Cite this article. 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 panels will use data from each facility in the three study clusters covering the period from at least 12 months before and 12 months after the intervention began in the two intervention clusters and equivalent periods for the control cluster. autocorrelation), and important covariates will also be adjusted for, while multilevel methods will be used to address variation across health facilities. Conversely, it could also lead to the admission of more high-risk pregnancies, causing an increase in facility deaths. Pommier J, Guevel M-R, Jourdan D. Evaluation of health promotion in schools: a realistic evaluation approach using mixed methods. Los Angeles: SAGE Publications; 2012. 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. Neither of the funders had any role in the design of this study. © 2020 BioMed Central Ltd unless otherwise stated. Realist impact evaluation draws on the realism school of philosophy. Last, at least two FGDs will be conducted, each involving 6–8 service users including members of their families, to enable comparison of their views and exploring the dynamics of their discussion. Correspondence to J Health Organ Manag. Each IWT identified specific Cs, Ms and Os. Other services might also be affected by resources (or their lack) such as drugs and theatre time that are channelled into the new programme. Developing and Evaluating Complex Interventions. It was identified in consultation with the Federal and State Ministry of Health (MOH) and the SURE-P national team lead. In 2012, the Federal Government of Nigeria launched the Subsidy Reinvestment and Empowerment Programme (SURE-P) to invest the revenue from fuel subsidy reduction into a social protection programme to improve the lives of the most vulnerable populations [29]. A coherent LM is a thread of evidence-based logic that connects design, planning, implementation and evaluation of programmes [47]. Realist impact evaluation draws on the realism school of philosophy. 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). The assessment of the ITS design against standard quality checklist [42] is shown in Additional file 1. 2011;94(1):74–85. 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. 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 suggested protocol uses a realist evaluation with multiple cases across the 3 country sites: Turkey, Iraq and Lebanon. Question guides will be adapted to the different actor groups, commensurate to their backgrounds and roles in the design and implementation of the programme. Only members of teams identified by the PIs in each institution will have access to the data. First, the initial Logic Model (LM) (see Additional file 5) was developed for the SURE-P/MCH. J Dev Econ. Lehmann U, Gilson L. Actor interfaces and practices of power in a community health worker programme: a South African study of unintended policy outcomes. 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. Unnecessary collection of personal data will be avoided, and respondents will have the right to review outputs and withdraw consent. 2012;10(1):38. Implementing community-based perinatal care: results from a pilot study in rural Pakistan. It describes five key ideas which frame realism and their implications for impact evaluation. The development of interview question guides will be informed by the study conceptual framework and structured around the study research questions to explore the specific hypothetical pathways identified in step 1. Privacy 2011;38(2):65–76. 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. Mirzoev T, Lê G, Green A, Orgill M, Komba A, Esena RK, et al. Thus, the final explanation of a programme considers context-mechanism-outcome.[5]. studies, policy documents and so on) and so it is a form of secondary research. intra-component and inter-component, respectively. Disabil Soc. Abuja, Nigeria: National Primary Health Care Development Agency; 2012. it is a form of primary research. During step 1, we will develop specific hypothetical pathways (i.e. Phases 1 and 2 have been completed (2014–2017) and a summary of this work is presented. Since the start of the project, a detailed methodology handbook has been developed to guide data collection and analysis [30]. 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, RE was founded on the need to better understand, identify and evaluate why complex interventions succeed or fail in order to inform spread and replicability of effective interventions [].RE is well placed to provide much needed transferable findings that are of practical use for practitioners and decision makers. 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’. 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. Ebenso B, Manzano A, Uzochukwu B, Huss R, Etiaba E, Ensor T, et al. While studies have explored the effects of supply- and demand-side interventions separately [15, 18, 19], the combined effects of the two—such as the added value of CCTs within health programmes—are rarely assessed within the same intervention. It is important to stress that realist evaluation cannot be achieved simply by following a protocol in a technically correct manner. Specific emphasis will be placed on confidentiality and other data protection issues, which will include security of data storage and access rights to data. In: Bryman A, Burgess R, editors. All interviews will be audio-recorded (subject to informed consent), transcribed and translated into English where required. with and without CCTs) of a Nigerian CHW programme to understand what contextual factors promote equitable access to quality services and examining the conditions under which these changes can be sustained following withdrawal of funding. 2013;13(1):847. The two interventions (i.e. Jokhio AH, Winter HR, Cheng KK. We will also assess the relationship between the supply and demand programme components, which are recognised to provide the continuum of care [40]. The commitment by key health decision-makers at Anambra state to engage with this research is particularly encouraging. Bull World Health Organ. Realist evaluation provides an overall methodological approach for the project and will guide development, testing and refining of middle-range theories through the analysis of the relationships between the context (at macro, meso and micro levels), mechanisms and outcomes [31]. Accountability for Maternal, Newborn and Child Survival: An Update on Progress in Priority Countries. Health Policy Plan. [1] It is based on the epistemological foundations of critical realism. 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. PubMed  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). The relationships between and amongst these Cs, Ms and Os will be explored as part of the data collection and analysis. This 5-year study is implemented in Anambra state, located in the southeast of Nigeria with a total of 4420 PHC facilities serving a population of 4.2 million. Gopalan SS, Mohanty S, Das A. Assessing community health workers’ performance motivation: a mixed-methods approach on India's Accredited Social Health Activists (ASHA) programme. 2007;21:554–72. Abuja: Federal Ministry of Health; Save the Children, Jhpiego; 2011. New York: Routledge; 1994. London: Sage Publications Limited; 1997. The study is guided by the research questions shown in Table 1, alongside the corresponding objectives. Research Methodology. Evaluation of complex interventions requires a comprehensive understanding of intervention context, mechanisms and outcomes. It explains when a realist impact evaluation may be most Bull World Health Organ. METHODS AND ANALYSIS: The study will be conducted in four phases. It explains when a realist impact evaluation may be most Wolff N. Randomised trials of socially complex interventions: promise or peril? A cluster is made up of four PHC facilities and one General Hospital (GH). capabilities, values and interests of individuals) [38, 39]. Saving newborn lives in Nigeria: Newborn health in the context of the Integrated Maternal, Newborn and Child Health Strategy. Therefore, instead of attributing changes in health outcomes to the SURE-P/MCH only, we will explore the contribution of the interventions to achievement of desired effects within the real context. Leeds, UK: University of Leeds; 2015. realist evaluation covering the same kind of project or programme. Protocol for a mixed methods realist evaluation of regional District Health Board groupings in New Zealand Tim Stokes , 1 Carol Atmore , 1 Erin Penno , 1 Lauralie Richard , 1 Emma Wyeth , 2 Rosalina Richards , 3 Fiona Doolan-Noble , 1 Andrew R Gray , 4 Trudy Sullivan , 5 and Robin Gauld 6 'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. However, if we reach data saturation earlier, these numbers may decrease. Realist evaluation is a form of theory-driven evaluation, but is set apart by its explicit philosophical underpinnings. Realist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). In realist evaluation the researcher or evaluator’s task is to gather the data – i.e. Realist evaluation is a type of theory-driven evaluation method used in evaluating social programmes. 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). At the outcome level, increased rates of facility delivery could help improve delivery outcomes, leading to a reduction in perinatal deaths. A framework approach will be used for analysis to test hypotheses, while allowing for emergence of new themes [41]. A realist evaluation study protocol. BMJ Open 2012, 2(2). Whereas in realist review the primary data comes from documents (e.g. Realist evaluation reports need to be developed in line with the realist nature of the evaluation. https://doi.org/10.1186/s13012-016-0443-1, DOI: https://doi.org/10.1186/s13012-016-0443-1. it Abuja, Nigeria: Subsidy Reinvestment and Empowerment Programme (SURE-P); 2013. $${Y}_t = {\beta}_0+\kern0.5em {\beta}_1{T}_t+\kern0.5em {\beta}_2{I}_t+\kern0.5em {\beta}_3{T}_t{I}_t + {\beta}_4{X}_t + {\varepsilon}_t$$, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/, https://doi.org/10.1186/s13012-016-0443-1. 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. PubMed Central  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. 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 … Implementation Sci 11, 83 (2015). Health Policy Plan. exploring the intervention mechanisms); identify the key contextual facilitators and constraints and analyse in what ways these contextual influences affected the achievement of outcomes. A LM is a visual way of organising and displaying information about a strategy or programme. 2003;19(4):613–23. Evidence suggests that the use of CHWs can be effective in broadening access to, and coverage of, health services and improving MCH outcomes [4–6]. Article  The hypotheses can also cover links within and between components of the conceptual framework (Fig. These costs represent opportunity costs of the programme that contribute to the overall cost that may vary across contexts. Jaskiewicz W, Tulenko K. Increasing community health worker productivity and effectiveness: a review of the influence of the work environment. This technique assumes that knowledge is a social and historical product, thus the social and political context as well as theoretical mechanisms, need consideration in analysis of programme or policy effectiveness. 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. This study will make an important and timely contribution to health systems strengthening in Nigeria. individual), meso (organisational) and macro (i.e. Central to the supply component was the recruitment, training and deployment of 2000 formal service providers (e.g. NPHCDA. 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. (PDF 555 kb), Ethical approvals from the University of Nigeria. Adam T, Lim SS, Mehta S, Bhutta ZA, Fogstad H, Mathai M, et al. 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. political and resource environment), at the meso level (e.g. Malar J. Gilmore B, McAuliffe E. Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic review. Article  Cookies policy. We will explore views of MCH service users on SURE-P, its costs and effects. Health Policy Plan. Ethics approvals for this study were obtained from the University of Leeds and the University of Nigeria. Since December 2012, CCTs have been implemented in selected SURE-P/MCH sites in 9 of the 36 states of Nigeria (SURE-P/MCH + CCT). 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. 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. SURE-P/MCH and SURE-P/MCH + CCT) will be assessed against each other and against the no implementation site. Options discussed included stopping or amending the research, as well as technical and political implications of each option from the different (policymakers’ and the funder’s) perspectives. CHW programmes are inherently complex, and their success is mediated by how the intervention is implemented within the health system context. Fiona Keogh, Maria Pierce, Karen Neylon, Padraic Fleming, Intensive home care packages for people with dementia: a realist evaluation protocol, BMC Health Services Research, 10.1186/s12913-018-3630-8, 18, 1, (2018). This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question ‘what interventions … statement and On the demand side, there are costs of the cash transfers themselves (conditional on using services), transportation to the health facility and opportunity costs of facility use to the women and their carers. Excerpt "A realist approach assumes that programs are “theories incarnate”. By using this website, you agree to our This combination was intended to improve access to quality health services and ultimately reduce maternal and child morbidity and mortality. 2nd ed. BMJ Open 2012, 2(1). Cochrane Database of Systematic Reviews 2010 2010(Issue 3). This is known as the C-M-O configuration [26], and without accounting for all these dimensions, some aspects of the programme may go unrecorded, thus affecting the validity and reliability of results [27] and preventing replication [28]. financial incentives to pregnant women to register at a Primary Health Care (PHC) centre, receive health check-ups while pregnant, deliver at a health facility and take their baby for vaccinations.

## realist evaluation protocol

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