District Hospital In Kenya Research Articles

Training 750 General surgeons in this decade for district hospitals in Kenya

Training 750 General surgeons in this decade for district hospitals in Kenya

A space-time analysis of recurrent malnutrition-related hospitalisations in Kilifi, Kenya for children under-5 years

BackgroundGlobally, malnutrition underlies 45% of under-5 s mortality, mainly from potentiating common infections such as diarrhoea and pneumonia. Malnutrition as a public health problem is not evenly disbursed because of disparities in food insecurity and health, and children commonly suffer recurrent episodes of opportunistic infections. We aimed to understand better the spatial and temporal structure of multiple paediatric hospital admissions associated with malnutrition-related illnesses. This paper aimed to investigate the spatial-temporal variations in malnutrition-related recurrent morbidity of children under-5 years from the Kilifi County in Kenya between 2002 and 2015.MethodsThe study included data from children under-5 years old who had more than one admission to a rural district hospital in Kenya within the Kilifi Health and Demographic Surveillance System (KHDSS). The primary outcome was a malnutrition-related admission, based on wasting (WHZ < -2) or nutritional oedema. Individual, household and environmental level covariates were examined as exposures. We first fitted a SARIMA model for the temporality, and the Moran’s Index affirmed spatial clustering in malnutrition admissions. Kulldorf Statistics using SaTScan were applied to detect hotspots. Then, bivariate analysis was done using repeated values tabulation and analysis of covariance (ANCOVA). Inferential analysis was done using a mixed effect multivariable negative-binomial regression model, adjusting for spatiotemporal random effects.ResultsA total of 2821 children were admitted more than once, giving a total of 6375 admissions. Of these 6375 admissions, 1866 were malnutrition-related, and 3.9% (109/2821) of the children with repeat admissions died. There was a seasonal pattern of re-admissions, peaking from May to July over the years. Hotspots were found in both the Northern and Southern areas of the KHDSS, while the areas near Kilifi Town were least affected. We found that disease severity was most likely associated with a malnutrition re-admission to the hospital.ConclusionDisease severity was strongly associated with admission with malnutrition but its effect reduced after adjusting for the spatial and temporal random effects. Adjusting for clustering in space and in time (spatial-temporal) in models helps to improve the understanding of recurrent hospitalisations involving malnutrition.

Hybrid clinical-managers in Kenyan hospitals

PurposeThe purpose of this paper is to explore the way “hybrid” clinical managers in Kenyan public hospitals interpret and enact hybrid clinical managerial roles in complex healthcare settings affected by professional, managerial and practical norms.Design/methodology/approachThe authors conducted a case study of two Kenyan district hospitals, involving repeated interviews with eight mid-level clinical managers complemented by interviews with 51 frontline workers and 6 senior managers, and 480 h of ethnographic field observations. The authors analysed and theorised data by combining inductive and deductive approaches in an iterative cycle.FindingsKenyan hybrid clinical managers were unprepared for managerial roles and mostly reluctant to do them. Therefore, hybrids’ understandings and enactment of their roles was determined by strong professional norms, official hospital management norms (perceived to be dysfunctional and unsupportive) and local practical norms developed in response to this context. To navigate the tensions between managerial and clinical roles in the absence of management skills and effective structures, hybrids drew meaning from clinical roles, navigating tensions using prevailing routines and unofficial practical norms.Practical implicationsUnderstanding hybrids’ interpretation and enactment of their roles is shaped by context and social norms and this is vital in determining the future development of health system’s leadership and governance. Thus, healthcare reforms or efforts aimed towards increasing compliance of public servants have little influence on behaviour of key actors because they fail to address or acknowledge the norms affecting behaviours in practice. The authors suggest that a key skill for clinical managers in managers in low- and middle-income country (LMIC) is learning how to read, navigate and when opportune use local practical norms to improve service delivery when possible and to help them operate in these new roles.Originality/valueThe authors believe that this paper is the first to empirically examine and discuss hybrid clinical healthcare in the LMICs context. The authors make a novel theoretical contribution by describing the important role of practical norms in LMIC healthcare contexts, alongside managerial and professional norms, and ways in which these provide hybrids with considerable agency which has not been previously discussed in the relevant literature.

Informing thresholds for paediatric transfusion in Africa: the need for a trial

Background: Provision of adequate supplies of donor blood for paediatric transfusion remains a challenge. Guidelines recommend restrictive transfusion practices, based on expert opinion. We examined whether survival among children admitted to hospital varied by admission haemoglobin status and whether this was influenced by malaria infection and/or transfusion. Methods: A retrospective analysis in an unselected population of children admitted to a rural district hospital in Kenya over an 8-year period. We describe baseline parameters with respect to categories of anaemia and outcome (in-hospital death) with respect to haemoglobin, malaria and transfusion status. Results: Among 29,226 admitted children, 1,143 (3.9%) had profound anaemia (Hb &lt;4g/dl) and 3,469 (11.9%) had severe anaemia (Hb 4-6g/d). In-hospital mortality was; 97/1,143 (8.5%) in those with Hb&lt;4g/dl and 164/2,326 (7.1%) in those with severe anaemia (Hb ≥4.0-&lt;6g/dl). Admission Hb &lt;3g/dl was associated with higher risk of death versus those with higher Hbs (OR=2.41 (95%CI: 1.8 - 3.24; P&lt;0.001), increasing to OR=6.36, (95%CI: 4.21–9.62; P&lt;0.001) in malaria positive children. Conversely, mortality in non-malaria admissions was unrelated to Hb level. Transfusion was associated with a non-significant improvement in outcome if Hb&lt;3g/dl (malaria-only) OR 0.72 (95%CI 0.29 - 1.78), albeit the number of cases were too few to show a statistical difference. For those with Hb levels above 4g/dl, mortality was significantly higher in those receiving a transfusion compared to the non-transfused group. For non-malarial cases, transfusion did not affect survival-status, irrespective of baseline Hb level compared to children who were not transfused at higher Hb levels. Conclusion: Although severe and complicated anaemia is common among children admitted to hospital in sSA (~16%), our data do not indicate that outcome is improved by transfusion irrespective of malaria status. Given the limitations of observational studies, clinical trials investigating the role of transfusion in outcomes in children with severe anaemia are warranted.

Basic newborn resuscitation guidelines for healthcare providers in Maragua District Hospital: a best practice implementation project.

The overall aim of this project was to assess compliance with evidence-based criteria regarding newborn resuscitation among healthcare workers in the maternity units in Maragua District Hospital (a busy district hospital in Kenya). Globally, the majority of deaths under five years are attributable to neonatal causes. Perinatal asphyxia accounts for a significant portion of these deaths, especially in developing countries. These deaths are largely preventable, and interventions geared towards assisting newborns to initiate their first breath within the first minute of life have markedly reduced mortality. This implementation project was conducted in the maternity units of a busy district hospital. Evidence-based audit criteria were developed on the basis of an evidence summary developed by the Joanna Briggs Institute (JBI). Using the JBI Practical Application of Clinical Evidence System software (JBI PACES), a baseline audit was conducted including a sample size of 55 healthcare providers and 300 patient case notes followed by an identification of potential barriers and strategies to overcome them. A follow-up audit including a sample size of 55 healthcare providers was conducted by using the same audit criteria. Improvements in practice were demonstrated in all criteria. The baseline audit demonstrated that three of the five audit criteria were found to be less than 50%, indicating moderate compliance with current evidence with regards to newborn resuscitation. Following implementation of the strategies, which included a six-week education and demonstrative skills training, and updating of the protocols and equipment, there was a significant improvement in all the criteria audited, with the first four criteria achieving 100% compliance, and the fifth criteria achieving 90% compliance. On completion of the project, the participants demonstrated an increase in knowledge and skills on newborn resuscitation, which led to a significant reduction in admission of newborns with birth asphyxia to the newborn unit.

Multidimensional needs of patients living and dying with heart failure in Kenya: a serial interview study

BackgroundHeart failure is an emerging challenge for Sub Saharan Africa. However, research on patients’ needs and experiences of care is scarce with little evidence available to support and develop services. We aimed to explore the experiences of patients living and dying with heart failure in Kenya.MethodsWe purposively recruited 18 patients admitted with advanced heart failure at a rural district hospital in Kenya. We conducted serial in depth interviews with patients at 0, 3 and 6 months after recruitment, and conducted bereavement interviews with carers. Interviews were recorded, transcribed into English and analyzed using a thematic approach, assisted by Nvivo software package.ResultsForty-four interviews were conducted. Patients experienced physical, psychosocial, spiritual and financial distress. They also had unmet needs for information about their illness, how it would affect them and how they could get better. Patients experience of and their interpretation of symptoms influenced health care seeking. Patients with acute symptoms sought care earlier than those with more gradual symptoms which tended to be normalised as part of daily life or assumed to be linked to common treatable conditions. Nearly all patients expected to be cured and were frustrated by a progressive illness poorly responsive to treatment. Accumulating costs was a barrier to continuity of care and caused tensions in social relationships. Patients valued information on the nature of their illness, prognosis, self-care, lifestyle changes and prevention strategies, but this was rarely available.ConclusionsThis is the first in-depth study to explore the experiences of people living with advanced heart failure in Kenya. This study suggests that patients would benefit from holistic care, such as a palliative approach that is aimed at providing multidimensional symptom management. A palliative approach to services should be provided alongside chronic disease management aimed at primary prevention of risk factors, and early identification and initiation of disease modifying therapy. Further research is needed to determine best practice for integrating palliative care for people living and dying with heart failure.

Neonatal tetanus in an African newborn

•Tetanus is caused by the toxin of Clostridium tetani.•Neonatal tetanus occurs after the contamination of the umbilical stump with the spores of C. tetani in newborns without protective antibodies.•Inadequate maternal vaccination and poor perinatal hygiene are the main risks factors.•The diagnosis is mainly clinical and the early onset of a specific treatment can improve the prognosis.•Prevention of neonatal tetanus is achieved with improvement in perinatal and ante-natal care, with vaccination of unimmunised pregnant women. A 7-day-old newborn was brought to our hospital with fever. The mother had not followed any ante-natal care. She gave birth at home and the umbilical cord was cut with a non-sterile blade. The newborn had been well up to the day of admission, when fever and some difficulties for breastfeeding appeared. Physical examination was unremarkable, including a preserved suction reflex. A urinary dipstick ruled out a urinary infection. A rapid test for malaria was negative. There was no possibility to perform blood cell count or cultures due to the limited resources. A lumbar puncture showed clear spinal fluid, but biochemical or microbiological tests were unavailable. Regardless of ampicillin and gentamicin administration, the fever increased and the baby developed an impossibility to suck. He had muscular spasms, aggravated by touch. Trismus and rigidity were marked (Figure 1). The evolution and epidemiology posed the suspicion of neonatal tetanus, a disease caused by the toxin of Clostridium tetani, still common in low income countries due to limited access to ante-natal care, inadequate maternal vaccination and home-deliveries with no use of clean delivery kits and poor hygiene of the umbilical stump (WHO, 2017). The early onset of a specific treatment may modify the prognosis, so human tetanus immunoglobulin (500 UI intramuscularly) and metronidazole (15 mg/kg as loading dose, followed by 7.5 mg/kg every 12 h for 10 days) were administered. A nasogastric-tube was placed for feeding, the newborn was located in a quiet, dark place, and diazepam was initiated to control the spasms (Thwaites et al., 2015Thwaites C.L. Beeching N.J. Newton C.R. Maternal and neonatal tetanus.Lancet. 2015; 385: 362-370Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar, Gibson et al., 2009Gibson K. Bonaventure Uwineza J. Kiviri W. Parlow J. Tetanus in developing countries: a case series and review.Can J Anaesth. 2009; 56: 307-315Crossref PubMed Scopus (36) Google Scholar). Despite the high mortality of this entity (Mwaniki et al., 2010Mwaniki M.K. Gatakaa H.W. Mturi F.N. Chesaro C.R. Chuma J.M. Peshu N.M. et al.An increase in the burden of neonatal admissions to a rural district hospital in Kenya over 19 years.BMC Public Health. 2010; 10: 591-604Crossref PubMed Scopus (34) Google Scholar), the evolution was good, with spasm disappearance and recovery of suction capacity (Figure 2). The baby was discharged 15 days after arrival. As tetanus infection does not confer immunity, he received the first dose of tetanus toxoid vaccination before discharge and was included in immunization program for the following two doses. The mother was also vaccinated. Prevention of neonatal tetanus is achieved with a combination of improvement in perinatal care and vaccination of women of childbearing age and unimmunised pregnant women, since maternal antibodies are passively transferred to the fetus and protect the newborn (Demicheli et al., 2015Demicheli V. Barale A. Rivetti A. Vaccines for women to prevent neonatal tetanus.Cochrane Database Syst Rev. 2015; 7 (CD002959)Crossref Scopus (39) Google Scholar, WHO, 2000WHO Maternal and neonatal tetanus elimination (MNTE).2000Google Scholar).Figure 2Recovery of the capacity to suck after the treatment.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Author contributions: M.A.P.J.A. and M.L gave medical attention to the newborn. M.A.P.J.A. wrote the paper. Funding sources: No funding sources. Conflict of interest: The authors declare no conflict of interest. Acknowledgement: We acknowledge the mother of the baby for giving her written consent for the publication of her son’s images and signing the informed consent form.

Spiritual issues of people living and dying with advanced heart failure in Kenya: a qualitative serial interview study

BackgroundExploring patients' spiritual issues is vital for informing holistic care. The spiritual concerns of patients living and dying with advanced heart failure in sub-Saharan Africa remains unknown. Our aim was...

Perceptions of the preparedness of medical graduates for internship responsibilities in district hospitals in Kenya: a qualitative study.

BackgroundAga Khan University is developing its undergraduate medical education curriculum for East Africa. In Kenya, a 1 year internship is mandatory for medical graduates’ registration as practitioners. The majority of approved internship training sites are at district hospitals. The purposes of this study were to determine: (1) whether recent Kenyan medical graduates are prepared for their roles as interns in district hospitals upon graduation from medical school; (2) what working and training conditions and social support interns are likely to face in district hospital; and (3) what aspects of the undergraduate curriculum need to be addressed to overcome perceived deficiencies in interns’ competencies.MethodsFocus group discussions and semi-structured interviews were conducted with current interns and clinical supervisors in seven district hospitals in Kenya. Perceptions of both interns and supervisors regarding interns’ responsibilities and skills, working conditions at district hospitals, and improvements required in medical education were obtained.ResultsFindings included agreement across informants on deficiencies in interns’ practical skills and experience of managing clinical challenges. Supervisors were generally critical regarding interns’ competencies, whereas interns were more specific about their weaknesses. Supervisor expectations were higher in relation to surgical procedures than those of interns. There was agreement on the limited learning, clinical facilities and social support available at district hospitals including, according to interns, inadequate supervision. Supervisors felt they provided adequate supervision and that interns lacked the ability to initiate communication with them. Both groups indicated transition challenges from medical school to medical practice attributable to inadequate practical experience. They indicated the need for more direct patient care responsibilities and clinical experience at a district hospital during undergraduate training.ConclusionPerception of medical graduates’ unpreparedness seemed to stem from a failure to implement the apprenticeship model of learning in medical school and lack of prior exposure to district hospitals. These findings will inform curriculum development to meet stakeholder requirements, improve the quality of graduates, and increase satisfaction with transition to practice.

Immunogenicity of 10-valent pneumococcal conjugate vaccine among infants attending Mbagathi District Hospital, Kenya

Introduction: This study aimed to determine the serum concentration of IgG antibodies as an indicator of immunogenicity, alongside the assessment of socio-demographic factors that affect IgG antibody levels in infants immunized with 10-valent pneumococcal conjugate vaccine (PCV-10) at the Mbagathi District Hospital in Kenya.Materials and methods: This cross-sectional study measured serum IgG antibodies among infants who had completed a 3-dose course of PCV-10. IgG antibodies to pneumococcal serotype-specific capsular polysaccharide were measured through enzyme-linked immunosorbent assay (ELISA).Results: The majority (83%) of infants who completed the required dose of pneumococcal conjugate vaccine had serum titres of pneumococcal disease- (PD) specific IgG antibodies of between 0.34 mg/dl and 0.36 mg/dl. 4% of infants had serum titres of 0.30 mg/dl to 0.33 mg/dl. The remaining 2% had IgG antibody titres of either ≤0.25 mg/dl, or between 0.25 mg/dl to 0.29 mg/dl. Additionally, there was multi-collinearity among the IgG antibody levels of the infants studied and several variables that had an effect on these levels. These included: alcohol consumption by infants’ biological mothers during pregnancy (r =.595, p ≤ 0.05); maternal diet during pregnancy (r =.137, p ≤ 0.05); breastfeeding frequency (r =.220, p ≤ 0.05); proximity to other children (r =.133, p ≤ 0.05); child hospitalization (r =.131, p ≤ 0.05) and chronic illness (r =.154, p ≤0.01).Conclusion: PCV-10 is immunogenic against PD four weeks after completion of 3-doses among the infants attending the Child Welfare clinic at the Mbagathi District Hospital in Kenya. Socio-demographic factors which include consumption of alcoholic drinks by infant’s biological mother during pregnancy and study infant chronic illness negatively affect the development of PD specific IgG. A balanced maternal diet during pregnancy and a breastfeeding frequency superior to three times per day have a significant positive effect on serum pneumococcal IgG levels among infants.

G594 Tackling high mortality in a kenyan district hospital

Context Completed in a Kenyan hospital paediatric Emergency Department. Clinical officers, Nurses and administration team involved. Problem Stabilisation of paediatric admissions High mortality levels within first 24 h of admission. Often no identifiable cause of death from note keeping. Lack of documentation of stabilisation procedures. Clinically unstable children on ward Assessment of problem and analysis of its causes Liasion with the clinical staff identified lack of full stabilisation of patients prior to ward transfer. Assessing patient files revealed poor note keeping of stabilisation/lack of early stabilisation interventions. Intervention Five point checklist designed to standardise early care for all paediatric admissions. Filled out by nurses. The 5 points covered were Airway, Breathing and Circulation stable Check glucose if not alert Take haemoglobin and cross match samples if pale Medications written up regulalry on drug chart First dose of medications given The checklist informed staff that each of the points must be completed before the child was to be transferred to the paediatric ward and what to do if these were not performed. Patient demographics, staff details included. Study design Retrospective analysis of mortality cases over a 3 month period. End point examined was change in mortality rates within first 24 h of admission in intervention and non intervention populations. Strategy for change ‘Safety checklist’ designed and trialled by nursing team in the Emergency Department. This was refined and expanded to cover 5 key clinical points. Several meetings with nursing staff were undertaken. Nurses designated to complete the checklist for new admissions. Local consultant paediatrician agreed to trial of checklist in notes. From September 2014 administration staff were able to put the checklist in every child’s file prior to Emergency Department clerking. Results of the study have been discussed with the teams involved and both nurses and clinical officers in the emergency department have agreed to continue working with the checklist. Further data from the hospital has been requested to monitor for ongoing change. Measurement of improvement All available mortality files over a three month period July–September 2014 were reviewed. Groups with a checklist and without were compared at different time intervals from admission. All availabel notes of paediatric admissions to the hospital during the same period were reviewed to identify the uptake of the checklist prior to it being put in to all medical files. A 24% reduction in mortality within the first 24 h was observed in the checklist group compared with the non-checklist group. Effects of changes Initial results reveal that a lower percentage of deaths were in the first 24 h of admission in the checklist versus non checklist group. Further data is required to allow month on month comparisons now that every child is receiving a checklist in their notes to see if there is a direct effect on total mortality figures. Objectively fewer numbers of unstable patients seen on the ward. There were initial difficulties with getting people to fill in the checklist and insert it in to the patient’s file. This was much improved by getting the checklist put in the patient notes by the clinical records team before the child was admitted. Nurses team nominated for a Kenyan award for their using checklist to improve clinical governance measures. Lessons learnt To liaise early with nursing team regarding additions to improvement project. To get one group of staff to take responsibility for checklist completion as avoids confusion of roles. To get records department to include checklist in admission clerking sheets to allow ease of use and continuity of provision of checklist. Message for others Simple checklist intervention can have a substantial influence on child mortality within the first 24 h of admission and lead to better level of standardisation of care for acutely unwell children.

Safety and efficacy of allogeneic umbilical cord red blood cell transfusion for children with severe anaemia in a Kenyan hospital: an open-label single-arm trial

SummaryBackgroundIn sub-Saharan Africa, children are frequently admitted with severe anaemia needing an urgent blood transfusion, but blood is often unavailable. When conventional blood supplies are inadequate, allogeneic umbilical cord blood could be a feasible alternative. The aim of this study was to assess the safety and efficacy of cord blood transfusion in children with severe anaemia.MethodsBetween June 26, 2007, and May 20, 2008, 413 children needing an urgent blood transfusion were admitted to Kilifi District Hospital in Kenya. Of these, 87 children were eligible for our study—ie, younger than 12 years, no signs of critical illness, and haemoglobin 100 g/L or lower (if aged 3 months or younger) or 40 g/L or lower (if older than 3 months). Cord blood was donated at Coast Provincial General Hospital, Mombasa, and screened for transfusion-transmitted infections and bacterial contamination. Red blood cells were stored vertically at 2–6°C to enable sedimentation. After transfusion, children were monitored closely for adverse events and followed up for 28 days. The primary outcome measure was the frequency and nature of adverse reactions associated with the transfusion. Secondary outcomes were the changes in haemoglobin concentrations 24 h and 28 days after transfusion, compared with pretransfusion levels. This trial is registered on ISRCTN.com, number ISRCTN66687527.FindingsOf the 87 children eligible for the study, cord blood was unavailable for 24, six caregivers declined consent, and two children were withdrawn before transfusion. Therefore, 55 children received umbilical cord red blood cells from 74 donations. Ten (18%) children had ten serious adverse events and 43 (78%) had 94 adverse events; the most frequent adverse events were anaemia (n=14), weight loss (n=12), and vomiting (n=10). An independent expert panel judged none of these adverse events to be probably or certainly caused by the cord blood transfusion (one-sided 97·5% CI 0–6·5). Haemoglobin increased by a median of 26 g/L (IQR 21–31) 24 h after transfusion and by 50 g/L (10–68) a median of 29 days (28–35) after transfusion.InterpretationThese preliminary data suggest that cord blood could be an important supplementary source of blood for transfusion in children in sub-Saharan Africa. Further studies are needed to compare the safety and efficacy of cord blood with conventional adult-donated blood for transfusions. Challenges associated with cost, infrastructure, and scale up also need investigating.FundingWellcome Trust.

Health Care Workers Adherence to Infection Prevention Practices and Control Measures: A Case of a Level Four District Hospital in Kenya

Infection prevention practices and control are critical activities that influence the quality of health care services. This study was conducted to determine the health workers adherence to infection prevention and control policies and procedures at a Level 4 Hospital in Kenya. A descriptive cross-sectional survey design were used. The objectives of the study were to: -Identify existing infection prevention and control policy guidelines at the level four hospital; -Evaluate the implementation of infection prevention and control measures; 3) Identify the barriers to compliance with infection prevention practices and control measures. Data was collected by questionnaire, record review and a focus group discussion. Quantitative data was analyzed by the statistical Package for Social Sciences (SPSS) while information from focus group was analyzed thematically. The results revealed that Health Care Workers (HCWs) had good knowledge on infection prevention practices and control. There were written infection prevention practices and control (IPPC) policy guidelines and high awareness (98.7%) of the IPPC policy guidelines. The record review showed that there was approximately 6.7% nosocomial infections rate among hospitalized patients. Barriers to IPPC compliance among the health care workers (HCWs) included frequent shortage of water, inadequate updates on IPPC through continuing professional education and inactive IPPC committee. The study concluded that there was adequate compliance with IPPC, though there were challenges to implementation that needed to be addressed. The study was done in October 2010 to January 2011

Assessment of paediatric inpatient care during a multifaceted quality improvement intervention in Kenyan district hospitals--use of prospectively collected case record data.

BackgroundIn assessing quality of care in developing countries, retrospectively collected data are usually used given their availability. Retrospective data however suffer from such biases as recall bias and non-response bias. Comparing results obtained using prospectively and retrospectively collected data will help validate the use of the easily available retrospective data in assessing quality of care in past and future studies.MethodsProspective and retrospective datasets were obtained from a cluster randomized trial of a multifaceted intervention aimed at improving paediatric inpatient care conducted in eight rural Kenyan district hospitals by improving management of children admitted with pneumonia, malaria and diarrhea and/or dehydration. Four hospitals received a full intervention and four a partial intervention. Data were collected through 3 two weeks surveys conducted at baseline, after 6 and 18 months. Retrospective data was sampled from paediatric medical records of patients discharged in the preceding six months of the survey while prospective data was collected from patients discharged during the two week period of each survey. Risk Differences during post-intervention period of16 quality of care indicators were analyzed separately for prospective and retrospective datasets and later plotted side by side for comparison.ResultsFor the prospective data there was strong evidence of an intervention effect for 8 of the indicators and weaker evidence of an effect for one indicator, with magnitude of effect sizes varying from 23% to 60% difference. For the retrospective data, 10 process (these include the 8 indicators found to be statistically significant in prospective data analysis) indicators had statistically significant differences with magnitude of effects varying from 10% to 42%. The bar-graph comparing results from the prospective and retrospective datasets showed similarity in terms of magnitude of effects and statistical significance for all except two indicators.ConclusionMultifaceted interventions can help improve adoption of clinical guidelines and hence improve the quality of care. The similar inference reached after analyses based on prospective assessment of case management is a useful finding as it supports the utility of work based on examination of retrospectively assembled case records allowing longer time periods to be studied while constraining costs.Trial registrationCurrent Controlled Trials ISRCTN42996612. Trial registration date: 20/11/2008

Using health worker opinions to assess changes in structural components of quality in a Cluster Randomized Trial.

BackgroundThe ‘resource readiness’ of health facilities to provide effective services is captured in the structure component of the classical Donabedian paradigm often used for assessment of the quality of care in the health sector. Periodic inventories are commonly used to confirm the presence (or absence) of equipment or drugs by physical observation or by asking those in charge to indicate whether an item is present or not. It is then assumed that this point observation is representative of the everyday status. However the availability of an item (consumables) may vary. Arguably therefore a more useful assessment for resources would be one that captures this fluctuation in time. Here we report an approach that may circumvent these difficulties.MethodsWe used self-administered questionnaires (SAQ) to seek health worker views of availability of key resources supporting paediatric care linked to a cluster randomized trial of a multifaceted intervention aimed at improving this care conducted in eight rural Kenyan district hospitals. Four hospitals received a full intervention and four a partial intervention. Data were collected pre-intervention and after 6 and 18 months from health workers in three clinical areas asked to score item availability using an 11-point scale. Mean scores for items common to all 3 areas and mean scores for items allocated to domains identified using exploratory factor analysis (EFA) were used to describe availability and explore changes over time.ResultsSAQ were collected from 1,156 health workers. EFA identified 11 item domains across the three departments. Mean availability scores for these domains were often <5/10 at baseline reflecting lack of basic resources such as oxygen, nutrition and second line drugs. An improvement in mean scores occurred in 8 out of 11 domains in both control and intervention groups. A calculation of difference in difference of means for intervention vs. control suggested an intervention effect resulting in greater changes in 5 out of 11 domains.ConclusionUsing SAQ data to assess resource availability experienced by health workers provides an alternative to direct observations that provide point prevalence estimates. Further the approach was able to demonstrate poor access to resources, change over time and variability across place.

Linking Women Who Test HIV-Positive in Pregnancy-Related Services to HIV Care and Treatment Services in Kenya: A Mixed Methods Prospective Cohort Study

IntroductionThere has been insufficient attention to long-term care and treatment for pregnant women diagnosed with HIV.Objective and MethodsThis prospective cohort study of 100 HIV-positive women recruited within pregnancy-related services in a district hospital in Kenya employed quantitative methods to assess attrition between women testing HIV-positive in pregnancy-related services and accessing long-term HIV care and treatment services. Qualitative methods were used to explore barriers and facilitators to navigating these services.Structured questionnaires were administered to cohort participants at enrolment and 90+ days later. Participants’ medical records were monitored prospectively. Semi-structured qualitative interviews were carried out with a sub-set of 19 participants.FindingsOnly 53/100 (53%) women registered at an HIV clinic within 90 days of HIV diagnosis, of whom 27/53 (51%) had a CD4 count result in their file. 11/27 (41%) women were eligible for immediate antiretroviral therapy (ART); only 6/11 (55%) started ART during study follow-up. In multivariable logistic regression analysis, factors associated with registration at the HIV clinic within 90 days of HIV diagnosis were: having cared for someone with HIV (aOR:3.67(95%CI:1.22, 11.09)), not having to pay for transport to the hospital (aOR:2.73(95%CI:1.09, 6.84)), and having received enough information to decide to have an HIV test (aOR:3.61(95%CI:0.83, 15.71)). Qualitative data revealed multiple factors underlying high patient drop-out related to women’s social support networks (e.g. partner’s attitude to HIV status), interactions with health workers (e.g. being given unclear/incorrect HIV-related information) and health services characteristics (e.g. restricted opening hours, long waiting times).ConclusionHIV testing within pregnancy-related services is an important entry point to HIV care and treatment services, but few women successfully completed the steps needed for assessment of their treatment needs within three months of diagnosis. Programmatic recommendations include simplified pathways to care, better-tailored counselling, integration of ART into antenatal services, and facilitation of social support.

Identification of group B respiratory syncytial viruses that lack the 60‐nucleotide duplication after six consecutive epidemics of total BA dominance at coastal Kenya

Respiratory syncytial virus BA genotype has reportedly replaced other group B genotypes worldwide. We report the observation of three group B viruses, all identical in G sequence but lacking the BA duplication, at a coastal district hospital in Kenya in early 2012. This follows a period of six consecutive respiratory syncytial virus (RSV) epidemics with 100% BA dominance among group B isolates. The new strains appear only distantly related to BA variants and to previously circulating SAB1 viruses last seen in the district in 2005, suggesting that they were circulating elsewhere undetected. These results are of relevance to an understanding of RSV persistence.

Service delivery in Kenyan district hospitals – what can we learn from literature on mid-level managers?

BackgroundThere is a growing emphasis on the need to tackle inadequate human resources for health (HRH) as an essential part of strengthening health systems; but the focus is mostly on macro-level issues, such as training, recruitment, skill mix and distribution. Few attempts have been made to understand the capability of health workers, their motivation and other structural and organizational aspects of systems that influence workforce performance. We have examined literature on the roles of mid-level managers to help us understand how they might influence service delivery quality in Kenyan hospitals. In the Kenyan hospital settings, these are roles that head of departments who are also clinical or nursing service providers might play.MethodsA computerized search strategy was run in Pub Med, Cochrane Library, Directory of Open Access Journals Social Science Research Network, Eldis, Google Scholar and Human Resources for Health web site databases using both free-text and MeSH terms from 1980 to 2011. In addition, citation searching from excluded and included articles was used and relevant unpublished literature systematically identified.Results and discussionA total of 23 articles were finally included in the review from over 7000 titles and abstracts initially identified. The most widely documented roles of mid-level managers were decision-making or problem-solving, strategist or negotiator and communicator. Others included being a therapist or motivator, goal setting or articulation and mentoring or coaching. In addition to these roles, we identified important personal attributes of a good manager, which included interpersonal skills, delegation and accountability, and honesty. The majority of studies included in the review concerned the roles that mid-level managers are expected to play in times of organizational change.ConclusionThis review highlights the possible significance of mid-level managers in achieving delivery of high-quality services in Kenyan public hospitals and strongly suggests that approaches to strengthen this level of management will be valuable. The findings from this review should also help inform empirical studies of the roles of mid-level managers in these settings.

The Incidence and Clinical Burden of Respiratory Syncytial Virus Disease Identified through Hospital Outpatient Presentations in Kenyan Children

BackgroundThere is little information that describe the burden of respiratory syncytial virus (RSV) associated disease in the tropical African outpatient setting.MethodsWe studied a systematic sample of children aged <5 years presenting to a rural district hospital in Kenya with acute respiratory infection (ARI) between May 2002 and April 2004. We collected clinical data and screened nasal wash samples for RSV antigen by immunofluorescence. We used a linked demographic surveillance system to estimate disease incidence.ResultsAmong 2143 children tested, 166 (8%) were RSV positive (6% among children with upper respiratory tract infection and 12% among children with lower respiratory tract infection (LRTI). RSV was more likely in LRTI than URTI (p<0.001). 51% of RSV cases were aged 1 year or over. RSV cases represented 3.4% of hospital outpatient presentations. Relative to RSV negative cases, RSV positive cases were more likely to have crackles (RR = 1.63; 95% CI 1.34–1.97), nasal flaring (RR = 2.66; 95% CI 1.40–5.04), in-drawing (RR = 2.24; 95% CI 1.47–3.40), fast breathing for age (RR = 1.34; 95% CI 1.03–1.75) and fever (RR = 1.54; 95% CI 1.33–1.80). The estimated incidence of RSV-ARI and RSV-LRTI, per 100,000 child years, among those aged <5 years was 767 and 283, respectively.ConclusionThe burden of childhood RSV-associated URTI and LRTI presenting to outpatients in this setting is considerable. The clinical features of cases associated with an RSV infection were more severe than cases without an RSV diagnosis.

Out‐of‐pocket costs for paediatric admissions in district hospitals in Kenya

ObjectiveTo describe out-of-pocket costs of inpatient care for children under 5 years of age in district hospitals in Kenya.MethodsA total of 256 caretakers of admitted children were interviewed in 2-week surveys conducted in eight hospitals in four provinces in Kenya. Caretakers were asked to report care seeking behaviour and expenditure related to accessing inpatient care. Family socio-economic status was assessed through reported expenditure in the previous month.ResultsSeventy eight percent of caretakers were required to pay user charges to access inpatient care for children. User charges (mean, US$ 8.1; 95% CI, 6.4–9.7) were 59% of total out-of-pocket costs, while transport costs (mean, US$ 4.9; 95% CI, 3.9–6.0) and medicine costs (mean, US$ 0.7; 95% CI, 0.5–1.0) were 36% and 5%, respectively. The mean total out-of-pocket cost per paediatric admission was US$ 14.1 (95% CI, 11.9–16.2). Out-of-pocket expenditures on health were catastrophic for 25.4% (95% CI, 18.4–33.3) of caretakers interviewed. Out-of-pocket expenditures were regressive, with a greater burden being experienced by households with lower socio-economic status.ConclusionDespite a policy of user fee exemption for children under 5 years of age in Kenya, our findings show that high unofficial user fees are still charged in district hospitals. Financing mechanisms that will offer financial risk protection to children seeking care need to be developed to remove barriers to child survival.