Pakistan is one of two countries globally still endemic for poliovirus. While increasing immunization coverage is a concern, providing equitable access to care is also a priority, especially for conflict-affected populations. Recognizing these challenges, Naunehal, an integrated model of maternal, newborn, and child health (MNCH), immunization, and nutrition services delivered through community mobilization, mobile outreach, and private-sector engagement was implemented in conflict-affected union councils (UCs) with high poliovirus transmission, including Kharotabad 1(Quetta, Balochistan) and Bakhmal Ahmedzai (Lakki Marwat, Khyber Pakhtunkhwa). A quasi-experimental pre-post-design was used to assess the impact of the interventions implemented between April 2021 and April 2022, with a baseline and an endline survey. For each of the intervention UCs, a separate, matched-control UC was identified. At endline, the proportion of fully immunized children increased significantly from 27.5% to 51.0% in intervention UCs with a difference-in-difference (DiD) estimate of 13.6%. The proportion of zero-dose children and non-recipients of routine immunization (NR-RI) children decreased from 31.6% to 0.9% and from 31.9% to 3.4%, respectively, with a significant decrease in the latter group. Scaling up and assessing the adoption and feasibility of integrated interventions to improve immunization coverage can inform policymakers of the viability of such services in such contexts.

UNASSIGNED: Evidence on the impact of Maternal Newborn and child health (MNCH) and Water, Sanitation and Hygiene (WASH) interventions on skilled birth attendance (SBA) and neonatal sepsis remains unclear. We conducted this study in Amuru district to generate evidence.
UNASSIGNED: A before-and-after study design was conducted. Interventions implemented included; training of HCWs, construction of WASH facilities, and health education of communities. A digitized structured questionnaire was used to obtain data on ANC and SBA, WASH practices and prevalence of pneumonia and diarrhea among 466 expectant mothers and caretakers of under-fives at baseline, midterm and endline. Data on sepsis incidence, ANC, SBA and WASH status was obtained from six healthcare facilities. A total of 12 KIIs and 12 FGDs were conducted. Data were analyzed using STATA 15. Two sample tests of proportions were used to compare findings at baseline and endline. Qualitative data were analyzed using thematic content analysis.
UNASSIGNED: The number of women delivering at HCFs significantly increased from 41.4% to 63.0% (p < .0001). Incidence of neonatal sepsis reduced from 0.6% to 0.2% (p = .0687), although the difference was not significant. Community-level findings also indicated a decline in cases of water-borne illnesses; cases of dysentery decreased from 10.0% to 0.6%, cases of cholera decreased from 8.9% to 1.9% at endline, cases of typhoid decreased from 26.5% to 12.7% at endline.
UNASSIGNED: This study revealed that integrated WASH/MNCH interventions can significantly increase ANC and SBA, reduce incidences of neonatal sepsis, diarrhea, pneumonia, and other related diseases and improve WASH practices in communities. Significant improvements in WASH/IPC and the capacity of HCWs to deliver safe MNCH services are realized.

Physical exercise and cognitive remediation represent the psychosocial interventions with the largest basis of evidence attesting their effectiveness in improving cognitive performance in people living with schizophrenia according to recent international guidance. The aims of this review are to provide an overview of the literature on physical exercise as a treatment for cognitive impairment in schizophrenia and of the studies that have combined physical exercise and cognitive remediation as an integrated rehabilitation intervention. Nine meta-analyses and systematic reviews on physical exercise alone and seven studies on interventions combining physical exercise and cognitive remediation are discussed. The efficacy of physical exercise in improving cognitive performance in people living with schizophrenia is well documented, but more research focused on identifying moderators of participants response and optimal modalities of delivery is required. Studies investigating the effectiveness of integrated interventions report that combining physical exercise and cognitive remediation provides superior benefits and quicker improvements compared to cognitive remediation alone, but most studies included small samples and did not explore long-term effects. While physical exercise and its combination with cognitive remediation appear to represent effective treatments for cognitive impairment in people living with schizophrenia, more evidence is currently needed to better understand how to implement these treatments in psychiatric rehabilitation practice.

High smoking prevalence leads to increased morbidity and mortality in individuals with depression/anxiety. Integrated interventions targeting both smoking and mood have been found to be more effective than those targeting smoking alone, but the mechanisms of change of these interventions have not been investigated. This qualitative study aimed to understand participants\' experiences of the mechanisms underlying change in smoking behaviour following an integrated cognitive behavioural technique-based intervention for smoking cessation and depression/anxiety.
This study was embedded within an ongoing randomized-controlled acceptability and feasibility trial (http://www.isrctn.com/ISRCTN99531779). Semistructured interviews were conducted with 15 IAPT service users. Data were analysed using thematic analysis. During the interviews, participants were asked open-ended questions about their quitting experience and perception of how the intervention aided their behaviour change.
Five themes were identified. Acquiring an increased awareness of smoking patterns: participants described an increased understanding of how smoking was contributing towards their mental health difficulty. Developing individualized strategies: participants described acquiring \'a couple of tricks up your sleeve\' that were helpful in making smoking cessation feel more \'manageable\'. Practitioner style as \'supportive but not lecture-y\': participants expressed how important the therapeutic alliance was in helping change their smoking behaviour. Importance of regular sessions: participants expressed the importance of \'having someone that\'s checking in on you\'. Having the opportunity to access the intervention at \'the right time\': participants described the intervention as the \'push\' that they \'needed\'.
Participants identified key factors towards smoking behaviour change. Perceived increased awareness of how smoking negatively impacted participants\' mental health, and the opportunity to be offered smoking cessation treatment in a \'non-judgemental\', \'supportive\' environment, with regular sessions and individualized strategies contributed to successful smoking cessation outcomes. If similar results are found in more diverse samples, these aspects should be embedded within integrated interventions for smoking cessation and depression/anxiety.
Persons with lived experience of depression, anxiety and tobacco addiction contributed towards the design of the interview schedule, participant information sheets and the debriefing process. This was to ensure that interview questions were relevant, nonjudgemental and acceptable for those who did not manage to quit smoking.

BACKGROUND: The Centers for Disease Control and Prevention launched the Colorectal Cancer Control Program to increase colorectal cancer screening among groups with low screening uptake. This engagement has enabled the health systems participating in the program to enhance infrastructure, systems, and process to implement interventions for colorectal cancer screening. These improvements have enabled other health promotion innovations such as the delivery of integrated interventions and supporting activities (referred to as integrated approaches) for multiple cancers. Using implementation science frameworks, the program evaluation team has examined these integrated approaches to capture the experiences of the awardees, health systems, and clinics.
RESULTS: The findings from this comprehensive evaluation are presented in a series of 3 manuscripts. The first manuscript provides a conceptual framework for integrated approaches for cancer screening to support comprehensive evaluations and offers recommendations for future research. The second manuscript presents findings on key factors that support readiness for implementing integrated approaches based on qualitative interviews guided by implementation science constructs. The final manuscript reports on the challenges and benefits of integrated approaches to increase cancer screening in primary care facilities based on lessons learned from three real-world implementation case studies.
CONCLUSIONS: Integrated models for implementing cancer screening could offer cost-effective approaches to reduce healthcare disparities. Additional implementation science-based systematic evaluations are needed to ensure integrated approaches are optimized, and cost-efficient models are scaled up.

BACKGROUND: Screening for colorectal, breast, and cervical cancer has been shown to reduce mortality; however, not all men and women are screened in the USA. Further, there are disparities in screening uptake by people from racial and ethnic minority groups, people with low income, people who lack health insurance, and those who lack access to care. The Centers for Disease Control and Prevention funds two programs-the Colorectal Cancer Control Program and the National Breast and Cervical Cancer Early Detection Program-to help increase cancer screenings among groups that have been economically and socially marginalized. The goal of this manuscript is to describe how programs and their partners integrate evidence-based interventions (e.g., patient reminders) and supporting activities (e.g., practice facilitation to optimize electronic medical records) across colorectal, breast, and cervical cancer screenings, and we suggest research areas based on implementation science.
METHODS: We conducted an exploratory assessment using qualitative and quantitative data to describe implementation of integrated interventions and supporting activities for cancer screening. We conducted 10 site visits and follow-up telephone interviews with health systems and their partners to inform the integration processes. We developed a conceptual model to describe the integration processes and reviewed screening recommendations of the United States Preventive Services Task Force to illustrate challenges in integration. To identify factors important in program implementation, we asked program implementers to rank domains and constructs of the Consolidated Framework for Implementation Research.
RESULTS: Health systems integrated interventions for all screenings across single and multiple levels. Although potentially efficient, there were challenges due to differing eligibility of screenings by age, gender, frequency, and location of services. Program implementers ranked complexity, cost, implementation climate, and engagement of appropriate staff in implementation among the most important factors to success.
CONCLUSIONS: Integrating interventions and supporting activities to increase uptake of cancer screenings could be an effective and efficient approach, but we currently do not have the evidence to recommend widescale adoption. Detailed multilevel measures related to process, screening, and implementation outcomes, and cost are required to evaluate integrated programs. Systematic studies can help to ascertain the benefits of integrating interventions and supporting activities for multiple cancer screenings, and we suggest research areas that might address current gaps in the literature.

Purpose: Participants\' engagement in a project requires intrinsic motivations, which may evolve during the intervention thanks to lifestyle changes and positive challenges. Over the years, tailored programs based on physical activity and psychological sessions have been promoted to support the quality of life and well-being of breast cancer survivors. Personal expectations and needs are essential to predict participant adherence to the intervention as well as their possibility to reach positive outcomes. This study presents a preliminary understanding of the differences between motives and outcomes obtained after an integrated physical and psychological intervention conducted by professional trainers and psychologists. Methods: Forty-five women with a history of breast cancer answered some questions before and after the program, and the results were analyzed in accordance with the procedure of the thematic analysis. Results: Physical and psychological well-being are the two main themes that emerged from the participants. Interestingly, some differences emerged between the two data collections. Themes such as aesthetic evaluation interest and the need to learn psychological strategies disappeared at the end of the intervention; on the other hand, the need to make a distance from the illness experiences emerged as an obtained outcome. Conclusions: The discussion explains these differences and highlights the importance of considering breast cancer patients\' needs and motives to take part in interventions to promote quality of life.

UNASSIGNED: Adults living with Type 2 diabetes (T2D) and severe mental illness (SMI) disproportionally experience premature mortality and health inequality. Despite this, there is a limited evidence-base and evaluation of non-pharmacological integrated interventions that may contribute to improved patient experience and outcomes. To improve our understanding of how to optimise integrated care for this group, this review evaluates the effectiveness, acceptability, and feasibility of non-pharmacological integrated interventions for adults with SMI and T2D.
UNASSIGNED: Studies from nine electronic databases were searched. Of the 6750 papers retrieved, seven papers (five quantitative and two qualitative) met the inclusion/exclusion criteria. A convergent integrated approach was used to narratively synthesise data into four main themes: effectiveness, acceptability, feasibility, integrated care.
UNASSIGNED: There is moderate evidence to suggest non-pharmacological integrated interventions may be effective in improving some diabetes-related and psychosocial outcomes. Person-centred integrated interventions that are delivered collaboratively by trained facilitators who exemplify principles of integrated care may be effective in reducing the health-treatment gap.
UNASSIGNED: Recommendations from this review can provide guidance to healthcare professionals, commissioners, and researchers to inform improvements to non-pharmacological integrated interventions that are evidence-based, theoretically driven, and informed by patient and healthcare professionals\' experiences of care.

UNASSIGNED: Integrated psychological and physical treatments can improve recovery for whiplash-associated disorders (WADs). Little is known about how these interventions work.
UNASSIGNED: To examine the mechanisms by which a physiotherapist-delivered integrated intervention for acute WAD improves health outcomes.
UNASSIGNED: Secondary analysis using structural equation modelling of a randomized controlled trial comparing integrated stress inoculation training and exercise to exercise alone for acute WAD. Outcomes were disability, pain self-efficacy, pain intensity, and health-related quality of life at 12 months. The intended intervention target and primary mediator, stress was tested in parallel with pain-related coping, an additional cognitive behavioral mediator that significantly improved at posttreatment (Model 1). Stress-related constructs that commonly co-occur with stress and pain were also tested as parallel mediators: depression and pain-related coping (Model 2); and posttraumatic stress and pain-related coping (Model 3).
UNASSIGNED: Reductions in stress mediated the effect of the integrated intervention on disability (β = -0.12, confidence interval [CI] = -0.21 to -0.06), pain self-efficacy (β = 0.09, CI = 0.02-0.18), pain (β = -0.12, CI = -0.21 to -0.06), and health-related quality of life (β = 0.11, CI = 0.04-0.21). There was an additional path to pain self-efficacy through pain-related coping (β = 0.06, CI = 0.01-0.12). Similar patterns were found in Models 2 and 3.
UNASSIGNED: Improvements in stress and related constructs of depression and posttraumatic stress, and pain-related coping were causal mechanisms of effect in a physiotherapist-delivered integrated intervention. As integrated interventions are growing in popularity, it is important to further personalize interventions for improved benefit.

BACKGROUND: Children admitted to nutritional rehabilitation units (NRUs) for inpatient treatment of severe acute malnutrition (SAM) are at high risk of poor developmental and nutritional outcomes. The Kusamala Program is an interactive hospital-based counseling program for primary caregivers of children with SAM that integrates three modules: nutrition and feeding; water, sanitation, and hygiene (WASH); and psychosocial stimulation. This mixed methods feasibility study aimed to evaluate the implementation of the Kusamala Program in an NRU setting and developmental outcomes in children with SAM 6 months after inpatient treatment.
METHODS: An internal pilot trial including the first 30 children and their primary caregivers enrolled to a cluster-randomized controlled trial of the Kusamala Program was performed. Barriers and enablers were identified in a qualitative study with a focus group discussion (FGD) and in-depth interviews (IDIs) with 12 hospital staff members, including five NRU nurses who deliver the Kusamala Program.
RESULTS: Results demonstrated high participant engagement (100%) and adherence (87%) of primary caregivers to the Kusamala Program. Potential barriers to implementation identified through the qualitative study were caregivers\' perceived value of the program, prioritization of other ward activities, and shortages of staff. On the other hand, enablers to implementation were engaging other staff members, motivation and work ethic, and refresher training.
CONCLUSIONS: This mixed methods study demonstrates the feasibility of implementing the Kusamala Program in a real NRU setting. The full cluster-randomized controlled trial will be completed to evaluate the effectiveness of the Kusamala Program.
BACKGROUND: ClinicalTrials.gov, NCT03072433. Registered on 7 March 2017-retrospectively registered.