Perspective on Opportunities for Research and Interventions provided by Community Based Health Information System illustrated by the Potential use of Motivational Interviewing Intervention

Background: With the growth of Community-Based Health Information (CBHIS) for decision making and service provision in the low income settings, innovative models of addressing Maternal and Newborn Health (MNH) morbidity and mortality are necessary. World Health Organization (WHO) estimates that five hundred thousand mothers and about three million newborns die each year in middle and low income countries. Objectives: To stimulate interest in utilisation CBHIS for research and interventions, with an illustration of potential using on Motivational Interviewing intervention. Data Source: Literature searched electronically, discussion with behavioural experts, health system researchers, and maternal and Newborn Health (MNH) experts, and book reviews. Study Selection: Broad selection criteria including all current literature relevantsubjects including CBHIS, behaviour change methods and Community MNH. Data Extraction: A checklist for relevance was used to identify the relevant behaviour change intervention to use in the illustration. Data Synthesis: A method that met the criteria was identified, and based on a discussion with behavioural experts, the decision to use it the illustration was reached. Conclusion: Motivational Interviewing Intervention (MII) should be considered for implementation and study on near-term Pregnant women in a setting where these mothers can be identified and a targeted intervention instituted

Outcomes of neonates requiring surgical interventions in Eldoret

Background: Neonatal surgical conditions account for 11% of the Global Burden of Diseases (GBD); neglect of their management has been reported though most are amenable to surgery. Timely surgical interventions play a major role in determining better outcomes, thus improving quality of life and reducing disability. Several factors—sepsis control, care in newborn intensive care unit and availability of total parenteral nutrition—have been shown to improve the outcomes of neonates with surgical conditions.Objective: To evaluate the outcomes of neonates with conditions requiring surgical interventions.Methods: A prospective descriptive study in the Newborn Unit, Moi Teaching and Referral Hospital (MTRH). Data on the following study variables were obtained and analyzed: maternal age, place and mode of delivery, newborn’s age at admission, birth weight, surgical condition, co-morbid conditions, treatment outcomes (discharge, death or referral to Kenyatta National Hospital for specialized care), surgical complications, time-to-initiation of oral feeds post-operatively, antenatal history and laboratory parameters; and length of hospital stay.Results: A total of 124 neonates were recruited; male to female ratio was 1.1:1 and median age at admission was 2 days (IQR 1, 5). Most (59.7%) were in the birth weight range of 2.5–3.9 kg. The leading neonatal surgical conditions were gastroschisis 33(26.6%), neural tube defects 25(20.2%) and ARM 25(20.2%). Overall mortality rate was 31.5%. Antenatal clinic attendance was associated with decreased odds of mortality (OR 0.126; 95% CI 0.025–0.6429; p=0.013), while neonatal sepsis, respiratory distress and electrolyte imbalance were associated with increased odds of mortality ([OR 3.4; 95% CI 1.09–22.06; p=0.049], [OR 4.9; CI 0.91–11.61; p=0.001] and [OR 3.1; CI 1.21–31.60; p=0.029], respectively).Conclusions: The overall mortality rate of neonates requiring surgical interventions at MTRH was 31.5% and the median length of hospital stay was 14.5 days. Co-morbid conditions that increased the odds of mortality among these neonates were neonatal sepsis, respiratory distress and electrolyte imbalance.Keywords: Neonates, Surgical, Interventions, Outcome

Nutritional status of children admitted for diarrhoeal diseases in a referral hospital in western Kenya

Objectives: To determine the prevalence of malnutrition among children admitted with acute diarrhoea disease at Moi Teaching and Referral Hospital and to establish the effect of malnutrition on duration of hospital stay. Design: Prospective observational study. Setting: Paediatric wards of Moi Teaching and Referral Hospital, Eldoret, Kenya Subjects: A total of 191 children aged 6 and 59 months admitted with acute diarrhoea disease, without chronic co-morbidities or visible severe malnutrition, were systematically enrolled into the study between November 2011 and March 2012. Outcome Measures: Nutritional status based on WHO WHZ scores taken at admission and duration of hospital stay. Results:The mean age was 13.2 months with a male to female sex ratio of 1.16:1. Of all the children seen with acute diarrhoeal diseases, 43.9% had acute malnutrition ( Conclusion: Routine anthrometry including weight for height identifies more children with malnutrition in acute diarrhoeal diseases. Presence of malnutrition did not affect duration of hospital stay

Setting research priorities to improve global newborn health and prevent stillbirths by 2025

Background: In 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013–2025. Methods: We used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts. Results: Nine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour. Conclusion: These findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed

Harnessing the power of the grassroots to conduct public health research in sub-Saharan Africa: a case study from western Kenya in the adaptation of community-based participatory research (CBPR) approaches

Background: Community-based participatory research (CBPR) is a collaborative approach to research that involves the equitable participation of those affected by an issue. As the field of global public health grows, the potential of CBPR to build capacity and to engage communities in identification of problems and development and implementation of solutions in sub-Saharan Africa has yet to be fully tapped. The Orphaned and Separated Children’s Assessments Related to their Health and Well-Being (OSCAR) project is a longitudinal cohort of orphaned and non-orphaned children in Kenya. This paper will describe how CBPR approaches and principles can be incorporated and adapted into the study design and methods of a longitudinal epidemiological study in sub-Saharan Africa using this project as an example. Methods: The CBPR framework we used involves problem identification, feasibility and planning; implementation; and evaluation and dissemination. This case study will describe how we have engaged the community and adapted CBPR methods to OSCAR’s Health and Well-being Project’s corresponding to this framework in four phases: 1) community engagement, 2) sampling and recruitment, 3) retention, validation, and follow-up, and 4) analysis, interpretation and dissemination. Results: To date the study has enrolled 3130 orphaned and separated children, including children living in institutional environments, those living in extended family or other households in the community, and street-involved children and youth. Community engagement and participation was integral in refining the study design and identifying research questions that were impacting the community. Through the participation of village Chiefs and elders we were able to successfully identify eligible households and randomize the selection of participants. The on-going contribution of the community in the research process has been vital to participant retention and data validation while ensuring cultural and community relevance and equity in the research agenda. Conclusion: CBPR methods have the ability to enable and strengthen epidemiological and public health research in sub-Saharan Africa within the social, political, economic and cultural contexts of the diverse communities on the continent. This project demonstrates that adaptation of these methods is crucial to the successful implementation of a community-based project involving a highly vulnerable population

Characteristics of HIV-infected children seen in Western Kenya

Objectives: To describe the characteristics and outcomes of children registered for care in a large HIV care programme in Western Kenya. Design: A retrospective descriptive study. Setting: USAID-AMPATH HIV clinics in health centres; district and sub-district hospitals; Moi Teaching and Referral Hospital in Western Kenya. Subjects: HIV-infected children below age of 15 years seen in a network of 18 clinics in Western Kenya. Interventions: Paediatric HIV diagnosis and care including treatment and prevention of opportunistic infections and provision of combination antiretroviral therapy (CART). Main outcome measures: Diagnosis, clinical stage and immune status at enrollment and follow-up; hospitalisation and death. Descriptive statistical analyses and chi square tests were performed. Results: Four thousand and seventeen HIV-infected children seen between June 2002 and April 2008. Median age at enrollment was four years (0-14.2 years), 51% girls, 25% paternal orphans, 10% total orphans and 13% maternal orphans. At enrollment, 25% had weight-for-Age Z scores (WAZ)\u3e -1 and 21% had WAZ scores \u3c 3. Orphaned children had worse WAZ scores (p=0.0001). Twenty five per cent of children were classified as WHO clinical stage 3 and 4, 56% were WHO clinical stages 1 and 2 with 19% missing clinical staging at enrollment. Cough (25%), gastroenteritis (21%), fever (15%), pneumonia (10%) were the commonest presenting features. Twenty six per cent had been diagnosed with tuberculosis and only 25% started on cotrimoxazole preventive therapy (CPT). Median CD4% at enrollment was 16% (0-64%); latest recorded values were 22% (0-64). Sixty four per cent were on cART (cART+), median age at start was 5.4 (014.4 years).The median initial CD4% among cART+ was 13 (0-62) compared to 24 (0-64) for those not on ART (cART-). Median CD4% for cART+ improved to 22% (0-59); whereas cART- was 23% (0- 64) at last appointment. During the period of follow-up, one fifth (19%) of children on cART were lost to follow-up compared to slightly over one third (37%) for those not on cART. Thirty four percent were hospitalised; 41% diagnosed with pneumonia. Six per cent of 4017 were confirmed dead. Conclusions: HIV -infected children were enrolled in care early in childhood. Orphanhood was prevalent in these children as were gastroenteritis, fever, pneumonia and advanced immuno-suppression. Orphans were more likely to be severely malnourished. Only a quarter of children were put on cotrimoxazole preventive therapy. Children commenced on cART late but responded well to treatment. Loss to follow-up was less prevalent among those on cART

Models of care for orphaned and separated children and upholding children’s rights: cross-sectional evidence from western Kenya

Background Sub-Saharan Africa is home to approximately 55 million orphaned children. The growing orphan crisis has overwhelmed many communities and has weakened the ability of extended families to meet traditional care-taking expectations. Other models of care and support have emerged in sub-Saharan Africa to address the growing orphan crisis, yet there is a lack of information on these models available in the literature. We applied a human rights framework using the United Nations Convention on the Rights of the Child to understand what extent children’s basic human rights were being upheld in institutional vs. community- or family-based care settings in Uasin Gishu County, Kenya. Methods The Orphaned and Separated Children’s Assessments Related to their Health and Well-Being Project is a 5-year cohort of orphaned children and adolescents aged ≤18 year. This descriptive analysis was restricted to baseline data. Chi-Square test was used to test for associations between categorical /dichotomous variables. Fisher’s exact test was also used if some cells had expected value of less than 5. Results Included in this analysis are data from 300 households, 19 Charitable Children’s Institutions (CCIs) and 7 community-based organizations. In total, 2871 children were enrolled and had baseline assessments done: 1390 in CCI’s and 1481 living in households in the community. We identified and described four broad models of care for orphaned and separated children, including: institutional care (sub-classified as ‘Pure CCI’ for those only providing residential care, ‘CCI-Plus’ for those providing both residential care and community-based supports to orphaned children , and ‘CCI-Shelter’ which are rescue, detention, or other short-term residential support), family-based care, community-based care and self-care. Children in institutional care (95%) were significantly (p < 0.0001) more likely to have their basic material needs met in comparison to those in family-based care (17%) and institutions were better able to provide an adequate standard of living. Conclusions Each model of care we identified has strengths and weaknesses. The orphan crisis in sub-Saharan Africa requires a diversity of care environments in order to meet the needs of children and uphold their rights. Family-based care plays an essential role; however, households require increased support to adequately care for children

Models of care for orphaned and separated children and upholding children\u27s rights: cross-sectional evidence from western Kenya

Background: Sub-Saharan Africa is home to approximately 55 million orphaned children. The growing orphan crisis has overwhelmed many communities and has weakened the ability of extended families to meet traditional care-taking expectations. Other models of care and support have emerged in sub-Saharan Africa to address the growing orphan crisis, yet there is a lack of information on these models available in the literature. We applied a human rights framework using the United Nations Convention on the Rights of the Child to understand what extent children\u27s basic human rights were being upheld in institutional vs. community- or family-based care settings in Uasin Gishu County, Kenya. Methods: The Orphaned and Separated Children\u27s Assessments Related to their Health and Well-Being Project is a 5-year cohort of orphaned children and adolescents aged ≤18 year. This descriptive analysis was restricted to baseline data. Chi-Square test was used to test for associations between categorical /dichotomous variables. Fisher\u27s exact test was also used if some cells had expected value of less than 5. Results: Included in this analysis are data from 300 households, 19 Charitable Children\u27s Institutions (CCIs) and 7 community-based organizations. In total, 2871 children were enrolled and had baseline assessments done: 1390 in CCI\u27s and 1481 living in households in the community. We identified and described four broad models of care for orphaned and separated children, including: institutional care (sub-classified as \u27Pure CCI\u27 for those only providing residential care, \u27CCI-Plus\u27 for those providing both residential care and community-based supports to orphaned children , and \u27CCI-Shelter\u27 which are rescue, detention, or other short-term residential support), family-based care, community-based care and self-care. Children in institutional care (95%) were significantly (p \u3c 0.0001) more likely to have their basic material needs met in comparison to those in family-based care (17%) and institutions were better able to provide an adequate standard of living. Conclusions: Each model of care we identified has strengths and weaknesses. The orphan crisis in sub-Saharan Africa requires a diversity of care environments in order to meet the needs of children and uphold their rights. Family-based care plays an essential role; however, households require increased support to adequately care for children

A qualitative study using traditional community assemblies to investigate community perspectives on informed consent and research participation in western Kenya

Background: International collaborators face challenges in the design and implementation of ethical biomedical research. Evaluating community understanding of research and processes like informed consent may enable researchers to better protect research participants in a particular setting; however, there exist few studies examining community perspectives in health research, particularly in resource-limited settings, or strategies for engaging the community in research processes. Our goal was to inform ethical research practice in a biomedical research setting in western Kenya and similar resource-limited settings. Methods: We sought to use mabaraza, traditional East African community assemblies, in a qualitative study to understand community perspectives on biomedical research and informed consent within a collaborative, multinational research network in western Kenya. Analyses included manual, progressive coding of transcripts from Mabaraza to identify emerging central concepts. Results: Our findings from two mabaraza with 108 community members revealed that, while participants understood some principles of biomedical research, they emphasized perceived benefits from participation in research over potential risks. Many community members equated health research with HIV testing or care, which may be explained in part by the setting of this particular study. In addition to valuing informed consent as understanding and accepting a role in research activities, participants endorsed an increased role for the community in making decisions about research participation, especially in the case of children, through a process of community consent. Conclusions: Our study suggests that international biomedical research must account for community understanding of research and informed consent, particularly when involving children. Moreover, traditional community forums, such as mabaraza in East Africa, can be used effectively to gather these data and may serve as a forum to further engage communities in community consent and other aspects of research

Community Perspectives on Research Consent Involving Vulnerable Children in Western Kenya

Involving vulnerable pediatric populations in international research requires culturally appropriate ethical protections. We sought to use mabaraza, traditional East African community assemblies, to understand how a community in western Kenya viewed participation of children in health research and informed consent and assent processes. Results from 108 participants revealed generally positive attitudes towards involving vulnerable children in research, largely because they assumed children would directly benefit. Consent from parents or guardians was understood as necessary for participation while gaining child assent was not. They felt other caregivers,community leaders, and even community assemblies could participate in the consent process. Community members believed research involving orphans and street children could benefit these vulnerable populations, but would require special processes for consent