"Stronger with Breastmilk Only" Initiative in 5 African Countries: Case Study on the Implementation Process and Contribution to the Enabling Environment for Breastfeeding.

Background: The practice of giving water before 6 mo of age is the biggest barrier to exclusive breastfeeding in West and Central Africa. To address this challenge, a regional initiative, "Stronger with Breastmilk Only" (SWBO), was rolled out at country level in several countries of the region. Objective: We examined the implementation process of the SWBO initiative and the contribution of its advocacy component to a more supportive environment for breastfeeding policies and programs. Methods: This study was based on 2 assessments at the national level carried out in 5 countries (Burkina Faso, Chad, Democratic Republic of the Congo, Senegal, and Sierra Leone) using qualitative methods. We combined 2 evaluative approaches (contribution analysis and outcome harvesting) and applied 2 theoretical lenses (Breastfeeding Gear Model and Consolidated Framework for Implementation Research) to examine the implementation process and the enabling environment for breastfeeding. Data sources included ∼300 documents related to the initiative and 43 key informant interviews collected between early 2021 and mid-2022. Results: First, we show how a broad initiative composed of a set of combined interventions targeting multiple levels of determinants of breastfeeding was set up and implemented. All countries went through a similar pattern of activities for the implementation process. Second, we illustrate that the initiative was able to foster an enabling environment for breastfeeding. Progress was achieved notably on legislation and policies, coordination, funding, training and program delivery, and research and evaluation. Third, through a detailed contribution story of the case of Burkina Faso, we illustrate more precisely how the initiative, specifically its advocacy component, contributed to this progress. Conclusion: This study shed light on how an initiative combining a set of interventions to address determinants of breastfeeding at multiple levels can be implemented regionally and contributes to fostering an enabling environment for breastfeeding at scale.

Teachers' Lived Experiences of Workplace Violence and Harassment Committed by Learners from Selected High Schools in Limpopo Province, South Africa.

Despite several studies on learner-to-teacher workplace violence and harassment, the problem persists in some South African schools. Learner-to-teacher violence and harassment is a form of workplace violence and harassment, as schools are workplaces for teachers. Learner-to-teacher violence and harassment is therefore an important occupational health and safety issue for teachers. Employers are obliged to provide a safe working environment for teachers to enable quality teaching and learning in schools. The purpose of this interpretative phenomenological study was to explore and describe the lived experiences of high school teachers who have been targets of workplace violence and harassment perpetrated by learners at selected schools in Limpopo Province of South Africa. Many teachers were willing to share their lived experiences but, due to data saturation, only eleven participated after being selected through purposive sampling from seven high schools under a chosen sub-district. The research ethics of voluntary participation, informed consent, ethical clearance, and gatekeeper permission were observed. Data were collected through semi-structured interviews using an interview guide. The interviews were audio-taped, and field notes were also taken. Voice recordings were transcribed verbatim and analysed using interpretative phenomenological analysis into themes and sub-themes. The findings were confirmed by an independent coder to achieve trustworthiness. Teachers experienced physical workplace violence and harassment, verbal workplace violence and harassment, and nonverbal workplace violence and harassment from learners. Learner-to-teacher workplace violence and harassment affects teachers emotionally, and in turn, affects the quality of teaching and learning in schools. Some teachers propose the involvement of a community policing forum, the strengthening of schools' governing bodies, and reducing overcrowding in classrooms as possible solutions to deal with learner-to-teacher workplace violence and harassment.

Towards cholera elimination in Zanzibar: analysis of evidences on what have worked.

Cholera, an enteric disease caused by Vibrio cholera claims thousands of lives yearly. The disease is a disease of inequality that affect populations which have poor access to safe water and sanitation facilities. Zanzibar, an archipelago in the Indian ocean which is part of the United Republic of Tanzania has been affected by recurrent cholera outbreak for the past decades. A multi-sectoral and multi-year three pillar approach namely Enabling Environment, Prevention and Response, for the elimination of cholera were initiated by the stewardship of the government, engagement of the community and technical and financial support of partners. The approach has enabled Zanzibar to interrupt the recurrent cholera outbreak for the past five years. The analysis of evidences have proven that creating an enabling environment through multi-sectoral involvement, mobilizing communities, intensifying surveillance complemented by the traditional disease prevention and control interventions has resulted to interruption of cholera transmission in the country.

Government Budget for Nutrition-Sensitive Agriculture in Nigeria Increased Following Development of Related Strategy.

BACKGROUND: Financial resources that are commensurate with the magnitude of malnutrition problem are requisite for effective interventions to reduce malnutrition. Understanding the amount and nature of sectoral investments in nutrition is important for advocating and mobilizing increased government budgetary allocations and release. OBJECTIVE: This study assessed trends in Nigeria's agriculture sector nutrition allocations and whether launch of nutrition-sensitive agriculture strategy and/or the COVID-19 pandemic may have affected these nutrition allocations. METHODS: Agricultural budgets from 2009 to 2022 of Nigeria's federal government were analyzed. Nutrition-related budget lines were identified using a keyword search and were then classified as nutrition-specific, nutrition-sensitive, or potentially nutrition-sensitive, based on defined criteria. Potentially nutrition-sensitive items were further screened. Budget lines finally included as nutrition allocations directly targeted improvements in nutrition or intermediate outcomes in pathways between agriculture and nutrition. Budget lines were summed, and these nominal values were adjusted for inflation (using the consumer price index for each year) to obtain real values. RESULTS: Nutrition allocations in the agriculture budget increased considerably even after adjusting for inflation and went from 0.13% of agriculture capital budget in 2009 to 2.97% in 2022; while the real value of total government agricultural budget declined. Large budgetary increases coincided with the development/launch of costed strategies with nutrition-sensitive agriculture components. Still, there were some missed opportunities to increase nutrition allocations. CONCLUSIONS: Existence of nutrition-sensitive agriculture strategies has facilitated increased nutrition funding and improved the enabling environment. There is need to optimize existing nutrition allocations while advocating for additional funds.

Stories of change in nutrition in Burkina Faso 1992-2018: a macro-level perspective.

Looking back at the development of successful enabling environments for nutrition may inform policymakers on how to accelerate progress to end all forms of malnutrition by 2030. As under-five stunting declined substantially in Burkina Faso, from a peak at 45% in 1998/99 to 25% in 2018, we analyzed through a stories of change approach the actors, ideas, initiatives, policies and capacities which enabled wide-scale nutrition progress. We triangulated findings from policy analysis, stakeholder mapping, and national-level semi-structured interviews (n = 20). We found that since 2002, nutrition has been anchored in the Ministry of Health, where leadership advocated for the creation of coordination bodies, enabling a coherent defining of nutrition and laying groundwork for better integration of nutrition into and prioritization of nutrition by the health and tangential ministries. Under the leadership of the Ministry of Health and its partners, horizontal and vertical coherence in nutrition action increased, through effective cooperation between nutrition actors; increasing intersectoral collaboration, particularly with the influential agriculture sector; and increasing funding to support nutrition-sensitive programming and build the capacity of nutrition staff. Nevertheless, sustainably organizing funding and human resources at the decentralized level remained challenging, in a context of emerging threats such as climate change and insecurity. Burkina Faso's health sector's success in creating an enabling environment for nutrition may have contributed to improvements in child nutrition alongside other sectoral improvements. Enhancing accountability of the Health, Agriculture, WASH, Education and Social Protection sectors and empowering decentralized bodies to take nutrition-relevant decisions may help accelerating progress in nutrition.

Nutrition Capacity Assessment of Agriculture Extension Services in Nigeria.

BACKGROUND: Achieving meaningful malnutrition reductions in Nigeria and other high-burden countries requires sustained improvements in diets, mediated through nutrition-sensitive agriculture and food systems. Yet, the capacity to design, plan, implement, and monitor such nutrition-sensitive systems is very limited, including within agricultural extension services delivery. Understanding existing capacity of actors required to implement nutrition change is crucial for effective capacity development. OBJECTIVE: This study assessed the nutrition capacity of agriculture extension agents (AEAs) in Nigeria and the capacity of their organizations and the institutions within which they operate. METHODS: The study assessed 31 extension training materials for inclusion of recommendations for nutrition-sensitive agriculture. Structured interviews and focus group discussions were conducted with 23 extension agents and were coded and analyzed for major themes. RESULTS: Training materials hardly included nutrition objectives and or nutrition-related services to be delivered. Some nutrition-related services were being delivered, including promotion of biofortified crops and nutrient-dense crops and animals, home gardening, food safety, and dietary diversification. However, these services were limited, and service delivery was unstructured, nonuniform, and inconsistent. Numbers of AEAs are quite inadequate while available AEAs had high workloads, are poorly motivated, and had limited funding, supervision, and logistics capacity to perform roles. Physical security was also a challenge for service delivery. Further, complementary activities in other sectors that were necessary for adequate delivery of nutrition-sensitive agriculture did not always exist. CONCLUSION: Extensive development of nutrition capacities of extension agents appears unlikely to achieve nutrition-related changes if limiting institutional and organizational capacity deficits are not addressed. PLAIN LANGUAGE TITLE: Capacity of Agriculture Extension Agents in Nigeria to Deliver Nutrition Services. PLAIN LANGUAGE SUMMARY: Reducing the significant burden of malnutrition in Nigeria requires increased availability and consumption of foods that are nutritious and free from harmful substances. To produce such foods, farmers need adequate nutrition and food safety knowledge and skills. The production of such food will also need to support nutrition in other ways, including increased women's empowerment. Extension agents traditionally support farmers to adopt new methods of food production and/or processing that support increased food yields. These agents can also be used to deliver services that will address nutrition if they have the necessary knowledge and skills. This study assessed the capacity of agriculture extension agents in Nigeria to deliver nutrition services, in order to determine how to increase their capacity to deliver these services. The results from the study are that the extension agents do not have sufficient knowledge and skills to deliver nutrition services, and that their organizations and the wider context in which they work do not have the capacity to enable them to deliver nutrition services effectively. For instance, the organizations do not have sufficient numbers of staff and do not provide current staff with adequate means of transportation to visit farmers. Insecurity is high and so extension agents are unable to visit farmers frequently because of the potential threats to their lives. The study concludes that effectively using extension agents to deliver nutrition services will require not just training of the extension agents but also improvements in organizational capacity and contextual factors.

Exploring Strategies for Developing Enabling Environments for People with Chronic Heart Disease: An Ethnographic Study Protocol.

The impact of chronic diseases on people's daily lives and the exponential number of people affected is a major public health issue. The consequences on individuals and their families is significant, particularly in terms of quality of life. In the literature, this phenomenon is well described in terms of care policy and cost. Although there is a link between a supportive environment and empowerment, there is little literature describing a supportive environment and the daily lives of people living with cardiovascular disease. The objectives of this study are to identify the strategies people use to develop an enabling environment. It will be a qualitative ethnographic study that will address both human behavior and the notion of culture in a broad sense. In the context of this study, an orientation towards critical ethnography will be considered for its particular interest in vulnerable people and in the power relations that may exist in the socio-cultural system. Data will be collected directly in people's homes through observations and interviews with 10 people with cardiovascular disease. For each person, the data collection will take place over three days and will represent approximately 210 h of observation. This protocol was registered in the Research Register on 30 June 2021 and its number is 6933. This study will explore strategies for developing an enabling environment for people living with heart disease and eventually provide recommendations for nursing practices in terms of support.

Stakeholders, Relationships, and Coordination: 2015 Baseline Study of Needed Enablers for Bridging Agriculture-Nutrition Gaps in Nigeria.

BACKGROUND: Renewed efforts by the Nigerian government to address malnutrition have led to nutrition actions by several sectors, including the agriculture sector. However, the success of these actions depends on the characteristics of the stakeholders involved, including their relationships and coordination. OBJECTIVE: This article reports a 2015 study of nutrition-sensitive agricultural stakeholders in Nigeria that assessed what the stakeholders do, where they work and how they are organized to improve nutrition. The study provides a baseline for assessing progress and measuring stakeholder and coordination changes in the Nigerian nutrition-sensitive agriculture landscape. METHODS: Semi-structured interviews (n = 17) and focus group discussions (n = 2) were held with federal, state, and local government level stakeholders; reviews of stakeholder program documents were also conducted. RESULTS: The study identified 7 groups of nutrition-sensitive agriculture stakeholders and several coordination challenges. Political leadership, advocacy and provision of material and human resource support by nongovernmental organizations, and donor interest and funding have been vital for mobilizing nutrition-sensitive agriculture. Still, although stakeholders frequently highlighted that nutrition was an important consideration in their interventions, nutrition goals and activities and/or indicators to measure outcomes were not regularly communicated. Also, while coordination mechanisms existed, there appeared to be minimal actual cross-sectoral partnerships because of inadequate trust, competition, and conflicts over institutional turf and mandates. CONCLUSIONS: Needed enablers for improving nutrition-sensitive agriculture in Nigeria included improved stakeholder nutrition literacy, as well as enhanced stakeholder engagement facilitated by role definition, clarification, and consensus. Exploring different approaches to coordination may also be necessary.

Implementing adaptive youth-centered adolescent sexual reproductive health programming: learning from the Adolescents 360 project in Tanzania, Ethiopia, and Nigeria (2016-2020).

Adolescents 360 (A360) was a 4.5-year project working directly with young people to increase demand for, and voluntary uptake of, modern contraception among adolescent girls aged 15 to 19 years. A360 utilized human centered design (HCD) to create four adolescent sexual and reproductive health (ASRH) interventions across three countries - Smart Start in Ethiopia, Kuwa Mjanja in Tanzania, Matasa Matan Arewa (MMA) in northern Nigeria, and 9ja Girls in southern Nigeria. A360's interventions tap into girls' aspirations and position contraception as a tool that can support them in pursuing their life goals. As A360 transitioned from its first program phase into its follow-on in 2020, the project examined what it had accomplished, where it had failed, and what it had learned in the process, with the goal of contributing to the global evidence base and building on these lessons in its follow-on program. A360 draws out five key lessons in this publication. These lessons speak to 1) the value of A360's aspirational program components and the need to meaningfully support girls to pursue their life goals holistically; 2) the necessity of taking a consistent and rigorous approach to improving the enabling environment for contraceptive use to promote transformative change; 3) the need to find program and measurement approaches that respond to girls' unique patterns of sexual activity, and support contraceptive continuation; 4) the usefulness of continuous program improvement during implementation to maintain a user-centered focus and create a culture of curiosity and innovation; and 5) the tension between designing for users and beginning with program sustainability in mind from the outset. A360 continues to grow in its understanding of what it takes to support sustained, transformative, holistic change for adolescent girls and commits to openness and transparency regarding successes and failures during its next project phase.

The experiences of sex workers accessing HIV care services in Bulawayo, Zimbabwe.

BACKGROUND: Although sub-Saharan African countries have rolled out massive HIV treatment and care programmes, there is little evidence of these having embraced key population groups particularly female sex workers. Due to the criminalisation of sex work in countries like Zimbabwe, research on HIV and its impact on this group is sparse. The absence of an enabling environment has hindered access to HIV care and treatment services for female sex workers. OBJECTIVES: To gain an in-depth understanding of the experiences of female sex workers accessing HIV care and treatment services to enhance programming and planning for this key population group. METHODS: This study was qualitative and phenomenological. Data saturation determined the sample size of 20 participants. Data was collected using in-depth interviews that were audio recorded, transcribed, and subjected to thematic content analysis. RESULTS: Our findings demonstrate varying dynamics between the private and public sector HIV care services for sex workers, with facilitators and barriers to access to care. CONCLUSION: Health workers need sensitization and training in the provision of differentiated care. For effective linkage to and retention in care an enabling environment is critical.

The lived experiences of men who have sex with men when accessing HIV care services in Zimbabwe.

BACKGROUND: Key populations such as men who have sex with men are disproportionately affected by human immunodeficiency virus (HIV), yet they are underserved. This vulnerable group also faces stigma and discrimination when utilising the healthcare services. However, to achieve the HIV epidemic control, it is important for them to have access to HIV care services. AIM: The aim of this study was to explore and describe the experiences of men who have sex with men (MSM) as they accessed HIV care services in healthcare settings in Bulawayo, Zimbabwe. SETTING: The study setting was healthcare facilities (state and private owned) in Bulawayo, Zimbabwe, that offer HIV care services. METHODS: The study used a descriptive phenomenological design targeting self-identified MSM living with HIV. Data were gathered by using in-depth individual interviews that were audio recorded. Data saturation determined sample size. Data were transcribed verbatim and later analysed thematically. RESULTS: The study revealed that counselling given to MSM was generalised and not individualised. Some clients faced stigma and discrimination after disclosure. Peer and family support were important in the journey to access HIV care services. CONCLUSION: An enabling environment was not provided for MSM clients to access HIV care services in the majority of health facilities. This calls for sensitisation and competency clinical training of service providers so that the diverse needs of MSM are met. Peer and family support for MSM needs to be strengthened.

Exploring Private Sector Engagement for Faecal Sludge Emptying and Transport Business in Khulna, Bangladesh.

In Khulna, Bangladesh, mechanical faecal sludge (FS) emptying and transport (E&T) service is provided by community development committees (CDCs) and the Khulna City Corporation (KCC). Without considering capital expenditure and depreciation, financial analysis for one year revealed that a CDC-1 m3 vacutug made a profit of Bangladeshi taka (BDT) 145,780 (USD $1746) whereas a KCC-2 m3 vacutug was in the loss of BDT 218,179 (USD $2613). There is a need to engage the private sector for sustainable service provision. Some of the key elements of enabling the environment for private sector engagement are policy/strategy, institutional and regulatory framework, implementation capacity, and financial viability. Existing policy/strategy/frameworks acknowledged the need and suggested plans for private sector engagement, and decentralised authority to city corporations. With increasing private-public partnership projects and collaboration in the sanitation sector, capacity of the KCC and the private sector are increasing. Financial viability of the FS E&T business is primarily dependent on the number of trips and the emptying fee. For the E&T business to be financially viable, a 2 m3 vacutug should make six trips/day (internal rate of return (IRR)-13%, discount rate-6.5%) with an emptying fee of BDT 750 (USD $9)/m3. Despite the lack of operative guidelines for faecal sludge management (FSM), enabling the environment for private sector engagement in FS E&T business in Khulna seems favourable.

Understanding the Unmet Needs among Community-Dwelling Disabled Older People from a Linkage Perspective.

One of the challenges in response to population aging is to meet needs for elderly care among older people especially for those who want to age in their homes or communities. However, disabled older people have more challenges due to their restricted mobility to access care resources than non-disabled ones. We propose a new framework based on the changing relationship between older people and their environment, in which resource linkage in elderly care utilization is emphasized. We conducted a survey with 139 participants (i.e., older people age 60 years or over with different level of disabilities) in three types of neighborhoods in Beijing, China. By conducting a decision tree analysis under the Person-Environment Link (P-E Link) model, we (1) characterized unmet needs for elderly care (activities of daily living (ADL) and instrumental activities of daily living (IADL) assistance) among community-dwelling disabled older people; (2) found disabled older people had more unmet needs for both ADL and IADL assistance because of a lack in linkages to care resources than non-disabled ones; and (3) characterized the linkages to care resources for better supporting disabled older people to age in place, including family support, social connection, and spatial environment. Our findings help improve the Anderson behavioral model by characterizing enabling environments, which highlights that not only the availability of enabling resources but also linkages to these enabling resources play an important role in meeting needs for care among disabled older people. Our findings can also inform improvements in policy design that are targeted to reduce elderly care inequalities.

Impact of Covid-19 on farming systems in Europe through the lens of resilience thinking.

Context: Resilience is the ability to deal with shocks and stresses, including the unknown and previously unimaginable, such as the Covid-19 crisis. Objective: This paper assesses (i) how different farming systems were exposed to the crisis, (ii) which resilience capacities were revealed and (iii) how resilience was enabled or constrained by the farming systems' social and institutional environment. Methods: The 11 farming systems included have been analysed since 2017. This allows a comparison of pre-Covid-19 findings and the Covid-19 crisis. Pre-Covid findings are from the SURE-Farm systematic sustainability and resilience assessment. For Covid-19 a special data collection was carried out during the early stage of lockdowns. Results and conclusions: Our case studies found limited impact of Covid-19 on the production and delivery of food and other agricultural products. This was due to either little exposure or the agile activation of robustness capacities of the farming systems in combination with an enabling institutional environment. Revealed capacities were mainly based on already existing connectedness among farmers and more broadly in value chains. Across cases, the experience of the crisis triggered reflexivity about the operation of the farming systems. Recurring topics were the need for shorter chains, more fairness towards farmers, and less dependence on migrant workers. However, actors in the farming systems and the enabling environment generally focused on the immediate issues and gave little real consideration to long-term implications and challenges. Hence, adaptive or transformative capacities were much less on display than coping capacities. The comparison with pre-Covid findings mostly showed similarities. If challenges, such as shortage of labour, already loomed before, they persisted during the crisis. Furthermore, the eminent role of resilience attributes was confirmed. In cases with high connectedness and diversity we found that these system characteristics contributed significantly to dealing with the crisis. Also the focus on coping capacities was already visible before the crisis. We are not sure yet whether the focus on short-term robustness just reflects the higher visibility and urgency of shocks compared to slow processes that undermine or threaten important system functions, or whether they betray an imbalance in resilience capacities at the expense of adaptability and transformability. Significance: Our analysis indicates that if transformations are required, e.g. to respond to concerns about transnational value chains and future pandemics from zoonosis, the transformative capacity of many farming systems needs to be actively enhanced through an enabling environment.

Delivering an enabling environment and multiple benefits for land degradation neutrality: Stakeholder perceptions and progress.

Achieving land degradation neutrality (LDN) was adopted by countries in 2015 as one of the targets of the global Sustainable Development Goals (SDGs). As LDN is a relatively new concept there is an increasing need for evidence on the potential socio-economic and environmental benefits of LDN as well as how an enabling environment for implementing LDN measures can be developed. This paper summarises the results from a global survey of LDN stakeholders, and a review of national progress in target setting that was commissioned by the United Nations Convention to Combat Desertification (UNCCD) in 2018. The study presents the perceptions of relevant stakeholders on the key components of an enabling environment for achieving and maintaining LDN (institutional, financial, policy/regulatory, and science-policy) as well as expectations of multiple benefits from its implementation. We also highlight key challenges and gaps in progress to date that are emerging from ongoing national target setting programs to implement LDN. The study finds that progress in implementing LDN has been widespread across countries. However there remains a lack of awareness of LDN and its key concepts along with high-level political buy-in. This may be impeding the integration of LDN into national development planning and budgeting processes where progress was assessed as limited. National capacities for securing land tenure and governance arrangements and integrated land use planning were perceived as comparatively low, further hampering the implementation of LDN. Despite these gaps, most stakeholders (>90 %) who participated in the global survey expected LDN to deliver a broad range of multiple benefits for human wellbeing, livelihoods and the natural environment. We argue that greater efforts are needed to raise awareness of LDN, educate core stakeholders in its concepts, enablers and benefits, raise its political profile, and provide evidence on national measures that will support implementation of LDN.

Comparing the German enabling environment for nationwide Water Safety Plan implementation with international experiences: Are we still thinking big or already scaling up?

Ensuring safe drinking-water is the target of the Water Safety Plan (WSP) approach, which has been successfully applied to a large number of water supply systems around the world. Effective country-wide scaling up of WSP implementation requires an enabling environment at the policy level. By utilizing a multi-step mixed methods approach, this study summarizes international experience with WSP implementation and scaling-up efforts following the 8 steps of the WSP road map published by WHO and IWA for an enabling environment, shows what steps Germany has in place, and compares this with published international experience to inspire further policy action. Contrasting the international experience to the German situation revealed several overlaps but also profound differences, which, in turn, offer opportunities for mutual learning. Most experience in Germany and internationally is documented for the earlier steps of the WSP road map. Information particularly on developing a national strategy, securing financial instruments, activities to support continual implementation of WSPs and on review of the overall WSP experiences and sharing lessons learned appears to be scarce, while the importance of training, collaboration and alliances, and the value of a regulatory push are often stressed. In Germany, stakeholder engagement, guidance documents and workshop materials have been of vital importance. Information that could particularly inform further action in Germany mostly relate to considering a national WSP strategy, and how to shape an approach for external quality assurance of WSPs.

Scaling agricultural mechanization services in smallholder farming systems: Case studies from sub-Saharan Africa, South Asia, and Latin America.

There is great untapped potential for farm mechanization to support rural development initiatives in low- and middle-income countries. As technology transfer of large machinery from high-income countries was ineffective during the 1980s and 90s, mechanization options were developed appropriate to resource poor farmers cultivating small and scattered plots. More recently, projects that aim to increase the adoption of farm machinery have tended to target service providers rather than individual farmers. This paper uses the Scaling Scan tool to assess three project case studies designed to scale different Mechanization Service Provider Models (MSPMs) in Mexico, Zimbabwe, and Bangladesh. It provides a useful framework to assess the gap between international lessons learned on scaling captured in forty tactical questions over ten "scaling ingredients" as perceived by stakeholders involved in the projects, as well as private sector actors and government employees. Although at first sight the case studies seem to successfully reach high numbers of end users, the assessment exposes issues around the sustainable and transformative nature of the interventions. These are highly influenced by the design of the projects and by the environment and context of the intervention areas. Across the three case studies, large-scale adoption of the models was found to be hampered by lack of finance to set up MSPMs and insufficient collaboration among the value chain actors to strengthen and foster Mechanization Service Provider (MSP) entrepreneurs. Applying a scaling perspective on each case study project exposed important lessons on minimizing project dependencies. Positive examples include integration of capacity development materials in vocational training centers in Zimbabwe, promotion of MSPMs by other donors in East Africa and levering of nearly USD six million of private sector investment in appropriate machinery in Bangladesh. On the other hand, there is still a high dependency on the projects in terms of coaching of service providers, facilitating collaboration along the value chain, and provision of leadership and advocacy to address issues at governance level. These results have important implications for similar development interventions aimed at increasing smallholder access to mechanization services at scale and is to our knowledge the first cross-continental assessment of these issues to date.

"We do what we can do to save a woman" health workers' perceptions of health facility readiness for management of postpartum haemorrhage.

Background: In many low-resource settings, in-service training is a common strategy to improve the performance of health workers and ultimately reduce the persistent burden of maternal mortality and morbidities. An evaluation of the Helping Mothers Survive Bleeding After Birth (HMS BAB) training as a single-component intervention in Tanzania found some positive albeit limited effect on clinical management and reduction of postpartum haemorrhage (PPH).Aim: In order to better understand these findings, and particularly the contribution of contextual factors on the observed effects, we explored health workers' perceptions of their health facilities' readiness to provide PPH care.Methods: We conducted 7 focus group discussions (FGDs) and 12 in-depth interviews (IDIs) in purposively selected intervention districts in the HMS BAB trial. FGDs and IDIs were audio-recorded, transcribed and translated verbatim. Thematic analysis, using both inductive and deductive approaches, was applied with the help of MAXQDA software.Results: Health workers perceive that their facilities have a low readiness to provide PPH care, leading to stressful situations and suboptimal clinical management. They describe inconsistencies in essential supplies, fluctuating availability of blood for transfusion, and ineffective referral system. In addition, there are challenges in collaboration, communication and leadership support, which is perceived to prevent effective management of cases within the facility as well as in referral situations. Health workers strive to provide life-saving care to women with PPH despite the perceived challenges. In some health facilities, health workers perceive supportive clinical leadership as motivating in providing good care.Conclusion: The potential positive effects of single-component interventions such as HMS BAB training on clinical outcome may be constraint by poor health facility readiness, including communication, leadership and referral processes that need to be addressed.

Empowerment-enabling home and school environments and self-rated health among Finnish adolescents.

Perceived health during adolescence has not only immediate consequences for individuals and for society, but also long-term. We need to understand better the health development in this period of the lifespan. Empowerment may be one pathway through which social factors and conditions translate into health effects. This study aimed to examine whether empowerment-enabling home and school environments are associated with self-rated health among adolescents, and whether the associations differ between genders, age or majority/minority language groups. Anonymous questionnaire data from respondents aged 11, 13 and 15 years were obtained from the Health Behaviour in School-aged Children study, conducted in Finland in 2014 in Finnish- and Swedish-speaking schools (n = 5925/1877). The proportion rating their health as excellent varied between 33.6 (11-year-olds) and 23.1% (15-year-olds), boys rating their health as excellent more often than girls in all age groups. Findings showed that indicators of both empowerment-enabling home and school environments were independently and positively related to adolescents' self-rated health. Whereas a respectful, accepting, kind and helpful attitude among classmates and a good home atmosphere were quite consistently associated with excellent health, there were gender and age differences with concern to the other empowerment-enabling indicators. Moreover, there were gender-, age- and language-related differences regarding adolescents' perceptions of how empowerment enabling their environments were. Home and school environments that create opportunities through encouragement and care, and through strengthening feelings of being secure, accepted and respected are potentially empowerment enabling. This study suggests that such environmental qualities are important for the perceived health of young people.

How to improve public participation in disaster risk management: A case study of Buein Zahra, a small city in Iran.

Identifying and providing basic solutions using a collaborative approach in earthquake-stricken cities of Iran has not yet been addressed. This article focuses on an area of practice and views disaster risk management from the point of view of volunteer groups to illustrate how the main components of disaster risk management affect the strengthening of public participation. In this article, Buein Zahra, a small city in Iran, is considered as a high-risk earthquake zone. The basic components of risk management are identified, namely public awareness, knowledge, skills, enabling environment, organisational development and social participation. An assessment of these indicators was done, and multidimensional relationships were established between them to enable an increase in the capacity for public participation. Accordingly, the results indicate that a mere increase in public awareness and knowledge, as seen today, and an improvement in enabling environment, although affecting disaster risk reduction, cannot by themselves lead to real public participation. Organisational development and strengthening of crisis coping skills are two key components to improving participation during crises in the small cities of Iran. According to the results of this study, institutional capacity and unreal political commitment have caused inefficiency of public participation in earthquake preparedness.