The Breastfeeding Heritage and Pride program (BHP) provides evidence-based breastfeeding peer counseling to low-income women. Due to the COVID-19 pandemic, BHP shifted from delivering in-person and virtual services to providing only virtual services. Program adaptations can impact implementation success, which could influence program effectiveness. We documented program adaptations and explored their impacts on implementation outcomes, guided by the Model for Adaptation Design and Impact.Through a community-clinical-academic partnership, we conducted in-depth interviews with 12 program implementers and peer counselors and conducted a rapid qualitative analysis. To efficiently capture information on adaptations over time, we collected and analyzed information from program meetings and extracted data from a program report. We then triangulated data from these multiple sources.Peer counselors received training on virtual service delivery and increased supportive supervision. They recruited women via phone instead of in hospitals, which was viewed as feasible. In-person counseling visits at hospitals and clients' homes were replaced with phone and video calls. Examples of changes to the content delivered included breastfeeding education in the context of the pandemic such as the latest COVID-related infant feeding guidance, provision of face masks, and more assistance with social and economic challenges. Although peer counselors increasingly adopted video calls as a substitute for in-person visits, they emphasized that in-person visits were better for relationship building, helping with breastfeeding problems like latching, and identifying barriers to breastfeeding in the home environment like limited familial support. While adaptations were reactive in that they were made in response to the unanticipated COVID-19 pandemic, most were made with clear goals and reasons such as to ensure the safety of peer counselors and clients while maintaining service delivery. Most adaptations were made through a systematic process based on program implementers' expertise and best practices for peer counseling and were largely but not fully consistent with BHP's core functions.BHP was able to shift to virtual service delivery for continued provision of breastfeeding counseling during the pandemic. Overall, virtual services worked well but were less optimal for several aspects of counseling. Evaluations of program effectiveness of virtual services are still needed. Community health workers (CHWs) are an expanding part of the healthcare workforce in the United States . CHWs plPrevious research indicates that digital health tools such as telehealth need to be tailored to the context. Socio-economically disadvantaged individuals and communities are more likely than better-off groups to have less access to digital technology as well as lower digital literacy which has been linked to discomfort with telehealth or low uptake . The COVThis study was conducted by researchers through an equitable partnership with community and clinical partners implementing the Breastfeeding Heritage and Pride program (BHP), an evidence-based breastfeeding peer counseling program for women with low incomes delivered by specialized CHWs known as peer counselors . In respBHP was created in 1993 by the Hispanic Health Council (HHC), a community-based organization promoting health equity. Detailed descriptions of the community-engaged process for designing and implementing BHP, as well as the rigorous program evaluations and their findings, have been presented elsewhere  provide peer counselors with ongoing training and clinical guidance through regular group and individual meetings, onsite observation, and phone calls as needed. Program IBCLCs also directly support clients who face breastfeeding challenges that require more specialized knowledge and skills. A program manager provides peer counselors with supportive supervision tailored to their specific supervision needs. When clients face housing and food insecurity or other social determinants of health challenges, they are connected by the program manager to health and social services to address them, as this is outside the scope of the specialized peer counselor role.Continuous quality improvement is supported by a robust monitoring and evaluation system. During each client contact, peer counselors collect data that are entered into a data management system. The data are used to generate assessments of process indicators  and clients' breastfeeding goals and outcomes such as exclusive breastfeeding for 6 months, which informs the program manager as she supports peer counselors and promotes quality assurance.post-hoc  hospitals in Connecticut and Massachusetts. The project brought together a core implementation team comprised of BHP leaders from HHC , Trinity Health staff , and researchers from the Yale School of Public Health (RPE and ER), one of which (RPE) served as lead BHP evaluator for three decades. To optimize program implementation, they held semiannual meetings at each hospital with BHP peer counselors and providers supporting integration of BHP into the healthcare setting, such as physicians, nurses, medical assistants, IBCLCs, and midwives. The purpose of these meetings was to jointly apply a program impact pathway (PIP) method, which involves using a causal map of the steps and processes linking program goals, activities, and outcomes and identifying bottlenecks along the pathway, and then to devise ways to improve program implementation . When COThe study as initially designed applied the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) by Stirman and colleagues to systematically document adaptations to BHP. It also applied the Implementation Outcomes Framework by Proctor and colleagues to evaluate the implementation of the adapted program, with a specific focus on three implementation outcomes: feasibility, appropriateness, and acceptability , 22. WhiMADI is comprised of three domains. Domain 1, adaptation characteristics, includes constructs from the FRAME: what was modified, the nature of the adaptation, who participated in decision-making, and for whom/what the adaptation was made. Based on Moore's research, Domain 2 consists of possible mediators or moderators of the impact of adaptation characteristics on outcomes, namely constructs from the FRAME. These constructs are whether the adaptation aligns with core functions of the intervention, reasons for the adaptation, whether the adaptation was systematic, and whether the adaptation was proactive. Domain 3 comprises implementation and intervention outcomes delineated in the Implementation Outcomes Framework that could be impacted by adaptations . MADI prWe used a qualitative multimethod approach to document and evaluate adaptations between April and December 2020 , which iWe conducted in-depth interviews with program implementers  and all seven peer counselors. We developed, pilot tested, and refined two semi-structured interview guides, one tailored for program implementers and one for peer counselors see , 2. ThesApplying MADI, we categorized adaptations into three types: content , contextual , and training and supportive supervision (defined as changes made to the procedures for training and providing supportive supervision to personnel) . We thenOnce in-depth interviews were completed, it became clear that the COVID-19 pandemic would necessitate that BHP continue virtual services for longer than anticipated. We therefore initiated a process of ongoing data collection to capture any additional adaptations made after interviews were completed, as well as the influence of these adaptations on implementation outcomes. To minimize the burden of data collection on program implementers, we collected data by attending and taking notes during bimonthly implementation team meetings and PIP meetings held between the end of October to mid-December 2020 at the three Trinity Health hospitals. We probed throughout the discussions to obtain detailed information about adaptations and their perceived impact on implementation. Meeting notes were used to add to the results from in-depth interviews. Throughout this process, we consulted with program implementers to help ensure comprehensiveness, verify interpretations, and correct categorization of adaptations.The program manager developed a detailed report describing program adaptations made between March and July 2020 in response to the COVID-19 pandemic. To write the report, she drew on her in-depth knowledge of these adaptations given her role in the decision-making process for adaptations, managing day-to-day program operations, and providing training and supportive supervision to peer counselors throughout the pandemic. We reviewed this report to capture information for describing the elements of adaptation delineated in the FRAME.We integrated data from in-depth interviews, program meeting notes, and an internal report to generate detailed and comprehensive information on adaptations. After this triangulation of data was completed, we used member checking to validate the results . We sharThere were two major contextual adaptations: virtual recruitment and virtual counseling, which prompted training adaptations and content adaptations. We present the findings regarding these adaptations following the steps for retrospective application of MADI . First, To support all HHC staff including BHP peer counselors to plan and implement virtual services, HHC leadership provided training and support on topics such as maintaining confidentiality of client information . AdditioSupportive supervision intensified. Weekly online group meetings were instituted so that the program manager, program IBCLC, and peer counselors could continue to share program updates, review client cases, and maintain ongoing training on relevant topics, as well as to discuss hospital-specific protocols and challenges regarding virtual service delivery and potential solutions. The program manager held individual weekly supervisory meetings with each peer counselor by phone, and the IBCLC met with each peer counselor bi-weekly or weekly over the phone to discuss clinical topics. Both the program manager and IBCLC were also available to meet with peer counselors between scheduled meetings to offer additional support.Recognizing that some clients may not be familiar with video platforms, peer counselors were trained to assess each client's readiness to use these platforms and identify their preferred platform. Some clients did not want to use video calls, or only wanted video calls prenatally but not postpartum. Because program implementers were primarily concerned with maintaining contact at the scheduled touchpoints, peer counselors were advised to schedule video calls in place of in-person visits whenever possible, but if video calls were not possible or preferred by clients to contact them by phone and then lastly text.Training and providing supportive supervision to peer counselors on setting up and using platforms like Zoom and providing virtual breastfeeding peer counseling was viewed by program implementers to be important for increasing peer counselors' use of video calls. This was particularly important given that Zoom was a new technology to many peer counselors and video calls were a different mode of service delivery that peer counselors did not readily adopt when services initially transitioned to being virtual. Training and supportive supervision also promoted the adoption of content adaptations like the provision of breastfeeding education and support in the context of COVID-19, ensuring consistency in the content delivered by all peer counselors.Training on working remotely and virtual service delivery, as well as increased supportive supervision, enabled peer counselors to continue recruitment and service delivery during the pandemic. Specifically, program implementers emphasized that the feasibility of recruiting and delivering services virtually was largely due to peer counselors having the knowledge, skills, and ongoing assistance from program implementers to do so.Training influenced the appropriateness of the shift to virtual recruitment and service delivery. For example, maintaining privacy and confidentiality was viewed as an essential aspect of service delivery. Therefore, training and supportive supervision that helped ensure privacy and confidentiality was maintained made virtual recruitment and service delivery appropriate, particularly from the perspectives of program implementers.The program manager found remote training and supportive supervision to be acceptable, in part because she was accustomed to providing some supportive supervision via phone pre-pandemic since she was based at HHC and peer counselors were based at hospitals. A dedicated time that was convenient for all peer counselors to come together for weekly meetings and receive ongoing training was viewed by the program manager as a positive consequence of the pandemic. A few peer counselors echoed this sentiment. In particular, they described the training on how to use Zoom and other platforms such as WhatsApp and FaceTime for counseling as well as the opportunity to apply this knowledge in practice as a “great learning experience.”The reason that adaptations were made to training and supportive supervision was that program implementers recognized that successful implementation of virtual recruitment, virtual service delivery, and content adaptations would require that peer counselors build on their previous training and skills. For program implementers, a primary goal for offering additional training and supportive supervision was to facilitate successful implementation of services, and to maintain service quality to the best of their ability within the constraints imposed by the COVID-19 pandemic. Because this adaptation was made due to the unanticipated challenge of the COVID-19 pandemic, it was categorized as reactive. Still, this adaptation was systematic. At the program level, program implementers with rich experience implementing BHP identified the need for this adaptation immediately once the decision was made to stop in-person service delivery. They selected the training and supportive supervision topics based on their expertise and knowledge of the specific training needs of peer counselors as well as needs identified by peer counselors themselves. At the organizational level, HHC leadership determined to provide training on topics like maintaining confidentiality based on their extensive experience implementing CHW-led programs and knowledge of what would be required for CHWs to work remotely. With a clear rationale and systematic process, the adaptations to training and supportive supervision played a key role in maintaining alignment of program services with the core function of providing high-quality breastfeeding education and lactation management services.Peer counselors identified pregnant women in Epic and received referrals from healthcare providers through Epic as well as by phone or email . Of noteThe shift to virtual recruitment was feasible in part because it occurred within the context of HHC transitioning to remote work through a well-thought-out process. Several days before BHP made the shift, senior management at HHC met to determine what would be needed for remote work, met with all staff to discuss the situation, and equipped staff including BHP peer counselors with resources and support for remote work . AdditioWhat matters is the systematic approach that was taken to the behind-the-scenes stuff that aren't specific to the program model but are necessary to support it…So when we called it [work would be remote] a lot happened fast right before…to put everything in place. And after we put it all in place, there were still some things that needed fine tuning. (HHC staff member)Initially, recruitment of new clients through Epic was not possible because peer counselors were unable to remotely access Epic due to internet security restraints. Program implementers worked with hospital administrators to ensure proper HIPAA compliance and grant peer counselors remote Epic access. Several program implementers reported that granting peer counselors this access was a major challenge. Furthermore, although remote access was granted at the beginning of the pandemic, upgrades subsequently made to Epic for security reasons made it difficult for some peer counselors to access Epic remotely later on in the pandemic. Since many peer counselors were back onsite at hospitals when the upgrades occurred, they had less of a need to access Epic remotely. When peer counselors could access Epic, they used it to identify pregnant women to call for recruitment but quickly found that some women were reluctant to answer calls from numbers they did not recognize or were unsure why a peer counselor was calling. These “cold calls” were viewed as quite different than having a peer counselor dressed in business casual with a hospital ID meet with a woman in the prenatal clinic to discuss BHP. The program manager therefore increased referrals by regularly reminding providers that BHP was still operating. She also shared information about the program with providers who newly joined prenatal clinics and were not yet aware of BHP. She encouraged providers to refer patients to the program through Epic and to introduce the program to patients during prenatal visits so they could anticipate peer counselors' calls. Both peer counselors and program implementers emphasized the importance of referrals from providers as a determinant of feasibility with regards to recruitment both pre-pandemic and during the pandemic. Women knowing ahead of time that peer counselors would be calling made recruitment easier for peer counselors.Most peer counselors found it more difficult to reach women by phone than in person in prenatal clinics. Pre-pandemic, providers could easily bring peer counselors in and introduce them to potential clients, which was widely considered to be a highly effective recruitment strategy. Additional perceived barriers to reaching women included women not picking up “cold calls” due to not recognizing peer counselors' phone numbers, not listening to voicemail or viewing returning voicemail messages as a “priority,” and not responding to text messages. However, peer counselors felt that it was easy to recruit women into the program once they answered their phones. As such, peer counselors perceived remote recruitment to be feasible, though it sometimes required substantial effort and persistence.Program implementers and a couple peer counselors highlighted advantages of remote recruitment compared with in-person recruitment. For example, talking with women over the phone offered ample time to discuss BHP, whereas recruitment in hospitals felt rushed if women needed to leave soon after their prenatal visits or, in other instances, led to missed opportunities to talk with women if they left before peer counselors could catch them.While peer counselors thought that sharing information about the program over the phone or text messages was appropriate, they found remote communication to be less optimal for building rapport with potential clients compared with in-person communication, especially when “cold calling” women since they may wonder who the peer counselor is and why she is calling.Peer counselors pointed out that women “love texting” about BHP, and in some cases, preferred communicating via text. In some instances, women explicitly asked peer counselors not to call them because they were working and unable to talk. Peer counselors described sharing information via text messages as more “complicated” and “tedious” than conveying information over the phone because it required them to write a lot in the text messages. However, peer counselors expressed a commitment to being responsive to women's preferences and therefore regularly communicated about BHP via text during the recruitment process.The reason BHP shifted to virtual recruitment was to adhere to an HHC policy requiring all staff to work remotely in order to follow public health guidance for social distancing, and a Trinity Health policy limiting non-hospital staff from operating within the hospital to minimize spread of SARS-CoV-2. The primary goal was to ensure the safety of program staff, peer counselors, and clients, while sustaining program operations and maintaining reach and engagement to prevent breastfeeding inequities from widening during the pandemic. The shift to conducting recruitment virtually was reactive since it was made in response to the unforeseen pandemic and systematic in that it was made with consideration of implementation and intervention outcomes. Notably, the primary driver of this adaptation was safety. Program implementers therefore made the adaptation – and made it quickly – out of an urgent need, despite knowing that doing so may have negative effects on implementation outcomes, especially in the short run. For example, program implementers and peer counselors explained that recruitment prior to and during the pandemic was generally more successful at hospitals where peer counselors had strong working relationships with providers than at hospitals where peer counselors did not work as closely with providers. However, the unexpected and immediate shift to a new referral process in response to the COVID-19 pandemic initially had a negative effect on the feasibility of recruitment, even at hospitals where peer counselors and providers worked together closely. For example, one program implementer pointed out the initial challenges faced by one hospital:They [peer counselors] are integrated into a great prenatal team that is so supportive that they're fluidly interacting with each other about patients all the time. And it might be that that dynamic is so rich that it's the displacement into doing it individually in a home by phone call without the clinical team all around might just be a hard adjustment to make. (HHC staff member)Additionally, healthcare providers who were new to prenatal clinics and thus unaware of BHP quickly learned about the program from the program manager. The process of referrals through Epic was also disrupted since gaining access to Epic while working from home took some time, further reducing the feasibility of virtual recruitment initially. Once peer counselors and providers were reminded or made aware of BHP, gained experience with the referral process, and found ways to overcome barriers to implementation like issues with Epic access, the feasibility of virtual recruitment increased. Further, once initial challenges were addressed, virtual recruitment was consistent with the core function of the program to provide integrated peer counselor-delivered services across clinical and community settings, as peer counselors continued to be an integral part of the clinical teams and communicate with providers to recruit women into the program.Peer counselors substituted in-person visits with phone and video calls . Of notePeer counselors initially conducted most visits through phone calls because many clients opted for phone calls over video calls. Peer counselors themselves were reluctant to use video calls. Over time, however, peer counselors adopted video calls to approximate in-person visits using each client's preferred platform. Factors that increased peer counselors' adoption of video calls included encouragement from the program manager to use video calls, individual meetings with the program manager to identify barriers to use and ways to overcome them, training on how to use video platforms, and practice with these platforms. As peer counselors' comfort with video calls grew, they began presenting video calls as a good option for counseling when speaking with clients, which in turn increased clients' uptake of counseling via video calls. To further promote adoption of video calls, HHC updated the program protocol to include video calls as a substitute for in-person visits during the COVID-19 pandemic.Like the shift to virtual recruitment, the shift to only virtual service provision was viewed by program implementers as feasible and “smooth.” Two key facilitators were that HHC as an organization supported its various programs in transitioning to remote work and peer counselors received training and supportive supervision to deliver virtual services.Peer counselors reported that they were typically able to reach clients, though some clients were difficult to reach. Factors that were thought to make reaching clients feasible included clients picking up calls because they recognized peer counselors' phone numbers and clients often being home during the pandemic. Communication with clients was also facilitated by healthcare providers during pregnancy and the early postpartum period but not later during the postpartum period:Working alongside with the clinic…a little more so that they're gather[ing] information from that mom, whether it's call them when they're there or pass them a message along from us…but that's only feasible throughout their pregnancy and early postpartum, not past 6 weeks, 'cause after that, they're not seen any more by the gynecologist. (Peer counselor)Perceived barriers to communication included clients frequently being too busy to talk and, in some instances, not joining scheduled video calls as a result. Additionally, some clients were unfamiliar with video platforms in the beginning. However, some peer counselors reported that clients' comfort with using video calls increased over time, hypothesizing that this was due to clients gaining experience with using video calls for counseling visits and communicating with friends and family during the pandemic. Peer counselors found reaching clients during their birth hospitalization stay and immediately after they returned home particularly challenging, as some clients did not answer their phones during this time. In addition, peer counselors viewed younger clients as harder to communicate with than older clients because many younger clients did not answer their phones or listen to voicemails, leaving texting as the only way to reach them. Texting was perceived to be feasible but less efficient than phone calls:getting information from them [younger clients] takes me 3 days vs. it can take me 10 min, because they forget to text you back, and then they text you back, going with the back and forth, but I have to do it ‘cause I'd rather get somethin' than nothing. And my first go-to is a phone call, and if I call and call and call, and they're never calling me back and neither are they answering the phone, I text them. (Peer counselor)…Program implementers and peer counselors reported that the appropriateness of video calls as a substitute for in-person visits varied depending on the timing of the visit. Some peer counselors perceived video calls to be appropriate for delivering prenatal education because they could still show clients props such as dolls and demonstrate latching. However, HHC staff explained that part of the reason that prenatal visits are in-person is to build rapport with clients, and both HHC staff and peer counselors frequently described the challenges of building strong relationships with clients when not interacting in person. In-person visits during the postpartum period were also viewed as important for aspects of counseling like showing clients how to use a breast pump and observing a feeding to support clients with positioning and latching. To describe the value of home visits pre-pandemic, one HHC staff member highlighted that clients may feel more comfortable in their own homes than in other settings, which can facilitate the identification of challenges that may impede breastfeeding as well as potential issues that require follow-up by a healthcare provider:When they [peer counselor] finally got to the home, the mother felt more comfortable pulling up her shirt and pulling down her bra, and she [peer counselor] saw a serious breast anatomy problem [that she] never had seen before. So, there's things like that that happen in the comfort of one's home that may not happen elsewhere. (HHC staff member)The appropriateness of video calls also varied depending on the specific needs of clients. A major limitation was that peer counselors and IBCLCs were unable to offer hands-on lactation management support to assist clients with breastfeeding difficulties such as problems with latching, which was described as “best practice.” Peer counselors were also unable to observe home environments:The challenge is gonna be that they can't see the whole environment, they can't pick up the same way on the dynamics between people in that environment or the kinds of needs that they'd observe in that environment. (HHC staff member)Several peer counselors disliked that some aspects of counseling were lost when only delivering services virtually. For example, one peer counselor shared that connecting with and supporting clients in person was rewarding, but this aspect of her work was lost during the pandemic. Similarly, another peer counselor missed the in-person relationships that she had with clients, explaining that she missed being able to go to the clinic to see clients' progress and check in to see how they were doing emotionally. For one peer counselor, losing the ability to reach clients in person was stressful because she wanted to offer clients more support than what she could provide by only communicating remotely.Peer counselors shared their views on the acceptability of virtual service delivery from clients' perspectives. Some peer counselors found phone calls to be an acceptable mode of communication for their clients, with one peer counselor noting that some clients preferred phone calls. Similarly, some peer counselors thought that clients liked video calls. For example, postpartum clients liked showing peer counselors their infants during video calls, especially when clients had built relationships with their peer counselors prenatally. At the same time, peer counselors described some challenges regarding the acceptability of virtual service delivery. For instance, one potential client decided to not participate in the program because the program was not offering hands-on support. One peer counselor shared that she did not see many clients breastfeeding during video calls, hypothesizing that clients may not want to breastfeed while cameras were on due to privacy concerns.Similar to the reasons and goals for shifting to virtual recruitment, BHP shifted to virtual service delivery to adhere to HHC and Trinity Health COVID-19 policies, with the primary goal of preventing program staff, peer counselors, and clients from being exposed to or spreading SARS-CoV-2. Maintaining service delivery also enabled BHP to sustain reach and engagement to promote breastfeeding equity during a time when health inequities were growing. By delivering virtual services, BHP was also able to retain clients in the program who may have otherwise dropped out due to not wanting to have in-person visits due to potential exposure to SARS-CoV-2 from peer counselors, especially while pregnant or having a newborn. An additional goal was to continue providing services that are person-centered, namely meeting clients' needs and preferences for the continuation of counseling during the pandemic.Like the other adaptations, the shift to virtual service delivery was reactive since it was made in response to an unforeseen public health emergency. Program implementers reported that this adaptation was made using a systematic process that involved review of the needs of the clients and peer counselors in light of the restrictions and requirements imposed by the COVID-19 situation, and careful consideration of how to continue services in alignment with the BHP program model and protocol. This was accomplished by: drawing on the implementers' expertise on breastfeeding support in general, and the support offered by BHP specifically; close review and revision of the BHP protocol to meet emergency needs; and monitoring of program process indicators  overall and by each hospital and peer counselor.To continuously improve implementation of virtual services, recurring program meetings and PIP meetings as well as ongoing supportive supervision of peer counselors allowed program implementers and peer counselors to identify implementation challenges and strategies for overcoming them. Thus, the adoption and feasibility of virtual service delivery continuously improved. Furthermore, HHC staff members observed that peer counselors were highly motivated to make virtual service delivery work so that they could continue to support clients:The people who become peer counselors are really devoted…They want to help other people. They are well trained. They are well mentored….I think that even though there are adjustments to be made, staff are really throwing themselves into this. (HHC staff member)With the systematic shift to virtual service delivery, BHP maintained some but not full alignment with the core function of providing high-quality breastfeeding education and lactation management services. The main departure from this core function was that best practice for breastfeeding counseling calls for some in-person support at key points, such as when women are experiencing breastfeeding challenges like problems with latching. Additionally, in-person visits are optimal for building rapport, and in-person home visits are critical for observing the home environment and identifying social determinants of health that may impede a woman's ability to meet her breastfeeding goals. This misalignment with the core function of the program was perceived to have reduced the appropriateness of services, particularly for women with breastfeeding challenges. Acceptability also decreased among peer counselors who felt that virtual service delivery resulted in a loss of some aspects of counseling like relationship building. In contrast, the shift to virtual service delivery did not lead to a misalignment with the core function of promoting breastfeeding as a social norm and an empowering practice, since peer counselors were able to continue serving as role models for clients.The shift to virtual service delivery prompted three adaptations to program content, which involved increasing and adding elements . First, One vital thing that a postpartum mother needs, prenatal, too, but particularly at this time, sometimes it's just a caring person to speak with. They [peer counselors] certainly have been there for these participants in that way. So, you know, there are the usual anxieties and concerns of pregnancy and the new baby. But with COVID-19 added on top and changes in lifestyle…They have a listening ear. You know that has been vital. It was vital before this and it continues to be even more so. (HHC staff member)Overall, the content adaptations made to the program were perceived to be feasible. Some peer counselors noted that providing Spanish-language online educational videos and materials to Spanish-speaking clients required more effort compared with providing English-language content. For example, one peer counselor explained that there were not a lot of online videos or materials for Spanish-speaking mothers and that much of the content was misinformation, requiring her to spend time checking Spanish materials and consulting with the program IBCLC to make sure they were evidence-informed before sending them to clients. One program implementer from HHC shared that BHP was able to provide increased support to help address social and economic needs faced by BHP clients because HHC had sought and received funds for expanded support for clients of all the programs implemented by the organization.Content adaptations were viewed by peer counselors and program implementers as highly appropriate considering the challenges faced by clients during the COVID-19 pandemic. Furthermore, content adaptations increased the appropriateness of virtual service delivery, as they enabled peer counselors to continue to provide breastfeeding education and support and address social determinants of health.The reason for content adaptations was to address clients' limited access to resources, including information and social and economic resources. These content adaptations were made with the goal of promoting equity, delivering person-centered services, and maintaining program effectiveness. Although these adaptations were reactive, they were systematic. Program implementers planned many of these adaptations with consideration of their impact on implementation outcomes and effectiveness. When individual peer counselors made changes to the content delivered to clients given their needs and best practices, these changes were then adopted by all peer counselors.The content adaptations were aligned with the core function of providing high-quality breastfeeding education and lactation management services. By sharing more online breastfeeding resources and offering the most up-to-date scientific guidance about breastfeeding during the pandemic, peer counselors helped to meet the needs of clients during this public health emergency, which aligns with the program's emphasis on providing services that are person-centered and evidence-informed. Moreover, addressing social determinants of health is an evidence-based strategy for supporting women in meeting their breastfeeding goals. The content adaptation to intensify this aspect of the program was therefore consistent with BHP's focus on delivering services informed by available evidence.Despite the changes and challenges brought about by the COVID-19 pandemic, program implementers and peer counselors were able to shift to virtual service delivery for continued provision of breastfeeding counseling for BHP clients. A key reason for the continued delivery of services throughout the pandemic was to make sure there were no gaps in programming for clients facing breastfeeding inequities –30. WhilSome researchers have contended that reactive adaptations are more likely to be made using an unsystematic process, and an unsystematic process may compromise core functions . In our Our findings showed that adaptations can impact implementation outcomes in intended and unintended ways. For example, replacing home visits with video calls could increase acceptability of face-to-face interactions when peer counselors want to minimize exposure to SARS-CoV-2 but they lose rewarding aspects of their work like building relationships with and supporting clients in person. Other CHW-led programs that may be using or planning to incorporate telehealth into service delivery may benefit from considering the effect of such a change on job satisfaction and motivation among CHWs, which may influence retention. Further, these findings underscore the importance of identifying and addressing both intended and unintended impacts of adaptations on implementation outcomes .We found that the fast initiation of new activities and processes to provide services virtually posed some implementation challenges, especially initially. This finding indicates that attention should not only be given to how adaptations to core functions may compromise implementation success but also how a change in forms may also affect implementation outcomes. CHW programs can undertake emergency planning so that adaptations required during emergencies are identified and planned through a systematic process that considers alignment with core functions and necessary changes to forms. Training program implementers and CHWs so that they are well-prepared to adapt programming in the face of an emergency could also enhance implementation success as programs strive to continue programming in emergency contexts.A major strength of this study is that in addition to systematically documenting the adaptations of BHP we also evaluated the impacts of adaptations on implementation outcomes. Another strength was that multiple sources of data were used, allowing for triangulation of data. By incorporating notes from recurring program meetings into our analysis, we were able to offset the limitations of conducting in-depth interviews at one time point. Moreover, we captured the perspectives of program implementers and peer counselors who were highly involved in the adaptation process. Program implementers provided insights on adaptation characteristics such as what was modified and who participated in adaptation decision-making and potential mediators and moderators like the reasons and goals for adaptations and the extent to which the adaptations were systematic and aligned with core functions. They also described the influence of adaptations on implementation outcomes, particularly with regards to feasibility and appropriateness. Peer counselors provided insight into these topics, providing particularly rich information on what was modified and the impact of adaptations on feasibility, appropriateness, and acceptability drawing on their day-to-day experiences delivering services and interacting with clients. The use of a rapid analytic approach allowed for the timely dissemination of findings to program implementers to inform decision-making regarding the future use of telehealth.This study has several notable limitations. First, real-time data collection on adaptations was initiated after the completion of interviews when it became clear that BHP would need to continue only delivering virtual services due to the continued COVID-19 pandemic. It is therefore possible that some adaptations that occurred prior to the initiation of real-time data collection were missed. To address this potential limitation, program implementers reviewed the final list of adaptations during the member checking process to confirm that the list was comprehensive. Second, we did not conduct interviews with healthcare providers who work closely with program implementers and peer counselors. A diversity of healthcare providers participated in PIP meetings and thus their views were captured in meeting notes and included in our analysis. Third, Kirk and colleagues point out that adaptations can have both intended and unintended impacts, and, thus, encourage researchers to consider each implementation outcome when selecting outcomes to evaluate . Prior tFindings from this study have important implications for breastfeeding peer counselors in particular, as well as for CHWs in general. Taking our findings together, considering best practices for breastfeeding counseling, and drawing on our collective expertise in breastfeeding counseling, we do not recommend that breastfeeding counseling programs serving similar populations as BHP transition to offering only virtual services in the post-pandemic future . InsteadOur experience conducting partner-engaged research and using a multimethod and pragmatic evaluation approach can offer lessons that can inform future CHW studies investigating program changes in both emergency and non-emergency contexts. A key lesson from our study was that strong existing partnerships between researchers and program implementers can increase readiness to immediately begin research in the context of emergencies. We also found that meaningful partner engagement substantially shaped the objectives of the research and ensured that the knowledge generated was useful for those it aimed to benefit. Clinical and community partners were largely aware of program adaptations given their role in these adaptations and frequent meetings with peer counselors and healthcare providers, and thus, the information of greatest interest and value was that of the impact of adaptations on implementation outcomes. Our multimethod approach was intentionally designed to collect the necessary data for meeting our research objectives, while reducing the burden on program implementers and peer counselors. Doing so was crucial for enhancing the feasibility and acceptability of the study given that program implementers and peer counselors were focused on maintaining service delivery during the pandemic. We added goals, such as safety and equity, to the codes available for categorizing goals for adaptations to accurately capture the rationale for BHP's shift to virtual service delivery. These additional goals may be applicable in other CHW studies, particularly those evaluating adaptations of programs designed to promote healthcare and health equity in the context of emergencies.The shift to virtual breastfeeding counseling was largely systematic and enabled service continuity for women with low incomes during the COVID-19 pandemic. This study is a case example of partner-engaged, multimethod, and pragmatic research to evaluate program adaptations in response to a public health emergency that can contribute to advancing methods for assessment of adaptations across healthcare and community settings. Our findings can help inform emergency planning and increase the speed and successful implementation of the program adaptations needed by breastfeeding peer counseling programs as well as other CHW-led programs in response to public health emergencies.The original contributions presented in the study are included in the article/This project was reviewed by the Yale University Institutional Review Board and exempted from requiring human subjects approval. In spite of being exempt, we chose to obtain informed consent from all study participants.ER designed the study in collaboration with all co-authors and was responsible for overseeing qualitative data collection and analysis and drafting the manuscript. MZ and NA recruited participants, conducted interviews, and contributed to data analysis. All coauthors gave substantive comments during the iterative writing of the manuscript. All authors conceptualized the study, read, and approved the final manuscript.ER was supported by grant number K12HL138037 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute. This abstract was supported by the Cooperative Agreement Number 5 U48DP006380-02-00 funded by the Centers for Disease Control and Prevention, Prevention Research Center Program (PI. RP-E). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services. CC and RS were supported by grant number P0131174 from the W.K. Kellogg Foundation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the W.K. Kellogg Foundation.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Nonmedical use of prescription medications—particularly controlled substances—has risen dramatically in recent decades, resulting in alarming increases in overdose-related health care utilization, costs, and mortality. The Centers for Disease Control and Prevention estimate that 80% of abused and misused controlled substances originate as legal prescriptions. As such, policymakers and payers have the opportunity to combat nonmedical use by regulating controlled substance accessibility within legal prescribing and dispensing processes. One common policy strategy is found in Medicaid controlled substance lock-in programs. Lock-in programs identify Medicaid beneficiaries exhibiting high-risk controlled substance seeking behavior and “lock in” these patients to, typically, a single prescriber and pharmacy from which they may obtain Medicaid-covered controlled substance prescriptions. Lock-in restrictions are intended to improve care coordination between providers, reduce nonmedical use behaviors, and limit Medicaid costs stemming from nonmedical use and diversion. Peer-reviewed and gray literature have been examined to assess the current prevalence and design of Medicaid lock-in programs, as well as the current evidence base for informing appropriate program design and understanding program effectiveness. Forty-six state Medicaid agencies currently operate lock-in programs. Program design varies widely between states in terms of defining high-risk controlled substance use, the scope of actual lock-in restrictions, and length of program enrollment. Additionally, there is a remarkable dearth of peer-reviewed literature evaluating the design and effectiveness of Medicaid lock-in programs. Nearly all outcomes evidence stemmed from publicly accessible internal Medicaid program evaluations, which largely investigated cost savings to the state. Lock-in programs are highly prevalent and poised to play a meaningful role in curbing the prescription drug abuse epidemic. However, achieving these ends requires a concerted effort from the academic and policy communities to rigorously evaluate the effect of lock-in programs on patient outcomes, determine optimal program design, and explore opportunities to enhance lock-in program impact through coordination with parallel controlled substance policy efforts, namely prescription drug-monitoring programs.


The recent COVID-19 pandemic has led many countries to adopt emergency cashtransfer policies as a way to contain the economic and humanitarian crisis. Suchinitiatives were developed in a context of exacerbated gender, race, ethnicityand class inequalities resulting from physical and social distancing measures.The article analyzes, by means of an exploratory study and the so-calledtheory-driven evaluation of the program, the theoretical premises of theBrazilian Income Transfer Program (2003), Brazilian Emergency Assistance (2020)and Brazil Assistance (2021) programs, and their corresponding implementationdynamics. As cash transfer programs are given centrality in the contemporarypublic agenda, the conclusion is that evaluating their limits and advances - asto theoretical conception and mechanisms triggered in each context - contributesto trace evidence about their effectiveness in addressing long-term inequalitiesand those inequalities that arise in health emergency contexts. The pandemic caused by the SARS-CoV-2 has systemically impacted social and economicrelations, with structural effects on public health and the outreach of primaryhealth care services. The multiple impacts of COVID-19 on unemployment rates, workerproductivity, and consumption dynamics have exacerbated social inequalities. Thereduction of social spending based on fiscal austerity Bolsa Família, in Portuguese),created in 2003, was reexamined in relation to other possibilities such as theinstitution of universal income policies, with or without conditions ,,Accordingly, income guarantee has been assigned priority on the political agenda. TheBrazilian Income Transfer Program  wasestablished, which enabled the inclusion of information on Brazilian families inorder to guide the formulation and implementation of public policies. At the sametime, cash transfer was conditional on social requirements aimed at improving accessto health care, education, and social welfare services.The Brazilian Income Transfer Program, regulated by Auxílio Brasil, in Portuguese) was instituted throughLaw n. 14,284/2021The program was ended in 2021 and, in the same year, the Brazil Assistance program Law n. 13,982/2020AuxílioEmergencial, in Portuguese) in the amount of BRL 600.00 with a validityof three months and focus on individuals living on less than half a minimum wage,unemployed people, informal workers, and mothers in single-parent families. In somecases, such as that of women heads of families, it was possible to receive up to twoquotas totaling BRL 1,200.00. However, as of September 2020, throughProvisional Measures n. 1,000/2020n. 1,039/2021As alternatives to deal with this situation, many countries have strengthened socialprotection and cash transfer policies. In Brazil, on April 2, 2020, the government,through The Brazilian Emergency Assistance program mitigated the impact of the economiccrisis on the most vulnerable families, as well as on the upper classes, throughindirect effect and, therefore, contributed positively to mitigate the effects ofthe pandemic. However, several analysts have warned about the importance oflong-term measures to ensure adequate social protection in the country The effects of the Brazilian Emergency Assistance program still need to beinvestigated. In this study, the aim is to analyze the process of transition fromthe Brazilian Income Transfer Program to Brazil Assistance program by means of theso-called theory-driven evaluation, which combines a set of authors from the SocialSciences and from the field of Evaluation, on the analytical distinction between thetheoretical premises of the programs and the dynamics of implementation.,,,,Based on authors who dialogue with the evaluation of public programs and policies,socio-anthropological analyses of social inequalities and critical realism, the workpresents reflections on the social changes intended in the theory of the BrazilianIncome Transfer Program ,The program theory-driven approach aims at the analytical distinction between theprogram’s set of premises and its implementation process In this analytical framework, there is emphasis on social processes and theconstruction of public agendas For this study, the selected empirical material has different dimensions. TheBrazilian Income Transfer Program, established in 2003, was the subject of severalresearch and investigative efforts; therefore, their results could be monitored,compared and evaluated. The Brazilian Emergency Assistance program, of shortduration, has several mechanisms aimed at mitigating the effects of the pandemic. Inturn, the Brazil Assistance program was established in the late 2021 in a context offierce electoral clashes and without an explicit formulation on the changes to beachieved and the evaluation strategies to be adopted.The article is structured into three sessions. The first session presents a succinctanalysis of the debate on poverty and social inequality correlated with the proposedtheoretical framework. Next, there is an overview of the Brazilian Income TransferProgram considering the theory-driven approach, its implementation and the mainresults. Finally, there are reflections on health care and social inequalities,considering the post-pandemic challenges. In the conclusions, we highlight thecumulative experience of the analyses of the Brazilian Income Transfer Program andwhat these lessons warn us about the Brazilian Emergency Assistance and BrazilAssistance programs.Poverty is not considered as a state, but a phenomenon consisting of multipleobjective and subjective dimensions, intertwined with the social categories ofclass, gender, race/ethnicity and generation, which involve different mechanisms,visible and invisible, producing change over time, not necessarily linearly. Withinthe framework of critical realism, the mechanism is understood as something that cancause effects or make something happen in the world In general terms, the debate on poverty draws attention to the different factors thataffect living conditions. Monetary income, despite presenting difficulties formeasurement and establishment of consensus for the definition of “poverty lines”, isseen as a relevant information especially in modern economies. It is also one of themain mechanisms of access to goods and services that can affect livingconditions.According to Himmelfarb According to the analysis of Tilly ,,,In Brazil, the theoretical perspectives that approach inequalities only from a classperspective are insufficient as an explanatory axis As Brito However, since the 1990s the universalization of cash transfer benefits versus theirfocalization - that is, the creation of criteria to reach specific groups of thepopulation living in poverty - has constituted one of the main dilemmas of socialprotection policies Poverty, social inequalities and vulnerabilities pose conceptual and methodologicalchallenges for the formulation and implementation of public policies. Cash transferpolicies can be understood as a response to this challenge, within the framework ofthe debate on social protection. Direct transfers enable beneficiaries to choose touse the resource in any way that suits them. Although arguments about the “improper”use of the resource are highlighted in different studies, in general, it isrecognized that the initiative fosters productive activities and stimulates themarket Federal Constitution (1988) ensured a socialprotection system  for all citizens,guaranteeing public, universal, and free access. However, as pointed out by LavinasIn Brazil, the From the perspective of program theory-driven evaluation, it is necessary to describethe objectives, activities and resources provided for, and determine the mechanismsthrough which the intervention design operates or is intended to operate. Comparingprograms is relevant, as it enables understanding the consistency of the theoreticalpremises that support the different initiatives and also the practices adopted ineach context. Differently from the expectation that the program's logical frameworkprovides a clear representation of the causal links between activities, resourcesand results, the theory-driven evaluation explores ambivalences, controversies andinconsistencies both in the program’s normative design and implementation process.The local context is seen as a constitutive analytical dimension of the programs, asit sheds light on the dynamics involving cooperation and conflict of interest, whichhinder or further the achievement of the objectives.Law n. 10,836/2004provides central aspects: the target public are poor and extremely poor families,according to income criteria; expansion of access to universal policies ; combat against hunger and poverty by meeting basic needs andinducing access to social rights; establishment of conditions understood asmechanisms and social requirements If we take into consideration the Brazilian Income Transfer Program theory, it ispossible to perceive some contradictions and tensions with regard to the intendedeffects and the prospect of reducing inequalities. We know that the Brazilian IncomeTransfer Program’s explanatory statement in However, based on the literature on program theory, it is worth asking The Brazilian Income Transfer Program makes use of vulnerability factors andcorrelates them to the families’ social requirements, seen as “concrete elements fortheir socioeconomic emancipation”. In addition to the conditions, it emphasizes thecomplementary programs that include actions in the areas of training and microcreditto be implemented in coordination with state governments.The main goals of change are the fight against hunger and poverty, considered in itsmultidimensionality. Hunger was seen not only as a consequence of poverty, but as aresult of inadequate and/or discoordinated public policies in the areas of healthcare, education and social welfare. In turn, making the degree of food insecuritymeasurable and visible requires a set of intersectoral actions in order to providefood, including in schools and daycare centers, and monitor child development. Onthe other hand, the cash transfer itself does not mean adherence to the intendedchanges, which demands requirements; families were induced to comply with amonitoring schedule in the preestablished but not necessarily preexisting servicenetwork. This adherence also involved managers and professionals working in anintersectoral manner. The scope of the intended changes involved families, and women(and mothers) were recognized as the main responsible for the care and the task ofconverting income into well-being.The choice of having the financial benefit be registered in the name of women followsan international trend, either by recognizing the increasing number of women headsof families, especially among the poorest; or by the sexual division of labor thatentails a double shift for women; or because women, in caring for children and thehousehold unit, face more difficulties to enter the labor market. Other factors canalso be listed, such as domestic violence and gender discrimination, whichcontribute to making women more vulnerable. Thus, making them holders of the benefitcan be seen, in the logic of program theory, as a more effective mechanism for statecontrol over compliance with conditions. When they become holders, to some extent,they become responsible for the financial management of resources; however, on theother hand, they also become the main person accountable for compliance withrequirements, which reinforces gender inequalities.The conditional cash transfer in the scope of the Brazilian Income Transfer Programimposed changes at multiple levels, since it involved the fulfillment of conditionsin the health and education areas and, it can be affirmed, required the coordinationof actions with the other components of the program and the development of anintersectoral network. At the origin of the Brazilian Income Transfer Program, theobjective of focalization resulted in a better inclusion of poor and extremely poorfamilies and, therefore, in the provision of more accurate information in theCadÚnico registry system. For better integration of the social protection system,the program provided that the implementation should be conducted in a decentralizedand intersectoral manner. A key aspect was the development, in 2004, of theBrazilian National Social Assistance Policy (PNAS) and, in 2005, of the BrazilianBasic Operational Standard of the Unified Social Assistance System (NOB/SUAS).Subsequently, 2008 saw the institution of the Conditionality System Some weaknesses persisted. The complementary programs associated with the BrazilianIncome Transfer Program program and aimed at the development of labor capacitieslacked institutional coordination and political priority in their implementationDespite socioeconomic inequalities between regions, communities and populationgroups, since 1990 the Brazilian health system has incrementally achieved greatercoverage and outreach in health care The association between the FHS and Brazilian Income Transfer Program enabled newdevices to reach the poorest; however, difficulties still persisted, either in termsof the scope of cash transfers, access to basic health services, or both. The healthcondition of populations can be a good measure to understand inequalities in acountry and, in this regard, in Brazil, social advances have not been made in anequitable manner, which is why it is relevant to observe how the Brazilian IncomeTransfer Program and other social programs contribute not only to the improvement ofhealth, but also to the reduction of inequalities Despite the evidence on the positive effects of the FHS, some challenges remain. Themain explanatory reasons include the low number of professionals, municipal budgetconstraints, and precarious infrastructure. However, in a study that analyzed itsexpansion and coverage in Brazilian municipalities, between 1998 and 2012, thepositive impacts suggest the improvement of local health systems Access to health is considered one of the main mechanisms for breaking theintergenerational cycle of poverty, either because malnutrition has concrete andsevere consequences for child development, or because the absence of primary healthcare can produce irreducible consequences throughout the life cycle. These and otheraspects reinforce the importance and potentiating effects of the coordinationbetween the Brazilian Income Transfer Program and the FHS since, in manymunicipalities, the conditional cash transfer policy finds, in the FHS, themechanisms for compliance with the required health conditions and for improvement ofthe health conditions of the beneficiary population.,Attention to food insecurity rates, vaccination coverage, basic health care forpregnant women, nursing mothers, children and adolescents are practices that alreadyexist in the health policy, but that have become the object of monitoring inconjunction with the poverty reduction policy Brazilian NationalHousehold Sample Survey (PNAD), from 2001 to 2015, and Continuous PNAD,from 2016 and 2017 According to a recent study, based on the traditional With regard to the Brazilian Income Transfer Program theory, conditional cashtransfer was consistent in a context in which public health, through the expansionof FHS coverage, enhanced the intended effects, although it is questionable to treata right as a social requirement. On the other hand, the expansion of programs aimedat the autonomy of families seems to have been the great problem of the BrazilianIncome Transfer Program: if the low value of the benefit associated with otherpolicies contributes to reduce poverty and extreme poverty, the same does not occurfor these families to be able to access the labor market and, consequently,guarantee the sustainability of efforts to overcome social vulnerability.,,Some challenges remain related to protection policies: the financialization of socialpolicies and the consequent underfunding of health policies Cash transfer measures can be seen as an effective epidemiological strategy,considering the context of the COVID-19 pandemic and its multiple and systemiceffects When defining certain social groups as eligible, it becomes relevant to consider theheterogeneity of the inclusion and of the conditions and life of workers in thelabor market. Precarious conditions of housing, sanitation, infrastructure andtransport have direct implications on the physical distancing that, associated withthe health protocols, affected the measures to be followed during the differenttimes of the pandemic.The Brazilian Income Transfer Program theory indicates that emergency actions must becombined with structural policies, based on the coordination of state governmentsand civil society, in addition to conditions, which did not occur in the BrazilianEmergency Assistance benefit. The health policy during the health emergency tocombat COVID-19 was not directly linked to the benefit. For example, the lack offree virus detection tests and specific guidelines within the scope of the FHS mayhave contributed to increase the difficulty of inclusion and permanence of workersin the labor market, which was aggravated by the delay in immunization and even byit not being considered a requirement to receive the aid.On the other hand, studies indicate that the articulation with civil societyorganizations allowed mitigating some effects arising from the low intersectoralcoordination. If the impact of the emergency aid is not directly related to health,but to the economy, consumption and employment It is also worth investigating the epidemiological consequences of COVID-19 on thepopulation, in an intersectional approach, in addition to the clinical trials thatspecifically address this subject and the capacity of the primary health carenetwork to absorb new demands stemming from the long-term effects of the disease.Since 2016, a decline in immunization rates and coverage levels against measles andother diseases has already been observed ,The context in which the transition from Brazilian Income Transfer Program toBrazilian Emergency Assistance and to Brazil Assistance occurred still requiresin-depth studies and research. In the program theory-driven approach, the localpanorama is a key aspect for understanding the context-mechanism-resultconfigurations The changes intended by the Brazil Assistance are not limited to social welfarepolicies or projects to reduce social inequalities, but concern broader conceptionsabout the dynamics of social processes in which some elements  have gained prominence amid political and partisan disputesin the recent Brazilian conjuncture.The use of nationalist symbols such as the Brazilian flag and the permanent referenceto the idea of fatherland express a tendency to homogenize and naturalize theprocess of sharing meanings, which can obscure the constitutive multiplicity ofsociety. At the same time, the appreciation of the notion of aid as something morefluid, transitory and distanced from the language of social rights of citizenshiptends to reveal a challenging environment for the construction of equitable publicpolicies. In addition, there is a symbolic break from the name of the BrazilianIncome Transfer Program and, in contrast, an identification with the BrazilianEmergency Assistance, conveying the notion of continuity with the cash transferimplemented during the pandemic, reaffirming the conception that it is an occasionalbenefit and dissociated from a long-term prospect.Provisional Measure n.161, signed by a few hundred civil society entities. The dismantling of thecountry’s social protection system, the denial of the experiences accumulated by theBrazilian Income Transfer Program and by the Brazilian Food Acquisition Program arenoted, in addition to the neoliberal vision that guides current policies. Lessonslearned from previous cash transfer programs in the country and in the world are notvalued and evaluation strategies are not incorporated, hindering future analyses ofthe evidence of effectiveness of actions.The Brazil Assistance is also marked by the absence of strategies for dialogue withorganized civil society. Maria Emília Pacheco, in an interview with the HumanitasUnisinos Institute Auxílio Criança Cidadã,in Portuguese) can be used to expand the “provision of child care in daycarecenters”, in an induction of its use for payment of private daycare centers. The lowlevel of access to basic education and public daycare centers is not questioned,which limits productive inclusion as well as its coordination with educationpolicies and its expansion, since it is known that women with children  face greater difficulty to enter the labor market. Fostering the“scientific and technological performance of excellence” of children, adolescentsand young people is also a measure intended by the Brazil Assistance throughspecific benefits. However, the program theory is not clear as to how this changewill be achieved. Families entitled to Brazilian Child Citizen Assistance are thosein situation of poverty (monthly family income per capita between BRL 105.01 and BRL210.00) and extreme poverty (monthly family income per capita of up to BRL 105.00)and in “rule of emancipation” In the program theory, the Brazil Assistance indicates the integration of publicpolicies  as anintended change, as had occurred in the Brazilian Income Transfer Program. Thecriteria for inclusion in the Brazil Assistance are similar to those of theBrazilian Income Transfer Program; however, emphasis is given to the “simplificationof the basket of benefits” for the emancipation of families, achievement ofautonomy, and overcoming of social vulnerability. These aspects were stronglypresent in the theory of the Brazilian Income Transfer Program and constituted themain challenges of the implementation process. The Brazil Assistance theorycontinues to prioritize pregnant and nursing women, as in the Brazilian IncomeTransfer Program, but the reasoning is different: instead of recognizing theincreased number of in single-parent families and the difficulties experienced bywomen heads of families, the benefit can be seen as a “compensation” for thiscondition. The target public, as in the Brazilian Income Transfer Program, alsoconsists of children and adolescents, and it is proposed that the financial benefitcalled Brazilian Child Citizen Assistance  of the programs, whichrequires conceptualizations and knowledge about the design and execution of actionsor interventions to be implemented in the specific social contexts. The BrazilianIncome Transfer Program was the subject of different evaluation studies throughout18 years. Successes and errors were debated on the basis of evidence. The BrazilAssistance program - by not providing for the evaluation of its achievements andlimits - fails to contribute with lessons about the issue of combating poverty inthe country.Conditional cash transfer programs are public strategies introduced in socialcontexts. These are complex initiatives that are not limited to a set of isolatedcomponents or practices. In addition to establishing associations between theintervention and the effective results, the theory-driven evaluation of programsseeks to leverage the learning process, the formulation of new hypotheses, and theproduction of knowledge about the complex nature of public interventions.Econometric parameters and those based on the perspective of linear causation do notcontribute to the understanding of possible evidence of effectiveness of multilevelactions. Comparing the theories of the programs and the corresponding implementationprocesses questions the rationalist view of public policies and enables analyzingthe consistency of the normative design and the challenges of the local context inwhich mechanisms are triggered, barriers are faced, and different power arrangementsemerge. In turn, the evaluation based on the experimental model produces thedescription of the results, but does not clarify how the programs operate.The theory-driven evaluation research With regard to conditional cash transfer policies, the strategies of publicinvestment, renewal of collective facilities, and improvement of access toeducation, health care and social welfare should be associated with attentiveconsideration of the biographical trajectories of the impoverished individuals. Theconstruction of more robust criteria for the distribution of goods and servicestaking into account the diversity of the individuals’ initial conditions tends to bea guarantee of greater equity At the same time, the introduction of social requirements associated with a monetarybenefit can break the false opposition between universalizing programs and programsfocused on contexts of extreme poverty. The Brazilian Income Transfer Programcontributed to advances in the coverage of the FHS and to the intersectoriality anddecentralization of public interventions against poverty. The Brazil Assistanceprogram theory reflects a view of poverty pervaded by the prospect of electoralgains by neglecting previous institutional lessons and not providing solidguarantees of sustainability.According to the literature on program theory and authors that examine socialinequalities in health care, the Brazilian Income Transfer Program contributed toreduce poverty and extreme poverty, as well as enabled, through differentmechanisms, a greater outreach of social protection policies. Therefore, by relyingon a successful program theory, tested in evaluation studies, conditional cashtransfer remains a generative mechanism capable of producing changes.Investigating the Brazil Assistance program, through the program theory approach,shows the weaknesses of its conception and implementation, and its limitations infacing enduring inequalities and those that emerge from a new context of urgency,which may become permanent. Similarly, proposals currently under discussion anddevelopment, aimed at a universal basic income, could also benefit from the analyseson the Brazilian Income Transfer Program.It is worth emphasizing the importance of a research agenda on the effects of theBrazilian Emergency Assistance and Brazil Assistance programs on the coordinationwith other social protection programs and, in particular, the FHS. The investigationand analysis of the processes for implementation of actions enable examining thepoints of contact and distance between discourses and strategies that seek toassociate the debate on risks, vulnerabilities and human rights with regard tosocial protection.The article was finished and reviewed in the transition of the Federal Government,with the election of Luiz Inácio Lula da Silva as president of Brazil from 2023 to2026. The debate on guaranteeing the budget for the cash transfer program had majorprominence in the period, reaffirming the importance of the topic in the publicagenda. Certainly, there will be significant changes in the execution of socialprotection and, especially, conditional cash transfer programs. We hope thatevaluation will occupy a central place in this agenda.


Ear and hearing care programs are critical to early detection and management of otitis media (or middle ear disease). Otitis media and associated hearing loss disproportionately impacts First Nations children. This affects speech and language development, social and cognitive development and, in turn, education and life outcomes. This scoping review aimed to better understand how ear and hearing care programs for First Nations children in high-income colonial-settler countries aimed to reduce the burden of otitis media and increase equitable access to care. Specifically, the review aimed to chart program strategies, map the focus of each program against 4 parts of a care pathway , and to identify the factors that indicated the longer-term sustainability and success of programs.A database search was conducted in March 2021 using Medline, Embase, Global Health, APA PsycInfo, CINAHL, Web of Science Core Collection, Scopus, and Academic Search Premier. Programs were eligible or inclusion if they had either been developed or run at any time between January 2010 to March 2021. Search terms encompassed terms such as First Nations children, ear and hearing care, and health programs, initiatives, campaigns, and services.Twenty-seven articles met the criteria to be included in the review and described a total of twenty-one ear and hearing care programs. Programs employed strategies to: (i) connect patients to specialist services, (ii) improve cultural safety of services, and (iii) increase access to ear and hearing care services. However, program evaluation measures were limited to outputs or the evaluation of service-level outcome, rather than patient-based outcomes. Factors which contributed to program sustainability included funding and community involvement although these were limited in many cases.The result of this study highlighted that programs primarily operate at two points along the care pathway—detection and diagnosis/management, presumably where the greatest need lies. Targeted strategies were used to address these, some which were limited in their approach. The success of many programs are evaluated as outputs, and many programs rely on funding sources which can potentially limit longer-term sustainability. Finally, the involvement of First Nations people and communities typically only occurred during implementation rather than across the development of the program. Future programs should be embedded within a connected system of care and tied to existing policies and funding streams to ensure long term viability. Programs should be governed and evaluated by First Nations communities to further ensure programs are sustainable and are designed to meet community needs.The online version contains supplementary material available at 10.1186/s12913-023-09338-2. First Nations people, a collective term used here to describe the original inhabitants of Australia, New Zealand, Canada, and the United States,. Among these health disparities, otitis media (middle ear disease resulting from upper respiratory tract infections) presents in First Nations children with some of the highest prevalence rates in the world [First Nations people in Australia, New Zealand, Canada, and the United States present with below average life expectancy and poor health –17, desphe world –28. Firshe world  and morehe world , 27, andhe world , 27. Acqhe world ., behavioural skills [, employment, and socio-economic status later in life [. Hearing is also an integral part of learning, culture, and storytelling for First Nations people [Even mild levels of hearing loss can have a significant impact on communication of young school-aged children . In turnl skills , 39, socl skills , employm in life . Hearings people –45..Otitis media is classified as a ‘wicked problem’ in First Nations people. Otitis media is an issue of complexity and is particularly challenging to solve among First Nations populations owing to social and historical determinants of health such as overcrowded living conditions and low socio-economic status , 47. ThePrograms providing early detection and timely management of otitis media and associated hearing loss are fundamental to preventing downstream impacts on health, social, and educational outcomes. Yet, to date, little is known about the ways in which ear and hearing care programs that exist for First Nations children have been designed to mitigate barriers to accessing care. Therefore, this scoping review aimed to identify ear and hearing care programs for First Nations children in high-income colonial-settler countries to; (i) chart program strategies, and (ii) map the programs according to care pathway focus. This review also aimed to identify reported factors of program sustainability and measures of program success.In late 2020, the Aboriginal Children’s Hearing Health Project team identified the need to better understand approaches, areas of focus, and sustainability factors for healthcare programs that focus on ear and hearing issues among First Nations children in high-income colonial-settler countries. Ten non-Aboriginal members  of the Aboriginal Children’s Hearing Health Project and six Aboriginal and Torres Strait Islander members  made significant contributions to the review with expertise in scoping reviews and Aboriginal and Torres Strait Islander healthcare, culture, and lived experience.The current scoping review was conducted in accordance with Joanna Briggs Institute methodology .The database search was conducted in March 2021 and programs were eligible for inclusion if they had either been developed or run at any time between January 2010 to March 2021. Programs which were not developed or operational at least partially within this time was excluded on the basis that these programs do not capture recent approaches to ear and hearing care for First Nations children. Studies both qualitative and quantitative were included if they described healthcare programs that focused on ear and hearing problems for First Nations children aged up to 12 years of age in high-income colonial-settler countries, namely Australia, New Zealand, Canada, and the United States. Studies describing ear and hearing care programs which did not service First Nations children were excluded. Health awareness programs and campaigns regarding ear and hearing care were included if the targeted population was parents, carers, early childhood educators, teachers or health professionals who had First Nations children under their care.A Macquarie University librarian was consulted to compile the search strategy with MeSH terms and key word phrases including search terms such as ear and hearing care, First Nations, and health programs. Eight electronic databases were systematically searched: Medline, Embase, Global Health, APA PsycInfo, CINAHL, Web of Science Core Collection, Scopus, and Academic Search Premier. Grey literature including Google, Google Scholar, and Indigenous HealthInfoNet were also searched. References from included studies was scanned to identify additional studies.The full search strategy used to search the Medline database is provided in Table Two independent reviewers (KN and RM) screened by abstract and title and then screened by full text. The reviewers critically appraised eligible programs, and one independent reviewer (KN) extracted data from included studies. Any disagreement was settled with discussion and inclusion of a third reviewer (CM).The content of each article was extracted with reference to characteristics of ear and hearing care programs described including approaches, areas of focus across the care pathway, and sustainability factors. Indicators which studies reported on regarding program success were also captured. Data extraction was conducted by one of the independent reviewers (KN) and verified by a second independent reviewer (RM). Any disagreements were resolved through discussion with a third reviewer (CM).The data extraction spreadsheet contained the following items: First author, program/activity name, program/activity details, care pathway focus, years active, state and country, setting, participants, approach, access challenges, solutions to access challenges, First Nations involvement in design, implementation or evaluation, sustainability factors, indicators used to identify program success.Data regarding programs were reported using descriptive and narrative synthesis with reference to program care pathway focus, years active, state and country, setting, participants, program/activity details, program approach, access challenges, solutions to access challenges, First Nations involvement in design, implementation or evaluation, sustainability factors and indicators used to identify program success.Programs typically were focussed on addressing specific barriers along the care pathway. Therefore, these were mapped onto one or more of four parts of a typical care pathway . For the purposes of understanding care pathways within the ear and hearing care context, prevention was conceptualised as including education/awareness campaigns on prevention of speech and language delay, middle ear disease, and hearing loss. Detection included awareness of ear disease and hearing loss symptoms, surveillance, and screening. Diagnosis was the determination of condition or severity of the condition. Management included ENT surgery and medical treatment such as antibiotics. As diagnosis and management often occur within the same service or are carried out by the same provider, these two components of the care pathway have been conceptualised as occurring at the same care pathway stage. Finally, rehabilitation was conceptualised as involving learning support in schools, speech therapy and counselling as well as hearing aids and cochlear implants.The formal search identified 1,700 studies. Grey literature searches identified a further 97 studies. There were 1,106 studies remaining after duplication removal and these records were all screened by abstract/title. There were 120 studies assessed by full text according to eligibility criteria and 93 of these studies were removed with stated reasons. Twenty-seven studies were included in the synthesis. Study selection follows the PRISMA reporting guidelines and is illustrated in Fig. N = 27) were published between December 2010 and February 2021. Eight articles were classified as descriptive reports [, five were retrospective [Identified articles , one program was active in Canada (N = 1), and two programs were active in Alaska (N = 2). No programs were identified as being active in New Zealand. Supplementary Table Twenty-one programs were reported across 27 studies. Programs were active between 1985 – 2021. Most programs were conducted in Australia (N = 4) included, although not exclusively, prevention strategies. Thirteen programs focussed on detection, most of which related to screening of otitis media and hearing loss (N = 11). Ten programs were identified as focussing on management, which involved medical management and ENT specialist services. Four programs contained a rehabilitation component. Of the 21 programs, eight focused on more than one part of the care pathway.Understanding the care pathway is essential to ensuring continuity of care through identifying treatment processes and timeframes . MappingThe two most commonly identified barriers to accessing existing (mainstream) services were geographical , 69–73 aEight programs employed telehealth to extend geographical reach of services and connect patients to timely care. The mobile screening and surveillance service in Queensland (QLD) Australia , 71–73, An ENT program in Australia (no name) utilised telehealth for post-operative review to address geographical challenges and deliver a cost-effective model of care . This seFive programs were identified as employing an outreach approach to connect services to communities in regional or remote locations. The Hearing Health Outreach Program utilised an outreach approach to offer rehabilitative services . HealthyThe Hearing and Otitis Program (HOP) in Nunavik Canada was established in a specific location in the north in response to geographical barriers. This program also offered to send individual’s hearing aids to specialists via mail , 21. TheEleven programs were identified as employing IHWs to ensure cultural safety. The HOP in Nunavik Canada delivered hearing aid services such as fitting, follow-up and minor repairs facilitated through the program’s culturally identified role of the ‘aaniasiurtiapiit’ – a role similar to that of an IHW. If necessary, the aaniasiurtiapiit would send the hearing aid via mail to another specialist for further assistance. Counselling was provided by the siutilirijiit, a cultural counsellor who ensured safety of linguistic and cultural needs regarding proposed solutions to hearing loss , 21.Aboriginal Health Workers (AHWs) provided clinical services, support, follow-up services or use of resource kits in seven programs including the Hearing Health Outreach Program , HealthyThe Hearing Health Outreach Program in the NT delivered diagnostic services through outreach teams, which consisted of an audiologist and at least one other additional staff member  . This ouThree programs employed a workforce who had been trained in culturally safe work practices. The AFHCAN program aimed to ensure cultural safety through providing an audiologist who understands cultural subtleties of non-verbal communication such as facial movements and eye contact. This program also aimed to provide hearing technology choices that considered the patient’s cultural needs, which varied substantially due to diverse choices of lifestyle and environments including lakes, rivers and tundra . The HOPSelf-determination is a key aspect of health services for First Nations communities, whereby community collaboration and design of heath programs ensures services are delivered in a manner that meets local needs and facilitates better health outcomes . Of the Of the 27 identified articles, 23 stated indicators used to identify program success. Half of these articles stated outputs which included number of patients receiving various ear and hearing care services. Number of patients receiving services included those who received screening services , 72, 74,Most of the studies identified that programs relied on government funding mechanisms which could either ensure sustainability or lead to program discontinuation , 63, 65.The mobile screening and surveillance service identified that sustainability of these programs was due to their cost-effectiveness, close alignment and integration with existing community services, and ongoing community consultation participation , 71–73. This scoping review aimed to identify key strategies, areas of focus relative to the care pathway, and factors that could ensure or threaten a program’s sustainability for First Nations children in high-income colonial-settler countries. Programs identified indicated three main strategies; (i) connecting patients to specialist services , 70–74, The current scoping review found that focal points of the identified programs were concentrated on early detection of ear disease and hearing loss as well as management of ear conditions through specialist services. Programs focused on achieving detection through raising awareness of ear disease and hearing loss symptoms, and conducting surveillance and screening , 69–74. Many programs aimed to ensure cultural safety of services through involvement of IHWs , 70–73 oPrograms which included IHWs in service delivery may, in addition to achieving cultural safety, have been aiming to bolster sustainability. Although further research is needed, inclusive dialogue with IHWs has been recognised as contributing to sustainable workplace environments . AlthougThe current scoping review indicates that the majority of programs focus on output measures, presumably a by-product of a discrete program (capturing an episode of care) rather than a program embedded within a connected system of care. Output measures give an indication of program reach but assess only health system qualities, while outcome measures evaluate to long-term goals. Outcome measures regarding ear and hearing care should include mitigation of ear disease and hearing loss impacts with respect to wellbeing , speech n = 12) which addressed geographical access as a key barrier to care, indicates that many programs focused on servicing First Nations people residing in rural, regional or remote areas. This is presumably due to issues such as inequitable workforce distribution and extended wait times [Due to inconsistent study reporting, the current scoping review was unable to fully capture population-based demographic data of participants who received care. Rather, program location and setting were consistently reported and captured in this review. The high number of programs (it times  that freit times –90 and tit times .Findings should be interpreted with caution because whilst the scoping review utilised database search strategies to capture eligible articles on programs in Australia, New Zealand, Canada and the United States, most studies found were Australian programs. Only one program in Canada and two in Alaska were identified. No programs were identified as operating in New Zealand. Given the search terms utilised in the search strategy were inclusive of First Nations terms in New Zealand, we conclude that First Nations specific programs in these countries are scarce and/or unreported upon in both formal and grey literature. The methodological approach taken required program information to be publicised, hence information provided verbally through stakeholders could not be used to populate the results tables. This review aimed to capture reported measures of program success and although this information was not always reported in publications does not necessarily mean no data was captured.Substantial efforts have been made to provide ear and hearing care to First Nations children to address the high burden of otitis media and hearing loss. However, discrete programs can limit long-term viability given the need to seek or advocate for funding on an ongoing basis. While they might solve one part of the pathway, failing to address other significant gaps could potentially limit their longer-term benefit to the child and family. As the Lancet Global Health Commission on High Quality Health Systems in the SDG Era states, “high quality health systems should be informed by four values: they are for people, and they are equitable, resilient and efficient” . TherefoAdditional file 1: Supplementary Table 1. Program activities. *Aboriginal refers to Aboriginal and Torres Strait Islander peoples.Additional file 2: Supplementary Table 2. Program core elements. *Aboriginal refers to Aboriginal and Torres Strait Islander peoples.