What mechanisms drive uptake of family planning when integrated with childhood immunisation in Ethiopia? A realist evaluation

Abstract

Background Maternal and child health are key priorities among the Sustainable Development Goals, which include a particular focus on reducing morbidity and mortality among women of reproductive age, newborns, and children under the age of five. Two components of maternal and child health are family planning (FP) and immunisation. Providing these services through an integrated delivery system could increase the uptake of vaccines and modern contraceptive methods (MCMs) particularly during the post-partum period. Methods A realist evaluation was conducted in two woredas in Ethiopia to determine the key mechanisms and their triggers that drive successful implementation and service uptake of an intervention of integrated delivery of immunisations and FP. The methodological approach included the development of an initial programme theory and the selection of relevant, published implementation related theoretical frameworks to aid organisation and cumulation of findings. Data from 23 semi-structured interviews were then analysed to determine key empirical mechanisms and drivers and to test the initial programme theory. These mechanisms were mapped against published theoretical frameworks and a revised programme theory comprised of context-mechanism-outcome configurations was developed. A critique of theoretical frameworks for abstracting empirical mechanisms was also conducted. Results Key contextual factors identified were: the use of trained Health Extension Workers (HEWs) to deliver FP services; a strong belief in values that challenged FP among religious leaders and community members; and a lack of support for FP from male partners based on religious values. Within these contexts, empirical mechanisms of acceptability, access, and adoption of innovations that drove decision making and intervention outcomes among health workers, religious leaders, and community members were identified to describe intervention implementation. Conclusions Linking context and intervention components to the mechanisms they triggered helped explain the intervention outcomes, and more broadly how and for whom the intervention worked. Linking empirical mechanisms to constructs of implementation related theoretical frameworks provided a level of abstraction through which findings could be cumulated across time, space, and conditions by theorising middle-range mechanisms.

Acceptability of family planning in a changing context in Uganda: a realist evaluation at two time points

“…Realist evaluation seeks to understand what works, for whom and under what circumstances within a particular intervention, using context-mechanism-outcome (CMO) configurations 23. In recognition of the impact that different actors and their reactions to intervention components have on intervention outcomes, the standard CMO configuration was expanded where relevant to include context-actor-mechanism-outcome (CAMO) or context-intervention-actor-mechanism-outcome (CIAMO) configurations; this methodology has been used previously to acknowledge the importance of actor reactions to intervention components 24 25…”

“…We used two published theoretical frameworks to provide a structure against which findings could be ordered. These frameworks have been used previously to explore FP acceptability in Ethiopia 24. The first of these was Roger’s diffusion (and adoption) of innovations, which provides a framework for examining factors influencing how an intervention is adopted and diffused through a system.…”

“…These two frameworks were used to guide and structure the analysis of data with the aim of matching empirically identified mechanisms to constructs from the frameworks. These linked mechanisms and constructs would then act as middle range mechanisms24 to aid in cumulation of findings. Such middle range mechanisms have recently been used to develop CATs, which theorise what intervention/s will work in what context to trigger mechanisms that increase acceptability 25…”

“…These frameworks have been used previously to explore FP acceptability in Ethiopia. 24 The first of these was Roger’s diffusion (and adoption) of innovations, which provides a framework for examining factors influencing how an intervention is adopted and diffused through a system. This framework consists of five constructs: relative advantage, compatibility, trialability, observability and complexity.…”

Community Health Workers as Vaccinators: A Rapid Review of the Global Landscape, 2000–2021

“…In 5 of the 20 countries where CHWs administered vaccines, CHWs also administered injectable contraceptives. 21,23,40,50,59,61 Most routine immunizations are delivered via injection, but some are delivered via an oral route. Geographic context: Rural areas.…”