| PurposeBased on the theory of change and child health intervention theories,this study constructs the logical framework of the effect evaluation and mechanism analysis of child health comprehensive intervention.According to the logical framework,through the method of case study,this study analyzes the background of a comprehensive intervention project for child health,designs intervention activities,evaluates effect,analyzes intervention mechanism,and puts forward policy suggestions on child health intervention project in poverty and minority areas of Western China in order to improve child health in the similar areas of China.Contents and MethodsThrough the literature study and focus group discussion,the logical framework of the effect evaluation and mechanism analysis of child health comprehensive intervention was constructed.Under the guidance of this logical framework,the method of case study was used to analyze the background of a comprehensive intervention project for child health,design and implement intervention activities,evaluate effect and expolre intervention mechanism.1.Construction of the logical framework of the effect evaluation and mechanism analysis of child health comprehensive interventionThrough the literature study and focus group discussion,the theories of project evaluation and child health intervention were systematically reviewed,the evaluation dimensions and contents for child health intervention were determined.Combined with the main purpose of child health intervention,the logical framework of the effect evaluation and mechanism analysis of child health comprehensive intervention was constructed.2.Analysis of background,design and implementation of a comprehensive intervention project for child healthAccording to the logical framework of this study,the case study method was used to analyze the background of the project implementation.A baseline survey of child health intervention project was conducted in Nujiang,Yunnan.The data sources included questionnaire survey,interview,field investigation,documents and archives.The questionnaire survey of service provider was conducted in Nujiang prefecture and county maternal and child health(MCH)facilities,to understand the basic situation of MCH service.The questionnaire survey of service demander using multistage random sampling was conducted among 880 caregivers of children under 7 years and 150 pregnant women who were selected from 24 administrative villages of 12 towns of 4 counties in Nujiang prefecture,to understand the child health status,health knowledge,behavior and demand of health education.A total of 869 questionnaires of caregivers and 138 questionnaires of pregnant women were colleted.The interviews with service provider were conducted among 29 MCH providers,leaders of MCH facilities and government officials to understand the basic situation of MCH service and demand of capacity construction.The interviews with service demander were conducted among 10 caregivers to understand service utilization and demand of health education.According to the logical framework of this study,descriptive statistic was used to analyze the quantitative data,and induction was used to analyze the qualitative data.Based on the results of the background analysis,the design principles of the intervention,the intervention activities suitable for Nujiang and the expected outputs were determined through the focus group discussion.Based on the design of the intervention activities,the comprehensive intervention project for child health was carried out in all counties of Nujiang prefecture from September 2012 to October 2015.The intervention object included MCH providers,children under 7 years and their caregivers,pregnant women and government officials in Nujiang.3.Effect evaluation of comprehensive intervention on child healthTo collecte data about effect of the intervention,an end-line survey was conducted in Nujiang from November 2015 to January 2016.The data sources included questionnaire survey,interview,field investigation,documents and archives.The questionnaire survey of service provider was conducted among MCH facilities at the prefecture,county and township levels,to understand the project implementation process,MCH service capacity,service utilization and health outcomes of children.The questionnaire survey of service demander using the same sampling methods as baseline survey was conducted among caregivers of children under 7 years and pregnant women,to understand the changes of health knowledge,health behavior,etc.A total of 897 questionnaires of caregivers and 184 questionnaires of pregnant women were colleted.The interviews with service provider were conducted among 24 MCH providers to understand the implementation process and the effect of the intervention project.The interviews with 14 government officials and project specialists were conducted to understand the effect,problems and suggestions of the project.According to the logical framework of this study,the data obtained from the end-line survey was systematically analyzed,and the effect of comprehensive intervention on child health was evaluated from three levels of activities,outputs and outcomes.On the level of activities,based on the expected goals of the project,whether the activities were completed was described.On the level of outputs,based on results of baseline survey,descriptive statistical analysis,single factor analysis and thematic framework method were used to analyze the difference of the project output indicators before and after the project implementation.Meanwhile taking Diqing prefecture of Yunnan province as the control,the difference of child health service coverage between Nujiang and Diqing was analyzed through descriptive statistical analysis.On the level of outcomes,descriptive statistical analysis and single factor analysis were used to understand the difference of the outcome indicators before and after the project implementation.4.Analysis of the mechanism of child health interventionOn the basis of the effect evaluation,the intervention mechanism of child health was explored.The data also came from the end-line survey of intervention project,while the content of investigation focused on causes of intervention effect,including influence factors of MCH service provision and utilization,determinants of child health.A thematic framework method was used to analyze qualitative data from three aspects of health service provider,demander and management.Descriptive statistical analysis,single factor analysis and Logistic regression analysis were used to describe change of some output and outcome indicators and explore the determinants of child nutritional disease.Main Results1.The logical framework of the effect and mechanism of a comprehensive intervention project for child healthBased on the theory of change and child health intervention theories,the logical framework of the effect and mechanism of a comprehensive intervention project for child health was constructed.This logical framework included background,activities,outputs and outcomes.The background of the project involved individual/family,health system and social background.The project activities included 4 aspects of nutrition supplement,health education,capacity building,coordination and policy development,while the specific intervention activities should be determined combined with the background analysis.The outputs of the project involved the service demander,the provider and the management,which described the change of the awareness of health knowledge,living behavior and the accessibility of health services.Project outcomes included prevalence of child nutritional disease and child mortality.2.Analysis of the project background and determination of intervention activitiesIn Nujiang,the poverty level was high,the social and culture condition was special,MCH policy was not suitable enough.Although there was a MCH service network in Nujiang,the quantity and quality of MCH providers need to be improved:the proportion of MCH providers with bachelor degree or above was only 7.6%;the proportion of qualified MCH providers was 70%;transportation facilities and basic medical equipment were insufficient;MCH services were provided mainly relying on the national basic and major public health services project;newborn disease screening were not fully carried on;and effect of capacity building for MCH providers was limited.There were 71%of households surveyed with annual income less than RMB 5000,and 70%of caregivers with primary and lower education level.The proportion of caregivers who could identify 5 kinds of signs of neonatal risk and 3 kinds of signs of nutritional diseases were 48.0%and 21.6%,respectively.The proportion of pregnant women who could identify 5 kinds of signs of pregnancy risk was 73.4%.The proportions of children eat 1-2 times milk,meat and eggs per day within a month were less than 15%,while the proportions of children who did not eat milk,meat and eggs within a month were as high as 42.9%,13.4%and 22.8%respectively.The prevalence of stunting,underweight and rickets among children under 7 years were as high as 36.1%,25.8%and 20.9%respectively.Based on the results of the background analysis,a total of ten intervention activities were identified.They were personnel training,advanced study in higher medical institutions,expert assistance in the county,establishment of a newborn screening network,purchase and allocation of medical equipment,health communication materials development,health education,nutrient packages providing,coordination and policy development.3.Effect evaluation of comprehensive intervention on child health(1)The project activities evaluationThe nine of ten intervention activities were implemented smoothly in Nujiang,including personnel training,advanced study in higher medical institutions,expert assistance in the county,establishment of a newborn screening network,purchase and allocation of medical equipment,health communication materials development,nutrient packages providing,coordination and policy development.The community-based health education did not carry out,but MCH facility-based health education implemented successfully,the annual number of audience increased from 41 thousand in 2012 to 340 thousand in 2015.The proportion of MCH providers received the professional training was nealy 100%,the proportion of MCH providers received advanced study was 27%,and the distribution rate of nutrient packages was more than 90%.All these indicators reached or exceeded the project goals.(2)The project outputs evaluationThe accessibility of MCH services in Nujiang increased significantly.The number of MCH hospitals providing inpatient obstetric services increased from two to three,and the number of township health center providing seven kinds of basic MCH services also increased.However,there were two MCH hospitals which could not provide obstetric services,and 46.4%of township health centers could not provide laboratory testing.The coverage of MCH service increased significantly.Compared with the baseline level,the percentages of in-hospital delivery,antenatal care,and growth monitoring for children younger than three years increased by 20.7%,18.1%and 0.7%,respectively.The screening rate of neonatal metabolic diseases and hearing screening were 79.5%and 73.0%respectively.In addition to antenatal care,other indicators exceeded the project goals.Compared with the control area,the percentages of in-hospital delivery,antenatal care and growth monitoring for children younger than three years were lower than that of Diqing.The gap of the percentages of in-hospital delivery and growth monitoring for children younger than three years between Nujiang and Diqing declined gradually,which indicated that the improvement of in-hospital delivery and child growth monitoring in Nujiang was greater than that in Diqing.The awareness of health knowledge improved obviously.Compared with the baseline level,the proportions of pregnant women who could identify 5 kinds of signs of pregnancy risk,caregivers who could identify 5 kinds of signs of neonatal risk and 3 kinds of signs of child nutritional diseases increased by 19.4%,65.2%and 304.4%,the difference was statistically significant(P<0.01).All these indicators reached the project goals.Behavior of the service demander improved significantly.Compared with the baseline level,the proportion of children who ate nutritional supplements increased by 58.1%,the difference was statistically significant(P<0.01).The frequency of eating meat,milk,beans and eggs among children surveyed changed obviously before and after intervention,the difference was statistically significant(P<0.01).The proportions of children who ate less than 5 times milk,meat,eggs and beans within a month declined significantly,while the proportions of children eat 3-4 times and 5-6 times all kinds of food within a week increased significantly.(3)The project outcome evaluationCompared with the baseline level,the prevalences of stunting,underweight,rickets and anemia decreased by 29.2%,44.4%,27.4%and 77.2%,the difference was statistically significant(P<0.01).The prevalences of rickets and underweight were lower one and three percentage points than expected project goals;other indicators achieved the expected goals.4.The project intervention mechanism(1)Service providerThe training activities using participatory training methods improved the technical level and training ability of MCH providers.At the conclusion of the project,the personnel structure of MCH facilities had improved significantly,the number of MCH providers with bachelor degree or above increased 226.7%,and the proportion of qualified MGH providers increased from 70%in 2011 to 96%in 2015.The medical equipment in MCH facilities had been greatly improved.In addition to the lever weight scale,the number of MCH hospitals equipped with other medical equipment increased.The number of township hospitals equipped with four basic equipments also increased significantly.The interviewees believed that the allocation of medical equipment improved MCH services.In addition,the expert assistance and the establishment of neonatal screening network were helpful to improve the accessibility of MCH service.(2)Service demanderThrough health education in accordance with the local culture,language,education status and the demand,local residents effectively accessed to health knowledge,so that their health awareness and living behavior improved.The promotional materials developed by the project were popular with local residents.The end-line survey showed that 95.6%of people had seen the promotional materials and 97.8%of people believed that promotional materials were useful,indicating that the demander had effectively obtained health knowledge.The interviewees thought that the health awareness of the demander had been enhanced through the health education.The questionnaire survey also supported this view.Taking the in-hospital delivery as an example,the proportion of pregnant women who intended to take in-hospital delivery increased by 47.1%compared with the baseline level,and the percentage of in-hospital delivery increased from 79.5%in 2011 to 95.9%in 2015.The proportion of children who supplemented nutrients increased significantly,and the frequency of eating meat,milk,eggs and beans improved significantly.With the training,health education and policy support,nutritional packages were distributed and taken effectively,thus reducing the risk of children suffering from nutritional diseases.Logistic regression analysis showed that children who took the nutrient packages had lower risk of rickets and underweight.The study found that a set of mechanisms including organization and mobilization mechanism,incentive mechanism for rural doctors,and supervision mechanism were important to ensure that children could obtain and use the nutrient packages.(3)Service management sideCoordination of activities and policy development was conducive to the improvement of the leadership,resource acquisition and allocation,and then helped to improve the accessibility and coverage of MCH services.The study found that,after the implementation of the project,leaders at all levels attached more importance to MCH in Nujiang.Through the establishment of the project coordination mechanism the three party were effectively mobilized and a lot of resources and policy support were given to health career in Nujiang,the problem of irrational allocation of resources and procurement of the nutrient packages were addressed.The training about MCH policy tailored to local context was fully affirmed by the government officials,and played an important role in improving their ability of policy development.The localization policy development activities were conducive to develop the local policies in line with the actual situation of MCH service.For example,the maternal allowance policy for in-hospital delivery increased the coverage of MCH services by improving the incentive mechanism.Conclusions and SuggestionsBased on the results of background analysis,child health intervention activities can be successfully implemented in the project area.The comprehensive intervention project for child health has effect on reducing the prevalences of child nutritional diseases in poverty and minority areas of western china.Capacity building activities in line with the actual needs of the MCH providers enhance the accessibility of MCH services.Health education activities in line with the local ethnic culture,language and education status can effectively improve the living behaviors of the residents in the poverty and minority areas of western China.Coordination mechanism is helpful to obtain resources in the poverty areas.The development of MCH policy tailored to the local context is conducive to improve the coverage of MCH services.Base on the analysis of case of Nujiang,this study puts forward the following suggestions:1)developing a intervention project for child health by a comprehensive intervention strategy;2)based on the theoretical framework designing child health intervention activities in accordance with the project background;3)establishing cooperation mechanism of national,provincial and prefecture(city)level to effectively obtain resources;4)adopting participatory training methods to carry out capacity building;5)propagating health knowledge in accordance with local resources and cultural characteristics;6)strengthening training,publicity and management to ensure the effective distribution and use of the nutrient packages;7)problem oriented to develop MCH policy tailored to the local context. |
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