Predictors of post-partum family planning uptake in Webuye Hospital, western Kenya

Background: A short inter-pregnancy interval increases the risk for maternal and neonatal deaths in addition to other pregnancy complications including: preterm delivery, low birth weight, anaemia and premature rupture of membranes. However, only one half of Kenyan women, who have no desire to conceive immediately after birth, are using contraception one year after delivery.   Aim: The aim of this study was to determine the predictors of uptake of post-partum family planning (PPFP).   Setting: The study was conducted among post-partum women accompanying their children for their first measles vaccination at Webuye County Hospital (WCH), in western Kenya.   Methods: This was a cross-sectional study involving 259 randomly sampled post-partum women, accompanying their children for their first measles vaccination. A structured, interviewer-administered questionnaire was used to collect data. Logistic regression was used to identify correlates of PPFP uptake.   Results: The uptake of PPFP among women at 9 months post-partum at WCH was found to be 78.4% ± 5.0%. The odds of PPFP uptake among women living with their sexual partners was 88.2% less than among those not living with their partners with the true population effect between 97% and 51% (OR = 0.118; 95% CI: 0.028–0.494; p = 0.003).   Conclusions: Not living with her sexual partner in the same house is the key predictor of a woman’s PPFP uptake in WCH. This study recommends that any programme aimed at improving post-partum contraceptive use in WCH should target women who live with their partners in the same house

Mitigating The Burden Of Diabetes In Sub-Saharan Africa Through An Integrated Diagonal Health Systems Approach

Diabetes is a chronic non-communicable disease (NCD) presenting growing health and economic burdens in sub-Saharan Africa (SSA). Diabetes is unique due to its cross-cutting nature, impacting multiple organ systems and increasing the risk for other communicable and non-communicable diseases. Unfortunately, the quality of care for diabetes in SSA is poor, largely due to a weak disease management framework and fragmented health systems in most sub-Saharan African countries. We argue that by synergizing disease-specific vertical programs with system-specific horizontal programs through an integrated disease-system diagonal approach, we can improve access, quality, and safety of diabetes care programs while also supporting other chronic diseases. We recommend utilizing the six World Health Organization (WHO) health system building blocks – 1) leadership and governance, 2) financing, 3) health workforce, 4) health information systems, 5) supply chains, and 6) service delivery – as a framework to design a diagonal approach with a focus on health system strengthening and integration to implement and scale quality diabetes care. We discuss the successes and challenges of this approach, outline opportunities for future care programming and research, and highlight how this approach can lead to the improvement in the quality of care for diabetes and other chronic diseases across SSA

Layering and scaling up chronic non-communicable disease care on existing HIV care systems and acute care settings in Kenya: a cost and budget impact analysis

Like many countries in sub-Saharan Africa, Kenya is experiencing a rapid rise in the burden of non-communicable diseases (NCDs): NCDs now contribute to over 50% of inpatient admissions and 40% of hospital deaths in the country. The Academic Model Providing Access to Healthcare (AMPATH) Chronic Disease Management (CDM) programme builds on lessons and capacity of HIV care to deliver chronic NCD care layered into both HIV and primary care platforms to over 24,000 patients across 69 health facilities in western Kenya. We conducted a cost and budget impact analysis of scaling up the AMPATH CDM programme in western Kenya using the International Society for Pharmacoeconomics and Outcomes Research guidelines.; Costs of the CDM programme for the health system were measured retrospectively for 69 AMPATH clinics from 2014 to 2018 using programmatic records and clinic schedules to assign per clinic monthly costs. We quantified the additional costs to provide NCD care above those associated with existing HIV or acute care services, including clinician, staff, training, travel and equipment costs, but do not include drugs or consumables as they would be paid by the patient. We projected the budget impact of increasing CDM coverage to 50% of the eligible population from 2021 to 2025, and compared it with the county budgets from 2019.; The per visit cost of providing CDM care was $10.42 (SD$2.26), with costs at facilities added to HIV clinics $1.00 (95$2:11 to $0.11) lower than at primary care facilities. The budget impact of adding 26,765 patients from 2021 to 2025 to the CDM programme was 3,088,928 under constant percent growth, and 3,451,732 under steady-state enrolment. Scaling up under the constant percent growth scenario resulted in 12% cost savings in the budget impact. The county programmatic CDM cost in 2025 was <1% of the county healthcare budgets from 2019.; The budget impact of scaling up AMPATH's CDM programme will be driven by annual growth scenarios, and facility/provider mix. By leveraging task shifting, referral systems and partnering with public and non-profit clinics without NCD services, AMPATH's CDM programme can provide critical NCD care to new, rural populations with minimal financial impact

Symptoms of depression among patients attending a diabetes care clinic in rural western Kenya

Objective: The prevalence of diabetes in sub-Saharan Africa is rising, but its relationship to depression is not well-characterized. This report describes depressive symptom prevalence and associations with adherence and outcomes among patients with diabetes in a rural, resource-constrained setting. Methods: In the Webuye, Kenya diabetes clinic, we conducted a chart review, analyzing data including medication adherence, hemoglobin A1c (HbA1c), clinic attendance, and PHQ-2 depression screening results. Results: Among 253 patients, 20.9% screened positive for depression. Prevalence in females was higher than in males; 27% vs 15% (p = 0.023). Glycemic control trends were better in those screening negative; at 24 months post-enrollment mean HbA1c was 7.5 for those screening negative and 9.5 for those screening positive (p = 0.0025). There was a nonsignificant (p = 0.269) trend toward loss to follow-up among those screening positive. Conclusions: These findings suggest that depression is common among people with diabetes in rural western Kenya, which may profoundly impact diabetes control and treatment adherence

The relationship between a microfinance-based healthcare delivery platform, health insurance coverage, health screenings, and disease management in rural Western Kenya

BACKGROUND: Structural barriers often prevent rural Kenyans from receiving healthcare and diagnostic testing. The Bridging Income Generation through grouP Integrated Care (BIGPIC) Family intervention facilitates microfinance groups, provides health screenings and treatment, and delivers education about health insurance coverage to address some of these barriers. This study evaluated the association between participation in BIGPIC microfinance groups and health screening/disease management outcomes. METHODS: From November 2018 to March 2019, we interviewed a sample of 300 members of two rural communities in Western Kenya, 100 of whom were BIGPIC microfinance members. We queried participants about their experiences with health screening and disease management for HIV, diabetes, hypertension, tuberculosis, and cervical cancer. We used log-binomial regression models to estimate the association between microfinance membership and each health outcome, adjusting for key covariates. RESULTS: Microfinance members were more likely to be screened for most of the health conditions we queried, including those provided by BIGPIC [e.g. diabetes: aPR (95% CI): 3.46 (2.60, 4.60)] and those not provided [e.g. cervical cancer: aPR (95% CI): 2.43 (1.21, 4.86)]. Microfinance membership was not significantly associated with health insurance uptake and disease management outcomes. CONCLUSIONS: In rural Kenya, a microfinance program integrated with healthcare delivery may be effective at increasing health screening. Interventions designed to thoughtfully and sustainably address structural barriers to healthcare will be critical to improving the health of those living in low-resource settings

Evaluation of malaria rapid diagnostic test (RDT) use by community health workers: a longitudinal study in western Kenya

Abstract Background Malaria rapid diagnostic tests (RDTs) are a simple, point-of-care technology that can improve the diagnosis and subsequent treatment of malaria. They are an increasingly common diagnostic tool, but concerns remain about their use by community health workers (CHWs). These concerns regard the long-term trends relating to infection prevention measures, the interpretation of test results and adherence to treatment protocols. This study assessed whether CHWs maintained their competency at conducting RDTs over a 12-month timeframe, and if this competency varied with specific CHW characteristics. Methods From June to September, 2015, CHWs (n = 271) were trained to conduct RDTs using a 3-day validated curriculum and a baseline assessment was completed. Between June and August, 2016, CHWs (n = 105) were randomly selected and recruited for follow-up assessments using a 20-step checklist that classified steps as relating to safety, accuracy, and treatment; 103 CHWs participated in follow-up assessments. Poisson regressions were used to test for associations between error count data at follow-up and Poisson regression models fit using generalized estimating equations were used to compare data across time-points. Results At both baseline and follow-up observations, at least 80% of CHWs correctly completed 17 of the 20 steps. CHWs being 50 years of age or older was associated with increased total errors and safety errors at baseline and follow-up. At follow-up, prior experience conducting RDTs was associated with fewer errors. Performance, as it related to the correct completion of all checklist steps and safety steps, did not decline over the 12 months and performance of accuracy steps improved (mean error ratio: 0.51; 95% CI 0.40–0.63). Visual interpretation of RDT results yielded a CHW sensitivity of 92.0% and a specificity of 97.3% when compared to interpretation by the research team. None of the characteristics investigated was found to be significantly associated with RDT interpretation. Conclusions With training, most CHWs performing RDTs maintain diagnostic testing competency over at least 12 months. CHWs generally perform RDTs safely and accurately interpret results. Younger age and prior experiences with RDTs were associated with better testing performance. Future research should investigate the mode by which CHW characteristics impact RDT procedures

How do malaria testing and treatment subsidies affect drug shop client expenditures? A cross-sectional analysis in Western Kenya

Objectives To examine how drug shop clients’ expenditures are affected by subsidies for malaria diagnostic testing and for malaria treatment, and also to examine how expenditures vary by clients’ malaria test result and by the number of medications they purchased.Design Secondary cross-sectional analysis of survey responses from a randomised controlled trial.Setting The study was conducted in twelve private drug shops in Western Kenya.Participants We surveyed 836 clients who visited the drug shops between March 2018 and October 2019 for a malaria-like illness. This included children &gt;1 year of age if they were physically present and accompanied by a parent or legal guardian.Interventions Subsidies for malaria diagnostic testing and for malaria treatment (conditional on a positive malaria test result).Primary and secondary outcome measures Expenditures at the drug shop in Kenya shillings (Ksh).Results Clients who were randomised to a 50% subsidy for malaria rapid diagnostic tests (RDTs) spent approximately Ksh23 less than those who were randomised to no RDT subsidy (95% CI (−34.6 to −10.7), p=0.002), which corresponds approximately to the value of the subsidy (Ksh20). However, clients randomised to receive free treatment (artemisinin combination therapies (ACTs)) if they tested positive for malaria had similar spending levels as those randomised to a 67% ACT subsidy conditional on a positive test. Expenditures were also similar by test result, however, those who tested positive for malaria bought more medications than those who tested negative for malaria while spending approximately Ksh15 less per medication (95% CI (−34.7 to 3.6), p=0.102).Conclusions Our results suggest that subsidies for diagnostic health products may result in larger household savings than subsidies on curative health products. A better understanding of how people adjust their behaviours and expenditures in response to subsidies could improve the design and implementation of subsidies for health products.Trial registration number NCT03810014

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Additional file 1. Information on missing CHW baseline data. Information pertaining to missing baseline data

Data from: Improving rational use of ACTs through diagnosis-dependent subsidies: evidence from a cluster-randomized controlled trial in western Kenya

Background: More than half of artemisinin combination therapies (ACTs) consumed globally are dispensed in the retail sector where diagnostic testing is uncommon, leading to overconsumption and poor targeting. In many malaria-endemic countries, ACTs sold over-the-counter are available at heavily subsidized prices, further contributing to their misuse. Inappropriate use of ACTs can have serious implications for the spread of drug resistance and leads to poor outcomes for non-malaria patients treated with incorrect drugs. We evaluated the public health impact of an innovative strategy that targets ACT subsidies to confirmed malaria cases by coupling free diagnostic testing with a diagnosis-dependent ACT subsidy. Methods and Findings: We conducted a cluster-randomized controlled trial in 32 community clusters in western Kenya (population ~160,000). Eligible clusters had retail outlets selling ACTs and existing community health worker (CHW) programs and were randomly assigned 1:1 to control and intervention arms. In intervention areas, CHWs were available in their villages to perform malaria rapid diagnostic tests on demand for any individual >1 year of age experiencing a malaria-like illness. Malaria RDT positive individuals received a voucher for a discount on a quality-assured ACT, redeemable at a participating retail medicine outlet. In control areas, CHWs offered a standard package of health education, prevention and referral services. We conducted four population-based surveys, at baseline, 6 months, 12 months and 18 months, of a random sample of households with fever in the last 4 weeks to evaluate predefined, individual-level outcomes. The primary outcome was uptake of malaria diagnostic testing at 12 months. The main secondary outcome was rational ACT use, defined as the proportion of ACTs used by test-positive individuals. Analyses followed the intention-to-treat principle using generalized estimating equations to account for clustering with pre-specified adjustment for gender, age, education and wealth. All descriptive statistics and regressions were weighted to account for sampling design. Between July 2015 and May 2017, 32,404 participants were tested for malaria and 10,870 vouchers were issued. 7416 randomly-selected participants with recent fever from all 32 clusters were surveyed. The majority of recent fevers were in children under 18 years (62.9%, n=4653). The gender of enrolled participants was balanced in children (50.0%, n=2318 v 50.2%, n=2335), but more adult women were enrolled than men (78.0%, n=2139 v 22.0%, n=604). At baseline, 67.6% (n=1362) of participants took an ACT for their illness and 40.3% (n=810) of all participants took an ACT purchased from a retail outlet. At 12 months, 50.5% (n=454) in the intervention arm and 43.4% (n=389) in the control arm had a malaria diagnostic test for their recent fever (Adjusted Risk Difference=9 percentage points [pp], 95%CI: 2-15pp, p=0.015; Adjusted Risk Ratio=1.20, 95%CI:1.05-1.38, p=0.015). By 18-months, the ARR had increased to 1.25 (95%CI:1.09-1.44, p=0.005). Rational use of ACTs in the intervention area increased from 41.7% (n=279) at baseline to 59.6% (n=403) and was 40% higher in the intervention arm at 18 months (Adj RR 1.40, 95%CI: 1.19-1.64). While intervention effects increased between 12 and 18 months, we were not able to estimate longer-term impact of the intervention and could not independently evaluate the effects of the free testing and the voucher on uptake of testing. Conclusions: Diagnosis-dependent ACT subsidies and community-based interventions that include the private sector can have an important impact on diagnostic testing and population-wide rational use of ACTs. Targeting of the ACT subsidy itself to those with a positive malaria diagnostic test may also improve sustainability and reduce the cost of retail sector ACT subsidies.

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Additional file 2. Errors observed at follow-up observations. A list of the steps and corresponding errors observed at follow-up (12 month) observations