Uptake of best-practice recommendations for management of acutely ill children admitted in Kenyatta National Hospital: a longitudinal study employing participatory action research in a complex environment

Abstract

The need for improving practice in low-income settings has been demonstrated in recent research assessing the quality of hospital care. Consequently, the Ministry of Health developed clinical practice guidelines and an evidenced-based programme for their dissemination. This thesis explored what factors influence the uptake of the best-practice recommendations in a university teaching hospital. This thesis used a mixed methods research approach that utilized a before and after design and participatory action research. This approach recognizes that health recommendations are compiled for universal use, but that their successful implementation requires particular attention to the individual and complex socio-political contexts of each setting, both at the micro and -macro level, which in this case was the Kenyatta National Hospital (KNH). This thesis is supported by eighteen months of participant observation, based on ethnographic research methodology and action research. Patients' care was largely inconsistent with best-practice recommendations, with nine of the 17 key indicators having performance of below 10% in the pre-intervention period. The intervention had an absolute effect size of over 20% in eight of the 17 key indicators; three of which had an effect size of over 50%. The indicators that required collective efficacy achieved performance of less than 10% in the post-intervention period. The activities during the action research component failed to predict the trend in practitioners' performance, illustrating the difficulty of gaining a holistic understanding of the quantitative results using component parts of the qualitative results as the lens. The notion of professionalism provided an overarching understanding of the implementation process. There were clear gaps between the stated values espoused in the ideal of professionalism and the observed actions of professionals in KNH. Gaps spanned knowledge management, expertise and skills, teamwork, conscientiousness and patient centeredness. I attributed the gaps in professionalism to complexity of professional development.