Pulled in two directions: the tensions between implementation and established methods to evaluate in the same project, with marginalised communities

Harm Van Marwijk, Tom Grice-Jackson, Elizabeth Ford, Geofrey Musinguzi, Linda Gibson, Anne Van Marwijk, Hilde Bastiaens

Keywords: Implementation science, community health workers, mixed methods, lifestyle advice, cardiovascular risk, marginalisation

Background:

This paper addresses ways of evaluating implementation approaches with vulnerable communities, such as (remote) health coaching by community health workers for lifestyle improvement. We describe the tensions we experienced between implementation, and the use of qualitative, pragmatic evaluation methods or rigid randomised trial structures in ‘Scaling-up Packages of Interventions for Cardiovascular disease (CVD) prevention in sites in Europe and Sub-Saharan Africa’ (SPICES) during COVID19.

Research questions:

Method:

We reflect on method choices, particularly when working with ‘vulnerable’ groups, and particularly on how to share power with them, in an international intermediate CVD-risk prevention study. We discuss six SPICES projects in five countries and two continents to demonstrate tensions we faced when opening the research toolbox while working with vulnerable communities.

Results:

All tensions were linked to power differentials and how these impact on implementation and research in such complex marginalised settings. Tension 1 was in chosing between more or less participative evaluation methods. Tension 2 was to distinguish between 'strategies' and 'interventions'. Tension 3 was between short-term evaluation purposes and longer-term actual implementation/change. Tension 4 was about ‘evidence’: what is it, who defines it, how would we generate it, and who interprets it and how? Most participants from the South with high CVD 'risk' receive no CVD care, so we included them (5); and (6), 'vulnerability': entire countries are deprived in the South, versus particular areas in the North. 7 was the COVID19 pandemic.

Conclusions:

We advise co-designing projects early on, particularly in marginalised settings, including who sets the research questions and the research/implementation agenda.

Points for discussion:

Working with marginalised groups

Mixing methods

#112