Methodology

The methodology for this research was designed to generate new and actionable insights through the application of implementation-science methods to selected Exemplar countries.

This was done by identifying and evaluating the steps countries took when deciding on policies and evidence-based interventions to reduce mortality among children under age five (under-five mortality or U5M), and in executing their implementation strategies.

In addition, researchers sought to identify any contextual factors that either obstructed or facilitated the implementation of evidence-based interventions within these countries during the 2000–2015 study period.

In collaboration with the University of Global Health Equity (UGHE) team, and with support from Gates Ventures, the team carried out a desk review of published materials, in addition to documents produced outside of formal commercial or academic channels (so-called “gray literature”) related to Bangladesh’s general political, cultural, and economic context, and to the evidence-based interventions the country implemented to reduce U5M.

The team also drew upon analyses from the International Center for Equity in Health (Federal University of Pelotas, Brazil) and geospatial mapping from the Institute for Health Metrics and Evaluation (IHME; University of Washington, USA) to understand changes in health equity over time.

Project Framework

Both the desk review and the primary research were informed by an implementation-science framework designed specifically for this project. Identifying policies and evidence-based interventions chosen by a country to reduce U5M is often possible, but the key lessons in how these were chosen, adapted, implemented, and sustained are often missing from available published or gray literature.

Because the same policies and interventions often produce different results in different countries, implementation science offers important tools for how to think more holistically about how and why countries were able to reduce U5M, and from where lessons in replication can be drawn.

To guide the overall work, we developed a framework to understand the contribution of contextual factors at varying levels, from the country as a whole to specific communities and even individual facilities. This approach combines elements of existing frameworks, notably the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework by Aarons and colleagues in 2011¹, and the Feasibility, Fidelity, Acceptability, Reach, and Effectiveness implementation outcomes by Proctor and colleagues in 2010. We also added a new step – Adaptation – to the EPIS framework (resulting in a modified abbreviation, EPIAS).¹

Desk Review

In collaboration with UGHE and Gates Ventures, the team undertook an extensive review of available information and published data on U5M in Bangladesh. Gates Ventures researchers conducted initial research through Medline (PubMed) and Google Scholar using the search terms “child mortality” or “under-5 mortality” and “Bangladesh.” Further searches included specific evidence-based interventions, causes of death, or contextual factors as search terms (e.g., “insecticide-treated nets,” “malaria,” or “community health workers”).

The desk review was an iterative process, with ongoing additions occurring throughout the initial research and case study development processes as additional sources (published articles, reports, case studies, policy papers, and other country documents) were identified. Researchers explored various non-health care interventions that may have contributed to U5M reduction, including education, poverty reduction, water and sanitation access, and programs designed to improve nutritional status.

Following these initial steps, the UGHE team expanded the review to incorporate additional published literature and other relevant documents relevant to the overall research.

Primary Research

In collaboration with our in-country partners in Bangladesh – the Dhaka-based International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) – we identified key informants who reflected a broad range of experience and viewpoints relevant to the campaign to reduce U5M.

These individuals had been identified during the desk review process or otherwise brought to our attention by our colleagues at ICDDR,B. In selecting potential informants, we sought practitioners and policy makers who could specifically discuss the Exploration, Preparation, Implementation, Adaptation, and Sustainment (EPIAS) stages of Bangladesh’s efforts to reduce U5M during the study period.

Informants included current and former Ministry of Health and Family Welfare employees responsible for high-level strategic direction of the ministry or specific disease or intervention areas, implementing partners, and representatives of multilateral organizations or donor organizations who had managed partner-supported or partner-led activities. In total, 18 individuals were interviewed for this report.

Some key informants represented more than one area or role based on their experience during the 15-year study period, and the interviews sought to capture their multiple viewpoints.

Informed by our framework and the review of relevant literature on contextual factors and implementation outcomes, we developed core interview guides for four main expert categories:

• Global and national-level policy makers
• Ministry of Health and Family Welfare (MOHFW) officials
• Project managers and implementers for specific causes of death or evidence-based interventions
• Other partners

The interviews were designed to address the evidence-based intervention implementation process across all of the EPIAS stages, and at the relevant global, national, ministry, and local levels. The interviews also identified additional sources of data and information that could be added to the knowledge base already developed from the desk review.

Interview guides were adapted from the core tools and translated to Bangla. Interviews were conducted in Bangla or English, depending on the linguistic comfort of the individual informant.

All interviews were led by the project primary investigators, Lisa Hirschhorn and Kelechi Udoh, with support from in-country lead Dr. Fauzia Akhter Huda, research associate Dr. Hassan Rushekh Mahmood, and research coordinator Md. Omar Faruk.

Following the close of the interviews, notes were combined and the recordings (if allowed) were used to clarify interview responses as needed. Recorded interviews were translated, transcribed, and reviewed for quality and consistency by both ICDDR,B and UGHE.

Interviews were coded by one of the researchers using the framework developed for the overall U5M Exemplars in Global Health project, to extract the EPIAS steps, implementation strategies, outcomes, and contextual factors.

Analysis and Synthesis

The UGHE team used a mixed-methods explanatory approach, applying the framework to understand the progress (or lack thereof) for each cause of death and the coverage of chosen evidence-based interventions, as well as facilitators and barriers at the local, national, and global levels.

This approach was designed to understand how and why Bangladesh was able to achieve success in decreasing U5M, and the primary obstacles it faced. The analyses were also informed by other projects, including Countdown to 2015, equity analyses from the International Center for Equity in Health, and geospatial mapping from IHME, among others.

In addition, the research team collaborated with the Institute for Health Metrics and Evaluation (IHME) to look at quantitative modeling results using a decomposition method, and also collaborated with the Johns Hopkins Bloomberg School of Public Health to model results using the Lives Saved Tool (LiST).These quantitative analyses complement the primary research by looking at what the models suggest about the likely contribution of specific interventions in reducing child mortality.

The decomposition analysis conducted by IHME breaks down changes over time for a series of factors that directly influence child mortality levels using the Das Gupta method. The overall change in mortality between years is divided into contributions from:

• Interventions and risk factors – Interventions and risk factors influence mortality rates through changes in the proportion of the population exposed to each, and through changes in their corresponding relative risks of mortality. Increased coverage of specific interventions is known to reduce mortality rates, whereas increased exposure to certain risk factors increases mortality rates. The relative risk for each specific disease outcome is established through a literature review.
• Population change – The total number of deaths in a given year is a product of both age-specific mortality rates and the population size in each age group, so changes in population are factored into the decomposition. For example, if mortality rates are cut in half while the population size doubles in each age group, total deaths will remain the same.

The Lives Saved Tool (LiST), developed by the Johns Hopkins Bloomberg School of Public Health, calculates changes in cause-specific mortality based on intervention coverage change, intervention effectiveness for that cause, and the percentage of cause-specific mortality sensitive to that intervention. Coverage data come from large-scale household surveys – typically Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), as well as WHO/UNICEF and the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP).

Default effectiveness values come from systematic reviews, meta-analyses, Delphi estimations, and randomized control trials based upon the Child Health Epidemiology Reference Group guidelines. Baseline mortality is drawn from country-level estimates from DHS, WHO, UNICEF, UNFPA, World Bank Group, and the United Nations Population Division and the UN Inter-Agency Group for Child Mortality Estimation (IGME). Additionally, users who have more recent or alternative data sources can easily replace default data with their own.

Human Subjects Review

Primary research for this study was approved by the Research Review Committee and Ethical Review Committee of ICDDR,B. The ethics review committees of UGHE and Northwestern University also approved the study. All informants were informed about the goals and structure of the project, and consent for participation and recording was obtained separately from the interview.

No quotes or specific viewpoints were included that would identify the source without explicit permission. All recordings and interviews had names removed and were kept in password-protected computers and stored on a limited access Google Drive. All recordings were destroyed once the interview coding had been completed.