Association between household food security and infant feeding practices in urban informal settlements in Nairobi, Kenya.

Studies in urban informal settlements show widespread inappropriate infant and young child feeding (IYCF) practices and high rates of food insecurity. This study assessed the association between household food security and IYCF practices in two urban informal settlements in Nairobi, Kenya. The study adopted a longitudinal design that involved a census sample of 1110 children less than 12 months of age and their mothers aged between 12 and 49 years. A questionnaire was used to collect information on: IYCF practices and household food security. Logistic regression was used to determine the association between food insecurity and IYFC practices. The findings showed high household food insecurity; only 19.5% of the households were food secure based on Household Insecurity Access Score. Infant feeding practices were inappropriate: 76% attained minimum meal frequency; 41% of the children attained a minimum dietary diversity; and 27% attained minimum acceptable diet. With the exception of the minimum meal frequency, infants living in food secure households were significantly more likely to achieve appropriate infant feeding practices than those in food insecure households: minimum meal frequency (adjusted odds ratio (AOR)=1.26, P=0.530); minimum dietary diversity (AOR=1.84, P=0.046) and minimum acceptable diet (AOR=2.35, P=0.008). The study adds to the existing body of knowledge by demonstrating an association between household food security and infant feeding practices in low-income settings. The findings imply that interventions aimed at improving infant feeding practices and ultimately nutritional status need to also focus on improving household food security.

Microscopy and outpatient malaria case management among older children and adults in Kenya.

OBJECTIVE: To evaluate the accuracy of routine malaria microscopy, and appropriate use and interpretation of malaria slides under operational conditions in Kenya. METHODS: Cross-sectional survey, using a range of quality of care assessment tools, at government facilities with malaria microscopy in two Kenyan districts of different intensity of malaria transmission. All patients older than 5 years presenting to outpatient departments were enrolled. Two expert microscopists assessed the accuracy of the routine malaria slide results. RESULTS: We analysed 359 consultations performed by 31 clinicians at 17 facilities. Clinical assessment was suboptimal. Blood slide microscopy was performed for 72.7% of patients, who represented 78.5% of febrile patients and 51.3% of afebrile patients. About 95.5% of patients with a positive malaria microscopy result and 79.3% of patients with a negative result received antimalarial treatment. Sulphadoxine-pyremethamine monotherapy was more commonly prescribed for patients with a negative test result (60.7%) than for patients with a positive result (32.4%). Conversely, amodiaquine or quinine were prescribed for only 14.7% of patients with a negative malaria microscopy result compared to 57.7% of patients with a positive result. The prevalence of confirmed malaria was low in both high (10.0%) and low-(16.3%) transmission settings. Combining data from both settings, the sensitivity of routine microscopy was 68.6%; its specificity, 61.5%; its positive predictive value, 21.6% and its negative predictive value, 92.7%. CONCLUSIONS: The potential benefits of microscopy are currently not realised because of the poor quality of routine testing and irrational clinical practices. Ambiguous clinical guidelines permitting treatment of older children and adults with a negative blood slide also undermine rational use of antimalarial drugs.

Predictors of the quality of health worker treatment practices for uncomplicated malaria at government health facilities in Kenya.

BACKGROUND: When replacing failing drugs for malaria with more effective drugs, an important step towards reducing the malaria burden is that health workers (HW) prescribe drugs according to evidence-based guidelines. Past studies have shown that HW commonly do not follow guidelines, yet few studies have explored with appropriate methods why such practices occur. METHODS: We analysed data from a survey of government health facilities in four Kenyan districts in which HW consultations were observed, caretakers and HW were interviewed, and health facility assessments were performed. The analysis was limited to children 2-59 months old with uncomplicated malaria. Treatment was defined as recommended (antimalarial recommended by national guidelines), a minor error (effective, but non-recommended antimalarial), or inappropriate (no effective antimalarial). RESULTS: We evaluated 1006 consultations performed by 135 HW at 81 facilities: 567 children received recommended treatment, 314 had minor errors, and 125 received inappropriate treatment (weighted percentages: 56.9%, 30.4%, and 12.7%). Multivariate logistic regression analysis revealed that programmatic interventions such as in-service malaria training, provision of guidelines and wall charts, and more frequent supervision were significantly associated with better treatment quality. However, neither in-service training nor possession of the guideline document showed an effect by itself. More qualified HW made more errors: both major and minor errors (but generally more minor errors) when second-line drugs were in stock, and more major errors when second-line drugs were not in stock. Child factors such as age and a main complaint of fever were also associated with treatment quality. CONCLUSIONS: Our results support the use of several programmatic strategies that can redress HW deficiencies in malaria treatment. Targeted cost-effectiveness trials would help refine these strategies and provide more precise guidance on affordable and effective ways to strengthen and maintain HW practices.

Use of intermittent presumptive treatment and insecticide treated bed nets by pregnant women in four Kenyan districts.

The roll back malaria (RBM) movement promotes the use of insecticide-treated bednets (ITNs) and intermittent presumptive treatment (IPT) of malaria infection as preventive measures against the adverse effects of malaria among pregnant women in Africa. To determine the use of these preventive measures we undertook a community-based survey of recently pregnant women randomly selected from communities in four districts of Kenya in December 2001. Of the 1814 women surveyed, only 5% had slept under an ITN. More than half of the 13% of women using a bednet (treated or untreated) had bought their nets from shops or markets. Women from rural areas used bednets less than urban women (11% vs. 27%; P < 0.001), and 41% of the bednets used by rural women had been obtained free of charge from a research project in Bondo or a nationwide UNICEF donation through antenatal clinics (ANCs). Despite 96% of ANC providers being aware of IPT with sulphadoxine-pyrimethamine (SP), only 5% of women interviewed had received two or more doses of SP as a presumptive treatment. The coverage of pregnant women with at least one dose of IPT with SP was 14%, though a similar percentage also had received at least a single dose as a curative treatment. The coverage of nationally recommended strategies to prevent malaria during pregnancy during 2001 was low across the diverse malaria ecology of Kenya. Rapid expansion of access to these services is required to meet international and national targets by the year 2005. The scaling up of malaria prevention programmes through ANC services should be possible with 74% of women visiting ANCs at least twice in all four districts. Issues of commodity supply and service costs to clients will be the greatest impediments to reaching RBM targets.

Defining equity in physical access to clinical services using geographical information systems as part of malaria planning and monitoring in Kenya.

Distance is a crucial feature of health service use and yet its application and utility to health care planning have not been well explored, particularly in the light of large-scale international and national efforts such as Roll Back Malaria. We have developed a high-resolution map of population-to-service access in four districts of Kenya. Theoretical physical access, based upon national targets, developed as part of the Kenyan health sector reform agenda, was compared with actual health service usage data among 1668 paediatric patients attending 81 sampled government health facilities. Actual and theoretical use were highly correlated. Patients in the larger districts of Kwale and Makueni, where access to government health facilities was relatively poor, travelled greater mean distances than those in Greater Kisii and Bondo. More than 60% of the patients in the four districts attended health facilities within a 5-km range. Interpolated physical access surfaces across districts highlighted areas of poor access and large differences between urban and rural settings. Users from rural communities travelled greater distances to health facilities than those in urban communities. The implications of planning and monitoring equitable delivery of clinical services at national and international levels are discussed.

Treatment of malaria tropica with a fixed combination of rifampicin, co-trimoxazole and isoniazid: a clinical study.

The treatment of malaria tropica is becoming difficult because of the increasing drug resistance rates of Plasmodium falciparum against several of the currently available antimalarias. A fixed combination of rifampicin, co-trimoxazole and isoniazid (CotrifazidTM, CF) was found to be highly effective for the treatment of malaria tropica. The aim of the present study in Kenya was to scrutinize this finding in a 14-day trial. Patients with malaria tropica were given in an open, double-arm randomized study CF for 5 days, or chloroquine or pyrimethamine/sulphadoxine as the control. Because of an apparently better activity and tolerance of CF, the randomization had to be stopped after the enrollment of 50 patients. A total of 61 patients in both groups (35 of them between 2 months and 6 years of age) were available for final analysis. All 41 patients treated with CF, originally positive in their blood smears, turned negative; in 2 cases blood smear positivity reappeared on day 14. There were 7 failures in the control group, 4 of them a primary one. Four of those failures were turned negative with CF, 2 failed with CF also, and 1 disappeared. The tolerance of CF was excellent even in infants. In our experience, CF is very well suited for the treatment of malaria tropica, also in cases of apparent drug resistance of P. falciparum against other antimalarials, and even in severe cases of the disease.