在马里开展社区个案管理以加快医疗服务的普及:嵌套在分组随机试验中的现实主义过程评估。

IF 2.9 3区 医学 Q2 HEALTH CARE SCIENCES & SERVICES
Caroline Whidden, Amadou Beydi Cissé, Faith Cole, Saibou Doumbia, Abdoulaye Guindo, Youssouf Karambé, Emily Treleaven, Jenny Liu, Oumar Tolo, Lamine Guindo, Bréhima Togola, Calvin Chiu, Aly Tembely, Youssouf Keita, Brian Greenwood, Daniel Chandramohan, Ari Johnson, Kassoum Kayentao, Jayne Webster
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引用次数: 0

摘要

在马里开展的 "积极主动的社区病例管理"(ProCCM)试验通过取消使用费、配备专业社区保健员(CHWs)和升级初级保健中心(PHCs)等措施加强了两臂的保健系统,并随机分组,让各村接受由社区保健员进行的积极主动的家访(干预)或由被动的社区保健员提供的固定地点服务(对照)。与基线相比,在这两个干预组中,患病儿童的 24 小时治疗率和孕妇的四次或四次以上产前检查率都翻了一番,五岁以下儿童死亡率在三年内降低了一半。与对照组相比,在干预组中,儿童保健工作者的主动家访对儿童治疗和妇女产前检查的利用率影响不大,但对五岁以下儿童死亡率没有影响。我们旨在通过研究两组的实施情况、机制和背景来解释这些结果。我们采用混合方法融合设计进行了过程评估,包括在两个时间点对医疗服务提供者和参与者进行的 79 次深入访谈、对 195 名医疗服务提供者进行的调查以及对临床数据的二次分析。我们以新颖的方式嵌入了现实主义方法,以检验、完善和巩固有关 ProCCM 如何发挥作用的理论,产生了三个背景--干预--行为者--机制--结果的节点,并以级联的方式展开。首先,取消使用费并在每个群组部署专业的社区保健员使参与者能够及时寻求卫生部门的医疗服务,并创造了便利就医的环境。其次,卫生系统为所有社区保健员和初级保健中心提供支持,实现了公平、相互尊重和高质量的医疗保健,从而促进了更多人快速利用医疗保健服务。第三,积极主动的儿童保健工作者家访促进了儿童保健工作者和参与者提供和寻求医疗服务,并建立了关系、信任和期望,但这些机制也在两个臂膀中被激活。解决医疗服务的多重结构性障碍、取消使用费、专业的儿童保健工作者和升级的诊所与医疗服务提供者和患者的代理机构相互作用,从而在两支队伍中实现快速医疗服务和儿童存活率。积极主动的家访加快或加强了已启动的机制,并改变了两臂的环境。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Community case management to accelerate access to healthcare in Mali: a realist process evaluation nested within a cluster randomized trial.

The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional community health workers (CHWs) and upgraded primary health centres (PHCs)-and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children's 24-hour treatment and pregnant women's four or more antenatal visits doubled, and under-5 mortality halved, over 3 years compared with baseline. In the intervention arm, proactive CHW home visits had modest effects on children's curative and women's antenatal care utilization, but no effect on under-5 mortality, compared with the control arm. We aimed to explain these results by examining implementation, mechanisms and context in both arms We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs and upgraded clinics interacted with providers' and patients' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms.

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来源期刊
Health policy and planning
Health policy and planning 医学-卫生保健
CiteScore
6.00
自引率
3.10%
发文量
98
审稿时长
6 months
期刊介绍: Health Policy and Planning publishes health policy and systems research focusing on low- and middle-income countries. Our journal provides an international forum for publishing original and high-quality research that addresses questions pertinent to policy-makers, public health researchers and practitioners. Health Policy and Planning is published 10 times a year.
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