What Drives Outpatient Care Costs in Kenya? An Analysis With Generalized Estimating Equations.

Objective: This study aimed to identify the factors associated with outpatient expenses incurred by households in Kenya. Background: The problem of outpatient healthcare expenses incurred by citizens in countries with limited resources has received little attention. Thus, this study aimed to determine the predictors of household spending on outpatient expenses in Kenya. Method: We conducted a cross-sectional analysis on households in Kenya using data from the 2018 Kenya Household Health Expenditure and Utilization Survey. We applied the generalized estimating equations method to determine the best subset of predictors of outpatient care cost. Findings: The best predictors of outpatient care expenses in Kenya are age, wealth index, and education level of the household head. Conclusions: There were no differences regarding age in the mean spending on outpatient care. Moreover, we found that the cost of outpatient care changes with age in a sinusoidal manner. We observed that rich households spent more on outpatient care, mostly owing to their financial ability. Households whose heads reported primary or secondary school education level spent less on outpatient costs than households headed by those who never went to school.

Longitudinal-Survival Models for Case-Based Tuberculosis Progression.

Introduction: Tuberculosis (TB) disease continues to be responsible for a high global burden with an estimated 10 million people falling ill each year and an estimated 1.45 million deaths. Widely carried out analyses to utilize routine data coming from this disease, and well-established in literature, have paid attention to time-to-event with sputum smear results being considered only at baseline or even ignored. Also, logistic regression models have been used to demonstrate importance of sputum smear results in patient outcomes. A feature presented by this disease, however, is that each individual patient is usually followed over a period of time with sputum smear results being documented at different points of the treatment curve. This provides both repeated measures and survival times, which may require a joint modeling approach. This study aimed to investigate the association between sputum smear results and the risk of experiencing unfavorable outcome among TB patients and dynamically predict survival probabilities. Method: A joint model for longitudinal and time-to-event data was used to analyze longitudinally measured smear test results with time to experiencing unfavorable outcome for TB patients. A generalized linear mixed-effects model was specified for the longitudinal submodel and cox proportional hazards model for the time-to-event submodel with baseline hazard approximated using penalized B-splines. The two submodels were then assumed to be related via the current value association structure. Bayesian approach was used to approximate parameter estimates using Markov Chain Monte Carlo (MCMC) algorithm. The obtained joint model was used to predict the subject's future risk of survival based on sputum smear results trajectories. Data were sourced from routinely collected TB data stored at National TB Program database. Results: The average baseline age was 35 (SD: 15). Female TB patients constituted 36.42%. Patients with previous history of TB treatment constituted 6.38% (event: 15.25%; no event: 5.29%). TB/HIV co-infection was at 31.23% (event: 47.87%; no event: 29.20%). The association parameter 1.03 (CI[1.03,1.04]) was found to be positive and significantly different from zero, interpreted as follows: The estimate of the association parameter α = 1.033 denoted the log hazard ratio for a unit increase in the log odds of having smear positive results. HIV status (negative) 0.47 (CI [0.46,49]) and history of TB treatment (previously treated) (2.52 CI [2.41,2.63]), sex (female) (0.82 CI [0.78,0.84]), and body mass index (BMI) categories (severe malnutrition being reference) were shown to be statistically significant. Conclusion: Sputum smear result is important in estimating the risk to unfavorable outcome among TB patients. Men, previously treated, TB/HIV co-infected and severely malnourished TB patients are at higher risk of unfavorable outcomes.

Skewed logit model for analyzing correlated infant morbidity data.

BACKGROUND: Infant morbidity is a topic of interest because it is used globally as an indicator of the status of health care in a country. A large body of evidence supports an association between bacterial vaginosis (BV) and infant morbidity. When estimating the relationship between the predictors and the estimated variable of morbidity severity, the latter exhibits imbalanced data, which means that violation of symmetry is expected. Two competing methods of analysis, that is, (1) probit and (2) logit techniques, can be considered in this context and have been applied to model such outcomes. However, these models may yield inconsistent results. While non-normal modeling approaches have been embraced in the recent past, the skewed logit model has been given little attention. In this study, we exemplify its usefulness in analyzing imbalanced longitudinal responses data. METHODOLOGY: While numerous non-normal methods for modeling binomial responses are well established, there is a need for comparison studies to assess their usefulness in different scenarios, especially under a longitudinal setting. This is addressed in this study. We use a dataset from Kenya about infants born to human immunodeficiency virus (HIV) positive mothers, who are also screened for BV. We aimed to investigate the effect of BV on infant morbidity across time. We derived a score for morbidity incidences depending on illnesses reported during the month of reference. By adjusting for the mother's BV status, the child's HIV status, sex, feeding status, and weight for age, we estimated the standard binary logit and skewed logit models, both using Generalized Estimating Equations. RESULTS: Results show that accounting for skewness in imbalanced binary data can show associations between variables in line with expectations documented by the literature. In addition, an in-depth analysis accounting for skewness has shown that, over time, maternal BV is associated with multiple health conditions in infants. INTERPRETATION: Maternal BV status was positively associated with infant morbidity incidences, which highlights the need for early intervention in cases of HIV-infected pregnant women.

Limonoids as larvicidal components against mosquito larvae (Aedes aegypti Linn.).

The study focussed on four limonoids (calodendrolide, harrisonin, pedonin and pyroangolensolide) as larvicidal components against mosquito 2nd instar larvae of the species Aedes aegypti Linn. senso stricto. Since pyroangolensolide is close to calodendrolide in structure, it was synthesized through reduction of calodendrolide with chromium(II) chloride in acetone. Harrisonin and pedonin were extracted with cold methanol from the root bark of Harrisonia abyssinica while calodendrolide was extracted with the same solvent from the root bark of Calodendrum capense. The structure of pyroangolensolide was elucidated using physical and spectroscopic techniques. 25, 50, 75, and 100 microM of each compound were tested against the mosquito larvae. Calodendrolide was the most toxic since 100% mortality was registered at all concentrations, while pyroangolensolide showed 100% mortality up to 50 microM and for contents of 25 microM, a mortality of 70% was registered. As a result of this toxicity, lower concentrations (5, 10 and 15 microM) were tested for both calodendrolide and pyroangolensolide. Toxicity of harrisonin and pedonin was lower. The relative toxicity was in the order: calodendrolide > pyroangolensolide > harrisonin > pedonin with LC50 values of 13.2, 16.6, 28.1 and 59.2 microM, respectively.