A realist evaluation of implementing better care practices and bundled technologies in Kenyan Hospitals
Progress has been made in reducing child mortality in Kenya and other African countries but levels of neonatal mortality still remains high. Reducing neonatal mortality will in part require significant improvements in the quality of care provided to sick newborns in Kenyan hospitals. A major programme of work to improve the care provided on Kenyan hospital newborn units (NBU) is beginning in 2019 led by an Oxford and Kenyan team, it is linked to work by a wider set of international partners focused on implementing a bundle of low-cost technologies. The purpose of this DPhil is to conduct an ‘external evaluation’ of this major programme of work in the form a Realist Evaluation.
The major project will deliver a set of interventions through a network of 10 to 12 hospitals including: training, outreach from a central coordinator, regular performance feedback, peer to peer learning and in some a bundle of supportive care technologies – the NEST package. Over the course of the project and for each hospital the characteristics of NBU admissions, process measures of the care they receive and their health outcomes will be continuously measured. The major project already has some planned evaluation activities in addition to this NBU performance tracking including qualitative studies of the experiences of senior and frontline health workers in the target NBUs and more specific implementation research around specific technologies (eg. CPAP).
The DPhil proposed will complement and advance the planned research by developing an evaluation approach that draws on systems thinking and complexity theory to help distil lessons that can guide and optimise large scale intervention strategies in Low and Middle Income Country’s health systems. The research approach is likely to take the form of in-depth, mixed-method case studies and contribute to efforts to link complexity theory and Realist Evaluation.
Realist Evaluation is informed by established theories from social science but is especially focused on developing middle range theories that explain how programmes achieve their effects as a result of the interaction of contexts that triggers (often multiple) mechanisms to produce outcomes. The overall aim or realist evaluations is therefore to address the question “What works, for whom, in what respects, to what extent, in what contexts, and how?” as a means of offering transferable lessons to guide later intervention approaches. This DPhil will aim to develop an initial programme theory encompassing the entire intervention approach drawing on literature and the experience and reasoning of those conducting the intervention. The initial programme theory developed with the Kenyan team delivering the intervention. We envisage the evaluation design will use a case study approach of hospital sites and use realist interviews, with data analysis using a realist logic of analysis to further develop, confirm, refute or refine the programme theory.
The purpose of this DPhil is enable the successful candidate to develop their understanding of large scale global health service change interventions and introduce them to bodies of theory that can be used to understand the reasons for success (or failure) of change efforts. The successful candidate will also have the additional benefit of being able to develop their knowledge and skills in the Realist Evaluation approach. There will likely be opportunities for specific training in Realist Evaluation. Skills in proposal writing to satisfy the requirements of scientific and ethical review will also be developed. Training in qualitative and quantitative research methods will also be provided as needed. It is anticipated that during the course of the DPhil and linked to the collection of interview data approximately 6 months may be spent in Kenya based at the Nairobi offices of the KEMRI-Wellcome Trust Research Programme.
Start date: Anticipated start in October 2020 (Michaelmas Term 2020)