Lessons learned in using realist evaluation to assess maternal and newborn health programming in rural Bangladesh

Abstract

Realist evaluation furnishes valuable insight to public health practitioners and policy makers about how and why interventions work or don't work. Moving beyond binary measures of success or failure, it provides a systematic approach to understanding what goes on in the 'Black Box' and how implementation decisions in real life contexts can affect intervention effectiveness. This paper reflects on an experience in applying the tenets of realist evaluation to identify optimal implementation strategies for scale-up of Maternal and Newborn Health (MNH) programmes in rural Bangladesh. Supported by UNICEF, the three MNH programmes under consideration employed different implementation models to deliver similar services and meet similar MNH goals. Programme targets included adoption of recommended antenatal, post-natal and essential newborn care practices; health systems strengthening through improved referral, accountability and administrative systems, and increased community knowledge. Drawing on focused examples from this research, seven steps for operationalizing the realist evaluation approach are offered, while emphasizing the need to iterate and innovate in terms of methods and analysis strategies. The paper concludes by reflecting on lessons learned in applying realist evaluation, and the unique insights it yields regarding implementation strategies for successful MNH programming.

From favours to entitlements: community voice and action and health service quality in Zambia

“…Moreover, CVA can potentially be a game changer insofar as it fosters implementation of national level strategies at the local level. The discrepancy between evidence-based national health objectives and on the ground implementation is much-lamented, but we lack adequate knowledge of how to ensure “the rubber hits the road” (Adams, Sedalia, McNab and Sarker 2015). As evidenced with enhanced compliance with opening hours and enhanced community consensus on development goals, CVA has the potential to push implementation of programs that the community can easily monitor.…”

Efficacy of Telephone Information and Advice on Welfare: the Need for Realist Evaluation

“…Indeed, others emphasise the importance of qualitative methods in relation to realist enquiry (Maxwell, 2012) and realist evaluation Adams et al, 2016), particularly in relation to eliciting outcomes (Jagosh, 2014).…”

Realist evaluations in low- and middle-income countries: reflections and recommendations from the experiences of a foreign researcher

“…Sharing lessons from practice and ensuring these important methodological discussions occur is an important step to move realist evaluation forward within these contexts. Several authors have shared reflections or recommendations for realist evaluation from projects that were conducted within LMICs;26 27 but their focus was not on the cross-cultural challenges. This paper therefore contributes towards the further development of this traction-gaining methodology and aims to inform future work as well as contribute new knowledge on how to conduct realist evaluations within cross-cultural contexts through experiences of a non-local researcher in an LMIC.…”

“…The studies discussed herein took a number of steps to mitigate contextual misunderstanding at the onset. Following the suggestion by Adams and colleagues,26 the study designs included multidisciplinary partnerships to enable insights that go beyond technical recommendations. Clear communication channels were established to support the contribution by team members, and procedures were taken to ensure the engagement of programme decision-makers throughout the research process.…”

“…Clear communication channels were established to support the contribution by team members, and procedures were taken to ensure the engagement of programme decision-makers throughout the research process. Reflexivity was also built into the process which enabled methodological challenges to be identified and addressed throughout the study 8 26…”