系统方法评估卫生干预措施的复杂性:综合社区病例管理的效果衰减模型。
A systems approach to assessing complexity in health interventions: an effectiveness decay model for integrated community case management.
机构信息
Department of Epidemiology & Public Health, Swiss Tropical and Public Health Institute (Swiss TPH) , Basel, Switzerland.
Department of Epidemiology & Public Health, University of Basel , Basel, Switzerland.
出版信息
Glob Health Action. 2020 Dec 31;13(1):1794106. doi: 10.1080/16549716.2020.1794106.
Complexity is inherent to any system or program. This is especially true of integrated interventions, such as integrated community case management (iCCM). iCCM is a child health strategy designed to provide services through community health workers (CHWs) within hard-to-reach areas of low-and-middle-income countries (LMICs). It is comprised of many interlinked program components, processes and stakeholders. Elucidating the complexity of such programs is essential to designing interventions that respond to local contexts and successfully plan for sustainable integration. A pragmatic approach has yet to be developed that holistically assesses the many dimensions of iCCM or other integrated programs, their alignment with local systems, and how well they provide effective care. We propose an accessible systems approach to both measuring systems effectiveness and assessing its underlying complexity using a combination of systems thinking tools. We propose an effectiveness decay model for iCCM implementation to measure where patient loss occurs along the trajectory of care. The approach uses process mapping to examine critical bottlenecks of iCCM processes, their influence on effectiveness decay, and their integration into local systems; regression analysis and structural equation modeling to determine effects of key indicators on programmatic outcomes; and qualitative analysis with causal loop diagramming to assess stakeholder dynamics and their interactions within the iCCM program. An accurate assessment of the quality, effectiveness, and strength of community-based interventions relies on more than measuring core indicators and program outcomes; it requires an exploration of how its actors and core components interact as part of a system. Our approach produces an interactive iCCM effectiveness decay model to understand patient loss in context, examines key systems issues, and uses a range of systems thinking tools to assess the dynamic interactions that coalesce to produce observed program outcomes.
任何系统或程序都具有复杂性。这对于综合干预措施来说尤其如此,例如综合社区病例管理(iCCM)。iCCM 是一种儿童健康战略,旨在通过中低收入国家(LMIC)难以到达的地区的社区卫生工作者(CHWs)提供服务。它由许多相互关联的项目组成部分、流程和利益相关者组成。阐明此类计划的复杂性对于设计针对当地情况的干预措施以及成功规划可持续整合至关重要。尚未开发出一种实用的方法,可以全面评估 iCCM 或其他综合计划的许多方面、它们与当地系统的一致性以及它们提供有效护理的程度。我们提出了一种易于理解的系统方法,使用系统思维工具的组合来衡量系统的有效性并评估其潜在的复杂性。我们提出了一种 iCCM 实施效果衰减模型,以衡量患者在护理过程中的损失发生在哪里。该方法使用流程映射来检查 iCCM 流程的关键瓶颈、它们对效果衰减的影响以及它们如何融入当地系统;回归分析和结构方程建模来确定关键指标对项目结果的影响;以及使用因果回路图进行定性分析来评估利益相关者动态及其在 iCCM 计划中的相互作用。准确评估基于社区的干预措施的质量、效果和强度不仅需要衡量核心指标和项目结果;它还需要探索其参与者和核心组件如何作为系统的一部分相互作用。我们的方法生成了一个交互式 iCCM 效果衰减模型,以了解上下文中的患者流失情况,检查关键系统问题,并使用一系列系统思维工具来评估产生观察到的项目结果的动态相互作用。