Mechanisms for achieving adolescent-friendly services in Ecuador: a realist evaluation approach

Policies for expanding family planning coverage: lessons from five successful countries

Background

Enhancing the design of family planning interventions is crucial for promoting gender equality and improving maternal and child health outcomes. We identified, critically appraised, and synthesized policies and strategies from five selected countries that successfully increased family planning coverage.

Methods

We conducted a policy analysis through a scoping review and document search, focusing on documents published from 1950 to 2023 that examined or assessed policies aimed at enhancing family planning coverage in Brazil, Ecuador, Egypt, Ethiopia, and Rwanda. A search was conducted through PubMed, SCOPUS, and Web of Science. Government documents and conference proceedings were also critically analyzed. National health surveys were analyzed to estimate time trends in demand for family planning satisfied by modern methods (mDFPS) at the national level and by wealth. Changes in the method mix were also assessed. The findings of the studies were presented in a narrative synthesis.

Findings

We selected 231 studies, in which 196 policies were identified. All countries started to endorse family planning in the 1960s, with the number of identified policies ranging between 21 in Ecuador and 52 in Ethiopia. Most of the policies exclusively targeted women and were related to supplying contraceptives and enhancing the quality of the services. Little focus was found on monitoring and evaluation of the policies implemented.

Conclusion

Among the five selected countries, a multitude of actions were happening simultaneously, each with its own vigor and enthusiasm. Our findings highlight that these five countries were successful in increasing family planning coverage by implementing broader multi-sectoral policies and considering the diverse needs of the population, as well as the specific contextual factors at play. Successful policies require a nuanced consideration of how these policies align with each culture's framework, recognizing that both sociocultural norms and the impact of past public policies shape the current state of family planning.

Key informants' perspectives on policy- and service-level challenges and opportunities for delivering adolescent and youth-friendly health services in public health facilities in a Nigerian setting

BACKGROUND

Integrating the care of adolescents and young people into existing public health facilities requires deliberate efforts to address challenges related to policy and service provision. This study assessed key informants' perspectives on policy- and service-level challenges, and opportunities, for implementing a strategic framework for adolescent and youth-friendly health services (AYFHS) in public health facilities in a Nigerian setting.

METHODS

Seventeen key informants were interviewed including members of the Adolescent sexual and reproductive health (ASRH) Technical Working Group (TWG), program managers of non-governmental organizations (NGO), State and local level health officials, and youth representatives, in Ogun State, Southwest Nigeria.

RESULT

Findings from this study indicate that some health workers continue to have a negative attitude toward young people's sexual and reproductive health. There was some level of inclusion of adolescents and young people living with disabilities in ASRH programming which is welcome and extremely important. Some of the challenges in ASRH service provision included insufficient coordination of activities of donors/partners working in the adolescent health space. Also found was the missed opportunity to strengthen policy implementation with research, and the need for increased focus on mental health, substance use, and other aspects of adolescent and young people's health. There was noted the opportunity to explore the Basic Health Care Provisions Funds (BHCPF) as a new source of funding for health services for AYP in Nigeria.

CONCLUSION

This study provided the context of the implementation of a strategic framework for adolescent reproductive health in a Nigerian setting from the perspectives of policy and service-level stakeholders. Opportunities for improving program delivery identified include ensuring research-based policy implementation and seeking program sustainability through tapping into new sources of funding.

The More You Know, the Less You Stress: Menstrual Health Literacy in Schools Reduces Menstruation-Related Stress and Increases Self-Efficacy for Very Young Adolescent Girls in Mexico

Improving the menstrual health literacy of girls and boys is a key strategy within a holistic framework of Save the Children's school health and comprehensive sexuality education programming. As menstrual health is an emerging area of study and programming, Save the Children continues to learn and adjust its interventions using program evaluations and rigorous monitoring. This paper will examine program-monitoring data from three cohorts, representing 47 public schools in Mexico City, Puebla, and Mérida, Mexico. The study focuses on female students in 5th and 6th grade who participated in We See Equal, a school-based program centered on gender equality and puberty education, between September 2018 and December 2019. This study used a cross-sectional quantitative cohort approach to document changes in girls' experiences and perceptions around managing menstruation in school. The analysis compares girls' knowledge and experiences before and after participation in We See Equal to understand how knowledge changes over the program and how those changes may contribute to menstruation-related school engagement, stress, and self-efficacy (MENSES) outcomes. Multivariate regression models explored relationships between MENSES outcomes, knowledge and socioeconomic status (SES). Overall, results show that the more knowledge girls acquired, the higher their self-efficacy score and the lower their stress score, however, certain MHH knowledge was more predictive of MENSES outcomes and varied by SES. Among girls from lower SES, we observed significant relationships between knowing what their period was prior to menarche and the three MENSES outcomes. Decreases in menstruation-related stress were driven by items related to the practical knowledge of how to dispose of sanitary pads and reduced feelings of nervousness on days they had their period at school. Increases in self-efficacy were primarily driven by girls' confidence in their ability to track their period from month to month, feelings that they could still do well on an exam if they had their period at school, and security that they could ask a friend to lend them a pad if they needed one. Implications for future menstrual health literacy programming and targeting populations for menstrual health education, as well as priorities for future research will be discussed.

Mecanismos de evaluaciones realistas en intervenciones de atención primaria en salud en poblaciones rurales y urbanas marginales

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.

What makes advocacy work? Stakeholders' voices and insights from prioritisation of maternal and child health programme in Nigeria

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.

Making Health Services Adolescent-Friendly in Northeastern Peninsular Malaysia: A Mixed-Methods Study

A mixed-methods study was conducted in a Malaysian state beginning with a cross-sectional quantitative study to determine the relationship between clinic characteristics and clinic score of adolescent-friendliness. Subsequently, perceptions of healthcare providers on the facilitating factors for the provision of adolescent-friendly health services were explored qualitatively to support the quantitative findings. Availability of trained healthcare providers, adequate privacy, dedicated adolescent health services team, and adolescent health promotional activities were the clinic characteristics that significantly (p < 0.05) related with clinics' scores of adolescent-friendliness. The facilitating factors required for adolescent-friendly health services were (1) healthcare providers' commitment and prioritization towards adolescent-friendly health services; (2) organizational supports; (3) appropriate clinic settings; and (4) external supports for adolescent health promotional activities. The qualitative findings reaffirmed those of the quantitative study on the significant clinic characteristics required for adolescent-friendly health services. This study provides valuable insight for the Ministry of Health to elicit the required facilitating factors to further improve the quality of adolescent health services in Malaysia.

Realist evaluations in low- and middle-income countries: reflections and recommendations from the experiences of a foreign researcher

Realist evaluation, a methodology for exploring generative causation within complex health interventions to understand 'how, why and for whom' programmes work, is experiencing a surge of interest. Trends indicate that the proliferation in the use of this methodology also applies to research in low- and middle-income countries (LMICs). The value of using realist evaluation for project evaluation is also being noticed by non-governmental organisations (NGOs) and other programme implementers within such contexts. Yet, there is limited exploration of the use of realist evaluations in LMICs, especially their use by foreign researchers. This paper draws on the author's experience of conducting two realist evaluations across three different sub-Saharan African settings: Mundemu, Tanzania; Kabale, Uganda and Marsabit, Kenya. The realist evaluations were used as an operations research methodology to study two NGO community health programmes. This paper highlights four main challenges experienced by the author throughout the methodological process: (1) power imbalances prevalent during realist interviews, (2) working through translation and what this means for identfying Context-Mechanism-Outcome Configurations, (3) limited contextual familiarity and being an 'engaged researcher' and (4) the use or dependence on 'WEIRD' theories (i.e. theories based on the study of Western, Educated, Industrialized, Rich, Democratic people) within testing and refinement. Realist evaluation's enticing and straightforward slogan of finding 'what works, for whom and why' is in contrast to the complexity of the methodology used to generate these results (and often to the results themselves). Striking a balance between theory and pragmatism, while adhering to realist ontological underpinnings of generative causation and retroduction, is no easy task. This paper concludes by providing concrete recommendations for those who want to undertake a realist evaluation, with particular attention to cross-cultural settings, in light of the aforementioned challenges. In doing so, it aims to foster improved methodological rigour and help those engaging in this research methodology to work towards more appropriate and contextually relevant findings.

Exploring the factors impacting on access and acceptance of sexual and reproductive health services provided by adolescent-friendly health services in Nepal

Adolescent-friendly health programs have been in place in Nepal since 2008, yet uptake of the services for sexual and reproductive health remains suboptimal. For uptake of these services to improve, a rich understanding is needed of the factors impacting their acceptance and utilization from the perspectives of adolescents, health care staff, and key community informants. This study applied a qualitative research design involving six focus groups with 52 adolescents and in-depth interviews with 16 adolescents, 13 key informants, and 9 health care providers from six adolescent-friendly health facilities in Nepal. Thematic analysis was conducted for data analysis. The key themes identified as barriers include access issues due to travel, institutional health care barriers, perceived lack of privacy and confidentiality, and the unprofessional attitudes of staff towards the sexual health needs of adolescents. These themes are underpinned by gendered ideology and a moral framework around the sexual behavior of adolescents. Interview responses suggested that health care providers take a policing role in prescribing adolescents’ conformity to this moral framework in their delivery of reproductive health care and services. While physical access to health services may be problematic for some adolescents, this is not the priority issue. Attention needs to be given to increasing the capacity of health care providers to deliver services without imposing their own and socially sanctioned moral frameworks around adolescent sexual behavior. Such capacity building should include training that is experiential and emphasizes the importance of confidentiality and non-judgmental attitudes.

Community based interventions for strengthening adolescent sexual reproductive health and rights: how can they be integrated and sustained? A realist evaluation protocol from Zambia

BACKGROUND

Research that explores how community-based interventions for strengthening adolescent sexual reproductive health and rights (SRHR) can be integrated and sustained in community health systems, is, to the best of our knowledge, very scarce, if not absent. It is important to document mechanisms that shape integration process in order to improve health systems' responsiveness towards adolescents' SRHR. This realist evaluation protocol will contribute to this knowledge in Zambia where there is increased attention towards promoting maternal, neonatal and child health as a means of addressing the current high early pregnancy and marriage rates. The protocol will ascertain: why, how, and under what conditions the integration of SRHR interventions into Zambian community health systems will optimise (or not) acceptability and adoption of SRHR services. This study is embedded within a randomized controlled trial - "Research Initiative to Support the Empowerment of Girls (RISE)"- which aims to reduce adolescent girl pregnancies and marriages through a package of interventions including economic support to families, payment of school fees to keep girls in school, pocket money for girls, as well as youth club and community meetings on reproductive health.

METHODS

This is a multiple-case study design. Data will be collected from schools, health facilities and communities through individual and group interviews, photovoice, documentary review, and observations. The study process will involve 1) developing an initial causal theory that proposes an explanation of how the integration of a community-based intervention that aimed to integrate adolescent SRHR into the community health system may lead to adolescent-friendly services; 2) refining the causal theory through case studies; 3) identifying contextual conditions and mechanisms that shape the integration process; and 4) finally proposing a refined causal theory and set of recommendations to guide policy makers, steer further research, and inform teaching programmes.

DISCUSSION

The study will document relevant values as well as less formal and horizontal mechanisms which shape the integration process of SRHR interventions at community level. Knowledge on mechanisms is essential for guiding development of strategies for effectively facilitating the integration process, scaling up processes and sustainability of interventions aimed at reducing SRH problems and health inequalities among adolescents.

Assessing youth-friendly sexual and reproductive health services: a systematic review

BACKGROUND

Over the last quarter century, there has been an emergence of evidence-based research directed toward the development, implementation, and assessment of youth-friendly health services (YFHS) to improve the delivery of sexual and reproductive health services for young people. Despite these research efforts, evidence supporting the effectiveness of YFHS is limited, which may be attributed to a lack of consensus on how to define and measure youth-friendliness to track progress and evaluate outcomes. The purpose of this systematic review is to assess how youth-friendly sexual and reproductive health services are measured worldwide.

METHODS

We conducted a systematic review of studies measuring youth-friendly sexual and reproductive health services at health facilities published between January 2000 and June 2015 using PubMed, Web of Science, and POPLINE databases. Additional studies were identified by reviewing references of selected articles. Studies were screened to identify measurements and indicators that have been used to measure YFHS.

RESULTS

Our review identified 20 studies from an initial search of more than 11,000 records, including six from high-income countries and 14 from low-and middle-income countries. The review identified 115 indicators used for measuring youth-friendly sexual and reproductive health services. Our review found a lack of consistency in the tools and indicators used to measure YFHS. The three most frequently assessed domains were accessibility, staff characteristics and competency, and confidentiality and privacy. The majority of the indicators were not specific to young people's needs and often reflected basic standards of care.

CONCLUSIONS

This review shows the need for standardization and prioritization of indicators for the evaluation of YFHS. The results can be used to identify a core set of indicators that can be incorporated into a framework for assessing youth-friendly sexual and reproductive health services. There is a need to further distinguish between those variables that may have greatest impact on the use of services by young people, such as respect and privacy, those that impact the quality of services offered, and those that have limited relevance. Conducting more rigorous studies using a refined set of indicators is critical to measure and compare the impact and effectiveness of YFHS efforts.

Health care access for rural youth on equal terms? A mixed methods study protocol in northern Sweden

Background

The purpose of this paper is to propose a protocol for researching the impact of rural youth health service strategies on health care access. There has been no published comprehensive assessment of the effectiveness of youth health strategies in rural areas, and there is no clearly articulated model of how such assessments might be conducted. The protocol described here aims to gather information to; i) Assess rural youth access to health care according to their needs, ii) Identify and understand the strategies developed in rural areas to promote youth access to health care, and iii) Propose actions for further improvement. The protocol is described with particular reference to research being undertaken in the four northernmost counties of Sweden, which contain a widely dispersed and diverse youth population.

Methods

The protocol proposes qualitative and quantitative methodologies sequentially in four phases. First, to map youth access to health care according to their health care needs, including assessing horizontal equity (equal use of health care for equivalent health needs,) and vertical equity (people with greater health needs should receive more health care than those with lesser needs). Second, a multiple case study design investigates strategies developed across the region (youth clinics, internet applications, public health programs) to improve youth access to health care. Third, qualitative comparative analysis of the 24 rural municipalities in the region identifies the best combination of conditions leading to high youth access to health care. Fourth, a concept mapping study involving rural stakeholders, care providers and youth provides recommended actions to improve rural youth access to health care.

Discussion

The implementation of this research protocol will contribute to 1) generating knowledge that could contribute to strengthening rural youth access to health care, as well as to 2) advancing the application of mixed methods to explore access to health care.

Health policy making for street children: challenges and strategies

Background The phenomenon of street children is a bio-psychological and social issue that not only harms children, but also endangers the health of a society. In line with the national programs for the development and promotion of street children's health in Iran, health policy making and essential strategies for this group of children will be presented in this paper. This paper will discuss the main issues and challenges of street children's health and, also, health policy and guidelines for this population. Methods In this review study, the keywords; street children, health, challenges, policy, and health policy making were searched through PubMed, SID, Iranmedex, World Health Organization (WHO), Emro, the Cochran Library, Medline and Google scholar to collect data. The search resulted in 84 related resources from which 48 cases that were more relevant to this research and covered the issue more comprehensively, were used. All data published during 2002-2015 have been included in this paper. Results Key concepts including street children and their health, health policy, strategies to improve the health of street children, health policy approaches for street children, the WHO's strategies, and social support program for street children must be considered in the health policy making processes for street children, as precise identification of the relevant information makes planning more effective in health policy making for this group of children. Conclusion The phenomenon of street children is a growing problem in the world and it has turned into a serious concern in many countries including Iran. The findings of this study can be used for identifying necessary measures in order to use research outcomes more effectively in policy making processes and reforming street children's health policies in Iran.

Validation of a questionnaire to measure youth-friendliness of Swedish youth clinics

AIM

This study presents the validation process of a tool to assess the youth-friendliness of Swedish youth clinics, based on the Youth-Friendly Health Services - World Health Organization Plus (YFHS-WHO+) questionnaire but adapted to the specific context of differentiated services catering only for young people in this country.

METHODS

The validation process followed five steps: (1) translation, (2) revision by professionals, (3) pretests with young people, (4) back-translation and discussion with the developers of the original YFHS-WHO+ questionnaire and (5) internal consistency and test-retest reliability testing.

RESULTS

The final Swedish version, titled Youth-Friendly Health Services-Sweden (YFHS-Swe), differs from the original in terms of adjustments in language and in changes to make it better correspond to the reality of the Swedish youth clinics, while maintaining the meaning and intention of the original questionnaire. The YFHS-Swe questionnaire generated reproducible responses (test-retest coefficient of 0.79 for the total score) and can be considered a measure of a cohesive construct (Cronbach alpha of 0.95 for the total score).

CONCLUSIONS

The study suggests that the YFHS-Swe questionnaire is a reliable instrument that can be an asset for youth clinics to evaluate their work and make regional and national comparisons between clinics. The YFHS-Swe could also serve as a basis for validating instruments to assess youth-friendliness of differentiated services for young people in other countries.

Quality of reproductive healthcare for adolescents: A nationally representative survey of providers in Mexico

OBJECTIVE

Adolescents need sexual and reproductive health services but little is known about quality-of-care in lower- and middle-income countries where most of the world's adolescents reside. Quality-of-care has important implications as lower quality may be linked to higher unplanned pregnancy and sexually transmitted infection rates. This study sought to generate evidence about quality-of-care in public sexual and reproductive health services for adolescents.

METHODS

This cross-sectional study had a complex, probabilistic, stratified sampling design, representative at the national, regional and rural/urban level in Mexico, collecting provider questionnaires at 505 primary care units in 2012. A sexual and reproductive quality-of-healthcare index was defined and multinomial logistic regression was utilized in 2015.

RESULTS

At the national level 13.9% (95%CI: 6.9-26.0) of healthcare units provide low quality, 68.6% (95%CI: 58.4-77.3) medium quality and 17.5% (95%CI: 11.9-25.0) high quality reproductive healthcare services to adolescents. Urban or metropolitan primary care units were at least 10 times more likely to provide high quality care than those in rural areas. Units with a space specifically for counseling adolescents were at least 8 times more likely to provide high quality care. Ministry of Health clinics provided the lowest quality of service, while those from Social Security for the Underserved provided the best.

CONCLUSIONS

The study indicates higher quality sexual and reproductive healthcare services are needed. In Mexico and other middle- to low-income countries where quality-of-care has been shown to be a problem, incorporating adolescent-friendly, gender-equity and rights-based perspectives could contribute to improvement. Setting and disseminating standards for care in guidelines and providing tools such as algorithms could help healthcare personnel provide higher quality care.

The health status of adolescents in Ecuador and the country's response to the need for differentiated healthcare for adolescents

Background

Adolescents face a range of health problems but many barriers block their access to health services, and in particular to sexual and reproductive health services. The objective of this study was to assess the health needs of adolescents in Ecuador and to draw lessons from the ways the country has responded to their need for differentiated care.

Methods

We conducted a literature review and consulted key stakeholders.

Results

Adolescents in Ecuador today have a wide range of health care needs, in particular related to sexual and reproductive health. A major concern is the high rates of adolescent pregnancy. A national programme was established in 2007 to offer differentiated health care for adolescents—an effort that featured specially trained staff, enclaved facilities, respect for adolescents’ privacy and confidentiality, a friendly atmosphere, and a dedication to establishing trust. It resulted in rapid increases in visits by young persons both for preventive and curative services. In 2011, the government initiated a model for “integrated family and community health care” which led to a disruption of the central support for capacity building and follow-up of adolescent friendly services.

Conclusion

The Ecuadorian experience has demonstrated the need for institutionalised differentiated care for adolescents who are facing a wide range of health issues.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-017-0294-5) contains supplementary material, which is available to authorized users.

Challenges and strategies for sustaining youth-friendly health services - a qualitative study from the perspective of professionals at youth clinics in northern Sweden

Background

Youth-friendly health-care services — those that are accessible, acceptable, equitable, appropriate and effective for different youth subpopulations – are beneficial for youth health, but not easy to implement and sustain. Sweden is among the few countries where youth-friendly health-care services have been integrated within the public health system and sustained for a long time.

This study explores the challenges and strategies in providing sustainable youth-friendly health-care services, from the perspective of professionals working in youth clinics in northern Sweden.

Methods

Eleven semi-structured interviews with various health-care professionals working in youth clinics in northern Sweden were conducted. The interviews were transcribed verbatim, and analysed using thematic analysis in relation to the World Health Organization domains of youth friendliness.

Results

Four themes emerged from the analysis of the data: 1) ‘Meeting youths on their own terms – the key to ensuring a holistic and youth-centred care’ was related to the acceptability and appropriateness of the services; 2) ‘Organizational challenges and strategies in keeping professionals’ expertise on youth updated’ referred to the domain of effectiveness; 3) ‘Youth clinics are accessible for those who know and can reach them’ was related to the domains of accessibility and equity, and 4) ‘The challenge of combining strong directions and flexibility in diverse local realities’ focused on the struggle to sustain the youth clinics organization and their goals within the broader health system.

Conclusions

Professionals working in youth clinics are perceived as motivated, interested and knowledgeable about youth, and the clinics ensure confidentiality and a youth-centred and holistic approach. Challenges remain, especially in terms of ensuring equitable access to different youth subpopulations, improving monitoring routines and ensuring training and competence for all professionals, independently of the location and characteristics of the clinic. Youth clinics are perceived as an indisputable part of the Swedish health system, but organizational challenges are also pointed out in terms of weak clear directives and leadership, heavy workload, local/regional diversity and unequitable distribution of resources.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-016-0261-6) contains supplementary material, which is available to authorized users.

How do community health committees contribute to capacity building for maternal and child health? A realist evaluation protocol

INTRODUCTION

The proposed research is part of ongoing operations research within World Vision's Access: Infant and Maternal Health Programme. This study aims to identify key context features and underlying mechanisms through which community health committees build community capacity within the field of maternal and child health. This may help to improve programme implementation by providing contextually informed and explanatory findings for how community health committees work, what works best and for whom do they work for best for. Though frequently used within health programmes, little research is carried out on such committees' contribution to capacity building-a frequent goal or proposed outcome of these groups.

METHODS AND ANALYSIS

The scarce information that does exist often fails to explain 'how, why, and for whom' these committees work best. Since such groups typically operate within or as components of complex health interventions, they require a systems thinking approach and design, and thus so too does their evaluation. Using a mixed methods realist evaluation with intraprogramme case studies, this protocol details a proposed study on community health committees in rural Tanzania and Uganda to better understand underlying mechanisms through which these groups work (or do not) to build community capacity for maternal and child health. This research protocol follows the realist evaluation methodology of eliciting initial programme theories, to inform the field study design, which are detailed within. Thus far, the methodology of a realist evaluation has been well suited to the study of community health committees within these contexts. Implications for its use within these contexts are discussed within.

ETHICS AND DISSEMINATION

Institutional Review Boards and the appropriate research clearance bodies within Ireland, Uganda and Tanzania have approved this study. Planned dissemination activities include via academic and programme channels, as well as feedback to the communities in which this work occurs.

Developing and sustaining adolescent-friendly health services: A multiple case study from Ecuador and Peru

Adolescent-Friendly Health Services (AFHSs) are those that are accessible, acceptable, equitable, appropriate and effective for different youth sub-populations. This study investigated the process through which four clinics in two countries - Peru and Ecuador - introduced, developed and sustained AFHSs. A multiple case study design was chosen, and data from each clinic were collected through document review, observations and informant interviews. National level data were also collected. Data were analysed following thematic analysis. The findings showed that the process of introducing, developing and sustaining AFHSs was long term, and required a creative team effort and collaboration between donors, public institutions and health providers. The motivation and external support was crucial to initiating and sustaining the implementation of AFHSs. Health facilities' transformation into AFHSs was linked to the broader organisation of country health systems, and the evolution of national adolescent health policies. In Peru, the centralised approach to AFHSs introduction facilitated the dissemination of a comprehensive national model to health facilities, but dependency on national directives made it more difficult to systemise them when ideological and organisational changes occurred. In Ecuador, a less centralised approach to introducing AFHSs made for easier integration of the AFHSs model.

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Perceptions and experiences of access to public healthcare by people with disabilities and older people in Uganda

Introduction

In the year 2000, a set of eight Millennium Development Goals (MDGs) were presented as a way to channel global efforts into the reduction of poverty and the promotion of social development. A global discussion regarding how to renew these goals is underway and it is in this context that the Goals and Governance for Global Health (Go4Health) research consortium conducted consultations with marginalized communities in Asia, Latin America, the Pacific and Africa as a way to include their voices in world’s new development agenda. The goal of this paper is to present the findings of the consultations carried out in Uganda with two groups within low-resource settings: older people and people living with disabilities.

Methods

This qualitative study used focus group discussions and key informant interviews with older people in Uganda’s Kamwenge district, and with persons with disabilities from the Gulu region. Thematic analysis was performed and emerging categories and themes identified and presented in the findings.

Findings

Our findings show that a sense of community marginalization is present within both older persons and persons living with disabilities. These groups report experiencing political sidelining, discrimination and inequitable access to health services. This is seen as the key reason for their poor health. Clinical services were found to be of low quality with little or no access to facilities, trained personnel, and drugs and there are no rehabilitative or mental health services available.

Conclusion

Uganda must fulfil its international obligations and take progressive measures to meet the right to health for all its peoples, but especially allocate its limited resources to proactively support its most marginalized citizens. The growing impetus within post-2015 development negotiations to redress in-country health and other inequalities through a comprehensive systems approach is of importance in the Ugandan development context. This approach reflects the participant’s perspectives, which also calls for a more equitable approach to health and development as opposed to a narrow, vertical focus on specific population groups, as was the case with the MDGs.

Evaluation of capacity-building program of district health managers in India: a contextualized theoretical framework

Performance of local health services managers at district level is crucial to ensure that health services are of good quality and cater to the health needs of the population in the area. In many low- and middle-income countries, health services managers are poorly equipped with public health management capacities needed for planning and managing their local health system. In the south Indian Tumkur district, a consortium of five non-governmental organizations partnered with the state government to organize a capacity-building program for health managers. The program consisted of a mix of periodic contact classes, mentoring and assignments and was spread over 30 months. In this paper, we develop a theoretical framework in the form of a refined program theory to understand how such a capacity-building program could bring about organizational change. A well-formulated program theory enables an understanding of how interventions could bring about improvements and an evaluation of the intervention. In the refined program theory of the intervention, we identified various factors at individual, institutional, and environmental levels that could interact with the hypothesized mechanisms of organizational change, such as staff's perceived self-efficacy and commitment to their organizations. Based on this program theory, we formulated context-mechanism-outcome configurations that can be used to evaluate the intervention and, more specifically, to understand what worked, for whom and under what conditions. We discuss the application of program theory development in conducting a realist evaluation. Realist evaluation embraces principles of systems thinking by providing a method for understanding how elements of the system interact with one another in producing a given outcome.

Primary healthcare providers' views on improving sexual and reproductive healthcare for adolescents in Bolivia, Ecuador, and Nicaragua

Objectives

To elicit the views of primary healthcare providers from Bolivia, Ecuador, and Nicaragua on how adolescent sexual and reproductive health (ASRH) care in their communities can be improved.

Methods

Overall, 126 healthcare providers (46 from Bolivia, 39 from Ecuador, and 41 from Nicaragua) took part in this qualitative study. During a series of moderated discussions, they provided written opinions about the accessibility and appropriateness of ASRH services and suggestions for its improvement. The data were analyzed by employing a content analysis methodology.

Results

Study participants emphasized managerial issues such as the prioritization of adolescents as a patient group and increased healthcare providers’ awareness about adolescent-friendly approaches. They noted that such an approach needs to be extended beyond primary healthcare centers. Schools, parents, and the community in general should be encouraged to integrate issues related to ASRH in the everyday life of adolescents and become ‘gate-openers’ to ASRH services. To ensure the success of such measures, action at the policy level would be required. For example, decision-makers could call for developing clinical guidelines for this population group and coordinate multisectoral efforts.

Conclusions

To improve ASRH services within primary healthcare institutions in three Latin American countries, primary healthcare providers call for focusing on improving the youth-friendliness of health settings. To facilitate this, they suggested engaging with key stakeholders, such as parents, schools, and decision-makers at the policy level.

How do primary health care teams learn to integrate intimate partner violence (IPV) management? A realist evaluation protocol

BACKGROUND

Despite the existence of ample literature dealing, on the one hand, with the integration of innovations within health systems and team learning, and, on the other hand, with different aspects of the detection and management of intimate partner violence (IPV) within healthcare facilities, research that explores how health innovations that go beyond biomedical issues-such as IPV management-get integrated into health systems, and that focuses on healthcare teams' learning processes is, to the best of our knowledge, very scarce if not absent. This realist evaluation protocol aims to ascertain: why, how, and under what circumstances primary healthcare teams engage (if at all) in a learning process to integrate IPV management in their practices; and why, how, and under what circumstances team learning processes lead to the development of organizational culture and values regarding IPV management, and the delivery of IPV management services.

METHODS

This study will be conducted in Spain using a multiple-case study design. Data will be collected from selected cases (primary healthcare teams) through different methods: individual and group interviews, routinely collected statistical data, documentary review, and observation. Cases will be purposively selected in order to enable testing the initial middle-range theory (MRT). After in-depth exploration of a limited number of cases, additional cases will be chosen for their ability to contribute to refining the emerging MRT to explain how primary healthcare learn to integrate intimate partner violence management.

DISCUSSION

Evaluations of health sector responses to IPV are scarce, and even fewer focus on why, how, and when the healthcare services integrate IPV management. There is a consensus that healthcare professionals and healthcare teams play a key role in this integration, and that training is important in order to realize changes. However, little is known about team learning of IPV management, both in terms of how to trigger such learning and how team learning is connected with changes in organizational culture and values, and in service delivery. This realist evaluation protocol aims to contribute to this knowledge by conducting this project in a country, Spain, where great endeavours have been made towards the integration of IPV management within the health system.

Mechanisms for achieving adolescent-friendly services in Ecuador: a realist evaluation approach

BACKGROUND

Despite evidence showing that adolescent-friendly health services (AFSs) increase young people's access to these services, health systems across the world are failing to integrate this approach. In Latin America, policies aimed at strengthening AFS abound. However, such services are offered only in a limited number of sites, and providers' attitudes and respect for confidentiality have not been addressed to a sufficient extent.

METHODS

The aim of this study was to explore the mechanisms that triggered the transformation of an 'ordinary' health care facility into an AFS in Ecuador. For this purpose, a realist evaluation approach was used in order to analyse three well-functioning AFSs. Information was gathered at the national level and from each of the settings including: (i) statistical information and unpublished reports; (ii) in-depth interviews and focus group discussions with policy makers, health care providers, users and adolescents participating in youth organisations and (iii) observations at the health care facilities. Thematic analysis was carried out, driven by the realist evaluation approach, namely exploring the connections between mechanisms, contexts and outcomes.

RESULTS

The results highlighted that the development of the AFSs was mediated by four mechanisms: grounded self-confidence in trying new things, legitimacy, a transformative process and an integral approach to adolescents. Along this process, contextual factors at the national and institutional levels were further explored.

CONCLUSION

The Ministry of Health of Ecuador, based on the New Guidelines for Comprehensive Care of Adolescent Health, has started the scaling up of AFSs. Our research points towards the need to recognise and incorporate these mechanisms as part of the implementation strategy from the very beginning of the process. Although contextually limited to Ecuador, many mechanisms and good practices in these AFS may be relevant to the Latin American setting and elsewhere.