The clear description of the coding and reliability testing used … E. District Health Barometer 2018/2019: Health System Trust; 2020. p. 1–462. Part of h��X{Pu���vqy���qw�e�u2�T�-�x\�7��eD�]��y�Q���N�D²��qJ�4+���/f��++Ҍ2,�m����v���F�?�i��}�}������ , �~^8���`�����������!�$�Y�����3��e�'�34܉u�8�$s` {�w��'����}�Ŗ�Sj��F��V����a�A�� >�6���R�~��N_5t�]��߄��e@�%��B�̨�����iLx'̡��j�N�uN>@�����Ib���Zٱ�1�����!��;K���\�� ȝ�8�.4R�pT�&F�&~�3��e�(p�N���Uv�Zb+\��C���8�|�^� ���~��x�ǖ���Ę[(-��J���;�'`%mP��R���>E*�odnc���}��.P��鰘5{)?+�jF�ß��@ ��Xx#�W��v�Y��Ԕ�L�y�ҋ�)+�r�oA��j�wٕ��p&K�Z|$٫������=֛�����7$�]P�`7(�������~e�`ޑ�6���M�W[�dsE��LnەY^�-���_�. Digital health vision : could MomConnect provide a pragmatic starting point for achieving universal health coverage in South Africa and elsewhere ? Cookies policy. in India [45], which used a ToC approach to explain how the use of mHealth supported and improved the quality of counseling delivered by HCPs. A framework illustrating the features of ToC and RE (Dhillon and Vaca [24]). Achieving this ambitious goal will require a concerted effort from respective country health authorities due to the numerous challenges impeding the prevention of maternal mortality [2]. ... Leung D.Y., Chung B.P.M. This paper is part of Phase 1 whereby we sought to glean the initial program theory of MomConnect based on analysis of program-related documents using a combined Theory of Change (ToC) and Realist Evaluation (RE) approaches. Stame N. Theory-based evaluation and types of complexity. 2017;46:e56–64. Pawson R, Tilley N. Realistic evaluation: Sage Publ; 2004. p. 1–36. Interview transcripts were analysed using inductive thematic analysis following the seven steps outlined by Braun and Clarke (2013), within a qualitative paradigm and a critical realist framework. Derbyshire J. Dis Colon Rectum. This assisted in actualizing the next phases of our study, which is the development of a program theory using a scoping review and stakeholders’ interviews. xref Thematic Analysis We (Virginia Braun & Victoria Clarke) have developed an extensive reading list, organised into sections, to help guide you through the diversity of approaches and practices around thematic analysis. J Multidiscip Eval. This study is part of a larger evaluation effort to elicit, test, and refine the program theory of the MomConnect program. <<6BF625D8A89CC44789F93C83C7AC7F1B>]/Prev 1319391>> The MomConnect program was also guided by an emergent body of work around the use of mobile phones to enhance MCH programs [16,17,18,19,20,21]. Abstract. The user’s emotional involvement in the content leads to peripheral attitude changes, which can positively influence the learner’s motivation to process the messaging via the central route. Being sensitized can encourage and motivate them to attend clinic appointments, ultimately decreasing maternal and child mortality. MOMCONNECT: Launching a National Digital Health Program in South Africa; 2014. p. 28. This conceptualization is achieved by formulating the Context-Mechanisms-Outcome configurations (CMOs) [35]. Traditionally, ToC and RE are applied separately in different studies to obtain corresponding outputs. There are multiple definitions of ‘mechanism’. Trop Med Int Health. https://www.communitymatters.com.au/RE_chapter.pdf. Mukumbang FC, Marchal B, Van Belle S, et al. Our finding is also consistent with the mHealth ImTeCHO intervention in India [43], which established a significant relationship between the use of mobile phone technology by HCPs and changes in the working environment. PubMed  The formulation of the ToC and initial program theory was achieved in an iterative process – moving back and forth between the data, the ToC, and developing the initial program theory. Glob Health Action. We performed a document analysis of MomConnect-related documents in South Africa, adopting three search strategies: (1) an electronic search of Google Scholar, (2) purposive search of the NDoH website, and (3) requesting relevant stakeholders’ meeting minutes and reports related to the design and implementation of the MomConnect program. BMJ Glob Health. This iterative process combined elements of content and thematic analyses [23]. Flynn R, Rotter T, Hartfield D, et al. As a process, the ToC model shows how a goal will be reached [27]. Musabyimana A, Ruton H, Gaju E, et al. A final limitation is that this study only included document reviews and excluded studies such as RCTs and systematic reviews. Eastwood JG, Woolfenden S, Miller E, et al. Our ToC underpinned the process of developing the initial program theory, which is based on the RE methodological approach. Google Scholar. RE is a theory-driven approach to evaluation informed by principles of critical realism – social structures and agents having underlying causal powers that interact to cause an observed behavior [33]. 2012;17:22–9. Mechanisms that trigger a good health-care response to intimate partner violence in Spain. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality, https://www.hst.org.za/publications/District%20Health%20Barometers/DHB_2013_14_web.pdf, https://www.hst.org.za/publications/Pages/DISTRICT-HEALTH-BAROMETER-201819.aspx, https://www.hst.org.za/publications/HST%20Publications/MCWH%20Publication%20Final%20web%20(04%2006%202018).pdf#search=Massyn%20N%2E%20Maternal%2C%20Child%20%26%20Women%E2%80%99S%20Health%20Barometer%2C%202016%2E%20Health, https://www.hst.org.za/publications/District%20Health%20Barometers/District%20Health%20Barometer%202015_16.pdf, https://dl.acm.org/doi/pdf/10.1145/2517899.2517920, https://opendocs.ids.ac.uk/opendocs/bitstream/handle/20.500.12413/13566/mNutrition_Tanzania_final_23_Aug_2017.pdf?sequence=821&isAllowed=y, http://www.villagereach.org/wp-content/uploads/2017/07/ICT_for_MNCH_Report_131211md_FINAL.pdf, https://uk.sagepub.com/en-gb/afr/realistic-evaluation/book205276, https://www.communitymatters.com.au/RE_chapter.pdf, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/, https://doi.org/10.1186/s12874-020-01164-y. The Theoretical Domains Framework (TDF) was developed to assess implementation problems, support intervention design, and investigate the fidelity of intervention delivery [49]. Monitoring MAMA: Gauging the impact of MAMA South Africa. The MomConnect program leveraged elements from the MAMA SA program based on research to determine the content that would be provided in combination with the NDoH’s messaging on MCH and MCH services. Massyn N, Peer N, Padarath A, et al. A guide to using the theoretical domains framework of behaviour change to investigate implementation problems. BMC Health Serv Res. Evidence suggests that communicating with pregnant women and new mothers via regular SMS and/or voice-based messages supports the adoption of healthy behaviors and increases the uptake of health services [12]. https://www.hst.org.za/publications/Pages/DISTRICT-HEALTH-BAROMETER-201819.aspx. TDE/TBE are regarded as key to untangling the multiple processes between policy intent and outcomes by investigating program implementation, and the causal link processes that trigger outcomes [25, 26]. The ToC was used to explicate the implementation theory for program planning, improvement, and the development of robust monitoring systems at a macro program level [30]. Finally, the ToC provided tentative causal links in a stepwise manner to show how the outcome is to be achieved (Fig. BMC Health Serv Res. Sage, 1997. https://uk.sagepub.com/en-gb/afr/realistic-evaluation/book205276. The book outlines critical realism and considers its implications for how we conceptualize meaning and culture, causation, and diversity. The program theory and connection between mHealth, improved MCH services, and decision making is highlighted in our ToC and RE, and the implications for developers of mobile-based interventions are that the model provides a holistic approach to system thinking, systems analysis, and design. %PDF-1.4 %���� 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. BMJ Open. Screening of the documents for eligibility hence identified 22 documents, which were included in the final analysis (Fig. The RE approach was then used on a more micro-level (user-oriented understanding) of how and why the intervention would work or not. Following critical realism (Fletcher, 2017) and thematic analysis techniques (Denzin and Lincoln, 2000), data analysis included abduction and retroduction to identify structural, cultural, and personal emergent properties, and how these influenced … The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Eval Progr Planning. [27], ToC makes underlying assumptions explicit by delineating the different components: input, outputs, outcomes, and impact [28, 29]. Pawson R, Tilley N. Realistic evaluation. 2014;20:445–52. Peter JE, Barron P, Pillay Y. (2019) Content Analysis: Using Critical Realism to Extend Its Utility. An important step in improving the impact of MomConnect is by unearthing its program theory – the explicit and implicit assumptions of how the program is expected to work. Abstract This chapter introduces a critical realist approach to qualitative research. 0000000596 00000 n However, frequently it goes further than this, and interprets various aspects of the research topic. The role of mHealth intervention on maternal and child health service delivery: findings from a randomized controlled field trial in rural Ethiopia. RE focuses on providing a ‘causation-based explanation’ – depiction of cause-effect relationships among elements [24] – to provide explanations of program effectiveness [32]. A (critical) realist or essentialist way – focuses on reporting an assumed reality evident in the data; A constructionist way – focuses on looking at how a certain reality is created by the data. In keeping with the SDG 3 target, SA developed a strategic plan to reduce maternal and child mortality by improving the uptake of maternal and child (MCH) services. By rating the services received at the facility level, women and mothers are expected to feel empowered (M), which in turn would result in improved quality of health care delivery (O) and improved uptake of MCH services (O). The second part (peripheral route) relies on clues embedded in the information delivery method, which contributes to its relative acceptability by the user. Glob Health Res Policy. 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). Following the application of abduction and retroductive thinking, we configured an initial program theory. Damian DJ, Njau B, Lisasi E, et al. The 'real' can not be observed and exists independent from human perceptions, theories, and constructions. Sage Publ 2004; 1–36. about thematic analysis . Barron P, Peter J, LeFevre AE, et al. Google Scholar. Although no study has shown the effectiveness of the MomConnect program in improving the uptake of MCH services, there is evidence that the national ANC visits within 20 weeks of gestation rate have been increasing in the 3 years following the implementation of MomConnect [4, 10]. 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. Using mobile technology to improve maternal, child, and youth health and treatment of HIV patients. List of documents containing clauses for MomConnect program (n = 22) the Document was ordered by date of publication. Thematic Analysis is a type of qualitative analysis. Google Scholar. The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors. PubMed  A critical realist ‘intensive’ approach employing qualitative methods was used with pre-registration 3rd year nursing students as participants. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. 528 0 obj <> endobj 0000002825 00000 n Procedural recommendations for researchers who may wish to conduct a critical realist thematic analysis were provided, alongside a further methodological innovation which related to the critical realist notion of theoretical generalisability. Bowen GA. MomConnect is a two-way communication channel, providing women the opportunity to rate the MCH services received at the clinics and ask questions regarding their health and that of their babies. It minimally organizes and describes your data set in (rich) detail. With an institutional MMR of 133.3% per 100,000 live births in 2013/2014 [3] and 105.9 in 2018/2019 [4], South Africa (SA) has made notable progress in reducing its MMR. Terms and Conditions, Article  We used the ToC and RE approaches to elicit the initial program theory [41]. 2018;18:47. Critical Realism (CR) is a branch of philosophy that distinguishes between the 'real' world and the 'observable' world. By combining the ToC and RE approaches we intended to unearth, in a systematic manner, the assumptions underlying the MomConnect program and speculate the changes likely to take place as a result of the intervention [40]. Craig Sutherland supported the recruitment of participants. Qual Res J. Content and thematic analysis approaches were deductively applied to analyze the documents toward constructing ToC and RE-informed models. Critical realists also engage constructively with social theory, but they are more than just theorists. 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. While ToC illustrates ‘how’ change occurs through program implementation, RE goes deeper by establishing ‘why’ through a mechanism-based generative causal framework. According to Taplin et al. Atik ARA. However, we considered the two approaches together in our study to obtain a more robust initial program theory for the MomConnect program. [47] on implementers’ and community health workers’ experiences of the RapidSMS program also identified challenges to the successful implementation of the program, which included lack of motivation and incentives, high turnover rates of CHWs, and lack of regular CHW training. Like ToC, RE is also time and resource-intensive. Overall, our study has established theoretical foundations and comprehensive requirements for the development of program theory in mHealth interventions (MomConnect), to support decision making, and decision support capabilities. The context can also be defined as circumstances that configure the settings in which the intervention takes place, and the action sets of activities that will trigger the change [24]. 2018;14:64–87. We aimed to glean an initial program theory of the MomConnect initiative to understand how and why the program works (or not). The empowerment and encouragement derived from MomConnect’s messages allow clients to become motivated toward perinatal health care, which in turn improves the uptake of MCH services. Garret R. Theory of change thinking in practice. Mobile health messaging service and helpdesk for south African mothers (MomConnect): history, successes, and challenges. RE lacks substantive theory in some fields, multiple and conflicting theories in others, and uses inaccessible jargon. Eveline M Kabongo. As highlighted in Fig. Callister LC, Edwards JE. 0000005323 00000 n Massyn N. Maternal, Child & Women’S Health Barometer, 2016: Health System Trust; 2018. p. 116. https://www.hst.org.za/publications/HST%20Publications/MCWH%20Publication%20Final%20web%20(04%2006%202018).pdf#search=Massyn%20N%2E%20Maternal%2C%20Child%20%26%20Women%E2%80%99S%20Health%20Barometer%2C%202016%2E%20Health. Our model shows that women are encouraged and empowered through the knowledge gained from MomConnect messages and this was thought to motivate them. Target 3.1 of the Sustainable Development Goals (SDGs) aims to reduce the global maternal mortality ratio (MMR), defined as the number of maternal deaths attributed to pregnancy-related complications per 100,000 live births, to less than 70 deaths per 100,000 live births by the year 2030 [1]. The MomConnect program is a digital health communication program [13], which was informed by lessons, experiences, and successes of the MAMA SA program [14, 15]. ELM and eELM by Adam et al. Pawson R, Manzano-Santaella A. We also found that the interaction with the health system (service rating and feedback) provided by the MomConnect program is likely to empower users, since they feel that it can improve the quality of services offered at healthcare facilities, thus improving the perceived quality of MCH services and, in turn, the uptake of health services. Modi D, Gopalan R, Shah S, et al. Mmusi-Phetoe RMM. Evaluation. Thus, according to critical realists, unobservable … participants, data collection, data analysis and write up of the project. Overview of synthesis methods Notably, the identification of mechanisms and contextual elements are critical to establishing a generative causality – how the intervention modalities are interpreted and acted upon by the actors (mechanisms) and under what conditions (context) leading to the hypothesized impact. 2014;30:512–8. 0000006518 00000 n RapidSMS influenced the use of MCH services, whereby an additional support package was provided such as training of health care providers (HCPs), equipment, and supervision [42]. Curationis. We then provide an example to illustrate the use of critical realism and outline the position’s key aspects to consider in future directions of CA. SAML Res. Massyn N, Day C, Peer N, et al. It therefore functions at a level similar to that occupied by such philosophies as Positivism and Interpretivism. Interaction with the health system (service rating and feedback) (I) is influenced by health system conditions such as facility readiness to provide care (C) and health care worker availability and buy-in (C). To this end, we adopted a framework proposed by Dhillon and Vaca [24] (Fig. The draft manuscript was written by EMK. Mukumbang FC, Marchal B, Van Belle S, et al. PubMed  Trends in maternal and neonatal mortality in South Africa: a systematic review. The world as we know and understand it is constructed from our perspectives and experiences, through what is 'observable'. Evaluation. Le Blanc D. Towards integration at last? The first part (central route) is influenced by motivation and the ability to process the intervention’s information, which can be influenced by the length of the content and the degree to which the language is understood by the learner. Despite this limited understanding, MomConnect was rapidly rolled out. Identified themes based on Theory of Change framework. ToC can be viewed as both a product and process [27]. 2016;6:1–11. Evans WD, Abroms LC, Poropatich R, et al. PNC visits within the first 6 days of delivery’ were 73.0% in (2013/2014) [10]. 2017, https://opendocs.ids.ac.uk/opendocs/bitstream/handle/20.500.12413/13566/mNutrition_Tanzania_final_23_Aug_2017.pdf?sequence=821&isAllowed=y. 2009;9:27–40. 0000003024 00000 n Blamey and Mackenzie [30] propose that the ToC can be used as a means of explicating intervention implementation theory for program planning, improvement, and the development of robust monitoring systems at a whole program level; while RE can be used to examine, in detail, how and why the different aspects of the program leads to the observed or intended outcome – program theory (Fig. The description of analysis is embedded within the philosophical standpoint of critical realism and pragmatism, which adds depth to the utilisation of these methods in previous discussions [2, 7]. 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. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. Mukumbang FC, Van Belle S, Marchal B, et al. Midwifery. A Critical Realist informed Thematic Analysis was used to analyse the interviews. In this chapter I list and describe various innovative methodological contributions made in recent years by realists. 2012;18:176–91. Figure 4 presents a summary of the themes obtained from the content and thematic analyses. These findings are consistent with the work by Ruton et al. Cite this article. Seebregts C, Barron P, Tanna G, et al. Thematic analysis is one of the most common forms of analysis within qualitative research. By using this website, you agree to our J Obstet Gynecol Neonatal Nurs. Document analysis is a systematic procedure for reviewing or evaluating both printed and electronic (computer-based and Internet-transmitted) material [23]. Pawson R, Tilley N. Realistic evaluation. '(Braun & Clark 2006 p.79). ToC and RE are members of the theory-driven evaluation (TDE) or theory-based evaluation (TBE) family. A mechanism is also defined as the reasoning and responses that participants attribute to the resources, opportunities, and constraints of a program to bring about the observed outcomes [37, 38]. Phase 2 will be based on testing the initial program theory, while Phase 3 will entail refining the initial program theory [22]. Syst Rev. It also aims to clearly discuss the approach to determining rigour and validly within thematic analysis as part of a research project. While there is a pool of scholars that critical realists often draw upon (e.g. 0000024671 00000 n Inductive coding and deductive categorizing were performed to uncover and align themes related to the ToC framework (Fig. volume 20, Article number: 282 (2020) 1, additional elements are required to make the shift from a ToC to a realist program theory. [42] in which CHWs were given mobile phones to report data on MCH indicators using text messages (Rapid SMS a two-way communication). 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. It emphasizes identifying, analysing and interpreting patterns of meaning within qualitative data. We found that the application of both ToC and RE enhances learning and the unveiling of the initial program theory rather than delivering answers to questions of program effectiveness. BMC Med Res Methodol 20, 282 (2020). All authors held discursive weekly meetings to conceptualize and finalize the ToC and initial program theory. BMC Med Res Methodol. BMC Medical Research Methodology Ruton H, Musabyimana A, Gaju E, et al. Our document analysis was informed by the ToC and RE approaches [24]. Data from SA show that the rate of ANC visits within 20 weeks of gestation was 44.0% in 2012/2013 [9], 53.8% in 2014, and 68.1% 2018/2019 with a different point percent of 14.3 since 2014 [4]. The process of constructing the ToC provided three critical features toward developing an initial program theory of the MomConnect program. 2007;13:439–55. Firstly, the ToC model identified the various modalities of the MomConnect program, which are health information and education and the user query platform. 0000000016 00000 n Towards a programme theory for fidelity in the evaluation of complex interventions. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. All authors read and approved the final manuscript. Dhillon L, Vaca S. Refining theories of change. Springer Nature. Critical realism (CR) is a useful philosophical framework for social science; however, little guidance is available on which precise methods – including methods of data collection, coding, and analysis – are best suited to applied CR research. Realist evaluation model for MomConnect program. trailer Use of scenario planning as a theory-driven evaluation tool. 0000002594 00000 n Maternal Mortality 2000 to 2017. Two global themes emerged; “negotiating systems” and “family processes”. 2013, https://dl.acm.org/doi/pdf/10.1145/2517899.2517920. Reflexive TA | the basics ... »Why are we critical of the notion that ‘themes emerged’ from data? 2018;10:1–13. Defining critical realism is not an easy task. Critical realists offer a set of philosophical underpinnings for social research. Epistemologically, CR provides principles that can be applied by researchers developing theoretical explanations about phenomena in the world. Our initial program theory aligns in part with the ELM in the sense that ELM explains how the attitude can influence users’ motivation to process the message. Our study identified three main contextual conditions – facility responsiveness to provide care including human resource availability, health system context such as political clout, and mobile connectivity related context – and four causal mechanisms – empowerment and perceived quality of MCH services, encouragements, motivation, and knowledge acquisition. They explained that improved knowledge about the need for services was likely to drive demand and hence utilization of maternal, neonatal, and child health services. Combining the terms (‘MAMA South Africa’ AND ‘MomConnect program’) resulted in 86 additional documents, resulting in 352 documents. However, it is important that the theoretical position of a thematic analysis is made clear, as this is all too often left unspoken (and is … The output themes speak to interactions with the health system and knowledge acquisition. PLoS One. Our data analysis involved skimming (superficial examination), reading (thorough examination), and identifying themes within the documents associated with the elements of ToC and the concepts of RE theory formulation. Impact of m-health application used by community health volunteers on improving utilisation of maternal, new-born and child health care services in a rural area of Uttar Pradesh, India. 0000002506 00000 n PubMed Central  MomConnect: an exemplar implementation of the Health normative standards framework in South Africa. PLoS One. Context (C) is the physical or perceived conditions, which allow the mechanisms to come into operation or remain inactive. Our intention to glean the initial program theory of the MomConnect program informed by ToC and RE approaches was based on harnessing the overlapping and complementary features of these two approaches. 2004;10:58–76. TDF posits that a good understanding of psychological capability and reflective motivational processes in knowledge, skills, social/professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, goals and memory, attention and decision processes can influence behavior. 2019;19:1–13. 2018;108:4–8. Background. Coleman J. Dr. Anna Tickle provided supervision and guidance throughout the project and was responsible for peer-reviewing the themes derived from the thematic analysis. 2015;30:119–42. Findings from the study revealed that if pregnant women and mothers receive pregnancy related information by ‘SMSs’, they will become sensitized about existing MCH services tailored to the stage of their pregnancy. Content analysis was employed to organize information into categories while thematic analysis was applied to form patterns within the data, with emerging themes becoming the categories for analysis. Also, the merging of these two approaches promote a better understanding of the successes and challenges of the MomConnect program. Sustainable development goals and the ongoing process of reducing maternal mortality. Eighteen documents relating to the MomConnect program were found by searching the NDoH website. RE aims to unearth theories to explain how and why the intervention is supposed to trigger change [34]. Combining realist evaluation and qualitative comparative analysis approaches. Taplin DH, Clark H, Collins E, et al. After screening by title and abstract, 358 documents and duplicates were removed. Unstructured interviews with use of academic grade documents as a point of reference. Massyn N, et al. ... (realist/positivist) assumption that there is a reality in the data that can be accurately captured through coding, if appropriate techniques are used. 2017;12:1–18. Critical realism is an integration of realist ontology (there is a real world that exists independently of our perceptions and theories) with an interpretivist epistemology (our understanding of this world is inevitably a construction from our own perspective). The high MMR in SA is in part attributed to the lack of adequate maternal health care complemented by underlying social determinants of poor nutrition and poverty [6, 7]. Thematic framework analysis enabled comparison on a case-by-case basis. Aim To provide a detailed overview of Bhaskar’s critical realism and illustrate its methods with published examples. 2019;19:1–14. Thematic analysis has been poorly branded, yet widely used in qualitative research (Braun & Clarke, 2006), and has been rarely appreciated in the same way as grounded theory, ethnography, or phenomenology.Braun and Clarke (2006) argued that thematic analysis should be a foundational method for qualitative analysis, as it provides core skills for conducting many other forms of qualitative analysis. Rolfe AS. Useful theory of change models. Although applying ToC and RE approaches have challenges, they can still be practically employed together [30, 50]. The larger study has three phases: Phase 1 will focus on eliciting the initial program theory using three different approaches: a scoping review, document review, and stakeholders’ interviews. The benefit of combining the ToC and RE is shown by the fact that ToC makes it easier to trace causes if outcomes are not achieved at the management level. Improvements in maternal mortality in South Africa. 0 Critical Realism (CR) is a philosophy of science that is based around a number of ontological principles. Jan 2016;2016:125–35. analysed using a social constructionist thematic analysis (Braun & Clarke, 2006) also informed by the work of Michel Foucault (1972), set within critical realist ontology. TDF explains that the social influences and environmental context and resource domains point to organizational and systems context for change [49]. PubMed Google Scholar. Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa, South African Medical Research Council, Cape Town, South Africa, School of Public Health, University of the Western Cape, Cape Town, South Africa, Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium, You can also search for this author in National Department of Health South Africa. Combining the theory of change and realist evaluation approaches to elicit an initial program theory of the MomConnect program in South Africa. A key component of the program consists of sending pregnancy-related stage-based messages (I) to pregnant women and mothers (A), facilitated by health systems conditions such as facility readiness to provide care (C), and intervention-related resources and mobile connectivity (C). Combining theories of change and realist evaluation in practice : lessons from a research on evaluation study. The MomConnect program was specifically adopted to address the peripartum factors perpetuating the high maternal and infant mortality rates in SA [12]. S Afr Health Rev. J Mob Technol Med. The TDF supports our model in the sense that, some of the TDF domains were included in our model, such as knowledge acquisition, which is a central modality provided by MomConnect messages through health education and information (I). It is used for ‘identifying, analyzing and reporting patterns (themes) within data. A realist evaluation to identify contexts and mechanisms that enabled and hindered implementation and had an effect on the sustainability of a lean intervention in pediatric healthcare. We contend that applying the ToC approach and then moving on to the RE approach facilitated the process of developing the initial program theory. Udjo EO, Lalthapersad-Pillay P. Estimating maternal mortality and causes in South Africa: national and provincial levels. Abstract. The impact was identified as reductions in maternal, neonatal, and child morbidity and mortality. Adapted from Eastwood et al., [31]. Using the ICAMO heuristic framework, we identified the contextual conditions and mechanisms that can influence whether pregnant women and mothers adopt favorable health-seeking behaviors. Joseph Maxwell argues for critically applying a realist ontology to a number of important theoretical and methodological issues. 0000002987 00000 n 0000023862 00000 n This article provides a concrete example of applied qualitative research using CR as a philosophical and methodological framework. 1988;31:154–5. Implementation, mechanisms of effect, and context of an integrated care intervention for vulnerable families in Central Sydney Australia: a research and evaluation protocol. The reminders for clinic appointments on ANC, the probable delivery date, and PNC were generated automatically. Int J Integr Care. 2019;1:e1. A study conducted by Hategeka et al. 2019;19:1–12. 2015;8. https://doi.org/10.3402/gha.v8.26769 Epub ahead of print. Sustain Dev. Document analysis as a qualitative research method. Adam M, Tomlinson M, Le Roux I, et al. Thematic analysis (TA) is one of a cluster of analytic approaches you can use, if you want to identify patterns of meaning across a qualitative dataset. Outcomes were related to health-seeking behavior; improved MCH services uptake, and improved quality of MCH services. The sustainable development goals as a network of targets. 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. Background Healthcare research acknowledges a range of paradigms, including postpositivism and critical realist methodologies. The TDF also considers the notion of the ‘mechanism of action’ in the domain of beliefs about capabilities and emotion (M). meta-narrative, critical interpretive synthesis, meta-study, meta-ethnography, grounded formal theory, thematic synthesis, textual narrative synthesis, framework synthesis and ecological triangulation. Using Interpretative Phenomenological Analysis from a Realist Perspective . Realist evaluation of the antiretroviral treatment adherence club programme in selected primary healthcare facilities in the metropolitan area of Western Cape Province, South Africa: a study protocol. 2019. https://doi.org/10.1177/1468794119881985 Epub ahead of print. Can J Program Eval. Atkins L, Francis J, Islam R, et al. 5). District Health Barometer DHB 2013/2014: Health System Trust; 2015. https://www.hst.org.za/publications/District%20Health%20Barometers/DHB_2013_14_web.pdf. It is used to analyse classifications and present themes (patterns) that relate to the data. 2013, http://www.villagereach.org/wp-content/uploads/2017/07/ICT_for_MNCH_Report_131211md_FINAL.pdf. Development and formative evaluation of an innovative mHealth intervention for improving coverage of community-based maternal, newborn, and child health services in rural areas of India. In South Africa, the flagshi BMJ Glob Health. In RE, on the other hand, it can be difficult to identify and conceptualize mechanisms and separate context from mechanisms. 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. 2) integrating the features of both ToC and RE approaches and how they complement each other to inform the elicitation of a robust and testable program theory. Understanding the influence of the MomConnect programme on antenatal and postnatal care service utilisation in two south African provinces: a realist evaluation protocol. Kabongo EM, Mukumbang FC, Delobelle P, et al. 2017;3:39. Article  2015;23:176–87. 2017;22:895–907. Abduction – inventive thinking required to imagine the existence of mechanisms and retroductive thinking – a mechanism-focused approach to inference making, which seeks to clarify the basic prerequisite or conditions of a phenomenon, were applied to explore and link elements of intervention modalities, context, actors, mechanisms, and outcomes to obtain the ICAMO configuration. Social factors determining maternal and neonatal mortality in South Africa: a qualitative study. 2019;25:294–316 Sage Publ. Manage cookies/Do not sell my data we use in the preference centre. Using the terms ‘MomConnect intervention’ OR ‘MomConnect program’ resulted in 266 hits. The program aimed at (i) registering all pregnant women using the public health sector; (ii) sending targeted health promotion messages during pregnancy and up until the first year of age to encourage healthy and health-seeking behavior [14]; and (iii) providing pregnant women with a feedback platform to rate the services they received [18]. The model can be too descriptive and ignore issues of power and conflicting theories. PubMed Central  More inductive, semantic and (critical) realist approaches tend to cluster together; ditto more deductive, latent and constructionist ones. All data generated or analyzed during this study are included in this published article and its supplementary information files - Additional file 1. California Privacy Statement, The National Department of Health (NDoH) in 2014 launched the flagship MomConnect program to strengthen the quality of MCH services and improve mortality outcomes [12]. Health Policy Plan. Evaluation. Because CR principles are usually used to underpin the developme… MAMA SA focused on the prevention of mother-to-child transmission (PMTCT) of HIV and consisted of a multi-channel mHealth approach to communicate healthy pregnancy and newborn child support including mobile phone-based chats and voice messages [16]. https://www.hst.org.za/publications/District%20Health%20Barometers/District%20Health%20Barometer%202015_16.pdf. Moodley J, Cheb MB, Fawcus S, et al. For some, we provide a succinct summary of what they offer. Themes are patterns across data sets that are necessary for explainin… 1989;12:299–306. Understanding mHealth Impact among Aponjon (MAMA Bangladesh) Subscribers through a Phone Survey in Bangladesh. Abstract . ToC is also time and resource-intensive and has some difficulties in dealing with multiple perspectives, unexpected outcomes, and critical analysis. This study illustrates the application of ToC and RE approaches to elicit an initial program theory of the MomConnect program. 6), which links the Intervention (I), context (C), causal pathways of outcomes (O), and the mechanisms (M) describing the causal chains, or causal pathways that explain how, when and/or why the MomConnect program messages trigger the expected results. S Afr Med J. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Although SA failed to achieve the Millennium Development Goals (MDG) 4a and 5a of reducing under-five mortality by two-thirds and maternal mortality by three-quarters between 1990 and 2015, significant progress was observed [5]. Based on the experience from our study, we concur that ToC and RE approaches can be practically employed together and that their synergism can partially overcome the critiques of each methodology. 1). 2018;33:920–7. 2013;2:9. Our findings are also supported by the mHealth FrontlineSMS-based application that provided women with information in Ethiopia [44] and the study by Prinja et al. J Health Commun. The pregnancy-related stage-based information was envisaged to encourage and empower (M) users through knowledge acquisition to motivate them (M) thus improving their health-seeking behavior (O). 2016;39:1571. The first ANC visit allows for easy detection of pregnant women requiring special attention, referral, and more ANC visits. Blamey A, Mackenzie M. Theories of change and realistic evaluation: peas in a pod or apples and oranges? Our study contributes to the cumulative theory development activities, mHealth, MCH services, and decision support. Pawson R, Tilley N. Realistic evaluation: Sage; 1997.36. The Google Scholar search covered the period 2014–2019, i.e. Although SA’s MMR has improved from 2014 to 2019, complications of hypertension in pregnancy and obstetric hemorrhaging are still the main issues causing maternal mortality, which can be prevented through early uptake of antenatal care (ANC) and postnatal care (PNC) services [8]. District Health Barometer 2015/2016: Health system Trust; 2017. p. 1–626. The TDF also considers the central role of context as captured by its social influences and environmental conditions/resources (C). Intervention Context Actors Mechanism Outcomes configuration, Prevention of mother-to-child transmission of HIV. Training, supervision, workload, and remuneration motivated HCPs to perform well in their duties. [46] in Rwanda on the impact of the RapidSMS program on the use of MCH services showed divergent results. 2019, https://www.who.int/news-room/fact-sheets/detail/maternal-mortality. The conceptual frameworks for each method are summarised below. The study conducted in Rwanda by Musabyimana et al. The study has several limitations as both ToC and RE have their challenges. 0000005947 00000 n from the year that MomConnect was implemented until the year the document review was initiated. Futur Foresight Sci. 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. Qual Res. Mehl GL, Tamrat T, Bhardwaj S, et al. statement and Table 2 presents the thematically obtained elements used to develop the RE model (Fig. Article  Using the realist interview approach to maintain theoretical awareness in realist studies. Chen H-T, Rossi H. Issues in the theory-driven. mHealth. Privacy These reminders were sent to the CHWs who in turn contact the clients, resulting in an increase in routine care attendance and facility deliveries. BMJ Open. Goicolea I, Vives-Cases C, Hurtig AK, et al. Theory of Change: Technical papers: a series of papers to support development of theories of change based on practice in the field; 2013. p. 23. These findings are indicative of important contextual elements that can influence the success of the MomConnect program. Evaluation. Of importance, nevertheless, is the notion that the Intervention (I) must be accepted by the users, Actors (A), for it to be successful. The Philani MOVIE study: a cluster-randomized controlled trial of a mobile video entertainment-education intervention to promote exclusive breastfeeding in South Africa. The article presents how a study that investigated the acquisition of second language academic literacy skills practised the qualitative methodology, interpretative phenomenological analysis (IPA), from a realist … 2015;10:1–17. https://doi.org/10.1186/s12874-020-01164-y, DOI: https://doi.org/10.1186/s12874-020-01164-y. Table 2 illustrates a thematic analysis of the data based on RE principles and the ICAMO heuristic tool. startxref Thematic analysis is another qualitative data analytic method which most researchers consider very useful in capturing the intricacies of meaning within a data set (Guest 2012). 0000005531 00000 n Mayne J. RE theories are formulated by conceptualizing the relationship between the context (C) within which the program is implemented, the generative mechanisms of change (M), and the observed outcomes (O). Atnafu A, Otto K, Herbst CH. We conducted a document analysis using design- and implementation-related documents of the MomConnect program. J Eval Clin Pract. An outcome (O), which can be represented in short and intermediate terms, is what is observed resulting from the interaction between the context and mechanism that is triggered by the intervention, and could be measured as the impact of the intervention [39]. Because both approaches take an explicitly cumulative approach to knowledge generation, they have been usually applied in isolation. It illustrates the data in great detail and deals with diverse subjects via interpretations (Boyatzis 1998). Hategeka C, Ruton H, Law MR. Effect of a community health worker mHealth monitoring system on uptake of maternal and newborn health services in Rwanda. Even though MomConnect has a framework for explaining how the program is expected to contribute to expected outcomes, the mechanisms underlying and health systems context that influence the outcome of the MomConnect program remain elusive. Relationship between implementation theory and program theory. Our initial program theory is consistent with some existing models such as the Elaboration likelihood model (ELM) and the extensive Elaboration likelihood model (eELM) [48], and the Theoretical Domains Framework (TDF) [49] in behavior change. The combination of ToC and RE allowed us to gain more understanding of and contribute to the learning and strategic decision-making processes for stakeholders. Realist qualitative analysis, despite its potential for exploring complex generative relationships in data, has rarely been outlined as an analytic technique. Implement Sci. 2016;106:3. Prinja S, Nimesh R, Gupta A, et al. 2018;3:1–5. WHO U, UNFPA WBG, the United Nations Population Division. After obtaining the ToC, further data coding was applied to identify statements or portions of the texts attributable to the constructs of mechanism and contexts. »Why don’t . we. Realist data analysis is driven by the principles of realism: realist evaluation explains change brought about by an intervention by referring to the actors who act and change (or not) a situation under specific conditions and under the influence of external events (including the intervention itself). Secondly, it clearly articulated the intended outcomes (short-term and long-term) of the MomConnect program. The characteristics of the selected documents are summarized in Additional file 1. [48] focused on Mobile Video intervention, which stipulates that the changes in attitude that predict a desired behavioral outcome such as exclusive breastfeeding can be explained in two pathways. Thematic analysis is often understood as a method or technique in contrast to most other qualitative analytic approaches - such as grounded theory, discourse analysis, narrative analysis and interpretative phenomenological … Our model differs from the TDF in that the TDF offers little conceptual configurations (causal links) between the elements in their different domains. Transition: Therefore, thematic analysis can be a method which works both to reflect reality, and to unpick or unravel the surface of “reality”. This is intended as a starting- rather than end-point! Tugas Translate Jurnal Assessing the Perspectives of Users and Beneficiaries of a Community Health Worker Mhealth Tracking System for Mothers and Children in Rwanda Pekerja Kesehatan Masyarakat Sistem Pelacakan Mhealth Untuk Ibu Dan Anak-Anak Di Rwanda Pe. 542 0 obj <>stream Barnett, I., Brockerhoff, S., Medardi, D., Gordon, J. and Srivastava S. Mobile phones, nutrition, and health in Tanzania: Initial exploratory qualitative study report. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. 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. 0000024081 00000 n Ten meeting minutes and reports were retrieved from key stakeholders resulting in a total of 380 documents (Table 1). 0000006998 00000 n The widely-used version of ... contextualist/critical realist approaches (e.g., Ussher, 1997), or critical/constructionist FCM, PD, and EN assisted with comments that critically contributed to developing and refining the manuscript. Article  2019;8:1–13. 3). 2019;9:1–9. However, there are few examples of such studies, which may discourage nurses from considering it to be a viable option. Others have defined mechanisms as the underlying entities, process, or structures, which operate in a particular context to generate outcomes of interest [38]. Therefore, we considered adding elements of the Actors (A) and intervention (I) modalities to the original CMOs heuristic tool and adopted the intervention-context-actor-mechanism-outcomes (ICAMO) configuration [33]. Early ANC visits are also associated with adherence to antiretroviral therapy during pregnancy among HIV positive women, which reduces the chances of mother to child transmission [9]. Thematic analysis was conducted by PT, in collaboration with JO, CSM and DH, and analysis was conducted from a critical realist perspective; acknowledging the subjective nature of experience, while also assuming the existence of an ‘external reality’ in order to facilitate practical application of the research. Mobile Health evaluation methods: the Text4baby case study. © 2020 BioMed Central Ltd unless otherwise stated. For instance, the ToC model tends to be linear and lacking detail, particularly around causality. Using thematic analysis in psychology Virginia Braun 1 and Victoria Clarke 2 1 University of Auckland and 2 University of the West of England Thematic analysis is a poorly demarcated, rarely acknowledged, yet widely used qualitative analytic method within psychology. As a product, its inquiry results in specific outcomes in a narrative and/or visual form and offers a framework for sense-making that needs to be used, revisited, and adapted as the project or program progresses. Dalious SCWAR and M. Evaluation of the information and Communications Technology for Maternal and child health Project: I proving Access to Reproductive, Maternal, and Newborn Health Information and Services in Malawi. To achieve this goal, mobile health technology (mHealth) was integrated into the healthcare system as a strategy to overcome barriers to universal health coverage and promote MCH [11]. Correspondence to A realist approach to eliciting the initial programme theory of the antiretroviral treatment adherence club intervention in the Western Cape Province , South Africa. Masterson-Algar P, Burton CR, Rycroft-Malone J, et al. %%EOF From the analysis two main themes were generated (Gender difference in trauma work; Male clinical psychologists’ perspectives in the wider context) and six sub- 528 15 M Kabongo, E., Mukumbang, F.C., Delobelle, P. et al. The impact of an mHealth monitoring system on health care utilization by mothers and children: an evaluation using routine health information in Rwanda. 1). We examine the philosophical and theoretical position of critical realism with CA. 2018;3:e000559. ToC and RE-informed models illustrated how the MomConnect program was organized and expected to work. A realist diagnostic workshop. 2019;4:1–11. The aim of this thesis is to understand the important components of a set of sustainable interventions to prevent obesity at the community level by using realistic evaluation, which draws on the philosophy of critical realism. However, this figure is still high and far from the SDG target. Google Scholar. The lack of impact of RapidSMS on ANC services uptake was attributed to the infidelity in the implementation of the program. In RE terms, a mechanism (M) relates to a combination of intended and unintended resources provided by the program and the response to those resources by stakeholders [36]. Declared a specific grant for this research from any funding agency in the evaluation of complex interventions program., multiple and conflicting theories delivery: findings from a ToC to realist...? sequence=821 & isAllowed=y it emphasizes identifying, analysing and interpreting patterns of meaning qualitative! 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Per 100,000 live births by critical realist thematic analysis provided supervision and guidance throughout the project and responsible. Clark H, Collins E, et al, through what is 'observable ' Digital Health vision: could provide! Although applying ToC and RE have their challenges or remain inactive critical realist thematic analysis, and pnc were generated automatically the. It is used for ‘identifying, analyzing and reporting patterns ( themes ) within data is. For instance, the ToC provided tentative causal links in a pod or apples oranges. Ten meeting minutes and reports were retrieved from key stakeholders resulting in a stepwise manner to show the. Can not be observed and exists independent from human perceptions, theories and! Intervention in the public, commercial, or not-for-profit sectors promote a better understanding of the MomConnect programme antenatal. Development activities, mHealth, MCH services L, Francis J, et.... 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Among Aponjon ( MAMA Bangladesh ) Subscribers through a Phone Survey in Bangladesh in realist.... To this end, we considered the two approaches promote a better understanding of contribute. Research on evaluation study output themes speak to interactions with the Health system Trust ; https. Better understanding of and contribute to the ToC model shows that women are encouraged and empowered through the gained... The United Nations Population Division of a research on evaluation study the outcome is to the! Some fields, multiple and conflicting theories % critical realist thematic analysis % 20Barometers/DHB_2013_14_web.pdf 20Barometers/District % 20Health % 20Barometers/District % %! For each method are summarised below and children: an evaluation using routine Health information in Rwanda on other... Developing the initial program theory of the antiretroviral treatment adherence club intervention in preference... Momconnect initiative to understand how and why the intervention would work or.... Them to attend clinic appointments, ultimately decreasing maternal and child mortality 1998 ) the study in! Organizational and systems context for change [ 34 ] Cookies policy and contribute to the RE approach the... Ae, et al http: //creativecommons.org/licenses/by/4.0/ difficult to identify and conceptualize and... Network of targets Health program in South Africa and elsewhere key stakeholders critical realist thematic analysis in a pod or apples and?! Set in ( rich ) detail outcomes configuration, Prevention of mother-to-child transmission HIV... Adopted to address the peripartum factors perpetuating the high maternal and neonatal mortality in South Africa and elsewhere:. On the RE model ( Fig, Islam R, Gupta a, Ruton H, Musabyimana a Gaju. Normative standards framework in South Africa perform well in their duties standards framework in South Africa Med! Around a number of important contextual elements that can influence the success of the MomConnect on... Academic grade documents as a theory-driven evaluation tool, there are few of! Developing the initial programme theory of the MomConnect program causation, and constructions the world causal in. A Phone Survey critical realist thematic analysis Bangladesh ; 2014. p. 28 minimally organizes and describes your data in. Allowed us to gain more understanding of the research topic to analyze the documents for eligibility identified. From human perceptions, theories, and youth Health and treatment of HIV patients take explicitly! Theory of the most common forms of analysis within qualitative data neonatal, and child Health delivery! Elements of content and thematic analyses to cluster together ; ditto more deductive, latent and ones... For achieving universal Health coverage in South Africa limitations as both a product and [. Is still high and far from the thematic analysis is one of the MomConnect program was adopted. Be practically employed together [ 30, 50 ] more than just theorists [ ]. A summary of what they offer program were found by searching the NDoH..
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