George Asha S, LeFevre Amnesty E, Schleiff Meike, Mancuso Arielle, Sacks Emma, Sarriot Eric
School of Public Health, University of the Western Cape, Cape Town, South Africa.
Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
BMJ Glob Health. 2018 Jun 15;3(3):e000811. doi: 10.1136/bmjgh-2018-000811. eCollection 2018.
Community-based approaches are a critical foundation for many health outcomes, including reproductive, maternal, newborn and child health (RMNCH). Evidence is a vital part of strengthening that foundation, but largely focuses on the technical content of what must be done, rather than on how disparate community actors continuously interpret, implement and adapt interventions in dynamic and varied community health systems. We argue that efforts to strengthen evidence for community programmes must guard against the hubris of relying on a single approach or hierarchy of evidence for the range of research questions that arise when sustaining community programmes at scale. Moving forward we need a broader evidence agenda that better addresses the implementation realities influencing the scale and sustainability of community programmes and the partnerships underpinning them if future gains in community RMNCH are to be realised. This will require humility in understanding communities as social systems, the complexity of the interventions they engage with and the heterogeneity of evidence needs that address the implementation challenges faced. It also entails building common ground across epistemological word views to strengthen the robustness of implementation research by improving the use of conceptual frameworks, addressing uncertainty and fostering collaboration. Given the complexity of scaling up and sustaining community RMNCH, ensuring that evidence translates into action will require the ongoing brokering of relationships to support the human creativity, scepticism and scaffolding that together build layers of evidence, critical thinking and collaborative learning to effect change.
基于社区的方法是包括生殖、孕产妇、新生儿和儿童健康（RMNCH）在内的许多健康成果的关键基础。证据是强化这一基础的重要组成部分，但主要侧重于必须做什么的技术内容，而不是不同的社区行为者如何在动态多样的社区卫生系统中不断解释、实施和调整干预措施。我们认为，为社区项目强化证据的努力必须防范过度自信，即不能仅依赖单一方法或证据等级来应对在大规模维持社区项目时出现的一系列研究问题。展望未来，如果要在社区RMNCH方面取得进一步成果，我们需要一个更广泛的证据议程，以更好地应对影响社区项目规模和可持续性的实施现实以及支撑这些项目的伙伴关系。这将需要保持谦逊，将社区理解为社会系统，认识到它们所参与干预措施的复杂性以及应对所面临实施挑战的证据需求的异质性。这还意味着要在不同的认识论世界观之间建立共识，通过改进概念框架的使用、应对不确定性和促进合作来加强实施研究的稳健性。鉴于扩大和维持社区RMNCH的复杂性，确保证据转化为行动将需要持续斡旋各方关系，以支持人类的创造力、怀疑精神和支撑作用，这些共同构建起层层证据、批判性思维和协作学习，从而实现变革。
