Intensification of modern swine production has led to many new technologies, including needleless injectors. Although needleless injectors may increase productivity (by reducing injection time) and reduce needlestick injuries, the effect on risk for musculoskeletal disorders is not clear. This project will compare conventional needles with needleless injectors in terms of cost, productivity, injury rates, biomechanical exposures, and worker preference. Muscle activity (EMG) and hand/wrist posture will be measured on swine workers performing injection tasks with both injection methods. Video recordings during the exposure assessments will compare the duration and productivity for each injection method using time-and-motion methods. Injury claim data from up to 60 pig barns will be analyzed for needlestick and musculoskeletal injuries before/after needleless injector adoption. Workers and managers will be asked about what they like and dislike about each method and what helps and hinders successful implementation. The information above will be input into a cost-benefit model to determine the incremental effects of needleless injectors in terms of occupational health, worker preference, and the financial “bottom line” of the farm. Findings will be relevant to the swine industry and are intended to be transferable to other new technologies in animal production. A recent review of musculoskeletal disorders (MSD) among farmers reported 91% lifetime prevalence for any type of MSD and one-year prevalence of 77% . LivestoAgricultural MSD occur within a changing industrial context. Between 2001 and 2011, the number of pig farms in Canada decreased from 15,472 to 7,371 (~52% decrease), demonstrating the overall trend of consolidating pork production into larger barns , 9. ThisEconomic pressures also drive technological advancement, especially in those areas that will enhance productivity or reduce production costs. For example, needleless injectors are now available to replace hypodermic needle injectors. They may help reduce needlestick injuries in workers, although the possibility of accidental injection into workers remains, as does the possibility of abscess at the injection site . NeedlelThe need for ergonomic interventions that limit musculoskeletal risk factors in agriculture  is widely acknowledged , 17. TheInjection for nutritional supplements, immunizing animals, and providing treatment to sick animals is a standard practice in the swine industry . Historically, barn workers performed injections using a hypodermic needle and injecting (subcutaneous or intramuscular) into the animals. However, an alternative needleless method uses pressure to force a jet of vaccine or other liquid through the dermal layer and into the subcutaneous tissue . AlthougAlthough needleless injectors eliminate needlestick injuries and needle contamination of meat (benefits), they may introduce an unintended consequence of increased forearm activity, frequency of gripping motion, and awkward postures (costs in terms of injury claims and lost productivity). Repetitive movements during work tasks have been consistently shown to increase risk of musculoskeletal disorders , 30. SucThis project will use a combination of quantitative and qualitative data collection strategies: (1) electronic measurement of muscle activity and hand/wrist postures; (2) time-and-motion productivity analysis of each method; (3) employer records of needlestick, upper limb, and other musculoskeletal injuries ; (4) worker focus groups and key informant interviews to determine barriers and facilitators to safe injection advantages of each method; and (5) an economic analysis of the comparative costs and benefits. A subsequent decision-making toolkit will be based on project outcomes as shown in This project has been approved by the University of Saskatchewan research ethics board (certificate number Beh 16-161). All participation will be completely voluntary after seeking informed consent.The typical range of costs for each method will be assessed by querying research partners, with confirmation by producer records where needed. Relevant costs include equipment purchase, maintenance, consumable supplies, and worker training. Although we have secured participation of 60 barns in the Canadian provinces of Saskatchewan and 40 barns in Manitoba, we anticipate that costs will be fairly consistent due to the relatively low number of needleless injector systems available for purchase in North American, so only a 10% sample (6 barns) will be needed. If costs are very diverse, an additional 6 barns will be contacted.Injury records  will be obtained from large, multisite pork producers, representing a population of 420 swine workers in Saskatchewan and 300 workers in Manitoba. These data are already collected in the course of business operations, with the addition of noting which barns have needleless injectors and the date they were introduced. All barn and personal identifiers will be anonymized before delivery to the research team.Volunteer swine workers will be recruited from the swine production barn of the Prairie Swine Centre, a research-intensive barn with ties to the University of Saskatchewan. This study will measure both needleless injectors and conventional needle injectors shown in  for commParticipant characteristics including sociodemographic variables, employment history, recent musculoskeletal pain or discomfort, and history of MSD will be collected by a questionnaire. Video of the workers using each injection method will be recorded for subsequent analysis using time-and-motion description to determine worker productivity. Wrist flexion-extension and radioulnar deviation angles and finger joint flexion angles of the dominant upper limb will be measured using an instrumented data glove . The data glove is made of stretchable fabric to accommodate a range of hand sizes, and the fingertips are open to enable routine tool use. The embedded sensors are thin and flexible to allow for unimpeded performance of work tasks. The data glove was previously used to assess kinematics during precision gripping  and handTo infer musculoskeletal loading, forearm flexor and extensor muscle activity will be collected via surface electromyography (sEMG). Bipolar surface electrodes with a fixed interelectrode distance of 20 mm  will be positioned over the bulk of the forearm flexor compartment and the forearm extensor compartment . These eReduction of exposures does not guarantee a reduction in MSD . AlthougData are available both for in-barn incident reports and provincial Workers' Compensation Board claims  for the past 6 years; both of these sources will be investigated for both needlestick/accidental injection injuries and upper limb musculoskeletal injuries. Comparisons will be made before and after needleless injector implementation, with implementation for at least 15 months. The postimplementation injury rates will be calculated following a 3-month “implementation period” after needleless injectors are delivered to the barn. Injury data will be divided into equal-duration periods before and after the injectors were introduced. For example, where a barn that implemented needleless injectors 30 months ago, a 27-month period after intervention (30 months less the 3-month implementation period) would be compared to a 27-month period before intervention. The maximum duration for comparison will be 60 months after implementation and an unlimited preimplementation period. We anticipate approximately 40 barns being eligible, representing approximately 300 full-time equivalents (FTE) per year over the past 10 years  for a sample of 3000 FTE-years. Incident rates will be calculated for the pre- and postimplementation periods, and survival analysis will be performed to determine the highest-risk milieu for both needlestick and upper limb MSD. We hypothesize that needleless barns will have reduced needlestick injuries but increased upper limb claims.Time-and-motion analysis involves dividing a work task such as “injecting pigs” into subtasks, activities, and discrete movements or elements, using a stopwatch to time these elements and determine the total task time, cycle time , and the duty cycle (the proportion of time spent doing productive work) . In addiEMG will be normalized  to muscle-specific preshift maximum voluntary efforts and summarized via amplitude probability distribution function . Wrist and finger joint kinematics, including joint angles, angular velocities, and angular acceleration will also be summarized by APDF. In addition to joint kinematics and EMG, video-based task observation will be used to assess exposures and injury risk with standardized ergonomic tools for the upper limb: Revised Strain Index  and HandFocus groups and interviews will be audio recorded and transcribed and then given to participants to check for accuracy. This qualitative data will identify barriers and enablers of injector implementation success and identify any unintended consequences. In addition to developing a potential “wish list” of specifications for improved designs, this information will be used to identify pork industry specific organizational factors and “readiness for implementation” indicators. Worker focus group feedback and manager perceptions of advantages and disadvantages of each process will be analyzed qualitatively using an inductive thematic analysis approach  with NViA cost-benefit analysis of the needleless injector compared with current practice will be performed from the perspective of the swine producer over a 5-year time frame (based on estimated working life of needleless injector system). The costs of the needleless injection technique will be estimated and compared to standard practice of conventional needles in terms of capital costs (equipment), variable costs of production, absenteeism, and injury claims. The benefits of the needleless injector in terms of worker productivity will be estimated and expressed in monetary terms. The sum of the net present value of incremental costs and benefits of the needleless injector will be compared with current practice. The technology with the highest net present value will be considered the most cost-effective from the perspective of the swine producer. The costs and benefits will be used to inform a business case for employers considering implementing needleless injectors, including return on investment and estimates of enterprise scale to identify which producers (if any) will see a net benefit from the investment. This analysis will be performed using the pork production enterprise model developed by the Prairie Swine Centre –51. The Developing the Decision Toolkit. One of the major industry-relevant outcomes of this project will be the development of a decision-making toolkit capable of balancing the impact of multiple inputs: productivity, injury, and so forth. This tool will be translated into a web-based application where users can enter characteristics of their organization, current injury rates, anticipated implementation costs, and then receive an estimate of the cost-benefit that a certain innovation will deliver. The algorithm to estimate cost-benefit will be developed using the data collected during this project, as well as prioritizations and input from the stakeholder advisory group. To address situations where the nature of the proposed innovation differs substantially from the needleless injector case study, margins of error will also be estimated.To ensure that the results of this study remain relevant to the pork industry, the research team will maintain strong industry connections through the use the Canadian Institutes of Health Research integrated knowledge translation (KT) approach, engaging stakeholders throughout the research process . IntegraIntensification of Canadian pig farms  has resuThe need for ergonomic interventions has been identified for agriculture in general , 54 and Safety interventions (such as a needleless injector) are often multifaceted and introduced into complex environments; personal factors such as self-efficacy and skills, as well as organizational factors such as management support and device accessibility, can impact the degree to which an intervention is implemented . BecauseA comprehensive decision-making tool needs to incorporate all the dimensions of successful implementation, as well as those which influence decision-making regarding adopting a new technology. For example, Schell et al. describe nine main areas of influence for public health intervention sustainability: “Political Support, Funding Stability, Partnerships, Organizational Capacity, Program Evaluation, Program Adaptation, Communications, Public Health Impacts, and Strategic Planning” . The fraWhile this project aims to fill a specific gap in knowledge, it also has some limitations. For example, the sampling strategy will likely include more large firms than small firms ; however, this may provide fewer samples on the conditions of smaller firms. In the case that these smaller firms are very diverse, we may consider oversampling them to get a more robust estimate of costs in this group; this will help to identify the production levels which derive a net benefit from adopting new technology. While this study will account for loss of a total pig carcass from a broken needle, meat quality losses arising from abscess, lesions, or infection at the injection site will not be included.The study described in this protocol will use comprehensive evaluation to determine whether needleless injectors have a net health/economic benefit and also promote a highly industry-relevant and applicable set of research methods (the decision-making toolkit) that will be useful in OH&S throughout the pork value chain and highly applicable to other industries. We anticipate the first users of this research will be the swine industry representatives involved in our stakeholder advisory group. This work will also be transferable to other animal care tasks in the agriculture industry, including dairy, cattle production, veterinary services, and equestrian work. In addition to these benefits to the industrial sector, this project will contribute to future research by developing a parsimonious suite of methods for comprehensive evaluation of occupational health and safety interventions.


The Doris Duke Charitable Foundation’s African Health Initiative supported the implementation of Population Health Implementation and Training (PHIT) Partnership health system strengthening interventions in designated areas of five countries: Ghana, Mozambique, Rwanda, Tanzania, and Zambia. All PHIT programs included health system strengthening interventions with child health outcomes from the outset, but all increasingly recognized the need to increase focus to improve health and outcomes in the first month of life. This paper uses a case study approach to describe interventions implemented in newborn health, compare approaches, and identify lessons learned across the programs’ collective implementation experience.Case studies were built using quantitative and qualitative methods, applying the World Health Organization Health Systems Strengthening Framework, and maternal, newborn and child health continuum of care framework. We identified the following five primary themes in health systems strengthening intervention strategies used to target improvement in newborn health, which were incorporated by all PHIT projects with varying results: health service delivery at the community level (Tanzania), combining community and health facility level interventions (Zambia), participatory information feedback and clinical training (Ghana), performance review and enhancement (Mozambique), and integrated clinical and system-level improvement (Rwanda), and used individual case studies to illustrate each of these themes.Tanzania and Zambia included significant community-based components, including mobilization and sensitization for increased uptake of essential services, while Ghana, Mozambique, and Rwanda focused more efforts on improving the quality of services delivered once a patient enters a health facility. All countries included aspects that improved communication across levels of the health system, whether through district-wide data sharing and peer learning networks in Mozambique and Rwanda, or improved referral processes and systems in Tanzania, Zambia, and Ghana.Key lessons learned include the importance of focusing intervention components on addressing drivers of neonatal mortality across the maternal and newborn care continuum at all levels of the health system, matching efforts to improve service utilization with provision of high quality facility-based services, and the critical role of leadership to catalyze improvements in newborn health. While child mortality has improved worldwide, catalyzing similar advances during the newborn period has proven more challenging . Key intDespite numerous evidence-based interventions to improve newborn survival, coverage and quality remain significant challenges to accelerating change . DriversThe Doris Duke Charitable Foundation’s African Health Initiative (AHI) created a platform for implementation and rigorous evaluation of health system strengthening interventions to improve population health in selected areas of five countries: Ghana, Mozambique, Rwanda, Tanzania, and Zambia. All country programs included were implemented in politically stable settings, a mix of rural and urban settings, and with a broad goal of reducing mortality among children under 5. Within the first few years of broader health systems strengthening, all of the Population Health Implementation and Training (PHIT) Partnership teams recognized that neonatal mortality was representing a larger proportion of under-5 deaths in their countries and in their implementation areas specifically, and so initiated or strengthened strategies designed to improve neonatal health outcomes. We used case study methodology to retrospectively describe the design and implementation of the neonatal-focused interventions to compare approaches, and identify lessons learned across the collective experience.Each country program team designed their broader PHIT intervention following the World Health Organization (WHO) building block framework . Case stQuantitative and qualitative methods were used to build each case in its country context. Each PHIT team chose a representative to lead their participation. Indicators related to maternal and newborn health used in all PHIT programs were identified and collected by these representatives from routinely and non-routinely collected programmatic data. These data were reviewed and compared to contextualize each program case study. Representatives also had the option of including additional program-specific quantitative data relevant to their intervention implementation  or implicitly  related to neonatal health. Interventions were also analyzed to identify key processes targeting specific steps along the continuum of care lifecycle approach to newborn health   see Fig. InductiBaseline data were collected at the start of the African Health Initiative in all five PHIT countries using agreed-upon common indicators . Descri. All setAll country PHIT programs focused on health system improvement approaches designed to address the gaps identified in their local setting , 8–12. WThe PHIT Partnership in Tanzania (Connect) was designed as a randomized cluster trial in 2011 to measure the impact of posting paid community health workers, named community health agents (CHAs), on child mortality rates in three rural districts of Tanzania  . This waTo improve access to maternal and newborn health services, Connect implemented a number of strategies, including community-based service provision, improved case detection and referrals, support for telecommunication, vehicle support, and data feedback. First, CHAs were trained for 9 months to enable them to provide a number of key services. CHAs in communities conducted home visits during pregnancy to counsel on and promote early initiation of ANC within the first 4 months of pregnancy and at least four subsequent ANC visits, and to discuss birth preparedness and the importance of facility-based deliveries. When deliveries occurred at home, CHAs coordinated immediate facility assessment. CHAs were tasked with conducting at least four postnatal home visits starting 24 hours after delivery, followed by visits at three, seven, and 28 days after delivery. The CHAs’ main tasks during these visits were to identify mothers and newborns with complications and refer them to the nearest health facility; provide intensive counseling on essential newborn care, including immunizations and exclusive breastfeeding; screen for low birth weight; and educate households on maternal and newborn postpartum danger signs.Finally, the Connect team organized a one-day annual meeting to share results with CHAs and their supervisors (nurses and midwives), as well as representatives from the District Medical Office. By the 2013 annual meeting, results had shown that the intervention had not led to changes in neonatal mortality rates. Therefore, from that point forward, improving the use of the emergency referral systems for sick newborns immediately to health facilities was prioritized. Connect complemented this community-based referral process with additional investments, including: 1) extending the provision of cell phones to all health facilities (CHAs and their supervisors had this service before) with unlimited calls to a closed user group for emergency referrals; 2) repairing six ambulances in Kilombero and Ulanga districts; 3) purchasing a vehicle ambulance and a boat ambulance for Rufiji district, and; 4) training health workers and ambulance drivers in first aid.Table Health improvements have been seen in both the intervention and comparison groups. Despite the improvement seen, the intervention did not appear to have any additional effect in terms of antenatal care utilization of four or more visits, use of a skilled attendant at birth, or postnatal care utilization at the health facility and community levels for both the mother and the newborn, indicating that improvements were unlikely to have been related to the interventions implemented by the Connect project. Additional qualitative study is underway to explore potential reasons for this lack of impact.Challenges encountered in the program included delays in payment of the CHAs’ monthly salary, which affected their motivation and activity level; shortage of supplies and supervision activities, and; poor quality of care at facilities when referrals by CHAs were achieved, since the project did not improve the quality of service at the facility level.The PHIT project in Zambia  implemented a complex quality improvement program in 42 rural health facilities in the districts of Chongwe, Kafue, and Luangwa in Lusaka province beginning in 2011. The detailed methodology of BHOMA has been reported elsewhere  and inclProject efforts at the community level worked to improve health-seeking among pregnant women through community mobilization. Community volunteers conducted home visits to pregnant women, during which they discussed birth preparedness and the importance of facility-based deliveries. Traditional birth attendants (TBAs) were provided with register books to report contact with pregnant women and pregnancy outcomes for women in the catchment areas. TBAs were trained to identify women having home deliveries and escort them to the nearest health facility as soon as possible. The TBAs also conducted postnatal home visits at 2 days of life for every newborn within their communities. The main activities during these visits were to screen for neonatal danger signs and to encourage the mothers to attend facility-based postnatal clinics. Additionally, in each village, community-based Safe Motherhood Action Groups were trained to provide continuous sensitization activities around key maternal and newborn health topics.At the health facility level, the BHOMA intervention focused on strategies to improve quality of antenatal, delivery, and postnatal care. This included the initial supply of key equipment to ensure that providers had the necessary tools to provide quality care, training, and mentoring.In ANC, providers were trained to counsel pregnant women on key health topics, including the importance of at least four ANC visits, facility-based delivery, and prevention of infectious diseases, such as malaria, HIV, and syphilis. To improve delivery management, simplified partographs were introduced and facility health care providers were trained in essential maternal and newborn care. Furthermore, PHIT program staff conducted onsite mentoring and supervisory visits at the delivery sites to assess the adherence to guidelines for managing the normal births as well as those with common complications. From these chart reviews, areas of weak performance were identified and retraining was undertaken accordingly. Mentoring visits were jointly conducted with District Medical Office teams with supervision plans integrated into annual district plans to support integration of the program into the public system and ongoing sustainability beyond the BHOMA project period.To improve postnatal facility-based care, a “sick” neonatal form was designed to augment the existing pediatric form to address specific neonatal illnesses and facilitate clinical decision-making. Furthermore, a week one visit encounter data point was added to data monitoring to track early health system contact with the neonate and facilitate efforts to improve coverage of postnatal care.Across all system levels, facilitating data collection and use was also a core intervention. Community health workers were provided with special phones and trained on tracking and completing follow up data collection using these phones . Touch sBetween 2013 and 2015, using PHIT-supported cross-sectional surveys, steady improvements were recorded in key indicators related to newborn health, including ANC attendance, at least four ANC visits, use of modern contraceptives, and health facility deliveries  was designed to increase universal access to health care by expanding coverage of the national primary health care system, called Community-Based Health Planning and Services (CHPS) , at the The GEHIP project objectives were accomplished through targeted audits, midwife training, and the development of clinical skills among community nurses. First, participatory feedback of information was derived from a program of targeted audits: death audits of all maternal and neonatal deaths that occurred in facilities in the region, and a 2011 audit of health system referrals of mothers and neonates . The matThe GEHIP program trained midwives at the sub-district and village levels in neonatal resuscitation using a bag and mask to prevent birth asphyxia –24. GEHIOverall evaluation of outcomes was through the baseline and endline population health surveys, in combination with the DHS data and facility process data. The project team looked at change in neonatal mortality over time and process measures for the delivery of the intervention.The audits brought to the attention of senior management key challenges to neonatal survival, such as the high number of deaths due to birth asphyxia and processes contributing to asphyxia. Informational feedback involved UERHA leadership and health staff at all levels in problem solving and led to the development of an enhanced neonatal survival intervention package implemented by GEHIP at all levels of the health system Table . CorrectThe Mozambique PHIT strategy to improve the delivery of newborn care had two main objectives: 1) improved data use and analysis, and 2) strengthened capacity in health system management. These were combined through district performance review and enhancement meetings as an approach to use data to motivate quality improvement activities. These meetings brought together front-line health workers with district and provincial managers to review key performance indicators, identify gaps in performance, plan solutions, and monitor the implementation of these action plans.Beginning with their initial pilot in 2012, these cycles have become a cornerstone of the Mozambique PHIT project’s implementation strategy, as they effectively bridge data quality assessment and improvement efforts , 33, 34,Part of the success of these meetings was that they were co-organized between the PHIT project staff and the local Provincial Health Department, and participants included Ministry of Health (MOH) paid and supported managers and front-line clinical providers. MOH leaders of the program for maternal and child health led decision-making on how to best conduct the meetings, provided feedback on the action plans, and led supervision efforts after action planning. This increased acceptability, uptake, and attendance of provincial, district, and health facility representatives, as this was seen as a core duty for their position as health system managers.During these meetings, which were planned to occur at least every 6 months, health facility leadership presented and reviewed secular trends in outputs and coverage estimates across a range of MCH services, including reproductive health  and child health. Meetings were jointly organized between provincial and district MCH leadership, along with technical support from Health Alliance International field staff. The district MCH director or the Chief Medical Officer for the district facilitated meetings. Four days prior to the meetings, district MCH supervisors, along with leadership and Health Alliance International technical staff, reviewed data and presentations, and provided mentorship around data interpretation and presentation. At the meetings, action plans were developed and updated based on new data trends to reflect priority activities and timelines to respond to identified problems. MCH nurses at each health facility worked with district leadership to develop and implement feasible action plans. Implementation of previous action plans was shared at subsequent meetings, facilitating accountability and peer learning across facilities of commonly shared challenges and spread of successful interventions.Challenges related to the performance review and enhancement meetings centered on monitoring and evaluation of targeted areas for improvement, tracking of action plans over time and across multiple meetings, and standardization of evaluation components for the program. Given the myriad different problems identified . This approach: 1) equipped health facilities by filling gaps in essential equipment and materials for neonatal care identified through a structured assessment process; 2) provided training and on-site, regular clinical mentorship to improve delivery of evidence-based interventions; and 3) launched district-wide learning collaboratives to build healthcare workers’ leadership in data utilization for continuous QI. The factors contributing to newborn deaths occur across pregnancy, delivery, and postnatal periods, as well as multiple levels of the health system. This combination of clinical mentorship and health system strengthening aimed to address the multi-causal nature of neonatal mortality and overcome identified weaknesses of vertical, fragmented interventions while addressing multiple points along the maternal newborn continuum of care , 40 . During a series of four to five mentor-led learning sessions in each district, QI teams met to review performance, identify specific process barriers, and innovate, implement, and test ideas to improve quality of care. Teams used standard plan-do-study-act QI cycles, which were supported by ABC mentors, targeted key indicators in the neonatal care continuum—antenatal care, delivery, and post-partum care—and worked to build leadership skills.The ABC intervention formally began with the first set of baseline trainings and a learning session in September 2013. Targeted process indicators focused on the antenatal, intrapartum, and postnatal periods. These data were derived from routinely collected mentor tools. Indicators derived from the health management information system were validated by register review and corrected as needed. Data for newly introduced indicators were derived from registers introduced to facilities at the start of the program period.At 18 months of implementation, health facilities had received an average of one visit per month by the clinical/QI mentor, and all health facilities had participated in each of the five learning sessions. All health facilities maintained at least two nurses trained in essential newborn care, and 60 QI projects were being implemented by facility teams across the districts. Over the 18-month learning collaborative period, improvement in targeted process indicators in the antenatal, intrapartum, and postnatal periods was seen Table .Table 5AWhile there were a number of implementation successes, significant challenges had to be addressed throughout the intervention period, and the design was adapted to optimize impact. For example, after observing that quality improvement activities took longer for rural facility teams to engage in than anticipated, the learning collaborative length was increased from 12 to 18 months, coaching was intensified, and health system leaders were more strongly engaged in learning session leadership and participation. Additionally, some QI teams found that their leadership was reluctant to support activities that they were not technically familiar with themselves; QI trainings were therefore offered to health facility and district leadership to build their comfort with and understanding of their role in catalyzing improvement. Furthermore, existing MOH supervisors were engaged throughout the collaborative period as co-mentors with the ABC mentors to build their capacity to sustain and deepen improvement moving beyond the collaborative period. However, staff turnover of these supervisors occurred towards the end of the collaborative, which served as a challenge to long-term capacity building at the mentor level. A sustainability analysis is underway to evaluate the durability of improvements achieved 1 year after the end of the formal collaborative.Across the PHIT projects, there were a number of commonalities, differences, and lessons learned in the strategies designed and implemented to improve newborn care and health. While each country emphasized the different themes described above, all included components focused on supporting at least some, if not all, of the WHO Health Systems Framework building blocks to improve systems of care for vulnerable newborns Table .Table 7PWhen PHIT projects were analyzed using a continuum of care framework Table , some diThere were a number of key lessons learned based on these experiences. First, all PHIT projects found that an intentional focus on improving care delivery by targeting drivers of neonatal deaths and reflecting local context was critical to improving newborn health and outcomes. Each PHIT project appropriately adapted their intervention to reflect baseline needs, local context, and government priorities, using the resources available. The All Babies Count initiative in Rwanda was a focused neonatal quality of care improvement initiative across the neonatal care continuum and at all facility levels; however, they did not have a large focus on demand creation, reflecting results from the formative assessment and baseline high facility delivery rate. The Zambia PHIT project designed their neonatal work partway into the implementation time period, after finding that they were not seeing the desired neonatal health improvements using their more general quality improvement approach in routine outpatient service strengthening.Second, given the complex nature of the drivers of neonatal health outcomes—occurring at multiple time points from pregnancy through delivery and postnatal care, and at all system levels—we found that consistent with the continuum of care framework , 41–44, Third, we found that encouraging utilization of services must be met with high quality services. The Tanzania Connect project focused its efforts entirely at the community level . However, this approach assumed that health facilities were adequately prepared to care for these complicated cases. While these efforts improved the rates of emergency referrals, they were not sufficient to markedly reduce the rate of neonatal deaths . Similar to other studies, they found that the burden of newborn deaths shifted from the community to the health facility, as most health facilities were unprepared to adequately treat newborns with serious complications , 45–47.Finally, leadership engagement and ownership was critical to interventions aimed at changing the culture of care provision. In the Mozambique PHIT project, district performance review and enhancement meetings were led by district-level public sector staff, helping to create a culture of data review and data-driven decision-making. The Rwanda ABC initiative relied on leaders’ ownership of the initiative at the central, district, and facility levels as critical to programmatic success, since the learning collaborative approach and site-level coaching required high participation and engagement in order to create change.Many of the PHIT projects encountered similar implementation challenges to feasibility and ensuring fidelity to the strategies including staff turnover, leader ownership of technical programs to support sustainability of improvements gained, shortage of system inputs such as equipment and medications, and data quality. For example, sustainability of these improvements in the face of MOH leadership and mentor turnover remains to be seen and is the subject of further investigation. Additionally, follow-through on action plans made was a common challenge across multiple programs including the Mozambique and Rwanda PHIT projects. Yet, all programs worked to address these challenges using the resources available with variable results. In three countries – Rwanda, Tanzania, and Ghana – broader policy impact is being witnessed, as some of the PHIT partners’ interventions have been adopted or expanded nationally. For example, in Rwanda, the partners have worked with the MOH to expand the ABC program to seven new districts, and over 50,000 additional women .This analysis has some limitations. Creating cross-site metrics was a challenge given the variability in local data sources and definitions across country cases (despite common core indicators), and therefore limited the scope of baseline metrics presented for understanding individual project context. As each PHIT program included intervention elements related to neonatal health at different time points in their intervention based on their context and experience, differing intervention-specific evaluation strategies and timelines limited ability to present outcomes or impact data for most case studies. Additionally, measuring impact on neonatal mortality relates to vital events recording, which is limited by the lack of birth/death registration in many resource-limited settings. Additionally, case study methodology can have limits to generalizability, as it involves an in-depth look at a small number of examples. However, using the combination of the WHO building block of health systems framework and the maternal newborn child health continuum of care framework allows for extraction of key similarities and differences to distill critical lessons that could be of relevance to implementers, public health practitioners, donors, and local and global policy makers when considering how to best positively impact newborn health through a health system strengthening approach.The PHIT projects across five countries all employed strategies to improve newborn health, an area where it has been difficult to create change, using multifaceted integrated health system approaches. These diverse experiences, while adapted to each implementation setting and challenges encountered, shared a common theme of integration—integration across health system levels with an emphasis on leadership development, and across the maternal and newborn care continuum.


Creutzfeldt-Jakob disease (CJD) is a fatal neurodegenerative disorder that, according to the most well accepted hypothesis  in the United Kingdom  patients had received a dura mater graft as part of a surgical procedure ; 41 (95%) of these dCJD patients had received a Lyodura graft , Lyodura was identified as the probable vehicle of transmission; the graft brand for the other 12 dCJD patients was unknown ; the brand of dural graft received by 14 patients was not identified. The most common medical conditions for which patients received the cadaveric dura mater grafts were brain tumors (including meningioma) , facial palsy or trigeminal neuralgia , and brain hemorrhage . Less common conditions included intracranial aneurysm , unspecified anomalies , intracranial hematoma , trauma , and other . The median age at symptom onset among dCJD patients was 58 years ; 89 (58%) patients were female. All patients had received their dura mater graft during 1975–1993  Figure , and datAlthough the shelf life of Lyodura established by the manufacturer was 5 years, three dCJD patients had surgical procedures in 1993, at least 6 years after the company had changed their collection and processing procedures. J-CJDSC determined that all three patients had received a Lyodura graft, and that at least one of the grafts was processed before 1987, and had therefore expired (the processing date of the second and third patients’ grafts are unknown). Eleven (7%) dCJD patients identified by J-CJDSC received grafts during 1988–1993 , includiIn Japan, it is estimated that 20,000 persons received a Lyodura graft each year during 1983–1987, approximately 50 times more than the estimated number of U.S. recipients . Since tA comprehensive 2012 global summary of dCJD cases by country  whenever human tissues, particularly of cadaveric origin, might be used to treat other patients. In addition, a system of human disease surveillance to detect the possible emergence of new sources of prion disease transmissions is needed. Furthermore, physicians maintaining a high index of suspicion for unusual prion disease cases, as well as a system of human disease surveillance to detect the emergence of new sources of prion disease transmissions, is needed to enable the prevention of infections Finally, maintaining surveillance for CJD in Japan is important to better assess the impact of the outbreak of dCJD and to identify additional cases.During 1975–2008, a total of 132 cases of dura mater graft-associated Creutzfeldt-Jakob disease (dCJD), a fatal neurodegenerative disease caused by replicating, transmissible prion proteins, had been identified in Japan and accounted for >60% of patients worldwide with dCJD. This relatively high number of cases was most likely related to the increased use in Japan of the primary vehicle of transmission, Lyodura brand cadaveric grafts produced before May 1987, when the manufacturer changed its production process to reduce the risk for prion transmission.During 2008–2017, an additional 22 dCJD patients, with onset from 1985 through 2016, were identified in Japan, resulting in 154 dCJD patients in Japan. No new dCJD patient whose surgery occurred after 1993 has been identified. However, the latency period is now known to be at least 30 years and because of the known potential for even longer latency periods for prion diseases, this outbreak is likely to continue. The dCJD outbreak underscores the importance of strict screening of donors, appropriate record keeping, avoidance of comingling of grafts, and ideally, the use of validated sterilization procedures whenever dura mater grafts are manufactured. The long latency (decades) of human prion diseases can pose challenges to the detection of new sources of infection and highlights the need to recognize prion disease outbreaks and implement preventive measures as early as possible.


The global landscape for reproductive health in humanitarian settings has changed dramatically since the International Conference on Population and Development (ICPD) in 1994. Mainstreaming of reproductive health into humanitarian health responses has grown, and awareness of the consequences of neglecting reproductive health services, such as maternal and neonatal mortality, HIV transmission, and unsafe abortion, has expanded. Despite these advances, significant gaps remain, and meeting the reproductive health needs of crisis-affected communities is more urgent than ever: the United Nations High Commissioner for Refugees (UNHCR) reported that 51.2 million people remained forcibly displaced due to conflict and persecution by the end of 2013—the largest number since World War II [a (IAWG), an international network dedicated to improving the reproductive health of communities affected by conflict and natural disaster. IAWG arose from a growing concern with the lack of attention to reproductive health, despite increasing evidence of its need in emergency settings [Reproductive Health for Refugees: An Inter-agency Field Manual [Field Manual was the first technical guidance on implementing reproductive health in emergencies and articulated a minimum standard in reproductive health service delivery—the Minimum Initial Service Package (MISP) for Reproductive Health.b IAWG also supported the creation of the Inter-agency Reproductive Health Kits, twelve kits of essential medicines and supplies, to support rapid implementation of the MISP [A concentrated effort to address reproductive health in emergencies commenced in 1995 when a coalition of UN agencies, national and international nongovernmental organizations (NGOs), government agencies, donors, and academic institutions established the Inter-agency Working Group on Reproductive Health in Crisessettings . In its d Manual . The Fiec—had achieved substantial gains. A 1999 study documented an increase in evidence, funding, policies, conferences, and new NGOs addressing reproductive health in emergencies, reflecting marked progress in advancing reproductive health on the global humanitarian agenda [By the early 2000s, IAWG and its partners—including the Reproductive Health Response in Crises (RHRC) Consortiumn agenda . From 20n agenda . The finSphere Humanitarian Charter and Minimum Standards in Disaster Response and the Inter-Agency Standing Committee Health Cluster Guide[Granada Consensus on Sexual and Reproductive Health during Protracted Crises and Recovery, which reaffirmed comprehensive reproductive health as a right in protracted settings and fragile states [Field Manual, which included an extra chapter dedicated to comprehensive abortion care—a particularly neglected area in reproductive health service provision—as well as outlined additional priority activities to the MISP [IAWG’s second decade, from 2004 to 2014, saw the maturation of the coalition and further advancements to institutionalize reproductive health into humanitarian health responses and improve access to services. Members successfully advocated integrating the MISP as a minimum health standard in the 2004 and 2011 revisions of the ter Guide, 9. Throter Guide. In 2009the MISP . IAWG alMembership expanded as IAWG actively sought to decentralize and establish regional networks. By the end of 2014, IAWG had 1,680 individual members representing 124 countries and 450 different agencies—a significant increase from approximately 50 members in 2004. With more members, IAWG was able to establish regional chapters as well as roughly ten sub-working groups on specialized issues related to reproductive health, such as new technologies, urban displacement, and disaster risk reduction. Indeed, IAWG’s disaster risk reduction and emergency preparedness efforts, including the SPRINT Initiative and the reproductive health group within the UN International Strategy for Disaster Reduction, have helped promote a comprehensive approach to reproductive health that considers both pre- and post-crisis phases. IAWG has galvanized the field despite lack of sustained, dedicated funding since the coalition’s inception.Supplement: a systematic review of peer-reviewed research evaluating reproductive health programs in crises from 2004 to 2013 [From 2012 to 2014, IAWG conducted a second global review to assess progress, document gaps, and determine future directions. Seven complementary studies were undertaken to provide a snapshot of the field. The studies build on those undertaken for the 2004 evaluation and explore key aspects of the field, including new research, changes in funding and institutional capacity, and implementation of both MISP and comprehensive reproductive health services in selected settings. Four studies are presented in this  to 2013 ; and a s to 2013 . Three aOverall, the studies documented broad progress for reproductive health in humanitarian settings. Tanabe et al. found that of the roughly 11,300 health and protection proposals issued between 2002 and 2013, almost 4,000 contained reproductive health components, more than a third of the issued proposals . The numAt the same time, although requests for funding and absolute funding received for reproductive health in humanitarian appeals have increased since 2002, Tanabe et al. determined that just 43% of these funding requests were met over the last 12 years, slightly above the health sector average of 41% and well below the total humanitarian sector average of 68% . PrelimiThe MISP comprises the priority reproductive health activities to be implemented in an acute emergency and should be built upon with comprehensive programming as soon as possible. In 2004, the first global evaluation found that attention to the MISP was gaining ground, but implementation was not systematic, particularly during the early days of a response, and awareness among health actors remained low . Over thThe other studies paint a more complex picture. Casey et al.’s research revealed significant gaps in the clinical components of the MISP in three settings well past the acute emergency phase . SimilarProgress in maternal and newborn health followed a similar trajectory. In 2004, the global evaluation found that some maternal and newborn health services were available in stable refugee settings, but implementation of antenatal care and emergency obstetric care lagged . The 201d These differences across settings likely reflect the relative availability of these services prior to the crisis. Indeed, the availability of this care in Jordan is unsurprising given its advanced health care system as opposed to the weak health systems in Burkina Faso, DRC, and South Sudan. Preliminary findings from the study of 56 refugee camps in ten countries show that none of the countries met the standard for proportion of live births performed by caesarian section (5% to 15%), and all but two countries were far below the standard of 100% of all births attended by a skilled health worker . Further, maternal and infant deaths appeared to be underreported across all ten countries.Despite this progress, gaps remain, particularly regarding emergency obstetric and newborn care. A closer analysis of the trends in humanitarian appeals divulged that antenatal and postnatal activities were more frequently mentioned in proposals than emergency obstetric care . AlthougComprehensive abortion care, which includes post-abortion care and safe abortion, is an essential component of reproductive health and is particularly important in settings with limited access to family planning and vulnerability to sexual violence—both of which characterize many humanitarian contexts. Safe abortion saves lives: UNFPA estimates that 25% to 50% of maternal deaths in refugee settings are due to complications of unsafe abortion . Yet aboIn Jordan, post-abortion care was generally available for Syrian refugees in the two settings assessed . Casey eComprehensive family planning services, which can avert up to 32% of maternal deaths and almost 10% of childhood deaths , have alDespite more concerted efforts to bring family planning to the fore, such as IAWG’s 2010 statement highlighting family planning as a life-saving intervention in humanitarian settings , most ofIn 2004, gender-based violence was an emerging area and, unsurprisingly, the weakest of the reproductive health components assessed in the global evaluation . Gender-Preliminary findings from the UNHCR Health Information System study show that, although rape appeared to be underreported, five of the ten countries consistently met the standard of 100% of eligible survivors receiving post-exposure prophylaxis within 72 hours of an assault to minimize HIV transmission . Gender-based violence, as related to reproductive health programming, comprised the second highest (46%) of all reproductive health proposals in humanitarian health and protection appeals from 2009 to 2013, a total increase of 34% over five years . This suselected elementse of clinical management of rape, and it was unclear whether these three facilities provided all components of the minimum package of post-rape treatment [The other studies highlighted concerning gaps. The MISP assessment in Jordan found weak protection measures against sexual violence generally and only one assessed site had skilled staff and sufficient supplies to provide clinical care for rape survivors . In the reatment . The sysreatment ; a 2013 reatment .While the area of gender-based violence is expanding, HIV in emergencies has long been a field in its own right. HIV has historically received disproportionate more funding and attention relative to other reproductive health areas . Indeed,Field Manual and as a minimum standard in the IASC Guidelines for Addressing HIV in Humanitarian Settings[The 2004 global evaluation found uneven availability of condoms and STI treatment as well as very limited coverage of anti-retroviral therapy for people living with HIV . Now, te Settings, 30. Pre Settings, suggestPreliminary findings from a survey of development and humanitarian organizations mirrored the findings above. The humanitarian and development agencies surveyed reported increased attention to MISP and all technical areas since 2004 as well as more efforts to address disaster risk reduction, accountability, and inter-agency coordination. They also reported, however, limited attention to safe abortion and cervical cancer screening and treatment .Two notable findings from the 2004 evaluation were the lack of reproductive health services for adolescents and internally displaced, as opposed to refugee, populations . In the Regarding reproductive health services for internally displaced persons, the 2004 evaluation and other research primarily focused on maternal health, found better reproductive health outcomes in stable refugee camp settings than in neighboring host communities or in refugees’ home countries , 32–34. One of the more striking and urgent findings of the 2014 evaluation was that, even when reproductive health services were in place, uptake of many services lagged across all settings. Many affected communities were unaware of existing services or did not know of their benefits. Even those who could identify advantages—such as accessing post-exposure prophylaxis for HIV within 72 hours after rape—reported that communities largely shunned services, citing socio-cultural barriers such as shame and anxieties about possible social sanctions. This finding challenges the “if you build it, they will come” assumption that at times permeates health programming. Reproductive health refracts cultural sensitivities, and effective programming requires community mobilization activities, particularly for services to which the community may not have previously had access. IAWG has made some inroads in recognition of this, such as the inclusion of “ensuring community awareness of available services” as an activity of the MISP  and the Many of the other challenges identified in these studies are long-standing. Poor commodity management and security were key barriers to good quality care. Negative provider attitudes and behaviors, such as disrespect towards women seeking family planning services, hindered some people from seeking care. Restrictive policies and misinformation about existing policies prevented implementation of critical services, and poor quality data collection undermined service monitoring. Some gaps in care resulted from a dearth of skilled staff. Although integration of reproductive health into comprehensive primary health care was evident in some sites, further efforts are needed for effective integration across all levels of care.The studies for the 2014 IAWG global review documented considerable progress in the field since the previous evaluation a decade ago. Funding and awareness have increased significantly, and service provision has expanded. However, programmatic needs continue to outweigh financial support, implementation is not systematic and is of variable quality, and evidence for program efficacy remains scarce. The review spotlighted poor commodity management and security, limited availability of comprehensive abortion care, and lack of community mobilization to increase reproductive health service uptake as particularly critical gaps.The Nobel Prize-winning economist Elinor Ostrom imagined the ideal aid system as one that would “reward people for developing imaginative ideas that draw on the complexity of the real world, that leave people in developing countries more autonomous, less dependent, and more capable of crafting their own future” . She proThe way forward would benefit from applying dynamic approaches that knit together disparate elements of the emergency management universe, including pre-crisis preparedness and risk reduction efforts, crisis response interventions, and early recovery and rehabilitation activities. Humanitarian response must be integrated as an essential piece of health systems work and reproductive health as an essential component of health. Indeed, the findings from the 2014 review indicate that the relative robustness of the pre-existing health care system and the availability of reproductive health services before an emergency determine the availability and uptake of these services during the response and recovery. Long before a crisis, donors, UN agencies, governments, and international and national NGOS, among others, must support the capacity of Ministries of Health and Disaster Management, national and community-based organizations, health workers, and communities themselves to strengthen health systems with an emphasis on comprehensive reproductive health, accessibility, and resilience-building. This includes, for example, funders supporting community involvement in the design and delivery of reproductive health services, national governments addressing policy barriers to reproductive health service implementation, and national medical and nursing schools integrating reproductive health into their curricula. Humanitarian and development agencies addressing reproductive health must engage, coordinate, and reinforce each others’ work, and donors are called upon to support cohesive programming that integrates both pre- and post-crisis efforts. With the increasing urbanization of displacement—as demonstrated in Krause et al.’s study—implementing agencies need to adapt and develop appropriate operational frameworks and forge new relationships with municipal authorities and urban service providers. Preliminary findings from the institutional capacity survey indicate that an increasing number of stakeholders are addressing emergency preparedness, disaster risk reduction, and recovery measures related to reproductive health, but much more effort is needed to systematically and sustainably bridge the humanitarian-development divide.Casey et al. and Krause et al.’s studies highlight the urgent need to address reproductive health commodity security. Ministries of Health and health NGOs must strengthen commodity management processes to prevent stock-outs and provide consistent access to care. At the global level, with donor support, IAWG could link with the Reproductive Health Supplies Coalition and other development actors to spearhead a concerted effort to promote effective reproductive health supply chain management from the onset of a crisis response throughout recovery.The significant growth in funding for and implementation of gender-based violence and HIV programming, as found by Tanabe et al., illustrates the expansion of these fields over the past decade. As such, the protection and health clusters/sectors, led by UNHCR and WHO, respectively, as well as the gender-based violence area of responsibility, co-led by UNFPA and UNICEF, must strengthen coordination and delineation of roles to support an aligned approach and integrated interventions. Gender-based violence and HIV focal points ought to maintain linkages with reproductive health actors to ensure a harmonized response by, for example, attending respective coordination meetings in the field. Indeed, the lynchpin for an effective reproductive health humanitarian response is sustained, inter-agency reproductive health coordination with a designated lead agency; funders are obliged to support this type of coordination and not just direct service provision.Granada Consensus[Casey et al. and Krause et al.’s studies demonstrate the need to enhance providers’ knowledge base and address personal beliefs that affect professional conduct. Service providers should explore competency-based clinical trainings on reproductive health within a rights-based framework. These two studies also show the importance of a coherent transition from MISP to comprehensive reproductive health services, as outlined in the Consensus. PrelimiIn order to realize Ostrom’s vision for aid, UN agencies, donors, and international NGOs must listen to, engage, and work with local, national, and government agencies in a way that addresses power dynamics and promotes ownership and leadership. The 2014 review clearly highlights that humanitarian and development actors must identify and develop effective strategies to meaningfully engage affected communities to increase use of reproductive health services, meet their reproductive health needs, and augment participation in the programs that affect their lives. Implementing agencies can explore contextually appropriate new technologies, such as social media and mobile technologies, to increase two-way communication with communities .The studies also bring to the fore the marked lack of attention to adolescent reproductive health in terms of funding, access to services, programming, and program evaluation; donors and implementing agencies must prioritize adolescents as well as other marginalized groups, such as people with disabilities, sex workers, elderly, and lesbian, gay, bisexual, and transgender persons, to ensure they access and enjoy good quality reproductive health care. In addition, Casey et al.’s research in Burkina Faso, DRC, and South Sudan sheds light on the challenges of providing good quality care in remote settings with limited health providers; more attention to task-sharing to address human resource gaps and to developing alternative service delivery models can help facilitate the provision of services even in the most hard to reach areas. These and other efforts should be underpinned by humanitarian principles and grounded in a culture that fosters accountability, learning, adaptation, and flexibility.Tanabe et al.’s study as well as preliminary findings from the long-term trend analysis of official development assistance demonstrate the need for increased funding for reproductive health in crises. Donor governments such as Australia, Belgium, and the U.S. have thankfully stepped up in recent years to support humanitarian reproductive health and protection programming, but more donor champions are required to close the funding gap, ensure equitable funding across reproductive health areas, and support fluid, innovative humanitarian programs rather than short-term, quantifiable interventions.Multi-sectoral efforts to advance reproductive health in crises are also needed at the global level. The architects of the Sustainable Development Goals, for example, should integrate comprehensive reproductive health care for communities affected by humanitarian crises into the post-2015 agenda. Reproductive health and gender issues remain on the periphery of climate change adaptation and mitigation planning, and climate change leaders should ensure reproductive health actors are at the table.There is no panacea to addressing reproductive health needs in increasingly complex humanitarian crises. But we do know that effective humanitarian action is contingent on the capacity, ability, and desire of agencies to work together . CollaboThe author has been a member of the Inter-agency Working Group on Reproductive Health in Crises since 2003.a Formerly known as the Inter-agency Working Group for Reproductive Health in Refugee Situationsb The MISP is a set of priority activities designed to ensure coordination, prevent sexual violence and provide care for survivors, prevent maternal and neonatal morbidity and mortality, and HIV transmission, and plan for comprehensive reproductive health services. Additional priorities include ensuring the availability of contraceptives to meet demand, syndromic treatment of STIs, anti-retrovirals for continuing users, and menstrual hygiene supplies.c Formerly known as the Reproductive Health for Refugees Consortium, the RHRC Consortium is comprised of the American Refugee Committee, CARE, Columbia University, International Rescue Committee, JSI Research and Training Institute, Marie Stopes International, and the Women's Refugee Commission.d Health centers should provide basic emergency obstetric and newborn care, which includes: 1. administering parenteral antibiotics; 2. administering uterotonic drugs; 3. administering parenteral anticonvulsants ; 4. performing manual removal of placenta; 5. performing removal of retained products of conception ; 6. performing assisted vaginal delivery ; 7. performing neonatal resuscitation (with bag and mask). Hospitals should provide comprehensive emergency obstetric and newborn care, which includes the seven functions outlined above as well as: 8. performing blood transfusion; and 9. performing surgery .e The selected elements of clinical management of rape assessed were the availability of emergency contraception, post-exposure prophylaxis for HIV, and antibiotics for prevention of sexually transmitted infections; the provision of these drugs in the previous three months; and at least one staff trained to provide clinical management of rape. The full minimum package of clinical management of rape for low-resource settings includes 25 elements [elements .


Electronic mental health interventions  can be used to increase accessibility of mental health services for mood disorders, with indications of comparable clinical outcomes as face-to-face psychotherapy. However, the actual use of eMH in routine mental health care lags behind expectations. Identifying the factors that might promote or inhibit implementation of eMH in routine care may help to overcome this gap between effectiveness studies and routine care.This paper reports the results of a systematic review of the scientific literature identifying those determinants of practices relevant to implementing eMH for mood disorders in routine practice.A broad search strategy was developed with high sensitivity to four key terms: implementation, mental health care practice, mood disorder, and eMH. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework was applied to guide the review and structure the results. Thematic analysis was applied to identify the most important determinants that facilitate or hinder implementation of eMH in routine practice.A total of 13,147 articles were screened, of which 48 studies were included in the review. Most studies addressed aspects of the reach (n=33) of eMH, followed by intervention adoption (n=19), implementation of eMH (n=6), and maintenance (n=4) of eMH in routine care. More than half of the studies investigated the provision of mental health services through videoconferencing technologies (n=26), followed by Internet-based interventions (n=20). The majority (n=44) of the studies were of a descriptive nature. Across all RE-AIM domains, we identified 37 determinants clustered in six main themes: acceptance, appropriateness, engagement, resources, work processes, and leadership. The determinants of practices are expressed at different levels, including patients, mental health staff, organizations, and health care system level. Depending on the context, these determinants hinder or facilitate successful implementation of eMH.Of the 37 determinants, three were reported most frequently: (1) the acceptance of eMH concerning expectations and preferences of patients and professionals about receiving and providing eMH in routine care, (2) the appropriateness of eMH in addressing patients’ mental health disorders, and (3) the availability, reliability, and interoperability with other existing technologies such as the electronic health records are important factors for mental health care professionals to remain engaged in providing eMH to their patients in routine care. On the basis of the taxonomy of determinants of practices developed in this review, implementation-enhancing interventions can be designed and applied to achieve better implementation outcomes. Suggestions for future research and implementation practice are provided. Electronic mental health interventions  for mood disorders such as depression can increase reach and accessibility of mental health services while maintaining comparable clinical outcomes as face-to-face interventions and superior outcomes compared with waiting lists -3. eMH eA logical approach in addressing this implementation challenge is to identify the factors that might promote or inhibit implementation of eMH in routine practice . On the The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework provides a heuristic tool for bridging interventions’ internal validity established in well-controlled conditions and their external validity in real-world conditions ,17. It iGiven the absence of a comprehensive overview of determinants of practices, we systematically reviewed the literature to develop a taxonomy relevant to the implementation of eMH. Knowledge on these determinants can inform the study of interventions that aim to improve the implementation of eMH in routine practice. The following research question guided the research: “What determinants of practice are identified as relevant to implementing eMH interventions for mood disorders in routine practice?” A broad view on eMH and care practice settings, including clinical and community practices, was adopted to provide a comprehensive taxonomy of determinants of mental health practice relevant to implementing eMH.A systematic review of scientific literature was conducted. RE-AIM was used to structure the review. Various implementation studies in the area of mental health care using RE-AIM substantiate the utility of this framework, including evaluations of the implementation of behavior mental health assessment tools ; smokingDue to the novelty of the topics concerned , a broad search strategy was developed with high sensitivity to four key terms (as opposed to a focused strategy with higher specificity ): “impleThe inclusion and exclusion criteria are shown in A systematic qualitative narrative approach was applied for the data extraction, analyses, and synthesis of the results -30. A fiThematic analysis was applied to identify the recurrent and most important determinants to implementing eMH in routine practice  arising in the included literature. Thematic analysis is a common method for identifying, grouping, and summarizing findings from included studies in narrative review . The  component The psychotherapeutic intervention targeted a mood disorder.The study targeted (1) an adult population, (2) mental health care professionals (HCPs) or, (3) other persons or organizations involved in implementation of eMH.The study took place in routine mental health care settings.Studies were reporting clinical effectiveness data only.The full-text article was not available through Open Access or library loaning services.The full-text article was not available in the English language.The searches resulted in 16,718 records. After removing the duplicates, 13,417 unique titles remained and were screened for eligibility against the inclusion and exclusion criteria. In total, 13,159 articles were excluded on the basis of the information in titles and abstracts. A total of 258 articles were retained, and after examining the full-text articles, a total of 48 studies were included in the analysis. Most studies investigated reach (n=33), followed by adoption (n=19), implementation (n=6), and maintenance (n=4). The specific type of the target disorder was often described in broad terms such as common mental disorders or mood disorders (n=20), or in exemplary disorders such as depression or anxiety (n=17). Most studies (n=39) did not explicitly report the therapeutic principles of the clinical intervention that was implemented. More than half of the studies investigated the provision of mental health services for mood disorders through videoconferencing technologies (n=26), most often by using videoconferencing for support and consultations. The remainder of the studies focused on Internet-based interventions (n=20). Three studies looked at purely self-help interventions (through Web and mobile technologies), and 10 studies did report on a specific eMH intervention but did not report the guidance modality. Eighteen studies specified the eMH intervention and described the guidance modality. The majority (n=44) of the studies were of an observational, that is, descriptive nature. Most of these (n=20) applied mixed-methods , followed by a large proportion (n=16) of studies that applied qualitative methods such as ethnography or consensus-seeking methods using focus-group discussions. Five studies were of an experimental design, applying either quantitative or mixed-methods. More information about the specific studies’ aims, designs, settings, participants, and clinical and implementation-related interventions are reported in In total, 37 specific determinants of practices relevant to implementing eMH in routine care were identified. The 37 determinants were clustered resulting in a taxonomy of six groups: (1) acceptance of eMH by patients and service delivery staff, (2) appropriateness or clinical relevance of eMH, (3) engagement of participants in implementing and delivering eMH, (4) resources for implementing and delivering eMH, (5) work processes in delivering eMH, and (6) leadership in implementing and delivering eMH. Group definitions are provided in A detailed list of the determinants is included in The domain reach includes determinants of practices that are related to patients’ participation in eMH and their characteristics. Of the 33 studies that were categorized under reach, most investigated patients’ and mental HCPs perceptions and attitudes of patients and professionals (n=20), or the actual use (n=9) of eMH in a routine care setting. Most studies were of an observational nature (n=31). Two studies used an experimental design for testing interventions aimed at increasing access and use of eMH.From the perspective of patients, two main groups of factors appeared to be relevant in implementing eMH in routine care: acceptance and appropriateness. Determinants grouped under acceptance concern the perceived and actual feasibility of interacting with eMH. For example, knowledge about the existence of eMH  and technological aspects of the treatment  were most often reported in the included literature.Determinants categorized under appropriateness refers to the patients’ perceived fit, relevance, or compatibility of eMH in addressing his or her mental disorder. Within this group, the professional-patient relationship was reported most often by both care providers and patients to be an important aspect that requires consideration when implementing eMH. For example, the perceived importance of interaction and verbal communication was highlighted by van der Vaart, et al , showingFrom the perspective of staff, engagement emerged as a group of factors next to the determinants grouped under acceptance and appropriateness. Engagement relates to the sustained and effective involvement of staff in implementing and delivering eMH for mood disorders in routine care. Most notably, engagement seem to be related to the organizing structures, policies, and procedures within an organization (n=4), as well as the availability and stability of the required information and communication technology . For example, in a qualitative study on expectations of both patients and health professionals in commencing in Internet-based psychotherapy, Montero-Marin et al  noted thFrom the perspective of mental health service providing organizations, resources in terms of available and stability of facilitating infrastructure was mentioned (n=2) as an important determinant. In addition, the modus operandi in service delivery both in terms of primary care processes  as well as facilitating processes  require consideration when implementing eMH in routine practice. Additionally, leadership in terms of existing cultures, strategies, and priorities emerged from the included articles as a determinant of practice (n=1). Regarding the primary care processes, Buist et al  showed tAt health care system level, there were three aspects reported to be of importance, namely policy-making processes (n=2), the availability of appropriate resources including qualified staff (n=2), and collaboration and cooperation within the system and across disciplines (n=1).Adoption mirrors the decision of staff and organizations involved in delivering the eMH services and the extent to which they actually use and deploy the services to their patients. Of the 19 studies that were characterized under adoption, 16 studies investigated adoption-related perceptions and attitudes toward eMH (n=9), or actual use (n=7) of eMH in routine care settings showing adoption. Three studies investigated and tested an adoption-enhancing intervention aimed at increasing the number of staff involved in the delivery of eMH.Seen from the perspective of staff delivering the services, a frequently mentioned determinant grouped under acceptance was patients’ awareness and knowledge of the existence of eMH (n=5). Similarly, the awareness of eMH as a viable treatment option among staff was also identified as a relevant determinant in staff adopting eMH (n=6). Adoption can be facilitated by allowing clinicians to gain experience with eMH and the observability of eMH (n=7). In terms of appropriateness of eMH, the studies indicated that patient-professional relationship is an important determinant to consider when designing interventions aimed at improving adoption rates (n=7). To illustrate, May et al  reportedFrom the organizations’ perspective, the determinants addressing adoption related mostly to the availability of infrastructural resources (n=5) and the primary care process (n=5). Infrastructural resources included the availability, quality, and stability of facilitating structures such as office rooms and ICT equipment. Determinants related to the primary care processes included issues with referral procedures, diagnostic procedures, and therapy guidelines and manuals. For instance, Jameson et al  highlighOne article reported determinants from a health care system perspective. Buist et al  reportedDeterminants categorized under implementation relate to the extent to which eMH is used in real-world settings as intended , implementation costs, or deliberate and purposive actions to implement eMH. Of the 6 studies identified under implementation, 2 investigated an implementation-related intervention focusing on training mental health providers to use eMH in daily practice. The other 4 studies performed a process evaluation (n=1) and investigated use and utilization of eMH (n=3).The most frequently reported determinants from the perspective of staff were related to acceptance. These concerned raising staffs’ awareness about the existence of eMH (n=3) and providing education to staff (n-4) in applying eMH in routine care. Specific determinants included references to technical and therapeutic training, formal education and credentialing, and peer-group learning and supervision. For example, Willhelmsen et al  showed tFurthermore, from the perspective of staff, engagement was found to be influenced by the availability of support and facilitating services (n=4). For example, Avey et al  reportedFrom the viewpoint of an organization, the availability of resources such as staffing (n=2), funding (n=2), and infrastructural facilities (n=2) were reported as relevant determinants. In addition, various factors emerged from the literature related to the primary modes operandi (n=3). For example, Reifels et al  discusseFrom the perspective of health care systems, less rich information was found in the included studies. However, Buist et al  did repoUnder maintenance, determinants were categorized that relate to keeping the eMH as a normal part of routine care practices. All 4 maintenance studies were of a descriptive nature aiming to establish usage and utility figures of videoconferencing- delivered mental health services (n=2), capture end-user perceptions (n=1), or describe potential success factors (n=1) of programs that remained in practice after their implementation phase.From the patients’ viewpoint, the convenience of eMH was seen as an important determinant in maintaining the service in practice (n=4). In an evaluation of patients’ perceptions of a routine tele-psychiatry service in central Alberta, Simpson et al  highlighFrom the perspective of mental health staff, the clinical culture in terms of socially defined and agreed ways of doing (n=2), including norms, habits, and roles, are considered to be important in maintaining the services in routine practice. Hailey et al  showed tAt the organizational level, various determinants were reported, including availability of funds (n=2) and infrastructure (n=2), the primary modes of operation (n=2), supporting structures and activities (n=2), and leadership and management (n=3). Regarding the latter, Whitten et al  showed iFrom the perspective of the health care system, besides the importance of policy (n=1), community acceptance (n=2), and organizing and organized plans of health services , the availability and appropriateness of resources required in maintaining eMH in practice were mentioned (n=2).We developed a taxonomy of 37 determinants of mental health care practices known in the literature as relevant to successfully implement eMH for mood disorders. The determinants of practices clustered in six groups are expressed at (a combination of) patient, staff, organization, and setting levels and address one or more RE-AIM dimensions see . Three dThe search strategy in this review aimed to capture as much relevant scientific literature as possible. For this reason, broadly defined search terms were used. By applying a standardized integrative approach , we were able to search for commonalities in the concepts and underlying study characteristics while preserving the heterogeneous nature of the data retrieved from the studies. However, and although we searched three important bibliographic databases, it is likely that important work from social scientist generalist databases was excluded.The evidence supporting the determinants identified in this study is mostly of a descriptive nature obtained from observational studies. Due to the limited empirical evidence verifying causality of specific determinants of practices and implementation successes, the findings of this work should be interpreted with care. In an attempt to substantiate this, we conducted a quality appraisal analysis. We included a wide variety of studies ranging from observational case studies using qualitative ethnographic methods to randomized controlled trials quantitatively testing specific implementation interventions. However, because of the heterogeneity of these studies and the absence of validated instruments to assess quality, it proved impossible to come to sensible conclusions about the quality of the evidence. An elaborate approach as done by Greenhalgh et al ,82, metaDrozd et al  conducteSimilarly, Ross et al  updated Implementation practitioners might benefit in implementing eMH in routine care practices by taking into account the barriers and facilitators that are identified in this systematic review. Specific implementation activities can be designed and applied on the basis of these factors to achieve better implementation outcomes.One of the most frequently mentioned barriers emerging from the literature concerns the expectations and preferences of patients and professionals about eMH services. Negative individual and collective attitudes, expectations, and existing preferences can prohibit successful implementation of eMH. Ebert et al  showed tA second important determinant of practice is related to the appropriateness of the eMH intervention in addressing the mental disorder. Within this cluster, the nature and quality of the interactions between the professional and the patient is thought to be highly influential in obtaining favorable clinical outcomes. This includes aspects such as building trust, comfort, and the quality of the therapeutic interactions. eMH interventions delivered through ICT are thought to influence these interactions negatively. Hadjistavropoulos et al ,86 showeThird, the availability and reliability of required technologies is considered an important determinant for mental HCPs to remain engaged in providing eMH to their patients in routine care. This includes the interoperability with other existing technologies such as electronic health records. It seems important to ensure that the user perspective, including that of the service delivery staff, is taken into account and that the eMH service seamlessly fits within existing technologies and work processes. Here, single-sign on technology and intelligent portal designs might be fruitful avenues to explore.To increase impact and added value of future research on implementation of eMH for mood disorders in routine practice, the following two topics should be taken into account: (1) identifying organization and system-level determinants and (2) empirical evidence on the effects of implementation strategies in addressing specific barriers and exploiting facilitating factors.Until now, most implementation research was focused on practitioner and patient-level determinants. Service delivery takes place in a social context at micro , mesa (organizations), and macro (systems) level. Knowledge about how these different contexts influence implementation efforts can facilitate further scaling up of eMH. Research on systems level might focus on the possible policy measures that enhance implementation of eMH at service deliverer level. For example, what resources at organization or health care system-level are required to deliver eMH? This can include processes of task shifting, curricula and certification of mental health staff, ICT and standardization, funding, and other infrastructural aspects. Or, what role does community acceptance have in implementing eMH in routine practice, and how can the shared perception of community as a whole be changed? Detailed knowledge of organization and setting level factors might be more likely to come from a combination of clinical psychology, social sciences, organizational psychology, and policy research. Here, the MasterMind project  might prFurthermore, the field would benefit from well-performed experiments designed to test implementation interventions addressing specific determinants of practices. As shown in this review, there is limited evidence on the causal relationship between determinants and implementation outcomes. Well-designed experiments studying the effects of to the local context–tailored implementation strategies might contribute to the understanding of mechanisms of implementation processes. Do, for example, educational meetings (and in what formats) contribute in raising awareness among GPs about which patient might benefit most from which eMH intervention? Or can championing an Internet-based cognitive behavioral therapy service increase the adoption of other therapists in mental health care team while maintaining the flexibility therapists need to adapt parts of the treatments to the patients’ needs? Fusing implementation practices and research into natural implementation laboratories might be a valuable approach to engage in comparative effectiveness studies of implementation interventions. In these types of studies, experimental implementation interventions can be compared with usual implementation activities for their effects on the degree of normalization of a clinical intervention in real-world service delivery settings. The ImpleMentAll project (project position paper and study protocol forthcoming) might be a good example of this approach. This type of future research might lead to a shift from practice-based and evidence-informed to evidence-based implementation of clinically effective and relevant eMH interventions.This study systematically reviewed scientific literature and developed an evidence-informed taxonomy of six clusters of 37 determinants of practices we found in literature: (1) acceptance of eMH interventions among patients, providers, organizations, and health care settings; (2) appropriateness of eMH interventions in addressing the disorder; (3) engagement in implementing, delivering, and receiving eMH interventions and remain doing so; (4) the availability and appropriateness of resources for implementing and delivering eMH interventions; (5) processes relating to the modus of operandi in delivering eMH interventions; and (6) leadership directing and controlling processes and organizing activities enabling implementation and delivery of eMH interventions. On the basis of these determinants of practices, implementation-enhancing interventions can be designed, tested, and applied to achieve better implementation outcomes. Suggestions for implementation practice are discussed, such as in-depth training of professionals, careful selection, and continuous development of the eMH technology used. In addition, focal points for future research are provided, including implementation-related factors on organization and system level, as well as (quasi) experimental research to test the effectiveness of specific implementation interventions in attaining better implementation outcomes for eMH service provision.