Populations around the world are facing an increasing number of adversities such as the global financial crisis, terrorism, conflict, and climate change. The aim of this paper was to investigate self-reported strategies and sources of support used to get through "tough times" in an Australian context and to identify patterns of response in the general population and differences in potentially vulnerable subgroups.Data were collected through a cross-sectional survey of the New South Wales population in Australia. The final sample consisted of 3,995 New South Wales residents aged 16 years and above who responded to the question: "What are the things that get you through tough times?"Respondents provided brief comments that were coded into 14 main subject-area categories. The most frequently reported responses were family and self (52%); friends and neighbors (21%); use of positive emotional and philosophical strategies (17%), such as sense of humor, determination, and the belief that things would get better; and religious beliefs (11%). The responses of four population subgroups were compared, based on gender, household income, level of psychological distress, and whether a language other than English was spoken at home. Women reported greater use of friends and neighbors and religious or spiritual beliefs for support, whereas men reported greater use of drinking/smoking and financial supports. Those with lower incomes reported greater reliance on positive emotional and philosophical strategies and on religious or spiritual beliefs. Those with high levels of psychological distress reported greater use of leisure interests and hobbies, drinking/smoking, and less use of positive lifestyle strategies, such as adequate sleep, relaxation, or work/life balance. Those who spoke a language other than English at home were less likely to report relying on self or others (family/friends) or positive emotional and philosophical strategies to get through tough times.Understanding strategies and sources of support used by the population to get through adversity is the first step toward identifying the best approaches to build and support strengths and reduce vulnerabilities. It is also possible to reflect on how large-scale threats such as pandemics, disasters, conflict, bereavement, and loss could impact individual and population resilience. The metaphor "tough times" is used with increasing frequency in the media and in general conversation to describe any of a number of stressors and adversities acting on individuals or the population. Within Australia, the phrases "going through tough times" and "doing it tough" are part of everyday language, phrases that are matter-of-fact and somewhat impassive. Such phrases are popular in the media and are often used by national charities and welfare agencies, including ReachOut Australia, Wesley Mission, and Child Support Agency, as the phrases can be used to engage people across a range of demographics, especially males and people who may be reluctant to seek help and advice. This terminology has also been adopted by Australian researchers working in the field of resilience and men's mental health for similar reasons .For the general population, the phrase "tough times" is a nonthreatening and inclusive phrase that can be used in the context of a wide range of adversities, such as financial hardship, coping with pressures, and mental health concerns as well as wider issues such as working through the global financial crisis, living with the consequences of drought, or dealing with disasters and emergencies, such as floods and bush fires. The widespread use and acceptance of the phrase in the Australian language also promotes a nationally proud and resilient culture that acknowledges that we all encounter adversities but that we adapt and bounce back.In the context of the current research, resilience is regarded, in general terms, as the capacity for successful adaptation or change in the face of adversity , and theA number of researchers have been able to investigate individual and population response to adversities and investigate associations between certain strategies and coping approaches and psychological health. In research before and after the September 11 terrorist attacks in New York, Fredrickson et al  found thThe current climate has led us to re-examine population data collected in Australia during the first six months of 2007 as part of a series of question modules included in the New South Wales (NSW) Population Health Survey ,9. The aThe question -- "What are the things that get you through tough times?" -- was included in a series of short question modules incorporated into the NSW Population Health Survey between Jan. 22 and June 30, 2007. These questions were field-tested on a sample of 200 NSW residents to quantify test re-test reliability and ensure ease of understanding and lack of ambiguity before being included in the main survey. This research was approved by the human research ethics committees of the University of Western Sydney and the NSW Department of Health.The NSW Population Health Survey is an ongoing survey of the health, health behaviors, and service use of people living in NSW. It is administered using computer-assisted telephone interviewing (CATI). The target population for the survey is adult NSW residents aged 16 and older living in households with private telephones stratified by geographic location. Households are sampled using list-assisted random digit dialing, and one person aged 16 years and older from each household is randomly selected for inclusion in the survey. Trained interviewers at the Health Survey Program CATI facility carry out interviews. Up to seven calls are made to establish initial contact with a household, and up to five calls are made in order to contact a selected respondent. Data are collected from approximately 1,000 NSW residents each month. The population survey data are weighted to adjust for probability of selection and for differing nonresponse rates among males and females and different age groups. Further details of the NSW Population Health Survey methodology, sampling procedure, and weighting procedure may be found in Barr et al .The question -- "What are the things that get you through tough times?" -- was an open-ended question, and the telephone interviewers recorded each respondent's answer verbatim. As the context of data collection was within the larger health survey, in which respondents mostly were asked to provide ratings or simple yes/no responses, the responses were typically short, one- or two-word responses -- "my faith." "family," "friends," "going fishing," etc. Occasionally, they were more descriptive -- "positive outlook," "talking to husband/friends," "sense of humor," for example. As there was very little detail and no discursive comment data recorded, the categorization of these qualitative data was straightforward. Most comments were discrete and unambiguous, although they covered a wide range of emotional, practical, and symptom-related strategies and also included the use of a variety of resources, such as significant social support , financial resources, and professional assistance.A sample of responses (approximately 10%) was reviewed independently by two researchers to develop a keyword-driven coding frame. In general, there was a high level of concordance between the two independently developed coding frames. As there was no predetermined number of categories agreed before coding, the only aspect that required further agreement was the overall number of categories to code and analyze. This led to the merging of some small coding groups to form a "miscellaneous" category , and there was further separation of the single positive/active lifestyle category to form a positive lifestyle category and a sport and physical activity category. This resulted in identification of 17 content-specific, mutually exclusive categories, and the full set of responses was then coded into these categories. As respondents could provide a number of different comments, their responses were assigned to as many categories as required, typically one to three categories.As the target question was included as part of a larger survey, it was possible to investigate differences in the patterns of responses for different subgroups in the population. For the analysis presented here, we focused on four potentially vulnerable subgroups: women, those with low household incomes , those with high psychological distress, and those who speak a language other than English at home.Demographic questions relating to gender and income were used to identify the first two subgroups. For the present analysis, those with a household income of below AUD$40,000 were distinguished from those with an income of AUD$40,000 or greater. Socioeconomic factors are known to be related to a wide range of health and other vulnerabilities. Also, in the context of the current global financial crisis, it was felt that it would be interesting to investigate the strategies employed by less affluent individuals to see if differences existed and to try to understand how patterns of resilience in the population might be impacted by loss of income or reduction in financial resources.Psychological distress was assessed using the Kessler 10 (K10) measure. The K10 provides a composite measure of nonspecific psychological distress, largely anxiety and depressive symptoms. The K10 has been used extensively in Australian population health research, with baseline data available at both state and national levels ,12. The The language other than English subgroup was selected for further investigation in the current analysis as previous research has identified differences in threat perceptions and responses by this group to specific threats of pandemic influenza and terrorism ,9,15. It2 tests.Survey data were weighted to adjust for probability of selection and for differing response rates among males and females and different age groups. Data were manipulated and analyzed using Stata V9.2, which allowed for adjustments for sampling weights. Prevalence estimates and 95% confidence bands were calculated for each category coded. Statistical analysis of differences among these estimates for subgroups in the population was tested using ΧData were collected from 3,995 respondents during the period Jan. 22 to June 30, 2007. During this time, the reported response rate of the NSW Population Health Survey was 65%.Responses to the question "What are the things that get you through tough times?" were coded into 17 categories, as previously described; 14 were the main subject-area categories, and the three remaining categories were "don't know" (9.0%), "refused" (0.2%), and "miscellaneous" (0.4%). The latter category contained diverse responses provided by very small numbers of respondents, and as such was not included in the developed coding frame.Data were weighted, and prevalence estimates for each category of comment were calculated for the whole population and the four subpopulations. Of the weighted sample, 50.2% were female, 34.2% had household income less than AUD$40,000, 11.8% had high psychological distress, and 17.2% spoke a language other than English at home.Table As can be seen from Table To compare relative differences in the response profiles of subgroups in the population, Tables In Table With regard to the effects of household income, those on lower incomes  were significantly less likely than those on higher incomes to report using social supports, such as family and self and friends and neighbors to get through tough times (both p < 0.001). Similarly, the lower-income group was less likely to use sports and physical activity as a strategy (p = 0.009). Those on lower incomes were, however, more likely to report finding emotional and philosophical strategies and religious and spiritual beliefs helpful for getting through tough times (both p < 0.001).Table Compared to those who speak English at home, those who speak a language other than English at home were found to be less likely to report using social support to get through tough times, both family and self (p < 0.001) and friends and neighbors (p = 0.025). They were also much less likely to report using emotional and philosophical approaches or to turn to their pets . There was some evidence that those who speak a language other than English at home were more likely to use leisure interests and hobbies, but this difference did not reach a level of statistical significance (p = 0.066).When asked the question "What are the things that get you through tough times?" the vast majority of respondents (>90%) were able to identify at least one strategy they found helpful. Many respondents identified the importance of key people or groups, such as family, friends, and neighbors, and to a lesser extent, the importance of wider social support, such as social groups and church groups. The finding that social support is fundamental to handling adversity effectively is widely acknowledged and supported in the research literature ,3,6.Women were significantly more likely to report turning to friends and neighbors to get through tough times. This has also been reported in prior studies ,17. HoweGiven the high levels of reliance on the support of others to get through tough times and the apparent awareness of this in the general population, it is easy to appreciate the vulnerability that may be felt through temporary or permanent loss of such support due to bereavement, arguments, relocation, job loss, or social dislocation. Such losses may also be caused by natural disasters or drought resulting in job losses and erosion of rural communities, or by economic adversities, such as the global financial crisis, resulting in job loss or financial insecurity. Potential global health threats, such as pandemic influenza or emerging infectious diseases, could also require the use of physical control measures, such as social distancing, home quarantine, and school and work closures, all resulting in disruption to social support networks at a time when they may be needed most.Internal- and emotion-focused strategies were frequently reported, including positive emotional and philosophical strategies, such as feeling optimistic and thinking about other people being worse off or a general belief that things would get better. As mentioned earlier, the benefits of such approaches have been shown to have measurable psychological benefits ,2, and tThe importance of religious and spiritual beliefs was also noted by many as providing a source of strength in tough times. This was particularly so for women and those on lower incomes. In early research, there has been a general finding that women display more signs of religiosity than men . It is pIn the general population, leisure pursuits and activities were regarded as helpful, with people reporting their reliance on sporting activities, exercise, hobbies, and interests to get through tough times. It is unclear how effective such avoidant strategies are likely to be in the longer term. Leisure activities and hobbies may provide helpful distraction and diversion and may be helpful in reducing stress and improving affect; however, it is unlikely that such strategies alter the source or course of tough times unless they are practical in nature or lead to a cognitively based solution to such problems. Interestingly, those on lower incomes were significantly less likely to report using sporting and physical activity as a strategy for getting through tough times. This finding could be due to the associated costs -- e.g., gym memberships or clothing/equipment -- as well as other forms of support needed to allow for such activities, such as child care and time.Importantly, many people mentioned specific actions they take to give themselves strength, including finding time to unwind and relax, taking holidays, eating healthfully, and getting rest. Those with higher psychological distress were significantly less likely to report employing such techniques. Given that the K10 measure of psychological distress comprises elements of depression and anxiety, it is possible that those with high levels of distress may be unlikely to draw on internal resources required to take care of, prioritize, or value their own needs or well-being. Disaster research has found that loss of resources such as these, termed "energy" resources, are associated with higher levels of acute stress disorder and depression in disaster-affected populations . Taken tA surprisingly small proportion of respondents reported a practical or instrumental approach to tackling tough times, such as applying previous experience or training, seeking further information or advice, or breaking the problems down into smaller issues that could be managed. It is possible that the question and use of the term "tough times" was too general to evoke this category of response and did not convey a focus on practical approaches or solutions. In the context of disasters or adversity, practical, pragmatic approaches are helpful and widely used , both inSymptom-based coping strategies, such as drinking alcohol, smoking, and taking medication, were reported but by a generally small proportion of the population. Alcohol consumption and smoking were more likely to be reported by those with high psychological distress and by men. Although the benefits of a single beer or glass of wine as a way to relax or unwind might be seen as an effective and harmless quick fix to a tough day, increases in drinking alcohol or smoking would be harmful as longer-term strategies and would be unlikely to resolve tough times.Finally, and of relevance in the current tough economic times, a small proportion of respondents reported the use of money or financial security as a means to get through tough times. This was reported significantly less frequently by women and those with high psychological distress. A possible implication of this finding is that men may be more vulnerable in the current global financial crisis if exposed to financial loss, and in the wider context of disaster and adversity, would similarly want to rely more on financial security that may be compromised.Although the data presented in this paper are taken from a large representative sample of the NSW population, there are limitations to this study that should be considered. A single question provides a simple snapshot of key strategies reported by respondents during an interview. Participant responses may not have been exhaustive. Some respondents appeared to be able to report more strategies that get them through tough times, including women, respondents with higher incomes, respondents with high psychological distress, and respondents who did not speak a language other than English at home. These groups may have a greater variety of sources of support, or they may be better able to articulate their responses to the question.The data reported here were provided through the use of an open-ended question, and therefore are open to errors of transcription and coding. Coding errors and subjectivity were reduced by the use of keywords and phrases and using two independent raters to code the comments. Transcription errors were possible but were likely to be low due to the high level of experience and proficiency of the CATI facility interviewers.The question used in this research study was deliberately inclusive and general, and was intended to evoke a wide range of approaches to the generalized, but inherently meaningful, concept of "tough times." As such, the responses do not address a single specific problem or threat but convey a generalized approach or response to adversity. Equally, the question did not aim to quantify the relative effectiveness or efficiency of strategies, although the wording implied that the strategies mentioned by respondents would be regarded as effective and supportive of individual resilience. Finally, the question relied on respondents being able to declare their strategies. This appears to have been possible, as the vast majority of respondents were able to provide answers. However, 9% could not provide answers in the context of the interview, and therefore their contribution is absent.Despite these limitations, this study has been able to collect meaningful and insightful data from a representative sample of the general population and enable an appreciation of differential use and reporting of strategies and supports used to get people in different subgroups in the population through tough times.In the broad context of tough times in Australia, more than 90% of our general population sample has been able to report at least one helpful strategy or source of support for getting through tough times. Such findings are encouraging, although not surprising, given the generally high resilience and strength of individuals.Our data quantified the importance of social support. This finding serves to expose the vulnerability we have, individually and collectively, to disruption in our relationships and how large-scale threats, such as pandemics, natural disasters, and even cyber-terrorism, could impact individual and population resilience.In addition, this study was able to identify statistical differences in the relative reporting of supports and strategies in certain subgroups of the population. Findings that have implications for these subgroups include: less reliance on social support and greater reliance on positive emotional and philosophical strategies in those on lower household incomes; greater reliance on smoking and drinking and financial security in men; and greater reliance on smoking and drinking for those with high psychological distress.Although this study does not attempt to judge the relative effectiveness of the reported strategies used to tackle tough times, it does provide baseline information that can be used as a comparison to reported coping strategies when adversities or tough times occur. Knowledge of the strategies the population uses to tackle tough times is the first step toward identifying the most effective strategies, which should be a focus for future research. This would provide a starting point for possible population-based interventions designed to promote the use of effective coping strategies following adversity and provide a useful reference for those tasked with supporting individuals and families through a range of tough times.The authors declare that they have no competing interests.All authors contributed equally to this work. All authors have read and approved the final manuscript.


The importance and complexity of handovers is well-established. Progress for intervening in the emergency department change of shift handovers may be hampered by lack of a conceptual framework. The objectives were to gain a better understanding of strategies used for change of shift handovers in an emergency care setting and to further expand current understanding and conceptualizations.Observations, open-ended questions and interviews about handover strategies were collected at a Veteran's Health Administration Medical Center in the United States. All relevant staff in the emergency department was observed; 31 completed open-ended surveys; 10 completed in-depth interviews. The main variables of interest were strategies used for handovers at change of shift and obstacles to smooth handovers.Of 21 previously identified strategies, 8 were used consistently, 4 were never used, and 9 were used occasionally. Our data support ten additional strategies. Four agent types and 6 phases of the process were identified via grounded theory analysis. Six general themes or clusters emerged covering factors that intersect to define the degree of handover smoothness.Including phases and agents in conceptualizations of handovers can help target interventions to improve patient safety. The conceptual model also clarifies unique handover considerations for the emergency department setting. Clinical handovers occur when healthcare providers transfer information and primary responsibility for patient care. Clinical handovers are increasingly surfacing in discussions of patient safety, patient flow, and quality of care. -4 The prThere is also increasing appreciation for the role communication plays in the occurrence and understanding of medical errors ,7, incluThus, without a more complete appreciation of the process and the context within which particular handovers occur, recommended interventions and changes may inadvertently negate or eliminate the positive aspects and decrease the likelihood that meaningful changes to improve the process are achieved ,21. IndeSome recent ethnographic studies have contributed to understanding handovers in EDs. Patterson et al  generateAlthough handovers permeate the health care system, we focused on handovers at change of shift in the ED at a large urban Veteran Affairs Medical Center (VAMC). We focused on the ED because EDs have unique considerations ,22. ManyIn order to develop a better understanding of handover processes in emergency medicine and provide insights that will inform interventions and redesign strategies to enhance patient care and safety ,18,22,23This study took place in a VAMC ED serving veterans residing in Northeastern Ohio and referrals from Veterans Affairs (VA) and non-VA nursing home care units, VA outpatient clinics, and non-VA EDs and inpatient units. The ED is part of a full-service teaching hospital with residents rotating every two weeks. It is also affiliated with 12 community-based outpatient clinics that serve veterans in northeast Ohio. The ED has a triage system that designates care to fast-track and acute areas between 8 am and 5:30 pm Monday through Friday and at all other times patients are triaged to be seen in the acute area. For physicians, Monday through Friday there are 4 changes of shifts daily (3 non-overlapping) . On each weekend day, physicians have 3 changes of shift (2 non-overlapping) . For nurses, there are 4 changes of shifts 7 days a week (3 non-overlapping) . Physician Assistants (PAs) have 1 non-overlapping shift Monday through Friday that starts in the morning. Residents hand over to residents, attendings, and moonlighting attendings working nights, weekends, and holidays who serve as medical officers of the day (MOD). Attendings and MODs hand over to attendings and MODs. PAs hand over to attendings and residents. Nurses hand over to nurses. The average monthly volume during 2006 was 1969.3 patients .During the day shift (8 am to 6 pm) there are one to two attending physicians, three PAs, and several medical residents staffing the facility. At the 6 pm physician and PA shift changes, the MOD assumes care and responsibility for the patients. At 8 am the "night shift" physician signs out to the day shift attending physician and resident. At 8 am there generally are few or no patients in the department. Five to six interns and residents arrive at approximately 9 am. One resident joins the three PAs in the ED fast track. There are 4 to 5 interns and residents working in the acute area until 6 pm. At 1 pm the "morning shift" attending leaves, and, as needed, hands cases over to two attendings. These two "afternoon attendings" work until 6 pm when the MOD arrives and works until 8 am. The 1 pm and 6 pm handovers are the major handovers of the day for physicians.There are 12 examination suites, 11 of which are equipped to manage critically ill patients and 1 that is a seclusion room for acute psychiatric patients. In addition there are 4 "fast track" rooms in an adjacent hallway for patients with minor injuries or illnesses.The VAMC has an electronic medical record (EMR) and a white dry-erase board for tracking patients. The director introduced a sign-out tool for the ED that includes columns for room number, patient's name, last 4 numbers of the patient's social security number, main problem, disposition, and "to do" list.Qualitative methods were used as the best approach to clarify parameters and issues of a process that is complex and complicated by many factors, and to help identify new pieces of information about the process and participants. There were two main phases that followed an initial observation period: 1) open-ended survey and 2) in-depth interviews. This order for the methods was chosen so that information from the previous phase could be used to help inform the next phase.The study required ethical consideration, and was reviewed and approved by the Human Studies Office  of the VAMC Cleveland which oversees the human research protection program. Participation was voluntary and confidentiality was protected. In-depth interviews were audio recorded with permission of the interviewee  and transcribed without any identifying information included. Once the quality of the transcription was verified, the recordings were erased.Field observations were conducted by all three investigators at different times over a one year period and focused on physician handovers at change of shift. The objectives of the observations were to obtain a sense of the process and help formulate the study's survey and interview guide. The observers arrived fifteen to thirty minutes before the scheduled shift change and stayed for ten to fifteen minutes after the change was completed. No weekend changes of shifts were observed. One author observed over 120 handovers at the 6 pm shift change on randomly selected weekdays. Another observed a random sampling of handovers drawn from all possible change of shifts for physicians (26 hours of observation). The third investigator participated in 4 handovers per week (1 pm and 6 pm) for an extended period. Although in some ways video recording would seem ideal, it was deemed impractical given the setting: high quality recordings would be a challenge in the ED, particularly near the white board due to others working in the area, interruptions, and ambulance traffic. We also felt it unnecessary for our immediate purposes because the number of observation periods and observers most likely resulted in blending in after the first couple occasions. In addition, minimal field notes were taken during the observation period and then expanded afterwards, as is typical of ethnographic field methods.A letter of introduction was sent informing potential participants about the survey and in-depth interviews. This was followed a week later by a copy of the open-ended survey coded for tracking purposes along with a self-addressed envelope to return the survey. Reminders and an additional copy were sent two weeks later for unreturned surveys.The survey consisted of a cover page with questions about demographics related to the work setting and four open-ended questions. The survey was developed as a brief interview by one author and was reviewed for clarity and feasibility by the two authors who are physicians in emergency departments. The instrument was not piloted. Two versions were used, one with wording for individuals directly involved in the handover /Licensed Practical Nurses (LPNs)) and one with wording for those not directly involved in handovers but who may be impacted . Three open-ended questions were used to identify parameters that may be currently overlooked in structured and closed-ended formats. ,25 TheseAfter collecting and reviewing the open-ended surveys, in-depth interviews were conducted with a subset of participants. One investigator conducted interviews in a private setting removed from the ED at a time convenient to the respondent. Two versions were included, one for individuals directly involved in the handover  and one for those not directly involved but may be impacted . The wording was changed to elicit information about what they may have observed about the process. The general interview questions and probes that were used to guide the interview were designed to elicit examples of handovers that didn't go as smoothly as expected, discussion of the benefits and risks, and strategies to deal with the risks.Participants for the self-administered open-ended survey included all staff members involved and potentially impacted by the handover procedures at change of shift in the ED: attendings, residents, MODs, PAs, RNs, LPNs, health technicians, and clerks. Other eligibility criteria included the ability to read and speak English. The three groups of potential participants included 51 physicians and 3 physician assistants, 18 nurses , 6 clinical assistants  and 6 clerks. In-depth interviews were planned with at least one staff member from each group and would be conducted until we obtained thematic saturation, where no new ideas surface.Any identifying information was removed from all study materials and coded according to respondents' positions. Observational data was used to help develop the open-ended survey and guide the in-depth interview. Observations were also used to provide supplemental information about contextual factors and additional triangulation information for interpretation of findings.The analytic approach chosen for analyzing the in-depth interviews was based on grounded theory ,26,27. TThirty-one surveys (37%) were returned: 21 physicians ; 6 nurses (5 RNs and the Nurse Manager); 3 PAs; and 0 Clerks. Of the 31 respondents, 15 (48.4%) were female and the majority of participants was Caucasian (74%). Of the 21 physicians, internal medicine was the area of specialty for 76.2% (n = 16). Not including the residents and one respondent who did not fill in length of time they have worked in the ED, the average length of time working in the ED was 5.33 years .A total of 10 interviews were conducted: 2 attendings; 1 MOD; 2 residents; 2 PAs, 1 nurse, 1 clerk and 1 health technician (the last 2 hadn't completed a survey). Forty percent of those interviewed were female and 60% were Caucasian. Excluding residents, the average length of time working in the ED for those interviewed was 4.20 years . Interviews averaged about 32 minutes (range: 21 to 48 minutes).Direct observations and interviews were used to expand understanding of issues organized around responses to the open-ended survey items.Additional file Our findings lend further support to strategies identified by Patterson et al  and repoIn analyzing the issues and themes, a more comprehensive understanding of the process necessitated a discussion of the primary agent or agents linked to the strategies . "Agent"prior to the handover and done by the outgoing to hand to the incoming. Thus, for some strategies there is one primary agent. The actual handover phase is where the formal exchange takes place and both agents are primary (dyad is primary).For example, strategy #16, where the incoming receives paperwork that includes handwritten annotations, is classified in our matrix under preparatory phase and aligned with the outgoing party as the agent because the key time for the strategy was Both direct observation and analysis of responses identified two other types of important agents: other staff and cultural/environmental factors. While some discussions have recognized the incoming and outgoing ,18,23, fMoreover, to fully appreciate the strategies, it was clear from our observations and analyses that it is important to identify phases of a handover to fully understand the processes surrounding the handover, consistent with other recent approaches . AccordiFor example, one type of strategy relates to reducing the number of handovers and engaging in timely admissions. Such activities suggest an anticipatory phase where the outgoing party is actively anticipating the upcoming handover and engages in behaviors to reduce the number of patients that have to be handed over  and/or ensure that some handovers are completed or brought to closure so that they don't have to be handed over , or there is minimal work needed if they do have to be handed over . Thus, issues relevant to enhancing the handover clearly begin before the actual handover.Similarly, the preparatory (prep) phase is a separate phase that happens just prior to the actual handover phase (where the two agents meet and exchange information), and reflects activities to prepare for the handover such as updating information, writing a summary, preparing handwritten annotations to provide to the incoming agent. The next phase is the actual handover and includes numerous strategies to enhance the transfer of care, such as efforts to limit interruptions, giving the incoming information about care plans and contingency plans, update information during the handover, see patients or make walking rounds. The immediate post-handover phase is that window of time right after the exchange. Strategies related to this include the outgoing staying to complete or bring cases to closure as much as possible so that the incoming can attend to new cases or other cases in the midst of the work-up and/or treatment. For the incoming, the immediate post-phase strategies include seeing patients, particularly those that are less stable or complicated, and reassessing and refining plans. The post-handover phase reflects that time when the environment is adjusting to the new staff taking over the shift. The cycle of phases then repeats itself as the next change of shift approaches.Analyses of the questions about obstacles and suggestions to improve the process revealed similar themes and categories, with the suggestion often addressing the obstacle. As such, Additional file Specifically, six general themes or clusters emerged covering the gamut of factors that intersect to define the degree of smoothness and patient safety involved in a particular handover. It is important at the outset to recognize the interconnectedness of the categories and themes. There was one non-general theme that related to training of residents.Functions or the business of the ED theme encompasses aspects that are part and parcel of an ED. The categories that emerged included clinical patient challenges , patient volume , patient flow , time pressures (the environment by nature has time constraints related to doing the work), and non-clinical patient challenges ."Operations" relate to aspects and decisions made about how to structure the ED to meet those aspects that, by definition, are part of the setting. The categories under this theme are shift overlap , non-clinical demands , physical structure/setting of the board , and triage arrangements ."Resources" relate to categories that were mentioned relevant to physical space/rooms  and personnel, including staffing ratio and personal limitations (fatigue) that impact on the handover process."Professionalism" also emerged with three general categories: ownership ; consideration ; and punctuality ."Communication" relates to various factors that impact on the process and nature of information exchange. The categories include interruptions/distractions that occur during the time of the actual handover that make it challenging and reduce the smoothness of the process , formal communication mechanisms for the sign-out process , completeness of knowledge available , adequacy of information exchanged , status of tasks , and external factors .Another theme or cluster relates to aspects of "clinical decision processes" that impact on the smoothness of the handover. We identified four categories within this theme: degree of closure or completeness of the cases ; focus of attention ; degree of testing and work-ups ; and timing and speed .The importance of understanding handovers is well-recognized. Patient handovers in an emergency department present unique challenges and obstacles. Patients have an undifferentiated presentation and are generally of higher acuity than those on general medical wards. Clinical status changes can be measured in timeframes of seconds to minutes for emergency department patients with unstable medical conditions. Previous attempts to organize handover coordination and communication strategies, although providing an important foundation, are conceptually limiting. We have expanded previous efforts by differentiating two critical factors (timeframe and agents) consistent with recent human factors approaches . ExpandiExplicit consideration of the obvious agents also provides a more comprehensive approach to organizing strategies and interventions . Our finAs emphasized by Behara et al. , the ED Figures The top half of figure Figure One challenge to smooth handovers that was identified related to excessive testing and the reference to the 'internal medicine focus,' with the suggestion being "don't do the million dollar work-up on everyone." This issue cuts across all phases of the handover process and suggests opportunities related to training since our ED is staffed by mostly internal medicine trained physicians who are also training residents in the context of the ED. Thus, one recommendation would be to take advantage of the presence of residents. Specifically, this suggests that a training program may be developed to educate trainees to the unique aspects related to the nature of providing care in the ED. This training may bridge the gap in knowledge of trainees and remind the other providers that the focus of the ED is upon timely identification, management, and disposition of patients with acute and sub-acute problems. As trainees return to the ED during their residency the principles of this training can be reinforced by having the returning residents contribute to the teaching of their peers who are on their first rotation in the ED.This training might also include other critical staff, such as the nurses and physician assistants, giving them a more visible role in the training process including the critical nature of the handover in care and the preparation for a successful handover. This presents an opportunity to highlight the importance of communication between nursing and physicians that was described by some respondents as inadequate in our study, particularly increasing the awareness of the "plan of care" for the nursing staff.Other considerations to improve the handover relate to emphasizing the finding that the handover exchange is critically embedded in a process and a context, which suggests recommendations that while not directly altering the actual handover, may improve it. In particular, the anticipatory and preparatory phases could easily be lost or truncated in a chaotic environment such as the ED, resulting in compromised or lost strategies related to these phases. Technology or environmental supports for these phases of the process to prevent losing track of time and suddenly realizing it is time to handover cases might be helpful to avoid incomplete information at the time of the handover or a prolonged handover. For example, if an electronic tracking system is available, it is possible to change the color of the screen two hours before change of shift and then having a blinking screen 40 minutes before hand. Also, other environmental cues, such as reminder or warning bells, might be helpful with or without electronic tracking systems. These cues could help to support those strategies directly related to those phases and at the same time, since the intervention informs all parties , help with other challenges such as the overall flow of patients  and reinforcing timeliness of activities .On a related note, appreciating the embedded nature of the ED and the phases of the handover process results in recommendations sensitive to the whole context. Focusing on challenges that impact on all phases, as summarized in Additional file In addition, as the providers and other ED staff work to adopt some of the strategies described for the anticipatory and preparatory phases of the handover, and to acknowledge the influence of the larger health care system, there may be an opportunity to develop a tool or checklist to assist with the management of the actual handover. That is, as other broader issues get addressed, the inherent variability in the handover moment may be lessened by smoothing other interrelated components across the phases, making a tool that helps to structure the exchange potentially more useful. At the same time, the tool and its implementation will need to be flexible given the very nature of the frequently changing pace and composition of work in the ED. It may be helpful to consider the communication challenges described in this study when developing this tool. Also, with the inclusion of electronic tracking system that integrates with the electronic medical record, there may be opportunities to develop a tool that incorporates the results of patient testing. Additionally, an electronic tracking system that includes a handover tool permits updating by providers and clerical and nursing staff, which again may facilitate communication of patients' plan of care.There are limitations to our study that should be acknowledged and placed in context. Our objective was to identify strategies, opportunities and challenges related to handovers in the urgent care/emergency department. The response rate for the open-ended surveys was 37%. While we considered this a good response rate for an open-ended survey in a group that works in a fast pace environment, was experiencing staff turnover, and was dealing with demanding and unpredictable clinical cases, the analysis did not include written input from some of the participants in the handover process. Therefore, although we included field observations, we may still be missing strategies, challenges, and opportunities despite having achieved saturation. We feel this is unlikely given the multiple methods and the overlap with findings from other larger studies. Similarly, we did not design the study to determine how effective or important strategies were. However, by investigating barriers to smooth handovers, we believe we have identified issues relevant to ensuring that handover strategies are effective and important. Another limitation may be the lack of an electronic or computerized tracking system that has replaced white boards in some ED settings. While the electronic tracking boards render some strategies less relevant because they permit updating patient status and diagnostic testing, the ability to create and modify clinical information and decision-making in real time remains problematic with these electronic systems. It is worth noting that since completing this study, our ED put in a computerized tracking system.In addition, we are limited to one setting that potentially has some unique circumstances, including that it is a teaching environment, a VAMC with only an adult patient population, electronic medical records, and an emergency department staffed with primarily non-emergency medicine trained physicians. Nevertheless, staffing by non-emergency medicine trained physicians is a common arrangement both in the VA and elsewhere. A follow-up study that includes emergency departments of varying organizational and contextual parameters would help further our understanding of the factors that impact on successful and less successful handovers. Finally, our focus was on only one type of handover: change of shift. However, the findings have relevance for most transitions in terms of appreciating both the similarities and differences.Despite these limitations, the findings expand important frameworks that are evolving to better understand transitions of care in emergency care settings. These frameworks will provide the foundation to implement successful patient and provider safety improvements in this unique setting. ,18,20,23The importance and complexity of handovers, the commonly occurring situation in which both information and primary responsibility for a patient are transferred, is well-established. This study of clinical handovers identified limitations in the current approaches to conceptualization. Using a grounded theory approach, we developed a more comprehensive conceptual framework that will facilitate improvement of this problematic transition in care. Based on assessment of strategies, obstacles to smooth handovers, and suggestions for improving handovers, we identified relevant themes, phases, and core agents of the handover process as key conceptual components. The conceptual model also clarifies unique handover considerations for the emergency department setting.The authors declare that they have no competing interests.RHL conceived and designed the study, survey and interview protocol, conducted interviews and analyses, developed the conceptual themes and model, and drafted and revised the manuscript. AMT conceived and designed the study and survey, helped with analysis and development of the model and manuscript. APG participated in the design of the study, analysis and interpretation of the data, and provided feedback on the conceptual model and revisions. DCA provided feedback about the design of the study and helped with revising of the manuscript. Authors are listed in order of contribution, and all read and approved the final manuscript.The pre-publication history for this paper can be accessed here:Table 1. Strategies reported or observed to enhance transfer of care at change of shift organized by primary agent of the strategyClick here for fileTable 2. Conceptualizing strategies reported or observed to enhance transfer of care at change of shift organized by agent and phase in the Emergency Department handover processClick here for fileTable 3. Themes and categories of challenges to smooth handovers and suggestions for improving handoversClick here for file


Support groups for families of persons with mental illness are emerging as significant components in psychosocial rehabilitation programmes.To ascertain the expectations of family members who attend family support group meetings and to find out the efficacy of such programmes.n=20) was drawn from family members who attended the support group meetings regularly for a minimum period of 6 months. Data analysis was done using percentile.The data were collected from support group members using a semi-structured interview schedule. The study sample (Analysis of the data revealed that members attending the support group meetings expected to get more information about the illness, develop skills to cope with problems at home and learn skills to deal with the ill person. An important finding of the study was that the members developed a ‘feeling of togetherness’ as a result of being a member of a group with common aims.Participation in a support group meeting positively affects key variables in the participant's adaptation to mental illness in a relative. The role that families play in the support and care of a relative with a mental illness has gained increasing attention over the past 30 years. There has been a rapid propagation of support, self-help, or mutual support groups for family members of persons with severe psychiatric disabilities. In 1979, representatives of 100 family support groups came together to form the National Alliance for the Mentally Ill (NAMI) in the US.1Family self-help groups are defined as ‘voluntary small group structures for mutual aid in the accomplishment of a specific purpose’. They are usually formed by peers who come together for mutual assistance in satisfying a common need, overcoming a common handicap or life-disrupting problem, and bringing about a desired social and/or personal change.34Despite the variation among groups, the sharing of experience among people with a history of a similar problem is the fundamental concept that distinguishes this helping approach from other helping exchanges.In India, the family is the primary caregiver for individuals who have physical or psychiatric illness. The family members of people affected by a mental illness face various problems—financial, emotional, interpersonal relationships, social relationships—affecting the caregiver's day-to-day activities, health and occupation. The families need information, support, knowledge and specific suggestions for coping with mentally ill relatives.There are self-help groups for families of persons with mental illness in India. Most of the self-help groups later developed into associations or agencies to improve the quality of life of caregivers (as most parents are aged) and for advocacy. Hence, the majority of these groups started including significant relatives and others as members, such as the Alliance for the Mentally ill, Chennai, Tamil Nadu; Association for the Mentally Disabled (AMEND), Bangalore, Karnataka; Marghadharshi, Bangalore, Karnataka; Marghadeepthi, Guwahati, Assam; Schizophrenia Awareness Association, Pune, Maharashtra; and Subitcham, Madurai, Tamil Nadu.The present study was done to find out the expectations of members of a family support group and assess the benefits of family support group meetings.The study was conducted at Chetana, a day-care centre run by the Richmond Fellowship Society (India), Bangalore. Admission to Chetana is open to any person 18–45 years of age with a diagnosis of schizophrenia or any other major psychiatric disorder or mild mental retardation. The facilities available include vocational training units of computer, typing, printing, plastic moulding, and tailoring and embroidery. In addition to vocational training, the centre has therapeutic programmes such as structured daily activities and afternoon group activities, namely, community meeting, group therapy, recreational activities such as going for movies, picnics, group games and horticulture activities. Regular individual and family therapy sessions, and family support group meetings are also held at the centre.The present article is a part of the ongoing programme. Hence, some of the tools were not used. As these programmes are service-oriented and ongoing, we are of the opinion that the use of scales is important. The sample consisted of 20 members who had attended the support group meetings regularly for a minimum period of 6 months. A semi-structured interview schedule was used to collect information from the group members to assess the usefulness of such meetings. It consisted of two domains, i.e. expectations and benefits received from the family support meetings along with sociodemographic details (developed by the authors). Each domain includes 4–5 items in the schedule .The family support group meeting was conducted by the psychiatric social worker regularly every month at the centre. The members of the family support group attended the meeting without fail. The duration of meeting was 60–75 minutes. The format of each meeting included introducing new members to the group, review of the previous month's problems and issues of the psychiatric rehabilitation centre, allowing members to express day-to-day problems faced by the families at home and in society. Family support group members were allowed to discuss in the language known to everyone. Professional interventions such as facilitating ventilation, active listening, providing support, reassurance, psychoeducation, realistic goal-setting, formulating future plans and advocacy were used as and when needed.The group members had various expectations from the family support group meetings. These are listed in The benefits of family support group meetings were analysed. The results are presented in The findings of the study suggested that family members of mentally ill persons with certain demographic characteristics are more likely to join support groups. For example, family members with a higher level of education are likely to join support groups. This finding is consistent with those reported by other authors.et al.et al.,Out results support the idea that participation in a support group meeting positively affects certain key variables in the participant's adaptation to mental illness in a relative. In this analysis, members reported more extensive adaptive coping skills and more emotional support and improvement in the relationship. As in the studies by Chamberlin et al.The results of the present study revealed that the highest expectation of the family members was information about the illness; this is consistent with the findings reported by Elangovan


The home-management of malaria strategy seeks to improve prompt and effective anti-malarial drug use through the informal sector, with a potential channel being the Private Medicine Retailers (PMRs). Previous evaluations of PMR programmes focused on their impact on retailer knowledge and practices, with limited evidence about the influence of implementation processes on the impacts at scale. This paper examines how the implementation processes of three PMR programmes in Kenya, each scaled up within a district, contributed to the outcomes observed. These were a Ministry of Health programme in Kwale district; and two programmes supported by non-governmental organizations in collaboration with government in Kisii Central and Bungoma districts.The research methods included 24 focus group discussions with clients and PMRs, 19 in-depth interviews with implementing actors, document review and a diary of events. The data were analysed using the combination of a broad policy analysis framework and more specific scaling up/diffusion of innovations frameworks.The Kisii programme, a case study of successful implementation, was underpinned by good relationships between district health managers and a “resource team”, supported by a memorandum of understanding which enabled successful implementation. It had flexible budgetary and decision making processes which were responsive to local contexts, and took account of local socio-economic activities. In contrast, the Kwale programme, which had implementation challenges, was characterised by a complex funding process, with lengthy timelines, that was tied to the government financial management system which constrained implementation Although there was a flexible funding system in Bungoma, a perceived lack of transparency in fund management, inadequate management of inter-organisational relationships, and inability to adapt and respond to changing circumstances led to implementation difficulties.For effective scaling up of PMR programmes, the provision of technical support and adequate resources are vital, but not sufficient on their own. An active strategy to manage relationships between implementing actors through effective communication mechanisms is essential. Successful outcomes may be realised if a strong and transparent management system, including management of financial resources, is put in place. This study provides evidence of the value of assessing implementation processes as part of impact evaluation for public health programmes. Prompt treatment with effective anti-malarial therapy remains the cornerstone of malaria control in sub-Saharan Africa ,2. The hInterventions to promote early treatment of childhood fevers through PMRs have been tested in small scale settings  with a rThe three programmes were implemented by the Ministry of Health (MoH) in Kwale district; by a collaboration of government health officials and a non-governmental organization (NGO), Merlin, in Kisii Central district; and by a collaboration of government health officials and NGO, African Medical Research Foundation (AMREF), with support from the United States Agency for International Development (USAID) in Bungoma district. Full implementation began in 2005 and 2006 in Kwale and Kisii, respectively; but the Bungoma district programme has a history dating back to 1998, with a new phase of intervention activities implemented in 2005 after the withdrawal of the first line drug, Sulphadoxine pyrimethamine (SP). The current evaluation was conducted six months after the implementation of the programmes in each site.The quantitative outcomes of these three programmes were assessed through a quasi-experimental design, involving comparisons between intervention and control areas, matched on the basis of similarity in geographical features, and malariometric indices. The primary indicator for the quantitative assessment was change in PMR knowledge and practice, following training on the use of amodiaquine as the drug of choice in the retail sector. As reported in detail elsewhere , positivThis paper compares implementation experiences across all three sites, considering what factors are likely to have contributed to differences in programme experiences, including the outcome differences between Kisii and Kwale districts.The study reported here was a retrospective policy analysis that investigated the three programmes’ implementation process. This involved data collection, both at district level and in the sub-district programme intervention areas. In Kwale, this included two out of the six divisions of the district; in Kisii, one out of eight divisions; and, in Bungoma, one out of ten divisions. Divisions are the third administrative tier in Kenya and have an average population of about 70,000 people.Kisii Central is located in Western Kenya with a highland/epidemic type of malaria transmission. The district, which relies on agricultural activities, has a population of 491 786 people served by 140 health facilities. Bungoma is also situated in Western Kenya and predominantly agricultural, but with an endemic malaria profile. It has a population of 876 491, served by 61 health facilities. Kwale district is on the Kenyan Coast with an endemic malaria transmission pattern  and a poTo understand the policy and programme context, the Principal investigator  reviewed documents such as reports, work plans, minutes of meetings, memos, financial returns and programme materials. A document review template was used to collect relevant information on the content of the intervention, policy environment, actors involved and the implementation processes. These data were used to develop tools at the initial stages and to validate data from interview materials as part of triangulation. The process also helped to construct a time line of the implementation process.Respondents for focus group discussions (FGDs) were selected purposively from the programme sites. For the client FGDs , the criterion for selection was mothers with children under five from the programme areas. For the retailer FGDs , the criteria were that the PMR was trained and was still operating a retail outlet within the programme area. All FGD respondents were recruited by local administrative leaders in each site, with the help of program officers. TA and two research assistants conducted all the FGDs. The number of participants varied in each group across the districts, averaging between 8-12 persons per session. All discussions were conducted in convenient venues for the participants. An attempt to capture group interaction was made through recording non-verbal expressions. All the interviews were recorded within the boundaries of confidentiality agreed at the time of discussions, and supplemented with written notes. All discussions were conducted in languages understandable to the participants, and focussed on normal client-PMR interactions, views on programme activities, goals, perceived barriers and facilitating factors.In-depth interviews were conducted with 8 community volunteers, selected to support training and monitoring programme activities, and referred to as co-trainers . Six main trainers , public health officers-government officers with three year tertiary training on environmental health, were then interviewed. These interviews allowed an exploration of implementation experiences at the point of delivery. For clarification, issues raised from both sets of interviews were followed up during seven interviews with district level officers and programme managers. The focus of the manager interviews was on the role of actors, views on programme goals, implementation experiences and perceptions of factors influencing that process.Finally, TA kept a field diary of daily activities in each district. Emerging issues and ideas were recorded, and detailed notes kept of activities and informal conversations with key actors. This enhanced reflexivity ,supporteData collection was planned around local community timetables and took local events into consideration. The research aim and processes were explained to all participants, and their informed consent obtained for participation, recording of interviews, and use of verbatim quotes, where applicable. Ethical clearance was obtained from the National Ethical Review Board .Qualitative interviews were taped, transcribed, and translated into English. Qualitative data were analysed using Nvivo7 . Analysis entailed open coding and progressive categorisation of issues in an iterative process that included debriefing sessions with respondents and regular consultations with the research team . The datThese two frameworks identify five main areas of influence over the successful uptake of an innovation, as summarised in Table Successful uptake of an innovation also depends on scaling up and organizational strategies. For example, if innovation implementation is led by a central government authority, like the MoH, it may be constrained by the rigid management processes of public bureaucracies that do not allow flexibility or take account of local context during implementation. An innovation is also less likely to be adopted if the resource team is dominated by experts and donors, in comparison to those where there is more participation by the user organisation . AlternaUsing the concepts outlined above, the experience of the three programmes around these two innovation aspects are outlined below.From the document review and interviews, five main programme activities were identified across sites: training, demand creation, accreditation, motivating actors, and monitoring and evaluation. For each programme, the details of these activities are outlined in Table In terms of training, in Kwale and Kisii, the intervention involved direct training of PMRs during participatory, skills-based workshops. The training covered information on malaria treatment and control; signs and symptoms of malaria, including danger signs; communication skills; and referral practices. In contrast, the Bungoma intervention did not have direct training of PMRs. Instead, it was primarily as a social marketing strategy, with one day’s training initially provided only for wholesale outlet and pharmacy owners to mobilise their support and enable them to engage with PMRs. The training provided wholesale outlet and pharmacy owners with information on the use of anti-malarial medicines and on the job aids that they were then intended to distribute to retailers in the periphery.Jirani kwa Jirani (JKJ- a Kiswahili phrase meaning neighbour to neighbour). This activity was based on a pyramid information dissemination approach in which trainers passed information and IEC materials to an initial group of community members, who then passed the same messages to five neighbours, who in turn trained five more neighbours – with the process repeated until all village members were covered. More active IEC dissemination strategies were also applied in Kisii district, compared to a more passive approach in Kwale.Based on early evaluation of its own passive dissemination strategy, the Bungoma programme developed a new information education and communication (IEC) aimed at demand creation activity, and called the “It enables you to know a period when you need to stock more drugs from the record that you have kept”.Closer examination of innovation attributes through the lens of innovation theory  members who were there then were transferred, apart from one. The new people who came in had no idea about this, so adapting to that was a big issue; there was no continuity after the changes”.Second, despite deliberate efforts to build user organisation capacity, a key challenge to implementation in Bungoma and Kwale was the transfer of key actors out of the districts, negatively affecting leadership stability Table . As a me“In Kisii Central, this programme took place in Kiamokama and Mosocho. These areas were facing the greatest malaria problems according to the International Centre for Insect physiology and Ecology (ICIPE) research, which was directing Merlin to areas where malaria was a big problem’.Third, only in the Kisii programme was there evidence that the programme responded to the felt needs of the user organisation, perhaps contributing to a supportive user environment Table . As noteFourth, all the programmes were linked to networks of actors. In innovations, such networks often provide resources that facilitate implementation and contribute to its sustainability . In KisiIn contrast, few efforts were made in Kwale to develop partnerships with other organizations as the implementation strategy emphasised the user organisation’s role in managing the programme locally as a way of strengthening sustainability. In Bungoma, meanwhile, there was a much more complex network with many partners. At the national level, USAID developed linkages with AMREF through a formalized, contractual agreement. USAID also contracted the Quality Assurance Project (QAP) and Centre for Diseases Control (CDC) to provide technical expertise to the programme, leading to an intervention with many external partners working through the government system. However, the strong research role of CDC generated negative perceptions of the programme among the user organization because it was perceived to prioritise research over programme implementation. The presence of well resourced external partners in this instance contributed to destabilizing relationships at the district and community levels.“You know different communities have different attitudes and my longer stay here has prepared me well to understand the type of people I deal with so that when I go there, I know the type of mechanism to put in place so that I can win them. So I think that enabled me to achieve a lot”. In the other sites, however, the constitution and composition of this team generated tensions within the user organisation. The selection of only one divisional PHO as the core team in Kwale limited district wide support, whilst in Bungoma the lack of involvement of divisional actors caused problems. As a member of the user organisation noted: “Actually because it is like they involved people at the DHMT level. But the PHO were brought on board later. And I think that is what they [implementing team] didn’t take nicely..... We didn’t do it wisely, the composition varied ...It is unfortunate that it is just the DHMT that took over, and we didn’t realize that at the end of it we will need other people who are the real stakeholders”.Finally, as Table Whilst innovation theory highlights the influence of a range of strategy issues on implementation success Table , programIn Kisii and Kwale, the implementation process began in selected geographical divisions, with the aim of covering the entire district through the gradual expansion of activities to other areas, illustrating a horizontal scaling up approach . This prIn Bungoma district, meanwhile, implementation occurred on a district-wide basis, and scaling up sought to expand programme coverage by adding a new element (community awareness through the JKJ strategy) to the existing intervention. This is referred to as a functional diversification or grafting scaling up strategy . This apThe implementation experiences demonstrate that relationships between the actors involved in every programme required deliberate management, and there was clear evidence that failure to manage these relationships affected implementation processes. For example, in Kwale, unrelated tensions over financial accounting among the user organisation members led to delays in convening DHMT meetings. This delayed implementation as one condition of the funding was to convene a DHMT meeting before any money was spent. On the other hand, a good illustration of a deliberate actor management strategy was noted in Kisii. Relationships between the resource team and user organisation were managed by a memorandum of understanding (MoU), introduced in the initial stages of implementation by the resource team. The MoU spelt out the roles of the resource team and the user organisation, and how resources would be shared. This MoU enabled constructive participation in intervention planning by both groups, resulting in successful implementation of most intervention elements. These characteristics were absent in the other sites.In Kisii, programme implementation was driven by action research, and this allowed the intervention to be adapted to the local environment. Decision making was also decentralized to the local Merlin offices, enabling local initiative, mutual learning and problem solving. Although action research was also used to guide implementation in Bungoma, adaption to local context was minimal, largely due to coordination challenges between the user organization members in relation to how the data was used for planning. In Kwale, meanwhile, implementation was managed by the user organisation through the much less flexible decision making processes of the government bureaucracy.The strength of management in the Kisii site was demonstrated by the deliberate efforts made to contain the impact on programme implementation of the national level decision to move from sulphadoxine pyrimithamine (SP) to artemisinin based combination as the first line drug for malaria treatment in 2004. Initial information on drug policy changes was relayed through formal government procedures; however, given a lack of clarity on the drug of choice for the retail sector, Merlin actively sought, through its own networks, further information and official documentation on this issue. The MoH then sent out a circular stating that PMRs could be trained on amodiaquine as the over the counter medicine until a proper policy was developed, allowing the resource team to revise all its IEC materials before the policy change occurred.In the other two sites, however, the drug policy change had negative influences on programme implementation. In Kwale, inadequate communication through official government channels led the DHMT to perceive that central government did not actively support the involvement of PMRs in malaria control. The slow response in communicating on the type of medicine to be used for the retail sector also created concerns over the continuity of the intervention among the user team. This generated challenges such as inadequate distribution of materials that had already been produced with SP medicines. Revision and production of new IEC materials referring to the new drug of choice could then not be undertaken because of budgetary constraints. In Bungoma, meanwhile, although AMREF, like Merlin, had national networks, it did little to secure clarification on the drug of choice for the retail sector in time to adapt its activities. Furthermore, as the JKJ strategy had emphasised SP, the drug policy change eroded the confidence of trainers and challenged the authenticity of information passed to clients, affecting delivery of the intervention.The process of financial disbursement mirrored the organisational arrangements of the organisations supporting each programme. In Kisii, the resource team was not only well funded but worked within an efficient system of disbursing funds for implementation. The flexible funding process facilitated changes in some hard core elements of the innovation. For example, in response to suggestions from PMRs on the need for more time to understand the content of training, the resource team prolonged the training period from two to three days. This promoted understanding and contributed to improved knowledge and PMRs practices compared to the other sites.“Mobilization was not extensively done because according to the plan, there was only a day or so for mobilizing the communities. Now you understand that some of areas are extensive that you cannot cover in a day or so many of the areas were not extensively sensitised of the programme.”In contrast, Kwale had a complex funding process, with lengthy timelines, that was tied to the government financial management system and constrained implementation, a feature that was particular to Kwale and not necessarily associated with other MoH programmes. Moreover, the failure to harmonise divisional level budgets with the district work plans meant that the budgetary needs were not fully met, or prevented funds from being used for local adaptation. This led, in particular, to inadequate demand creation, as illustrated here: “One of the biggest challenges was financial resources because people were not transparent. You see if we are partners and if you want us to have active participation then it is also good that people know what the inputs are. People did not know what went into this program for the five years if they knew then they read about it in the final reports. I think people were in the dark. This made people suspicious, and the credibility of the good project was damaged so people always feel they were being cheated’ .Finally, in Bungoma, all funds were disbursed to AMREF through a contractual agreement with USAID. The resource team in Bungoma therefore had direct control of programme funds, and this facilitated timely implementation of activities, as well as allowing programmatic adaptations to local realities. However, as the DHMT had no role in financial management this, combined with financial expectations among programme implementers, generated the perception of a lack of transparency and wider tensions: This study has firstly demonstrated the range of factors that influence the scaling up of PMR programmes and their successful implementation and, then, highlighted key approaches that can support successful scaling up of such programmes. The main limitation is that the study was not set up to test propositions about the factors explaining implementation problems and achievements derived from these frameworks. Nonetheless, the use of the frameworks in analysis helped guide systematic consideration, both within and across sites, of the factors that wider theory and empirical evidence suggest can facilitate or hamper effective implementation of innovative programmes. This process enabled reflection on explanations for the observed variations across programmes in implementation experience, including the primary outcome variable.The factors shown to influence PMR implementation are confirmed by wider experience. Many studies highlight the important influence of actors over the successful implementation of health programmes. For example, in Kenya, the introduction of the Malarone® donation programme showed the political and bargaining influence of national, regional or international actors over the development and implementation of the programme. International actors did not effectively involve national bodies responsible for drug policies, and there were many differences of opinion between regional bodies and international actors over the relevance of donation as a policy intervention. As a result, the programme was characterised by conflicts in its early stages and was only slowly implemented .The influence of implementing actors, specifically, on policy implementation, is well documented in studies from various settings. Front line providers have been shown, for example, to understand and implement policies differently from original intentions, often undermining effective implementation -19. In aWider evidence also highlights both the challenges of managing through inflexible government bureaucracies, and the importance of flexible management systems in successful scaling up processes. Often, the centralised bureaucratic procedures of government systems undermine local decision-making flexibility and so present challenges to the implementation of innovative interventions . For exaDrawing on the study findings, Figure Given the particular importance of actor management and flexible implementation processes, three main conclusions can be derived from this study for future implementation of PMR training programmes. First, it is important to appoint skilful leaders to drive scaling up processes. A strong and experienced resource team that has a good relationship with the user organisation is likely to be trusted within the local setting, and supports effective scaling-up. In addition, where this team has links into wider networks, additional informational and other resources can be drawn into supporting programme implementation. This conclusion has implications for the types of people that might be important in resource teams, and for the time that must be invested in setting up the relationships supporting policy implementation. Continuity in the implementation of PMR programmes is also dependent on the stability of district leadership. Moreover, in all three districts examined here, a core team Figure  was estaSecond, the study illustrates the importance of building and managing partnerships as part of intervention management, as recommended by World Health Organisation (WHO) guidelines for HMM programmes . ExperieFinally, the study provides ideas of how to address the challenges imposed by various features of context. To avoid the implementation gaps experienced in Kwale, future implementation of PMR programmes may need to find ways to allow greater authority in budgetary decisions at a local level, even within existing government procedures. Such authority brings the flexibility necessary to allow the user organisation to experiment with adapting different elements of PMR to local contexts, supporting positive outcomes Figure . The preOverall, the study shows that for effective scaling up of PMR programmes, the provision of technical support and adequate resources for successful adoption of the PMR intervention by the user organization are vital, but not sufficient on their own. Deliberate and careful management of the implementation process is key to successful uptake and impact at retailer level. Three keys aspects of management are critical for success. First, it is important to develop an active strategy to manage relationships between implementing actors through effective communication mechanisms, and by early, clear and transparent development of a set of principles to guide relationships (as the MoU in the Kisii cases study illustrated). Second, key actors responsible for implementation must have adequate management training and support. Third, successful outcomes may be realised if a strong and transparent management system, including management of financial resources, is put in place. This study, finally, provides evidence of the value of assessing implementation processes as part of impact evaluation for public health programmes, and the role of policy analysis approaches. Such assessment enhances the interpretation of quantitative outcomes and provides a basis for generating lessons about how to strengthen future implementation.The authors declare that they have no competing interests.TA was involved in the conceptual design of the study, collected and analysed the data and was responsible for the overall writing of the manuscript. AA was involved in the study design and revising the manuscript for intellectual content. WA provided information on policy discussions around the retail sector strategy and revised the manuscript. VM conceptualised the study and was involved in the overall design and writing the manuscript. LG was substantially involved in the study design and revising the manuscript for intellectual content.