Engaging communities as partners in health crisis response: a realist-informed scoping review for research and policy.

BACKGROUND: Health is increasingly affected by multiple types of crises. Community engagement is recognised as being a critical element in successful crisis response, and a number of conceptual frameworks and global guideline documents have been produced. However, little is known about the usefulness of such documents and whether they contain sufficient information to guide effective community engagement in crisis response. We undertake a scoping review to examine the usefulness of conceptual literature and official guidelines on community engagement in crisis response using a realist-informed analysis [exploring contexts, mechanisms, and outcomes(CMOs)]. Specifically, we assess the extent to which sufficient detail is provided on specific health crisis contexts, the range of mechanisms (actions) that are developed and employed to engage communities in crisis response and the outcomes achieved. We also consider the extent of analysis of interactions between the mechanisms and contexts which can explain whether successful outcomes are achieved or not. SCOPE AND FINDINGS: We retained 30 documents from a total of 10,780 initially identified. Our analysis found that available evidence on context, mechanism and outcomes on community engagement in crisis response, or some of their elements, was promising, but few documents provided details on all three and even fewer were able to show evidence of the interactions between these categories, thus leaving gaps in understanding how to successfully engage communities in crisis response to secure impactful outcomes. There is evidence that involving community members in all the steps of response increases community resilience and helps to build trust. Consistent communication with the communities in time of crisis is the key for effective responses and helps to improve health indicators by avoiding preventable deaths. CONCLUSIONS: Our analysis confirms the complexity of successful community engagement and the need for strategies that help to deal with this complexity to achieve good health outcomes. Further primary research is needed to answer questions of how and why specific mechanisms, in particular contexts, can lead to positive outcomes, including what works and what does not work and how to measure these processes.

Did aid to the Ebola crisis divert aid for reproductive, maternal, and newborn health? An analysis of donor-reported data in Sierra Leone.

BACKGROUND: Infectious disease outbreaks like Ebola and Covid-19 are increasing in frequency. They may harm reproductive, maternal and newborn health (RMNH) directly and indirectly. Sierra Leone experienced a sharp deterioration of RMNH during the 2014-16 Ebola epidemic. One possible explanation is that donor funding may have been diverted away from RMNH to the Ebola response. METHODS: We analysed donor-reported data from the Organisation for Economic Cooperation and Development (OECD)'s Creditor Reported System (CRS) data for Sierra Leone before, during and after the 2014-16 Ebola epidemic to understand whether aid flows for Ebola displaced aid for RMNH. We estimated aid for Ebola using key term searches and manual review of CRS records. We estimated aid for RMNH by applying the Muskoka-2 algorithm to the CRS and analysing CRS purpose codes. RESULTS: We find substantial increases in aid to Sierra Leone (from $484 million in 2013 to $1 billion at the height of the epidemic in 2015), most of which was earmarked for the Ebola response. Overall, Ebola aid was additional to RMNH funding. RMNH aid was sustained during the epidemic (at $42 m per year) and peaked immediately after (at $77 m in 2016). There is some evidence of a small displacement of RMNH aid from the UK during the period when its Ebola funding increased. CONCLUSIONS: Modest changes to RMNH donor aid patterns are insufficient to explain the severe decline in RMNH indicators recorded during the outbreak. Our findings therefore suggest the need for substantial increases in routine aid to ensure that basic RMNH services and infrastructure are strong before an epidemic occurs, as well as increased aid for RMNH during epidemics like Ebola and Covid-19, if reproductive, maternal and newborn healthcare is to be maintained at pre-epidemic levels.

A story of (in)coherence: climate adaptation for health in South African policies.

Climate adaptation strengthens and builds the resilience of health systems to future climate-related shocks. Adaptation strategies and policies are necessary tools for governments to address the long-term impacts of climate change and enable the health system to respond to current impacts such as extreme weather events. Since 2011 South Africa has national climate change policies and adaptation strategies, yet there is uncertainty about: how these policies and plans are executed; the extent to which health policies include adaptation; and the extent of policy coherence across sectors and governance levels. A policy document analysis was conducted to examine how South African climate change, development and health policy documents reflect the health adaptation response across national and Western Cape levels and to assess the extent of coherence across key health and environment sector policy documents, including elements to respond to health-related climate risks, that can support implementation. Our findings show that overall there is incoherence in South African climate adaptation within health policy documents. Although health adaptation measures are somewhat coherent in national level policies, there is limited coherence within Western Cape provincial level documents and limited discussion on climate adaptation, especially for health. Policies reflect formal decisions and should guide decision-makers and resourcing, and sectoral policies should move beyond mere acknowledgement of adaptation responses to a tailored plan of actions that are institutionalized and location and sector specific. Activities beyond documents also impact the coherence and implementation of climate adaptation for health in South Africa. Clear climate risk-specific documents for the health sector would provide a stronger plan to support the implementation of health adaptation and contribute to building health system's resilience.

Examining the militarised hierarchy of Sierra Leone's Ebola response and implications for decision making during public health emergencies.

BACKGROUND: In September, 2014, Médecins Sans Frontières (MSF) called for militarised assistance in response to the rapidly escalating West Africa Ebola Epidemic. Soon after, the United Kingdom deployed its military to Sierra Leone, which (among other contributions) helped to support the establishment of novel and military-led Ebola Virus Disease (Ebola) response centres throughout the country. To examine these civil-military structures and their effects, 110 semi-structured interviews with civilian and military Ebola Response Workers (ERWs) were conducted and analysed using neo-Durkheimian theory. RESULTS: The hierarchical Ebola response centres were found to be spaces of 'conflict attenuation' for their use of 'rule-bound niches', 'neutral zones', 'co-dependence', and 'hybridity', thereby not only easing civil-military relationships (CMRel), but also increasing the efficiency of their application to Ebola response interventions. Furthermore, the hierarchical response centres were also found to be inclusive spaces that further increased efficiency through the decentralisation and localisation of these interventions and daily decision making, albeit for mostly privileged groups and in limited ways. CONCLUSIONS: This demonstrates how hierarchy and localisation can (and perhaps should) go hand-in-hand during future public health emergency responses as a strategy for more robustly including typically marginalised local actors, while also improving necessary efficiency-in other words, an 'inclusive hierarchical coordination' that is both operationally viable and an ethical imperative.

The political economy of expedience: examining perspectives on military support to Sierra Leone's Ebola response.

The 2013-2016 West Africa Ebola Epidemic is the largest outbreak of Ebola in history. By September, 2014 the outbreak was worsening significantly, and the international president of Médecins Sans Frontières called for military assistance. In Sierra Leone, the British and Sierra Leonean militaries intervened. They quickly established a National Ebola Response Centre and a constituent network of District Ebola Response Centres. Thereafter, these inherently militarised centres are where almost all Ebola response activities were coordinated. In order to examine perspectives on the nature of the militaries' intervention, 110 semi-structured qualitative interviews were conducted and analysed. Military support to Sierra Leone's Ebola response was felt by most respondents to be a valuable contribution to the overall effort to contain the outbreak, especially in light of the perceived weakness of the Ministry of Health and Sanitation to effectively do so. However, a smaller number of respondents emphasised that the military deployments facilitated various structural harms, including for how the perceived exclusion of public institutions (as above) and other local actors from Ebola response decision making was felt to prevent capacity building, and in turn, to limit resilience to future crises. The concurrent provision of life-saving assistance and rendering of structural harm resulting from the militaries' intervention is ultimately found to be part of a vicious cycle, which this article conceptualises as the 'political economy of expedience', a paradox that should be considered inherent in any militarised intervention during humanitarian and public health crises.

Humanitarian sector (international non-governmental organisations) support to the community in Goma city/DRC during the COVID-19 pandemic period: Expectations and reality.

COVID-19 was the largest public health emergency to disrupt social life and health systems worldwide. The pandemic affected all world continents creating fear and stress in many aspects of social life. The pandemic spread from China to Europe, then to Africa carrying with it all the negative impacts affecting population wellbeing. The COVID-19 pandemic was declared in the Democratic Republic of Congo (DRC) in March 2020 and created huge shock and stress countrywide. Goma city accommodates more than 30 international non-governmental humanitarian organisations (HO) who have sought to support local communities to help them overcome COVID-19 stress. Few studies to date have considered the role of these HO from the perspective of the beneficiary populations. This is a descriptive, analytical study, reporting data collected from a survey questionnaire to 100 community members (including 21 healthcare professionals) in Karisimbi health zone in Goma city in DRC. The study's main aim was to explore how community members viewed the contribution and impact of HO actions during COVID-19 in Goma city. We identified some important mis-matches between community expectations and HO actions which must be addressed in future outbreaks. First, community members had big expectations of HO in terms of practice support to tackle the pandemic (including providing handwashing devices and mobile support teams), yet the vast majority of respondents reported seeing little or no such actions. This can create resentment against HO and it is critically important that they rapidly engage with communities at the start of any outbreak to understand their needs and concerns and develop strategies to directly respond to these. Second, HO played a very limited role in dissemination of information about COVID-19 and were not trusted messengers. Our findings showed that most people's preferred source of information about COVID-19, specifically vaccines, was local healthcare workers-particularly those who were known well and therefore trusted. HO (and national responders) should therefore map trusted spokespersons (including healthcare professionals) in the targeted communities and involve them in the planning and implementation of interventions as essential steps in the response. Among our respondents, social media played a large role in information sharing. Further research is needed to understand the role that social media (particularly Facebook and WhatsApp which were most frequently used) could play in sharing messages from trusted sources, including official government communications. Collectively, these actions could help create a positive attitude towards COVID-19 vaccine and similar interventions in future outbreaks.

The Promise of Grassroots Approaches to Solving Absenteeism in Primary Health-Care Facilities in Nigeria: Evidence from a Qualitative Study.

Absenteeism among primary health-care (PHC) workers in Nigeria is widespread and is a major obstacle to achieving Universal Health Coverage (UHC). There is increasing research on the forms it takes and what drives them, but limited evidence on how to address it. The dominant approach has involved government-led topdown solutions (vertical approach). However, these have rarely been successful in countries such as Nigeria. This paper explores alternative approaches based on grassroots (horizontal) approaches. Data collected from interviews with 40 PHC stakeholders in Enugu, Nigeria, were organized in thematic clusters that explored the contribution of horizontal interventions to solving absenteeism in primary health-care facilities. We applied phenomenology to analyze the lived (practical) experiences of respondents. Absenteeism by PHC workers was prevalent and is encouraged by the complex configuration of the PHC system and its operating environment, which constrains topdown interventions. We identified several horizontal approaches that may create effective incentives and compulsions to reduce absenteeism, which include leveraging community resources to improve security of facilities, tapping the resources of philanthropic individuals and organizations to provide accommodation for health workers, and engaging trained health workers as volunteers or placeholders to address shortages of health-care staff. Nevertheless, a holistic response to absenteeism must complement horizontal approaches with vertical measures, with the government supporting and encouraging the health system to develop self-enforcing mechanisms to tackle absenteeism.

Improving health system readiness to address violence against women and girls: a conceptual framework.

BACKGROUND: There is an increasing focus on readiness of health systems to respond to survivors of violence against women (VAW), a global human rights violation damaging women's health. Health system readiness focuses on how prepared healthcare systems and institutions, including providers and potential users, are to adopt changes brought about by the integration of VAW care into services. In VAW research, such assessment is often limited to individual provider readiness or facility-level factors that need to be strengthened, with less attention to health system dimensions. The paper presents a framework for health system readiness assessment to improve quality of care for intimate partner violence (IPV), which was tested in Brazil and Palestinian territories (oPT). METHODS: Data synthesis of primary data from 43 qualitative interviews with healthcare providers and health managers in Brazil and oPT to explore readiness in health systems. RESULTS: The application of the framework showed that it had significant added value in capturing system capabilities - beyond the availability of material and technical capacity - to encompass stakeholder values, confidence, motivation and connection with clients and communities. Our analysis highlighted two missing elements within the initial framework: client and community engagement and gender equality issues. Subsequently, the framework was finalised and organised around three levels of analysis: macro, meso and micro. The micro level highlighted the need to also consider how the system can sustainably involve and interact with clients (women) and communities to ensure and promote readiness for integrating (and participating in) change. Addressing cultural and gender norms around IPV and enhancing support and commitment from health managers was also shown to be necessary for a health system environment that enables the integration of IPV care. CONCLUSION: The proposed framework helps identify a) system capabilities and pre-conditions for system readiness; b) system changes required for delivering quality care for IPV; and c) connections between and across system levels and capabilities.

Nutrient profiles of commercially produced complementary foods available in Cambodia, Indonesia and the Philippines.

OBJECTIVE: To assess the nutritional suitability of commercially produced complementary foods (CPCF) marketed in three South-East Asian contexts. DESIGN: Based on label information declared on the products, nutrient composition and content of CPCF were assessed against the WHO Europe nutrient profile model (NPM). The proportion of CPCF that would require a 'high sugar' warning was also determined. SETTING: Khsach Kandal district, Cambodia; Bandung City, Indonesia; and National Capital Region, Philippines. PARTICIPANTS: CPCF products purchased in Cambodia (n 68) and Philippines (n 211) in 2020, and Indonesia (n 211) in 2017. RESULTS: Only 4·4 % of products in Cambodia, 10·0 % of products in Indonesia and 37·0 % of products in the Philippines fully complied with relevant WHO Europe NPM nutrient composition requirements. Sixteen per cent of CPCF in Cambodia, 27·0 % in Indonesia and 58·8 % in the Philippines contained total sugar content levels that would require a 'high sugar' warning. CONCLUSIONS: Most of the analysed CPCF were not nutritionally suitable to be promoted for older infants and young children based on their nutrient profiles, with many containing high levels of sugar and sodium. Therefore, it is crucial to introduce new policies, regulations and standards to limit the promotion of inappropriate CPCF in the South-East Asia region.

Integrated delivery of family planning and childhood immunization services: a qualitative study of factors influencing service responsiveness in Malawi.

Evidence from several countries in sub-Saharan Africa suggests that the integration of family planning (FP) with childhood immunization services can help reduce the unmet need for FP among postpartum women without undermining the uptake of immunizations. However, the quality and responsiveness of FP services that are integrated with childhood immunizations remain understudied. A qualitative study was conducted in two districts of Malawi, which examined the factors influencing the responsiveness of FP services that were integrated with childhood immunizations in monthly public outreach clinics. Semi-structured interviews with clients (n = 23) and FP providers (n = 10) and a clinic audit were carried out in six clinics. Hardware (material) and software (relational) factors influencing service responsiveness were identified through thematic and framework analyses of interview transcripts, and clinic characteristics were summarized from the audit data to contextualize the qualitative findings. Overall, 13 factors were found to influence service responsiveness in terms of the ease of access, choice of provider, environment, service continuity, confidentiality, communication, dignity and FP counselling afforded to clients. Among these factors, hardware deficiencies, including the absence of a dedicated building for the provision of FP services and the lack of FP commodities in clinics, were perceived to negatively affect service responsiveness. Crucially, the providers' use of their agency to alter the delivery of services was found to mitigate the negative effects of some hardware deficits on the ease of access, choice of provider, environment and confidentiality experienced by clients. This study contributes to an emerging recognition that providers can offset the effect of hardware deficiencies when services are integrated if they are afforded sufficient flexibility to make independent decisions. Consideration of software elements in the design and delivery of FP services that are integrated with childhood immunizations is therefore critical to optimize the responsiveness of these services.

Integrated delivery of family planning and childhood immunisation services: a mixed methods assessment of service responsiveness.

BACKGROUND: Postpartum women represent a considerable share of the global unmet need for modern contraceptives. Evidence suggests that the integration of family planning (FP) with childhood immunisation services could help reduce this unmet need by providing repeat opportunities for timely contact with FP services. However, little is known about the clients' experiences of FP services that are integrated with childhood immunisations, despite being crucial to contraceptive uptake and repeat service utilisation. METHODS: The responsiveness of FP services that were integrated with childhood immunisations in Malawi was assessed using cross-sectional convergent mixed methods. Exit interviews with clients (n=146) and audits (n=15) were conducted in routine outreach clinics. Responsiveness scores across eight domains were determined according to the proportion of clients who rated each domain positively. Text summary analyses of qualitative data from cognitive interviewing probes were also conducted to explain responsiveness scores. Additionally, Spearman rank correlation and Pearson's chi-squared test were used to identify correlations between domain ratings and to examine associations between domain ratings and client, service and clinic characteristics. RESULTS: Responsiveness scores varied across domains: dignity (97.9%); service continuity (90.9%); communication (88.7%); ease of access (77.2%); counselling (66.4%); confidentiality (62.0%); environment (53.9%) and choice of provider (28.4%). Despite some low performing domains, 98.6% of clients said they would recommend the clinic to a friend or family member interested in FP. The choice of provider, communication, confidentiality and counselling ratings were positively associated with clients' exclusive use of one clinic for FP services. Also, the organisation of services in the clinics and the providers' individual behaviours were found to be critical to service responsiveness. CONCLUSIONS: This study establishes that in routine outreach clinics, FP services can be responsive when integrated with childhood immunisations, particularly in terms of the dignity and service continuity afforded to clients, though less so in terms of the choice of provider, environment, and confidentiality experienced. Additionally, it demonstrates the value of combining cognitive interviewing techniques with Likert questions to assess service responsiveness.

The Challenges of Working in the Heat Whilst Pregnant: Insights From Gambian Women Farmers in the Face of Climate Change.

BACKGROUND: The expected increase in heat in The Gambia is one of the most significant health threats caused by climate change. However, little is known about the gendered dynamics of exposure and response to heat stress, including women's perceived health risks, their adaptation strategies to heat, and their perceptions of climate change. This research project aims to answer the question of whether and how pregnant farmers in The Gambia perceive and act upon occupational heat stress and its health impacts on both themselves and their unborn children, against the backdrop of current and expected climatic changes. METHOD: In-depth semi-structured interviews were conducted with 12 women who practice subsistence farming and were either pregnant or had delivered within the past month in West Kiang, The Gambia. Participants were selected using purposive sampling. Translated interview transcripts were coded and qualitative thematic content analysis with an intersectional lens was used to arrive at the results. RESULTS: All women who participated in the study experience significant heat stress while working outdoors during pregnancy, with symptoms often including headache, dizziness, nausea, and chills. The most common adaptive techniques included resting in the shade while working, completing their work in multiple shorter time increments, taking medicine to reduce symptoms like headache, using water to cool down, and reducing the amount of area they cultivate. Layered identities, experiences, and household power structures related to age, migration, marital situation, socioeconomic status, and supportive social relationships shaped the extent to which women were able to prevent and reduce the effects of heat exposure during their work whilst pregnant. Women who participated in this study demonstrated high awareness of climate change and offered important insights into potential values, priorities, and mechanisms to enable effective adaptation. CONCLUSION: Our findings reveal many intersecting social and economic factors that shape the space within which women can make decisions and take adaptive action to reduce the impact of heat during their pregnancy. To improve the health of pregnant working women exposed to heat, these intersectionalities must be considered when supporting women to adapt their working practices and cope with heat stress.

(Re)arranging "systems of care" in the early Ebola response in Sierra Leone: An interdisciplinary analysis.

Despite an expanding literature on Ebola-response, few studies detail or reflect on the responses of diverse systems of care. Little is known about how, why or in what ways, strategies of ill-health management were enacted locally, how health-systems power, authority and hierarchy were perceived and contested, or how other social systems, institutions and relationships shaped the response. This paper presents an interdisciplinary analysis of local responses in two early affected districts in Sierra Leone. Drawing on anthropological theories of social ordering and assemblage, we present an analysis of contrasting infection chains in three extended case studies from Bo and Moyamba districts. In contrast to previous scholarship which has understood local actions as being reactive (supporting or obstructing) to a national Ebola response, we show that local arrangements lead and shape responses. Our cases show how multiple, entangled, dynamic and co-existing systems of care influence these responses. Some individuals and communities collaborated with health authorities on measures like reporting and quarantine, others actively opposed them, or played an intermediary role. Collectively, formal health systems actors, local authorities and ordinary citizens negotiated and enacted new arrangements. These arrangements involved compromise and sometimes power was reconfigured. They were also shaped by wider political and historical contexts and by availability or absence of formal healthcare resources. Our research shows the critical importance of understanding how institutions and people involved in healthcare enact diverse "systems of care" and thereby shape Ebola response. Most importantly, our work underlines the need for alignment between formal health-systems and wider social, cultural, political and economic forms of organisation at family and community levels to improve crisis-response and promote sustainable care. In particular, health systems responders need to identify and engage with key brokers - or arrangers - in frontline care systems, with whom mutually acceptable, and effective, reconfigurations of care can be achieved.

National health governance, science and the media: drivers of COVID-19 responses in Germany, Sweden and the UK in 2020.

The COVID-19 pandemic is an unprecedented global crisis in which governments had to act in a situation of rapid change and substantial uncertainty. The governments of Germany, Sweden and the UK have taken different paths allowing learning for future pandemic preparedness. To help inform discussions on preparedness, inspired by resilience frameworks, this paper reviews governance structures, and the role of science and the media in the COVID-19 response of Germany, Sweden and the UK in 2020. We mapped legitimacy, interdependence, knowledge generation and the capacity to deal with uncertainty.Our analysis revealed stark differences which were linked to pre-existing governing structures, the traditional role of academia, experience of crisis management and the communication of uncertainty-all of which impacted on how much people trusted their government. Germany leveraged diversity and inclusiveness, a 'patchwork quilt', for which it was heavily criticised during the second wave. The Swedish approach avoided plurality and largely excluded academia, while in the UK's academia played an important role in knowledge generation and in forcing the government to review its strategies. However, the vivant debate left the public with confusing and rapidly changing public health messages. Uncertainty and the lack of evidence on how best to manage the COVID-19 pandemic-the main feature during the first wave-was only communicated explicitly in Germany. All country governments lost trust of their populations during the epidemic due to a mix of communication and transparency failures, and increased questioning of government legitimacy and technical capacity by the public.

Community-level integration of health services and community health workers' agency in Malawi.

Despite a large literature on integration of health services, there is a dearth of scholarship assessing service integration in its totality at the community level. Similarly, across the wide evidence base on community health workers (CHWs), there is little that analyses the ways in which they interact with both formal and informal structures and how these interactions shape their agency and ultimately the delivery of integrated services. A better understanding of agency in the work of CHWs would help health systems, policy makers and practitioners to better design and support the delivery of community-level integrated health packages to improve health outcomes. In this study, we explored the agency of CHWs in Malawi known as Health Surveillance Assistants (HSAs). We used qualitative methods: participant observation, in-depth interviews, and focus group discussions between July and October 2018. Overall, the ethnographic study utilised actors-centred frameworks (structuration theory and street-level bureaucracy). The study findings unravel the complexities involving HSAs' agency shaped by health system structures (staffing, infrastructure, drugs, and supplies) and informal structures (community relations, local power structures, gendered-household relations) which narrowed or widened their discretionary decision-making space. The flexibility of HSAs was a distinctive feature in their work, but they developed other coping mechanisms: task shifting, teamwork, creative community engagement, and referrals to deliver integrated maternal and child health services. HSAs' unique position as community-based providers meant they needed to consider diverse factors that constrained or facilitated their work. Overall, we argue that HSAs need to be fully involved in the design of community-level integrated health programmes. There should be a consideration to address both informal and formal structures that together shape agency. Additionally, CHWs' flexibility and agency to make locally informed decisions must be protected and maintained because it enhances their ability to deliver essential health services.

The pathways between natural disasters and violence against children: a systematic review.

BACKGROUND: Natural disasters are increasingly affecting a larger segment of the world's population. These highly disruptive events have the potential to produce negative changes in social dynamics and the environment which increase violence against children. We do not currently have a comprehensive understanding of how natural disasters lead to violence against children despite the growing threat to human populations and the importance of violence as a public health issue. The mapping of pathways to violence is critical in designing targeted and evidence-based prevention services for children. We systematically reviewed peer-reviewed articles and grey literature to document the pathways between natural disasters and violence against children and to suggest how this information could be used in the design of future programming. METHODS: We searched 15 bibliographic databases and six grey literature repositories from the earliest date of publication to May 16, 2018. In addition, we solicited grey literature from humanitarian agencies globally that implement child-focused programming after natural disasters. Peer-reviewed articles and grey literature that presented original quantitative or qualitative evidence on how natural disasters led to violence against children were included. The authors synthesized the evidence narratively and used thematic analysis with a constant comparative method to articulate pathways to violence. RESULTS: We identified 6276 unduplicated publications. Nine peer-reviewed articles and 17 grey literature publications met the inclusion criteria. The literature outlined five pathways between natural disasters and violence, including: (i) environmentally induced changes in supervision, accompaniment, and child separation; (ii) transgression of social norms in post-disaster behavior; (iii) economic stress; (iv) negative coping with stress; and (v) insecure shelter and living conditions. CONCLUSIONS: Service providers would benefit from systematic documentation to a high-quality standard of all possible pathways to violence in tailoring programming after natural disasters. The identified pathways in this review provide a foundation for designing targeted prevention services. In addition, the positive coping strategies within certain affected families and communities can be leveraged in implementing strength-based approaches to violence prevention.

Responding to the 2018-2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches.

The Democratic Republic of Congo (DRC) presents a challenging context in which to respond to public health crises. Its 2018-2020 Ebola outbreak was the second largest in history. Lessons were known from the previous West African outbreak. Chief among these was the recognition that local action and involvement are key to establishing effective epidemic-response. It remains unclear whether and how this was achieved in DRC's Ebola response. Additionally, there is a lack of scholarship on how to build resilience (the ability to adapt or transform under pressure) in crisis-response. In this article, we critically review literature to examine evidence on whether and how communities were involved, trust built, and resilience strengthened through adaptation or transformation of DRC's 2018-2020 Ebola response measures. Overall, we found limited evidence that the response adapted to engage and involve local actors and institutions or respond to locally expressed concerns. When adaptations occurred, they were shaped by national and international actors rather than enabling local actors to develop locally trusted initiatives. Communities were "engaged" to understand their perceptions but were not involved in decision-making or shaping responses. Few studies documented how trust was built or analyzed power dynamics between different groups in DRC. Yet, both these elements appear to be critical in building effective, resilient responses. These failures occurred because there was no willingness by the national government or international agencies to concede decision-making power to local people. Emergency humanitarian response is entrenched in highly medicalized, military style command and control approaches which have no space for decentralizing decision-making to "non-experts". To transform humanitarian responses, international responders can no longer be regarded as "experts" who own the knowledge and control the response. To successfully tackle future humanitarian crises requires a transformation of international humanitarian and emergency response systems such that they are led, or shaped, through inclusive, equitable collaboration with local actors.

Framing universal health coverage in Kenya: an interpretive analysis of the 2004 Bill on National Social Health Insurance.

In 2004, President Mwai Kibaki of Kenya refused to sign a popular Bill on National Social Health Insurance into law. Drawing on innovations in framing theory, this research provides a social explanation for this decision. In addition to document review, this study involved interpretive analysis of transcripts from 50 semi-structured interviews with leading actors involved in the health financing policy process in Kenya, 2014-15. The frame-critical analysis focused on how actors engaged in (1) sensemaking, (2) naming, which includes selecting and categorizing and (3) storytelling. We demonstrated that actors' abilities to make sense of the Bill were largely influenced by their own understandings of the finer features of the Bill and the array of interest groups privy to the debate. This was reinforced by a process of naming, which selects and categorizes aspects of the Bill, including the public persona of its primary sponsor, its affordability, sustainability, technical dimensions and linkages to notions of economic liberalism. Actors used these understandings and names to tell stories of ideational warfare, which involved narrative accounts of policy resistance and betrayal. This analysis illustrates the difficulty in enacting sweeping reform measures and thus provides a basis for understanding incrementalism in Kenyan health policy.