Loevinsohn Michael, Mehta Lyla, Cuming Katie, Nicol Alan, Cumming Oliver, Ensink Jeroen H J
Knowledge, Technology and Society Team, Institute of Development Studies, Library Road, Brighton BN1 9RE, UK, Noragric, Norwegian University of Life Sciences, P.O. Box 5003, NO-1432 Aas, Norway, Environmental Health Group, Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT and Present address: CARE International in Uganda, Box 7280 Kampala, Uganda
Knowledge, Technology and Society Team, Institute of Development Studies, Library Road, Brighton BN1 9RE, UK, Noragric, Norwegian University of Life Sciences, P.O. Box 5003, NO-1432 Aas, Norway, Environmental Health Group, Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT and Present address: CARE International in Uganda, Box 7280 Kampala, Uganda Knowledge, Technology and Society Team, Institute of Development Studies, Library Road, Brighton BN1 9RE, UK, Noragric, Norwegian University of Life Sciences, P.O. Box 5003, NO-1432 Aas, Norway, Environmental Health Group, Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT and Present address: CARE International in Uganda, Box 7280 Kampala, Uganda.
Health Policy Plan. 2015 Jun;30(5):660-74. doi: 10.1093/heapol/czu039. Epub 2014 May 29.
Divisions between communities, disciplinary and practice, impede understanding of how complex interventions in health and other sectors actually work and slow the development and spread of more effective ones. We test this hypothesis by re-reviewing a Cochrane-standard systematic review (SR) of water, sanitation and hygiene (WASH) interventions' impact on child diarrhoea morbidity: can greater understanding of impacts and how they are achieved be gained when the same papers are reviewed jointly from health and development perspectives? Using realist review methods, researchers examined the 27 papers for evidence of other impact pathways operating than assumed in the papers and SR. Evidence relating to four questions was judged on a scale of likelihood. At the 'more than possible' or 'likely' level, 22% of interventions were judged to involve substantially more actions than the SR's label indicated; 37% resulted in substantial additional impacts, beyond reduced diarrhoea morbidity; and unforeseen actions by individuals, households or communities substantially contributed to the impacts in 48% of studies. In 44%, it was judged that these additional impacts and actions would have substantially affected the intervention's effect on diarrhoea morbidity. The prevalence of these impacts and actions might well be found greater in studies not so narrowly selected. We identify six impact pathways suggested by these studies that were not considered by the SR: these are tentative, given the limitations of the literature we reviewed, but may help stimulate wider review and primary evaluation efforts. This re-review offers a fuller understanding of the impacts of these interventions and how they are produced, pointing to several ways in which investments might enhance health and wellbeing. It suggests that some conclusions of the SR and earlier reviews should be reconsidered. Moreover, it contributes important experience to the continuing debate on appropriate methods to evaluate and synthesize evidence on complex interventions.
社区之间、学科与实践之间的划分，阻碍了人们对卫生及其他领域复杂干预措施实际运作方式的理解，并减缓了更有效干预措施的开发与推广。我们通过重新审视一篇符合Cochrane标准的关于水、环境卫生和个人卫生（WASH）干预措施对儿童腹泻发病率影响的系统评价（SR）来检验这一假设：当从卫生和发展的角度联合审查同一组论文时，是否能对影响及其实现方式有更深入的理解？研究人员采用现实主义审查方法，检查了这27篇论文，以寻找除论文和系统评价中假设的之外其他起作用的影响途径的证据。针对四个问题的相关证据按可能性程度进行判断。在“极有可能”或“很可能”的层面上，22%的干预措施被判定涉及的行动比系统评价所标注的要多得多；37%的干预措施除了降低腹泻发病率外，还产生了大量额外影响；在48%的研究中，个人、家庭或社区的意外行动对影响有很大贡献。在44%的研究中，判定这些额外影响和行动会对干预措施对腹泻发病率的效果产生重大影响。在筛选范围没那么窄的研究中，这些影响和行动的发生率很可能更高。我们确定了这些研究提出的六条系统评价未考虑的影响途径：鉴于我们所审查文献的局限性，这些途径是初步的，但可能有助于激发更广泛的审查和初步评估工作。这次重新审查使人们对这些干预措施的影响及其产生方式有了更全面的理解，指出了一些投资可增进健康和福祉的方式。这表明系统评价及早期审查的一些结论应重新考虑。此外，它为持续进行的关于评估和综合复杂干预措施证据的适当方法的辩论提供了重要经验。
