Exploring healthcare workers’ perceptions of child health research at Kamuzu Central Hospital, Malawi: an interpretative phenomenological analysis

Abstract

Background

Children’s health is a global public health priority and a determinant of development and sustainability. Its effective delivery and further improvements require constant and dedicated research on children, especially by child healthcare workers (HCWs). Studies have shown a high involvement of child HCWs from developed countries in child health research, with an under-representation from the global south in authorship and leadership in international collaborations. To our knowledge, there is very little literature on challenges faced by child HCWs in Malawi in conducting child health research. We sought to explore the lived experiences of child HCWs at Kamuzu Central Hospital (KCH) in Malawi by examining their perceptions of child health research and assessing the availability of child health research opportunities.

Methods

From July 2023 to August 2023, we conducted five key informant interviews with purposively sampled policymakers and 20 in-depth interviews with child HCWs at KCH. The interviews were conducted in English, audio-recorded, and transcribed verbatim. We utilised interpretative phenomenological analysis by reviewing initial transcripts for familiarity, generating codes manually, and refining them into broader themes through comparisons and iterative processes.

Results

The analysis revealed three main themes on perceptions of child HCWs at KCH in child health research. These are (i) perceived motivation and challenges for engaging in child health research, (ii) perceptions of resource availability and research opportunities at KCH, and (iii) perceptions of gaps in research training and participation among child HCWs.

Conclusions

Our study has uncovered critical factors influencing the low participation of child HCWs in child health research at KCH. Lack of collaboration, limited financial opportunities, and non-research-based training were the key barriers to participation in child health research among child HCWs at KCH. We advocate for the inclusion of child HCWs at all stages of collaborative health research, transparency on funding opportunities for child health research, and inclusion of research in the training of HCWs. These initiatives can strengthen the participation of child HCWs in child health research and ultimately enhance child health outcomes in Malawi.

Background

Children’s health is a global public health priority and a determinant of development and sustainability [1,2,3]. Studies show a significant improvement in children’s health as evidenced by a sustained reduction in global child mortality from 12.7 to 5.7 million between 1990 and 2015. Child health research has significantly reduced mortality and morbidity [1, 4,5,6,7]. Despite the reduction, estimated 16,000 children worldwide continue to die daily due to preventable causes [8]. Most of these deaths are clustered in developing countries [9,10,11] and comprise preventable infectious diseases [12, 13]. Despite the higher burden of child mortality in developing countries, research in child health is dominated by researchers from developed countries [2, 12, 14,15,16].

Participation in child health research is one of the glaring inequalities between the developed and the developing world [17, 18]. Previous studies have reported an under-representation in research by health professionals from the developing world in authorship and leadership in international collaborative research [18]. For instance, a global literature search on HIV/AIDs reported high dominance by North America and Western and Central Europe in scientific productions [18]. The study also showed low levels of leadership by Africans in international collaborative HIV/AIDS research [18]. It is argued that the absence of infrastructure and inadequate funding exacerbates the low participation in research leadership and authorship in the global south [19,20,21].

Africans do not take the leading roles in studies and authorship because of inadequate methodological skills in research design, analytical skills, and language problems (English), which hinder them in writing publications [18]. A study in Malawi on research experience among health professionals reported that all participants (100%) indicated a willingness to be trained in research, 3 (5.3%) had ever written a journal article, 23 (40.4%) had ever participated in research projects, and 18 (31.6%) had been trained in research methods [22].

Research has further shown that limitations of child health research in different areas result in gaps that cause physicians to extrapolate from adult studies, implement interventions that may not have been adequately evaluated, and even give out medications that may be potentially harmful to children or culturally and socially unacceptable [12].

Like other developing countries, Malawi needs medical treatments that reflect biological and non-biological variations [12, 23] to make evidence-based decisions on the most efficient and cost-effective interventions [24]. In support, the Government of Malawi emphasises the need to conduct health research on child health [25]. The Malawi National Health Policy II points to insufficient capacity in research, among others, as a serious challenge that affects service delivery [26, 27]. However, to our knowledge, there needs to be more literature on the perspectives of child healthcare workers (HCWs) at Kamuzu Central Hospital (KCH) in Malawi in conducting child health research. Therefore, this study sought to explore child HCWs’ experiences conducting child health research at KCH, assessing their perspectives and the availability of research opportunities at both delivery and policy levels.

Methods

Study design and setting

We applied interpretative phenomenological analysis (IPA), a qualitative research approach that investigates how individuals make sense of their lived experiences [28,29,30,31,32,33], to examine how child HCWs perceive their research experiences. IPA is suitable when more knowledge of the explored phenomenon is needed.

Key Informant Interviews (KIIs) and Individual In-Depth Interviews (IDIs) generated detailed descriptions of child HCWs' experiences in conducting child health research at KCH, a tertiary hospital with a well-established paediatric section in Lilongwe, Malawi (Fig. 1). KCH is a primary site for child health studies, making it suitable for exploring child HCWs' research experiences. Policymakers are also at Lilongwe's Ministry of Health (MoH) Headquarters.

Fig. 1

Map showing the study area

Recruitment

We purposively [34] sampled 20 HCWs involved in child healthcare delivery and five policymakers responsible for the paediatric section at KCH. Previous research has shown that at least six IDIs are enough to reach saturation [35]. Being an IPA approach, 25 participants were more than enough to get detailed research perceptions without targeting saturation [29]. Policymakers included health directors, managers, and a coordinator in the child health space. HCWs included doctors, clinicians, nurses, pharmacists, lab technicians, and biomedical engineers. The principal investigator (MKN) and the unit leader at the KCH paediatric unit compiled a list of prospective participants. MKN contacted them to explain the study before sending consent forms and planning for interviews. All contacted participants agreed to participate.

Data collection

MKN collected data using the same interview guide for both categories from July 2023 to August 2023. The interview guide was developed in English (Supplementary Information 1) and pre-tested by MKN at Area 25 Health Centre in Lilongwe to five purposively sampled HCWs involved in child healthcare delivery. The pre-test results assisted in refining the questions for clarity. The interview guide included questions on perceptions of child health research in Malawi, the importance of child health research, child HCWs’ current capacity in research, and the availability of research opportunities among child HCWs.

The IDIs provided a detailed exploration of everyone’s perspective [36], and KIIs created room for triangulation of results. Participants were explained the study, and MKN obtained signed informed consent. All participants were identified using numbers. MKN conducted interviews in English and audio-taped to make sure that everything was captured. All participants were professional HCWs who had gone up to tertiary education level and were conversant with English. Participants were interviewed in their offices for confidentiality and to create a safe environment to explain their perceptions freely. The interviews lasted 30–45 min, and we provided lunch allowances to all the participants. MKN took notes and summarised key points after every interview for validation [30].

Data analysis

The recordings were transcribed verbatim in English by MKN. TBN listened to all recordings and cross-checked the verbatim transcription. Using IPA, we analysed data flexibly in five steps described by Smith et al. [29]. Firstly, MKN was immersed in the data set by repeatedly reading the transcripts while stepping into the participants’ shoes as deeply as possible to note the initial thoughts, observations, and responses concerning the research objectives [37]. Secondly, MKN developed a codebook examining codes related to general perceptions of child health research.

Thirdly, LMT and TBN checked the codebook for validation by independently reading the first two transcripts line by line and identifying emerging codes to ensure coding reliability and consistency. The researchers regrouped for a final codebook through a consensus process by looking at commonalities and differences [38]. The final codebook was agreed upon by the joint consensus of all authors [38, 39]. Fourthly, MKN coded all transcripts manually using the validated codebook by grouping similar excerpts in a Word document for easy immersion/familiarisation with the data through repeatedly and active reading [40]. Fifthly, all authors regrouped again and identified relationships between codes. The frequently identified codes were merged, and themes were generated from these codes. Throughout these steps, we focused on participants’ interpretations of their experiences in research. This manuscript comprises summaries, interpretations, and quotes from participants’ excerpts.

Ethical considerations

The College of Medicine Research Ethics Committee (COMREC) [P.06/23-0089] approved this study. Before data collection, we obtained written informed consent from all participants. We maintained confidentiality and anonymity by allocating numbers and transcripts to the participants. Each participant was informed about voluntary participation and the option to withdraw at any stage without repercussions. This study was conducted per the Declaration of Helsinki guidelines and regulations [41].

Reflexivity

We were mindful of our prior experiences and preconceptions shaped by our backgrounds in health research [31,32,33, 37, 42]. As researchers immersed in data collection, transcription, and analysis, we acknowledged that our understanding could influence interpretations. Through ongoing reflexive practices, such as team discussions and journaling, we recognised the subjectivity of our perspectives [31,32,33, 37, 42].

MKN played a pivotal role throughout the study, engaging in data collection, transcription, and leading the analysis, which enabled nuanced interpretations of HCWs' participation in child health research [43]. Our collective experience in qualitative research shaped our analytical stance and guided the emphasis on certain themes. By acknowledging our positionality and the iterative nature of our interpretations, we aimed to enhance the transparency and rigour of our study [43]. Reflexivity enriched our understanding and guided the interpretation and presentation of findings.

Results

There were more female participants in the HCW category (60%) but one female participant in the policymaker category (20%) (Table 1). Most participants in the HCW category were aged between 25 and 34 years (65%), with most policymakers being above 45 years old (60%). All the nurses were females. Two doctors in the HCW group have a publication each, a pharmacist has two publications, and the publications for all the policymakers who participated in the KIIs add up to 104.

Table 1 Demographic characteristics of interview participants

Themes

Participants in this study reported low involvement in research. Three key themes emerged from the transcripts. These are (i) perceived motivation and challenges for engaging in child health research, (ii) perceptions of resource availability and research opportunities at KCH, and (iii) perceptions of gaps in research training and participation among child HCWs. The themes are discussed below.

Perceived motivation and challenges for engaging in child health research

Participants reported some intrinsic professional motivation and multifaceted challenges for engaging in child health research. A willingness to better understand child health issues was reported as a strong motivator among child HCWs at KCH to engage in child health research.

“We know that part of our job is to look at the progress of the diseases and how the evolution has been for many years… looking at the fact that medicine is dynamic…all the changes that are happening in terms of vaccines, medicines, and all the changes, make everybody who works in the pediatric department to have that feeling and need to do more research. So yes, the willingness is there.” ID1 18, Doctor

“Research that can tell us about the changing epidemiology of the disease would be paramount, and that should be very well documented and disseminated through the layers for implementation purposes to influence decision making that is still not happening... emerging conditions like Non Communcable Dseases (NCDs) in children...” KII 04, Policymaker

Child HCWs and policymakers expressed that financial incentives influence their motivation for engaging in research. Participants associate research with significant economic gains despite the struggles researchers have to go through to secure grants.

“…research comes with a lot of resources, so some can be used to improve the lives of the people conducting research.” IDI 10, Clinical Administrator

“There is freedom of money in research if you find a grant. I know you have to struggle to find a grant, but after the struggle, there’s something you can benefit from. Healthcare workers do not know that research has some monetary benefits.” KII 04, Policymaker

However, other participants showed reluctance to engage in research due to various barriers within their environment, as explained below.

“…People are not oriented on how they can conduct research in children… in our lab, we generate data, so we expect that people will come to ask what they have noted, but only a few have come to ask us for data... So, it just shows that people are not interested in the data.” IDI 05, Lab Technician

“Most of us get discouraged because we do not see the results of most studies happening here.” 1D1 19, Pediatric nurse

Policymakers emphasised the need for increased research initiatives to empower child HCWs to research in their respective hospital settings.

“The effort of research itself is low… We need to move in a direction where you can wake up and start writing a research question independently. It is something that needs to be pushed.” KII 04, Policymaker

Participants highlighted the limited involvement of nursing professionals in research, attributing it to insufficient capacity. Nurses reported that, unlike medical professionals, they are mostly overlooked in child health research.

“Most of us, especially nurses, are quiet. We are not active, unwilling, and do not participate more compared to the other side of medical, like the clinicians and the other team. Most of us are not experienced in research. So, with a lack of knowledge and expertise in research, we are not active compared to the other team.” IDI 01, Palliative nurse

“No, in nursing, no. In pediatric? I have never heard of it, but the medical ones, like the doctors, are the ones who do that. For us, it is just continued professional development (CPD). Maybe because I am a junior, I don’t know much, but I have worked here for four years.” 1DI 20, Pediatric nurse

Some participants attributed their limited involvement in research to their busy clinical schedules, as outlined below.

“We don’t have time... doing normal clinical work is a lot of burden, and then there is the administration, clinical work, and teaching. … You need to formulate a time frame for research. People are torn between sitting behind their laptops and working on research or seeing patients. So the patient always takes precedence.” IDI 10, Clinical Administrator

” Research needs time, and for health professionals in Government hospitals, there is so much pressure for work, so we prioritise seeing clients over doing research. … We are so much interested in doing research, especially in medical equipment for neonates, children, and all that, but what limits us is the time factor.” IDI 16, Biomedical Engineer

In addition to time constraints, female nurses link their limited participation in research to gender roles, which hinder their ability to pursue research opportunities outside of their working hours.

“Women are too busy than men in our culture. Males find a lot of information on the Internet on how to conduct research. For females, we come to work and are busy with our daily routine; we go back home, are tired with the kids, and go to bed ...” IDI 19, Pediatric nurse.

These findings underscore the importance of addressing these barriers and enhancing support for child HCWs and policymakers to foster a conducive environment for research in child health.

Perceptions of resource availability and research opportunities at KCH

In this study, we were keen to understand the available research opportunities for child HCWs at KCH. Participants reported that research is not a priority in the annual budget at KCH, with only a small portion allocated for research activities. Child HCWs indicated that these funds often get diverted into clinical expenditures, leaving little-to-no resources available for research endeavours.

“Government policy demands every institution to allocate 1-2% of the annual funding to research, but in most cases, this money is not available for research …maybe the priority is on the clinical part of treating the patients. So, if I am interested in doing a study, I have to find funding to conduct it even though it will benefit the hospital.” IDI 05, Pharmacist.

Participants, therefore, emphasised the need for institutional support, including allocating a budget line specifically for research to minimise the diversion of funds from research to service delivery and encourage child HCWs to engage in research activities.

“They should allocate a certain amount for research because if they can, it will have its budget line within the hospital that the hospital cannot tap from for other expenses... That would make people interested in research because they would know there are already some funds I can utilise elsewhere.” IDI 05, Pharmacist

Child HCWs expressed concerns about limited funding opportunities for research, advocating for funders to be more open to supporting new researchers. They suggested that funders should allow new researchers to participate in grant writing competitions and allocate grants to encourage early career researchers.

“Funders should be more open to new people writing grants. The case of looking for proven records and experience. Where do you get the experience if you are starting? Give new people some small grants and see how they handle that...” IDI 10, Clinical Administrator

These sentiments were echoed by policymakers who admitted that, as a country, very little money is allocated for research.

“As a country, we are not investing in research in terms of money. People can have ideas, but we do not expect them to take the little money from their pockets. ” KII 04, Policymaker

Child HCWs highlighted the challenge of securing external funding for research projects due to the need for more institutional support and resources. The theme exposes the systemic challenges child HCWs face at KCH in pursuing research opportunities, including inadequate funding and competing priorities within the healthcare system.

Perceptions of gaps in research training and participation among child HCWs

Participants expressed a clear need for more emphasis on research training to address capability gaps among HCWs.

“…if we were exposed to training … I think I can be confident enough to research on my own and develop some manuscripts for publication.” 1D1 19, Pediatric Nurse

“When someone is doing a study, we ask for our involvement to get mentored. But how involved are we? They have already developed a concept, done everything, and now they are on data collection; that is when we are involved. So, I would say our involvement should start from conceptualisation.” IDI 03, Nurse Administrator

Participants expressed inadequate training and capacity-building opportunities among HCWs, hindering their ability to engage in research activities effectively.

“I would say the opportunities are limited; if we had such opportunities, we have the team of people that are always willing to work in research, to do more research, but such opportunities are minimal…we need some sort of training here and there...” IDI 05, Pharmacist

“I wouldn’t say there is any training in the department or at a hospital level to enhance someone’s progress with research. We get interested in doing research, but at the hospital level, there are no training and capacity-building activities.” 1DI 18, Doctor

Participants highlighted the need for more exposure to research training due to the absence of research concepts in clinical, medical, and nursing education curricula. They suggested incorporating research concepts into CPD programs as a potential solution to bridge this gap.

We underwent medical training and internship and were introduced to research concepts when we started working. It is a new concept to us, so it becomes a challenge... Again, it should be part of CPD. We do CPD as professionals, but mostly, it’s the same things that we do in the hospitals. I have never seen research being part of it.” ID1 18, Doctor

Policymakers acknowledged the importance of incorporating child HCWs into technical working group meetings to expose them to research gaps in the health system.

“I think it is about including them in our technical working groups; that is when they will be open and be exposed to implementation arrangements. They will also be motivated to say this is the area we can do something on.” KII 01, Policymaker

There was a perceived need to strengthen collaborations with stakeholders in various areas of healthcare to improve child HCWs' participation in research.

“…People should know that who is there in this area. We have people specialising in child health, but where are they? Do we know them? Why? They are somewhere in an organisation where we can’t even access them. But why do we have people specialising in child health? They are the ones who are supposed to be in the forefront...” IDI 03, Nurse Administrator

The results under this theme describe the multifaceted gaps that hinder child HCWs’ engagement in research activities and the importance of addressing these gaps through enhanced researcher involvement, training and capacity-building opportunities, policy support on health education curriculum, and improved collaboration with stakeholders.

Discussion

This study offers valuable insights into the perceptions of child HCWs at KCH regarding child health research. Despite a general willingness among child HCWs to engage in research, participation still needs to improve due to various challenges.

A significant challenge identified was the need for more research capacity among child HCWs at KCH. Our study identified that child HCWs at KCH have a low drive to engage in child health research due to a lack of research training during their studies. This is in contrast to Tanzania, where a similar study found that over half of the participants had received research training at a university or medical college [44], which may result in regional differences in research capacity among child HCWs in sub-Saharan Africa. These disparities could impact research outcomes and the effectiveness of child health interventions in different countries. We recommend urgent reforms in the clinical education curriculum in Malawi to incorporate research training and bridge this gap.

Our findings highlight a significant involvement gap in research collaboration practices at KCH, where child HCWs are mainly involved in data collection rather than other processes, such as developing protocols, data analysis, and manuscript writing. The challenge is further exacerbated by the absence of a dedicated child health department within the Ministry of Health to foster collaboration and ownership of child health initiatives. In addition to advocating for establishing a standalone child health department to improve stakeholder collaboration and child health outcomes [45, 46], we also advocate for a comprehensive engagement approach for child HCWs in research from conceptualisation to report writing. Collaboration between academic and research institutions can provide cost-effective training and expertise sharing, as recommended by the previous studies [44, 47,48,49].

Gender constraints were also identified as a significant challenge for participation in research among female child HCWs at KCH. While male child HCWs have taken the initiative to self-train in research during their spare time using the internet, female child HCWs lack such opportunities due to household gender roles which fill their non-professional work time. Similar findings from other African countries have been reported [44, 50]. Policymakers are urged to implement strategies to empower female child HCWs, including early involvement in research processes and creating supportive environments conducive to research engagement. Additionally, KCH child HCWs face significant time constraints due to heavy workloads, similar to findings from both African and developed countries [50,51,52,53,54,55]. To address this, we recommend allocating protected research time within the hospital, supported by increased human resources and integration of research into duty rosters.

Financial constraints were another significant challenge to research participation at KCH as the annual budget needs to prioritise research. This highlights the need for a dedicated budget line for research to ensure adequate funding. Lack of financial resources limits the ability to conduct research and affects the quality and scope of studies. With sufficient funding, procuring materials, compensating participants, and covering other essential expenses is easier. Prior research has also identified insufficient finances as a barrier to African research [44, 47], indicating a broader systemic issue. Addressing this financial gap is crucial to fostering a research culture, building capacity among child HCWs, and improving healthcare outcomes through evidence-based practices. Enhanced funding mechanisms from governmental and non-governmental sources are needed to overcome these obstacles and promote a research-oriented healthcare environment.

Limitations

This is the first study to explore HCW experiences in child health research at KCH in Malawi. Our child HCW sample had more females, while the Policymaker sample included only one female, potentially introducing gender bias. Interpretative Phenomenological Analysis (IPA) allowed for detailed and nuanced perceptions of child health research at KCH. However, a qualitative study cannot establish causality, and the sample from a single hospital in central Malawi may limit generalizability. Despite this, the identified barriers and recommendations likely apply to all government hospitals in Malawi, as they share common health education institutions and policies. Further research involving multiple sites and more balanced gender representation is needed to validate and extend these findings.

Conclusion

Our study has identified crucial factors contributing to the low participation of child HCWs in child health research at KCH. We found notable gaps in research participation among child HCWs at KCH, including a lack of collaboration, limited financial opportunities, and non-research-based training. Some child HCWs expressed a strong research interest, but challenges at both individual and institutional levels hinder engagement. We advocate for targeted capacity-building interventions to address these challenges and promote a culture of research excellence. Prioritising these initiatives can foster a conducive environment for child health research and enhance outcomes in Malawi.