TY - JOUR
T1 - Challenging logics of complex intervention trials
T2 - Community perspectives of a health care improvement intervention in rural Uganda
AU - Okwaro, Ferdinand M.
AU - Chandler, Clare I.R.
AU - Hutchinson, Eleanor
AU - Nabirye, Christine
AU - Taaka, Lilian
AU - Kayendeke, Miriam
AU - Nayiga, Susan
AU - Staedke, Sarah G.
N1 - Funding Information:
We are grateful to the community members who participated in the focus group discussions, the key informants who shared their experiences and perspectives over the intervention period, the health workers who participated in our interviews and questionnaires and the local politicians who allowed the study and shared their insights. We are grateful to those who supported our work in the field, including James Kizito, Nicholas Wendo, Lucas Othieno, and Michael Obbo. We are grateful to the wider PRIME trial team who supported our study, in particular Deborah DiLiberto, Catherine Maiteki-Sebuguzi and Florence Nankya. The study was funded by the ACT Consortium through a grant from the Bill and Melinda Gates Foundation to the London School of Hygiene and Tropical Medicine.
Publisher Copyright:
© 2015 Elsevier Ltd.
PY - 2015/4/1
Y1 - 2015/4/1
N2 - Health systems in many African countries are failing to provide populations with access to good quality health care. Morbidity and mortality from curable diseases such as malaria remain high. The PRIME trial in Tororo, rural Uganda, designed and tested an intervention to improve care at health centres, with the aim of reducing ill-health due to malaria in surrounding communities. This paper presents the impact and context of this trial from the perspective of community members in the study area.Fieldwork was carried out for a year from the start of the intervention in June 2011, and involved informal observation and discussions as well as 13 focus group discussions with community members, 10 in-depth interviews with local stakeholders, and 162 context descriptions recorded through quarterly interviews with community members, health workers and district officials.Community members observed a small improvement in quality of care at most, but not all, intervention health centres. However, this was diluted by other shortfalls in health services beyond the scope of the intervention. Patients continued to seek care at health centres they considered inadequate as well as positioning themselves and their children to access care through other sources such as research and nongovernmental organization (NGO) projects.These findings point to challenges of designing and delivering interventions within a paradigm that requires factorial (reduced to predictable factors) problem definition with easily actionable and evaluable solutions by small-scale projects. Such requirements mean that interventions often work on the periphery of a health system rather than tackling the murky political and economic realities that shape access to care but are harder to change or evaluate with randomized controlled trials. Highly projectified settings further reduce the ability to genuinely 'control' for different health care access scenarios. We argue for a raised consciousness of how evaluation paradigms impact on intervention choices.
AB - Health systems in many African countries are failing to provide populations with access to good quality health care. Morbidity and mortality from curable diseases such as malaria remain high. The PRIME trial in Tororo, rural Uganda, designed and tested an intervention to improve care at health centres, with the aim of reducing ill-health due to malaria in surrounding communities. This paper presents the impact and context of this trial from the perspective of community members in the study area.Fieldwork was carried out for a year from the start of the intervention in June 2011, and involved informal observation and discussions as well as 13 focus group discussions with community members, 10 in-depth interviews with local stakeholders, and 162 context descriptions recorded through quarterly interviews with community members, health workers and district officials.Community members observed a small improvement in quality of care at most, but not all, intervention health centres. However, this was diluted by other shortfalls in health services beyond the scope of the intervention. Patients continued to seek care at health centres they considered inadequate as well as positioning themselves and their children to access care through other sources such as research and nongovernmental organization (NGO) projects.These findings point to challenges of designing and delivering interventions within a paradigm that requires factorial (reduced to predictable factors) problem definition with easily actionable and evaluable solutions by small-scale projects. Such requirements mean that interventions often work on the periphery of a health system rather than tackling the murky political and economic realities that shape access to care but are harder to change or evaluate with randomized controlled trials. Highly projectified settings further reduce the ability to genuinely 'control' for different health care access scenarios. We argue for a raised consciousness of how evaluation paradigms impact on intervention choices.
KW - Community perceptions
KW - Health care interventions
KW - Malaria
KW - Randomized controlled trials
KW - Treatment seeking
KW - Uganda
UR - http://www.scopus.com/inward/record.url?scp=84924066171&partnerID=8YFLogxK
U2 - 10.1016/j.socscimed.2015.02.032
DO - 10.1016/j.socscimed.2015.02.032
M3 - Article
C2 - 25748110
AN - SCOPUS:84924066171
SN - 0277-9536
VL - 131
SP - 10
EP - 17
JO - Social Science and Medicine
JF - Social Science and Medicine
ER -
