Science Shops as key intermediary structures to respond to the current health research agenda bias: Evidence from the InSPIRES project.

INTRODUCTION: To increase the likelihood of research responding to societal needs, intermediary structures such as Science Shops are being created. Science Shops respond to research needs identified and prioritized through participatory processes involving civil society. However, these are not mainstream structures, and most research needs addressed by the scientific community are not defined by a diversity of stakeholders (including citizens) but are mostly prioritized by researchers and funders. Literature shows this often leads to bias between the research topics investigated and the research needs of other relevant stakeholders. This study analyses how 14 Science Shops contribute to decreasing bias in health research agenda setting. METHODOLOGY: We compare the research priorities identified through participatory processes by the Science Shops, which participated in the European Union-funded project InSPIRES (2017-2021), to the available research addressed in the literature (identified in Web of Science), which we use as a proxy for current research priorities. RESULTS: Science Shop projects contributed to decreasing the existing bias in health research agenda setting: (1) between drug and nondrug treatments and (2) between clinical trials of treatments for illnesses affecting high-income versus middle- and low-income countries, which leads to a lack of local strategies for high disease burdens in nonhigh-income regions. CONCLUSION: This study provides the first evidence of Science Shops' effectiveness in addressing current biases in health research agenda setting. We conclude they could play a key role in shaping local, national and international research policies.

Master's degree in sexual and reproductive health: enhancing career development opportunities for midwives in Mali.

BACKGROUND: Midwives' contribution to improving outcomes for women and newborns depends on factors such as quality of pre-service training, access to continuing professional development, and the presence of an enabling work environment. The absence of opportunities for career development increases the likelihood that health professionals, including midwives, will consider leaving the profession due to a lack of incentives to sustain and increase motivation to remain in the field. It also limits the opportunities to better contribute to policy, training, and research. This study aimed to assess the influence of a Master in Sexual and Reproductive Health (SRH) at the INFSS on midwives' career progression in Mali. METHODS: This mixed methods study was conducted using an online questionnaire, semi-structured interviews, and a document review. The study participants included graduates from two cohorts (N = 22) as well as employers, managers, and teachers of the graduates (N = 20). Data were analysed according to research questions, comparing, and contrasting answers between different groups of respondents. RESULTS: The study revealed that graduates enrolled in the programme primarily to improve their knowledge and skills in management and public health. The graduates' expected roles are those of programme and health project manager and participation in planning and monitoring activities at national or sub-national level. The managers expected the programme to reflect the needs of the health system and equip midwives with skills in management and planning. The Master enhanced opportunities for graduates to advance their career in fields they are not usually working in such as management, research, and supervision. However, the recognition of the master's degree and of the graduates' profile is not yet fully effective. CONCLUSION: The master's degree in SRH is a capacity building programme. Graduates developed skills and acquired advanced knowledge in research and management, as well as a postgraduate degree. However, the master programme needs to be better aligned with health system needs to increase the recognition of graduates' skills and have a more positive impact on graduates' careers.

A System-Oriented Dialogue Model to Design Community Partnerships for More Effective Sars-Cov-2 Prevention in Schools: The Case of Spain.

Objectives: The European Centre for Disease Control (ECDC) COVID-19 guidelines for non-pharmaceutical interventions (NPI) identify safety, hygiene and physical distancing measures to control SARS-Cov-2 transmission in schools. Because their implementation requires complicated changes, the guidelines also include "accompanying measures" of risk communication, health literacy and community engagement. Although these are considered crucial, their implementation is complex. This study aimed to co-define a community partnership that a) identifies systemic barriers and b) designs recommendations on how to implement the NPI to improve SARS-Cov-2 prevention in schools. Methods: We designed and piloted a System-Oriented Dialogue Model with the participation of 44 teachers and 868 students and their parents from six Spanish schools during 2021. The results were analysed using thematic analysis. Results: Participants identified 406 items addressing issues related to system characteristics, which is indicative of the complexity of the challenge. Using a thematic analysis, we defined 14 recommendations covering five categories. Conclusion: These findings could help in developing guidelines for initiating community engagement partnerships in schools to provide more integrated prevention interventions.

Community participation in the health system: analyzing the implementation of community health committee policies in Kenya.

BACKGROUND: Community health committees (CHCs) are a mechanism for communities to voluntarily participate in making decisions and providing oversight of the delivery of community health services. For CHCs to succeed, governments need to implement policies that promote community participation. Our research aimed to analyze factors influencing the implementation of CHC-related policies in Kenya. METHODS: Using a qualitative study design, we extracted data from policy documents and conducted 12 key informant interviews with health workers and health managers in two counties (rural and urban) and the national Ministry of Health. We applied content analysis for both the policy documents and interview transcripts and summarized the factors that influenced the implementation of CHC-related policies. FINDINGS: Since the inception of the community health strategy, the roles of CHCs in community participation have been consistently vague. Primary health workers found the policy content related to CHCs challenging to translate into practice. They also had an inadequate understanding of the roles of CHCs, partly because policy content was not adequately disseminated at the primary healthcare level. It emerged that actors involved in organizing and providing community health services did not perceive CHCs as valuable mechanisms for community participation. County governments did not allocate funds to support CHC activities, and policies focused more on incentivizing community health volunteers (CHVs) who, unlike CHCs, provide health services at the household level. CHVs are incorporated in CHCs. CONCLUSION: Kenya's community health policy inadvertently created role conflict and competition for resources and recognition between community health workers involved in service delivery and those involved in overseeing community health services. Community health policies and related bills need to clearly define the roles of CHCs. County governments can promote the implementation of CHC policies by including CHCs in the agenda during the annual review of performance in the health sector.

Isolation: The experience of adolescent motherhood in Laos.

Background: Teenage pregnancy is a persistent public health problem with pervasive socio-economic consequences, particularly in in low- and middle-income countries, often related to low social participation and low economic security. The experiences of adolescent pregnancy and motherhood have seldom been described from a personal point of view. This study aimed to gain insights into how adolescent mothers in Laos experience their motherhood, how they perceive their situation and try to cope with it. Methods: This qualitative study was undertaken with 20 pregnant adolescents and young mothers living in peri-urban areas in two of the 18 provinces in Laos. Data were collected during 20 semi-structured interviews and two focus group discussions (n = 10). Digital recordings were transcribed verbatim, summarised and thematically analysed using an inductive analysis and exploratory approach. Results: The most common theme was that the young mothers experienced exclusion individually, socially and in relation to official systems. In only two cases was the pregnancy intended. All were determined to be good mothers, but were overwhelmed and unsure how to overcome structural barriers to educational, social and economic participation. Conclusion: Participants revealed that their adolescent pregnancy was tied to losses of past and future aspirations, and believed that working to prevent unintended adolescent pregnancy is worthwhile, but also advised that community support structures would help young women in their position.

How context influences the functionality of community-level health governance structures: A case study of community health committees in Kenya.

Community Health Committees (CHCs) are mechanisms through which communities participate in the governance and oversight of community health services. While there is renewed interest in strengthening community participation in the governance of community health services, there is limited evidence on how context influences community-level structures of governance and oversight. The objective of this study was to examine how contextual factors influence the functionality of CHCs in Kajiado, Migori, and Nairobi Counties in Kenya. Using a case study design, we explored the influence of context on CHCs using 18 focus group discussions with 110 community members (clients, CHC members, and community health volunteers [CHVs]) and interviews with 33 health professionals. Essential CHC functions such as 'leadership' and 'management' were weak, partly because Health professionals did not involve CHCs in developing health plans. Community Health Committees were active in the supervision of CHVs, reviewing their household reports, although they did not utilise these data for making decisions. Resource mobilisation and evaluation of health programs were affected by the lack of administrative and operational support, such as training. Despite having influential membership, CHCs could not provide leadership and management functions. Health system actors perceived the roles of CHCs as service providers rather than structures for governance and oversight. Insufficient awareness of CHC roles among health professionals, lack of training and operational support for community-based activities constrained CHCs' functionality and thus their role in community participation. While there are efforts to institutionalise community-level governance structures for health at sub-national level, there is a need to scale-up these efforts countrywide. We recommend that community-level governance structures be empowered, mandated, and provided with resources to take on the responsibility of overseeing community health services and exacting accountability from health providers.

Scaling up task-sharing psychological interventions for refugees in Jordan: a qualitative study on the potential barriers and facilitators.

Training nonspecialists in providing evidence-based psychological interventions (i.e. task-sharing) can effectively increase community access to psychological support. However, task-sharing interventions for this purpose are rarely used at scale. The aim of this study was to examine the factors influencing the potential for scaling up (i.e. scalability) of a task-sharing psychological intervention called Problem Management Plus (PM+) for Syrian refugees in Jordan. Semi-structured individual (n = 17) and group interviews (n = 20) were conducted with stakeholders knowledgeable about PM+ and the mental health system for Syrian refugees in Jordan. Using 'system innovation perspective', this study conceptualized the context as landscape developments, and systemic considerations were divided into culture (shared ways of thinking) and structure (ways of organizing). Political momentum was identified as a landscape trend likely facilitating scaling up, while predicted reductions in financial aid was regarded as a constraint. In terms of culture, the medicalized approach to mental health, stigma and gender were reported barriers for scaling up PM+. Using non-stigmatizing language and offering different modalities, childcare options and sessions outside of working hours were suggestions to reduce stigma, accommodate individual preferences and increase the demand for PM+. In relation to structure, the feasibility of scaling up PM+ largely depends on the ability to overcome legal barriers, limitations in human and financial resources and organizational challenges. We recommend sustainable funding to be made available for staff, training, supervision, infrastructure, coordination, expansion and evaluation of 'actual' scaling up of PM+. Future research may examine the local feasibility of various funding, training and supervision models. Lessons learned from actual scaling up of PM+ and similar task-sharing approaches need to be widely shared.

How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda.

BACKGROUND: The need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. METHODS: The study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention. RESULTS: A shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up. CONCLUSIONS: Despite the identification of the facilitators of the scale-up, full integration of the intervention into the health system has proven challenging in all countries. Approaching scale-up from a systems change perspective could be useful in future scale-up efforts, as it focuses on sustainable systems change at scale (e.g. improving district health management) by testing a combination of interventions that could contribute to the envisaged change, rather than horizontally scaling up and trying to embed one particular intervention in the system.

Cancer as a death sentence: developing an initial program theory for an IVR intervention.

To address current trends in poor health-seeking behaviour and late cancer diagnosis in many low- and middle-income countries, like Uganda, it is important to explore innovative awareness building interventions. One possible intervention is a common digital format, an interactive voice response (IVR) system, which is suitable for individuals with low technological and reading literacy. It is increasingly acknowledged that developing digital interventions requires co-creation with relevant stakeholders and explication of program developers' assumptions, to make them effective, sustainable, and scalable. To this end, we sought to develop an initial program theory for a co-created IVR system for cancer awareness in Uganda. Utilising principles of the realist approach, a qualitative exploratory study was conducted through seven focus group discussions (FGDs) with people living with cancer (PLWC), health workers, and policy makers. Thematic analysis of the transcripts resulted in the emergence of four major themes. Through all themes the most consistent finding was that myths, misconceptions, and misinformation about cancer were related to every aspect of the cancer journey and influenced the experiences and lives of PLWC and their caregivers. Participants were positive about the potential of an IVR system but also had reservations about the design and reach of the system. The resulting initial program theory proposes that a context-specific IVR system has the potential to improve awareness on cancer, provided attention is given to aspects such as language, message framing, and accuracy.

Art for public engagement on emerging and controversial technologies: A literature review.

Art is increasingly used to engage publics on emerging and controversial technologies, but we still know little about what works in art-based engagement and why. To investigate what art can do for public engagement, we systematically reviewed academic work published from 2000 to 2018 about the effect of art on organized public engagement. We used the dimensions of Responsible Research and Innovation as an analytical framework to identify what outcomes are achieved and what processes contribute to those outcomes. The 30 included studies showed that art mainly supported engagement by (1) reaching wider audiences, (2) fueling individual reflection, and (3) making visible how technologies come into being and interact with the world. With due consideration of the risks of instrumentalization, future research should empirically and reflexively investigate the outcomes and methodologies of art-based engagement, especially concerning collective reflection and change.

Understanding Discrepancies in Nutritional Outcomes Among Under-Fives in Laos: A Mixed-Methods Study Using the Positive Deviance Approach.

BACKGROUND: Stunting is one of the main contributing factors in the under-five mortality rate worldwide. In Laos, the prevalence of stunting remains high, particularly in mountainous rural areas. To prevent stunting, insight into positive deviant behaviors can help understand how people can cope or adapt in resource-poor settings. OBJECTIVE: This study aims to analyze the practices and underlying factors that explain discrepancies in nutritional outcomes in children under the age of 5 in remote mountainous areas in Laos. METHODS: This mixed-methods study included all children under the age of 5 living in 6 selected villages. Anthropometric measurements were taken, and a Z-score for stunting was calculated to select the positive and negative deviant children. To identify the causes of discrepancies in childhood stunting, household questionnaires, focus group discussions, observations, and individual interviews with family members and health workers were conducted. RESULTS: Fifty-five percent of children were stunted. Inappropriate care and feeding practices were observed such as providing unbalanced diets and not attending health facilities. Positive deviant mothers were less likely to follow inappropriate practices, experienced less food insecurity, and had higher motivation and autonomy, which resulted in prioritizing their children's health. An active role of fathers seemed to benefit positive practices within households. CONCLUSIONS: The combination of many different practices in which positive deviant families are doing slightly better was associated with in less stunting of children. Those practices are related to the household resources, such as access to food and social support; and the mother's motivation, autonomy, and perspectives on child health.

Qualitative evidence for improved caring, feeding and food production practices after nutrition-sensitive agriculture interventions in rural Vietnam.

Background: Research on nutrition-sensitive agriculture (NSA) has mostly been aimed at demonstrating its impact on nutrition and explicating underlying pathways, and more rarely at understanding processes and lessons learnt from them. This study aimed to gain insights into the processes that influence behaviour change, contributing to improved caring, feeding and food production practices, using a program theory perspective. It also investigated perceived challenges to the sustainability of interventions and potential solutions, in the context of an NSA program in rural Vietnam. Using a participatory approach, data were gathered on impact pathways and perceived outcomes, on elements of program theory that led to behavioural change, as well as barriers and facilitators. Respondents in semi-structured interviews (n = 30) and seven focus group discussions (total n = 76) were selected purposively among program participants. Data was collected and triangulated across several stakeholder groups. Results: The impact pathways (production-consumption, caring and feeding, and home-grown school feeding) envisaged in the NSA program functioned as intended; synergies were revealed. The increased supply of locally produced nutrient-rich foods not only contributed to the emergence of a promising income sub-pathway but also reinforced synergy with the home-grown school feeding pathway. Improved diets, feeding and caring practices, and school attendance were key outcomes of the program. Successful elements were pathway-specific, such as flexibility in implementing context-appropriate agricultural models. Others, such as benefit-driven motivation and improved knowledge, triggered changes in multiple pathways. Role models, increased self-confidence, and change agents were the main process facilitators. The biggest barrier to both implementation and sustainability was the poor socio-economic conditions of the most disadvantaged households. Conclusions: This study showed the relevance of NSA programs in addressing undernutrition in remote areas by enhancing self-reliance in local communities. The integration of behaviour change activities proved to be a key strategy in the process to enhance the impact of agriculture on nutrition outcomes. Though outcomes and influencing factors are very context-dependent, lessons on what worked and what did not work could inform the design and implementation of effective behaviour change strategies in future NSA programs in Vietnam and elsewhere.

Home-Grown School Feeding: Implementation Lessons From a Pilot in a Poor Ethnic Minority Community in Vietnam.

BACKGROUND: Undernutrition threatens the health and future of preschool children in disadvantaged remote communities. Home-grown school feeding (HGSF) in nursery schools could positively impact children's nutrition while creating multiple benefits for the whole community. However, evidence is lacking on implementation of HGSF within multi-sectoral programs in remote areas. OBJECTIVE: This study assessed an HGSF pilot intervention, part of a nutrition-sensitive agriculture (NSA) program, in a mountain ethnic minority community in Vietnam. It aimed to identify the changes brought about by the intervention, in particular diversity of children's food, food sources, barriers and facilitators to change, and future challenges and strategies. METHODS: Mixed-methods assessment covered school meal diversity, cost, and food sources but the key focus was on observed changes resulting from the HGSF intervention and perceived barriers and facilitators to its implementation. Data were collected mainly through semi-structured interviews (n = 30) and seven focus group discussions (n = 76). RESULTS: School meals contributed to increasing diversity of food consumed by children. Above 30% of foods used were home-grown. Respondents reported increased school attendance; children's food preferences and hygiene practices improved as did parents' caring and feeding practices. Local food systems became less cash-crop-oriented and more self-reliant, contributing to household food security and income generation. Social capital increased. Positive changes were attributed to HGSF and synergy among NSA program components. Poverty and limited resilience to external shocks threatened sustainability. CONCLUSIONS: Implementing HGSF within an NSA program in a mountainous ethnic minority area with a high prevalence of undernutrition benefitted children and their communities.

Mapping the complex everyday challenges and needs of people with rheumatic disease and their surroundings using a multi-actor approach.

INTRODUCTION: This study aimed to gain insight into the real-world complexity of the challenges experienced by patients, their significant others, care professionals and the work and education environment concerning rheumatic diseases as well as the interrelation between these challenges; it also aimed to prioritise the identified challenges. METHOD: Using the Dialog Model, 21 people with various rheumatic diseases, 24 care professionals, 9 significant others, and 3 education and work representatives were asked about rheumatic disease-related challenges and needs in a series of focus groups and interviews. Data were inductively coded and analysed, resulting in a mind map thematically displaying the challenges. The mind map was translated into a survey, and respondents (N = 1802) prioritised themes and challenges. RESULTS: Of the six identified themes, 'physical complaints' was prioritised the most, followed by 'collaboration in healthcare', 'social and mental wellbeing', 'self-management', 'information and options in healthcare' and 'work and education'. Challenges of people with rheumatic diseases appeared to be complexly interrelated. For instance, fatigue and pain affect everyday functioning, but can also heavily impact social and mental wellbeing. To facilitate support for these challenges, which many patients desire, patients and care professionals said that better collaboration between primary and secondary care professionals is needed. Additionally, patients felt that their experiential expertise deserves more acknowledgement from care professionals. Results were similar across different rheumatic diseases. CONCLUSION: Many patients desire more support to manage life with their disease. To facilitate this, collaboration and communication between healthcare professionals, and between healthcare professionals and individual patients, should be improved.

Inclusion strategies in multi-stakeholder dialogues: The case of a community-based participatory research on immunization in Nigeria.

BACKGROUND: Community-Based Participatory Research (CBPR) has been used to address health disparities within several contexts by actively engaging communities. Though dialogues are recognized as a medium by which community members and other actors can make their voices heard through processes that support shared-decision making, power asymmetries often impede the achievement of this objective. Traditionally such relationship asymmetries exist between communities, health workers, and other professionals resulting in the exclusion of communities from decision making in participatory practices and dialogues. This study aimed to explore the experiences in the dialogues between different groups within communities, health workers and local government officials in a CBPR project on immunization in Nigeria. We adapted the framework by Elberse et al. (2011) to structure the possible exclusion mechanisms that could exist in dialogues between the three groups and we set up inclusion strategies to diminish the inequalities as much as possible. METHODS AND FINDINGS: This is an exploratory and descriptive case study, using qualitative methods. Data was collected through observation and semi-structured interviews (SSI) with dialogue participants. All 24 participants in the multi-stakeholder dialogues were interviewed. Inclusion strategies involved creating enabling circumstances; influencing behaviour; and influencing use of language. Verbal and circumstantial strategies were of limited value in reducing exclusion. Behavioural inclusion strategies created more awareness of the importance of inclusion; and enabled different community stakeholders to direct their influences towards achieving the collective goals of the collaboration. An important learning is that if evidence is used in the dialogues, even when exclusion of certain individuals occurs, the outcomes could still favour them. A key issue is the difference between participation and representation and the need for more efficient ways of carrying out such interactive processes to ensure that the participation of the vulnerable groups is not merely symbolic. The study makes a case for the use of 'boundary spanners' in this dynamic-these are 'elite' individuals (or community champions) who can be a voice for the minorities and who could have the opportunity to influence decision making. CONCLUSION: CBPR can enable local governments to develop effective partnerships with health workers and communities to achieve health-related goals even in the presence of asymmetries in relationships. Inclusion strategies in dialogues can improve participation and enable shared decision making, however exclusion of vulnerable groups may still occur. Intra-community dynamics and socio-cultural contexts can drive exclusion and less privileged community members require proper representation to enable their issues to be captured effectively.

Participation in primary health care through community-level health committees in Sub-Saharan Africa: a qualitative synthesis.

BACKGROUND: Health committees are key mechanisms for enabling participation of community members in decision-making on matters related to their health. This paper aims to establish an in-depth understanding of how community members participate in primary health care through health committees in sub-Saharan Africa (SSA). METHODS: We searched peer-reviewed English articles published between 2010 and 2019 in MEDLINE, Popline and CINAHL databases. Articles were eligible if they involved health committees in SSA. Our search yielded 279 articles and 7 duplicates were removed. We further excluded 255 articles following a review of titles and abstracts by two authors. Seventeen abstracts were eligible for full text review. After reviewing the full-text, we further excluded two articles that did not explicitly describe the role of health committees in community participation. We therefore included 15 articles in this review. Two authors extracted data on how health committees contributed to community participation in SSA using a conceptual framework for assessing community participation in health. We derived our themes from five process indicators in this framework, namely, leadership, management and planning, resource mobilization from external sources, monitoring and evaluation and women involvement. FINDINGS: We found that health committees work well in voicing communities' concerns about the quality of care provided by health facility staff, day-to-day management of health facilities and mobilizing financial and non-financial resources for health activities and projects. Health committees held health workers accountable by monitoring absenteeism, quality of services and expenditures in health facilities. Health committees lacked legitimacy because selection procedures were often not transparent and participatory. Committee members were left out in planning and budgeting processes by health workers, who perceived them as insufficiently educated and trained to take part in planning. Most health committees were male-dominated, thus limiting participation by women. CONCLUSION: Health committees contribute to community participation through holding primary health workers accountable, voicing their communities' concern and mobilizing resources for health activities and projects. Decision makers, health managers and advocates need to fundamentally rethink how health committees are selected, empowered and supported to implement their roles and responsibilities.

Designing a Healthy Food-Store Intervention; A Co-Creative Process Between Interventionists and Supermarket Actors.

BACKGROUND: Without consideration for the food system in which healthy food-store interventions (HFIs) are implemented, their effects are likely to be unsustainable. Co-creation of HFIs by interventionists and food-store actors may improve contextual fit and therefore the effectiveness and sustainability of interventions, but there are few case studies on the topic. This study aims to provide insights into the integration of knowledge from contextual actors into HFI designs, through a co-creative process, to illustrate potential challenges, advantages, and outcomes. METHODS: We describe the co-creative design of an HFI in a Dutch supermarket chain, conducted through three increasingly in-depth design phases. Each phase consisted of a cycle of theorizing (gather insights from literature, feedback, and pilot studies), building (develop intervention designs), and evaluating (interviews or workshops with supermarket actors, to explore barriers and facilitators for sustainable implementation), feeding back into the next phase (drafting adapted intervention designs, based on feedback, and research input). Interview transcripts underwent a qualitative content analysis. RESULTS: We co-creatively designed four types of interventions to promote healthier food choices in supermarkets: (1) price strategies, (2) product presentation and positioning, (3) signage, and (4) interactive messaging. Interventions were aligned with the culture, structures and practices of the supermarket chain, while simultaneously challenging these system characteristics. For example, the idea of price promotions on healthy foods was well-received and encountered only practical barriers, which were easily resolved. However, the specification of tax-like price increases on unhealthy foods led to substantial resistance on cultural and commercial grounds, which were resolved through support from a key supermarket actor. CONCLUSION: Our results illustrate the potential benefits of co-creation approaches in HFI design. We reflect on the value of more easily accepted interventions to develop collaborative momentum and more radical interventions to drive more substantial changes.

Adoption of harmonisation policy for the midwives' training programme in Mali: A policy analysis.

West Africa is engaged in a process of harmonising health workers' training programmes as a means to regulate regional training standards and thus improve their quality. There is currently a lack of documented information regarding the adoption of these revised training programmes. In 2012 a harmonised programme, the WAHO competency-based curriculum, was introduced in Mali for training midwives. The present study explores the barriers and facilitators of the adoption of this programme and how the content, context, process, and actor-related factors influenced this. We used a qualitative research design consisting of document analysis (n = 25) and semi-structured interviews (n = 21) with policymakers, students, and those in charge of implementing the training programme. Information was collected on education and training policies, the context and process of the harmonised curriculum development, its adoption, and the actors involved in the adoption strategy, along with their role. The study shows that the adoption of the harmonised curriculum in Mali offered midwives an opportunity to attain a higher standard of training and level of qualification than before. It also displayed both the government's and the public school's willingness and commitment to improve maternal and child health through enhancing midwives' training standards. The most salient factors that influenced adoption were the lack of available resources, and the lack of involvement of, and coordination with, relevant actors for successful policy adoption. Mali's experience of adopting the harmonisation policy of training curricula demonstrates the need for the authorities to collaborate with relevant actors for information dissemination and in the adoption process. It also demonstrates the need for finding innovative ways to secure and diversify funding opportunities, as well as establish a supervisory body for health worker training.

Unraveling the politics of 'doing inclusion' in transdisciplinarity for sustainable transformation.

Transdisciplinary research and innovation (R&I) efforts have emerged as a means to address challenges to sustainable transformation. One of the main elements of transdisciplinary efforts is the 'inclusion' of different stakeholders, values and perspectives in participatory R&I processes. In practice, however, 'doing inclusion' raises a number of challenges. In this article, we aim to contribute to re-politicizing inclusion in transdisciplinarity for transformation, by (1) empirically unraveling four key challenges that emerge in the political practice of 'doing inclusion', (2) illustrating how facilitators of inclusion processes perform balancing acts when confronted with these challenges, and (3) reflecting on what the unfolding dynamics suggests about the politics of stakeholder inclusion for societal transformation. In doing so, we analyze the transdisciplinary FIT4FOOD2030 project (2017-2020)-an EU-funded project that aimed to contribute to fostering EU R&I systems' ability to catalyze food system transformation through stakeholder engagement in 25 Living Labs. Based on 3 years of action-research (including interviews, workshops and field observations), we identified four inherent political challenges to 'doing inclusion' in FIT4FOOD2030: (1) the challenge to meaningfully bring together powerful and marginalized stakeholders; (2) combining representation and deliberation of different stakeholder groups; (3) balancing diversities of inclusion with directionalities implied by transformative efforts; and (4) navigating the complexities of establishing boundaries of inclusion processes. We argue that by understanding 'doing inclusion' as a political practice, necessitating specificity about the (normative) ambitions in different inclusion settings, facilitators may better grasp and address challenges in transdisciplinarity for transformation.