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We explain social and organisational processes influencing health professionals in a Kenyan clinical network to implement a form of quality improvement (QI) into clinical practice, using the concept of ‘pastoral practices’. Our qualitative empirical case study, conducted in 2015–16, shows the way practices constructing and linking local evidence-based guidelines and data collection processes provided a foundation for QI. Participation in these constructive practices gave network leaders pastoral status to then inscribe use of evidence and data into routine care, through championing, demonstrating, supporting and mentoring, with the support of a constellation of local champions. By arranging network meetings, in which the professional community discussed evidence, data, QI and professionalism, network leaders also facilitated the reconstruction of network members' collective professional identity. This consequently strengthened top-down and lateral accountability and inspection practices, disciplining evidence and audit-based QI in local hospitals. By explaining pastoral practices in this way and setting, we contribute to theory about governmentality in health care and extend Foucauldian analysis of QI, clinical networks and governance into low and middle income health care contexts. [ABSTRACT FROM AUTHOR]

There is a dearth of literature on priority setting and resource allocation (PSRA) practices in hospitals, particularly in low and middle income countries (LMICs). Using a case study approach, we examined PSRA practices in 2 public hospitals in coastal Kenya. We collected data through a combination of in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), review of documents such as hospital plans and budgets, minutes of meetings and accounting records, and non-participant observations of PSRA practices in case study hospitals over a period of 7 months. In this paper, we apply complex adaptive system (CAS) theory to examine the factors that influence PSRA practices. We found that PSRA practices in the case hospitals were influenced by, 1) inadequate financing level and poorly designed financing arrangements, 2) limited hospital autonomy and decision space, and 3) inadequate management and leadership capacity in the hospital. The case study hospitals exhibited properties of complex adaptive systems (CASs) that exist in a dynamic state with multiple interacting agents. Weaknesses in system ‘hardware’ (resource scarcity) and ‘software’ (including PSRA guidelines that reduced hospitals decision space, and poor leadership skills) led to the emergence of undesired properties. The capacity of hospitals to set priorities should be improved across these interacting aspects of the hospital organizational system. Interventions should however recognize that hospitals are CAS. Rather than rectifying isolated aspects of the system, they should endeavor to create conditions for productive emergence. [ABSTRACT FROM AUTHOR]

• We report findings from a point prevalence survey across 14 Kenyan public hospitals. • About half of the hospitalised patients received appropriate antibiotic therapy. • Laboratory investigations supported less than 1% of the antibiotic prescriptions. • Physical availability of treatment guidelines influenced treatment appropriateness. • There is need for context-specific, up-to-date, and accessible treatment guidelines. To examine prescription patterns and explore to what extent guidelines are available and how they might influence treatment appropriateness among hospitalised patients in Kenyan hospitals. Data on antimicrobial usage were collected from hospitalised patients across 14 Kenyan public hospitals. For each prescription, appropriateness of treatment was defined using available local and international treatment guidelines and through consensus with local medical specialists. Association between appropriate treatment, guideline availability and other possible explanatory factors was explored using univariate and multiple regression analysis. There were 1675 (46.7%) of the 3590 hospitalised patients on antimicrobials with 3145(94%) of the 3363 antimicrobial prescriptions being antibiotics. Two patients (0.1%), had treatment based on available antibiotic susceptibility tests. Appropriate treatment was assessed in 1502 patients who had a single diagnosis. Of these, 805 (53.6%) received appropriate treatment. Physical availability of treatment guidelines increased the odds of receiving appropriate treatment Odds Ratio 6.44[95% CI 4.81–8.64]. Appropriate antibiotic prescription remains a challenge in Kenyan public hospitals. This may be improved by the availability of context-specific, up-to-date, and readily accessible treatment guidelines across all the departments, and by providing better diagnostic support. [ABSTRACT FROM AUTHOR]

Objective: To explore the evidence translation process during a 1-week national guideline development workshop ("Child Health Evidence Week") in Kenya.Study Design and Setting: Nonparticipant observational study of the discussions of a multidisciplinary guideline development panel in Kenya. Discussions were aided by GRADE (Grading of Recommendations Assessment, Development, and Evaluation) grid.Results: Three key thematic categories emerged: 1) "referral to other evidence to support or refute the proposed recommendations;" 2) "assessment of the presented research evidence;" and 3) "assessment of the local applicability of evidence." The types of evidence cited included research evidence and anecdotal evidence based on clinician experiences. Assessment of the research evidence revealed important challenges in the translation of evidence into recommendations, including absence of evidence, low quality or inconclusive evidence, inadequate reporting of key features of the management under consideration, and differences in panelists' interpretation of the research literature. A broad range of factors with potential to affect local applicability of evidence were discussed.Conclusion: The process of the "Child Health Evidence Week" combined with the GRADE grid may aid transparency in the deliberative process of guideline development, and provide a mechanism for comprehensive assessment, documentation, and reporting of multiple factors that influence the quality and applicability of guideline recommendations. [ABSTRACT FROM AUTHOR]

Abstract: The ethics of research continue to attract considerable debate, particularly when that research is sponsored by partners from the North and carried out in the South. Ethical research should contribute to social value in the country where research is being carried out, but there is significant debate around how this might be achieved and who is responsible. The literature suggests that researchers might employ two inter-related strategies to maximise social value: collaborative partnerships with policy makers and communities from the outset of research, and dissemination of research results to participants, policy makers and implementers once the research is over. These areas have received relatively little empirical attention. In this study, we carried out 40 in-depth interviews to explore the role of collaborative partnerships in health research priority setting, and the way in which research findings are disseminated to aid policy making and implementation in Kenya. Interviewees included policy makers, researchers, policy implementers and representatives of organisations funding health reforms in Kenya. Two policy issues were drawn upon as tracers wherever possible: (1) the introduction of Artemesinin- based Combination Therapies (ACTs), an anti-malarial treatment policy; and (2) Haemophilus influenzae (Hib) vaccine for the prevention of pneumococcal diseases among children. The findings point to significant gaps in the ‘research to policy to practice’ pathway, particularly for national research institutions with a focus on clinical/biomedical research. These gaps reflect poorly effective partnerships among stakeholders and limit the potential social value of much research. While more investment is needed to establish strong structures for promoting and directing collaboration and partnership, how to target this investment is not entirely clear, especially in the context of the considerable power of the global health agenda and the research financing tied to it. [Copyright &y& Elsevier]

Kenyan neonatal nurses are asked to do the impossible: to bridge the gap between international standards of nursing and the circumstances they face each day. They work long hours with little supervision in ill-designed wards, staffed by far too few nurses given the pressing need. Despite these conditions, a single neonatal nurse can be tasked with looking after forty sick babies for whom very close care is a necessity. Our 18-month ethnography explores this uniquely stressful environment in order to understand how nurses operate under such pressures and what techniques they use to organise work and cope. Beginning in January 2015, we conducted 250 h of non-participant observation and 32 semi-structured interviews in three newborn units in Nairobi to describe how nurses categorise babies, balance work across shifts, use routinised care, and demonstrate pragmatism and flexibility in their dealings with each other in order to reduce stress. In so doing, we present an empirically based model of the ways in which nurses cope in a lower-middle income setting and develop early work in nursing studies that highlighted collective strategies for reducing anxiety. This allows us to address the gap left by prevalent theories of nursing stress that have focused on the personal characteristics of individual nurses. Finally, we extend outwards from our ethnographic findings to consider how a deeper understanding of these collective strategies to reduce stress might inform policy, and why, even when the forces that create stress are alleviated, the underlying model of nursing work may prevail. • Describes the understudied environment of LMIC inpatient newborn wards. • Details how stress is managed through the design and enactment of nursing work. • Develops and extends early theories of nurses' collective coping methods. • Offers an alternative to questionnaire-based understandings of nursing stress. • Links low-resource environments to nurse coping mechanisms. [ABSTRACT FROM AUTHOR]