Putting interventions and evaluations into context

Prakash Fernandes shows the importance of context in evaluation using an intervention to reduce maternal mortality in Indian slums 

World Moving back to India after 13 years in the UK has helped me reflect on the importance of outlining the context in evaluation.

Context is often reported as background information, or limited to socio economic and demographic details. 

In this post, I wanted to share how an intervention to reduce maternal mortality in the urban slums of Mumbai is being evaluated with its context detailed explicitly.

Putting this post into context

I left India in 2002 and have moved back to a country where the evaluation agenda is much more integrated into social programmes.

The number of randomised controlled trials in education and health-related initiatives are testament to how organisations in India value the importance of generating quality evidence to optimise the use of scarce resources.

The context of this change is also due to the active involvement of organisations in development as part of mandatory corporate social responsibility.

This is leading to greater innovation in non-governmental organisation (NGO) programmes and generating evidence of impact for donors. 

Interventions and evaluations in India

During my first month back in India, I met an NGO in Dharavi, Mumbai - India’s largest slum. We discussed a realist evaluation design for a domestic violence prevention programme, trying to understand what works, who it works for, under what circumstances and why.

Since then, I’ve also been involved in looking at the evaluation designs of interventions to prevent child malnutrition and reduce maternal mortality in urban slums, as well interventions for children with developmental difficulties.

A big challenge organisations face, similar to my experience in the UK, is generating evidence on how programme learnings can be generalised beyond the area they operate in.

The realist evaluation design offers a framework to map the context and mechanisms leading to outcomes: this has appealed to several organisations I have spoken to in India. 

Improving maternal health in Indian slums

I’m involved with an intervention to improve maternal health in urban slums. The evaluation outlines 4 dimensions of context related to this intervention, drawing on critical realist perspectives.

Here are the 4 dimensions with examples for each one:

  1. Structure. Inadequately resourced primary health care centres leading to overburdening at secondary and tertiary care
  2. Cultural aspects. Secrecy about disclosing pregnancies
  3. Agency dimensions. Women not wanting to attend antenatal clinics
  4. Relationships. Power differentials between males and females and between doctors and patients.

The literature review maps the context at the start of the intervention and also traces historical changes caused by communities becoming more disempowered (decision-making powers becoming more centralised, for example).

Changing contexts

The four dimensions of structure, culture, agency and relationship are interlinked, but delineating the role of each one is helpful to understand which aspects of the programme contribute to changing contexts.

This theory of change outlines how the intervention aims to transform each aspect of the context, leading to outcomes that could reduce maternal mortality.

The intervention aims to address structure by:

  • organising clinical training with healthcare staff to adopt new referral practices
  • empowering communities to be more aware of their role in accessing health care
  • upgrading emergency facilities in hospitals to increase resources
  • developing a protocol for referrals between different levels of the health care system.

The intervention aims to change cultural aspects by:

  • introducing community awareness programmes to promote the importance of antenatal care.

The intervention aims to support agency dimension by:

  • working with individual women to support them in their decision-making.

The intervention aims to change relationships by:

  • making families more confident about their right to healthcare
  • making healthcare professionals more aware of – and more sensitive about - the situation in slum communities.

Using context as a tool for undersatnding 

Since returning to India, my understanding of context in realist evaluation has been enriched through examining these four dimensions, as well as appreciating the historical and changing nature of contexts.

Explicitly underpinning elements of context in an evaluation should aid a better understanding when these findings are generalised to other regions across India. 

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