Facilitators and Barriers of ‘Doing Reflection’ in Action Research: Lessons Learned from the PERFORM2Scale Health Systems Research Project in Ghana, Uganda, and Malawi

While Action Research (AR) in health systems is well established, there is a dearth of research about how its reflection phase is pragmatically employed with time-poor healthcare teams, especially within AR implemented in the Global South. This paper presents the findings of a nested qualitative study within PERFORM2Scale, a 5-year Health Systems AR project in Ghana, Malawi, and Uganda. It aimed to unpack the challenges, facilitators, and lessons learned about enacting the reflection phase of the AR cycle with district health management teams (DHMTs) implementing a management strengthening intervention (MSI). Semi-structured interviews and focus groups with district health managers and country research teams (CRTs) were conducted, and thematically analysed. Study findings indicate that pragmatic barriers such as time constraints, high staff turnover, and challenges utilizing a reflection diary impeded enaction of reflection. However, DHMTs more effectively engaged in reflection when conducted collectively and dialogically, and when the mechanism of reflection aligned with existing workplace processes and context. The findings indicate that for the reflection phase to be effective, it requires consistent engagement and focused support throughout all phase of the AR cycle and in ways which are contextually relevant, responsive, and collaborative.