1
|
Wahi G, Kandasamy S, Bangdiwala SI, Baumann A, Crea-Arsenio M, Desai D, DiLiberto D, Georgiades K, Jackson-Best F, Kwan M, Montague P, Newbold KB, Sherifali D, Sim A, de Souza RJ, Anand SS. Strengthening Community Roots: Anchoring Newcomers in Wellness and Sustainability (SCORE!): A protocol for the co-design and evaluation of a healthy active living program among a newcomer community in Canada. PLoS One 2023; 18:e0288851. [PMID: 37768908 PMCID: PMC10538726 DOI: 10.1371/journal.pone.0288851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND The burden of childhood obesity and cardiometabolic risk factors affecting newcomer Canadians living in lower socioeconomic circumstances is a concerning public health issue. This paper describes Strengthening Community Roots: Anchoring Newcomers in Wellness and Sustainability (SCORE!), an academic-community research partnership to co-design interventions that nurture and optimize healthy activity living (HAL) among a community of children and families new to Canada in Hamilton, Ontario, Canada. METHODS/DESIGN Our overarching program is informed by a socio-ecological model, and will co-create HAL interventions for children and families new to Canada rooted in outdoor, nature-based physical activity. We will proceed in three phases: Phase 1) synthesis of existing evidence regarding nature based HAL interventions among children and families; Phase 2) program development through four data collection activities including: i) community engagement activities to build trustful relationships and understand barriers and facilitators, including establishing a community advisory and action board, qualitative studies including a photovoice study, and co-design workshops to develop programs; ii) characterizing the demographics of the community through a household survey; iii) characterizing the built environment and HAL programs/services available in the community by developing an accessible real-time systems map; and iv) reviewing municipal policies relevant to HAL and sustainability; leading to Phase 3) implementation and evaluation of the feasibility of co-designed HAL programs. CONCLUSION The etiology of childhood obesity and related chronic diseases is complex and multifactorial, as are intervention strategies. The SCORE! program of research brings together partners including community members, service providers, academic researchers, and organizational leaders to build a multi-component intervention that promotes the health and wellness of newcomer children and families.
Collapse
Affiliation(s)
- Gita Wahi
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- Chanchlani Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - Sujane Kandasamy
- Chanchlani Research Centre, McMaster University, Hamilton, Ontario, Canada
- Child and Youth Studies, Brock University, St Catherines, Ontario, Canada
| | - Shrikant I. Bangdiwala
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Baumann
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
- Global Health Office, McMaster University, Hamilton, Ontario, Canada
| | - Mary Crea-Arsenio
- Global Health Office, McMaster University, Hamilton, Ontario, Canada
| | - Dipika Desai
- Chanchlani Research Centre, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Deborah DiLiberto
- Global Health Office, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Katholiki Georgiades
- Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Offord Centre for Child Studies, Ron Joyce Children’s Health Centre, Hamilton, Ontario, Canada
| | - Fatimah Jackson-Best
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Matthew Kwan
- Child and Youth Studies, Brock University, St Catherines, Ontario, Canada
| | - Patricia Montague
- Chanchlani Research Centre, McMaster University, Hamilton, Ontario, Canada
| | - K. Bruce Newbold
- School of Earth, Environment & Society, McMaster University, Hamilton, Ontario, Canada
| | - Diana Sherifali
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Sim
- Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Russell J. de Souza
- Chanchlani Research Centre, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sonia S. Anand
- Chanchlani Research Centre, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | |
Collapse
|
2
|
Archer N, Lokker C, Ghasemaghaei M, DiLiberto D. eHealth Implementation Issues in Low-Resource Countries: Model, Survey, and Analysis of User Experience. J Med Internet Res 2021; 23:e23715. [PMID: 34142967 PMCID: PMC8277330 DOI: 10.2196/23715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/01/2020] [Accepted: 05/15/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The implementation of eHealth in low-resource countries (LRCs) is challenged by limited resources and infrastructure, lack of focus on eHealth agendas, ethical and legal considerations, lack of common system interoperability standards, unreliable power, and shortage of trained workers. OBJECTIVE The aim of this study is to describe and study the current situation of eHealth implementation in a small number of LRCs from the perspectives of their professional eHealth users. METHODS We developed a structural equation model that reflects the opinions of professional eHealth users who work on LRC health care front lines. We recruited country coordinators from 4 LRCs to help recruit survey participants: India, Egypt, Nigeria, and Kenya. Through a web-based survey that focused on barriers to eHealth implementation, we surveyed 114 participants. We analyzed the information using a structural equation model to determine the relationships among the constructs in the model, including the dependent variable, eHealth utilization. RESULTS Although all the model constructs were important to participants, some constructs, such as user characteristics, perceived privacy, and perceived security, did not play a significant role in eHealth utilization. However, the constructs related to technology infrastructure tended to reduce the impact of concerns and uncertainties (path coefficient=-0.32; P=.001), which had a negative impact on eHealth utilization (path coefficient=-0.24; P=.01). Constructs that were positively related to eHealth utilization were implementation effectiveness (path coefficient=0.45; P<.001), the countries where participants worked (path coefficient=0.29; P=.004), and whether they worked for privately or publicly funded institutions (path coefficient=0.18; P<.001). As exploratory research, the model had a moderately good fit for eHealth utilization (adjusted R2=0.42). CONCLUSIONS eHealth success factors can be categorized into 5 groups; our study focused on frontline eHealth workers' opinions concerning 2 of these groups: technology and its support infrastructure and user acceptance. We found significant disparities among the responses from different participant groups. Privately funded organizations tended to be further ahead with eHealth utilization than those that were publicly funded. Moreover, participant comments identified the need for more use of telemedicine in remote and rural regions in these countries. An understanding of these differences can help regions or countries that are lagging in the implementation and use of eHealth technologies. Our approach could also be applied to detailed studies of the other 3 categories of success factors: short- and long-term funding, organizational factors, and political or legislative aspects.
Collapse
Affiliation(s)
- Norman Archer
- Information Systems, DeGroote School of Business, McMaster University, Hamilton, ON, Canada
| | - Cynthia Lokker
- Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Maryam Ghasemaghaei
- Information Systems, DeGroote School of Business, McMaster University, Hamilton, ON, Canada
| | - Deborah DiLiberto
- Global Health, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
3
|
Burchett HED, Leurent B, Baiden F, Baltzell K, Björkman A, Bruxvoort K, Clarke S, DiLiberto D, Elfving K, Goodman C, Hopkins H, Lal S, Liverani M, Magnussen P, Mårtensson A, Mbacham W, Mbonye A, Onwujekwe O, Roth Allen D, Shakely D, Staedke S, Vestergaard LS, Whitty CJM, Wiseman V, Chandler CIR. Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence. BMJ Open 2017; 7:e012973. [PMID: 28274962 PMCID: PMC5353269 DOI: 10.1136/bmjopen-2016-012973] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts. DESIGN A comparative case study approach, analysing variation in outcomes across different settings. SETTING Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case. PARTICIPANTS 28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria. INTERVENTIONS The interventions included different mRDT training packages, supervision, supplies and community sensitisation. OUTCOME MEASURES Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider adherence to positive mRDTs (% Plasmodium falciparum positive prescribed/given Artemisinin Combination Treatment); (3) provider adherence to negative mRDTs (% P. falciparum negative not prescribed/given antimalarial). RESULTS Outcomes varied widely across cases: 12-100% mRDT uptake; 44-98% adherence to positive mRDTs; 27-100% adherence to negative mRDTs. Providers appeared more motivated to perform well when mRDTs and intervention characteristics fitted with their own priorities. Goodness of fit of mRDTs with existing consultation and diagnostic practices appeared crucial to maximising the impact of mRDTs on care, as did prior familiarity with malaria testing; adequate human resources and supplies; possible alternative treatments for mRDT-negative patients; a more directive intervention approach and local preferences for ACTs. CONCLUSIONS Basic training and resources are essential but insufficient to maximise the potential of mRDTs in many contexts. Programme design should respond to assessments of provider priorities, expectations and capacities. As mRDTs become established, the intensity of supporting interventions required seems likely to reduce.
Collapse
Affiliation(s)
- Helen E D Burchett
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Baptiste Leurent
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Frank Baiden
- Epidemiology Unit, Ensign College of Public Health, Kpong, Ghana
| | - Kimberly Baltzell
- Department of Family Health Care Nursing, and Global Health Science, University of California, Berkeley, California, USA
| | - Anders Björkman
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Katia Bruxvoort
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Siân Clarke
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Deborah DiLiberto
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristina Elfving
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Heidi Hopkins
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Sham Lal
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Mårtensson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Wilfred Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé, Yaoundé, Cameroon
| | - Anthony Mbonye
- School of Public Health- Makerere University and Commissioner Health Services, Ministry of Health, Uganda
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria Enugu-Campus, Nigeria
| | | | - Delér Shakely
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
- Department of Medicine, Kungälv Hospital, Sweden
| | - Sarah Staedke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Lasse S Vestergaard
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital Rigshospitalet, Denmark
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Denmark
| | - Christopher J M Whitty
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health and Community Medicine, Australia
| | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
4
|
Chandler CIR, Burchett H, Boyle L, Achonduh O, Mbonye A, DiLiberto D, Reyburn H, Onwujekwe O, Haaland A, Roca-Feltrer A, Baiden F, Mbacham WF, Ndyomugyenyi R, Nankya F, Mangham-Jefferies L, Clarke S, Mbakilwa H, Reynolds J, Lal S, Leslie T, Maiteki-Sebuguzi C, Webster J, Magnussen P, Ansah E, Hansen KS, Hutchinson E, Cundill B, Yeung S, Schellenberg D, Staedke SG, Wiseman V, Lalloo DG, Whitty CJM. Examining Intervention Design: Lessons from the Development of Eight Related Malaria Health Care Intervention Studies. Health Syst Reform 2016; 2:373-388. [PMID: 31514719 PMCID: PMC6176770 DOI: 10.1080/23288604.2016.1179086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract—Rigorous evidence of “what works” to improve health care is in demand, but methods for the development of interventions have not been scrutinized in the same ways as methods for evaluation. This article presents and examines intervention development processes of eight malaria health care interventions in East and West Africa. A case study approach was used to draw out experiences and insights from multidisciplinary teams who undertook to design and evaluate these studies. Four steps appeared necessary for intervention design: (1) definition of scope, with reference to evaluation possibilities; (2) research to inform design, including evidence and theory reviews and empirical formative research; (3) intervention design, including consideration and selection of approaches and development of activities and materials; and (4) refining and finalizing the intervention, incorporating piloting and pretesting. Alongside these steps, projects produced theories, explicitly or implicitly, about (1) intended pathways of change and (2) how their intervention would be implemented.The work required to design interventions that meet and contribute to current standards of evidence should not be underestimated. Furthermore, the process should be recognized not only as technical but as the result of micro and macro social, political, and economic contexts, which should be acknowledged and documented in order to infer generalizability. Reporting of interventions should go beyond descriptions of final intervention components or techniques to encompass the development process. The role that evaluation possibilities play in intervention design should be brought to the fore in debates over health care improvement.
Collapse
Affiliation(s)
- Clare I R Chandler
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Helen Burchett
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Louise Boyle
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Olivia Achonduh
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé I , Yaoundé , Cameroon
| | - Anthony Mbonye
- School of Public Health-Makerere University & Commissioner Health Services, Ministry of Health , Kampala , Uganda
| | - Deborah DiLiberto
- Clinical Research Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Hugh Reyburn
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics , University of Nigeria Enugu-Campus , Enugu , Nigeria
| | - Ane Haaland
- Institute of Health and Society , Department of Community Medicine , Blindern , Oslo , Norway
| | | | - Frank Baiden
- Malaria Group, Kintampo Health Research Centre , Kintampo , Ghana
| | - Wilfred F Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé I , Yaoundé , Cameroon
| | | | - Florence Nankya
- Infectious Diseases Research Collaboration , Kampala , Uganda
| | - Lindsay Mangham-Jefferies
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Sian Clarke
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Hilda Mbakilwa
- Joint Malaria Programme, Kilimanjaro Christian Medical Centre , Moshi , Tanzania
| | - Joanna Reynolds
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Sham Lal
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Toby Leslie
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | | | - Jayne Webster
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Pascal Magnussen
- Centre for Medical Parasitology, Faculty of Health and Medical Sciences, University of Copenhagen , Copenhagen , Denmark
| | - Evelyn Ansah
- Dangme West District Health Directorate, Ghana Health Service , Dodowa , Ghana
| | - Kristian S Hansen
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Eleanor Hutchinson
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - Bonnie Cundill
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Shunmay Yeung
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK
| | - David Schellenberg
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Sarah G Staedke
- Disease Control Department , London School of Hygiene & Tropical Medicine , London , UK
| | - Virginia Wiseman
- Department of Global Health and Development , London School of Hygiene & Tropical Medicine , London , UK.,School of Public Health and Community Medicine , Kensington , New South Wales , Australia
| | | | | |
Collapse
|
5
|
Nayiga S, DiLiberto D, Taaka L, Nabirye C, Haaland A, Staedke SG, Chandler CIR. Strengthening patient-centred communication in rural Ugandan health centres: A theory-driven evaluation within a cluster randomized trial. Evaluation (Lond) 2014; 20:471-491. [PMID: 25983612 PMCID: PMC4425297 DOI: 10.1177/1356389014551484] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This article describes a theory-driven evaluation of one component of an intervention to improve the quality of health care at Ugandan public health centres. Patient-centred services have been advocated widely, but such approaches have received little attention in Africa. A cluster randomized trial is evaluating population-level outcomes of an intervention with multiple components, including 'patient-centred services.' A process evaluation was designed within this trial to articulate and evaluate the implementation and programme theories of the intervention. This article evaluates one hypothesized mechanism of change within the programme theory: the impact of the Patient Centred Services component on health-worker communication. The theory-driven approach extended to evaluation of the outcome measures. The study found that the proximal outcome of patient-centred communication was rated 10 percent higher (p < 0.008) by care seekers consulting with the health workers who were at the intervention health centres compared with those at control health centres. This finding will strengthen interpretation of more distal trial outcomes.
Collapse
Affiliation(s)
- Susan Nayiga
- Infectious Disease Research Collaboration, Uganda
| | | | - Lilian Taaka
- Infectious Disease Research Collaboration, Uganda
| | | | | | | | | |
Collapse
|
6
|
DiLiberto D, Staedke S, Maiteki-Sebuguzi C, Naiga S, Chandler C. Impacts beyond primary outcomes: a mixed-methods study exploring multiple perspectives of a health system intervention in Eastern Uganda. BMC Health Serv Res 2014. [PMCID: PMC4122907 DOI: 10.1186/1472-6963-14-s2-p29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
7
|
Reynolds J, DiLiberto D, Mangham-Jefferies L, Ansah EK, Lal S, Mbakilwa H, Bruxvoort K, Webster J, Vestergaard LS, Yeung S, Leslie T, Hutchinson E, Reyburn H, Lalloo DG, Schellenberg D, Cundill B, Staedke SG, Wiseman V, Goodman C, Chandler CIR. The practice of 'doing' evaluation: lessons learned from nine complex intervention trials in action. Implement Sci 2014; 9:75. [PMID: 24935096 PMCID: PMC4079170 DOI: 10.1186/1748-5908-9-75] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/13/2014] [Indexed: 01/16/2023] Open
Abstract
Background There is increasing recognition among trialists of the challenges in understanding how particular ‘real-life’ contexts influence the delivery and receipt of complex health interventions. Evaluations of interventions to change health worker and/or patient behaviours in health service settings exemplify these challenges. When interpreting evaluation data, deviation from intended intervention implementation is accounted for through process evaluations of fidelity, reach, and intensity. However, no such systematic approach has been proposed to account for the way evaluation activities may deviate in practice from assumptions made when data are interpreted. Methods A collective case study was conducted to explore experiences of undertaking evaluation activities in the real-life contexts of nine complex intervention trials seeking to improve appropriate diagnosis and treatment of malaria in varied health service settings. Multiple sources of data were used, including in-depth interviews with investigators, participant-observation of studies, and rounds of discussion and reflection. Results and discussion From our experiences of the realities of conducting these evaluations, we identified six key ‘lessons learned’ about ways to become aware of and manage aspects of the fabric of trials involving the interface of researchers, fieldworkers, participants and data collection tools that may affect the intended production of data and interpretation of findings. These lessons included: foster a shared understanding across the study team of how individual practices contribute to the study goals; promote and facilitate within-team communications for ongoing reflection on the progress of the evaluation; establish processes for ongoing collaboration and dialogue between sub-study teams; the importance of a field research coordinator bridging everyday project management with scientific oversight; collect and review reflective field notes on the progress of the evaluation to aid interpretation of outcomes; and these approaches should help the identification of and reflection on possible overlaps between the evaluation and intervention. Conclusion The lessons we have drawn point to the principle of reflexivity that, we argue, needs to become part of standard practice in the conduct of evaluations of complex interventions to promote more meaningful interpretations of the effects of an intervention and to better inform future implementation and decision-making.
Collapse
Affiliation(s)
- Joanna Reynolds
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Banek K, Nankabirwa J, Maiteki-Sebuguzi C, DiLiberto D, Taaka L, Chandler CIR, Staedke SG. Community case management of malaria: exploring support, capacity and motivation of community medicine distributors in Uganda. Health Policy Plan 2014; 30:451-61. [PMID: 24816572 PMCID: PMC4385822 DOI: 10.1093/heapol/czu033] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In Uganda, community services for febrile children are expanding from presumptive treatment of fever with anti-malarials through the home-based management of fever (HBMF) programme, to include treatment for malaria, diarrhoea and pneumonia through Integrated Community Case Management (ICCM). To understand the level of support available, and the capacity and motivation of community health workers to deliver these expanded services, we interviewed community medicine distributors (CMDs), who had been involved in the HBMF programme in Tororo district, shortly before ICCM was adopted. METHODS Between October 2009 and April 2010, 100 CMDs were recruited to participate by convenience sampling. The survey included questionnaires to gather information about the CMDs' work experience and to assess knowledge of fever case management, and in-depth interviews to discuss experiences as CMDs including motivation, supervision and relationships with the community. All questionnaires and knowledge assessments were analysed. Summary contact sheets were made for each of the 100 interviews and 35 were chosen for full transcription and analysis. RESULTS CMDs faced multiple challenges including high patient load, limited knowledge and supervision, lack of compensation, limited drugs and supplies, and unrealistic expectations of community members. CMDs described being motivated to volunteer for altruistic reasons; however, the main benefits of their work appeared related to 'becoming someone important', with the potential for social mobility for self and family, including building relationships with health workers. At the time of the survey, over half of CMDs felt demotivated due to limited support from communities and the health system. CONCLUSIONS Community health worker programmes rely on the support of communities and health systems to operate sustainably. When this support falls short, motivation of volunteers can wane. If community interventions, in increasingly complex forms, are to become the solution to improving access to primary health care, greater attention to what motivates individuals, and ways to strengthen health system support are required.
Collapse
Affiliation(s)
- Kristin Banek
- Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Joaniter Nankabirwa
- Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Catherine Maiteki-Sebuguzi
- Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Deborah DiLiberto
- Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Lilian Taaka
- Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Clare I R Chandler
- Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Sarah G Staedke
- Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda Uganda Malaria Surveillance Project, Infectious Disease Research Collaboration, P.O. Box 7475, Kampala, Uganda, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and Departments of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| |
Collapse
|
9
|
Chandler CIR, DiLiberto D, Nayiga S, Taaka L, Nabirye C, Kayendeke M, Hutchinson E, Kizito J, Maiteki-Sebuguzi C, Kamya MR, Staedke SG. The PROCESS study: a protocol to evaluate the implementation, mechanisms of effect and context of an intervention to enhance public health centres in Tororo, Uganda. Implement Sci 2013; 8:113. [PMID: 24079992 PMCID: PMC3849653 DOI: 10.1186/1748-5908-8-113] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 09/17/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Despite significant investments into health improvement programmes in Uganda, health indicators and access to healthcare remain poor across the country. The PRIME trial aims to evaluate the impact of a complex intervention delivered in public health centres on health outcomes of children and management of malaria in rural Uganda. The intervention consists of four components: Health Centre Management; Fever Case Management; Patient- Centered Services; and support for supplies of malaria diagnostics and antimalarial drugs. METHODS The PROCESS study will use mixed methods to evaluate the processes, mechanisms of change, and context of the PRIME intervention by addressing five objectives. First, to develop a comprehensive logic model of the intervention, articulating the project's hypothesised pathways to trial outcomes. Second, to evaluate the implementation of the intervention, including health worker training, health centre management tools, and the supply of artemether-lumefantrine (AL) and rapid diagnostic tests (RDTs) for malaria. Third, to understand mechanisms of change of the intervention components, including testing hypotheses and interpreting realities of the intervention, including resistance, in context. Fourth, to develop a contextual record over time of factors that may have affected implementation of the intervention, mechanisms of change, and trial outcomes, including factors at population, health centre and district levels. Fifth, to capture broader expected and unexpected impacts of the intervention and trial activities among community members, health centre workers, and private providers. Methods will include intervention logic mapping, questionnaires, recorded consultations, in-depth interviews, focus group discussions, and contextual data documentation. DISCUSSION The findings of this PROCESS study will be interpreted alongside the PRIME trial results. This will enable a greater ability to generalise the findings of the main trial. The investigators will attempt to assess which methods are most informative in such evaluations of complex interventions in low-resource settings. TRIAL REGISTRATION Clinicaltrials.gov, NCT01024426.
Collapse
Affiliation(s)
- Clare IR Chandler
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK
| | - Deborah DiLiberto
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, WC1E 7HT, London, UK
| | - Susan Nayiga
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| | - Lilian Taaka
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| | - Christine Nabirye
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| | - Miriam Kayendeke
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK
| | - James Kizito
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| | | | - Moses R Kamya
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, WC1E 7HT, London, UK
- Infectious Disease Research Collaboration, PO Box 7475, Kampala, Uganda
| |
Collapse
|
10
|
Staedke SG, Chandler CIR, DiLiberto D, Maiteki-Sebuguzi C, Nankya F, Webb E, Dorsey G, Kamya MR. The PRIME trial protocol: evaluating the impact of an intervention implemented in public health centres on management of malaria and health outcomes of children using a cluster-randomised design in Tororo, Uganda. Implement Sci 2013; 8:114. [PMID: 24079295 PMCID: PMC3851935 DOI: 10.1186/1748-5908-8-114] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 09/19/2013] [Indexed: 11/10/2022] Open
Abstract
Background In Africa, inadequate health services contribute to the lack of progress on malaria control. Evidence of the impact of interventions to improve health services on population-level malaria indicators is needed. We are conducting a cluster-randomised trial to assess whether a complex intervention delivered at public health centres in Uganda improves health outcomes of children and treatment of malaria, as compared to the current standard of care. Methods/Design Twenty public health centres (level II and III) in Tororo district will be included; 10 will be randomly assigned to the intervention and 10 to control. Clusters will include households located within 2 km of health centres. The trial statistician will generate the random allocation sequence and assign clusters. Health centres will be stratified by level, and restricted randomisation will be employed to ensure balance on cluster location and size. Allocation will not be blinded. The intervention includes training in health centre management, fever case management with use of rapid diagnostic tests (RDTs) for malaria, and patient-centered services, and provision of artemether-lumefantrine (AL) and RDTs when stocks run low. The impact of the intervention on population-level health indicators will be assessed through community surveys conducted at baseline in randomly selected children from each cluster, and repeated annually for two years. The impact on individuals over time will be assessed in a cohort study of children recruited from households randomly selected per cluster. The impact on health centres will be assessed using patient exit interviews, monthly surveillance, and assessment of health worker knowledge and skills. The primary outcome is the prevalence of anaemia (haemoglobin <11.0 g/dL) in individual children under five measured in the annual community surveys. The primary analysis will be based on the cluster-level results. Discussion The PRIME trial findings will be supplemented by the PROCESS study, an evaluation of the process, context, and wider impact of the PRIME intervention which will be conducted alongside the main trial, together providing evidence of the health impact of a public sector intervention in Uganda. Trial registration and funding This trial is registered at Clinicaltrials.gov (NCT01024426) and is supported by the ACT Consortium.
Collapse
Affiliation(s)
- Sarah G Staedke
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Chandler CIR, Kizito J, Taaka L, Nabirye C, Kayendeke M, DiLiberto D, Staedke SG. Aspirations for quality health care in Uganda: How do we get there? Hum Resour Health 2013; 11:13. [PMID: 23521859 PMCID: PMC3610284 DOI: 10.1186/1478-4491-11-13] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 02/28/2013] [Indexed: 06/01/2023]
Abstract
BACKGROUND Despite significant investments and reforms, health care remains poor for many in Africa. To design an intervention to improve access and quality of health care at health facilities in eastern Uganda, we aimed to understand local priorities for qualities in health care, and factors that enable or prevent these qualities from being enacted. METHODS In 2009 to 2010, we carried out 69 in-depth interviews and 6 focus group discussions with 65 health workers at 17 health facilities, and 10 focus group discussions with 113 community members in Tororo District, Uganda. RESULTS Health-care workers and seekers valued technical, interpersonal and resource qualities in their aspirations for health care. However, such qualities were frequently not enacted, and our analysis suggests that meeting aspirations required social and financial resources to negotiate various power structures. CONCLUSIONS We argue that achieving aspirations for qualities valued in health care will require a genuine reorientation of focus by health workers and their managers toward patients, through renewed respect and support for these providers as professionals.
Collapse
Affiliation(s)
- Clare I R Chandler
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - James Kizito
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, PO Box 7475, Kampala, Uganda
| | - Lilian Taaka
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, PO Box 7475, Kampala, Uganda
| | - Christine Nabirye
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, PO Box 7475, Kampala, Uganda
| | - Miriam Kayendeke
- Infectious Diseases Research Collaboration, Mulago Hospital Complex, PO Box 7475, Kampala, Uganda
| | - Deborah DiLiberto
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel St, London, WCIE 7HT, UK
| | - Sarah G Staedke
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel St, London, WCIE 7HT, UK
| |
Collapse
|
12
|
De Niz M, Eziefula AC, Maiteki-Sebuguzi C, Gonahasa S, DiLiberto D, Tumwebaze P, Staedke SG, Drakeley CJ. Mass screening tools for glucose-6-phosphate dehydrogenase deficiency: validation of the WST8/1 -methoxy-PMS enzymatic assay in a highly malaria-endemic area in Uganda. Malar J 2012. [PMCID: PMC3472219 DOI: 10.1186/1475-2875-11-s1-o28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|