The readiness of malaria services and uptake of intermittent preventive treatment in pregnancy in six sub-Saharan countries.

Background: Malaria infection during pregnancy is associated with an increased risk of maternal death, as well as adverse birth outcomes. Intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) is known to improve pregnancy outcomes. However, the coverage of IPTp-SP in antenatal care (ANC) in sub-Saharan Africa remains well below the target. This study aims to estimate to what extent malaria service readiness affects the uptake of IPTp-SP during ANC visits in sub-Saharan African countries. Methods: This study included 3267 pregnant women attending ANC for the first time and 2797 pregnant women who had attended ANC more than a month ago in six sub-Saharan African countries. The readiness of malaria services at each institution includes four indicators: the presence of IPTp-SP guidelines, SP availability, integration of IPTp-SP service into ANC, and provider training on IPTp-SP. The outcome variable indicates whether a pregnant woman received IPTp-SP at her current ANC visit. A modified Poisson regression model estimated the associations between malaria service readiness and IPTp-SP uptake for women eligible for the first and subsequent doses. Results: For women eligible for their first dose, visiting an institution with available SP was associated with an increased probability of receiving IPTp-SP (risk ratio (RR) = 1.43; 95% confidence interval (CI) = 1.22 to 1.67, P < 0.001). For women who were eligible for their next dose, the availability of SP (RR = 1.17; 95% CI = 1.04 to 1.32, P = 0.008) and integration of IPTp-SP service into ANC (RR = 1.82; 95% CI = 1.21 to 2.74, P = 0.004) in the institution were associated with increased likelihood of IPTp-SP uptake. Counterfactual predictions indicated that enhanced provider training could boost IPTp-SP uptake in high-uptake countries, while better SP availability and IPTp-SP integration into ANC would significantly impact low-uptake countries. Conclusions: For better IPTp-SP coverage, strategies should be customised. High uptake countries should focus on provider training, while low uptake ones should ensure IPTp-SP availability and service integration.

Perceptions on Adherence to Dietary Prescriptions for Adults with Chronic Kidney Disease on Hemodialysis: A Qualitative Study.

Diet is one of the modifiable lifestyle factors in management of kidney disease. We explored perceptions on adherence to dietary prescriptions for adults with chronic kidney disease on hemodialysis. This was a qualitative descriptive study. Participants were purposively selected at renal clinics/dialysis units at national referral hospitals in Kenya. Data were collected using in-depth interviews, note-taking and voice-recording. The data were managed and analyzed thematically in NVIV0-12 computer software. Study participants were 52 patients and 40 family caregivers (42 males and 50 females) aged 20 to 69 years. Six sub-themes emerged in this study: "perceived health benefits"; "ease in implementing prescribed diets"; "cost of prescribed renal diets"; "nutrition information and messages"; "transition to new diets" and "fear of complications/severity of disease". Both patients and caregivers acknowledged the health benefits of adherence to diet prescriptions. However, there are mixed messages to the patients and caregivers who have challenges with management and acceptability of the prescriptions. Most of them make un-informed dietary decisions that lead to consumption of unhealthy foods with negative outcomes such as metabolic waste accumulation in the patients' bodies negating the effects of dialysis and undermining the efforts of healthcare system in management of patients with chronic kidney disease.

Mothers' knowledge of mother-to-child transmission of HIV and infant feeding practices in Juba, South Sudan

Introduction: While exclusive breastfeeding for the first six months of life is recommended for HIV-infected mothers, this may not be practiced fully in South Sudan; exclusive formula feeding, which is the best alternative to breastfeeding, may not be practical. Objective: To assess the knowledge of mother-to-child transmission of HIV (MTCT) and practices of feeding infants in the first six months of life among HIV-infected mothers attending Antiretroviral Therapy Centres in Juba Teaching Hospital (JTH) and Juba Military Hospital (JMH). Method: A cross-sectional study in which 304 HIV-infected mothers with children aged 6-18 months were interviewed between October and December 2016 using structured questionnaires. Key informant interviews (KIIs) and focus group discussions (FGDs) were also conducted using interview guides. Quantitative data was analysed using Statistics Package for Social Sciences software. Chi-square test was used to test the presence of significant association between the variables and the association is statistically significant when the p-value is < 0.05. Multiple logistic regression analysis was used to identify which predictor variables have major effect on the dependent variable. Qualitative data was transcribed in English and summarized according to the key themes, and the information obtained was used to supplement and interpret the findings of the quantitative data. Results: Only 120 (40%) of the HIV-infected mothers had a good knowledge of MTCT; 213 mothers (70.1%) practiced mixed feeding, 70 (23.0%) practiced exclusive breastfeeding and 20 (6.6%) practiced exclusive formula feeding. The factors that were found to have a positive effect on choice of infant feeding methods were having more than one child (odds ratio = 0.303, 95% Confidence interval: 0.161-0.571, p = 0.001) and participation in the prevention of motherto-child transmission of HIV programme (PMTCT) (odds ratio = 2.260, 95% Confidence interval: 1.251-4.084, p = 0.007). Stigma (p = 0.248) and mothers' knowledge of MTCT (p = 0.072) were not statistically significantly associated with the mothers' infant feeding practices. Conclusion: Knowledge of MTCT is low. Mixed feeding before six months of age is predominant among the HIV-infected mothers. It is therefore recomm;ended that HIV-infected mothers receive adequate information from counsellors regarding MTCT and exclusive breastfeeding for the first six months of an infant's life

Perception of medical professionalism among the surgical community in the University of Nairobi: a mixed method study.

BACKGROUND: Professionalism defines the relationship between colleagues, patients and the society as a whole. Furthermore, being a social construct, professionalism is sophisticated to be regarded simply as a single concept across different cultural contexts. This study sought to explore how professionalism is conceptualized by the clinicians, students and patients in a teaching hospital in Kenya. METHODS: A sequential mixed methods study was conducted among clinicians, students and patients at Kenyatta National Hospital on the surgical wards from March 1(st)-December 31(st), 2014. The first phase of the study involved focus group discussions (FGDs) of between 10-12 persons and individual in-depth interviews of senior faculty and patients. Grounded theory method was used for collecting perceptions of participants on professionalism. These views were then coded using Atlas 5.2, allowing the development of a questionnaire that provided the survey tool for the second phase of the study. For the questionnaire, response options utilized a 4-point Likert scale with a range from "strongly agree" to "strongly disagree". Factor analysis was used to analyse the responses to the survey. Internal reliability was determined by Cronbach's α. RESULTS: Sixteen FGDs and 18 in-depth interviews were held with 204 clinicians, students and patients. A further 188 participants completed the questionnaire. Respect was the most frequently mentioned or picked component of professionalism during the interview and survey respectively, with 74.5 % of participants reporting "strongly agree". Factor analysis showed that 3 factors accounted for the majority of the variance in the items analysed; respect in practice, excellence in service and concern for the patient. The Cronbach's α for this analysis was 0.927. CONCLUSION: The study cohort predominantly conceptualizes professionalism as relating to respect between colleagues and toward patients. Respect, being a cultural norm, should form part of the core curriculum of professionalism in order to be relevant for the Kenyan context.

Young people's perception of sexual and reproductive health services in Kenya.

BACKGROUND: Addressing the Sexual and Reproductive Health (SRH) needs of young people remains a big challenge. This study explored experiences and perceptions of young people in Kenya aged 10-24 with regard to their SRH needs and whether these are met by the available healthcare services. METHODS: 18 focus group discussions and 39 in-depth interviews were conducted at health care facilities and youth centres across selected urban and rural settings in Kenya. All interviews were tape recorded and transcribed. Data was analysed using the thematic framework approach. RESULTS: Young people's perceptions are not uniform and show variation between boys and girls as well as for type of service delivery. Girls seeking antenatal care and family planning services at health facilities characterise the available services as good and staff as helpful. However, boys perceive services at health facilities as designed for women and children, and therefore feel uncomfortable seeking services. At youth centres, young people value the non-health benefits including availability of recreational facilities, prevention of idleness, building of confidence, improving interpersonal communication skills, vocational training and facilitation of career progression. CONCLUSION: Providing young people with SRH information and services through the existing healthcare system, presents an opportunity that should be further optimised. Providing recreational activities via youth centres is reported by young people themselves to not lead to increased uptake of SRH healthcare services. There is need for more research to evaluate how perceived non-health benefits young people do gain from youth centres could lead to improved SRH of young people.

Sexual reproductive health service provision to young people in Kenya; health service providers' experiences.

BACKGROUND: Addressing the sexual and reproductive health (SRH) needs of young people remains a challenge for most developing countries. This study explored the perceptions and experiences of Health Service Providers (HSP) in providing SRH services to young people in Kenya. METHODS: Qualitative study conducted in eight health facilities; five from Nairobi and three rural district hospitals in Laikipia, Meru Central, and Kirinyaga. Nineteen in-depth interviews (IDI) and two focus group discussions (FGD) were conducted with HSPs. Interviews were tape recorded and transcribed. Data was coded and analysed using the thematic framework approach. RESULTS: The majority of HSPs were aware of the youth friendly service (YFS) concept but not of the supporting national policies and guidelines. HSP felt they lacked competency in providing SRH services to young people especially regarding counselling and interpersonal communication. HSPs were conservative with regards to providing SRH services to young people particularly contraception. HSP reported being torn between personal feelings, cultural and religious values and beliefs and their wish to respect young people's rights to accessing and obtaining SRH services. CONCLUSION: Supporting youth friendly policies and competency based training of HSP are two common approaches used to improve SRH services for adolescents. However, these may not be sufficient to change HSPs' attitude to adolescents seeking help. There is need to address the cultural, religious and traditional value systems that prevent HSPs from providing good quality and comprehensive SRH services to young people. Training updates should include sessions that enable HSPs to evaluate how their personal and cultural values and beliefs influence practice.

Study protocol for promoting respectful maternity care initiative to assess, measure and design interventions to reduce disrespect and abuse during childbirth in Kenya.

BACKGROUND: Increases in the proportion of facility-based deliveries have been marginal in many low-income countries in the African region. Preliminary clinical and anthropological evidence suggests that one major factor inhibiting pregnant women from delivering at facility is disrespectful and abusive treatment by health care providers in maternity units. Despite acknowledgement of this behavior by policy makers, program staff, civil society groups and community members, the problem appears to be widespread but prevalence is not well documented. Formative research will be undertaken to test the reliability and validity of a disrespect and abuse (D&A) construct and to then measure the prevalence of disrespect and abuse suffered by clinic clients and the general population. METHODS/DESIGN: A quasi-experimental design will be followed with surveys at twelve health facilities in four districts and one large maternity hospital in Nairobi and areas before and after the introduction of disrespect and abuse (D&A) interventions. The design is aimed to control for potential time dependent confounding on observed factors. DISCUSSION: This study seeks to conduct implementation research aimed at designing, testing, and evaluating an approach to significantly reduce disrespectful and abusive (D&A) care of women during labor and delivery in facilities. Specifically the proposed study aims to: (i) determine the manifestations, types and prevalence of D&A in childbirth (ii) develop and validate tools for assessing D&A (iii) identify and explore the potential drivers of D&A (iv) design, implement, monitor and evaluate the impact of one or more interventions to reduce D&A and (v) document and assess the dynamics of implementing interventions to reduce D&A and generate lessons for replication at scale.

A qualitative study of barriers to consistent condom use among HIV-1 serodiscordant couples in Kenya.

This study explored barriers to consistent condom use among heterosexual HIV-1 serodiscordant couples who were aware of the HIV-1 serodiscordant status and had been informed about condom use as a risk reduction strategy. We conducted 28 in-depth interviews and 9 focus group discussions among purposively selected heterosexual HIV-1 serodiscordant couples from Thika and Nairobi districts in Kenya. We analyzed the transcribed data with a grounded theory approach. The most common barriers to consistent condom use included male partners' reluctance to use condoms regardless of HIV-1 status coupled with female partners' inability to negotiate condom use, misconceptions about HIV-1 serodiscordance, and desire for children. Specific areas of focus should include development of skills for women to effectively negotiate condom use, ongoing information on HIV-1 serodiscordance and education on safer conception practices that minimize risk of HIV-1 transmission.

"Once I begin to participate, people will run away from me": understanding stigma as a barrier to HIV vaccine research participation in Kenya.

PURPOSE: Participation of volunteers in clinical research is essential to the development of effective HIV prevention methods, including an HIV vaccine. This study expands current knowledge of stigma and discrimination related to participation in HIV vaccine research in sub-Saharan Africa by exploring the perception of stigma and discrimination as a barrier to participation in HIV vaccine research in Kenya. METHODS: Eighteen focus groups with a total of 133 participants and 82 individual interviews were conducted with a range of respondents at two centers in Nairobi, Kenya: a preventive AIDS vaccine trial center; and a preparatory clinical and epidemiological study center. Respondents included peer leaders, community advisory board members, former and current volunteers in clinical research, study staff, community leaders and community members. Data were analyzed using an iterative coding process. RESULTS: Four prominent stigma-related barriers to participation emerged among all respondent groups, across both centers: (1) volunteers are often assumed by family and community members to be HIV positive because of their participation in vaccine research; (2) HIV-related stigma is perceived as pervasive and damaging in the communities where volunteers live, thus they fear consequent stigma if people believe them to be HIV positive; (3) potential volunteers fear being tested for HIV, a prerequisite for participation, because of possible disclosure of HIV status in communities with high perceived HIV-related stigma; and (4) volunteers must carefully manage information about their participation because of misperceptions and assumptions about vaccine research volunteers. CONCLUSIONS: HIV-related stigma and discrimination influence people's decisions to join HIV-vaccine related research. Findings underscore a need for integration of stigma-reduction programming into education and outreach activities for volunteers, and the communities in which they live. This is particularly critical for trials recruiting individuals with higher HIV risk, who are often already highly stigmatized.

Who is to blame? Perspectives of caregivers on barriers to accessing healthcare for the under-fives in Butere District, Western Kenya.

BACKGROUND: Kenya, like many developing nations, continues to experience high childhood mortality in spite of the many efforts put in place by governments and international bodies to curb it. This study sought to investigate the barriers to accessing healthcare services for children aged less than five years in Butere District, a rural district experiencing high rates of mortality and morbidity despite having relatively better conditions for child survival. METHODS: Exit interviews were conducted among caregivers seeking healthcare for their children in mid 2007 in all the 6 public health facilities. Additionally, views from caregivers in the community, health workers and district health managers were sought through focus group discussions (FGDs) and key informant interviews (KIs). RESULTS: Three hundred and ninety-seven respondents were surveyed in exit interviews while 45 respondents participated in FGDs and KIs. Some practices by caregivers including early onset of child bearing, early supplementation, and utilization of traditional healers were thought to increase the risk of mortality and morbidity, although reported rates of mosquito net utilization and immunization coverage were high. The healthcare system posed barriers to access of healthcare for the under fives, through long waiting time, lack of drugs and poor services, incompetence and perceived poor attitudes of the health workers. FGDs also revealed wide-spread concerns and misconceptions about health care among the caregivers. CONCLUSION: Caregivers' actions were thought to influence children's progression to illness or health while the healthcare delivery system posed recurrent barriers to the accessing of healthcare for the under-fives. Actions on both fronts are necessary to reduce childhood mortality.

Provider views on the acceptability of an IUD checklist screening tool.

INTRODUCTION: Family Health International developed a simple checklist to help family planning providers apply the new medical eligibility criteria (MEC) of the World Health Organization (WHO) for the use of the intrauterine device (IUD) contraceptive method. METHODS: One hundred thirty-five providers in four countries participated in focus groups to field test the checklist. Before participating in a discussion about the checklist, each provider was given a copy of the checklist, its instructions and hypothetical client scenarios. Providers used the checklist to answer questions about the client scenarios in order to determine if they understood the checklist and if they would correctly determine IUD eligibility for women in updated categories of eligibility on the basis of the checklist. RESULTS: Providers found the checklist easy to use and thought that it would enhance identification of eligible IUD users. Nevertheless, many providers relied on prior knowledge of IUD eligibility rather than the checklist recommendations. Providers only correctly determined eligibility for new categories of IUD use 69% of the time. CONCLUSIONS: The IUD checklist is a useful job tool for providers, but training and effective dissemination of the WHO MEC should precede its introduction to ensure that it is correctly used.

Evaluation of an emergency contraception introduction project in Kenya.

The Consortium for Emergency Contraception introduced Postinor-2, a progestin-only EC product, into Kenya as part of its work to expand access to EC in developing countries. Introduction activities included registering Postinor-2, training providers, and developing provider and client materials. We surveyed family planning clients and providers to assess the impact of these activities. Knowledge of EC among clients and providers improved between the baseline and evaluation surveys. More women and providers had heard of EC and more providers were distributing it. Support for access to EC in Kenya also improved. The results indicate, though, that further information is needed. Only one-fifth of women at the evaluation had heard of EC and almost half of the women expressed concerns about EC at baseline and evaluation. More research and experience using novel ways of informing women about EC in Africa is needed, and information needs to address women's concerns.