What mechanisms drive uptake of family planning when integrated with childhood immunisation in Ethiopia? A realist evaluation

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Study Justification:
The study aimed to investigate the mechanisms that drive the uptake of family planning (FP) when integrated with childhood immunization in Ethiopia. This research is justified by the importance of maternal and child health, which is a key priority in achieving the Sustainable Development Goals. By integrating FP and immunization services, there is potential to increase the uptake of vaccines and modern contraceptive methods, particularly during the post-partum period.
Highlights:
1. Realist Evaluation Approach: The study utilized a realist evaluation approach, which focuses on understanding what works, for whom, and under what circumstances. This approach helps explain how interventions work based on the decisions made by actors in response to available resources.
2. Context-Mechanism-Outcome Configurations: The study used the context-mechanism-outcome (CMO) configuration of realist evaluation to explore the relationship between context, mechanisms, resources/intervention, and outcomes. This configuration helps identify the specific actors, contexts, and mechanisms that contribute to successful implementation and service uptake.
3. Initial Program Theory: An initial program theory was developed through discussions with intervention designers and implementers. This theory identified key drivers of the intervention, such as adherence to clinical and counseling guidelines among Health Extension Workers (HEWs) and community and religious leader support for FP.
4. Theoretical Frameworks: The study mapped its findings against the constructs of implementation-related theoretical frameworks. This approach helped identify transferrable theories that could be used by implementers in similar contexts. The frameworks used included the Theoretical Framework of Acceptability, diffusion of innovations framework, and access framework.
Recommendations:
1. Strengthen Training and Support for Health Extension Workers (HEWs): Given the important role of HEWs in delivering FP services, it is recommended to provide comprehensive training and support to enhance their skills and knowledge in counseling, contraceptive methods, and implant removals.
2. Engage Religious Leaders and Community Members: Addressing the strong beliefs and values that challenge FP among religious leaders and community members is crucial. It is recommended to engage religious leaders in sensitization and awareness campaigns to promote the acceptability and importance of FP.
3. Improve Male Partner Involvement: Addressing the lack of support for FP from male partners based on religious values is essential. Strategies should be developed to engage and educate male partners about the benefits of FP and involve them in decision-making processes.
Key Role Players:
1. Health Extension Workers (HEWs): Trained HEWs play a key role in delivering FP services and should receive adequate training and support.
2. Religious Leaders: Engaging religious leaders is important to address religious beliefs and values that challenge FP.
3. Community Members: Community members should be involved in awareness campaigns and education programs to promote the acceptability of FP.
4. Implementing Partners: Organizations and agencies involved in implementing integrated FP and immunization services should collaborate and provide support to ensure successful implementation.
Cost Items for Planning Recommendations:
1. Training Programs: Budget should be allocated for comprehensive training programs for HEWs, religious leaders, and community members to enhance their knowledge and skills related to FP.
2. Awareness Campaigns: Funds should be allocated for awareness campaigns targeting religious leaders, community members, and male partners to promote the acceptability and importance of FP.
3. Supportive Materials: Resources should be allocated for the development and distribution of educational materials, counseling tools, and information materials to support the implementation of integrated FP and immunization services.
4. Monitoring and Evaluation: Budget should be allocated for monitoring and evaluation activities to assess the effectiveness and impact of the recommendations and interventions implemented.
Please note that the cost items mentioned are for planning purposes and do not represent actual costs. The specific budget requirements would depend on the context and scale of implementation.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides a detailed description of the methods used in the study, including the realist evaluation approach, data collection, and analysis. It also presents the key contextual factors, empirical mechanisms, and outcomes identified in the study. However, the abstract does not provide specific results or findings from the study, which limits the strength of the evidence. To improve the evidence, the abstract could include a summary of the main findings and their implications for integrated delivery of immunizations and family planning in Ethiopia.

Background: Maternal and child health are key priorities among the Sustainable Development Goals, which include a particular focus on reducing morbidity and mortality among women of reproductive age, newborns, and children under the age of five. Two components of maternal and child health are family planning (FP) and immunisation. Providing these services through an integrated delivery system could increase the uptake of vaccines and modern contraceptive methods (MCMs) particularly during the post-partum period. Methods: A realist evaluation was conducted in two woredas in Ethiopia to determine the key mechanisms and their triggers that drive successful implementation and service uptake of an intervention of integrated delivery of immunisations and FP. The methodological approach included the development of an initial programme theory and the selection of relevant, published implementation related theoretical frameworks to aid organisation and cumulation of findings. Data from 23 semi-structured interviews were then analysed to determine key empirical mechanisms and drivers and to test the initial programme theory. These mechanisms were mapped against published theoretical frameworks and a revised programme theory comprised of context-mechanism-outcome configurations was developed. A critique of theoretical frameworks for abstracting empirical mechanisms was also conducted. Results: Key contextual factors identified were: the use of trained Health Extension Workers (HEWs) to deliver FP services; a strong belief in values that challenged FP among religious leaders and community members; and a lack of support for FP from male partners based on religious values. Within these contexts, empirical mechanisms of acceptability, access, and adoption of innovations that drove decision making and intervention outcomes among health workers, religious leaders, and community members were identified to describe intervention implementation. Conclusions: Linking context and intervention components to the mechanisms they triggered helped explain the intervention outcomes, and more broadly how and for whom the intervention worked. Linking empirical mechanisms to constructs of implementation related theoretical frameworks provided a level of abstraction through which findings could be cumulated across time, space, and conditions by theorising middle-range mechanisms.

Process-focused, theory based realist evaluation presents a useful framework when seeking to answer questions of what works, for whom, and under what circumstances. A central tenet of realist evaluation is that interventions work, or do not work, based upon the decisions that actors make in response to available resources. These decisions constitute mechanisms which are triggered in some contexts and not in others. We explored this relationship between context, mechanism, resources/intervention, and resulting oucome(s) using the context-mechanism-outcome (CMO) configuration of realist evaluation [14]. Where a CMO relates to a specific category of actor, a context-actor-mechanism-outcome (CAMO) is useful, and where the CMO relates to an intervention or component of an intervention, then a context-intervention-actor-mechanism-outcomes (CIAMO) configuration is better able to specify what works, for whom, why and where. We used two further theory based approaches alongside the CMO/CAMO/CIAMO heuristic in our interrogation of the uptake of FP within the integrated service delivery model. The first of these was the development of an initial programme theory (Fig. 1). Discussions were held with intervention designers and implementers in a workshop 15 months into the implementation of the intervention. This exercise focussed on implementers’ understanding of how the intervention and its components were expected to work, how they were currently perceived to be working, and how CMO/CAMO/CIAMO configurations could be used to determine and explain factors enabling or hindering the intervention. In constructing the initial programme theory we were able to elucidate factors that intervention designers and implementers perceived as the major drivers of the intervention [15]. These were adherence to clinical and counselling guidelines among HEWs, and community and religious leader support for FP. The initial programme theory also described potential barriers and mitigating factors to intervention implementation including the lack of tracking for referrals to higher level facilities for FP made by HEWs at health posts, long wait times at health posts in densely populated communities, and the lack of HEW training on implant removals. This initial programme theory was used in developing themes for interview guides and in identifying stakeholders for empirical interviews used to develop CMO/CAMO/CIAMOs. Initial programme theory Our second approach was to map our findings against the constructs of implementation related theoretical frameworks. Our reasons for using this approach hinge upon two methodological axes which are that the major challenge for evaluation is the cumulation of findings across time, space and conditions [14] and that for realist evaluation, such generalisation or transferability of findings occurs through abstraction. Abstraction is achieved through linking to theories including those from cognitive psychology, and behavioural science [16] and more recently also including a range of theories relating to behaviour change in health systems [17]. We assumed that the use of the constructs of implementation related frameworks rather than broader behavioural theories, for example, would provide more insight on mechanisms driving implementation outcomes and opportunites for cumulation of findings across evaluations. We considered several theories and concluded that our initial programme theory had best fit with constructs of three theoretical frameworks. These were acceptability of FP and MCMs by both health workers and community members [18], adoption and diffusion of innovations particularly with respect to health workers [19, 20], and access by women [21]. The constructs described by these frameworks align with the concept of mechanisms within realist evaluation as they describe factors that drive or lead to decision making among different actors. By mapping our findings against these constructs, we aimed to identify transferrable theories which could be used by implementers in similar contexts. Sekhon et al describe acceptability using seven constructs in the Theoretical Framework of Acceptability (TFA): affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy [18]. Rogers’ diffusion (and adoption) of innovations framework consists of five contructs: relative advantage, compatibility, trialability, observability and complexity [20]. Finally, Penchansky and Thomas describe access using five constructs: availability, accessibility, accommodation, affordability and acceptability [21]. We linked the empirical mechanisms identified in the data to a construct(s) of the frameworks and critiqued the potential of this approach as an aid to cumulation of findings across studies. BGRS is one of nine regional states in Ethiopia. It is predominantly rural and consists of twenty woredas (districts) and 398 kebeles (smallest administrative unit) [22]. Assosa and Bambasi are part of BGRS and encompass 74 and 40 kebeles respectively. Within BGRS, there are five native Ethnic groups (Bertha, Gumuz, Mao, Komo and Shenash) and other dwellers (predominantly Oromo and Amhara). The region has relatively low levels of literacy (60.9% of women and 30.3% of men are illiterate), and high religiosity, with Islam and Orthodox Christianity being the predominant religions (51.3 and 28.2% respectively) [22, 23]. At the time of the 2016 Demographic Health Survey (DHS), full immunisation coverage in BGRS was 57.4% compared to nearly 89.2% in the capital of Addis Ababa and a national average of 38.3% [23]. The proportion of women aged 15 to 49 using any FP method in BGRS was 28.5% compared to 55.9% in Addis Ababa. Knowledge about FP was only slighty lower in BGRS compared to Addis Ababa (97.6% vs 100.0% respectively). There was also more male involvement in decision-making about FP in BGRS compared to Addis Ababa: 9.8% compared to 2.4% of women reported that their male partner was the main decision maker about FP, while 14.4% compared to 25% of women said they made the decisions about FP. However, the majority of respondents said that decision making was done jointly (75.9% vs 72.2%) [23]. In BGRS, the Health Extension Programme (HEP) plays a key role in health service delivery by providing primary health services at health posts in rural communities. It was adopted by the government of Ethiopia in 2003 to achieve universal health coverage among rural populations by 2009 [24]. The HEP is driven by model families, the Health Development Army (HDA) and HEWs [24]. Model families are male and female headed households that have received specific training on the HEP and that follow best practices for health and hygiene. They serve as role models within the community [24]. The HDA is an organised community based movement aimed at improving health sector capacity by engaging with communities and community leaders [24]. HEWs, commonly women, typically staff health posts in pairs and provide services such as community integrated management of childhood illness, immunisations, injectable contraceptives, implant insertions (but not removals), as well as basic curative services such as first aid and malaria treatment. HEWs are the lowest level health cadre in Ethiopia, usually with an education up to Grade 10, supplemented with a 1 year didactic and practical training in different health care packages. Among other responsibilities, HEWs conduct household visits and outreach activities and refer cases to health centers as needed. Semi-structured interviews (SSIs) with key stakeholders involved in the delivery and uptake of the intervention were conducted to identify contextual factors that triggered the mechanisms driving intervention outcomes. Purposive sampling was used for SSIs to select key stakeholders involved in, or with an interest in, the intervention including implementing partners, government officials, HEWs, and community leaders. Participants were selected to offer a range of perspectives and opinions of the intervention. HEWs selected were involved in the delivery of childhood immunisation and/or FP services and were from health posts where the intervention was perceived to be more, or less, well received based on project monitoring data. An interview and discussion guide for SSIs was developed specifically for this study and was informed by the initial programme theory. Broad themes encompassed workload, socio-cultural norms, and healthcare access, and questions specific to particular participant groups and specific aspects of the intervention within the study context were included. This ensured that key issues captured within the initial programme theory were included in the interviews. Please see supplementary file S1 for the interview guide that was used. CMOs developed with the implementers were also included in interview and discussion guides [25]. Interviews were conducted in October 2017 and March 2018 in Amharic and Afan Oromo by local research assistants with guidance and oversight from a London School of Hygiene & Tropical Medicine researcher and an implementation supervisor. All interviews were recorded, transcribed verbatim and then translated into English. Translated transcripts were imported into NVivo 11.2 for coding and analysis. Quotes were anonymized, but the type of respondent attributable to each quote was retained to aid analyses. Key themes were identified based on the interview guides and supported by quotes from interview transcripts. Coding and analysis was based on an intial framework of: interventions; actors; context; mechanisms; outcomes and initial CAMO and CIAMO configurations. These categories were populated inductively with themes and sub-themes as they were identified from the data. We developed CMO/CAMO/CIAMO configurations from the analysis of stakeholder interviews. Overarching contexts were identified as well as contextual and intervention triggers for specific mechanisms driving outcomes. The outcomes included in the CAMOs and CIAMOs were both outputs and outcomes. We then linked the identified mechanisms with constructs of the acceptability, adoption and diffusion of innovations, and access frameworks. Finally, we used the CMO/CAMO/CIAMO configurations to construct a revised programme theory.

Based on the provided description, here are some potential innovations that could be used to improve access to maternal health:

1. Integrated delivery system: Implementing an integrated delivery system that combines family planning (FP) and immunization services could increase the uptake of vaccines and modern contraceptive methods (MCMs) during the post-partum period. This approach would ensure that women have access to both services in a convenient and coordinated manner.

2. Trained Health Extension Workers (HEWs): Utilizing trained HEWs to deliver FP services can improve access to maternal health. HEWs, who are typically women, can provide services such as community integrated management of childhood illness, immunizations, injectable contraceptives, and basic curative services. They can also conduct household visits and outreach activities, ensuring that women in rural communities have access to essential maternal health services.

3. Addressing religious beliefs and values: Recognizing and addressing religious beliefs and values that challenge family planning among religious leaders and community members is crucial. This could involve engaging with religious leaders to promote the importance of maternal health and family planning, and addressing any misconceptions or concerns they may have.

4. Male partner involvement: Encouraging male partner involvement and support for family planning can significantly improve access to maternal health. This could involve educational campaigns targeting men, highlighting the benefits of family planning and the importance of their involvement in decision-making.

5. Improving access to higher-level facilities: Ensuring that referrals to higher-level facilities for family planning made by HEWs at health posts are tracked and followed up on can improve access to comprehensive maternal health services. Additionally, addressing long wait times at health posts in densely populated communities can enhance access to timely care.

6. Training on implant removals: Providing HEWs with training on implant removals can improve access to long-acting reversible contraceptives. This would enable HEWs to offer a wider range of contraceptive options to women in their communities.

These innovations, when implemented effectively, have the potential to improve access to maternal health services and contribute to reducing morbidity and mortality among women of reproductive age, newborns, and children under the age of five.
AI Innovations Description
Based on the provided description, the recommendation to improve access to maternal health is to implement an integrated delivery system that combines family planning (FP) and immunization services. This integrated approach can increase the uptake of vaccines and modern contraceptive methods (MCMs), particularly during the post-partum period.

To develop this recommendation into an innovation, the following steps can be taken:

1. Conduct a realist evaluation: Use a process-focused, theory-based realist evaluation to understand what works, for whom, and under what circumstances. This evaluation approach focuses on the decisions made by actors in response to available resources and identifies the mechanisms that drive successful implementation and service uptake.

2. Develop an initial program theory: Engage with intervention designers and implementers to develop an initial program theory that outlines how the integrated delivery system is expected to work and the major drivers of the intervention. This theory should also identify potential barriers and mitigating factors to intervention implementation.

3. Use theoretical frameworks: Map the findings of the evaluation against the constructs of implementation-related theoretical frameworks to gain insight into the mechanisms driving implementation outcomes. Theoretical frameworks related to acceptability, adoption and diffusion of innovations, and access can provide valuable guidance in understanding decision-making processes among different actors.

4. Conduct stakeholder interviews: Conduct semi-structured interviews with key stakeholders involved in the delivery and uptake of the intervention. These interviews should aim to identify contextual factors that trigger the mechanisms driving intervention outcomes. Purposive sampling can be used to select stakeholders with a range of perspectives and opinions.

5. Analyze and code the data: Transcribe and translate the interview recordings, and import them into a qualitative data analysis software. Analyze the data using an initial framework that includes interventions, actors, context, mechanisms, outcomes, and initial context-actor-mechanism-outcome (CAMO) and context-intervention-actor-mechanism-outcome (CIAMO) configurations. Identify key themes and sub-themes based on the interview guides and quotes from the transcripts.

6. Develop revised program theory: Use the analysis of stakeholder interviews and the identified mechanisms to construct a revised program theory. This theory should link the mechanisms with the constructs of the theoretical frameworks used, providing a level of abstraction through which findings can be cumulated across time, space, and conditions.

By following these steps, the integrated delivery system combining family planning and immunization services can be further developed into an innovation that improves access to maternal health. The realist evaluation approach, along with the use of theoretical frameworks and stakeholder interviews, will provide valuable insights into the mechanisms driving successful implementation and service uptake.
AI Innovations Methodology
The study described is a realist evaluation conducted in Ethiopia to determine the mechanisms that drive the uptake of family planning (FP) when integrated with childhood immunization. The goal is to understand what works, for whom, and under what circumstances in order to improve access to maternal health.

The methodology used in this study includes the development of an initial program theory, the selection of relevant theoretical frameworks, and the analysis of data from semi-structured interviews. The initial program theory was developed through discussions with intervention designers and implementers, focusing on their understanding of how the intervention and its components were expected to work. This theory identified factors such as adherence to guidelines among health workers and community and religious leader support for FP.

The study also mapped the findings against the constructs of three theoretical frameworks: the Theoretical Framework of Acceptability, the diffusion of innovations framework, and the access framework. These frameworks provided insight into the mechanisms driving implementation outcomes and opportunities for cumulation of findings across evaluations.

Semi-structured interviews were conducted with key stakeholders involved in the delivery and uptake of the intervention. Purposive sampling was used to select participants, and the interviews were guided by an interview and discussion guide informed by the initial program theory. The interviews were transcribed, translated, and analyzed using NVivo software. Key themes were identified, and CMO/CAMO/CIAMO configurations were developed to explain the relationships between context, mechanisms, and outcomes.

The study found that contextual factors such as the use of trained Health Extension Workers (HEWs), religious beliefs, and lack of support from male partners influenced the acceptability, access, and adoption of FP services. The revised program theory developed from the analysis of the data helps explain how and for whom the intervention worked.

In summary, the methodology used in this study combines realist evaluation with the analysis of theoretical frameworks to understand the mechanisms driving the uptake of family planning when integrated with childhood immunization. This approach provides valuable insights into what works, for whom, and under what circumstances, and can inform the development of interventions to improve access to maternal health.

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