Stigma, lost opportunities, and growth: Understanding experiences of caregivers of persons with mental illness in Tamil Nadu, India.

This study aimed to address gaps in understanding of the lived experiences of caregivers of persons with mental illness in low-income countries. It was conducted among caregivers of persons with mental illness making use of a free non-governmental clinic in and around Chennai, India. The study adopted a qualitative methodology, with semi-structured interviews and life history exercises (n = 29) and six focus group discussions with caregivers (n = 21) and mental health professionals and community-based workers (n = 39). The experiences of caregivers were analyzed in the framework of "The Banyan model of caregiving," which identifies six phases. Major themes in caregivers' experience were: embarrassment and losing honor; fear; awareness; stigma and social exclusion; and reduced social interaction and loneliness. Posttraumatic growth considered as the result of caregiver experiences was found to consist mainly of personal growth and focusing on positive life experiences. Lost opportunities particular to the context of Tamil Nadu were described as the inability to get married, obtaining less education than desired, and loss of employment. Siblings faced lower levels of burden, while elderly mothers experienced especially high levels of burden and lack of happiness in life. Caregiver gains were identified as greater compassion for other people with disabilities, resulting in a desire to help others, as well as increased personal strength and confidence. Understanding the nuances of the caregiving experiences over time can provide a framework to devise more fine-tuned support structures that aim to prevent reductions in social interaction and lost opportunities, and improve a sense of meaning, in order to assist caregivers to continue providing care for their relatives with mental illness in a context with scarce mental health resources.

Addressing health needs of the homeless in Delhi: Standardising on the issues of Street Medicine practice.

Due to barriers in accessing and using healthcare services, a large proportion of the care homeless populations receive comes from informal providers. In Delhi, one such informal programme, called Street Medicine, provides healthcare outreach to homeless communities. Clinical practice guidelines are set to be developed for Street Medicine teams in India and form the object of this research. This study uses a social-ecological model to understand the barriers facing Street Medicine teams and the homeless as they attempt to address the latter's healthcare needs; coupling it with an analytical approach which situates these barriers as the issues within practice through which standardisation can take place. A qualitative inquiry, comprising three months of observations of Street Medicine outreach and interviews with over 30 key informants, was conducted between April and July 2018. The analysis identified novel barriers to addressing the needs of homeless individuals, which bely a deficit between the design of health and social care systems and the agency homeless individuals possess within this system to influence their health outcomes. These barriers - which include user-dependent technological inscriptions, collaborating with untargeted providers and the distinct health needs of homeless individuals - are the entry points for standardising, or opening up, Street Medicine practices .

Assessment of a website aimed at providing information on mental health to secondary school students in Can Tho city, Vietnam.

BACKGROUND: The stigmatization of mental health problems is a primary barrier for young people to approach mental health services when they suspect they might have such problems. Nevertheless, the internet has become a common platform on which they are likely to seek information on mental health. As such, this study aimed to explore responses from secondary school students in Can Tho city regarding suckhoetre.vn website. This website provided information on health and mental health, and this study assessed the potential relevance, appeal, accessibility, usefulness, and sustainability of the website. METHODS: A cross-sectional study included 643 secondary school students in Can Tho city selected by cluster sampling. Two weeks after the students were introduced to the website, they were invited to evaluate it using an anonymous questionnaire. The Chi-squared test was used to assess the significance of differences in the distribution of selected students' sociodemographic characteristics. RESULTS: Most (98.6%) participants visited the website in the two-week period, 74% once or twice a week, the others more often, up to once a day. Their activities included reading information (85.8%), seeking help (17.7%), sharing information (15.5%), giving advice to others (11.0%), and chatting or giving comments (9.8%). Most students rated the website very highly in terms of appeal, relevance, accessibility, and usefulness, and wanted to have access to the website in the future. These findings are positive signals to pursue the possible use of a website on mental health for secondary school students to help raise awareness and support good mental health among adolescents in Can Tho city and beyond. CONCLUSION: A website designed to provide information to secondary school students appeared to be a promising way to provide access to information on the topic of mental health. The website should be maintained and introduced widely to students, teachers and parents, with regular evaluation of the effectiveness of this website.

Factors associated with homelessness among women: a cross-sectional survey of outpatient mental health service users at The Banyan, India.

BACKGROUND: Homelessness has multifaceted and damaging effects on women with mental illness. This makes it imperative to identify and address the factors leading to homelessness among women with mental illness in order to inform policy on providing relevant services for this vulnerable population. METHOD: A cross-sectional survey was conducted among 346 women in active contact with one of four outpatient clinics at The Banyan, a non-profit organization in the Indian state of Tamil Nadu. A semi-structured instrument and modified version of the List of Threatening Experiences Questionnaire was used for data collection. Multivariate logistic regression analysis was used to examine predictive variables for homelessness among women with mental illness. RESULT: 32.65% of participants reported a history of homelessness. Less than 5 years of schooling (OR = 2.914, 95% CI = 1.027-8.269, P < 0.05) and disrupted relationships (OR = 1.807, 95% CI = 1.23-2.655, P < 0.01) were associated with a greater likelihood of women with mental illness to experience homelessness. CONCLUSION: In the study cohort, this was explained mainly by factors rooted in gender-based disadvantage. Further practice and research are needed to develop interventions that address issues with a sociological basis to mental illness and prevent these predictive factors.

"If somebody could just understand what I am going through, it would make all the difference": Conceptualizations of trauma in homeless populations experiencing severe mental illness.

Exposure to violence, vulnerability due to lack of shelter, alienation due to stigma, the experiences of severe mental illness (SMI) and subsequent institutionalization, make homeless persons with SMI uniquely susceptible to trauma exposure and subsequent mental health consequences. This study aims to contribute to the development of culturally sensitive interventions for identifying and treating trauma in a population of homeless persons with SMI in Tamil Nadu, India by understanding the manifestations of trauma and its associated consequences in this population. Free-listing exercises followed by in-depth interviews were conducted with a convenience sample of 26 user-survivors who have experienced homelessness or were at risk of homelessness, and suffered from SMI. Topics explored included events considered to be traumatic, pathways to trauma, associated emotional, physical and social complaints, and coping strategies. Results indicate discrepancies in classification of traumatic events between user-survivors and the Diagnostic and Statistical Manual of Mental Disorders. Traumatic experiences, particularly relating to social relationships and poverty, mentioned by user-survivors did not match traditional conceptualizations of trauma. Positive coping strategies for trauma included being mentally strong, knowledge and awareness, whereas the main negative coping strategy is avoidance. User-survivors attributed their experiences of homelessness and SMI to past traumas. Differing views of trauma between user-survivors and mental health professionals can lead to misdiagnosis and under-recognition of trauma in this population of homeless persons with SMI.

Low Self-Esteem and Its Association With Anxiety, Depression, and Suicidal Ideation in Vietnamese Secondary School Students: A Cross-Sectional Study.

Background: There is a correlation between self-esteem in adolescents and risks and protective factors for their health and welfare. The study was conducted to determine the prevalence of low self-esteem and sociodemographic features related to anxiety, depression, educational stress, and suicidal ideation in secondary school students in Vietnam. Methods: A cross-sectional design was employed for this study with participation of 1,149 students in Cantho City in Vietnam. A structured questionnaire was applied to ask about self-esteem, depression, anxiety, educational stress, and suicidal ideation. Results: Students with low self-esteem were detected at a prevalence of 19.4%. High educational stress and physical and emotional abuse by parents or other adults in the household were major risk factors correlated to low self-esteem, while a protective factor for low self-esteem was attending supplementary classes. An association among lower self-esteem and increased anxiety, depression, and suicidal ideation was detected. Conclusions: Self-esteem is associated with anxiety, depression, and academic stress, which significantly affect students' quality of life and links to suicidal ideation. These results therefore suggested the need for a school-based or web-based provision aimed at proactively increasing students' self-esteem and skills for dealing with academic stress.

Responsive mental health systems to address the poverty, homelessness and mental illness nexus: The Banyan experience from India.

BACKGROUND: Mental health has gained prominence as a global public health priority. However, a substantial treatment gap persists in many low- and middle-income countries. Within this scenario, the nexus between homelessness, poverty and mental illness represents a particularly complex issue. This article presents the experience of The Banyan, a 25 years old non-profit organisation providing mental health care to people living in poverty in Tamil Nadu, India. CASE PRESENTATION: The case study describes the evolution of The Banyan using a timeline narrative. By applying an action learning framework, the organisation's evolution through four lifecycles, strategy and the key elements underlying mental health system responses are identified and presented. 'User centred' and 'service integration' emerge as the main dimensions of The Banyan's responsive health system. Relating to these two attributes, a typology of services is derived, indicating the responsiveness of mental health systems in addressing complex problems. The role of the organisational culture and the expressed values during the transition is considered. CONCLUSIONS: The case study serves as an example of how responsive mental health systems may be constructed with both a user centred and a service integration focus.

Assessing the Impact of the Twin Track Socio-Economic Intervention on Reducing Leprosy-Related Stigma in Cirebon District, Indonesia.

The consequences of leprosy go beyond the physical, social and psychological, as leprosy can drive persons affected and their families into poverty, stigmatization and disability. This paper describes the impact of a socio-economic development (SED) intervention that uses a twin-track approach (two micro-credit models) to reduce leprosy-related stigma in Cirebon District, Indonesia. A randomized-controlled mixed-methods study design was used to test the effectiveness of the SED intervention. Three scales were used to measure stigma and participation restrictions among 30 SED clients and 57 controls, 20 in-depth interviews with SED clients and seven Focus Group Discussions (FGDs) with key persons were held and 65 profiles of the clients were written up and analysed. The qualitative data shows the socio-economic status of 44 out of 65 SED clients (67%) improved. The median family income increased by 25%, more clients reported higher self-esteem, better interaction with neighbours and less stigma than before, although disclosure concerns remained an issue. The scales indicate a positive effect of the intervention on reducing stigma (e.g., Stigma Assessment and Reduction of Impact (SARI) stigma scale mean difference total score of pre and post assessment for SED clients versus the control group was 8.5 versus 5.6). A twin track socio-economic intervention, if embedded and integrated, can increase participation, and be constructive in reducing leprosy-related stigma.

Understanding caregiver burden from a long-term perspective: The Banyan model of caregiver experiences.

PURPOSE: A multiphase model for experiences of family members of persons with mental illness that considers both positive and negative aspects is proposed. DESIGN AND METHODS: Mixed methods (semistructured interviews, life history timelines, focus group discussions, and the Experience of Caregiving Inventory) were used with caregivers accessing outpatient services of a nongovernmental organization in urban and rural locations around Chennai, India. FINDINGS: Based on our results, we constructed a multiphase model, which we named The Banyan model of caregiver experiences. The phases are (1) manifestation of symptoms, (2) seeking help, (3) helplessness and attribution, (4) relative control and insight, (5) loss and worries, and (6) finding new meaning. PRACTICAL IMPLICATIONS: Our multiphase model allows us to identify in more detail the needs of caregivers at various stages.

The challenges of living with bipolar disorder: a qualitative study of the implications for health care and research.

BACKGROUND: In mental health care, clinical practice is often based on the best available research evidence. However, research findings are difficult to apply to clinical practice, resulting in an implementation gap. To bridge the gap between research and clinical practice, patients' perspectives should be used in health care and research. This study aimed to understand the challenges people with bipolar disorder (BD) experience and examine what these challenges imply for health care and research needs. METHODS: Two qualitative studies were used, one to formulate research needs and another to formulate healthcare needs. In both studies focus group discussions were conducted with patients to explore their challenges in living with BD and associated needs, focusing on the themes diagnosis, treatment and recovery. RESULTS: Patients' needs are clustered in 'disorder-specific' and 'generic' needs. Specific needs concern preventing late or incorrect diagnosis, support in search for individualized treatment and supporting clinical, functional, social and personal recovery. Generic needs concern health professionals, communication and the healthcare system. CONCLUSION: Patients with BD address disorder-specific and generic healthcare and research needs. This indicates that disorder-specific treatment guidelines address only in part the needs of patients in everyday clinical practice.

Reliving, Replaying Lived Experiences Through Auditory Verbal Hallucinations: Implications on Theories and Management.

Objective: This study aims to understand the impact of negative life experience (NLE) in auditory hallucinations (AHs) and explain the heterogeneity in phenomenology of auditory verbal hallucinations (AVHs). Method: In depth interviews were conducted with 21 individuals (7 males and 14 females) experiencing AHs and accessing mental health treatment services at a not-for-profit organization. Maximum variation purposive sampling technique was used to select the sample to ensure variegation is accounted for and was collected until saturation of themes data was obtained. Results: Various different forms and functions of hallucinations are obtained with an evident pattern that links voices back to the NLE of the individual. Implications for therapeutic methods focusing on distress arising from said NLE is emphasized. Conclusions: The results obtained from this study implicate NLEs as a contributing factor in the development and maintenance of hallucinations. Sociocultural factors act as a catalyst with psychological factors creating distress and contributing to the voice-hearing experience. Treatment strategies must thus focus on content of voices and past experiences of the individual to promote recovery. A model toward conceptualization of the diversity in phenomenology is put forth.

A research agenda for bipolar disorder developed from a patients' perspective.

BACKGROUND: Diagnosis and treatment of bipolar disorder is complex. Health care is supported by clinical guidelines, which are highly based on scientific evidence. However, such care does not necessarily correspond to preferred care according to patients. In order to narrow the gap between scientifically based guidelines and the patient's perceptions of the best clinical practice, additional research is needed. The aim of this study was to create a patient based research agenda for bipolar disorder to enhance the alignment between patients' needs and care system. METHODS: A mixed method study design was employed consisting of two phases: consultation and prioritization. In the consultation phase, six focus group discussions with patients (n = 35) were conducted to explore research needs according to patients, resulting in 23 research topics. Subsequently, these topics were prioritized by means of a questionnaire with patients (n = 219). RESULTS: Patients with bipolar disorder mentioned a variety of research topics covered by the following five themes: causes of disorder; pharmacotherapy; non-pharmacological treatment; diagnosis; and recovery & recovery oriented care. 'Etiology' was the topic with highest priority. DISCUSSION: The theme 'causes of disorder' is prioritized highest. We argue that this can be explained by the added value of an explanatory framework for appropriate treatment and recovery. The theme 'recovery & recovery oriented care' is currently underrepresented in actual research. It is argued that in order to bridge the knowledge and implementation gap, social science and health system research is needed in addition to biomedical research.

Non-communicable diseases in Indian slums: re-framing the Social Determinants of Health.

BACKGROUND: The epidemic of non-communicable diseases (NCDs) in slums has pushed its residents to heightened vulnerability. The Social Determinants of Health (SDH) framework has been used to understand the social dynamics and impact of NCDs, especially in poorly resourced communities. Whilst the SDH has helped to discredit the characterisation of NCDs as diseases of affluence, its impact on policy has been less definite. Given the multitude of factors that interact in the presentation of NCDs, operationalising the SDH for policies and programmes that account for the contextual complexity of slums has stalled. OBJECTIVE: To organise the complex networks of relations between SDH in slums so as to identify options for Indian municipal policy that are feasible to implement in the short term. METHODS: The study reviews the literature describing SDH in Indian slums, specifically those that establish causal relations between SDH and NCDs. Root cause analysis was then used to organise the identified relations of SDH and NCDs. RESULTS: Although poverty remains the largest structural determinant of health in slums, the multi-dimensional relations between SDH and NCDs are structured around four themes that describe the dynamics of slums, namely scarce clean water, low education, physical (in)activity and transportation. From the reviewed literature, four logic trees visualising the relations between SDH in slums and NCDs were constructed. The logic trees separate symptomatic problems from their more distal causes, and recommendations were formulated based on features of these relationships that are amenable to policy intervention. CONCLUSION: Root cause analysis provides a means to focus the lens of examination of SDH, as evidenced here for Indian slums. It provides a guide for the development of policies that are grounded in the actual health concerns of people in slums, and takes account of the complex pathways through which diseases are socially constituted.

Ineffective Healthcare Technology Management in Benin's Public Health Sector: The Perceptions of Key Actors and Their Ability to Address the Main Problems.

BACKGROUND: Low-income countries face many contextual challenges to manage healthcare technologies effectively, as the majority are imported and resources are constrained to a greater extent. Previous healthcare technology management (HTM) policies in Benin have failed to produce better quality of care for the population and costeffectiveness for the government. This study aims to identify and assess the main problems facing HTM in Benin's public health sector, as well as the ability of key actors within the sector to address these problems. METHODS: We conducted 2 surveys in 117 selected health facilities. The first survey was based on 377 questionnaires and 259 interviews, and the second involved observation and group interviews at health facilities. The Temple-Bird Healthcare Technology Package System (TBHTPS), tailored to the context of Benin's health system, was used as a conceptual framework. RESULTS: The findings of the first survey show that 85% of key actors in Benin's HTM sector characterized the system as failing in components of the TBHTPS framework. Biomedical, clinical, healthcare technology engineers and technicians perceived problems most severely, followed by users of equipment, managers and hospital directors, international organization officers, local and foreign suppliers, and finally policy-makers, planners and administrators at the Ministry of Health (MoH). The 5 most important challenges to be addressed are policy, strategic management and planning, and technology needs assessment and selection - categorized as major enabling inputs (MEI) in HTM by the TBHTPS framework - and installation and commissioning, training and skill development and procurement, which are import and use activities (IUA). The ability of each key actor to address these problems (the degree of political or administrative power they possess) was inversely proportional to their perception of the severity of the problems. Observational data gathered during site visits described a different set of challenges including maintenance and repair, distribution, installation and commissioning, use and training and personnel skill development. CONCLUSION: The lack of experiential and technical knowledge in policy development processes could underpin many of the continuing problems in Benin's HTM system. Before solutions can be devised to these problems, it is necessary to investigate their root causes, and which problems are most amenable to policy development.

Mental health treatment in Kenya: task-sharing challenges and opportunities among informal health providers.

BACKGROUND: The study was conducted to explore challenges faced by trained informal health providers referring individuals with suspected mental disorders for treatment, and potential opportunities to counter these challenges. METHODS: The study used a qualitative focus group approach. It involved community health workers, traditional and faith healers from Makueni County in Kenya. Ten Focus Group Discussions were conducted in the local language, recorded and transcribed verbatim and translated. Using a thematic analysis approach, data were entered into NVivo 7 for analysis and coding. RESULTS: Results demonstrate that during the initial intake phase, challenges included patients' mistrust of informal health providers and cultural misunderstanding and stigma related to mental illness. Between initial intake and treatment, challenges related to resource barriers, resistance to treatment and limitations of the referral system. Treatment infrastructure issues were reported during the treatment phase. Various suggestions for solving these challenges were made at each phase. CONCLUSIONS: These findings illustrate the commitment of informal health providers who have limited training to a task-sharing model under difficult situations to increase patients' access to mental health services and quality care. With the identified opportunities, the expansion of this type of research has promising implications for rural communities.

Quality of life of depressed and suicidal patients seeking services from traditional and faith healers in rural Kenya.

BACKGROUND: In rural Kenya, traditional and faith healers provide an alternative pathway to health care, including mental health care. However, not much is known about the characteristics of the populations they serve. The purpose of this study was to determine the relationship between depression, suicidal ideation, and socio-demographic variables with Quality of Life (QoL) indicators in a sample seeking mental health services from traditional and faith healers in rural Kenya. Understanding QoL in this sample can help develop mental health policy and training to improve the well-being of this population. METHOD: This was a cross-sectional epidemiological survey (n = 443) conducted over a period of 3 months among adult patients seeking care from traditional and faith healers in rural Kenya. Data were collected using the Beck Depression Inventory II (BDI-II), Beck Scale for Suicide Ideation (BSS) and WHO Quality of Life Survey- BREF (WHOQOL-BREF), and analyzed using correlation analyses, parametric tests, and regression analyses. RESULTS: Increasing levels of depression were associated with lower QoL among patients seeking care from traditional and faith healers. BSS scores were significantly negatively correlated with overall, physical, psychological, and environmental QoL, p < .05. There was a statistically significant difference between mean scores for overall QoL between depressed (M = 2.35, SD = 0.76) and non-depressed participants (M = 3.03, SD = 0.67), t(441) = 8.899, p < .001. Overall life satisfaction for depressed participants (M = 2.23, SD = 0.69) was significantly lower than non-depressed participants. Regression analyses indicated that depression, suicidal ideation, and being married predicted lower overall QoL controlling for other variables. Post hoc tests and subgroup analysis by gender revealed significant differences for females only. Depression, and older age predicted lower life satisfaction whereas being self-employed predicted higher life satisfaction, when controlling for other variables. CONCLUSION: This study sheds light on correlates of QoL in depressed and non-depressed patients in rural Kenya. Evidence suggests that traditional and faith healers treat patients with a variety of QoL issues. Further research should focus on understanding how these issues tie into QoL, and how these healers can target these to improve care.

Mental Health Outcomes of Psychosocial Intervention Among Traditional Health Practitioner Depressed Patients in Kenya.

Task-shifting in mental health such as engaging Traditional Health Practitioners (THPs) in appropriate management of mental disorders is crucial in reducing global mental health challenges. This study aims to determine the outcomes of using evidence-based mental health Global Action Programme Intervention guide (mhGAP-IG) to provide psychosocial interventions among depressed patients seeking care from THPs. THPs were trained to deliver psychosocial interventions to their patients screening positive for mild to severe depression on Beck's Depression Inventory (BDI). Assessments were conducted at 0, 6 and 12 weeks and Analysis of Variance (ANOVA) performed to determine the change in depression scores over the three time period. BDI mean score was 26.52 before intervention and reduced significantly at 6 (13%) and 12 (35%) weeks after intervention. 58 and 78% of patients showed reduction in symptoms of depression at 6 and 12 weeks. It is therefore crucial to engage THPs in the care of patients with depression and the need for inclusion of training packages; and other mental disorders in order to establish and maintain collaboration between THPs and conventional health workers and promote evidence-based care among marginalized populations. Moreover, further research on randomized control trials of mhGAP-IG intervention versus usual care is required.

Impact of socio-economic development, contact and peer counselling on stigma against persons affected by leprosy in Cirebon, Indonesia ­a randomised controlled trial.

Objectives: People affected by leprosy are often stigmatised, but stigma is rarely quantified and the effectiveness of interventions is often not evaluated. The SARI Project aimed to test and evaluate three interventions: counselling (involving peer counsellors), socio-economic development (SED) and contact between community members and affected people. Results: This study used a controlled trial design in which pairs of the stigma-reduction interventions were randomly allocated to sub-districts in Cirebon District,Indonesia. The study sample consisted of one cohort of people affected by leprosy (on treatment or treated) and two independent samples of community members. The latter were selected through purposive sampling. Three scales (e.g. SARI Stigma Scale, Participation scale) were applied among leprosy-affected people and two scales (e.g. Social Distance Scale) were used among community members pre- and post-intervention. Among affected people (n=237), significant differences in reduction of stigma and participation restrictions were found in all intervention areas and an improvement in quality of life in some intervention areas. Social distance and social stigma significantly reduced among community members (n=213 and 375) in the two intervention areas where the contact intervention was implemented. Two of the five instruments indicated changes in the control area, but the changes in the intervention areas were much larger. Conclusion: The SARI Project has demonstrated that a measurable reduction in leprosy-related stigma can be achieved, both at community level and among people affected by leprosy, using reproducible interventions that can be adapted to different settings and target groups.

Cultural validation of a new instrument to measure leprosy-related stigma: the SARI Stigma Scale.

Background: There is a need for comprehensive, valid and reliable instruments to assess leprosy-related stigma. This paper presents the process of the cross-cultural validation of an instrument in Cirebon District, Indonesia initiated by the Stigma Assessment and Reduction of Impact (SARI) project. Methods: The Berger Scale was initially developed to assess HIV/AIDS-related stigma. This study explores the conceptual, item, semantic, operational and measurement equivalence of this scale for leprosy. The process included a qualitative study, translation and back-translation, training of interviewers, a pilot and the main data collection. We aimed for a sample of 154 people affected by leprosy with 60 repeat interviews. They were selected through convenience sampling. Results: The original scale showed acceptable conceptual equivalence, but insufficient item, semantic and operational equivalences. For instance, there were irrelevant HIV-related items and the respondents found it difficult to indicate their level of agreement with the given statements. Major adjustments were necessary, leading to a new version of the scale. The measurement properties of the new version showed good internal consistency (Cronbach's alpha 0·88); no floor or ceiling effects; and a good reliability (intra-class correlation coefficient 0·75).

When to invest in clinical guidelines for children? A practice oriented tool to facilitate decision-making.

RATIONALE, AIMS AND OBJECTIVES: Children are not just small adults; they need to be diagnosed and treated in the context of their rapid growth and development. However, in guideline development, children's needs and interests are still overlooked. This study aims (1) to develop a tool that could stimulate guideline developers to take children into account on a more structural basis and (2) to explore how to facilitate children's participation in the process of guideline development. METHODS: The method used was a three-phase multimethod sequential design. Professionals involved in guideline development participated in interviews (n = 12), filled in a questionnaire (n = 60) and/or participated in the focus group meeting (n = 11). RESULTS: This study results in a comprehensive understanding of the considerations that professionals take into account when deciding whether guidelines need to apply to children specifically. This resulted in a tool that assists guideline developers to make this assessment more accurately. It takes the form of a flowchart that guides users through a series of critical questions. CONCLUSIONS: The flowchart reminds guideline developers to consider children as a particular patient population when prioritizing and demarcating new guideline topics. It will help to ensure that clinical guidelines address children's unique health care needs and perspectives. Facilitating children's and parents' participation in the process of guideline development is perceived as challenging; nevertheless, it should be the next step in making paediatric guidelines more child-centred and family-centred.