A realist synthesis of randomised control trials involving use of community health workers for delivering child health interventions in low and middle income countries
A realist synthesis of randomised control trials involving use of community health workers for delivering child health interventions in low and middle income countries
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DOI：
10.1186/1472-6963-10-286
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发表时间：
2010-10-13
影响因子：
2.8
通讯作者：
Dieleman, Marjolein
中科院分区：
文献类型：
--
作者：
Kane, Sumit S.;Gerretsen, Barend;Dieleman, Marjolein
背景：低收入和中等收入国家降低儿童疾病负担干预措施覆盖面饱和的一个关键制约因素是缺乏人力资源。社区卫生工作者在弥合这一差距方面具有潜在的重要作用。有证据表明，CHW对某些儿童疾病(IMCI)的管理有效。然而，我们需要知道这是如何以及何时发生的。我们从现实主义的角度考察了LMIC中CHW干预IMCI的随机对照试验(RCT)的证据，目的是看看当从不同的角度检查时，它们是否能够洞察干预的工作原理。方法：现实主义方法涉及得出干预在特定背景下产生结果的机制。“机制”是由干预和一定的背景相互作用而引发的反应，这些反应导致了变化。这些通常只是含蓄的，实际上是由评审者假设的。结果：改善社区卫生服务绩效的干预措施包括“社区卫生服务技能培训”、“公共卫生服务的监督和转诊支持”、“社区卫生服务的定位”。如果将干预措施应用于当地卫生服务中嵌入的社区卫生和妇女方案，受益者重视服务并有未得到满足的需求，干预措施就会奏效，前提是触发以下机制：期望得到社区的重视；社会地位的改善；与受益者和公共服务的关联感；增加自尊；自我效能感和积极掌握任务；可信度、合法性和对后备支持系统的保证。研究还表明，如果背景不同，即使是类似的干预措施，也可能触发负面机制，损害CHW的绩效。结论：本综述的目的是探索随机对照试验是否能够从不同的、现实主义的角度审视干预措施的工作原理。我们发现，随机对照试验确实产生了一些洞察力，但产生的假设非常笼统，没有很好地细化。这些假说需要在进一步的研究中加以检验和完善。
Background: A key constraint to saturating coverage of interventions for reducing the burden of childhood illnesses in Low and Middle Income Countries (LMIC) is the lack of human resources. Community health workers (CHW) are potentially important actors in bridging this gap. Evidence exists on effectiveness of CHW in management of some childhood illnesses (IMCI). However, we need to know how and when this comes to be. We examine evidence from randomized control trials (RCT) on CHW interventions in IMCI in LMIC from a realist perspective with the aim to see if they can yield insight into the working of the interventions, when examined from a different perspective.Methods: The realist approach involves educing the mechanisms through which an intervention produced an outcome in a particular context. 'Mechanisms' are reactions, triggered by the interaction of the intervention and a certain context, which lead to change. These are often only implicit and are actually hypothesized by the reviewer. This review is limited to unravelling these from the RCTs; it is thus a hypothesis generating exercise.Results: Interventions to improve CHW performance included 'Skills based training of CHW', 'Supervision and referral support from public health services', 'Positioning of CHW in the community'. When interventions were applied in context of CHW programs embedded in local health services, with beneficiaries who valued services and had unmet needs, the interventions worked if following mechanisms were triggered: anticipation of being valued by the community; perception of improvement in social status; sense of relatedness with beneficiaries and public services; increase in self esteem; sense of self efficacy and enactive mastery of tasks; sense of credibility, legitimacy and assurance that there was a system for back-up support. Studies also showed that if context differed, even with similar interventions, negative mechanisms could be triggered, compromising CHW performance.Conclusion: The aim of this review was to explore if RCTs could yield insight into the working of the interventions, when examined from a different, a realist perspective. We found that RCTs did yield some insight, but the hypotheses generated were very general and not well refined. These hypotheses need to be tested and refined in further studies.