1
|
Ibiloye O, Decroo T, Masquillier C, Okonkwo P, Lynen L, Jwanle P, van Olmen J, van Belle S. Realist evaluation of a community-based antiretroviral therapy (CBART) programme for key populations in Benue State in Nigeria. BMC Infect Dis 2024; 24:892. [PMID: 39217280 PMCID: PMC11366157 DOI: 10.1186/s12879-024-09808-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 08/26/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND World Health Organization recommended community-based ART (CBART) approaches to improve access to antiretroviral treatment (ART) and treatment outcomes among key populations living with (KPLHIV). Key populations (KP) are female sex workers, men who have sex with men, persons who inject drugs, and transgender people. How CBART for KP (KP-CBART) worked and why, for whom and in what circumstances it worked within KP communities or at community sites, are yet to be described. The aim of this study is to describe the different KP-CBART approaches or models in Nigeria, identifying the context conditions and mechanisms that are likely to produce the desired outcomes. METHOD Building on our previous study eliciting an initial programme theory for KP-CBART, we used a multiple case design and cross-case analysis to evaluate 3 KP-CBART approaches, namely: One Stop Shop clinic; community drop-in centre; and outreach venue. Between 2021 and 2023, we conducted a retrospective cohort study, 99 indepth interviews and 5 focused group discussions with various actors. Using realist evaluation, we synthesised context-mechanism-outcome configurations (CMOCs) and developed programme theory for each of the cases and an overall theory. RESULT The analysis showed the central importance of decentralizing ART service delivery to a safe place within the community for KPLHIV. The provision of ART in a KP friendly environment triggered a feeling of safety and trust in the healthcare workers among KPLHIV, resulting in KP-CBART acceptance and improved ART uptake, medication adherence and retention on ART. KP community engagement in ART delivery, peer support through support group meetings, and linkages with KP-led organizations improved self-efficacy, fostered solidarity and a sense of belonging among KP. These resources encouraged and motivated clients to engage with the KP-CBART model. However, fear of disclosure of HIV and KP status, and lack of trust between KP groups, demotivated and discouraged KPLHIV from initiating ART and continuing their treatment in KP-CBART. CONCLUSION To optimise access to ART and treatment outcomes for KPLHIV, policy makers and health practitioners should ensure the provision of a safe place for ART service delivery that can be trusted by the clients and the KP communities.
Collapse
Affiliation(s)
- Olujuwon Ibiloye
- Institute of Tropical Medicine, Antwerp, Belgium.
- APIN Public Health Initiatives, Abuja, Nigeria.
- University of Antwerp, Antwerp, Belgium.
| | - Tom Decroo
- Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | | | | | | | | |
Collapse
|
2
|
Dziruni TB, Hutchinson AM, Keppich-Arnold S, Bucknall T. A realist evaluation protocol: assessing the effectiveness of a rapid response team model for mental state deterioration in acute hospitals. FRONTIERS IN HEALTH SERVICES 2024; 4:1400060. [PMID: 39076771 PMCID: PMC11284174 DOI: 10.3389/frhs.2024.1400060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 07/01/2024] [Indexed: 07/31/2024]
Abstract
Background Mental state deterioration poses significant challenges in healthcare, impacting patients and providers. Symptoms like confusion and agitation can lead to prolonged hospital stays, increased costs, and the use of restrictive interventions. Despite its prevalence, there's a lack of consensus on effective practices for managing mental state deterioration in acute hospital settings. To address this gap, a rapid response team model has been proposed as a potential intervention, aiming to provide early identification and targeted interventions. Methods Based on realist evaluation steps, first, initial program theories are formulated to understand the logic behind the intervention. Second, literature synthesis identifies empirical evidence on contexts, mechanisms, and outcomes elements, refining initial theories. During the third step, data will be collected using qualitative methods such as field observations and interviews, as well as quantitative methods such as surveys of the staff, audits of electronic medical records, and analysis of incident records of mental state deterioration. Analysing this data informs configurations of contexts, mechanisms, and outcomes. In the fifth step, the configurations are synthesised, presenting refined, evidence-informed program theories. Conclusion This study addresses the knowledge gap by evaluating the rapid response model's effectiveness in managing mental state deterioration in acute hospital settings. Realist principles guide the exploration of causal mechanisms and their interaction with specific implementation contexts. The objective is to identify what works, for whom, and under what circumstances, aiming to manage deterioration, reduce restrictive interventions, and enhance the experience for patients and staff by implementing a proactive model of care. The findings contribute to evidence-based approaches for managing mental state deterioration in hospital settings, informing policy and practice in this crucial area of healthcare.
Collapse
Affiliation(s)
- Tendayi Bruce Dziruni
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
- Alfred Health, Melbourne, VIC, Australia
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| | - Alison M. Hutchinson
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
- Barwon Health, Geelong, VIC, Australia
| | - Sandra Keppich-Arnold
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
- Alfred Health, Melbourne, VIC, Australia
| | - Tracey Bucknall
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
- Alfred Health, Melbourne, VIC, Australia
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, VIC, Australia
| |
Collapse
|
3
|
Abbott P, Nixon G, Stanley I, D’Ambruoso L. A protocol for a critical realist synthesis of school mindfulness interventions designed to promote pupils' mental wellbeing. Front Public Health 2024; 11:1309649. [PMID: 38264247 PMCID: PMC10803664 DOI: 10.3389/fpubh.2023.1309649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/27/2023] [Indexed: 01/25/2024] Open
Abstract
Introduction The review described in this protocol will be the first critical realist review of the literature reporting on the impact of school-based mindfulness interventions on the mental wellbeing of pupils. Mindfulness interventions are increasingly being introduced into schools to promote children's (and teachers') wellbeing. Findings from impact evaluations, including systematic reviews and metanalysis, suggest that school-based mindfulness interventions promote pupils' wellbeing. However, there is a need for further evidence on the underlying causal mechanisms and contexts that explain program outcomes, to provide insight into how mindfulness programs can be successfully implemented in other contexts. Methods and analysis A critical realist review methodology will be used to provide a causal interdisciplinary understanding of how school-based mindfulness interventions promote the mental wellbeing of pupils. This will be done through a systematic literature review and extrapolating context, agency, intervention, mechanisms, and outcome configurations. This will enable an understanding of how, in certain contexts, pupils can use the resources offered by a mindfulness intervention knowingly or unknowingly to trigger mechanisms that promote their mental wellbeing and what mechanisms in the context support, restrict or prevent change. We will then use retrodiction and retroduction to develop the most plausible interdisciplinary middle-range theory to explain the findings. Discussion The review findings will inform a critical realist evaluation of a mindfulness intervention in schools. The findings from the review will also enable us to inform policymakers and other stakeholders about what conditions need to be in place for mindfulness interventions to promote pupils' mental wellbeing. We will publish the findings from the review in academic and professional publications, policy briefs, workshops, conferences, and social media.PROSPERO registration number: CRD42023410484.
Collapse
Affiliation(s)
- Pamela Abbott
- Centre for Global Development, University of Aberdeen, Aberdeen, United Kingdom
- School of Education, University of Aberdeen, Aberdeen, United Kingdom
| | - Graeme Nixon
- Centre for Global Development, University of Aberdeen, Aberdeen, United Kingdom
- School of Education, University of Aberdeen, Aberdeen, United Kingdom
| | - Isabel Stanley
- Centre for Global Development, University of Aberdeen, Aberdeen, United Kingdom
- School of Education, University of Aberdeen, Aberdeen, United Kingdom
| | - Lucia D’Ambruoso
- Centre for Global Development, University of Aberdeen, Aberdeen, United Kingdom
- Aberdeen Centre for Health Data Science, University of Aberdeen, Aberdeen, United Kingdom
| |
Collapse
|
4
|
Jager A, Wong G, Papoutsi C, Roberts N. The usage of data in NHS primary care commissioning: a realist review. BMC Med 2023; 21:236. [PMID: 37400837 DOI: 10.1186/s12916-023-02949-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/19/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Primary care has been described as the 'bedrock' of the National Health Service (NHS) accounting for approximately 90% of patient contacts but is facing significant challenges. Against a backdrop of a rapidly ageing population with increasingly complex health challenges, policy-makers have encouraged primary care commissioners to increase the usage of data when making commissioning decisions. Purported benefits include cost savings and improved population health. However, research on evidence-based commissioning has concluded that commissioners work in complex environments and that closer attention should be paid to the interplay of contextual factors and evidence use. The aim of this review was to understand how and why primary care commissioners use data to inform their decision making, what outcomes this leads to, and understand what factors or contexts promote and inhibit their usage of data. METHODS We developed initial programme theory by identifying barriers and facilitators to using data to inform primary care commissioning based on the findings of an exploratory literature search and discussions with programme implementers. We then located a range of diverse studies by searching seven databases as well as grey literature. Using a realist approach, which has an explanatory rather than a judgemental focus, we identified recurrent patterns of outcomes and their associated contexts and mechanisms related to data usage in primary care commissioning to form context-mechanism-outcome (CMO) configurations. We then developed a revised and refined programme theory. RESULTS Ninety-two studies met the inclusion criteria, informing the development of 30 CMOs. Primary care commissioners work in complex and demanding environments, and the usage of data are promoted and inhibited by a wide range of contexts including specific commissioning activities, commissioners' perceptions and skillsets, their relationships with external providers of data (analysis), and the characteristics of data themselves. Data are used by commissioners not only as a source of evidence but also as a tool for stimulating commissioning improvements and as a warrant for convincing others about decisions commissioners wish to make. Despite being well-intentioned users of data, commissioners face considerable challenges when trying to use them, and have developed a range of strategies to deal with 'imperfect' data. CONCLUSIONS There are still considerable barriers to using data in certain contexts. Understanding and addressing these will be key in light of the government's ongoing commitments to using data to inform policy-making, as well as increasing integrated commissioning.
Collapse
Affiliation(s)
- Alexandra Jager
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, Medical Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
5
|
Thijssen M, Graff MJL, Lexis MAS, Nijhuis-van der Sanden MWG, Radford K, Logan PA, Daniels R, Kuijer-Siebelink W. Collaboration for Developing and Sustaining Community Dementia-Friendly Initiatives: A Realist Evaluation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4006. [PMID: 36901017 PMCID: PMC10001691 DOI: 10.3390/ijerph20054006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/18/2023] [Accepted: 02/21/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Dementia-friendly communities (DFCs) are seen as key to the inclusion and participation of people with dementia and carers. Dementia-friendly initiatives (DFIs) are important building blocks for the growth of DFCs. The collaboration between different stakeholders is a central aspect in developing and sustaining DFIs. AIM This study tests and refines an initial theory about collaborating for DFIs with special attention for the involvement of people with dementia and their carers during the collaboration for DFIs. The realist approach is used for deepening contextual aspects, mechanisms, outcomes, and its explanatory power. METHODS A participatory case study design using qualitative data (focus groups, observations, reflections, minutes from meetings, and exit interviews) was executed in four Dutch municipalities that have ambitions to become dementia- friendly communities. RESULTS The refined theory on the collaboration for DFIs incorporates contextual aspects such as diversity, shared insights, and clarity. It draws attention to the importance of mechanisms such as the recognition of efforts and progress, informal distributed leadership, interdependency, belonging, significance, and commitment. These mechanisms resonate with feeling useful and feeling collectively powerful in the collaboration. The outcomes of collaboration were activation, getting new ideas, and fun. Our findings address how stakeholders' routines and perspectives impact the involvement of people with dementia and their carers during collaboration. CONCLUSION This study provides detailed information about collaboration for DFIs. The collaboration for DFIs is largely influenced by feeling useful and collectively powerful. Further research is needed to understand how these mechanisms can be triggered with the involvement of people with dementia and their carers in the heart of the collaboration.
Collapse
Affiliation(s)
- Marjolein Thijssen
- Radboud University Medical Center, Radboudumc Research Institute, Scientific Center for Quality of Healthcare (IQ Healthcare), 6525 GA Nijmegen, The Netherlands
- Radboud Alzheimer Center, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Department Occupational Therapy, School of Allied Health, HAN University of Applied Sciences, 6525 EN Nijmegen, The Netherlands
| | - Maud J. L. Graff
- Radboud University Medical Center, Radboudumc Research Institute, Scientific Center for Quality of Healthcare (IQ Healthcare), 6525 GA Nijmegen, The Netherlands
- Radboud Alzheimer Center, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Monique A. S. Lexis
- Research Centre Assistive Technology in Care, Zuyd University of Applied Sciences, 6419 DJ Heerlen, The Netherlands
| | - Maria W. G. Nijhuis-van der Sanden
- Radboud University Medical Center, Radboudumc Research Institute, Scientific Center for Quality of Healthcare (IQ Healthcare), 6525 GA Nijmegen, The Netherlands
| | - Kate Radford
- Centre for Rehabilitation and Ageing Research, School of Medicine, University of Nottingham, Nottingham NG7 2TU, UK
| | - Pip A. Logan
- Centre for Rehabilitation and Ageing Research, School of Medicine, University of Nottingham, Nottingham NG7 2TU, UK
- Nottingham City Care Partnership, Nottingham NG6 8WR, UK
| | - Ramon Daniels
- Research Centre Assistive Technology in Care, Zuyd University of Applied Sciences, 6419 DJ Heerlen, The Netherlands
| | - Wietske Kuijer-Siebelink
- School of Education, HAN University of Applied Sciences, 6525 EN Nijmegen, The Netherlands
- Radboudumc Health Academy, Research on Learning and Education, Radboud University MEDICAL Center, 6525 GA Nijmegen, The Netherlands
| |
Collapse
|
6
|
Abraham JM, Melendez-Torres GJ. A realist review of interventions targeting maternal health in low- and middle-income countries. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231205687. [PMID: 37899651 PMCID: PMC10617292 DOI: 10.1177/17455057231205687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 09/04/2023] [Accepted: 09/19/2023] [Indexed: 10/31/2023]
Abstract
Maternal mortality is disproportionately higher in low- and middle-income countries compared to other parts of the world. International research efforts are reflective of the urgency to improve global maternal outcomes. The existing literature of maternal health interventions in low- and middle-income countries targets a variety of populations and intervention types. However, there is a notable lack of systemic reviews that examine the wider contextual and mechanistic factors that have contributed to the outcomes produced by interventions. This article aims to use realist synthesis design to identify and examine the relationships between the contexts, mechanisms and outcomes of maternal health interventions conducted in low- and middle-income countries. This will inform evidence-based practice for future maternal health interventions. In May 2022, we searched four electronic databases for systematic reviews of maternal health interventions in low- and middle-income countries published in the last 5 years. We used open and axial coding of contexts, mechanisms and outcomes to develop an explanatory framework for intervention effectiveness. After eligibility screening and full-text analysis, 44 papers were included. The majority of effective interventions reported good healthcare system contexts, especially the importance of infrastructural capacity to implement and sustain the intervention. Most intervention designs used increasing knowledge and awareness at an individual and healthcare-provider level to produce intended outcomes. The majority of outcomes reported related to uptake of healthcare services by women. All mechanism themes had a relationship with this outcome. Health system infrastructure must be considered in interventions to ensure effective implementation and sustainability. Healthcare-seeking behaviours are embedded within social and cultural norms, environmental conditions, family influences and provider attitudes. Therefore, effective engagement with communities and families is important to create new norms surrounding pregnancy and delivery. Future research should explore community mobilization and involvement to enable tailored interventions with optimal contextual fit.
Collapse
|
7
|
Klingberg S, Adhikari B, Draper CE, Bosire EN, Tiigah P, Nyirenda D, Mukumbang FC. Engaging communities in non-communicable disease research and interventions in low- and middle-income countries: a realist review protocol. BMJ Open 2021; 11:e050632. [PMID: 34290072 PMCID: PMC8296813 DOI: 10.1136/bmjopen-2021-050632] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Engaging communities and intended beneficiaries at various stages of health research is a recommended practice. The contribution of community engagement to non-communicable disease research in low- and middle-income countries has not yet been extensively studied or synthesised. This protocol describes the steps towards generating an understanding of community engagement in the context of non-communicable disease research, prevention and health promotion using a realist review approach. A realist lens enables a rich explanatory approach to causation while capturing complexity, and an openness to multiple outcomes, including unintended consequences. The review will thus develop an understanding of community engagement without assuming that such practices result in more ethical research or effective interventions. METHODS AND ANALYSIS We propose a realist approach aiming to examine how, why, under what circumstances and for whom community engagement works or does not work. The iterative review steps include clarifying the review scope; searching for evidence; appraising studies and extracting data; synthesising evidence and drawing conclusions; and disseminating, implementing and evaluating the findings. Principles of meta-narrative review (pragmatism, pluralism, historicity, contestation, reflexivity and peer review) are employed to ensure practicable and contextualised review outputs. The proposed review will draw on theoretical and empirical literature beyond specific diseases or settings, but with a focus on informing non-communicable disease research and interventions in low- and middle-income countries. The synthesis of existing literature will be complemented by qualitative realist interviews and stakeholder consultation. Through drawing on multiple types of evidence and input from both experts and intended beneficiaries, the review will provide critical and pragmatic insights for research and community engagement in low- and middle-income countries. ETHICS AND DISSEMINATION Ethical approval has been obtained from the University of the Witwatersrand. Dissemination will include traditional academic channels, institutional communications, social media and discussions with a wide range of stakeholders.
Collapse
Affiliation(s)
- Sonja Klingberg
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Bipin Adhikari
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Catherine E Draper
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Edna N Bosire
- SAMRC/Wits Developmental Pathways for Health Research Unit (DPHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Priscilla Tiigah
- Health Equity and Strategy Unit, Public Health England, London, UK
| | - Deborah Nyirenda
- Community Engagement and Bioethics, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, University of Malawi, Blantyre, Malawi
| | | |
Collapse
|
8
|
Kabongo EM, Mukumbang FC, Delobelle P, Nicol E. Explaining the impact of mHealth on maternal and child health care in low- and middle-income countries: a realist synthesis. BMC Pregnancy Childbirth 2021; 21:196. [PMID: 33750340 PMCID: PMC7941738 DOI: 10.1186/s12884-021-03684-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 02/28/2021] [Indexed: 01/11/2023] Open
Abstract
Background Despite the growing global application of mobile health (mHealth) technology in maternal and child health, contextual factors, and mechanisms by which interventional outcomes are generated, have not been subjected to a systematic examination. In this study, we sought to uncover context, mechanisms, and outcome elements of various mHealth interventions based on implementation and evaluation studies to formulate theories or models explicating how mHealth interventions work (or not) both for health care providers and for pregnant women and mothers. Method We undertook a realist synthesis. An electronic search of five online databases (PubMed/Medline, Google Scholar, Scopus, Academic Search Premier and Health Systems Evidence) was performed. Using appropriate Boolean phrases terms and selection procedures, 32 articles were identified. A theory-driven approach, narrative synthesis, was applied to synthesize the data. Thematic content analysis was used to delineate elements of the intervention, including its context, actors, mechanisms, and outcomes. Abduction and retroduction were applied using a realist evaluation heuristic tool to formulate generative theories. Results We formulated two configurational models illustrating how and why mHealth impacts implementation and uptake of maternal and child health care. Implementation-related mechanisms include buy-in from health care providers, perceived support of health care providers’ motivation and perceived ease of use and usefulness. These mechanisms are influenced by adaptive health system conditions including organization, resource availability, policy implementation dynamics, experience with technology, network infrastructure and connectivity. For pregnant women and mothers, mechanisms that trigger mHealth use and consequently uptake of maternal and child health care include perceived satisfaction, motivation and positive psychological support. Information overload was identified as a potential negative mechanism impacting the uptake of maternal and child health care. These mechanisms are influenced by health system conditions, socio-cultural characteristics, socio-economic and demographics characteristics, network infrastructure and connectivity and awareness. Conclusion Models developed in this study provide a detailed understanding of implementation and uptake of mHealth interventions and how and why they impact maternal and child health care in low- and middle-income countries. These models provide a foundation for the ‘white box’ of theory-driven evaluation of mHealth interventions and can improve rollout and implementation where required. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03684-x.
Collapse
Affiliation(s)
- Eveline M Kabongo
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa.
| | - Ferdinand C Mukumbang
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Peter Delobelle
- School of Public Health, University of the Western Cape, Cape Town, South Africa.,Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium.,Chronic Disease Initiative for Africa, University of Cape Town, Cape Town, South Africa
| | - Edward Nicol
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa.,Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
| |
Collapse
|
9
|
Yakovchenko V, McCullough MB, Smith JL, Gabrielian S, Byrne T, Bruzios KE, Koosis E, Smelson DA. Implementing a complex psychosocial intervention for unstably housed Veterans: A realist-informed evaluation case study. IMPLEMENTATION RESEARCH AND PRACTICE 2021; 2:26334895211049483. [PMID: 37090015 PMCID: PMC9978638 DOI: 10.1177/26334895211049483] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Only 7% of individuals with co-occurring mental health and substance use disorder (COD) receive services for both conditions. We implemented and evaluated maintaining independence and sobriety through systems integration, outreach and networking-Veteran's edition (MISSION-Vet), an evidence-based manualized psychosocial intervention for Veterans with CODs. This paper identifies the generative mechanisms that explain "how, for whom, and under what conditions" MISSION-Vet adoption, implementation, and fidelity work when applied in a complex adaptive system with facilitation support. Methods Within two VA healthcare systems (Sites A and B), a hybrid III trial tested facilitation to implement MISSION-Vet. We conducted a two-site case study based on 42 semi-structured consolidated framework for implementation research (CFIR) guided interviews with site leadership, implementers (social workers, peer specialists), and team members (facilitators, site leads). Interviews were coded and CFIR constructs used to generate "Context + Mechanism = Outcome" configurations to understand the conditions of MISSION-Vet adoption, implementation, and fidelity. Results Site A was low, and Site B was high in adoption, implementation, and fidelity. Adoption hesitancy/eagerness (outcome) resulted from the interaction of "external policy" (context) dampening/encouraging a "tension for change" (mechanism). Implementation intensity (outcome) was based on how "peer pressure" or practice culture (context) activated staff "self-efficacy" (mechanism) to engage with MISSION-Vet and appraise its "relative advantage" over current practices (mechanism). Fidelity relied on how "staffing structure and availability" (context) activated/muted "facilitation" (mechanism) to result in strategy and intervention adaptation (outcome). Conclusions We delineated how specific contexts activated certain mechanisms to drive the different stages of implementation of a multi-faceted COD treatment intervention. Trial registration ClinicalTrials.gov, NCT02942979. Plain language abstract Implementation is inherently dynamic and influenced by interdependent factors operating at the individual, organizational, and system levels. This is especially true for complex interventions addressing co-occurring mental health and substance use disorders because such interventions involve multiple treatment modalities delivered simultaneously, in busy practice settings, with challenging populations. This paper pairs consolidated framework for implementation research (CFIR) constructs with a realist evaluation approached to generate configurations important to the adoption, implementation, and adaptation stages of a highly complex intervention addressing the behavioural health and housing needs of a vulnerable population. Each configuration describes how contextual factors trigger mechanisms to generate implementation outcomes and answers "what works for whom, in what circumstances and in what respects, and how?" These findings further our understanding of possible mechanisms of change and push us to be more precise about identifying causal relationships among constructs that contribute to the success of implementing complex interventions. This work also moves us to think theoretically and methodologically in a more dynamic fashion, thereby leading to more responsive implementation practice.
Collapse
Affiliation(s)
- Vera Yakovchenko
- Center for Healthcare Organization and
Implementation Research, Bedford, MA, USA
- VA Bridging the Care Continuum-Quality Enhancement Research
Initiative, Bedford, MA, USA
| | - Megan B. McCullough
- Center for Healthcare Organization and
Implementation Research, Bedford, MA, USA
- VA Bridging the Care Continuum-Quality Enhancement Research
Initiative, Bedford, MA, USA
- Boston University School of Public
Health, Boston, MA, USA
| | - Jeffrey L. Smith
- Central Arkansas Veterans
Healthcare System, Little Rock, AR, USA
| | - Sonya Gabrielian
- Veterans Affairs Greater Los Angeles
Health Care System, Los Angeles, CA, USA
| | - Thomas Byrne
- Center for Healthcare Organization and
Implementation Research, Bedford, MA, USA
- VA Bridging the Care Continuum-Quality Enhancement Research
Initiative, Bedford, MA, USA
- Boston University School of School of Social Work, Boston, MA,
USA
| | - Kathryn E. Bruzios
- Center for Healthcare Organization and
Implementation Research, Bedford, MA, USA
- VA Bridging the Care Continuum-Quality Enhancement Research
Initiative, Bedford, MA, USA
- Department of Psychiatry, University of
Massachusetts Medical School, Worcester, MA, USA
| | - Ella Koosis
- Veterans Affairs Greater Los Angeles
Health Care System, Los Angeles, CA, USA
| | - David A. Smelson
- Center for Healthcare Organization and
Implementation Research, Bedford, MA, USA
- VA Bridging the Care Continuum-Quality Enhancement Research
Initiative, Bedford, MA, USA
- Department of Psychiatry, University of
Massachusetts Medical School, Worcester, MA, USA
| |
Collapse
|
10
|
Tennant E, Miller E, Costantino K, De Souza D, Coupland H, Fotheringham P, Eastwood J. A critical realist evaluation of an integrated care project for vulnerable families in Sydney, Australia. BMC Health Serv Res 2020; 20:995. [PMID: 33129332 PMCID: PMC7603742 DOI: 10.1186/s12913-020-05818-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 10/12/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative was established to improve the care of families with complex health and social needs who reside in Sydney Local Health District. HHAN seeks to provide long-term multi-disciplinary care coordination as well as enhance capacity building and promote integrated care. The critical realist study reported here is part of the longitudinal development and evaluation of complex integrated health and social care interventions in Sydney, Australia. METHODS We describe the qualitative component of a critical realist pilot case study aimed at exploring, explaining and refining emerging HHAN programme theories in relation to care coordination. Qualitative interviews were undertaken with HHAN clients (n = 12), staff and other stakeholders (n = 21). Interviews and coding used a context (C), mechanism (M) and outcome (O) framework. Inductive, deductive, retroductive and abductive modes of reasoning were used with the CMO heuristic tool to inform the developing programme theory. RESULTS The mechanisms underpinning effective engagement of clients by care coordinators included: building trust, leveraging other family, social and organisational relationships, meeting clients on their own terms, demonstrating staff effectiveness as quickly as possible, and client empowerment. Mechanisms for enhancing care integration included knowledge transfer activities and shared learning among collaborators, structural and cultural changes, enhancing mutual respect, co-location of multidisciplinary and/or interagency staff and cultivating faith in positive change among staff. CONCLUSIONS Use of a critical realism case study approach served to elucidate the varied influences of contexts and mechanisms on programme outcomes, to highlight what works for whom and in what context. Findings supported the initial programme theory that engagement and trust building with clients, alongside enhanced collaboration and integration of services, improved outcomes for vulnerable families with complex needs. Further research is needed to explore the cost-effectiveness of integrated care initiatives, in view of the long term nature of service provision and the risk of staff burnout.
Collapse
Affiliation(s)
- E. Tennant
- Healthy Homes and Neighbourhoods Integrated Care Initiative, Community Health Services, Sydney Local Health District, 24 Liverpool Road, Croydon, NSW 2132 Australia
- School of Public Health and Community Medicine, The University of New South Wales, Kensington, NSW 2052 Australia
| | - E. Miller
- Healthy Homes and Neighbourhoods Integrated Care Initiative, Community Health Services, Sydney Local Health District, 24 Liverpool Road, Croydon, NSW 2132 Australia
| | - K. Costantino
- Healthy Homes and Neighbourhoods Integrated Care Initiative, Community Health Services, Sydney Local Health District, 24 Liverpool Road, Croydon, NSW 2132 Australia
| | - D. De Souza
- Centre for Research in Education, Torrens University Australia, Flinders Street Campus, Melbourne, VIC 3000 Australia
| | - H. Coupland
- Drug Health Services, Royal Prince Alfred Hospital, Level 6, King George V Building Missenden Road, Camperdown, NSW 2050 Australia
- Discipline of Addiction Medicine, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - P. Fotheringham
- Healthy Homes and Neighbourhoods Integrated Care Initiative, Community Health Services, Sydney Local Health District, 24 Liverpool Road, Croydon, NSW 2132 Australia
| | - J. Eastwood
- Healthy Homes and Neighbourhoods Integrated Care Initiative, Community Health Services, Sydney Local Health District, 24 Liverpool Road, Croydon, NSW 2132 Australia
- Population child health group, School of Women’s and Children’s Health, The University of New South Wales, Kensington, NSW 2052 Australia
- Ingham Institute for Applied Medical Research, 1 Campbell St, Liverpool, NSW 2170 Australia
- Charles Perkins Centre, Menzies Centre for Health Policy, Discipline of Child and Adolescent Health, Central Clinical School, and School of Public Health, University of Sydney, Sydney, New South Wales 2006 Australia
- Sydney Institute for Women Children and their Families, Camperdown, NSW 2050 Australia
- Community Paediatrics, Croydon Community Health Centre, 24 Liverpool Road, Croydon, NSW 2132 Australia
| |
Collapse
|
11
|
Clark J, Sweet L, Nyoni S, Ward PR. Improving male involvement in antenatal care in low and middle-income countries to prevent mother to child transmission of HIV: A realist review. PLoS One 2020; 15:e0240087. [PMID: 33057353 PMCID: PMC7561142 DOI: 10.1371/journal.pone.0240087] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 09/21/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Childhood Human Immunodeficiency Virus (HIV) infection occurs almost exclusively via mother to child transmission (MTCT) during pregnancy, birth, or through breastfeeding. Recent studies have shown that male involvement (MI) in antenatal care (ANC) and HIV testing, including couples voluntary counselling and testing (CVCT), increases the likelihood that women will adhere to prevention advice and comply with HIV treatment if required during their pregnancy; hence reducing the rates of MTCT of HIV. This realist review investigates how, why, when, and for whom MI in ANC works best to provide contextual advice on how MI in ANC can be best used for prevention of mother to child transmission (PMTCT) of HIV. METHODS A realist review of existing evidence was conducted. Realist review seeks to explain how and why an intervention works, or does not work, in a given context. This was completed through the five stages of realist synthesis; Eliciting the program theory, search strategy, study selection criteria, data extraction, and data analysis and synthesis. Findings are presented as context-mechanism-outcome (CMO) configurations outlining the mechanisms that work in given contexts to give an outcome. RESULTS Three CMO configurations were developed. These describe that 1) Couples in monogamous relationships have higher levels of trust, commitment and security leading to increased uptake of PMTCT programs together; 2) ANC spaces that make 'male friendly' adaptions promote normalisation of MI in PMTCT and are more welcoming, leading to increased willingness of male partners to participate in ANC; and 3) couples and communities with higher health literacy encourage increased informed decision making, ownership, and responsibility and thus increased participation in PMTCT of HIV. CONCLUSIONS The CMOs developed in this review give contextual advice on how one might improve ANC services to increase MI and help reduce MTCT of HIV. We propose that MI in ANC works best where couples are monogamous and trusting, where ANC spaces actively promote being a 'male friendly space' and where there are high levels of community education programs around MTCT.
Collapse
Affiliation(s)
- Jacinta Clark
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Linda Sweet
- School of Nursing and Midwifery, Deakin University and Western Health Partnership, Burwood, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Simangaliso Nyoni
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Paul R. Ward
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| |
Collapse
|
12
|
Abstract
Introduction The Healthy Homes and Neighbourhoods (HHAN) Integrated Care Program seeks to enhance vulnerable family engagement with health and social services through a care coordination model. Besides servicing families in Sydney, HHAN has also established place-based initiatives (PBIs) in areas of disadvantage such as Redfern. The Redfern PBI co-locates HHAN with housing, drug and alcohol services, and financial and legal services. This integration aims to facilitate service access and multi-agency support for vulnerable families in Redfern. Hence, this study aims to evaluate for whom, when and why HHAN's PBI at Redfern works, or not, and what are its outcomes. Methods The project utilises critical realist methodology to undertake a qualitative evaluation of the impact of the PBI on clients, services and the community. Purposive sampling was used to identify 21 participants including HHAN clients, HHAN staff and stakeholders (HHAN partners). In-depth, semi-structured interviews were audio-recorded, transcribed, coded and analysed using a context (C), intervention (I), mechanism (M) outcome (O) (CIMO) approach to abductive analysis. Results Five key CIMO configurations of the Redfern PBI emerged - whole-of-family involvement, flexibility, trust, building connections and co-location. Whilst each theory had specific outcomes, overall client outcomes included improved access to services, better outlook, empowerment and engagement with services. Service outcomes included increased collaboration and foundation for integration between HHAN and other services. Negative outcomes included lack of full integration, the risk associated with integration and difficulty evaluating impact. Conclusion This study successfully refined the program theory for subsequent use in later implementation of critical realist evaluation studies.
Collapse
|
13
|
Bannister-Tyrrell M, Meiqari L. Qualitative research in epidemiology: theoretical and methodological perspectives. Ann Epidemiol 2020; 49:27-35. [PMID: 32711056 DOI: 10.1016/j.annepidem.2020.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/30/2020] [Accepted: 07/15/2020] [Indexed: 11/26/2022]
Abstract
Increasingly, modern epidemiology has adopted complex causal frameworks incorporating individual- and population-level determinants of health. Despite the growing use of qualitative methodologies in public health research generally, discussion of causal reasoning in epidemiology rarely considers evidence derived from qualitative research. This article argues for a coherent role of qualitative research within epidemiology through analysis of the principles of causal reasoning that underlie current debates about causal inference in epidemiology. It introduces two approaches to causal inference by Russo and Williamson (2009) and Reiss (2012) that emphasize the relevance of both the nature of causation and how knowledge is gained about causation in assessing evidence for a causal relation. Both theories have scope for incorporating multiple types of evidence to assess causal claims. We argue that these theories align with the empirical focus of epidemiology and allow for different types of evidence to evaluate causal claims, including evidence originating from qualitative research; such evidence can contribute to a mechanistic understanding of causal relations and to understanding the effects of context on health-related outcomes. Finally, we discuss this approach in light of previous literature on the role of qualitative research in epidemiology and implications for future epidemiologic research.
Collapse
Affiliation(s)
| | - Lana Meiqari
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| |
Collapse
|
14
|
Mukumbang FC, Knight L, Masquillier C, Delport A, Sematlane N, Dube LT, Lembani M, Wouters E. Household-focused interventions to enhance the treatment and management of HIV in low- and middle-income countries: a scoping review. BMC Public Health 2019; 19:1682. [PMID: 31842846 PMCID: PMC6916449 DOI: 10.1186/s12889-019-8020-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 11/29/2019] [Indexed: 12/31/2022] Open
Abstract
Background HIV remains a major public health challenge in many low- and middle-income countries (LMICs). The initiation of a greater number of people living with HIV (PLHIV) onto antiretroviral therapy (ART) following the World Health Organization’s ‘universal test and treat’ recommendation has the potential to overstretch already challenged health systems in LMICs. While various mainstream and community-based care models have been implemented to improve the treatment outcomes of PLHIV, little effort has been made to harness the potential of the families or households of PLHIV to enhance their treatment outcomes. To this end, we sought to explore the characteristics and effectiveness of household-focused interventions in LMICs on the management of HIV as measured by levels of adherence, viral suppression and different dimensions of HIV competence. Additionally, we sought to explore the mechanisms of change to explain how the interventions achieved the expected outcomes. Methods We systematically reviewed the literature published from 2003 to 2018, obtained from six electronic databases. We thematically analysed the 11 selected articles guided by the population, intervention, comparison and outcome (PICO) framework. Following the generative causality logic, whereby mechanisms are postulated to mediate an intervention and the outcomes, we applied a mechanism-based inferential reasoning, retroduction, to identify the mechanisms underlying the interventions to understand how these interventions are expected to work. Results The identified HIV-related interventions with a household focus were multi-component and multi-dimensional, incorporating aspects of information sharing on HIV; improving communication; stimulating social support and promoting mental health. Most of the interventions sought to empower and stimulate self-efficacy while strengthening the perceived social support of the PLHIV. Studies reported a significant positive impact on improving various aspects of HIV competent household – positive effects on HIV knowledge, communication between household members, and improved mental health outcomes of youths living in HIV-affected households. Conclusion By aiming to strengthen the perceived social support and self-efficacy of PLHIV, household-focused HIV interventions can address various aspects of household HIV competency. Nevertheless, the role of the household as an enabling resource to improve the outcomes of PLHIV remains largely untapped by public HIV programmes; more research on improving household HIV competency is therefore required. Trial registration PROSPERO registration: CRD42018094383.
Collapse
Affiliation(s)
| | - Lucia Knight
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | | | - Anton Delport
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Neo Sematlane
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | | | - Martina Lembani
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Edwin Wouters
- Department of Social Sciences, Antwerp University, Antwerp, Belgium
| |
Collapse
|
15
|
Designing an Integrated Care Initiative for Vulnerable Families: Operationalisation of Realist Causal and Programme Theory, Sydney Australia. Int J Integr Care 2019; 19:10. [PMID: 31367209 PMCID: PMC6659766 DOI: 10.5334/ijic.3980] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction: In July 2015 Sydney Local Health District (SLHD) implemented an integrated care initiative for vulnerable families in the Inner West region of Sydney, Australia. The initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. We will describe the development of the design that drew on earlier realist causal and program theoretical work. Methods: Realist causal and program theory were used to inform the collaborative design of an initiative for vulnerable families. The collaborative design process included: identification of desirable and undesirable outcomes and contextual factors, stakeholder consultation, interagency planning, and development of a service proposal. Results: The design elements included: identification of vulnerable family cohorts; care coordination; evidence-informed intervention(s); general practice engagement and support; family health improvement; placed-based neighbourhood initiatives; interagency system change and collaborative planning; monitoring of individual and family outcomes; and evaluation. Conclusions: The design study described advances toward the implementation of a whole-of-government integrated health and social care initiative. The initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. In so doing we aim to break intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours, through strengthening family resilience, improving access to services, and addressing the social determinants of health and wellbeing.
Collapse
|
16
|
Making a Realist Turn: Applying a Critical Realist Translational Social Epidemiology Methodology to the Design and Evaluation of Complex Integrated Care Interventions. Int J Integr Care 2019; 19:7. [PMID: 31367206 PMCID: PMC6659754 DOI: 10.5334/ijic.4725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
17
|
A Critical Realist Translational Social Epidemiology Protocol for Concretising and Contextualising a "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD)", Sydney Australia. Int J Integr Care 2019; 19:8. [PMID: 31367207 PMCID: PMC6659581 DOI: 10.5334/ijic.3962] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: We will describe here a translational social epidemiology protocol for confirming a critical realist “Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD). The approach will include the concretising and contextualising of the above causal theory into programme theories for child and adolescent interventions that aim to break intergenerational cycles of disadvantage and poor life outcomes. In undertaking this work we seek to advance realist translational methodology within the discipline of applied perinatal and paediatric social epidemiology. Theory and Methods: The research settings are in metropolitan Sydney. The design will be a longitudinal, multi-level, mixed method realist evaluation of applied programme interventions that seek to break the intergeneration cycle of social disadvantage and poor child health and developmental outcomes. The programme of research will consist of three components: 1) Operationalisation of the theory and designing of programme initiatives for implementation; 2) Evaluation of the translated programme and implementation theory using Theory of Change and critical realist evaluation; and 3) Theory Testing of realist hypotheses using both intensive and extensive critical realist research methods including realist structural modelling. Discussion: The proposed programme of research will assist in translating empirical explanatory theory building to theory driven interventions. The research will be situated in socially disadvantaged regions of Sydney where the local child and family inter-agencies will collaborate to design and implement new initiatives that address significant disparities in childhood development and adolescent outcomes attributed to neighbourhood circumstances, family stress and intergenerational cycles of disadvantage and poor mental health.
Collapse
|
18
|
Kabongo EM, Mukumbang FC, Delobelle P, Nicol E. Understanding the influence of the MomConnect programme on antenatal and postnatal care service utilisation in two South African provinces: a realist evaluation protocol. BMJ Open 2019; 9:e029745. [PMID: 31266842 PMCID: PMC6609052 DOI: 10.1136/bmjopen-2019-029745] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Timely antenatal care (ANC) and postnatal care (PNC) attendance decrease maternal and child mortality by improving maternal and child health (MCH) outcomes. Mobile health or mHealth has been identified as an effective way of improving the uptake of MCH services. The MomConnect programme is an mHealth initiative launched by the National Department of Health of South Africa in August 2014 to support MCH. Although widely used, there is a limited understanding of how, why, for whom and under which health system conditions, the implementation of MomConnect improves the health-seeking behaviour of pregnant women and mothers of infants in ANC and PNC facilities. This paper describes the protocol for a realist evaluation of the MomConnect programme, to provide a theory-based understanding of how, why and under what healthcare conditions the MomConnect programme works or not. METHOD AND ANALYSIS We will use the realist evaluation approach through its research cycle conducted in three phases. In phase I, a multimethod elicitation study design will be used, including a document review, key informant interviews and a scoping review to formulate an initial programme theory of the MomConnect intervention. Content and thematic analytic approaches will be used to analyse the data that will be fitted into a realist framework to formulate the initial programme theory. In phase II, a multi-case study design will be applied using a multimethod approach in two South African provinces. In each case, a theory-testing approach underpinned by the hypothetico-deduction analytic model will be used to test the initial programme theory. Surveys, interviews and focus group discussions will be conducted with various programme actors and analysed using appropriate methods. Phase III will entail refining the tested/modified programme theory through cross-case analysis. EXPECTED OUTCOMES An improved understanding of how and why the MomConnect intervention improves the health-seeking behaviour of pregnant women and mothers of infants, and the health system conditions that influence its implementation. ETHICS AND DISSEMINATION Ethics approval was granted by the Stellenbosch University Ethics Committee (S18/09/189). The protocol has been designed and the study will be conducted in line with the principles of the Declaration of Helsinki (1964).
Collapse
Affiliation(s)
- Eveline M Kabongo
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa
| | | | - Peter Delobelle
- School of Public Health, University of the Western Cape, Cape Town, South Africa
- Chronic Disease Initiative for Africa, Department of Medicine, University of Cape Town, Cape Town, Western Cape Province, South Africa
| | - Edward Nicol
- Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
| |
Collapse
|
19
|
Mukumbang FC, van Wyk B, Van Belle S, Marchal B. 'At this [ adherence] club, we are a family now': A realist theory-testing case study of the antiretroviral treatment adherence club, South Africa. South Afr J HIV Med 2019; 20:922. [PMID: 31308968 PMCID: PMC6620516 DOI: 10.4102/sajhivmed.v20i1.922] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 02/28/2019] [Indexed: 01/08/2023] Open
Abstract
Background An estimated 7.9 million people were living with HIV in South Africa in 2017, with 63.3% of them remaining in antiretroviral therapy (ART) care and 62.9% accessing ART. Poor retention in care and suboptimal adherence to ART undermine the successful efforts of initiating people living with HIV on ART. To address these challenges, the antiretroviral adherence club intervention was designed to streamline ART services to 'stable' patients. Nevertheless, it is poorly understood exactly how and why and under what health system conditions the adherence club intervention works. Objectives The aim of this study was to test a theory on how and why the adherence club intervention works and in what health system context(s) in a primary healthcare facility in the Western Cape Province. Method Within the realist evaluation framework, we applied a confirmatory theory-testing case study approach. Kaplan-Meier descriptions were used to estimate the rates of dropout from the adherence club intervention and virological failure as the principal outcomes of the adherence club intervention. Qualitative interviews and non-participant observations were used to explore the context and identify the mechanisms that perpetuate the observed outcomes or behaviours of the actors. Following the retroduction logic of making inferences, we configured information obtained from quantitative and qualitative approaches using the intervention-context-actor-mechanism-outcome heuristic tool to formulate generative theories. Results We confirmed that patients on ART in adherence clubs will continue to adhere to their medication and remain in care because their self-efficacy is improved; they are motivated or are being nudged. Conclusion A theory-based understanding provides valuable lessons towards the adaptive implementation of the adherence club intervention.
Collapse
Affiliation(s)
| | - Brian van Wyk
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bruno Marchal
- School of Public Health, University of the Western Cape, Cape Town, South Africa.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| |
Collapse
|
20
|
Power J, Gilmore B, Vallières F, Toomey E, Mannan H, McAuliffe E. Adapting health interventions for local fit when scaling-up: a realist review protocol. BMJ Open 2019; 9:e022084. [PMID: 30679286 PMCID: PMC6347947 DOI: 10.1136/bmjopen-2018-022084] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 06/21/2018] [Accepted: 10/23/2018] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Scaling-up is essential to ensure universal access of effective health interventions. Scaling-up is a complex process, which occurs across diverse systems and contexts with no one-size-fits-all approach. To date, little attention has been paid to the process of scaling-up in how to make adaptations for local fit. The aim of this research is to develop theory on what actions can be used to make adaptations to health interventions for local fit when scaling-up across diverse contexts that will have practical application for implementers involved in scaling-up. METHODS AND ANALYSIS Given the complexity of this subject, a realist review methodology was selected. Specifically, realist review emphasises an iterative, non-linear process, whereby the review is refined as it progresses. The identification of how the context may activate mechanisms to achieve outcomes is used to generate theories on what works for whom in what circumstances. This protocol will describe the first completed stage of development of an initial programme theory framework, which identified potential actions, contexts, mechanisms and outcomes that could be used to make adaptations when scaling-up. It will then outline the methods for future stages of the review which will focus on identifying case examples of scale-up and adaptation in practice. This realist review consists of six stages: (i) clarifying scope and development of a theoretical framework, (ii) developing a search strategy, (iii) selection and appraisal, (iv) data extraction, (v) data synthesis and analysis and (vi) further theory refinement with stakeholders. ETHICS AND DISSEMINATION This review will develop theory on how adaptations can be made when scaling-up. Findings will be disseminated in a peer-reviewed journal and through stakeholder engagement as part of the research process. Ethical approval has been received through Health Policy and Management/Centre for Global Health Research Ethics Committee of Trinity College Dublin.
Collapse
Affiliation(s)
- Jessica Power
- Centre for Global Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Brynne Gilmore
- Centre for Global Health, School of Psychology, Trinity College, Dublin, Ireland
| | - Frédérique Vallières
- Centre for Global Health, School of Psychology, Trinity College, Dublin, Ireland
| | - Elaine Toomey
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Hasheem Mannan
- School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Eilish McAuliffe
- School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| |
Collapse
|
21
|
Mukumbang FC, van Wyk B, Van Belle S, Marchal B. Unravelling how and why the Antiretroviral Adherence Club Intervention works (or not) in a public health facility: A realist explanatory theory-building case study. PLoS One 2019; 14:e0210565. [PMID: 30650129 PMCID: PMC6334969 DOI: 10.1371/journal.pone.0210565] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 12/27/2018] [Indexed: 12/03/2022] Open
Abstract
Background Although empirical evidence suggests that the adherence club model is more effective in retaining people living with HIV in antiretroviral treatment care and sustaining medication adherence compared to standard clinic care, it is poorly understood exactly how and why this works. In this paper, we examined and made explicit how, why and for whom the adherence club model works at a public health facility in South Africa. Methods We applied an explanatory theory-building case study approach to examine the validity of an initial programme theory developed a priori. We collected data using a retrospective cohort quantitative design to describe the suppressive adherence and retention in care behaviours of patients on ART using Kaplan-Meier methods. In conjunction, we employed an explanatory qualitative study design using non-participant observations and realist interviews to gain insights into the important mechanisms activated by the adherence club intervention and the relevant contextual conditions that trigger the different mechanisms to cause the observed behaviours. We applied the retroduction logic to configure the intervention-context-actor-mechanism-outcome map to formulate generative theories. Results A modified programme theory involving targeted care for clinically stable adult patients (18 years+) receiving antiretroviral therapy was obtained. Targeted care involved receiving quick, uninterrupted supply of antiretroviral medication (with reduced clinic visit frequencies), health talks and counselling, immediate access to a clinician when required and guided by club rules and regulations within the context of adequate resources, and convenient (size and position) space and proper preparation by the club team. When grouped for targeted care, patients feel nudged, their self-efficacy is improved and they become motivated to adhere to their medication and remain in continuous care. Conclusion This finding has implications for understanding how, why and under what health system conditions the adherence club intervention works to improve its rollout in other contexts.
Collapse
Affiliation(s)
- Ferdinand C. Mukumbang
- School of Public Health, University of the Western Cape, Cape Town, South Africa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | - Brian van Wyk
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bruno Marchal
- School of Public Health, University of the Western Cape, Cape Town, South Africa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| |
Collapse
|
22
|
Mukumbang FC, Marchal B, Van Belle S, van Wyk B. "Patients Are Not Following the [Adherence] Club Rules Anymore": A Realist Case Study of the Antiretroviral Treatment Adherence Club, South Africa. QUALITATIVE HEALTH RESEARCH 2018; 28:1839-1857. [PMID: 30033857 PMCID: PMC6154254 DOI: 10.1177/1049732318784883] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
There is growing evidence that differentiated care models employed to manage treatment-experienced patients on antiretroviral therapy could improve adherence to medication and retention in care. We conducted a realist evaluation to determine how, why, for whom, and under what health system context the adherence club intervention works (or not) in real-life implementation. In the first phase, we developed an initial program theory of the adherence club intervention. In this study, we report on an explanatory theory-testing case study to test the initial theory. We conducted a retrospective cohort analysis and an explanatory qualitative study to gain insights into the important mechanisms activated by the adherence club intervention and the relevant context conditions that trigger the different mechanisms to achieve the observed outcomes. This study identified potential mitigating circumstances under which the adherence club program could be implemented, which could inform the rollout and implementation of the adherence club intervention.
Collapse
Affiliation(s)
- Ferdinand C. Mukumbang
- University of the Western Cape,
Bellville, South Africa
- The Institute of Tropical Medicine,
Antwerp, Belgium
| | - Bruno Marchal
- University of the Western Cape,
Bellville, South Africa
- The Institute of Tropical Medicine,
Antwerp, Belgium
| | | | - Brian van Wyk
- University of the Western Cape,
Bellville, South Africa
| |
Collapse
|
23
|
Mukumbang FC, Marchal B, Van Belle S, van Wyk B. A realist approach to eliciting the initial programme theory of the antiretroviral treatment adherence club intervention in the Western Cape Province, South Africa. BMC Med Res Methodol 2018; 18:47. [PMID: 29801467 PMCID: PMC5970495 DOI: 10.1186/s12874-018-0503-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 05/02/2018] [Indexed: 11/23/2022] Open
Abstract
Background The successful initiation of people living with HIV/AIDS on antiretroviral therapy (ART) in South Africa has engendered challenges of poor retention in care and suboptimal adherence to medication. The adherence club intervention was implemented in the Metropolitan area of the Western Cape Province to address these challenges. The adherence club programme has shown potential to relieve clinic congestion, improve retention in care and enhance treatment adherence in the context of rapidly growing HIV patient populations being initiated on ART. Nevertheless, how and why the adherence club intervention works is not clearly understood. We aimed to elicit an initial programme theory as the first phase of the realist evaluation of the adherence club intervention in the Western Cape Province. Methods The realist evaluation approach guided the elicitation study. First, information was obtained from an exploratory qualitative study of programme designers’ and managers’ assumptions of the intervention. Second, a document review of the design, rollout, implementation and outcome of the adherence clubs followed. Third, a systematic review of available studies on group-based ART adherence support models in Sub-Saharan Africa was done, and finally, a scoping review of social, cognitive and behavioural theories that have been applied to explain adherence to ART. We used the realist evaluation heuristic tool (Intervention-context-actors-mechanism-outcome) to synthesise information from the sources into a configurational map. The configurational mapping, alignment of a specific combination of attributes, was based on the generative causality logic – retroduction. Results We identified two alternative theories: The first theory supposes that patients become encouraged, empowered and motivated, through the adherence club intervention to remain in care and adhere to the treatment. The second theory suggests that stable patients on ART are being nudged through club rules and regulations to remain in care and adhere to the treatment with the goal to decongest the primary health care facilities. Conclusion The initial programme theory describes how (dynamics) and why (theories) the adherence club intervention is expected to work. By testing theories in “real intervention cases” using the realist evaluation approach, the theories can be modified, refuted and/or reconstructed to elicit a refined theory of how and why the adherence club intervention works. Electronic supplementary material The online version of this article (10.1186/s12874-018-0503-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ferdinand C Mukumbang
- School of Public Health, University of the Western Cape, Cape town, South Africa. .,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Bruno Marchal
- School of Public Health, University of the Western Cape, Cape town, South Africa.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Brian van Wyk
- School of Public Health, University of the Western Cape, Cape town, South Africa
| |
Collapse
|
24
|
Cleverley PH, Burnett S. Enterprise search and discovery capability: The factors and generative mechanisms for user satisfaction. J Inf Sci 2018. [DOI: 10.1177/0165551518770969] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many organisations are re-creating the ‘Google-like’ experience behind their firewall to exploit their information. However, surveys show dissatisfaction with enterprise search is commonplace. No prior study has investigated unsolicited user feedback from an enterprise search user interface to understand the underlying reasons for dissatisfaction. A mixed-methods longitudinal study was undertaken analysing feedback from over 1000 users and interviewing search service staff in a multinational corporation. Results show that 62% of dissatisfaction events were due to human (information and search literacy) rather than technology factors. Cognitive biases and the ‘Google Habitus’ influence expectations and information behaviour and are postulated as deep underlying generative mechanisms. The current literature focuses on ‘structure’ (technology and information quality) as the reason for enterprise search satisfaction, agency (search literacy) appears downplayed. Organisations which emphasise ‘systems thinking’ and bimodal approaches towards search strategy and information behaviour may improve capabilities.
Collapse
|
25
|
Unearthing how, why, for whom and under what health system conditions the antiretroviral treatment adherence club intervention in South Africa works: A realist theory refining approach. BMC Health Serv Res 2018; 18:343. [PMID: 29743067 PMCID: PMC5944119 DOI: 10.1186/s12913-018-3150-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/25/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Poor retention in care and suboptimal adherence to antiretroviral treatment (ART) undermine its successful rollout in South Africa. The adherence club intervention was designed as an adherence-enhancing intervention to enhance the retention in care of patients on ART and their adherence to medication. Although empirical evidence suggests the effective superiority of the adherence club intervention to standard clinic ART care schemes, it is poorly understood exactly how and why it works, and under what health system contexts. To this end, we aimed to develop a refined programme theory explicating how, why, for whom and under what health system contexts the adherence club intervention works (or not). METHODS We undertook a realist evaluation study to uncover the programme theory of the adherence club intervention. We elicited an initial programme theory of the adherence club intervention and tested the initial programme theory in three contrastive sites. Using a cross-case analysis approach, we delineated the conceptualisation of the intervention, context, actor and mechanism components of the three contrastive cases to explain the outcomes of the adherence club intervention, guided by retroductive inferencing. RESULTS We found that an intervention that groups clinically stable patients on ART in a convenient space to receive a quick and uninterrupted supply of medication, health talks, counselling, and immediate access to a clinician when required works because patients' self-efficacy improves and they become motivated and nudged to remain in care and adhere to medication. The successful implementation and rollout of the adherence club intervention are contingent on the separation of the adherence club programme from other patients who are HIV-negative. In addition, there should be available convenient space for the adherence club meetings, continuous support of the adherence club facilitators by clinicians and buy-in from the health workers at the health-care facility and the community. CONCLUSION Understanding what aspects of antiretroviral club intervention works, for what sections of the patient population, and under which community and health systems contexts, could inform guidelines for effective implementation in different contexts and scaling up of the intervention to improve population-level ART adherence.
Collapse
|
26
|
Richter N, Jackson P, Schildhauer T. Outsourcing creativity: An abductive study of open innovation using corporate accelerators. CREATIVITY AND INNOVATION MANAGEMENT 2017. [DOI: 10.1111/caim.12252] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Nancy Richter
- Alexander von Humboldt Institute for Internet and Society; Berlin Germany
| | | | - Thomas Schildhauer
- Alexander von Humboldt Institute for Internet and Society; Berlin Germany
| |
Collapse
|
27
|
Eastwood JG, Kemp LA, Jalaludin BB. Realist theory construction for a mixed method multilevel study of neighbourhood context and postnatal depression. SPRINGERPLUS 2016; 5:1081. [PMID: 27468381 PMCID: PMC4945545 DOI: 10.1186/s40064-016-2729-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 06/30/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND We have recently described a protocol for a study that aims to build a theory of neighbourhood context and postnatal depression. That protocol proposed a critical realist Explanatory Theory Building Method comprising of an: (1) emergent phase, (2) construction phase, and (3) confirmatory phase. A concurrent triangulated mixed method multilevel cross-sectional study design was described. The protocol also described in detail the Theory Construction Phase which will be presented here. METHODS The Theory Construction Phase will include: (1) defining stratified levels; (2) analytic resolution; (3) abductive reasoning; (4) comparative analysis (triangulation); (5) retroduction; (6) postulate and proposition development; (7) comparison and assessment of theories; and (8) conceptual frameworks and model development. THEORY CONSTRUCTION The stratified levels of analysis in this study were predominantly social and psychological. The abductive analysis used the theoretical frames of: Stress Process; Social Isolation; Social Exclusion; Social Services; Social Capital, Acculturation Theory and Global-economic level mechanisms. Realist propositions are presented for each analysis of triangulated data. Inference to best explanation is used to assess and compare theories. A conceptual framework of maternal depression, stress and context is presented that includes examples of mechanisms at psychological, social, cultural and global-economic levels. Stress was identified as a necessary mechanism that has the tendency to cause several outcomes including depression, anxiety, and health harming behaviours. The conceptual framework subsequently included conditional mechanisms identified through the retroduction including the stressors of isolation and expectations and buffers of social support and trust. CONCLUSION The meta-theory of critical realism is used here to generate and construct social epidemiological theory using stratified ontology and both abductive and retroductive analysis. The findings will be applied to the development of a middle range theory and subsequent programme theory for local perinatal child and family interventions.
Collapse
Affiliation(s)
- John G. Eastwood
- />Community Paediatrics, Sydney Local Health District, Croydon Community Health Centre, 24 Liverpool Road, Croydon, NSW 2132 Australia
- />School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia
- />School of Women’s and Children’s Health, The University of New South Wales, Sydney, NSW 2052 Australia
- />Ingham Institute of Applied Medicine, The University of New South Wales, Liverpool, NSW 2170 Australia
- />School of Public Health, The University of Sydney, Sydney, NSW 2006 Australia
- />School of Medicine, Griffith University, Gold Coast, QLD 4222 Australia
| | - Lynn A. Kemp
- />Ingham Institute of Applied Medicine, The University of New South Wales, Liverpool, NSW 2170 Australia
- />School of Nursing and Midwifery, Western Sydney University, Campbelltown, NSW 2560 Australia
| | - Bin B. Jalaludin
- />School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia
- />Ingham Institute of Applied Medicine, The University of New South Wales, Liverpool, NSW 2170 Australia
| |
Collapse
|
28
|
|
29
|
Eastwood JG, Kemp LA, Jalaludin BB. Being alone and expectations lost: a critical realist study of maternal depression in South Western Sydney. SPRINGERPLUS 2015; 4:700. [PMID: 26609502 PMCID: PMC4646882 DOI: 10.1186/s40064-015-1492-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 10/30/2015] [Indexed: 11/29/2022]
Abstract
The study reported here is part of a critical realist multilevel study. It seeks to identify and explain complex perinatal contextual social and psychosocial mechanisms that may influence the developmental origins of health and disease, with a focus on the role of postnatal depression. The aims of the greater study are to: (1) describe the phenomenon of postnatal depression in South Western Sydney; and (2) identify mechanisms that would add to our understanding of the psycho-social causes of maternal depression. This paper will move beyond our previous quantitative descriptions of individual-level predictors of depressive symptoms by seeking the views of local mothers and practitioners, to explain the mechanisms that might be involved. The study was set in South Western Sydney, New South Wales, Australia. An Explanatory Theory Building Method was used. The previously reported quantitative study was a non-linear principal component analysis and logistic regression study of 15,389 months delivering in 2002 and 2003. This intensive qualitative study used open coding of interviews, of seven practitioners and three naturally occurring mothers groups, to enable maximum emergence. The theoretical concepts identified were: attachment and nurturing, infant temperament, unplanned pregnancy and sole parenthood, support for mothers, access to services, stress, financial hardship, isolation and marginalisation, mothers' "loss of control" and "power", and expectations and dreams. Being alone and expectations lost emerged as possible triggers of stress and depression for mothers. These findings might also apply to others who have their dreams shattered during life's transitions. In these situations social and cultural context can either nurture and support or marginalise and isolate. The challenge for policy and practice is to support mothers and their partners during the transition to parenthood within a challenging social and material context.
Collapse
Affiliation(s)
- John G. Eastwood
- />Community Paediatrics, Sydney Local Health District, Croydon Community Health Centre, 24 Liverpool Road, Croydon, NSW 2132 Australia
- />School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia
- />School of Women’s and Children’s Health, The University of New South Wales, Sydney, NSW 2052 Australia
- />Ingham Institute of Applied Medicine, The University of New South Wales, Liverpool, NSW 2170 Australia
- />School of Public Health, The University of Sydney, Sydney, NSW 2006 Australia
- />School of Medicine, Griffith University, Gold Coast, QLD 4222 Australia
| | - Lynn A. Kemp
- />Ingham Institute of Applied Medicine, The University of New South Wales, Liverpool, NSW 2170 Australia
- />School of Nursing and Midwifery, Western Sydney University, Campbelltown, NSW 2560 Australia
| | - Bin B. Jalaludin
- />School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia
- />Ingham Institute of Applied Medicine, The University of New South Wales, Liverpool, NSW 2170 Australia
| |
Collapse
|
30
|
Eastwood JG, Jalaludin BB, Kemp LA, Phung HN. Bayesian hierarchical spatial regression of maternal depressive symptoms in South Western Sydney, Australia. SPRINGERPLUS 2014; 3:55. [PMID: 24555171 PMCID: PMC3921342 DOI: 10.1186/2193-1801-3-55] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 01/20/2014] [Indexed: 11/26/2022]
Abstract
Background There is increasing interest in the role played by maternal depression in mediating the effects of adversity during pregnancy and poor infant outcomes. There is also increasing evidence from multilevel regression studies for an association of area-level economic deprivation and poor individual mental health. The purpose of the study reported here is to explore the spatial distribution of postnatal depressive symptoms in South Western Sydney, Australia, and to identify covariate associations that could inform subsequent multilevel studies. Methods Mothers (n = 15,389) delivering in 2002 and 2003 were assessed at 2–3 weeks after delivery for risk factors for depressive symptoms. The individual-level binary outcome variables were Edinburgh Depression Scale (EDS) >9 and >12. The association between social, demographic and ecological factors and aggregated outcome variables were investigated using exploratory factor analysis and multivariate hierarchical Bayesian spatial regression. Relative risks from the final EDS >12 regression model were mapped to visualise the contribution from explanatory covariates and residual components. Results The exploratory factor analysis identified six factors: neighbourhood adversity, social cohesion, health behaviours, housing quality, social services, and support networks. Variables associated with neighbourhood adversity, social cohesion, social networks, and ethnic diversity were consistently associated with aggregated depressive symptoms. Measures of social disadvantage, lack of social cohesion and lack of social capital were associated with increased depressive symptoms. The association with social disadvantage was not significant when controlling for ethnic diversity and social capital. Conclusions The findings support the theoretical proposition that neighbourhood adversity causes maternal psychological distress and depression within the context of social buffers including social networks, social cohesion, and social services. The finding have implications for the distribution of health services including early nurse home visiting which has recently been confirmed to be effective in preventing postnatal depression. Electronic supplementary material The online version of this article (doi:10.1186/2193-1801-3-55) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- John G Eastwood
- Community Paediatrics, South Western Sydney Local Health District, Locked Mail Bag 7008, Liverpool, BC 1871 New South Wales Australia ; School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia ; School of Women's and Children's Health, The University of New South Wales, Sydney, NSW 2052 Australia ; School of Public Health, University of Sydney, Sydney, NSW 2006 Australia ; School of Public Health, Griffith University, Gold Coast, Queensland, 4222 Australia
| | - Bin B Jalaludin
- Community Paediatrics, South Western Sydney Local Health District, Locked Mail Bag 7008, Liverpool, BC 1871 New South Wales Australia ; School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia
| | - Lynn A Kemp
- Community Paediatrics, South Western Sydney Local Health District, Locked Mail Bag 7008, Liverpool, BC 1871 New South Wales Australia ; School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia
| | - Hai N Phung
- Community Paediatrics, South Western Sydney Local Health District, Locked Mail Bag 7008, Liverpool, BC 1871 New South Wales Australia ; School of Public Health and Community Medicine, The University of New South Wales, Sydney, NSW 2052 Australia ; School of Public Health, Griffith University, Gold Coast, Queensland, 4222 Australia
| |
Collapse
|
31
|
Eastwood J, Kemp L, Jalaludin B. Explaining ecological clusters of maternal depression in South Western Sydney. BMC Pregnancy Childbirth 2014; 14:47. [PMID: 24460690 PMCID: PMC3909479 DOI: 10.1186/1471-2393-14-47] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 01/08/2014] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The aim of the qualitative study reported here was to: 1) explain the observed clustering of postnatal depressive symptoms in South Western Sydney; and 2) identify group-level mechanisms that would add to our understanding of the social determinants of maternal depression. METHODS Critical realism provided the methodological underpinning for the study. The setting was four local government areas in South Western Sydney, Australia. Child and Family practitioners and mothers in naturally occurring mothers groups were interviewed. RESULTS Using an open coding approach to maximise emergence of patterns and relationships we have identified seven theoretical concepts that might explain the observed spatial clustering of maternal depression. The theoretical concepts identified were: Community-level social networks; Social Capital and Social Cohesion; "Depressed community"; Access to services at the group level; Ethnic segregation and diversity; Supportive social policy; and Big business. CONCLUSIONS We postulate that these regional structural, economic, social and cultural mechanisms partially explain the pattern of maternal depression observed in families and communities within South Western Sydney. We further observe that powerful global economic and political forces are having an impact on the local situation. The challenge for policy and practice is to support mothers and their families within this adverse regional and global-economic context.
Collapse
Affiliation(s)
- John Eastwood
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia
- Department of Community Paediatrics, South Western Sydney Local Health District, Locked Bag 7279, Liverpool BC, NSW 1871, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW 2052, Australia
- School of Public Health, University of Sydney, Sydney, NSW 2006, Australia
| | - Lynn Kemp
- Centre for Health Equity Training Research and Evaluation, University of New South Wales, Sydney, NSW 2052, Australia
| | - Bin Jalaludin
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia
| |
Collapse
|