Context-sensitive Interventions Research Articles

Determinants of diarrhoeal diseases among under-five children in Africa (2013–2023): a comprehensive systematic review highlighting geographic variances, socioeconomic influences, and environmental factors

BackgroundDiarrhea diseases continue to present a significant threat to the well-being of children under the age of five in Africa, thereby contributing substantially to both morbidity and mortality rates. The period spanning between January 2013 and December 2023 has witnessed persistent challenges in the fight against these diseases, thereby necessitating a thorough investigation into the factors that determine their occurrence. It is important to note that the burden of diarrhea diseases is not evenly distributed across the continent, with residence, socioeconomic, and environmental factors playing pivotal roles in shaping the prevalence and incidence rates. Consequently, this systematic review aimed to consolidate and analyze the existing body of literature on the determinants of diarrhea diseases among children under the age of five in Africa between January 2013 and December 2023.MethodThe systematic review employed a rigorous methodological approach to examine the determinants of diarrhea diseases among children under the age of five in Africa between January 2013 and December 2023. A comprehensive search strategy was implemented, utilizing databases such as PubMed, Scopus, and Web of Science, and incorporating relevant keywords. The inclusion criteria focused on studies published within the specified timeframe, with a specific focus on the determinants of diarrhea disease among children under the age of five in Africa. The study selection process involved a two-stage screening, with independent reviewers evaluating titles, abstracts, and full texts to determine eligibility. The quality assessment, employing a standardized tool, ensured the inclusion of studies with robust methodologies. Data extraction encompassed key study details, including demographics, residence factors, socioeconomic influences, environmental variables, and intervention outcomes.ResultsThe search yielded a total of 12,580 articles across 25 African countries; however, only 97 of these articles met the inclusion criteria and were ultimately included in the systematic review. The systematic review revealed geographic and seasonal disparities in the prevalence of diarrhoeal diseases across different countries in Africa. Factors such as age-related vulnerabilities, gender disparities, maternal occupation, disposal of young children’s stools, and economic status were identified as significant determinants of the prevalence of diarrhea disease.ConclusionThis systematic review provides a comprehensive understanding of the determinants of diarrhea diseases among children under the age of five in Africa between January 2013 and December 2023. The nuanced analysis of residence variations, socioeconomic influences, environmental factors, and intervention outcomes underscores the complex nature of this issue. The findings highlight the necessity for region-specific and context-sensitive interventions to address the unique challenges faced by diverse communities. This review serves as a valuable resource for policymakers, healthcare professionals, and researchers, guiding the development of evidence-based strategies aimed at reducing the burden of diarrhea diseases and improving child health outcomes in Africa.

Financial Hardship: A Qualitative Study Exploring Perspectives of Seriously Ill Patients and Their Family

ContextSeriously ill patients, such as those who experience critical illness, and their families experience a variety of poor outcomes, including financial hardship. However, little is known about the ways in which these seriously ill patients and their families experience financial hardship. ObjectiveTo examine seriously ill patients’ and families’ experiences of financial hardship and perspectives on addressing these concerns during and after critical illness. MethodsWe conducted a thematic analysis of semi-structured interviews with seriously ill patients who recently experienced a critical care hospitalization (n=15) and family caregivers of these patients (n=18). ResultsOur analysis revealed three themes: 1) Prioritizing Survival and Recovery; 2) Living with Uncertainty—including experiences of prolonged uncertainty, navigating bureaucratic barriers, and long-term worries; and 3) Preferences for Financial Guidance. Our results suggest patients and families prioritize survival over financial hardship initially, and feelings of uncertainty about finances persist. However, patients and family caregivers are reluctant to have their physicians address financial hardship. ConclusionsOur findings suggest that the acute and time sensitive nature of treatment decisions in critical care settings provides a unique context for experiences of financial hardship. Additional research is needed to better understand these experiences and design context-sensitive interventions to mitigate financial hardship and associated poor patient- and family-centered outcomes.

Managing concussion in the real world: Stakeholder perspectives of New Zealand Rugby's concussion management pathway

The potential adverse consequences associated with poor concussion management highlights the need to improve the translation of concussion guidelines into consistent use in real-world sport settings. To facilitate this process, New Zealand Rugby developed a community concussion management pathway to support concussion recognition, diagnosis, and management. This study adopted a pragmatic, descriptive qualitative approach to explore key stakeholders’ perceptions of the concussion management pathway, with the aim to inform policy and practice. Interviews were conducted with 123 participants, including players, parents, coaches, healthcare professionals, and school and provincial union representatives. The framework method was used to analyze data. Themes were organized according to the principles of realist process evaluation that considers contextual factors and mechanisms influencing a program's operation to produce specific outcomes. Contextual factors influencing the concussion management pathway's implementation included governing bodies’ support, existing local resources, general concussion attitudes, or concussion severity. The optimal functioning of the concussion management pathway ( mechanism) was influenced by (i) pathway resources, (ii) roles and relationships, (iii) buy-in and support towards the concussion management pathway, and (iv) diligence and communication. Outcomes identified included (i) hitting the target (optimally managed and enhanced awareness) or (ii) missing the mark (dissatisfaction or management gaps). Overall, participants found the concussion management pathway valuable. However, the acceptability of certain policy-related aspects and the underlying attitudes associated with these perceptions, are some areas requiring further investigation and support. Tailoring programs according to end-users’ perceptions is crucial in developing context-sensitive interventions appropriate for a specific setting. These findings may act as a foundation for investigations of concussion management in other settings.

Building Bridges, Forging New Frontiers: Meaning-Making in Action

The need to experience life as meaningful is fundamental to human nature. Recent years have witnessed a growing sophistication in assessing meaning in life (MIL) and new conceptualizations regarding its place within general models of well-being and coping. As part of this surge in research, increased attention has been given to the understanding, assessment, and practice of MIL in numerous arenas and contexts. However, despite these advancements, further knowledge is needed to explore the application of meaning interventions across more diverse contexts and non-clinical populations in the general community. The purpose of the present paper is to expand the existing knowledge on meaning-oriented interventions by introducing a community-based initiative that is directly responsive to this need. This includes describing its approach to meaning-making on multiple fronts: (1) Socratic Questions in the Public Sphere; (2) the Tribe Intergenerational Life Stories Project; (3) Literature, Arts, and Museums as Meaning-Making Sites; and (4) Education for Meaning. Each of these initiatives is described to propose more context-sensitive interventions that are applicable to everyday life in general society.

Gender Is the Name of the Frame: Understanding Gender through the Lens of Relational Frame Theory

While researchers continue to develop their understanding of gender as a complex and multifaceted concept, the detrimental impact of gender-related inequity and social injustice persists. This conceptual paper describes the potential benefits of incorporating Relational Frame Theory (RFT) as a contextual and pragmatic approach to gender. An RFT lens might enhance our understanding of gender as a language-based phenomenon, involving patterns of derived relational responding and rule-governed behavior. Such an understanding might then facilitate the development of assessments and context-sensitive interventions that support flexible and expansive experiences of gender that promote thriving. Despite the potential utility of an RFT approach, RFT has rarely been applied to gender-related concerns. This paper aims to provide a starting point for exploring gender from an RFT perspective, highlight relevant RFT studies, acknowledge limitations of current lines of research, and provide recommendations regarding future research. We hope that the paper will also act as a call to action for contextual behavioral scientists, as well as demonstrate how an RFT perspective might both align with, as well as add to, existing perspectives from other disciplines.

Burden of mental health problems among pregnant and postpartum women in sub-Saharan Africa: systematic review and meta-analysis protocol

IntroductionPregnancy and postpartum-related mental health problems pose serious public health threat to the society, but worryingly, neglected in sub-Saharan Africa (SSA). This review will assess the burden and distribution of...

Factors Influencing Fixed-Route Transit Decision-Making: Exploring Differences by Disability and Community Type

Transit agencies utilize the following complementary initiatives to encourage greater fixed-route transit usage by people with disabilities: (1) implementing more rigorous paratransit eligibility determination practices, and (2) addressing the factors that deter people with disabilities from using fixed-route transit. This research focuses on the latter and uses previously conducted survey data to determine the most important factors individuals with disabilities consider when deciding to use various transportation options, and how these factors vary by disability and community type. Findings indicate that individuals with mobility impairments consistently rated the built environment factors as more important to their transit mode decision-making than scheduling-related factors. Findings also highlight the importance of addressing complex trips when assisting riders with intellectual and cognitive disabilities. The current study also reveals that people with disabilities experience barriers differently based on where they live, suggesting the need for context sensitive interventions to support fixed-route ridership. Transit agencies should utilize this information to employ more targeted interventions to encourage greater fixed-route transit usage for individuals with disabilities.

A granular analysis of service delivery for surgical system strengthening: Application of the Lancet indicators for policy development in Colombia

The Lancet Commission on Global Surgery (LCoGS) surgical indicators have given the surgical community metrics for objectively characterizing the disparity in access to surgical healthcare. However, aggregate national statistics lack sufficient specificity to inform strengthening plans at the community level. We performed a second-stage analysis of Colombian surgical system service delivery to inform the development of resource- and context-sensitive interventions to inform a revision of the Decennial Public Health Plan for access inequity resolution. Data from the year 2016 to inform total operative volume (TOV) and 30-day non-risk adjusted peri-operative mortality (POMR) were collected from the Colombian national health information system. TOV and POMR were sub-characterized by demographics, urgency, service line, disease pathology and facility location. In 2016, aggregate national mortality was 0·87%, while mortality attributable to elective and emergency surgery was 0·73% and 1·30%, respectively. The elderly experienced a 5·6-fold higher mortality, with 4·2% undergoing an operation within 30 days of dying. Individuals undergoing hepatobiliary, thoracic, cardiac, and neurosurgical operations experienced the highest mortality rates while obstetrics, general surgery, orthopaedics, and urology performed the largest procedure volume. Finally, analysis of operation and service line specific POMR reveals opportunities for improvement. This granular second-stage analysis provides actionable data which is fundamental to the development of resource and context-sensitive interventions to address gaps and inequities in surgical system service delivery. Furthermore, this analysis validates the modeling underlying development of the LCoGS indicators. These data will inform the assessment of implementation priorities and revision of the Colombian Decennial Public Health Plan. None.

Predictors of low antiretroviral adherence at an urban South African clinic: A mixed-methods study.

BackgroundLow adherence to antiretroviral treatment (ART) in people living with HIV (PLHIV) remains a critical issue, especially in vulnerable populations. Although ART is responsible for greatly reducing the mortality and morbidity associated with HIV, low treatment adherence continues to impact the effectiveness of ART. Considering that a high level of adherence to ART is required for the excellent clinical outcomes with which ART is often associated, understanding the complex contextual and personal factors that limit high levels of treatment adherence remains paramount. Poor adherence remains an issue in many South African communities many years after the introduction of ART.ObjectivesOur study sought to understand the specific factors and the interactions among them that contribute to non-adherence in this patient population in order to devise successful and contextually appropriate interventions to support ART adherence in PLHIV.MethodsThis mixed-methods study employed a study-specific questionnaire (N = 103) and semi-structured interviews (N = 8) to investigate the factors linked to non-adherence at the Heideveld Community Day Centre in Cape Town, South Africa.ResultsOver half (57.3%) of participants were ART non-adherent. Non-adherence was correlated with younger age, negative self-image and a low belief in the necessity of ART (P < 0.05). In patient interviews, alcohol use, treatment fatigue and stigmatisation emerged as contributors to suboptimal adherence.ConclusionThe results suggest that there remains a need for context-sensitive interventions to support PLHIV in South African communities. Future research needs to ensure that these targeted interventions take these factors into consideration.

On the importance of context-sensitive interventions for college student mental health: Commentary on “Prevention and treatment of mental health and psychosocial problems in college students: An umbrella review”.

On the importance of context-sensitive interventions for college student mental health: Commentary on “Prevention and treatment of mental health and psychosocial problems in college students: An umbrella review”.

Coaching Context, Coachee Regulatory Focus and Pre-Coaching Motivation: An Experimental Study

This study responds to the call for a closer look at the role that contextual and individual factors play in workplace coaching as a context-sensitive intervention. Drawing on and integrating theories of regulatory focus and training we proposed and examined a model that explains the impact of organizational coaching context on coachee pre-coaching motivation using coachee situational regulatory focus as an underlying mechanism. Results of a scenario-based experimental study (N=175) demonstrated that organizational coaching context affects coachees’ situational regulatory foci beyond chronic dispositions. Further, the indirect relationship between developmental organizational coaching context and pre-coaching motivation was mediated by coachee situational promotion focus. However, we did not find the hypothesized indirect relationship between remedial organizational coaching context and coachee pre-coaching motivation via coachee situational prevention focus. The study highlights the important role that organizations’ management and human resource personnel play in the ‘kick-off’ of a workplace coaching intervention by shaping the context of coaching assignments prior to coaching. Furthermore, this study emphasizes the importance of including the organization’s informal feedback for the employee prior to coaching as a key contractual element that contributes to coachees’ pre-coaching motivation. We conclude with implications for future workplace coaching research and practice.

Promises and perils of mobile health in Burkina Faso

Mobile health (mHealth) has attracted much attention in the global health community as a technological fix that can short-circuit inadequate health-system infrastructure and build access. But like many other technology-based approaches to remedy structural health inequities, mHealth interventions can be overhyped. We discusses here [email protected], an mHealth network launched in 2013 by the Centre de Recherche en Santé de Nouna (CRSN), Burkina Faso, with funding from the International Development Research Centre, Canada. Revitalising global social medicineWhat is global social medicine? This group of art of medicine essays argues for a revitalisation of the field of social medicine as a way to reaffirm a health agenda that promotes human rights and social justice. This approach requires understanding the histories of social medicine in diverse locations, the decolonisation and democratisation of knowledge flows in global health, and a more explicit acknowledgment of the historical and structural conditions that shape the burden of disease and the opportunities for health care and caregiving. Full-Text PDF Mutual aid, pandemic politics, and global social medicine in BrazilIn the face of persistent neglect and denial of the severity of COVID-19 by the administration of President Jair Bolsonaro, residents in many of Brazil's favelas have been left to organise their own responses to the pandemic. Community leaders have raised funds and volunteers are going door-to-door to distribute food, masks, and hygiene kits, using megaphones to educate residents about mask use, physical distancing, and handwashing. Local journalists are also using social media to counter fake news, and activists are converting schools into isolation wards, facilitating cash transfers, and fighting for the accurate documentation of COVID-19 deaths. Full-Text PDF Climate disasters and global social medicineHenry suffered a stroke in 2008, 3 years after Hurricane Katrina destroyed his home in New Orleans's Lower 9th Ward, a historic Black community. His diabetes had worsened in the aftermath of Katrina as he struggled to find pharmacies with insulin and other necessary supplies. His wife, Gladys, blamed the stroke on the receipt of a second denial-of-funds letter from the Road Home Program; without that assistance, they could not rebuild their home. The stroke left him paralysed. Gladys did her best to care for him, but she saw Katrina as the disaster that never ended. Full-Text PDF The social in psychiatries: depression in Myanmar, China, and JapanIn the wake of new ways of calculating disease burdens through disability-adjusted life-years, depression emerged as the world's second most common disorder after cardiovascular disease, affecting more than 264 million people worldwide. In Asia, depression as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases (ICD) has also become far more recognised and diagnosed over the past two decades. On the surface, this change seems to underline the universality of the neurobiological model of depression. Full-Text PDF Infant mental health in southern Africa: nurturing a fieldThe promotion of early cognitive and emotional development is a core aim of the field of infant mental health (IMH). Yet models of early development and IMH have often been developed for high-income settings, and sometimes carry under-examined assumptions about care and wellbeing. Although this discipline is well established in Euro–American contexts, questions have been raised about how to tailor it to contexts that may differ considerably from those in which these models were developed. The ways that care, attachment, and relationship are given form in everyday practices are not universally the same, raising the challenge of shaping therapeutic models and interventions so as to ask appropriate questions, design context-sensitive interventions, and meet caregivers and infants in ways that are meaningful to them while still retaining general applicability. Full-Text PDF Beyond COVID-19: scaling up and sustaining mobile health in Africa – Authors' replyWe thank Yap Boum for taking the time to respond to our Perspective.1 Full-Text PDF Beyond COVID-19: scaling up and sustaining mobile health in AfricaIn their Perspective,1 N Hélène Sawadogo and colleagues highlight the challenges of mobile health care in Africa with the [email protected] project, which provided medical support to pregnant women but ran out of funding 3 years into operation. Securing longer-term funding to sustain mobile health is a challenge in Africa.2 Social innovations such as BIMA (Ghana), AccesAfya (Kenya), Idocta (Cameroon), and Healthforce (South Africa) use telemedicine to improve access to quality health care but have not managed to scale up. Full-Text PDF

Mutual aid, pandemic politics, and global social medicine in Brazil

In the face of persistent neglect and denial of the severity of COVID-19 by the administration of President Jair Bolsonaro, residents in many of Brazil's favelas have been left to organise their own responses to the pandemic. Community leaders have raised funds and volunteers are going door-to-door to distribute food, masks, and hygiene kits, using megaphones to educate residents about mask use, physical distancing, and handwashing. Local journalists are also using social media to counter fake news, and activists are converting schools into isolation wards, facilitating cash transfers, and fighting for the accurate documentation of COVID-19 deaths. Revitalising global social medicineWhat is global social medicine? This group of art of medicine essays argues for a revitalisation of the field of social medicine as a way to reaffirm a health agenda that promotes human rights and social justice. This approach requires understanding the histories of social medicine in diverse locations, the decolonisation and democratisation of knowledge flows in global health, and a more explicit acknowledgment of the historical and structural conditions that shape the burden of disease and the opportunities for health care and caregiving. Full-Text PDF Climate disasters and global social medicineHenry suffered a stroke in 2008, 3 years after Hurricane Katrina destroyed his home in New Orleans's Lower 9th Ward, a historic Black community. His diabetes had worsened in the aftermath of Katrina as he struggled to find pharmacies with insulin and other necessary supplies. His wife, Gladys, blamed the stroke on the receipt of a second denial-of-funds letter from the Road Home Program; without that assistance, they could not rebuild their home. The stroke left him paralysed. Gladys did her best to care for him, but she saw Katrina as the disaster that never ended. Full-Text PDF Promises and perils of mobile health in Burkina FasoMobile health (mHealth) has attracted much attention in the global health community as a technological fix that can short-circuit inadequate health-system infrastructure and build access. But like many other technology-based approaches to remedy structural health inequities, mHealth interventions can be overhyped. We discusses here [email protected], an mHealth network launched in 2013 by the Centre de Recherche en Santé de Nouna (CRSN), Burkina Faso, with funding from the International Development Research Centre, Canada. Full-Text PDF The social in psychiatries: depression in Myanmar, China, and JapanIn the wake of new ways of calculating disease burdens through disability-adjusted life-years, depression emerged as the world's second most common disorder after cardiovascular disease, affecting more than 264 million people worldwide. In Asia, depression as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases (ICD) has also become far more recognised and diagnosed over the past two decades. On the surface, this change seems to underline the universality of the neurobiological model of depression. Full-Text PDF Infant mental health in southern Africa: nurturing a fieldThe promotion of early cognitive and emotional development is a core aim of the field of infant mental health (IMH). Yet models of early development and IMH have often been developed for high-income settings, and sometimes carry under-examined assumptions about care and wellbeing. Although this discipline is well established in Euro–American contexts, questions have been raised about how to tailor it to contexts that may differ considerably from those in which these models were developed. The ways that care, attachment, and relationship are given form in everyday practices are not universally the same, raising the challenge of shaping therapeutic models and interventions so as to ask appropriate questions, design context-sensitive interventions, and meet caregivers and infants in ways that are meaningful to them while still retaining general applicability. Full-Text PDF

Infant mental health in southern Africa: nurturing a field

The promotion of early cognitive and emotional development is a core aim of the field of infant mental health (IMH). Yet models of early development and IMH have often been developed for high-income settings, and sometimes carry under-examined assumptions about care and wellbeing. Although this discipline is well established in Euro–American contexts, questions have been raised about how to tailor it to contexts that may differ considerably from those in which these models were developed. The ways that care, attachment, and relationship are given form in everyday practices are not universally the same, raising the challenge of shaping therapeutic models and interventions so as to ask appropriate questions, design context-sensitive interventions, and meet caregivers and infants in ways that are meaningful to them while still retaining general applicability.

Phronetically Guided Use of Knowledge: Interstitial Work at Barnahus and How It Can Inform the Knowledge Debate in Social Work

Abstract In this article, the ‘evidence–relevance’ dilemma in the ‘knowledge for social work’ debate is approached empirically, departing from a concrete practice observed amongst social workers managing police-reported child abuse cases within the Norwegian Barnahus model (children’s house model). This practice can be conceptualised as interstitial work and is noted as providing children who are victims of abuse with holistic and context-sensitive interventions relevant to their particular situations and needs. The relevant questions addressed are what knowledge sources are used and how is knowledge applied in practice by social workers who are able to provide their clients with relevant interventions. Based on the findings and drawing on Flyvbjerg’s approach to phronetic knowledge, it is argued that for social work practice to result in knowledge-based and relevant interventions that account for the complex nature of social problems and social work reality, the use of formal knowledge sources and evidence must be ‘phronetically guided’.

Urban social environment and low birth weight in 360 Latin American cities

ObjectiveUsing data compiled by the SALURBAL project (Urban Health in Latin America; ‘Salud Urbana en América Latina’) we quantified variability in low birth weight (LBW) across cities in Latin America, and evaluated the associations of socio-economic characteristics at various levels (maternal, sub-city and city) with the prevalence of LBW.MethodsThe sample included 8 countries, 360 cities, 1321 administrative areas within cities (sub-city units) and birth registers of more than 4.5 million births for the year 2014. We linked maternal education from birth registers to data on socioeconomic characteristics of sub-cities and cities using the closest available national population census in each country. We applied linear and Poisson random-intercept multilevel models for aggregated data.ResultsThe median prevalence of city LBW by country ranged from a high of 13% in Guatemala to a low of 5% in Peru (median across all cities was 7.8%). Most of the LBW variability across sub-cities was between countries, but there were also significant proportions between cities within a country, and within cities. Low maternal education was associated with higher prevalence of LBW (Prevalence rate ratios (PRR) for less than primary vs. completed secondary or more 1.12 95% CI 1.10, 1.13) in the fully adjusted model. In contrast, higher sub-city education and a better city social environment index were independently associated with higher LBW prevalence after adjustment for maternal education and age, city population size and city gross domestic product (PRR 1.04 95% CI 1.03, 1.04 per SD higher sub-city education and PRR 1.02 95% CI 1.00, 1.04 per SD higher SEI). Larger city size was associated with a higher prevalence of LBW (PRR 1.06; 95% CI 1.01, 1.12).ConclusionOur findings highlight the presence of heterogeneity in the distribution of LBW and the importance of maternal education, local and broader social environments in shaping LBW in urban settings of Latin America. Implementing context-sensitive interventions guided to improve women’s education is recommended to tackle LBW in the region.

Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol.

BackgroundSocio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam.MethodsWe will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors’ expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions’ actual performance.DiscussionThe study’s key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities.

The influence of contextual factors on healthcare quality improvement initiatives: a realist review

BackgroundRecognising the influence of context and the context-sensitive nature of quality improvement (QI) interventions is crucial to implementing effective improvements and successfully replicating them in new settings, yet context is still poorly understood. To address this challenge, it is necessary to capture generalisable knowledge, first to understand which aspects of context are most important to QI and why, and secondly, to explore how these factors can be managed to support healthcare improvement, in terms of implementing successful improvement initiatives, achieving sustainability and scaling interventions. The research question was how and why does context influence quality improvement initiatives in healthcare?MethodsA realist review explored the contextual conditions that influence healthcare improvement. Realist methodology integrates theoretical understanding and stakeholder input with empirical research findings. The review aimed to identify and understand the role of context during the improvement cycle, i.e. planning, implementation, sustainability and transferability; and distil new knowledge to inform the design and development of context-sensitive QI initiatives. We developed a preliminary theory of the influence of context to arrive at a conceptual and theoretical framework.ResultsThirty-five studies were included in the review, demonstrating the interaction of key contextual factors across healthcare system levels during the improvement cycle. An evidence-based explanatory theoretical model is proposed to illustrate the interaction between contextual factors, system levels (macro, meso, micro) and the stages of the improvement journey. Findings indicate that the consideration of these contextual factors would enhance the design and delivery of improvement initiatives, across a range of improvement settings.ConclusionsThis is the first realist review of context in QI and contributes to a deeper understanding of how context influences quality improvement initiatives. The distillation of key contextual factors offers the potential to inform the design and development of context-sensitive interventions to enhance improvement initiatives and address the challenge of spread and sustainability. Future research should explore the application of our conceptual model to enhance improvement-planning processes.Systematic review registrationPROSPERO CRD42017062135

SmokingOpp: Detecting the Smoking 'Opportunity' Context Using Mobile Sensors.

Context plays a key role in impulsive adverse behaviors such as fights, suicide attempts, binge-drinking, and smoking lapse. Several contexts dissuade such behaviors, but some may trigger adverse impulsive behaviors. We define these latter contexts as 'opportunity' contexts, as their passive detection from sensors can be used to deliver context-sensitive interventions. In this paper, we define the general concept of 'opportunity' contexts and apply it to the case of smoking cessation. We operationalize the smoking 'opportunity' context, using self-reported smoking allowance and cigarette availability. We show its clinical utility by establishing its association with smoking occurrences using Granger causality. Next, we mine several informative features from GPS traces, including the novel location context of smoking spots, to develop the SmokingOpp model for automatically detecting the smoking 'opportunity' context. Finally, we train and evaluate the SmokingOpp model using 15 million GPS points and 3,432 self-reports from 90 newly abstinent smokers in a smoking cessation study.

Improving primary care Access in Context and Theory (I-ACT trial): a theory-informed randomised cluster feasibility trial using a realist perspective

BackgroundPrimary care access can be challenging for older, rural, socio-economically disadvantaged populations. Here we report the I-ACT cluster feasibility trial which aims to assess the feasibility of trial design and context-sensitive intervention to improve primary care access for this group and so expand existing theory.MethodsFour general practices were recruited; three randomised to intervention and one to usual care. Intervention practices received £1500, a support manual and four meetings to develop local, innovative solutions to improve the booking system and transport.Patients aged over 64 years old and without household car access were recruited to complete questionnaires when booking an appointment or attending the surgery. Outcome measures at 6 months included: self-reported ease of booking an appointment and transport; health care use; patient activation; capability; and quality of life. A process evaluation involved observations and interviews with staff and participants.ResultsThirty-four patients were recruited (26 female, eight male, mean age 81.6 years for the intervention group and 79.4 for usual care) of 1143 invited (3% response rate). Most were ineligible because of car access. Twenty-nine participants belonged to intervention practices and five to usual care. Practice-level data was available for all participants, but participant self-reported data was unavailable for three. Fifty-six appointment questionnaires were received based on 150 appointments (37.3%).Practices successfully designed and implemented the following context-sensitive interventions: Practice A: a stacked telephone system and promoting community transport; Practice B: signposting to community transport, appointment flexibility, mobility scooter charging point and promoting the role of receptionists; and Practice C: local taxi firm partnership and training receptionists. Practices found the process acceptable because it gave freedom, time and resource to be innovative or provided an opportunity to implement existing ideas. Data collection methods were acceptable to participants, but some found it difficult remembering to complete booking and appointment questionnaires. Expanded theory highlighted important mechanisms, such as reassurance, confidence, trust and flexibility.ConclusionsRecruiting older participants without access to a car proved challenging. Retention of participants and practices was good but only about a third of appointment questionnaires were returned. This study design may facilitate a shift from one-size-fits-all interventions to more context-sensitive interventions.Trial registrationISRCTN18321951, Registered on 6 March 2017.