BackgroundHealth education interventions are generally complex. Their outcomes result from both the intervention itself and the context for which they are developed. Thus, when an intervention carried out in one context is reproduced in another, its transferability can be questionable. We performed a literature review to analyze the concept of transferability in the health education field.MethodsArticles included were published between 2000 and 2010 that addressed the notion of transferability of interventions in health education. Articles were analyzed using a standardized grid based on four items: 1) terminology used; 2) factors that influenced transferability; 3) capacity of the research and evaluation designs to assess transferability; and 4) tools and criteria available to assess transferability.Results43 articles met the inclusion criteria. Only 13 of them used the exact term “transferability” and one article gave an explicit definition: the extent to which the measured effectiveness of an applicable intervention could be achieved in another setting. Moreover, this concept was neither clearly used nor distinguished from others, such as applicability. We highlight the levels of influence of transferability and their associated factors, as well as the limitations of research methods in their ability to produce transferable conclusions.ConclusionsWe have tried to clarify the concept by defining it along three lines that may constitute areas for future research: factors influencing transferability, research methods to produce transferable data, and development of criteria to assess transferability. We conclude this review with three propositions: 1) a conceptual clarification of transferability, especially with reference to other terms used; 2) avenues for developing knowledge on this concept and analyzing the transferability of interventions; and 3) in relation to research, avenues for developing better evaluation methods for assessing the transferability of interventions.

Summary Background Acral lesions, mainly chilblains, are the most frequently reported cutaneous lesions associated with COVID‐19. In more than 80% of patients tested, nasopharyngeal swabs were negative on reverse transcription polymerase chain reaction (RT‐PCR) for SARS‐CoV‐2 when performed, and serology was generally not performed. Methods A national survey was launched on 30 March 2020 by the French Society of Dermatology asking physicians to report cases of skin manifestations in patients with suspected or confirmed COVID‐19 by using a standardized questionnaire. We report the results for acral manifestations. Results We collected 311 cases of acral manifestations [58.5% women, median age 25.7 years (range 18–39)]. The most frequent clinical presentation (65%) was typical chilblains. In total, 93 cases (30%) showed clinical suspicion of COVID‐19, 67 (22%) had only less specific infectious symptoms and 151 (49%) had no clinical signs preceding or during the course of acral lesions. Histology of skin biopsies was consistent with chilblains. Overall, 12 patients showed significant immunological abnormalities. Of the 150 (48%) patients who were tested, 10 patients were positive. Seven of 121 (6%) RT‐PCR‐tested patients were positive for SARS‐CoV‐2, and five of 75 (7%) serology‐tested patients had IgG anti‐SARS‐CoV‐2. Tested/untested patients or those with/without confirmed COVID‐19 did not differ in age, sex, history or acral lesion clinical characteristics. Conclusions The results of this survey do not rule out that SARS‐CoV‐2 could be directly responsible for some cases of chilblains, but we found no evidence of SARS‐CoV‐2 infection in the large majority of patients with acral lesions during the COVID‐19 lockdown period in France. What is already known about this topic? About 1000 cases of acral lesions, mainly chilblains, were reported during the COVID‐19 outbreak. Chilblains were reported to occur in young people within 2 weeks of infectious signs, which were mild when present. Most cases did not have COVID‐19 confirmed by reverse transcription polymerase chain reaction (RT‐PCR), and few serology results were available. What does this study add? Among 311 patients with acral lesions, mainly chilblains, during the COVID‐19 lockdown period in France, the majority of patients tested had no evidence of SARS‐CoV‐2 infection. Overall, 70 of 75 patients were seronegative for SARS‐Cov‐2 serology and 114 of 121 patients were negative for SARS‐CoV‐2 RT‐PCR.

Background Evaluation of complex interventions (CI) is challenging for health researchers and requires innovative approaches. The objective of this work is to present the main methods used to evaluate CI. Methods A systematic review of the scientific literature was conducted to identify methods used for the evaluation of CI. We searched MEDLINE via PubMed databases for articles including an evaluation or a pilot study of a complex intervention, published in a ten-year period. Key-words of this research were (“complex intervention*” AND “evaluation”). Results Among 445 identified articles, 100 research results or protocols were included. Among them, 5 presented 2 different types of design in the same publication, thus our work included 105 designs. Individual randomized controlled trials (IRCT) represented 21.9% ( n = 23) of evaluation designs, randomized clinical trials adaptations 44.8% ( n = 47), quasi -experimental designs and cohort study 19.0% ( n = 20), realist evaluation 6.7% ( n = 7) and other cases studies and other approaches 8.6% ( n = 9). A process/mechanisms analysis was included in 80% ( n = 84) of these designs. Conclusion A range of methods can be used successively or combined at various steps of the evaluation approach. A framework is proposed to situate each of the designs with respect to evaluation questions. The growing interest of researchers in alternative methods and the development of their use must be accompanied by conceptual and methodological research in order to more clearly define their principles of use.

BackgroundHealth promotion interventions are often complex and not easily transferable from one setting to another. The objective of this article is to present the development of a tool to analyze the transferability of these interventions and to support their development and adaptation to new settings.MethodsThe concept mapping (CM) method was used. CM is helpful for generating a list of ideas associated with a concept and grouping them statistically. Researchers and stakeholders in the health promotion field were mobilized to participate in CM and generated a first list of transferability criteria. Duplicates were eliminated, and the shortened list was returned to the experts, scored for relevance and grouped into categories. Concept maps were created, then the project team selected the definitive map. From the final list of criteria thus structured, a tool to analyze transferability was created. This tool was subsequently tested by 15 project leaders and nine experts.ResultsIn all, 18 experts participated in CM. After testing, a tool, named ASTAIRE, contained 23 criteria structured into four categories: population, environment, implementation, and support for transfer. It consists of two tools—one for reporting data from primary interventions and one for analyzing interventions’ transferability and supporting their adaptation to new settings.ConclusionThe tool is helpful for selecting the intervention to transfer into the setting being considered and for supporting its adaptation. It also facilitates new interventions to be produced with more explicit transferability criteria.

BackgroundPopulation health intervention research raises major conceptual and methodological issues. These require us to clarify what an intervention is and how best to address it.This paper aims to clarify the concepts of intervention and context and to propose a way to consider their interactions in evaluation studies, especially by addressing the mechanisms and using the theory-driven evaluation methodology.Main textThis article synthesizes the notions of intervention and context. It suggests that we consider an “interventional system”, defined as a set of interrelated human and non-human contextual agents within spatial and temporal boundaries generating mechanistic configurations – mechanisms – which are prerequisites for change in health. The evaluation focal point is no longer the interventional ingredients taken separately from the context, but rather mechanisms that punctuate the process of change. It encourages a move towards theorization in evaluation designs, in order to analyze the interventional system more effectively. More particularly, it promotes theory-driven evaluation, either alone or combined with experimental designs.ConclusionConsidering the intervention system, hybridizing paradigms in a process of theorization within evaluation designs, including different scientific disciplines, practitioners and intervention beneficiaries, may allow researchers a better understanding of what is being investigated and enable them to design the most appropriate methods and modalities for characterizing the interventional system. Evaluation methodologies should therefore be repositioned in relation to one another with regard to a new definition of “evidence”, repositioning practitioners’ expertise, qualitative paradigms and experimental questions in order to address the intervention system more profoundly.

BackgroundPublic health interventions are increasingly being recognised as complex and context dependent. Related to this is the need for a systemic and dynamic conception of interventions that raises the question of delineating the scope and contours of interventions in complex systems. This means identifying which elements belong to the intervention (and therefore participate in its effects and can be transferred), which ones belong to the context and interact with the former to influence results (and therefore must be taken into account when transferring the intervention) and which contextual elements are irrelevant to the intervention.DiscussionThis paper, from which derives criteria based on a network framework, operationalises how the context and intervention systems interact and identify what needs to be replicated as interventions are implemented in different contexts. Representing interventions as networks (composed of human and non-human entities), we introduce the idea that the density of interconnections among the various entities provides a criterion for distinguishing core intervention from intervention context without disconnecting the two systems. This differentiates endogenous and exogenous intervention contexts and the mediators that connect them, which form the fuzzy and constantly changing intervention/context interface.ConclusionWe propose that a network framework representing intervention/context systems constitutes a promising approach for deriving empirical criteria to delineate the scope and contour of what is replicable in an intervention. This approach should allow better identification and description of the entities that have to be transferred to ensure the potential effectiveness of an intervention in a specific context.

Objective. In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it. The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues. Methods. We searched for all articles published until 6th of February 2020, mentioning “Proportionate Universalism” or its synonyms “Targeted universalism” OR “Progressive Universalism” as a topic in all Web of Science databases. Results. This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs. Conclusion. This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.

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