Enhancing climate-resilient primary health care: A mixed-method implementation research on JAMUNA-supported community clinic in Bogura and Sirajganj districts, Bangladesh

Abstract

Background: Community clinics are the first point of contact for availing primary healthcare in rural Bangladesh. Every year climate stress hampers CC functionality, accessibility and often massive destruction of the CC infrastructure. To address this threat the JAMUNA project aims to make CC climate resilient. Considering the evidence gap on perceptions of implementors and providers, this study aimed to explore the perceived acceptability as well as the contextual factors influencing the implementation process in the climate vulnerable context.

Objectives: This study aimed to assess and explore the acceptability of JAMUNA-supported community clinic rehabilitation among service providers and JAMUNA implementation staff, and to identify contextual barriers and facilitators influencing the implementation.

Methods: This study used a mixed method implementation research design with convergent approach and was conducted in Bogura and Sirajganj, covering seven community clinics. Study participants were service providers at community clinics and JAMUNA implementation staff. Quantitative and qualitative sample size was 25 (census sampling) and 12 Key Informant Interviews using a (purposive sampling). Quantitative and Qualitative data were analyzed separately, using statistical software STATA version 17 and framework analysis method respectively. Quantitative and qualitative findings were integrated at the interpretation stage.

Results: The quantitative findings reveal strong positive perceptions among both categories of stakeholders, with the mean AIM score of 19.48 out of 20. Acceptability remained high across all groups. The qualitative findings further explained the reasons for shaping this high acceptability across TFA domains. Strong satisfaction regarding the rehabilitation yielded by aesthetically pleasant, structurally improved and functionally beneficial infrastructure; clear understanding of the rehabilitation purpose prior to the initiative inauguration; consistent and nurtured mutual relationships throughout and even post rehabilitation; professionally aligned and exceeding expectations, as well as predicted long sustainability. While complete rehabilitation was perceived as highly climate responsive, participants from partially rehabilitated clinics reported persistent structural vulnerabilities, particularly flood risk at the low-lying clinic premises; with consistent need for sufficient human resources, logistics and equipment. The CFIR findings demonstrated that implementation was facilitated by flexible and context-suitable design, strong community ownership, strong commitment of the providers to continue service delivery at any situation, collaborative and well-planned implementation process, involving all stakeholders, strong co-ordination between providers and implementers and highly experienced and contextually adapted implementing staff. However, the findings also highlighted important implementation barriers, such as infrastructure gaps especially in partially rehabilitated design, capacity restriction because of resource constraints and training gaps, challenges to smooth implementation driven by local as well as environmental barriers.

Conclusions: This study reveals that despite high acceptability, implementation outcome can be affected by contextual factors. Without addressing contextual vulnerability, infrastructure upgrade alone cannot be enough for continued and sustained service provision.