District Stakeholders Research Articles

Strengthening anthrax outbreak response and preparedness: simulation and stakeholder education in Namisindwa district, Uganda

BackgroundAnthrax is a zoonotic disease caused by Bacillus anthracis that poses a significant threat to both human health and livestock. Effective preparedness and response to anthrax outbreak at the district level is essential to mitigate the devastating impact of the disease to humans and animals. The current diseaae surveillance in animals and humans uses two different infrastructure systems with online platform supported by established diagnostic facilities. The differences in surveillance systems affect timely outbreak response especially for zoonotic diseases like anthrax. We therefore aimed to assess the feasibility of implementing a simulation exercise for a potential anthrax outbreak in a local government setting and to raise the suspicion index of different district stakeholders for a potential anthrax outbreak in Namisindwa District, Uganda.MethodsWe conducted a field-based simulation exercise and a health education intervention using quantitative data collection methods. The study participants mainly members of the District Taskforce (DTF) were purposively selected given their role(s) in disease surveillance and response at the sub-national level. We combined 26 variables (all dichotomized) assessing knowledge on anthrax and knowledge on appropriate outbreak response measures into an additive composite index. We then dichotomized overall score based on the 80% blooms cutoff i.e. we considered those scoring at least 80% to have high knowledge, otherwise low. We then assessed the factors associated with knowledge using binary logistic regression with time as a proxy for the intervention effect. Odds ratios (ORs) and 95% Confidence intervals (95%CI) have been reported.ResultsThe overall district readiness score was 35.0% (24/69) and was deficient in the following domains: coordination and resource mobilization (5/16), surveillance (5/11), laboratory capacity (3/10), case management (4/7), risk communications (4/12), and control measures (4/13). The overall community readiness score was 7 out of 32 (22.0%). We noted poor scores of readiness in all domains except for case management (2/2). The knowledge training did not have an effect on the overall readiness score, but improved specific domains such as control measures. Instead tertiary education was the only independent predictor of higher knowledge on anthrax and how to respond to it (OR = 1.57, 95% CI = 1.07–2.31). Training did not have a significant association with overall knowledge improvement but had an effect on several individual knowledge aspects.ConclusionWe found that the district’s preparedness to respond to a potential anthrax outbreak was inadequate, especially in coordination and mobilisation, surveillance, case management, risk communication and control measures. The health education training intervention showed increased knowledge levels compared to the pre-test and post-test an indicator that the health education sessions could increase the index of suspicion. The low preparedness underscores the urgency to strengthen anthrax preparedness in the district and could have implications for other districts. We deduce that trainings of a similar nature conducted regularly and extensively would have better effects. This study’s insights are valuable for improving anthrax readiness and safeguarding public and animal health in similar settings.

Government of Batam City's Strategy in Implementing SEZ Policy

Regional autonomy, FTZ, KEK, institutional dualism, and special autonomy One of Indonesia's cities with the quickest growth is Batam. The Batam Authority, now known as BP Batam, constructed Batam Island in the 1970s, and it has since grown and gained a number of economic advantages. The issues Batam City is currently experiencing have existed since Batam implemented regional autonomy. An institutional dualism with the BCG, which had existed since the 1970s, evolved as a result of the BCG's arrival in 2000. The BCG served as the regional autonomy's executor and had a very strong legal and political standing. This study's goal is to acquire a general understanding of the difficulties that the City is now facing. One essential role of regional governments in the planning of regional development is their capacity to manage and implement regional development projects. because the success of the process of managing government and development operations in the region is dependent on the regional government. In Manatuto District, the community, village, village council, sub-district, and regional stakeholders are involved at the beginning of the regional development planning process. The community was unhappy when it looked at the central government's procedure for approving regional planning papers because it found that it was not based on the planning documents that were submitted to the central government. This study's objectives were to: a) Describe and examine the function of local government as an entrepreneur, coordinator, facilitator.

Strengthening district health management and planning: an evaluation of a multi-country initiative in Eastern and Southern Africa

Background District health management and leadership capacity is increasingly recognised as critical to health system performance. District health managers play a central role in effective implementation and tailoring of national health policies, and they need adequate skills and support. The District Health System Strengthening Initiative (DHSSi) was implemented over 2019-22 in Malawi, Kenya, Tanzania and Uganda to strengthen sub-national capacity for evidence-based planning and a broader set of management competencies needed to operationalize district plans. To support learning and adaptation, a three-year evaluation was conducted to assess progress against outcomes and to inform ongoing implementation and future investment. Methods The evaluation used a mixed-methods theory-based approach. Evaluation questions were structured using criteria of relevance, coherence, efficiency, effectiveness, sustainability and impact, and corresponded to outputs, outcomes and impacts in the DHSSi Theory of Change. The evaluation was conducted over three annual rounds, and combined data from document review, observation, interviews and group discussions with cross-country, national and district stakeholders, and analysis of secondary quantitative data. Results Experience of DHSSi implementation indicated the relevance of supporting district management and planning, with gaps in current capacity, government interest, and indications of the potential to improve district practice. DHSSi experience also highlighted challenges to effective achievement of stronger capacity, and to translation of skills to improved management practice and, ultimately, to improved service delivery. A range of factors beyond skills affected district capacities, motivation and opportunities for effective planning and management, including areas such as funding, planning templates, health information systems, staff turnover, partner alignment and political structures. Conclusions Strengthening sub-national health management is an important agenda in efforts to expand high-quality primary health care. Future initiatives should prioritize detailed understanding of the range of influences on district management, and work to strengthen the enabling environment for effective district practice.

Upholding Informed Consent: Experiences of Note –Taking without Audio Recording of in-Depth Individual Interviews in a Qualitative Study on the Implementation of the Pregnancy Re-Entry Policy in Zambia

The context of the research study needs to determine the data recording method to be used in order to ensure that no harm is done to the participants. In-depth individual Interviews (IDIs) is one of the main data collecting strategy used in qualitative research on sensitive topics such as teenage pregnancy. Audio recording in capturing data during IDIs is a common practice. However, audio recording of IDIs should be done in the context of informed consent. The objective of this paper is to elaborate on how note-taking was used to capture data within the context of informed consent. The research design was multiple cohort Case studies involving Chongwe district plus national stakeholders of the Pregnancy Re-entry policy in Zambia. Semi-structured interviews were conducted with hundred (100) participants from different cohorts of stakeholders using note-taking to capture the data. Ninety percent (90%) of the interviews involved physical note-taking with 10 % being electronic notes. The results are that note-taking increased the interview time but it afforded the interviewer the opportunity to probe further as the data was being collected. The major disadvantage with note –taking is that it reduces the pace of data collection as time has to be dedicated to consolidating the notes and memory recall of information shared. The conclusion drawn is that upholding informed consent in research is key, therefore the capturing of data during IDIs should be guided by what best upholds the rights of the participants. Therefore, note-taking offers an alternative to audio recording.

EVALUASI PROGRAM PERPUSTAKAAN KELILING DINAS PERPUSTAKAAN DAN KEARSIPAN KABUPATEN ACEH TENGAH

In Law Number 43 of 2007 concerning libraries, a library is defined as an institution that manages written works, printed works, and/or recorded works in a professional manner with a standardized system to meet the educational, research, preservation, information, and recreational needs of users. Mobile Library Program of Central Aceh Library and Archives Service in 2017. This study aims to evaluate the Mobile Library Program in Central Aceh District. This type of research is descriptive qualitative. The informants for this study included the Head of the Central Aceh District Library and Archives Service, schools that had mobile library programs in Central Aceh District, the community, and related stakeholders. The results showed that the mobile library program was ineffective as a whole because meeting the needs for books and providing services was only for junior high schools (SMP) and high schools (SMA) in the Central Aceh district, while the program's objective was to educate the people of Central Aceh. Besides that, there are several obstacles faced, namely the factor of natural conditions, the condition of the distance to the intended school is very far considering the travel time on the trip, the availability of local wisdom reading books, the absence of additional books on local wisdom, the factor of organizational commitment, collaborating with other parties related parties. The recommendations formulated need a study on the procurement of books according to the applicable curriculum and also the existence of supporting books in creating student interest in reading and the existence of a partnership with the Central Aceh District Library and Archives Service with academics.

A Framework for Implementing a District-Wide School Wellness Needs Assessment: Using the WSCC Model

Poor nutrition and insufficient amounts of physical activity are key contributing factors to childhood obesity and can adversely affect the physical, social, and emotional health, along with the academic success, of today’s youth. Comprehensive school-based initiatives, in combination with broader community efforts that target these behaviors, can help youth to develop and sustain healthy lifestyles through the adolescent years. The Whole School, Whole Community, Whole Child (WSCC) model emphasizes the connection between health and academic achievement and highlights the importance of school wellness assessments, stressing that schools serve as the nucleus in providing these supports with input, resources, and collaboration from the community. Inadequate amounts of attention have been given to the process of conducting school wellness assessments that promote collaboration between university research teams and key school district stakeholders. This article presents the process of conducting a district-wide wellness assessment with the WSCC model as the conceptual framework. It outlines practical steps for other districts to replicate and key collaboration principles, along with the specific use of a unique wellness assessment tool that includes a readiness for change component. It also discusses challenges and opportunities encountered, lessons learned along the way, and implications for school administrators and school health practitioners.

Implementation of PM-JAY in India: a qualitative study exploring the role of competency, organizational and leadership drivers shaping early roll-out of publicly funded health insurance in three Indian states

BackgroundThe Pradhan Mantri Jan Arogya Yojana (PM-JAY), a publicly funded health insurance scheme, was launched in India in September 2018 to provide financial access to health services for poor Indians. PM-JAY design enables state-level program adaptations to facilitate implementation in a decentralized health implementation space. This study examines the competency, organizational, and leadership approaches affecting PM-JAY implementation in three contextually different Indian states.MethodsWe used a framework on implementation drivers (competency, organizational, and leadership) to understand factors facilitating or hampering implementation experiences in three PM-JAY models: third-party administrator in Uttar Pradesh, insurance in Chhattisgarh, and hybrid in Tamil Nadu. We adopted a qualitative exploratory approach and conducted 92 interviews with national, state, district, and hospital stakeholders involved in program design and implementation in Delhi, three state capitals, and two anonymized districts in each state, between February and April 2019. We used a deductive approach to content analysis and interpreted coded material to identify linkages between organizational features, drivers, and contextual elements affecting implementation.Results and conclusionPM-JAY guideline flexibilities enabled implementation in very different states through state-adapted implementation models. These models utilized contextually relevant adaptations for staff and facility competencies and organizational and facilitative administration, which had considerable scope for improvement in terms of recruitment, competency development, programmatic implementation support, and rationalizing the joint needs of the program and implementers. Adaptations also created structural barriers in staff interactions and challenged implicit power asymmetries and organizational culture, indicating a need for aligning staff hierarchies and incentive structures. At the same time, specific adaptations such as decentralizing staff selection and task shifting (all models); sharing of claims processing between the insurer and state agency (insurance and hybrid model); and using stringent empanelment, accreditation, monitoring, and benchmarking criteria for performance assessment, and reserving secondary care benefit packages for public hospitals (both in the hybrid model) contributed to successful implementation. Contextual elements such as institutional memory of previous schemes and underlying state capacities influenced all aspects of implementation, including leadership styles and autonomy. These variations make comparisons across models difficult, yet highlight constraints and opportunities for cross-learning and optimizing implementation to achieve universal health coverage in decentralized contexts.

Approach for sustainable district-led production and distribution of alcohol-based hand rub in Uganda

Background: A sustainable, continuous supply of alcohol-based hand rub (ABHR) is essential for healthcare workers in health facilities. The WHO provides guidance for production in individual health facilities. In Uganda, using this guidance, an innovative approach was implemented at the district local government level to produce and subsequently distribute ABHR to primary-care health facilities that have limited capacity for local facility-level production. This project was supported by the CDC in collaboration with the Infectious Diseases Institute (IDI) and targeted governmental or district engagement with local partners to ensure sustainability. Methods: District stakeholders were engaged to obtain buy-in and define roles and responsibilities. Overall, 4 staff members in each of 6 supported districts were nominated by District Health Officers for training: 2 staff members were trained to produce ABHR and conduct internal quality control and 2 were trained on external quality control. Districts provided ABHR production-unit facilities and facilitated integration within the government essential supplies delivery system, National Medical Stores in Uganda, which supports last-mile delivery to facilities. An implementing partner purchased initial raw materials necessary for production. The cost of materials for local production was compared to the price of commercial ABHR available in Uganda. Results: Between January and August 2021, 23 staff members were trained, and 380 batches of quality-assured ABHR (17,820 L) were produced and distributed to 278 health facilities. Consumption of ABHR in the first distribution was used to benchmark predicted ABHR consumption per targeted facility in subsequent months. Increased demand for ABHR due to the COVID-19 pandemic and the Ebola virus disease outbreak in central Uganda (September 2022) was addressed through emergency requests on a case-by-case basis. ABHR local production costs $3 per liter for materials, less than half of commercial ABHR ($8 per liter). Conclusions: Early results suggest that this approach is potentially sustainable but requires national advocacy as well. Leveraging existing distribution systems while building local capacity for ABHR production and distribution may improve longevity of such innovations in similar resource-limited settings.Disclosure: None

Exploring the feasibility of integrating health, nutrition and stimulation interventions for children under three years in Nepal's health system: A qualitative study.

Community-based primary care settings are a potential entry point for delivering Early Childhood Development (ECD) interventions in Nepal. Past studies have suggested that integrating stimulation with nutrition interventions is an effective way to deliver multiple benefits for children, but there is limited knowledge of how to do this in Nepal. We conducted a qualitative study in Nepal's Dhanusha district to explore how stimulation interventions for early learning could be integrated into existing health and nutrition programmes within the public health system. Between March and April 2021, we completed semi-structured interviews with caregivers (n = 18), health service providers (n = 4), district (n = 1) and national stakeholders (n = 4), as well as policymakers (n = 3). We also carried out focus group discussions with Female Community Health Volunteers (FCHVs) (n = 2) and health facility operation and management committee members (n = 2). We analysed data using the framework method. Respondents were positive about introducing stimulation interventions into maternal and child health and nutrition services. They thought that using health system structures would help in the implementation of integrated interventions. Respondents also highlighted that local governments play a lead role in decision-making but must be supported by provincial and national governments and external agencies. Key factors impeding the integration of stimulation into national programmes included a lack of intersectoral collaboration, poor health worker competency, increased workload for FCHVs, financial constraints, a lack of prioritisation of ECD and inadequate capacity in local governments. Key barriers influencing the uptake of intervention by community members included lack of knowledge about stimulation, caregivers' limited time, lack of paternal engagement, poverty, religious or caste discrimination, and social restrictions for newlywed women and young mothers. There is an urgent need for an effective coordination mechanism between ministries and within all three tiers of government to support the integration and implementation of scalable ECD interventions in rural Nepal.

Facilitating professional learning for technology coaches through cross-district collaboration

Purpose This two-year study illuminates the experiences of technology coaches (digital learning coaches [DL] and science technology engineering and mathematics/literacy coaches [STEM/L]) as they engaged in their own professional learning (PL) facilitated by a faculty researcher.Design/methodology/approach Technology coaches from different school districts and their respective colleagues participated in book studies as part of their PL. They reflected and debriefed individually and collaboratively with a researcher facilitator. Data were collected through interviews, field notes at meetings, observations, researchers’ reflections and artefacts. Qualitative data analysis methods were employed.Findings The findings offer a glimpse into (1) benefits of cross-district collaboration, (2) challenges finding resources for coaching, (3) career-long desire to learn and (4) time to build and sustain cross-collaborations.Practical implications Conclusions suggest that DL and STEM/L coaches benefit from their own dedicated, differentiated programme of PL supported by each other (as from other districts) and a researcher facilitator. Educational implications are offered for researchers and other school district stakeholders for consideration for them to foster coaches’ collaborative PL.Originality/value Importantly, this project is an exemplar of how to support coaches’ PL and growth through researcher facilitation of cross-district collaborative learning.

Development pathways for co-management in the Sundarban mangrove forest: A multiple stakeholder perspective

The emergence of co-management, where various government and non-government actors work together, is one of the most important governance mechanisms for natural resource management. However, local stakeholders' understanding of forest co-management has thus far been poorly appreciated. This study examined stakeholders' views on the forest co-management system of the Sundarban mangrove forest in Bangladesh. Four villages in the Chandpai range of the Sundarban mangrove forest were selected for the study. Primary data were collected through key informant interviews with multiple stakeholder levels, and focus group discussions with men and women either involved in forest co-management or not. Thematic coding and content analysis of the qualitative data was used to analyse stakeholders' views on key forest co-management activities and practices: forest protection, monitoring, meeting role, training and organisational support. These co-management activities are largely implemented through local stakeholders who are members of a number of institutions: the Village Conservation Forum (VCF), the People's Forum (PF) and the Community Patrol Group (CPG) at the local level, and the Co-management Committee (CMC) at the higher level, in which local, district and national stakeholders are involved. Stakeholders reported both positive and negative views on these co-management activities. While the positive views were mostly related to the benefits obtained from forest co-management practices (e.g., increased knowledge, awareness and ability to obtain entry permits), the negative views were related to the obstacles frequently faced by the local stakeholders, such as limited harvesting opportunities, poor meeting support and strict rules on eligibility for VCF/PF membership. The findings indicated that while stakeholders' views of forest co-management activities were mixed, it did identify the types of existing co-management benefits, problems and challenges of the local people and showed where they differed. Furthermore, this study identified particular ways to strengthen the co-management activities from the local people's perspective, which would enable their participation in the co-management system of the Sundarban mangrove forest.

Understanding Stakeholder Perspectives on the Impact of Peace Education in Secondary Schools of Arunachal Pradesh

The goal of the study is to learn what the instructors in Arunachal Pradesh secondary schools think about the inclusion of peace education in the modules. It sought to investigate their perspectives, difficulties, and willingness to incorporate practices of peace education into their pedagogy. In order to achieve this, the researchers evaluated the quality of peace education in two secondary schools and one semi-government residential school in the lower and Dibang Valley using both quantitative and qualitative approaches. They used tactics like group talks, observations, and interviews to interview 12 individuals from these districts. In order to gather information, the researchers spoke with class teachers and principals at each school, held interviews with district stakeholders, and generally engaged themselves as responsible and exemplary citizens. The results showed that educators and interested parties stressed how crucial it is to include peace education in the modules. They believed it could reduce discords among students and contribute to shaping.

How to scale-up: a comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda

BackgroundThe need to scale up public health interventions in low- and middle-income countries to ensure equitable and sustainable impact is widely acknowledged. However, there has been little understanding of how projects have sought to address the importance of scale-up in the design and implementation of their initiatives. This paper aims to gain insight into the facilitators of the scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda.MethodsThe study took a comparative case study approach with two rounds of data collection (2019 and 2021) in which a combination of different qualitative methods was applied. Interviews and group discussions took place with district, regional and national stakeholders who were involved in the implementation and scale-up of the intervention.ResultsA shared vision among the different stakeholders about how to institutionalize the intervention into the existing system facilitated scale-up. The importance of champions was also identified, as they influence buy-in from key decision makers, and when decision makers are convinced, political and financial support for scale-up can increase. In two countries, a specific window of opportunity facilitated scale-up. Taking a flexible approach towards scale-up, allowing adaptations of the intervention and the scale-up strategy to the context, was also identified as a facilitator. The context of decentralization and the politics and power relations between stakeholders involved also influenced scale-up.ConclusionsDespite the identification of the facilitators of the scale-up, full integration of the intervention into the health system has proven challenging in all countries. Approaching scale-up from a systems change perspective could be useful in future scale-up efforts, as it focuses on sustainable systems change at scale (e.g. improving district health management) by testing a combination of interventions that could contribute to the envisaged change, rather than horizontally scaling up and trying to embed one particular intervention in the system.

Let's Get Critical: The Rights and Obligations of School District Stakeholders under State Laws Limiting or Banning Discussion of Critical Race Theory in K-12 Classrooms

Let's Get Critical: The Rights and Obligations of School District Stakeholders under State Laws Limiting or Banning Discussion of Critical Race Theory in K-12 Classrooms

A Case Study of a Low-Income African American Career Academy’s Approach to Student Services

The provision of support services has been found critical for meeting the needs of students and their families, but related research in predominantly low-income, African American/Black communities, is limited. Thus, through a case study we explored how a school, located in a low-income area with a predominantly African American/Black population, adopted and enacted support services. The setting was an urban high school with an enrollment of 700 students who are predominantly African American (98%) and 100% low-income. We conducted interviews with district, school, and community stakeholders; and we followed a thematic approach for the analysis. A major finding was that the adoption of support services built on the shared belief that the school should serve as a central place of support for students and the community. We identified two distinct strands of support services, one represented by in-school supports for students and the other designed to help families in the community. Further, we found an underlying philosophy of removing obstacles for students as a means to help them succeed in school. Regarding implications for practice, it is important to note the difficulty in replicating the efficacy of support services without culturally relevant leadership at the district and school level.

A collaborative care package for depression comorbid with chronic physical conditions in South Africa

IntroductionA task-sharing collaborative care model for integrated depression care for South Africa’s burgeoning primary health care population with chronic conditions was developed and tested through two pragmatic cluster randomized controlled trials. One trial focused on patients with hypertension and was located in one district where a collaborative care model was co-designed with district stakeholders. The other trial, focused on patients on antiretroviral treatment, was located in the same district site, with the addition of a second neighbouring district, without adaptation of the original model. This paper describes the package used to implement this model, and implementation outcomes across the two sites, and summarises lessons and challenges.MethodsThe Template for Intervention Description and Replication (TIDieR) framework, adapted for complex health systems interventions, was used to describe components of the package. Additional elements of ‘modifications made’ and ‘actual implementation’ introduced in the ‘Getting messier with TIDieR’ framework, were used to describe implementation outcomes in terms of reach, adoption and implementation across the two trial districts.ResultsIn the absence of a co-design process to adapt the model to the context of the second site, there was less system level support for the model. Consequently, more project employed human resources were deployed to support training of primary care nurses in identification and referral of patients with depression; and supervise co-located lay counsellors. Referrals to co-located lay counselling services were more than double in the second site. However, uptake of counselling sessions was greater in the first site. This was attributed to greater in-vivo supervision and support from existing mental health specialists in the system. There was greater reliance on online supervision and support in the second site where geographical distances between clinics were larger.ConclusionThe need for in-country co-designed collaborative care models, and ‘implementation heavy’ implementation research to understand adaptations required to accommodate varying in-country health system contexts is highlighted.

Linking health system inputs, processes and outputs to identify medical deserts in Serbia

Abstract Background Medical deserts (regions where the population does not have adequate access to health care) indicate the failure of the health system to achieve the goals of improving the health of the population. Identifying medical deserts (MD) is far from simple. The aim of this study is to describe the approach to identification of medical deserts in Serbia using indicators for the health system inputs, processes and outputs. Methods We investigated the basic healthcare-related medical deserts using the indicators of primary health care centers’ inputs (accessibility: annual number of patients per physician), processes (performance: annual workload of patient visits per physician) and outputs (unmet needs: percentage of patients unable to access health services) in all 25 Serbian districts in 2020, using data of the Health Statistical Yearbook of the Republic of Serbia and the National Patient Satisfaction Survey of the Institute of Public Health. We developed a Multiple Criteria Scoring System (MCSS) incorporating the weighting and scoring of accessibility and performance for four types of physicians (general practitioners, pre-school pediatricians, youth pediatricians, and gynecologists) and five dimensions of unmet needs (financial reasons, waiting times, lack of personal time, long-distance and COVID-19). MCSS final scores 0 (none) - 100% (MDs on all indicators) are assessed using the regulatory norms. Results MDs partially overlap by different criteria: accessibility, 4-10 districts; performance, three districts; unmet needs: 2-5 districts. Top five medical deserts identified according to the MCSS are Mačvanski, Šumadijski, Moravički, Srednjebanatski, and Podunavski district. Conclusions Serbia has at least one MD per administrative region according to the objective normative indicators and patients’ subjective experiences. The study findings can be used to inform district stakeholders on how to use health workforce policy and planning to address medical deserts. Key messages • MCSS indicates potential medical deserts in 20% of all districts in the Republic of Serbia. • Evidence on poor health workforce accessibility and performance in light of the patient unmet healthcare needs could be used to inform stakeholders on medical deserts in the country.

Organizational Barriers to Equity: Stories From Virginia Gifted Education Coordinators

ABSTRACT This article emanated from a narrative inquiry into the stories of three Virginia gifted education coordinators whose years in service coincided with years of improved equitable representation in their gifted programs. By analyzing their experiences, the article sheds light on the organizational barriers they encountered. Organizational barriers developed from the system of relationships between district stakeholders and the subcomponents of the organization, creating an environment in which underrepresentation could flourish. Findings suggest the need for systemic solutions. Professional learning is implicated for all district leaders. For gifted education coordinators, professional learning experiences should strengthen their ability to discuss issues related to racism while helping them manage the multiple relationships complicit in underrepresentation. Recommendations for research and district reform are also suggested.

Policy instruments for energy-efficient renovations at district level

IEA EBC Annex 75 aims to investigate, amongst other policy for reducing carbon emissions and energy use in buildings at district level, combining both energy efficiency measures and renewable energy measures. Particularly policy instruments deployed at the local level targeting owners and investors could increase residential building renovation and renewable energy systems to a district scale. A desk and empirical research using 38 expert interviews from 8 European countries was used to investigate the use and development of various types of policy instruments, including regulations, incentives, communication and facilitating instruments. The research confirms interest of frontrunners to use or develop specific policy instruments further, such as enforcement of energy standards and inspections, financial incentives for district stakeholders and for groups of homeowners, renovation services and energy desks, digital communication and network meetings in districts. It also finds that low relative advantage for some stakeholders, lack of good examples, an incompatible legal or national framework and high complexity are serious risks that can further hinder adoption of energy efficiency and renewable energy systems in districts. Renovations at district scale including energy efficiency and renewable energy can benefit from adapted or improved regulations, incentives, communication and facilitation to better support renovations at district scale including energy efficiency and renewable energy systems.

Factors impacting sustainability of community health worker programming in rural Uganda: a qualitative study.

Despite significant global progress towards decreased child mortality in past decades, maternal and child mortality continues to be high, especially in sub Saharan Africa. Most of these deaths are preventable with known interventions. Community health workers (CHWs) are well-positioned to promote these life-saving interventions; however, sustaining CHW programs remains a challenge. A sustainability-focused qualitative evaluation, was done between July and August 2018 in 2 rural districts in southwest Uganda. Using semi-structured interview tools, we conducted 6 Focus Group discussions (FGDs) with CHWs and 17 in-depth interviews (IDIs) with various district stakeholders to gain insights into factors affecting sustainability of a district-wide maternal, newborn and child health (MNCH)-oriented CHW intervention. Data was managed using NVivo software (version 12) with themes using thematic analysis. Identified factors impacting CHW program sustainability included 'health system effectiveness' (availability of supplies, medicines and services and availability of facility health providers), CHW program-related factors' (CHW selection and training, CHW recognition), 'community attitudes and beliefs' and 'stakeholder engagement'. To sustain CHW programs in rural Uganda and globally, planners, policymakers and funders should maximize community engagement in establishing CHW networks and strengthen accountability, supply chains and linkages with communities and health facilities.