Utilizing implementation science approaches to evaluate and guide scale-up of child health programs involving trusted local influencers in Ethiopia

Abstract

In Ethiopia, as in many low- and middle-income countries, high infant mortality and undernutrition remain major public health challenges, driven in part by low uptake of evidence-based newborn care practices such as exclusive breastfeeding, timely immunization, appropriate nutrition, hygiene, and early identification of illness. Strategies that engage trusted local influencers to partner with local health workers may help address these gaps by improving caregiver knowledge, motivation, and self-efficacy to adopt recommended newborn care practices. This dissertation focuses on the LAUNCH strategy (Leading Advancements in the Uptake of Newborn Community Health), a community-based strategy implemented in Ethiopia that paired Ethiopian Orthodox priests with community health workers, locally known as Health Development Army members, to promote maternal and newborn health behaviors through structured home visits and health education during community and religious gatherings. The first study evaluated the effectiveness of LAUNCH using a community-randomized trial in Central Gondar, Ethiopia. Exclusive breastfeeding was significantly higher in intervention than in control communities, but no significant differences were observed for child growth, immunization, malnutrition, illness, or care-seeking. These findings suggest that faith leader–community health worker partnerships can improve selected newborn care behaviors, particularly exclusive breastfeeding, but may need to be complemented by other strategies to improve outcomes shaped by factors beyond caregiver behavior, including household conditions and health system service availability. The second study examined stakeholder readiness and perceived capacity to support scale-up of LAUNCH and used social network analysis to identify key stakeholders who could support scale-up decision-making and implementation. Overall readiness and perceived capacity were moderately high, although respondents with a master’s degree and those working at the regional level tended to report lower readiness and capacity. The most central stakeholders were concentrated largely at the regional and zonal levels, with the Regional Maternal and Child Health Director and Regional Safe Motherhood Officer emerging as key actors in the network, meaning they occupied highly central network positions with strong potential to connect others and shape coordination, information flow, and scale-up processes. Readiness perceptions were positively associated between directly connected key and non-key stakeholders. These findings suggest moderate support for scaling up strategies that engage local leaders, while also highlighting the need for tailored, multi-level strategies to strengthen readiness. They also show that social network analysis can help identify influential actors beyond formal organizational structures who may serve as champions for scale-up. The third study examined stakeholder perspectives on scaling LAUNCH using a qualitative design guided by the Consolidated Framework for Implementation Research. Two core elements were identified as essential to preserve during scale-up: ongoing implementer support through capacity strengthening, supervision, and review, and engagement of trusted local influencers who are most relevant to the sociocultural context. Stakeholders also identified two enhancements needed to strengthen implementation: improving implementer motivation through incentives and practical communication materials, and strengthening social support and referrals for vulnerable households. Scale-up potential was further shaped by high acceptability, perceived feasibility within existing structures if government ownership and financing were secured, and outer-setting barriers, particularly weak facility responsiveness, political instability, and insecurity. Overall, this dissertation offers insights relevant to implementation science and to efforts to scale strategies that engage trusted local influencers in community-based child health in low- and middle-income countries. The findings advance understanding of the conditions under which such strategies are most likely to be implemented and sustained successfully, and identify the core functions and enhancements needed for scale-up. They also advance implementation science by showing that readiness may be shaped not only by individual and system conditions but also by stakeholder relationships, suggesting that network-informed strategies may help strengthen readiness and related implementation determinants that may influence scale-up. Collectively, these findings highlight the value of implementation science approaches to assess strategy effectiveness, identify what is needed for successful scale-up, and help close the know–do gap.