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BackgroundDigital innovations have shown promise for improving maternal health service delivery. However, low- and middle-income countries are still at the adoption-utilization stage. Evidence on mobile health has been described as a black box, with gaps in theoretical explanations that account for the ecosystem of health care and their effect on adoption mechanisms. Bliss4Midwives, a modular integrated diagnostic kit to support antenatal care service delivery, was piloted for 1 year in Northern Ghana. Although both users and beneficiaries valued Bliss4Midwives, results from the pilot showed wide variations in usage behavior and duration of use across project sites. ObjectiveTo strengthen the design and implementation of an improved prototype, the study objectives were two-fold: to identify causal factors underlying the variation in Bliss4Midwives usage behavior and understand how to overcome or leverage these in subsequent implementation cycles. MethodsUsing a multiple case study design, a realist evaluation of Bliss4Midwives was conducted. A total of 3 candidate program theories were developed and empirically tested in 6 health facilities grouped into low and moderate usage clusters. Quantitative and qualitative data were collected and analyzed using realist thinking to build configurations that link intervention, context, actors, and mechanisms to program outcomes, by employing inductive and deductive reasoning. Nonparametric t test was used to compare the perceived usefulness and perceived ease of use of Bliss4Midwives between usage clusters. ResultsWe found no statistically significant differences between the 2 usage clusters. Low to moderate adoption of Bliss4Midwives was better explained by fear, enthusiasm, and high expectations for service delivery, especially in the absence of alternatives. Recognition from pregnant women, peers, supervisors, and the program itself was a crucial mechanism for device utilization. Other supportive mechanisms included ownership, empowerment, motivation, and adaptive responses to the device, such as realignment and negotiation. Champion users displayed high adoption-utilization behavior in contexts of participative or authoritative supervision, yet used the device inconsistently. Intervention-related (technical challenges, device rotation, lack of performance feedback, and refresher training), context-related (staff turnover, competing priorities, and workload), and individual factors (low technological self-efficacy, baseline knowledge, and internal motivation) suppressed utilization mechanisms. ConclusionsThis study shed light on optimal conditions necessary for Bliss4Midwives to thrive in a complex social and organizational setting. Beyond usability and viability studies, advocates of innovative technologies for maternal care need to consider how implementation strategies and contextual factors, such as existing collaborations and supervision styles, trigger mechanisms that influence program outcomes. In addition to informing scale-up of the Bliss4Midwives prototype, our results highlight the need for interventions that are guided by research methods that account for complexity.

We urgently need answers to basic epidemiological questions regarding SARS-CoV-2 infection in pregnant and postpartum women and its effect on their newborns. While many national registries, health facilities, and research groups are collecting relevant data, we need a collaborative and methodologically rigorous approach to better combine these data and address knowledge gaps, especially those related to rare outcomes. We propose that using a sequential, prospective meta-analysis (PMA) is the best approach to generate data for policy- and practice-oriented guidelines. As the pandemic evolves, additional studies identified retrospectively by the steering committee or through living systematic reviews will be invited to participate in this PMA. Investigators can contribute to the PMA by either submitting individual patient data or running standardized code to generate aggregate data estimates. For the primary analysis, we will pool data using two-stage meta-analysis methods. The meta-analyses will be updated as additional data accrue in each contributing study and as additional studies meet study-specific time or data accrual thresholds for sharing. At the time of publication, investigators of 25 studies, including more than 76,000 pregnancies, in 41 countries had agreed to share data for this analysis. Among the included studies, 12 have a contemporaneous comparison group of pregnancies without COVID-19, and four studies include a comparison group of non-pregnant women of reproductive age with COVID-19. Protocols and updates will be maintained publicly. Results will be shared with key stakeholders, including the World Health Organization (WHO) Maternal, Newborn, Child, and Adolescent Health (MNCAH) Research Working Group. Data contributors will share results with local stakeholders. Scientific publications will be published in open-access journals on an ongoing basis.

Objective: To describe and compare the characteristics of people with SUD and their use of healthcare services in two ways: 1) across varying levels of marginalization and 2) before and during the pandemic. Methods: We conducted a population-based cross-sectional study using administrative data from Ontario, Canada. We included individuals age 16+ with a recorded diagnosis of SUD between June 2018–2019 (pre-pandemic) and June 2021–2022 (during-pandemic). Baseline sociodemographic and clinical characteristics and use of healthcare services were enumerated across the five quintiles of the Ontario Marginalization Index. Results: 259,497 pre-pandemic and 276,459 during-pandemic people with SUD were identified. Over 40% belonged to the two highest marginalization quintiles (Q4/Q5). Most had an outpatient visit with similar percentages across quintiles, however the number of visits increased with increasing marginalization (pre-pandemic: mean 8.5 visits in Q1 vs 13.0 visits in Q5; during-pandemic: mean 9.5 in Q1 vs 13.4 in Q5). There was no consistent pattern in percent of people who sought alcohol-related outpatient care, however more marginalized people sought drug-related outpatient care (pre-pandemic: 19.1% in Q1 vs 31.7% in Q5; during-pandemic: 18.7% in Q1 vs 32.5% in Q5). Almost half of people with SUD had an emergency department (ED) visit, of which more belonged to higher marginalization quintiles (pre-pandemic: 43.5% in Q1 vs 49.8% in Q5; during-pandemic: 41.4% in Q1 vs 49.3% in Q5). Conclusions: SUD prevalence and most health service utilization remained similar from pre- to during-pandemic. Increasing marginalization was associated with increased use of healthcare among people with SUD. Future research should aim to further explore the complex relationship between marginalization and substance use. [ABSTRACT FROM AUTHOR]

Introduction: Adolescent pregnancy is defined as pregnancy at the age of 19 or below. Pregnancy and childbirth complications are the most significant cause of death among 15–19-year-old girls. Several studies have indicated that inequitable gender norms can increase the vulnerability of adolescent girls, including violence exposure, early marriage, and adolescent pregnancy. To address these disparities, gender transformative approaches aim to challenge and transform restrictive gender norms, roles, and relations through targeted interventions, promoting progressive changes. This realist review aims to synthesise existing evidence from a broad range of data sources to understand how, why, for whom, and in what contexts gender transformative approaches succeed in reducing adolescent pregnancy in low- and middle-income countries. Method and analysis: We employ a five-step realist synthesis approach: (1) clarify the scope of review and assessment of published literature, (2) development of initial programme theories, (3) systematic search for evidence, (4) development of refined programme theories, and (5) expert feedback and dissemination of results. This protocol presents the results of the first three steps and provides details of the next steps. We extracted data from 18 studies and outlined eight initial programme theories on how gender transformative approaches targeting adolescent pregnancy work in the first three steps. These steps were guided by experts in the field of sexual and reproductive health, implementation science, and realist methodology. As a next step, we will systematically search evidence from electronic databases and grey literature to identify additional studies eligible to refine the initial programme theories. Finally, we will propose refined programme theories that explain how gender transformative approaches work, why, for whom, and under which circumstances. Ethics and dissemination: Ethics approval is not required because the included studies are published articles and other policy and intervention reports. Key results will be shared with the broader audience via academic papers in open-access journals, conferences, and policy recommendations. The protocol for this realist review is registered in PROSPERO (CRD42023398293). [ABSTRACT FROM AUTHOR]

Over the last three decades, integrated care has emerged as an important health system strategy to improve population health while addressing the unique needs of structurally marginalised communities. However, less attention has been given to the role of integrated care in addressing issues related to inequities in health and health care. In this commentary we introduce the concept of Equity Promoting Integrated Care (EPIC) that situates integrated care in a social justice context to frame the actions necessary to center equity as a priority for integrated care. We suggest that efforts to advance the design and implementation of integrated care should focus on three avenues for future research and practice, namely, the collaborative mobilization of a global network of integrated care stakeholders to advocate for social justice and health equity, investing in equity-focused approaches to implementation science that highlight the importance of social concepts such as colonialism and intersectionality to advance the theory and practice of implementing EPIC models of care, and leveraging innovative approaches to measuring equity-related aspects of integrated care to inform continuous improvement of health systems. [ABSTRACT FROM AUTHOR]

Realist evaluation is in essence a theory-building and testing approach. We argue that in practice, the theory-building potential of realist evaluation, review and research is not fully exploited in the field of global health. Our assumption is that the Structure-Agency-Culture explanatory framework of critical realist Margaret Archer could stimulate realist evaluators to conceptualize and systematically explore how structural and cultural conditions interact with programmes that aim at introducing social change. We propose step-wise guidance towards integrating the Structure–Agency–Culture framework into the development of realist programme theories. We present a worked example from an urban adolescent health study in poor neighbourhoods of Kampala, Mumbai, New Delhi and Cotonou. The guidance aims to bring to the fore the role of agency and context through the analysis of the interactions between structure, culture, agency and mechanisms. This is helpful in realist research in general, and in evaluations of complex interventions oriented towards social change. [ABSTRACT FROM AUTHOR]

Background: The declaration of Coronavirus disease 2019 (COVID‐19) as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 required rapid implementation of early investigations to inform appropriate national and global public health actions. Methods: The suite of existing pandemic preparedness generic epidemiological early investigation protocols was rapidly adapted for COVID‐19, branded the 'UNITY studies' and promoted globally for the implementation of standardized and quality studies. Ten protocols were developed investigating household (HH) transmission, the first few cases (FFX), population seroprevalence (SEROPREV), health facilities transmission (n = 2), vaccine effectiveness (n = 2), pregnancy outcomes and transmission, school transmission, and surface contamination. Implementation was supported by WHO and its partners globally, with emphasis to support building surveillance and research capacities in low‐ and middle‐income countries (LMIC). Results: WHO generic protocols were rapidly developed and published on the WHO website, 5/10 protocols within the first 3 months of the response. As of 30 June 2021, 172 investigations were implemented by 97 countries, of which 62 (64%) were LMIC. The majority of countries implemented population seroprevalence (71 countries) and first few cases/household transmission (37 countries) studies. Conclusion: The widespread adoption of UNITY protocols across all WHO regions indicates that they addressed subnational and national needs to support local public health decision‐making to prevent and control the pandemic. [ABSTRACT FROM AUTHOR]