M Kabongo Eveline, Mukumbang Ferdinand C, Delobelle Peter, Nicol Edward
Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa.
South African Medical Research Council, Cape Town, South Africa.
BMC Med Res Methodol. 2020 Nov 26;20(1):282. doi: 10.1186/s12874-020-01164-y.
One of the Sustainable Development Goals is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. In South Africa, the flagship National Department of Health MomConnect program was launched in 2014 to strengthen the quality of maternal and child health (MCH) services and improve mortality outcomes. MomConnect was rapidly rolled out with a limited understanding of how and why the program was expected to work even though studies had shown the effectiveness of the MomConnect program in improving the uptake of MCH services. This study aimed to unearth the initial program theory of the MomConnect program based on explicit and implicit assumptions of how the program was organized and expected to work.
We conducted a document analysis using design- and implementation-related documents of the MomConnect program guided by the principles of Theory of Change (ToC) and Realist Evaluation (RE). Content and thematic analysis approaches were deductively applied to analyze the documents toward constructing ToC and RE-informed models. Abductive thinking and retroduction were further applied to the realist-informed approach to link program context, mechanisms, and outcomes to construct the initial program theory.
ToC and RE-informed models illustrated how the MomConnect program was organized and expected to work. The process of constructing the ToC provided the platform for the development of the initial program theory, which identified three critical elements: (1) the central modalities of the MomConnect program; (2) the intended outcomes; and (3) the tentative causal links indicating, in a stepwise manner of, how the outcomes were intended to be achieved. The RE approach 'enhanced' the causal links by identifying relevant programmatic contexts and linking the postulated mechanisms of action (empowerment, encouragement, motivation, and knowledge acquisition) to program outcomes.
The application of ToC and RE provided an explicitly cumulative approach to knowledge generation in unveiling the initial program theory of MomConnect rather than delivering answers to questions of program effectiveness.
可持续发展目标之一是到2030年将全球孕产妇死亡率降至每10万活产少于70例。在南非，卫生部的旗舰项目MomConnect于2014年启动，旨在提高母婴健康（MCH）服务质量并改善死亡率情况。尽管研究表明MomConnect项目在提高MCH服务利用率方面有效，但该项目在对其预期如何以及为何发挥作用了解有限的情况下迅速推广。本研究旨在基于该项目组织和预期运作方式的显性和隐性假设，挖掘MomConnect项目的初始项目理论。
我们在变革理论（ToC）和现实主义评价（RE）原则的指导下，使用MomConnect项目与设计和实施相关的文件进行了文献分析。内容和主题分析方法被演绎性地应用于分析文件，以构建基于ToC和RE的模型。归纳性思维和追溯法进一步应用于基于现实主义的方法，以将项目背景、机制和结果联系起来，构建初始项目理论。
基于ToC和RE的模型说明了MomConnect项目是如何组织以及预期如何运作的。构建ToC的过程为初始项目理论的发展提供了平台，该理论确定了三个关键要素：（1）MomConnect项目的核心模式；（2）预期结果；（3）表明结果预期如何逐步实现的初步因果联系。RE方法通过识别相关的项目背景并将假定的行动机制（赋权、鼓励、激励和知识获取）与项目结果联系起来，“强化”了因果联系。
ToC和RE的应用为揭示MomConnect的初始项目理论提供了一种明确的累积性知识生成方法，而不是为项目有效性问题提供答案。
