a business case to improve dementia care; (5) Identify gaps in dementia-capable practices; (6) Provide technical assistance, tools, and staff training to address the gaps in dementia-capable practices; and (7) Track systems change. Systems change data were collected through participant observation with HPs and interviews with key informants representing partnering organizations or government entities. RESULTS: Participating HPs reported making systems changes toward more dementia-capable practices such as: better pathways for detection and diagnosis; better identification, assessment, support, and engagement of caregivers; and improved systems of referral to community-based organizations (CBOs), including Alzheimer's CBOs. Some indicators of systems change were inconclusive due to flawed assumptions around HP's care coordination, and the availability of common electronic health records between HPs and providers. CONCLUSION: The application of this advocacy model in California has led to systems changes that can improve care for PLwD and their caregivers and should be replicated to expand the dementia-capability of other health systems. Continued efforts to refine indicators are needed to capture systems change in complex and changing health systems.

Best Practices for Conducting Clinical Trials With Indigenous Children in the United States.

We provide guidance for conducting clinical trials with Indigenous children in the United States. We drew on extant literature and our experience to describe 3 best practices for the ethical and effective conduct of clinical trials with Indigenous children. Case examples of pediatric research conducted with American Indian, Alaska Native, and Native Hawaiian communities are provided to illustrate these practices. Ethical and effective clinical trials with Indigenous children require early and sustained community engagement, building capacity for Indigenous research, and supporting community oversight and ownership of research. Effective engagement requires equity, trust, shared interests, and mutual benefit among partners over time. Capacity building should prioritize developing Indigenous researchers. Supporting community oversight and ownership of research means that investigators should plan for data-sharing agreements, return or destruction of data, and multiple regulatory approvals. Indigenous children must be included in clinical trials to reduce health disparities and improve health outcomes in these pediatric populations. Establishment of the Environmental Influences on Child Health Outcomes Institutional Development Award States Pediatric Clinical Trials Network (ECHO ISPCTN) in 2016 creates a unique and timely opportunity to increase Indigenous children's participation in state-of-the-art clinical trials.

United in earnest: First pilot sites for increased surgical capacity for rheumatic heart disease announced by Cardiac Surgery Intersociety Alliance.

BACKGROUND: Rheumatic heart disease (RHD) affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration On Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for RHD patients. METHODS: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites. RESULTS: The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care, and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda). CONCLUSIONS: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for RHD patients.

Evaluation of Successfulness of Capacity Building Programmes on Smokeless Tobacco and Areca Nut Cessation.

BACKGROUND: Prevalence of smoking in Sri Lanka has shown a gradual reduction whilst the use of smokeless tobacco and areca nut exhibits an increasing trend. At present, only a few well-structured smokeless tobacco (SLT)/areca nut (AN) cessation programs have been conducted in Sri Lanka, which is a gross underachievement as betel chewing-related oral squamous cell carcinoma is the most common cancer in Sri Lankan males. As General Dental Practitioners (GDP) do not contribute significantly to SLT/AN cessation activities at present, capacity building programs on SLT/AN control were carried out. The study evaluated the knowledge, attitude and practices  imparted on SLT/AN control among dental surgeons. METHODS: Following a single day capacity building program on smokeless tobacco / areca nut control, two self-administered questionnaires were used to assess the improvement of knowledge and change of attitudes among 663 GDPs. RESULTS: Majority had a good knowledge on harmful effects of SLT but not on areca nut. Knowledge of the current legislation on SLT control in Sri Lanka and carcinogenicity of areca nut was not satisfactory. Almost all agreed that proper counseling leads to patient quitting the habit, a formal training is necessary to conduct tobacco control activities and it should be a part of the regular treatment modalities. More than 80% of the participants support strict legislation. Most important factors leading to poor involvement in tobacco cessation activities were lack of expertise and inadequate educational material and not breach of patient privacy and lack of financial incentives. 20.1% dental surgeons had consumed smokeless tobacco / areca nut products in the past and only a few were current users of tobacco and/or areca nut. CONCLUSIONS: Well planned workshops are efficient in improving knowledge, practices and attitudes of dental surgeons towards SLT/AN cessation.
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