A process evaluation plan for assessing a complex community-based maternal health intervention in Ogun State, Nigeria

Abstract

BackgroundDespite increased investment in community-level maternal health interventions, process evaluations of such interventions are uncommon, and can be instrumental in understanding mediating factors leading to outcomes. In Nigeria, where an unacceptably number of maternal deaths occur (maternal mortality ratio of 814/100,000 livebirths), the Community Level Interventions for Pre-eclampsia (CLIP) study (NCT01911494) aimed to reduce maternal and neonatal mortality and morbidity with a complex intervention of five interrelated components. Building from previous frameworks, we illustrate a methodology to evaluate implementation processes of the complex CLIP intervention, assess mechanisms of impact and identify emerging unintended causal pathways.MethodsThe study was conducted from 2013–2016 in five Local Government Areas in Ogun State, Nigeria. A six-step approach was developed to evaluate key constructs of context (external factors related to intervention), implementation (fidelity, dose, reach, and adaption) and mechanisms of impact (unintended outcomes and mediating pathways). The steps are: 1) describing the intervention by a logic model, 2) defining acceptable delivery, 3) formulating questions, 4) determining methodology, 5) planning resources in context, lastly, step 6) finalising the plan in consideration with relevant stakeholders.ResultsQuantitative data were collected from 32,785 antenatal and postnatal visits at the primary health care level, from 66 community engagement sessions, training assessments of community health workers, and standard health facility questionnaires. Forty-three focus group discussions, 38 in-depth interviews, and 23 structured observations were conducted to capture qualitative data. A total of 103 community engagement reports and 182 suspected pre-eclampsia case reports were purposively collected. Timing of data collection was staggered to understand feedback mechanisms that may have resulted from the delivery of the intervention. Data will be analysed using R and NVivo. Diffusions of innovations and realist evaluation theories will underpin analysis of the interaction between context, mechanisms and outcomes.ConclusionThis comprehensive approach can serve as a guide for researchers and policy makers to plan the evaluation of similar complex health interventions in resource-constrained settings, and to aid in measuring 'effectiveness' of interventions and not just 'efficacy'.Trial registrationThis research is a part of the Community Level Interventions for Pre-eclampsia Study, NCT01911494. The trial is registered in Clinicaltrials.gov, the URL is https://clinicaltrials.gov/ct2/show/NCT01911494 The trial was registered on June 28, 2013 and the first participant was enrolled for intervention on March 1, 2014.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2124-4) contains supplementary material, which is available to authorized users.

The Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials in Mozambique, Pakistan, and India: an individual participant-level meta-analysis

“…A full process evaluation is planned to explore more comprehensively the context (including cost), implementation, and mechanisms of effect of our intervention in each of the three CLIP countries. 31 …”

“…A full process evaluation is planned to explore more comprehensively the context (including cost), implementation, and mechanisms of effect of our intervention in each of the three CLIP countries. 31 Management and detection of pregnancy hypertension provide a gateway to excellence in maternity care. Ideally a health system should be able to identify and respond to pregnancy hypertension, induce labour, and provide both safe caesarean deliveries and care in the postpartum period.…”

Evaluación de procesos de una intervención: actividad física durante el embarazo y postparto

“…Si no se evalúan los procesos, se asume que la implementación es adecuada a lo planeado y se corre el riesgo de no tener ningún impacto. Lo anterior, es relevante dado el escenario de recursos limitados y problemas de salud pública prevalentes (32) , y en donde, se requieren intervenciones factibles y sostenibles que permitan la promoción de la salud en las poblaciones.…”

Access to primary care for socio-economically disadvantaged older people in rural areas: exploring realist theory using structural equation modelling in a linked dataset

“…Meditation analysis, one component of structural equation modelling, has been proposed as a technique for analysing quantitative data within realist methods by three studies, but none have yet reported findings [ 33 – 35 ]. In their protocol, Jamal and colleagues propose mediation analysis to explore mechanisms within a realist RCT.…”