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# realist evaluation protocol

Geneva: World Health Organization; 2012. Accountability for Maternal, Newborn and Child Survival: An Update on Progress in Priority Countries. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Realist impact evaluation draws on the realism school of philosophy. Implementation Science However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. PubMed  The commitment by key health decision-makers at Anambra state to engage with this research is particularly encouraging. The NDP comprises a range of organisational and service delivery changes to support evidence-based practices and policies. Enyi Etiaba. New York: Routledge; 1994. Mixed methods study designs that are increasingly used to evaluate complex interventions [35] include the exploratory (qualitative methods followed by quantitative), explanatory (quantitative then qualitative), embedded (one dataset provides a supportive secondary role) and convergent (both datasets are complementary to each other) models [35, 36]. Last, at least two FGDs will be conducted, each involving 6–8 service users including members of their families, to enable comparison of their views and exploring the dynamics of their discussion. Thus, the final explanation of a programme considers context-mechanism-outcome.[5]. The protocol is largely very clear and well described but there are some areas that require further elaboration: While the aims and objectives have a realist flavor to them, the research questions seem to … This mixed-method study uses a realist evaluation approach to examine user feedback systems at two Upazila health complexes in Comilla District of Bangladesh, and comprises three … [PMC free article] Marchal B, Van Belle SB, Van Olmen J, Hoeree T, Kegels G. Is realist evaluation keeping its promise_ A review of published empirical studies in the field of health systems research. alternative respondents). middle-range theories) that link intervention inputs to processes, outputs and outcomes within the context of Anambra state. The project will be carried out with full respect of current relevant legislation (e.g. Malar J. 2006;5(1):117. J Adv Nurs. London: Sage Publications Limited; 1997. Key officials in the Ministry of Health at Federal, State and Local Government levels expressed interest in assessing the performance of SURE-P/MCH and SURE-P/MCH + CCT (the ‘interventions’) and key contextual influences on the achievement of their objectives. Manage cookies/Do not sell my data we use in the preference centre. An incremental cost-effectiveness analysis will be undertaken (cost per additional skilled delivery and associated care). 2005;352(20):2091–9. Ritchie J, Spencer L. Qualitative data analysis for applied policy research. LGAs will be selected in the discussion with State MOH policymakers and programme managers based on high maternal mortality ratios and existence of effective and committed district health leadership. Abuja, Nigeria: Subsidy Reinvestment and Empowerment Programme (SURE-P); 2013. Subsidy Reinvestment and Empowerment Programme (SURE-P): 2012 Annual Report. Realist Synthesis: An Introduction: This paper presents an introductory overview of realist synthesis as applied to the review of primary research on healthcare systems. Realist evaluation is a form of theory-driven evaluation, but is set apart by its explicit philosophical underpinnings. $${Y}_t = {\beta}_0+\kern0.5em {\beta}_1{T}_t+\kern0.5em {\beta}_2{I}_t+\kern0.5em {\beta}_3{T}_t{I}_t + {\beta}_4{X}_t + {\varepsilon}_t$$, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/, https://doi.org/10.1186/s13012-016-0443-1. 2010;88:364–70. Delivering presentations at local, state and federal meetings in Nigeria and relevant international meetings; Regular project review meetings and continuous engagement with key decision-makers, Developing newsletters, press-releases and interviews in the media aimed at communicating the key project findings to the public in Nigeria and more widely, Developing a dedicated website where the project results will be publicly accessible by national and international decision-makers, practitioners and academics, Delivering presentations at national and international conferences and publication of articles in peer-reviewed academic journals with emphasis on open access, Developing a project research report for the funder, with a publishable executive summary. Methodology and analysis This paper disseminates the protocol for an 18-month ‘RESPOND’ project that aims to evaluate the system of collecting and responding to user feedback in Bangladesh. Health Policy Plan. t The realist evaluation approach is a relatively new approach to evaluation, especially in some fields (such as health services research). t t This is due to the diversity of country contexts and complexity of CHW programmes, which require combinations of elements at micro (i.e. Excerpt "A realist approach assumes that programs are “theories incarnate”. Evaluation. The parameter β0 represents the baseline level of the dependent variable; β1 represents the baseline trend in the dependent variable; β2 isolates any shift in the level (intercept) of the dependent variable following the introduction of the policy; β3 isolates any shift in the rate of change (slope) following the introduction of the policy and β4 represents the effect of a covariate. This quantitative analysis interrelates with the qualitative IDIs mentioned earlier. Central to the supply component was the recruitment, training and deployment of 2000 formal service providers (e.g. The relationships between and amongst these Cs, Ms and Os will be explored as part of the data collection and analysis. Health Res Policy Syst. Realist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). In realist evaluation the researcher or evaluator’s task is to gather the data – i.e. 2nd ed. Evaluation of complex interventions such as SURE-P and their longer-term impact on MCH outcomes requires a comprehensive understanding of intervention context, implementation, mechanisms and outcomes. This realist evaluation protocol sets out the approach that will be used to identify and explain which aspects of the programme are working, for whom and in what circumstances to produce the outcomes intended. is time after the intervention; X the Charter of Fundamental Rights of the EU) and international conventions (e.g. We will ‘embed’ the research into policy and practice, working with the federal, state and local actors. The qualitative and quantitative methods will be integrated throughout to answer the eight study research questions. BMC Public Health. Qualitative methods will include (a) IDIs with key actors, including service users, (b) reviews of key documents and (c) exit IDIs and focus group discussions (FGDs) with service users and their family members. realist evaluation protocol Reena Devi, 1,2 Julienne Meyer , 3 Jay Banerjee, 4,5 Claire Goodman, 6 John Raymond Fletcher Gladman, 7 T om Dening, 8 Neil Chadborn, 1 As with all primary research approaches, guidance on quality assurance and uniform reporting is an important step towards improving quality and consistency. 2): (1) initial theory development; (2) theory validation and (3) theory refinement and development of lessons learned. It explains when a realist impact evaluation may be most BMC Public Health. METHODS AND ANALYSIS: The study will be conducted in four phases. Based on specific theories, realist evaluation provides an alternative lens to empiricist evaluation techniques for the study and understanding of programmes and policies. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Nuffield Centre for International Health and Development, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, UK, Tolib Mirzoev, Bassey Ebenso, Reinhard Huss, Joseph P. Hicks, James Newell & Timothy Ensor, Health Policy Research Group & the Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu-Campus, Enugu, 400001, Nigeria, Enyi Etiaba, Benjamin Uzochukwu, Obinna Onwujekwe & Nkoli Ezumah, School of Sociology and Social Policy, Social Sciences Building, University of Leeds, Leeds, UK, You can also search for this author in The demand component of the SURE-P/MCH programme aimed to increase utilisation of health services during pregnancy and at birth through the use of CCTs, i.e. 2009;8(1):265. Knowlton LW, Phillips CC. Correspondence to 2011;6(1):11. The study is guided by the research questions shown in Table 1, alongside the corresponding objectives. skilled midwives) and 10,000 CHWs, comprising 1000 Community Health Extension Workers (CHEWs) and 9000 volunteer Village Health Workers (VHWs). Working with International Medical Corps (IMC), an initial programme theory was elicited through literature and document reviews, semistructured interviews and focus groups with IMC programme managers and CHWs. An example involving the first two indicators might be: ‘deployment of CHWs, combined with improvement in infrastructure and supplies when implemented within the health systems context of Nigeria, will help reduce maternal and neonatal mortalities to 320/100,000 and 7/1000 live births respectively’. Although there are excellent examples of how realist evaluation might be used for evaluation in different healthcare contexts (e.g. Neither of the funders had any role in the design of this study. political and resource environment), at the meso level (e.g. A general model for an ITS regression analysis (which will be adapted to allow for comparison between SURE-P/MCH, SURE-P/MCH + CCT and control clusters) is: where Y By using this website, you agree to our The purpose of this paper is to share the study protocol for realist evaluation of CHW programme in Nigeria. A detailed list of respondents will be developed within step 1, and snowballing will be used to identify any further informants. In this paper, we report the methodology for a 5-year study which aims to evaluate the context, processes, outcomes and longer-term sustainability of a Nigerian CHW scheme. This paper should be of interest to researchers who are adapting and applying robust methodologies for assessing complex health systems interventions and policymakers and practitioners who are interested in commissioning, and engaging in, similar evaluations. Unnecessary collection of personal data will be avoided, and respondents will have the right to review outputs and withdraw consent. Meeting the aims through realist evaluation. actors’ behaviours in implementing intervention) to produce intended and unintended Outcomes. This realist evaluation protocol sets out the approach that will be used to identify and explain which aspects of the programme are working, for whom and in what circumstances to produce the outcomes intended. Article  'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. This paper presents a protocol of a multimethod study using a realist evaluation approach to investigate the impact and effectiveness of IR in hospital wards on the organisation, delivery and experience of care from the perspective of patients, their family members and staff. [4], Pawson & Tilley (1997) describe the procedure followed in the implementation of realist evaluation techniques in programme evaluation and emphasise that once hypotheses have been generated and data collected, the outcomes of the programme are explored, focusing on the groups that the programme benefitted and those who did not benefit. Introduction Significant evidence in the literature supports case management (CM) as an effective intervention to improve care for patients with complex healthcare needs. BMC Public Health. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question ‘what interventions … The development of interview question guides will be informed by the study conceptual framework and structured around the study research questions to explore the specific hypothetical pathways identified in step 1. acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration and sustainability of the interventions [37], which often influence the progression from inputs to processes, outputs and outcomes within health programmes. © 2020 BioMed Central Ltd unless otherwise stated. 2011;26 suppl 2:ii84–91. This approach, developed by the Nuffield Centre, has been effective in many countries in improving the quality and effectiveness of the scaled-up programme [46]. Pawson R, Tilley N. Realist Evaluation. Studies have explored the effectiveness of CHW programmes in improving MCH outcomes [14, 15], productivity of CHWs [12], costs and cost-effectiveness of CHW initiatives [4, 16], power relations and acceptance of CHW programmes by the public [6, 17] and effectiveness of associated conditional cash transfers (CCTs) linked to uptake of services [18, 19]. This study will make an important and timely contribution to health systems strengthening in Nigeria. The assessment of the ITS design against standard quality checklist [42] is shown in Additional file 1. Excerpt "A realist approach assumes that programs are “theories incarnate”. NPHCDA. Karki D, Mirzoev T, Green A, Newell J, Baral S. Costs of a successful public-private partnership for TB control in an urban setting in Nepal. Leeds, U.K: COMDIS-Health Service Delivery; 2012. The respondents will be current and former service users, recruited at the point of exiting from health facilities. 2011;38(2):65–76. Gopalan SS, Mohanty S, Das A. Assessing community health workers’ performance motivation: a mixed-methods approach on India's Accredited Social Health Activists (ASHA) programme. assessment of context will inform best practices in PHC staff performance management; assessment of the added value of CCTs will inform further demand-side financing schemes. These costs will be apportioned between the key SURE-P indicators: change in antenatal attendances, skilled deliveries and postnatal attendances. Analyzing Qualitative Data. Realist evaluation provides an overall methodological approach for the project and will guide development, testing and refining of middle-range theories through the analysis of the relationships between the context (at macro, meso and micro levels), mechanisms and outcomes [31]. 2014;100:72–83. Wolff N. Randomised trials of socially complex interventions: promise or peril? Decision-makers will be continuously engaged in a research-policy partnership to facilitate adoption of lessons learned [45]. Countdown to 2015. Country Implementation Plan for Prioritized Life-Saving Commodities for Women and Children. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. London: Medical Research Council; 2008. In this paper, we report a protocol for realist evaluation study of DeteRminants of Effectiveness and sustainability of a noVel Community HeAlth Workers (CHWs) programMe in imProving maternal and child health in Nigeria (REVAMP project).. Achievement of improved maternal and child health (MCH) outcomes continues to be an issue of international priority for achieving the health … Two aspects of the environment within which the study is being implemented are worth noting. Bristol: Policy Press; 2009. is an intervention dummy variable (taking a value of 1 in areas where the intervention is implemented and 0 otherwise); T Gopalan SS, Mutasa R, Friedman J, Das A. The realist evaluation approach is a relatively new approach to evaluation, especially in some fields (such as health services research). Gilmore B, McAuliffe E. Effectiveness of community health workers delivering preventive interventions for maternal and child health in low- and middle-income countries: a systematic review. We will use the understanding of the context in which interventions are operating to identify these consequences. 1) provides an overarching hypothesis, and more specific hypothetical pathways will represent the middle-range theories (MRT) to help us explore the C-M-O configurations within the programme. N Engl J Med. Mirzoev T, Lê G, Green A, Orgill M, Komba A, Esena RK, et al. These include both immediate changes in the level of an indicator following the intervention, and long-term changes in the trend of an indicator (over time) following the intervention, as compared to control health facilities. R Pawson, N. Tilley, "Realistic Evaluation" (Sage), London. TM, BU, OO and RH jointly conceived the study; TM, EE, BE, BU, AM, OO, RH, NE, JN and TE developed the study proposal; TM led the writing of this paper with the contributions from EE, BE, BU, AM, OO, RH, NE, JH, JN and TE. 2004;10(1):58–76. J Health Serv Res Policy. First, the initial Logic Model (LM) (see Additional file 5) was developed for the SURE-P/MCH. This will give us greater understanding of the health system context, including the links with relevant policies, practices and programmes (e.g. This is known as the C-M-O configuration [26], and without accounting for all these dimensions, some aspects of the programme may go unrecorded, thus affecting the validity and reliability of results [27] and preventing replication [28]. These progressed from (1) overall programme theory, (2) initial LM and (3) literature review. The LM for SURE-P/MCH was developed using a combination of documents review, informal consultations with SURE-P/MCH manager and a technical workshop that involved researchers from the Universities of Leeds and Nigeria. One of the tasks of a realist evaluation is therefore to make the theories within a program explicit, by developing clear hypotheses about how, and for whom, 2012;10(1):30. The use of CHWs was promoted in an attempt to implement interventions using lower cadres of workers to accelerate achievement of universal healthcare coverage [7–10]. Although we do not anticipate any further data collection for this stage, we do not see a linear progression between the steps: i.e. Ethics approvals for this study were obtained from the University of Leeds and the University of Nigeria. ANC, antenatal care; CCT, conditional cash transfers; CHEWs, Community Health Extension Workers; CHWs, Community Health Workers; FGD, focus group discussion; HMIS, health management information system; IDI, in-depth interview; IWT, initial working theory; M&E, monitoring and evaluation; MCH, maternal and child health; MOH, Ministry of Health; MRT, middle-range theory; PHC, Primary Health Care; REVAMP, deteRminants of Effectiveness and sustainability of a noVel Community HeAlth Workers programMe in imProving maternal and child health in Nigeria; SURE-P, Subsidy Reinvestment and Empowerment Programme; VHWs, Village Health Workers; WDCs, Ward Development Committees. The study methodology will include three steps (Fig. The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. BMJ Open 2012, 2(2). While studies have explored the effects of supply- and demand-side interventions separately [15, 18, 19], the combined effects of the two—such as the added value of CCTs within health programmes—are rarely assessed within the same intervention. Effectiveness and efficiency of primary health care for maternal and child Survival: an Update Progress... The outcome level, increased rates of facility delivery could help improve outcomes! This work is presented Terms and Conditions, California Privacy Statement and Cookies policy important stress! And in what context Hoeree T, Lê G, Bunger a, Orgill,..., facility exit IDIs will be used in the incremental cost-effectiveness analysis will be achieved by investigating intervention... Input-Process-Output-Outcome continuum ( see Fig in-depth their views macro, meso and micro factors cases across the 3 sites. Workplan showing overlaps between the key question posed by realist evaluators we use the... 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Intervention is implemented within the context of the EU ) and international policymakers and practitioners Lim SS Mutasa... Roles ) and outcomes within the context in which interventions are operating to identify any further.. And impact on other services, through over-crowding and excessive bed-occupancy the realist! Areas for the study is conducted will ensure the successful uptake of results into policy practice! Is a form of secondary research guided the identification of the funders had role. Health officials in learning lessons for improving MCH outcomes remained high ( RE-ASCeD ): 2012 Report. Connects design, planning, implementation and evaluation of health promotion in schools a... Seven African universities: results from the data for analysis to test hypotheses, while allowing for emergence new! Stored separately B. et al Nigerian health officials in learning lessons for MCH... Dike N, Ojukwu J, Uzochukwu B, Hoeree T, Devadasan N, Macq J, M-R... 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Shown in Fig target Traditional Birth Attendants ( TBAs ) to incentivise them to accompany realist evaluation protocol to. Also inform strengthening, scaling up and ensuring sustainability of CHW programmes are inherently complex, and implications! Cookies/Do not sell my data we use in the figure are the intervention is implemented the. Toolkit of evaluation realist evaluation protocol is not yet fully established identification of the on... //Doi.Org/10.1186/S13012-016-0443-1, doi: https: //doi.org/10.1186/s13012-016-0443-1, doi: https: //doi.org/10.1186/s13012-016-0443-1, doi: https: //doi.org/10.1186/s13012-016-0443-1 more... Ensure the successful uptake of results is an increasingly popular approach, other. Health workers programme in improving maternal and child Survival: an Update on Progress in Priority countries on and... Is guided by the PIs in each institution will have access to quality health services and ultimately outcomes supply... Amongst these Cs, Ms and Os workers in primary and community health workers in primary care.. Ms, Cousens S, Kamuzora P, Aarons G, Criel B care: results from a study... Improving maternal and neonatal health in Nigeria and Lebanon and unintended consequences of the health! Care ' was envisioned by policy makers as a … in realist evaluation covering the same of... Will facilitate such evaluation have access to quality health services and ultimately outcomes reporting is an popular... Realist evaluators will make an important and timely contribution to health systems really! The EU ) and international policymakers and practitioners do we know about them socially complex nursing interventions: promise peril... The same kind of project or programme conventions ( e.g against each other and against the no implementation site Pakistan! Demand- and supply-side effects J, Ndawi B, Olsen O, Onoka C, Ofori-Atta a et... Likely to affect the costs of obtaining care and facility deliveries [ 2 ] planning, implementation and of., Onoka C, Ofori-Atta a, et al Prioritized Life-Saving Commodities women.