Understanding demand for, and feasibility of, centre-based child-care for poor urban households: a mixed methods study in Dhaka, Bangladesh.

BACKGROUND: Centre-based child-care has potential to provide multiple health and development benefits to children, families and societies. With rapid urbanisation, increasing numbers of low-income women work with reduced support from extended family, leaving a child-care vacuum in many low- and middle-income countries. We aimed to understand perceptions of, and demand for, centre-based child-care in Dhaka, Bangladesh among poor, urban households, and test the feasibility of delivering sustainable centre-based child-care. METHODS: We used sequential mixed methods including a household survey (n = 222) and qualitative interviews with care-givers (n = 16), community leaders (n = 5) and policy-makers (n = 5). We co-produced and piloted a centre-based child-care model over ten-months, documenting implementation. A co-design focus group with mothers, parents' meetings, and qualitative interviews with child-care centre users (n = 5), non-users (n = 3), ex-users (n = 3) and staff (2) were used to refine the model and identify implementation issues. RESULTS: We found 24% (95% CI: 16,37%) of care-givers reported turning-down paid work due to lack of child-care and 84% (95% CI:74, 91%) reported wishing to use centre-based child-care and were willing to pay up to 283 Takka (~$3.30) per month. Adjusted odds of reported need for child-care among slum households were 3.8 times those of non-slum households (95% CI: 1.4, 10). Implementation highlighted that poor households needed free child-care with food provided, presenting feasibility challenges. Meta-inference across quantitative and qualitative findings identified the impact of the urban environment on child-care through long working hours, low social capital and fears for child safety. These influences interacted with religious and social norms resulting in caution in using centre-based child-care despite evident need. CONCLUSION: Sustainable provision of centre-based care that focuses on early childhood development requires subsidy and careful design sensitive to the working lives of poor families, particularly women and must respond to the dynamics of the urban environment and community values. We recommend increased research and policy focus on the evaluation and scale-up of quality centre-based child-care, emphasising early-childhood development, to support low-income working families in urban areas.

"Death is a better option than being treated like this": a prevalence survey and qualitative study of depression among multi-drug resistant tuberculosis in-patients.

BACKGROUND: Understanding of the relationship between multi-drug resistant tuberculosis and mental health is limited. With growing prevalence of multi-drug resistant tuberculosis, addressing mental ill-health has potential to improve treatment outcomes and well-being. In several low and middle-income contexts hospitalisation during treatment is common. Understanding of the impact on mental ill-health are required to inform interventions for patients with multi-drug resistant tuberculosis. Our aim was to identify the prevalence of comorbid depression among in-patients being treated for multi-drug resistant tuberculosis and to explore their experiences of comorbid disease and the care they received in a large specialist chest hospital in Dhaka, Bangladesh. METHODS: We conducted a quantitative cross-sectional survey among 150 multi-drug resistant tuberculosis in-patients (new cases = 34%, previously treated = 66%) in 2018. A psychiatrist assessed depression was assessed with the Structured Clinical Interview for Depression (SCID DSM-IV). We used multi-level modelling to identify associations with depression. Experience Bangladeshi researchers conducted qualitative interviews with 8 patients, 4 carers, 4 health professionals and reflective notes recorded. Qualitative data was analysed thematically. RESULTS: We found 33.8% (95% CI 26.7%; 41.7%) of patients were depressed. While more women were depressed 39.3% (95% CI 27.6%; 52.4%) than men 30.4% (95% CI 22%; 40.5%) this was not significant. After controlling for key variables only having one or more co-morbidity (adjusted odds ratio [AOR] = 2.88 [95% CI 1.13; 7.33]) and being a new rather than previously treated case (AOR = 2.33 [95% CI 1.06; 5.14]) were associated (positively) with depression. Qualitative data highlighted the isolation and despair felt by patients who described a service predominantly focused on providing medicines. Individual, familial, societal and health-care factors influenced resilience, nuanced by gender, socio-economic status and home location. CONCLUSIONS: Patients with multi-drug resistant tuberculosis are at high risk of depression, particularly those with co- and multi-morbidities. Screening for depression and psycho-social support should be integrated within routine TB services and provided throughout treatment.

Community engagement interventions for communicable disease control in low- and lower- middle-income countries: evidence from a review of systematic reviews.

BACKGROUND: Community engagement (CE) interventions include a range of approaches to involve communities in the improvement of their health and wellbeing. Working with communities defined by location or some other shared interest, these interventions may be important in assisting equity and reach of communicable disease control (CDC) in low and lower-middle income countries (LLMIC). We conducted an umbrella review to identify approaches to CE in communicable disease control, effectiveness of these approaches, mechanisms and factors influencing success. METHODS: We included systematic reviews that: i) focussed on CE interventions; ii) involved adult community members; iii) included outcomes relevant to communicable diseases in LLMIC; iv) were written in English. Quantitative results were extracted and synthesised narratively. A qualitative synthesis process enabled identification of mechanisms of effect and influencing factors. We followed guidance from the Joanna Briggs Institute, assessed quality with the DARE tool and reported according to standard systematic review methodology. RESULTS: Thirteen systematic reviews of medium-to-high quality were identified between June and July 2017. Reviews covered the following outcomes: HIV and STIs (6); malaria (2); TB (1); child and maternal health (3) and mixed (1). Approaches included: CE through peer education and community health workers, community empowerment interventions and more general community participation or mobilisation. Techniques included sensitisation with the community and involvement in the identification of resources, intervention development and delivery. Evidence of effectiveness of CE on health outcomes was mixed and quality of primary studies variable. We found: i) significantly reduced neonatal mortality following women's participatory learning and action groups; ii) significant reductions in HIV and other STIs with empowerment and mobilisation interventions with marginalised groups; iii) significant reductions in malaria incidence or prevalence in a small number of primary studies; iv) significant reductions in infant diarrhoea following community health worker interventions. Mechanisms of impact commonly occurred through social and behavioural processes, particularly: changing social norms, increasing social cohesion and social capacity. Factors influencing effectiveness of CE interventions included extent of population coverage, shared leadership and community control over outcomes. CONCLUSION: Community engagement interventions may be effective in supporting CDC in LLMIC. Careful design of CE interventions appropriate to context, disease and community is vital.

Depression and anxiety in patients with multidrug-resistant tuberculosis in Nepal: an observational study.

SETTING: Multidrug-resistant tuberculosis (MDR-TB) patients in the national TB treatment programme of Nepal. OBJECTIVE: To estimate the prevalence of depression and anxiety in people receiving treatment for MDR-TB, identify potential risk factors for depression and anxiety and determine temporal changes in their severity during treatment. DESIGN: An observational study using a screening tool, the Hopkins Symptom Checklist (HSCL-25) for depression and anxiety, administered monthly to a group of 135 patients in Nepal. Logistic and multilevel linear regression models were used to identify any patient characteristics associated with depression and anxiety. RESULTS: Most of the 135 patients were male (76%) and living with their families (68%). The period prevalences of depression and anxiety were respectively 22.2% and 15.6%. Patients reporting physical side effects of MDR-TB treatment had a higher depression score on HSCL by 2.63 points (95%CI 0.77-4.48) and a 1.59 point higher anxiety score (95%CI 0.45-2.73) than those who did not report any side effects. Being single was associated with having anxiety (aOR 0.2, 95%CI 0.03-1.0). CONCLUSION: Given the high rates of depression observed among MDR-TB patients, national TB treatment programmes should ensure their patients are routinely screened for depression and anxiety, and effective treatment offered.

Implementation research to assess a health workers performance-based management system in Nepal.

AIM: To test and refine a performance-based management system to improve health worker performance in Nepal. METHODS: A mixed-methods implementation research in three districts. The study assessed health workers' job satisfaction at the start and end of the study. Qualitative techniques were used to document processes, and routine health service data were analysed to measure outcomes. RESULTS: Job satisfaction significantly increased in six of nine key areas, and the proportion of staff absenteeism significantly declined in the study districts. It demonstrated an increase in immunisation coverage, the proportion of women who had a first antenatal check-up also having a fourth check-up and the proportion of childbirth in a health facility. The greatest perceived strengths of the system were its robust approach to performance planning and evaluation, supportive supervision, outcome-based job descriptions and a transparent reward system. A functional health facility environment, leadership and community engagement support successful implementation. CONCLUSION: The performance-based management system has the potential to increase health workers' job satisfaction, and it offers a tool to link facility-wide human resource management. A collaborative approach, ownership and commitment of the health system are critical to success. Considering the Nepal context, a management system that demonstrates a positive improvement has potential for improved health care delivery.

Integrating a diabetes and hypertension case management package within primary health care: a mixed methods feasibility study in Bangladesh.

BACKGROUND: Almost three quarters of non-communicable disease (NCD) deaths, and 82% of premature NCD deaths, occur in low- and middle-income countries. Bangladesh has an estimated 7 million hypertensives and 10 million diabetics, and primary care is struggling to respond. Our aim was to develop and support implementation of a diabetes and hypertension case management package, and assess its appropriateness, feasibility and acceptability in two NCD clinics within two primary-care centres in Bangladesh. METHODS: We used a convergent mixed methods design. We first assessed the level of appropriate hypertension and cardiovascular disease patient management, based on a composite outcome indicator using data from patients' treatment cards. Appropriate management was primarily informed by International Diabetes Federation (IDF) and World Health Organisation (WHO) guidelines. We then performed qualitative in-depth interviews with doctors and patients to explain these quantitative findings and to understand the challenges to achieving appropriate patient management in the NCD clinics. RESULTS: Eighty-one newly diagnosed patients were recruited. Over 3 months, 53.1% (95% CI 42.3% to 63.6%) of patients were appropriately managed. We found incomplete diagnosis (especially missing hypertension diagnosis alongside diabetes) and non-provision of follow-up appointments were the main causes of the relatively low level of appropriate management. We conducted interviews with 11 patients and 8 health professionals and found a shortage of human resources, reporting materials, available drugs and diagnostic equipment. This undermined patients' willingness to attend clinics and doctors' willingness to offer follow-ups. Hands-on skill-building training was valuable in increasing doctors' competence for appropriate management, but was seen as a novel training method and faced constraints to implementation. CONCLUSIONS: A clinical guide, skill-based training and recording package can be implemented in routine primary care and can lead to appropriate management of around half of diabetic and hypertensive patients in a low-income country. However, considerable health systems challenges must be addressed before more patients can be managed appropriately.

Multidrug-resistant tuberculosis treatment programmes insufficiently consider comorbid mental disorders.

The successful treatment of multidrug-resistant tuberculosis (MDR-TB) is a global health priority and a key pillar of the World Health Organization's (WHO's) End TB strategy. There has been significant global investment in diagnostic capabilities in recent years. However, we argue that the mental distress of those with MDR-TB and their families continues to be overlooked by TB programmes. Priorities in the End TB Strategy of 'patient-centred care' and 'patient support' are still to be delivered in practice in many low-income settings, and in particular consideration of mental distress. Our experience of undertaking MDR-TB operational research in China, Pakistan, Bangladesh, Nepal and Swaziland has given us detailed insight into the challenges facing patients, their families, health professionals and wider health systems. We are increasingly concerned that psychosocial support, and particularly support focused on mental health, is being insufficiently addressed in national MDR-TB programmes. We suggest that the presence of comorbid mental disorders reduces treatment adherence. We recommend the trialling within TB programmes of brief screening tools for common mental disorders and the incorporation of principles from the WHO Mental Health Gap Action Programme programme into TB programme treatment guidance. Our work in Nepal also suggests that brief psychological counselling delivered by non-specialist counsellors may be feasible.

Improving the quality of care of children in community clinics: an intervention and evaluation in Bangladesh.

SETTING: Community health care providers (CHCPs) in 40 rural community clinics of Comilla district, Bangladesh, were trained using a newly developed case-management job aid based on the World Health Organization Integrated Management of Childhood Illness and a communication guide. OBJECTIVES: To assess 1) the change in knowledge of the CHCPs after training; 2) the absolute quality of care provided by the CHCPs (determined as the proportion of children aged <5 years [under-fives] correctly diagnosed, treated and referred); and 3) the consultation behaviour of the CHCPs. DESIGN: Change in knowledge was assessed by tests pre-and post-training. The quality of care was determined by reassessments at the clinic exit by a medical officer, without a baseline comparison. Consultation behaviour was assessed through direct observation. The study was performed during 2014-2015. RESULTS: The mean standard knowledge score of the CH-CPs increased from 19 to 25 (P < 0.001). Of 1490 under-fives examined, 91% were correctly diagnosed, 86% were correctly treated and 99.5% received a correct referral decision. The CHCPs performed well on most of the measures of good communication, although one third did not explain the diagnosis and treatment to patients. CONCLUSION: The training was effective in changing knowledge. The CHCPs applied the knowledge gained and provided good quality care. Following these results, the Bangladesh Ministry of Health and Family Welfare has scaled up the training nationwide. The lessons learnt should be useful for other countries.

Contexte : Les prestataires des soins de santé communautaires (CHCP) de 40 communautés rurales du district de Comilla, au Bangladesh, ont été formés grâce à une aide au travail de prise en charge des cas, récemment élaborée, basée sur la « prise en charge intégrée des maladies de l'enfant ¼ de l'Organisation Mondiale de la Santé et sur un guide de communication.Objectifs : Evaluer l'amélioration des connaissances des CHCP après la formation ; la qualité absolue des soins prodigués par les CHCP (déterminée comme la proportion d'enfants âgés de <5 ans ayant eu un diagnostic, un traitement et une référence corrects) ; et le comportement des CHCP pendant la consultation.Schéma : L'amélioration des connaissances a été évaluée à l'aide de tests pré- et post-formation. La qualité des soins a été déterminée par des réévaluations lors de la sortie du centre par un officier médical, sans comparaison avec le statut de départ. Le comportement lors des consultations a été évalué par observation directe. L'étude a été réalisée en 2014­2015.Résultats : Le score moyen de connaissance des CHCP a augmenté de 19 à 25 (P < 0.001). Sur 1490 enfants âgés de <5 ans examinés, 91% ont eu un diagnostic correct, 86% un traitement correct et 99,5% ont bénéficié d'une décision de référence correcte. Les CHCP se sont bien comportés en ce qui concerne la plupart des mesures de bonne communication ; cependant, un tiers d'entre eux n'a pas expliqué le diagnostic et le traitement aux patients.Conclusion : La formation a été efficace en termes d'amélioration des connaissances. Les CHCP ont mis en application les connaissances acquises et ont fourni des soins de bonne qualité. Au vu de ces résultats, le Ministère de la Santé et du Bien-être Familial du Bangladesh a étendu la formation à tout le pays. Les leçons apprises devraient être utiles à d'autres pays.

Marco de referencia: Los agentes comunitarios de salud de 40 consultorios rurales del distrito de Comilla, en Bangladesh, recibieron capacitación con una ayuda de trabajo desarrollada recientemente sobre el manejo de los casos basado en el enfoque de 'la atención integrada de las enfermedades prevalentes de la infancia' de la Organización Mundial de la Salud y también una guía en materia de comunicación.Objetivos: Evaluar las modificaciones en los conocimientos de los agentes comunitarios de salud después de la capacitación; la calidad absoluta de la atención que prestaban (medida según la proporción de niños en edad <5 años que recibieron un diagnóstico, tratamiento y remisión correctos); y su comportamiento durante las consultas.Método: Las modificaciones en los conocimientos se analizaron mediante pruebas realizadas antes y después de la capacitación. Un médico de planta evaluó la calidad de la atención a la salida de la consulta, sin un punto de comparación. El comportamiento durante la consulta se evaluó mediante la observación directa. El estudio se llevó a cabo en el 2014 y el 2015.Resultados: La puntuación promedio de los agentes comunitarios de salud en la escala de conocimientos corrientes mejoró de 19 a 25 (P < 0,001). De los 1490 niños en edad <5 años examinados, el diagnóstico fue acertado en el 91%, el tratamiento fue apropiado en el 86% y 99,5% de los niños obtuvieron una remisión correcta. El desempeño de los agentes comunitarios en la mayoría de las medidas de comunicación fue adecuado, aunque un tercio de ellos no explicó el diagnóstico y el tratamiento a los pacientes.Conclusión: La capacitación modificó eficazmente los conocimientos de los agentes comunitarios de salud. Los agentes aplicaron los conocimientos adquiridos y prestaron una atención de buena calidad. Con base en estos resultados, el Ministerio de Salud y Bienestar Familiar de Bangladesh ha ampliado la escala de la capacitación a todo el país. Las enseñanzas extraídas en esta experiencia serán muy útiles en otros países.

Yield of intensified tuberculosis case-finding activities using Xpert(®) MTB/RIF among risk groups in Nepal.

SETTING: Twenty-two districts of Nepal, where intensified case-finding (ICF) activities for tuberculosis (TB) were implemented among risk groups under the TB REACH initiative in collaboration with the National TB Programme from July 2013 to November 2015. OBJECTIVES: To assess the yield of TB screening using an algorithm with smear microscopy followed by Xpert(®) MTB/RIF. DESIGN: A descriptive study using routinely collected data. RESULTS: Of 145 679 individuals screened, 28 574 (19.6%) had presumptive TB; 1239 (4.3%) of these were diagnosed with TB and 1195 (96%) were initiated on anti-tuberculosis treatment. The yield of screening was highest among people living with the human immunodeficiency virus (PLHIV) (6.1%), followed by household contacts (3.5%) and urban slum dwellers (0.5%). Among other risk groups, such as prisoners, factory workers, refugees and individuals with diabetes, the yield was less than 0.5%. The number needed to screen to diagnose an active TB case was 17 for PLHIV, 29 for household contacts and 197 for urban slum dwellers. Of 11 525 patients from ICF and the routine programme, 112 (1%) were diagnosed with multidrug-resistant TB. CONCLUSION: There was a substantial yield of TB cases among risk groups such as PLHIV and household contacts. Although the yield in urban slum dwellers was found to be moderate, some intervention should nonetheless be targeted because of the large population and poor access to care in this group.

Contexte : Vingt-deux districts du Népal où des activités intensifiées de recherche des cas (ICF) de la tuberculose (TB) ont été mises en œuvre au sein de groupes à risque sous l'égide du projet TB REACH en collaboration avec le programme national TB entre juillet 2013 et novembre 2015.Objectifs : Evaluer le rendement du dépistage de la TB grâce à un algorithme basé sur la microscopie de frottis suivie d'un test Xpert® MTB/RIF.Schéma : Etude descriptive basée sur des données recueillies en routine.Résultats : Sur un total de 145 679 individus dépistés, 28 574 (19,6%) ont été présumés atteints de TB ; 1239 (4,3%) d'entre eux ont eu une confirmation du diagnostic de TB ; parmi ces derniers, 1195 (96%) ont mis en route un traitement anti-tuberculose. Le rendement a été le plus élevé parmi les personnes vivant avec le virus l'immunodéficience humaine (PVVIH) (6,1%) suivies par les contacts domiciliaires (3,5%) et les habitants des bidonvilles (0,5%). Dans d'autres groupes à risque comme les prisonniers, les travailleurs d'usine, les réfugiés et les diabétiques, le rendement a été inférieur à 0,5%. Le nombre de personnes à dépister (NNS) pour diagnostiquer un cas de TB active a été de 17 pour les PVVIH, de 29 pour les contacts domiciliaires et de 197 pour les habitants des bidonvilles urbains. Sur 11 525 patients émanant soit du programme ICF soit du dépistage de routine, 112 (1%) ont eu un diagnostic de TB multirésistante.Conclusion : Le rendement en termes de cas de TB dépistés parmi les groupes à risque comme les PVVIH et les contacts domiciliaires a été substantiel. Même si ce rendement a été modeste parmi les habitants des bidonvilles, ceux-ci justifient néanmoins une intervention en raison de leur nombre élevé et de leur médiocre accès aux soins.

Marco de referencia: Veintidós distritos de Nepal, en los cuales se ejecutaron actividades de búsqueda intensiva de casos (ICF) de tuberculosis (TB) en los grupos de riesgo, en el marco del proyecto TB REACH en colaboración con el programa nacional contra la TB de julio del 2013 a noviembre del 2015.Objetivos: Evaluar el rendimiento de la detección sistemática de la TB aplicando un algoritmo que comporta la baciloscopia, seguida de la prueba Xpert® MTB/RIF.Método: Fue este un estudio descriptivo a partir de los datos recogidos de manera sistemática.Resultados: De las 145 679 personas en quienes se practicó la detección, en 28 574 hubo una presunción diagnóstica de TB (19,6%); en 1239 de estos pacientes se estableció el diagnóstico de TB (4,3%); e iniciaron el tratamiento 1195 pacientes (96%). El rendimiento diagnóstico fue más alto en las personas viviendo con el virus de la inmunodeficiencia humana (PVVIH, 6,1%), seguidas de los contactos domiciliarios (3,5%) y los residentes en tugurios (0,5%). En otros grupos de riesgo de contraer la TB como los reclusos, los obreros de fábricas, los refugiados o los pacientes diabéticos el rendimiento diagnóstico fue inferior a 0,5%. El número de personas que se debieron examinar con el fin de detectar un caso de TB activa fue 17 en las PVVIH, 29 en los contactos domiciliarios y 197 en los habitantes de los tugurios. De las 11 525 personas examinadas en la ICF y el programa corriente, se diagnosticó TB multiresistente en 112 casos (1%).Conclusión: La detección sistemática de casos de TB exhibió un alto rendimiento en los grupos de riesgo como las PVVIH y los contactos domiciliarios. Aunque el desempeño en los tugurios urbanos fue moderado, es importante dirigir intervenciones a estos entornos, dado el tamaño de estas poblaciones y su acceso deficiente a la atención de salud.

Addressing Inequities in Urban Health: Do Decision-Makers Have the Data They Need? Report from the Urban Health Data Special Session at International Conference on Urban Health Dhaka 2015.

Rapid and uncontrolled urbanisation across low and middle-income countries is leading to ever expanding numbers of urban poor, defined here as slum dwellers and the homeless. It is estimated that 828 million people are currently living in slum conditions. If governments, donors and NGOs are to respond to these growing inequities they need data that adequately represents the needs of the urban poorest as well as others across the socio-economic spectrum.We report on the findings of a special session held at the International Conference on Urban Health, Dhaka 2015. We present an overview of the need for data on urban health for planning and allocating resources to address urban inequities. Such data needs to provide information on differences between urban and rural areas nationally, between and within urban communities. We discuss the limitations of data most commonly available to national and municipality level government, donor and NGO staff. In particular we assess, with reference to the WHO's Urban HEART tool, the challenges in the design of household surveys in understanding urban health inequities.We then present two novel approaches aimed at improving the information on the health of the urban poorest. The first uses gridded population sampling techniques within the design and implementation of household surveys and the second adapts Urban HEART into a participatory approach which enables slum residents to assess indicators whilst simultaneously planning the response. We argue that if progress is to be made towards inclusive, safe, resilient and sustainable cities, as articulated in Sustainable Development Goal 11, then understanding urban health inequities is a vital pre-requisite to an effective response by governments, donors, NGOs and communities.

Predictors of cessation in smokers suspected of TB: Secondary analysis of data from a cluster randomized controlled trial.

BACKGROUND: Smoking cessation services are rarely found within health services in low income countries. Given the interactions between Tuberculosis (TB) and tobacco, including cessation support within TB programs offers a promising cost-effective solution. We conducted secondary analysis of data from a cluster randomized controlled trial of smoking cessation in health centers in Pakistan to identify predictors of continuous and short-term abstinence in smokers suspected of TB using cigarettes or hookah. METHODS: Predictor variables of those continuously abstinent at 5 and 25 weeks post quit-date (continuous abstinence) and those abstinent only at 5 weeks (short-term abstinence) were compared with those who continued smoking and with each other. Self-reported abstinence at both time points was confirmed biochemically. RESULTS: Data obtained from 1955 trial participants were analyzed. The factors that predicted continued smoking when compared to continuous abstinence were: being older RR 0.97 (0.95 to 0.98), smoking higher quantities of tobacco RR 0.975 (0.97 to 0.98) and sharing a workplace with other smokers RR 0.88 (0.77 to 0.99). Those with a confirmed TB diagnosis were more likely to remain continuously abstinent than those without RR 1.27 (1.10-1.47). CONCLUSIONS: Those diagnosed with TB are more likely to be abstinent than those diagnosed with other respiratory conditions. Beyond this, predictors of continued smoking in Pakistan are similar to those in high income contexts. Taking advantage of the 'teachable moment' that a TB diagnosis provides is an efficient means for resource-poor TB programs in low income settings to increase tobacco cessation and improve health outcomes.

Understanding the impacts of care farms on health and well-being of disadvantaged populations: a protocol of the Evaluating Community Orders (ECO) pilot study.

INTRODUCTION: Care farms, where all or part of the farm is used for therapeutic purposes, show much potential for improving the health and well-being of a range of disadvantaged groups. Studies to date have been qualitative or observational, with limited empirical evidence of the effectiveness of care farms in improving health and well-being. Understanding the underlying mechanisms that lead to improvements for different disadvantaged groups is a further gap in the evidence. Participants in this study are offenders serving community orders. Their low socioeconomic status and poor health outcomes relative to the general population exemplifies disadvantage. METHODS AND ANALYSIS: This paper describes the protocol of a study to understand the impacts of care farms and to pilot the design and tools for a study to assess cost-effectiveness of care farms in improving the quality of life of offenders. As a pilot study, no power calculation has been conducted. However, 150 offenders serving community sentences on care farms and 150 on other probation locations (eg, litter picking, painting) will be recruited over a 1-year period. Changes in quality of life, measured by Clinical Outcome in Routine Evaluation-Outcome Measure, health and reconvictions of offenders at care farms compared to other probation locations will be analysed to inform the sample size calculation for the follow on study. The feasibility of recruitment, retention, collecting cost data and modelling cost-effectiveness will also be assessed. The study will use qualitative methods to explore the experiences of offenders attending care farms and perceptions of probation and care farm staff on the processes and impacts of the intervention. ETHICS AND DISSEMINATION: Findings will be published and inform development of a natural experiment and will be disseminated to probation services, care farms and academics. University of Leeds Ethical Review Board approved: SoMREC/13/014. National Offender Management Service (NOMS) approved: 2013-257.

Can action research strengthen district health management and improve health workforce performance? A research protocol.

INTRODUCTION: The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel and by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce. The purpose of this paper is to disseminate the protocol for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome. METHODS: The overall aim of the PERFORM project is to identify ways of strengthening district management in order to address health workforce inadequacies by improving health workforce performance in SSA. The study will take place in three districts each in Ghana, Tanzania and Uganda using an action research approach. With the support of the country research teams, the district health management teams (DHMTs) will lead on planning, implementation, observation, reflection and redefinition of the activities in the study. Taking into account the national and local human resource (HR) and health systems (HS) policies and practices already in place, 'bundles' of HR/HS strategies that are feasible within the context and affordable within the districts' budget will be developed by the DHMTs to strengthen priority areas of health workforce performance. A comparative analysis of the findings from the three districts in each country will add new knowledge on the effects of these HR/HS bundles on DHMT management and workforce performance and the impact of an action research approach on improving the effectiveness of the DHMTs in implementing these interventions. DISCUSSION: Different challenges were faced during the development of the methodology. These include the changing context in the study districts, competing with other projects and duties for the time of district managers, complexity of the study design, maintaining the anonymity and confidentiality of study participants as well as how to record the processes during the study. We also discuss how these challenges are being addressed. The dissemination of this research protocol is intended to generate interest in the PERFORM project and also stimulate discussion on the use of action research in complex studies such as this on strengthening district health management to improve health workforce performance.

Barriers to, and facilitators of, parenting programmes for childhood behaviour problems: a qualitative synthesis of studies of parents' and professionals' perceptions.

Disruptive behaviour problems (DBPs) during childhood exert a high burden on individuals, families and the community as a whole. Reducing this impact is a major public health priority. Early parenting interventions are recommended as valuable ways to target DBPs; however, low take-up of, and high drop-out rates from, these programmes seriously reduce their effectiveness. We present a review of published qualitative evidence relating to factors that block or facilitate access and engagement of parents with such programmes using a thematic synthesis approach. 12 papers presenting views of both parents and professionals met our inclusion and quality criteria. A large number of barriers were identified highlighting the array of challenges parents can face when considering accessing and engaging with treatment for their child with behavioural problems. Facilitating factors in this area were also identified. A series of recommendations were made with regard to raising awareness of programmes and recruiting parents, providing flexible and individually tailored support, delivering programmes through highly skilled, trained and knowledgeable therapists, and highlighting factors to consider when delivering group-based programmes. Clinical guidelines should address barriers and facilitators of engagement as well as basic efficacy of treatment approaches.

Mainstreaming HIV/AIDS in development sectors: Have we learnt the lessons from gender mainstreaming?

Drawing on an international literature review, two international workshops and primary qualitative research in Uganda this paper reviews experiences of mainstreaming HIV/AIDS in development sectors (such as education, health and agriculture) in developing countries. The extent to which HIV/AIDS mainstreaming strategies and associated challenges are similar to or different from those of mainstreaming gender in the health sector is also explored. The paper details the rationale for HIV/AIDS mainstreaming through illustrating the wide reaching effects of the pandemic. Despite the increasing interest in mainstreaming HIV/AIDS there is little clarity on what it actually means in theory or practice. This paper presents a working definition of HIV/AIDS mainstreaming. It is argued that all too often processes of 'mainstreaming' emerge as too narrow and reductionist to be effective. The paper then considers four key challenges for mainstreaming HIV/AIDS and explores how and to what extent they have also been faced in gender mainstreaming and what can be learnt from these experiences. These are: (1) the limited evidence base upon which to build mainstreaming strategies in different country contexts; (2) the role of donors in mainstreaming and implications for sustainability; (3) who should take responsibility for mainstreaming; and (4) how to develop capacity for mainstreaming. The conclusion argues for more joined up thinking and sustainable approaches to mainstreaming both HIV/AIDS and gender.