Complex Public Health Interventions Research Articles

Co-developing a theory of change for a personalised multimodal cancer prehabilitation programme in South Wales

BackgroundEvidence suggests that prehabilitation interventions, which optimise physical and mental health prior to treatment, can improve outcomes for surgical cancer patients and save costs to the health system through faster recovery and fewer complications. However, robust, theory-based evaluations of these programmes are needed. Using a theory of change (ToC) approach can guide evaluation plans by describing how and why a programme is expected to work. Theories of Change have not been developed for cancer prehabilitation programmes in the literature to date. This paper aims to provide an overview of the methodological steps we used to retrospectively construct a ToC for Prehab2Rehab (P2R), a cancer prehabilitation programme being implemented by the Cardiff and Vale University Health Board.MethodsWe used an iterative, participatory approach to develop the ToC. Following a literature review and document analysis, we facilitated a workshop with fourteen stakeholders from across the programme using a ‘backwards mapping’ approach. After the workshop, stakeholders had three additional opportunities to refine and validate a final working version of the ToC.ResultsOur process resulted in the effective and timely development of a ToC. The ToC captures how P2R’s interventions or activities are expected to bring about short, medium and long-term outcomes that, collectively, should result in the overarching desired impacts of the programme, which were improved patient flow and reduced costs to the health system. The process of developing a ToC also enabled us to have a better understanding of the programme and build rapport with key stakeholders.ConclusionsThe ToC has guided the design of an evaluation that covers the complexity of P2R and will generate lessons for policy and clinical practice on supporting surgical cancer patients in Wales and beyond. We recommend that evaluators apply a ToC development process at the outset of evaluations to bring together stakeholders and enhance the utilisation of the findings. This paper details a pragmatic, efficient and replicable process that evaluators could adopt to develop a ToC. Theory-informed evaluations may provide better evidence to develop and refine cancer prehabilitation interventions and other complex public health interventions.

From Daunting to Doable: Tools for Qualitative Evaluation of a Complex Public Health Intervention.

To address complex problems like health disparities, public health interventions have become increasingly ''complex''-engaging multisector partners and communities at multiple ecological levels. Complex interventions are intentionally flexible, making them challenging to evaluate with predetermined measures. While innovative evaluation methods tailored to complex interventions have been developed, there is a need for practical guidance to enhance capacity within public health. This article describes the qualitative FIND (Frame, Identify, Narrow, Do) evaluation process for a complex, community-engaged health equity intervention. Illustrative examples and take-away tools are provided. The FIND process is sensitive to complexity, involving ongoing data collection that helps guide implementation. The evaluator is embedded within the project team, facilitating frequent, direct interaction between the evaluator and those whose roles position them to hear or see happenings with the on-the-ground implementation in real time. The FIND process includes (a) developing a flexible framework for determining relevant processes and outcomes, (b) identifying important project events, (c) narrowing in on the most impactful events, and (d) making decisions informed by data. Using the FIND process, the project team learned about significant project events that would have been missed without a complexity-sensitive approach. Having the evaluator embedded within the project team, rather than as an independent entity, was crucial for understanding and utilizing on-the-ground developments in an evolving intervention. There is a need for more practical guidance to build capacity for evaluating complex public health interventions, including strategies for communicating with stakeholders about approaches that diverge from traditional scientific norms.

The Development of an Electronic Medical Record System to Improve Quality of Care for Individuals With Type 1 Diabetes in Rwanda: Qualitative Study.

Electronic medical record (EMR) systems have the potential to improve the quality of care and clinical outcomes for individuals with chronic and complex diseases. However, studies on the development and use of EMR systems for type 1 (T1) diabetes management in sub-Saharan Africa are few. The aim of this study is to analyze the need for improvements in the care processes that can be facilitated by an EMR system and to develop an EMR system for increasing quality of care and clinical outcomes for individuals with T1 diabetes in Rwanda. A qualitative, cocreative, and multidisciplinary approach involving local stakeholders, guided by the framework for complex public health interventions, was applied. Participant observation and the patient's personal experiences were used as case studies to understand the clinical care context. A focus group discussion and workshops were conducted to define the features and content of an EMR. The data were analyzed using thematic analysis. The identified themes related to feature requirements were (1) ease of use, (2) automatic report preparation, (3) clinical decision support tool, (4) data validity, (5) patient follow-up, (6) data protection, and (7) training. The identified themes related to content requirements were (1) treatment regimen, (2) mental health, and (3) socioeconomic and demographic conditions. A theory of change was developed based on the defined feature and content requirements to demonstrate how these requirements could strengthen the quality of care and improve clinical outcomes for people with T1 diabetes. The EMR system, including its functionalities and content, can be developed through an inclusive and cocreative process, which improves the design phase of the EMR. The development process of the EMR system is replicable, but the solution needs to be customized to the local context.

Key factors in complex public health interventions to address vaccine hesitancy using a multidisciplinary approach: the VAX-TRUST project.

The VAX-TRUST project addresses vaccine hesitancy in seven European countries with a systematic and evidence-based approach. Interventions, targeting healthcare professionals, draw from behavioural and social theories. A checklist, inspired by the TIDieR (Template for Intervention Description and Replication), ensures a detailed description of actions, transparency and replicability. The intervention development process begins with collaborative meetings and systematic revisions, concluding with external evaluations for replicability in diverse public health contexts. This study aims to provide valuable insights for future complex interventions in public health, based on lessons learnt to reduce the risk of vaccine-preventable diseases. The analysis of educational interventions within the VAX-TRUST project has led to the definition of precise guidelines to ensure their replicability and adaptation to various contexts, attempting to establish a universally applicable approach. Active participant engagement and consideration of local social dynamics, beyond information transmission, have emerged as key factors to improve intervention effectiveness. Various educational tools and collaboration with academic institutions have contributed to strengthening credibility.

Development Of A Complex Public Health Intervention To Reduce Anxiety Of Children Aged 13-15 Years Attending Government Sinhala Medium Schools In Colombo District, Sri Lanka

Background: Anxiety disorders (AD) are the most prevalent psychological problem among adolescents. Both anxiety disorders and anxiety symptoms can lead to adverse outcomes. The aim of the study was to develop an evidence-based intervention package to reduce anxiety among school children aged 13-15 years.Methods: Design: UK Medical Research Council guidance for development of complex interventions were followed. Identification of evidence based was done by literature-search and expert opinions. Most suitable theory was identified based on level of evidence through consensus of Advisory committee (AC) consisting of experts. Subcomponents of the selected theory were mapped with associated factors of the AD. Eleven KII were conducted with school principals, teachers, parents, and students. Framework of the intervention package with suitable deliverables was designed with consensus of the AC by triangulating the findings. This was further fine-tuned with by using Modified-Delphi technique with participation of broader group of experts. These Delphi items were systematically derived from findings of the systematic reviews, expert opinion, and inputs from intervention recipients. The content development was done based on the proposed framework. Modeling process was done by conducting four consultative meetings with stakeholders with the aim of ensuring content and consensual validity followed by a consensus workshop. Feasibility study and pretesting of deliverables were done. Participants: Advisory committee [n=6] and stakeholder group [n=11] in Delphi component & four consultative meetings and a wider stakeholder group [n=23] in 1-day consensus workshop were involved.Results: Four RCTs and 12 RCTs/cRCTs were identified through literature review. Six types of intervention modalities were identified. CBT based intervention modality was shortlisted by AC considering the level of evidence. Five broad solutions, namely psycho education, realistic thinking, problem solving, graded exposure and relaxation techniques under CBT were mapped against the associated factors with consensus of the AC. Activities were developed under these broad solutions and most suitable options of these activities were selected by a stakeholder group using Modified Delphi technique. The intervention package was finalized by conducting a consensual workshop followed by feasibility study and pretesting of deliverables.Conclusions: A CBT-based universal intervention package was developed to reduce anxiety among children with ToT workshop for teachers with a field training, eight weekly 40 minutes sessions for children and one 40-minute session for parents. Teachers’ guide, Student’s workbook and leaflet for parents were deliverables. A process evaluation framework was used to monitor implementation.

Rapid-cycle evaluation and learning for the effective delivery of integrated interventions in early childhood in rural India.

Effective and real-time data analytics plays an essential role in understanding gaps and improving the quality and coverage of complex public health interventions. Studies of public health information systems identify problems with data quality, such as incomplete records and untimely reporting. Effective data collection and real-time analysis systems for rapid-cycle learning are necessary to monitor public health programs and take timely evidence-based decisions. Early childhood development (ECD) programs are very diverse. Rapid-cycle evaluation and learning (REAL) guides the implementation process of such complex interventions in real time. Stepping stones was one such early childhood development program implemented in Central India. The objective was to improve the delivery of complex, integrated public health interventions for early childhood development in remote areas of rural India. The program was developed according to the principles of inclusion and community-centeredness, which can be tested quickly and iteratively. To enhance the decision-making process and improve delivery and coverage, the core team implemented an information system for rapid-cycle learning. We developed performance indicators and a performance measurement matrix after defining the specific needs. Following that, we trained staff to collect complete data using electronic data collection tools and transfer it the same day to the server for quality review and further analysis. A variety of data/information was triangulated to address the gaps in intervention delivery, and those decisions were subsequently implemented. We observed that the quality of data collection improved, and errors were reduced by 50% in the third quarter. The quality of the narrative was also enhanced; it became more elaborate and reflective. Sharing their field output in meetings and improving the quality of the narrative enhanced the self-reflection skills of field staff and consequently improved the quality of the intervention delivery. Refresher training and mentoring by supervisors helped to improve the data quality over time. Rapid-cycle evaluation and learning (REAL) can be implemented in resource-limited settings to improve the quality and coverage of integrated intervention in early childhood. It nurtures a reinforcing ecosystem that integrates providers, community, and family perspectives and guides interactions among stakeholders by integrating data from all available sources.

Left-Right-Position, party affiliation and regional differences explain low COVID-19 vaccination rates in Germany.

Established vaccine hesitancy measurement instruments, such as the Vaccine Hesitancy Determinants Matrix, are not sufficiently equipped to adequately and consistently measure political and ideological attitudes. Focusing on Germany, which is a particularly interesting case since it witnessed the establishment of the by far most well-organized and sustained 'anti-Covid' movement in Europe, this quantitative study explores the impact of political ideology and partisanship on the degree of vaccine hesitancy based on four surveys (February-October 2021) among more than 30,000 individuals. We demonstrate that party affiliation, political ideology and region of residence all impact vaccine hesitancy. In fact, they turn out to have a greater impact than two factors often analysed with respect to vaccine hesitancy: gender and educational background. Further interaction models show that the effect of political ideology on vaccine hesitancy is moderated by age, gender and region of residency. For instance, while the more rightwing a young individual is, the more hesitant they are towards SARS-CoV-2 vaccination-for older individuals, this is not the case. Our findings are relevant for future investigators measuring vaccine hesitancy and policy makers contemplating the differential impact of complex public health interventions: as the impact of political and ideological attitudes on vaccine hesitancy are not adequately captured by established vaccine hesitancy measurement instruments, we recommend its modification to include a clear and harmonised definition of the political-ideological dimension of vaccine hesitancy together with pre-validated measurement items that improve future studies. In addition, we reason that vaccine hesitancy, while being an outcome of complex socio-political factors, is in itself an indicator for societal cohesion and anomie, the degree of which is associated with trust in (health) policy makers, (public) health authorities, health service providers, etc. Therefore, we further recommend that vaccine hesitancy questions should be integrated in pertinent national surveys.

Incentivising public transport use for physical activity gain: process evaluation of the COVID-19 disrupted trips4health randomised controlled trial

BackgroundPartnering with a public transport (PT) provider, state government, and local government, the single-blinded randomised controlled trial, trips4health, investigated the impact of PT use incentives on transport-related physical activity (PA) in Tasmania, Australia. The intervention involved 16-weeks of incentives (bus trip credits) for achieving weekly PT use targets, supported by weekly text messages. This study objective was to conduct a process evaluation of the COVID-19 disrupted trips4health study.MethodsThe Medical Research Council UK’s framework for complex public health interventions guided the process evaluation. Participant reach, acceptability, fidelity and feasibility were evaluated. Administrative and post-intervention survey data were analysed descriptively. Semi-structured interviews with intervention participants (n = 7) and PT provider staff (n = 4) were analysed thematically.ResultsDue to COVID-19, trips4health was placed on hold (March 2020) then stopped (May 2020) as social restrictions impacted PT use. At study cessation, 116 participants (approximately one third of target sample) had completed baseline measures, 110 were randomised, and 64 (n = 29 in the intervention group; n = 35 in the control group) completed post-intervention measures. Participants were 18 – 80 years (average 44.5 years) with females (69%) and those with tertiary education (55%) over-represented. The intervention was delivered with high fidelity with 96% of bus trip credits and 99% of behavioural text messages sent as intended. Interviewed PT staff said implementation was highly feasible. Intervention participant acceptability was high with 90% reporting bus trip incentives were helpful and 59% reporting the incentives motivated them to use PT more. From a total of 666 possible bus trip targets, 56% were met with 38% of intervention participants agreeing and 41% disagreeing that ‘Meeting the bus trip targets was easy’. Interviews and open-ended survey responses from intervention participants revealed incentives motivated bus use but social (e.g., household member commitments) and systemic (e.g., bus availability) factors made meeting bus trip targets challenging.Conclusionstrips4health demonstrated good acceptability and strong fidelity and feasibility. Future intervention studies incentivising PT use will need to ensure a broader demographic is reached and include more supports to meet PT targets.Trial registrationACTRN12619001136190.

‘A priori’ external contextual factors and relationships with process indicators: a mixed methods study of the pre-implementation phase of ‘Communities in Charge of Alcohol’

BackgroundIt is widely recognised that complex public health interventions roll out in distinct phases, within which external contextual factors influence implementation. Less is known about relationships with external contextual factors identified a priori in the pre-implementation phase. We investigated which external contextual factors, prior to the implementation of a community-centred approach to reducing alcohol harm called ‘Communities in Charge of Alcohol’ (CICA), were related to one of the process indicators: numbers of Alcohol Health Champions (AHCs) trained.MethodsA mixed methods design was used in the pre-implementation phase of CICA. We studied ten geographic communities experiencing both high levels of deprivation and alcohol-related harm in the North West of England. Qualitative secondary data were extracted from pre-implementation meeting notes, recorded two to three months before roll-out. Items were coded into 12 content categories using content analysis. To create a baseline ‘infrastructure score’, the number of external contextual factors documented was counted per area to a maximum score of 12. Descriptive data were collected from training registers detailing training numbers in the first 12 months. The relationship between the baseline infrastructure score, external contextual factors, and the number of AHCs trained was assessed using non-parametric univariable statistics.ResultsThere was a positive correlation between baseline infrastructure score and total numbers of AHCs trained (Rs = 0.77, p = 0.01). Four external contextual factors were associated with significantly higher numbers of lay people recruited and trained: having a health care provider to coordinate the intervention (p = 0.02); a pool of other volunteers to recruit from (p = 0.02); a contract in place with a commissioned service (p = 0.02), and; formal volunteer arrangements (p = 0.03).ConclusionsData suggest that there were four key components that significantly influenced establishing an Alcohol Health Champion programme in areas experiencing both high levels of deprivation and alcohol-related harm. There is added value of capturing external contextual factors a priori and then testing relationships with process indicators to inform the effective roll-out of complex interventions. Future research could explore a wider range of process indicators and outcomes, incorporating methods to rate individual factors to derive a mean score.Trial registrationISRCTN81942890, date of registration 12/09/2017.

The contribution of peer research in evaluating complex public health interventions: examples from two UK community empowerment projects

BackgroundPeer-research is steered and conducted by people with lived experience of the issues being researched. This paper explores the value of peer-research in two complex public health intervention evaluations in the UK.MethodsReports from 18 peer research projects, completed by residents from 12 communities in the UK taking part in two community empowerment interventions, were analysed using cross-case analysis.ResultsUndertaking peer research helped to build the evaluation and research skills within individual projects as well as providing data on other outcomes related to the programmes Theory of Change. Some peer researchers, however, felt unprepared for the activity despite support from the academic team and were unsatisfied with project outcomes. While peer research projects provided more opportunities for local residents to engage with the overall evaluations, there was an overreliance on people closely connected to the programmes to be peer researchers. The peer research projects explored topics that were broader than the aims and objectives of the overall programme evaluations. All provided insight into the context in which projects occurred, while some also informed understanding of programme change mechanisms.ConclusionsIncluding peer research as part of complex public health intervention evaluations can help uncover important contextual and ecological details beyond the reach of more traditional evaluation data collection. Peer research can also empower and build research/evaluation capacity within communities, which is particularly pertinent for community empowerment interventions.

Challenges and lessons learned from Scotland and England using linked administrative data to evaluate the Family Nurse Partnership: two administrative data cohort studies

BackgroundThe Family Nurse Partnership (FNP) is an early intervention aiming to support adolescent mothers and their children. The FNP has been evaluated in England and Scotland in two separate studies using linked administrative data from health, education, and social care. We aimed to make recommendations for studies using linked administrative data to evaluate public health interventions. MethodsWe constructed two cohorts of all mothers aged 13–19 years giving birth in NHS hospitals between 2010 and 2016–17 using data from Hospital Episode Statistics (England) and Maternity Inpatient and Day Case (Scotland). FNP participation was identified through linkage to FNP programme data. We also linked to health, educational, and social care data for mothers and their babies (data from the National Pupil Database and electronic Data Research and Innovation Service). Ethical approval was obtained but no consent was required because we used secondary data. We used these data to evaluate the effect of the FNP on maternal and child outcomes. FindingsKey challenges included characterising the intervention and usual care, understanding quality of multi-sector data linkage, data access delays, constructing appropriate comparator groups, and interpreting outcomes captured in administrative data. Lessons learned included that evaluations required detailed data on intervention activity (dates and geography) and assessment of usual care, which are rarely readily available and are time-consuming to gather; data linkage quality information was variable or not available, making defining denominators challenging; data access delays impeded on data analysis time; and unmeasured confounders not captured in administrative data possibly prevented the generation of an appropriate comparator group. We recommend that characteristics informing targeting should be explicitly documented, and could be enhanced by using linked primary care data and information on household members (eg, fathers). Process evaluation and qualitative research could help to provide a better understanding of mechanisms of effect. InterpretationLinkage of administrative data presents opportunities for efficient evaluation of large-scale, complex public health interventions. However, sufficient information is needed on programme metadata, targeting, and important confounders to generate meaningful results. Our findings should help to stimulate exploration by practitioners about how such programmes can be improved. FundingNational Institute for Health and Care Research.

A protocol for monitoring fidelity of a preconception-life course intervention in a middle-income setting: the Healthy Life Trajectories Initiative (HeLTI), South Africa

IntroductionDespite the importance of intervention fidelity in interpreting the outcomes of complex public health interventions, there is a lack of both reporting fidelity trial protocols and uniformity. In evaluating complex, adaptable/pragmatic interventions in resource-strapped settings with systemic issues, unique challenges to intervention adherence and monitoring are introduced, increasing the importance of a fidelity protocol. We aim to describe the intervention fidelity and monitoring protocol for the Healthy Life Trajectories Initiative (HeLTI) South Africa, a complex four-phase intervention set in urban Soweto, starting preconceptionally and continuing through to pregnancy, infancy, and early childhood to improve the health of young women and reduce the intergenerational risk of obesity.MethodsThe HeLTI SA fidelity protocol was based on the NIH Behaviour Change Consortium (NIH BCC) Treatment Fidelity Framework, outlining the following components of intervention fidelity: study design, provider training, intervention delivery, intervention receipt, and intervention enactment. Context-specific fidelity challenges were identified. The intervention fidelity components and associated monitoring strategies were developed to align with HeLTI SA. Strategies for fidelity monitoring include, amongst others, qualitative process evaluation methods, reviewing observed and recorded intervention sessions, monitoring of activity logs, standardized training, and intervention session checklists. Possible challenges to fidelity and fidelity monitoring include high provider turnover, lack of qualification amongst providers, difficulty tracing participants for follow-up sessions, participant health literacy levels, and the need to prioritize participants’ non-health-related challenges. Solutions proposed include adapting intervention delivery methods, recruitment methods, and provider training methods.DiscussionThe NIH BCC Treatment Fidelity Framework provided a solid foundation for reporting intervention fidelity across settings to improve intervention validity, ability to assess intervention effectiveness, and transparency. However, context-specific challenges to fidelity (monitoring) were identified, and transparency around such challenges and possible solutions in low- and middle-income settings could help foster solutions to improve adherence, reporting, and monitoring of intervention fidelity in this setting.Trial registrationPan African Clinical Trials Registry PACTR201903750173871. Registered on 27 March 2019

Exploration of barriers and facilitators to the implementation of the DREPADO randomized controlled trial: A qualitative study

PurposeDREPADO is a randomized controlled trial (RCT) assessing the impact of a pediatric-adult transition program, on the health status of adolescents with sickle cell disease. Using a biopsychosocial approach with three main facets (educational, psychological and social interactions), it constitutes a complex transition program, which is quite difficult to implement. To facilitate the implementation of this complex program, the aim of this ancillary study is to explore barriers and facilitators at the early stages of this implementation. MethodsA qualitative study with semi-structured interviews was conducted, according to COREQ quality criteria, in patients with sickle cell disease who had already experienced the transition to adult care before DREPADO, and healthcare professionals working on the DREPADO RCT. ResultsSemi-structured interviews were conducted with patients (n = 12) and healthcare professionals (n = 12) from November 2019 to May 2020. The main barriers identified by patients were time and implication required by this transition program. Healthcare professionals involved in the coordinating center mentioned changes in their working habits and also elements about the RCT regulatory procedures. Main facilitators reported by both patients and healthcare professionals were the positive perception of the transition program design, and especially the home setting for therapeutic education sessions. ConclusionThis study led to the identification of main barriers and facilitators to the implementation of both the DREPADO intervention and RCT. These propositions could also be used to promote other complex public health interventions or/and other randomized controlled trials.

Challenges and lessons learned from two countries using linked administrative data to evaluate the Family Nurse Partnership.

ObjectivesWe describe the challenges and lessons learned from two studies using linked administrative data from health, education and social care sectors to evaluate the Family Nurse Partnership (FNP), an intervention supporting adolescent mothers in England(E) and Scotland(S). We present recommendations for studies using linked administrative data to evaluate complex interventions. ApproachWe constructed two cohorts of all mothers aged 13-19 giving birth in NHS hospitals in England and Scotland between 2010-2016/17 using linkage of mothers and babies in hospital admissions data (E:Hospital Episode Statistics/S:Maternity Inpatient and Day Case), and identified FNP participation through linkage to FNP programme data. We additionally linked to health, educational and social care data for mothers and their babies (E:National Pupil Database/S:eDRIS). We used these data to identify key risk factors for enrolment in the FNP, assess the effect of the FNP on maternal and child outcomes, and determine programme characteristics modifying the effect of the FNP. ResultsKey challenges: characterising the intervention and usual care, understanding quality of multi-sector data linkage, data access delays, constructing appropriate comparator groups and interpreting outcomes captured in administrative data. Lessons learned: evaluations require detailed data on intervention activity (dates/geography), and assessment of usual care, which are rarely readily available and are time-consuming to gather; data linkage quality is variable/not available, making defining denominators challenging; data access delays impeded on data analysis time; unmeasured confounders not captured in administrative data may prevent generation of an appropriate comparator group. Recommendations: Characteristics informing targeting should be explicitly documented, and could be enhanced using linked primary care data and information on household members (e.g. fathers). Process evaluation and qualitative research could help to provide better understanding of mechanisms of effect. ConclusionLinkage of administrative data presents exciting opportunities for efficient evaluation of large-scale, complex public health interventions. However, sufficient information is needed on programme meta-data, targeting and important confounders in order to generate meaningful results. Study findings should help stimulate exploration with practitioners about how programmes can be improved.

The epidemiology of smoking and e-cigarette use in the Hungarian adult population in 2018

The body of evidence suggests that smoking increases the risk of the most prevalent chronic diseases. Although the proportion of traditional smokers in Hungary has been on a declining trend since 2009, the proportion of those who tried e-cigarette has been steadily increasing in recent years. To present - in the light of previous studies - the results of the Public Health Survey among adults in 2018 on smoking and e-cigarette use. 1586 persons were personally interviewed in a survey. The iterative weighting algorithm considered both the design effect of multistaged sampling and the 2016 Hungarian microcensus. In 2018, the proportion of smokers in the Hungarian adult population was 28.7% (95% CI 26.3-31.1%), and the proportion of e-cigarette users was 1.7% (95% CI 1.1-2.5%). Educational level was a predictor of smoking among respondents younger than 65 years old (OR 3.32; 95% CI 2.53-4.34), but not for those aged 65 years or older (OR 1.11; 95% CI 0.59-2.09). Among e-cigarette ever or current users, the most commonly mentioned (54.3% 95% CI 44.0-64.5%) motivational factor-group to try or use e-cigarettes included motivations to quit smoking, to reduce harm, and to avoid relapsing. In the population aged 65 years old or older, the proportion of smokers increased compared to 2015. The proportion of smokers was the highest among those with primary education in 2018, while in 2014, it was the highest among those with secondary education without a graduation certificate. In Hungary, although overall smoking rates are declining, the smoking rate in the low educational group and among the elderly increased. The number of people trying or using e-cigarettes is showing an increasing trend in our country. Our results call for a complex public health intervention program including prevention and smoking cessation supporting subprograms with high focus on those with primary education. Orv Hetil. 2022; 163(1): 31-38.

One Health approach for elimination of human anthrax in a tribal district of Odisha: Study protocol.

BackgroundAnthrax is a major but neglected zoonotic disease of public health concern in India with Odisha contributing a major share to the disease burden. Bacillus anthracis spores can be found naturally in soil and commonly affect both animals and humans around the world. Domestic and wild animals such as cattle, sheep, goats, and deer can become infected when they inhale or ingest spores from contaminated soil, plants, or water. Anthrax can be fatal if patients are not treated promptly with antibiotics. This protocol aims to describe the implementation and evaluation of the ‘One Health’ intervention model based on the principles of Theory of Change (ToC) to eliminate human anthrax from a tribal district in Odisha, India.MethodsThis study would test the effectiveness of a complex public health intervention package developed using the ToC framework for the elimination of human anthrax in Koraput district by a comparative analysis of baseline and end-line data. We plan to enroll 2640 adults across 14 geographically divided blocks in Koraput district of Odisha for baseline and end-line surveys. After baseline, we would provide capacity building training to stakeholders from the department of health, veterinary, forest, academic and allied health institutions followed by workshops on sensitization and awareness through IEC (Information Education Communication)/BCC (Behavior Change Communication) activities in the community. We would establish a state-level laboratory facility as a robust system for timely diagnosis and management of human anthrax cases. Surveillance network will be strengthened to track the cases in early stage and risk zoning will be done for focused surveillance in endemic areas. Advocacy with district level administration will be done for maximizing the coverage of livestock vaccination in the entire district. Interdepartmental coordination would be established for the effective implementation of the intervention package.ConclusionThis would be a first study applying One Health concept for the elimination of human anthrax in India. The findings from this study will offer important insights for policy-making and further replication in other endemic regions of the state and country.Trial registrationThe authors confirm that all ongoing and related trials for this intervention are prospectively registered with the Clinical Trials Registry of India [CTRI/2020/05/025325] on 22 May 2020.

Evidencing the contribution of social enterprise to health and social care: approaches and considerations

PurposeAs the provision of public services in many advanced welfare states has increasingly come to be marked by competition, social enterprises have actively been encouraged by governments to become involved in the delivery of public services. While the evaluation of complex public health interventions has arguably become increasingly more sophisticated, this has not been the case where social enterprise is concerned: evaluation of the actual impacts of social enterprises remains significantly underdeveloped by comparison. This study aims to support the establishment of a robust evidence base for the use of social enterprise as a policy instrument.Design/methodology/approachThis paper assesses the potential of three methodological approaches common in the evaluation of complex public health interventions and applies them to the complex realm of community-led social enterprise.FindingsOnly through the involvement of different comparator groups, based on the research questions addressed, would it be possible to disentangle the embedded characteristics of organisations such as social enterprises. Each of the methods adopted in this research is time-consuming and resource-intensive and requires the researcher to possess advanced skills. Public officials should recognise the complexity and resource-intensive nature of such evaluation and resource it accordingly. If the aim of policymakers is to understand the added value of social enterprise organisations, an integrative research approach combining different research methods and design should be implemented to improve generalisability.Originality/valueThis study applies a range of favoured approaches to evaluate “complex” public health interventions include systematic reviews, realist evaluation and quasi-experimental investigation. However, such evaluation approaches have rarely been applied before in the context of social enterprise.

Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control.

Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site–specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems’ capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.

Unpack the Salt: an evaluation of the Victorian Salt Reduction Partnership\u2019s media advocacy activities to highlight the salt content of different foods

BackgroundAustralians are consuming almost double the recommended maximum salt intake. The Victorian Salt Reduction Partnership was established to coordinate efforts to reduce salt intake in the state of Victoria. As part of an intervention strategy, media advocacy strategies were used to raise public awareness and stimulate industry and government action on salt reduction. This study aimed to evaluate the Victorian Salt Reduction Partnership’s media advocacy activities by determining the extent to which activities contributed to the overall strategy aims and the effectiveness of the activities in gaining media and industry engagement.MethodsA framework for evaluating media advocacy strategies used in complex public health interventions was used to guide this evaluation. Media advocacy activities were monitored and documented throughout the intervention period. A content analysis of media release press statements was performed. Indicators of media coverage (media items, cumulative audience reach, advertising space rate) and food industry engagement (number of meetings, number and type of follow up actions) were tracked.ResultsSix media releases were issued between March 2017 and November 2018 on different processed food categories including breads, cooking sauces, ready meals, dips and crackers, processed meats and Asian-style sauces. Three main themes were identified in the qualitative analysis of the press statements: general information on salt and health, salt levels in foods, and calls to action for consumers, industry and/or government. These themes were aligned with the overall intervention strategy. Media items (print and online news, radio and TV) generated by each release ranged from 36 to 274, and cumulative audience reach (opportunities to see) ranged from 2.3 to 7.5 million Australians per release. One to three food manufacturers were met with per media release.ConclusionsDisseminating sodium-monitoring data through media releases can be used as a tool to gain access to the media and reach consumers with salt reduction messages, and to engage food manufacturers in discussions about salt reduction. Characteristics of media advocacy activities, including alignment with the overall strategy, and external factors outside the of control of the program implementers, can influence media and industry engagement. When planning future nutrition interventions that include media advocacy activities, internal and external factors impacting outcomes, should be considered, documented and evaluated.

An example of involving lay people to enhance complex public health intervention evaluations

Abstract Background Despite growing interest in understanding complex systems and public health interventions, research methodologies that take account of system-wide action are relatively underdeveloped. Community-based participatory research (CBPR) is steered and conducted by people with lived experience of the issues being researched. This paper explores the value of CBPR in complex public health intervention evaluations. The 'Local People' and 'Local Conversations' programmes use a community empowerment approach in 50 communities across the UK experiencing social disadvantage to increase social connections and collective control, improve health and wellbeing, and reduce inequalities (linked to SDG 3 and 11). Methods Evaluation of the programmes followed a mixed-methods design, including qualitative case studies, longitudinal survey, process appraisal, and CBPR. Residents from 10 communities across the programmes each undertook 2 rounds of CBPR. These projects resulted in written reports, which were analysed thematically alongside other data sources. Results There was some variation in the scope and design of the 20 completed CBPR projects. Whilst projects did not generally extend beyond the scope of the overall evaluation, peer research provided information from residents that were inaccessible to other data collection streams. Gathering community (lay) knowledge improved understanding of local priorities and actions within the programmes. However, the utility of CBPR was less consistent for community-researchers and local communities, often failing to support project development. Some community-researchers felt unprepared for the activity despite support from the academic team. Conclusions Conducted appropriately, CBPR can elicit data that would be less accessible through externally led research. This study highlights the value of CBPR in complex programme evaluations, enabling a deeper understanding of social context in which interventions occur. Key messages CBPR complements more traditional research methodologies in complex public health evaluation designs. CBPR can enable a deeper understanding of social processes necessary for the success of complex public health interventions that might be beyond the scope of other methodologies.