Translating global evidence into local implementation through technical assistance: a realist evaluation of the Bloomberg philanthropies initiative for global Road safety.

BACKGROUND: Traffic-related crashes are a leading cause of premature death and disability. The safe systems approach is an evidence-informed set of innovations to reduce traffic-related injuries and deaths. First developed in Sweden, global health actors are adapting the model to improve road safety in low- and middle-income countries via technical assistance (TA) programs; however, there is little evidence on road safety TA across contexts. This study investigated how, why, and under what conditions technical assistance influenced evidence-informed road safety in Accra (Ghana), Bogotá (Colombia), and Mumbai (India), using a case study of the Bloomberg Philanthropies Initiative for Global Road Safety (BIGRS). METHODS: We conducted a realist evaluation with a multiple case study design to construct a program theory. Key informant interviews were conducted with 68 government officials, program staff, and other stakeholders. Documents were utilized to trace the evolution of the program. We used a retroductive analysis approach, drawing on the diffusion of innovation theory and guided by the context-mechanism-outcome approach to realist evaluation. RESULTS: TA can improve road safety capabilities and increase the uptake of evidence-informed interventions. Hands-on capacity building tailored to specific implementation needs improved implementers' understanding of new approaches. BIGRS generated novel, city-specific analytics that shifted the focus toward vulnerable road users. BIGRS and city officials launched pilots that brought evidence-informed approaches. This built confidence by demonstrating successful implementation and allowing government officials to gauge public perception. But pilots had to scale within existing city and national contexts. City champions, governance structures, existing political prioritization, and socio-cultural norms influenced scale-up. CONCLUSION: The program theory emphasizes the interaction of trust, credibility, champions and their authority, governance structures, political prioritization, and the implement-ability of international evidence in creating the conditions for road safety change. BIGRS continues to be a vehicle for improving road safety at scale and developing coalitions that assist governments in fulfilling their role as stewards of population well-being. Our findings improve understanding of the complex role of TA in translating evidence-informed interventions to country-level implementation and emphasize the importance of context-sensitive TA to increase impact.

A realist evaluation of a support and training program for family caregivers in the municipality of Envigado: A research protocol.

AIMS: In Envigado, Colombia, the Secretariat of Health has implemented, since 2011, an interprofessional program involving nurses to support and train relatives to improve the quality of life of people with a loss of autonomy and their family caregivers. The objectives of this study are to assess the outcomes of this program and to explore the contextual elements and mechanisms that can explain these outcomes. DESIGN: This article presents the research protocol for a realist evaluation that will be carried out to gather the perspectives of various local stakeholders involved. METHODS: Four outcomes on family caregivers will be measured quantitatively using self-administered questionnaires and numerical scales. Contextual elements and mechanisms will then be explored qualitatively through focus groups and individual interviews. An iterative analysis will enable the refinement of a program theory. RESULTS: The results will inform a program theory that underlies the outcomes of the family caregiver support and training program. PATIENT OR PUBLIC CONTRIBUTION: Community stakeholders, family caregivers, people with a loss of autonomy and their relatives will be involved in data collection and/or in the validation of the program theory.

Intersectoral oral health promotion interventions for schoolchildren living in remote rural Andean communities: a realist evaluation.

BACKGROUND: Intersectoral oral health promotion entails the participation of local communities. IOHP interventions were introduced in Peru in primary schools in 2013 but oral health among schoolchildren living in rural Andean communities remains suboptimal. OBJECTIVES: To understand the contextual elements and the underlying mechanisms associated with intersectoral oral health promotion interventions' current effects on schoolchildren living in remote rural Andean communities. METHOD: A realist evaluation was carried out in three rural Andean communities where intersectoral oral health promotion interventions aimed at schoolchildren have been implemented. Following an evaluation of the effects among schoolchildren, contextual elements and mechanisms were explored with various stakeholders involved in intersectoral oral health promotion through focus groups and semi-structured interviews. Subsequently, an iterative data analysis and a validation process resulted in the identification of context-mechanism configurations. RESULTS: Previous positive experiences of collaboration, a focus on communication, feelings of being respected and considered, and development of leadership and trust among stakeholders involved in intersectoral oral health promotion were elements of configurations that positively influence intersectoral oral health promotion. On the other hand, unfavorable physical, social and political environments, previous negative health experiences, feelings of not being respected or considered, demotivation, development of mistrust and insufficient leadership were shown to negatively influence outcomes. CONCLUSION: This research highlights the complexity associated with the deployment of intersectoral oral health promotion interventions in rural communities. Local stakeholders should be further involved to build trust, to facilitate coordination processes among remote rural communities and oral health professionals, and to optimize deployment of intersectoral oral health promotion interventions.

Realist evaluation of intersectoral oral health promotion interventions for schoolchildren living in rural Andean communities: a research protocol.

BACKGROUND: Intersectoral collaboration, known to promote more sustainable change within communities, will be examined in an oral health promotion program (OHPP). In Peru, an OHPP was implemented by the Ministry of Health, to reduce the incidence of caries in schoolchildren. In rural Andean communities, however, these initiatives achieved limited success. The objectives of this project are: (1) to understand the context and the underlying mechanisms associated with Peruvian OHPP's current effects among school children living in rural Andean communities and (2) to validate a theory explaining how and under which circumstances OHP intersectoral interventions on schoolchildren living in rural Andean communities produce their effects. METHODS AND ANALYSIS: Through a realist evaluation, the context, underlying mechanisms and programme outcomes will be identified. This process will involve five different steps. In the first and second steps, a logic model and an initial theory are developed. In the third step, data collection will permit measurement of the OHHP's outcomes with quantitative data, and exploration of the elements of context and the mechanisms with qualitative data. In the fourth and fifth steps, iterative data analysis and a validation process will allow the identification of Context-Mechanism-Outcome configuration, and validate or refine the initial theory. ETHICS AND DISSEMINATION: This research project has received approval from the Comité d'éthique de la recherche en santé chez l'humain du Centre hospitalier universitaire de Sherbrooke. The initial theory and research results will be published in relevant journals in public health and oral health. They will also be presented at realist evaluation and health promotion international conferences.

Mechanisms for achieving adolescent-friendly services in Ecuador: a realist evaluation approach.

BACKGROUND: Despite evidence showing that adolescent-friendly health services (AFSs) increase young people's access to these services, health systems across the world are failing to integrate this approach. In Latin America, policies aimed at strengthening AFS abound. However, such services are offered only in a limited number of sites, and providers' attitudes and respect for confidentiality have not been addressed to a sufficient extent. METHODS: The aim of this study was to explore the mechanisms that triggered the transformation of an 'ordinary' health care facility into an AFS in Ecuador. For this purpose, a realist evaluation approach was used in order to analyse three well-functioning AFSs. Information was gathered at the national level and from each of the settings including: (i) statistical information and unpublished reports; (ii) in-depth interviews and focus group discussions with policy makers, health care providers, users and adolescents participating in youth organisations and (iii) observations at the health care facilities. Thematic analysis was carried out, driven by the realist evaluation approach, namely exploring the connections between mechanisms, contexts and outcomes. RESULTS: The results highlighted that the development of the AFSs was mediated by four mechanisms: grounded self-confidence in trying new things, legitimacy, a transformative process and an integral approach to adolescents. Along this process, contextual factors at the national and institutional levels were further explored. CONCLUSION: The Ministry of Health of Ecuador, based on the New Guidelines for Comprehensive Care of Adolescent Health, has started the scaling up of AFSs. Our research points towards the need to recognise and incorporate these mechanisms as part of the implementation strategy from the very beginning of the process. Although contextually limited to Ecuador, many mechanisms and good practices in these AFS may be relevant to the Latin American setting and elsewhere.