Background: This article describes the integration of an innovative network-mapping tool within a monitoring, evaluation and learning system. We describe how it serves to strengthen vulnerable families to care for their children. We discuss the use of this tool as part of the process of measurement for change in the preparation for the sustainable scaling of programme implementation. Tajikistan has a legacy of Soviet-style institutional care of children. Traditionally, very young children separated from their families have been cared for in institutional baby homes. This research is part of a wider project to transform these baby homes into community-oriented Family and Child Support Centres.Methods: We mapped the networks of child support experienced by parents and service providers. We used interactive, semi-structured interviews, and the tool evolved through an iterative process. We generated data to describe the connexions between children, families, professionals and supporting organisations. The resulting information revealed strengths and weaknesses in support provided, attitudes and perceptions towards the quality of the support as well as identifying processes through which changes strengthening the system can be stimulated.Results: The data showed that the main support for children comes from within their immediate household, but, over time, more distal support gained value. Variation in the networks of support related to gender, specific subgroups of need and location. Gender was the most influential determinant of patterns of support. Mothers' knowledge of service provision, represented by a greater number and variety of contacts on their network-maps, was more diverse than fathers'. In contrast, fathers' more limited networks showed connexions to individuals and organisations with potentially more powerful decision-making roles. Participation in the discussions around the network-mapping contributed towards a change in the use of data and evidence in the implementation team.Conclusions: Network-mapping is a valuable and adaptable tool that feeds into monitoring and evaluation at multiple levels. The process reveals the nature and extent of relationships of support for childcare and protection. It exposes the changes in these networks over time. Both the information provided and the process of collection can enrich care plans, create links within the network and inform decision-making that improves efficacy of delivery as we move to scale. Keeping families together creates continuity in the support necessary for a child to make a successful transition to healthy adulthood . The UK HealthProm has worked on the Putting Families First (PFF) project in collaboration with government departments, local NGO partners, staff of the Baby Homes and international partners to establish family support services next to all the Baby Homes. The specific objectives are to provide vulnerable families with a more effective alternative to institutional care for their young children; to strengthen practises of nurturing care and child protection; and, to build alternative family based care for children who cannot live with their birth parents.Through this partnership centres have been established that offer a range of services to support families at risk of abandoning a child. Individualised programmes meet the needs of families either facing difficult life situations or caring for children living with a disability. Services offered include physical and speech therapy, parent training, social welfare and psychological support. We have gained increasing support from the community. In 2019 we received official recognition of the shift towards community oriented child support. The Ministry of Health and Social Protection of the Population, and Local Government Authorities agreed new regulations to merge the Family Support Centres and the Baby Homes forming new community-oriented Family and Child Support Centres.This article describes how we used a network-mapping tool to reveal the relationships that impact upon the community based system for long-term care of vulnerable children. The tool forms an integral part of monitoring and evaluating the theory of change that guides the PFF programme. We sought proof of the concept that replacing institutional care in Tajikistan with an innovative set of interventions has a positive effect on child development. Central to the theory of change is strengthening families to support their children's development. A tool that examines social interactions and social support was seen to be an essential part of the suite of tools required to produce evidence of this pathway . The infAt independence in 1991 the country inherited a state-run care system for children that was almost entirely institution based. Alternative support systems provided by the non-state sector were very limited and uncoordinated. Very young children whose families struggled to care for their children because of social, economic pressures, or who felt unable to manage their child's disability were placed in state-run Baby Homes. In law, these Baby Homes were closed institutions. This restricted family contact, and left the care of children to the staff who worked on a rota system and had inconsistent contact with their charges. Although children in the Baby Homes were provided with basic needs, they were exposed to the potential for significantly disrupted attachment .Tajikistan is predominantly a traditional rural society  where chThis traditional model does not hold for the 27.3% of the population who live in urban areasThe local environment comprises a range of local government administration, health and education services. At the most grass-roots level of local government, the Mahala Committees address street-level matters. Access to government services in health and education is dependent upon appropriate registration. Unregistered families are excluded. Local Government Authorities provide a basic safety net of social protection through Child Rights Units. Families can receive a degree of social protection from the state, such as small pensions, but not a comprehensive and coordinated network of care and support. Practical advice for families, parenting programmes and child development services are only provided by a few non-governmental organisations, such as HealthProm's local partners.We took Bronfenbrenner's Ecological Systems Theory (EST)  as our cTo describe in detail the networks of support and to stimulate conversations around providing nurturing care we followed a process outlined in Thus, the formative component of the project Stage B (Information Gathering) both informs the next step Stage C (Application) and is informed by it. Likewise Stage D (the Review of Policy and Practise), both influences decision making at the meso and macro level, as well as guiding future Design (Stage A) as the project transitions to scale.The network-mapping sessions were designed to strengthen the networks of support in multiple ways. Strengths, weaknesses and suggested improvements in the existing networks were to be identified using the maps. The sessions were to provide a forum for sharing knowledge and making bonds between families in need. The changes observed over time tracked the influence of the PFF intervention on the support network. By sharing information on patterns and trends with policy-makers, we intended to strengthen communication channels between the different levels of support. Ethical approval for this process was granted by the Ministry of Health, and informed consent obtained from participants prior to each session.The initial objective was to develop a process to monitor systematically the childcare networks of families receiving support from the PFF programme. Two monitoring and evaluation consultants, one local and one international, guided the design phase. Working with the management and service delivery teams, materials and methods were evaluated to ensure the language used was accessible and that processes were feasible to administer and engaging for participants. The process of design was guided by the following questions, “Are participants actively contributing to the sessions?” And, “Are we able to capture the contributions systematically and accurately?”Network-mapsWe selected The maps summarised the collective experience of the participants, derived through consensus within each group. Information shared by participants was first captured on coloured sticky notes. The participants arranged these notes on a single sheet. Information on attributed value and motivation were added to the sticky notes. The sticky notes meant that they could, in the course of the conversation, return to the details, make adjustments, ask questions and add their own comments and contributions. The maps produced provided participants with a concrete way to see how their network was built. An example is provided in The network-mapping sessions also provided the opportunity for participants to share their personal experiences as a caregiver, as well as their experience of the PFF intervention and of other services. We captured these narratives in the meeting notes.We designed separate data capture forms to provide a systematic framework for making comparisons between groups and sub groups of participants.Source of support: defined by their role or organisation name.Type of support: categorised as Services Directly to the Child, Integrating the Child into Community and or Family Systems, Skill Development, Resources Supplied, the Promotion of Child Protection.Perceived value/level of importance: categorised as minimal, some value, very important/valued.Motivation attributed to the provider: categorised as Social Responsibility (because they care about the child), Social Change (because they want to create change), Personal or Professional Responsibility (in the course of meeting their expected role or responsibilities).These characteristics were rated according to categories suggested by responses given in the first round of sessions, and validated through application in later rounds. Data tables provided a summary of the ratings across each characteristic.As this was an experimental process we chose to use one key facilitator to run all of the sessions. This had the advantage that diverse groups of informants were managed in a consistent way. It also provided a coordinated approach to data capture, analysis, application and reflection. Using a facilitator not directly involved in service delivery or programme management was seen as a key factor in stimulating the high degree of candidness with which parents shared their opinions and feelings. However, the key facilitator had to cover large distances over remote mountainous terrain,The perspective of the primary or key caregiver was the main focus of the initiative; however, we included sessions with care staff and team managers as part of the process of review and reflection on developing individualised care plans. Initially all parents who were registered at the Family and Child Support Centres were given an open invitation to attend on a specified date. These families included both those who were referred from health or social services, as well as those who self-referred. After the initial sessions we applied a more purposive sampling approach to intentionally capture a diverse range of experiences. For example, we held sessions with mothers from rural and from urban areas, and with fathers/grandfathers, and parents who had attended parenting courses.In total, 41 network-mapping sessions were carried out over 2-years. We included 48 mothers and 12 fathers, all of whom were parents of children with disabilities. The care staff/service delivery personnel at the different centres involved in the PFF programme also completed network-mapping sessions at different points in the cycle of the programme.The experience of completing the first two rounds of data gathering suggested expanding the sessions to explore the networks of mothers already observed to display different levels of skills in scaffolding their children's behaviours, a key contributor to early childhood development and resilience . These sThe sessions are outlined in Initially it was exclusively mothers who answered the invitation to attend, with group sizes ranging between 1 and 11. The enthusiasm among mothers to attend these sessions remained consistent. Among mothers who received direct invitations, those with high and low scores on the OMCI, all attended. To include the voice of fathers we also contacted them directly, but struggled to attract more than one or two fathers/grandfathers per session.Answering the question, “Are participants actively contributing to the sessions?” we established that a group size of between 4 and 6 best generated shared discussions, while smaller groups , 2 were In this stage the focus of activity was the use of systematic reporting to effectively summarise and share the learning. The implementation team, in reviewing the details of the network-mapping sessions, drew out key takeaways from the maps themselves; the data capture forms (providing quantitative summaries on each characteristic of support); and the accompanying narratives. The team also reviewed the contribution made by each data source in guiding their understanding of the way in which systems of support are experienced.The following because we are family” . There were exceptions to these positive reports raised by a number of groups. An example was the sister-in-law, who, while resident in the same household, was rated as the least valued member of the support network. Another key figure in the household is the mother-in-law, and assumptions previously held that they were the main influence behind the abandoning of children to institutional care was not supported. Our caregivers rated the importance of the mother-in-law in a more positive way. Exploring the details of different roles within the family, and how they can be encouraged and strengthened needs further exploration.We saw the importance of the immediate family across all study sites. From the mothers' groups we learnt that the immediate family, with its multiple generation households, was consistently the most active source of support, providing direct care to the child, as well as financial and other resources. Mothers highly valued this support, which they ascribed to the social responsibility felt by other family members. One mother said: “Even in the early network-maps, mothers identified links to sources of support other than the family, at each of the five levels described in The biggest difference across sites was in the strength of the links to more distal providers, in particular the international NGOs. Mothers living in the capital, Dushanbe, were initially far more likely to mention this source of support than those living elsewhere. Following more active engagement in rural areas, network-maps increasingly identified local centres and services as an important provider of support. Few mothers were aware that the centres they attended received support directly from international NGOs. This suggests that the influence of PFF on rural families was more indirect, coming through local service delivery networks.In early network-maps mothers commonly characterised the father's role as providing resources rather than directly interacting with the child. This observation led us to explore in more detail how fathers understood their role, and how they themselves felt supported as caregivers of a young child in need. We found fathers have far fewer connexions in their support network than mothers. They did not perceive a clear connexion between the services provided and the needs of their children and were generally less aware of which services and activities were available. Some fathers had connected to additional financial resources, but none we interviewed had attended parental training sessions. We did, however, learn from the later network-mapping sessions that, as the PFF programme progressed, mothers saw some positive changes in the contributions made by fathers. Fathers who had attended parental training courses, for example, were reported to have become more supportive and to spend more time with their children. Overall, relationships with the key figures of the husband and mother-in-law were reported by mothers to have improved.Exploring motivation was a useful way to understand the quality of support caregivers felt they received. Mothers, for example, recognised that the Family and Child Support Centres met a range of social and psychological care needs. They experienced centre staff as socially responsible, listening and responding to individual needs, and motivated to create social change. Before these centres opened, mothers had primarily sought support from medical services, and the onward connexion, through referral to social services, for more social/psychological care was rare. As we explored the differences in how different service providers were valued we came to understand that when mothers feel valued they also accord those service providers greater value. The difference in ratings between different services appears to centre on the presence or absence of shared respect, a central feature of strong relationships.Many organisations help, they bring us humanitarian aid, but your project is the only one that helps us psychologically” . The benefit of psychological support was linked to more positive relationships with their children. As another mother said, “We are now friends with our children. They are more open. They do not fear us and share their feelings and their mistakes” . A further mother told us, “We became more strong and independent, more confident, more open; we know our rights. Our motto is, ‘Now I can do it'” .In all later network-mapping sessions mothers reported having observed significant changes and improvements in their children's speech, behaviour, socialisation skills as well as developing greater independence. They described their children as requiring much less help from others. Mothers attributed this change to having attended the Family and Child Support Centres and valued receiving the services offered free of charge. They also described increased agency, having acquired new knowledge and skills from the centres to better care for their children. As one mother said, “Exploring the association between social networks and wellbeing was the focus of the comparison of the mothers with high vs. low OMCI scores. Mothers with a high score were able to name people or organisations at all levels. These mothers also recognised specific improvements in their children's progress, reported that their partners showed an increasing understanding of what they could contribute, and were generally aware of the nature of their children's rights. In contrast, mothers with low OMCI scores felt largely unsupported, were less likely to seek help, and were much less aware of the possibility of stimulating changes in their children. They were, nonetheless, grateful for the support provided by the Family and Child Support Centres. The interaction between having a support network to draw upon, and being able to identify and meet the needs of your child, will be an important focus for exploration in case management within the programme in the future.We learned how to build relationships with others” (Mother Khujand).Overall, while the range of network sources mentioned by participants did not expand over the 2-year project period, we did observe shifts towards greater access to sources of support outside of the family. Another important change was the more positive relationships reported with those providing support, both inside and outside the immediate family. As one mother said in later network-mapping session, “When asked to share their feelings about participating in the network-mapping sessions, parents expressed their gratitude for being listened to, and having their views acted upon. They also valued the opportunity to learn from and develop friendships with each other. This shared learning enabled them to expand further their support networks as they became aware of the availability of other rehabilitation centres, of the existence of inclusive schools or kindergartens, as well as of the financial support they were entitled to from the state. The network-mapping sessions became a part of the network of support that brings people together to share information, experiences and knowledge.Further evidence of the value of the measurement process in decision-making was observed through the sessions held with staff and management groups. Sharing the information collected from parents' groups provided the opportunity to reflect on service delivery strengths and weaknesses and to identify potential targets for improvement. In these sessions the teams also reviewed the resources available in the nurturing care system, from the perspective of the service delivery system. They also examined gaps in their current links to these resources to suggest where communication channels could be improved. While the provision of training in parental skills featured more regularly in later network-maps of the mothers, limitations remained in the inclusion in this and other services of fathers. Another concern was that few families were aware of the child protection services offered by local government, highlighting the need to strengthen the capacity building initiatives provided by the PFF programme for other services. Stronger ties with local government systems, for example, were identified as a priority.The focus of this stage was to reflect on the network-mapping process and generate recommendations that guide the continuous strengthening of a community based approach to nurturing care. In our application of network-maps we found a functioning tool that contributes to decision-making in multiple aspects of implementation . NetworkUsing this tool has brought to life Bronfenbrenner's EST by superimposing representations of real social interactions and influences upon a generic nested model. The ecology of support systems in Tajikistan, described through the network-maps, initially pointed to the relevance of the nested structure described by Bronfenbrenner . Throughby focusing attention on patterns of social interaction, the networked model offers the possibility of using the precise tools of social network analysis to move EST from a theory to a method.” The network-mapping tool we adapted for use in Tajikistan is an example of such a tool, making the connexion from theory to method. A network approach avoids a hierarchical framework to programme design, providing an interactional dynamic framework for connecting the theory-practise-policy cycle.This adds an extra dimension of “networks” to Bronfenbrenner's “nested” model. As Neal and Neal  also sugOne of the primary means through which this tool has connected theory to method has been to provide families with a voice, and involve them directly in monitoring services. We have learnt of the impact of the project on their daily lives. We have heard both positive and negative feedback in their own words. This dialogue has strengthened the programme, guided the improvement of services and changed the course of the project. It has enabled us to learn more about the needs of specific individuals and discrete sub-groups of the more vulnerable. This shift in thinking, and in the details of the process of implementation, has influenced review of our theory of change. Accordingly, project managers focused more on a rights-based approach that recognises and counters the sources of social exclusion.For example, among mothers whom we observed as providing their children with limited stimulation and responsiveness, those scoring low on the OMCI, we also found very limited networks of support. The network-mapping sessions helped us learn about the social needs of these mothers, and deepened the thinking around how the programme can link social with psychological support. In fact the experience of taking part in network-mapping prompted some mothers struggling to care for their children to opt into project activities and join parent to parent support groups from which they had previously felt excluded.Discussions with fathers exposed the sparseness of their networks and their lack of involvement in parenting activities. Project managers came to understand better the challenges fathers face in integrating effectively into the childcare system, prompting the design of activities specifically for these key caregivers. We also observed that strengthening fathers' skills and parenting knowledge, leading to greater participation in childcare, served to reduce gender inequality as well as contributing to Sustainable Development Goal 5.Through this process we have learnt of the association between being valued and actively engaging with services. This narrative was expanded upon by centre staff, who felt that health services lacked an awareness of both the complex needs of children with disabilities and of the network of services available to meet them. We were also concerned by the limited role of State child protection agencies in the network-maps drawn. The network-mapping process highlighted these gaps, and suggested the need for further outreach to professional groups.place- by understanding where they fit into the big picture; and in time- by helping people see their purpose and direction for future development. We were struck by the insight network-maps gave participants about their own motivation, as well as understanding their place in a wider network. We repeatedly heard how participants felt included, and for team members, this indicated that network-mapping is a tool for team cohesion. Network-mapping sessions made an important contribution to the understanding of the bigger picture of the network of support for all involved the process. In addition to knowledge building, this tool also shaped the skills required to improve community outreach through the inclusion of caregivers as equal partners.For both parents and professionals, we found that network-mapping helps people orient themselves in Network-mapping sessions therefore contributed to a beneficiary-led review of how services should change to better meet individual and group needs. The detail of information collected improved the awareness of need, and informed the development of individual care plans, training programmes and the structure of service delivery. Other applications in diverse settings of similar methods have similarly found both the concept and the process of mapping networks valuable for creating individualised and interactive care plans , 15.The use of a network-mapping process has generated detailed information on the development of a systematic and rigorous monitoring, evaluation and learning system. The feedback from the team has highlighted the value of more qualitative information and visual displays in earlier stages of development. The maps and narratives were also influential when used in dialogue with relevant ministries. More extensive experience is required before quantitative data is usefully interpreted. Sensitivity is needed in selecting appropriate methods of data capture and sharing in order to help effectively involve individuals, communities, organisation and institutions to meet their needs and create lasting change –18.In reflecting on the learning derived from the network mapping process the following recommendations were generated by the senior management team.Informed, responsive design. This methodology was valued as a key activity in monitoring, informing, and communicating family needs, and system strengths and weaknesses. As the programme progresses the team will continue to share the network-maps and the details of the conversations they generate to cement communication systems between the different parts of the network. This sharing will generate ideas on how to improve the system and services still further, while also uniting parents through peer support groups. In addition, network-mapping generated detailed information useful for advocacy and policy development. As the programme is extended to other regions, network-mapping will be an essential monitoring and evaluation tool to help us effectively reach individuals and communities, and meet their needs. As we apply this tool in future settings we will focus on integrating this work more directly into the structure of delivery.Individualised Services. Embedding the procedural connexion between network-mapping and case management in future delivery systems will create a more international connexion between lessons learned around a family's social interactions and the care plans made. This will require building capacity within the service delivery team to carry out individual network-mapping sessions.Flexible Application. Expand the use of the methodology to explore more specific foci in the networks of support for childcare.An important network to expand knowledge of is the child's learning environment, both formal and informal, mapping opportunities for play, language stimuli and inclusion.Another key area of focus will be the social connexions that support the adaptation of child protection policies and practise to a community based childcare framework.We need to explore the needs of specific subgroups in more detail, in particular, mothers unsupported by immediate family.Address the issue of support networks from different perspectives, from the micro, meso, and macro levels.Utilise an integrated MEL process. The network-mapping process illustrates a practical application of the aspirations of Measurement for Change, that advocate for a continuous process of consultation, measurement, review and reflection to build capacity to achieve a sustainable and scalable implementation process  for the publication of any potentially identifiable images or data included in this article.All authors contributed equally to the development of the process presented in this paper.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Age management practices refer to the development and implementation of workplace strategies to support and improve the health and productivity of workers aged 45 years or older. The objective of this study was to analyze the scientific evidence available to support age management practices toward older workers. An integrative review was conducted, with the following databases searched in February 2019: LILACS, MEDLINE, Web of Science, and SCOPUS. Inclusion criteria consisted of original primary studies with full-text availability, published in Portuguese, English or Spanish. Secondary studies were excluded. No restrictions were imposed on publication dates given the paucity of literature on this topic. The final sample consisted of 11 primary studies published between 2006 and 2017, which addressed the following age management practices: workplace health promotion; employment exit and transition to retirement; knowledge transfer, training and lifelong learning; career development; flexible working time practices; and occupational safety and health management. Age management practices are promising tools to promote a work environment that is adequate to the needs of older workers. Current estimates suggest that, starting in 2040, the majority of workers will be at least 45 years old, prompting a need for specific management practices to address the needs of these workers.4As the workforce ages, strategies targeting disease prevention and health promotion in the workplace become increasingly necessary in order to preserve worker capacity and quality of life.5In light of these observations, age will become an important factor in human resource management, demanding new policies, instruments and interventions to ensure a prolonged, healthy and productive working life.3Organizations that wish to retain their employees for longer periods of time will have to adapt to their needs. These issues have given rise to the concept of age management, which refers to a set of practices to adapt environments to older workers and reduce age barriers in order to support and retain these professionals.4,6The World Health Organization (WHO) defines older workers as individuals aged 45 years or older; according to the literature, this age marks the onset of physical and cognitive changes associated with aging.3Benefits of age management for workers include increased motivation and satisfaction with work, improved work-life balance and the maintenance of work capacity and employability throughout one’s career. Age management also brings advantages to employers, including the ability to retain experienced workers and anticipate the scarcity of qualified professionals, reduce turnover and cut hiring and training costs, as well as recognize the strengths and weaknesses of different age groups in order to distribute tasks more effectively.7To this end, the European Agency for Safety & Health at Work (EU-OSHA) published an electronic guide in 2016 to contribute to the implementation of age management practices, which consist of the following: recruitment of older workers; knowledge transfer, training and lifelong learning; career development; flexible working time practices; workplace health promotion; occupational safety and health management; job rotation and redeployment; and employment exit and transition to retirement.Age management strategies have become a crucial concern in the current context of workforce aging. Managers who know how to work effectively with different age groups in their companies will be able to achieve better results and improve the health and safety of employees, creating favorable conditions for the implementation of age management practices in Brazilian companies.No studies to date have provided a picture of the current literature on age management, highlighting the need for an integrative review on the topic. The aim of this study was therefore to analyze the scientific evidence on age management practices in the literature.8This integrative review was conducted according to the following steps: description of the topic and development of the research question, collection of primary studies, data extraction and assessment, analysis of results and presentation of review findings.This review was guided by the following research question: “What scientific evidence is available to support age management practices?”Inclusion criteria consisted of original primary studies which addressed the subject of the review, with full-text availability, and publication in Portuguese, English or Spanish. Secondary studies such as theses, dissertations, systematic, integrative or narrative reviews, letters to the editor and editorials were excluded. No restrictions were imposed on publication dates given the paucity of literature on this topic.saúde do trabalhador” and “envelhecimento”, from the Health Sciences Descriptors  of the Virtual Health Library, and the MeSH terms “worker’s health” and “aging”. The uncontrolled keywords saúde ocupacional, occupational health, and age management were also used.In February 2019, the following databases were searched: LILACS, MEDLINE, Web of Science and SCOPUS. The search was conducted using the controlled keywords “envelhecimento) AND  OR ). No additional results were retrieved when the keyword “gestão da idade” was included in the query, and as such, it was excluded from the search parameters. The remaining databases were searched using the following query:  AND ((Aging) OR (Age management)).The LILACS database was searched using the following query:  - systematic review or meta-analysis of randomized controlled trials or clinical practice guidelines based on systematic reviews of randomized controlled trials; level II - at least one well-designed randomized controlled trial; level III -well designed, non-randomized clinical trial; level IV - well-designed cohort and case-control study; level V - systematic review of descriptive and qualitative studies; level VI - a single descriptive or qualitative study; level VII - expert opinions and/or expert committee reports.Studies were analyzed descriptively and summarized in a table containing the following information: country, database, authors, year, objectives, main findings and age management practices analyzed. A summary of how the findings of each study relate to age management practices was also produced.10-13; this was followed by 2006 and 2015 with 2 publications14-17; and the years 2011, 2012 and 2016, with one article each.18-20This review included 11 primary studies, 4 of which were published in 2017, the year with the most publicationsOnly 11 of the 418 articles retrieved in the search met inclusion criteria for the review. This speaks to the paucity of studies on age management in both the national and international literature.The information extracted from the included studies and the age management practices addressed by each investigation are presented in 10-16,18-20 and only one study was published in Portuguese and conducted in Brazil,17 reflecting the paucity of the national literature on age management.Ten of the articles were published in English10-18; evidence, one provided level VII evidence in the form of expert recommendations20; and one randomized clinical trial provided level II evidence19 of age management practices.The analysis of evidence levels revealed that 9 studies provided level VI10-18,20; employment exit and transition to retirement, analyzed by 2 studies17,18; and knowledge transfer, lifelong training, career development,12 flexible working time practices,18 occupational safety and health management,11 examined by one study each. The recruitment of older workers, job rotation and redeployment were not addressed by any of the studies included in this review.The dimensions of age management addressed by the articles included workplace health promotion, which was discussed in 10 studies21The changes proposed in the recent reform of the Brazilian pension system include an extension of contribution periods, with workers having to stay active for longer in order to retire. These individuals will therefore need to remain in the workforce for longer periods of time.These circumstances highlight the need to identify management practices and strategies that contribute to worker retention and help workers remain active and productive in their respective jobs. Therefore, the aim of this study was to identify existing initiatives in this area, with a focus on age management practices and their benefits.To this end, included studies will be discussed according to the specific age management practices they chose to address. The practices examined in the studies reviewed included the following: workplace health promotion; occupational safety and health management; flexible working time practices; knowledge transfer, training and lifelong learning; career development; employment exit and transition to retirement; recruitment of older workers; and job rotation and redeployment.11,14-16,19,20The first dimension of age management identified in the studies reviewed was workplace health promotion. The literature on the subject showed that the work environment is an important setting for measures that improve worker quality of life, health and safety. These measures include promoting the approximation of workers and health care services by monitoring clinical exams and raising awareness of the importance of health care, nutrition, physical activity and disease prevention.10,12,13,18 These results corroborate those of a study involving psychologists in the Brazilian state of Ceará, who observed that psychological services contributed to worker health promotion, and recommended that companies implement worker health initiatives in a permanent, regular and systematic manner.22Another important initiative is the implementation of health promotion programs that provide continued psychological support for workers, promoting emotional strengthening and reducing the negative impact of job demands and work-related stress.23 The success of workplace health promotion programs depends on the workers’ commitment to changing or improving their habits, but also on the support of managers who help create an organizational culture that supports worker well-being.24The introduction or expansion of institutional programs to improve worker health can reduce health care costs, occupational accidents and absenteeism due to health issues.7The second component of age management addressed in the studies reviewed was occupational safety and health management. An important strategy in this regard was the constant assessment of the occupational risks to which workers are exposed, followed by adaptations or adjustments to the work environment in order to improve safety and health conditions.11 These observations corroborate the conclusions of a review on the role of nurses in risk prevention, which found that these professionals make a crucial contribution to the prevention, reduction and elimination of ergonomic risks, highlighting their importance in organizational settings.25Studies which examined these issues found that inadequate safety conditions contributed to absenteeism and reduced performance, while safe workplaces that considered the skills and workloads of employees and offered health promotion programs had lower absenteeism and higher productivity rates. The studies also emphasized the need to eliminate accident causes in order to create a healthy working environment.7The first step in ensuring a safe working environment is the assessment of the risks to which workers are exposed, while considering the diversity of workers and the needs of every age group. Risk assessment allows for the implementation of changes such as replacing old equipment, equipping the work environment for employees of all ages, automating repetitive tasks and ensuring adequate lighting.26 The small number of work safety studies identified in this review highlights the need for further research on how employers can improve the health and safety of working conditions for older employees.Work safety practices should aim to reduce occupational accidents and illnesses, while also preserving the mental health of workers. These measures should also consider the skills of workers in order to help them carry out their activities safely and efficiently.18The third category, flexible working time practices, was discussed in a study which identified it as a potential solution for the management of older workers. However, this is still a remote possibility, since few institutions have the necessary conditions to implement it. The study mentions that flexible hours could allow older workers to stay home for longer periods of time, contributing to the adaptation and transition to retirement, an important component of age management with which flexible working time practices are clearly associated.27 Flexible working time practices include giving workers the freedom to choose when they start and end work on a given day, as well as where they will carry out their activities, while keeping the same total daily hours. These agreements are negotiated between employers and employees, considering the applicability of these practices to the particular workplace. Flexible working hours can increase worker commitment and awareness of their role in the institution.28 The work hours demanded by an institution may conflict with workers’ needs for family and social interaction; however, flexible working time practices can help balance these needs, becoming an important human resource management tool.29A study that compared the implementation of flexible working time practices across multiple European countries demonstrated that the autonomy in determining working hours could improve the work-life balance for employees.The fourth and fifth components of age management addressed by the studies reviewed were knowledge transfer and lifelong learning, as well as career development. These practices were combined into a single category since each was only addressed by one study.30 Training programs offered by institutions should be in line with the needs of older workers, encouraging the acquisition of relevant knowledge in order to promote the career growth and development.31As companies strive to retain qualified professionals who are also attuned to technological developments in the modernization of work processes, the promotion of continuous training has emerged as an important management strategy to ensure that older workers continue to play an active and participative role in the work force. In addition to institutional initiatives, it is important that workers themselves commit to investing in continuous training.7,32The sixth category, employment exit and transition to retirement, was addressed by two studies which focused on the preparation of older workers for retirement and work exit. The pre-retirement period should be dedicated to the planning of life in retirement and to deciding on the best time to leave one’s job.17Brazilian researchers conducted a study of workers in a public university to explore their feelings and perspectives toward retirement, finding that most participants expressed positive feelings such as freedom and satisfaction. It was also noted that workers can exercise agency in their career decisions by keeping their jobs even after retiring. Another relevant finding was that most pre-retirement workers reported no preparations for retirement. The few who did prepare were primarily concerned with seeking information about financial and emotional issues. These data underscore the need for the implementation of retirement preparation programs in companies.18Another study, which aimed to present the perspective of older workers in the United Kingdom about the influence of work commitments on the decision to retire, reported that financial insecurity was the most influential factor in this decision, and that workers adopt a progressive approach to retirement out of fear. The transition to retirement may also be negatively impacted by feelings of commitment to the organization, to colleagues and their profession, described by the authors as feelings of moral responsibility for the institution.32These findings agree with those obtained in a study conducted in South Korea, Japan, Germany, the United States and United Kingdom, which found that workers do prepare for retirement, but do not usually have an effective retirement plan. It is therefore essential that policies and educational measures to provide support in the preparation for retirement are made available to workers.33The increased free time experienced by workers after retirement can also have a negative impact on individual health. This further highlights the need for retirement planning programs to help individuals understand the physical and mental health issues they may experience after employment exit, addressing issues such as post-career activities and financial education, in order to reduce the negative effects of retirement.34Despite the growth in the aging -and retired -population, few Brazilian companies have implemented retirement preparation programs, demonstrating the need for further scientific research to support the introduction of these practices in Brazilian companies.35 Despite the relevance of the issue of hiring older workers, this topic was not addressed in any of the articles selected.The seventh component refers to the recruitment of older workers. Currently, the hiring process in most companies is predominantly skewed toward younger workers, since some managers still believe that older workers are associated with decreased productivity. Yet older workers can bring several advantages to employers, such as the ability to rely on a wealth of accumulated experience and in-depth knowledge of work processes, a commitment to ethical principles, low absenteeism rates, and increased loyalty and reliability due to the corporate maturity and emotional strength acquired throughout their careers.7The eighth and last dimension of age management, job rotation and redeployment, pertains to the transfer of workers between shifts or areas in the organization in a planned manner at regular intervals, based on a pre-established arrangement between employer and employee, so as to increase productivity and improve performance. Though this can be advantageous to both workers and employers, its implementation in organizations has not been sufficiently examined by scientific research.7All but one of the studies selected (n = 11) were conducted outside of Brazil, suggesting that developed countries may be more interested in the study of workforce aging, and consequently, are actively seeking to extend the working life of employees, improve their quality of life, and increase the productivity and participation of older adults in the workforce. In fact, these have been important goals in European policy since the late 1990s, which marked the beginning of the workforce aging process.Limitations of this study include the scarcity of studies with high levels of evidence, and the predominance of descriptive studies with little statistical sophistication. There is a need for additional studies to affirm and extend current knowledge on age management practices and their implementation in organizations, with a special focus on the recruitment of older workers, job transfer and redeployment. The absence of studies into these practices, as identified in this review, points to a gap in the literature on age management practices. We also found that a significant number of articles (n = 14) were not available in full text, which can be a limitation, since these studies could have made important contributions to this review.Nevertheless, this study makes a relevant contribution to the literature by synthesizing primary articles that discuss age management practices that can adjust and improve working conditions for older employees, compiling scientific evidence to support the implementation of these strategies.The age management practices discussed by articles in this review included workplace health promotion, occupational safety and health management, flexible working time practices, knowledge transfer, training and lifelong learning, career development, employment exit and transition to retirement. These practices have emerged as promising management strategies to ensure that workplaces are adequate to the needs of older workers, which could ultimately benefit all age groups, improving quality of life and promoting continued career growth.Age management practices can also help reduce occupational accidents and illnesses, cut recruitment and training costs, and improve the retention of experienced and qualified professionals who are motivated to stay active and productive. We also conclude that the scarcity of age management studies in Brazil reflects a lack of concern with the study of these practices and their implementation, and a low interest in investing in these issues, on the part of local researchers and organizations.


Trichomonas vaginalis is responsible for trichomoniasis, a common sexually transmitted infection associated with an increased risk of HIV infection and adverse pregnancy outcomes. The protozoon has the surprising ability to establish a symbiotic relationship with other microorganisms. In fact, most T.vaginalis isolates intracellularly host the vaginal bacterium Mycoplasma hominis and can harbor up to four dsRNA viruses. Moreover, a novel Mycoplasma species named Ca. Mycoplasma girerdii has been recently described as associated with trichomonad cells. Trichomonas vaginalis colonizes the human vagina and its presence causes profound alterations of the resident microbiota, leading to dysbiosis. In healthy women, vaginal microbiota is characterized by the presence of a complex population of aerobic and anaerobic microorganisms living in a physiologically dynamic system dominated by bacteria of the genera Lactobacillus. The most common microbial vaginal imbalance is bacterial vaginosis, a polymicrobial disease associated with several adverse reproductive outcomes and increased risk of HIV infection. Here, we review the current knowledge regarding the interactions between both T.vaginalis and M.hominis and the vaginal microbiota, and we discuss the possibility of a cooperation between T.vaginalis and its symbionts in the development of vaginal dysbiosis.The protozoon  Trichomonas vaginalis is a parasite of the human urogenital tract and is responsible for trichomoniasis, the most common non-viral sexually transmitted disease. Clinical presentation of trichomoniasis in women may vary from asymptomatic to severe vaginitis, while men tend to be mostly asymptomatic carriers of the protozoon , while one, CST-IV, does not show a dominant species and is composed of a more complex microbial community. Lactobacilli exert a protective effect on the host by lowering vaginal pH through lactic acid production and by competing for nutrients. Growth of adverse microbiota is also inhibited by the production of antimicrobial compounds such as bacteriocins and hydrogen peroxide.Interestingly, the presence of the protozoon in females can profoundly alter the composition of the vaginal microbiota. The human vaginal ecosystem of women of childbearing age is characterized by the presence of a complex population of aerobic and anaerobic microorganisms that are able to establish interactions among each other and with the host in a physiologically dynamic system. Development of “next-generation” sequencing technology led to the identification of five different vaginal microbiota, which we call community state types (CSTs)  , which affects 10–30% of women worldwide  compared to healthy women (8.9%) (P < 0.001)  compared to non-BV (8.8%) women   that become malodorous in a high pH environment. The increased production of amine is caused by the great number of anaerobic bacteria that are able to produce the proteolytic enzymes that breakdown vaginal peptides , which have infection rates in protozoan isolates ranging from 40 to 100%  may have a profound impact on vaginal microbiota; this remains to be investigated.It is known that the presence of trichomonad endosymbionts may interfere with the pathogenicity of the protozoon and modify the immune response, but no data are available on its impact on the vaginal microbiota. To the best of our knowledge, no studies focusing on the effect of the consortium M.hominis and T.vaginalis infections are associated with complications in pregnancy. M.hominis is a microbe frequently isolated from both placental membranes and amniotic fluid in women with PPROM, suggesting a potential direct effect of bacteria to initiate the synthesis of prostaglandins resulting in spontaneous preterm labor  and preterm prelabor rupture of membranes (PPROM), has been confirmed by several studies in the last 20 years (Guaschino et al., With respect to vaginal dysbiosis, it has been shown that bacterial vaginosis acquired during the first trimester of pregnancy is associated with a five- to seven-fold increased risk of spontaneous preterm labor and PTB (Taylor-Robinson and Lamont, T.vaginalis, have been widely studied in the last years.A healthy vaginal microbiota plays a major role in protecting the female genital tract against pathogenic organisms. Five different community state types have been identified based on the profile and complexity of microbiomes, and their relationships with single vaginal pathogens, including M.hominis and Ca.M.girerdii and the dsRNA viruses, leading to a complex pathogenic consortium, suggests that further studies that take into account their potential synergistic effects are necessary. In a context of vaginal dysbiosis, the microbiota, T.vaginalis and its endosymbionts make up a singular microbial entity that can lead to severe sequelae, including preterm delivery and the acquisition and transmission of HIV.Nevertheless, the existence of symbiotic relations among the protozoan and the bacteria VM, PF and PR contributed to the conception and design of the study and wrote the manuscript. All authors contributed to manuscript revision and read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Restraint use is a complex and challenging issue in home care. Due to socio-demographic trends, worldwide home healthcare providers are faced with an increasing demand for restraint use from informal caregivers, patients and healthcare providers, resulting in the use of various types of restraints in home care. Awareness and knowledge of restraint use in home care, its implications and the ethical challenges surrounding it are of crucial importance to its reduction. This research aimed to describe the development process of an evidence-based practice guideline to support caregivers to optimize home care.The practice guideline was developed according to the framework of the Belgian Centre for Evidence-Based Medicine and AGREE II. The guideline was developed over several stages: (1) determination of the target population and scope, (2) literature search, (3) drafting and (4) validation. A multidisciplinary working group determined the proposed purpose, target group, and six clinical questions for the guideline. A consensus procedure and consultation by experts were used to develop the guideline.The guideline provides an answer to six clinical questions and contains ten key recommendations based on the classification of GRADE, with the objective of increasing healthcare providers’ awareness, knowledge and competence to adequately deal with situations or questions related to restraint use. The guideline also includes a flowchart for dealing with complex situations where the use of restraints is requested, already present or considered.The guideline was validated by the Belgian Centre for Evidence-Based Medicine. Increasing competence, awareness and knowledge related to restraint use are key objectives of the guideline for reducing restraint use in home care. A multicomponent intervention to support healthcare workers in implementing the guideline in clinical practice needs to be developed. Research indicates that, depending on the definition used, the prevalence of restraint use in home care varies between 7% , 9.9% 22 and 24.Experiences from daily practice and the limited literature on restraint use in home care strongly suggest that healthcare providers  are insufficiently aware of the meaning and content of the existing concepts related to restraint use , resulting in restraint use in clinical practice and its subsequent negative impact on patients . PatientDecision-making related to restraint use is a complex process that is influenced by various factors. Research from nursing homes indicates that not only patient characteristics such as cognitive decline and poor mobility but also nonpatient-related factors such as the attitude and knowledge of healthcare providers and legislation affect decision-making about restraint use , 14–19. Being exposed to decisions and practice related to restraint use has a considerable impact on nurses, as illustrated in the study of Scheepmans et al. . Nurses Considering the complexity of restraint use in home care , healthcThe practice guideline was developed according to the framework of the Belgian Centre for Evidence-Based Medicine (CEBAM) and the Appraisal of Guidelines for Research & Evaluation II (AGREE II) . The guiThe target patient population was determined as home-dwelling persons, aged 60 or older, in home care and with an increased risk for physical restraint use . The decision to focus on this specific target population was made in collaboration with a specially constructed multidisciplinary working group based on the expertise of the members of the working group, the state of the art of the current literature  and the results of a qualitative study on the experiences of home nurses regarding restraint use in older persons in home care in Flanders (Belgium) .The target users of the guideline were healthcare providers in home care .Considering the lack of knowledge of and available evidence on restraint use in home care and based on the experience of the multidisciplinary working group, six clinical questions were formulated based on consensus among the members of the working group to define the guideline’s scope: (1) What is meant by physical restraint use in home care? (2) What factors increase the risk of physical restraint use in home care? (3) What are the consequences and impact of physical restraint use in home care? (4) What ethical and legal framework can support healthcare providers in decisions about the use of physical restraint in home care? (5) How can healthcare workers reduce physical restraint use in home care? (6) What steps and persons need to be involved in the decision-making process regarding and application of physical restraints in home care? The first five questions aim to increase awareness and knowledge of the problem of restraint use in home care. These insights and knowledge are required to understand the flowchart and how to deal with complex situations where the use of restraints is considered, requested or already present (question 6).n = 7) comprising home nurses (n = 2), domestic aides (n = 2), a general practitioner (n = 1) and representatives of patients and informal caregivers (n = 2). Members were selected to match the expertise of the research team (n = 4), consisting of persons with expertise in home care (n = 2); physical restraints, delirium, and falls (n = 1); and the ethics of care (n = 1). In addition, 2 lawyers and an ethicist were consulted to explain the legal and ethical frameworks for restraint use in home care.The research team recruited a multidisciplinary working group  reporting on older persons, restraint use, chronic care and (practice) guidelines and (2) written in English, French or Dutch. Guidelines on restraint use related to children; schools; psychiatry; seclusion; acute, emergency or intensive care; or dentistry were excluded. Five databases  and online (inter)national guideline databases  were searched from March 2013. Five guidelines –28 were  reportinNext, a literature search (July 2015) focused on the aforementioned six predetermined clinical practice questions. For each question, the literature search consisted of two phases. First, the articles were checked for relevance to the topic of home care, and articles of any design written in English, Dutch or French were eligible for inclusion. Second, this review was supplemented by a search of review articles related to the residential setting published in the last 5 years, with the same language criteria as for home care.PubMed and Cinahl were the databases consulted for both searches. For only the first clinical question in the home care setting, an additional database  was consulted. To construct the search string, medical subject headings were combined with free search terms using Boolean operators (AND / OR). The same groups of search terms  were used for both searches and combined with search terms in function of the subject of the clinical question and setting. The search string of the home care setting was completed with variations on the term ‘home care’. For the residential setting, combinations of key words for review were added  conducted the guideline and literature search, removed duplicate publications and made first selection of articles based on titles and abstracts. The methodological quality of the articles was assessed by two authors . Differences between their scores were discussed within the research team.Various tools were used to assess the quality of the articles according to the study design: VAKS  , MINORS The literature search confirmed that no guidelines specific to restraint use in home care and that research on restraint use in home care settings was scarce. For this reason, the multidisciplinary working group used a consensus procedure to develop the practice guideline , 44. OurThe development of the practice guideline resulted in ten recommendations in response to the six clinical practice questions and a flowchart to support the decision-making process when the use of physical restraints is requested or considered. To indicate the quality of evidence and strength of the recommendations, we used the methodology based on GRADE , which was required by the validation committee .A preliminary version of the guideline was read by the organizations to which the members of the multidisciplinary working group belonged. They checked whether the content of the guideline was applicable to their organization. The guideline was revised based on the experience of and feedback from these organizations. Furthermore, the revised version of the guideline was discussed with the multidisciplinary working group using clinical cases. Based on this feedback, a penultimate version was developed by the research team and presented to and discussed with a group of clinical practitioners . The text was again adapted one last time.The resultant practice guideline was presented to the Belgian Centre for Evidence-Based Medicine (CEBAM) for validation. The aim of this independent validation was to guarantee the methodological quality of the guideline. A validation committee was formed consisting of one methodological expert, one content expert, a chair  and three experienced clinicians representing the disciplines for which the guideline was developed . The validators assessed the guideline using the AGREE II instrument , and thewww.fixatiearmethuiszorg.be. The practice guideline answers six clinical questions, makes 10 recommendations   was usedPhysical restraints were often considered by nurses and informal caregivers to be safety measures . For thiThe overview of the negative consequences of the use of physical restraints is based primarily on evidence from the literature on residential care settings (mainly from nursing homes) and considers the patient, the family and the healthcare provider. Patients can experience physical consequences such as pressure injuries, urinary incontinence, constipation, increased risk of falls, increased dependence in activities of daily living and decreased muscle strength and mobility , 42, 46.Informal caregivers  are important for the continuity of home care and play an important role in the use of restraints. Depending on the home care situation and the level of involvement, the impacts of physical restraint use on the experiences and psychosocial wellbeing of informal caregivers may differ (positively or negatively) , 11, 47.Physical restraint use also involves healthcare workers. Indeed, considerations of physical restraint use are complex decision-making processes influenced by patient-, nurse- and context-related factors . The facThe important impact of restraint use on all involved persons has resulted in the recommendations that the use of physical restraint be avoided as much as possible [recommendation 4] and that healthcare providers [recommendation 5] and healthcare organizations [recommendation 6] be aware of the consequences of their use.Reduction of physical restraint use requires a critical and thorough consideration and weighing of values, norms and reasons within the framework of human, person-centred care , 43, 48.Although there is no specific legislation pertaining to physical restraint use in Belgium, some legal principles need to be respected and are included in the guideline. In general, the use of physical restraint is not allowed . An exception for physical restraint use can be made, provided that legal considerations are respected and there is strict compliance with the existing regulations. In Belgium, only nurses and physicians are allowed to apply physical restraints in the context of providing healthcare. The guideline integrates the patient’s rights  , 36, 50.The guideline describes interventions other than restraints that can be considered for each of the four types of risks/behaviours  that often lead to the unjustified use of  restraints. For each risk behaviour, the alternatives are subdivided into evaluating and reviewing possible medical or physiologic causes ; optimizing the environment ; alternatives in and around the bed ; supporting the person ; support in walking ; and transfer in or out of the bed, seat or chair.In developing more appropriate interventions, it is important that all involved healthcare workers, older persons and informal caregivers be involved in the decision-making process regarding restraint, with the goal of avoiding, minimizing or discontinuing the use , 39, 42.The complexity of restraint use in home care requires a careful and deliberate process of dealing with situations in which restraints are considered, requested or already in use, with the goal of keeping the use as low as possible. Minimizing restraint use requires critical analysis of the reasons leading to restraint use and, at the same time, a search for preventive actions and more appropriate interventions.A comprehensive assessment of the person- and context-related factors will lead to a better understanding of the patient and the home environment. These insights are the basis for developing an individual care plan for the patient, through the cooperation of all involved clinicians, the patient and informal caregivers. Other key elements include proactive and transparent communication and the commitment that each involved person has to fulfil his or her responsibilities  , 39, 42 The patient and the family, together with all involved healthcare workers, must be included in the decision-making process regarding restraint use and the discussion of alternative or more appropriate interventions from the beginning. The various means of meeting the patients’ needs must be considered first; any use of restraint is always a last and temporary resort. If continued restraint is deemed necessary, then the device or method used should be least restrictive given the patient’s behaviour, increased supervision should be implemented and the use of restraints should be stopped as soon as possible , 26 [recA flowchart has been developed Fig.  to suppoThe first step consists of an evaluation of the individual patient situation, i.e., whether the patient’s behaviour poses a physical risk and/or mental harm to the patient or others. If there is no risk of harm, physical restraints may not be used. If there is a risk for harm, a distinction should be made between urgent and non-urgent situations.Urgent situations require immediate action be taken in the interests of the patient’s health and safety and that of others. In assessing a patient’s behaviour and responding to meet the need expressed, nurses and physicians act autonomously and can decide to apply physical restraints. Other healthcare providers  ask for medical assistance  and immediately inform the patient’s general practitioner and family. A meeting between the patient, the family, the general practitioner and other healthcare workers involved must be planned to re-assess the urgency of the patient’s situation and the necessity of restraint use to limit the use of restraints over time and as quickly as possible.In a non-urgent situation, information on patient- and context-related factors needs to be collected and discussed with all involved persons. The general practitioner needs to assess the capability of the patient to make decisions, consulting with the multidisciplinary team on this point as needed. The pros and cons of all options to manage the home care situation need to be assessed and discussed. Considering that the use of restraints is almost never the first choice, the team jointly decides with the patient and the informal caregiver which option  is most suitable. If physical restraint use is considered, the team must ensure that the benefits of the restraint use outweigh the associated risks and that the physical restraint is stopped as soon as possible and used solely for the interest and wellbeing of the patient. The permission of the patient, or his/her representative in the case of a person who is incapable of making decisions, is required before applying physical restraints.The decision-making process, the caregiving and regular evaluations must always be reported in the patient record, and all involved persons must be informed.Current evidence indicates that restraints are regularly used in home care; that they are mainly applied to vulnerable older persons; and that informal caregivers, who have less knowledge of the negative consequences of restraint use, play a prominent role in the application of restraints, by granting permission for the use of restraints and deciding to use restraints , 48. NurThe current guideline aims to support healthcare workers in reducing the use of physical restraints and optimizing the quality of care for older adults receiving home care.To ensure a deliberate and careful approach to limiting or preventing physical restraint use in home care, our guideline focuses on increasing knowledge and awareness by providing information on this topic (Question 1–5), which is necessary for understanding and implementing the flowchart (Question 6). The knowledge obtained through the answers to the different questions and the flowchart aim to stimulate a deliberate and careful decision-making process related to restraint use in home care.When using this guideline, the following points should be taken into account. The guideline is not a protocol or standing order but a tool to support professional healthcare providers dealing with situations where restraints are requested or already in place. The guideline explicitly aims to support healthcare providers in reducing restraint use in aged community care by increasing home health care providers’ awareness, knowledge and competence regarding restraint use. More concretely, the guideline provides information about the concept and the negative impact and consequences of restraint use in home care as well as a flowchart to support a careful and well-considered decision-making process in practice. Healthcare providers must ensure that the use of restraint use is always a last and temporary resort.The guideline integrates Belgian legislation on restraint use with patient rights legislation. A limited literature search suggests that, despite international differences in legislation, the European Convention on Human Rights (2010) is (mainly) used as a guiding principle for dealing with restraint use .Evidence on restraint use in home care is scarce. For this reason, the multidisciplinary working group translated, adapted and used the strong evidence on restraint use in the residential setting (mainly nursing homes). The resulting recommendations in the current guideline were achieved through consensus. More research on specific issues, such as the experiences of the patient, family and other involved healthcare providers in home care and in the use of patient-centred interventions rather than restraints in home care, is necessary.Insufficient time and resources precluded us from conducting a systematic literature review including all types of empirical studies. A recently published systematic review , howeverThe full guideline has been published in a Dutch book format . The attThe guideline was validated by an independent organization, e.g., the Belgian Centre for Evidence-Based Medicine (CEBAM), which guarantees the methodological quality of the practice guideline. Thorough testing of its acceptability and usability in the field, however is necessary. Our follow-up project, which aims to develop and evaluate a multicomponent programme to implement the practice guideline, will provide this testing.Finally, the development of the practice guideline focused solely on the use of ‘physical’ restraints as defined by Retsas 1998) . The new98 . The The availability of an evidence-based guideline is an essential first step towards a reduction of restraint use in home care. Next, the current guideline needs to be implemented in practice, and the effect of this implementation needs to be evaluated. Evidence from the residential care setting shows that guidelines alone are insufficient to reduce restraint use. Furthermore, the success of reducing physical restraint use in the long term depends on a multicomponent strategy that involves policy change, leadership, education, and expert consultation , 51, 52.www.fixatiearmezorg.be. Eight components were developed: a summary of the guideline, a flyer to promote communication with informal caregivers, a website, social media , a promo film, a physical restraint checklist, 2 online tutorials and an ‘ambassador for restraint-free home care’ training programme. The programme was tested in a pilot study and evaluated using a mixed methods design [Therefore, the authors developed a new multicomponent programme to implement the guideline in clinical practice. By using the six steps of intervention mapping, a multicomponent programme was developed in a systematic manner in conjunction with an expert group of stakeholders. Various implementation aids are available for free on the website s design .The current guideline is the first validated, evidence-based guideline for reducing the use of physical restraints at home. Due to the limited but recent evidence available in the home care setting, evidence from the residential setting was also used to develop this guideline. This evidence was translated to the home care setting according to a consensus procedure using a multidisciplinary working group. Representatives of patients and informal caregivers were among the members of the multidisciplinary working group. An updated guideline that includes the perspectives of patients and informal caregivers is therefore necessary. This updated guideline should be pilot tested in real home care situations, be made available in English, and be made widely accessible. Further investments in its implementation will demonstrate the potential of the current guideline. Considering the complexity of the home care setting, there is an urgent need for effective multidisciplinary collaboration and further research.Additional file 1: Figure S1. Overview of all searches per clinical question .