A Comparative Analysis of Malaria Control Programmes Targeting Delivery of Over-the counter Antimalarial Drugs in Kenya

Background: The retail sector is an important channel for increasing access to adequate treatment of fevers in Africa. The objectives of the thesis were to assess the performance of three malaria control programmes targeting private medicine retailers (PMRs) by addressing coverage, utilisation, impact on PMRs' knowledge, practices and implementation processes in Kisii central, Kwale and Bungoma districts of Kenya. Methods: The thesis used mixed methods including retail audits, surrogate client surveys based on post intervention cross sectional surveys in intervention and controls and mapping of outlets in intervention areas. Qualitative methods including record reviews, in-depth interviews and focus group discussions with programme stakeholders were analysed using thematic framework and policy analysis. Results: There was a significant impact on PMR knowledge and practice of an NGO-led participatory training programme in Kisii-central district with 60.5% of trained PMRs selling AQ medicines adequately compared to 2.8% in the untrained ones (OR; 53.5: 95% CI 6.7, 428.3). There was some evidence of a limited impact for the MoH-led participatory training programme in the Kwale district, where 18.8% of trained PMRs sold AQ medicines adequately compared to 2.3% of control PMRs (OR; 9.4: 95% CI 1.1, 83.7). This study was unable to show evidence of impact in the social marketing programme in Bungoma district. In terms of coverage, Kisii central covered 27.1% of all outlets in the study sites, compared to 14.1% and 16.7% in Kwale and Bungoma districts, respectively. Policy analysis indicated that, deliberate and careful management of the implementation process, actors involved and establishing a transparent management system with a flexible decision-making processes, is key to successful uptake and impact at retailer level. Conclusions: PMR interventions operationalised through various institutions in the district level settings at moderate scale are likely to impact on PMR knowledge and practices and lead to increased coverage of appropriate treatment to target populations. Implementation management play a major role in determining programme impact, and should be areas of focus in planning and managing public health programmes

Evaluation of a Tool for Assessing Clinical Competence of Msc Nurse Students

This paper reports the first of a four phase study whose aim is to develop and validate an instrument for assessing the clinical competence of Master of Science (Msc) - medical-surgical nurse students. The objective of the first phase of the study was to evaluate the existing instrument, currently being used for assessing clinical competence of MSc nurse students pursuing medical/surgical specialty. It also explores ideas and content for the development of a new tool. The target population was nurse educators and nurse clinicians with a minimum of MSc-Medical/surgical nursing. Twenty seven (27) participants who participated in this study were drawn from eight (8) of Kenya’s recognized universities offering nursing training. The participants had been involved in the training of undergraduate and post-graduate nurse students for a minimum of two (2) years. The aim was to capture participants with current knowledge in nursing practice and those who are familiar with emerging issues in nursing education and practice.  Qualitative and quantitative research approaches were used.  Data were analyzed using SPSS version 17.  The study findings showed that the tool has a low average congruency percentage at 60%.  Only seven (20.6%) out of 34 items/competencies demonstrated the minimum content validity index (CVI) of 0.78 (Lynn, 1986).  This calls for urgent revision of the tool specifically in terms of adding some performance competencies and probably deleting others. Keywords: Instrument evaluation, Clinical competence, Clinical competence assessment instrument, Content evidence, Average Congruency Percentag

Impact of ministry of health interventions on private medicine retailer knowledge and practices on anti-malarial treatment in Kenya.

Small-scale interventions on training medicine retailers on malaria treatment improve over-the-counter medicine use, but there is little evidence on effectiveness when scaled up. This study evaluated the impact of Ministry of Health (MoH) training programs on the knowledge and practices of medicine retailers in three districts in Kenya. A cluster randomized trial was planned across 10 administrative divisions. Findings indicated that 30.7% (95% confidence interval [CI]: 23.3, 39.0) and 5.2% (95% CI: 2.1, 10.3) of program and control retailers, respectively, sold MoH amodiaquine with correct advice on use to surrogate clients (OR = 8.8; 95% CI: 2.9, 26.9; P < 0.001). Similarly, 61.8% (95% CI: 54.2, 69.1) and 6.3% (95% CI: 2.7, 12.1) of program and control retailers, respectively, reported correct knowledge on dosing with amodiaquine (OR = 29.8; 95% CI: 8.2, 108.8). Large-scale retailer training programs within the national malaria control framework led to significant improvements in retailers' practices across three districts

The policy-practice gap: describing discordances between regulation on paper and real-life practices among specialized drug shops in Kenya.

BACKGROUND: Specialized drug shops (SDSs) are popular in Sub-Saharan Africa because they provide convenient access to medicines. There is increasing interest in how policymakers can work with them, but little knowledge on how their operation relates to regulatory frameworks. This study sought to describe characteristics and predictors of regulatory practices among SDSs in Kenya. METHODS: The regulatory framework governing the Kenya pharmaceutical sector was mapped, and a list of regulations selected for inclusion in a survey questionnaire. An SDS census was conducted, and survey data collected from 213 SDSs from two districts in Western Kenya. RESULTS: The majority of SDSs did not comply with regulations, with only 12% having a refrigerator and 22% having a separate dispensing area for instance. Additionally, less than half had at least one staff with pharmacy qualification (46%), with less than a third of all interviewed operators knowing the name of the law governing pharmacy.Regulatory infringement was more common among SDSs in rural locations; those that did not have staff with pharmacy qualifications; and those whose operator did not know the name of the pharmacy law. Compliance was not significantly associated with the frequency of inspections, with over 80% of both rural and urban SDSs reporting an inspection in the past year. CONCLUSION: While compliance was low overall, it was particularly poor among SDSs operating in rural locations, and those that did not have staff with pharmacy qualification. This suggested the need for policy to introduce levels of practice in recognition of the variations in resource availability. Under such a system, rural SDSs operating in low-resource setting, and selling a limited range of medicines, may be exempted from certain regulatory requirements, as long as their scope of practice is limited to certain essential services only. Future research should also explore why regulatory compliance is poor despite regular inspections

Nairobi informal settlements: COVID-19 knowledge, attitudes and practices—Preliminary findings

To control the spread of coronavirus, the Kenyan Ministry of Health COVID-19 Taskforce has implemented initial prevention and mitigation measures. Of concern are the densely overcrowded, poor urban slums where sanitation and social distancing measures are near impossible. COVID-19 would spread rapidly and be devastating under these conditions. To inform the Taskforce strategy, the Population Council COVID-19 study team utilizes rapid phone-based surveys to collection information on knowledge, attitudes and practices among ~2,000 heads of household sampled from existing prospective cohort studies across five Nairobi urban slums. Iterations of the survey will be conducted every 1-2 weeks. Baseline findings on awareness of COVID-19 symptoms, perceived risk, awareness of and ability to carry out preventive behaviors, misconceptions, and fears will inform Taskforce interventions. In subsequent rounds, behavior change messages will be randomly assigned to measure effectiveness, or if randomization is not feasible, survey questions on exposure and response to government campaigns will be evaluated using causal inference approaches

Getting it Right! Improving Kenya’s Human Capital by Reducing Stunting—A Household Account

In the last two decades, Kenya has attained middle-income status and established a diverse and private-sector-driven economy. On several socIo-economic indicators, such as education, gender equality, and democracy, Kenya scores much higher than its peers. More than two-thirds of Kenyans are under 35 years of age, thus the country’s development hinges on the quality of its youth—their levels of education and skills, their values and attitudes, and the quality of their health and productivity. While Kenya’s investments in the development of its human capital positions the country well to sustain accelerated growth, the trajectory is threatened by high rates of malnutrition, which contributes to the country’s disease burden and has a large effect on socio-economic development. About 26 percent of children in Kenya are stunted, and evidence indicates that poor nutrition in early life can create consequences for learning and future productivity. Women who were stunted as children are likely to give birth to low-birth-weight babies, which is associated with higher levels of morbidity and mortality. This report analyzes the status of stunting in Kenya from a household perspective and points to pathways for addressing it

Family planning use and fertility desires among women living with HIV in Kenya.

BACKGROUND: Enabling women living with HIV to effectively plan whether and when to become pregnant is an essential right; effective prevention of unintended pregnancies is also critical to reduce maternal morbidity and mortality as well as vertical transmission of HIV. The objective of this study is to examine the use of family planning (FP) services by HIV-positive and HIV-negative women in Kenya and their ability to achieve their fertility desires. METHODS: Data are derived from a random sample of women seeking family planning services in public health facilities in Kenya who had declared their HIV status (1887 at baseline and 1224 at endline) and who participated in a longitudinal study (the INTEGRA Initiative) that measured the benefits/costs of integrating HIV and sexual/reproductive health services in public health facilities. The dependent variables were FP use in the last 12 months and fertility desires (whether a woman wants more children or not). The key independent variable was HIV status (positive and negative). Descriptive statistics and multivariate logistic regression analysis were used to describe the women's characteristics and to examine the relationship between FP use, fertility desires and HIV status. RESULTS: At baseline, 13 % of the women sampled were HIV-positive. A slightly higher proportion of HIV-positive women were significantly associated with the use of FP in the last 12 months and dual use of FP compared to HIV-negative women. Regardless of HIV status, short-acting contraceptives were the most commonly used FP methods. A higher proportion of HIV-positive women were more likely to be associated with unintended (both mistimed and unwanted) pregnancies and a desire not to have more children. After adjusting for confounding factors, the multivariate results showed that HIV-positive women were significantly more likely to be associated with dual use of FP (OR = 3.2; p < 0.05). Type of health facility, marital status and household wealth status were factors associated with FP use. Factors associated with fertility desires were age, education level and household wealth status. CONCLUSIONS: The findings highlight important gaps related to utilization of FP among WLHIV. Despite having a greater likelihood of reported use of FP, HIV-positive women were more likely to have had an unintended pregnancy compared to HIV-negative women. This calls for need to strengthen family planning services for WLHIV to ensure they have better access to a wide range of FP methods. There is need to encourage the use of long-acting reversible contraceptive (LARC) to reduce the risk of unintended pregnancy and prevention of vertical transmission of HIV. However, such policies should be based on respect for women's right to informed reproductive choice in the context of HIV/AIDS. TRIAL REGISTRATION: NCT01694862

Examining user fee reductions in public primary healthcare facilities in Kenya, 1997-2012: effects on the use and content of antenatal care.

BACKGROUND: In 2004, The Kenyan government removed user fees in public dispensaries and health centers and replaced them with registration charges of 10 and 20 Kenyan shillings (2004 $US 0.13 and$0.25), respectively. This was termed the 10/20 policy. We examined the effect of this policy on the coverage, timing, source, and content of antenatal care (ANC), and the equity in these outcomes. METHODS: Data from the 2003, 2008/9 and 2014 Kenya Demographic and Health Surveys were pooled to investigate women's ANC care-seeking. We conducted an interrupted time series analysis to assess the impact of the 10/20 policy on the levels of and trends in coverage for 4+ ANC contacts among all women; early ANC initiation and use of public facility-based care among 1+ ANC users; and use of public primary care facilities and receipt of good content, or quality, of ANC among users of public facilities. All analyses were conducted at the population level and separately for women with higher and lower household wealth. RESULTS: The policy had positive effects on use of 4+ ANC among both better-off and worse-off women. Among users of 1+ ANC, the 10/20 policy had positive effects on early ANC initiation at the population-level and among better-off women, but not among the worse-off. The policy was associated with reduced use of public facility-based ANC among better-off women. Among worse-off users of public facility-based ANC, the 10/20 policy was associated with reduced use of primary care facilities and increased content of ANC. CONCLUSIONS: This study highlights mixed findings on the impact of the 10/20 policy on ANC service-seeking and content of care. Given the reduced use of public facilities among the better-off and of primary care facilities among the worse-off, this research also brings into question the mechanisms through which the policy achieved any benefits and whether reducing user fees is sufficient for equitably increasing healthcare access