Research evidence underpins best practice, but is not always used in healthcare. The Promoting Action on Research Implementation in Health Services (PARIHS) framework suggests that the nature of evidence, the context in which it is used, and whether those trying to use evidence are helped (or facilitated) affect the use of evidence. Urinary incontinence has a major effect on quality of life of older people, has a high prevalence, and is a key priority within European health and social care policy. Improving continence care has the potential to improve the quality of life for older people and reduce the costs associated with providing incontinence aids.This study aims to advance understanding about the contribution facilitation can make to implementing research findings into practice via: extending current knowledge of facilitation as a process for translating research evidence into practice; evaluating the feasibility, effectiveness, and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management; assessing the impact of contextual factors on the processes and outcomes of implementation; and implementing a pro-active knowledge transfer and dissemination strategy to diffuse study findings to a wide policy and practice community.Four European countries, each with six long-term nursing care sites  for people aged 60 years and over with documented urinary incontinencePragmatic randomised controlled trial with three arms (standard dissemination and two different programmes of facilitation), with embedded process and economic evaluation. The primary outcome is compliance with the continence recommendations. Secondary outcomes include proportion of residents with incontinence, incidence of incontinence-related dermatitis, urinary tract infections, and quality of life. Outcomes are assessed at baseline, then at 6, 12, 18, and 24 months after the start of the facilitation interventions. Detailed contextual and process data are collected throughout, using interviews with staff, residents and next of kin, observations, assessment of context using the Alberta Context Tool, and documentary evidence. A realistic evaluation framework is used to develop explanatory theory about what works for whom in what circumstances.ISRCTN11598502.Current Controlled Trials  Evidence-based healthcare has featured as a policy concern in many healthcare systems for over a decade driven by a growing recognition and concern that healthcare practice does not always reflect what is known to be best practice. Some studies ,2 suggesDespite significant investment, translating research in to healthcare decision making and practice remains a considerable challenge. In the United Kingdom (UK), a national evaluation of the extent and pattern of implementation of guidance issued by the National Institute for Health and Clinical Excellence (NICE) demonstrated a highly variable level of uptake, ranging from no change to significant changes in practice in line with the guidance . AdditioTranslating and using research in practice is complex, involving significant and planned individual, team, and organisational change. A case study meta analysis of evidence into practice projects highlights the social, organisational, and professional factors that mediate evidence use  and are The complexities inherent in the implementation of evidence into practice are represented in the Promoting Action on Research Implementation in Health Services (PARIHS) framework -21. In cThe subsequent development and refinement of the framework has been comprehensively described in recent publications ,20. ThisThe PARIHS framework has been well received by those working in the field of evidence-based healthcare, and has been used by others as a heuristic to guide implementation efforts at the point of care delivery -27 and aA key element of the PARIHS framework is facilitation, which could be described as a mechanism or intervention for the implementation of evidence into practice. A facilitator is an individual who is skilled in working with the concepts of change management and individual and organisational development. Facilitation involves the facilitator working with individuals, teams, and organisations to prepare, guide, and support them through the implementation process. This involves attentiveness to both the context (including barriers and enablers of change) and to the evidence to be implemented and how it fits with local circumstances. Two important features were identified in a concept analysis of facilitation . FirstlyThe findings from the concept analysis of facilitation suggest that the key to successful implementation is matching the purpose, role, and skills of the facilitator to the specific needs of the situation, i.e., appropriate facilitation . A systeDespite the increasing use of facilitation type models and techniques within implementation projects, to date, facilitation has received little attention in the formal classification of methods and interventions to change professional and organisational behaviour . Systematic reviews of various implementation interventions across a variety of settings show mixed effects -37. TherThis protocol describes a theory driven study to evaluate the effectiveness of facilitation as an intervention to implement evidence into practice. Drawing on the core elements of evidence, context, and facilitation, we will test a number of theoretical propositions about facilitation and the implementation of continence promotion evidence within nursing home settings across four European countries. The research will start to uncover the relationship between particular facilitation methods and the impact of the use of these methods on evidence use, contextual change, team effectiveness, and the creation of organisational infrastructures that support and enable knowledge utilisation.1. Extend current knowledge of facilitation as a process for translating research evidence into practice. Based on the PARIHS framework, two different models of facilitation will be developed , requiring different levels of facilitator skills and knowledge and the application of different methods of implementation, with corresponding different levels of resource requirements in terms of preparation and support of facilitators and the ways in which they work with individuals and teams who are attempting to implement research into practice.2. Evaluate the feasibility, effectiveness, and cost-effectiveness of two different models of facilitation in promoting the uptake of research evidence on continence management. An intervention study in four countries  will be set up to test the two different models of facilitation against a standard method of disseminating evidence of best practice on continence promotion. Six units per country will participate in the study (two units for each of the three study arms). The research evidence to be implemented will draw on existing evidence in the form of systematic reviews and guidance on continence management.3. Assess the impact of contextual factors on the processes and outcomes of implementation. The research will be underpinned by a theory-driven methodology, with a particular focus on explaining what works, for whom, how and in what circumstances. A detailed set of contextual, process, and outcome data will be collected in all the study sites to track the processes of implementation, to account for and explain contextual differences between and within countries, to monitor changes over time, and any diffusion beyond each study setting.4. Implementing a pro-active knowledge transfer and dissemination strategy to diffusion of the study findings to a wide policy and practice community. Dissemination will be planned in parallel to the design and implementation of the study, reflecting the theory-driven nature of the research and the importance of stakeholder involvement at all stages of the research process. Stakeholders will include the commissioners of the research, key interest groups at a European level, and policy-makers, managers, and practitioners in EU countries not actively participating in the research. Stakeholder involvement will inform the development and refinement of theoretical propositions as the study progresses and findings begin to emerge. A range of networking and dissemination methods will be used to promote the input and involvement of countries from throughout Europe and beyond.The design of this study is a pragmatic randomised controlled trial (RCT) with integral qualitative, quantitative and health economic evaluative components. The RCT has three arms: standard dissemination of recommendations; standard dissemination plus Type A  facilitation; and standard dissemination plus Type B (enabling) facilitation.We will assess the impact of the different facilitation programmes on processes and outcomes when implementing continence recommendations in long-term nursing care settings for older people. A dissemination or knowledge transfer strategy runs concurrently with the rest of the study.Whilst researchers investigating knowledge translation routinely collect summative data in RCTs of interventions, they rarely collect process data . Critical questions about the context of implementation, the feasibility of interventions, participant response, and resource implications need to be addressed in order to appraise why interventions worked (or not), in what situations, and with which stakeholders. This study has been designed to ensure that the experimental design is combined with exploratory and explanatory research in order to develop a richer and more detailed picture of the process and impact of implementation. As such, the findings of the study will have the potential to significantly build on and contribute to the international evidence base about research implementation. This study enables us to explore the factors that affect implementation over time within sites. The process evaluation has been designed as a realistic evaluation, and is embedded into the trial design. Realistic evaluation  is partiLong-term nursing care settings with publically funded places, at least 60 residents, are interested in taking part, have residents who are aged 60 years or older, with documented urinary incontinence. Settings will be excluded if they have previously taken part in other externally led improvement projects and/or where staff have already had facilitation development.Staff who have consented to be involved as: internal facilitators engaged in intervention delivery; staff at all levels working in sites delivering care; and key stakeholders related to sites .All residents meeting the following criteria are eligible for the study: aged 60 or over with no or mild dementia who consent to access to their continence related notes and/or being observed and/or completing quality of life questionnaires and/or taking part in interviews. Next of kin or consultee will be asked about looking at continence-related notes of residents with moderate to severe dementia. .Informal carers such as next of kin of residents who consent to be interviewed are eligible.Residents with moderate to severe dementia will not be interviewed or asked to complete quality of life scales. However, advice from next of kin or consultee will be sought about looking at their nursing home notes about continence care. In addition, next of kin or consultee of residents with moderate to severe dementia will be asked to completed a proxy quality of life scale (EQ-5D).The participants on the facilitation development programmes, known as internal facilitators, will be members of staff in the organisations in which the long-term care settings are located. They will be staff who are usually asked by their managers to lead and/or facilitate projects, change, or innovate in that organisation. Payment at a specified level will be made by the study to meet the costs of covering shifts while the internal facilitators take part in the study. The facilitation programmes will be led by expert external facilitators from the study team, working with the internal facilitators. To manage the risk associated with an internal facilitator leaving during the study, a co-facilitation model will be used, where a second person works with the internal facilitator, using this as a development opportunity, including taking the lead if the initial facilitator is unable to continue. This has been used successfully in other settings by the external facilitators .Two facilitation programmes were developed (type A and type B described below) to help participants implement recommendations for continence care in long-term nursing care settings for older people. These two types of facilitation intervention were informed by relevant theoretical and empirical knowledge, and facilitated by international experts in the area .The control group will receive standard dissemination that involves distributing the recommendations for continence care to the head of the long-term care setting, with a PowerPoint presentation about implementation. This is seen as standard practice (RCN 2007).This technical facilitation focuses particularly on addressing issues of implementation at the level of clinical teams, in terms of enabling them to design systems and processes of care that will enhance the transfer of evidence into their day-to-day practice. Type A facilitation draws on an eclectic range of theories, derived from management science, organisational learning, quality improvement, and humanistic psychology. It adopts a pragmatic approach to implementation, whilst recognising the need to pay attention to task, group, and individual needs. Individuals are prepared to take on the role of facilitator and are provided with a 'toolkit' of methods and techniques that they can use with health care teams to facilitate both the task and the process of implementing evidence . This isThis enabling facilitation uses critical social science concepts  on the basis that the emphasis on inquiry and the development of individual practitioners, cultures, and contexts within which they work, will result in overcoming difficulties, through emancipatory action, and thus bring about sustainable change. Such action is collaborative, inclusive, and participative. Theoretical underpinnings also draw on critical creativity and its focus on creating conditions for person-centredness and human flourishing and engaging in praxis  through professional artistry. Enabling facilitation is concerned with change and innovation, individual and team effectiveness, leadership and evidence use and development. Recent evidence suggests that practice development achieved through enabling facilitation methods requires a minimum of two years of sustained enabling facilitation . Arm thrIn stage one, the aim is to provide an opportunity for internal facilitators to develop, use, and refine a practitioner inquiry approach to enabling stakeholders in their organisations to improve continence care of residents by getting research into practice. This comprises the delivery of an 18-month enabling facilitation development programme, including planning, implementation, and evaluation of the continence recommendations. Stage two is a six-month diffusion study with the aim of enabling internal facilitators to develop further person-centred, evidence-informed practice in their workplaces/organisations. Internal facilitators will have 43 protected days over the two years , and 12 half days for self-directed study and research, culminating in the production of a portfolio of evidence. External facilitators will require 31 days each over two years. The external facilitators for Type B facilitation are BMcC and AT.The following characteristics are discussed with the manager of the setting to select an appropriate internal facilitator:1. Has some knowledge of good practice in continence care and has an interest in the topic2. Knows co-workers3. Knows the environment4. Knows the organisation5. Occupies a clinical leadership position6. Possesses effective communication skills7. Is self-aware and resilient8. Is reliable and dependableA review of research evidence was conducted as part of the fourth International Consultation on Incontinence (ICI) . They baThe recommendations to be implemented in this study were thus taken from the algorithm developed by Committee 11 who examined the research relevant to Incontinence in the Frail Elderly . The draRecommendations to be implemented in FIRE study1. The patient/resident should be actively screened for urinary incontinence.(Grade A)2. A detailed assessment should be carried out including:• Relevant co-morbid conditions should be assessed:- rectal examination; constipation (Grade C)- functional assessment  (Grade A)- screen for depression (Grade B)- assess cognitive status (Grade C)- any medications that could cause or worsen UI (ICI recommendation)- any medical conditions that could cause or worsen UI (ICI recommendation)• Urinalysis should be undertaken  (Grade C)• Undertake wet checks to assess frequency of urinary incontinence (Grade C)• Ensure diagnosis of the type of UI is recorded (ICI recommendation):- Urgency- Stress- Mixed- Other3. An individualised treatment plan should be in place for:• Individualised goals of care (Grade C)• Treatment preferences of resident and/or next of kin (Grade B)• Bladder retraining (Grade A), or tailored prompted voiding [if able to state name] (Grade A)• Degree of bother to resident/next of kin of UI (Grade B)4. Specialist referral should be made if needed . (ICI recommendation).The researchers will adhere to ethical standards for research involving people. In addition, all researchers will abide by their institutional and national ethical requirements. Ethical Committee approval was obtained in England, Sweden, and Republic of Ireland. In the Netherlands, the researchers were advised to get permission from either an ethical committee at site level, or where this did not exist, from a scientific or residents committee at the site. Research Governance approval was also obtained in England, and permission to collect data at the sites obtained in Sweden and Republic of Ireland.Percentage compliance with continence recommendations  will be calculated, and a data profile constructed.These include number of referrals for specialist continence assessment, incidence of documented incontinence-related dermatitis, urinary tract infections , and patients' health-related quality of life using I-QoL ,46 and tThe embedded process evaluation will focus on four areas: facilitation residential programme evaluation; facilitation  implementation ; influences on implementation ; and the impact of intervention implementation on continence care processes and care home environments.Qualitative and quantitative data collection methods will be used to strengthen our conclusions through method triangulation. Consistent with a realistic evaluation approach ,49 our aData are being collected through interviews with relevant stakeholders including staff, residents, and next of kin, a questionnaire to assess the context of practice , observations and documentary evidence. Our intention is to construct a comprehensive picture of the impact of facilitation on continence practice, nursing home contexts, and residents.ACT has been designed to be a reliable and valid measure of context within complex healthcare settings where care is provided to patients/residents . The ACTSemi-structured interviews (telephone and face-to-face) will be conducted with internal and external facilitators, staff, stakeholders, and residents as well as their next of kin during the lifetime of the project. Interviews will be conducted at critical points in the programme pre-, during, and post-intervention. Interviews will focus on the experience of implementation, barriers and facilitators, key events, social, political, and financial aspects of care and service delivery, and more specifically how continence care is delivered. The questions asked in interview will be adapted, depending on the purpose of the interview, and who the stakeholder is.Data from interviews will enable the capture of intervention specific process information  as well as more general features of the study sites with which to contextualise outcome data from the main intervention project. Interviews will be audio-recorded, and later transcribed.We will undertake non-participant observation of care delivery, significant events in the implementation processes and facilitation residential programmes. Non-participant observation will contribute to identifying barriers and facilitators to implementation and practice change, to provide evidence about the role and influence of the facilitators including identifying what are the elements of the role that contribute to 'good enough' facilitation, the reasons for the particular adaptations of the facilitation models to local contexts, and the interactions between facilitation and the context(s) of care.Observations will be recorded as field notes, including descriptive accounts, and interpretive/reflective comments. Where appropriate and possible, interviews will be timed to follow periods of non-participant observation. Observations will be informed by nine dimensions   and the We will gather any available routinely collected local data relevant to the delivery of continence care, and to help us understand the context of care. This may include, for example, an audit of continence care or product use.Relevant continence care specific documentation will be collected from each site such as policies, procedures, and guidelines. These should provide useful sources of information about expected continence care practice. Documents will be monitored through from pre- to post- intervention, and any changes made to them noted.Process data will be collected by facilitators as part of both facilitation interventions, which may include for example the administration of the Context Assessment Index , internaThe embedded economic evaluation will take a public sector, multi-agency perspective ,53. The There is no information available on the current level of compliance with the recommendations, so for the purposes of the power calculation our initial assumption is that there is 50% compliance. It is assumed that in each nursing home 50 patients would be available for assessing compliance with the recommendations. For 90% power to detect if compliance with the recommendations is 15% better in the facilitation arms compared to the standard dissemination arm and allowing for an intracluster correlation of 0.01 and statistical tests carried out at the 5% level, we will, for cluster size 50, require 7 clusters (nursing homes) per intervention arm . Thus 21If compliance with recommendations is lower than 50%, for example 10% (0.1) then for 50 residents per cluster, 4 clusters would be needed per intervention . If there were 20 residents per cluster, then 8 clusters per intervention would be needed , and if 10 residents per cluster then 14 clusters per intervention  would be needed.This gives the range of number of clusters potentially needed, given lack of information on current compliance, and allowing for a range of numbers of available residents in each cluster. In this study, it was decided that having 8 clusters per intervention  would give the study the best chance of detecting a 15% improvement in compliance between the standard dissemination and facilitation arms.Up to five members of nursing staff, five residents, five next of kin and managers and other stakeholders will be interviewed in each site at baseline. Exact numbers will be determined by data saturation and local factors. Further interviews to explore the processes of implementation and its impact will be conducted at points during the study where there have been changes either to continence care or in the context locally at the home, region or nationally.In each country , six sites will be selected which meet the inclusion criteria. These sites will be randomised from a central randomisation point, which will ensure allocation concealment. We will use a stratified random allocation, stratifying by country, and within each strata we will use randomised block of size six. Each site will be randomly allocated to one of three groups: standard dissemination; Type A  facilitation; or Type B (enabling) facilitation. In each country there will be two sites randomly allocated to each arm. The randomisation schedule will be computer generated and prepared by a statistician who is independent of the project team. The country co-ordinators will convey allocation to each site to ensure the research fellows remain blinded.There are many challenges of maintaining blinding in this study. However, research fellows collecting outcome and process data will be blind to the random allocation of each site for baseline data collection. From previous experience, we anticipate that the blinding may be inadvertently broken by the sites either during or after baseline data collection. . If and when blinding is broken will be recorded for each site. It is not possible to blind the external facilitators delivering the facilitation programmes as they are delivering the programme because they have specific expertise in that type of facilitation.Baseline data will be collected at each site before the intervention. The intervention will take place over 12 months in arm two, and over 24 months in arm three. Outcome data will be collected at 6, 12, 18, and 24 months after the start of the intervention for all groups. This will be concurrent with longitudinal process evaluative data collection.Interview schedules and recommendations were translated into Dutch and Swedish. These translations were checked by the country co-ordinators. The Quality of Life Scales already had validated Swedish and Dutch versions. The Alberta Context Tool was translated into Swedish and Dutch. A systematic process of translation, back translation, revision, and feasibility assessment based on several years experience and translation into several languages with the ACT was followed.Research Fellow training was provided before baseline data collection to ensure a common understanding of the process, and reinforced at training sessions throughout the study.Data will initially be entered onto an excel spreadsheet, uploaded by each country onto a secure central site, and then transferred to SPSS version 18 for analysis. An intention to treat analysis will be carried out on the primary and secondary outcomes. Descriptive statistics will be calculated for all variables of interest. Continuous measures will be summarised using means and standard deviations; categorical variables will be summarized using counts and percentages. Descriptive analyses within and across data sets and within and across sites by country, as well as across countries, will be carried out.The primary outcome measure, compliance with the recommendations, will be compared at cluster level . RepeateA Data Management and Monitoring Committee has been set up with agreed terms of reference to review quantitative data management and monitor emerging results.Each set of data will first be analysed separately first using a thematic content analysis, within a realist evaluation framework . This foQualitative data will managed through AtlasTi. Data analysis will be an iterative process between data sets and study phases. Integration and synthesis of data will be guided by our theoretical framework and principles of conducting mixed methods research .An integrated knowledge transfer strategy underpins the study, encompassing three key strands of activity. First, we are developing and implementing a model of stakeholder involvement that complements the theory-driven approach to the study design and enables stakeholder involvement throughout the research process. Second, we are developing a portfolio of networking and dissemination activities that will promote active diffusion of the study findings to key individuals and organisations in the EU, Europe and internationally. Third, we will be supporting study participants to disseminate their experiences and learning as a result of their involvement in the research, thus enhancing the sustainability and spread of the study findings. We will evaluate the effectiveness of stakeholder involvement and dissemination activities as the study progresses and revise accordingly.The Committee and Management Structure include:1. A project board comprising all members of the consortium, chaired by project co-ordinator.The Project Board assures co-ordination and supervision of all activities, including time lines and project reports and publications. The Board will meet twice a year, and maintain regular communication as appropriate. Decisions will be normally taken by consensus. In exceptional cases where this is not possible a majority vote will be used.2. An advisory committee comprising key stakeholders and including external experts, to provide advice and review progress.Their role is to provide advice, guidance, and challenge to the project board throughout the project, and to help ensure the research contributes to knowledge at a European and International level, but final responsibility lies with the project board. This committee will meet three times, at the start, mid- and end-phases of the study .KS is the overall project co-ordinator. Each country site will be managed and overseen by a member of the consortium nominated as country co-ordinator. .Initial experiences with data collection so far suggest this pan-European study is complex to run, with many and varied challenges. A 'lessons learned' log and risk register are important aspects of managing these challenges.New understandings and empirical testing of the facilitation element of the PARIHS framework have the potential to make substantial contributions to knowledge in this area.The authors declare that they have no competing interests.KS  led the application for funding. She contributed to the overall design of the study and designed to pragmatic RCT aspect of the study. She led the design of the outcomes to be assessed and led the writing of this protocol manuscript. KC (collaborator) participated in designing the study and provided critical commentary to the manuscript. She is country co-ordinator for the Netherlands. NC (statistician) advised on study design and contributed to the analysis plan within the pragmatic RCT, and provided critical commentary on the manuscript. RTE  is responsible for the economic evaluation study design and has contributed to the manuscript. ACE (research fellow) participated in the design and development of the evaluation package and commented on the manuscript. CAE (collaborator) participated in study design, participates in the evaluation stream and coordinated the use of the Alberta context tool including its translation into Swedish and Dutch. She commented on the manuscript. GH (collaborator) participated in the design of the overall study and in the design of the facilitator intervention in particular. She co-leads Arm two of the intervention and work package that is concerned with knowledge translation and dissemination. GH has inputted to and commented on the manuscript. AK (collaborator) participated in the design of the overall study and in the design of the facilitator intervention in particular. She co-leads Arm two of the intervention. AK has commented on the manuscript. PL  contributed to the economic evaluation design, is responsible for the day to day running of the economic evaluation, and contributed to the manuscript. BMcC (collaborator) participated in the design of the overall study and in the design of the facilitation intervention in particular. He contributed to the text about Arm three and commented on drafts of the manuscript. He co-leads Arm three of the intervention and is the Country Coordinator for Ireland. GMcC (collaborator) participated in the initial design of the study and commented on the manuscript. CH (research fellow) participated the design of the process evaluation and associated data collection tools, the development of the economic evaluation, and is responsible for the day to day running of the process evaluation. She commented on the manuscript. CM (research fellow) participated in the design of the RCT and associated data collection tools. She commented on the manuscript. JRM (collaborator) participated in designing the study. She led the design of the evaluation package and is country co-ordinator for England. JRM commented on drafts of the manuscript. AT (collaborator) participated in the design of the overall study, especially the Type B facilitation intervention and the design of the evaluation package. She co-leads Arm three of the intervention, has contributed to the text about Arm three and commented on the manuscript. LW (collaborator) participated in the design of the overall study and in the design of the intervention evaluation in particular. He has commented on the manuscript. He is the Country Coordinator for Sweden. All authors read and approved the final manuscript.


This paper is based on data gathered from a 2006 survey of 1,098 "street children" in Northern Tanzania. It examines the role that school may play in preventing the migration of vulnerable youth to become homeless "street children". Specific focus is placed on the correlations found between children's attendance in school, their reports of abuse or support in their family, and their status of living "on the street" full-time or part-time.th and 27th, 2006. Respondents were given survey questions about their home, school and street life experiences, in order to measure the impact of outreach work being performed by a Tanzanian NGO. Interviewers used purposive sampling, approaching all young people who appeared to be under the age of 25 years within a number of precincts in each town known to be where 'street children' were known to congregate.This study is from quantitative interview data gathered from 1,098 children and youth between 5 and 24 years old on the streets of Moshi and Arusha, Tanzania, over a 48-hour period during the school year on October 26Results suggest that regular attendance in school may be a significant protective factor for children in preventing migration to the street life. Statistical analysis revealed that those young people who dropped out of school had nearly 8 times higher chances for ending up on the streets permanently than those who attended school daily.This study supports the new concept of "multi-layered social resilience", providing evidence from research completed by one NGO on how community-based organizations can help enhance resilience in a broader social context, spanning individuals, households and community structures. It is estimated that as of 2009, over 50% of the world's population lives in urban areas, and this global urbanization process is having particularly profound effects on the physical and mental health of children who live there . One of http://www.mkombozi.org, a local NGO that has operated for over 12 years in the northern regions of Kilimanjaro and Arusha in Tanzania. Mkombozi has offered a variety of outreach services to prevent children coming to the streets, collaborating with local families, schools and community leaders to identify youth who may be vulnerable of becoming homeless and establishing community support mechanisms. Mkombozi's efforts illustrate how NGO's can contribute to building equitable development and long-term poverty eradication for citizens of all ages in low-income countries.As a response to this epidemic of youth homelessness internationally, organizations tend to focus on offering services to assist these "street children" with a goal of removing them from the streets and re-integrating them with their families and communities. There are many methods being utilized to contact and engage with street children on the streets, including offering sports, play, non-formal education and vocational training programs to get them involved and eventually off the streets. This paper will examine the work of one youth agency, Mkombozi The Mkombozi organization hypothesizes that children's attendance in school plays a particularly crucial role in keeping them engaged and living in their communities, and thus preventing them from migrating away to live and work on the streets of urban areas. In Tanzania school attendance is compulsory but free for elementary school children, and free for all children that wish to attend. Unfortunately, there are additional costs for families to send their children to school, such as the purchase of uniforms and books. For poor families these additional costs can be prohibitive, which can inhibit their ability to afford sending their child to school.Many youth are under pressure to leave school prematurely because of family poverty, whilst others are tempted to spend time on the streets during the day by the prospect of freedom and lack of supervision . HoweverThe Mkombozi organization has identified the need to understand more precisely the forces pushing children to the streets and to test its assumption that keeping children in school would keep them off the streets. Thus, in 2003, 2005 and 2006 Mkombozi implemented a series of census-surveys in order to begin to (1) measure the impact of their preventive work; (2) to estimate the numbers and trends in the "street children" population; and (3) to examine the survival strategies that the street children use .This paper is based on the statistical analysis of a second subset of data gathered during the school year from 1,098 children and youth from the 2006 census-survey of "street children" in the urban areas of Arusha and Moshi, Tanzania. The first subset of data identified where children lived - at home, part-time or full-time on the streets - and whether they reported having supportive or abusive relationship with their families ["a dynamic process encompassing positive adaptation within the context of significant adversity. Implicit within this notion are two critical conditions: 1.) Exposure to significant threat or severe adversity; and 2.) the achievement of positive adaptation despite major assaults on the developmental process" [Conceptually, this paper examines the influence that school attendance has on children and youth from the theoretical framework of individual "resilience". The construct of individual psychosocial resilience has evolved from extensive research in the developmental psychology field -14, and process" . In thisprocess" . In thisprocess" ,17.Much literature on street children tends to emphasize the physical and emotional risks that the lifestyle incurs, and to examine how they cope in the face of such adversity, but it does little to examine the extent of their positive adaptation in the face of that environment and what skills and behaviors may be nurtured by that environment -20.Current resilience researchers are urging more attention be paid to how "resilience processes" can be enhanced in young people via their involvement in structured sport/play, educational and vocational training programs ,22. It i"feeling competent" and "elevating expectations" that can be facilitated within the context of relationships with reliable, caring, and competent adults [Adolescence is a time of rapid cognitive, social, emotional and physical changes, with particularly dramatic changes in pathways of adaptation occurring during the late adolescent period of emerging adulthood . In thist adults . PreventThe significance of social factors for enhancing the development of resilience processes in young people leads us to consider another important and new conceptualization of resilience, which involves the current work of Obrist, et al , who def"the capacity of actors to not only cope with and adjust to adverse conditions (i.e. reactive capacity) - but search for and create options (i.e. proactive capacity), and thus develop increased competence (i.e. experience positive outcomes) in dealing with threats" [Obrist further defines social resilience as threats" . Social th and October 27th, 2006. Interviewers used purposive sampling, approaching all young people who appeared to be under the age of 25 years, within a number of precincts in each town known to be where 'street children' were known to congregate.This study sample is from quantitative interview data gathered from a population of 1,098 children and youth between 5 and 24 years old in Northern Tanzania, with 70% of the respondents between the ages of 10 and 19 years old, 78.5% of who are males. Respondents were given survey questions about their home, school and street life experiences, in order to measure the impact of outreach work being performed by the Tanzanian NGO "Mkombozi". Data was collected through on-the-street interviews with all children and young people visible on the streets in the towns of Arusha and Moshi in northern Tanzania, during the school year over a 24-hour period on October 26The census-survey was conducted with the approval of the local Moshi and Arusha Government Social Welfare departments in northern Tanzania, who believed that the information gained by interviewing homeless children was a significant public health benefit. The study was then given a retroactive ethics clearance for publication by the Tanzania National Institute of Medical Research (NIMR). Finally, once the ethics clearance was approved by NIMR, it was as well approved by the State (canton) of Zurich ethics review process.Each child or youth approached by interviewers were provided information about the nature of the study, and asked for their "informed consent": where all interviewed young persons were first informed of their rights to participate in an interview or not, to be able to refuse to answer a question or be able to end the interview at any time, and that in all circumstances their wishes would be respected and questioning stopped. If informed consent was not received from the child, they were not interviewed. Any interviewees were also given information about whom they could talk with for counselling support, should they desire further support anytime after the interview. All data was collected anonymously, with no details of names or other identifying information asked for or retained. Further, the data sets shared with the University of Zurich were sent as completely anonymous secondary data on electronic excel spreadsheets.Collection of field research data with street children is complicated by the fact of these children being "restless and reluctant responders" who are generally mistrustful of unfamiliar adults . To encoA questionnaire was developed in English, then translated into Swahili and then back-translated into English with further refinements among bi-lingual members of the Mkombozi staff. The questionnaire was then pilot-tested by giving it to former street children who were in care at a residential centre to assess face validity. The questions disaggregated children living on the streets full time from those who had only partial contact with the following questions: "Do you live and sleep on the streets all of the time, both day and night?" In response to a negative reply they were asked: "Do you come to the streets during the day and return home at night?" Interviewees were also asked what activities they engaged in, and to rate the range of time spent on the street using a four point Likert-type scale. There was also a section in the survey that asked questions about school attendance. For example, "Are you a primary school student?" (yes or no), and if yes, "Are you attending daily", "Playing truant", or "Have dropped out".Lastly, possible supportive and abusive factors in family homes were assessed by inserting eight Likert-type questions adapted from the Adverse Childhood Experiences (ACE) test , which wThe survey collected data on demographic information, school attendance patterns, and an assessment of how the interviewee saw family life. This covered eight variables of family life addressing three positive items  and five negative items . When completing the questionnaire the children could rate the frequency of these experiences from never (0) to very often (3), with each of the variables being analyzed as single items. The self-reported information on whether children were living on the street (permanently or temporarily) at the moment, served as an outcome in following analyses.Street children status was numerically assigned in 3 ways, namely whether they self-identified as living "part-time" or "full time" on the street, or if they did not identify as living on the street at all e.g., 1) "Not living on the street"; 2) "Living part-time on the street"; or (3) "Living full-time on the street"). These responses were considered as a polytomous outcome variable, with these three categories as possible answers. Explanatory variables were selected based on theoretical considerations. As displayed in Table  "Not liv "Living  "Not livAs displayed in Table A hierarchic sequence of three multinomial logistic regression models was performed to determine risk factors for street life among children surveyed by Mkombozi. Street status served as outcome variable with "never been on streets" as reference category. Odds ratios were estimated for all variables that were significantly associated to street status in univariate analyses  is significantly associated with increased "living on the street" status in all models . Also, "full-time" street life is more highly associated with age than "part-time" street life .When adding self-reported supportive and abusive factors to the equation (model 2), lower level associations were found for reports of physical abuse and neglect as additional risk factors for street life, while the latter was only associated to permanent street life. However, reports of higher "family love", "family protection", as well as "having enough food at home", turned out to be important protective factors against ending up on streets, both temporarily and permanently, except for "family protection" which revealed no elevated risk for part-time street life.The final model (model 3) revealed that school attendance plays a crucial prevention role in the likelihood of a child ending up living on the streets, independently of all other factors. A child dropping out of school, as well as being truant, is highly associated with taking up a life on the street, and especially a "full-time" street life. Whereas, being truant had no associations to part-time street life. Those who dropped out of school had nearly 8 times higher chances for ending up on the streets permanently than those who attend school daily, while the odds for migrating to the streets temporarily is only a bit lower (OR = 5.5). In this last model, most former associations between support/abuse and street status disappeared. Having enough food was sufficiently protective against a part-time but not full-time street life. Reports of physical abuse and neglect (whether at home or at school) remained significant risk factors for migration to permanent street life.The key findings from the statistical analysis of the survey results gathered from 1098 children and youth on the streets in the urban areas of Moshi and Arusha in Tanzania, supports the hypothesis that school attendance plays a crucial protective role in preventing children from migrating to live on the streets. In Tanzania attendance in school is compulsory but free for elementary school children, and free for all children that wish to attend beyond that, although there are additional costs  that can inhibit a poor families' ability to pay for a child to attend school.The results suggest that children who drop out of school are highly associated with becoming homeless, and highly correlated with taking up a "full time" street life. Those who dropped out of school have an eight times higher chance for ending up on the streets, compared to those who attend school daily. Therefore, beyond the obvious benefits of gaining an education (in the form of knowledge and competencies), significant positive developmental outcomes are also gained from participation in a school environment, having to do with the mental, social and behavioural health benefits that engagement in a school community can provide. School attendance was not only found to be a significant protective factor in preventing migration to street life, it was also found to be a significant protective factor in counteracting the negative factors of abuse, trauma and neglect that some children experience in their homes.There are some significant limitations to this research: The subjects were not randomly selected, there wasn't a comparison group, and the survey did not gather enough precise information to provide a more detailed understanding of whether the sources and effects of support or abuse in the home, in the school, and/or on the streets. We don't know if the children went to the street and then dropped out from school, or vice versa, and to what extent violence in school caused the migration to the street . More information could have been gathered about the role that school plays from the perspectives of the "street children". And lastly, the data that was collected was not originally intended to be used for published empirical research, but rather, as a means to monitor and evaluate the effectiveness of an NGO's implemented program services.Nonetheless, this census-survey undertaken by the NGO Mkombozi is important for the new knowledge that was gained and shared with their local communities. For example, Mkombozi has been able to adapt its services and interventions based on the survey data gathered, allowing them to identify specific neighbourhoods and schools that had more school attendance problems, thus enabling them to identify and focus on implementing the most effective prevention practices for support of individuals, families, schools and communities. Anecdotal information was also provided by Mkombozi about how the collected data was shared with school and community leaders, who either intervened with families who made their children go to work rather than allow them to attend school; or who developed creative ways to support those in the community who couldn't afford the extra fees required to enrol their children in school. In one example, a school started selling lunches on-site, and with the profits paid a local tailor to sew new school uniforms for the children of families who couldn't afford to buy these for their children, thus enabling the children to attend school.The results of this research, despite the above noted limitations, offer glimpses into the key role that educational can play in enhancing individual, organizational and community resilience to adversity, and in turn improve opportunities for more successful and sustainable development. It is strongly recommended that more research be focused on how school attendance and participation can enhance the psychosocial strengths and competencies of children and youth to more successfully meet the challenges they will face.The significant statistical correlations found between "full time" street status, reports of supportive or abusive households, and school attendance provides support for the "multi-layered social resilience" conceptual model. The practices of the NGO Mkombozi, originally founded to help individual street children "on the street", have been adapted and expanded to offer improved educational services for troubled children in a number of contexts: 1). For those still living with their families and attending school regularly. 2. To provide informed outreach and advocacy services to more effectively engage, collaborate with, and encourage increased community involvement with its families and children. 3. And to both educate and support the efforts of local health and law enforcement agencies in more effectively addressing the root problems faced by "street children" in their community context. This is "multi-layered resilience" in action: a community organization working to improve the quality of life for individuals, households, and community structures. These research efforts have resulted in helping Tanzanian communities to be more resilient through strengthening collective coping skills , and also through the development and strengthening of local problem-solving strategies , thus enhancing resilience competencies on many layers: for the individual, household, community, regionally, and potentially, even nationally.The authors declare that they have no competing interests.RH: Conceptual development, principal writer, resource research, data analysis, data interpretation, and editing. KM: Conceptual development, designer, principal investigator and writer. MM: Investigator, statistical analysis and interpretation. SV: Investigator, writer and final editing. All authors read and approved the final manuscript.


The high maternal and neonatal mortality rates in South Asia and Sub-Saharan Africa can be attributed to the lack of access and utilization of health services for delivery. Data from the Demographic and Health Surveys conducted in Bangladesh, India, Pakistan, Kenya, Nigeria, and Tanzania show that more than half of the births in these countries were delivered outside a health facility. Institutional delivery was closely associated with educational level, family wealth, place of residence, and women's media exposure status, but it was not influenced by women's work status and their roles in decision-making (with the exception of Nigeria). Controlling for other variables, higher parity and younger women were less likely to use a health facility for delivery. Within each country, the poorer, less educated and rural women had higher unmet need for maternal care services. Service related factors (accessibility in terms of cost and distance) and sociocultural factors  also posed as barriers to institutional delivery. The paper concludes with some suggestions to increase institutional delivery. Globally, approximately 287,000 women died from causes related to pregnancy and childbirth in 2010. Of these, 162,000 were in Sub-Saharan Africa and 83,000 were in South Asia. The maternal mortality ratio  ranges from 16 in the developed countries to 220 in South Asia and 500 in Sub-Saharan Africa [The major complications that account for 80 percent of all maternal deaths are severe bleeding and infections after childbirth, high blood pressure during pregnancy and unsafe abortion . AntenatFactors that prevent women from receiving or seeking health care during pregnancy and childbirth include inadequate services, poverty, distance, lack of information, and cultural practices , 8. HealNumerous studies on the utilization of health facilities have been carried out at the national or subnational level in various parts of the world, including Sub-Saharan Africa and South Asia –19. HoweThe main objective of this paper is to examine the determinants of sociocultural, service and information related barriers to the use of health facilities for childbirth. A better understanding of these barriers is essential for implementing various strategies to increase women's utilization of health facilities to reduce maternal and child deaths.Data for this study come from the Demographic and Health Surveys (DHS) conducted in 3 selected South Asian countries and 3 African countries in 2006–2010. MEASURE DHS Project has been funded by USAID with contributions from other donors to carry out surveys in developing countries on demographic and health issues that can inform policy. The DHS apply multistage probability sampling to provide nationally representative samples of women of reproductive age . Since 1984, DHS have been conducted in 85 countries based on a set of core questionnaires to allow comparison across countries. The data are available to researchers through an online database .Bangladesh, India, and Pakistan were chosen to represent South Asia subcontinent, while Kenya, Nigeria, and Tanzania were chosen to represent the Sub-Saharan Africa. These countries were selected based on the population size and the availability of DHS data for the most recent period—2007 for Bangladesh, 2006 for India, 2007 for Pakistan, 2009 for Kenya, 2008 for Nigeria, and 2010 for Tanzania.The proportion of women who had more than one birth in the five years prior to the survey ranged from about one-quarter in Bangladesh to one-third in India and 45–52 percent in the other four countries in this study. This analysis is based on the most recent birth within the reference period.Place of delivery, type of birth attendants, and reasons for not using a health facility for the delivery are the dependent variables for this study. For logistic regression analysis, place of delivery and type of birth attendant were recoded into binary variables, taking the value 1 for institutional delivery, 0 otherwise, and 1 for delivery by trained personnel, 0 otherwise. The independent variables may be classified as individual-level variables ; household-level variables ; and community-level variables . In previous studies, education, household socioeconomic status, and urban-rural residence are consistently significant predictors of service utilization, while all other variables are less consistent predictors across studies , 23–38.Household income data were not collected in DHS. Instead, the data sets contain a variable on the household's quintile classification of wealth index generated through principal component analysis based on household ownership of various assets and on housing characteristics. Description of the construction of this variable can be read from the report for each country.Women's status is represented by a variable on whether a woman has a final say on her own health care .frequency of reading newspaper or magazine (more frequent = 1/less frequent = 0);frequency of listening to radio;frequency of watching television.Media exposure is an index based on the following:Women who scored 0 to 1 were grouped as a “Low” exposure to the media and 2 to 3 were grouped as a “High” exposure to the media.We began with a description of the sample distribution for each independent variable, followed by the distribution of place of delivery and the type of birth attendant for each country. The independent variables were interrelated with one another, with confounding effects on delivery care. For instance, family wealth index was closely associated with the educational level of women and their husband; higher educated women tended to marry higher educated men; and educational level and financial status were also closely associated with media exposure and birth parity. Binary logistic regression analyses were used to examine the odds of using health facilities and services for delivery within the multivariate context. Each of these variables represents a different construct, and the problem with multicollinearity is not a concern.Odds ratio of value greater than 1 shows that the likelihood of the occurrence of an event is higher in a particular group as compared to the reference group, and vice versa. Odds ratio of less than 1 is deducted from 1 and interpreted as a percent less likely. For instance, an odds ratio of 0.8 is interpreted as 20 percent less likely for the occurrence of an event as compared to the reference group.The sample for this study was based on the last birth of currently married women aged 15–49 years who had given birth 5 years preceding the survey. The level of urbanization in all the six countries was considerably lower than the average for the less developed world which stood at 46 percent in 2010. A significant proportion of women and their husbands in these countries had never been to school. Gender gap in education was most pronounced in Pakistan, where two-thirds of the women had never been to school. Women in the three Sub-Saharan African countries, especially in Tanzania, had very high labor force participation rate. In contrast, few women in South Asia were reported as working. In the five countries where data are available, women in Kenya had relatively high status in the family as compared to the rest. In contrast, Tanzanian women had the lowest status within the family. Women in all the six countries in this study had low media exposure.For the wealth quintile, the deviation from 20 percent for the various subgroups can be explained by the uneven distribution of childbearing women in the 5 years preceding the survey. In Kenya, Nigeria, and Pakistan, women giving births in the five years before the survey were over-represented by those in the poorest wealth quintile, but they were over-represented by those in the richest quintile in Bangladesh and India.The modal age group was below 30 years for all the six countries, with Bangladesh and India having the youngest age structure. Except for Bangladesh and India, the number of women having 1-2, 3-4, and 5 or more children was rather evenly split.In all the six countries, more than half of the births occurred outside a health facility, and most of these were home delivery. Use of trained attendant for delivery corresponded closely with the place of delivery. All the births that occurred in a hospital or clinic were delivered by a trained attendant. A sizable proportion of home delivery was attended by trained personnel, and this ranged from 5-6 percent in Bangladesh, Kenya, and Nigeria to 15–17 percent in Tanzania and India. The proportion of births attended by an untrained attendant, including traditional midwives, was highest in Bangladesh (76.9 percent) and lowest in India (46.9 percent). There was no discernible difference in births attended by untrained personnel between South Asia and Sub-Saharan Africa. In South Asia, most of the deliveries by trained attendants were conducted by doctors, but nurses were the main birth attendants in the three Sub-Saharan African countries .Logistic regressions were used to examine the determinants of the use of health facilities for childbirth in the multivariate context . In all Utilization of health facilities for delivery also varied widely by region within each country, probably due to the uneven distribution of hospitals, health centers, and clinics, with concentration in the more developed regions. More detailed tabulations of DHS data show that women from the more developed regions were much more likely than those from the less developed region to deliver in a health facility. In all countries, rural women were much less likely than urban women to use a health facility for delivery .In all the six countries, women who had never been to school were least likely to have institutional delivery, while those with at least secondary education were most likely to do so. The educational effect on institutional delivery was weakest in Tanzania. In Nigeria and all the three countries in South Asia, the effect of the wife's education on the use of a health facility for childbirth was much stronger than that of the husband's education.The odds of using a health facility for delivery were about the same for both working and nonworking women in Tanzania and the three South Asian countries. In these four countries, higher educated women were less likely to work as compared to their lesser educated counterparts. In Kenya and Nigeria, where working women had higher odds of institutional delivery, higher educated women were more likely than lesser educated women to be currently working.With the exception of Nigeria, there was no significant difference in institutional delivery between women who had a say in their own health care and those who did not have a say. In Nigeria, women with no say were significantly less likely to use a health facility for delivery. Contrary to expectation, Indian women who did not have a say in their health care were a little more likely than those who have a say to deliver in a health facility.Except for Bangladesh, the odds of institutional delivery decreased monotonically from the richest quintile families to the poorest quintile families. In India and Nigeria, women from the poorest quintile families were 86–90 percent less likely than those from the richest quintile families to give birth in a health facility. In all the five countries where data are available, women with low media exposure were much less likely than those with high media exposure to give birth in a health facility.Of the two demographic control variables, birth parity was a more important predictor of the use of a health facility for childbirth as compared to maternal age. Lower parity women were much more likely than higher parity and older women to deliver in a hospital or clinic. This suggests that the more experience a woman had in childbirth, the less likely she would use a health facility for delivery. However, controlling for other variables in the model, younger women were less likely than older women to use the health facilities for delivery.The determinants in the utilization of trained personnel for delivery corresponded rather closely to that of the place of delivery, as shown in Family wealth index provides consistently the sharpest differentials in the odds for delivery by a trained attendant across all the six countries. Poorest women in Nigeria were 92 percent less likely to have their births attended by a trained attendant, and in India where the differential was smallest, the corresponding figure was 74 percent. Place of residence, educational level of women and their husbands, and birth parity are significant variables in predicting delivery by a trained attendant, and the findings are in congruence with that of the place of delivery. Except for Bangladesh, DHS in the other five countries collected information on the reasons for not delivering in a hospital or clinic. The mean number of responses ranged from 1.03 in Tanzania to 1.3 in Pakistan. Several studies found that women living far away from a health facility were much less likely to have a skilled attendant and an institutional delivery , 17. In High cost was the second most often stated reason for the nonuse of health services in India and Pakistan. However, it was of lesser concern to women from the three African countries, especially Tanzania. It is notable that a rather sizable proportion of nonusers of health services in Kenya mentioned abrupt delivery, and more than one in ten in Nigeria reported that it was not customary to give birth in a health facility. Other barriers to institutional delivery include objection from husband/family , no facility, and lack of trust in the facility. Only a small proportion mentioned nonavailability of female health provider for not delivering at a health facility. More detailed tabulations of data show the very wide variations of reasons for the nonuse of health facility for delivery by region and ethnicity within each country. For instance, in India the proportion of respondents who mentioned “cost too much” ranged from none in Kerala to 48 percent in Bihar; the percentage not using a health facility for delivery because of distance ranged from 4.7 percent in Delhi to 75 percent in Kerala; family objections ranged from none in Kerala to 17.5 percent in West Bengal and “not necessary to use” ranged from 25 percent in Kerala to more than three-quarters in a number of districts.The ethnic differentials in the reasons for not using a health facility for delivery were most striking in Pakistan, as shown in Between 1990 and 2010, maternal mortality ratio (MMR) declined by 64 percent in Southern Asia and 41 percent in Sub-Saharan Africa. The MMR in these two regions remains the highest in the world, and it appears unlikely for Sub-Saharan Africa to achieve the target under MDG 5 to reduce the MMR by three-quarters between 1990 and 2015. Because the majority of maternal deaths occur just before, during, or just after delivery, often from complications that cannot be predicted, institutional delivery can reduce the risk of complications and death of mother and baby significantly. Nonetheless, a very high proportion of births in Sub-Saharan African and Southern Asia are occurring outside a health facility and are not delivered by a skilled attendant. Concerted efforts must be made to increase the utilization of maternal care services to achieve the MDG goals in the two regions.Consistent with the findings of previous research , 38, 40,Urban-rural differentials in health care utilization were due to the concentration of health infrastructure and personnel in urban areas . There iAlthough primary school enrolments have increased dramatically in Sub-Saharan Africa and South Asia, these regions are still lagging behind in education. Of the 72 million out-of-school children worldwide, nearly half reside in Sub-Saharan Africa . Less deThe family wealth index was found to be the most important predictor of the use of institutional delivery. Hence, the high cost of health services (of much concern in India and Pakistan) and the inability of the poor to pay would pose as a serious barrier to the use of health facilities for delivery. Programs and strategies aimed at removing financial barriers in some countries have been found to be effective in increasing the utilization of delivery care services , 45.Past studies found that women who had a say in their own health care were more likely to use a health facility for health care, including delivery , 46, 47.Lack of exposure to media also posed as a barrier to the utilization of maternal and child health services . Our finThe likelihood of institutional delivery decreased with the number of children, as women may feel more confident and feel that there is no need for institutional delivery. There is therefore a need to inform women of the increased risk of the complications of higher order pregnancies and older maternal age and to encourage them to continue using the health services for subsequent births. Barriers to the use of health facilities for delivery varied widely across and within a country. Service related factors such as cost (not affordable), distance/lack of transport, and availability were the main barriers to institutional delivery in Kenya and Pakistan, while sociocultural factors, especially the perception that there was no need to use the health services for delivery, were the main reasons for noninstitutional delivery in India, Nigeria, and Tanzania. Hence, appropriate strategies need to be implemented to remove these barriers by the respective countries to reduce the unmet need for services for specific target groups, especially the poor and those living in remote areas. Cultural beliefs and practices and the lack of awareness and knowledge often pose as barriers to the utilization of health services for delivery , 48–51. The private sector plays a very important role in maternal care services, especially in Pakistan and India. However, services provided by the private sector were not so accessible to the poor because of the higher cost. Hence, there is a need to form a strong public-private partnership in delivering the health services. Private hospitals and doctors should be encouraged to play their role in fulfilling their corporate social responsibilities. Besides, the government could consider providing some forms of incentives such as tax rebate and subsidies to private doctors to make their services more readily available and accessible to the poor. More efforts should be made to engage the private hospitals and doctors in the national health programs.More than half of the births in South Asia and Sub-Saharan Africa are delivered by traditional birth attendants and other untrained attendants. Delivery by untrained attendant is probably the main reason for the high maternal mortality in the regions, as traditional birth attendants are neither ready to handle complications during and after delivery nor do they have the necessary equipment and medicine to treat hemorrhage (uncontrolled bleeding), sepsis (infection), and hypertensive disorders, which are the main causes of maternal death. The services of traditional birth attendants will continue to be sought after in the foreseeable future, and hence, there is a need to give them the necessary support and equip them with the necessary skills, including basic knowledge and information on HIV/AIDS. Further, traditional birth attendants should be encouraged and given some incentives to refer their clients to the hospitals and clinics. A previous study found that young women who initiated antenatal care were more likely to use skilled professional assistance at delivery than their counterparts who initiated antenatal care later . Women sOf the six countries in this study, Bangladesh had the lowest hospital bed-population ratio at 3 per 10,000 population, while Kenya and India had a relatively higher ratio at 14 and 9 per 10,000 population, respectively , provideDespite making substantial progress towards improving maternal health, many countries in South Asia and Sub-Saharan Africa are still grappling with the problems of high maternal mortality and are struggling to achieve the Millennium Development Goals (MDG) to reduce the MMR by three-quarters by 2015. Given the low institutional delivery and high maternal mortality in the regions, there is a need to target the groups who do not use health services for delivery and address the barriers that exist. Besides removing the service-related barriers, public health information and education need to be widely disseminated to influence the public opinion on the benefits and the importance of health care utilization. The successes and good practices of some countries in implementing various policies and programs to increase institutional delivery could serve as models for other developing countries. The effective implementation of programs and strategies directed at specific target groups requires the involvement of various stakeholders to remove the barriers to the utilization of maternal care services.


Patients at high risk of emergency hospitalisation are particularly likely to experience fragmentation in care. The virtual ward model attempts to integrate health and social care by offering multidisciplinary case management to people at high predicted risk of unplanned hospitalisation.To describe the care practice in three virtual ward sites in England and to explore how well each site had achieved meaningful integration.Case studies conducted in Croydon, Devon and Wandsworth during 2011–2012, consisting of semi-structured interviews, workshops, and site visits.Different versions of the virtual wards intervention had been implemented in each site. In Croydon, multidisciplinary care had reverted back to one-to-one case management.To integrate successfully, virtual ward projects should safeguard the multidisciplinary nature of the intervention, ensure the active involvement of General Practitioners, and establish feedback processes to monitor performance such as the number of professions represented at each team meeting. Patients at high risk of emergency hospitalisation typically have multiple chronic conditions, which are often compounded by psychological and social issues.,2 As a rTo be successful, any hospital avoidance programme must target patients who are both at high risk of a future unplanned hospitalisation and who are likely to respond to the proposed intervention . ImportaIn an attempt to address these challenges, an intervention known as ‘virtual wards’ was introduced at Croydon primary care trust in 2005  using a predictive model to identify individual patients in a population who are at high risk of future unplanned hospital admission; and (2) offering these people a period of intensive, multidisciplinary, case management at home using the systems, staffing and daily routines of a hospital ward .A survey published in 2012 suggested that virtual wards had mutated in several ways from the original model described in In this paper, we explore how well each of three virtual ward sites has achieved meaningful integration, based on the ‘success factors’ identified by Rosen and Shaw . These fEthics approval for this study was obtained through the Integrated Research Application System . Our case studies were conducted during the period 2011-2012 by means of semi-structured interviews, workshops, and site visits. We held semi-structured interviews with a range of staff in each of the three study sites, including General Practitioners, nurses, finance department staff, and social care workers. A total of 14 staff members were interviewed with four from Croydon and five each from Wandsworth and Devon. During the course of the study, we held three workshops at which representatives from all three sites were present. The purpose of these workshops was to share and sense-check our emerging observations on the similarities and differences between the sites.We begin with the Croydon case study, as it was the original model, followed by two other sites that subsequently implemented their own versions of virtual wards: Devon and Wandsworth.When they were implemented initially, the virtual wards in Croydon closely followed the original virtual ward model . HoweverWhen the Croydon virtual wards were launched in 2005, the health care policy environment in England was broadly supportive of this type of intervention. At the time, both the National Health Service and local authorities were being encouraged by the Department of Health to reduce hospital admissions . HoweverWhile the wider environment was broadly conducive to the virtual ward project, within Croydon primary care trust itself there were some unsupportive elements. For example, frequent changes in the organisation's management structure were seen as being disruptive and destabilising.The organisational culture at Croydon primary care trust was generally supportive leading the implementation, the project was given. Since staff working in the trust headquarters were leading the implementation of virtual ward, the project was given a relatively high priority. All three practice-based commissioning groups signalled their support, as did the Professional Executive Committee and the Local Medical Committee. However, this official support did not appear to extend fully to ‘frontline’ general practitioners.Combined Predictive Model in order to generate lists of high-risk patients [In terms of the infrastructure of the project, members of the public health department at Croydon had the experience and capacity to run the patients . Indeed,Memorandum of Understanding between the primary care trust and one of the practice-based commissioning groups. These processes included, for example, procedures for information exchange ; an alert system to highlight any virtual ward patients who attended a local accident and emergency department; processes for agreeing a joint care plan with the London Ambulance Service; and a regular ‘mortality and morbidity’ meeting, which was attended by staff from multiple organisations, where adverse events were discussed. Rather tellingly, however, no general practitioners attended these meetings.Many of the processes needed to support integration in the pilot phase of the project were described in a Finally, the community matrons and other community health care providers used a common electronic medical record; however, this system was not available to general practitioners, nor to local hospital staff, mental health professionals or social workers. Although shared assessments and common standards were developed during the pilot phase, these resources were subsequently withdrawn. Instead, community matrons were required to rely on informal collaboration with general practitioners to develop management plans for each patient; these joint plans were not always documented . More gAs originally envisaged, one of the main purposes of the virtual wards was to streamline and coordinate care for patients who were receiving treatment from multiple professionals and clinical teams. Initially, multidisciplinary virtual ward team meetings were held regularly. Known as ‘ward rounds’, these meetings were attended by the community matrons, district nurses, physiotherapists, occupational therapists, social workers and other community clinicians although no general practitioners attended.However, these meetings were discontinued once the pilot phase ended. Therefore, although initially the virtual wards in Croydon were multidisciplinary in nature, after the pilot phase, each virtual ward consisted only of a community matron and a ward clerk. In other words, they were no longer providing multidisciplinary case management but rather traditional (one-to-one) case management. One of the reasons why this change may have occurred is that some staff viewed coordination as being less ‘important’ than directly providing care.Although some patients being cared for on the Croydon virtual wards were ‘activated’  , for manCompared with Croydon, the virtual ward in Devon was more firmly rooted in primary care, with a general practitioner championing the development and implementation of the entire project. In this case study, we focus on the virtual ward covering South Molton and Chulmleigh; however, a further 22 virtual wards have since been established across the county of Devon, which build on an existing infrastructure of complex care teams.Quality, Innovation, Productivity and Prevention policy [Official Journal of the European Union  was contingent on their providing proactive, multidisciplinary care. The virtual ward staff and general practice were also set targets, for example by specifying a minimum proportion of virtual ward patients that were to be identified by the predictive model as opposed to clinical referral.As in Croydon, one of the major challenges facing the project was to avoid a regression away from multidisciplinary case management back to traditional care. To prevent such a reversion from occurring, virtual ward and primary care staff were repeatedly reminded by the project champion that the funding for the project  the extraction of data from general practice systems for predictive modelling, and (2) the system for informing general practitioners about their patients’ predictive risk scores. In particular, it was difficult at times to navigate between the provisions of the Data Protection Act and the advice issued by various authorities, such as the National Information Governance Board, the NHS Care Records Guarantee and the local Caldicott guardian. Ultimately, a series of pragmatic solutions were reached, for example, by issuing primary care trust analysts with honorary contracts at each participating general practice.A notable feature of the Devon virtual ward was that staff had admitting privileges at South Molton community hospital and had access to the general practice electronic health record. Indeed, to help with the process of integration, an electronic single assessment process and common assessment framework were introduced . HoweverHome from Hospital service, and a pharmacist.The Devon virtual ward project was staffed by a multidisciplinary team drawn from several health and social care organisations. Over the course of the project, additional team members were added, including discharge coordinators from the local acute trust, representatives of the British Red Cross As the project developed, members of the virtual ward teams were granted increased access to different organisations’ information technology infrastructure. For example, real-time synchronisation was established between the general practice electronic record in some practices and the electronic records system used by community health services, social care teams and the out-of-hours service. To facilitate this integration, a range of common standards was first agreed, which covered issues such as data confidentiality and care coordination.Expert Patients Programme [The degree to which different virtual ward patients were actively involved in their own health care varied considerably. Where appropriate, virtual ward patients were referred by virtual ward staff to the rogramme , or theyThe most notable feature of the Wandsworth virtual wards project was the inclusion of a full-time general practitioner as part of the virtual ward team. This new role for general practitioners was viewed as the primary care equivalent of intensive care doctors in a hospital, in the sense that they dealt with only the most complex patients within a given population.Patients at Risk of Re-hospitalisation model [As in Devon, there was a clear general practitioner champion supporting the virtual ward project in Wandsworth. In comparison with the other two study sites, social care colleagues were much more closely involved. Another difference was that the virtual wards in Wandsworth used the on model  to identVirtual wards were not established in Wandsworth as a direct response to any specific national or primary care trust policy; rather, this was a general practice-led initiative based on conversations with the established virtual ward teams in the neighbouring London borough of Croydon. Being general practice-led, the project in Wandsworth remained relatively free from influence and regulation by the primary care trust and there was nothing in the broader operating environment that directly undermined the project.The initial start-up costs for the project were paid by Wandsworth Primary Care Trust, which also funded a project manager. The virtual ward general practitioners were salaried employees of the primary care trust until the local acute trust took over their contract, at which time they became employees of the acute trust.. There was, however, a general appetite for better horizontal integration between health and social care, and vertical integration between primary, community and hospital care. As the project progressed, primary care trust managers became increasingly supportive. Indeed, the integrative processes developed in the virtual wards came to be regarded as trailblazing.At the start of the project, there were very few cross-organisational processes in place: for example, there was no shared information technologyAs with Croydon and Devon, the Wandsworth virtual wards were not supported by a fully integrated information technology system. Virtual ward staff used the general practice electronic record for recording their notes rather than using the community services’ information technology system. However, staff did also have the ability to access the information technology systems used by colleagues working in social services, community services and secondary care.Over time, the virtual ward team began using shared assessments and developed shared care plans; however, social services staff and mental health staff continued to use separate assessments. Overall, the implementation of common standards was hampered by cross-organisational cultural differences. A prime example related to means-testing for social care services, a practice that was seen by health service staff as conflicting with the National Health Service's ethos of providing care to all that is free at the point of delivery.reactively as an individual practitioner rather than proactively as part of a multidisciplinary team.In Wandsworth, the virtual wards (which were subsequently renamed ‘community wards’) consisted of multidisciplinary teams with members drawn from several organisations, including the primary care trust and the local authority. Due to recruitment difficulties, staffing levels did not reach their full capacity in any of the four virtual wards for some considerable time. Nonetheless, practitioners working in the virtual wards were generally positive about the virtual ward concept, although they were sometimes resistant at first to change their own working patterns to accommodate this new way of working. In other words, the default was to work In Wandsworth, the process of ‘activating’ patients to take a more active role in their health care was seen as one of the key roles of the virtual ward.Any analysis based on case studies is going to face the challenge of producing findings that are generalisable. However, we believe that it is important to document the nature of integrated care interventions, especially at a time when new organisational models for managing chronic disease are emerging all the time, and when the labels that are applied to these ‘innovations’ are neither consistent nor always clear about the nature of the service offered.The principal goal of the virtual wards in Devon, Croydon and Wandsworth was to reduce rates of unplanned hospital admissions and readmissions in the local population. Since patients at high risk of hospitalisation frequently have complex health and social care needs, such patients are typically cared for by several practitioners belonging to more than one health and social care team. This complexity often leads to fragmentation in care, and also to failures of communication, which may manifest themselves as gaps in care or as unnecessary duplications in care . Since these patients have multifaceted needs, they tend to be ill served by single-disease protocols and care pathways. Instead, the organising principle for care integration in these virtual ward projects was to make the individual patient the focus of care.directed enhanced service) is likely to ensure continued primary care support for this model of care in these two sites.In all three study sites, organisational support for the goals of the project was reinforced by policies aimed at reducing rates of unplanned hospital admissions and at improving the quality and cost effectiveness of the care provided to patients with long-term conditions. In two of the case studies, there was a ‘general practitioner champion’ who assumed overall responsibility for the project; however, there was no equivalent sponsor in Croydon beyond an initial pilot. It seems that having a general practice sponsor was invaluable for engaging the general practice community and it also appears to have helped sustain the multidisciplinary nature of the intervention in Devon and Wandsworth. Moreover, the inclusion of specific funding for risk stratification and case management as part of the general practice contract  and at the meso-level  . SpecifiYear-of-Care funding model - a form of capitation that may also promote better integration in vertically integrated trusts [As we have seen, the financial and policy motivations for integration varied across the different professional groups, teams and organisations that were involved in the commissioning and provision of virtual ward care in the three sites. More recently, some of the previously misaligned financial incentives have started to be addressed. For example, since April 2011, National Health Service hospitals have been incentivised to reduce their 30-day readmission rates and to cap their total number of admissions in a year . This med trusts .Within the virtual wards projects, integration occurred mostly at the coordination and linkage levels, rather than through full financial and organisational integration . It seemThe virtual ward projects in Croydon, Devon and Wandsworth represent a novel approach to integrating care for patients at high risk of unplanned hospital admission. High-risk patients often experience fragmented care; therefore, this is a fertile area for improving integration. Many high-income countries regard reducing unplanned hospitalisation rates as a strategy for improving the cost effectiveness and quality of care for their populations and for moving care away from hospitals and into the home. Virtual wards could provide both a focus for integration  and a forum at which that integration can occur (i.e. regular multidisciplinary meetings or ‘ward rounds’). However, the experience in Croydon, where multidisciplinary care gave way to one-to-one case management, is a reminder of the challenges of maintaining new work patterns.key performance indicators, may be helpful in avoiding regression back to old ways of working (e.g. record the number of professions represented at each multidisciplinary team meeting). Third, that an assessment of the efficacy of virtual wards in reducing unplanned hospital admissions cannot be made on the pooled results of these three case studies, since the nature of the intervention varies so widely. Finally, that there may be advantages to greater standardisation across projects, both in order to facilitate evaluation with sufficient numbers of patients and homogeneity of the intervention, but also to safeguard fidelity to the model itself. For example, in the USA the GRACE project [These case studies suggest a number of lessons for policy-makers. First is the importance of involving general practitioners in the design and delivery of innovative models of care: simply obtaining the backing of a general practice-led committee may be insufficient. Second, that safeguards, such as  project  is also