(DOCX 29 kb), Ethics approval from the University of Leeds. Delivering presentations at local, state and federal meetings in Nigeria and relevant international meetings; Regular project review meetings and continuous engagement with key decision-makers, Developing newsletters, press-releases and interviews in the media aimed at communicating the key project findings to the public in Nigeria and more widely, Developing a dedicated website where the project results will be publicly accessible by national and international decision-makers, practitioners and academics, Delivering presentations at national and international conferences and publication of articles in peer-reviewed academic journals with emphasis on open access, Developing a project research report for the funder, with a publishable executive summary. 2nd ed. 1), i.e. Terms and Conditions, The IWTs subsequently guided the identification of the specific information areas for the data collection and analysis. studies, policy documents and so on) and so it is a form of secondary research. During the data collection and analysis stages, the case studies are used to refine or further generate CMOCs ( Marchal, Van Belle, van Olmen, Hoeree, & Kegels, 2012 ). t The specific hypotheses will draw upon two data collection methods: (a) review of key documents (SURE-P implementation manual, relevant federal and state-level policies, e.g. The relationships between and amongst these Cs, Ms and Os will be explored as part of the data collection and analysis. Int J Technol Assess Health Care. Findings from step 1 will be used to hypothesise the likely changes (interruptions in trends and levels) in the time series to make predictions to be verified during the ITS analyses. PubMed  Central to the supply component was the recruitment, training and deployment of 2000 formal service providers (e.g. BMJ Open 2012, 2(2). 2nd ed. The additional costs on the supply side are likely to be training midwives and CHWs, salaries, equipment and other supplies (Table 2). PubMed Central  Achievement of improved maternal and child health (MCH) outcomes continues to be an issue of international priority for achieving the health-related Sustainable Development Goals (SDGs), particularly for sub-Saharan African countries [1]. We will explore views of MCH service users on SURE-P, its costs and effects. Design: A multimethod study design was undertaken using realist evaluation methodology. Methodology and analysis This paper disseminates the protocol for an 18-month ‘RESPOND’ project that aims to evaluate the system of collecting and responding to user feedback in Bangladesh. 1) provides an overarching hypothesis, and more specific hypothetical pathways will represent the middle-range theories (MRT) to help us explore the C-M-O configurations within the programme. All interviews will be audio-recorded (subject to informed consent), transcribed and translated into English where required. J Health Serv Res Policy. BMC Public Health. METHODS AND ANALYSIS: The study will be conducted in four phases. Ethical approvals for this study were obtained from the School of Medicine Research Ethics Committee at the Faculty of Medicine and Health at the University of Leeds (ref: SoMREC/14/097) and the Health Research Ethics Committee at the University of Nigeria Teaching Hospital, Enugu (ref: NHREC/05/02/2008B-FWA00002458-1RB00002323). Los Angeles: SAGE Publications; 2012. The UK Medical Research Council (MRC) guidance for evaluating complex interventions also states that process evaluation can help ‘assess fidelity and quality of implementation, clarify causal mechanisms and identify contextual factors associated with variation in outcomes’ [22]. This is a protocol for a realist evaluation of a collective leadership intervention. Soc Sci Med. This is the key question posed by realist evaluators. Studies have explored the effectiveness of CHW programmes in improving MCH outcomes [14, 15], productivity of CHWs [12], costs and cost-effectiveness of CHW initiatives [4, 16], power relations and acceptance of CHW programmes by the public [6, 17] and effectiveness of associated conditional cash transfers (CCTs) linked to uptake of services [18, 19]. 1, the mixed methods approach will enable us to also analyse the intervention implementation outcomes, e.g. Based on specific theories, realist evaluation provides an alternative lens to empiricist evaluation techniques for the study and understanding of programmes and policies. studies, policy documents and so on) and so it is a form of secondary research. The uncertainty and likely variability of costs and effectiveness, particularly the spill-over effects, mean that sensitivity analysis will form an important part of the reporting of the economic evaluation. More accessible midwives/CHWs, for example, may reduce the cost to households of obtaining care. Assessment of capacity for Health Policy and Systems Research and Analysis in seven African universities: results from the CHEPSAA project. This paper should be of interest to researchers who are interested in adapting and applying robust methodologies for assessing complex health system interventions. Realist evaluation reports need to be developed in line with the realist nature of the evaluation. Mirzoev T, Omar M, Green A, Bird P, Lund C, Ofori-Atta A, et al. system) levels [7, 13]. Leeds, UK: University of Leeds; 2015. Realist approaches to evaluation assume that nothing works everywhere or for everyone: context really does make a difference to programme outcomes. COMDIS-HSD. Evaluation. We will explore context at the macro level (e.g. SURE-P/MCH and SURE-P/MCH + CCT) will be assessed against each other and against the no implementation site. is an intervention dummy variable (taking a value of 1 in areas where the intervention is implemented and 0 otherwise); T Resources Overview Realist Synthesis: An Introduction: This paper presents an introductory overview of realist synthesis as applied to the review of primary research on healthcare systems. assessment of context will inform best practices in PHC staff performance management; assessment of the added value of CCTs will inform further demand-side financing schemes. The demand component of the SURE-P/MCH programme aimed to increase utilisation of health services during pregnancy and at birth through the use of CCTs, i.e. It explains when a realist impact evaluation may be most In addition to clinical service outcomes shown in Fig. J Adv Nurs. PubMed  The methods development, data collection and analysis will take account of the following issues: Anonymity of study respondents will be preserved and ensured at all times as respondent(s) request. We expect to have 30–45 IDIs to represent views of key actor groups in Anambra state (10–15 per each cluster) and about 30 at federal level. An example of the former is: ‘training and deployment of CHWs combined with a working supplies system, and implemented in the context Nigerian health system, will achieve increase in skilled birth attendance by over 60 % and improve equitable provision of MCH care’. Consumers stated and revealed preferences for community health workers and other strategies for the provision of timely and appropriate treatment of malaria in southeast Nigeria. Implementing accountability for reasonableness framework at district level in Tanzania: a realist evaluation. However, to guide further development and implementation of CHW programmes in different contexts, it is necessary to better understand what makes CHW programmes successful in achieving desired outcomes and under what circumstances they succeed [11, 12]. This paper presents a protocol of a multimethod study using a realist evaluation approach to investigate the impact and effectiveness of IR in hospital wards on the organisation, delivery and experience of care from the perspective of patients, their family members and staff. Ethical approvals for this study were obtained from the University of Leeds (ref: SoMREC/14/097) and the University of Nigeria (ref: NHREC/05/02/2008B-FWA00002458-1RB00002323). All personal data will be coded, removed from the data for analysis and stored separately. Question guides will be adapted to the different actor groups, commensurate to their backgrounds and roles in the design and implementation of the programme. However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. Achievement of improved maternal and child health (MCH) outcomes continues to be an issue of international priority, particularly for sub-Saharan African countries such as Nigeria. Uzochukwu B, Obikeze E, Onwujekwe O, Onoka C, Griffiths U. PubMed  This means, among other things, describing theories in terms of context -mechanism outcome (CMO) … Part of Methods will be used that adjust, where necessary, for problems typical to time-series estimation (e.g. it Theory-driven forms of evaluation help understanding such complexity by studying how the different elements are intertwined [20] and recognising the role of context as a key influence in the production of outcomes [21]. The qualitative and quantitative methods will be integrated throughout to answer the eight study research questions. This is due to the diversity of country contexts and complexity of CHW programmes, which require combinations of elements at micro (i.e. 2011;26 suppl 2:ii84–91. TM, BU, OO and RH jointly conceived the study; TM, EE, BE, BU, AM, OO, RH, NE, JN and TE developed the study proposal; TM led the writing of this paper with the contributions from EE, BE, BU, AM, OO, RH, NE, JH, JN and TE. In addition to changes in exogenous variables such as pay scales and size of the programme, we will include key contextual changes that can impact on the cost-effectiveness of the programme. Lehmann U, Sanders D. Community health workers: What do we know about them? Springer Nature. During step 1, we will develop specific hypothetical pathways (i.e. A coherent LM is a thread of evidence-based logic that connects design, planning, implementation and evaluation of programmes [47]. These progressed from (1) overall programme theory, (2) initial LM and (3) literature review. The paper will also be useful to policymakers and practitioners who are interested in commissioning and engaging in such complex evaluations to inform policies and practices. Quantitative methods will include analysis of quantitative and costing data from (a) HMIS, (b) SURE-P M&E and (c) a structured facility exit survey. Abuja: Federal Ministry of Health; 2013. is a time series trend variable; I Bull World Health Organ. Assessment of ITS design against quality criteria. A realist evaluation study protocol. Countdown to 2015. These hypotheses will be developed in discussions with programme managers and implementers. [1] It is based on the epistemological foundations of critical realism. Whereas in realist review the primary data comes from documents (e.g. MRC. Working with International Medical Corps (IMC), an initial programme theory was elicited through literature and document reviews, semistructured interviews and focus groups with IMC programme managers and CHWs. Cost Eff Resour Alloc. alternative respondents). These costs will be captured through a small facility exit survey of women who have used services both before and after implementation of the SURE-P/MCH to understand how user costs have changed over time. 2007;21:554–72. Enyi Etiaba. In realist evaluation the researcher or evaluator’s task is to gather the data – i.e. Conversely, it could also lead to the admission of more high-risk pregnancies, causing an increase in facility deaths. The qualitative evaluation proposed will be based on the document analysis of yearly ICP progress reports, selected case studies and focus group interviews with stakeholders. CHW programmes are inherently complex, and their success is mediated by how the intervention is implemented within the health system context. Based on this interest, and following the competitive evaluation of research proposals from the Joint MRC/ESRC/DFID/Wellcome Trust health systems research initiative call 1, in June 2015, we initiated a 5-year research programme to assess the MCH component in Anambra state. The specific hypotheses will be driven by the study research questions (see Table 1) and will relate to the key programme targets ([40] p. 17), Reduction of MMR by 59 % from 545/100,000 live births to 320/100,000 live births, Reduction of neonatal mortality rate by 22 % from 37/1000 live births to 29/1000 live births, Increased percentage of pregnant women receiving focused antenatal care (ANC) by 52% from 50 % coverage, Increased percentage of skilled birth attendance by 63 % (from 16 % baseline), Increased postnatal care attendance within 2 days of birth by 63 % (from 16 % baseline), Increased family planning attendance by 26 % (from 1 % baseline). consistency of SURE-P management with overall governance approaches; or support to CHWs within staff supervision and performance appraisal systems). 2012;10(1):38. The aim of this study is to inform strengthening, scaling up and ensuring sustainability of CHW programmes. REVAMP project: ‘Determinants of effectiveness and sustainability of a novel community health workers programme in improving mother and child health in Nigeria’. Evaluation of complex interventions requires a comprehensive understanding of intervention context, mechanisms and outcomes. This study will make an important and timely contribution to health systems strengthening in Nigeria. political and resource environment), at the meso level (e.g. Stame N. Theory-Based Evaluation and Types of Complexity. intra-component and inter-component, respectively. Thus, the final explanation of a programme considers context-mechanism-outcome.[5]. BMJ. It explains when a realist impact evaluation may be most Pommier J, Guevel M-R, Jourdan D. Evaluation of health promotion in schools: a realistic evaluation approach using mixed methods. 2008;6(1):20. R Pawson, N. Tilley, "Realistic Evaluation" (Sage), London. Ricketts JA. Two aspects of the environment within which the study is being implemented are worth noting. Specific methods for data collection will include in-depth interviews and focus group discussions with purposefully identified key stakeholders (managers, service providers and service users), document reviews, analyses of quantitative data from the CHW programme and health information system, and a small-scale survey. These include both immediate changes in the level of an indicator following the intervention, and long-term changes in the trend of an indicator (over time) following the intervention, as compared to control health facilities. It is based on the epistemological foundations of critical realism.Based on specific theories, realist evaluation provides an alternative lens to empiricist evaluation techniques for the study and understanding of programmes and policies. The aim of the ITS analysis is to identify discontinuities in the time series associated with, and potentially caused by, the introduction of the SURE-P programme to health facilities. Article  Lehmann U, Gilson L. Actor interfaces and practices of power in a community health worker programme: a South African study of unintended policy outcomes. alternative respondents). it is a form of primary research. During step 2, we shall use a mix of methods to validate hypothetical pathways. As with all primary research approaches, guidance on quality assurance and uniform reporting is an important step towards improving quality and consistency. This study will provide a timely and important contribution to health systems strengthening specifically within Anambra state in southeast Nigeria but also more widely across Nigeria. This handbook is available upon request. Realist evaluation is a type of theory-driven evaluation method used in evaluating social programmes. The data will be collected using three methods. One of the tasks of a realist evaluation is therefore to make the theories within a program explicit, by developing clear hypotheses about how, and for whom, Implicit in the figure are the intervention implementation outcomes, i.e. Evaluation. CAS  Manage cookies/Do not sell my data we use in the preference centre. Pawson R, Manzano-Santaella A. I The study protocol reported in this paper has been evaluated through open competitive peer-review process as part of the Joint MRC/ESRC/DFID/Wellcome Trust health systems research initiative call 1 and accepted for funding (grant ref: MR/M01472X/1). This combination was intended to improve access to quality health services and ultimately reduce maternal and child morbidity and mortality. Realistic evaluation is an increasingly popular approach, but few published examples exist, particularly in implementation research. Whereas in realist review the primary data comes from documents (e.g. Outcomes for Implementation Research: Conceptual Distinctions, Measurement Challenges, and Research Agenda. 2017 Dec 22;17(1):843. doi: 10.1186/s12913-017-2795-x. Decision-makers will be continuously engaged in a research-policy partnership to facilitate adoption of lessons learned [45]. Research-policy partnerships - experiences of the Mental Health and Poverty Project in Ghana, South Africa, Uganda and Zambia. t 2014;100:72–83. This includes ensuring regular communication between the partners and engagement with policymakers and practitioners; quality assurance through regular peer-review within and between the teams; appropriate mentoring and coaching support to more junior researchers and equal opportunities to both genders. Although there are excellent examples of how realist evaluation might be used for evaluation in different healthcare contexts (e.g. The impact of the programme on key output and outcome indicators will be assessed through an interrupted time-series analysis (ITS) of monthly quantitative data from health information system and programme reports. Country Implementation Plan for Prioritized Life-Saving Commodities for Women and Children. One SURE-P component focused on maternal and child health (SURE-P/MCH), which comprised supply and demand components. Where project data are stored on an institutional server, it will be password-protected and only members of the research team will have access to the passwords. FMoH. Methods and analysis The study will be conducted in four phases. The use of CHWs was promoted in an attempt to implement interventions using lower cadres of workers to accelerate achievement of universal healthcare coverage [7–10]. The hypotheses can also cover links within and between components of the conceptual framework (Fig. Our study should improve understanding of the performance and functioning of complex system interventions involving both supply and demand sides. Guide Evidence-Based Policy - A Realist Perspective: This book by Ray Pawson provides detailed guidance on realist synthesis including a range of examples from across a variety of policy … 2003;19(4):613–23. acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration and sustainability of the interventions [37], which often influence the progression from inputs to processes, outputs and outcomes within health programmes. Leeds, U.K: COMDIS-Health Service Delivery; 2012. London: Sage Publications Limited; 1997. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Excerpt "A realist approach assumes that programs are “theories incarnate”. The realist evaluation is a relatively new approach to evaluation and its overall place in the is not yet fully established. A LM is a visual way of organising and displaying information about a strategy or programme. The study results will also inform strengthening the different aspects of the Nigerian health system, e.g. Economic evaluation will be used to identify the programme costs against the outcomes [32, 33], using an incremental approach to compare intervention costs with benefits, compared with standard practice [16, 34]. Each IWT identified specific Cs, Ms and Os. Specific methods of communicating research will include combinations of: Developing short and practical policy briefs to national and international policymakers and practitioners. N Engl J Med. Second, two initial hypothetical pathways or initial working theories (IWTs) (see Additional file 6) were developed, focusing on SURE-P/MCH supply and demand components, respectively. In this paper, we report a protocol for realist evaluation study of DeteRminants of Effectiveness and sustainability of a noVel Community HeAlth Workers (CHWs) programMe in imProving maternal and child health in Nigeria (REVAMP project).. Achievement of improved maternal and child health (MCH) outcomes continues to be an issue of international priority for achieving the health … Geneva: World Health Organization; 2012. Implementation Science J Health Organ Manag. The commitment by key health decision-makers at Anambra state to engage with this research is particularly encouraging. We will ‘embed’ the research into policy and practice, working with the federal, state and local actors. The study is guided by the research questions shown in Table 1, alongside the corresponding objectives. Qualitative methods will include (a) IDIs with key actors, including service users, (b) reviews of key documents and (c) exit IDIs and focus group discussions (FGDs) with service users and their family members. statement and This realist evaluation protocol sets out the approach that will be used to identify and explain which aspects of the programme are working, for whom and in what circumstances to produce the outcomes intended. Adequate communication of results is an essential component of this study. A detailed list of respondents will be developed within step 1, and snowballing will be used to identify any further informants.
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