Utility of brush cytology in evaluation of pre-malignant and malignant oral mucosal lesions among dental patients attending Kenyatta National Hospital

Objectives: The main objective was to determine the utility of brush cytology in evaluation of pre-malignant and malignant oral mucosal lesions.Methodology: This was a prospective cross sectional descriptive study which was carried out at Kenyatta National Hospital (KNH), Dental clinic, Surgery unit and University of Nairobi, Dental Hospital (UoN DH) from November, 2015 to April, 2016 after obtaining ethical clearance from Kenyatta National Hospital – University of Nairobi Ethics and Research Committee (KNH-UoN ERC) on participants who presented with pre malignant and malignant oral lesions. Participation in the study was voluntary and an informed consent was obtained from all participants. A structured questionnaire was used to collect socio-demographic information and clinical history. A cervical cytobrush brush (Andwin Scientific – Woodland Hills, CA 91303 USA) was used to sample oral mucosal lesions and later biopsy performed for histopathology. Oral brush cytology samples were fixed in 95% ethanol, cytospined and stained with Pap stain. Data was entered and analyzed using SPSS v 22. The results were presented using tables, charts and disseminated through presentations in conferences and publication in peer reviewed journals.Results: A total of 47 cytology and histology specimens were taken during the study and all samples were satisfactory for evaluation. The female to male ratio of participants was 1: 1.2 with an age range of 25-79 years and mean of 55 years. The main cytological patterns established at KNH and UoN Dental School Hospital was HSIL and SCC representing 97% of dysplastic and malignant lesions. Histology confirmed dysplasia and malignancy in 28 of 30 cytologically diagnosed cases. There were 2 false positives and 1 false negative cases reported. The sensitivity, specificity, positive predictive value and negative predictive values were 97%, 89%, 93% and 94% respectively with a substantial diagnostic agreement (kappa value) between cytopathology and histopathology of 86% and a p-value of ≤ 0.001.Conclusion: Brush cytology has been shown to be a reliable cytological technique for screening and early detection of oral mucosal abnormalities as it has a high sensitivity and a substantial diagnostic agreement with histopathology

Review of Health Sector Services Fund Implementation and Experience

The Health Sector Services Fund (HSSF) is an innovative scheme established by the Government of Kenya (GOK) to disburse funds directly to health facilities to enable them to improve health service delivery to local communities. HSSF empowers local communities to take charge of their health by actively involving them through the Health Facility Management Committees (HFMCs) in the identification of their health priorities and in planning and implementation of initiatives responsive to the identified priorities. Following a successful pilot of a similar mechanism, the strategy was scaled up nationwide, starting in 2010. Following the recent general election in Kenya, dramatic changes to the health system are being considered and introduced, including devolution of government functions to 47 semi-autonomous counties, the merging of the two ministries of health, and the abolition of user fees at health centres and dispensaries. Given the experience of nearly 3 years of HSSF implementation, and the context of these important changes in the organisation of health service delivery, a review of experiences to date with HSSF and key issues to consider moving forward is timely. The overall goal of HSSF is to generate sufficient resources for providing adequate curative, preventive and promotive services at community, dispensary and health centre levels, and to account for the resources in an efficient and transparent manner. HSSF can cover items such as facility operations and maintenance, refurbishment, support staff, allowances, communications, utilities, non-drug supplies, fuel and community based activities. DANIDA and the World Bank are currently partnering with the MOPHS in supporting the HSSF’s phased implementation which began in October 2010 with public health centres, and public dispensaries in July 2012. Following a facility stakeholder’s forum, HFMCs should develop annual work plans (AWPs) and quarterly implementation plans (QIPs). HSSF resources are credited directly to each designated facility’s bank account every quarter and to the District Health Management Team (DHMT): KSH 112,000 (1,339 USD) for health centres, KSH 27,500 (327 USD) for dispensaries and 131,500 (1,565 USD) for DHMTs. Other funds available to the facility, such as user fee revenue, and grants and donations received locally, should be banked in the same account, and managed and accounted for together with HSSF funds from national level. All funds should be managed by the Health Facility Management Committee (HFMC) which includes community representatives, according to the financial guidelines approved by the Ministry of Health (MOH). Funds can only be spent on receipt of an Authority to Incur Expenditure (AIE) from national level. Facilities must then account for funds using monthly and quarterly financial reports, and expenditures are recorded in a specific software called Navision. Facility level supervision and support is provided by the DHMT and county based accountants (CBAs) hired specifically for HSSF; and at national level HSSF oversight is provided by the National Health Sector Committee. This review had the following objectives: 1. To describe the process of HSSF implementation to date, including facilities covered, funds disbursed, and activities undertaken. 2. To review evidence on the experience with HSSF implementation 3. To identify key issues including devolution for consideration in future planning around HSSF These objectives have been addressed through review of policy documents, administrative reports, and research studies related to HSSF; and interviews with key stakeholders in MOPHS, DANIDA and the World Bank, to obtain updates on HSSF implementation and experience

EFFECTS OF CAPITAL FLOWS ON ECONOMIC GROWTH IN KENYA

Purpose -This study investigated the immediate and lagged effects of the various forms of capital flows - FDI flows, portfolio flows and “Other investments capital flows” (which mainly represents corporate, financial institutions and general government borrowings as well as remittances from the diaspora) - on economic growth in Kenya over a 30 year period from 1984 to 2014.   Methodology – The study adopted a quantitative research design in the form of an econometric model known as Auto Regressive Distributed Lag Model (ARDLM). Findings -FDI and portfolio investments flows have a negative impact on the GDP growth rate and that their impact is not statistically significant.However, other investments flows, which mainly represent corporate, financial institutions, general government borrowings and remittances from the diaspora, have a positive impact on GDP growth rate and the impact is statistically significant.Based  on the  study findings, it can  be inferred  that a  significant slowdown or a reversal in capital flows in form of “Other investments capital flows” into Kenya result into significant slowdown in economic growth in the country. Implications -Policy makers may lay much emphasis on attracting portfolio investment flows and “Other investments capital flows”, while investors and firms should consider the upside opportunities that may be created by increase in other investments capital flows and the downside risks that could results from a significant slowdown or a reversal in these forms of capital flows into the country

Independent impact assessment report: Participatory Rangeland Management (PRM) in Kenya and Tanzania

This report comprises findings from an independent impact assessment of the Piloting Participatory Rangeland Management project in Kenya and Tanzania. The study was conducted in November and December 2021 by African Re search and Economic Development Consultants (AFREDEC), contracted by ILRI Livestock CRP (CGIAR Research Program). The main objective was to determine the impacts of participatory rangeland management (PRM) on rangelands, environment, good governance and management processes, security of rights to land and resources, livestock production, gender issues, women’s empowerment and other social equity aspects and on policy influence. The study identified key lessons learnt and best practices and opportunities for scaling up. The assessment applied a mixed-method approach comprising quantitative data collected using household surveys and qualitative data collected using key informant interviews and focus group discussions. In total, 2,000 household representatives were interviewed through the survey, with almost 150 focus group discussion participants and more than 40 key informants

PLoS One

Introduction Patient-centered care (PCC) is an approach to involve patients in health care delivery, to contribute to quality of care, and to strengthen health systems responsiveness. This article aims to highlight patient perspectives by showcasing their perceptions of their experience of PCC at primary health facilities in two districts in Uganda. Methods A mixed methods cross-sectional study was conducted in three public and two private primary health care facilities in rural eastern Uganda. In total, 300 patient exit survey questionnaires, 31 semi-structured Interviews (SSIs), 5 Focus Group Discussions (FGDs) and 5 feedback meetings were conducted. Data analysis was guided by a conceptual framework focusing on (1) understanding patients’ health needs, preferences and expectations, (2) describing patients perceptions of their care experience according to five distinct PCC dimensions, and (3) reporting patient reported outcomes and their recommendations on how to improve quality of care. Results Patient expectations were shaped by their access to the facility, costs incurred and perceived quality of care. Patients using public facilities reported doing so because of their proximity (78.3% in public PHCs versus 23.3% in private PHCs) and because of the free services availed. On the other hand, patients attending private facilities did so because of their perception of better quality of care (84.2% in private PHCs versus 21.7% in public PHCs). Patients expectations of quality care were expressed as the availability of medication, shorter waiting times, flexible facility opening hours and courteous health workers. Analysis of the 300 responses from patients interviewed on their perception of the care they received, pointed to higher normalized scores for two out of the five PCC dimensions considered: namely, exploration of the patient’s health and illness experience, and the quality of the relationship between patient and health worker (range 62.1–78.4 out of 100). The qualitative analysis indicated that patients felt that communication with health workers was enhanced where there was trust and in case of positive past experiences. Patients however felt uncomfortable discussing psychological or family matters with health workers and found it difficult to make decisions when they did not fully understand the care provided. In terms of outcomes, our findings suggest that patient enablement was more sensitive than patient satisfaction in measuring the effect of interpersonal patient experience on patient reported outcomes. Discussion and conclusion Our findings show that Ugandan patients have some understanding of PCC related concepts and express a demand for it. The results offer a starting point for small scale PCC interventions. However, we need to be cognizant of the challenges PCC implementation faces in resource constrained settings. Patients’ expectations in terms of quality health care are still largely driven by biomedical and technical aspects. In addition, patients are largely unaware of their right to participate in the evaluation of health care. To mitigate these challenges, targeted health education focusing on patients’ responsibilities and patient’s rights are essential. Last but not least, all stakeholders must be involved in developing and validating methods to measure PCC

Stakeholder perceptions on patient-centered care at primary health care level in rural eastern Uganda: A qualitative inquiry

Background: Patient-centered care (PCC) offers opportunities for African health systems to improve quality of care. Nonetheless, PCC continually faces implementation challenges. In 2015, Uganda introduced PCC as a concept in their national quality improvement guidelines. In order to investigate whether and how this is implemented in practice, this study aims to identify relevant stakeholders’ views on the current quality of primary health care services and their understanding of PCC. This is an important step in understanding how the concept of PCC can be implemented in a resource constrained, sub-Saharan context like Uganda. Methods: This qualitative study was conducted in Uganda at national, district and facility level, with a focus on three public and three private health centres. Data collection consisted of in-depth interviews (n = 49); focus group discussions (n = 7); and feedback meetings (n = 14) across the four main categories of stakeholders identified: patients/communities, health workers, policy makers and academia. Interviews and discussions explored stakeholder perceptions on the interpersonal aspects of quality primary health care and meanings attached to the concept of PCC. A content analysis of Ugandan policy documents mentioning PCC was also conducted. Thematic content analysis was conducted using NVivo 11 to organize and analyze the data. Findings and conclusion: While Ugandan stakeholder groups have varying perceptions of PCC, they agree on the following: the need to involve patients in making decisions about their health, the key role of healthcare workers in that endeavor, and the importance of context in designing and implementing solutions. For that purpose, three avenues are recommended: Firstly, fora that include a wide range of stakeholders may offer a powerful opportunity to gain an inclusive vision on PCC in Uganda. Secondly, efforts need to be made to ensure that improved communication and information sharing–important components of PCC–translate to actual shared decision making. Lastly, the Ugandan health system needs to strengthen its engagement of the transformation from a community health worker system to a more comprehensive community health system. Cross-cutting the entire analysis, is the need to address, in a culturally-sensitive way, the many structural barriers in designing and implementing PCC policies. This is essential in ensuring the sustainable and effective implementation of PCC approaches in low- and middle-income contexts

The development of bone char-based filters for the removal of flouride from drinking water

Millions of people rely on drinking water that contains excess fluoride. Only few fluoride removal techniques have been implemented on a wider scale in low and middle income countries. One of these methods, bone char filtration, is highly efficient. However, its lifespan is rather limited. This paper presents first laboratory results and field testing of a new fluoride removal technology, based on a combination of bone char and calcium-phosphate pellets. These chemicals are slowly released to the water for fluoride precipitation. Although this method, commonly referred to as contact precipitation is known, the development of such pellets is new. Fixed-bed laboratory experiments show that this mixture of materials can increase filter uptake capacity by a factor of 3 and more. However, to reduce the phosphate concentration in the treated water, the design of full-scale community filters for field testing has to be slightly modified

Behavioral and cognitive interventions to improve treatment adherence and access to HIV care among older adults in sub-Saharan Africa: an updated systematic review

BACKGROUND: Approximately 14% of Africans infected with HIV are over the age of 50, yet few intervention studies focus on improving access to care, retention in care, and adherence to antiretroviral therapy (ART) in this population. A review of the published literature until 2012, found no relevant ART management and care interventions for older people living with HIV (OPLHIV) in sub-Saharan Africa. The aim of this systematic review is to update the original systematic review of intervention studies on OPLHIV, with a focus on evidence from sub-Saharan Africa. METHODS: We conducted a systematic review of the available published literature from 2012 to 2017 to explore behavioral and cognitive interventions addressing access to ART, retention in HIV care and adherence to ART in sub-Saharan Africa that include older adults (50+). We searched three databases (MEDLINE, EMBASE, and Education Resources Information Center) using relevant Medical Subject Headings (MeSH) terms as well as a manual search of the reference lists. No language restrictions were placed. We identified eight articles which were analyzed using content analysis with additional information obtained directly from the corresponding authors. RESULTS AND DISCUSSION: There were no studies that exclusively focused on OPLHIV. Three studies referred only to participants being over 18 years and did not specify age categories. Therefore, it is unclear whether these studies actively considered people living with HIV over the age of 50. Although the studies sampled older adults, they lacked sufficient data to draw conclusions about the relevance of the outcomes of this group. CONCLUSIONS: These findings underscore the need to increase the evidence-base of which interventions will work for older Africans on ART

Correlates of Out-of-Pocket and Catastrophic Health Expenditures in Tanzania: Results from a National Household Survey.

Inequality in health services access and utilization are influenced by out-of-pocket health expenditures in many low and middle-income countries (LMICs). Various antecedents such as social factors, poor health and economic factors are proposed to direct the choice of health care service use and incurring out-of-pocket payments. We investigated the association of these factors with out-of-pocket health expenditures among the adult and older population in the United Republic of Tanzania. We also investigated the prevalence and associated determinants contributing to household catastrophic health expenditures. We accessed the data of a multistage stratified random sample of 7279 adult participants, aged between 18 and 59 years, as well as 1018 participants aged above 60 years, from the first round of the Tanzania National Panel survey. We employed multiple generalized linear and logistic regression models to evaluate the correlates of out-of-pocket as well as catastrophic health expenditures, accounting for the complex sample design effects. Increasing age, female gender, obesity and functional disability increased the adults' out-of-pocket health expenditures significantly, while functional disability and visits to traditional healers increased the out-of-pocket health expenditures in older participants. Adult participants, who lacked formal education or worked as manual laborers earned significantly less (p < 0.001) and spent less on health (p < 0.001), despite having higher levels of disability. Large household size, household head's occupation as a manual laborer, household member with chronic illness, domestic violence against women and traditional healer's visits were significantly associated with high catastrophic health expenditures. We observed that the prevalence of inequalities in socioeconomic factors played a significant role in determining the nature of both out-of-pocket and catastrophic health expenditures. We propose that investment in social welfare programs and strengthening the social security mechanisms could reduce the financial burden in United Republic of Tanzania

Mixed methods study protocol for combining stakeholder-led rapid evaluation with near real-time continuous registry data to facilitate evaluations of quality of care in intensive care units [version 1; peer review: awaiting peer review]

BACKGROUND: Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. METHODS: Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. CONCLUSIONS: The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services