Acceptability of isoniazid preventive therapy among Healthcare providers in selected HIV clinics in Nairobi County, Kenya

A research report submitted to the Faculty of Health Sciences in Partial fulfillment of the requirements for the degree of Master of Science in Epidemiology in the field of Implementation Science School of Public Health.The University of The Witwatersrand, 25 January 2018.Background: HIV/TB co-infection causes high morbidity and mortality among people living with HIV and places immense burden to health systems in developing settings. Isoniazid Preventive Therapy (IPT) is recognised as one of the most effective means of reducing TB burden in PLHIV yet its implementation still remains suboptimal, especially in sub-Saharan Africa. IPT implementation in Kenya (a high HIV/TB burden country) remains sub-optimal and little is known about the factors that influence its implementation. Data is also limited on the acceptability of IPT among health care providers in this context. This study assessed the factors influencing the acceptability of IPT among health care providers in selected HIV clinics in Nairobi County, Kenya. Methods: The study employed a cross-sectional design with an exploratory sequential mixed methods approach whereby a qualitative study was conducted followed by a quantitative survey. It was conducted in the HIV clinics of three purposively selected public health facilities. Qualitative data were collected through in-depth interviews with 18 purposively selected health care providers while quantitative data was collected from all health care providers in the clinics (74). Qualitative data on factors influencing IPT acceptability were analysed thematically and guided the development of the quantitative tool. An acceptability score was developed from nine items guided by four constructs of the Theoretical Framework for Acceptability. Explanatory variables were generated by grouping questionnaire items that assessed factors affecting acceptability. Multivariable linear regression analysis was performed to assess the relationship between the hypothesised factors and the acceptability scores. Results The qualitative inquiry found that policy and guideline-related, provider-related, patient-related, intervention-related, structural and operational factors influenced the acceptability of IPT among health care providers. The overall mean acceptability score in the study population was 70.33% (SD: 12.79) which was categorized as moderate. The health care providers did not find the intervention fully comfortable, agreeable or satisfactory to use. Among the determinants of acceptability of IPT, patient-related: model coefficient 5.12 (95% CI -0.39 – 10.63; P=0.050) and intervention-related: model coefficient 6.72 (95% CI 3.42– 10.01; P=0.000) factors were significantly associated with the acceptability scores in the quantitative analysis. An increase in the average composite score of these factors increased the acceptability score on average. Patient-related factors included patients’ adherence to IPT, pill burden, information on IPT, development of severe side-effects, refusal of IPT medication, clinical state and drug regimen. Intervention-related factors included INH resistance, side-effects and deaths, effectiveness of IPT, procedure of IPT related activities. Conclusion IPT was generally not fully acceptable among health care providers and was influenced by a number of different contextual factors. Among these, patient-related and intervention-related factors were important factors that affected the acceptability of IPT in the context of the three clinics. The promotion of evidence-based awareness and enforcement of implementation guidelines by policy makers and program managers are required to improve the acceptability of IPT among health care providers in the HIV clinics.LG201

Impact of DREAMS interventions on experiences of violence among adolescent girls and young women: Findings from population-based cohort studies in Kenya and South Africa

DREAMS aims to reduce HIV incidence among adolescent girls and young women (AGYW) by tackling drivers of HIV risk including gender-based violence. We evaluate the impact of DREAMS on recent experiences of violence perpetuated by men against AGYW. AGYW cohorts were randomly selected from demographic platforms in South Africa (rural KwaZulu-Natal) and Kenya (Nairobi informal settlements and rural Gem sub-county). AGYW aged 13-22 years were enrolled in 2017 (Nairobi, KwaZulu-Natal) or 2018 (Gem), with annual follow-up to 2019. We described proportions of AGYW who self-reported experiences of violence perpetrated by males in the 12 months preceding the interview, overall and by form (physical, sexual, emotional). We investigated associations with DREAMS (invitation to participate during 2017-2018) through multivariable propensity score-adjusted logistic regression and estimated the causal effect of DREAMS on experiences of violence, under counter-factual scenarios in which all versus no AGYW were DREAMS beneficiaries. Among 852, 1018 and 1712 AGYW followed-up in 2019 in Nairobi, Gem and KZN, respectively, proportions reporting any violence in 2019 were higher in Nairobi (29%) than Gem (18%) and KwaZulu-Natal (19%). By sub-type, emotional and physical violence were more frequently reported than sexual violence. We found no evidence of an impact attributable to DREAMS on overall levels of violence, in any setting. Nor was there evidence of impact on sub-types of violence, with one exception: an increase in physical violence in Nairobi if all, versus no, AGYW were DREAMS beneficiaries (16% vs 11%; +5% difference [95% CI: +0.2%, +10.0%]). Experiences of gender-based violence were common among AGYW, especially in urban settings, and DREAMS had no measurable impact on reducing violence within three years of implementation. Violence prevention programming that reaches more men and the broader community, sustained for longer periods, may yield greater gains in violence reduction than AGYW-focused programming. Additionally, more investment in implementation research is needed to bridge trial-based study findings from efficacy to population-level effectiveness

Perceived health system facilitators and barriers to integrated management of hypertension and type 2 diabetes in Kenya: a qualitative study

Objective Understanding the facilitators and barriers to managing hypertension and type 2 diabetes (T2D) will inform the design of a contextually appropriate integrated chronic care model in Kenya. We explored the perceived facilitators and barriers to the integrated management of hypertension and T2D in Kenya using the Rainbow Model of Integrated Care.Design This was a qualitative study using data from a larger mixed-methods study on the health system response to chronic disease management in Kenya, conducted between July 2019 and February 2020. Data were collected through 44 key informant interviews (KIIs) and eight focus group discussions (FGDs).Setting Multistage sampling procedures were used to select a random sample of 12 study counties in Kenya.Participants The participants for the KIIs comprised purposively selected healthcare providers, county health managers, policy experts and representatives from non-state organisations. The participants for the FGDs included patients with hypertension and T2D.Outcome measures Patients’ and providers’ perspectives of the health system facilitators and barriers to the integrated management of hypertension and T2D in Kenya.Results The clinical integration facilitators included patient peer support groups for hypertension and T2D. The major professional integration facilitators included task shifting, continuous medical education and integration of community resource persons. The national referral system, hospital insurance fund and health management information system emerged as the major facilitators for organisational and functional integration. The system integration facilitators included decentralisation of services and multisectoral partnerships. The major barriers comprised vertical healthcare services characterised by service unavailability, unresponsiveness and unaffordability. Others included a shortage of skilled personnel, a lack of interoperable e-health platforms and care integration policy implementation gaps.Conclusions Our study identified barriers and facilitators that may be harnessed to improve the integrated management of hypertension and T2D. The facilitators should be strengthened, and barriers to care integration redressed

Association between invitation to DREAMS and physical violence among AGYW in Nairobi using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and physical violence among adolescent girls and young women in Nairobi using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and physical violence among AGYW in uMkhanyakude using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and physical violence among adolescent girls and young women in uMkhanyakude using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and emotional violence among AGYW in Gem using conventional logistic regression, 13–22 year-olds

Table showing the association between invitation to DREAMS and emotional violence among adolescent girls and young women in Gem using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and sexual violence among AGYW in uMkhanyakude using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and sexual violence among adolescent girls and young women in uMkhanyakude using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and sexual violence among AGYW in Nairobi using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and sexual violence among adolescent girls and young women in Nairobi using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and physical violence among AGYW in Gem using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and physical violence among adolescent girls and young women in Gem using conventional logistic regression, 13–22 year-olds

Association between invitation to DREAMS and any experience of violence among AGYW in uMkhanyakude using conventional logistic regression

Table showing the association between invitation to DREAMS and any experience of violence among adolescent girls and young women in uMkhanyakude using conventional logistic regression