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Background: Above cuff vocalisation (ACV) involves the application of an external flow of air via the subglottic port of a tracheostomy. ACV can facilitate vocalisation and may improve swallowing and quality of life for patients with a tracheostomy. A recent systematic review highlighted the limited evidence available for the acceptability, effectiveness, safety or optimal implementation of ACV. Aims: To explore the experience of healthcare professionals (HCPs) using ACV and their perceptions of best practice. Methods and Procedures: Semi‐structured interviews were conducted with a range of HCPs with experience using ACV. Topics included: experiences with ACV, management of ACV, opinions about ACV, impact of COVID‐19, future directions for ACV and impact on length of stay. Interviews were conducted online from December 2020 to March 2022. Data were analysed using reflexive thematic analysis. Outcomes and Results: Twenty‐four HCPs were interviewed from seven countries and five professional groups. Four interconnected themes were developed: (1) moral distress amplifying the need to fix patients; (2) subjectivity and uncertainty leading to variations in practice and purpose; (3) knowledge and experience leading to control and caution; and (4) worth a try or a last resort. Theme four contained three sub‐themes: (a) part of the toolbox; (b) useful but limited tool; and (c) following the patient's lead. The moral distress experienced by HCPs and their essential 'need to fix' patients seems to underpin the varied opinions of ACV. These opinions appear to be formed primarily on the basis of experience, because of the underlying subjectivities and uncertainties. As knowledge and experience with ACV increased, and adverse events were experienced, most HCPs became more cautious in their approach to ACV. Conclusions and Implications: More research is needed to reduce the subjectivities and uncertainties surrounding ACV. The implementation of standardised procedures, processes, and competencies may help to reduce the frequency of adverse events and support a more controlled approach. Widening the focus of the purpose of ACV to include swallowing may help to maximise the potential benefits. WHAT THIS PAPER ADDS: What is already known on the subject: There is limited and low‐quality evidence for above cuff vocalisation (ACV) and clinical application and practice varies substantially. However, the reasons for this variation in practice and healthcare professionals' (HCPs') opinions of ACV were unclear. What this study adds: HCPs' experiences and opinions of ACV vary as a result of the uncertainty and subjectivity surrounding ACV compounded by their personal experiences with it. A need for caution also appears to emerge as HCPs become more familiar and experienced with using ACV. What are the clinical implications of this work?: Implementing standardised procedures, safety processes and competencies may help to compensate for the uncertainty and subjectivity surrounding ACV and may reduce the frequency of adverse events. Widening the focus of purpose of ACV, including swallowing in addition to communication, may increase the number of potential candidates and increase the potential benefits of ACV. Using multidisciplinary team (MDT) simulation training for ACV competency development might help to improve MDT working and ACV implementation. [ABSTRACT FROM AUTHOR]

Background: Literature shows that in South Africa there are insufficient resources to meet mental healthcare needs. At general or district hospital level, the non-specialist doctor is often responsible for the holistic assessment and management of mental health service users. Such situations inevitably increase doctors' care load as they are required to treat across disciplines. We highlight the particular challenges faced by a community service (CS) doctor in this context. Methods: The presented case study formed part of a larger project that investigated public mental healthcare provision in the Eastern Cape province. Data were collected through a once-off semi-structured interview with the participant. The interview was transcribed and data analysed by utilising thematic analysis to yield results. Results: The study suggests that the CS doctor experiences being overloaded with duties, and feels overwhelmed in a healthcare context that lacks resources needed for service provision, which may lead to inadequate mental healthcare provision to public health service users. Conclusion: Healthcare facilities in rural parts of the Eastern Cape province are in need of assistance. This in-depth account highlighted the consequences of working on the front line of a disadvantaged and under-resourced health system. The presented account can be interpreted as a cry for help by CS doctors for relevant authorities to improve access and provision of mental healthcare in the area. Contribution: The paper provides an exploration of the circumstances wherein mental healthcare is provided in rural parts of South Africa. [ABSTRACT FROM AUTHOR]

This paper presents the findings from a qualitative study that sought to understand the experiences of frontline staff working in Oxfordshire County Council (OCC) Children's Social Care Services and their views on a new family safeguarding model (Family Solutions Plus). Focus group interviews were conducted with 20 frontline staff and managers in different teams across OCC Children's Social Care Services using video conferencing software. Thematic analysis identified three overarching themes: Preparation for the implementation of Family Solutions Plus, staff views on the implemented model, and challenges to its implementation. Staff voiced strong support for the new model, which places a much greater emphasis than previous practice on supporting the whole family, developing parenting skills and keeping children safe with their families. The challenges associated with the transition to a new model were considerable in the short term, partly due to the COVID‐19 pandemic, but there was optimism that the new model could be sustained and stabilized over time. [ABSTRACT FROM AUTHOR]

Background: Acquired laryngotracheal stenosis (LTS) is a rare condition that causes breathlessness and dyspnoea. Patients have reconstructive airway surgery to improve their breathing difficulties, but both LTS and the surgery can cause voice difficulties. The existing evidence base for management of voice difficulties for adults with LTS focuses on symptoms. There is limited information to provide clinical guidance for speech and language therapists (SLTs) and a limited understanding of the impact of voice changes on adults with LTS. Aim: To investigate the lived experience of adults with laryngotracheal stenosis (LTS), who have had reconstructive surgery; here focussing on voice concerns with the aim of guiding clinical care for SLTs. Methods and Procedures: A phenomenological, qualitative study design was used. Focus groups and semi‐structured interviews were completed with adults living with LTS who had had reconstructive surgery. Audio recordings were transcribed and inductive thematic analysis was used by the research team to identify themes and sub‐themes. Outcomes and Results: A total of 24 participants (five focus groups and two interviews) took part in the study before thematic saturation was identified in analysis. Three main themes were identified specific to the experience of living with LTS: the Medical, Physical and Emotional journey. All participants referenced voice difficulties as they related to each of these overall themes. Sub‐themes directly related to voice included experience of surgery, information provision, staff expertise/complacency, symptoms, symptom management, identity, support networks, impact on life and living with a chronic condition. Conclusions and Implications: In this qualitative study participants have described the integral part voice difficulties play in their lived experience of LTS and reconstructive surgery. This is considered in the context of their clinical care and the need for individualised management and information provision throughout the course of their condition. The broader research literature relating to voice difficulties is explored with links made to people with LTS and recommendations made for future research into people living with LTS and dysphonia. What this paper adds: What is already known on this subject: Adults with laryngotracheal stenosis (LTS) experience voice changes as a result of their condition, and the surgeries necessary as a treatment. These changes can lead to altered pitch, vocal fatigue, loss of pitch range and loss of volume control. Although there are known psychosocial implications both to living with a chronic condition and voice difficulties there has been no research exploring this in adults with LTS, and there is minimal clinical guidance for speech and language therapists (SLTs) working with these patients. What this paper adds to existing knowledge: This research is the first study to explore the lived experience of adults with LTS who undergo reconstructive surgery, focusing on their voice concerns. This study demonstrates the multifactorial impacts of voice changes on all aspects of the lives of adults with LTS and the need for individualised information provision and clinical care to help support them. What are the potential or actual clinical implications of this work?: Adults with LTS want expert SLTs to facilitate their care and support them throughout their LTS journey alongside other support networks. They want to be carefully prepared for reconstructive surgery and given clear information about symptoms and management of their voice difficulties. This has led to the reorganisation of the care pathway at our centre, and the introduction of a patient‐led pretreatment session. [ABSTRACT FROM AUTHOR]

Objective: The coronavirus disease 2019 (COVID-19) pandemic precipitated a major shift in the use of telehealth in Australia. The changes highlighted gaps in our knowledge regarding the efficacy of, and clinician attitudes to, the use of telehealth. The current study expands and deepens the available evidence as a result of being collected in unique circumstances that removed one of the major barriers (lack of Medicare rebates) and also one major enablers (willingness) of telehealth uptake. Methods: Using a semi-structured interview, we invited clinicians (N = 39) to share their perspectives, attitudes and experiences of using telehealth. Topics covered included perceptions of the strengths and challenges of telehealth, and how experience of using telehealth during the COVID-19 pandemic had influenced clinicians' views and intentions regarding their future practice. Participants included clinicians from five disciplines across public and private practice: paediatrics, neurology, immunology, rural general practice, and orthopaedics. Results: We found three key dimensions for consideration when assessing the suitability of telehealth for ongoing practice: the attributes of the patient population, the attributes of the clinical context and environment, and the risks and benefits of a telehealth approach. These findings map to the existing literature and allow us to infer that the experiences of clinicians who previously would have chosen telehealth did not differ significantly from those of our 'pandemic-conscripted' clinicians. Conclusions: Our findings map clearly to the existing literature and allow us to infer that the experiences of the clinicians who have chosen telehealth (and are already represented in the literature) did not differ significantly from those trying out telehealth under the unique circumstances of the removal of the Medicare Benefits Scheme barrier and external pressure that over-rides the 'willingness' enabling factor in uptake decisions. What is known about the topic? Clinician and patient experiences of telehealth use have already been documented in contexts where both clinician and patient have opted-in to that process. What does this paper add? The paper adds data on clinician experience across a range of specialities, from a context (pandemic public-heath measures) where the choice element was reduced for both patient and clinician. What are the implications for practitioners? The data speak to the generalisability of existing evidence, but also provide practical considerations in planning for the inclusion of telehealth for specialist health services in the Australian context. [ABSTRACT FROM AUTHOR]

Paediatric Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) is a disabling condition. Schools play a key role in adolescents' experiences with managing ME/CFS. However, little is known about the experiences of adolescents with ME/CFS (and their families) in schools. This paper is an incidental qualitative study, which combines data from two independent ME/CFS studies: study 1 researched ethnic minority adolescents with ME/CFS; study 2 explored Acceptance and Commitment Therapy for adolescents with ME/CFS who had not recovered after one year. Participants included: adolescents with ME/CFS; their families; and medical professionals (ME/CFS specialists and non‐specialists). Adolescents, their families, and ME/CFS medical professionals were recruited from a UK specialist paediatric ME/CFS service. Non‐ME/CFS medical professionals were recruited from the same region. Semi‐structured qualitative interviews and focus groups were undertaken. Participants' views on schools from each study were combined and thematic analysis was used to identify themes. Fifteen adolescents with ME/CFS (11–17 years old), sixteen family members, and ten medical professionals (GPs, school nurses and ME/CFS specialists) were interviewed. Four key themes were found: (1) adolescents identified school was important for aiding ME/CFS recovery, especially educationally and socially; (2) families described varying levels of support from schools and local authorities with help managing ME/CFS – some described significant practical and emotional difficulties to accessing education, whereas others recounted examples of positive supportive strategies, particularly when teachers had previous experience or knowledge of ME/CFS; (3) parents thought three‐way communication between schools, healthcare and families could improve support; (4) participants felt schools were an appropriate place for knowledge building and raising awareness of ME/CFS amongst teachers and pupils, to aid improved supportive measures. In conclusion, this paper provides rich data that highlights the importance of education and the realistic fears and hurdles for adolescents with ME/CFS remaining engaged in education and the impact on their future. Some families described positive strategies in school, which were viewed as helpful to manage ME/CFS in the classroom. These strategies could be implemented alongside knowledge building initiatives and improved communication between healthcare and education. There is a need to further investigate useful strategies and determine how teachers can be best supported in implementing them. [ABSTRACT FROM AUTHOR]

Background: Face mask use has become widespread as a means of reducing transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Research suggests face coverings can impact speech discrimination, therapeutic alliance and the interpretation of non‐verbal cues. However, there is little research into the impact of face masks on people with communication difficulties (pwCD) post‐stroke. Aims: To explore the perspectives of service users and staff on a stroke rehabilitation unit in order to understand the impact of staff wearing face masks on the experience of rehabilitation for pwCD. Strategies that might improve the experience of rehabilitation for pwCD were also explored. Methods & Procedures: Semi‐structured interviews and a focus group were conducted with six pwCD and five health professionals (HPs) on a stroke rehabilitation unit. The data were analysed using reflexive thematic analysis. Outcomes & Results: Four main interacting themes were identified from the data: (1) face masks as a barrier to effective communication; (2) face masks as a barrier to human connection and therapeutic relationships; (3) the impact of face masks on an individual is influenced by multiple internal and external factors; and (4) there is a need for service provision to evolve to meet pwCD's needs when using face masks. Conclusions & Implications: Findings shed light on how face masks can act as a barrier for pwCD within the rehabilitative process, and emphasize that each individual with communication difficulties is likely to be affected to a differing extent, as a result of multiple interacting factors. HPs are encouraged to consider the individual holistically, tailor strategies and adapt to each individual's needs. Further research is required to understand how to optimize rehabilitation outcomes when face masks are used. WHAT THIS PAPER ADDS: What is already known on the subject: There is evidence face masks can affect speech discrimination, therapeutic alliance and interpretation of non‐verbal cues. The existing literature predominantly considers people with hearing impairments, mental health needs or the general public. The potential for face masks to impact pwCD post‐stroke is high, given pre‐existing communication barriers and evidence of increased social isolation. What this paper adds to existing knowledge: This study is the first of its kind to explore how face mask use by HPs impacts the experience of rehabilitation for pwCD post‐stroke. The authors consider the need to tailor compensatory strategies to each individual and adapt them to meet service users' needs. What are the potential or actual clinical implications of this work?: HPs should monitor closely the impact of face mask use on pwCD with whom they are working, and consider what adaptations to delivery are required. It would be helpful for clinicians to have a discussion with pwCD post‐stroke to understand the impact of face mask use on them personally and what strategies they would find most helpful within rehabilitation. Additional training by speech and language therapists on supporting effective communication and successful interaction with pwCD may be indicated in the context of face mask use. [ABSTRACT FROM AUTHOR]

Translation of evidence into practice in healthcare is challenging, particularly with new innovations. Indocyanine Green (ICG) lymphography is a novel innovation where the superficial lymphatics are imaged to provide information about lymphoedema diagnosis and to guide individualised therapy for a person's long‐term chronic management of lymphoedema, supporting care across the continuum to the community setting. Despite the unique information ICG lymphography provides, the technology itself is complex and highly specialised and currently has limited adoption in clinical practice. This paper sought to determine the barriers and enablers to establishing an ICG lymphography clinic within an outpatient lymphoedema service by exploring staff perceptions and experiences. An interpretive descriptive design was used with semi‐structured interviews of key staff participants from a quaternary public hospital six months after ICG lymphography clinic establishment. An interview guide was developed, underpinned by the Consolidated Framework for Implementation Research (CFIR), to guide the inquiry. Interview data were transcribed, inductively coded and analysed to identify themes. All eligible management, clinical and ancillary staff were included (N = 8). Four key themes were identified from the data as essential to implementation success. These were support is critical for implementation; beliefs about the technology; practicalities are achievable; and sustainability for ongoing success. Themes were found to be interrelated and centred around support from staff and the organisation as a critical process facilitator. The study demonstrated an ICG lymphography clinic can be successfully established as part of an outpatient lymphoedema service. Key enablers related to positive staff attitudes and beliefs about ICG lymphography and its application. Future implementation sites may consider that although the complexity of this innovation creates process challenges, the use of an implementation framework can assist in identifying determinants of success for effective implementation to practice. [ABSTRACT FROM AUTHOR]

Cognitive behavioural therapy (CBT) is an effective treatment for depression. There are established education programmes which prepare specialist mental health workers to practice CBT. CBT is a complex treatment requiring intensive preparation and clinical skill to deliver. An alternative and simpler psychological treatment, behavioural activation (BA), may be as effective as CBT. An advantage of BA over CBT is that you do not need to be a specialist mental health worker nor require lots of training to deliver it. The relative simplicity of BA and the brief education required for workers to deliver it may increase access to psychological treatments for depression. In 2020, we developed an online educational programme in BA targeting non‐specialist healthcare workers. In this paper, we wanted to understand healthcare workers' perceptions and experiences of completing a professional certificate programme which prepares them to deliver BA for people living with depression. We report the feedback from seven non‐specialist mental health workers who completed the online education programme in BA. Twelve workers were invited to enrol on the programme, of which four declined. All but one of the eight participants lived and worked in rural South Australia. A thematic analysis of the interview data identified three themes: Course was simple to follow, Ease of integration into clinical practice and Ongoing support and supervision. The overall meta‐theme was 'Easy to train and easy to apply'. Participants reported that the online training prepared them to practice BA and they were able to apply the skills in their clinical practice. Future work needs to examine if online training for healthcare workers in BA translates to clinical outcomes for people living with depression. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic presented numerous challenges to acute malnutrition screening and treatment. To enable continued case identification and service delivery while minimising transmission risks, many organisations and governments implemented adaptations to community‐based management of acute malnutrition (CMAM) programmes for children under 5. These included: Family mid‐upper arm circumference (MUAC); modified admission and discharge criteria; modified dosage of therapeutic foods; and reduced frequency of follow‐up visits. This paper presents qualitative findings from a larger mixed methods study to document practitioners' operational experiences and lessons learned from these adaptations. Findings reflect insights from 37 interviews representing 15 organisations in 17 countries, conducted between July 2020 and January 2021. Overall, interviewees indicated that adaptations were mostly well‐accepted by staff, caregivers and communities. Family MUAC filled screening gaps linked to COVID‐19 disruptions; however, challenges included long‐term accuracy of caregiver measurements; implementing an intervention that could increase demand for inconsistent services; and limited guidance to monitor programme quality and impact. Modified admission and discharge criteria and modified dosage streamlined logistics and implementation with positive impacts on staff workload and caregiver understanding of the programme. Reduced frequency of visits enabled social distancing by minimising crowding at facilities and lessened caregivers' need to travel. Concerns remained about how adaptations impacted children's identification for and progress through treatment and programme outcomes. Most respondents anticipated reverting to standard protocols once transmission risks were mitigated. Further evidence, including multi‐year programmatic data analysis and rigorous research, is needed in diverse contexts to understand adaptations' impacts, including how to ensure equity and mitigate unintended consequences. Key messages: COVID‐19 CMAM programme adaptations enabled service continuity despite pandemic‐related challenges. Further evidence is needed on long‐term impacts.Family MUAC was well‐accepted and addressed screening gaps from COVID‐19 disruptions. Challenges included sustaining caregiver measurement accuracy; handling inaccurate self‐referrals to encourage health‐seeking behaviours; and limited programme design and monitoring guidance and tools.Modified admission criteria and therapeutic food dosage reduced contact between staff and children and streamlined logistics and implementation. Concerns remained about effects on programme admissions and outcomes.Reduced frequency of follow‐up visits successfully reduced facility crowding and need for caregiver travel. However, infrequent monitoring of childrenmay miss deterioration. [ABSTRACT FROM AUTHOR]

This paper presents findings from the evaluation of an Australian trial of self‐managed home aged care. The self‐management model was codesigned by advocacy organisation COTA Australia, consumers and service providers. The primary aim of the evaluation was to examine whether self‐management improved consumers' perceptions of their choice, control, and wellbeing. The secondary aim was to examine whether provider prior experience with self‐managed packages significantly influenced consumers' perceptions of choice, control and wellbeing, thereby confounded trial effects. A pre‐test post‐test quasi‐experimental design and mixed‐methods design were used to collect data over nine months in 2018–2019. The pre‐trial methods and findings have been published. The post‐trial evaluation replicated the pre‐trial data collection method of an online survey (n = 60) and semi‐structured telephone interviews with consumers (n = 9), family carers (n = 13), and consumers and carers jointly (n = 2), totalling 24 interviews. Semi‐structured telephone interviews were also conducted with CEOs and senior managers from each of the seven providers (n = 14). Three providers had prior experience supporting self‐management. Parametric and non‐parametric tests examined the statistical data. Qualitative data were analysed thematically and framed according to self‐determination principles and ecological systems theory. Both datasets demonstrated that consumers reported greater choice and control at post‐trial than pre‐trial. This finding was not affected by providers' prior experience with self‐management; therefore, it was not a confounding factor. Participants reported improved wellbeing in interviews, however this was not reinforced statistically. Key desirable features of self‐management included greater autonomy and control over spending, recruiting support staff and paying lower administration fees. There was no evidence of increased risks or fraud. The research limitations included a small sample size, convenience sampling with providers recruiting interview participants, no control group and differences in trial implementation. The findings support the expansion of self‐management opportunities and more comprehensive evaluations that use mixed methods. [ABSTRACT FROM AUTHOR]

Women living with HIV (WLWH) are at increased risk of anal cancer compared to women without HIV, often due to persistent human papillomavirus (HPV) infections. This paper describes current practices and challenges conducting anal cancer screening for WLWH at an urban integrated safety-net system and a non-profit community-based HIV clinic. We conducted 25 semi-structured interviews with clinical and administrative stakeholders to assess knowledge, clinic practices and procedures, and experiences with anal cancer screening. Interview transcripts and fieldnotes were thematically analyzed using an iterative deductive and inductive coding scheme. Findings were organized by the Consolidated Framework for Implementation Research (CFIR) domains and constructs. Provider-level barriers to conducting anal cancer screening included limited knowledge of guidelines. System-level barriers included: structural characteristics such as lack of coordination between clinics to discern provider roles and responsibilities; and limitations in available resources such as configuration of electronic health records and infrastructure to manage referrals of abnormal anal Pap results. We conclude that anal cancer screening and follow-up for WLWH requires organization and coordination between multiple care teams, updated clinical information systems to facilitate communication and support anal Pap ordering and result documentation, and infrastructure that includes policies and protocols for management of abnormal results. Trial registration: ClinicalTrials.gov identifier: NCT02135419. [ABSTRACT FROM AUTHOR]

Background: Despite emerging evidence of validity and reliability, speech and language therapists' (SLT) uptake of telehealth has been limited and barriers remain to the effective and confident use of this service model. The COVID‐19 pandemic has caused significant disruption to essential health services, including speech and language therapy assessment and intervention, meaning that telehealth must now be considered as part of the suite of service delivery options for all clinicians. Aims: To explore the perceived barriers and facilitators of telehealth among community paediatric SLTs before and after their use of a telehealth platform with an embedded standardised assessment tool. Methods & Procedures: Mixed‐methods questionnaires were developed for this study and completed by SLTs before and after the 3‐month trial of the telehealth platform. A total of 38 SLTs completed the pre‐trial questionnaire and training in the use of telehealth platform (Coviu), including instruction in using a standardised, norm referenced language test as an integrated tool within the Coviu platform. A total of 27 SLTs went on to use the telehealth platform, and 25 of these completed the post‐trial questionnaire on which subsequent qualitative and quantitative analysis was completed. Outcomes & Results: Prior to using the platform, perceived barriers included technology issues, limited clinician experience and concerns around parent acceptance of the service. Potential facilitators included access to appropriate platforms, tools and resources as well as increased clinician confidence with telehealth. Following the trial, barriers to telehealth use continued to include technology barriers, particularly internet stability, and client issues, including suitability for telehealth services. Facilitators for future telehealth use included access to appropriate platforms for telehealth, stable and appropriate internet connectivity, and more extensive telehealth resources for both assessment and intervention for this mode of service delivery. Conclusions & Implications: This study provides insights into the perceptions of the barriers and facilitating factors for telehealth use among community‐based SLTs. This information will be useful in developing strategies to promote uptake and effective and confident use of telehealth as a mode of service delivery beyond the pandemic. What this paper adds: What is already known on the subject: Research about telehealth has shown that it is a reliable and valid way of delivering speech pathology services, yet many clinicians have been wary of its use and uptake of telehealth prior to COVID‐19 had been limited. We wanted to know what SLTs thought about using telehealth before and after participating in a 3‐month trial of a telehealth platform with an embedded formal language assessment. What this study adds to existing knowledge: This study indicates that technology issues including internet stability are a barrier to effective telehealth services, but that appropriate telehealth platforms, resources and experience are facilitators of uptake and successful use of telehealth. What are the potential or actual clinical implications of this work?: This information will be useful in developing strategies to promote uptake and effective and confident use of telehealth as a mode of service delivery for children during and beyond the pandemic, including those isolated by geographical or transport barriers. [ABSTRACT FROM AUTHOR]

India and the global community are facing a critical crisis of antimicrobial resistance (AMR), significantly contributed to by on-going and increasing antimicrobial misuse. Information as to what drives misuse of antimicrobials within India is essential to inform strategies to address the crisis. This papers aims to identify perceived influences on antimicrobial use in Hyderabad, India. We conducted semi-structured qualitative interviews conducted with thirty participants (15 doctors, 15 pharmacists) around their experiences of antimicrobials in Hyderabad, India. Thematic analysis was performed and four themes identified around (1) Perceptions of the problem of resistance and antimicrobial use; (2) Social pressures to prescribe/dispense; (3) Financial pressures driving antimicrobial over-use; and (4) Lack of regulation around training and qualifications. We conclude that antimicrobial use within India is embedded with, and occurs as a result of, complex social and economic factors including issues of resource limitation, structural/governance limitations and social relationships. Strategies to address misuse without acknowledging and addressing the critical driving forces of use will be unlikely to induce significant change. [ABSTRACT FROM AUTHOR]