'Triangulating' AMPATH: demonstration of a multi-perspective strategic programme evaluation method.

Clinical programmes are typically evaluated on operational performance metrics of cost, quality and outcomes. Measures of patient satisfaction are used to assess the experience of receiving care, but other perspectives, including those of staff and communities, are not often sought or used to assess and improve programmes. For strategic planning, the Kenyan HIV/AIDS programme AMPATH (Academic Model Providing Access to Healthcare) sought to evaluate its performance in 2006. The method used for this evaluation was termed 'triangulation', because it used information from three different sources--patients, communities, and programme staff. From January to August 2006, Indiana University external evaluators and AMPATH staff gathered information on strengths, weaknesses and suggestions for improvement of AMPATH. Activities included in-depth key-informant semi-structured interviews of 26 AMPATH clinical and support staff, 56 patients at eight clinic sites, and seven village health dialogues (mabaraza) at five sublocations within the AMPATH catchment area. Data sources included field notes and transcripts of translated audio recordings, which were subjected to qualitative content analysis. Eighteen recommendations for programme improvement emerged, including ten from all three respondent perspectives. Three recommendations were cited by patients and in mabaraza, but not by staff. Triangulation uncovered improvement emphases that an internal assessment would miss. AMPATH and Kenyan Ministry of Health leadership have deliberated these recommendations and accelerated strategic change actions, including rural satellite programmes, collaboration with village-based workers, and door-to-door village-based screening and counselling.

Psychological distress symptoms of individuals seeking HIV-related psychosocial support in western Kenya.

While researchers in many western countries have documented the nature of psychological distress that is commonly present among individuals living with HIV, there has been virtually no research on the same topic among other high prevalence areas of the world, particularly in countries like Kenya. This study sought to document the nature of psychological distress among 397 individuals living with HIV in western Kenya and who were participating in psychosocial support groups in conjunction with their enrollment in HIV-related treatment. Psychological distress was assessed using the Brief Symptom Inventory (BSI), a 53-item self-report psychological inventory that asks individuals to recall symptoms experienced in the prior seven days. The levels of psychological distress in this sample were moderate with a substantial proportion of participants meeting the criteria that suggested a need for further psychiatric evaluation. Findings support the need for further assessments of the range and nature of psychological distress among the diverse communities of countries like Kenya and the need for greater attention to the inclusion of mental health services in the rapidly developing treatment and prevention programs in this region of the world.

Equitable treatment for HIV/AIDS clinical trial participants: a focus group study of patients, clinician researchers, and administrators in Western Kenya.

OBJECTIVES: To describe the concerns and priorities of key stakeholders in a developing country regarding ethical obligations held by researchers and perceptions of equity or "what is fair" for study participants in an HIV/AIDS clinical drug trial. DESIGN: Qualitative study with focus groups. SETTING: Teaching and referral hospital and rural health centre in Western Kenya. PARTICIPANTS: Potential HIV/AIDS clinical trial participants, clinician researchers, and administrators. RESULTS: Eighty nine individuals participated in a total of 11 focus groups over a four month period. The desire for continued drug therapy, most often life long, following an HIV/AIDS clinical trial was the most common priority expressed in all focus groups. Patients with and without HIV/AIDS also thought subsidizing of drug therapies and education were critical forms of compensation for clinical trial participation. Financial incentives were considered important primarily for purchasing drug therapy as well as obtaining food. Patients noted a concern for the potential mismanagement of any money offered. Clinician researchers and administrators felt strongly that researchers have a moral obligation to participants following a trial to provide continued drug therapy, adverse event monitoring, and primary care. Finally, clinician researchers and administrators stressed the need for thorough informed consent to avoid coercion of study participants. CONCLUSIONS: Kenyan patients, clinician researchers, and administrators believe that it would be unfair to stop antiretroviral therapy following an HIV/AIDS clinical trial and that researchers have a long term obligation to participants.

Unmet needs, beliefs and treatment-seeking for infertility among migrant Ghanaian women in the Netherlands.

Studies on infertility in the Netherlands have little information on migrant Ghanaian women, even though Ghanaians are the third largest migrant group in Amsterdam. An exploratory study on the unmet needs, attitudes, and beliefs of migrant Ghanaian women with infertility problems living in the Netherlands, and the kinds of treatment they sought was undertaken in 1999. Qualitative data were collected from 12 women with primary or secondary infertility through narratives and 20 key informant interviews. The women described seeking treatment for infertility in Ghana, the Netherlands and other European countries, included use of infertility drugs, surgery, donor insemination and in vitro fertilisation. Illegal migrant women are not entitled to treatment paid by the national health system, and being of low income they cannot afford to pay directly for this or to obtain private health insurance. Herbalists and spiritual healers in both Amsterdam and Ghana were regularly consulted, especially for their willingness to address the social and spiritual aspects of infertility. To produce a pregnancy where male infertility was suspected, transfer of sexual rights to another man in the husband/partner's family, or a healer or priest, was a practical remedy that kept male infertility hidden. This study revealed difficulties experienced in clinical settings due to language barriers and cultural differences. Ghanaian women living in the Netherlands need much more information on the causes of infertility and their options.