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      Combining the theory of change and realist evaluation approaches to elicit an initial program theory of the MomConnect program in South Africa

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          Abstract

          Background

          One of the Sustainable Development Goals is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030. In South Africa, the flagship National Department of Health MomConnect program was launched in 2014 to strengthen the quality of maternal and child health (MCH) services and improve mortality outcomes. MomConnect was rapidly rolled out with a limited understanding of how and why the program was expected to work even though studies had shown the effectiveness of the MomConnect program in improving the uptake of MCH services. This study aimed to unearth the initial program theory of the MomConnect program based on explicit and implicit assumptions of how the program was organized and expected to work.

          Methods

          We conducted a document analysis using design- and implementation-related documents of the MomConnect program guided by the principles of Theory of Change (ToC) and Realist Evaluation (RE). Content and thematic analysis approaches were deductively applied to analyze the documents toward constructing ToC and RE-informed models. Abductive thinking and retroduction were further applied to the realist-informed approach to link program context, mechanisms, and outcomes to construct the initial program theory.

          Results

          ToC and RE-informed models illustrated how the MomConnect program was organized and expected to work. The process of constructing the ToC provided the platform for the development of the initial program theory, which identified three critical elements: (1) the central modalities of the MomConnect program; (2) the intended outcomes; and (3) the tentative causal links indicating, in a stepwise manner of, how the outcomes were intended to be achieved. The RE approach ‘enhanced’ the causal links by identifying relevant programmatic contexts and linking the postulated mechanisms of action (empowerment, encouragement, motivation, and knowledge acquisition) to program outcomes.

          Conclusion

          The application of ToC and RE provided an explicitly cumulative approach to knowledge generation in unveiling the initial program theory of MomConnect rather than delivering answers to questions of program effectiveness.

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          Most cited references41

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          Document Analysis as a Qualitative Research Method

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            Towards Integration at Last? The Sustainable Development Goals as a Network of Targets

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              Clinical practice guidelines for the management of chronic musculoskeletal pain in primary healthcare: a systematic review

              Background Up-to-date, high quality, evidence-based clinical practice guidelines (CPGs) that are applicable for primary healthcare are vital to optimize services for the population with chronic musculoskeletal pain (CMSP). The study aimed to systematically identify and appraise the available evidence-based CPGs for the management of CMSP in adults presenting in primary healthcare settings. Methods A systematic review was conducted. Twelve guideline clearinghouses and six electronic databases were searched for eligible CPGs published between the years 2000 and May 2015. CPGs meeting the inclusion criteria were appraised by three reviewers using the Appraisal of Guidelines Research and Evaluation (AGREE) II. Results Of the 1082 records identified, 34 were eligible, and 12 CPGs were included based on the inclusion and exclusion criteria. The methodological rigor of CPG development was highly variable, and the median domain score was 66%. The median score for stakeholder involvement was 64%. The lowest median score was obtained for the domain applicability (48%). There was inconsistent use of frameworks to aggregate the level of evidence and the strength of the recommendation in the included CPGs. The scope and content of the included CPGs focussed on opioid prescription. Conclusion Numerous CPGs that are applicable for the primary healthcare of CMSP exists, varying in their scope and methodological quality. This study highlights specific elements to enhance the development and reporting of CPGs, which may play a role in the uptake of guidelines into clinical practice. These elements include enhanced reporting of methodological aspects, the use of frameworks to enhance decision making processes, the inclusion of patient preferences and values, and the consideration of factors influencing applicability of recommendations. Trial registration PROSPERO CRD42015022098. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0533-0) contains supplementary material, which is available to authorized users.
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                Author and article information

                Contributors
                evekabo@gmail.com
                Journal
                BMC Med Res Methodol
                BMC Med Res Methodol
                BMC Medical Research Methodology
                BioMed Central (London )
                1471-2288
                26 November 2020
                26 November 2020
                2020
                : 20
                Affiliations
                [1 ]GRID grid.11956.3a, ISNI 0000 0001 2214 904X, Division of Health Systems and Public Health, , Stellenbosch University, ; Cape Town, South Africa
                [2 ]GRID grid.415021.3, ISNI 0000 0000 9155 0024, South African Medical Research Council, ; Cape Town, South Africa
                [3 ]GRID grid.8974.2, ISNI 0000 0001 2156 8226, School of Public Health, , University of the Western Cape, ; Cape Town, South Africa
                [4 ]GRID grid.8767.e, ISNI 0000 0001 2290 8069, Department of Public Health, , Vrije Universiteit Brussel, ; Brussels, Belgium
                Article
                1164
                10.1186/s12874-020-01164-y
                7691101
                33243136
                cf1a9ae7-dc31-44e5-ad61-2895a7015ced
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                Categories
                Research Article
                Custom metadata
                © The Author(s) 2020

                Medicine
                mhealth,momconnect,theory of change,realist evaluation,maternal and child health
                Medicine
                mhealth, momconnect, theory of change, realist evaluation, maternal and child health

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