Protocol for the Pathways Study: a realist evaluation of staff social ties and communication in the delivery of neonatal care in Kenya
Authors: Wanyama C , Blacklock C , Jepkosgei J , English M , Hinton L , McKnight J , Molyneux S , Boga M , Musitia P , Wong G 
Published: June 2022

AbstractIntroductionInitiatives to improve the quality of neonatal care in low- and middle-income countries are vital to meet the Sustainable Development Goal 3 of reducing to at most 12 neonatal deaths per 1,000 by the year 2030. These initiatives have included enhancing human resources for health (HRH), and post-basic neonatal nurse training. However, the informal social ties that health workers form with colleagues and how these influence application of learned knowledge and skills and individual and group behaviours and norms in the workplace, have remained neglected in health systems research.This study seeks to better understand these relational components in Kenyan neonatal care, and how such understanding might improve design and implementation of quality improvement interventions targeting health workers’ behaviours. The Pathways Study is a realist evaluation which will develop theory for guiding quality improvement interventions.Methods and analysisWe will collect data in two phases. Phase One will be a case study of 2 large urban public hospitals in Kenya, where we will conduct: non-participant observation of hospital staff during patient care and hospital meetings, a social network questionnaire with staff, in-depth interviews, key informant interviews, and focus group discussions. Data will be collected purposively and analysed using a realist logic of analysis, with interim analyses including thematic analysis of qualitative data and quantitative analysis of social network metrics.Phase Two will be a stakeholder workshop in which findings from Phase One are presented, discussed and theory refined. Recommendations for theory-informed interventions will be developed, to enhance quality improvement efforts in Kenyan hospitals.Ethics and disseminationEthical approval for the Pathways Study has been received from Kenya Medical Research Institute (KEMRI/SERU/CGMR-C/241/4374) and Oxford Tropical Research Ethics Committee (OxTREC 519-22). Findings will be shared with the two study hospitals, relevant educational institutions, KEMRI-WELLCOME Trust Research Programme and the University of Oxford. Study findings will also be disseminated in seminars, local and international conferences, and as academic theses and research articles published in open access scientific journals.Strengths and limitations of this studyStrengthsRealist evaluation will enable development of programme theory, which will be useful for informing the practical design and implementation of quality improvement interventions in neonatal units.The Pathways Study is the first to use social network analysis to explore the influence of staff social ties on the delivery and quality of neonatal care in Kenya.LimitationsRelational ties and other aspects of health systems ‘software’ are notoriously difficult to capture and measure in health systems research.The Pathways Study uses a mixed methods approach to collect diverse data, but it is possible that some relevant data may still not be captured. The research team will mitigate this risk by using an iterative and exploratory approach to data collection and analysis, seeking triangulation of emergent findings, promoting reflexivity of the research team, and sense-checking emergent findings with relevant stakeholders, whilst at the same time comparing with substantive sociological theory.