How can intersectoral collaboration and action help improve the education, recruitment, and retention of the health and care workforce? A scoping review.

Inadequate numbers, maldistribution, attrition, and inadequate skill-mix are widespread health and care workforce (HCWF) challenges. Intersectoral-inclusive of different government sectors, non-state actors, and the private sector-collaboration and action are foundational to the development of a responsive and sustainable HCWF. This review presents evidence on how to work across sectors to educate, recruit, and retain a sustainable HCWF, highlighting examples of the benefits and challenges of intersectoral collaboration. We carried out a scoping review of scientific and grey literature with inclusion criteria around intersectoral governance and mechanisms for the HCWF. A framework analysis to identify and collate factors linked to the education, recruitment, and retention of the HCWF was carried out. Fifty-six documents were included. We identified a wide array of recommendations for intersectoral activity to support the education, recruitment, and retention of the HCWF. For HCWF education: formalise intersectoral decision-making bodies; align HCWF education with population health needs; expand training capacity; engage and regulate private sector training; seek international training opportunities and support; and innovate in training by leveraging digital technologies. For HCWF recruitment: ensure there is intersectoral clarity and cooperation; ensure bilateral agreements are ethical; carry out data-informed recruitment; and learn from COVID-19 about mobilising the domestic workforce. For HCWF retention: innovate around available staff, especially where staff are scarce; improve working and employment conditions; and engage the private sector. Political will and commensurate investment must underscore any intersectoral collaboration for the HCWF.

How international research consortia can strengthen organisations' research systems and promote a conducive environment and culture.

Research systems and cultures have been criticised for their detrimental effect on members' mental health and well-being. Many international research programmes operate through research consortia that have the resources to make a substantial contribution to improving the research environment in their member organisations. This paper collates real-life examples from several large international consortia-based research programmes about how they strengthened organisations' research capacity. The consortia primarily involved academic partners from the UK and/or sub-Saharan Africa and covered research topics including health, natural sciences, conservation agriculture and vector control. They were partly or wholly funded by UK agencies including the Wellcome, Foreign and Commonwealth Development Office, UK Research and Innovation Fund, and the Medical Research Council and they operated for 2-10 years between 2012 and 2022.Consortia's size and ability to access and share resources among their member organisations according to need meant they were uniquely placed to target actions to address weaknesses in member organisations' research capacity, to widen networks and collaborations, and to build in sustainability of capacity gains. Consortia's actions covered: (a) individuals' knowledge and skills; (b) capacity strengthening ethos; (c) organisations' visibility and prestige; and (d) inclusive and responsive management practices. Evidence about these actions formed the basis of recommendations for funders and leaders of consortium-based programmes about how they could make more effective use of consortia's resources to enhance organisations' research systems, environments and cultures.Key lessons were that training should cover management and research leadership and should be offered beyond consortium members, including to research support staff such as technicians and managers. Consortia often tackle complex problems requiring multidisciplinary inputs, but overcoming disciplinary boundaries-and making everyone feel valued and respected-takes time and skill on the part of consortium leaders. Consortia need clear guidance from funders about their commitment to strengthening research capacity. Without this, consortia leaders may continue to prioritise research outputs over creating and embedding sustainable improvements in their organisations' research systems.

Maternity care provision for women living with female genital mutilation/cutting: A qualitative study from a high asylum-seeking dispersal context in the UK.

OBJECTIVE: To explore the perspectives of midwives and obstetrician/gynaecologists providing maternity care to women living with female genital mutilation/cutting (FGM/C) in a high asylum-seeker dispersal area in the North West of England. METHODS: We carried out a qualitative study in four hospitals providing maternal health services within the North West of England, with the highest population of asylum-seeking individuals (many from high-prevalence FGM/C countries) in the UK. Participants included 13 practicing midwives and an obstetrician/gynaecologist. In-depth interviews were conducted with study participants. Data collection and analysis were carried out concurrently until theoretical saturation was reached. Data were analysed thematically to generate three key overarching themes. RESULTS: There is a disconnect between Home Office dispersal policy and healthcare policy. Participants indicated that there was inconsistent identification or disclosure of FGM/C, constraining appropriate follow-up and care prior to labour and childbirth. All participants noted existing safeguarding policies and protocols, which were seen by most as being important to protect female dependants, but potentially detrimental to the patient-provider relationship and to the woman's care. Unique challenges around accessing and maintaining continuity of care for asylum-seeking women due to dispersal schemes were indicated. All participants highlighted a lack of specialised training for FGM/C to support provision of clinically appropriate and culturally sensitive care. CONCLUSIONS: There is a clear need for harmony between health and social policy as well as specialised training that centres holistic wellbeing for the woman living with FGM/C, particularly where there are increased numbers of asylum-seeking women from high-prevalence FGM/C countries.

Maternal anaemia care in Kano state, Nigeria: an exploratory qualitative study of experiences of uptake and provision.

Background: Maternal anaemia (anaemia in pregnancy, childbirth, and the postpartum period) remains a persistent challenge, particularly in Kano State, Nigeria, which has the highest prevalence of maternal anaemia globally, at 72%. Methods: We conducted a qualitative study in Murtala Muhammad Specialist Hospital in Kano State, Nigeria. We aimed to identify factors constraining uptake and provision of maternal anaemia care, exploring perspectives across different stakeholders. We carried out 10 key informant interviews with policymakers and hospital managers, 28 in-depth interviews with healthcare providers and pregnant women using antenatal services and four focus group discussions with pregnant women's husbands and mothers-in-law. Data were analysed thematically. Results: Issues with provision include a lack of provider training and guidelines specific to maternal anaemia and blood transfusion, insufficient staff to meet increasing demand, and inadequate resources. Issues with uptake include the inability to afford informal user fees, distrust in health services and the blood transfusion process, and a lack of understanding of the causes, consequences, and treatment for anaemia, resulting in poor uptake of care and adherence to treatment. Conclusions: This study recommends the implementation of standardized guidelines and training sessions to better support healthcare providers in offering quality services and increasing funding allocated to supporting maternal anaemia care. Education initiatives for service users and the public are also recommended to build public trust in health services and to improve understanding of maternal anaemia.

The BLOODSAFE program: Building the future of access to safe blood in Sub-Saharan Africa.

BACKGROUND: The supply of blood in many low- and middle-income nations in Sub-Saharan Africa (SSA) does not meet the patient care needs. Lack and delay of blood transfusion cause harm to patients and slow the rate of progress in other parts of the health system. Recognizing the power of implementation science, the BLOODSAFE Program was initiated which supports three SSA research study teams and one data coordinating center (DCC) with the goal to improve access to safe blood transfusion in SSA. STUDY DESIGN AND METHODS: The study team in Ghana is focusing on studying and decreasing iron deficiency in blood donors and evaluating social engagement of blood donors through different approaches. The study team in Kenya is building a "vein to vein" workflow model to elucidate and devise strategies to overcome barriers to blood donation and improve infrastructural components of blood product production and use. The Malawi team is studying the infectious disease ramifications of blood donation as well as blood donor retention strategies aimed at blood donors who commence their donation career in secondary schools. RESULTS AND DISCUSSION: Together the project teams and the DCC work as a consortium to support each other through a shared study protocol that will study donor motivations, outcomes, and adverse events across all three countries. The BLOODSAFE Program has the potential to lead to generalizable improvement approaches for increasing access to safe blood in SSA as well as mentoring and building the research capacity and careers of many investigators.

'You want to deal with power while riding on power': global perspectives on power in participatory health research and co-production approaches.

INTRODUCTION: Power relations permeate research partnerships and compromise the ability of participatory research approaches to bring about transformational and sustainable change. This study aimed to explore how participatory health researchers engaged in co-production research perceive and experience 'power', and how it is discussed and addressed within the context of research partnerships. METHODS: Five online workshops were carried out with participatory health researchers working in different global contexts. Transcripts of the workshops were analysed thematically against the 'Social Ecology of Power' framework and mapped at the micro (individual), meso (interpersonal) or macro (structural) level. RESULTS: A total of 59 participants, with participatory experience in 24 different countries, attended the workshops. At the micro level, key findings included the rarity of explicit discussions on the meaning and impact of power, the use of reflexivity for examining assumptions and power differentials, and the perceived importance of strengthening co-researcher capacity to shift power. At the meso level, participants emphasised the need to manage co-researcher expectations, create spaces for trusted dialogue, and consider the potential risks faced by empowered community partners. Participants were divided over whether gatekeeper engagement aided the research process or acted to exclude marginalised groups from participating. At the macro level, colonial and 'traditional' research legacies were acknowledged to have generated and maintained power inequities within research partnerships. CONCLUSIONS: The 'Social Ecology of Power' framework is a useful tool for engaging with power inequities that cut across the social ecology, highlighting how they can operate at the micro, meso and macro level. This study reiterates that power is pervasive, and that while many researchers are intentional about engaging with power, actions and available tools must be used more systematically to identify and address power imbalances in participatory research partnerships, in order to contribute to improved equity and social justice outcomes.

Co-production of two whole-school sexual health interventions for English secondary schools: positive choices and project respect.

BACKGROUND: Whole-school interventions represent promising approaches to promoting adolescent sexual health, but they have not been rigorously trialled in the UK and it is unclear if such interventions are feasible for delivery in English secondary schools. The importance of involving intended beneficiaries, implementers and other key stakeholders in the co-production of such complex interventions prior to costly implementation and evaluation studies is widely recognised. However, practical accounts of such processes remain scarce. We report on co-production with specialist providers, students, school staff, and other practice and policy professionals of two new whole-school sexual heath interventions for implementation in English secondary schools. METHODS: Formative qualitative inquiry involving 75 students aged 13-15 and 23 school staff. A group of young people trained to advise on public health research were consulted on three occasions. Twenty-three practitioners and policy-makers shared their views at a stakeholder event. Detailed written summaries of workshops and events were prepared and key themes identified to inform the design of each intervention. RESULTS: Data confirmed acceptability of addressing unintended teenage pregnancy, sexual health and dating and relationships violence via multi-component whole-school interventions and of curriculum delivery by teachers (providing appropriate teacher selection). The need to enable flexibility for the timetabling of lessons and mode of parent communication; ensure content reflected the reality of young people's lives; and develop prescriptive teaching materials and robust school engagement strategies to reflect shrinking capacity for schools to implement public-health interventions were also highlighted and informed intervention refinements. Our research further points to some of the challenges and tensions involved in co-production where stakeholder capacity may be limited or their input may conflict with the logic of interventions or what is practicable within the constraints of a trial. CONCLUSIONS: Multi-component, whole-school approaches to addressing sexual health that involve teacher delivered curriculum may be feasible for implementation in English secondary schools. They must be adaptable to individual school settings; involve careful teacher selection; limit additional burden on staff; and accurately reflect the realities of young people's lives. Co-production can reduce research waste and may be particularly useful for developing complex interventions, like whole-school sexual health interventions, that must be adaptable to varying institutional contexts and address needs that change rapidly. When co-producing, potential limitations in relation to the representativeness of participants, the 'depth' of engagement necessary as well as the burden on participants and how they will be recompensed must be carefully considered. Having well-defined, transparent procedures for incorporating stakeholder input from the outset are also essential. Formal feasibility testing of both co-produced interventions in English secondary schools via cluster RCT is warranted. TRIAL REGISTRATION: Project Respect: ISRCTN12524938 . Positive Choices: ISRCTN65324176.

Harnessing the health systems strengthening potential of quality improvement using realist evaluation: an example from southern Tanzania.

Quality improvement (QI) is a problem-solving approach in which stakeholders identify context-specific problems and create and implement strategies to address these. It is an approach that is increasingly used to support health system strengthening, which is widely promoted in Sub-Saharan Africa. However, few QI initiatives are sustained and implementation is poorly understood. Here, we propose realist evaluation to fill this gap, sharing an example from southern Tanzania. We use realist evaluation to generate insights around the mechanisms driving QI implementation. These insights can be harnessed to maximize capacity strengthening in QI and to support its operationalization, thus contributing to health systems strengthening. Realist evaluation begins by establishing an initial programme theory, which is presented here. We generated this through an elicitation approach, in which multiple sources (theoretical literature, a document review and previous project reports) were collated and analysed retroductively to generate hypotheses about how the QI intervention is expected to produce specific outcomes linked to implementation. These were organized by health systems building blocks to show how each block may be strengthened through QI processes. Our initial programme theory draws from empowerment theory and emphasizes the self-reinforcing nature of QI: the more it is implemented, the more improvements result, further empowering people to use it. We identified that opportunities that support skill- and confidence-strengthening are essential to optimizing QI, and thus, to maximizing health systems strengthening through QI. Realist evaluation can be used to generate rich implementation data for QI, showcasing how it can be supported in 'real-world' conditions for health systems strengthening.

Health workers' views on audit in maternal and newborn healthcare in LMICs: a qualitative evidence synthesis.

OBJECTIVES: To identify and summarise health workers' views on the use of audit as a method to improve the quality of maternal and newborn healthcare in low- and middle-income countries (LMICs). METHODS: We conducted a qualitative evidence synthesis. PubMed, CINAHL and Global Health databases were searched using keywords, synonyms and MeSH headings for 'audit', 'views' and 'health workers' to find papers that used qualitative methods to explore health workers' views on audit in LMICs. Titles and abstracts were then screened for inclusion. The remaining full-text papers were then screened. The final included papers were quality assessed using the Critical Appraisal Skills Programme tool for qualitative research. Data on audit type and health workers' perceptions were extracted and analysed using thematic synthesis. RESULTS: Nineteen papers were included in the review, most from sub-Saharan Africa. Health workers generally held favourable views of audit and expressed dedication to the process. Similarly, they described positive experiences conducting audit. The main barriers to implementing audit were the presence of a blame culture, inadequate training and the lack of time and resources to conduct audit. Health workers' motivation and dedication to the audit process helped to overcome such barriers. CONCLUSIONS: Health workers are dedicated to the process of audit, but must be supported with training, leadership and adequate resources to use it. Decision-makers and technical partners supporting audit should focus on improving audit training and finding ways to conduct audit without requiring too much staff time.

OBJECTIFS: Identifier et résumer les points de vue des agents de santé sur l'utilisation de l'audit comme méthode pour améliorer la qualité des soins de santé maternelle et néonatale dans les pays à revenu faible et intermédiaire (PRFI). MÉTHODES: Nous avons effectué une synthèse des données qualitatives. Les bases de données PubMed, CINAHL et Global Health ont été recherchées à l'aide de mots clés, de synonymes et de rubriques MeSH pour ''audit'', ''vues'' et ''agents de santé'' afin de trouver des articles qui utilisaient des méthodes qualitatives pour explorer les opinions des agents de santé sur l'audit dans les PRFI. Les titres et les résumés ont ensuite été sélectionnés pour inclusion. Les articles en texte intégral restants ont ensuite été examinés. La qualité des articles finaux inclus a été évaluée à l'aide de l'outil du Programme 'Critical Appraisal Skills' pour la recherche qualitative. Les données sur le type d'audit et les perceptions des agents de santé ont été extraites et analysées à l'aide d'une synthèse thématique. RÉSULTATS: 19 articles ont été inclus dans la revue, la plupart en provenance d'Afrique subsaharienne. Les agents de santé ont généralement une opinion favorable de l'audit et ont exprimé leur dévouement au processus. De même, ils ont décrit des expériences positives lors de l'audit. Les principaux obstacles à la mise en œuvre de l'audit étaient la présence d'une culture du blâme, une formation inadéquate et le manque de temps et de ressources pour mener l'audit. La motivation et le dévouement des agents de santé au processus d'audit ont aidé à surmonter ces obstacles. CONCLUSIONS: Les agents de santé sont dédiés au processus d'audit, mais doivent être soutenus par une formation, un leadership et des ressources adéquates pour l'utiliser. Les décideurs et les partenaires techniques qui soutiennent l'audit devraient se concentrer sur l'amélioration de la formation à l'audit et la recherche de moyens de réaliser l'audit sans nécessiter trop de temps de travail de la part du personnel.

Improving blood transfusion services.

Postpartum haemorrhage contributes to 25% of maternal deaths worldwide, rising to 40% in sub-Saharan Africa. Treatment of postpartum haemorrhage-particularly for women with anaemia -requires timely, quality blood transfusions. There are a number of barriers to the provision of transfusion services, especially in low- and middle-income settings where the need is the greatest. These include unavailability of blood, unsafe blood, poor uptake of labour and delivery care, difficulties getting blood to transfusing facilities and poor documentation of patient information. Examples of innovative and practical solutions to overcome these barriers are highlighted.

Delayed illness recognition and multiple referrals: a qualitative study exploring care-seeking trajectories contributing to maternal and newborn illnesses and death in southern Tanzania.

BACKGROUND: Maternal and neonatal mortality remain high in southern Tanzania despite an increasing number of births occurring in health facilities. In search for reasons for the persistently high mortality rates, we explored illness recognition, decision-making and care-seeking for cases of maternal and neonatal illness and death. METHODS: We conducted 48 in-depth interviews (16 participants who experienced maternal illnesses, 16 mothers whose newborns experienced illness, eight mothers whose newborns died, and eight family members of a household with a maternal death), and five focus group discussions with community leaders in two districts of Mtwara region. Thematic analysis was used for interpretation of findings. RESULTS: Our data indicated relatively timely illness recognition and decision-making for maternal complications. In contrast, families reported difficulties interpreting newborn illnesses. Decisions on care-seeking involved both the mother and her partner or other family members. Delays in care-seeking were therefore also reported in absence of the husband, or at night. Primary-level facilities were first consulted. Most respondents had to consult more than one facility and described difficulties accessing and receiving appropriate care. Definitive treatment for maternal and newborn complications was largely only available in hospitals. CONCLUSIONS: Delays in reaching a facility that can provide appropriate care is influenced by multiple referrals from one facility to another. Referral and care-seeking advice should include direct care-seeking at hospitals in case of severe complications and primary facilities should facilitate prompt referral.

Interventions integrating health and academic interventions to prevent substance use and violence: a systematic review and synthesis of process evaluations.

BACKGROUND: Within increasingly constrained school timetables, interventions that integrate academic and health education to reduce substance use and violence may hold promise as a category of intervention that can positively affect both academic and health outcomes. There are no current systematic reviews exploring the effectiveness of such interventions or factors that affect their implementation. METHODS: A total of 19 bibliographic databases and 32 websites were searched. References were also extracted from the reference lists of included studies, and experts and authors were contacted to identify relevant studies. We included reports with no restrictions on language or date. References were screened on title/abstract and those not thus excluded were screened on full report. Data extraction and appraisal followed the Critical Appraisal Skills Programme, Evidence for Policy and Practice Information and Co-ordinating Centre and Cochrane tools. Extracted process data were qualitatively meta-synthesised for common themes. RESULTS: Seventy-eight thousand four hundred fifty-one unique references were identified, and 62 reports were included. A total of 16 reports (reporting on 15 studies of 12 interventions) evaluated process. Key facilitators of integrated academic and health curricula were supportive senior management and alignment of the intervention with school ethos; a positive teaching environment, including positive perceptions around the ability to be flexible in the adaptation and delivery of integrated academic and health curricula; positive pre-existing student and teacher attitudes towards intervention content; and parental support of interventions, largely through reinforcement of messaging at home. Important barriers were over-burdened teachers, with little time to learn and implement integrated curricula. CONCLUSION: Several useful facilitating and inhibiting factors linked to the implementation of interventions that integrate academic and health education for reduced substance use and/or violence were identified, providing tentative but insightful evidence of context-specific issues that may impact intervention success. However, overall, there is still a considerable gap in our understanding of how to achieve the successful implementation of these interventions.

A systematic review and synthesis of theories of change of school-based interventions integrating health and academic education as a novel means of preventing violence and substance use among students.

BACKGROUND: Schools can play an important role in promoting health. However, many education policies and institutions are increasingly emphasising academic attainment targets, which appear to be diminishing the time available for health education lessons. Interventions that integrate both health and academic learning may present an ideal solution, simultaneously addressing health education and academic development. The theories of change underlying these interventions are therefore of interest, but are poorly studied. METHODS: A systematic review of evaluations of interventions that integrate academic and health education for reduced substance use and/or violence was carried out. As part of this, reports describing theory were assessed for quality and data extracted. Theoretical data were synthesised within and across individual interventions using reciprocal translation and meta-ethnographic line of argument synthesis to produce an overall theory of change for interventions that integrate health and academic education to prevent substance use and violence. RESULTS: Forty-eight reports provided theoretical descriptions of 18 interventions. An overarching theory that emerged was that eroding 'boundaries' at multiple and mutually reinforcing levels-by integrating academic and health education, by transforming relationships between teachers and students, by generalising learning from classrooms to the wider school environment and by ensuring consistent messages from schools and families-is intended to lead to the development of a community of engaged students oriented towards pro-social behaviour and away from substance use, violence and other risk behaviours. CONCLUSIONS: Eroding 'boundaries' between health and academic education, teachers and students, classrooms and the wider school and schools and families were seen to be the most critical to establishing new frameworks of family, classroom or school organisation that are conducive to promoting both academic and social-emotional outcomes. Whether such interventions are feasible to implement and effective in reducing risk behaviours will be examined in other reports arising from the review.

Integration of academic and health education for the prevention of physical aggression and violence in young people: systematic review, narrative synthesis and intervention components analysis.

OBJECTIVES: To systematically review evidence on the effectiveness of interventions including integration of academic and health education for reducing physical aggression and violence, and describe the content of these interventions. DATA SOURCES: Between November and December 2015, we searched 19 databases and 32 websites and consulted key experts in the field. We updated our search in February 2018. ELIGIBILITY CRITERIA: We included randomised trials of school-based interventions integrating academic and health education in students aged 4-18 and not targeted at health-related subpopulations (eg, learning or developmental difficulties). We included evaluations reporting a measure of interpersonal violence or aggression. DATA EXTRACTION AND ANALYSIS: Data were extracted independently in duplicate, interventions were analysed to understand similarities and differences and outcomes were narratively synthesised by key stage (KS). RESULTS: We included 13 evaluations of 10 interventions reported in 20 papers. Interventions included either full or partial integration, incorporated a variety of domains beyond the classroom, and used literature, local development or linking of study skills and health promoting skills. Evidence was concentrated in KS2, with few evaluations in KS3 or KS4, and evaluations had few consistent effects; evaluations in KS3 and KS4 did not suggest effectiveness. DISCUSSION: Integration of academic and health education may be a promising approach, but more evidence is needed. Future research should consider the 'lifecourse' aspects of these interventions; that is, do they have a longitudinal effect? Evaluations did not shed light on the value of different approaches to integration.

How people-centred health systems can reach the grassroots: experiences implementing community-level quality improvement in rural Tanzania and Uganda.

BACKGROUND: Quality improvement (QI) methods engage stakeholders in identifying problems, creating strategies called change ideas to address those problems, testing those change ideas and scaling them up where successful. These methods have rarely been used at the community level in low-income country settings. Here we share experiences from rural Tanzania and Uganda, where QI was applied as part of the Expanded Quality Management Using Information Power (EQUIP) intervention with the aim of improving maternal and newborn health. Village volunteers were taught how to generate change ideas to improve health-seeking behaviours and home-based maternal and newborn care practices. Interaction was encouraged between communities and health staff. AIM: To describe experiences implementing EQUIP's QI approach at the community level. METHODS: A mixed methods process evaluation of community-level QI was conducted in Tanzania and a feasibility study in Uganda. We outlined how village volunteers were trained in and applied QI techniques and examined the interaction between village volunteers and health facilities, and in Tanzania, the interaction with the wider community also. RESULTS: Village volunteers had the capacity to learn and apply QI techniques to address local maternal and neonatal health problems. Data collection and presentation was a persistent challenge for village volunteers, overcome through intensive continuous mentoring and coaching. Village volunteers complemented health facility staff, particularly to reinforce behaviour change on health facility delivery and birth preparedness. There was some evidence of changing social norms around maternal and newborn health, which EQUIP helped to reinforce. CONCLUSIONS: Community-level QI is a participatory research approach that engaged volunteers in Tanzania and Uganda, putting them in a central position within local health systems to increase health-seeking behaviours and improve preventative maternal and newborn health practices.

Facilitators and Barriers of Community-Level Quality Improvement for Maternal and Newborn Health in Tanzania.

A quality improvement intervention for maternal and newborn health was carried out in southern Tanzania at the community level. It sought to improve health-seeking behaviors and uptake of community-level maternal and newborn health practices. A process evaluation populated using data primarily from in-depth interviews and focus group discussions with the intervention's implementers was undertaken in four villages receiving the intervention to evaluate the intervention's implementation, uncover facilitators and barriers of quality improvement, and highlight contextual factors that might have influenced implementation. Performance implementation scores were used to rank the villages. Identifying higher- and lower-performing villages highlighted key facilitators and barriers of community-level quality improvement related to support from local leaders, motivation through use of local quality improvement data, and regular education around quality improvement and maternal and newborn health. These findings can be taken formatively in the design of similar interventions in the future.

Health policy and systems research training: global status and recommendations for action.

OBJECTIVE: To investigate the characteristics of health policy and systems research training globally and to identify recommendations for improvement and expansion. METHODS: We identified institutions offering health policy and systems research training worldwide. In 2014, we recruited participants from identified institutions for an online survey on the characteristics of the institutions and the courses given. Survey findings were explored during in-depth interviews with selected key informants. FINDINGS: The study identified several important gaps in health policy and systems research training. There were few courses in central and eastern Europe, the Middle East, North Africa or Latin America. Most (116/152) courses were instructed in English. Institutional support for courses was often lacking and many institutions lacked the critical mass of trained individuals needed to support doctoral and postdoctoral students. There was little consistency between institutions in definitions of the competencies required for health policy and systems research. Collaboration across disciplines to provide the range of methodological perspectives the subject requires was insufficient. Moreover, the lack of alternatives to on-site teaching may preclude certain student audiences such as policy-makers. CONCLUSION: Training in health policy and systems research is important to improve local capacity to conduct quality research in this field. We provide six recommendations to improve the content, accessibility and reach of training. First, create a repository of information on courses. Second, establish networks to support training. Third, define competencies in health policy and systems research. Fourth, encourage multidisciplinary collaboration. Fifth, expand the geographical and language coverage of courses. Finally, consider alternative teaching formats.

Birth preparedness and place of birth in Tandahimba district, Tanzania: what women prepare for birth, where they go to deliver, and why.

BACKGROUND: As making preparations for birth and health facility delivery are behaviours linked to positive maternal and newborn health outcomes, we aimed to describe what birth preparations were made, where women delivered, and why. METHODS: Outcomes were tabulated using data derived from a repeated sample (continuous) quantitative household survey of women aged 13-49 who had given birth in the past year. Insights into why behaviours took place emerged from analysis of in-depth interviews (12) and birth narratives (36) with recently delivered mothers and male partners. RESULTS: Five hundred-twenty three women participated in the survey from April 2012-November 2013. Ninety-five percent (496/523) of women made any birth preparations for their last pregnancy. Commonly prepared birth items were cotton gauze (93 %), a plastic cover to deliver on (84 %), gloves (72 %), clean clothes (70 %), and money (42 %). Qualitative data suggest that preparation of items used directly during delivery was perceived as necessary to facilitate good care and prevent disease transmission. Sixty-eight percent of women gave birth at a health facility, 30 % at home, and 2 % on the way to a health facility. Qualitative data suggested that health facility delivery was viewed positively and that women were inclined to go to a health facility because of a perception of: increased education about delivery and birth preparedness; previous health facility delivery; and better availability and accessibility of facilities in recent years. Perceived barriers: were a lack of money; absent health facility staff or poor provider attitudes; women perceiving that they were unable to go to a health facility or arrange transport on their own; or a lack of support of pregnant women from their partners. CONCLUSIONS: The majority of women made at least some birth preparations and gave birth in a health facility. Functional items needed for birth seem to be given precedence over practices like saving money. As such, maintaining education about the importance of these practices, with an emphasis on emergency preparedness, would be valuable. Alongside education delivered as part of focussed antenatal care, community-based interventions that aim to increase engagement of men in birth preparedness, and support agency among women, are recommended.