Strengthening Care Delivery in Primary Care Facilities: Perspectives of Facility Managers on the Immunization Program in Kenya

Abstract Background: Primary healthcare facility managers (PHFMs) occupy a unique position in the primary healthcare system, as the only cadre combining frontline clinical activities with managerial responsibilities. Often serving as ‘street-level bureaucrats,’ their perspectives can provide contextually relevant information about interventions for strengthening primary healthcare delivery, yet such perspectives are under-represented in the literature on primary healthcare strengthening. Our objective in this study was to explore perspectives of PHFMs in western Kenya regarding how to leverage human resource factors to improve immunization programs, in order to draw lessons for strengthening of primary healthcare delivery. Methods: We employed a sequential mixed methods approach. We conducted in-depth interviews with key informants in Kakamega County. Emergent themes guided questionnaire development for a cross-sectional survey. We randomly selected 94 facility managers for the survey which included questions about workload, effects of workload on immunization program, and appropriate measures to address workload effects. Participants provided self-assessment of their general motivation at work, their specific motivation to ensure that all children in their catchment areas were fully immunized, and recommendations to improve motivation. Participants were asked about frequency of supervisory visits, supervisor activities during those visits, and how to improve supervision. Results: The most frequently reported consequences of high workload were reduced accuracy of vaccination records (47%) and poor client counseling (47%). Hiring more clinical staff was identified as an effective remedy to high workload (69%). Few respondents (20%) felt highly motivated to ensure full immunization coverage and only 13% reported being very motivated to execute their role as a health worker generally. Increasing frequency of supervisory visits and acting on the feedback received during those visits were mostly perceived as important measures to improve program effectiveness. Conclusion: Besides increasing the number of staff providing clinical care, PHFMs endorsed introducing some financial incentives contingent on specified targets and making supervisory visits meaningful with action on feedback as strategies to increase program effectiveness in primary healthcare facilities in Kenya. Targeting health worker motivation and promoting supportive supervision may reduce missed opportunities and poor client counseling in primary healthcare facilities in Kenya

Cluster-randomized non-inferiority trial to compare supplement consumption and adherence to different dosing regimens for antenatal calcium and iron-folic acid supplementation to prevent preeclampsia and anaemia: rationale and design of the Micronutrient Initiative study

Background: To prevent pre-eclampsia in populations with insufficient dietary calcium (Ca) intake, the World Health Organisation (WHO) recommends routine Ca supplementation during antenatal care (ANC). WHO guidelines suggest a complex dosing regimen, requiring as many as 5 pill-taking events per day when combined with iron and folic acid (IFA) supplements. Poor adherence may undermine public health effectiveness, so simpler regimens may be preferable. This trial will compare the effect of the WHO-recommended (higher-dose) regimen vs. a simpler, lower-dose regimen on supplement consumption and pill-taking behaviours in Kenyan ANC clients. Design and methods: This is a parallel, non-inferiority, cluster-randomized trial; we examined 16 primary care health facilities in Kenya, 1047 pregnant women between 16-30 weeks gestational age. Higher-dose regimen: 1.5 g elemental calcium in 3 separate doses (500 mg Ca/pill) and IFA (60 mg Fe + 400 μg folic acid) taken with evening dose. Lower-dose regimen: 1.0 g calcium in 2 separate doses (500 mg Ca/pill) with IFA taken as above. Measurements: Primary outcome is Ca pills consumed per day, measured by pill counts. Secondary outcomes include IFA pills consumed per day, client knowledge, motivation, social support, and satisfaction, measured at 4 to 10 weeks post-enrolment. Statistical analyses: Unit of randomization is the health-care facility; unit of analysis is individual client. Intent-to-treat analysis will be implemented with multi-level models to account for clustering. Expected public health impact: If pregnant women prescribed lower doses of Ca ingest as many pills as women prescribed the WHO-recommended regimen, developing a lower-dose recommendation for antenatal Ca and IFA supplementation programs could save resources

Ketamine for sedation in acutely painful procedures in Kenya: findings after implementation of the Every Second Matters-Ketamine package

Background: Adequate pain management for painful procedures improves the quality and safety of patient care and has become accepted as a basic human right. In low-resource settings, pain relief for painful procedures is scarce because of cultural, attitudinal, legal, and system-related reasons, as well as a scarcity of anaesthetists. A practice of “hold still”, where patients are forcibly held down during painful procedures, remains common in Kenya and in other low-resource settings. In December, 2013, we launched the Every Second Matters-Ketamine (ESM-Ketamine) package in Kenya, for use during emergency surgery when no anaesthetist is available. Here, we aim to describe how non-anaesthetists who were trained in an ESM-Ketamine programme broadened use of their skills to provide procedural sedation for patients in need of painful procedures when an anaesthetist would not have been previously called. Methods: Medical officers, nurses, and clinical officers in Kenya undertook a 5-day ESM-Ketamine competency-based training programme for non-anaesthetists. We provided every facility in the ESM-Ketamine initiative with wall charts, checklists, and kits. Trained providers recorded patients' demographic data, pre-operative diagnoses, the procedure or procedures undertaken, medications administered, and ketamine-related adverse events. Partners Healthcare and Maseno University gave ethical approval for the programme. Findings: Between Dec 1, 2013, and July 30, 2018, 62 ESM-Ketamine providers across 11 facilities administered ketamine to 512 patients undergoing painful procedures in non-training settings where an anaesthetist would previously not have been called. 273 patients (53·3%) were male and median age was 23 years (IQR 11–36 years). The five most common indications were: incision and drainage, debridement, or both (159 [31·1%]); fracture reduction (56 [10·9%]); circumcision (41 [8·0%]); wound repair (29 [5·7%]); and foreign body removal (26 [5·1%]). Median ketamine dose was 2·0 mg/kg (IQR 2·0 –3·0). Hallucinations or agitation treated with diazepam were reported in 45 patients [8·8%]; brief oxygen desaturation occurred in 22 (4·3%) patients. Prolonged (>30s) desaturations below 92% occurred in two patients (0·4%). The lowest desaturation was 85%. All patients recovered uneventfully. There were no deaths or injuries associated with ketamine use in the programme. Interpretation: The ESM-Ketamine package appears safe for use by trained providers in support of procedural sedation when previously an anaesthetist would not have been called. Scale-up of the ESM-Ketamine package may support the human rights imperative that every person deserves pain relief when undergoing a painful procedure. Funding: None