We followed up each mother-baby pair for 3 months after birth and measured rates of consent, recruitment, and follow-up (our target rate was more than 80%). In addition, women in the intervention villages received ABHR, instructions on ABHR use, a poster on the ‘three moments of hand hygiene’, and training. Both clusters received the standard of care of antenatal health education, Maama Kit, and clinic appointments. Pregnant women of over 34 weeks’ gestation were recruited over a period of 3 months. We conducted a pilot parallel cluster randomised controlled trial across ten villages (clusters) in rural Eastern Uganda. Our study piloted a cluster randomised trial of providing ABHR to postpartum mothers to prevent neonatal infection-related morbidity in the communities. Health systems research projects would benefit from analyses beyond the implementation period, in order to better understand how adoption and diffusion happen, or not, over time, after the external catalyst departs.Īlcohol-based hand rub (ABHR) is widely used in both health and social facilities to prevent infection, but it is not known whether supplying it for regular perinatal use can prevent newborn sepsis in African rural homes. We found that the adapted model of diffusion of innovations facilitated the emergence of insights on barriers and facilitators to the implementation of health systems interventions. In this short report, we used an adaptation of Greenhalgh’s Model of Diffusion to reflect on these projects’ approaches to implementing innovative interventions, with the ultimate goal of reducing maternal and neonatal mortality in rural Uganda. Over time, the projects diverged in the content of the intervention and the modality in which they were implemented, providing an opportunity for reflection on innovation and scaling up. In this paper, we describe two of projects that were initially conceived to tackle the financial barriers to access to care – through a voucher program in the community - on the demand side - and a series of health systems strengthening activities at the district and facility level - on the supply side. For nearly the past decade, the Makerere University School of Public Health researchers, through various projects, have been spearheading innovative interventions, embedded in implementation research, to reduce barriers to access to care. Pregnant women, particularly in rural areas, often lack the financial resources and means to access health facilities in a timely manner for quality antenatal, delivery, and post-natal services. In Uganda, more than 336 out of every 100,000 women die annually during childbirth. This agile embedded research approach is designed to sustain scientific rigor while optimizing the integration of learning into managerial decision making. Known as "agile science," this paradigm combines scientific rigor with management decision making. ![]() Based on strategies that were effectively applied to offsetting challenges, a process of merging research with management is proposed that is derived from computer science. These and other embedded implementation science attributes are reviewed together with contradictions that challenged their pursuit in each case. Moreover, principles of scientific protocol leadership are inconsistent with managerial leadership. Structural contradictions impede host institution ownership of research processes and utilization of results. In general, rigorous statistical designs employ units of observation that are inconsistent with organizational units that managers can control. ![]() In the third example, statistical rigor was sustained, but this feature of the design was inconsistent with embedded science. In 2 of the cases, implementation research standards that are typically embraced without question were abandoned to ensure pursuit of embedded science. ![]() We present case studies of the application of embedded implementation research in Bangladesh, Ghana, and Tanzania where initiatives to strengthen community-based health systems were conducted using the embedded science model. However, contradictions associated with the approach often prevent its application. Embedding research within target organizational systems represents an effective response to this problem. Implementation research often fails to have its intended impact on what programs actually do.
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