How do community health committees contribute to capacity building for maternal and child health? A realist evaluation protocol

Introduction: The proposed research is part of ongoing operations research within World Vision’s Access: Infant and Maternal Health Programme. This study aims to identify key context features and underlying mechanisms through which community health committees build community capacity within the field of maternal and child health. This may help to improve programme implementation by providing contextually informed and explanatory findings for how community health committees work, what works best and for whom do they work for best for. Though frequently used within health programmes, little research is carried out on such committees’ contribution to capacity building – a frequent goal or proposed outcome of these groups. Methods and analysis: The scarce information that does exist often fails to explain ‘how, why, and for whom’ these committees work best. Since such groups typically operate within or as components of complex health interventions, they require a systems thinking approach and design, and thus so too does their evaluation. Using a mixed methods realist evaluation with intraprogramme case studies, this protocol details a proposed study on community health committees in rural Tanzania and Uganda to better understand underlying mechanisms through which these groups work (or do not) to build community capacity for maternal and child health. This research protocol follows the realist evaluation methodology of eliciting initial programme theories, to inform the field study design, which are detailed within. Thus far, the methodology of a realist evaluation has been well suited to the study of community health committees within these contexts. Implications for its use within these contexts are discussed within. Ethics and dissemination: Institutional Review Boards and the appropriate research clearance bodies within Ireland, Uganda and Tanzania have approved this study. Planned dissemination activities include via academic and programme channels, as well as feedback to the communities in which this work occurs.

Two case studies using the same complex health intervention involving community health committees were purposefully selected to best test and refine the IPT. The specific sites were chosen for two main reasons: First, by using case studies set across different contexts with the same programme design, individual programme theory refinement across the sites and the subsequent comparison between sites may work to identify theories that are of middle range for CHCs building community capacity; and second, specifically concerning the sites, reports from programme managers indicate that the two programmes are achieving different levels of their intervention aim of capacity building. Having contrasting perceived effectiveness may provide additional insight into ‘what works, for whom and why’ for community health committees. Each study will be conducted within World Vision’s Area Development Programmes (ADPs) implementing the AIM-Health Programme. A complex health intervention, World Vision Ireland’s AIM-Health programme works across 10 contexts in 5 sub-Saharan African countries (Kenya, Uganda, Tanzania, Sierra Leone and Mauritania) to reduce maternal and child mortality and morbidities by enhancing the health knowledge of women and households, and by increasing capacity within communities to respond to its citizens’ health needs. Using what World Vision titles the 7–11 Strategy, AIM-Health engages community health workers (CHWs) to deliver a number of timed and targeted counselling (ttC) to women and households at specific intervals throughout their pregnancy and throughout the first 2 years of a child’s life. These messages—7 for women and 11 for children under 2 years—were developed from cost-effective, evidence-based interventions delivered in the community.33–35 Using a multifaceted approach, the 7–11 Strategy works by targeting individuals, communities and their environment through CHWs, community health committees (which World Vision titles COMMs) and citizen voice in action networks and Positive Deviance (PD) Hearth interventions, respectively. Serving as a link between the community and more formal health services, COMMs are a health-focused community group that coordinates and manages health activities and civil society strengthening. Within the World Vision model, these committees are ideally initiated by the Ministry of Health in their respective countries, and jointly trained by World Vision on the 7–11 ttC strategy and other AIM-Health activities. The main duties of COMMs include: providing a support system for community health workers and other community health volunteers, assessing and tracking the community health situation, mobilising the community for improved health, responding to barriers to health-related behaviour change at the community level, assisting with communication with and from the health system and local administration and advocating around issues leading to improved health systems.36 The establishment and operationalisation of these groups is a prerequisite for any 7–11 Strategy implementation. World Vision’s COMMS are equivalent to community health committees (coalitions) in description and function, and are therefore referred to and treated as such. Both study sites initiated the COMM programme in mid-2014, several years after the start of the AIM-Health Programme. Programme managers in the sites have indicated that each parish has trained a COMM group. Though their actual membership make-up, organisational structures, training and support will most likely vary between contexts, guidelines suggest that membership should include 8–12 individuals selected by the community that represent diverse backgrounds and interests. It is suggested that members include: youth, religious leaders, community leadership and representatives, as well as a community health worker, a local health staff member and a minimum three females, one with a COMM leadership role (chair, cochair or secretary). The specifically selected sites for this research will occur in rural areas of two East African countries: North Rukiga, in the Kabale District of Southwestern Uganda and Mundemu, in the Bahi District of the Dodoma Region in central Tanzania. Table 2 presents key maternal and child health indicators for both sites. The accompanying figures highlight the need for strong child health programmes, and highlight some of the contextual similarities between the two sites. Key Demographic Health Survey (DHS) MCH indicators for study sites *For the southwest region of Uganda. †For the Dodoma region of Tanzania. ‡For the Central region. MCH, maternal and child health. Case Study 1, North Rukiga, Uganda: North Rukiga is located in Rukiga county, one of four counties in the Kabale district of Southwestern Uganda. North Rukiga comprises two subcounties, Kashambya and Rwamucucu, totalling 13 parishes and 162 villages with ∼52 500 residents.37 It was reported in 2010 that over 15% and 48% of Kabale’s population was under the age of 5 and 14 years, respectively.37 Background Case Study 2, Bahi, Tanzania: Bahi district is one of the six districts in the Dodoma region and comprises around 13% of the Dodoma land region.38 Bahi has 4 divisions, 20 wards and 56 villages, with Mundemu being among one of the administrative wards.38 According to 2013 figures, Bahi District’s population has 18% of citizens under the age of 5 years, and ∼48% under the age of 14.39 Following the development of the realist evaluation framework, the methods for this study were informed by the above IPT and research questions and purposefully selected to best fit the refinement of the theory. This research is planned to occur from November 2015 to June 2016. The proposed study consists of focus group discussions, in-depth interviews, observations and surveys administered to stakeholders involved in community health committees. Table 3 details the proposed data collection methods and tools of the field study. Data collection and tools *To be carried out in each CHC within each site. A proposed 2–3 groups will be studied in each location. †Methods will not be duplicated (ie, only 1 FGD with CHWs), but the theories will be explored within these. CHC, community health committee; CHWs, community health workers; FGD, focus group discussion; NA, not applicable. As detailed in table 3, this study employs a mix of qualitative and quantitative data tools including focus group discussions, in-depth interviews, key-informant interviews, document reviews and surveys. Qualitative methods will be used to explore and refine the theory collaboratively with research participants. Key informant interviews are used to collect specialist knowledge40 and within this study be done with Ministry of Health and NGO stakeholders, specifically to test the theory in regard to context (programme inputs), outcomes and mechanisms of external support and at the level of the community and society. The committees’ in-depth interviews and other stakeholder focus groups will be used to detail individuals’ views and interpretations of the intervention,41 and to explore the specific theories,42 in addition to contextual information and outcomes. Specifically, CHCs will be interviewed to refine mechanisms relating to the internal functioning and individual characteristics of the members, while also supplementing the survey information. Community members will be interviewed with the goal of refining theories relating to community responsiveness, context and committee outcomes. Quantitatively, the Coalition Self-Assessment Scale43 will be administered to all CHC members to explore the Community Coalition Action Theory (CCAT),44–47 and the internal workings of the group. Aligned with CCAT, the CSAS explores the experiences and perceptions of coalition members and group processes. The purpose of this is to examine theories regarding the internal workings of the CHC, specifically relating to membership, structures and processes, leadership, trustworthiness and communication, group synergy and engagement, as well as perceived outcomes of the CHC as reported by the members. The CSAS has been used in several studies of community coalitions48 49 and has been recommended based on high face validity and its in-depth nature.50 To further explore the elicited outcome of community capacity building, this research will use Laverack’s nine domains: participation, leadership, organisational structures, problem assessment, resource mobilisation, ‘asking why’, links with others, role of outside agents and programme management.51 52 Observational data and programme documents, including group meeting minutes and Ministry of Health (MoH) and NGO reports, will also be collected to provide further insight specifically into the context and outcomes of the CHCs. For qualitative methods, data collection will be performed using realist interview techniques, akin to the ‘teacher–learner technique’. This involves the researcher teaching their programme theories to the participant who then provides their own theory for collaborative conceptual refinement.31 Important to note is the iterative and ongoing nature of realist evaluation data collection, and as such the numbers given are only approximate since, as highlighted by Manzano, the “process of theory-testing is unpredictable, unstable and uncertain” (ref. 53. pg. 7). Using an iterative process by reinterviewing participants and later stages allows one’s understanding of the programme and process to be further refined as the researcher most likely has developed theories and become more knowledgeable on the programme.53 Revisiting participants for subsequent interviews has been built into the data collection schedule though details on what and who will be involved will be decided on after theory refinement has occurred. Data collection from case studies in site 1 (Uganda) will be collected and analysed prior to data collection within case studies in site 2 (Tanzania). As indicated in figure 2, the field study and data collection design of the second case study may change depending on the refined theory from the first case study. Convenience sampling will be conducted at the level of the CHC, with potential participants identified by World Vision. Two CHCs from each location will be sampled and considered as separate case studies. Once all CHC members have been identified, all other participants (CHWs, community members), bar key informants, will be sampled from the CHC’s catchment area. Since all willing CHC members will be surveyed with the CSAS, a sampling strategy for this group is not required. All participants for qualitative interviews will be purposefully sampled depending on their inclusion criteria For CHWs, this includes: trained in the 7–11 Strategy; working from the same health centre as the CHCs; and providing informed consent. For community members, the inclusion criteria is: being a potential beneficiary of the 7–11 Strategy; being within the CHC’s catchment area; and providing informed consent. Key informants will be chosen based on their interaction with the CHCs (eg, nurse from the same health unit and programme managers) and must provide informed consent. All participants will be administered the capacity assessment. Quantitative data will be used descriptively to inform mechanism development and analysed in Excel (V.14). Qualitative data, including documentation and interviews, will be analysed in NVivo for Mac (V.11). This study will use the CMOC as an analytical tool for the analysis. As highlighted by several authors,21 22 54 55 there is little guidance on the specific analysis approach to use in a realist evaluation. While some propose analytical induction,21 or thematic analysis,56 others such as Westhorp54 and Kazi17 have developed specific analysis techniques ‘realist qualitative analysis’ and the study of ‘enabling, disabling and generating mechanisms’, respectively. This study proposes to use CMOCs as a guide and analytic tool, with the qualitative data undergoing rounds of thematic analysis. Preliminary codes will be developed from themes in the IPT for the first round of qualitative coding. Subsequent rounds of coding will deduce more specific themes and work to generate CMOCs. Once this has occurred, findings will be compared to the IPT, and will work to refine the theories to best reflect the emerging findings. All participants will be required to provide written informed consent prior to data collection, unless they are unable to do so (eg, those who are illiterate), in which case verbal consent will be taken in addition to a thumbprint. This process includes the distribution of study materials a minimum of 7 days prior to planned collection for participant consideration. Study introduction and information including: study procedure, risks, benefits, right to withdrawal, provisions of confidentiality and potential for publication will all be explained with participants signing consent forms to this extent. All documents will be prepared in English and the local language (Rukiga in Uganda and Kiswahili in Tanzania). Except for consent forms, which will be kept in a separate locked location, all documents will use a participant number to maintain confidentiality. Dissemination will take place through academic and programme channels, via open access publications or presentations, and research/policy reports for AIM-Health stakeholders and participants, respectively. Researchers will be available during and after the research to work with implementing partners on translating findings into practice. Specifically for participants, policy briefs with contact information will be made available in the research language (Rukiga or Swahili) and distributed at the committees’ meeting place and/or nearest health facility. Additionally, dissemination meetings with MoH and NGO staff in the respective research countries have been planned.

N/A

• gilmore, brynne
• mcauliffe, eilish
• larkan, fiona
• conteh, magnus
• dunne, nicola
• gaudrault, michele
• mollel, henry
• tumwesigye, nazarius mbona
• vallières, frédérique