Access to adolescent sexual and reproductive health services in Accra, Ghana: An exploratory qualitative study.

Nearly 31% of the Ghanaian population are adolescents, and these populations persistently face high rates of teenage pregnancies and unsafe abortions. This is despite sexual and reproductive health (SRH) being taught in the school curriculum. In this qualitative study, we explore the factors affecting adolescents' access to, and experiences of, SRH services in Accra, Ghana. We conducted 12 focus group discussions (FGDs) with adolescents and 13 key informant interviews (KIs) in Ghana. The FGDs were conducted with school-going and out-of-school adolescents. KIIs were conducted with various stakeholders working with adolescents or in SRH services. All interviews were conducted in English, audio recorded and transcribed verbatim. We applied the Dahlgren-Whitehead Rainbow model of health determinants and used a thematic analysis. Eight themes were identified, across micro, meso and macro levels, that influence adolescents' SRH access and experience in Accra. These included: family, social networks, the role of schools, health providers and services, the policy landscape, gender norms, cultural norms, and poverty. The findings highlight several factors that influence adolescents' access to appropriate SRH services in this context and demonstrate the need for a multisectoral effort to address structural factors such as harmful gender norms and persistent poverty.

A Follow-Up Study of Boys With Gender Identity Disorder.

This study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33-12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07-39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R, or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the participants were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 participants: 82 (63.6%) were classified as biphilic/androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies. For sexual orientation in behavior, data were available for 108 participants: 51 (47.2%) were classified as biphilic/androphilic, 29 (26.9%) were classified as gynephilic, and 28 (25.9%) reported no sexual behaviors. Multinomial logistic regression examined predictors of outcome for the biphilic/androphilic persisters and the gynephilic desisters, with the biphilic/androphilic desisters as the reference group. Compared to the reference group, the biphilic/androphilic persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender-variant. The biphilic/androphilic desisters were more gender-variant compared to the gynephilic desisters. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation. The implications of the data for current models of care for the treatment of gender dysphoria in children are discussed.

Midwives' perspectives on (dis)respectful intrapartum care during facility-based delivery in sub-Saharan Africa: a qualitative systematic review and meta-synthesis.

BACKGROUND: In the past decade, the negative impact of disrespectful maternity care on women's utilisation and experiences of facility-based delivery has been well documented. Less is known about midwives' perspectives on these labour ward dynamics. Yet efforts to provide care that satisfies women's psycho-socio-cultural needs rest on midwives' capacity and willingness to provide it. We performed a systematic review of the emerging literature documenting midwives' perspectives to explore the broader drivers of (dis)respectful care during facility-based delivery in the sub-Saharan African context. METHODS: Seven databases (CINAHL, PsychINFO, PsychArticles, Embase, Global Health, Maternity and Infant Care and PubMed) were systematically searched from 1990 to May 2018. Primary qualitative studies with a substantial focus on the interpersonal aspects of care were eligible if they captured midwives' voices and perspectives. Study quality was independently assessed by two reviewers and PRISMA guidelines were followed. The results and findings from each study were synthesised using an existing conceptual framework of the drivers of disrespectful care. RESULTS: Eleven papers from six countries were included and six main themes were identified. 'Power and control' and 'Maintaining midwives' status' reflected midwives' focus on the micro-level interactions of the mother-midwife dyad. Meso-level drivers of disrespectful care were: the constraints of the 'Work environment and resources'; concerns about 'Midwives' position in the health systems hierarchy'; and the impact of 'Midwives' conceptualisations of respectful maternity care'. An emerging theme outlined the 'Impact on midwives' of (dis)respectful care. CONCLUSION: We used a theoretically informed conceptual framework to move beyond the micro-level and interrogate the social, cultural and historical factors that underpin (dis)respectful care. Controlling women was a key theme, echoing women's experiences, but midwives paid less attention to the social inequalities that distress women. The synthesis highlighted midwives' low status in the health system hierarchy, while organisational cultures of blame and a lack of consideration for them as professionals effectively constitute disrespect and abuse of these health workers. Broader, interdisciplinary perspectives on the wider drivers of midwives' disrespectful attitudes and behaviours are crucial if efforts to improve the maternity care environment - for women and midwives - are to succeed.

Behavior Problems and Psychiatric Diagnoses in Girls with Gender Identity Disorder: A Follow-Up Study.

This study evaluated the presence of clinical range behavior problems and psychiatric diagnoses in 25 girls referred for gender identity disorder (GID) in childhood (mean age: 8.88 years) at the time of follow-up in adolescence or adulthood (mean age: 23.2 years). At follow-up, three (12%) of the girls were judged to have persistent GID based on DSM-IV criteria. With regard to behavior problems at follow-up, 39.1% of the girls had a clinical range score on either the Child Behavior Checklist or Adult Behavior Checklist as rated by their mothers, and 33.3% had a clinical range score on either the Youth Self-Report or the Adult Self-Report. On either the Diagnostic Interview for Children and Adolescents or the Diagnostic Interview Schedule, the girls had, on average, 2.67 diagnoses (range: 0-10); 46% met criteria for three or more diagnoses. From the childhood assessment, five variables were significantly associated with a composite Psychopathology Index (PI) at follow-up: a lower IQ, living in a non-two-parent or reconstituted family, a composite behavior problem index, and poor peer relations. At follow-up, degree of concurrent homoeroticism and a composite index of gender dysphoria were both associated with the composite PI. Girls with GID show a psychiatric vulnerability at the time of follow-up in late adolescence or adulthood, although there was considerable variation in their general well-being.

Intense/obsessional interests in children with gender dysphoria: a cross-validation study using the Teacher's Report Form.

OBJECTIVE: This study assessed whether children clinically referred for gender dysphoria (GD) show symptoms that overlap with Autism Spectrum Disorder (ASD). Circumscribed preoccupations/intense interests and repetitive behaviors were considered as overlapping symptoms expressed in both GD and ASD. METHODS: To assess these constructs, we examined Items 9 and 66 on the Teacher's Report Form (TRF), which measure obsessions and compulsions, respectively. RESULTS: For Item 9, gender-referred children (n = 386) were significantly elevated compared to the referred (n = 965) and non-referred children (n = 965) from the TRF standardization sample. For Item 66, gender-referred children were elevated in comparison to the non-referred children, but not the referred children. CONCLUSIONS: These findings provided cross-validation of a previous study in which the same patterns were found using the Child Behavior Checklist (Vanderlaan et al. in J Sex Res 52:213-19, 2015). We discuss possible developmental pathways between GD and ASD, including a consideration of the principle of equifinality.

The impact of a human resource management intervention on the capacity of supervisors to support and supervise their staff at health facility level.

BACKGROUND: A systematic and structured approach to the support and supervision of health workers can strengthen the human resource management function at the district and health facility levels and may help address the current crisis in human resources for health in sub-Saharan Africa by improving health workers' motivation and retention. METHODS: A supportive supervision programme including (a) a workshop, (b) intensive training and (c) action learning sets was designed to improve human resource management in districts and health facilities in Tanzania. We conducted a randomised experimental design to evaluate the impact of the intervention. Data on the same measures were collected pre and post the intervention in order to identify any changes that occurred (between baseline and end of project) in the capacity of supervisors in intervention a + b and intervention a + b + c to support and supervise their staff. These were compared to supervisors in a control group in each of Tanga, Iringa and Tabora regions (n = 9). A quantitative survey of 95 and 108 supervisors and 196 and 187 health workers sampled at baseline and end-line, respectively, also contained open-ended responses which were analysed separately. RESULTS: Supervisors assessed their own competency levels pre- and post-intervention. End-line samples generally scored higher compared to the corresponding baseline in both intervention groups for competence activities. Significant differences between baseline and end-line were observed in the total scores on 'maintaining high levels of performance', 'dealing with performance problems', 'counselling a troubled employee' and 'time management' in intervention a + b. In contrast, for intervention a + b + c, a significant difference in distribution of scores was only found on 'counselling a troubled employee', although the end-line mean scores were higher than their corresponding baseline mean scores in all cases. Similar trends to those in the supervisors' reports are seen in health workers data in terms of more efficient supervision processes, although the increases are not as marked. CONCLUSION: A number of different indicators were measured to assess the impact of the supportive supervision intervention on the a + b and a + b + c intervention sites. The average frequency of supervision visits and the supervisors' competency levels across the facilities increased in both intervention types. This would suggest that the intervention proved effective in raising awareness of the importance of supervision and this understanding led to action in the form of more supportive supervision.

The impact of a supportive supervision intervention on health workers in Niassa, Mozambique: a cluster-controlled trial.

BACKGROUND: Regular supportive supervision is critical to retaining and motivating staff in resource-constrained settings. Previous studies have shown the particular contribution that supportive supervision can make to improving job satisfaction amongst over-stretched health workers in such settings. METHODS: The Support, Train and Empower Managers (STEM) study designed and implemented a supportive supervision intervention and measured its' impact on health workers using a controlled trial design with a three-arm pre- and post-study in Niassa Province in Mozambique. Post-intervention interviews with a small sample of health workers were also conducted. RESULTS: The quantitative measurements of job satisfaction, emotional exhaustion and work engagement showed no statistically significant differences between end-line and baseline. The qualitative data collected from health workers post the intervention showed many positive impacts on health workers not captured by this quantitative survey. CONCLUSIONS: Health workers perceived an improvement in their performance and attributed this to the supportive supervision they had received from their supervisors following the intervention. Reports of increased motivation were also common. An unexpected, yet important consequence of the intervention, which participants directly attributed to the supervision intervention, was the increase in participation and voice amongst health workers in intervention facilities.

Disrespectful intrapartum care during facility-based delivery in sub-Saharan Africa: A qualitative systematic review and thematic synthesis of women's perceptions and experiences.

The psycho-social elements of labour and delivery are central to any woman's birth experience, but international efforts to reduce maternal mortality in low-income contexts have neglected these aspects and focused on technological birth. In many contexts, maternity care is seen as dehumanised and disrespectful, which can have a negative impact on utilisation of services. We undertook a systematic review and meta-synthesis of the growing literature on women's experiences of facility-based delivery in sub-Saharan Africa to examine the drivers of disrespectful intrapartum care. Using PRISMA guidelines, databases were searched from 1990 to 06 May 2015, and 25 original studies were included for thematic synthesis. Analytical themes, that were theoretically informed and cognisant of the cultural and social context in which the dynamics of disrespectful care occur, enabled a fresh interpretation of the factors driving midwives' behaviour. A conceptual framework was developed to show how macro-, meso- and micro-level drivers of disrespectful care interact. The synthesis revealed a prevailing model of maternity care that is institution-centred, rather than woman-centred. Women's experiences illuminate midwives' efforts to maintain power and control by situating birth as a medical event and to secure status by focusing on the technical elements of care, including controlling bodies and knowledge. Midwives and women are caught between medical and social models of birth. Global policies encouraging facility-based delivery are forcing women to swap the psycho-emotional care they would receive from traditional midwives for the technical care that professional midwives are currently offering. Any action to change the current performance and dynamic of birth relies on the participation of midwives, but their voices are largely missing from the discourse. Future research should explore their perceptions of the value and practice of interpersonal aspects of maternity care and the impact of disrespectful care on their sense of professionalism and personal ethics.

Working relationships between obstetric care staff and their managers: a critical incident analysis.

BACKGROUND: Malawi continues to experience critical shortages of key health technical cadres that can adequately respond to Malawi's disease burden. Difficult working conditions contribute to low morale and frustration among health care workers. We aimed to understand how obstetric care staff perceive their working relationships with managers. METHODS: A qualitative exploratory study was conducted in health facilities in Malawi between October and December 2008. Critical Incident Analysis interviews were done in government district hospitals, faith-based health facilities, and a sample of health centres' providing emergency obstetric care. A total of 84 service providers were interviewed. Data were analyzed using NVivo 8 software. RESULTS: Poor leadership styles affected working relationships between obstetric care staff and their managers. Main concerns were managers' lack of support for staff welfare and staff performance, lack of mentorship for new staff and junior colleagues, as well as inadequate supportive supervision. All this led to frustrations, diminished motivation, lack of interest in their job and withdrawal from work, including staff seriously considering leaving their post. CONCLUSIONS: Positive working relationships between obstetric care staff and their managers are essential for promoting staff motivation and positive work performance. However, this study revealed that staff were demotivated and undermined by transactional leadership styles and behavior, evidenced by management by exception and lack of feedback or recognition. A shift to transformational leadership in nurse-manager relationships is essential to establish good working relationships with staff. Improved providers' job satisfaction and staff retentionare crucial to the provision of high quality care and will also ensure efficiency in health care delivery in Malawi.

Explaining retention of healthcare workers in Tanzania: moving on, coming to 'look, see and go', or stay?

BACKGROUND: In the United Republic of Tanzania, as in many regions of Sub-Saharan Africa, staff shortages in the healthcare system are a persistent problem, particularly in rural areas. To explore staff shortages and ways of keeping workers in post, we ask, (a) Which cadres are most problematic to recruit and keep in post? (b) How and for what related reasons do health workers leave? (c) What critical incidents do those who stay face? (d) And why do they stay and cope? METHODS: This is a multi-method paper based on analysis of data collected as part of a cross-sectional health facility study supporting maternal and reproductive health services in the United Republic of Tanzania. Qualitative data were generated through semi-structured interviews with Council Health Management Teams, and Critical Incident Technique interviews with mid-level cadres. Complementary quantitative survey data were collected from district health officials, which are used to support the qualitative themes. RESULTS: Mid-level cadres were problematic to retain and caused significant disruptions to continuity of care when they left. Shortage of highly skilled workers is not only a rural issue but also a national one. Staff were categorised into a clear typology. Staff who left soon after arrival and are described by 'Look, See and Go'; 'Movers On' were those who left due to family commitments or because they were pushed to go. The remaining staff were 'Stayers'. Reasons for wanting to leave included perceptions of personal safety, feeling patient outcomes were compromised by poor care or as a result of perceived failed promises. Staying and coping with unsatisfactory conditions was often about being settled into a community, rather than into the post. CONCLUSIONS: The Human Resources for Health system in the United Republic of Tanzania appears to lack transparency. A centralised monitoring system could help to avoid early departures, misallocation of training, and other incentives. The system should match workers' profiles to the most suitable post for them and track their progress and rewards; training managers and holding them accountable. In addition, priority should be given to workplace safety, late night staff transport, modernised and secure compound housing, and involving the community in reforming health services culture and practices.

Non-modifiable worker and workplace risk factors contributing to workplace absence: A stakeholder-centred synthesis of systematic reviews.

BACKGROUND: Workplace stakeholders report the identification and translation of relevant high quality research to inform workplace disability policy and practice is a challenge. The present study engaged academic and community stakeholders in conducting a best evidence-synthesis to identify non-modifiable risk and protective worker and workplace factors impacting work-related absence across a variety of health conditions. OBJECTIVE: To identify non-modifiable worker and workplace disability risk and protective factors impacting work-related absence across common health conditions. METHODS: The research team searched Medline, Embase, CINAHL, The Cochrane Library, PsycINFO, BusinessSource-Complete, and ABI/Inform from 2000 to 2011. Quantitative, qualitative, or mixed methods systematic reviews of work-focused population were considered for inclusion. Two or more reviewers independently reviewed articles for inclusion and methodological screening. RESULTS: The search strategy, including expert input and grey literature, led to the identification of 2,467 unique records. From this initial search, 2325 were eliminated by title or abstract review, 142 articles underwent comprehensive review to assess for inclusion, 26 systematic reviews met eligibility criteria for this synthesis. For non-modifiable worker and workplace factors we found consistent evidence across two or more health conditions for increased risk of disability in situations where workers experience lower education, older age, emotional distress, poor personal functioning, decreased physical functioning, psychological symptoms, overweight status, and greater sick leave history. LIMITATIONS: Heterogeneity of existing literature due to differences in outcome measures, definitions and research designs limited ability to assess effect size and results reflect findings limited to English-language papers.

Too few staff, too many patients: a qualitative study of the impact on obstetric care providers and on quality of care in Malawi.

BACKGROUND: Shortages of staff have a significant and negative impact on maternal outcomes in low-income countries, but the impact on obstetric care providers in these contexts is less well documented. Despite the government of Malawi's efforts to increase the number of human resources for health, maternal mortality rates remain persistently high. Health workers' perceptions of insufficient staff or time to carry out their work can predict key variables concerning motivation and attrition, while the resulting sub-standard care and poor attitudes towards women dissuade women from facility-based delivery. Understanding the situation from the health worker perspective can inform policy options that may contribute to a better working environment for staff and improved quality of care for Malawi's women. METHODS: A qualitative research design, using critical incident interviews, was used to generate a deep and textured understanding of participants' experiences. Eligible participants had performed at least one of the emergency obstetric care signal functions (a) in the previous three months and had experienced a demotivating critical incident within the same timeframe. Data were analysed using NVivo software. RESULTS: Eighty-four interviews were conducted. Concerns about staff shortages and workload were key factors for over 40% of staff who stated their intention to leave their current post and for nearly two-thirds of the remaining health workers who were interviewed. The main themes emerging were: too few staff, too many patients; lack of clinical officers/doctors; inadequate obstetric skills; undermining performance and professionalism; and physical and psychological consequences for staff. Underlying factors were inflexible scheduling and staff allocations that made it impossible to deliver quality care. CONCLUSION: This study revealed the difficult circumstances under which maternity staff are operating and the professional and emotional toll this exacts. Systems failures and inadequate human resource management are key contributors to the gaps in provision of obstetric care and need to be addressed. Thoughtful strategies that match supply to demand, coupled with targeted efforts to support health workers, are necessary to mitigate the effects of working in this context and to improve the quality of obstetric care for women in Malawi.

Do children with gender dysphoria have intense/obsessional interests?

This study examined whether children clinically referred for gender dysphoria (GD) show increased symptoms of autism spectrum disorder (ASD). Circumscribed preoccupations or intense interests were considered as overlapping symptoms expressed in GD and ASD. In gender-referred children (n = 534; 82.2% male) and their siblings (n = 419; 57.5% male), we examined Items 9 and 66 on the Child Behavior Checklist, which measure obsessions and compulsions, respectively. Non-GD clinic-referred (n = 1,201; 48.5% male) and nonreferred (n = 1,201; 48.5% male) children were also examined. Gender-referred children were elevated compared to all other groups for Item 9, and compared to siblings and nonreferred children for Item 66. A gender-related theme was significantly more common for gender-referred boys than male siblings on Item 9 only. A gender-related theme was not significantly more common for gender-referred girls compared to their female siblings on either item. The findings for Item 9 support the idea that children with GD show an elevation in obsessional interests. For gender-referred boys in particular, gender-related themes constituted more than half of the examples provided by their mothers. Intense/obsessional interests in children with GD may be one of the factors underlying the purported link between GD and ASD.

What makes staff consider leaving the health service in Malawi?

BACKGROUND: Malawi faces a severe shortage of health workers, a factor that has contributed greatly to high maternal mortality in the country. Most clinical care is performed by mid-level providers (MLPs). While utilization of these cadres in providing health care is a solution to the current shortages, demotivating factors within the Malawian health system are pushing them into private, non-governmental, and other non-health related positions. This study aims to highlight these demotivating factors by exploring the critical aspects that influence MLPs' intention to leave their jobs. METHODS: This descriptive qualitative study formed part of the larger Health Systems Strengthening for Equity (HSSE) study. Data presented in this paper were collected in Malawi using the Critical Incident Analysis tool. Participants were asked to narrate an incident that had happened during the past three months which had made them seriously consider leaving their job. Data were subjected to thematic analysis using NVivo 8 software. RESULTS: Of the 84 respondents who participated in a Critical Incident Analysis interview, 58 respondents (69%) indicated they had experienced a demotivating incident in the previous three months that had made them seriously consider leaving their job. The most commonly cited critical factors were being treated unfairly or with disrespect, lack of recognition of their efforts, delays and inconsistencies in salary payments, lack of transparent processes and criteria for upgrading or promotion, and death of patients. CONCLUSION: Staff motivation and an enabling environment are crucial factors for retaining MLPs in the Malawian health system. This study revealed key 'tipping points' that drive staff to seriously consider leaving their jobs. Many of the factors underlying these critical incidents can be addressed by improved management practices and the introduction of fair and transparent policies. Managers need to be trained and equipped with effective managerial skills and staff should have access to equal opportunities for upgrading and promotion. There is need for continuous effort to mobilize the resources needed to fill gaps in basic equipment, supplies, and medicine, as these are critical in creating an enabling environment for MLPs.

Modifiable worker risk factors contributing to workplace absence: a stakeholder-centred best-evidence synthesis of systematic reviews.

BACKGROUND: A challenge facing stakeholders is the identification and translation of relevant high quality research to inform policy and practice. This study engaged academic and community stakeholders in conducting a best evidence-synthesis to identify modifiable risk and protective worker factors across health conditions impacting work-related absence. OBJECTIVES: To identify modifiable worker disability risk and protective factors across common health conditions impacting work-related absence. METHODS: We searched Medline, Embase, CINHAL, The Cochrane Library, PsycINFO, BusinessSourceComplete, and ABI/Inform from 2000 to 2011. Quantitative, qualitative, or mixed methods systematic reviews of work-focused population were considered for inclusion. Two or more reviewers independently reviewed articles for inclusion and methodological screening. RESULTS: The search strategy, expert input and grey literature identified 2,467 unique records. One hundred and forty-two full text articles underwent comprehensive review. Twenty-four systematic reviews met eligibility criteria. Modifiable worker factors found to have consistent evidence across two or more health conditions included emotional distress, negative enduring psychology/personality factors, negative health and disability perception, decreased physical activity, lack of family support, poor general health, increased functional disability, increased pain, increased fatigue and lack of motivation to return to work. CONCLUSIONS: Systematic reviews are limited by availability of high quality studies, lack of consistency of methodological screening and reporting, and variability of outcome measures used.

District health managers' perceptions of supervision in Malawi and Tanzania.

BACKGROUND: Mid-level cadres are being used to address human resource shortages in many African contexts, but insufficient and ineffective human resource management is compromising their performance. Supervision plays a key role in performance and motivation, but is frequently characterised by periodic inspection and control, rather than support and feedback to improve performance. This paper explores the perceptions of district health management teams in Tanzania and Malawi on their role as supervisors and on the challenges to effective supervision at the district level. METHODS: This qualitative study took place as part of a broader project, "Health Systems Strengthening for Equity: The Power and Potential of Mid-Level Providers". Semi-structured interviews were conducted with 20 district health management team personnel in Malawi and 37 council health team members in Tanzania. The interviews covered a range of human resource management issues, including supervision and performance assessment, staff job descriptions and roles, motivation and working conditions. RESULTS: Participants displayed varying attitudes to the nature and purpose of the supervision process. Much of the discourse in Malawi centred on inspection and control, while interviewees in Tanzania were more likely to articulate a paradigm characterised by support and improvement. In both countries, facility level performance metrics dominated. The lack of competency-based indicators or clear standards to assess individual health worker performance were considered problematic. Shortages of staff, at both district and facility level, were described as a major impediment to carrying out regular supervisory visits. Other challenges included conflicting and multiple responsibilities of district health team staff and financial constraints. CONCLUSION: Supervision is a central component of effective human resource management. Policy level attention is crucial to ensure a systematic, structured process that is based on common understandings of the role and purpose of supervision. This is particularly important in a context where the majority of staff are mid-level cadres for whom regulation and guidelines may not be as formalised or well-developed as for traditional cadres, such as registered nurses and medical doctors. Supervision needs to be adequately resourced and supported in order to improve performance and retention at the district level.

Modifiable workplace risk factors contributing to workplace absence across health conditions: A stakeholder-centered best-evidence synthesis of systematic reviews.

BACKGROUND: A challenge facing stakeholders is the identification and translation of relevant high quality research to inform policy and practice. This study engaged academic and community stakeholders in conducting a best evidence-synthesis to enhance knowledge use. OBJECTIVES: To identify modifiable workplace disability risk and protective factors across common health conditions impacting work-related absence. METHODS: We searched MEDLINE, Embase, CINHAL, The Cochrane Library, PsycINFO, BusinessSourceComplete, and ABI/Inform from 2000 to 2011. Systematic reviews that employed quantitative, qualitative, or mixed methods of work-focused population were considered for inclusion. Two or more independent reviewers reviewed titles only, titles and abstracts, and/or full articles when assessing eligibility for inclusion. Selected articles underwent methodological screening. RESULTS: The search strategy, expert input and grey literature identified 2,467 unique records from which 142 full text articles underwent comprehensive review. Twenty-seven systematic reviews met eligibility criteria. Modifiable work factors found to have consistent evidence across two or more health conditions included lack of social support, increased physical demands at work, job strain, lack of supervisory support, increased psychological demands, low job satisfaction, low worker control of job, and poor leadership quality. CONCLUSIONS: The active engagement of stakeholders led to greater understanding of relevance of the study findings for community stakeholders and appreciation of the mutual benefits of collaboration.