Challenging logics of complex intervention trials: community perspectives of a health care improvement intervention in rural Uganda.
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.
Department of Global Health & Development, 15-17 Tavistock Place, London School of Hygiene & Tropical Medicine, WC1H 9SH London, UK. Electronic address: Ferdinand.Okwaro@lsthm.ac.uk.
Ferdinand M
FM
Okwaro
Department of Global Health & Development, 15-17 Tavistock Place, London School of Hygiene & Tropical Medicine, WC1H 9SH London, UK. Electronic address: Clare.Chandler@lshtm.ac.uk.
Clare I R
CI
Chandler
Department of Global Health & Development, 15-17 Tavistock Place, London School of Hygiene & Tropical Medicine, WC1H 9SH London, UK. Electronic address: Eleanor.Hutchinson@lshtm.ac.uk.
Eleanor
E
Hutchinson
Infectious Disease Research Collaboration, Mulago Hospital, P.O. Box 7475, Kampala, Uganda. Electronic address: cnabirye@gmail.com.
Christine
C
Nabirye
Infectious Disease Research Collaboration, Mulago Hospital, P.O. Box 7475, Kampala, Uganda. Electronic address: liliantaakaidrcact@yahoo.com.
Lilian
L
Taaka
Infectious Disease Research Collaboration, Mulago Hospital, P.O. Box 7475, Kampala, Uganda. Electronic address: miriamkayendeke@yahoo.com.
Miriam
M
Kayendeke
Infectious Disease Research Collaboration, Mulago Hospital, P.O. Box 7475, Kampala, Uganda. Electronic address: susannaiga@gmail.com.
Susan
S
Nayiga
Department of Clinical Research, London School of Hygiene & Tropical Medicine, UK. Electronic address: Sarah.Staedke@lshtm.ac.uk.
Sarah G
SG
Staedke
D000740:Anemia / Q000188:drug therapy*; D000962:Antimalarials / Q000627:therapeutic use*; D002648:Child; D003695:Delivery of Health Care / Q000458:organization & administration; D003906:Developing Countries; D005260:Female; D006282:Health Personnel / Q000193:education; D006297:Health Services Accessibility / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D007318:Inservice Training; D008288:Malaria / Q000188:drug therapy*; D008297:Male; D018512:Parasitemia / Q000188:drug therapy*; D058996:Quality Improvement / Q000458:organization & administration* / Q000592:standards; D011787:Quality of Health Care / Q000458:organization & administration* / Q000592:standards; D019035:Rural Health Services / Q000458:organization & administration* / Q000592:standards; D059039:Standard of Care / Q000458:organization & administration; D015996:Survival Rate; D014454:Uganda
D000962:Antimalarials
Community perceptions; Health care interventions; Malaria; Randomized controlled trials; Treatment seeking; Uganda