Mirzoev Tolib, Etiaba Enyi, Ebenso Bassey, Uzochukwu Benjamin, Ensor Tim, Onwujekwe Obinna, Huss Reinhard, Ezumah Nkoli, Manzano Ana
Nuffield Centre for International Health and Development, University of Leeds, Level 10 Worsley Building, Clarendon Way, LS2 9NL, Leeds, UK.
Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Old UNTH Road, Ogbete, Enugu State, Nigeria.
Health Policy Plan. 2020 Nov 20;35(9):1244-1253. doi: 10.1093/heapol/czaa076.
Realist evaluations (RE) are increasingly popular in assessing health programmes in low- and middle-income countries (LMICs). This article reflects on processes of gleaning, developing, testing, consolidating and refining two programme theories (PTs) from a longitudinal mixed-methods RE of a national maternal and child health programme in Nigeria. The two PTs, facility security and patient-provider trust, represent complex and diverse issues: trust is all encompassing although less tangible, while security is more visible. Neither PT was explicit in the original programme design but emerged from the data and was supported by substantive theories. For security, we used theories of fear of crime, which perceive security as progressing from structural, political and socio-economic factors. Some facilities with the support of communities erected fences, improved lighting and employed guards, which altogether contributed to reduced fear of crime from staff and patients and improved provision and uptake of health care. The social theories for the trust PT were progressively selected to disentangle trust-related micro, meso and macro factors from the deployment and training of staff and conditional cash transfers to women for service uptake. We used taxonomies of trust factors such as safety, benevolent concerns and capability. We used social capital theory to interpret the sustainability of 'residual' trust after the funding for the programme ceased. Our overarching lesson is that REs are important though time-consuming ways of generating context-specific implications for policy and practice within ever-changing contexts of health systems in LMICs. It is important to ensure that PTs are 'pitched at the right level' of abstraction. The resource-constrained context of LMICs with insufficient documentation poses challenges for the timely convergence of nuggets of evidence to inform PTs. A retroductive approach to REs requires iterative data collection and analysis against the literature, which require continuity, coherence and shared understanding of the analytical processes within collaborative REs.
现实主义评价（RE）在评估低收入和中等收入国家（LMICs）的卫生项目方面越来越受欢迎。本文反思了从尼日利亚一项全国妇幼卫生项目的纵向混合方法RE中收集、发展、测试、巩固和完善两个项目理论（PTs）的过程。这两个PTs，即机构安全和医患信任，代表了复杂多样的问题：信任虽然不太具体但涵盖面广，而安全则更显而易见。这两个PTs在最初的项目设计中都不明确，而是从数据中浮现出来并得到了实质性理论的支持。对于安全，我们使用了对犯罪恐惧的理论，该理论将安全视为从结构、政治和社会经济因素发展而来。一些机构在社区的支持下设置了围栏、改善了照明并雇佣了警卫，这些举措共同减少了工作人员和患者对犯罪的恐惧，并改善了医疗服务的提供和利用。信任PTs的社会理论是逐步选择的，以从工作人员的部署和培训以及向妇女提供有条件现金转移以促进服务利用中梳理出与信任相关的微观、中观和宏观因素。我们使用了信任因素的分类法，如安全性、善意关注和能力。我们使用社会资本理论来解释项目资金停止后“剩余”信任的可持续性。我们的总体经验是，REs虽然耗时，但对于在低收入和中等收入国家卫生系统不断变化的背景下为政策和实践产生针对具体背景的影响非常重要。确保PTs处于合适的抽象“水平”很重要。低收入和中等收入国家资源有限且文件记录不足的背景给及时整合证据以形成PTs带来了挑战。REs的追溯性方法需要针对文献进行迭代数据收集和分析，这需要协作式REs内部分析过程的连续性、连贯性和共同理解。
