Systems Approach Research Articles

The impact of humanitarian aid on financial toxicity among cancer patients in Northwest Syria.

The ongoing crisis in Syria has divided the country, leading to significant deterioration of the healthcare infrastructure and leaving millions of people struggling with poor socioeconomic conditions. Consequently, the affordability of healthcare services for the population has been compromised. Cancer patients in Northwest Syria have faced difficulties in accessing healthcare services, which increased their financial distress despite the existence of humanitarian health and aid programs. This study aimed to provide insights into how humanitarian assistance can alleviate the financial burdens associated with cancer treatment in conflict-affected regions. This research employed a quantitative, quasi-experimental design with a pre-test-post-test approach, focusing on evaluating the financial toxicity among cancer patients in Northwest Syria before and after receiving humanitarian aid. The study used purposeful sampling to select participants and included comprehensive demographic data collection. The primary tool for measuring financial toxicity was the Comprehensive Score for Financial Toxicity (FACIT-COST) tool, administered in Arabic. Data analysis was conducted using SPSS v25, employing various statistical tests to explore relationships and impacts. A total of 99 cancer patients were recruited in the first round of data collection, out of whom 28 patients affirmed consistent receipt of humanitarian aid throughout the follow-up period. The results of the study revealed that humanitarian aid has no significant relationship with reducing the financial toxicity experienced by cancer patients in Northwest Syria. Despite the aid efforts, many patients continued to face significant financial distress. The research findings indicate that current humanitarian assistance models might not sufficiently address the complex financial challenges faced by cancer patients in conflict zones. The research emphasizes the need for a more comprehensive and integrated approach in humanitarian aid programs. The study highlights the importance of addressing the economic burdens associated with cancer care in conflict settings and calls for a re-evaluation of aid delivery models to better serve the needs of chronic disease patients. The findings suggest a need for multi-sectoral collaboration and a systemic approach to improve the overall effectiveness of humanitarian assistance in such contexts.

The Emergency Burden in Low- and Middle-Income Countries

Injuries are the greatest single cause of surgical disease globally, disproportionately affecting low and middle-income countries and representing 10% of global mortality and 32% greater annual mortality than HIV/AIDS, tuberculosis, and malaria combined. Road traffic injuries are the single greatest contributor to the global injury burden and the leading cause of death for young people aged 5 to 29 years. In May 2023, the 76th World Health Assembly resolved that emergency, critical, and operative care services are an integral part of a comprehensive national primary health care approach and foundational for health systems to effectively address emergencies. However, robust trauma systems and emergency medical services are lacking in low and middle-income countries to adequately address the prehospital injury burden in systematic and financially sustainable approaches, despite the disproportionate burden faced. Replicating formal Tier 2 emergency medical services (staffed by professional emergency responders within well-defined jurisdictions using dedicated vehicles and equipment) from high-income countries has failed, and the World Health Organization recommends Tier 1 systems (community bystander-driven prehospital care by provided by lay first responders) as the first step toward formal emergency medical services in these same settings. The Global Prehospital Consortium has identified 7 priority areas as a framework for future emergency medical services development, forming the basis for the remaining articles in this series, spanning infrastructure and operations, communication, education/training, impact evaluation, financing, governance/legal, and transportation/equipment.

A Systemic Approach to the Product Life Cycle for the Product Development Process in Agriculture

A Systemic Approach to the Product Life Cycle for the Product Development Process in Agriculture

Regulatory framework for the assessment of the impacts of plant protection products on biodiversity: review of strengths and limits.

The placing of plant protection products (PPPs) on the market in the European Union is governed by numerous regulations. These regulations are among the most stringent in the world, however they have been the subject of criticisms especially because of the decline in biodiversity. The objectives of this work were to review (1) the functioning and actors involved in the PPP framework processes, (2) the construction of the environmental risk assessment focused on biodiversity, and (3) the suggested ways to respond to the identified limits. Both literature from social sciences and ecotoxicology were examined. Despite the protective nature of the European regulation on PPPs, the very imperfect consideration of biodiversity in the evaluation process was underlined. The main limits are the multiplicity of applicable rules, the routinization of the evaluation procedures, the lack of consideration of social data, and the lack of independence of the evaluation. Strengths of the regulation are the decision to integrate a systemic approach in the evaluation of PPPs, the development of modeling tools, and the phytopharmacovigilance systems. The avenues for improvement concern the realism of the risk assessment (species used, cocktail effects…), a greater transparency and independence in the conduct of evaluations, and the opening of the evaluation and decision-making processes to actors such as beekeepers or NGOs. Truly interdisciplinary reflections crossing the functioning of the living world, its alteration by PPPs, and how these elements question the users of PPPs would allow to specify social actions, public policies, and their regulation to better protect biodiversity.

An evidence-based approach to diagnosing patients presenting with orbital inflammatory syndromes (An American Ophthalmological Society Thesis).

The initial management of patients presenting with orbital inflammatory syndromes (OIS) varies - with some pursuing a diagnostic workup while others treat without any testing. The evidence behind this rationale is limited. A review of patients with orbital inflammation is performed with analysis of diagnostic testing to develop a workflow for such patients. A retrospective review of patients presenting with acute orbital inflammation at a single institution from 2011 - 2020 was conducted. Orbital imaging was required for inclusion. Patients with high suspicion of neoplasm, bacterial infection, vascular malformation, or thyroid eye disease were excluded. Review of presenting clinical findings, laboratory workup, orbital imaging, and biopsy were performed. Statistical analysis was performed identifying statistically significant diagnostic and treatment maneuvers. In total, 172 patients met inclusion criteria (66% female, mean age 46 years). The primary clinical presentation was myositis, dacryoadenitis, and infiltrative in 67, 73, and 32 patients (39.0, 43.0, 18.6%, respectively). Laboratory studies were conducted in 145 (84%) while biopsy was performed in 55 (32%). Specific orbital inflammation (SOI) was diagnosed in 29 (16.9%) with most frequent diagnoses being sarcoidosis, IgG4-related disease, inflammatory bowel disease, and systemic lupus erythematosus. The majority (147, 85.5%) was initially treated with steroids, but steroid-sparing agent use was statistically higher in patients with SOI. In patients presenting with OIS, distinguishing myositis, dacryoadenitis, and infiltrative disease has workup and differential diagnosis impacts. Because SOI is relatively common, sequelae of SOI, and potential steroid-sparing therapy needs, diagnosis via an evidence-based systemic approach is critical.

Correction to: Exploring the Methodological Foundation of a Systemic Approach in Grey Systems Theory

Correction to: Exploring the Methodological Foundation of a Systemic Approach in Grey Systems Theory

Immunological nanomaterials to combat cancer metastasis.

Metastasis causes greater than 90% of cancer-associated deaths, presenting huge challenges for detection and efficient treatment of cancer due to its high heterogeneity and widespread dissemination to various organs. Therefore, it is imperative to combat cancer metastasis, which is the key to achieving complete cancer eradication. Immunotherapy as a systemic approach has shown promising potential to combat metastasis. However, current clinical immunotherapies are not effective for all patients or all types of cancer metastases owing to insufficient immune responses. In recent years, immunological nanomaterials with intrinsic immunogenicity or immunomodulatory agents with efficient loading have been shown to enhance immune responses to eliminate metastasis. In this review, we would like to summarize various types of immunological nanomaterials against metastasis. Moreover, this review will summarize a series of immunological nanomaterial-mediated immunotherapy strategies to combat metastasis, including immunogenic cell death, regulation of chemokines and cytokines, improving the immunosuppressive tumour microenvironment, activation of the STING pathway, enhancing cytotoxic natural killer cell activity, enhancing antigen presentation of dendritic cells, and enhancing chimeric antigen receptor T cell therapy. Furthermore, the synergistic anti-metastasis strategies based on the combinational use of immunotherapy and other therapeutic modalities will also be introduced. In addition, the nanomaterial-mediated imaging techniques (e.g., optical imaging, magnetic resonance imaging, computed tomography, photoacoustic imaging, surface-enhanced Raman scattering, radionuclide imaging, etc.) for detecting metastasis and monitoring anti-metastasis efficacy are also summarized. Finally, the current challenges and future prospects of immunological nanomaterial-based anti-metastasis are also elucidated with the intention to accelerate its clinical translation.

Design and Analysis of Mode-Matched Decoupled Mass MEMS Gyroscope with Improved Thermal Stability

Abstract This paper presents an efficient design approach for microelectromechanical systems (MEMS) gyroscope considering the design constraint of MEMSCAP's Silicon-on-Insulator Multi-User MEMS Processes (SOIMUMPs). A design for a decoupled mass MEMS resonant gyroscope with tuning electrodes is presented to minimize cross-axis coupling and optimize the gyroscope's performance. The device features a size of 1.8 ×2.772 mm^2. A decoupled mass MEMS gyroscope has been designed using a novel mechanical beam configuration that optimizes the structural design to reduce unwanted interactions between drive and sense axes motions. Mode order has been achieved by obtaining the first two modes as drive and sense modes at 9946.3 Hz and 10202.7 Hz, respectively. Parallel plate electrostatic tuning electrodes have been added to adjust and match the drive and sense modes at the resonant frequencies of 9946 Hz. This mode matching is crucial for optimizing gyroscope performance, accuracy, and sensitivity. The effects of temperature variation on the performance of the designed decoupled mass MEMS gyroscope have been investigated, particularly in terms of its mode-matched operation achieved using tuning electrodes. Finite Element Method (FEM) simulations were conducted, demonstrating that thermal stability was achieved, and mode-matched operation was maintained within the temperature range of -40 ºC to 80 ºC. The gyroscope exhibits enhanced performance compared to existing MEMS gyroscopes under mode-matched conditions, featuring a lower temperature coefficient of frequency (TCF) at 0.0415 Hz/ºC in the drive mode and 0.0165 Hz/ºC in the sense mode. FEM analysis for the fabrication process tolerances has been done, where MEMS gyroscope’s resonant frequencies, output capacitance, output displacement, and sense mode quality factor have shown negligible changes to fabrication process tolerances. Transient analysis was conducted using CoventorWare MEMS+ 3D schematic, which was integrated with MATLAB Simulink to measure the MEMS gyroscope’s output response, which corresponded with the varying input angular velocity signal.

A maintainable and iterative development approach of critical systems with FoCaLiZe

The life-cycle development of critical systems follows mainly a V-cycle process overlapped with proofs and/or verification techniques. At the first development stage, a critical system must be, precisely, and as completely as possible described. Thus, it is recommended to use a graphical modeling language standard such as the Unified Modeling Language (UML) and the Object Constraint Language (OCL), to which both customers and developers could contribute. Then, the graphical design with its formal specification (requirements) is mapped into a complete formal development environment, using an MDE (Model-driven engineering) approach. The formal environment has to assess the development until the generation of a secure code. In this context, we propose a life-cycle development approach that combines UML/OCL and the FoCaLiZe formal environment for the secure development of critical systems. The proposed approach ensures essential development constraints such as strict boundaries and traceability between development phases. It also ensures a secure maintenance phase using partial transformation techniques from UML/OCL to FoCaLiZe. The latter enhances the transformation from UML/OCL into FoCaLiZe to support incremental development and assist developers in correcting modeling errors. The proposed approach is mostly dedicated to secure and maintainable lifecycle development processes of critical systems. The formal environment assesses the development process until the generation of a secure code. To illustrate the proposed approach, we present the stages of development of a constrained system controlling military objects. The development of this system uses the iterative, incremental, and maintainability stages as described by the development approach, until the generation of secure code.

Policy brief: Learning from Italy to promote sustainability education in Hong Kong

Education is recognised as an integral part of building the capacity of all ages to drive the transformation toward sustainable development. While the Hong Kong government aspires to achieve carbon neutrality by 2050 and has ramped up efforts to integrate sustainability into school curricula and raise public awareness through educational activities, this policy brief argues that Hong Kong’s existing measures failed to empower and motivate individuals and the community to keep pace with its climate action ambition. Drawing on Sterling's framework of education for sustainability (EFS), this paper presents a diagnosis of Hong Kong’s major problems in sustainability education policies and suggests that the Hong Kong government should learn from the Italian experience to take a more systemic, empowering, and democratic approach in advancing its EFS policies.

The Food and Nutrition Policy Environment and Drivers of Changes in Key Food System Outcomes in Ethiopia

Background: There seems to be huge gap in our understanding of the changes over time in food system outcomes and their drivers in Ethiopia. The main aim of this study is to examine the food and nutrition programs and policies and their corresponding key food system outcomes in Ethiopia. Methods: The bulk of the information was generated using scooping review of relevant articles and policy documents. About 67 full text records were used for the review. In addition, data were collected using Key Informant Interview (KIIs) purposefully selected from sectoral offices from two major cities (Hawassa and Dire Dawa), of two regions. The analytical framework used in this paper was adopted from previous studies on related subjects and addressed three key components of food system: review of food and nutrition policy environment, key food system outcomes and key drivers. Results: Despite improvement in some food system outcomes (such as child nutrition and survival), food security crises in Ethiopia are still becoming more frequent and more acute, affecting the poor disproportionately. Most food and nutrition policies are constrained by lack of implementation capacities. Indicating the presence of various barriers (socioeconomic, demographic, and environmental). Poor human capital (such as knowledge and attitude), food taboos and tradition, cultural practices such as gender-based norms, poor education, poor delivery/supply chain, demographic pressure and other environmental drivers play critical role in food and nutrition security of most vulnerable population groups in Ethiopia. Conclusion and implications: Given the challenges confronting Ethiopia today, it is imperative to assume that meeting Sustainable Development Goal (SDG) 2 (i.e., attaining zero hunger by 2030) becomes challenging. This calls for continuous capacity building to help implement, learn, and adapt a systems approach; and access to education and skill training on food production and consumption and narrowing down the gender differential in food access and consumption.

INFECTIOUS ENDOCARDITIS, ITS CHALLENGES AND UPDATING THE DUKE CRITERIA: A LITERATURE REVIEW

Infective endocarditis (IE) is an inflammatory process that occurs in the endocardium and also in implantable cardiac devices, the septum between the heart chambers, and in particular the heart valves, whether biological or prosthetic, this process comes from infection by some microorganism, especially bacteria. In 2023, the International Society of Cardiovascular Infectious Diseases (ISCVID) reformulated the diagnostic criteria, in particular those related to microbiological aspects. The aim of this study is to discuss the modified Duke criteria, therapeutic measures, and future challenges. The present study is a narrative bibliographical review that analyzed scientific production in online databases. Because it is a rare pathology, its annual incidence is between 3 and 10 cases per 100,000 people, and it is twice as common in males. Its treatment is complex, but its mainstay is antibiotic therapy and, when necessary, cardiac surgery. Empirical antibiotic treatment should be carried out as soon as possible after blood culture tests have been taken. In conclusion, IE is one of the most laborious and difficult medical conditions for physicians to practice, so it is important to employ a systemic approach based on scientific evidence for diagnostic investigation and therapeutic care for good results and patient well-being.

The Food and Nutrition Policy Environment and Drivers of Changes in Key Food System Outcomes in Ethiopia

Background: There seems to be huge gap in our understanding of the changes over time in food system outcomes and their drivers in Ethiopia. The main aim of this study is to examine the food and nutrition programs and policies and their corresponding key food system outcomes in Ethiopia. Methods: The bulk of the information was generated using scooping review of relevant articles and policy documents. About 67 full text records were used for the review. In addition, data were collected using Key Informant Interview (KIIs) purposefully selected from sectoral offices from two major cities (Hawassa and Dire Dawa), of two regions. The analytical framework used in this paper was adopted from previous studies on related subjects and addressed three key components of food system: review of food and nutrition policy environment, key food system outcomes and key drivers. Results: Despite improvement in some food system outcomes (such as child nutrition and survival), food security crises in Ethiopia are still becoming more frequent and more acute, affecting the poor disproportionately. Most food and nutrition policies are constrained by lack of implementation capacities. Indicating the presence of various barriers (socioeconomic, demographic, and environmental). Poor human capital (such as knowledge and attitude), food taboos and tradition, cultural practices such as gender-based norms, poor education, poor delivery/supply chain, demographic pressure and other environmental drivers play critical role in food and nutrition security of most vulnerable population groups in Ethiopia. Conclusion and implications: Given the challenges confronting Ethiopia today, it is imperative to assume that meeting Sustainable Development Goal (SDG) 2 (i.e., attaining zero hunger by 2030) becomes challenging. This calls for continuous capacity building to help implement, learn, and adapt a systems approach; and access to education and skill training on food production and consumption and narrowing down the gender differential in food access and consumption.

Perceptions of policymakers and ethicists on ethical considerations in the conduct of research during disease outbreaks in Nigeria

Background There is a dearth of literature on the perspectives of stakeholders from countries in Africa on the institution of a research culture as part of a holistic system of pandemic preparedness and response. This study aimed to explore the perspectives of policymakers, representatives from Research Ethics Committees (RECs), and international bioethics experts on the ethics of conducting research during infectious disease outbreaks in Nigeria. Methods We conducted structured interviews with six policymakers actively engaged in disease outbreak response. The interview themes included systems and structures for research, local researcher competency, regulatory oversight, study types, ethical review approaches, and integrating research into outbreak response. We further engaged 12 participants including REC members from Nigeria and Liberia, international bioethics experts, and study co-investigators in a structured discussion to appraise and expand on themes identified during the interviews at a 2-day meeting in December 2018. We also held two virtual consultations afterwards. The findings from these processes were synthesized to develop a comprehensive report. Results Participants stressed the significance of conducting research during disease outbreaks to understand causal factors, evaluate public health measures, and inform future prevention and treatment strategies, and identified the need for clear ethical guidelines for RECs during outbreaks. Participants proposed a sliding scale for prioritizing categorized studies, emphasizing immediate solutions over future-focused research. Discussants proposed a "systems approach" to ethics review, emphasizing interdependence, governance structures, communication infrastructure, effective communication with policymakers, and a funding structure. Conclusion Conducting ethical research during disease outbreaks requires a comprehensive, context-dependent approach, involving stakeholders, and ensuring robust ethical oversight through proficient RECs. The proposed "System Approach" offers a model for sustainable and effective ethics review during outbreaks, fostering locally relevant and socially valuable research while prioritizing the well-being of research participants and communities.

Approach to hyperuniformity of steady states of facilitated exclusion processes.

We consider the fluctuations in the number of particles in a box of size L^d in Z^d, d>=1, in the (infinite volume) translation invariant stationary states of the facilitated exclusion process, also called the conserved lattice gas model. When started in a Bernoulli (product) measure at density ρ, these systems approach, as t goes to infinity, a "frozen" state for ρ<=ρ_c, with ρ_c=1/2 for d=1 and ρ_c<1/2 for d>=2. At ρ=ρ_c the limiting state is, as observed by Hexner and Levine, hyperuniform, that is, the variance of the number of particles in the box grows slower than L^d. We give a general description of how the variances at different scales of L behave as ρ increases to ρ_c. On the largest scale, L>>L_2, the fluctuations are normal (in fact the same as in the original product measure), while in a region L_1<<L<<L_2, with both L_1 and L_2 going to infinity as ρ increases to ρ_c, the variance grows faster than normal. For 1<<L<<L_1 the variance is the same as in the hyperuniform system. (All results discussed are rigorous for d=1 and based on simulations for d>=2.).

MENTORING AS A FORM OF PSYCHOLOGICAL SUPPORT FOR CHILDREN LEFT WITHOUT PARENTAL CARE

Relevance. The loss of parental care like nothing else affects the psychological well-being of the child and can have detrimental consequences for their further social adaptation and self-realization in adulthood. The emergence of effective mechanisms for child&amp;apos;s social adaptation is the result of its productive interaction with a human social environment and an indispensable condition for successful socialization in society. The purpose of this study is to identify the influence of mentoring on the social and psychological adaptation of children left without parental care. Methodology. By means of theoretical analysis using the methodology of the systemic and cultural-historical approach, the article analyzes in detail the history of mentoring, its types and functions in working with children. Results. The paper proves that a child left without parental care faces a number of problems ( compensation for the level of mental deprivation, formation of basic trust in the world and gender-role identification, understanding ethical norms, and formation of relevant values), which negatively affect their ability to social adaptation. To solve them, she needs competent psychological support from adults. Mentoring is considered as an effective form of psychological support and guidance for children, which, by transforming and enriching itself in the processes of formation, has found due recognition in modern society and is widely used as a tool for the personal development of a person as a subject of activity. It is concluded that the psychological and pedagogical potential of mentoring should be used in the psychological support of children who were left without parental care due to military operations on the territory of Ukraine.

Implementing a systemic approach to water management: piloting a novel multi-level collaborative integrated water management framework in east London

ABSTRACT To address urban growth, resource competition, and environmental degradation, effective integrated water planning is crucial. In the UK, policy frameworks like the 25-Year Plan for the environment and the National Framework for Water Resources stress the need for a systemic approach. Despite efforts in stakeholder engagement and meta-models, integrating physical and human aspects in water management remains a challenge. This paper introduces a multi-level framework for regional water planning, demonstrated through London's Sub-Regional Integrated Water Management Strategy (SIWMS). The framework, depicted as an inverted triangle, starts with conceptual analysis, gathering stakeholder insights and data. Integrated modelling creates a baseline for scenario assessment, providing evidence through metrics and simulations. Integrated planning focuses on collaboration for option selection and implementation. Results show the framework's effectiveness for systems-level analysis at the river basin scale. The logical progression facilitates stakeholder engagement, enhancing shared understanding. The Water Systems Integration Modelling (WSIMOD) Framework allows simultaneous assessment of interventions on various indicators, aiding in prioritising multi-benefit schemes and identifying potential negative impacts. The study supports the prioritisation of schemes like Sustainable Drainage System (SuDS) and emphasises the importance of a multi-level collaborative approach for robust, stakeholder-supported regional water planning to achieve effective implementation of planning and environmental policies.

From the Reflex Machine to the Changeable Brain

AbstractThe brain is exceedingly complex. Neuroscientists have used the tried and tested simplification methods of physics, such as mathematical idealization, in order to deal with neural complexity. This paper queries the appropriateness of certain physics-derived strategies within this biological science by presenting a historical case study (the reflex theory) in which scientists fell into the trap of over-simplifying the brain and nervous system. It then considers whether more recent computational and dynamical systems approaches in neuroscience are also at risk of abstracting away from critical features of neural functionality related to the inherent changeability of those systems.

Comparative toxicological assessment of two bisphenols using a systems approach: Evaluation of the behavioral and transcriptomic responses of Danio rerio to Bisphenol A and Tetrabromobisphenol A.

The zebrafish (Danio rerio) is becoming a critical component of New Approach Methods (NAMs) in chemical risk assessment. As a whole organism in vitro NAM, the zebrafish model offers significant advantages over individual cell-line testing, including toxicokinetic and toxicodynamic competencies. A transcriptomic approach not only allows for insight into mechanism of action for both apical endpoints and unobservable adverse outcomes, but also changes in gene expression induced by lower, environmentally relevant concentrations. In this study, we used a larval zebrafish model to assess the behavioral and transcriptomic alterations caused by sub-phenotypic concentrations of two chemicals with the same structural backbone, the endocrine disrupting chemicals: Bisphenol A and Tetrabromobisphenol A. Following assessment of behavioral toxicity, we used a transcriptomic approach to identify molecular pathways associated with previously described phenotypes. We also determined the transcriptomic Point of Departure (POD) for each chemical by modelling gene expression changes as continuous systems which allows for the identification of a single concentration at which toxic effects can be predicted. This can then be investigated with confirmatory cell-based testing in an integrated approach to testing and assessment (IATA) to determine risk to human health and the environment with greater confidence. This paper demonstrates the impact of using a multi-faceted approach for evaluating the physiological and neurotoxic effects of exposure to structurally related chemicals. By comparing phenotypic effects with transcriptomic outcomes, we were able to differentiate, characterize and rank the toxicities of related bisphenols, which demonstrates methodological advantages unique to the larval zebrafish NAM.

Translating global evidence into local implementation through technical assistance: a realist evaluation of the Bloomberg philanthropies initiative for global Road safety

BackgroundTraffic-related crashes are a leading cause of premature death and disability. The safe systems approach is an evidence-informed set of innovations to reduce traffic-related injuries and deaths. First developed in Sweden, global health actors are adapting the model to improve road safety in low- and middle-income countries via technical assistance (TA) programs; however, there is little evidence on road safety TA across contexts. This study investigated how, why, and under what conditions technical assistance influenced evidence-informed road safety in Accra (Ghana), Bogotá (Colombia), and Mumbai (India), using a case study of the Bloomberg Philanthropies Initiative for Global Road Safety (BIGRS).MethodsWe conducted a realist evaluation with a multiple case study design to construct a program theory. Key informant interviews were conducted with 68 government officials, program staff, and other stakeholders. Documents were utilized to trace the evolution of the program. We used a retroductive analysis approach, drawing on the diffusion of innovation theory and guided by the context-mechanism-outcome approach to realist evaluation.ResultsTA can improve road safety capabilities and increase the uptake of evidence-informed interventions. Hands-on capacity building tailored to specific implementation needs improved implementers’ understanding of new approaches. BIGRS generated novel, city-specific analytics that shifted the focus toward vulnerable road users. BIGRS and city officials launched pilots that brought evidence-informed approaches. This built confidence by demonstrating successful implementation and allowing government officials to gauge public perception. But pilots had to scale within existing city and national contexts. City champions, governance structures, existing political prioritization, and socio-cultural norms influenced scale-up.ConclusionThe program theory emphasizes the interaction of trust, credibility, champions and their authority, governance structures, political prioritization, and the implement-ability of international evidence in creating the conditions for road safety change. BIGRS continues to be a vehicle for improving road safety at scale and developing coalitions that assist governments in fulfilling their role as stewards of population well-being. Our findings improve understanding of the complex role of TA in translating evidence-informed interventions to country-level implementation and emphasize the importance of context-sensitive TA to increase impact.