Program Startup Research Articles

The implementation and effectiveness of multi-tasked, paid community health workers on maternal and child health: A cluster-randomized pragmatic trial and qualitative process evaluation in Tanzania.

Community health worker programs have proliferated worldwide based on evidence that they help prevent mortality, particularly among children. However, there is limited evidence from randomized studies on the processes and effectiveness of implementing community health worker programs through public health systems. This paper describes the results of a cluster-randomized pragmatic implementation trial (registration number ISRCTN96819844) and qualitative process evaluation of a community health worker program in Tanzania that was implemented from 2011-2015. Program effects on maternal, newborn and child health service utilization, childhood morbidity and sick childcare seeking were evaluated using difference-in-difference regression analysis with outcomes measured through pre- and post-intervention household surveys in intervention and comparison trial arms. A qualitative process evaluation was conducted between 2012 and 2014 and comprised of in-depth interviews and focus group discussions with community health workers, community members, facility-based health workers and staff of district health management teams. The community health worker program reduced incidence of illness and improved access to timely and appropriate curative care for children under five; however, there was no effect on facility-based maternal and newborn health service utilization. The positive outcomes occurred because of high levels of acceptability of community health workers within communities, as well as the durability of community health workers' motivation and confidence. Implementation factors that generated these effects were the engagement of communities in program startup; the training, remuneration and supervision of the community health workers from the local health system and community. The lack of program effects on maternal and newborn health service utilization at facilities were attributed to lapses in the availability of needed care at facilities. Strategies that strengthen and align communities' and health systems core capacities, and their ability to learn, adapt and integrate evidence-based interventions, are needed to maximize the health impact of community health workers.

The relative value of Pre-Implementation stages for successful implementation of evidence-informed programs

BackgroundMost implementations fail before the corresponding services are ever delivered. Measuring implementation process fidelity may reveal when and why these attempts fail. This knowledge is necessary to support the achievement of positive implementation milestones, such as delivering services to clients (program start-up) and competency in treatment delivery. The present study evaluates the extent to which implementation process fidelity at different implementation stages predicts achievement of those milestones.MethodsImplementation process fidelity data—as measured by the Stages of Implementation Completion (SIC)—from 1287 implementing sites across 27 evidence-informed programs were examined in mixed effects regression models with sites nested within programs. Implementation process fidelity, as measured by the proportion of implementation activities completed during the three stages of the SIC Pre-Implementation phase and overall Pre-Implementation (Phase 1) and Implementation (Phase 2) proportion scores, was assessed as a predictor of sites achieving program start-up (i.e., delivering services) and competency in program delivery.ResultsThe predicted probability of start-up across all sites was low at 35% (95% CI [33%, 38%]). When considering the evidence-informed program being implemented, that probability was nearly twice as high (64%; 95% CI [42%, 82%]), and 57% of the total variance in program start-up was attributable to the program. Implementation process fidelity was positively and significantly associated with achievement of program start-up and competency. The magnitude of this relationship varied significantly across programs for Pre-Implementation Stage 1 (i.e., Engagement) only. Compared to other stages, completing more Pre-Implementation Stage 3 (Readiness Planning) activities resulted in the most rapid gains in probability of achieving program start-up. The predicted probability of achieving competency was very low unless sites had high scores in both Pre-Implementation and Implementation phases.ConclusionsStrong implementation process fidelity—as measured by SIC Pre-Implementation and Implementation phase proportion scores—was associated with sites’ achievement of program start-up and competency in program delivery, with early implementation process fidelity being especially potent. These findings highlight the importance of a rigorous Pre-Implementation process.

The early-stage comprehensive costs of routine PrEP implementation and scale-up in Zambia.

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention option, but cost-effectiveness is sensitive to implementation and program costs. Studies indicate that, in addition to direct delivery cost, PrEP provision requires substantial demand creation and client support to encourage PrEP initiation and persistence. We estimated the cost of providing PrEP in Zambia through different PrEP delivery models. Taking a guidelines-based approach for visits, labs and drugs, we estimated the annual cost of providing PrEP per client for five delivery models: one focused on key populations (men-who-have-sex-with-men (MSM) and female sex workers (FSW), one on adolescent girls and young women (AGYW), and three integrated programs (operated within HIV counselling and testing services at primary healthcare centres). Program start-up and support costs were based on program expenditure data and number of PrEP sites and clients in 2018. PrEP clinic visit costs were based on micro-costing at two PrEP delivery sites (2018 USD). Costs are presented in 2018 prices and inflated to 2021 prices. The annual cost/PrEP client varied by service delivery model, from $394 (AGYW) to $655 (integrated model). Cost differences were driven largely by client volume, which impacted the relative costs of program support and technical assistance assigned to each PrEP client. Direct service delivery costs ranged narrowly from $205-212/PrEP-client and were a key component in the cost of PrEP, representing 35-65% of total costs. The results show that, even when integrated into full service delivery models, accessing vulnerable, marginalised populations at substantial risk of HIV infection is likely to cost more than previously estimated due to the programmatic costs involved in community sensitization and client support. Improved data on individual client resource usage and outcomes is required to get a better understanding of the true resource utilization, expected outcomes and annual costs of different PrEP service delivery programs in Zambia.

Effects of a nursing home telehealth program on spending and utilization for Medicare residents.

To assess the effects of eLongTermCare (eLTC), a telehealth program implemented by an integrated health system in 45 nursing homes across the Midwest, on the use of acute hospital services and total expenditures for Medicare residents. Minimum Data Set, Medicare fee-for-service claims, and enrollment data from 2013 to 2018. We used a longitudinal difference-in-differences design to estimate the changes in outcomes for treatment beneficiaries before and after participating in the eLTC program, relative to changes for the matched comparison beneficiaries over the same period. We measured outcomes over a 24-month follow-up period, including total Medicare spending, emergency department (ED) visits, hospitalizations, and the likelihood of readmission. Using administrative data, we identified treatment beneficiaries who stayed at participating nursing facilities during the program period and matched comparison beneficiaries with similar baseline characteristics from non-participating facilities in the same geographic locations. For long-term care residents, the eLTC program led to an estimated reduction of 73 ED visits per 1000 beneficiaries (p < 0.01, 8.6% effect) over the two-year follow-up period. The estimated effects for this group were concentrated among beneficiaries who entered the nursing home after program startup, with sizable reductions in hospitalizations, ED visits, and spending. For skilled care residents, the program was associated with an estimated reduction of 85 ED visits per 1000 beneficiaries (p=0.03, 9.7% effect), but had no discernible effect on their hospitalizations or total Medicare spending. Telehealth can be a valuable tool for nursing homes to enhance care coordination and provide timely access to care, leading to lower spending for nursing home residents. Future research needs to explore payment methods that encourage telehealth expansion in nursing homes.

Challenges for Romanian SMEs: A Study of the Romanian Central Region SMEs

Abstract The 21st century is certainly the century of SMEs which represent, according to the Annual Report on SMEs for the years 2019-2020 prepared by the European Commission, over 99% of non- financial businesses at EU level, and which provide 66% of total jobs and 57% of value added in the EU non-financial businesses sector. SMEs are considered to be” vectors of innovation that contribute significantly to increasing long-term labor productivity and sustainable economic development. ” (CCE, Raport special, 2020). The need for permanent support for the development of the sector is recognized at EU level, especially for newly registered micro-enterprises, the support being decisive for the socio-economic changes that take place in society. The reality has unequivocally demonstrated the interdependent relationship between the activity of SMEs, economic development, and the creation of new jobs. In our country, the size of the sector and its importance are indisputable. Thus: Romania (Vasiliu, 2021) has around 500.000 SMEs, which account to 99% of the total companies in the economy – nonfinancial sectors. The general objective of the research that we present in this paper is to offer an overview of the current state of the regional economic environment of The Central Region (Central Region), the tendencies and external factors that act upon it, providing at the same time an analysis of the impact of de minimis funds on the companies financed through the Start-UP Hub: the Entrepreneurs’ Laboratory, following the interpretation of data collected through questionnaires for identifying the requirements and challenges that the entrepreneurs encountered. A specific objective of this research is to identify the solutions suggested by the entrepreneurs involved in the program Start-Up Hub: the Entrepreneurs’ Laboratory for overcoming the difficult challenges for the start-ups registered in the past two to three years which could apply to the entire SME sector.

Bringing Evidence-Based Interventions into the Schools: An Examination of Organizational Factors and Implementation Outcomes

Although schools are one of the largest providers of behavioral health services for youth, many barriers exist to the implementation of evidence-based interventions in schools. This study used the Stages of Implementation Completion (SIC) to examine school-based implementation outcomes for a computer-assisted cognitive behavioral therapy intervention for anxious youth. Organizational factors and predictors of program startup also were examined. Results indicated that the SIC detected implementation variability in schools and suggested that spending more time completing pre-implementation activities may better prepare schools for active implementation of program delivery. Furthermore, proficiency emerged as a potentially important organizational factor to examine in future school-based implementation research.

Speeding drug discovery targeting RNAs: An iterative “RNA selection-compounds screening cycle“ for exploring RNA-small molecule pairs

RNA is an emerging target of next-generation drug development. Recently, new small molecules targeting RNAs were discovered by several pharmaceutical companies. Methods have been reported to identify small molecules targeting a specific RNA sequence and structural motif, however, because of diverse sequence and structural motifs potentially present in the druggable functional RNAs, large sets of structure–activity relationships (SARs) information of small molecule – RNA interactions will be required for the acceleration and efficient startup of the discovery programs toward unprecedented RNA targets. Here we describe our iterative RNA selection and compounds screening to accumulate rich information about small molecules – RNA interaction. The RNAs that selectively bind to the initial molecular target, compound 1 from our in-house chemical library (JT-library), was isolated using in vitro selection technique from a hairpin-structured RNA library mimicking precursor microRNA (pre-miRNA). Then, we engineered pre-let-7f-2 to create its mutant that can bind to compound 1 by embedding the in vitro selected RNA motif for compound 1 in the hairpin loop region. The obtained mutant pre-let-7f-2-loop-mt was used as a target for screening 316 analogs of compound 1. A surface plasmon resonance (SPR) -based screening was performed against pre-let-7f-2-loop-mt-immobilized sensor surface and we obtained four compounds that can bind to the RNA. Among these four compounds, three compounds showed higher affinity to pre-let-7f-2-loop-mt than the parental compound 1, which suggests the feasibility of our strategy for gathering the SAR information on small molecule – RNA interactions. We demonstrated only one cycle of RNA selection and compounds screening in the present study, but can continue this cycle with the selected molecule to gain new RNAs and even new RNA motifs and gather much SAR information with improved accuracy.

Integration and Implementation Challenges of State-Based Long-Term Services and Supports Financing Programs

Several states are in the process of developing or implementing programs that use a social insurance approach to financing long-term services and supports (LTSS). The National Academy of Social Insurance developed a roadmap that highlights key design parameters for states to consider in crafting a program. It also outlines a range of vetted approaches states could adopt, and describes the building blocks and tradeoffs associated with a range of options. States that establish a new LTSS program will need to make decisions about the integration of the program with other payers and benefit programs as well as address concrete implementation challenges. This presentation summarizes these issues including coordination of benefits with other payers, Federal Medicaid funding issues, integration of LTSS and medical care, and challenges around program startup, administration and monitoring as well as evaluation and modification. Addressing such issues is critical to the success of these type of programs.

A CFI Countermeasure Against GOT Overwrite Attacks

In the Unix-like system, the Global Offset Table (GOT) overwrite attack is a long-lasting control flow hijacking attack. The attack, by leveraging the dynamic symbol binding mechanism, overwrites any GOT entry into the attacker's target address to take the execution flow on the library function call. Recently, Full Relro (Relocation Read only), which arranges the GOT section as read-only at program startup, is regarded as most useful against the threat. However, it entails nontrivial loading overhead and is not applicable to libraries. Furthermore, many software packages are currently distributed without Full Relro. As a result, programs are still exposed to the risk of GOT attacks. In this paper, we propose a CFI-based protection scheme against the GOT overwrite attack. Using dynamically bound function symbols as branch identifiers, the scheme secures inter-module function calls on PLT (Procedure Linkage Table) effectively with little performance overhead. Our LLVM based implementation and evaluation on binutils-gdb show that the branch protection scheme is difficult to bypass, fast, and compatible with existing library programs.

A virtual learning collaborative to implement health promotion in routine mental health settings: Protocol for a cluster randomized trial

BackgroundDespite widespread use of learning collaboratives in health care, few randomized trials have evaluated their effectiveness. The primary aim of this cluster randomized implementation trial is to evaluate the effectiveness of a virtual learning collaborative (VLC) in the implementation of a lifestyle intervention for persons with serious mental illness (SMI) in routine mental health settings, compared to standard individual technical assistance. MethodsForty-eight mental health provider organizations from across the United States will be recruited to participate in the trial. The evidence-based practice to be implemented is the InSHAPE health promotion intervention for persons with SMI. Sites will be stratified by size and randomized to receive an 18-month intensive group-based VLC with monthly learning sessions or individual technical assistance with four scheduled conference calls over 18 months. Sites will be enrolled in three blocks of 16 sites each. The primary outcomes are InSHAPE program participation and fidelity, and participant weight loss; secondary outcomes are program operation, program uptake, participant health behaviors of physical activity and nutrition, organizational change, and program sustainment. Implementation outcomes are measured at 3, 6, 12, 18, and 24 months after the program start-up. Participant-level outcomes are measured at fixed intervals every 3 months after each participant enrolls in the study. DiscussionThis study will determine whether VLCs are an effective implementation strategy among resource-limited providers when the new practice necessitates a shift in mission, scope of practice, type of services delivered, and new financing. Trial registrationClinicalTrials.gov identifier: NCT03891368Registered 25 March 2019, retrospectively registered.https://clinicaltrials.gov/ct2/show/NCT03891368?term=NCT03891368&rank=1

The design and implementation of the re-vitalised integrated disease surveillance and response (IDSR) in Uganda, 2013\u20132016

BackgroundUganda adopted and has been implementing the Integrated Disease Surveillance (IDSR) strategy since 2000. The goal was to build the country’s capacity to detect, report promptly, and effectively respond to public health emergencies and priorities. The considerable investment into the program startup realised significant IDSR core performance. However, due to un-sustained funding from the mid-2000s onwards, these achievements were undermined. Following the adoption of the revised World Health Organization guidelines on IDSR, the Uganda Ministry of Health (MoH) in collaboration with key partners decided to revitalise IDSR and operationalise the updated IDSR guidelines in 2012.MethodsThrough the review of both published and unpublished national guidelines, reports and other IDSR program records in addition to an interview of key informants, we describe the design and process of IDSR revitalisation in Uganda, 2013–2016. The program aimed to enhance the districts’ capacity to promptly detect, assess and effectively respond to public health emergencies.ResultsThrough a cascaded, targeted skill-development training model, 7785 participants were trained in IDSR between 2015 and 2016. Of these, 5489(71%) were facility-based multi-disciplinary health workers, 1107 (14%) comprised the district rapid response teams and 1188 (15%) constituted the district task forces. This training was complemented by other courses for regional teams in addition to the provision of logistics to support IDSR activities. Centrally, IDSR implementation was coordinated and monitored by the MoH’s national task force (NTF) on epidemics and emergencies. The NTF and in close collaboration with the WHO Country Office, mobilised resources from various partners and development initiatives. At regional and district levels, the technical and political leadership were mobilised and engaged in monitoring and overseeing program implementation.ConclusionThe IDSR re-vitalization in Uganda highlights unique features that can be considered by other countries that would wish to strengthen their IDSR programs. Through a coordinated partner response, the program harnessed resources which primarily were not earmarked for IDSR to strengthen the program nation-wide. Engagement of the local district leadership helped promote ownership, foster accountability and sustainability of the program.

Probability of pregnancy and risk factors of the Ovsynch program and its modification in dairy cows – a review

The Ovsynch programme is one of the most frequently used procedures in managing dairy cattle reproduction. There are many studies evaluating the effectiveness of the Ovsynch programme. However, few of them assess the impact of factors that can lead to a decrease in the pregnancy rate and thus, reduce the success of the Ovsynch programme. This review aims to examine the impact of both individual and environmental factors on the likelihood of pregnancy. The risk factors described include: the body condition, age, number and stage of lactation, production level, occurrence of diseases and postpartum complications, functional status of the ovaries, oestrous cycle phase, temperature, season and year, and program start-up after calving. Possible modifications of the Ovsynch programme are presented in order to increase its effectiveness and to determine the best time to start it. Additionally, attention was paid to pregnancy losses during the Ovsynch programme which ultimately decrease pregnancy rates. The impact of this many factors on the efficiency of the Ovsynch suggests the need to adjust the synchronization program each time to the individual situation of the herd.

A Mixed Methods Study of the Stages of Implementation for an Evidence-Based Trauma Intervention in Schools

A mixed methods study was conducted to examine the implementation process of 26 urban school-based mental health clinics that took part in a training and implementation support program for an evidence-based school trauma intervention. Implementation process was observed using the Stages of Implementation Completion (SIC) measure. Qualitative interviews were conducted with clinic leaders in order to gain insight into clinic processes related to the SIC. Results showed that almost all of the clinics engaged in some activities related to pre-implementation (engagement, feasibility, and readiness), but only 31% of the sites formally started delivering the program to youth. Completing more pre-implementation activities, particularly those related to readiness, predicted program start-up. Qualitative analysis comparing those that implemented the program to those that did not revealed critical differences in decision-making processes, leadership strategies, and the presence of local champions for the program. This study documented the patterns of clinic behavior that occurs as part of large-scale training efforts, suggests some unique challenges that occur in schools, and highlights the importance of engaging in particular implementation activities (i.e., readiness planning, stakeholder consensus and planning meetings) as part of program start-up. Findings indicate that pre-implementation and readiness-related consultation should be employed as part of broad-scale implementation and training efforts.

A national collaborative approach to reduce catheter-associated urinary tract infections in nursing homes: A qualitative assessment

Reducing health care-associated infections (HAIs), such as catheter-associated urinary tract infection (CAUTI), is a critical performance improvement target in nursing homes. The Agency for Healthcare Research and Quality Safety Program for Long-term Care: Health Care-Associated Infections/Catheter-Associated Urinary Tract Infection, a national performance improvement program, was designed to promote implementation of a CAUTI prevention program through state-based or regional collaboratives in more than 500 nursing homes across the United States. Qualitative interviews were conducted with 8 purposefully selected organizational leads (who led implementation activities for a group of facilities) and 8 facility leads (who led implementation activities at a given facility) to understand implementation successes and challenges and experiences of participants involved in the program. Key themes were identified using a rapid analysis approach. Key themes related to general perceptions, changes due to program participation, and factors influencing program implementation were identified. In general, the program was viewed positively by organizational and facility leads with changes in catheter care practices, staff empowerment, and improvements in knowledge identified as benefits. Implementation challenges included the time required for program start-up as well as issues with staff and physician support, logistic barriers, and staffing turnover. Despite some challenges, the observed program success and positive views of those participating suggest that collaboratives are an important strategy for providing nursing homes with enhanced expertise and support to prevent HAIs and ensure resident safety.

Commentaries on health services research

Commentaries on health services research

Transition Watchpoints: Teaching Old Debuggers New Tricks

Reversible debuggers and process replay have been developed at least since 1970. This vision enables one to execute backwards in time under a debugger. Two important problems in practice are that, first, current reversible debuggers are slow when reversing over long time periods, and, second, after building one reversible debugger, it is difficult to transfer that achievement to a new programming environment. The user observes a bug when arriving at an error. Searching backwards for the corresponding fault may require many reverse steps. Ultimately, the user prefers to write an expression that will transition to false upon arriving at the fault. The solution is an expression-transition watchpoint facility based on top of snapshots and record/replay. Expression-transition watch- points are implemented as binary search through the timeline of a program execution, while using the snapshots as landmarks within that timeline. This allows for debugging of subtle bugs that appear only after minutes or more of program execution. When a bug occurs within seconds of program startup, repeated debugging sessions suffice. Reversible debugging is preferred for bugs seen only after minutes. This architecture allows for an efficient and easy-to-write snapshot-based reversibe debugger on top of a conventional debugger. The validity of this approach was tested by developing four personalities (for GDB, MATLAB, Perl, and Python), with each personality typically requiring just 100 lines of code.

Does Feedback to Business-Plans Impact New Ventures? Evidence from a Field Experiment

Feedback about business plans is thought to potentially improve ventures’ decisions and outcomes. Nonetheless, there is no direct experimental evidence supporting that assumption. We show a randomized controlled trial that tests the effect of giving written feedback to entrepreneurs’ business plans on the subsequent survival of their venture. Out of 88 high-stakes entrepreneurs, half randomly received written feedback and half did not. Later on both groups participated in the incubator program Startup Chile and received $40,000. After four years treated entrepreneurs were 50% more likely to list their ventures in key websites like AngelList, a proxy for having lasted longer.

Measuring polymorphism in python programs

Following the increased popularity of dynamic languages and their increased use in critical software, there have been many proposals to retrofit static type system to these languages to improve possibilities to catch bugs and improve performance. A key question for any type system is whether the types should be structural, for more expressiveness, or nominal, to carry more meaning for the programmer. For retrofitted type systems, it seems the current trend is using structural types. This paper attempts to answer the question to what extent this extra expressiveness is needed, and how the possible polymorphism in dynamic code is used in practise. We study polymorphism in 36 real-world open source Python programs and approximate to what extent nominal and structural types could be used to type these programs. The study is based on collecting traces from multiple runs of the programs and analysing the polymorphic degrees of targets at more than 7 million call-sites. Our results show that while polymorphism is used in all programs, the programs are to a great extent monomorphic. The polymorphism found is evenly distributed across libraries and program-specific code and occur both during program start-up and normal execution. Most programs contain a few ``megamorphic'' call-sites where receiver types vary widely. The non-monomorphic parts of the programs can to some extent be typed with nominal or structural types, but none of the approaches can type entire programs.

Evaluation of two implementation strategies in 51 child county public service systems in two states: results of a cluster randomized head-to-head implementation trial.

BackgroundMuch is to be learned about what implementation strategies are the most beneficial to communities attempting to adopt evidence-based practices. This paper presents outcomes from a randomized implementation trial of Multidimensional Treatment Foster Care (MTFC) in child public service systems in California and Ohio, including child welfare, juvenile justice, and mental health.MethodsFifty-one counties were assigned randomly to one of two different implementation strategies (Community Development Teams (CDT) or independent county implementation strategy (IND)) across four cohorts after being matched on county characteristics. We compared these two strategies on implementation process, quality, and milestone achievements using the Stages of Implementation Completion (SIC) (Implement Sci 6(1):1–8, 2011).ResultsA composite score for each county, combining the final implementation stage attained, the number of families served, and quality of implementation, was used as the primary outcome. No significant difference between CDT and IND was found for the composite measure. Additional analyses showed that there was no evidence that CDT increased the proportion of counties that started-up programs (i.e., placed at least one family in MTFC). For counties that did implement MTFC, those in the CDT condition served over twice as many youth during the study period as did IND. Of the counties that successfully achieved program start-up, those in the CDT condition completed the implementation process more thoroughly, as measured by the SIC. We found no significant differences by implementation condition on the time it took for first placement, achieving competency, or number of stages completed.ConclusionsThis trial did not lead to higher rates of implementation or faster implementation but did provide evidence for more robust implementation in the CDT condition compared to IND implementation once the first family received MTFC services. This trial was successful from a design perspective in that no counties dropped out, even though this study took place during an economic recession. We believe that this methodologic approach of measurement utilizing the SIC, which is comprised of the three dimensions of quality, quantity, and timing, is appropriate for a wide range of implementation and translational studies.Trial registrationTrial ID: NCT00880126 (ClinicalTrials.gov).Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-014-0134-8) contains supplementary material, which is available to authorized users.

MDSLB: A new static load balancing method for parallel molecular dynamics simulations

Large-scale parallelization of molecular dynamics simulations is facing challenges which seriously affect the simulation efficiency, among which the load imbalance problem is the most critical. In this paper, we propose, a new molecular dynamics static load balancing method (MDSLB). By analyzing the characteristics of the short-range force of molecular dynamics programs running in parallel, we divide the short-range force into three kinds of force models, and then package the computations of each force model into many tiny computational units called “cell loads”, which provide the basic data structures for our load balancing method. In MDSLB, the spatial region is separated into sub-regions called “local domains”, and the cell loads of each local domain are allocated to every processor in turn. Compared with the dynamic load balancing method, MDSLB can guarantee load balance by executing the algorithm only once at program startup without migrating the loads dynamically. We implement MDSLB in OpenFOAM software and test it on TianHe-1A supercomputer with 16 to 512 processors. Experimental results show that MDSLB can save 34%–64% time for the load imbalanced cases.