TABLE 2.

Examples from Case Studies of Lessons Learned for Intervention Design. Note. CMD = community medicine distributor, RDT = rapid diagnostic test.

Defining scope: consideration of intended audience for results	In the Cameroon REACT project, the initial focus of the intervention, defined in 2008, reflected concerns about appropriate use of first-line antimalarial drugs after recent policy changes to ACTs. In 2010, the project's focus was changed to appropriate diagnosis and treatment of malaria, incorporating the use of malaria RDTs. This responded to the upcoming roll-out of RDTs by the government and questions raised by them as stakeholders and the malaria community more broadly around how this could best be supported, given findings elsewhere that basic training was insufficient to support uptake of RDT results and adherence to test results. The trial therefore set out to answer specific concerns of Cameroonian policy makers by providing information about the cost-effectiveness of introducing RDTs alongside either basic training or an enhanced training intervention, compared with existing practice without RDTs. Furthermore, the initial inclusion of private sector providers was removed after feedback from the Ministry of Health that they preferred the tests first to be introduced at public and mission facilities.
Defining scope: consideration of level of control	For example, in the two Ugandan trials that introduced RDTs among community medicine distributors and drug shops, the objective was to learn the effect of the intervention if all providers allocated to the intervention received the full intervention. Training and follow-up supervision were delivered by members of the research team. The intention was not to produce an off-the-shelf intervention directly applicable for scale-up. By contrast, in the Nigerian trial, which introduced RDTs at public health facilities and private pharmacies and patent medicine dealers, the objective was to learn the effect of an intervention under routine conditions. Providers were invited to training sessions but were not followed up if they did not attend, and for a school-based intervention, school teachers and students were provided with intervention ideas and materials but were encouraged to undertake whatever activities they considered feasible. The intention was to produce interventions and results that would be directly applicable in practice. The latter study was closer to an effectiveness design than the former two.
Evidence review: scoping to identify potential intervention components in Uganda	The Ugandan PRIME project aimed to improve the quality of health care at health facilities in order to improve health outcomes and uptake of services. The target problem was identified as multifaceted, with several components of quality of care identified as targets for improvement in the project's formative research with health workers and community members. The targets were used as a focus for reviewing evidence of previous interventions:  Interventions to improve communication of health workers with patients  Interventions to improve working relationships among health workers  Interventions to improve facility-based supervision or coaching of health workers  Interventions to improve the way patients are received and offered services equitably  Interventions to improve the management of primary health facilities For each scoping review, which were conducted in parallel over a period of about three months, the team compiled a document to detail the search strategy, including search terms; inclusion and exclusion criteria; specific aspects of the intervention, including a taxonomy of potential intervention types that followed Abraham and Michie99; and how to assess outcomes of evaluations, whether qualitative or quantitative. For each paper identified, the team documented details of the intervention and evaluation as well as their perceptions of whether the intervention might be effective and feasible in the project's setting and whether any intervention materials already existed that could be drawn on. This process enabled the team to narrow down their search to interventions that were found to be effective at changing the target problem of interest and that were potentially transferable to the project's setting. This short list of evidence was then reviewed in conjunction with a review of behavior change theory, review of the findings of formative research, and discussion with local stakeholders.
Formative research: utility	Formative research prior to the Ugandan trial with CMDs involved 29 in-depth interviews with CMDs, health workers, and district health officials and 13 focus group discussions with mothers, fathers, and community leaders. The research aimed to understand existing CMDs' motivations, practices, and experiences and to explore the potential for introducing RDTs into the work and profile of these voluntary workers. The findings suggested that specific liaison personnel would be required to provide support to CMDs and that acknowledgment of their work through provision of commodities to support their roles would be required to sustain motivation.
Formative research: challenges with “barriers” approach	First, many of the barriers identified in our research were not amenable to change within the predefined scope of the intervention. For example, where wider policy dictated that certain providers were not allowed to sell or distribute certain drugs, such as antibiotics, we were unable to meet demand for training on treatment of nonmalarial febrile illnesses. Second, even when a barrier might be amenable to change, the research focus on barriers and problems provided little to inform positive action through intervention. For example, the finding in the Cameroon formative research that clinicians considered treatment with antimalarials to be a psychological treatment suggested a need for a change in expectations of consultation outcomes but did not in itself indicate what might be effective in achieving this. Third, the focus on barriers diverted attention from the motivation and agency of those enacting the problem behaviors; the practices desired by the intervention may not be in line with their priorities and motivations. For example, the Cameroonian clinicians' motivation for prescribing antimalarial drugs was to treat the whole patient, rather than the laboratory result or the malaria parasite. This represented a fundamental conflict between the focus of the malaria policy and of the study clinicians.79
Formative research: value of appreciative enquiry	In one of our studies in Uganda, identifying the aspirations of health workers for strengthening the quality of health care they provided gave us a framework for designing the PRIME intervention, based on their desires to strengthen technical, interpersonal, and management capacities.70