Building programme theory to develop more adaptable and scalable complex interventions: Realist formative process evaluation prior to full trial

Brand, Sarah; Quinn, Cath; Pearson, Mark; Lennox, Charlotte; Owens, Christabel; Kirkpatrick, Tim; Callaghan, Lynne; Stirzaker, Alex; Michie, Susan; Maguire, Mike; Shaw, Jenny; Byng, Richard

doi:10.1177/1356389018802134

Cited by 49 publications

(65 citation statements)

References 38 publications

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“…According to Pawson and Tilley, 30 it is not programmes that work, rather, it is the resources offered by programmes that enable stakeholders (eg, implementers and service users) to make them work. Mechanisms are the ways in which programme resources or strategies interact with the reasoning of stakeholders to produce effects 31 and they can only be activated in certain circumstances, that is, in specific contexts. Context describes the features of the conditions in which programmes are implemented that trigger the mechanisms to produce intended and unintended outcomes.…”

Section: Methodsmentioning

confidence: 99%

Which mechanisms explain the motivation of primary health workers? Insights from the realist evaluation of a maternal and child health programme in Nigeria

et al. 2020

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IntroductionWell-trained, adequately skilled and motivated primary healthcare (PHC) workers are essential for attaining universal health coverage (UHC). While there is abundant literature on the drivers of workforce motivation, published knowledge on the mechanisms of motivation within different contexts is limited, particularly in resource-limited countries. This paper contributes to health workforce literature by reporting on how motivation works among PHC workers in a maternal and child health (MCH) programme in Nigeria.MethodsWe adopted a realist evaluation design combining document review with 56 in-depth interviews of PHC workers, facility managers and policy-makers to assess the impact of the MCH programme in Anambra State, Nigeria. A realist process of theory development, testing and consolidation was used to understand how and under what circumstances the MCH programme impacted on workers’ motivation and which mechanisms explain how motivation works. We drew on Herzberg’s two-factor and Adam’s equity theories to unpack how context shapes worker motivation.ResultsA complex and dynamic interaction between the MCH programme and organisational and wider contexts triggered five mechanisms which explain PHC worker motivation: (1) feeling supported, (2) feeling comfortable with work environment, (3) feeling valued, (4) morale and confidence to perform tasks and (5) companionship. Some mechanisms were mutually reinforcing while others operated in parallel. Other conditions that enabled worker motivation were organisational values of fairness, recognition of workers’ contributions and culture of task-sharing and teamwork.ConclusionsPolicy designs and management strategies for improving workforce performance, particularly in resource-constrained settings should create working environments that foster feelings of being valued and supported while enabling workers to apply their knowledge and skills to improve healthcare delivery and promote UHC. Future research can test the explanatory framework generated by this study and explore differences in motivational mechanisms among different cadres of PHC workers to inform cadre-related motivational interventions.

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Section: Methodsmentioning

confidence: 99%

Which mechanisms explain the motivation of primary health workers? Insights from the realist evaluation of a maternal and child health programme in Nigeria

et al. 2020

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“…RE is recommended for studying QI23 and has been used for studying the implementation and impact of large-scale QI programmes 24. There is increasing interest in use of realist methods in feasibility evaluations 25–27…”

Section: Methods and Analysismentioning

confidence: 99%

How, in what contexts, and why do quality dashboards lead to improvements in care quality in acute hospitals? Protocol for a realist feasibility evaluation

et al. 2020

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IntroductionNational audits are used to monitor care quality and safety and are anticipated to reduce unexplained variations in quality by stimulating quality improvement (QI). However, variation within and between providers in the extent of engagement with national audits means that the potential for national audit data to inform QI is not being realised. This study will undertake a feasibility evaluation of QualDash, a quality dashboard designed to support clinical teams and managers to explore data from two national audits, the Myocardial Ischaemia National Audit Project (MINAP) and the Paediatric Intensive Care Audit Network (PICANet).Methods and analysisRealist evaluation, which involves building, testing and refining theories of how an intervention works, provides an overall framework for this feasibility study. Realist hypotheses that describe how, in what contexts, and why QualDash is expected to provide benefit will be tested across five hospitals. A controlled interrupted time series analysis, using key MINAP and PICANet measures, will provide preliminary evidence of the impact of QualDash, while ethnographic observations and interviews over 12 months will provide initial insight into contexts and mechanisms that lead to those impacts. Feasibility outcomes include the extent to which MINAP and PICANet data are used, data completeness in the audits, and the extent to which participants perceive QualDash to be useful and express the intention to continue using it after the study period.Ethics and disseminationThe study has been approved by the University of Leeds School of Healthcare Research Ethics Committee. Study results will provide an initial understanding of how, in what contexts, and why quality dashboards lead to improvements in care quality. These will be disseminated to academic audiences, study participants, hospital IT departments and national audits. If the results show a trial is feasible, we will disseminate the QualDash software through a stepped wedge cluster randomised trial.

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“…implementers and service users) to make them work. Mechanisms are the ways in which programme resources or strategies interact with the reasoning of stakeholders to produce effects (26) and they can only be activated in certain circumstances, that is, in specific contexts. Context describes the features of the conditions in which programmes are implemented that trigger the mechanisms to produce intended and unintended outcomes.…”

Section: Methodsmentioning

confidence: 99%

Which mechanisms explain motivation of primary health workers? Insights from realist evaluation of a maternal and child health programme in Nigeria

Ebenso

Mbachu

Etiaba

et al. 2019

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Background: Well-trained, adequately skilled and motivated primary healthcare (PHC) workers are essential for attaining universal health coverage and the Sustainable Development Goal 3 of ensuring healthy lives and promoting well-being for all. While there is abundant literature on drivers of workforce motivation, published knowledge on the mechanisms of how motivation works within different contexts is limited, particularly from low- and middle-income countries. This paper contributes to health workforce literature by reporting on how motivation works among PHC workers in a maternal and child health (MCH) programme in Nigeria. Methods: We adopted a realist evaluation design including scoping review of literature, document review of policies and MCH programme handbook, and in-depth interviews of PHC workers (n=25), facility managers (n=16), policymakers (n=12) and programme managers (n=10) to assess the impact of the MCH programme in Anambra State, Nigeria. A realist process of theory development, testing, verification and consolidation was used to understand how and under what circumstances the MCH programme impacted on workers’ motivation and which mechanisms helped explain how motivation works. The developed programme theory drew upon Herzberg’s two-factor and Adam’s equity theories to unpack the influences of contextual conditions on worker motivation. Results: A complex and dynamic interaction between the MCH programme and organizational, societal and policy contexts triggered five mechanisms which explain PHC worker motivation: i) feeling supported, ii) feeling valued and committed to work, iii) morale and confidence to perform tasks, iv) companionship and v) feeling comfortable with work environment. Some mechanisms were mutually reinforcing while others operated in parallel. Further analysis showed that the conditions that enabled worker motivation to occur were organisational values of fairness, recognition of health workers’ contributions and a culture of task-sharing and teamwork. Conclusions: Policy designs and management strategies for improving performance of health workers, particularly in resource-constrained settings should create working environments that foster feelings of being valued and supported while enabling workers to apply their knowledge and skills to improve healthcare delivery. Future research can test the explanatory framework generated by this study and explore differences in motivational mechanisms among different cadres of PHC workers to inform cadre-related motivational interventions.

show abstract

Building programme theory to develop more adaptable and scalable complex interventions: Realist formative process evaluation prior to full trial

Cited by 49 publications

References 38 publications

Which mechanisms explain the motivation of primary health workers? Insights from the realist evaluation of a maternal and child health programme in Nigeria

Which mechanisms explain the motivation of primary health workers? Insights from the realist evaluation of a maternal and child health programme in Nigeria

How, in what contexts, and why do quality dashboards lead to improvements in care quality in acute hospitals? Protocol for a realist feasibility evaluation

Which mechanisms explain motivation of primary health workers? Insights from realist evaluation of a maternal and child health programme in Nigeria

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