"I realised it weren't about spending the money. It's about doing something together:" the role of money in a community empowerment initiative and the implications for health and wellbeing.

Community initiatives aiming to reduce health inequalities are increasingly common in health policy. Though diverse many such initiatives aim to support residents of disadvantaged places to exercise greater collective control over decisions/actions that affect their lives - which research suggests is an important determinant of health - and some seek to achieve this by giving residents control over a budget. Informed by theoretical work in which community capabilities for collective control are conceptualised as different forms of power, and applying a relational lens, this paper presents findings on the potential role of money as a mechanism to enhance these capabilities from an on-going evaluation of a major place-based initiative being implemented in 150 neighbourhoods across England:The Big Local (BL). The research involved semi-structured interviews with 116 diverse stakeholders, including residents and participant observation in a diverse sample of 10 BL areas. We took a thematic constant comparative approach to the analysis of data from across the sites. The findings suggest that the money enabled the development of capabilities for collective control in these communities primarily by enhancing connectivity amongst residents and with external stakeholders. However, residents had to engage in significant 'relational work' to achieve these benefits and tensions around the money could hinder communities' 'power to act'. Greater social connectivity has been shown to directly affect individual and population health by increasing social cohesion and reducing loneliness. Additionally, supporting enhanced collective control of residents in these disadvantaged communities has the potential to improve population health and reduce health inequalities.

Modern slavery and public health: a rapid evidence assessment and an emergent public health approach.

OBJECTIVES: Modern slavery is a human rights violation and a global public health concern. To date, criminal justice approaches have dominated attempts to address it. Modern slavery has severe consequences for people's mental and physical health, and there is a pressing need to identify and implement effective preventative measures. As such, a public health approach to modern slavery requires elucidation. The objectives of this study were to explore the case for public health involvement in addressing modern slavery and the components of a public health approach and to develop a globally relevant framework for public health action. STUDY DESIGN: A Rapid Evidence Assessment. METHODS: This study is a rapid systematic review of published literature and stakeholder consultation. RESULTS: The accounts of 32 consultees and evidence from 17 papers including reviews, commentaries and primary studies were included in the evidence assessment. A strong ethical rationale for public health engagement in addressing modern slavery was evident. Multilevel and multicomponent interventional strategies were identified across global, national, regional, local and service levels. Although public health could add value to existing approaches, multiple barriers and tensions exist. CONCLUSION: Published literature and stakeholder opinion indicate an emergent public health approach to modern slavery. It involves intervention at multiple levels and is guided by a rights-based, survivor-centred and trauma-informed approach. This synthesis offers an important early step in the construction of a globally relevant public health approach to modern slavery.

Equal North: how can we reduce health inequalities in the North of England? A prioritization exercise with researchers, policymakers and practitioners.

BACKGROUND: The Equal North network was developed to take forward the implications of the Due North report of the Independent Inquiry into Health Equity. The aim of this exercise was to identify how to reduce health inequalities in the north of England. METHODS: Workshops (15 groups) and a Delphi survey (3 rounds, 368 members) were used to consult expert opinion and achieve consensus. Round 1 answered open questions around priorities for action; Round 2 used a 5-point Likert scale to rate items; Round 3 responses were re-rated alongside a median response to each item. In total, 10 workshops were conducted after the Delphi survey to triangulate the data. RESULTS: In Round 1, responses from 253 participants generated 39 items used in Round 2 (rated by 144 participants). Results from Round 3 (76 participants) indicate that poverty/implications of austerity (4.87 m, IQR 0) remained the priority issue, with long-term unemployment (4.8 m, IQR 0) and mental health (4.7 m, IQR 1) second and third priorities. Workshop 3 did not diverge from findings in Round 1. CONCLUSIONS: Practice professionals and academics agreed that reducing health inequalities in the North of England requires prioritizing research that tackles structural determinants concerning poverty, the implications of austerity measures and unemployment.

Improving access to health care for chronic hepatitis B among migrant Chinese populations: A systematic mixed methods review of barriers and enablers.

Migrant Chinese populations in Western countries have a high prevalence of chronic hepatitis B but often experience poor access to health care and late diagnosis. This systematic review aimed to identify obstacles and supports to timely and appropriate health service use among these populations. Systematic searches resulted in 48 relevant studies published between 1996 and 2015. Data extraction and synthesis were informed by models of healthcare access that highlight the interplay of patient, provider and health system factors. There was strong consistent evidence of low levels of knowledge among patients and community members; but interventions that were primarily focused on increasing knowledge had only modest positive effects on testing and/or vaccination. There was strong consistent evidence that Chinese migrants tend to misunderstand the need for health care for hepatitis B and have low satisfaction with services. Stigma was consistently associated with hepatitis B, and there was weak but consistent evidence of stigma acting as a barrier to care. However, available evidence on the effects of providing culturally appropriate services for hepatitis B on increasing uptake is limited. There was strong consistent evidence that health professionals miss opportunities for testing and vaccination. Practitioner education interventions may be important, but evidence of effectiveness is limited. A simple prompt in patient records for primary care physicians improved the uptake of testing, and a dedicated service increased targeted vaccination coverage for newborns. Further development and more rigorous evaluation of more holistic approaches that address patient, provider and system obstacles are needed.

A formative review of physical activity interventions for minority ethnic populations in England.

Background: Physical activity (PA) levels are lower among some UK Black and minority ethnic (BME) groups than the majority White British population and a variety of tailored interventions have emerged. This study documents the characteristics and logic of local adaptations, a vital first step in evaluating such innovations. Methods: An English PA data set was examined to identify and characterize PA programmes focussed on BME populations. Three case studies were conducted, employing documentary analysis and qualitative interviews. Netto et al.'s principles of adapting health promotion interventions for BME populations guided the analysis. Results: Out of 861 PA interventions, 57 focussed on BME populations. These were typically aimed to engage the most inactive groups, improve both health and social outcomes and were largely publically/charitably funded. Tailored approaches matched Netto et al.'s five principles: using community resources for publicity, identifying and addressing barriers, developing sensitive communication strategies, working with values and accommodating cultural identification. Another common principle was identified: building community capacity for sustainability. Conclusions: PA interventions tailored to the needs of BME groups reflect their largely disadvantaged position in society and focus on inactivity. The six principles could be used as a framework for developing, designing and evaluating tailored interventions for BME populations.

The return of public health to local government in England: changing the parameters of the public health prioritization debate?

OBJECTIVES: To explore the influence of values and context in public health priority-setting in local government in England. STUDY DESIGN: Qualitative interview study. METHODS: Decision-makers' views were identified through semi-structured interviews and prioritization tools relevant for public health were reviewed. Interviews (29) were carried out with Health and Wellbeing Board members and other key stakeholders across three local authorities in England, following an introductory workshop. RESULTS: There were four main influences on priorities for public health investment in our case study sites: an organizational context where health was less likely to be associated with health care and where accountability was to a local electorate; a commissioning and priority-setting context (plan, do, study, act) located within broader local authority priority-setting processes; different views of what counts as evidence and, in particular, the role of local knowledge; and debates over what constitutes a public health intervention, triggered by the transfer of a public health budget from the NHS to local authorities in England. CONCLUSIONS: The relocation of public health into local authorities exposes questions over prioritizing public health investment, including the balance across lifestyle interventions and broader action on social determinants of health and the extent to which the public health evidence base influences local democratic decision-making. Action on wider social determinants reinforces not only the art and science but also the values and politics of public health.

Good on paper: the gap between programme theory and real-world context in Pakistan's Community Midwife programme.

OBJECTIVE: To understand why skilled birth attendance-an acknowledged strategy for reducing maternal deaths-has been effective in some settings but is failing in Pakistan and to demonstrate the value of a theory-driven approach to evaluating implementation of maternal healthcare interventions. DESIGN: Implementation research was conducted using an institutional ethnographic approach. SETTING AND POPULATION: National programme and local community levels in Pakistan. METHODS: Observations, focus group discussions, and in-depth interviews were conducted with 38 Community Midwives (CMWs), 20 policymakers, 45 healthcare providers and 136 community members. A critical policy document review was conducted. National and local level data were brought together. MAIN OUTCOMES: Alignment of programme theory with real-world practice. RESULTS: Data revealed gaps between programme theory, assumptions and reality on the ground. The design of the programme failed to take into account: (1) the incongruity between the role of a midwife and dominant class and gendered norms that devalue such a role; (2) market and consumer behaviour that prevented CMWs from establishing private practices; (3) the complexity of public-private sector cooperation. Uniform deployment policies failed to consider existing provider density and geography. CONCLUSIONS: Greater attention to programme theory and the 'real-world' setting during design of maternal health strategies is needed to achieve consistent results in different contexts.

Uptake of contraception during postpartum amenorrhoea: understandings and preferences of poor, urban women in Bangladesh.

In urban Bangladesh, as in many other settings, an immediate postpartum family planning strategy prevails, where providers seek to promote and provide contraception at 40-45 days following birth to women regardless of their breastfeeding or menstrual status. Despite such practices, the majority of women choose to delay the initiation of contraception until menses resumes, often several months after birth. The present paper seeks to explain this discrepancy by describing poor, urban women's understandings regarding the chances of conception and the risks associated with contraceptive use in the postpartum period. Findings from in-depth interviews reveal that the majority of women perceive no personal risk of pregnancy during amenorrhoea, though most do not recognise an association between this diminished risk of conception and breastfeeding. In addition, the data illustrate that women are primarily concerned with their own and their newly born child's health and well-being in the period following childbirth, both of which are perceived to be extremely vulnerable. These perceptions, plus an understanding that modern methods of contraception are "strong" and potentially damaging to the health, mean that the majority of women are reluctant to adopt family planning methods soon after birth, particularly during postpartum amenorrhoea. The paper advocates that, since breastfeeding affords good protection against pregnancy for six to nine months following birth, efforts should be made to actively incorporate lactational amenorrhoea into postpartum family planning strategies in Bangladesh. Recommendations are also made for ways in which women may be encouraged to adopt contraception during amenorrhoea beyond the period of high natural protection. The paper highlights the importance of taking the client's perspective into consideration in attempts to improve the quality and effectiveness of family planning programmes.

Postpartum contraceptive use in Bangladesh: understanding users' perspectives.

Qualitative and quantitative data are used to explore postpartum contraceptive use in two populations in Bangladesh. Findings from in-depth interviews with contraceptive users illustrate that women are primarily concerned with their own and their newborn child's health and well-being in the period following childbirth. In addition, women are aware of a diminished risk of pregnancy during the period of postpartum amenorrhea. These perceptions, plus a belief that modern methods of contraception are "strong" and potentially damaging to health, mean that the majority of women are reluctant to adopt family planning methods soon after birth, despite a desire to avoid closely spaced pregnancies. Supplementation of the child's diet is also shown to be an important factor determining the timing of postpartum contraceptive initiation. The findings suggest that current policies promoting contraception to women in the immediate postpartum period are inappropriate for many Bangladeshi women.

PIP: This study examined female contraceptive users' understandings, preferences, and behaviors during the postpartum period in Bangladesh. Qualitative and quantitative data focused on the vulnerability of mother and child, the risk of conception, breast feeding's protection against pregnancy, modern method use, postpartum use, and use during breast feeding. Two cohorts were used to examine the relationship between the timing of contraceptive use and resumption of menses, contraceptive use during postpartum amenorrhea, delays in adoption, and contraceptive use during breast feeding. Data were obtained from a range of qualitative data sources in the rural Matlab maternal health and family planning treatment area and in a Dhaka slum study area of the Urban Health Extension Project. Quantitative data were obtained from the Record Keeping System of Matlab and the Urban Surveillance System among a 2-year cohort of 5483 women who had given birth in Matlab in 1990-91. Findings indicate that family planning services should be integrated within maternal and child health care for women in the postpartum period. After childbirth, women are preoccupied with their and their child's health. This preoccupation influences women's priorities and behavior. Bangladeshi women seldom begin contraception soon after birth. Most breast feed for an extended period. The current policy that promotes contraception immediately after birth is inappropriate. Postpartum strategies should incorporate lactational amenorrhea and teach women about breast feeding's impact on fertility. Providers should be sensitive to women's fears and concerns.

The contraceptive potential of lactation for Bangladeshi women.

PIP: In Bangladesh, long durations of intensive breast-feeding have traditionally resulted in extended durations of postpartum amenorrhea and long intervals between births even in the absence of contraception. For example, the national Bangladesh Fertility Survey (BFS) of 1975 reported a median duration of postpartum amenorrhea of 14.6 months, while analyses of data from the 1989 BFS suggest that lactational amenorrhea still has an important contraceptive effect, reducing fertility overall by 35%. Findings are presented from an analysis of longitudinal survey data conducted to gain insight into the issue of lactational protection against pregnancy among Bangladeshi women. Data were drawn from surveillance systems maintained in 2 research sites of the International Center for Diarrheal Disease Research, Bangladesh: the Record Keeping System of the Matlab MCH-FP project treatment area and the Urban Surveillance System of the Dhaka slum study area of the Urban Health Extension Project. The results from both study populations indicate a high degree of protection against pregnancy for amenorrheic women.^ieng

Levels, trends and causes of mortality in children below 5 years of age in Bangladesh: findings from a national survey.

A nationwide survey, conducted in 1992-93 by the Control of Diarrhoeal Disease Programme, Government of Bangladesh, made national estimates of levels and causes of child mortality. A gradual downward trend in infant and child mortality was observed from the mid 1980s. Current mortality rates among infants and children below 5 years were estimated to be around 100 and 150 per 1,000 live births respectively. More than a quarter of deaths in children below 5 years were found to be associated with diarrhoea. Acute respiratory tract infections were also shown to be a major killer of young children.

PIP: Staff of the National Control of Diarrhoeal Disease Programme conducted interviews with 8171 urban and 3135 rural women, 13-50 years old, in Dhaka, Khulna, Rajshahi, and Chittagong divisions of Bangladesh during 1992-1993 to determine levels, trends, and leading causes of child mortality. Between 1978-1984 and 1991, child mortality fell from 200 to 155/1000 live births and infant mortality fell from 125 to 105/1000 live births. The leading symptoms in the two weeks before the death of the child were fever (42.7% rural and 44.7% urban) and inability to ingest breast milk or other food (38.1% and 30.3%, respectively). Other common symptoms included convulsions, diarrhea, breathing difficulties, and cough. Diarrhea alone contributed to 18.4% of all child deaths. 34% of diarrhea-related deaths were associated with bloody diarrhea. Diarrhea plus acute respiratory infection (ARI) accounted for 25.8% of all child deaths. ARI alone accounted for 15.5% of all child deaths. More than 50% of diarrheal deaths and more than 60% of ARI deaths had had a fever. 21.3% of all child deaths occurred during the first three days postpartum.

Introducing the low-dose pill to Bangladesh; issues of continuation and failure.

In response to government plans to introduce a low-dose pill to the national family planning program of Bangladesh, a comparison of the performance of low-dose and standard-dose pills among a rural Bangladeshi population was conducted. Continuation rates were found to be better among users of the low-dose pill and there was no evidence that failure rates were higher. The relative risk (standard-dose vs. low-dose) over the first 30 months following adoption was 1.25 for first method continuation, and 1.29 for extended use failure. This paper, thus, provides evidence that low-dose pills may be a suitable method of contraception for rural Bangladeshi women.

Levels and trends in post-partum amenorrhoea, breast-feeding and birth intervals in Matlab, Bangladesh: 1978-1989.

PIP: This study examines the trends in and determinants of length of postpartum amenorrhea during 1978-90 in Bangladesh. Data are obtained from the Matlab project. The sample comprises 6000 women per cohort for cohorts born in two year periods during 1978-80 and 1988-89. Reproductive and lactation records are available for up to 36 months following the birth of the index child. Findings indicate that the duration of postpartum amenorrhea is around 13 months for births during 1978-83. The median duration is 13.5 months for the birth cohort for 1982-83 and 9.4 months for the birth cohort for 1988-89. For 1989 alone the median duration is a further decline to 8.6 months. The seven year decline amounts to a 36% reduction. Findings indicate that age and duration of postpartum amenorrhea are positively related. All age groups show a decline in median duration. The shorter median durations occur among women with fewer than two living children and higher levels of education. Duration of breast feeding peaks in 1984-85 at 34.3 months and then declines to 30.7 months in 1986-87. Full breast feeding duration declines from around 6 months for cohorts 1978-79 to cohorts 1982-88 to 5.2 months in 1986-87 and lags behind durations of postpartum amenorrhea. Full breast feeding declines occur after the 1982-83 cohort among mothers with higher education and after the 1984-85 cohort for uneducated and less educated women. Age patterns of breast feeding women are inconsistent. The oldest mothers have the shortest breast feeding durations. The youngest cohorts show a decreasing trend. Breast feeding durations increase with an increase in the number of living children. However another trend shows initial increases in duration and then declines regardless of the number of living children. The suggestion is that full breast feeding may be important in determining the length of postpartum amenorrhea duration. Contraceptive use increases from 24% in 1977 to 39% in 1984. Median birth intervals increase from 38.7 to 48.8 months and increases pertain to all age and parity groups. Malnutrition is considered to be unrelated to postpartum amenorrhea periods. The trend is clearly reflective of declining postpartum amenorrhea duration, but the nature of the impact of breast feeding or contraceptive use is not clear.^ieng