Mendelian randomization analysis of 34,497 German Holstein cows to infer causal associations between milk production and health traits.

BACKGROUND: Claw diseases and mastitis represent the most important health issues in dairy cattle with a frequently mentioned connection to milk production. Although many studies have aimed at investigating this connection in more detail by estimating genetic correlations, they do not provide information about causality. An alternative is to carry out Mendelian randomization (MR) studies using genetic variants to investigate the effect of an exposure on an outcome trait mediated by genetic variants. No study has yet investigated the causal association of milk yield (MY) with health traits in dairy cattle. Hence, we performed a MR analysis of MY and seven health traits using imputed whole-genome sequence data from 34,497 German Holstein cows. We applied a method that uses summary statistics and removes horizontal pleiotropic variants (having an effect on both traits), which improves the power and unbiasedness of MR studies. In addition, genetic correlations between MY and each health trait were estimated to compare them with the estimates of causal effects that we expected. RESULTS: All genetic correlations between MY and each health trait were negative, ranging from - 0.303 (mastitis) to - 0.019 (digital dermatitis), which indicates a reduced health status as MY increases. The only non-significant correlation was between MY and digital dermatitis. In addition, each causal association was negative, ranging from - 0.131 (mastitis) to - 0.034 (laminitis), but the number of significant associations was reduced to five nominal and two experiment-wide significant results. The latter were between MY and mastitis and between MY and digital phlegmon. Horizontal pleiotropic variants were identified for mastitis, digital dermatitis and digital phlegmon. They were located within or nearby variants that were previously reported to have a horizontal pleiotropic effect, e.g., on milk production and somatic cell count. CONCLUSIONS: Our results confirm the known negative genetic connection between health traits and MY in dairy cattle. In addition, they provide new information about causality, which for example points to the negative energy balance mediating the connection between these traits. This knowledge helps to better understand whether the negative genetic correlation is based on pleiotropy, linkage between causal variants for both trait complexes, or indeed on a causal association.

Every loaf of bread is political - Reflections on collective care responses to Covid-19 in Cape Town.

Feminist perspectives on care have demonstrated how capitalism undervalues care work. The Covid-19 pandemic highlighted this further, as systems of production and social reproduction became destabilized globally. In many countries, the formal pandemic response fell short of attending to the daily, fundamental care needs of people living through the crisis, especially those compromised by the socio-economic effects of the pandemic. These needs were often attended to at the community level. This article explores a community-led network of care, known as CANs, that emerged in response to the pandemic in Cape Town. It makes three overarching observations. The first is that community-led responses were characterised by a push towards the collectivisation of care work. The second is that this enabled emergent strategies and relational practices of care, centring notions of solidarity, inter-dependence and horizontal exchange of resources and knowledge. Finally, we observed that, although the devaluation of care work limited the recognition and material support extended to CANs, opportunities to re-politicise care work as resistance work emerged. These represent a prefigurative moment in which alternative logics and strategies can transform the vision of our health and care systems, and the notion of community participation in and ownership of those systems.

A combined strategies intervention on the World Health Organization prescribing indicators: A quasi-randomised trial.

BACKGROUND: Irrational medicine use is a global problem that may potentiate antimicrobial resistance. AIM: This study aims to assess prescribing practices and the effect of a prescription audit and feedback coupled with small-group education intervention on prescribing indicators. SETTING: The study was conducted in public-sector healthcare facilities in Eswatini. METHODS: A cluster quasi-randomised controlled study was conducted from 2016 to 2019 using the World Health Organization/ International Network for Rational Use of Drugs (WHO/INRUD) prescribing indicators at baseline, post-intervention and post-follow-up. A 6-month unblinded intervention was tested in 32 healthcare facilities, randomly allocated to intervention (16) and control (16) arms. Prescribing practices were assessed post-intervention, and 6 months after the intervention, through an audit of 100 randomly selected prescriptions from each facility. Comparisons of WHO or INRUD prescribing indicators were conducted using the intention-to-treat analysis at the two times. RESULTS: At baseline, in both arms, rational prescribing standards were met by the number of medicines per prescription and the use of injections. Antibiotic use was above 50% in both arms. After adjustment for baseline antibiotics use, region and level of care, there were no significant differences in all prescribing indicators between the two arms, post-intervention and at 6 months follow-up. CONCLUSION: In a lower middle-income setting with a high prevalence of irrational prescribing practices, a prescription audit, feedback and small-group education intervention had no benefits in improving rational prescribing.Contribution: Multifaceted strategies, strengthening of pharmacy and therapeutics committees, and holistic monitoring of medicine use are recommended to promote rational medicine use.

Genomic dissection of the correlation between milk yield and various health traits using functional and evolutionary information about imputed sequence variants of 34,497 German Holstein cows.

BACKGROUND: Over the last decades, it was subject of many studies to investigate the genomic connection of milk production and health traits in dairy cattle. Thereby, incorporating functional information in genomic analyses has been shown to improve the understanding of biological and molecular mechanisms shaping complex traits and the accuracies of genomic prediction, especially in small populations and across-breed settings. Still, little is known about the contribution of different functional and evolutionary genome partitioning subsets to milk production and dairy health. Thus, we performed a uni- and a bivariate analysis of milk yield (MY) and eight health traits using a set of ~34,497 German Holstein cows with 50K chip genotypes and ~17 million imputed sequence variants divided into 27 subsets depending on their functional and evolutionary annotation. In the bivariate analysis, eight trait-combinations were observed that contrasted MY with each health trait. Two genomic relationship matrices (GRM) were included, one consisting of the 50K chip variants and one consisting of each set of subset variants, to obtain subset heritabilities and genetic correlations. In addition, 50K chip heritabilities and genetic correlations were estimated applying merely the 50K GRM. RESULTS: In general, 50K chip heritabilities were larger than the subset heritabilities. The largest heritabilities were found for MY, which was 0.4358 for the 50K and 0.2757 for the subset heritabilities. Whereas all 50K genetic correlations were negative, subset genetic correlations were both, positive and negative (ranging from -0.9324 between MY and mastitis to 0.6662 between MY and digital dermatitis). The subsets containing variants which were annotated as noncoding related, splice sites, untranslated regions, metabolic quantitative trait loci, and young variants ranked highest in terms of their contribution to the traits` genetic variance. We were able to show that linkage disequilibrium between subset variants and adjacent variants did not cause these subsets` high effect. CONCLUSION: Our results confirm the connection of milk production and health traits in dairy cattle via the animals` metabolic state. In addition, they highlight the potential of including functional information in genomic analyses, which helps to dissect the extent and direction of the observed traits` connection in more detail.

Reactive eutectic media for lignocellulosic biomass fractionation.

This study introduces an alternative approach towards lignocellulosic biomass fractionation. For this purpose, reactive eutectic media (REM) based on ammonium formate and different organic acids are investigated, possible products are identified, and the REM are employed for lignin extraction and terminal isolation of cellulose pulp from beech wood. The method promises a considerable process intensification by simultaneous separation of high purity cellulose pulp, lignin isolation as a cationically modified species, and production of value-added chemicals from reaction products of the REM. This study puts a further focus on the generated cellulose pulp and investigates it with respect to surface charge and fiber length.

Mistrust in government and National Health Insurance: A qualitative study of solo private practitioners in Cape Town.

BACKGROUND:  The participation of independent private general practitioners (GPs) is of fundamental importance to the successful implementation of key elements of the proposed National Health Insurance (NHI) reform, notably the contracting units for primary health care (CUPS). This study explored knowledge and perceptions of the NHI reforms of private GPs following the tabling of the NHI Bill in parliament in 2019. METHODS:  An explorative qualitative research methodology was adopted. Using a semi-structured guide, nine solo private GPs, purposefully selected to represent the range of practices in the southern peninsula of Cape Town were interviewed in depth by B.L.P. over the period from January 2021 to March 2022. RESULTS:  The GPs indicated support for the values of greater equity outlined in the NHI proposals. However, they had little engagement on or knowledge of their potential future roles in NHI. Concerns over financial viability and design were underpinned by an overall mistrust in the public sector to implement and manage NHI. CONCLUSION:  The study concurs with previous research that private GPs are broadly in support of the principles of, and are potential allies, in advancing NHI. General practitioners need a platform to share their concerns and contribute as co-designers of NHI reforms. In the interim, steps to increase collaboration between private and public sectors at local and provincial level through, for example, referral processes may help to build the trust that is necessary between the sectors.Contribution: This study foregrounds the role of trust relationships in advancing NHI.

Development of image-based decision support systems utilizing information extracted from radiological free-text report databases with text-based transformers.

OBJECTIVES: To investigate the potential and limitations of utilizing transformer-based report annotation for on-site development of image-based diagnostic decision support systems (DDSS). METHODS: The study included 88,353 chest X-rays from 19,581 intensive care unit (ICU) patients. To label the presence of six typical findings in 17,041 images, the corresponding free-text reports of the attending radiologists were assessed by medical research assistants ("gold labels"). Automatically generated "silver" labels were extracted for all reports by transformer models trained on gold labels. To investigate the benefit of such silver labels, the image-based models were trained using three approaches: with gold labels only (MG), with silver labels first, then with gold labels (MS/G), and with silver and gold labels together (MS+G). To investigate the influence of invested annotation effort, the experiments were repeated with different numbers (N) of gold-annotated reports for training the transformer and image-based models and tested on 2099 gold-annotated images. Significant differences in macro-averaged area under the receiver operating characteristic curve (AUC) were assessed by non-overlapping 95% confidence intervals. RESULTS: Utilizing transformer-based silver labels showed significantly higher macro-averaged AUC than training solely with gold labels (N = 1000: MG 67.8 [66.0-69.6], MS/G 77.9 [76.2-79.6]; N = 14,580: MG 74.5 [72.8-76.2], MS/G 80.9 [79.4-82.4]). Training with silver and gold labels together was beneficial using only 500 gold labels (MS+G 76.4 [74.7-78.0], MS/G 75.3 [73.5-77.0]). CONCLUSIONS: Transformer-based annotation has potential for unlocking free-text report databases for the development of image-based DDSS. However, on-site development of image-based DDSS could benefit from more sophisticated annotation pipelines including further information than a single radiological report. CLINICAL RELEVANCE STATEMENT: Leveraging clinical databases for on-site development of artificial intelligence (AI)-based diagnostic decision support systems by text-based transformers could promote the application of AI in clinical practice by circumventing highly regulated data exchanges with third parties. KEY POINTS: • The amount of data from a database that can be used to develop AI-assisted diagnostic decision systems is often limited by the need for time-consuming identification of pathologies by radiologists. • The transformer-based structuring of free-text radiological reports shows potential to unlock corresponding image databases for on-site development of image-based diagnostic decision support systems. • However, the quality of image annotations generated solely on the content of a single radiology report may be limited by potential inaccuracies and incompleteness of this report.

Service delivery interventions to improve maternal and newborn health in low- and middle-income countries: scoping review of quality improvement, implementation research and health system strengthening approaches.

INTRODUCTION: This review explores the characteristics of service delivery-related interventions to improve maternal and newborn health (MNH) in low-and middle-income countries (LMICs) over the last two decades, comparing three common framings of these interventions, namely, quality improvement (QI), implementation science/research (IS/IR), and health system strengthening (HSS). METHODS: The review followed the staged scoping review methodology proposed by Levac et al. (2010). We developed and piloted a systematic search strategy, limited to English language peer-reviewed articles published on LMICs between 2000 and March 2022. Analysis was conducted in two-quantitative and qualitative-phases. In the quantitative phase, we counted the year of publication, country(-ies) of origin, and the presence of the terms 'quality improvement', 'health system strengthening' or 'implementation science'/ 'implementation research' in titles, abstracts and key words. From this analysis, a subset of papers referred to as 'archetypes' (terms appearing in two or more of titles, abstract and key words) was analysed qualitatively, to draw out key concepts/theories and underlying mechanisms of change associated with each approach. RESULTS: The searches from different databases resulted in a total of 3,323 hits. After removal of duplicates and screening, a total of 231 relevant articles remained for data extraction. These were distributed across the globe; more than half (n = 134) were published since 2017. Fifty-five (55) articles representing archetypes of the approach (30 QI, 16 IS/IR, 9 HSS) were analysed qualitatively. As anticipated, we identified distinct patterns in each approach. QI archetypes tended towards defined process interventions (most typically, plan-do-study-act cycles); IS/IR archetypes reported a wide variety of interventions, but had in common evaluation methodologies and explanatory theories; and HSS archetypes adopted systemic perspectives. Despite their distinctiveness, there was also overlap and fluidity between approaches, with papers often referencing more than one approach. Recognising the complexity of improving MNH services, there was an increased orientation towards participatory, context-specific designs in all three approaches. CONCLUSIONS: Programmes to improve MNH outcomes will benefit from a better appreciation of the distinctiveness and relatedness of different approaches to service delivery strengthening, how these have evolved and how they can be combined.

Eutectic Media Open a Synthetic Route to Oligocitrazinic Acid Fluorophores of Purple Hue.

Under isochoric and solvent-free conditions, the reaction between ammonium formate and citric acid results in a deeply purple reaction product with fluorescent properties. This brings this reaction in the realm of bio-based fluorophores and bottom-up carbon nanodots from citric acid. The reaction conditions are optimized in terms of UV-vis spectroscopic properties and, subsequently, the main reaction product is separated. While the structural analysis does not give any indication for carbon nanodots in a general sense, it points towards the formation of molecular fluorophores that consist of oligomerized citrazinic acid derivatives. Furthermore, EPR spectroscopy reveals the presence of stable free radicals in the product. We hypothesize that such open-shell structures may play a general role in molecular fluorophores from citric acid and are not yet sufficiently explored. Therefore, we believe that analysis of these newly discovered fluorophores may contribute to a better understanding of the properties of fluorophores and CND from citric acid in general.

Intervention in Mothers and Newborns to Reduce Maternal and Perinatal Mortality in 3 Provinces in South Africa Using a Quality Improvement Approach: Protocol for a Mixed Method Type 2 Hybrid Evaluation.

BACKGROUND: The COVID-19 pandemic undermined gains in reducing maternal and perinatal mortality in South Africa. The Mphatlalatsane Initiative is a health system intervention to reduce mortality and morbidity in women and newborns to desired levels. OBJECTIVE: Our evaluation aims to determine the effect of various exposures, including the COVID-19 pandemic, and a system-level, complex, patient-centered quality improvement (QI) intervention (the Mphatlalatsane Initiative) on maternal and neonatal health services at 21 selected South African facilities. The objectives are to determine whether Mphatlalatsane reduces the institutional maternal mortality ratio, neonatal mortality rate, and stillbirth rate (objective 1) and improves patients' experiences (objective 2) and quality of care (objective 3). Objective 4 assesses the contextual and implementation process factors, including the COVID-19 pandemic, that shape Mphatlalatsane uptake and variation. METHODS: This study is an implementation science type 2 hybrid effectiveness, controlled before-and-after design with quantitative and qualitative components. The Mphatlalatsane intervention commenced at the end of 2019. For objective 1, intervention and control facility-level data from the District Health Information System are compared for changes in institutional maternal and neonatal mortality and stillbirth rates and associations with QI, the COVID-19 pandemic, and both. This first analysis includes data from 18 facilities, regardless of their allocation to intervention or comparison, to obtain a general idea of the effect of the COVID-19 pandemic. For objectives 2 to 3, data collectors abstract data from maternal and neonatal records, interview participants, and conduct neonatal facility assessments. For objective 4, interviews, program documentation, surveys, and observations are used to assess how contextual factors at the macro-, meso-, and microlevels explain variation in intervention uptake and outcome. The intervention dose is measured at the microlevel only in the intervention facilities. The study assesses the Mphatlalatsane Initiative from 2020 to 2022. RESULTS: From preliminary analysis, across the 3 provinces, maternal and neonatal deaths increased during the COVID-19 pandemic, whereas stillbirths remained unchanged. Maternal satisfaction with quality of care was >90%. The COVID-19 pandemic severely disrupted the QI teams functioning. However, the QI teams regained their pre-COVID-19 momentum by adapting the QI model, with advisers providing mentoring and support. Variation in adoption at the mesolevel was related to stable and motivated leadership (particularly at the facility level), poor integration into routine processes, and buy-in from senior district managers who were affected by competing priorities. Varying referral and specialist outreach systems, staff availability and development, and service delivery infrastructure are plausible factors in variable outcomes. CONCLUSIONS: Few evaluations rigorously evaluated the effect of health system interventions on improving health services and outcomes. Results will inform the scaling up of successful intervention components and strategies to mitigate the effects of the COVID-19 pandemic or similar emerging epidemics on maternal and neonatal mortality. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42041.

Genomic dominance variance analysis of health and milk production traits in German Holstein cattle.

Genomic analyses commonly explore the additive genetic variance of traits. The non-additive variance, however, is usually small but often significant in dairy cattle. This study aimed at dissecting the genetic variance of eight health traits that recently entered the total merit index in Germany and the somatic cell score (SCS), as well as four milk production traits by analysing additive and dominance variance components. The heritabilities were low for all health traits (between 0.033 for mastitis and 0.099 for SCS), and moderate for the milk production traits (between 0.261 for milk energy yield and 0.351 for milk yield). For all traits, the contribution of dominance variance to the phenotypic variance was low, varying between 0.018 for ovarian cysts and 0.078 for milk yield. Inbreeding depression, inferred from the SNP-based observed homozygosity, was significant only for the milk production traits. The contribution of dominance variance to the genetic variance was larger for the health traits, ranging from 0.233 for ovarian cysts to 0.551 for mastitis, encouraging further studies that aim at discovering QTLs based on their additive and dominance effects.

A genomic assessment of the correlation between milk production traits and claw and udder health traits in Holstein dairy cattle.

Claw diseases and mastitis represent the most important disease traits in dairy cattle with increasing incidences and a frequently mentioned connection to milk yield. Yet, many studies aimed to detect the genetic background of both trait complexes via fine-mapping of quantitative trait loci. However, little is known about genomic regions that simultaneously affect milk production and disease traits. For this purpose, several tools to detect local genetic correlations have been developed. In this study, we attempted a detailed analysis of milk production and disease traits as well as their interrelationship using a sample of 34,497 50K genotyped German Holstein cows with milk production and claw and udder disease traits records. We performed a pedigree-based quantitative genetic analysis to estimate heritabilities and genetic correlations. Additionally, we generated GWAS summary statistics, paying special attention to genomic inflation, and used these data to identify shared genomic regions, which affect various trait combinations. The heritability on the liability scale of the disease traits was low, between 0.02 for laminitis and 0.19 for interdigital hyperplasia. The heritabilities for milk production traits were higher (between 0.27 for milk energy yield and 0.48 for fat-protein ratio). Global genetic correlations indicate the shared genetic effect between milk production and disease traits on a whole genome level. Most of these estimates were not significantly different from zero, only mastitis showed a positive one to milk (0.18) and milk energy yield (0.13), as well as a negative one to fat-protein ratio (-0.07). The genomic analysis revealed significant SNPs for milk production traits that were enriched on Bos taurus autosome 5, 6, and 14. For digital dermatitis, we found significant hits, predominantly on Bos taurus autosome 5, 10, 22, and 23, whereas we did not find significantly trait-associated SNPs for the other disease traits. Our results confirm the known genetic background of disease and milk production traits. We further detected 13 regions that harbor strong concordant effects on a trait combination of milk production and disease traits. This detailed investigation of genetic correlations reveals additional knowledge about the localization of regions with shared genetic effects on these trait complexes, which in turn enables a better understanding of the underlying biological pathways and putatively the utilization for a more precise design of breeding schemes.

Early Reflections on Mphatlalatsane, a Maternal and Neonatal Quality Improvement Initiative Implemented During COVID-19 in South Africa.

Despite global progress in reducing maternal and neonatal mortality and stillbirths, much work remains to be done to achieve the Sustainable Development Goals. Reports indicate that coronavirus disease (COVID-19) disrupts the provision and uptake of routine maternal and neonatal health care (MNH) services and negatively impacts cumulative pre-COVID-19 achievements. We describe a multipartnered MNH quality improvement (QI) initiative called Mphatlalatsane, which was implemented in South Africa before and during the COVID-19 pandemic. The initiative aimed to reduce the maternal mortality ratio, neonatal mortality rate, and stillbirth rate by 50% between 2018 and 2022. The multifaceted design comprises QI and other intervention activities across micro-, meso-, and macrolevels, and its area-based approach facilitates patients' access to MNH services. The initiative commenced 6 months pre-COVID-19, with subsequent adaptation necessitated by COVID-19. The initial focus on a plan-do-study-act QI model shifted toward meeting the immediate needs of health care workers (HCWs), the health system, and health care managers arising from COVID-19. Examples include providing emotional support to staff and streamlining supply chain management for infection control and personal protection materials. As these needs were addressed, Mphatlalatsane gradually refocused HCWs' and managers' attention to recognize the disruptions caused by COVID-19 to routine MNH services. This gradual reprioritization included the development of a risk matrix to help staff and managers identify specific risks to service provision and uptake and develop mitigating measures. Through this approach, Mphatlalatsane led to an optimization case using existing resources rather than requesting new resources to build an investment case, with a responsive design and implementation approach as the cornerstone of the initiative. Further, Mphatlalatsane demonstrates that agile and context-specific responses to crises such as the COVID-19 pandemic can mitigate such threats and maintain interventions to improve MNH services.

Expressions of actor power in implementation: a qualitative case study of a health service intervention in South Africa.

BACKGROUND: Implementation frameworks and theories acknowledge the role of power as a factor in the adoption (or not) of interventions in health services. Despite this recognition, there is a paucity of evidence on how interventions at the front line of health systems confront or shape existing power relations. This paper reports on a study of actor power in the implementation of an intervention to improve maternal, neonatal and child health care quality and outcomes in a rural district of South Africa. METHODS: A retrospective qualitative case study based on interviews with 34 actors in three 'implementation units' - a district hospital and surrounding primary health care services - of the district, selected as purposefully representing full, moderate and low implementation of the intervention, some three years after it was first introduced. Data are analysed using Veneklasen and Miller's typology of the forms of power - namely 'power over', 'power to', 'power within' and 'power with'. RESULTS: Multiple expressions of actor power were evident during implementation and played a plausible role in shaping variable implementation, while the intervention itself acted to change power relations. As expected, a degree of buy-in of managers (with power over) in implementation units was necessary for the intervention to proceed. Beyond this, the ability to mobilise collective action (power with), combined with support from champions with agency (power within) were key to successful implementation. However, local empowerment may pose a threat to hierarchical power (power over) at higher levels (district and provincial) of the system, potentially affecting sustainability. CONCLUSIONS: A systematic approach to the analysis of power in implementation research may provide insights into the fate of interventions. Intervention designs need to consider how they shape power relations, especially where interventions seek to widen participation and responsiveness in local health systems.

Working Towards Inclusive, Socially Accountable and Resilient Community Health Systems: An Introduction to a Special Issue.

This editorial introduces the eleven papers in the special issue titled: The multiple lenses on the community health system: implications for research and action. Our editorial begins by describing the collaboration that led to the special issue, and then gives an overview of the contents of the special issue, which include two framing papers and nine empirical contributions from researchers in Zambia, Tanzania, Sweden, South Africa, India, and Australia. We conclude by considering how these papers collectively speak to the theme of resilience.

Exploring Politics and Contestation in the Policy Process: The Case of Zambia's Contested Community Health Strategy.

There have been increased calls for low- and middle-income countries to develop community health systems (CHS) policies or strategies. However, emerging global guidance brackets the inherent complexity and contestation of policy development at the country level. This is explored through the case of Zambia's 5-year Community Health Strategy (CH Strategy), formulated in 2017 and then summarily withdrawn and reissued two years later, with largely similar content. This paper examines the events, actors, and contexts behind this abrupt change in the Strategy, through an analysis of documentary sources and interviews with 21 stakeholders involved in the policy process. We describe an environment of contestation, characterised by numerous international partners weighing in on the CH Strategy, interfacing with shifting loci of responsibility for the CHS in the Ministry of Health (MoH). Despite the rhetoric of participation, providers and communities played no part in the policy process. These dynamics created the conditions for the abrupt change in strategy, illustrating the inherently fraught and political nature of policy development on the CHS in many countries. Going forward, we conclude that paying attention to processes of CHS policy development, and in particular the interaction between events, actors, and contexts, is as important as ensuring meaningful policy content.

Strengthening Research and Practice in Community Health Systems: A Research Agenda and Manifesto.

While there have been increased calls for strengthening community health systems (CHSs), key priorities for this field have not been fully articulated. This paper seeks to fill this gap, presenting a collaboratively defined research agenda, accompanied by a 'manifesto' on strengthening research and practice in the CHS. The CHS research agenda domains were developed through a modified concept mapping process with a team of 33 experts on the CHS including policy-makers, implementers and researchers from institutions in six countries: Uganda, Guatemala, South Africa, Sweden, Tanzania and Zambia. The process began remotely with brainstorming research priorities and concluded in a one-week workshop that was held in Zambia where priorities for strengthening CHS were discussed, grouped into domains, interpreted, and drafted into a collective declaration. Eight domains of research priorities for CHSs were identified: clarifying the purpose and values of the CHS, ensure inclusivity; design, implementation and monitoring of strategies to strengthen the CHS; social, political and historical contexts of CHS; community health workers (CHWs); social accountability; the interface between the CHS and the broader health system; governance and stewardship; and finally, the ethical methodologies for researching the CHS. By harnessing a set of diverse and rich experiences and perspectives on CHS through a structured process, a multifaceted research agenda and manifesto that transcend context, disciplines and time were developed. We posit this as an entry into greater debate and diversity in the field as we continue to find ways to strengthen research and practice in the CHS.

Factors Associated With Workplace and Interpersonal Trust in the Supervisory System of a Community Health Worker Programme in a Rural South African District.

BACKGROUND: Key to effective supportive supervision, and ultimately performance of community health workers (CHWs), is the nature of relationships in the formal health system at the coal face of programmes. The central character and defining feature of effective relationships, in turn, is the ability to engender trust. This study describes factors associated with workplace and interpersonal trust, the relationship between the two sets of trust factors and how this shaped perceived performance of CHWs in ward-based outreach teams (WBOTs) in a rural South African district. METHODS: In the context of a wider study of supportive supervision of CHWs, factors recognised to be associated with trust in the literature were studied qualitatively in Ngaka Modiri Molema district, North West Province. Focus group discussions (FGDs) and individual interviews were conducted by the first author with CHWs (23), team leaders (12), facility managers (10) and middle managers (5). Interviews were recorded, translated and transcribed. Perceptions of trust factors associated with workplace and interpersonal trust were analysed thematically. RESULTS: The interviews revealed a climate of considerable workplace mistrust due to the perceived abandonment of the WBOTs programme by managers at all levels, and this affected support and supervision of WBOTs. However, there was a degree of variability and discretion in expressions of interpersonal trust at the coal face, leading to different perceptions of the competence and functionality of the WBOTs. Mistrust in the workplace and poor interpersonal relationships translated into low confidence in the ability of CHWs, which in turn compromised the performance of these teams. CONCLUSION: The study contributes empirical evidence on how workplace trust factors impact on interpersonal trust factors and the possible implications of both sets of trust factors on perceived performance of CHWs. Wider trust in the health system have a significant bearing on interpersonal trust between CHWs and other players in the primary healthcare (PHC) system.

The Multiple Lenses on the Community Health System: Implications for Policy, Practice and Research.

Community health systems (CHSs) have historically been approached from multiple perspectives, with different purposes and methodological and disciplinary orientations. The terrain is, on the one hand, vast and diverse. On the other hand, under the banner of universal health coverage (UHC) and the Sustainable Development Goals (SDGs), a streamlined version of 'community health' is increasingly being consolidated in global health and donor communities. With the view to informing debate and practice, this paper seeks to synthesise approaches to the CHS into a set of 'lenses,' drawing on the collective and multi-disciplinary knowledge (both formal and experiential) of the authors, a collaborative network of 23 researchers from seven institutions across six countries (spanning low, middle and high income). With a common view of the CHS as a complex adaptive system, we propose four key lenses, referred to as programmatic, relational, collective action and critical lenses. The lenses represent different positionalities in community health, encompassing macro-level policy-maker, front-line and community vantage points, and purposes ranging from social justice to instrumental goals. We define and describe the main elements of each lens and their implications for thinking about policy, practice and research. Distilling a set of key lenses offers a way to make sense of a complex terrain, but also counters what may emerge as a dominant, single narrative on the CHS in global health. By making explicit and bringing together different lenses on the CHS, the limits and possibilities of each may be better appreciated, while promoting integrative, systems thinking in policy, practice and research.