Logic models help make sense of complexity in systematic reviews and health technology assessments

OBJECTIVE: To describe the development and application of logic model templates for systematic reviews and health technology assessments (HTA) of complex interventions STUDY DESIGN AND SETTING: This study demonstrates the development of a method to conceptualise complexity and make underlying assumptions transparent. Examples from systematic reviews with specific relevance to sub-Saharan Africa (SSA) and other low- and middle-income countries (LMICs) illustrate its usefulness. RESULTS: Two distinct templates are presented: the system-based logic model, describing the system in which the interaction between participants, intervention and context takes place; and the process-orientated logic model, which displays the processes and causal pathways that lead from the intervention to multiple outcomes. CONCLUSION: Logic models can help authors of systematic reviews and HTAs to explicitly address and make sense of complexity, adding value by achieving a better understanding of the interactions between the intervention, its implementation and its multiple outcomes among a given population and context. They thus have the potential to help build systematic review capacity -in SSA and other LMICs - at an individual level, by equipping authors with a tool that facilitates the review process; and at a system-level, by improving communication between producers and potential users of research evidence

Real-life effectiveness of ‘improved’ stoves and clean fuels in reducing PM2.5 and CO: Systematic review and meta-analysis

Background: 2.8 billion people cook with solid fuels, resulting in almost 3 million premature deaths from household air pollution (HAP). To date, no systematic assessment of impacts on HAP of ‘improved’ stove and clean fuel interventions has been conducted. Objective: This systematic review synthesizes evidence for changes in kitchen and personal PM2.5 and carbon monoxide (CO) following introduction of ‘improved’ solid fuel stoves and cleaner fuels in low- and middle-income countries (LMIC). Methods: Searches of published and unpublished literature were conducted through databases and specialist websites. Eligible studies reported mean (24 or 48 h) small particulate matter (majority PM2.5) and/or CO. Eligible interventions were solid fuel stoves (with/without chimneys, advanced combustion), clean fuels (liquefied petroleum gas, biogas, ethanol, electricity, solar) and mixed. Data extraction and quality appraisal were undertaken using standardized forms, and publication bias assessed. Baseline and post-intervention values and percentage changes were tabulated and weighted averages calculated. Meta-analyses of absolute changes in PM and CO were conducted. Results: Most of the 42 included studies (112 estimates) addressed solid fuel stoves. Large reductions in pooled kitchen PM2.5 (ranging from 41% (29–50%) for advanced combustion stoves to 83% (64–94%) for ethanol stoves), and CO (ranging from 39% (11–55%) for solid fuel stoves without chimneys to 82% (75–95%) for ethanol stoves. Reductions in personal exposure of 55% (19–87%) and 52% (− 7–69%) for PM2.5 and CO respectively, were observed for solid fuel stoves with chimneys. For the majority of interventions, post-intervention kitchen PM2.5 levels remained well above WHO air quality guideline (AQG) limit values, although most met the AQG limit value for CO. Subgroup and sensitivity analyses did not substantially alter findings; publication bias was evident for chimney stove interventions but this was restricted to before-and-after studies. Conclusions: In everyday use in LMIC, neither ‘improved’ solid fuel stoves nor clean fuels (probably due to neighbourhood contamination) achieve PM2.5 concentrations close to 24-hour AQG limit values. Household energy policy should prioritise community-wide use of clean fuels

Making sense of complexity in context and implementation: the Context and Implementation of Complex Interventions (CICI) framework.

BACKGROUND: The effectiveness of complex interventions, as well as their success in reaching relevant populations, is critically influenced by their implementation in a given context. Current conceptual frameworks often fail to address context and implementation in an integrated way and, where addressed, they tend to focus on organisational context and are mostly concerned with specific health fields. Our objective was to develop a framework to facilitate the structured and comprehensive conceptualisation and assessment of context and implementation of complex interventions. METHODS: The Context and Implementation of Complex Interventions (CICI) framework was developed in an iterative manner and underwent extensive application. An initial framework based on a scoping review was tested in rapid assessments, revealing inconsistencies with respect to the underlying concepts. Thus, pragmatic utility concept analysis was undertaken to advance the concepts of context and implementation. Based on these findings, the framework was revised and applied in several systematic reviews, one health technology assessment (HTA) and one applicability assessment of very different complex interventions. Lessons learnt from these applications and from peer review were incorporated, resulting in the CICI framework. RESULTS: The CICI framework comprises three dimensions-context, implementation and setting-which interact with one another and with the intervention dimension. Context comprises seven domains (i.e., geographical, epidemiological, socio-cultural, socio-economic, ethical, legal, political); implementation consists of five domains (i.e., implementation theory, process, strategies, agents and outcomes); setting refers to the specific physical location, in which the intervention is put into practise. The intervention and the way it is implemented in a given setting and context can occur on a micro, meso and macro level. Tools to operationalise the framework comprise a checklist, data extraction tools for qualitative and quantitative reviews and a consultation guide for applicability assessments. CONCLUSIONS: The CICI framework addresses and graphically presents context, implementation and setting in an integrated way. It aims at simplifying and structuring complexity in order to advance our understanding of whether and how interventions work. The framework can be applied in systematic reviews and HTA as well as primary research and facilitate communication among teams of researchers and with various stakeholders

ADAPT study: adaptation of evidence-informed complex population health interventions for implementation and/or re-evaluation in new contexts: protocol for a Delphi consensus exercise to develop guidance

Introduction Complex population health interventions that are effective in one context may not be effective elsewhere, and may even be harmful. As such, an intervention may require adaptation to ensure it fits with a new context. To date, there is no overarching guidance to help researchers to adapt and evaluate interventions in new contexts, and no criteria to support research funders or journals assess proposed or reported adaptations or evaluation. There is limited assistance for policy-makers and practitioners to decide if evidence-informed interventions are appropriate to their context, or if adaptation and further evaluation is needed. This Delphi exercise will contribute to the development of guidance for these communities to support the adaptation, implementation and/or re-evaluation of complex population health interventions in new contexts. Methods We will conduct a Delphi consensus exercise to gather expert opinion from researchers, research funders, journal editors and policy-makers. Expert opinion will be sought on: appropriate definitions and concepts, identifying key methodological considerations and establishing adaptations and processes to be undertaken during adaptation of complex population health interventions in new contexts. Ethics and dissemination Ethics approval for the Delphi exercise has been obtained from the University of Glasgow and and the RAND institutional research board. Dissemination of the results of this study will be through peer-reviewed publications, workshops at national and international conferences, and a summary of the guidance developed for key organisations and stakeholders

Energy security in a developing world

Energy security, a fuzzy concept, has traditionally been used to justify state control over energy and a reluctance to deal with energy issues at global level. However, over time, the concept is acquiring different meanings that are applicable at different levels of governance. Many of the elements of the new definitions also imply a number of inherent contradictions. Against this background, this article explores the dimensions of energy security with a special focus on the developing world. It argues that (1) within developing countries (DCs), energy security implies both access to modern energy services by the poorest as well as access by the rapidly developing industrial, services, and urban sectors. Lack of adequate resources has implied trade-offs in terms of who gets access and in terms of taking into account the social and ecological consequences of specific energy sources. Furthermore, (2) the growing DCs' need for energy is impacted by industrialized country perceptions of the various dimensions of energy security-recognizing the need for access to the poorest; industrialized countries are increasingly implicitly questioning the right of DCs to use fossil fuels because of its implications for climate change; or to build large dams because of ecological and social security concerns or expand nuclear energy because of its potential security implications. The development of reliable, continuous, affordable, and environmentally sound provision of energy services combined with a focus on energy efficiency and conservation is the only way of alleviating the various multi-level dimensions of energy security. © 2011 John Wiley & Sons, Ltd

Unintended health and societal consequences of international travel measures during the COVID-19 pandemic: A scoping review

RATIONALE FOR REVIEW International travel measures to contain the COVID-19 pandemic represent a relatively intrusive form of non-pharmaceutical intervention. To inform decision-making on the (re)implementation, adaptation, relaxation or suspension of such measures, it is essential to not only assess their effectiveness but also their unintended effects. This scoping review maps existing empirical studies on the unintended consequences, both predicted and unforeseen, and beneficial or harmful, of international travel measures. We searched multiple health, non-health and COVID-19-specific databases. The evidence was charted in a map in relation to the study design, intervention and outcome categories identified and discussed narratively. KEY FINDINGS Twenty-three studies met our inclusion criteria-nine quasi-experimental, two observational, two mathematical modelling, six qualitative, and four mixed-methods studies. Studies addressed different population groups across various countries worldwide. Seven studies provided information on unintended consequences of the closure of national borders, six looked at international travel restrictions, and three investigated mandatory quarantine of international travelers. No studies looked at entry and/or exit screening at national borders exclusively, however six studies considered this intervention in combination with other international travel measures. In total, eleven studies assessed various combinations of the aforementioned interventions. The outcomes were mostly referred to by the authors as harmful. Fifteen studies identified a variety of economic consequences, six reported on aspects related to quality of life, well-being, and mental health, and five on social consequences. One study each provided information on equity, equality, and the fair distribution of benefits and burdens, environmental consequences and health system consequences. CONCLUSIONS/RECOMMENDATIONS This scoping review represents the first step towards a systematic assessment of the unintended benefits and harms of international travel measures during COVID-19. The key research gaps identified might be filled with targeted primary research, as well as the additional consideration of gray literature and non-empirical studies

Low-smoke chulha in Indian slums: study protocol for a randomised controlled trial

Background Biomass fuel is used as a primary cooking source by more than half of the world’s population, contributing to a high burden of disease. Although cleaner fuels are available, some households continue using solid fuels because of financial constraints and absence of infrastructure, especially in non-notified slums. The present study documents a randomised controlled study investigating the efficacy of improved cookstove on the personal exposure to air pollution and the respiratory health of women and children in an Indian slum. The improved cookstove was based on co-creation of a low-smoke chulha with local communities in order to support adaption and sustained uptake. Methods The study will be conducted in a non-notified slum called Ashrayanagar in Bangalore, India. The study design will be a 1:1 randomised controlled intervention trial, including 250 households. The intervention group will receive an improved cookstove (low-smoke chulha) and the control group will continue using either the traditional cookstove (chulha) or a combination of the traditional stove and the kerosene/diesel stove. Follow-up time is 1 year. Outcomes include change in lung function (FEV1/FVC), incidence of pneumonia, change in personal PM2.5 and CO exposure, incidence of respiratory symptoms (cough, phlegm, wheeze and shortness of breath), prevalence of other related symptoms (headache and burning eyes), change in behaviour and adoption of the stove. Ethical clearance was obtained from the Institutional Ethics Committee of the Indian Institute of Public Health Hyderabad- Bengaluru Campus. Discussion The findings from this study aim to provide insight into the effects of improved cookstoves in urban slums. Results can give evidence for the decrease of indoor air pollution and the improvement of respiratory health for children and women. Trial registration The trial was registered with clinicaltrials.gov on 21 June 2016 with the identifier NCT02821650; A Study to Test the Impact of an Improved Chulha on the Respiratory Health of Women and Children in Indian Slums

Adapting evidence-informed population health interventions for new contexts: a scoping review of current practice

Background Implementing evidence-informed population health interventions in new contexts often requires adaptations. While the need to adapt interventions to better fit new contexts is recognised, uncertainties remain regarding why and when to adapt (or not), and how to assess the benefits (or not) of adaptation. The ADAPT Study aims to develop comprehensive guidance on adaptation. This scoping review informs guidance development by mapping and exploring how adaptation has been undertaken in practice, in public health and health services research. Methods We searched seven databases from January 2000 and October 2018 to identify eligible studies for this scoping review and a related systematic review of adaptation guidance. We mapped the studies of adaptation by coding data from all eligible studies describing the methods, contexts, and interventions considered for adaptation. From this map, we selected a sample of studies for in-depth examination. Two reviewers extracted data independently into seven categories: description, key concepts, types, rationale, processes, evaluation methods, evaluation justification, and accounts of failures and successes. Results We retrieved 6694 unique records. From 429 records screened at full text, we identified 298 eligible studies for mapping and selected 28 studies for in-depth examination. The majority of studies in our map focused on micro- (i.e., individual-) level interventions (84%), related to transferring an intervention to a new population group within the same country (62%) and did not report using guidance (73%). Studies covered a range of topic areas, including health behaviour (24%), mental health (19%), sexual health (16%), and parenting and family-centred interventions (15%). Our in-depth analysis showed that adaptation is seen to save costs and time relative to developing a new intervention, and to enhance contextual relevance and cultural compatibility. It commonly follows a structured process and involves stakeholders to help with decisions on what to adapt, when, and how. Conclusions Adaptation has been undertaken on a range of health topics and largely in line with existing guidance. Significant gaps relate to adaptation of macro- (e.g., national-) level interventions, consideration of programme theories, mechanisms and contexts (i.e., a functional view of interventions), nuances around stakeholder involvement, and evaluation of the adapted interventions. Registration Open Science Framework, 2019, osf.io/udzma

When and how do 'effective' interventions need to be adapted and/or re-evaluated in new contexts? The need for guidance

No abstract available

Structured methodology review identified seven (RETREAT) criteria for selecting qualitative evidence synthesis approaches

OBJECTIVE: To compare and contrast different methods of qualitative evidence synthesis (QES) against criteria identified from the literature and to map their attributes to inform selection of the most appropriate QES method to answer research questions addressed by qualitative research. STUDY DESIGN AND SETTING: Electronic databases, citation searching and a study register were used to identify studies reporting QES methods. Attributes compiled from 26 methodological papers (2001-2014) were used as a framework for data extraction. Data were extracted into summary tables by one reviewer and then considered within the author team. RESULTS: We identified seven considerations determining choice of methods from the methodological literature, encapsulated within the mnemonic RETREAT (Review question - Epistemology - Time/Timescale - Resources - Expertise - Audience and purpose - Type of Data). We mapped 15 different published QES methods against these seven criteria. The final framework focuses on stand-alone QES methods but may also hold potential when integrating quantitative and qualitative data. CONCLUSION: These findings offer a contemporary perspective as a conceptual basis for future empirical investigation of the advantages and disadvantages of different methods of QES. It is hoped that this will inform appropriate selection of QES approaches