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Social marketing campaigns use marketing techniques to influence human behavior for the greater social good. In the conservation sector, social marketing campaigns have been used to influence behavior for the benefit of biodiversity as well as society. However, there are few evaluations of their effectiveness. We devised an approach for evaluating the influences of social marketing campaigns on human behavior and conservation outcomes. We used general elimination methodology, a theory-driven qualitative evaluation method, to assess the long-term impacts of a 1998 Rare Pride campaign on the island of Bonaire that was designed to increase the population of the Lora (Amazona barbadensis), a threatened parrot. We interviewed stakeholder groups to determine their perceptions of the drivers of the changes in the Lora population over time. We used these data to develop an overall theory of change to explain changes in the Lora population by looking at the overlap in hypotheses within and between stakeholder groups. We then triangulated that theory of change with evidence from government reports, peer-reviewed literature, and newspapers. The increase in the Lora population was largely attributed to a decrease in illegal poaching of Loras and an associated decrease in local demand for pet Loras. Decreases in poaching and demand were likely driven by a combination of law enforcement, social marketing (including the Rare campaign), and environmental education in schools. General elimination methodology helped show how multiple interventions influenced a conservation outcome over time. There is a need for evidence-based evaluations of social marketing interventions to ensure that limited resources are spent wisely. Las campañas de mercadotecnia social usan técnicas de mercadotecnia para influenciar al comportamiento humano para el mayor beneficio social. En el sector de conservación, las campañas sociales se han usado para influenciar al comportamiento para el beneficio de la biodiversidad y de la sociedad. Sin embargo, existen pocas evaluaciones sobre su efectividad. Diseñamos una estrategia para evaluar la influencia de las campañas de mercadotecnia social sobre el comportamiento humano y los resultados de conservación. Usamos la metodología de eliminación general, un método de evaluación cualitativa llevada por la teoría, para evaluar los impactos a largo plazo de una campaña de Rare Pride de 1998 en la isla de Bonaire, la cual fue diseñada para incrementar la población de la lora (Amazona barbadensis), un psitácido amenazado. Entrevistamos a grupos de accionistas para determinar sus percepciones de los causantes del cambio en la población de loras con el tiempo. Usamos estos datos para desarrollar una teoría general de cambio para explicar los cambios en la población de loras al observar el traslape en las hipótesis dentro y entre los grupos de accionistas. Después triangulamos esa teoría de cambio con evidencia tomada de los reportes gubernamentales, la literatura revisada por pares, y los periódicos. El incremento poblacional de loras se atribuyó en su mayoría a una disminución en la demanda local de las loras como mascota. La disminución de la caza furtiva y de la demanda estuvo probablemente causada por una combinación de la aplicación de la ley, la mercadotecnia social (incluyendo a la campaña de Rare), y la educación ambiental en las escuelas. La metodología de eliminación general ayudóa mostrar cómo las múltiples intervenciones influyeron sobre un resultado de conservación con el tiempo. Existe una necesidad por tener evaluaciones basadas en evidencias de las intervenciones de mercadotecnia social para asegurar que los recursos limitados se usen racionalmente. 社会营销活动利用市场营销技术来影响人们的行为，以获得更高的社会利益。在保护领域，社会营销活动 也被用来影响那些有利于生物多祥性和社会的行为。然而，目前还少有对其有效性的评估。我们设计了ー种方 法来评估社会营销活动对人类行为和保护成效的影响。我们用一般消元法(一种理论驱动的定性评估方法)来 评估博内尔岛1998年为增加受胁迫的劳拉鸚賴(Amazona barbadensis)种群数量开展的瑞尔保护协会自豪 项目（Rare Pride campaign)的长期影响。我们采访了利益相关群体，以确定他们认为是娜些因素导致了劳拉 鹤鹉种群随时间变化而产生的变化。我们利用这些数据设计了变化的总体理论，通过分析利益相关者群体内部 和群体之间都认同的假说来解释劳拉鹦鹉的种群变化。接下来我们用来自政府报告、同行评议文献和报纸的i正 瑕对这十变化理论进行了三方面分析。劳拉鸚鹉数量増加主要是因为非法偷猎的減少，以及当地对宠物劳拉鶴 鶴需求的相应减少。偷猎和需求的减少可能是执法、社会营销（包括瑞尔保护协会运动）和学校的环境教育等 因素共同作用的結果。一般消元法有助于说明长期以来多种干预措施如何作用于ー项保护的成效。未来还需要 对社会营销干预措施进行以证据为基础的评估，以确保有限资源的合理利用。

Background Centralized dispensing of essential medicines is one of South Africa’s strategies to address the shortage of pharmacists, reduce patients’ waiting times and reduce over-crowding at public sector healthcare facilities. This article reports findings of an evaluation of the Chronic Dispensing Unit (CDU) in one province. The objectives of this process evaluation were to: (1) compare what was planned versus the actual implementation and (2) establish the causal elements and contextual factors influencing implementation. Methods This qualitative study employed key informant interviews with the intervention’s implementers (clinicians, managers and the service provider) [ N  = 40], and a review of policy and program documents. Data were thematically analyzed by identifying the main influences shaping the implementation process. Theory-driven evaluation principles were applied as a theoretical framework to explain implementation dynamics. Results The overall participants’ response about the CDU was positive and the majority of informants concurred that the establishment of the CDU to dispense large volumes of medicines is a beneficial strategy to address healthcare barriers because mechanical functions are automated and distribution of medicines much quicker. However, implementation was influenced by the context and discrepancies between planned activities and actual implementation were noted. Procurement inefficiencies at central level caused medicine stock-outs and affected CDU activities. At the frontline, actors were aware of the CDU’s implementation guidelines regarding patient selection, prescription validity and management of non-collected medicines but these were adapted to accommodate practical realities and to meet performance targets attached to the intervention. Implementation success was a result of a combination of ‘hardware’ (e.g. training, policies, implementation support and appropriate infrastructure) and ‘software’ (e.g. ownership, cooperation between healthcare practitioners and trust) factors. Conclusion This study shows that health system interventions have unpredictable paths of implementation. Discrepancies between planned and actual implementation reinforce findings in existing literature suggesting that while tools and defined operating procedures are necessary for any intervention, their successful application depends crucially on the context and environment in which implementation occurs. We anticipate that this evaluation will stimulate wider thinking about the implementation of similar models in low- and middle-income countries.

Projects to implement health care and social care innovations involving technologies are typically ambitious and complex. Many projects fail. Greenhalgh et al's nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework was developed to analyze the varied outcomes of such projects. We sought to extend the NASSS framework to produce practical tools for understanding, guiding, monitoring, and researching technology projects in health care or social care settings. Building on NASSS and a complexity assessment tool (CAT), the NASSS-CAT tools were developed (in various formats) in seven co-design workshops involving 50 stakeholders (industry executives, technical designers, policymakers, managers, clinicians, and patients). Using action research, they were and are being tested prospectively on a sample of case studies selected for variety in conditions, technologies, settings, scope and scale, policy context, and project goals. The co-design process resulted in four tools, available as free downloads. NASSS-CAT SHORT is a taster to introduce the instrument and gauge interest. NASSS-CAT LONG is intended to support reflection, due diligence, and preliminary planning. It maps complexity through stakeholder discussion across six domains, using free-text open questions (designed to generate a rich narrative and surface uncertainties and interdependencies) and a closed-question checklist; this version includes an action planning section. NASSS-CAT PROJECT is a 35-item instrument for monitoring how subjective complexity in a technology implementation project changes over time. NASSS-CAT INTERVIEW is a set of prompts for conducting semistructured research or evaluation interviews. Preliminary data from empirical case studies suggest that the NASSS-CAT tools can potentially identify, but cannot always help reconcile, contradictions and conflicts that block projects' progress. The NASSS-CAT tools are a useful addition to existing implementation tools and frameworks. Further support of the implementation projects is ongoing. We are currently producing digital versions of the tools, and plan (subject to further funding) to establish an online community of practice for people interested in using and improving the tools, and hold workshops for building cross-project collaborations. DERR1-10.2196/16861.

Background Evaluation of health technology programmes should be theoretically informed, interdisciplinary, and generate in-depth explanations. The NASSS (non-adoption, abandonment, scale-up, spread, sustainability) framework was developed to study unfolding technology programmes in real time—and in particular to identify and manage their emergent uncertainties and interdependencies. In this paper, we offer a worked example of how NASSS can also inform ex post (i.e. retrospective) evaluation. Methods We studied the TORPEDO (Treatment of Cardiovascular Risk in Primary Care using Electronic Decision Support) research programme, a multi-faceted computerised quality improvement intervention for cardiovascular disease prevention in Australian general practice. The technology ( HealthTracker ) had shown promise in a cluster randomised controlled trial (RCT), but its uptake and sustainability in a real-world implementation phase was patchy. To explain this variation, we used NASSS to undertake secondary analysis of the multi-modal TORPEDO dataset (results and process evaluation of the RCT, survey responses, in-depth professional interviews, videotaped consultations) as well as a sample of new, in-depth narrative interviews with TORPEDO researchers. Results Ex post analysis revealed multiple areas of complexity whose influence and interdependencies helped explain the wide variation in uptake and sustained use of the HealthTracker technology: the nature of cardiovascular risk in different populations, the material properties and functionality of the technology, how value (financial and non-financial) was distributed across stakeholders in the system, clinicians’ experiences and concerns, organisational preconditions and challenges, extra-organisational influences (e.g. policy incentives), and how interactions between all these influences unfolded over time. Conclusion The NASSS framework can be applied retrospectively to generate a rich, contextualised narrative of technology-supported change efforts and the numerous interacting influences that help explain its successes, failures, and unexpected events. A NASSS-informed ex post analysis can supplement earlier, contemporaneous evaluations to uncover factors that were not apparent or predictable at the time but dynamic and emergent.

Background Women with breast cancer face many barriers to return to work (RTW) after their cancer. The main objective of the FASTRACS-RCT is to evaluate the impact of the FASTRACS (Facilitate and Sustain Return to Work after Breast Cancer) intervention on the sustainable RTW of breast cancer patients, 12 months after the end of active treatment. Methods FASTRACS-RCT is a prospective, national, multicentre, randomized, controlled and open-label study. A total of 420 patients with early breast cancer scheduled for surgery and (neo)adjuvant chemotherapy, will be randomly assigned (1:1 ratio) to: (i) the intervention arm comprising four steps over 6 months : Handing over the intervention tools; transitional medical consultation with the general practitioner (GP); pre-RTW visit with the company’s occupational physician (OP); catch-up visit with a hospital-based RTW expert (if sick leave > 10 months) (ii) the control arm to receive usual care. The design of the FASTRACS intervention was informed by intervention mapping for complex interventions in health promotion planning, and involved patients and representatives of relevant stakeholders. Specific tools were developed to bridge the gap between the hospital, the GP, the OP and the workplace: a toolkit for breast cancer patients comprising a theory-based guide; specific checklists for the GP and the OP, respectively; and a theory-based guide for workplace actors (employer, manager, colleagues). The primary endpoint will associate sustainable RTW (full-time or part-time work at 50% or more of working time, for at least 28 consecutive days) and days off work. It will be assessed at 4, 8 and 12 months after the end of active oncological treatment. Secondary endpoints will include quality of life, anxiety, depression, RTW self-efficacy, physical activity, social support, job accommodations, work productivity, job status, and the usefulness and acceptability of the intervention’s tools. Discussion FASTRACS-RCT will be supplemented by a realist evaluation approach aimed at understanding the influence of context in activating the intervention’s mechanisms and effects. If the expected impact of the intervention is confirmed, the intervention will be adapted and scaled-up for other cancers and chronic diseases to better integrate healthcare and work disability prevention. Trial registration NCT04846972 ; April 15, 2021.

Introduction:  In March 2014, the New South Wales (NSW) Government (Australia) announced the NSW Integrated Care Strategy.  The NSW Government’s Integrated Care Strategy funding enabled the establishment of an integrated care initiative called Healthy Homes and Neighbourhoods (HHAN).  The Initiative was designed as a population-based, family-centered, care-coordination network that functioned across agencies to assist vulnerable families to navigate the health and social-care system, to keep themselves and their children safe, and in doing so, promote social cohesiveness.  The evaluation framework is described. Methods:  Since integrated care initiatives are an example of complex interventions in health and social care, we underpinned this programme of development, research and evaluation by the critical realist metatheory of science and the NSW Health Monitoring and Evaluation Framework, using the UK Medical Research Council (MRC) Framework for evaluating complex interventions.1  We adapted the iterative approach of development, feasibility/piloting, evaluation and implementation of the MRC framework to include critical realist, participatory, continuous and theory driven elements. Discussion:   Both the 2008 UK Medical Research Council framework for evaluating complex interventions, and our previously reported critical realist methodology, provided the tools to enable an iterative approach to development, design, testing and continuous evaluation.  The philosophical paradigms underpinning each approach are different.  Both the NSW Health and MRC frameworks were developed from in the “logical positivist” inductive and deductive reasoning traditions with a strong focus on activities and outcomes but little emphasis on process.  That weakness was been recognised and the MRC subsequently endorsed advice on process evaluation for complex interventions which accommodated the realist approach incorporated here. Conclusion: Integrated care initiatives are examples of complex interventions in health and social care.  The interventions are multi-layered and operationalization is strongly influenced by both historical and current context.  This aspect alone makes it imperative that the methodology used is post-positive and takes ontologically stratified context into account.  The NSW Health Monitoring and Evaluation Framework did not make provision for assessment of context or mechanism of effect.  We describe here a multilevel approach including a continuous improvement approach through constant comparison and triangulation of mixed method findings. Utilising the MRC framework for evaluating complex interventions within a critical realist methodology, enabled us to study both mechanisms of effect and context. Lessons learned: Evaluation of integrated care interventions will require a pluralist approach to methodology.  It is possible to design evaluation approaches that allow study of context, mechanism, reach and efficacy in a complex layered design as used for integrated care initiatives. Limitations: The approach utilised was contrained by the requirements of the policy and funding organisation.  We did not fully explore the application of Theory of Change  and complexity science within the MRC framework. Suggestions for future research: We recommend that further theoretical and applied research be undertaken to advance the methods and tools available for evaluation of complex multi-layered integrated care initiatives.  Reference: 1. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337:a1655

Collaborative professional learning is essential for teachers to work collectively in facilitating student learning. A program of Learning Community under Leadership for Learning was launched to support teacher learning in authentic situations in Taiwan. Applying the theory-driven evaluation model, the study aimed to investigate the impact of a program component of teacher learning communities (TLCs) on professional learning beliefs and behaviors. A sample of 226 elementary and junior high school teachers in Taiwan was surveyed and analyzed using structural equation modeling. The findings suggest that the experiences in TLCs had an impact on teachers’ professional learning beliefs and behaviors through their self-efficacy. Additionally, teacher self-efficacy was found to have a direct impact on their beliefs and behaviors, and beliefs were found to affect behaviors significantly. This study has expanded the understanding of self-efficacy in relation to professional learning beliefs and behaviors and provided practical insights for effective strategies for teacher development.

Background Paediatric palliative and hospice care aims to improve the quality of life of children with life-limiting and life-threatening conditions and their families. The number of these patients has risen significantly in recent years, resulting in an increased need for palliative care for this population. Although the need for paediatric palliative and hospice care is growing, meaningful outcome evaluation to demonstrate its effectiveness as a complex healthcare intervention is in its early stages. For complex interventions (programmes), theory-based evaluations have grown in prominence in recent years. They seek to understand how and why an intervention works by uncovering its underlying mechanisms by means of programme theory. To support both outcome evaluation in paediatric palliative care and a reflective practice of programme theorizing, we aimed to describe the construction of a programme theory for a specialist paediatric palliative and hospice care programme in Austria and to offer a reflective account of its development process. Methods We drew on a combination of theory-based evaluation frameworks to construct a programme theory consisting of an action and a change component. Through multiple iterations, incorporating different stakeholders’ perspectives and drawing on different sources of knowledge and theory, we theorized how and why the programme likely achieves its intended outcomes. Results The programme theory outlines the proposed chains of events, causal mechanisms and outcomes of a specialist paediatric palliative and hospice care programme for children and families in several areas corresponding to its main conceptual tenets. Through a range of activities and interventions, the programme triggers coping and adaptation mechanisms that ultimately contribute to family and child wellbeing in physical, psychological, social, and spiritual dimensions. Established trust and partnership between children/families and healthcare professionals as well as a person-centered and family-centered approach were identified as enabling factors. Conclusions Our findings provide insights into how a specialized paediatric palliative and hospice care programme works to achieve its intended outcomes for children and families. This helps demonstrate its impact, contributing to meaningful outcome evaluation and service improvement.

Despite the critical role academic medical institutions play in promoting equity and inclusion, these efforts are often undermined by fragmented and siloed evaluation approaches, a lack of theory-driven models, and inadequate data-driven methodologies. This commentary critically examines the factors contributing to the persistent challenges in implementing and advancing equity and inclusion initiatives in the United States (U.S.), focusing on academic medical institutions in particular. It underscores the need for theory-guided frameworks to better structure and evaluate such initiatives and highlights existing gaps in accountability and data-driven decision-making. Moreover, it argues for an integrated approach that combines multidisciplinary strategies, promoting collaboration across different sectors to develop more comprehensive and sustainable solutions. Ultimately, effective evaluation – grounded in data, theory, and diverse perspectives – is essential for promoting equity and inclusion and addressing disparities in U.S. academic medical institutions. By addressing these structural and evaluative shortcomings, institutions can move towards more impactful and equitable outcomes for underrepresented groups in STEM fields and the biomedical workforce more broadly.

Abstract Community health workers (CHWs) play major roles in delivering primary healthcare services, linking communities to the formal health system and addressing the social determinants of health. Available evidence suggests that the performance of CHW programmes in low- and middle-income countries can be influenced by context-dependent causal mechanisms such as motivation to perform. There are gaps regarding what these mechanisms are, and what their contribution is to CHW performance. We used a theory-driven case study to characterize motivational mechanisms among Accredited Social Health Activists (ASHAs) in Bihar, India. Data were collected through semi-structured interviews with CHWs and focus group discussions with beneficiary women. Data were coded using a combined deductive and inductive approach. We found that ASHAs were motivated by a sense of autonomy and self-empowerment; a sense of competence, connection and community service; satisfaction of basic financial needs; social recognition; and feedback and answerability. Findings highlight the potential of ASHAs’ intrinsic motivation to increase their commitment to communities and identification with the health system and of programme implementation and management challenges as sources of work dissatisfaction. Efforts to nurture and sustain ASHAs’ intrinsic motivation while addressing these challenges are necessary for improving the performance of Bihar’s ASHA programme. Further research is needed to characterize the dynamic interactions between ASHAs’ motivation, commitment, job satisfaction and overall performance; also, to understand how work motivation is sustained or lost through time. This can inform policy and managerial reforms to improve ASHA programme’s performance.