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Ataman R, Ahmed S, Berta W, Thomas A. Collaborative sustainability planning for an outcome measure in outpatient stroke rehabilitation: A qualitative description study. J Eval Clin Pract 2024; 30:459-472. [PMID: 38254335 DOI: 10.1111/jep.13963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/07/2023] [Accepted: 12/31/2023] [Indexed: 01/24/2024]
Abstract
RATIONALE Evidence suggests that sustainability planning and the use of a collaborative approach to planning result in better sustainability outcomes and more relevant knowledge. Yet, both approaches appear to be underutilized. A detailed description of collaborative sustainability planning may encourage the use of these two impactful strategies. AIMS AND OBJECTIVES To explore the collaborative sustainability planning process for a single outcome measure in three rehabilitation sites. METHODOLOGY Within the Mayo-Portland Adaptability Inventory-version 4 (MPAI-4) implementation project, we conducted a qualitative description study. We used data from 12 core sustainability planning meetings and 108 follow-up meetings that included a total of 31 clinical and research team participants. Sustainability planning was informed by an MPAI-4-specific implementation guide, and by the results from a realist review of the sustainability of rehabilitation practices and the Clinical Sustainability Assessment Tool. We analyzed qualitative data using thematic content analysis. RESULTS Three themes describe the collaborative sustainability planning process: (1) "collaboration as a driver for sustainability" which captures the active collaboration underpinning sustainability planning; (2) "co-creation of a sustainability plan to achieve shared objectives" which captures the identified barriers and facilitators, and selected sustainability strategies linked to one of six collaboratively identified shared objectives; and (3) "the iterative nature of sustainability planning" which captures the necessity of an agile and responsive sustainability planning process. CONCLUSION Identified strategies may be useful to support (collaborative) sustainment. Future research could investigate the effect of collaborative sustainability planning on sustainability objectives, and the relationship between these objectives.
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Affiliation(s)
- Rebecca Ataman
- School of Physical and Occupational Therapy, McGill University, Montréal, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montréal, Montréal, Québec, Canada
| | - Sara Ahmed
- School of Physical and Occupational Therapy, McGill University, Montréal, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montréal, Montréal, Québec, Canada
- Clinical Epidemiology, Center for Outcome Research and Evaluation (CORE), McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | - Whitney Berta
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Aliki Thomas
- School of Physical and Occupational Therapy, McGill University, Montréal, Québec, Canada
- Centre for Interdisciplinary Research in Rehabilitation of Greater Montréal, Montréal, Québec, Canada
- Institute of Health Sciences Education, McGill University, Montréal, Québec, Canada
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Ogu UU, Ebenso B, Mirzoev T, Uguru N, Etiaba E, Uzochukwu B, Ezumah N, Onwujekwe O. Demand and supply analysis for maternal and child health services at the primary healthcare level in Nigeria. BMC Health Serv Res 2023; 23:1280. [PMID: 37990190 PMCID: PMC10664650 DOI: 10.1186/s12913-023-10210-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 10/25/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND The low demand for maternal and child health services is a significant factor in Nigeria's high maternal death rate. This paper explores demand and supply-side determinants at the primary healthcare level, highlighting factors affecting provision and utilization. METHODS This qualitative study was undertaken in Anambra state, southeast Nigeria. Anambra state was purposively chosen because a maternal and child health programme had just been implemented in the state. The three-delay model was used to analyze supply and demand factors that affect MCH services and improve access to care for pregnant women/mothers and newborns/infants. RESULT The findings show that there were problems with both the demand and supply aspects of the programme and both were interlinked. For service users, their delays were connected to the constraints on the supply side. On the demand side, the delays include poor conditions of the facilities, the roads to the facilities are inaccessible, and equipment were lacking in the facilities. These delayed the utilisation of facilities. On the supply side, the delays include the absence of security (fence, security guard), poor citing of the facilities, inadequate accommodation, no emergency transport for referrals, and lack of trained staff to man equipment. These delayed the provision of services. CONCLUSION Our findings show that there were problems with both the demand and supply aspects of the programme, and both were interlinked. For service users, their delays were connected to the constraints on the supply side.
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Affiliation(s)
- Udochukwu U Ogu
- Department of Pharmacology and Therapeutics, College of Medicine, Health Policy Research Group, University of Nigeria, Enugu, 400001, Nigeria.
| | | | - Tolib Mirzoev
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nkolika Uguru
- Department of Pharmacology and Therapeutics, College of Medicine, Health Policy Research Group, University of Nigeria, Enugu, 400001, Nigeria
- Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, 400001, Nigeria
- Faculty of Dentistry, College of Medicine, University of Nigeria, Enugu, 400001, Nigeria
| | - Enyi Etiaba
- Department of Pharmacology and Therapeutics, College of Medicine, Health Policy Research Group, University of Nigeria, Enugu, 400001, Nigeria
- Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, 400001, Nigeria
| | - Benjamin Uzochukwu
- Department of Pharmacology and Therapeutics, College of Medicine, Health Policy Research Group, University of Nigeria, Enugu, 400001, Nigeria
- Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, 400001, Nigeria
| | - Nkoli Ezumah
- Department of Pharmacology and Therapeutics, College of Medicine, Health Policy Research Group, University of Nigeria, Enugu, 400001, Nigeria
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, College of Medicine, Health Policy Research Group, University of Nigeria, Enugu, 400001, Nigeria
- Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, 400001, Nigeria
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Wang R, Rouleau G, Booth GL, Brazeau AS, El-Dassouki N, Taylor M, Cafazzo JA, Greenberg M, Nakhla M, Shulman R, Desveaux L. Understanding Whether and How a Digital Health Intervention Improves Transition Care for Emerging Adults Living With Type 1 Diabetes: Protocol for a Mixed Methods Realist Evaluation. JMIR Res Protoc 2023; 12:e46115. [PMID: 37703070 PMCID: PMC10534286 DOI: 10.2196/46115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/27/2023] [Accepted: 07/24/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Emerging adults living with type 1 diabetes (T1D) face a series of challenges with self-management and decreased health system engagement, leading to an increased risk of acute complications and hospital admissions. Effective and scalable strategies are needed to support this population to transfer seamlessly from pediatric to adult care with sufficient self-management capability. While digital health interventions for T1D self-management are a promising strategy, it remains unclear which elements work, how, and for which groups of individuals. OBJECTIVE This study aims to evaluate the design and implementation of a multicomponent SMS text message-based digital health intervention to support emerging adults living with T1D in real-world settings. The objectives are to identify the intervention components and associated mechanisms that support user engagement and T1D health care transition experiences and determine the individual characteristics that influence the implementation process. METHODS We used a realist evaluation embedded alongside a randomized controlled trial, which uses a sequential mixed methods design to analyze data from multiple sources, including intervention usage data, patient-reported outcomes, and realist interviews. In step 1, we conducted a document analysis to develop a program theory that outlines the hypothesized relationships among "individual-level contextual factors, intervention components and features, mechanisms, and outcomes," with special attention paid to user engagement. Among them, intervention components and features depict 10 core characteristics such as transition support information, problem-solving information, and real-time interactivity. The proximal outcomes of interest include user engagement, self-efficacy, and negative emotions, whereas the distal outcomes of interest include transition readiness, self-blood glucose monitoring behaviors, and blood glucose. In step 2, we plan to conduct semistructured realist interviews with the randomized controlled trial's intervention-arm participants to test the hypothesized "context-intervention-mechanism-outcome" configurations. In step 3, we plan to triangulate all sources of data using a coincidence analysis to identify the necessary combinations of factors that determine whether and how the desired outcomes are achieved and use these insights to consolidate the program theory. RESULTS For step 1 analysis, we have developed the initial program theory and the corresponding data collection plan. For step 2 analysis, participant enrollment for the randomized controlled trial started in January 2023. Participant enrollment for this realist evaluation was anticipated to start in July 2023 and continue until we reached thematic saturation or achieved informational power. CONCLUSIONS Beyond contributing to knowledge on the multiple pathways that lead to successful engagement with a digital health intervention as well as target outcomes in T1D care transitions, embedding the realist evaluation alongside the trial may inform real-time intervention refinement to improve user engagement and transition experiences. The knowledge gained from this study may inform the design, implementation, and evaluation of future digital health interventions that aim to improve transition experiences. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/46115.
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Affiliation(s)
- Ruoxi Wang
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Geneviève Rouleau
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada
- Département des Sciences Infirmières, Université du Québec en Outaouais, St-Jérôme, QC, Canada
- Faculté des sciences infirmières, l'Université de Montréal, Montreal, QC, Canada
| | - Gillian Lynn Booth
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | - Noor El-Dassouki
- Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Madison Taylor
- Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Joseph A Cafazzo
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Centre for Digital Therapeutics, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
| | - Marley Greenberg
- Department of Philosophy, Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
- Diabetes Action Canada, Toronto, ON, Canada
| | - Meranda Nakhla
- Division of Endocrinology, Montreal Children's Hospital, McGill University, Montréal, QC, Canada
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Rayzel Shulman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- Division of Endocrinology, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Laura Desveaux
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Tougri H, Compaoré R, Ouédraogo AM, Bila B, Temmerman M, Kouanda S. Community health workers' involvement in mother-child care during the 1st year after birth, in Kaya health district, Burkina Faso: A contribution analysis. Front Public Health 2023; 10:938967. [PMID: 36711332 PMCID: PMC9875076 DOI: 10.3389/fpubh.2022.938967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 12/23/2022] [Indexed: 01/12/2023] Open
Abstract
Introduction Maternal and infant morbidity and mortality remain high in sub-Saharan Africa. However, actions to strengthen postpartum care are still weak and mainly limited to health facilities (HFs). In Kaya health district, Burkina Faso, community health workers (CHWs) were involved in mother and child care during the 1st year postpartum through home visits, outreach sessions and accompanying mothers to health facilities. The aim of this study was to assess the contribution of CHWs to postpartum women's attendance at the health facilities. Methods We conducted an effect assessment using Mayne and Lemire's contribution analysis framework. Qualitative and quantitative data were collected through project documents review and individual semi-structured interviews with key-informants. Results All the participants interviewed acknowledged that the number of women, who came to postpartum care, had increased since the implementation of the project activities. Postpartum consultation rates within the 1st week postpartum increased from 29% in 2011 to 80% in 2015 and from 19 to 50% within 6 weeks. Others interventions such as Performance based financing, Save The Children nutritional project and the health services component of Missed Opportunities in Mother and Infant Health (MOMI) were the alternative explanations. Conclusions CHWs involvement in women care contributed to improve their adherence to postpartum consultations in Kaya health district.
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Affiliation(s)
- Halima Tougri
- Département Biomedical/Santé Publique, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso,*Correspondence: Halima Tougri ✉ ; ✉
| | - Rachidatou Compaoré
- Département Biomedical/Santé Publique, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | - Adja Mariam Ouédraogo
- Département Biomedical/Santé Publique, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | - Blandine Bila
- Département Biomedical/Santé Publique, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | - Marleen Temmerman
- International Centre for Reproductive Health (ICRH) Ghent University, Ghent, Belgium,Aga Khan University, Nairobi, Kenya
| | - Séni Kouanda
- Département Biomedical/Santé Publique, Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso,Département d'Épidémiologie, Institut Africain de Santé Publique (IASP), Ouagadougou, Burkina Faso
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Etuknwa A, Daniels K, Nayani R, Eib C. Sustainable Return to Work for Workers with Mental Health and Musculoskeletal Conditions. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1057. [PMID: 36673814 PMCID: PMC9859362 DOI: 10.3390/ijerph20021057] [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: 10/28/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 06/17/2023]
Abstract
Common mental health and musculoskeletal disorders (CMDs and MSDs) are two of the most significant causes of non-participation in employment amongst working age adults. BACKGROUND This case study fills an important gap in the scientific literature on reintegration back to work after sickness absence due to CMDs and MSDs. It particularly examines the return to work (RTW) experiences of sick-listed employees to understand the facilitators and barriers of sustainable RTW. METHODS Using a realist evaluation approach within a qualitative inquiry, perceptions of employees were explored to provide in-depth understanding of what, how and under what circumstances sustainable RTW can be enabled for employees absent on a short- or long-term basis. Repeat face-to-face semi-structured interviews were conducted with 22 participants (15 women and 7 men, aged 30-50 years and sick-listed with MSDs and CMDs) who were recruited using purposive sampling. Data was thematically analysed. RESULTS A total of 2 main codes and 5 subcodes were developed and grouped into three theoretical abstractions. As a result of validating the context, mechanism, and outcome configurations with accounts of participants, all three initial theories explaining the most prominent mechanisms that either facilitates or impedes a sustainable RTW for people with CMDs and MSDs were justified. CONCLUSIONS Our findings reveal the active role of line managers on the RTW outcomes of returning employees. However, line-manager's competence and ability to effectively support and implement appropriate RTW strategies suited to employees' hinges on working in alignment with key stakeholders and returning employees.
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Affiliation(s)
| | - Kevin Daniels
- Norwich Research Park, Norwich Business School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Rachel Nayani
- Norwich Research Park, Norwich Business School, University of East Anglia, Norwich NR4 7TJ, UK
| | - Constanze Eib
- Department of Psychology, Uppsala University, 752 36 Uppsala, Sweden
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Abstract
Focus groups are valuable tools for evaluators to help stakeholders to clarify programme theories. In 1987, R.K. Merton, often attributed with the birth of focus groups, wrote about how these were 'being mercilessly misused'. In the 1940s, his team had conceived focus groups as tools for developing middle-range theory, but through their astonishing success focus groups have metamorphosed and are often an 'unchallenged' choice in many evaluation approaches, while their practice seems to provide a philosophically diverse picture. This article examines what knowledge focus group data generate, and how they support theory development. It starts with an overview of the history of focus groups, establishing a relationship between their emergence as a data collection method and the evaluation profession. Practical lessons for conducting groups in realist evaluation are suggested, while exploring how qualitative data can support programme and middle-range theory development using the example of realist evaluation.
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Affiliation(s)
- Ana Manzano
- Ana Manzano, School of Sociology
and Social Policy, University of Leeds, Social Sciences Building,
Leeds LS9 2JT, UK.
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Uzochukwu B, Mirzoev T, Okeke C, Hicks J, Etiaba E, Obi U, Ensor T, Uzochukwu A, Onwujekwe O. Did an Intervention Programme Aimed at Strengthening the Maternal and Child Health Services in Nigeria Improve the Completeness of Routine Health Data Within the Health Management Information System? Int J Health Policy Manag 2022; 11:937-946. [PMID: 33327687 PMCID: PMC9808167 DOI: 10.34172/ijhpm.2020.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 11/04/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND During 2012-2015, the Federal Government of Nigeria launched the Subsidy Reinvestment and Empowerment Programme, a health system strengthening (HSS) programme with a Maternal and Child Health component (Subsidy Reinvestment and Empowerment Programme [SURE-P]/MCH), which was monitored using the Health Management Information Systems (HMIS) data reporting tools. Good quality data is essential for health policy and planning decisions yet, little is known on whether and how broad health systems strengthening programmes affect quality of data. This paper explores the effects of the SURE-P/MCH on completeness of MCH data in the National HMIS. METHODS This mixed-methods study was undertaken in Anambra state, southeast Nigeria. A standardized proforma was used to collect facility-level data from the facility registers on MCH services to assess the completeness of data from 2 interventions and one control clusters. The facility data was collected to cover before, during, and after the SURE-P intervention activities. Qualitative in-depth interviews were conducted with purposefully-identified health facility workers to identify their views and experiences of changes in data quality throughout the above 3 periods. RESULTS Quantitative analysis of the facility data showed that data completeness improved substantially, starting before SURE-P and continuing during SURE-P but across all clusters (ie, including the control). Also health workers felt data completeness were improved during the SURE-P, but declined with the cessation of the programme. We also found that challenges to data completeness are dependent on many variables including a high burden on providers for data collection, many variables to be filled in the data collection tools, and lack of health worker incentives. CONCLUSION Quantitative analysis showed improved data completeness and health workers believed the SURE-P/MCH had contributed to the improvement. The functioning of national HMIS are inevitably linked with other health systems components. While health systems strengthening programmes have a great potential for improved overall systems performance, a more granular understanding of their implications on the specific components such as the resultant quality of HMIS data, is needed.
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Affiliation(s)
- Benjamin Uzochukwu
- Department of Community Medicine, College of Medicine, University of Nigeria (Enugu Campus), Nsukka, Nigeria
| | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Chinyere Okeke
- Department of Community Medicine, College of Medicine, University of Nigeria (Enugu Campus), Nsukka, Nigeria
| | - Joseph Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Enyi Etiaba
- Department of Health Administration and Management, College of Medicine, University of Nigeria (Enugu Campus), Nsukka, Nigeria
| | - Uche Obi
- Department of Community Medicine, College of Medicine, University of Nigeria (Enugu Campus), Nsukka, Nigeria
| | - Tim Ensor
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Adaora Uzochukwu
- Department of Management, University of Nigeria (Enugu Campus), Nsukka, Nigeria
| | - Obinna Onwujekwe
- Department of Health Administration and Management, College of Medicine, University of Nigeria (Enugu Campus), Nsukka, Nigeria
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García-Zapata LM, Alarcón-Gil MT. Mecanismos de evaluaciones realistas en intervenciones de atención primaria en salud en poblaciones rurales y urbanas marginales. Rev Panam Salud Publica 2022; 46:e27. [PMID: 35432499 PMCID: PMC9004694 DOI: 10.26633/rpsp.2022.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 01/27/2022] [Indexed: 11/24/2022] Open
Abstract
Objetivo.
Identificar los mecanismos reportados en intervenciones de atención primaria en salud (APS) en poblaciones rurales y urbanas marginales entre los años 1997 y 2019.
Métodos.
Se utilizó el método de revisión sistemática exploratoria para identificar la literatura. La búsqueda de literatura fue realizada en las bases de datos Medline (Pubmed y Ovid), Global health, Embase, Web of science, Scopus y Lilacs. La inclusión de literatura consideró estudios de intervención primaria, observacionales con metodologías cualitativas, cuantitativas o mixtas. Se incluyeron artículos en inglés, portugués y español publicados entre 1997 y 2019. Para la selección de documentos definitivos se utilizó Rayyan QCRI, se excluyeron fuentes de información de literatura gris o investigación en progreso.
Resultados.
A nivel individual se identificaron tres grupos de mecanismos: niveles de relaciones entre las intervenciones y los sujetos, transformaciones que pueden generar en los individuos y las relaciones recíprocas. A nivel institucional se relacionaron con la temporalidad, el dinero, relaciones de poder, relaciones de confianza, el sistema de salud, las expectativas y las condiciones administrativas.
Conclusiones.
Los mecanismos individuales son similares en los diferentes contextos, los mecanismos institucionales son susceptibles a la variación del contexto, se representan en la temporalidad, recursos económicos, relaciones de poder y de confianza, el sistema de salud, las expectativas y condiciones administrativas.
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Mbachu C, Etiaba E, Ebenso B, Ogu U, Onwujekwe O, Uzochukwu B, Manzano A, Mirzoev T. Village health worker motivation for better performance in a maternal and child health programme in Nigeria: A realist evaluation. J Health Serv Res Policy 2022; 27:222-231. [PMID: 35089105 PMCID: PMC9277337 DOI: 10.1177/13558196211055323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Community health workers play an important role in linking communities with
formal health service providers, thereby improving access to and utilization
of health care. A novel cadre of community health workers known as village
health workers (VHWs) were recruited to create demand for maternal health
services in the Nigerian Subsidy Reinvestment Programme (SURE-P/MCH). In
this study, we investigated the role of contextual factors and underlying
mechanisms motivating VHWs. Methods We used realist evaluation to understand the impact of a multi-intervention
maternal and child health programme on VHW motivation using Anambra State as
a case study. Initial working theories and logic maps were developed through
literature review and stakeholder engagement; programme theories were
developed and tested using focus group discussions and in-depth interviews
with various stakeholder groups. Interview transcripts were analysed through
an integrated approach of Context, Mechanism and Outcomes (CMO)
categorisation and connecting, and matching of patterns of CMO
configurations. Motivation theories were used to explain factors that
influence VHW motivation. Explanatory configurations are reported in line
with RAMESES reporting standards. Results The performance of VHWs in the SURE-P maternal and child health programme was
linked to four main mechanisms of motivation: feelings of confidence, sense
of identity or feeling of acceptance, feeling of happiness and
hopefulness/expectation of valued outcome. These mechanisms were triggered
by interactions of programme-specific contexts and resources such as
training and supervision of VHWs by skilled health workers, provision of
first aid kits and uniforms, and payments of a monthly stipend. The monthly
payment was considered to be the most important motivational factor by VHWs.
VHWs used a combination of innovative approaches to create demand for
maternity services among pregnant women, and their performance was
influenced by health system factors such as organisational capacity and
culture, and societal factors such as relationship with the community and
community support. Conclusion This paper highlights important contextual factors and mechanisms for VHW
motivation that can be applied to other interventions that seek to
strengthen community engagement and demand creation in primary health care.
Future research on how to sustain VHW motivation is also required.
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Affiliation(s)
- Chinyere Mbachu
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Enyi Etiaba
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Bassey Ebenso
- School of Sociology and Social Policy, 150514University of Leeds, Leeds, UK
| | - Udochukwu Ogu
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Benjamin Uzochukwu
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Ana Manzano
- School of Sociology and Social Policy, 150514University of Leeds, Leeds, UK
| | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, 150514University of Leeds, Leeds, UK.,Faculty of Public Health and Policy, 150514London School of Hygiene & Tropical Medicine, London, UK
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Freeland L, O’Reilly M, Fleury J, Adams S, Vostanis P. Digital Social and Emotional Literacy Intervention for Vulnerable Children in Brazil: Participants’ Experiences. INTERNATIONAL JOURNAL OF MENTAL HEALTH PROMOTION 2022. [DOI: 10.32604/ijmhp.2022.015706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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11
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Eruyar S, Haffejee S, Anderson ES, Vostanis P. Implementation of child mental health service improvement plans in four low- and middle-income countries: stakeholders' perspectives. J Interprof Care 2021:1-8. [PMID: 34657552 DOI: 10.1080/13561820.2021.1982881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/26/2021] [Accepted: 09/11/2021] [Indexed: 10/20/2022]
Abstract
Children in low- and middle-income countries (LMIC) have high levels of unmet mental health needs, especially in disadvantaged communities. To address this gap, we developed a child mental health service improvement programme. This was co-facilitated using interprofessional principles and values in four countries, South Africa, Kenya, Turkey and Brazil. Eighteen stakeholders from different professions were interviewed after six months on their perspectives on enabling factors and challenges they faced in implementing service plans. Participants valued the holistic case management approach and scaled service model that underpinned the service plans. Emerging themes on participants' priorities related to service user participation, integrated care, and different levels of capacity-building. We propose that an integrated care model in LMIC contexts can maximize available resources, engage families and mobilize communities. Implementation requires concurrent actions at micro-, meso- and macro-level.
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Affiliation(s)
- Seyda Eruyar
- Department of Psychology, Necmettin Erbakan University, Konya, Turkey
| | - Sadiyya Haffejee
- Centre for Social Development in Africa, University of Johannesburg, Johannesburg, South Africa
| | - E S Anderson
- School of Medicine, University of Leicester, Leicester, UK
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12
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Adedeji T, Fraser H, Scott P. Implementing Electronic Health Records in Primary Care Using the Theory of Change: A Nigerian Case Study (Preprint). JMIR Med Inform 2021; 10:e33491. [PMID: 35969461 PMCID: PMC9412900 DOI: 10.2196/33491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 03/25/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Objective Methods Results Conclusions
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Affiliation(s)
- Taiwo Adedeji
- School of Computing, University of Portsmouth, Portsmouth, United Kingdom
| | - Hamish Fraser
- Brown Center for Biomedical Informatics, Brown University, Providence, RI, United States
| | - Philip Scott
- Institute of Management and Health, University of Wales Trinity Saint David, Carmarthen, United Kingdom
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13
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Ezenwaka U, Manzano A, Onyedinma C, Ogbozor P, Agbawodikeizu U, Etiaba E, Ensor T, Onwujekwe O, Ebenso B, Uzochukwu B, Mirzoev T. Influence of Conditional Cash Transfers on the Uptake of Maternal and Child Health Services in Nigeria: Insights From a Mixed-Methods Study. Front Public Health 2021; 9:670534. [PMID: 34307277 PMCID: PMC8297950 DOI: 10.3389/fpubh.2021.670534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Increasing access to maternal and child health (MCH) services is crucial to achieving universal health coverage (UHC) among pregnant women and children under-five (CU5). The Nigerian government between 2012 and 2015 implemented an innovative MCH programme to reduce maternal and CU5 mortality by reducing financial barriers of access to essential health services. The study explores how the implementation of a financial incentive through conditional cash transfer (CCT) influenced the uptake of MCH services in the programme. Methods: The study used a descriptive exploratory approach in Anambra state, southeast Nigeria. Data was collected through qualitative [in-depth interviews (IDIs), focus group discussions (FGDs)] and quantitative (service utilization data pre- and post-programme) methods. Twenty-six IDIs were conducted with respondents who were purposively selected to include frontline health workers (n = 13), National and State policymakers and programme managers (n = 13). A total of sixteen FGDs were conducted with service users and their family members, village health workers, and ward development committee members from four rural communities. We drew majorly upon Skinner's reinforcement theory which focuses on human behavior in our interpretation of the influence of CCT in the uptake of MCH services. Manual content analysis was used in data analysis to pull together core themes running through the entire data set. Results: The CCTs contributed to increasing facility attendance and utilization of MCH services by reducing the financial barrier to accessing healthcare among pregnant women. However, there were unintended consequences of CCT which included a reduction in birth spacing intervals, and a reduction of trust in the health system when the CCT was suddenly withdrawn by the government. Conclusion: CCT improved the utilization of MCH, but the sudden withdrawal of the CCT led to the opposite effect because people were discouraged due to lack of trust in government to keep using the MCH services. Understanding the intended and unintended outcomes of CCT will help to build sustainable structures in policy designs to mitigate sudden programme withdrawal and its subsequent effects on target beneficiaries and the health system at large.
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Affiliation(s)
- Uchenna Ezenwaka
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu, Nsukka, Nigeria
| | - Ana Manzano
- School of Sociology and Social Policy, University of Leeds, Leeds, United Kingdom
| | - Chioma Onyedinma
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Pamela Ogbozor
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Uju Agbawodikeizu
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Enyi Etiaba
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu, Nsukka, Nigeria
| | - Tim Ensor
- Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu, Nsukka, Nigeria
| | - Bassey Ebenso
- Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Benjamin Uzochukwu
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Tolib Mirzoev
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Mirzoev T, Etiaba E, Ebenso B, Uzochukwu B, Ensor T, Onwujekwe O, Huss R, Ezumah N, Manzano A. Tracing theories in realist evaluations of large-scale health programmes in low- and middle-income countries: experience from Nigeria. Health Policy Plan 2021; 35:1244-1253. [PMID: 33450765 PMCID: PMC7810445 DOI: 10.1093/heapol/czaa076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2020] [Indexed: 11/19/2022] Open
Abstract
Realist evaluations (RE) are increasingly popular in assessing health programmes in low- and middle-income countries (LMICs). This article reflects on processes of gleaning, developing, testing, consolidating and refining two programme theories (PTs) from a longitudinal mixed-methods RE of a national maternal and child health programme in Nigeria. The two PTs, facility security and patient–provider trust, represent complex and diverse issues: trust is all encompassing although less tangible, while security is more visible. Neither PT was explicit in the original programme design but emerged from the data and was supported by substantive theories. For security, we used theories of fear of crime, which perceive security as progressing from structural, political and socio-economic factors. Some facilities with the support of communities erected fences, improved lighting and employed guards, which altogether contributed to reduced fear of crime from staff and patients and improved provision and uptake of health care. The social theories for the trust PT were progressively selected to disentangle trust-related micro, meso and macro factors from the deployment and training of staff and conditional cash transfers to women for service uptake. We used taxonomies of trust factors such as safety, benevolent concerns and capability. We used social capital theory to interpret the sustainability of ‘residual’ trust after the funding for the programme ceased. Our overarching lesson is that REs are important though time-consuming ways of generating context-specific implications for policy and practice within ever-changing contexts of health systems in LMICs. It is important to ensure that PTs are ‘pitched at the right level’ of abstraction. The resource-constrained context of LMICs with insufficient documentation poses challenges for the timely convergence of nuggets of evidence to inform PTs. A retroductive approach to REs requires iterative data collection and analysis against the literature, which require continuity, coherence and shared understanding of the analytical processes within collaborative REs.
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Affiliation(s)
- Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds, Level 10 Worsley Building, Clarendon Way, LS2 9NL, Leeds, UK
| | - Enyi Etiaba
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Old UNTH Road, Ogbete, Enugu State, Nigeria
| | - Bassey Ebenso
- Nuffield Centre for International Health and Development, University of Leeds, Level 10 Worsley Building, Clarendon Way, LS2 9NL, Leeds, UK
| | - Benjamin Uzochukwu
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Old UNTH Road, Ogbete, Enugu State, Nigeria
| | - Tim Ensor
- Nuffield Centre for International Health and Development, University of Leeds, Level 10 Worsley Building, Clarendon Way, LS2 9NL, Leeds, UK
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Old UNTH Road, Ogbete, Enugu State, Nigeria
| | - Reinhard Huss
- Nuffield Centre for International Health and Development, University of Leeds, Level 10 Worsley Building, Clarendon Way, LS2 9NL, Leeds, UK
| | - Nkoli Ezumah
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Old UNTH Road, Ogbete, Enugu State, Nigeria
| | - Ana Manzano
- University of Leeds, School of Sociology & Social Policy, Social Sciences Building, Leeds LS2 9JT, UK
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15
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Mirzoev T, Cronin de Chavez A, Manzano A, Agyepong IA, Ashinyo ME, Danso-Appiah A, Gyimah L, Yevoo L, Awini E, Ha BTT, Do Thi Hanh T, Nguyen QCT, Le TM, Le VT, Hicks JP, Wright JM, Kane S. Protocol for a realist synthesis of health systems responsiveness in low-income and middle-income countries. BMJ Open 2021; 11:e046992. [PMID: 34112643 PMCID: PMC8194331 DOI: 10.1136/bmjopen-2020-046992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Health systems responsiveness is a key objective of any health system, yet it is the least studied of all objectives particularly in low-income and middle-income countries. Research on health systems responsiveness highlights its multiple elements, for example, dignity and confidentiality. Little is known, however, about underlying theories of health systems responsiveness, and the mechanisms through which responsiveness works. This realist synthesis contributes to bridging these two knowledge gaps. METHODS AND ANALYSIS In this realist synthesis, we will use a four-step process, comprising: mapping of theoretical bases, formulation of programme theories, theory refinement and testing of programme theories using literature and empirical data from Ghana and Vietnam. We will include theoretical and conceptual pieces, reviews, empirical studies and grey literature, alongside the primary data. We will explore responsiveness as entailing external and internal interactions within health systems. The search strategy will be purposive and iterative, with continuous screening and refinement of theories. Data extraction will be combined with quality appraisal, using appropriate tools. Each fragment of evidence will be appraised as it is being extracted, for its relevance to the emerging programme theories and methodological rigour. The extracted data pertaining to contexts, mechanisms and outcomes will be synthesised to identify patterns and contradictions. Results will be reported using narrative explanations, following established guidance on realist syntheses. ETHICS AND DISSEMINATION Ethics approvals for the wider RESPONSE (Improving health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam) study, of which this review is one part, were obtained from the ethics committees of the following institutions: London School of Hygiene and Tropical Medicine (ref: 22981), University of Leeds, School of Medicine (ref: MREC19-051), Ghana Health Service (ref: GHS-ERC 012/03/20) and Hanoi University of Public Health (ref: 020-149/DD-YTCC).We will disseminate results through academic papers, conference presentations and stakeholder workshops in Ghana and Vietnam. PROSPERO REGISTRATION NUMBER CRD42020200353. Full record: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020200353.
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Affiliation(s)
- Tolib Mirzoev
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Cronin de Chavez
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Ana Manzano
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Irene Akua Agyepong
- Research and Development Division, Ghana Health Service, Accra, Greater Accra, Ghana
| | - Mary Eyram Ashinyo
- Department of Quality Assurance, Institutional Care Directorate, Ghana Health Service, Accra, Ghana
| | | | | | - Lucy Yevoo
- Research and Development Division, Ghana Health Service, Accra, Greater Accra, Ghana
| | - Elizabeth Awini
- Research and Development Division, Ghana Health Service, Accra, Greater Accra, Ghana
| | - Bui Thi Thu Ha
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | - Trang Do Thi Hanh
- Department of Environmental Health, Hanoi University of Public Health, Hanoi, Viet Nam
| | | | - Thi Minh Le
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | - Vui Thi Le
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | - Joseph Paul Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Judy M Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Sumit Kane
- Nossal Institute for Global Health, University of Melbourne Queen's College, Parkville, Victoria, Australia
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Okeke C, Manzano A, Obi U, Etiaba E, Onwujekwe O, Mirzoev T, Uzochukwu B. Exploring mechanisms that explain how coalition groups are formed and how they work to sustain political priority for maternal and child health in Nigeria using the advocacy coalition framework. Health Res Policy Syst 2021; 19:26. [PMID: 33648536 PMCID: PMC7923834 DOI: 10.1186/s12961-020-00660-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 11/12/2020] [Indexed: 11/22/2022] Open
Abstract
Background The unacceptably high rate of maternal and child mortality in Nigeria prompted the government to introduce a free maternal and child health (MCH) programme, which was stopped abruptly following a change in government. This triggered increased advocacy for sustaining MCH as a political priority in the country and led to the formation of advocacy coalitions. This study set out to explain the process involved in the formation of advocacy coalition groups and how they work to bring about sustained political prioritization for MCH in Nigeria. It will contribute to the understanding of the Nigerian MCH sector subsystem and will be beneficial to health policy advocates and public health researchers in Nigeria. Methods This study employed a qualitative case study approach. Data were collected using a pretested interview guide to conduct 22 in-depth interviews, while advocacy events were reviewed pro forma. The document review was analysed using the manual content analysis method, while qualitative data audiotapes were transcribed verbatim, anonymized, double-coded in MS Word using colour-coded highlights and analysed using manual thematic and framework analysis guided by the advocacy coalition framework (ACF). The ACF was used to identify the policy subsystem including the actors, their belief, coordination and resources, as well as the effects of advocacy groups on policy change. Ethics and consent approval were obtained for the study. Results The policy subsystem identified the actors and characterized the coalitions, and described their group formation processes and resources/strategies for engagement. The perceived deep core belief driving the MCH agenda is the right of an individual to health. The effects of advocacy groups on policy change were identified, along with the factors that enabled effectiveness, as well as constraints to coalition formation. External factors and triggers of coalition formation were identified to include high maternal mortality and withdrawal of the free MCH programme, while the contextual issues were the health system issues and the socioeconomic factors affecting the country. Conclusion Our findings add to an increasing body of evidence that the use of ACF is beneficial in exploring how advocacy coalitions are formed and in identifying the effects of advocacy groups on policy change.
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Affiliation(s)
- Chinyere Okeke
- Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria.
| | - Ana Manzano
- School of Sociology and Social Policy, University of Leeds, Leeds, United Kingdom
| | - Uche Obi
- Department of Community Medicine, University of Nigeria Teaching Hospital Enugu, Enugu, Nigeria
| | - Enyi Etiaba
- Department of Health Administration and Management College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Obinna Onwujekwe
- Department of Health Administration and Management College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, United Kingdom
| | - Benjamin Uzochukwu
- Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
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17
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Mirzoev T, Manzano A, Ha BTT, Agyepong IA, Trang DTH, Danso-Appiah A, Thi LM, Ashinyo ME, Vui LT, Gyimah L, Chi NTQ, Yevoo L, Duong DTT, Awini E, Hicks JP, Cronin de Chavez A, Kane S. Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol. PLoS One 2021; 16:e0245755. [PMID: 33481929 PMCID: PMC7822243 DOI: 10.1371/journal.pone.0245755] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/18/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Socio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam. METHODS We will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors' expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions' actual performance. DISCUSSION The study's key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities.
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Affiliation(s)
- Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
- * E-mail: (TM); (SK)
| | - Ana Manzano
- School of Sociology and Social Policy, University of Leeds, Leeds, United Kingdom
| | - Bui Thi Thu Ha
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | | | - Do Thi Hanh Trang
- Department of Undergraduate Education, Hanoi University of Public Health, Hanoi, Vietnam
| | | | - Le Minh Thi
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | - Mary Eyram Ashinyo
- Department of Quality Assurance, Institutional Care Directorate, Ghana Health Service, Accra, Ghana
| | - Le Thi Vui
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | | | - Nguyen Thai Quynh Chi
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | - Lucy Yevoo
- Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Doan Thi Thuy Duong
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | - Elizabeth Awini
- Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Joseph Paul Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Anna Cronin de Chavez
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Sumit Kane
- Nossal Institute for Global Health, University of Melbourne, Melbourne, VIC, Australia
- * E-mail: (TM); (SK)
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Sarkies MN, Francis-Auton E, Long JC, Partington A, Pomare C, Nguyen HM, Wu W, Westbrook J, Day RO, Levesque JF, Mitchell R, Rapport F, Cutler H, Tran Y, Clay-Williams R, Watson DE, Arnolda G, Hibbert PD, Lystad R, Mumford V, Leipnik G, Sutherland K, Hardwick R, Braithwaite J. Implementing large-system, value-based healthcare initiatives: a realist study protocol for seven natural experiments. BMJ Open 2020; 10:e044049. [PMID: 33371049 PMCID: PMC7757496 DOI: 10.1136/bmjopen-2020-044049] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/27/2020] [Accepted: 11/19/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Value-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond 'what works' towards more nuanced understanding of 'what tends to work for whom under which circumstances'. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts. METHODS AND ANALYSIS This exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context-mechanism-outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed. ETHICS AND DISSEMINATION Ethical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.
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Affiliation(s)
- Mitchell N Sarkies
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Emilie Francis-Auton
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Janet C Long
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Andrew Partington
- Centre for the Health Economy, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Chiara Pomare
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Hoa Mi Nguyen
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Wendy Wu
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Johanna Westbrook
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Richard O Day
- Clinical Pharmacology, St Vincents Hospital Sydney, Darlinghurst, New South Wales, Australia
- Pharmacology, University of New South Wales, Kensington, New South Wales, Australia
| | - Jean-Frederic Levesque
- Bureau of Health Information, St Leonards, New South Wales, Australia
- Centre for Primary Health Care and Equity, University of New South Wales, Kensington, New South Wales, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Frances Rapport
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Henry Cutler
- Centre for the Health Economy, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Yvonne Tran
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Diane E Watson
- Bureau of Health Information, St Leonards, New South Wales, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
- University of South Australia Division of Health Sciences, Adelaide, South Australia, Australia
| | - Reidar Lystad
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - George Leipnik
- New South Wales Ministry of Health, St Leonards, New South Wales, Australia
| | - Kim Sutherland
- New South Wales Agency for Clinical Innovation, St Leonards, New South Wales, Australia
| | | | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
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19
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Onwujekwe O, Ensor T, Ogbozor P, Okeke C, Ezenwaka U, Hicks JP, Etiaba E, Uzochukwu B, Ebenso B, Mirzoev T. Was the Maternal Health Cash Transfer Programme in Nigeria Sustainable and Cost-Effective? Front Public Health 2020; 8:582072. [PMID: 33251176 PMCID: PMC7673437 DOI: 10.3389/fpubh.2020.582072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The Subsidy Reinvestment and Empowerment Programme (SURE-P), Maternal and Child Health (MCH) was introduced by the Nigerian government to increase the use of skilled maternal health services and reduce maternal mortality. The programme, funded out of a reduction in the fuel subsidy, was implemented between October 2012 and April 2015 and incorporated a conditional cash transfer to women to encourage use of facility based maternal services. We seek to assess the incremental cost effectiveness and long term impact of the conditional cash transfer element of the programme. Methods: An impact analysis and incremental cost-effectiveness analysis of conditional cash transfers (CCTs) is undertaken taking a health service perspective toward costs of the intervention. The study was undertaken in Anambra state, comparing areas that received only the investment in health services with areas that implemented the conditional cash transfer programme. An interrupted time series analysis of the programme outputs was undertaken. These were combined with a programme costing to determine the incremental cost per output. Findings: Maternal services provided to patients in conditional cash transfer areas accelerated rapidly from the middle of 2014 until after the programme in late 2015. The costs of providing services in each Primary Health Center facility was US $52,128 in the areas that only invested in health services compared to US $90,702 in facilities that also provided cash transfers. Much of the additional cost was in managing cash transfers. The incremental cost in the cash transfer areas was $572 for delivery care and $11 for antenatal care. If the programme was to be integrated as a regular service in the public health system, the cost of a delivery is estimated to fall to $389 and to $188 if 2015 levels of activity are assumed. Conclusion: Although the cost of CCTs as originally constituted as a vertical programme are relatively high compared to other similar programmes, these would fall substantially if integrated into the main health system. There is also evidence of sustained impact beyond the end of the funding suggesting that short term programmes can lead to a long-term change in patterns of health seeking behavior.
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Affiliation(s)
- Obinna Onwujekwe
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - Tim Ensor
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Pamela Ogbozor
- Department of Psychology, Enugu State University of Science and Technology, Enugu, Nigeria
| | - Chinyere Okeke
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - Uche Ezenwaka
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - Joseph P Hicks
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Enyi Etiaba
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - Benjamin Uzochukwu
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - Bassey Ebenso
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
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Etiaba E, Manzano A, Agbawodikeizu U, Ogu U, Ebenso B, Uzochukwu B, Onwujekwe O, Ezumah N, Mirzoev T. "If you are on duty, you may be afraid to come out to attend to a person": fear of crime and security challenges in maternal acute care in Nigeria from a realist perspective. BMC Health Serv Res 2020; 20:903. [PMID: 32993630 PMCID: PMC7525946 DOI: 10.1186/s12913-020-05747-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/18/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Maternal and Child Health is a global priority. Access and utilization of facility-based health services remain a challenge in low and middle-income countries. Evidence on barriers to providing and accessing services omits information on the role of security within facilities. This paper explores the role of security in the provision and use of maternal health services in primary healthcare facilities in Nigeria. METHODS Study was carried out in Anambra state, Nigeria. Qualitative data were initially collected from 35 in-depth interviews and 24 focus groups with purposively identified key informants. Information gathered was used to build a programme theory that was tested with another round of interviews (17) and focus group (4) discussions. Data analysis and reporting were based on the Context-Mechanism-Outcome heuristic of Realist Evaluation methodology. RESULTS The presence of a male security guard in the facility was the most important security factor that facilitated provision and uptake of services. Others include perimeter fencing, lighting and staff accommodation. Lack of these components constrained provision and use of services, by impacting on behaviour of staff and patients. Security concerns of facility staff who did not feel safe to let in people into unguarded facilities, mirrored those of pregnant women who did not utilize health facilities because of fear of not being let in and attended to by facility staff. CONCLUSION Health facility security should be key consideration in programme planning, to avert staff and women's fear of crime which currently constrains provision and use of maternal healthcare at health facilities.
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Affiliation(s)
- Enyi Etiaba
- Department of Health Administration and Management, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria. .,Health Policy Research Group, Department of Pharmaco-therapeutics, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria.
| | - Ana Manzano
- School of Sociology and Social Policy, University of Leeds, 11.20 Social Sciences Building, Leeds, UK
| | - Uju Agbawodikeizu
- Health Policy Research Group, Department of Pharmaco-therapeutics, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria.,Department of Social Work, Faculty of Social Sciences, University of Nigeria, Nsukka, Nigeria
| | - Udochukwu Ogu
- Health Policy Research Group, Department of Pharmaco-therapeutics, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Bassey Ebenso
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Level 10 Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
| | - Benjamin Uzochukwu
- Health Policy Research Group, Department of Pharmaco-therapeutics, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria.,Department of Community Medicine, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Obinna Onwujekwe
- Department of Health Administration and Management, Faculty of Health Sciences and Technology, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria.,Health Policy Research Group, Department of Pharmaco-therapeutics, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Nkoli Ezumah
- Health Policy Research Group, Department of Pharmaco-therapeutics, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Level 10 Worsley Building, Clarendon Way, Leeds, LS2 9NL, UK
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Uzochukwu B, Onyedinma C, Okeke C, Onwujekwe O, Manzano A, Ebenso B, Etiaba E, Ezuma N, Mirzoev T. What makes advocacy work? Stakeholders' voices and insights from prioritisation of maternal and child health programme in Nigeria. BMC Health Serv Res 2020; 20:884. [PMID: 32948165 PMCID: PMC7501647 DOI: 10.1186/s12913-020-05734-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The Nigerian government introduced and implemented a health programme to improve maternal and child health (MCH) called Subsidy Reinvestment and Empowerment programme for MCH (SURE-P/MCH). It ran from 2012 and ended abruptly in 2015 and was followed by increased advocacy for sustaining the MCH (antenatal, delivery, postnatal and immunization) services as a policy priority. Advocacy is important in allowing social voice, facilitating prioritization, and bringing different forces/actors together. Therefore, the study set out to understand how advocacy works - through understanding what effective advocacy implementation processes comprise and what mechanisms are triggered by which contexts to produce the intended outcomes. METHODS The study used a Realist Evaluation design through a mixed quantitative and qualitative methods case study approach. The programme theory (PT) was developed from three substantive social theories (power politics, media influence communication theory, and the three-streams theory of agenda-setting), data and programme design documentation, and subsequently tested. We report information from 22 key informant interviews including national and State policy and law makers, policy implementers, CSOs, Development partners, NGOs, health professional groups, and media practitioners and review of relevant documents on advocacy events post-SURE-P. RESULTS Key advocacy organizations and individuals including health professional groups, the media, civil society organizations, powerful individuals, and policymakers were involved in advocacy activities. The nature of their engagement included organizing workshops, symposiums, town hall meetings, individual meetings, press conferences, demonstrations, and engagements with media. Effective advocacy mechanism involved alliance brokering to increase influence, the media supporting and engaging in advocacy, and the use of champions, influencers, and spouses (Leadership and Elite Gendered Power Dynamics). The key contextual influences which determined the effectiveness of advocacy measures for MCH included the political cycle, availability of evidence on the issue, networking with powerful and interested champions, and alliance building in advocacy. All these enhanced the entrenchment of MCH on the political and financial agenda at the State and Federal levels. CONCLUSIONS Our result suggest that advocacy can be a useful tool to bring together different forces by allowing expression of voices and ensuring accountability of different actors including policymakers. In the context of poor health outcomes, interest from policymakers and politicians in MCH, combined with advocacy from key policy actors armed with evidence, can improve prioritization and sustained implementation of MCH services.
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Affiliation(s)
- Benjamin Uzochukwu
- Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Chioma Onyedinma
- Department of Community Medicine, University of Nigeria Teaching Hospital Enugu, Enugu, Nigeria
| | - Chinyere Okeke
- Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Obinna Onwujekwe
- Department of Health Administration and Management College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Ana Manzano
- School of Sociology & Social Policy, University of Leeds, Leeds, UK
| | - Bassey Ebenso
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
| | - Enyi Etiaba
- Department of Health Administration and Management College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Nkoli Ezuma
- Health Policy Research Group (HPRG), College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
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Ebenso B, Mbachu C, Etiaba E, Huss R, Manzano A, Onwujekwe O, Uzochukwu B, Ezumah N, Ensor T, Hicks JP, Mirzoev T. Which mechanisms explain motivation the of primary health workers? Insights from the realist evaluation of a maternal and child health programme in Nigeria. BMJ Glob Health 2020; 5:e002408. [PMID: 32843524 PMCID: PMC7449364 DOI: 10.1136/bmjgh-2020-002408] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 07/09/2020] [Accepted: 07/12/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Well-trained, adequately skilled and motivated primary healthcare (PHC) workers are essential for attaining universal health coverage (UHC). While there is abundant literature on the drivers of workforce motivation, published knowledge on the mechanisms of motivation within different contexts is limited, particularly in resource-limited countries. This paper contributes to health workforce literature by reporting on how motivation works among PHC workers in a maternal and child health (MCH) programme in Nigeria. METHODS We adopted a realist evaluation design combining document review with 56 in-depth interviews of PHC workers, facility managers and policy-makers to assess the impact of the MCH programme in Anambra State, Nigeria. A realist process of theory development, testing and consolidation was used to understand how and under what circumstances the MCH programme impacted on workers' motivation and which mechanisms explain how motivation works. We drew on Herzberg's two-factor and Adam's equity theories to unpack how context shapes worker motivation. RESULTS A complex and dynamic interaction between the MCH programme and organisational and wider contexts triggered five mechanisms which explain PHC worker motivation: (1) feeling supported, (2) feeling comfortable with work environment, (3) feeling valued, (4) morale and confidence to perform tasks and (5) companionship. Some mechanisms were mutually reinforcing while others operated in parallel. Other conditions that enabled worker motivation were organisational values of fairness, recognition of workers' contributions and culture of task-sharing and teamwork. CONCLUSIONS Policy designs and management strategies for improving workforce performance, particularly in resource-constrained settings should create working environments that foster feelings of being valued and supported while enabling workers to apply their knowledge and skills to improve healthcare delivery and promote UHC. Future research can test the explanatory framework generated by this study and explore differences in motivational mechanisms among different cadres of PHC workers to inform cadre-related motivational interventions.
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Affiliation(s)
- Bassey Ebenso
- Nuffield Centre for International Health and Development, University of Leeds School of Medicine, Leeds, UK
| | - Chinyere Mbachu
- Health Policy Research Group, University of Nigeria Faculty of Medical Sciences, Nsukka, Enugu, Nigeria
| | - Enyi Etiaba
- Health Policy Research Group, University of Nigeria Faculty of Medical Sciences, Nsukka, Enugu, Nigeria
| | - Reinhard Huss
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ana Manzano
- Sociology & Social Policy, University of Leeds School of Sociology and Social Policy, Leeds, UK
| | - Obinna Onwujekwe
- Health Policy Research Group, University of Nigeria Faculty of Medical Sciences, Nsukka, Enugu, Nigeria
| | - Benjamin Uzochukwu
- Health Policy Research Group, University of Nigeria Faculty of Medical Sciences, Nsukka, Enugu, Nigeria
| | - Nkoli Ezumah
- Faculty of Social Sciences, University of Nigeria, Nsukka, Enugu, Nigeria
| | - Timothy Ensor
- Nuffield Centre for International Health and Development, University of Leeds School of Medicine, Leeds, UK
| | - Joseph Paul Hicks
- Nuffield Centre for International Health and Development, University of Leeds School of Medicine, Leeds, UK
| | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds School of Medicine, Leeds, UK
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O'Brien R, Buston K, Wight D, McGee E, White J, Henderson M. A realist process evaluation of Enhanced Triple P for Baby and Mellow Bumps, within a Trial of Healthy Relationship Initiatives for the Very Early years (THRIVE): study protocol for a randomized controlled trial. Trials 2019; 20:351. [PMID: 31196169 PMCID: PMC6567913 DOI: 10.1186/s13063-019-3395-3] [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] [Received: 08/27/2018] [Accepted: 05/06/2019] [Indexed: 11/10/2022] Open
Abstract
Background THRIVE is a three-arm randomised controlled trial (RCT) that aims to evaluate whether antenatal and early postnatal interventions, Enhanced Triple B for Baby (ETPB) plus care as usual (CAU) or Mellow Bumps (MB) plus CAU (versus CAU alone), can: 1) improve the mental health and well-being of pregnant women with complex health and social care needs; 2) improve mother-infant bonding and interaction; 3) reduce child maltreatment; and 4) improve child language acquisition. This paper focuses on THRIVE’s realist process evaluation, which is carefully monitoring what is happening in the RCT. Methods Realistic evaluation provides the theoretical rationale for the process evaluation. We question: 1) how faithfully are MB and ETPB implemented? 2) What are the mechanisms by which they work, if they do, and who do they work for and how? 3) What contextual factors are necessary for the programmes to function, or might prevent them functioning? The mixed-methods design includes quantitative measures, which are pre- and post-training/intervention questionnaires for facilitators and mothers-to-be, and post-session evaluation forms. Qualitative data collection methods include participant observation of facilitator training and the delivery of a series of antenatal sessions in selected intervention groups (n = 3 for ETPB and n = 3 for MB), semi-structured interviews with facilitators, pregnant women, partners, and referring facilitators, and telephone interviews examining the content of the postnatal components of ETPB and MB. Discussion The findings of this process evaluation will help researchers and decision makers interpret the outcomes of THRIVE. It will provide a greater understanding of: how the interventions work (if they do); the extent and quality of their implementation; contextual factors facilitating and constraining intervention functioning; variations in response within and between subgroups of vulnerable parents; and benefits or unintended consequences of either intervention. Few studies to date have published detailed research protocols illustrating how realist process evaluation is designed and conducted as an integral part of a randomised controlled trial. Trial registration ISRCTN, ISRCTN21656568. Registered on 8 November 2013. Electronic supplementary material The online version of this article (10.1186/s13063-019-3395-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rosaleen O'Brien
- Glasgow Caledonian University, Psychology, Social Work and Allied Health Professionals, School of Health and Life Sciences, 4th Floor, George Moore Building, Cowcaddens Road, Glasgow, G4 0BA, UK
| | - Katie Buston
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3AX, UK
| | - Daniel Wight
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3AX, UK
| | - Elizabeth McGee
- Glasgow Caledonian University, Psychology, Social Work and Allied Health Professionals, School of Health and Life Sciences, 4th Floor, George Moore Building, Cowcaddens Road, Glasgow, G4 0BA, UK
| | - Jane White
- Public Health Sciences, NHS Health Scotland, Gyle Square, 1 Gyle Crescent, Edinburgh, EH12 9EB, UK
| | - Marion Henderson
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3AX, UK.
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Ebenso B, Manzano A, Uzochukwu B, Etiaba E, Huss R, Ensor T, Newell J, Onwujekwe O, Ezumah N, Hicks J, Mirzoev T. Dealing with context in logic model development: Reflections from a realist evaluation of a community health worker programme in Nigeria. EVALUATION AND PROGRAM PLANNING 2019; 73:97-110. [PMID: 30578941 PMCID: PMC6403102 DOI: 10.1016/j.evalprogplan.2018.12.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/07/2018] [Accepted: 12/05/2018] [Indexed: 06/09/2023]
Abstract
Logic models (LMs) have been used in programme evaluation for over four decades. Current debate questions the ability of logic modelling techniques to incorporate contextual factors into logic models. We share experience of developing a logic model within an ongoing realist evaluation which assesses the extent to which, and under what circumstances a community health workers (CHW) programme promotes access to maternity services in Nigeria. The article contributes to logic modelling debate by: i) reflecting on how other scholars captured context during LM development in theory-driven evaluations; and ii) explaining how we explored context during logic model development for realist evaluation of the CHW programme in Nigeria. Data collection methods that informed our logic model development included documents review, email discussions and teleconferences with programme stakeholders and a technical workshop with researchers to clarify programme goals and untangle relationships among programme elements. One of the most important findings is that, rather than being an end in itself, logic model development is an essential step for identifying initial hypotheses for tentative relevant contexts, mechanisms and outcomes (CMOs) and CMO configurations of how programmes produce change. The logic model also informed development of a methodology handbook that is guiding verification and consolidation of underlying programme theories.
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Affiliation(s)
- Bassey Ebenso
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK.
| | - Ana Manzano
- School of Sociology and Social Policy, Social Sciences Building, University of Leeds, Leeds, UK.
| | - Benjamin Uzochukwu
- Health Policy Research Group & the Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu-Campus, 400001, Nigeria.
| | - Enyi Etiaba
- Health Policy Research Group & the Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu-Campus, 400001, Nigeria.
| | - Reinhard Huss
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK.
| | - Tim Ensor
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK.
| | - James Newell
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK.
| | - Obinna Onwujekwe
- Health Policy Research Group & the Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu-Campus, 400001, Nigeria.
| | - Nkoli Ezumah
- Health Policy Research Group & the Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu-Campus, 400001, Nigeria.
| | - Joe Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK.
| | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK.
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Ebenso B, Allsop MJ, Okusanya B, Akaba G, Tukur J, Okunade K, Akeju D, Ajepe A, Dirisu O, Yalma R, Sadeeq AI, Okuzu O, Ors T, Jagger T, Hicks JP, Mirzoev T, Newell JN. Impact of using eHealth tools to extend health services to rural areas of Nigeria: protocol for a mixed-method, non-randomised cluster trial. BMJ Open 2018; 8:e022174. [PMID: 30341123 PMCID: PMC6196841 DOI: 10.1136/bmjopen-2018-022174] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION eHealth solutions that use internet and related technologies to deliver and enhance health services and information are emerging as novel approaches to support healthcare delivery in sub-Saharan Africa. Using digital technology in this way can support cost-effectiveness of care delivery and extend the reach of services to remote locations. Despite the burgeoning literature on eHealth approaches, little is known about the effectiveness of eHealth tools for improving the quality and efficiency of health systems functions or client outcomes in resource-limited countries. eHealth tools including satellite communications are currently being implemented at scale, to extend health services to rural areas of Nigeria, in Ondo and Kano States and the Federal Capital Territory. This paper shares the protocol for a 2-year project ('EXTEND') that aims to evaluate the impact of eHealth tools on health system functions and health outcomes. METHODOLOGY AND ANALYSIS This multisite, mixed-method evaluation includes a non-randomised, cluster trial design. The study comprises three phases-baseline, midline and endline evaluations-that involve: (1) process evaluation of video training and digitisation of health data interventions; (2) evaluation of contextual influences on the implementation of interventions; and (3) impact evaluation of results of the project. A convergent mixed-method model will be adopted to allow integration of quantitative and qualitative findings to achieve study objectives. Multiple quantitative and qualitative datasets will be repeatedly analysed and triangulated to facilitate better understanding of impact of eHealth tools on health worker knowledge, quality and efficiency of health systems and client outcomes. ETHICS AND DISSEMINATION Ethics approvals were obtained from the University of Leeds and three States' Ministries of Health in Nigeria. All data collected for this study will be anonymised and reports will not contain information that could identify respondents. Study findings will be presented to Ministries of Health at scientific conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN32105372; Pre-results.
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Affiliation(s)
- Bassey Ebenso
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Matthew John Allsop
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Babasola Okusanya
- Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Godwin Akaba
- Department of Obstetrics and Gynaecology, University of Abuja, Abuja, Nigeria
| | - Jamilu Tukur
- Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Kehinde Okunade
- Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - David Akeju
- Department of Sociology, University of Lagos, Lagos, Nigeria
| | - Adegbenga Ajepe
- Department of Obstetrics and Gynaecology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Osasuyi Dirisu
- Department of Research, Population Council, Abuja, Nigeria
| | - Ramsey Yalma
- Department of Obstetrics and Gynaecology, University of Abuja, Abuja, Nigeria
| | - Abubakar Isa Sadeeq
- Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Okey Okuzu
- Corporate Office, InStrat Global Health Solutions, Abuja, Nigeria
| | - Tolga Ors
- Inmarsat Global Ltd., Inmarsat Solutions Global Limited, London, UK
| | - Terence Jagger
- Inmarsat Global Ltd., Inmarsat Solutions Global Limited, London, UK
| | - Joseph Paul Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - James Nicholas Newell
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
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Munar W, Wahid SS, Curry L. Characterizing performance improvement in primary care systems in Mesoamerica: A realist evaluation protocol. Gates Open Res 2018. [DOI: 10.12688/gatesopenres.12782.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background. Evaluations of performance measurement and management interventions in public, primary care delivery systems of low- and middle-income countries are scarce. In such contexts, few studies to date have focused on characterizing how, why and under what contextual conditions do such complex, multifaceted arrangements lead to intended and unintended consequences for the healthcare workforce, the healthcare organizations involved, and the communities that are served. Methods. Case-study design with purposeful outlier sampling of high-performing primary care delivery systems in El Salvador and Honduras, as part of the Salud Mesoamerica Initiative. Case study design is suitable for characterizing individual, interpersonal and collective mechanisms of change in complex adaptive systems. The protocol design includes literature review, document review, non-participant observation, and qualitative analysis of in-depth interviews. Data analysis will use inductive and deductive approaches to identify causal patterns organized as ‘context-mechanism-outcome’ configurations. Findings will be triangulated with existing secondary data sources collected including country-specific performance measurement data, impact, and process evaluations conducted by the Salud Mesoamerica Initiative. Discussion. This realist evaluation protocol aims to characterize how, why and under what conditions do performance measurement and management arrangements contribute to the improvement of primary care system performance in two low-income countries.
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Ford JA, Jones A, Wong G, Clark A, Porter T, Steel N. Access to primary care for socio-economically disadvantaged older people in rural areas: exploring realist theory using structural equation modelling in a linked dataset. BMC Med Res Methodol 2018; 18:57. [PMID: 29914411 PMCID: PMC6006834 DOI: 10.1186/s12874-018-0514-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 05/31/2018] [Indexed: 11/29/2022] Open
Abstract
Background Realist approaches seek to answer questions such as ‘how?’, ‘why?’, ‘for whom?’, ‘in what circumstances?’ and ‘to what extent?’ interventions ‘work’ using context-mechanism-outcome (CMO) configurations. Quantitative methods are not well-established in realist approaches, but structural equation modelling (SEM) may be useful to explore CMO configurations. Our aim was to assess the feasibility and appropriateness of SEM to explore CMO configurations and, if appropriate, make recommendations based on our access to primary care research. Our specific objectives were to map variables from two large population datasets to CMO configurations from our realist review looking at access to primary care, generate latent variables where needed, and use SEM to quantitatively test the CMO configurations. Methods A linked dataset was created by merging individual patient data from the English Longitudinal Study of Ageing and practice data from the GP Patient Survey. Patients registered in rural practices and who were in the highest deprivation tertile were included. Three latent variables were defined using confirmatory factor analysis. SEM was used to explore the nine full CMOs. All models were estimated using robust maximum likelihoods and accounted for clustering at practice level. Ordinal variables were treated as continuous to ensure convergence. Results We successfully explored our CMO configurations, but analysis was limited because of data availability. Two hundred seventy-six participants were included. We found a statistically significant direct (context to outcome) or indirect effect (context to outcome via mechanism) for two of nine CMOs. The strongest association was between ‘ease of getting through to the surgery’ and ‘being able to get an appointment’ with an indirect mediated effect through convenience (proportion of the indirect effect of the total was 21%). Healthcare experience was not directly associated with getting an appointment, but there was a statistically significant indirect effect through convenience (53% mediated effect). Model fit indices showed adequate fit. Conclusions SEM allowed quantification of CMO configurations and could complement other qualitative and quantitative techniques in realist evaluations to support inferences about strengths of relationships. Future research exploring CMO configurations with SEM should aim to collect, preferably continuous, primary data. Electronic supplementary material The online version of this article (10.1186/s12874-018-0514-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- John A Ford
- Norwich Medical School, University of East Anglia, Chancellor's Drive, Norwich, UK.
| | - Andy Jones
- Norwich Medical School, University of East Anglia, Chancellor's Drive, Norwich, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Chancellor's Drive, Norwich, UK
| | - Tom Porter
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Nick Steel
- Norwich Medical School, University of East Anglia, Chancellor's Drive, Norwich, UK
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Stroup DF, Smith CK, Truman BI. Reporting the methods used in public health research and practice. JOURNAL OF PUBLIC HEALTH AND EMERGENCY 2017; 1:89. [PMID: 29417955 PMCID: PMC5798489 DOI: 10.21037/jphe.2017.12.01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The methods section of a scientific article often receives the most scrutiny from journal editors, peer reviewers, and skeptical readers because it allows them to judge the validity of the results. The methods section also facilitates critical interpretation of study activities, explains how the study avoided or corrected for bias, details how the data support the answer to the study question, justifies generalizing the findings to other populations, and facilitates comparison with past or future studies. In 2006, the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Programme began collecting and disseminating guidelines for reporting health research studies. In addition, guidelines for reporting public health investigations not classified as research have also been developed. However, regardless of the type of study or scientific report, the methods section should describe certain core elements: the study design; how participants were selected; the study setting; the period of interest; the variables and their definitions used for analysis; the procedures or instruments used to measure exposures, outcomes, and their association; and the analyses. Specific requirements for each study type should be consulted during the project planning phase and again when writing begins. We present requirements for reporting methods for public health activities, including outbreak investigations, public health surveillance programs, prevention and intervention program evaluations, research, surveys, systematic reviews, and meta-analyses.
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Affiliation(s)
| | - C. Kay Smith
- Office of the Associate Director for Science, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Benedict I. Truman
- Office of the Associate Director for Science, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Ebenso B, Huque R, Azdi Z, Elsey H, Nasreen S, Mirzoev T. Protocol for a mixed-methods realist evaluation of a health service user feedback system in Bangladesh. BMJ Open 2017; 7:e017743. [PMID: 28679679 PMCID: PMC5734574 DOI: 10.1136/bmjopen-2017-017743] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Responsiveness to service users' views is a widely recognised objective of health systems. A key component of responsive health systems is effective interaction between users and service providers. Despite a growing literature on patient feedback from high-income settings, less is known about effectiveness of such systems in low-income and middle-income countries. METHODOLOGY AND ANALYSIS This paper disseminates the protocol for an 18-month 'RESPOND' project that aims to evaluate the system of collecting and responding to user feedback in Bangladesh. This mixed-method study uses a realist evaluation approach to examine user feedback systems at two Upazila health complexes in Comilla District of Bangladesh, and comprises three steps: (1) initial theory development; (2) theory validation; and (3) theory refinement and development of lessons learnt. The project also uses (1) process evaluation to understand causal mechanisms and contexts of implementation; (2) statistical analysis of patient feedback to clarify the nature of issues reported; (3) social science methods to illuminate feedback processes and user and provider experiences; and (4) health policy and systems research to clarify issues related to integration of feedback systems with quality assurance and human resource management. During data analysis, qualitative and quantitative findings will be integrated throughout to help achieve study objectives. Analysis of qualitative and quantitative data will be done using a convergent mixed-methods model, involving continuous triangulation of multiple data sets to facilitate greater understanding of the context of user feedback systems including the links with relevant policies, practices and programmes. ETHICS AND DISSEMINATION Ethics approvals were obtained from the University of Leeds and the Bangladesh Medical Research Council. All data collected for this study will be anonymised, and identifying characteristics of respondents will not appear in a final manuscript or reports. The study findings will be presented at scientific conferences and published in peer-reviewed journals.
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Affiliation(s)
- Bassey Ebenso
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Rumana Huque
- ARK Foundation, Dhaka, Bangladesh
- Department of Economics, University of Dhaka, Dhaka, Bangladesh
| | | | - Helen Elsey
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | | | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
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Wong G, Westhorp G, Manzano A, Greenhalgh J, Jagosh J, Greenhalgh T. RAMESES II reporting standards for realist evaluations. BMC Med 2016; 14:96. [PMID: 27342217 PMCID: PMC4920991 DOI: 10.1186/s12916-016-0643-1] [Citation(s) in RCA: 373] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/14/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Realist evaluation is increasingly used in health services and other fields of research and evaluation. No previous standards exist for reporting realist evaluations. This standard was developed as part of the RAMESES II project. The project's aim is to produce initial reporting standards for realist evaluations. METHODS We purposively recruited a maximum variety sample of an international group of experts in realist evaluation to our online Delphi panel. Panel members came from a variety of disciplines, sectors and policy fields. We prepared the briefing materials for our Delphi panel by summarising the most recent literature on realist evaluations to identify how and why rigour had been demonstrated and where gaps in expertise and rigour were evident. We also drew on our collective experience as realist evaluators, in training and supporting realist evaluations, and on the RAMESES email list to help us develop the briefing materials. Through discussion within the project team, we developed a list of issues related to quality that needed to be addressed when carrying out realist evaluations. These were then shared with the panel members and their feedback was sought. Once the panel members had provided their feedback on our briefing materials, we constructed a set of items for potential inclusion in the reporting standards and circulated these online to panel members. Panel members were asked to rank each potential item twice on a 7-point Likert scale, once for relevance and once for validity. They were also encouraged to provide free text comments. RESULTS We recruited 35 panel members from 27 organisations across six countries from nine different disciplines. Within three rounds our Delphi panel was able to reach consensus on 20 items that should be included in the reporting standards for realist evaluations. The overall response rates for all items for rounds 1, 2 and 3 were 94 %, 76 % and 80 %, respectively. CONCLUSION These reporting standards for realist evaluations have been developed by drawing on a range of sources. We hope that these standards will lead to greater consistency and rigour of reporting and make realist evaluation reports more accessible, usable and helpful to different stakeholders.
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Affiliation(s)
- Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Gill Westhorp
- Community Matters, PO Box 443, Mount Torrens, South Australia, 5244, Australia
| | - Ana Manzano
- School of Sociology and Social Policy, University of Leeds, Leeds, LS2 9JT, UK
| | - Joanne Greenhalgh
- School of Sociology and Social Policy, University of Leeds, Leeds, LS2 9JT, UK
| | - Justin Jagosh
- Centre for Advancement in Realist Evaluation and Synthesis, Institute of Psychology, Health and Society, University of Liverpool, Waterhouse Building, Block B, Brownlow Street, Liverpool, L69 3GL, UK
| | - Trish Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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