title: A process evaluation plan for assessing a complex community-based maternal health intervention in Ogun State, Nigeria.
abstract: Despite increased investment in community-level maternal health interventions, process evaluations of such interventions are uncommon, and can be instrumental in understanding mediating factors leading to outcomes. In Nigeria, where an unacceptably number of maternal deaths occur (maternal mortality ratio of 814/100,000 livebirths), the Community Level Interventions for Pre-eclampsia (CLIP) study (NCT01911494) aimed to reduce maternal and neonatal mortality and morbidity with a complex intervention of five interrelated components. Building from previous frameworks, we illustrate a methodology to evaluate implementation processes of the complex CLIP intervention, assess mechanisms of impact and identify emerging unintended causal pathways.
  
  
  
  The study was conducted from 2013-2016 in five Local Government Areas in Ogun State, Nigeria. A six-step approach was developed to evaluate key constructs of context (external factors related to intervention), implementation (fidelity, dose, reach, and adaption) and mechanisms of impact (unintended outcomes and mediating pathways). The steps are: 1) describing the intervention by a logic model, 2) defining acceptable delivery, 3) formulating questions, 4) determining methodology, 5) planning resources in context, lastly, step 6) finalising the plan in consideration with relevant stakeholders.
  
  
  
  Quantitative data were collected from 32,785 antenatal and postnatal visits at the primary health care level, from 66 community engagement sessions, training assessments of community health workers, and standard health facility questionnaires. Forty-three focus group discussions, 38 in-depth interviews, and 23 structured observations were conducted to capture qualitative data. A total of 103 community engagement reports and 182 suspected pre-eclampsia case reports were purposively collected. Timing of data collection was staggered to understand feedback mechanisms that may have resulted from the delivery of the intervention. Data will be analysed using R and NVivo. Diffusions of innovations and realist evaluation theories will underpin analysis of the interaction between context, mechanisms and outcomes.
  
  
  
  This comprehensive approach can serve as a guide for researchers and policy makers to plan the evaluation of similar complex health interventions in resource-constrained settings, and to aid in measuring 'effectiveness' of interventions and not just 'efficacy'.
  
  
  
  This research is a part of the Community Level Interventions for Pre-eclampsia Study, NCT01911494. The trial is registered in Clinicaltrials.gov, the URL is https://clinicaltrials.gov/ct2/show/NCT01911494 The trial was registered on June 28, 2013 and the first participant was enrolled for intervention on March 1, 2014.
authors.affiliation: Department of Obstetrics and Gynaecology and Child & Family Research Institute, University of British Columbia, Vancouver, Canada.
authors.forename: Sumedha
authors.initials: S
authors.lastname: Sharma
authors.affiliation: Centre for Research in Reproductive Health, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria. adetorolo@gmail.com.
authors.forename: Olalekan O
authors.initials: OO
authors.lastname: Adetoro
authors.affiliation: Department of Obstetrics and Gynaecology and Child & Family Research Institute, University of British Columbia, Vancouver, Canada.
authors.forename: Marianne
authors.initials: M
authors.lastname: Vidler
authors.affiliation: Department of Obstetrics and Gynaecology and Child & Family Research Institute, University of British Columbia, Vancouver, Canada.
authors.forename: Sharla
authors.initials: S
authors.lastname: Drebit
authors.affiliation: Department of Obstetrics and Gynaecology and Child & Family Research Institute, University of British Columbia, Vancouver, Canada.
authors.forename: Beth A
authors.initials: BA
authors.lastname: Payne
authors.affiliation: University of Lagos, Lagos, Nigeria.
authors.forename: David O
authors.initials: DO
authors.lastname: Akeju
authors.affiliation: Centre for Research in Reproductive Health, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria.
authors.forename: Akinmade
authors.initials: A
authors.lastname: Adepoju
authors.affiliation: Centre for Research in Reproductive Health, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria.
authors.forename: Ebunoluwa
authors.initials: E
authors.lastname: Jaiyesimi
authors.affiliation: Babcock University, Sagamu, Nigeria.
authors.forename: John
authors.initials: J
authors.lastname: Sotunsa
authors.affiliation: Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada.|Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan.
authors.forename: Zulfiqar A
authors.initials: ZA
authors.lastname: Bhutta
authors.affiliation: Institute of Cardiovascular and Cell Sciences, St George's, University of London, London, UK.|Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK.
authors.forename: Laura A
authors.initials: LA
authors.lastname: Magee
authors.affiliation: Institute of Cardiovascular and Cell Sciences, St George's, University of London, London, UK.|Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: von Dadelszen
authors.affiliation: Centre for Research in Reproductive Health, Olabisi Onabanjo University Teaching Hospital, Sagamu, Nigeria.
authors.forename: Olukayode
authors.initials: O
authors.lastname: Dada
mesh_terms: D003150:Community Health Workers; D005069:Evaluation Studies as Topic; D005260:Female; D017144:Focus Groups; D006295:Health Resources; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D000068097:Maternal Health; D008427:Maternal Health Services / Q000458:organization & administration*; D008428:Maternal Mortality; D009549:Nigeria; D011247:Pregnancy; D011320:Primary Health Care; D011795:Surveys and Questionnaires
keywords: Complex interventions; Implementation research; Maternal health; Nigeria; Ogun; Process evaluation