A global call for action to include gender in research impact assessment.

Global investment in biomedical research has grown significantly over the last decades, reaching approximately a quarter of a trillion US dollars in 2010. However, not all of this investment is distributed evenly by gender. It follows, arguably, that scarce research resources may not be optimally invested (by either not supporting the best science or by failing to investigate topics that benefit women and men equitably). Women across the world tend to be significantly underrepresented in research both as researchers and research participants, receive less research funding, and appear less frequently than men as authors on research publications. There is also some evidence that women are relatively disadvantaged as the beneficiaries of research, in terms of its health, societal and economic impacts. Historical gender biases may have created a path dependency that means that the research system and the impacts of research are biased towards male researchers and male beneficiaries, making it inherently difficult (though not impossible) to eliminate gender bias. In this commentary, we - a group of scholars and practitioners from Africa, America, Asia and Europe - argue that gender-sensitive research impact assessment could become a force for good in moving science policy and practice towards gender equity. Research impact assessment is the multidisciplinary field of scientific inquiry that examines the research process to maximise scientific, societal and economic returns on investment in research. It encompasses many theoretical and methodological approaches that can be used to investigate gender bias and recommend actions for change to maximise research impact. We offer a set of recommendations to research funders, research institutions and research evaluators who conduct impact assessment on how to include and strengthen analysis of gender equity in research impact assessment and issue a global call for action.

Improving treatment adherence for blood pressure lowering via mobile phone SMS-messages in South Africa: a qualitative evaluation of the SMS-text Adherence SuppoRt (StAR) trial.

BACKGROUND: Effective use of proven treatments for high blood pressure, a preventable health risk, is challenging for many patients. Prompts via mobile phone SMS-text messaging may improve adherence to clinic visits and treatment, though more research is needed on impact and patient perceptions of such support interventions, especially in low-resource settings. METHOD: An individually-randomised controlled trial in a primary care clinic in Cape Town (2012-14), tested the effect of an adherence support intervention delivered via SMS-texts, on blood pressure control and adherence to medication, for hypertensive patients. ( TRIAL REGISTRATION: ClinicalTrials.gov NCT02019823). We report on a qualitative evaluation that explored the trial participants' experiences and responses to the SMS-text messages, and identified barriers and facilitators to delivering adherence support via patients' own mobile phones. Two focus groups and fifteen individual interviews were conducted. We used comparative and thematic analysis approaches to identify themes and triangulated our analysis amongst three researchers. RESULTS: Most participants were comfortable with the technology of using SMS-text messages. Messages were experienced as acceptable, relevant and useful to a broad range of participants. The SMS-content, the respectful tone and the delivery (timing of reminders and frequency) and the relational aspect of trial participation (feeling cared for) were all highly valued. A subgroup who benefitted the most, were those who had been struggling with adherence due to high levels of personal stress. The intervention appeared to coincide with their readiness for change, and provided practical and emotional support for improving adherence behaviour. Change may have been facilitated through increased acknowledgement of their health status and attitudinal change towards greater self-responsibility. Complex interaction of psycho-social stressors and health service problems were reported as broader challenges to adherence behaviours. CONCLUSION: Adherence support for treatment of raised blood pressure, delivered via SMS-text message on the patient's own phone, was found to be acceptable, relevant and helpful, even for those who already had their own reminder systems in place. Our findings begin to identify for whom and what core elements of the SMS-text message intervention appear to work best in a low-resource operational setting, issues that future research should explore in greater depth.

Why do families still not receive the child support grant in South Africa? A longitudinal analysis of a cohort of families across South Africa.

BACKGROUND: Child cash transfers are increasingly recognised for their potential to reduce poverty and improve health outcomes. South Africa's child support grant (CSG) constitutes the largest cash transfer in the continent. No studies have been conducted to look at factors associated with successful receipt of the CSG. This paper reports findings on factors associated with CSG receipt in three settings in South Africa (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal). METHODS: This study used longitudinal data from a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding by peer-counsellors in South Africa (ClinicalTrials.gov: NCT00397150). 1148 mother-infant pairs were enrolled in the study and data on the CSG were collected at infant age 6, 12, 24 weeks and 18-24 months. A stratified cox proportional hazards regression model was fitted to the data to investigate factors associated with CSG receipt. RESULTS: Uptake of the CSG amongst eligible children at a median age of 22 months was 62% in Paarl, 64% in Rietvlei and 60% in Umlazi. Possessing a birth certificate was found to be the strongest predictor of CSG receipt (HR 3.1, 95% CI: 2.4 -4.1). Other factors also found to be independently associated with CSG receipt were an HIV-positive mother (HR 1.2, 95% CI: 1.0-1.4) and a household income below R1100 (HR1.7, 95% CI: 1.1 -2.6). CONCLUSION: Receipt of the CSG was sub optimal amongst eligible children showing administrative requirements such as possessing a birth certificate to be a serious barrier to access. In the spirit of promoting and protecting children's rights, more efforts are needed to improve and ease access to this cash transfer program.

Equity for excellence in academic institutions: a manifesto for change.

Higher academic institutions in the UK need to drive improvements in equity, diversity, and inclusion (EDI) through sustainable practical interventions. A broad view of inclusivity is based on an intersectional approach that considers race, geographical location, caring responsibilities, disability, neurodiversity, religion, and LGBTQIA+ identities. We describe the establishment of a diverse stakeholder group to develop practical grass-roots recommendations through which improvements can be advanced. We have developed a manifesto for change, comprising six domains through which academic institutions can drive progress through setting short, medium, and long-term priorities. Interventions will yield rewards in recruitment and retention of a diverse talent pool, leading to enhanced impact and output.

'To be a woman is to make a plan': a qualitative study exploring mothers' experiences of the Child Support Grant in supporting children's diets and nutrition in South Africa.

Food security and good nutrition are key determinants of child well-being. There is strong evidence that cash transfers such as South Africa's Child Support Grant (CSG) have the potential to help address some of the underlying drivers of food insecurity and malnutrition by providing income to caregivers in poor households, but it is unclear how precisely they work to affect child well-being and nutrition. We present results from a qualitative study conducted to explore the role of the CSG in food security and child well-being in poor households in an urban and a rural setting in South Africa. SETTING: Mt Frere, Eastern Cape (rural area); Langa, Western Cape (urban township). PARTICIPANTS: CSG recipient caregivers and community members in the two sites . We conducted a total of 40 in-depth interviews with mothers or primary caregivers in receipt of the CSG for children under the age of 5 years. In addition, five focus group discussions with approximately eight members per group were conducted. Data were analysed using manifest and latent thematic content analysis methods. RESULTS: The CSG is too small on its own to improve child nutrition and well-being. Providing for children's diets and nutrition competes with other priorities that are equally important for child well-being and nutrition. CONCLUSIONS: In addition to raising the value of the CSG so that it is linked to the cost of a nutritious basket of food, more emphasis should be placed on parallel structural solutions that are vital for good child nutrition outcomes and well-being, such as access to free quality early child development services that provide adequate nutritious meals, access to adequate basic services and the promotion of appropriate feeding, hygiene and care practices.

The drive for universal healthcare in South Africa: views from private general practitioners.

To address problems of inadequate public health services, escalating private healthcare costs and widening health inequalities, the South Africa (SA) Government has launched a bold new proposal to introduce a universal, comprehensive and integrated system for all SAs; National Health Insurance. Though attention has been devoted to the economics of universal coverage less attention has been paid to other potential challenges, in particular the important role played by the clinicians tasked with implementing the reforms. However, historical and comparative analysis reveals that whenever health systems undergo radical reform, the medical profession is instrumental in determining its nature and outcomes. Moreover, early indications suggest many SA private general practitioners (GPs) are opposed to the measures--and it is not yet known whether they will comply with the proposals. This study therefore analyses the dynamics and potential success of the reforms by directly examining the perceptions of the SA medical profession, in particular private-sector GPs. It draws on a conceptual framework which argues that understanding human motivation and behaviour is essential for the successful design of social policy. Seventy-six interviews were conducted with clinicians in the Eastern Cape Province in 2012. The findings suggest that the SA government will face significant challenges in garnering the support of private GPs. Concerns revolved around remuneration, state control, increased workload, clinical autonomy and diminished quality of care and working conditions. Although there were as yet few signs of mobilization or agency by private clinicians in the policy process, the findings suggests that it will be important for the government to directly address their concerns in order to ensure a stable transition and successful implementation of the reforms.

The experience of cash transfers in alleviating childhood poverty in South Africa: mothers' experiences of the Child Support Grant.

Cash transfer (CT) programmes are increasingly being used as policy instruments to address child poverty and child health outcomes in developing countries. As the largest cash-transfer programme in Africa, the South African Child Support Grant (CSG) provides an important opportunity to further understand how a CT of its kind works in a developing country context. We explored the experiences and views of CSG recipients and non-recipients from four diverse settings in South Africa. Four major themes emerged from the data: barriers to accessing the CSG; how the CSG is utilised and the ways in which it makes a difference; the mechanisms for supplementing the CSG; and the impact of not receiving the grant. Findings show that administrative factors continue to be the greatest barrier to CSG receipt, pointing to the need for further improvements in managing queues, waiting times and coordination between departments for applicants trying to submit their applications. Many recipients, especially those where the grant was the only source of income, acknowledged the importance of the CSG, while also emphasising its inadequacy. To maximise their impact, CT programmes such as the CSG need to be fully funded and form part of a broader basket of poverty alleviation strategies.

Regulation of junior doctors' work hours: an analysis of British and American doctors' experiences and attitudes.

Regulations of junior doctors' work hours were first enacted in the United States (US) and United Kingdom (UK) over a decade ago, with the goals of improving patient care and doctors' well-being while maintaining a high quality of medical training. This study examines experiences and attitudes regarding the implementation of these regulations among physicians and surgeons at two teaching hospitals, one in South-East England, and the other in New England, US. This paper presents the findings of a survey questionnaire and a series of in-depth interviews administered to a sample of junior doctors and the consultants responsible for their supervision. The study finds that the different policy mechanisms employed in the two countries have had different degrees of success in reducing the work hours of junior doctors. The results also indicate, however, that even in settings in which hours have been reduced significantly, the regulations have only had limited effects on the quality of medical care, junior doctors' well-being, and the quality of medical education. A number of barriers to the success of the regulations in achieving their objectives are identified, and the relative merits of political action and professional self-regulation are discussed. This research suggests that recently enacted policies requiring further reductions in junior doctors' hours in both the US and UK may face similar barriers when implemented. Understanding the lessons that emerge from implementation of the original regulations is essential if future reforms are to succeed and a high-quality system of health care is to be sustained.

Improving the food environment in UK schools: policy opportunities and challenges.

Childhood obesity and nutrition are high on the UK policy agenda because of their association with chronic illnesses and related costs. In 2007, to improve children's nutrition, the Government introduced new standards for all school food sources, including products sold from vending machines. Our research explores the factors influencing schools' decisions and children's food choices in relation to vending machines. We conducted in-depth interviews with staff and pupils in one English Local Education Authority. We found that pupils made food decisions based on cost considerations, and convenience, and they strongly valued individual choice. Schools' decisions to provide vending were influenced predominantly by fiscal and structural constraints. Although unhappy with the current quality of school food, staff and pupils criticised initiatives to restrict unhealthy foods. It appears that achieving a healthier school environment is a long-term project involving multiple strategies of education and incentives, as well as regulation. These must involve parents as well as pupils and schools.