London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.
Ethiopian Public Health Institute, Addis Ababa 5654, Ethiopia.
Int J Environ Res Public Health. 2020 Aug 11;17(16):5803. doi: 10.3390/ijerph17165803.
An intervention called 'Optimising the Health Extension Program', aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed methods to explore how the intervention was implemented. A fidelity analysis of each 31 intervention activities was performed, separately for the first phase and for the entire implementation period, to assess the extent to which what was planned was carried out. Qualitative interviews were undertaken with 39 implementers, to explore the successes and challenges of the implementation, and were analysed by using thematic analysis. Our findings show that the implementation was delayed, with only 19% ( = 6/31) activities having high fidelity in the first phase. Key challenges that presented barriers to timely implementation included the following: complexity both of the intervention itself and of administrative systems; inconsistent support from district health offices, partly due to competing priorities, such as the management of disease outbreaks; and infrequent supervision of health extension workers at the grassroots level. We conclude that, for sustainability, evidence-based interventions must be aligned with national health priorities and delivered within an existing health system. Strategies to overcome the resulting complexity include a realistic time frame and investment in district health teams, to support implementation at grassroots level.
一项名为“优化卫生延伸计划”的干预措施旨在增加埃塞俄比亚四个地区儿童疾病的就医率，于 2016 年至 2018 年实施，其中包括社区参与、能力建设以及地区自主权和问责制。一项比较接受干预的 26 个地区和未接受干预的 26 个地区服务利用情况的实用主义试验并未发现证据表明干预措施增加了服务的利用。在这里，我们使用混合方法来探讨干预措施的实施情况。对每个干预活动的 31 个进行了保真度分析，分别针对第一阶段和整个实施期间，以评估计划的执行程度。对 39 名实施者进行了定性访谈，以探讨实施的成功和挑战，并通过主题分析进行了分析。我们的研究结果表明，实施工作被推迟，只有 19%（=31）的活动在第一阶段具有高度保真度。实施过程中的主要挑战包括：干预本身和行政系统的复杂性；地区卫生办公室的支持不一致，部分原因是存在竞争优先级，例如疾病爆发的管理；以及基层卫生推广人员的监督不频繁。我们得出结论，为了可持续性，基于证据的干预措施必须与国家卫生重点保持一致，并在现有的卫生系统内实施。克服由此产生的复杂性的策略包括设定现实的时间框架和对地区卫生团队的投资，以支持基层的实施。
