Communities’ Perceptions of Reintegration of Al-Shabaab Returnees in Mombasa and Kwale Counties, Kenya

This study explores community perceptions of reintegration of returning foreign terrorist fighters (FTFs) from Al-Shabaab in coastal Kenya. Drawing from fieldwork accounts collected in Kwale and Mombasa Counties, Kenya, this study nuances and problematizes communities’ perception of reintegration.  The study fits into a growing yet unsettled discourse of what works well in reintegration initiatives for returning foreign terrorist fighters. Governments worldwide are focusing on fighting Islamist terror groups like ISIS and Al-Shabaab in East Africa. But the need to also build other strategic counter-terrorism capabilities has developed, even more so in the rehabilitation and reintegration of returning foreign terrorist fighters. How host communities perceive this shift from a whole-of-government, hard approach, to a whole-of-community, soft approach, will determine how effective this strategy is in the global fight against terrorism. In Kenya, it is estimated that at least 1,000 returnees live in communities along the coastal areas of Kwale and Mombasa. There is a paucity of research focusing on the perceptions of those communities absorbing the returnees in Kenya. This study draws on 31 interviews with government officials, returnees, academic experts, civil society actors, and 104 questionnaire interviews with community members in Kwale and Mombasa. The study’s findings show that while the family and the society at large may be longing to see their loved ones, there are competing dilemmas involved, including stigma and negative labelling. The study also found that there is a lack of structures to ensure proper involvement of host communities in the reintegration of returnees. As such, the process is marred by lack of trust and negative labelling, which affects positive reintegration. The study’s findings are useful for counter-radicalization policy formulation and practical peacebuilding interventions at the community level

Possible causes of fever among patients with blood smear negative for malaria parasites at Bombo Regional Referral Hospital in Tanga, Tanzania

Background: Due to its diverse and non‐specific clinical presentations, malaria has been associated with most infections causing febrile illnesses. Despite being non-specific, clinical diagnosis is still the main method of malaria diagnosis in most health facilities in sub-Saharan Africa. This study aimed to establish the probable diagnoses among fever cases admitted at Bombo Hospital in north-eastern Tanzania.Methods: This study involved patients admitted in Medical and Paediatric wards with a clinical diagnosis of severe malaria but having negative blood smears (BS) for malaria parasites. Finger prick blood specimens were collected for blood smear microscopy and rapid diagnostic test. Blood and urine cultures were done for all specimens collected.  Some patients were also screened for HIV infection.Results: A total of 227 patients were recruited and the majority (62.1%) were under-five children. Out of the 227 blood specimens cultured, 25 (11.0%) grew different bacteria species. Staphylococcus aureus was the most frequent pathogen (68.0%), followed by S. pneumoniae (24.0%), Salmonella species (4.0%) and Streptococcus pyogenes (4.0%).  Only 7 (3.2%) out of 219 urine specimens cultured showed growth of Escherichia coli, Pseudomonas aeruginosa, S. aureus and Klebsiella pneumoniae. Of the 215 patients screened for HIV, 17 (7.9%) had positive reaction.Conclusion: The findings indicate that S. aureus and S. pneumoniae as the commonest bacteria isolates from blood and P. aeruginosa, S. aureus and K. pneumoniae from urine cultures. These bacteria and HIV should be considered as important contributors to febrile illness cases among patients found with negative BS for malaria parasites

A qualitative study on the feasibility and acceptability of institutionalizing health technology assessment in Malawi

OBJECTIVE: The objective of this study was to assess the feasibility and acceptability of institutionalizing Health Technology Assessment (HTA) in Malawi. METHODS: This study employed a document review and qualitative research methods, to understand the status of HTA in Malawi. This was complemented by a review of the status and nature of HTA institutionalization in selected countries.Qualitative research employed a Focus Group Discussion (FGD ) with 7 participants, and Key Informant Interviews (KIIs) with12 informants selected based on their knowledge and expertise in policy processes related to HTA in Malawi.Data extracted from the literature was organized in Microsoft Excel, categorized according to thematic areas and analyzed using a literature review framework. Qualitative data from KIIs and the FGD was analyzed using a thematic content analysis approach. RESULTS: Some HTA processes exist and are executed through three structures namely: Ministry of Health Senior Management Team, Technical Working Groups, and Pharmacy and Medicines Regulatory Authority (PMRA) with varyingdegrees of effectiveness.The main limitations of current HTA mechanisms include limited evidence use, lack of a standardized framework for technology adoption, donor pressure, lack of resources for the HTA process and technology acquisition, laws and practices that undermine cost-effectiveness considerations. KII and FGD results showed overwhelming demand for strengthening HTA in Malawi, with a stronger preference for strengthening coordination and capacity of existing entities and structures. CONCLUSION: The study has shown that HTA institutionalization is acceptable and feasible in Malawi. However, the current committee based processes are suboptimal to improve efficiency due to lack of a structured framework. A structured HTA framework has the potential to improve processes in pharmaceuticals and medical technologies decision-making.In the short to medium term, HTA capacity building should focus on generating demand and increasing capacity in cost-effectiveness assessments. Country-specific assessments should precede HTA institutionalization as well as recommendations for new technology adoptions

The Role of Varietal Attributes on Adoption of Improved Seed Varieties. The Case of Sorghum in Kenya

This paper examines the effect of variety attributes on adoption of improved sorghum varieties in Kenya. Using data from 140 farmers, the paper uses a multivariate probit to identify variety-specific drivers of adoption. The results on the perception of farmers variety attributes show that improved varieties had desirable production and marketing attributes while the local varieties were perceived to have the best consumption attributes. Evidence further indicates that the major sorghum variety attributes driving rapid adoption are taste, drought tolerance, yield, ease of cooking and the variety’s ability to fetch a price premium. Early maturity, a major focus of research has no effect on adoption. The findings of the study imply that, while developing improved seed varieties, breeders should also focus on non yield attributes like taste and ease of cooking. Secondly, it is important that both producers and consumers of sorghum be involved in the seed evaluation process

Proposing the “Value- and Evidence-Based decision making and Practice” (VEDMAP) framework for Priority-Setting and knowledge translation in low and Middle-Income Countries: A novel framework for Decision-Making in Low-and middle income countries like Malawi

The existence and availability of evidence on its own does not guarantee that the evidence will be demanded and used by decision and policy makers. Decision and policy-makers, especially in low-income settings, often confront ethical dilemmas about determining the best available evidence and its utilization. This dilemma can be in the form of conflict of evidence, scientific and ethical equipoise and competing evidence or interests. Consequently, decisions are made based on convenience, personal preference, donor requirements, and political and social considerations which can result in wastage of resources and inefficiency. To mitigate these challenges, the use of “Value- and Evidence-Based Decision Making and Practice” (VEDMAP) framework is proposed. This framework was developed by Joseph Mfutso-Bengo in 2017 through a desk review. It was pretested through a scoping study under the Thanzi la Onse (TLO) Project which assessed the feasibility and acceptability of using the VEDMAP as a priority setting tool for Health Technology Assessment (HTA) in Malawi. The study used mixed methods whereby it conducted a desk review to map out and benchmark normative values of different countries in Africa and HTA; focus group discussion and key informant interviews to map out the actual (practised) values in Malawi. The results of this review confirmed that the use of VEDMAP framework was feasible and acceptable and can bring efficiency, traceability, transparency and integrity in decision- policy making process and implementation

Neonatal mortality in Kenyan hospitals: a multisite, retrospective, cohort study

Background Most of the deaths among neonates in low-income and middle-income countries (LMICs) can be prevented through universal access to basic high-quality health services including essential facility-based inpatient care. However, poor routine data undermines data-informed efforts to monitor and promote improvements in the quality of newborn care across hospitals.Methods Continuously collected routine patients’ data from structured paper record forms for all admissions to newborn units (NBUs) from 16 purposively selected Kenyan public hospitals that are part of a clinical information network were analysed together with data from all paediatric admissions ages 0–13 years from 14 of these hospitals. Data are used to show the proportion of all admissions and deaths in the neonatal age group and examine morbidity and mortality patterns, stratified by birth weight, and their variation across hospitals.Findings During the 354 hospital months study period, 90 222 patients were admitted to the 14 hospitals contributing NBU and general paediatric ward data. 46% of all the admissions were neonates (aged 0–28 days), but they accounted for 66% of the deaths in the age group 0–13 years. 41 657 inborn neonates were admitted in the NBUs across the 16 hospitals during the study period. 4266/41 657 died giving a crude mortality rate of 10.2% (95% CI 9.97% to 10.55%), with 60% of these deaths occurring on the first-day of admission. Intrapartum-related complications was the single most common diagnosis among the neonates with birth weight of 2000 g or more who died. A threefold variation in mortality across hospitals was observed for birth weight categories 1000–1499 g and 1500–1999 g.Interpretation The high proportion of neonatal deaths in hospitals may reflect changing patterns of childhood mortality. Majority of newborns died of preventable causes (>95%). Despite availability of high-impact low-cost interventions, hospitals have high and very variable mortality proportions after stratification by birth weight

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research