Context Of Processes Research Articles

A model to explain smokeless tobacco consumption in adults: A grounded theory study

IntroductionSmokeless tobacco use remains a significant public health concern, necessitating the acquisition of comprehensive and extensive data to effectively address and control its consumption. Understanding the underlying patterns of consumption is crucial for this purpose. ObjectiveThis study aimed to develop a model that explains smokeless tobacco consumption among adults in the southeastern province of Iran, specifically in the city of Chabahar. MethodsA qualitative study was conducted using a grounded theory approach with inductive processes. The participants consisted of 30 adults aged 18–64 years from Chabahar City in southeastern Iran. Purposive sampling was used to select participants, and data collection continued until theoretical saturation was achieved. Data analysis followed Strauss and Corbin's perspective, involving four stages: Analyzing Data for Concepts, Analyzing Data for Context, Bringing Process into the Analysis, and Integrating Categories. ResultsThe analysis of data yielded three main categories: “starting to use,” “continued use,” and “cessation attempts,” each with their respective subcategories. Additionally, two main categories related to the consequences of smokeless tobacco consumption were identified: “addiction and efforts to overcome addiction,” also with their respective subcategories. ConclusionThe Dependency Cycle Model in Consumption provides a comprehensive understanding of the contextual factors, processes, and consequences associated with smokeless tobacco consumption. This model serves as a valuable tool for researchers aiming to develop effective interventions in the field of smokeless tobacco consumption.

URBAN ECOLOGICAL FUTURES: Five Eco‐Community Strategies for more Sustainable and Equitable Cities

AbstractCities are critical sites for understanding, and potentially ameliorating, the effects of global ecological change, the climate emergency and natural resource depletion. Contemporary cities are sociomaterially connected through global markets, trade and transportation, placing ever‐increasing demands on the natural environment and generating dangerous pollutants and emissions. Current approaches to address these environmental crises are dominated by neoliberal forms of ‘green’ urban development, carbon accounting and techno‐economic solutions, which extend corporate control over cities and tend to entrench inequality. A more strategic approach for enabling ecologically sustainable and equitable urban futures is urgently needed. We present five strategies for urban ecological futures in the global North, derived from qualitative and ethnographic empirical research with international eco‐communities, which open up discussions about how to tackle this challenge by acknowledging the role and potential of: (1) non‐extractive community economies; (2) democratic processes of co‐operative action; (3) social approaches to resource management; (4) participatory collaborative governance; and (5) urban heterogeneity and social justice. We explore the relational, contested and contextual processes through which these approaches could become embedded in urban policy and planning, thereby offering the strategic capacity required to move towards truly sustainable cities.

The Ability to Use Contextual Information in Object and Scene Recognition in Patients with Mild Cognitive Impairment.

The ability to understand and make use of object-scene relationships are critical for object and scene recognition. The current study assessed whether patients with mild cognitive impairment (MCI), possibly in the preclinical phase of Alzheimer's disease, exhibited impairment in processing contextual information in scene and object recognition. In Experiment 1, subjects viewed images of foreground objects in either semantic consistent or inconsistent scenes under no time pressure, and they verbally reported the names of foreground objects and backgrounds. Experiment 2 replicated Experiment 1, except that subjects were required to name scene first. Experiment 3 examined object and scene recognition accuracy baselines, recognition difficulty, familiarity with objects/scenes, and object-scene consistency judgements. There were contextual consistency effects on scene recognition for MCI and healthy subjects, regardless of response sequence. Scenes were recognized more accurately under the consistent condition than the inconsistent condition. Additionally, MCI patients were more susceptible to incongruent contextual information, possibly due to inhibitory deficits or over-dependence on semantic knowledge. However, no significant differences between MCI and healthy subjects were observed in consistency judgement, recognition accuracy, recognition difficulty and familiarity rating, suggesting no significant impairment in object and scene knowledge among MCI subjects. The study indicates that MCI patients retain relatively intact contextual processing ability but may exhibit inhibitory deficits or over-reliance on semantic knowledge.

Exploring local spatial planning as practices of process design in the Stockholm region, Sweden

ABSTRACT The quest for sustainable urban development requires innovative planning approaches more apt to cater for transformative action. Based on a case study approach, this study aims to explore the potential for local planning to develop practical approaches able to accelerate the transition towards sustainable urban development. To guide spatial development towards sustainability, the analysis of the results shows that local planners need to envision a process design as to advance the understanding of how a site or area can be developed. The act of process design involves pending between processes of contextualization (i.e. exploring five distinguishable domains of planning inquiry) and concretization (i.e. deciding upon a course of action by executing activities that form a process trajectory). Regarding the potential of local planning to develop transformative approaches, it is concluded that: (i) local planners possess capabilities that allow them to probe the future of places and produce insights about prospective change, (ii) the transformative capacity of local planning practices is bound to the development of the identified domains of planning inquiry and (iii) forthcoming evaluations organized around the act of process design can reveal insights regarding the possibilities to put the notion of sustainability into practice at the local level.

Context as a barrier: Impaired contextual processing increases the tendency to develop PTSD symptoms across repeated exposure to trauma

Growing evidence links repeated traumatic exposure with impaired ability to process contextual information. Specifically, like individuals with PTSD, non-PTSD trauma-exposed individuals fail to react according to contextual demands. In the present study, we explored the process that underlies this impairment. First, we tested the ability of first responders to benefit from contextual primes to improve recognition. Second, we assessed its moderating role in the relationship between traumatic exposure and PTSD symptoms. Fifty-three active-duty firefighters and 33 unexposed civilians matched for age, gender, and years of education participated in the study. All participants completed the contextual priming paradigm, the CAPS-5 clinical interview, and the WAIS-IV vocabulary subtest and were assessed for depression and general traumatic exposure. Repeated traumatic exposure was assessed objectively using the fire-and-rescue-service tracking system. As predicted, we found that trauma-exposed individuals failed to use primes to facilitate rapid and accurate recognition of contextually related objects. Not only did contextual information not improve performance, but it achieved the opposite effect, manifested as negative priming. Hence, context appeared to be an obstacle for trauma-exposed individuals and delayed rapid and accurate recognition. Moreover, impaired ability to process contextual information predicted the tendency to develop PTSD symptoms across repeated exposure to trauma.

The ethnic density effect as a contextual influence in ecological disease models: Establishing its quantitative expression.

Research suggests higher neighbourhood ethnic minority density to be associated with lessened chances of ethnic group illness. We focus on the density effect on psychosis, arguing that (at higher ethnic concentrations) it acts as a contextual influence attenuating the compositional influence whereby minority ethnicity is associated with higher psychosis risk. In terms of ecological disease regression, the ethnic density effect will then be apparent in nonlinear impacts of minority concentration. Contextual effects may also be evident in spatially varying regression coefficient models for psychosis. Nonlinearity or heterogeneity may be associated with other contextual processes where geography modifies demography (e.g. deprivation amplification). We illustrate these issues with an analysis of psychosis prevalence in 4835 London neighbourhoods. The data are collected in primary care (during 2019/20) using clinical diagnosis (e.g. based on referrals to specialists or psychosis hospitalisation), and refer to patients currently under care: such care may extend retrospectively over several years. The data offer a complete population perspective in contrast to survey data, which typically offer limited geographic perspectives. We consider impacts on psychosis prevalence of non-white ethnicity, as well as those of deprivation, social fragmentation and urbanicity. We find evidence suggesting nonlinear impacts of non-white ethnicity on psychosis (essentially flat risk above a threshold concentration), but find no evidence for deprivation amplification.

The meandering trajectories of financial innovations: commercial paper and its uses in sixteenth-century Lyon's trading networks

This article explores the complex dynamics of financial innovation in early modern times, challenging linear models of temporal and spatial divisions that tend to shape our understanding of the evolution of financial systems. It supports the idea that innovation should be viewed as a non-linear and contextual process, involving diverse stakeholders and characterised by interactions and unexpected occurrences. The study focuses on the dissemination and trajectories of financial innovations, specifically the bill of exchange and its variation, the ricorsa, as well as the transferability and negotiability of commercial paper. It does so by investigating the interactions and exchanges between merchants and bankers from diverse backgrounds during the sixteenth-century Lyon fairs, using the archival records of one of the first Italian banks in Lyon (Salviati). The study reveals the mutual influence and acculturation among these agents and challenges the compartmentalisation of financial expertise. Through an analysis of transactions recorded in the Salviati bank's ledgers, the article highlights previously unknown uses of commercial paper by Southern merchant communities and discusses the factors that may have hindered the full-scale development of endorsement and discount in the Lyon trading networks, despite their potential benefits. The results provide insights into the intricate nature of financial innovation and the influence of structural and cultural factors on its development.

From purists to pragmatists: a qualitative evaluation of how implementation processes and contexts shaped the uptake and methodological adaptations of a maternal and neonatal quality improvement programme in South Africa prior to, and during COVID-19

BackgroundDespite progress, maternal and neonatal mortality and still births remain high in South Africa. The South African National Department of Health implemented a quality improvement (QI) programme, called Mphatlalatsane, to reduce maternal and neonatal mortality and still births. It was implemented in 21 public health facilities, seven per participating province, between 2018 and 2022.MethodsWe conducted a qualitative process evaluation of the contextual and implementation process factors’ influence on implementation uptake amongst the QI teams in 15 purposively selected facilities. Data collection included three interview rounds with the leaders and members of the QI teams in each facility; intermittent interviews with the QI advisors; programme documentation review; observation of programme management meetings; and keeping a fieldwork journal. All data were thematically analysed in Atlas.ti. Implementation uptake varied across the three provinces and between facilities within provinces.ResultsBetween March and August 2020, the COVID-19 pandemic disrupted uptake in all provinces but affected QI teams in one province more severely than others, because they received limited pre-pandemic training. Better uptake among other sites was attributed to receiving more QI training pre-COVID-19, having an experienced QI advisor, and good teamwork. Uptake was more challenging amongst hospital teams which had more staff and more complicated MNH services, versus the primary healthcare facilities. We also attributed better uptake to greater district management support. A key factor shaping uptake was leaders’ intrinsic motivation to apply QI methodology. We found that, across sites, organic adaptations to the QI methodology were made by teams, started during COVID-19. Teams did away with rapid testing of change ideas and keeping a paper trail of the steps followed. Though still using data to identify service problems, they used self-developed audit tools to record intervention effectiveness, and not the prescribed tools.ConclusionsOur study underscores the critical role of intrinsic motivation of team leaders, support from experienced technical QI advisors, and context-sensitive adaptations to maximise QI uptake when traditionally recognised QI steps cannot be followed.

Does Firm Size and Age Strengthen the Relationship Between Ambidexterity and Financial Performance? Empirical Evidence in MSME Perspective

A firm that combines entrepreneurship is often recognized as a critical contributor to economic growth, job creation, and development, as well as an essential component of economic vitality. This study investigates the moderating effect of firm size and age on the association between ambidexterity and financial performance. The idea is tested using a quantitative methodology in this study. The research instrument was a questionnaire that respondents filled out. The participants in this study are all MSME leaders in Tangerang City, Banten, Indonesia. For this study, 216 participants were chosen randomly, and data were analyzed using a structural equation model (SEM). Its results discovered that ambidexterity has a favorable and statistically significant effect on financial performance. In addition, firm age improves the association between all ambidexterity aspects (product exploration, product exploitation, market exploration, and market exploitation) and financial performance. However, company size has no moderating effect on the association between product and market exploitation and financial performance, only on the relationship between product and market exploration and financial performance. This research is contributing to the size of businesses with structural distinction through mechanisms underpinning resources and capabilities. In addition, the firm's age and expertise with contextual systems and processes, as well as the mechanisms underlying organizational learning, enable the company to maximize its performance. Although using MSMEs as the study's sample boosted internal validity, caution should be exercised when extending these findings to other industries, such as manufacturing.

Policy framework that addresses malnutrition in Namibia: A retrospective qualitative review.

Although Namibia has made strides in improving the policy enabling environment, eradication of malnutrition is still elusive. This review was aimed at determining the extent to which food and nutrition-related policies in Namibia address malnutrition. This study used a qualitative approach by retrospectively analysing policy frameworks that address malnutrition in Namibia from 1991 to 2022. The analysis employed the policy triangle framework to elucidate the contextual factors, content, actors and process involved in the policy development. Moreover, a comparative analysis of Namibian policies and those of other southern African countries was undertaken. The review showed that there is a considerable degree of coherence in policy goals and strategies to address malnutrition despite parallel coordination structures. Policy process involved limited consultations with local communities which might have jeopardised the formulation of community problem-tailored interventions, ownership and participation in policy implementation. There is a strong political commitment to the eradication of malnutrition in Namibia. The Office of the Prime Minister played a leading role in policy development. Influential actors such as the UN agencies elevated the nutrition agenda. Further, the Namibian policy framework was generally similar to those of other southern African countries. The review showed that Namibia has relevant and comprehensive policies to address malnutrition, however, contextual factors indicated high levels of malnutrition still exist in the communities. Further research is needed to understand the barriers and enablers to optimal nutrition for children under five years in Namibia.

Religious Education Curriculum Development

The curriculum plays a central role in educational institutions because it refers to the direction, content and process of education, which ultimately determines the nature and qualifications of graduates of these educational institutions. There are at least three institutions that are well known to the public in Indonesia, including pesantren, schools and madrasah, each of which has its own characteristics. This study discusses the curriculum development of Islamic boarding schools, madrasah and schools. With the aim to know how the development. The method used in this research is a qualitative approach that focuses on library research. The results of the research show that the development of a religious education curriculum in pesantren, schools and madrasas involves a complex and contextual process. The curriculum is designed to cover an understanding of religious teachings, worship practices, ethics, morals, and the application of religious values ​​in everyday life. Islamic boarding schools, schools and madrasas apply various strategies in implementing the religious education curriculum. Nevertheless, there are several challenges in the development of the religious education curriculum. Some of these challenges include the diversity of students, social and cultural changes, lack of resources, and the integration of religious education with the general curriculum. In order to overcome these challenges, it is necessary to make collaborative efforts between pesantren, schools and madrasas by involving relevant stakeholders. It is also necessary to periodically update curriculum content so that it remains relevant to the times and the needs of students.

Solving nonstationary Markov decision processes via contextual decomposition: A military air battle management application

Reinforcement learning for nonstationary problems is a subject of widespread research given that most realistic problems do not exist within static environments. Approaching these problems can require significant effort in feature engineering to provide a learning algorithm with enough useful information about the state space to uncover complex system dynamics. As an alternative for problems with sufficient data describing the nonstationary environment, we propose the contextual decomposition Markov decision process (CDMDP) as a collection of stationary sub-problems intended to approximate nonstationary problem dynamics using a linear combination of value functions. We demonstrate the effectiveness of the CDMDP approach with an application in military air battle management. We use a designed computational experiment and analysis of variance to show that a complex, nonstationary learning problem can be effectively approximated with a small set of stationary sub-problems, and that the CDMDP solution significantly improves solution quality over a baseline approach without the need for additional feature engineering. If a researcher suspects that a complex and continuously varying environment can be approximated by a small number of stationary contexts, the CDMDP framework may save significant computational resources and yield decision policies that are much easier to visualize and implement.

Neuromodulatory mechanisms of N,N-dimethyltryptamine

N,N-dimethyltryptamine (DMT) is the simplest psychedelic tryptamine and is produced naturally by many plant and animal species, including humans. While classical psychedelics, such as lysergic acid diethylamide, or psilocybin, are gaining interest because of their therapeutic potential, DMT has yet to be fully investigated. However, preliminary clinical evidence suggests that DMT and/or ayahuasca, a DMT-containing psychoactive beverage, both possess antidepressive, anxiolytic, and antiaddictive properties. In addition, the subjective effects of DMT are particularly potent. Both subjective and therapeutic cues can be largely explained via the neuromodulatory properties of DMT. In addition, DMT interacts with several neurochemical systems, including the glutamatergic, monoaminergic, and cholinergic systems. Consequently, large-scale brain dynamics can suffer acute and dramatic shifts in several networks, including visual and auditive networks, and the default-mode network. More broadly, top-down cognitive processes (predictive and contextual processing) can become restricted while bottom-up and stimuli-related processing is enhanced. Furthermore, the acute effects of DMT can crystallize to some extent by virtue of its plastogenic effects which are mediated by sigma 1 receptor, brain-derived neurotrophic factor, tropomyosin receptor kinase B, and serotonin receptor 2A. DMT-induced plasticity has been related mental well-being and therapeutic benefits. Here, I provide an updated review of the neuromodulatory effects of DMT and the mechanisms that underlie these effects. I consider the molecular targets that influence neurochemical systems, changes in large-scale cortical function and structure, and DMT-dependent neuroplasticity. Finally, I highlight the therapeutic relevance and/or risks associated with the neuromodulatory mechanisms of DMT.

Did Covid-19 reshape constructivism approach? A synthesis paper during the world-wide shift to full distance learning

The Covid-19 pandemic had a profound effect on the use of constructivism in learning. As schools and learning institutions around the world were forced to transition to online classrooms, teachers had to find new ways to reach their students and engage them in an educational environment. This study was conducted to synthesize the various researches about the impact of a pandemic on the constructivism theory of learning. This paper used the general principle of constructivism to conduct the synthesis review. The findings indicated that there was disruption in student engagement but collaboration among students was maintained. Also, the process of lesson contextualization was interrupted as classes were moved to online platforms. Teachers have used various tools to check the integrity of the students’ outputs and literature suggest that outputs have been upright and reliable. The support of the parents to the learning of the students was perceived to be enhanced. Hence, the constructivism approach was taken to a new level and was truly reshaped by the pandemic.

Arabic Ontology: Linguistic Engineering Foundations

This scientific intervention aims to raise the issue of the automatic processing of natural languages. Especially at its levels related to ontological studies, enabling the machine to recognize information and invest it accurately, beyond the constraints of semantic ambiguity is considered a scientific challenge. This would not be possible without relying on the contextual detection process of linguistic engineering, which is based on a hybrid approach that combines both statistical and linguistic methods. It is an approach that falls within the context of platform linguistics, or what is termed "fourth-generation linguistics", a natural outgrowth of the digital revolution, based on its horizontal extension in various domains and fields of knowledge, thus establishing a new indicative model in which platforms with linguistic and computer interact. In this context, the associative aspects within the compositional linguistic perceptions are a focal point in operating research operations that fall within the automatic processing of natural language, given the nature of its theoretical and methodological architecture with an empirical inductive basis. It also enables the building of computer platforms by preparing morphological, synthetic, semantic, and pragmatic analyzers. Investing in the advanced technological tools provided by the artificial intelligence system; especially in its aspects related to machine learning, deep learning, and neural network; will enable the provision of a linguistic platform capable of developing paths of teaching the Arabic language to non-native speakers.

Neurocognitive basis of model-based decision making and its metacontrol in childhood

Human behavior is supported by both goal-directed (model-based) and habitual (model-free) decision-making, each differing in its flexibility, accuracy, and computational cost. The arbitration between habitual and goal-directed systems is thought to be regulated by a process known as metacontrol. However, how these systems emerge and develop remains poorly understood. Recently, we found that while children between 5 and 11 years displayed robust signatures of model-based decision-making, which increased during this developmental period, there were substantial individual differences in the display of metacontrol. Here, we inspect the neurocognitive basis of model-based decision-making and metacontrol in childhood and focus this investigation on executive functions, fluid reasoning, and brain structure. A total of 69 participants between the ages of 6–13 completed a two-step decision-making task and an extensive behavioral test battery. A subset of 44 participants also completed a structural magnetic resonance imaging scan. We find that individual differences in metacontrol are specifically associated with performance on an inhibition task and individual differences in thickness of dorsolateral prefrontal, temporal, and superior-parietal cortices. These brain regions likely reflect the involvement of cognitive processes crucial to metacontrol, such as cognitive control and contextual processing.

Implementing a cirrhosis order set in a tertiary healthcare system: a theory-informed formative evaluation

BackgroundStandardized order sets are a means of increasing adherence to clinical practice guidelines and improving the quality of patient care. Implementation of novel quality improvement initiatives like order sets can be challenging. Before the COVID-19 pandemic, we conducted a formative evaluation to understand healthcare providers’ perspectives on implementing clinical changes and the individual, collective and organizational contextual factors that might impact implementation at eight hospital sites in Alberta, Canada.MethodsWe utilized concepts from the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) to understand the context, past implementation experiences, and perceptions of the cirrhosis order set. Eight focus groups were held with healthcare professionals caring for patients with cirrhosis. Data were coded deductively using relevant constructs of NPT and CFIR. A total of 54 healthcare professionals, including physicians, nurses, nurse practitioners, social workers and pharmacists and a physiotherapist, participated in the focus groups.ResultsKey findings revealed that participants recognized the value of the cirrhosis order set and its potential to improve the quality of care. Participants highlighted potential implementation challenges, including multiple competing quality improvement initiatives, feelings of burnout, lack of communication between healthcare provider groups, and a lack of dedicated resources to support implementation.ConclusionsImplementing a complex improvement initiative across clinician groups and acute care sites presents challenges. This work yielded insights into the significant influence of past implementation of similar interventions and highlighted the importance of communication between clinician groups and resources to support implementation. However, by using multiple theoretical lenses to illuminate what and how contextual and social processes will influence uptake, we can better anticipate challenges during the implementation process.

Pre-medical assessment of root-canal-filled teeth with asymptomatic apical periodontitis-A multifaceted balancing act.

Prior to certain medical therapies, dental assessment and treatment of oral foci of infection are recommended. The aim of the present study was to acquire a deeper understanding of the decision-making process regarding the pre-medical management of root-canal-filled teeth with asymptomatic apical periodontitis (AAP). Hospital-affiliated dentists in Sweden were contacted for a semi-structured, in-depth interview. The absolute inclusion criterion was that the dentists had experienced and could recount at least two authentic cases involving root-canal-filled teeth with AAP-one case having resulted in pre-medical treatment, and one having resulted in expectancy. Fourteen interviews, with fourteen informants, were conducted and included in the study. During the interviews, open-ended questions and comments encouraging the informants to elaborate and clarify their experiences were offered. The interviews were digitally recorded, transcribed verbatim and analysed using Qualitative Content Analysis with an inductive approach. A theme describing the latent content was identified through interpretation of the collected data: A multifaceted balancing act characterized by a sometimes-difficult risk-benefit-estimation, where an increased uncertainty entails an increased reliance on external opinions. Three main categories, comprising four sub-categories, describing the manifest content were recognized: The tipping scale, The team effort and The frame of reference. The current interview study found pre-medical decision-making regarding root-canal-filled teeth with AAP to be a multifactorial and contextual process marked by uncertainty and collaborative measures. Further research, resulting in the development of evidence-based treatment guidelines, is suggested necessary.

Ethnic context and fertility differential in post‐Soviet Kazakhstan

AbstractPrevious studies have often explained fertility differentials between racial groups by aggregate individual characteristics. Emphasizing a spatial perspective, this study argues that the fertility implications of race may depend on the ethnic composition of the local context. This study tested the explanatory power of contextual ethnic composition, measured by diversity and minority share, with the intriguing case of fertility differentials in post‐Soviet Kazakhstan. Multilevel Poisson regressions and decomposition techniques were performed on the pooled 1995 and 1999 Kazakhstan Demographic and Health Surveys. Further sensitivity tests were conducted with the Multiple Indicator Cluster Survey‐Kazakhstan 2010–2011 and 2015 surveys. We found that both diversity and minority share are significant contributors to the majority‐minority fertility differential. Specifically, context‐level ethnic diversity is associated with lower fertility (−0.22, p < 0.001) for both Russians and Kazakhs, while a higher share of Russians in the local context reduces the differential between the two groups (−0.26, p < 0.05). Sensitivity test using data from the 2010s reproduced the significant effect of the context‐level share of Russians on fertility. The findings suggest that minority individuals exhibit lower fertility levels in places where their presence is more suppressed. This study contributes to population geography's recognition of the importance of spatial and contextual processes in shaping fertility outcomes for racial/ethnic minorities by impacting their living environment.

Intervention in mothers and newborns to reduce maternal and perinatal mortality in three provinces in South Africa using a quality improvement approach: Protocol for a Mixed Method Type 2 Hybrid Evaluation.

The COVID-19 pandemic undermined gains in reducing maternal and perinatal mortality in South Africa. The Mphatlalatsane Initiative is a health system intervention to reduce mortality and morbidity in women and newborns to desired levels through universal coverage of sustainable quality health systems and clinical care. Our evaluation aims to determine the effect of various exposures, including COVID-19 and a system-level, complex, patient-centred quality improvement (QI) intervention (Mphatlalatsane Initiative) on maternal and neonatal health services at 21 selected facilities in South Africa. The objectives are to determine whether Mphatlalatsane reduces institutional maternal mortality ratio (iMMR), neonatal mortality rate and stillbirth rate (Objective 1); improves patients' experiences (Objective 2) and quality of care (Objective 3). Objective 4 assesses the contextual and implementation process factors, including COVID-19, that shape Mphatlalatsane and uptake variation. This study is an implementation science type 2 hybrid effectiveness, controlled-before-after design with quantitative and qualitative components. The Mphatlalatsane intervention commenced at the end of 2019. For Objective 1, intervention and control facility-level data from the District Health Information System is compared for changes in institutional maternal and neonatal mortality and stillbirth rate and associations with QI, the COVID-19 pandemic and with both. This first analysis will consider data from 18 facilities, regardless of their allocation to intervention or comparison catchment areas to obtain a general idea of the effect of COVID-19. For Objectives 2-3, data collectors' abstract data from maternal and neonatal records, interview participants and conduct neonatal facility assessments. For Objective 4, interviews, programme documentation, surveys, and observations are used to assess how contextual factors at macro-, meso-, and micro-levels, explain variation in intervention uptake and outcome. The intervention dose is measured at micro-level only in the intervention facilities. The study assesses the Mphatlalatsane Initiative from 2020 to 2022. In preliminary analysis, across three provinces there was an increase in maternal and neonatal deaths during COVID-19 while stillbirths remained unchanged. Maternal satisfaction with quality of care was above 95%., COVID-19 severely disrupted the functioning of the QI teams. However, the QI teams regained their pre-COVID-19 momentum adapting the QI model, with advisors providing mentoring and support. Variation in adoption at meso-level was related to stable and motivated leadership (particularly at facility level), lack of integration into routine processes and buy-in from senior district managers who were affected by competing priorities. Referral and specialist outreach systems, staff availability and development and service delivery infrastructures also varied, plausible factors in variable outcomes. Few evaluations rigorously evaluated the effect of health systems interventions on improving health services and outcomes. Results will inform upscaling successful intervention components, and strategies to mitigate the effect of COVID-19 or similar emerging epidemics on maternal and neonatal mortality. DERR1-10.2196/42041.