Why do women deliver where they had not planned to go? A qualitative study from peri-urban Nairobi Kenya.

BACKGROUND: In urban Kenya, couples face a wide variety of choices for delivery options; however, many women end up delivering in different facilities from those they had intended while pregnant. One potential consequence of this is delivering in facilities that do not meet minimum quality standards and lack the capacity to provide treatment for obstetric and neonatal complications. METHODS: This study investigated why women in peri-urban Nairobi, Kenya deliver in facilities they had not intended to use. We used 60 in-depth audio-recorded interviews in which mothers shared their experiences 2-6 months after delivery. Descriptive statistics were used to summarize socio-demographic characteristics of participants. Qualitative data were analyzed in three steps i) exploration and generation of initial codes; ii) searching for themes by gathering coded data that addressed specific themes; and iii) defining and naming identified themes. Verbatim excerpts from participants were provided to illustrate study findings. The Health Belief Model was used to shed light on individual-level drivers of delivery location choice. RESULTS: Findings show a confluence of factors that predispose mothers to delivering in unintended facilities. At the individual level, precipitate labor, financial limitations, onset of pain, complications, changes in birth plans, undisclosed birth plans, travel during pregnancy, fear of health facility providers, misconception of onset of labor, wrong estimate of delivery date, and onset of labor at night, contributed to delivery at unplanned locations. On the supply side, the sudden referral to other facilities, poor services, wrong projection of delivery date, and long distance to chosen delivery facility, were factors in changes in delivery location. Lack of transport discouraged delivery at a chosen health facility. Social influences included others\u27 perspectives on delivery location and lack of aides/escorts. CONCLUSIONS: Results from this study suggest that manifold factors contribute to the occurrence of women delivering in facilities that they had not intended during pregnancy. Future studies should consider whether these changes in delivery location late in pregnancy contribute to late facility arrival and the use of lower quality facilities. Deliberate counseling during antenatal care regarding birth plans is likely to encourage timely arrival at facilities consistent with women\u27s preferences

Refining a questionnaire to assess breast cancer knowledge and barriers to screening in Kenya: Psychometric assessment of the BCAM

Background Our study objective was to determine the validity and reliability of the breast module of a cancer awareness measure (BCAM) among adult women in western Kenya. Methods The study was conducted between October and November 2012, following three breast cancer screening events. Purposive and systematic random sampling methods were used to identity 48 women for cognitive focus group discussions, and 1061 (594 who attended vs. 467 who did not attend screening events) for surveys, respectively. Face and psychometric validity of the BCAM survey was assessed using cognitive testing, factor analysis of survey data, and correlations. Internal reliability was assessed using Cronbach’s alpha. Results Among survey participants, the overall median age was 34 (IQR: 26–44) years. Compared to those women who did not attend the screening events, women attendees were older (median: 35 vs. 32 years, p = 0.001) more often married (79% vs. 72%, p = 0.006), more educated (52% vs. 46% with more than an elementary level of education, p = 0.001), more unemployed (59% vs. 11%, p = 0.001), more likely to report doing breast self-examination (56% vs. 40%, p = 0.001) and more likely to report having felt a breast lump (16% vs. 7%, p = 0.001). For domain 1 on knowledge of breast cancer symptoms, one factor (three items) with Eigen value of 1.76 emerged for the group that did not attend screening, and 1.50 for the group that attended screening. For both groups two factors (factor 1 “internal influences” and factor 2 “external influences”) emerged among domain 4 on barriers to screening, with varied item loadings and Eigen values. There were no statistically significant differences in the factor scores between attendees and non-attendees. There were significant associations between factor scores and other attributes of the surveyed population, including associations with occupation, transportation type, and training for and practice of breast self-examination. Cronbach’s alpha showed an acceptable internal consistency. Conclusion Certain subpopulations are less likely than others to attend breast screening in Kenya. A survey measure of breast cancer knowledge and perceived barriers to screening shows promise for use in Kenya for characterizing clinical and community population beliefs, but needs adaptation for setting, language and culture

Barriers to uptake of breast cancer screening in Kenya

Objectives: To conduct clinical breast cancer screening in three sites in Western Kenya and explore community barriers to screening uptake.Design: Cross-sectional study.Setting: Western Kenya specifically, Mosoriot, Turbo, and Kapsokwony.Subjects: Community members (18 years and older) who did not attend the screening events.Outcome Measure: The outcome measure was having heard about the breast cancer screening events. Both structured and open-ended questions were used for datacollection. Item frequency, correlations, and content analyses were performed.Results: A total of 733 community members were surveyed (63% women, median age 33 years, IQR=26-43). More than half (55%) of respondents had heard about the screening but did not attend. The majority of those who had heard about this particular screening had knowledge of screening availability in general (45% vs. 25%, p<0.001). Only 8.0% of those who heard and 6.0% of those who had not heard of the screening event hadpreviously undergone clinical breast exam (p=0.20). Reasons for not attending the screening event were personal factors, including busy schedule (41.0%), perceived low personal risk (12.7%), lack of transport (4.2%), as well as health facility factors such as poor publicity (14.4%) and long queues (8.7%).Conclusion: Barriers to breast cancer screening uptake were associated with inadequate publicity, perceived long waits at event and busy lives among community women

Early detection of cervical cancer in western Kenya : determinants of healthcare providers performing a gynaecological examination for abnormal vaginal discharge or bleeding

Background In western Kenya, women often present with late-stage cervical cancer despite prior contact with the health care system. The aim of this study was to predict primary health care providers' behaviour in examining women who present with abnormal discharge or bleeding. Methods This was a cross-sectional survey using the theory of planned behaviour (TPB). A sample of primary health care practitioners in western Kenya completed a 59-item questionnaire. Structural equation modelling was used to identify the determinants of providers' intention to perform a gynaecological examination. Bivariate analysis was conducted to investigate the relationship between the external variables and intention. Results Direct measures of subjective norms (DMSN), direct measures of perceived behavioural control (DMPBC), and indirect measures of attitude predicted the intention to examine patients. Negative attitudes toward examining women had a suppressor effect on the prediction of health workers' intentions. However, the predictors of intention with the highest coefficients were the external variables being a nurse (beta = 0.32) as opposed to a clinical officer and workload of attending less than 50 patients per day (beta = 0.56). In bivariate analysis with intention to perform a gynaecological examination, there was no evidence that working experience, being female, having a lower workload, or being a private practitioner were associated with a higher intention to conduct vaginal examinations. Clinical officers and nurses were equally likely to examine women. Conclusions The TPB is a suitable theoretical basis to predict the intention to perform a gynaecological examination. Overall, the model predicted 47% of the variation in health care providers' intention to examine women who present with recurrent vaginal bleeding or discharge. Direct subjective norms (health provider's conformity with what their colleagues do or expect them to do), PBC (providers need to feel competent and confident in performing examinations in women), and negative attitudes toward conducting vaginal examination accounted for the most variance. External variables in this study also contributed to the overall variance. As the model in this study could not explain 53% of the variance, investigating other external variables that influence the intention to examine women should be undertaken

Early detection of cervical cancer in western Kenya: determinants of healthcare providers performing a gynaecological examination for abnormal vaginal discharge or bleeding

Background: In western Kenya, women often present with late-stage cervical cancer despite prior contact with the health care system. The aim of this study was to predict primary health care providers’ behaviour in examining women who present with abnormal discharge or bleeding. Methods: This was a cross-sectional survey using the theory of planned behaviour (TPB). A sample of primary health care practitioners in western Kenya completed a 59-item questionnaire. Structural equation modelling was used to identify the determinants of providers’ intention to perform a gynaecological examination. Bivariate analysis was conducted to investigate the relationship between the external variables and intention. Results: Direct measures of subjective norms (DMSN), direct measures of perceived behavioural control (DMPBC), and indirect measures of attitude predicted the intention to examine patients. Negative attitudes toward examining women had a suppressor effect on the prediction of health workers’ intentions. However, the predictors of intention with the highest coefficients were the external variables being a nurse (β = 0.32) as opposed to a clinical officer and workload of attending less than 50 patients per day (β = 0.56). In bivariate analysis with intention to perform a gynaecological examination, there was no evidence that working experience, being female, having a lower workload, or being a private practitioner were associated with a higher intention to conduct vaginal examinations. Clinical officers and nurses were equally likely to examine women. Conclusions: The TPB is a suitable theoretical basis to predict the intention to perform a gynaecological examination. Overall, the model predicted 47% of the variation in health care providers’ intention to examine women who present with recurrent vaginal bleeding or discharge. Direct subjective norms (health provider’s conformity with what their colleagues do or expect them to do), PBC (providers need to feel competent and confident in performing examinations in women), and negative attitudes toward conducting vaginal examination accounted for the most variance. External variables in this study also contributed to the overall variance. As the model in this study could not explain 53% of the variance, investigating other external variables that influence the intention to examine women should be undertaken

Impact of an Educational Intervention on Breast Cancer Knowledge in Western Kenya

Our objective was to assess the effectiveness of educational sessions that accompanied breast cancer screening events in three communities in western Kenya between October and November 2013. Five hundred and thirty-two women were recruited to complete a test of breast cancer-relevant knowledge and randomly allocated to ‘pre-test’ or ‘post-test’ groups that immediately preceded or followed participation in the educational sessions. The education was organized as a presentation by health professionals and focused mainly on causes of breast cancer, early and late cancer presentation signs, high-risk groups, screening methods to find early-stage breast cancer, self-breast exam procedures and treatment options for this disease. Participants were invited to ask questions and practice finding nodules in silicone breast models. The median age was 35 years (interquartile range: 28–45), and 86% had not undergone breast cancer screening previously. Many individual items in our test of knowledge showed statistically significant shifts to better-informed responses. When all items in the assessment questionnaire were scored as a ‘test’, on average there was a 2.80 point (95% CI: 2.38, 3.22) significant improvement in knowledge about breast cancer after the educational session. Our study provides evidence for the effectiveness of an educational strategy carefully tailored for women in these communities in Kenya

Qualitative exploration of perceived benefits of care and barriers influencing HIV care in trans Nzoia, Kenya

Background: Substantial efforts have been made to ensure people living with HIV (PLHIV) are linked to and retained in care but many challenges deter care utilization. We report perceived benefits of seeking HIV care and barriers to HIV care that were identified through a formative assessment conducted to advise the development of an alternative care model to deliver antiretroviral treatment therapy (ART) in Trans Nzoia County, Kenya. Methods: Data were collected in 2015 through key informant interviews (KIIs), in-depth interviews (IDIs), and focus group discussions (FGDs). The study involved 55 participants of whom 53% were female. Ten KIIs provided community contextual information and viewpoints on the HIV epidemic in Trans Nzoia County while 20 PLHIV (10 male and 10 female) participated in IDIs. Twenty-five individuals living with HIV participated in four FGDs - two groups for men and two for women. Key informants were purposively selected, while every third patient above 18 years at the Kitale HIV Clinic was invited to share their HIV care experience through IDIs or FGDs. Trained research assistants moderated all sessions and audio recordings were transcribed and analyzed thematically. Results: Findings showed that PLHIV in Trans Nzoia County used both conventional and complementary alternative care for HIV; however, public health facilities were preferred. Popular perceived benefits of adopting care were relief from symptoms and the chance to live longer. Benefits of care uptake included weight gain, renewed energy, and positive behavior change. Individual-level barriers to HIV care included lack of money and food, use of alternative care, negative side effects of ART, denial, and disclosure difficulties. At the community level, stigma, limited social support for conventional HIV treatment, and poor means of transport were reported. The health system barriers were limited supplies and staff, long distance to conventional HIV care, and unprofessional providers. Conclusions: Diverse individual, community and health system barriers continue to affect HIV care-seeking efforts in Kenya. Appreciation of context and lived experiences allows for development of realistic care models

Survival of cervical cancer patients at Moi teaching and Referral Hospital, Eldoret in western Kenya

Background Cervical cancer is a major health burden and the second most common cancer after breast cancer among women in Kenya. Worldwide cervical cancer constitutes 3.1% of all cancer cases. Mortality rates are greatest among the low-income countries because of lack of awareness, screening and early-detection programs and adequate treatment facilities. The main aim was to estimate survival and determine survival predictors of women with cervical cancer and limited resources in western Kenya. Methods Retrospective charts review of women diagnosed with cervical cancer and follow-up for two years from the date of the histologic diagnosis. The outcome of interest was death or survival at two years. Kaplan Meier estimates of survival, log-rank test and Cox proportional hazards regression were used in the survival analysis. Results One hundred and sixty-two (162) participants were included in the review. The median duration was 0.8 (interquartile range (IQR) 0.3, 1.6) years. The mean age at diagnosis was 50.6 years (SD12.5). The mean parity was 5.9 (SD 2.6). Fifty percent (50%) did not have health insurance. Twenty six percent (26%) used hormonal contraceptives, 25.9% were HIV positive and 70% of them were on anti-retroviral treatment. The participants were followed up for 152.6 person years. Of the 162 women in the study, 70 (43.2%) died giving an overall incidence rate (IR) of 45.9 deaths per 100 person years of follow up. The hazard ratios were better for the patients who survived (0.44 vs 0.88, p-value \u3c 0.001), those who had medical insurance (0.70 vs 0.48, p-value = 0.007) and those with early stage at diagnosis (0.88 vs 0.39, p-value \u3c 0.001). Participants who were diagnosed at late stage of the disease according to the International Federation of Gynecology and Obstetrics staging for cervical cancer (FIGO stage 2B-4B) had more than eight times increased hazard of death compared to those who were diagnosed at early stage (1-2A): Hazard Ratio: 8.01 (95% CI 3.65, 17.57). Similarly, those who underwent surgical management had 84% reduced hazard of mortality compared to those who were referred for other modes of care: HR: 0.16 (95% CI: 0.07, 0.38). Conclusion: Majority of the participants were diagnosed late after presenting with symptoms. The 1 and 2-year survival probability after diagnosis of cervical cancer was 57% AND 45% respectively. It is imperative that women present early since surgery gives better prognosis or better still screening of all women prioritized