Antenatal care and pregnancy outcomes in a safe motherhood health voucher system in rural Kenya, 2007-2013.

SETTING: A rural private health facility, Ruby Medical Centre (RMC), participating in a safe motherhood health voucher system for poor women in Kiambu County, Kenya. OBJECTIVES: Between 2007 and 2013, to determine 1) the number of women who delivered at the RMC, their characteristics and pregnancy-related outcomes, and 2) the number of women who received an incomplete antenatal care (ANC) package and associated factors. DESIGN: Retrospective cross-sectional study using routine programme data. RESULTS: During the study period, 2635 women delivered at the RMC: 50% were aged 16-24 years, 60% transferred in from other facilities and 59% started ANC in the third trimester of pregnancy. Of the 2635 women, 1793 (68%) received an incomplete ANC package: 347 (13%) missed essential blood tests, 312 (12%) missed the tetanus toxoid immunisation and 1672 (65%) had fewer than four visits. Presenting late and starting ANC elsewhere were associated with an incomplete package. One pregnancy-related mortality occurred; the stillbirth rate was 10 per 1000 births. CONCLUSION: This first assessment of the health voucher system in rural Kenya showed problems in ANC quality. Despite favourable pregnancy-related outcomes, increased efforts should be made to ensure earlier presentation of pregnant women, comprehensive ANC, and more consistent and accurate monitoring of reproductive indicators and interventions

Informal task-sharing practices in inpatient newborn settings in a low-income setting-A task analysis approach.

Aim To describe the complexity and criticality of neonatal nursing tasks and existing task‐sharing practices to identify tasks that might be safely shared in inpatient neonatal settings. Design We conducted a cross‐sectional study in a large geographically dispersed sample using the STROBE guidelines. Methods We used a task analysis approach to describe the complexity/criticality of neonatal nursing tasks and to explore the nature of task sharing using data from structured, self‐administered questionnaires. Data was collected between 26th April and 22nd August 2017. Results Thirty‐two facilities were surveyed between 26th April and 22nd August, 2017. Nearly half (42%, 6/14) of the “moderately critical” and “not critical” (41%, 5/11) tasks were ranked as consuming most of the nurses' time and reported as shared with mothers respectively. Most tasks were reported as shared in the public sector than in the private‐not‐for‐profit facilities. This may largely be a response to inadequate nurse staffing, as such, there may be space for considering the future role of health care assistants

Exploring the complex realities of nursing work in Kenya and how this shapes role enactment and practice-A qualitative study.

AIM: We explore how nurses navigate competing work demands in resource-constrained settings and how this shapes the enactment of nursing roles. DESIGN: An exploratory-descriptive qualitative study. METHODS: Using individual in-depth interviews and small group interviews, we interviewed 47 purposively selected nurses and nurse managers. We also conducted 57 hours of non-participant structured observations of nursing work in three public hospitals. RESULTS: Three major themes arose: (i) Rationalization of prioritization decisions, where nurses described prioritizing technical nursing tasks over routine bedside care, coming up with their own 'working standards' of care and nurses informally delegating tasks to cope with work demands. (ii) Bundling of tasks describes how nurses were sometimes engaged in tasks seen to be out of their scope of work or sometimes being used to fill for other professional shortages. (iii) Pursuit of professional ideals describes how the reality of how nursing was practised was seen to be in contrast with nurses' quest for professionalism

Effective coverage and budget implications of skill-mix change to improve neonatal nursing care: an explorative simulation study in Kenya

Introduction Neonatal mortality is an urgent policy priority to improve global population health and reduce health inequality. As health systems in Kenya and elsewhere seek to tackle increased neonatal mortality by improving the quality of care, one option is to train and employ neonatal healthcare assistants (NHCAs) to support professional nurses by taking up low-skill tasks.Methods Monte-Carlo simulation was performed to estimate the potential impact of introducing NHCAs in neonatal nursing care in four public hospitals in Nairobi on effectively treated newborns and staff costs over a period of 10 years. The simulation was informed by data from 3 workshops with >10 stakeholders each, hospital records and scientific literature. Two univariate sensitivity analyses were performed to further address uncertainty.Results Stakeholders perceived that 49% of a nurse full-time equivalent could be safely delegated to NHCAs in standard care, 31% in intermediate care and 20% in intensive care. A skill-mix with nurses and NHCAs would require ~2.6 billionKenyan Shillings (KES) (US$26 million) to provide quality care to 58$61 million) to provide quality of care to almost all newborns in need over 10 years.Conclusion Changing skill-mix in hospital care by introducing NHCAs may be an affordable way to reduce neonatal mortality in low/middle-income countries. This option should be considered in ongoing policy discussions and supported by further evidence

Developing metrics for nursing quality of care for low- and middle-income countries: a scoping review linked to stakeholder engagement.

BACKGROUND:The use of appropriate and relevant nurse-sensitive indicators provides an opportunity to demonstrate the unique contributions of nurses to patient outcomes. The aim of this work was to develop relevant metrics to assess the quality of nursing care in low- and middle-income countries (LMICs) where they are scarce. MAIN BODY:We conducted a scoping review using EMBASE, CINAHL and MEDLINE databases of studies published in English focused on quality nursing care and with identified measurement methods. Indicators identified were reviewed by a diverse panel of nursing stakeholders in Kenya to develop a contextually appropriate set of nurse-sensitive indicators for Kenyan hospitals specific to the five major inpatient disciplines. We extracted data on study characteristics, nursing indicators reported, location and the tools used. A total of 23 articles quantifying the quality of nursing care services met the inclusion criteria. All studies identified were from high-income countries. Pooled together, 159 indicators were reported in the reviewed studies with 25 identified as the most commonly reported. Through the stakeholder consultative process, 52 nurse-sensitive indicators were recommended for Kenyan hospitals. CONCLUSIONS:Although nurse-sensitive indicators are increasingly used in high-income countries to improve quality of care, there is a wide heterogeneity in the way indicators are defined and interpreted. Whilst some indicators were regarded as useful by a Kenyan expert panel, contextual differences prompted them to recommend additional new indicators to improve the evaluations of nursing care provision in Kenyan hospitals and potentially similar LMIC settings. Taken forward through implementation, refinement and adaptation, the proposed indicators could be more standardised and may provide a common base to establish national or regional professional learning networks with the common goal of achieving high-quality care through quality improvement and learning

Nursing knowledge of essential maternal and newborn care in a high‐mortality urban African setting: A cross‐sectional study

Aims To assess the knowledge of nurses of national guidelines for emergency maternity, routine newborn and small and sick newborn care in Nairobi County, Kenya. Background The vast majority of women deliver in a health facility in Nairobi. Yet, maternal and neonatal mortality remain high. Ensuring competency of health workers, in providing essential maternal and newborn interventions in health facilities will be key if further progress is to be made in reducing maternal and neonatal mortality in low‐resource settings. Design Cross‐sectional survey. Methods Questionnaires comprised of clinical vignettes and direct questions and were administered in 2015–2016 to nurses (n = 125 in 31 facilities) on duty in maternity and newborn units in public and private facilities providing 24/7 inpatient neonatal services. Composite knowledge scores were calculated and presented as weighted means. Associations were explored using regression. STROBE guidelines were followed. Results Nurses scored best for knowledge on active management of the mother after birth and immediate routine newborn care. Performance was worst for questions on infant resuscitation, checking signs and symptoms of sick newborns, and managing hypertension in pregnancy. Overall knowledge of care for sick newborns was particularly low (score 0.62 of 1). Across all areas assessed, nurses who had received training since qualifying performed better than those who had not. Poorly resourced and low case‐load facilities had lower average knowledge scores compared with better‐resourced and busier facilities. Conclusion Overall, we estimate that 31% of maternity patients, 3% of newborns and 39% of small and sick newborns are being cared for in an environment where nursing knowledge is very low (score <0.6). Relevance to clinical practice Focus on periodic training, ensuring retention of knowledge and skills among health workers in low‐case load setting, and bridging the know‐do gap may help to improve the quality of care delivered to mothers and newborns in Kenya

Quantifying nursing care delivered in Kenyan newborn units: protocol for a cross-sectional direct observational study

In many African countries, including Kenya, a major barrier to achieving child survival goals is the slow decline in neonatal mortality that now represents 45% of the under-5 mortality. In newborn care, nurses are the primary caregivers in newborn settings and are essential in the delivery of safe and effective care. However, due to high patient workloads and limited resources, nurses may often consciously or unconsciously prioritise the care they provide resulting in some tasks being left undone or partially done (missed care). Missed care has been associated with poor patient outcomes in high-income countries. However, missed care, examined by direct observation, has not previously been the subject of research in low/middle-income countries.The aim of this study is to quantify essential neonatal nursing care provided to newborns within newborn units. We will undertake a cross-sectional study using direct observational methods within newborn units in six health facilities in Nairobi City County across the public, private-for-profit and private-not-for-profit sectors. A total of 216 newborns will be observed between 1 September 2017 and 30 May 2018. Stratified random sampling will be used to select random 12-hour observation periods while purposive sampling will be used to identify newborns for direct observation. We will report the overall prevalence of care left undone, the common tasks that are left undone and describe any sharing of tasks with people not formally qualified to provide care.Ethical approval for this study has been granted by the Kenya Medical Research Institute Scientific and Ethics Review Unit. Written informed consent will be sought from mothers and nurses. Findings from this work will be shared with the participating hospitals, an expert advisory group that comprises members involved in policy-making and more widely to the international community through conferences and peer-reviewed journals

Risk factors for death among children aged 5-14 years hospitalised with pneumonia: a retrospective cohort study in Kenya

Introduction:There were almost 1 million deaths in children aged between 5 and 14 years in 2017, and pneumonia accounted for 11%. However, there are no validated guidelines for pneumonia management in older children and data to support their development are limited. We sought to understand risk factors for mortality among children aged 5-14 years hospitalised with pneumonia in district-level health facilities in Kenya. Methods:We did a retrospective cohort study using data collected from an established clinical information network of 13 hospitals. We reviewed records for children aged 5-14 years admitted with pneumonia between 1 March 2014 and 28 February 2018. Individual clinical signs were examined for association with inpatient mortality using logistic regression. We used existing WHO criteria (intended for under 5s) to define levels of severity and examined their performance in identifying those at increased risk of death. Results:1832 children were diagnosed with pneumonia and 145 (7.9%) died. Severe pallor was strongly associated with mortality (adjusted OR (aOR) 8.06, 95% CI 4.72 to 13.75) as were reduced consciousness, mild/moderate pallor, central cyanosis and older age (>9 years) (aOR >2). Comorbidities HIV and severe acute malnutrition were also associated with death (aOR 2.31, 95% CI 1.39 to 3.84 and aOR 1.89, 95% CI 1.12 to 3.21, respectively). The presence of clinical characteristics used by WHO to define severe pneumonia was associated with death in univariate analysis (OR 2.69). However, this combination of clinical characteristics was poor in discriminating those at risk of death (sensitivity: 0.56, specificity: 0.68, and area under the curve: 0.62). Conclusion:Children >5 years have high inpatient pneumonia mortality. These findings also suggest that the WHO criteria for classification of severity for children under 5 years do not appear to be a valid tool for risk assessment in this older age group, indicating the urgent need for evidence-based clinical guidelines for this neglected population

Examining the absorption of post-internship medical officers into the public sector at county-level in devolved Kenya: a qualitative case study

Availability of data and materials: All data relevant to the study are included in the article.A Correction to this article was published on 05 September 2023. This article has been updated. Change history: 05 September 2023A. Correction to this paper has been published: https://doi.org/10.1186/s12913-023-09992-6: Following publication of the original article [1], the authors identified errors in the affiliation assignment, caused by a typesetting mistake: affiliation 3 (instead of affiliation 2) was incorrectly assigned to Mike English as a second affiliation. This error is corrected in the affiliations list of this Correction article and the original article [1] has been updated.Background: After Kenya’s decentralization and constitutional changes in 2013, 47 devolved county governments are responsible for workforce planning and recruitment including for doctors/medical officers (MO). Data from the Ministry of Health suggested that less than half of these MOs are being absorbed by the public sector between 2015 and 2018. We aimed to examine how post-internship MOs are absorbed into the public sector at the county-level, as part of a broader project focusing on Kenya’s human resources for health. Methods: We employed a qualitative case study design informed by a simplified health labour market framework. Data included interviews with 30 MOs who finished their internship after 2018, 10 consultants who have supervised MOs, and 51 county/sub-county-level managers who are involved in MOs’ planning and recruitment. A thematic analysis approach was used to examine recruitment processes, outcomes as well as perceived demand and supply. Results: We found that Kenya has a large mismatch between supply and demand for MOs. An increasing number of medical schools are offering training in medicine while the demand for MOs in the county-level public sector has not been increasing at the same pace due to fiscal resource constraints and preference for other workforce cadres. The local Department of Health put in requests and participate in interviews but do not lead the recruitment process and respondents suggested that it can be subject to political interference and corruption. The imbalance of supply and demand is leading to unemployment, underemployment and migration of post-internship MOs with further impacts on MOs’ wages and contract conditions, especially in the private sector. Conclusion: The mismatched supply and demand of MO accompanied by problematic recruitment processes led to many MOs not being absorbed by the public sector and subsequent unemployment and underemployment. Although Kenya has ambitious workforce norms, it may need to take a more pragmatic approach and initiate constructive policy dialogue with stakeholders spanning the education, public and private health sectors to better align MO training, recruitment and management.YZ is supported by the University of Oxford Clarendon Fund Scholarship, an Oxford Travel Abroad Bursary and a Keble Association grant. ME is supported by a Wellcome Trust Senior Research Fellowship (#207522). CN receives funding from the Economic and Social Research Council [grant number ES/T008415/1] and from the National Institute for Health Research Applied Research Collaboration Oxford and Thames Valley at Oxford Health NHS Foundation Trust

How do foundation year and internship experience shape doctors’ career intentions and decisions? A meta-ethnography

Supplemental material is available at: https://www.tandfonline.com/doi/full/10.1080/0142159X.2022.2106839# .Correction Statement: This article has been corrected with minor changes. These changes do not impact the academic content of the article.Purpose: Foundation years or internships are an important period for junior doctors to apply their knowledge and gain clinical competency. Experiences gained during the foundation years or internships are likely to inform newly qualified doctors’ opinions about how they want to continue their career. We aimed to understand how medical doctors’ internship experiences influence their career intention/decision. Methods: We conducted qualitative evidence synthesis using meta-ethnography. We searched six electronic bibliographic databases for papers published between 2000–2020 and included papers exploring how foundation years or internship experiences shape doctors’ career intention/decisions, including in relation to migration, public/private/dual practice preference, rural/urban preference, and specialty choice. We used the GRADE-CERQual framework to rate confidence in review findings. Results: We examined 23 papers out of 6085 citations screened. We abstracted three high-level inter-related themes across 14 conceptual categories: (1) Deciding the personal best fit both clinically and in general (which option is ‘more me’?) through hands-on and real-life experiences (2) Exploring, experiencing and witnessing workplace norms; and (3) Worrying about the future in terms of job market policies, future training and professional development opportunities. Confidence in findings varied but was rated high in 8 conceptual categories. Conclusions: Our meta-ethnographic review revealed a range of ways in which internship experience shapes medical doctors’ career intentions/decisions allowing us to produce a broad conceptual model of this phenomenon. The results highlight the importance of ensuring sufficient, positive and inspiring clinical exposure, improving workplace environment, relationship and culture, refraining from undermining specific specialities and communicating contractual and job market policies early on to young doctors, in order to attract doctors to less popular specialties or work locations where they are most needed. We propose our conceptual model should be further tested in new research across a range of contexts.YZ is supported by the University of Oxford Clarendon Fund Scholarship. ME is supported by a Wellcome Trust Senior Research Fellowship [#207522]. CN receives funding from the Economic and Social Research Council [grant number ES/T008415/1] and from the National Institute for Health Research Applied Research Collaboration Oxford and Thames Valley at Oxford Health NHS Foundation Trust