Complex Health Research Articles

Digitalising Coordination Information in Long-Term Care: Experiences from an Innovation Project.

More patients are being discharged early from hospital and increasing numbers of patients have complex health care needs and receive care in the primary health care sector. To ensure efficient coordination and continuity of care, access to relevant information is crucial. We report from two Norwegian municipalities that, during an innovation project, transferred their information system from a paper-based to a digital coordination system. Workshops and interviews were conducted to address the considerations, reflections and dilemmas of the actors involved during the innovation process. The analysis provided three main themes which were: 1) transition from paper-based to digital overviews; 2) transition from individual patient information to a digital overview of groups of patients; and 3) transition from use of telephone to digital exchange of information. The actors had to overcome several challenges. Nevertheless, the outcome was that they were provided with contextualised information enabling efficiency and patient safety in their coordination work.

Enhancing Transition to Nursing Practice: The Mental Health Immersion Experience.

The number of people facing mental health issues continues to grow in the aftermath of COVID-19. Nurses are challenged with providing care for an increasing number of patients, including veterans, with complex mental health needs across healthcare settings. Of concern, many students transitioning into practice feel they lack the necessary confidence, education, and skills to competently care for patients with mental health illness. This article discusses an innovative mental health immersion experience strategically integrated within a new-nurse residency program.

The interplay between borderline personality disorder and oxytocin: a systematic narrative review on possible contribution and treatment options.

Borderline personality disorder (BPD) is a complex mental health condition marked by instability in mood, relationships, self-image, and behavior. Individuals with BPD often struggle with intense emotions, impulsivity, and maintaining stable relationships. Oxytocin, known as the "love hormone" or "bonding hormone," plays a crucial role in social bonding, trust, empathy, and emotional regulation and its dysregulation may contribute to BPD difficulties. This systematic review aims to analyze existing literature, examining the intricate interplay and encouraging future research and treatment strategies. A systematic search of Literature in PubMed, Embase and Psychinfo, without any language or time restriction, was performed until March 2024 combining thesaurus and free-search indexing terms related to "borderline personality disorder" and "oxytocin", producing 310 results (77 in PubMed, 166 in Embase and 67 in Psychinfo). Ninety-four full texts were analyzed, and 70 articles were included in qualitative analysis. Oxytocin may influence attachment styles, parental behaviors, and stress responses, particularly in individuals with a history of childhood trauma. The interaction between oxytocin, genetics, early life experiences, and environmental factors contributes to the complexity of BPD. Genetic variations in the oxytocin receptor gene may influence social and emotional abilities and contribute to the development of psychopathology. Additionally, early adverse experiences, such as childhood maltreatment, can alter oxytocin functioning, impacting social cognition and emotional regulation.However, oxytocin's role in BPD treatment remains uncertain, with some studies suggesting potential benefits for specific symptoms like social threat avoidance, while others indicate adverse effects on nonverbal behavior and mentalizing. Understanding oxytocin's role in BPD offers insights into potential therapeutic interventions. While oxytocin-based treatments may hold promise for addressing specific symptoms, further research is needed.

Centering Communities in Global Health: Using Human-Centered Design to Facilitate Collaboration and Intervention Development.

Utilizing iterative and collaborative tools, Human-centered Design (HCD) facilitates the creation of tailored solutions for multifaceted issues by fostering empathy and a deep understanding of human behaviors. This paper presents insights gleaned from employing HCD tools to center communities in global health intervention development. The study team collaborated with community members in Dailekh, Nepal to co-design interventions to address harms associated with menstrual seclusion, known as chhaupadi. A Community Design Team, comprising 10 women representing various castes and ages convened for a four-day intervention co-design workshop in the community. A Community Validation Team, comprising 12 individuals from diverse occupational and caste backgrounds provided feedback on the interventions. Additionally, six village leaders participated in Key Informant Interviews to garner additional insights. In the study's initial "discovery" phase, the Community Design Team employed HCD tools to generate a nuanced understanding of the context, stakeholders, and community experiences. Subsequently, in the second "design" phase, the Community Design Team crafted interventions to address harms associated with chhaupadi. Invaluable lessons gained from this study underscore the necessity of crafting contextually suitable tools, checklists, and prompts for participants, allocating sufficient staff, time, and resources, and adapting to participants' literacy levels and engagement preferences, whether through group or individual activities. Reflecting on these insights, our experience suggests HCD offers promising tools to authentically and equitably involve participants with diverse backgrounds in articulating their own ideas for community-based solutions in Nepal. Health practitioners, researchers, and intervention development experts are encouraged to consider adopting HCD methodologies to prioritize community voices in devising solutions for complex health challenges.

Using digital communication tools to improve interprofessional collaboration and satisfaction in a student-run free clinic.

Interprofessional collaboration can improve the quality of care in complex health conditions often seen in underserved populations. Communication is key to effective collaboration, and digital communication tools can enhance information sharing, collaboration, and satisfaction between professionals, especially when teams are distanced. In a semirural student-run free clinic that provides care to uninsured and underinsured patients with multifaceted health issues, there is a gap in communication and collaboration across interprofessional teams because of the frequent rotation of various staff, part-time hours, and electronic health record (EHR) function and interoperability limitations. The aim of this nurse practitioner-led quality improvement project was to determine whether implementing digital communication tools could enhance communication and improve provider collaboration and satisfaction during clinical decision-making among the several interprofessional teams at the student-run free clinic. Digital communication tools were implemented in a two-part intervention: (1) virtual case conferences to discuss patient care plans and (2) an EHR-linked tool to document the care plans. Survey evaluation across six virtual case conferences found above-average ratings for collaboration, satisfaction, and usability of the EHR-linked tool. There was a 15.78% improvement in global collaboration from the first to third conference, with a sustained improvement of 11.49%. Satisfaction improved by 4.62% from the first to the fourth conference. Digital communication tools can facilitate efficient communication and collaboration among staff while providing a more streamlined approach to patient care. These technologies can be useful in similar settings, especially when teams are distanced.

Isoproterenol induced cardiac hypertrophy: A comparison of three doses and two delivery methods in C57BL/6J mice.

Heart Failure (HF) continues to be a complex public health issue with increasing world population prevalence. Although overall mortality has decreased for HF and hypertrophic cardiomyopathy (HCM), a precursor for HF, their prevalence continues to increase annually. Because the etiology of HF and HCM is heterogeneous, it has been difficult to identify novel therapies to combat these diseases. Isoproterenol (ISP), a non-selective β-adrenoreceptor agonist, is commonly used to induce cardiotoxicity and cause acute and chronic HCM and HF in mice. However, the variability in dose and duration of ISP treatment used in studies has made it difficult to determine the optimal combination of ISP dose and delivery method to develop a reliable ISP-induced mouse model for disease. Here we examined cardiac effects induced by ISP via subcutaneous (SQ) and SQ-minipump (SMP) infusions across 3 doses (2, 4, and 10mg/kg/day) over 2 weeks to determine whether SQ and SMP ISP delivery induced comparable disease severity in C57BL/6J mice. To assess disease, we measured body and heart weight, surface electrocardiogram (ECG), and echocardiography recordings. We found all 3 ISP doses comparably increase heart weight, but these increases are more pronounced when ISP was administered via SMP. We also found that the combination of ISP treatment and delivery method induces contrasting heart rate, RR interval, and R and S amplitudes that may place SMP treated mice at higher risk for sustained disease burden. Mice treated via SMP also had increased heart wall thickness and LV Mass, but mice treated via SQ showed greater increase in gene markers for hypertrophy and fibrosis. Overall, these data suggest that at 2 weeks, mice treated with 2, 4, or 10mg/kg/day ISP via SQ and SMP routes cause similar pathological heart phenotypes but highlight the importance of drug delivery method to induce differing disease pathways.

Public Health Challenges and Responses to the Growing Ageing Populations

ABSTRACTBackgroundHuman populations are rapidly ageing worldwide due to declining birth rates and rising life expectancies. This profound demographic shift presents complex public health challenges. Synthesizing evidence on key public health issues impacting ageing populations and policy strategies is required to address these needs.MethodsThe study employs narrative literature review based on the PubMed database. Data have been extracted on public health challenges to ageing populations and its recommended policy solutions.ResultsThe key public health challenges identified include rising chronic disease burden, risks for preventable multi‐morbidities and co‐morbidities, disability and dependencies, mental health issues, caregiving gaps, long‐term care system deficiencies, health inequities, healthcare access barriers, end‐of‐life care needs, financial instability, ageism/elder abuse, adverse built environments, climate/disaster threats, and social isolation. Evidence‐based policy responses span interventions in healthcare, social services, urban planning, emergency preparedness, economics, technology, anti‐ageism advocacy and so on.ConclusionsProactively addressing the array of public health challenges faced by rapidly growing ageing populations globally requires implementing collaborative, multisectoral policy solutions focused on promoting healthy, equitable, and socially engaged ageing. Healthcare systems, communities, and policies must be optimized to meet the needs of elderly people and tap into their strengths.

Effectiveness of Acceptance and Commitment Therapy on Psychotic Severity Among Inpatients With Primary Psychoses: A Randomized Controlled Trial.

This study investigated the effectiveness of acceptance and commitment therapy (ACT) compared to treatment as usual in managing psychotic symptoms, emotional dysregulation, recovery and psychological flexibility in inpatients with primary psychoses. The Primary outcome assessed the positive and negative syndrome scale, while the secondary outcomes were to assess difficulties in the emotion regulation scale, recovery assessment scale and acceptance and action questionnaire. An open-label, two-arm parallel randomized controlled trial was conducted. Participants diagnosed with primary psychoses were randomly assigned to either the ACT (n = 33) or treatment-as-usual (n = 32) group. The intervention included six structured sessions of ACT. ACT significantly reduced psychotic symptoms from 128 to 104 (Z = 5.01) compared to treatment as usual from 130 to 117 (Z = 4.88). Emotional regulation improved significantly in the ACT group from 73 to 55 (Z = 4.835) compared to treatment as usual from 73 to 70 (Z = 2.406). Recovery increased in the ACT group from 50 to 88 (Z = 5.01) compared to treatment as usual from 51 to 61 (Z = 4.93). Psychological flexibility improved in the ACT group from 33 to 25 (Z = 4.98) compared to treatment as usual from 33 to 31 (Z = 4.75). Between-group differences after intervention were significant for psychotic symptoms, emotional regulation, recovery and psychological flexibility (Z = 2.356, 4.652, 3.881 and 4.453, respectively). Accordingly, the current study demonstrates the effectiveness of ACT in reducing psychotic symptoms and improving emotional regulation, recovery and psychological flexibility in patients with primary psychoses. Integrating ACT into standard care protocols can enhance treatment outcomes, offering a comprehensive approach to managing complex mental health conditions. Trial Registration: ClinicalTrials.gov identifier: NCT06160869.

Unpacking Perceptions on Patient Safety: A Study of Nursing Home Staff in Italy.

Nursing homes (NHs) are crucial for de-hospitalization and addressing the needs of non-self-sufficient individuals with complex health issues. This study investigates the patient safety culture (PSC) in NHs within a northern Italian region, focusing on factor influencing overall safety perceptions and their contributions to subjective judgements of safety. A cross-sectional study was conducted on 25 NHs in the Autonomous Province of Trento. The Nursing Home Survey on Patient Safety Culture (NHSPSC) was utilized to assess PSC among NH staff. Multilevel linear regression and post hoc dominance analyses were conducted to investigate variabilities in PSC among staff and NHs and to assess the extent to which PSC dimensions explain overall perceptions of PS. Analysis of 1080 questionnaires (44% response rate) revealed heterogeneity in PSC across dimensions and NHs, with management support, organizational learning, and supervisor expectations significantly influencing overall safety perceptions. Despite some areas of concern, overall safety perceptions were satisfactory. However, the correlation between individual dimensions and overall ratings of safety was moderate, suggesting the need to enhance the maturity level of PSCs. Promoting a shift in PSC could enhance transparency, prioritize resident safety, empower nursing staff, and increase family satisfaction with care provided in NHs. The support provided by management to PSC appears essential to influence NH staff perceptions of PS.

“Global challenge program” projects themed on preventing zoonosis: developing One Health core competences in medical students at SJTU

Abstract Objectives To develop One Health (OH) core competencies in medical students, Shanghai Jiao Tong University has conducted an OH practice project named the “Global Challenge Program” (GCP) for three years. This study aims to understand the outcomes and challenges of the pilot projects, thereby providing evidences to support the expansion of One Health education program on a larger scale. Methods We conducted a questionnaire survey to a purposive sample of 48 participants who were involved in GCP projects. A questionnaire was designed to assess the effect of GCP projects on improving the core competencies of OH professionals. It consists of 32 questions divided into four categories: basic information, overall assessment, communication skills, and interdisciplinary collaboration. Statistical analysis was conducted and reported based on the data collected from the survey. Results A total of 42 students (87.5 % of 48 participants) completed the follow-up survey. Among them, 64.3 % perceived a significant improvement in their understanding of the OH concept and approach after participating in the GCP projects. Benefiting from the communication opportunities offered by the GCP projects, 24.0 % and 49.0 % of the students reported significant and moderate improvement in their international communication abilities, respectively. In addition, 74 .0% of the students noted that the GCP projects greatly enhanced their capabilities in interdisciplinary cooperation and systematic thinking in addressing complex health issues. Conclusions The GCP project has served as a pilot initiative for participatory OH education, contributing to the development of OH core competencies in medical students, particularly in systems thinking, international communication, and interdisciplinary collaboration. However, generalizing the experience of the pilot project to a large-scale education program for medical students requires careful revisit of the gaps of resources and talents in curriculum building and project operation.

The Impact of Health Status on Health Care Utilization of Children in Foster Care.

This study sought to understand the health status of children in foster care; the relationship between their health status and health care utilization; and demographic and placement factors associated with health care utilization. To estimate relationships between health status and health care utilization, this study used electronic health records from 4976 children in foster care seen at a children's hospital in the southwestern United States, 2017 to 2020. An algorithm classified patients' health status as nonchronic, noncomplex chronic, or complex chronic. Descriptive statistics were used to describe patients and utilization. The χ 2 , Kruskal-Wallis, and pairwise comparison post hoc tests were used to examine relationships between health status and health care utilization. Zero-inflated negative binomial (ZINB) regression further estimated relationships between health status and health care utilization while factoring in demographic and placement characteristics. Within the sample, 35.6% had complex chronic health status. Significant differences were found among health status groups in age, gender, ethnicity, and maltreatment exposure. Both nonparametric pairwise comparisons and the ZINB regression model showed that having complex chronic health was associated with higher utilization of all hospital resources: emergency, admission, primary and specialty care, and various therapies, relative to having noncomplex chronic and nonchronic health. A high percentage of children in foster care had complex chronic health, and these patients used significantly more resources. This study suggests that hospital-based health clinics focused on children in foster care and care coordination may be warranted.

Mapping the global research landscape on depression for patients with chronic kidney disease: a bibliometric and visualized analysis from 2006 to 2022.

Chronic Kidney Disease (CKD), a complex and multifaceted health issue, significantly contributes to global mortality rates. Accompanying chronic conditions, depression notably exacerbates health outcomes, increasing both mortality risk and the burden on affected individuals. This study employs bibliometric and visual analytics to evaluate the evolution, current trends, and future research directions in the field of CKD and depression. We conducted a thorough investigation using the Web of Science Core Collection, focusing on literature published from 2006 to 2022 that examines the interplay between CKD and depression. The analysis was enriched with bibliometric and visualization tools such as bibliometrix, CiteSpace, and VOSviewer to distill the essence of the research corpus. Our analysis incorporated 2,409 CKD-related publications, with significant contributions from the United States, China, and England. BMC Nephrology emerged as the leading publication outlet, while the American Journal of Kidney Diseases featured the most cited articles. Key terms such as "depression," "quality-of-life," "mortality," "prevalence," and "hemodialysis" dominated the keyword landscape, indicating the research focus areas. This bibliometric analysis offers an in-depth view of the research trajectory in CKD and depression. It provides valuable insights for researchers seeking relevant literature, potential collaborators, and an understanding of the field's current hotspots and emerging frontiers. The findings of this study are instrumental in guiding and enriching future research endeavors in this domain.

Egyptian youth and eating disorders: a cross-sectional study on prevalence and contributing factors

BackgroundEating disorders (EDs) are complex mental health conditions with significant implications for the physical and psychological well-being of youth. This study aimed to determine the prevalence of eating disorders among a sample of Egyptian youth and explore the association between anxiety, social support, and sociodemographic characteristics with eating disorder behaviors.ResultsThe findings revealed a significant prevalence of eating disorders among the youth participants, with 13.3% meeting the diagnostic criteria. Bulimia Nervosa was the most commonly diagnosed eating disorder, affecting 8.4% of the participants, followed by 1.4% experiencing Binge Eating Disorder. No cases of Anorexia Nervosa were reported. There were no statistically significant sex differences in the prevalence of different types of eating disorders. Higher body mass index (BMI) values and greater anxiety levels were associated with an increased likelihood of having an eating disorder.ConclusionsThis study highlights a significant prevalence of eating disorders among Egyptian youth, with Bulimia Nervosa being the most common type. These findings emphasize the need for targeted interventions and support systems to address the mental health challenges faced by Egyptian youth and promote healthy relationships with food and body image.

The role of psychological formulation in inpatient settings in supporting staff empathy and therapeutic optimism for adults diagnosed with borderline personality disorder: A pre- and post-vignette study.

OBJECTIVES: National Health Service (NHS) values, such as empathy and therapeutic optimism, are integral when supporting service users with complex mental health presentations. There is some evidence to suggest that psychological formulation can increase empathy and optimism in healthcare professionals. This study, therefore, aimed to investigate whether a psychological formulation of a hypothetical service user with a complex presentation, typically labelled with a diagnosis of borderline personality disorder (BPD), increased empathy and therapeutic optimism in professionals working in mental health inpatient services. Sixty-six mental health professionals working in NHS inpatient services took part in a pre- and post-vignette study. Participants were asked to read a case vignette about a hypothetical service user, with a diagnostic label of BPD, and complete questionnaires capturing levels of empathy and therapeutic optimism. Participants were then randomized into two conditions and either asked to read the same information again (control condition) or read a psychological formulation based on the same hypothetical service user (intervention condition). The findings were analysed using a series of ANCOVAs/ANCOHETs. Two constructs of empathy (i.e. perspective taking and empathic concern), and therapeutic optimism significantly increased following exposure to the psychological formulation when compared to the control group condition. This study warrants further replication. These initial findings; however, indicate that psychological formulation can significantly increase the ability to perspective take, display empathic concern, and hold therapeutic optimism towards service users with a presentation associated with a diagnosis of BPD.

Māori nurse practitioners: The intersection of patient safety and culturally safe care from an Indigenous lens.

Dynamic and complex health systems require innovative and adaptive solutions to support patient safety and achieve equitable health outcomes for Indigenous populations. Understanding the ways by which Indigenous (and specifically Māori) nurse practitioners (NPs) practice patient safety is key to enhancing Indigenous health outcomes in predominantly westernized healthcare systems. To describe Māori NPs perspectives on patient safety when caring for Māori and understand how Māori NPs deliver safe health care. A group of five Māori NPs worked alongside a Māori nurse researcher to explore their perceptions of patient safety. Together, they held an online hui (focus group) in early 2024. Data were analysed collectively, informed by kaupapa Māori principles, using reflexive thematic analysis. Māori NP experiences, expressions and understandings of patient safety envelop cultural safety and have many facets that are specific to the needs of Māori populations. The three themes showed: (1) Te hanga a te mahi: the intersection of cultural and clinical expertise; (2) Mātauranga tuku iho: the knowledge from within, where safe practice was strongly informed by traditional knowledge and cultural practice; (3) Te Ao hurihuri: walking in two worlds, where Māori NPs navigated the westernized health system's policies and practices while acting autonomously to advocate for and deliver culturally safe care. The Māori NP lens on patient safety is vital for promoting culturally responsive and effective health care. By recognizing the unique needs of Māori patients and families and incorporating cultural perspectives into practice, Māori NPs contribute to a more comprehensive and inclusive approach to patient safety that goes beyond westernized principles and practices. No patient or public contribution.

Are they give you wings or cut you down - an analysis of the effects of energy drinks on human health

This work aims to study the effects of energy drink consumption on human health. In recent years, the consumption of energy drinks has increased significantly, which has sparked the interest of scientists and health experts. In Poland and a few other countries, new laws have been applied to regulate the consumption of energy drinks by minors. In this review paper, we analyze the available scientific research on the effects of energy drinks on physical and mental health. In this paper, we focus on the potential benefits and risks of consuming energy drinks, and the common and dangerous combination with alcohol. We discuss the effects of caffeine, taurine, guarana and other ingredients on the body, and their potential side effects. In addition, we consider the effects of these beverages on the cardiovascular system, cognitive ability, and possible health effects associated with excessive consumption. The conclusions of this work can help to understand the complex health effects of energy drinks and draw attention to the need for caution and moderation in their consumption. Ultimately, this work aims to provide up-to-date knowledge on this issue to assist in making informed decisions about energy drink consumption in the context of a healthy lifestyle.

Care Navigation and Coordination Program on Reducing Hospital Use for Adults with Complex Health and Psychosocial Needs in South West Sydney, Australia.

Complex and siloed health and social service systems can be difficult for people to navigate. The fragmented and poorly linked services leads to ineffective communication between care teams, delayed access to services, concerns regarding quality and safety of patient care, as well as patient frustration and disengagement. Planned Care for Better Health (PCBH) is a community-based care navigation and coordination program for people with complex health and psychosocial needs who are at risk of future hospitalisation. It focuses on early identification and holistic care to remove barriers and improve access to healthcare. By including a persons', family and carers in planning, listening to their needs, supporting the person to achieve their goals, and empowering them to make decisions on their own health, PCBH aims to enhance clients' healthcare experience and reduce preventable hospital utilisation. Building trusting and collaborative relationships with clients, families, carers, and health service providers requires commitment. Acknowledging and addressing psychosocial needs is critical for enhancing health outcomes. Equipping patients with self-management skills and knowledge to navigate and engage support services may generate lasting effects, even post-program enrolment. PCBH is associated with a notable reduction in unplanned hospitalisations and total bed days. However, reduction in ED presentations is similar between the intervention and comparison cohorts. Future initiatives should focus on a shared vision of integrated care, robust leadership, and participative co-creation with service-level stakeholders. Sustained program establishment, a multidisciplinary care coordinator team, and an early creation of robust evaluation strategy must be considered.

Current status and the urgent need for a geriatric healthcare system in a super-aged society

Background: The Korean healthcare system is ill-equipped to manage geriatric diseases, even though we are on the verge of becoming a super-aged society.Current Concepts: In Korea’s delivery of healthcare system, which is centered on subspecialty care from primary to tertiary care, older adults with multiple chronic diseases are forced to receive fragmented care from multiple doctors. In medical education and residency programs, even the most fundamental concepts of geriatrics are misunderstood, and geriatricians receive inadequate training. Consequently, along with the rapidly growing elderly population, elderly patients with complex health problems, frailty, and dysfunction are deprived of the opportunity to achieve healthy aging by taking multiple medications and suffering from geriatric syndromes caused by fragmented medical care.Discussion and Conclusion: Establishing a system for training geriatricians and strengthening geriatric education is necessary to ensure existing specialists can assign them the role of primary care geriatricians. Additionally, person-centered, integrated geriatric care that requires appropriate management of various complex diseases, as well as maintenance of function and frailty prevention, will be possible by establishing a geriatric healthcare system that ranges from frailty prevention, polypharmacy management, and home visits in primary healthcare to multidisciplinary geriatric care and transitional care in tertiary healthcare. Implementing this strategy as early as possible will help older adults age well and reduce the caregiving burden in later life. This could also ease concerns regarding physician shortages induced by the rapidly growing elderly population.

Examining the experiences of student peer support workers delivering care within post-secondary institutions

Objective: Despite experiencing exacerbation of mental health issues, post-secondary students may not seek help due to perceived stigma, overreliance on the self, or preference for nonprofessional supports – including peer support. This study aimed to understand peer support workers’ (PSWs) perspectives regarding providing support for mental health concerns in post-secondary institutions. Methods: 41 PSWs were recruited from two post-secondary institutions. 17 semi-structured interviews and three focus groups were conducted. Themes were identified using a qualitative descriptive approach. Results: Three themes emerged: (1) diverse presentations and approaches to operationalizing peer support for mental health issues on campus exist; (2) peer support has core ingredients; (3) reasons why students access peer support extend beyond mental health crisis. Conclusions: An inclusive peer support approach to mental health is needed for post-secondary students. Considerations for implementation hinge on providing standardized, foundational training to prepare PSWs for the complex mental health issues that present across services.

From PERFORM to PERFORM2Scale: lessons from scaling-up a health management strengthening intervention to support Universal Health Coverage in three African countries.

Strengthening management and leadership competencies among district and local health managers has emerged as a common approach for health systems strengthening and to achieve Universal Health Coverage (UHC). While the literature is rich with localized examples of initiatives that aim to strengthen the capacity of district or local health managers, particularly in sub-Saharan Africa, considerably less attention is paid to the science of 'how' to scale-up these initiatives. The aim of this paper is thus to examine the 'process' of scaling-up a management strengthening intervention (MSI) and identify new knowledge and key lessons learned that can be used to inform the scale-up process of other complex health interventions, in support of UHC. Qualitative methods were used to identify lessons learned from scaling-up the MSI in Ghana, Malawi and Uganda. We conducted 14 interviews with district health management team (DHMT) members, three scale-up assessments with 20 scale-up stakeholders, and three reflection discussions with 11 research team members. We also kept records of activities throughout MSI and scale-up implementation. Data were recorded, transcribed and analysed against the Theory of Change to identify both scale-up outcomes and the factors affecting these outcomes. The MSI was ultimately scaled-up across 27 districts. Repeated MSI cycles over time were found to foster greater feelings of autonomy among DHMTs to address longstanding local problems, a more innovative use of existing resources without relying on additional funding and improved teamwork. The use of 'resource teams' and the emergence of MSI 'champions' were instrumental in supporting scale-up efforts. Challenges to the sustainability of the MSI include limited government buy-in and lack of sustained financial investment.