Decentralising and integrating HIV services in community-based health systems: A qualitative study of perceptions at macro, meso and micro levels of the health system

Introduction HIV services at the community level in Kenya are currently delivered largely through vertical programmes. The funding for these programmes is declining at the same time as the tasks of delivering HIV services are being shifted to the community. While integrating HIV into existing community health services creates a platform for increasing coverage, normalising HIV and making services more sustainable in high-prevalence settings, little is known about the feasibility of moving to a more integrated approach or about how acceptable such a move would be to the affected parties. Methods We used qualitative methods to explore perceptions of integrating HIV services in two counties in Kenya, interviewing national and county policymakers, county-level implementers and community- level actors. Data were recorded digitally, translated, transcribed and coded in NVivo10 prior to a framework analysis. Results We found that a range of HIV-related roles such as counselling, testing, linkage, adherence support and home-based care were already being performed in the community in an ad hoc manner. But respondents expressed a desire for a more coordinated approach and for decentralising the integration of HIV services to the community level as parallel programming had resulted in gaps in HIV service and planning. In particular, integrating home-based testing and counselling within government community health structures was considered timely. Conclusion Integration can normalise HIV testing in Kenyan communities, integrate lay counsellors into the health system and address community desires for a household-led approach

'Do you trust those data?'-a mixed-methods study assessing the quality of data reported by community health workers in Kenya and Malawi.

High-quality data are essential to monitor and evaluate community health worker (CHW) programmes in low- and middle-income countries striving towards universal health coverage. This mixed-methods study was conducted in two purposively selected districts in Kenya (where volunteers collect data) and two in Malawi (where health surveillance assistants are a paid cadre). We calculated data verification ratios to quantify reporting consistency for selected health indicators over 3 months across 339 registers and 72 summary reports. These indicators are related to antenatal care, skilled delivery, immunization, growth monitoring and nutrition in Kenya; new cases, danger signs, drug stock-outs and under-five mortality in Malawi. We used qualitative methods to explore perceptions of data quality with 52 CHWs in Kenya, 83 CHWs in Malawi and 36 key informants. We analysed these data using a framework approach assisted by NVivo11. We found that only 15% of data were reported consistently between CHWs and their supervisors in both contexts. We found remarkable similarities in our qualitative data in Kenya and Malawi. Barriers to data quality mirrored those previously reported elsewhere including unavailability of data collection and reporting tools; inadequate training and supervision; lack of quality control mechanisms; and inadequate register completion. In addition, we found that CHWs experienced tensions at the interface between the formal health system and the communities they served, mediated by the social and cultural expectations of their role. These issues affected data quality in both contexts with reports of difficulties in negotiating gender norms leading to skipping sensitive questions when completing registers; fabrication of data; lack of trust in the data; and limited use of data for decision-making. While routine systems need strengthening, these more nuanced issues also need addressing. This is backed up by our finding of the high value placed on supportive supervision as an enabler of data quality

Healthcare equity analysis: applying the Tanahashi model of health service coverage to community health systems following devolution in Kenya

Background: Universal health coverage (UHC) is growing as a national political priority, within the context of recently devolved decision-making processes in Kenya. Increasingly voices within these discussions are highlighting the need for actions towards UHC to focus on quality of services, as well as improving coverage through expansion of national health insurance fund (NHIF) enrolment. Improving health equity is one of the most frequently described objectives for devolution of health services. Previous studies, however, highlight the complexity and unpredictability of devolution processes, potentially contributing to widening rather than reducing disparities. Our study applied Tanahashi's equity model (according to availability, accessibility, acceptability, contact with and quality) to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya.Methods: We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach.Results: Our findings reveal that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date.Conclusions: If Kenya is to achieve universal health coverage for all citizens, then county governments must address all aspects of equity, including quality. Through application of the Tanahashi framework, we find that community health services can play a crucial role towards achieving health equity

Microarray patch for HIV prevention and as a multipurpose prevention technology to prevent HIV and unplanned pregnancy: an assessment of potential acceptability, usability, and programmatic fit in Kenya

BackgroundMicroarray patches (MAPs), a novel drug delivery system, are being developed for HIV pre-exposure prophylaxis (PrEP) delivery and as a multipurpose prevention technology (MPT) to protect from both HIV and unintended pregnancy. Prevention technologies must meet the needs of target audiences, be acceptable, easy to use, and fit health system requirements.MethodologyWe explored perceptions about MAP technology and assessed usability, hypothetical acceptability, and potential programmatic fit of MAP prototypes using focus group discussions (FGD), usability exercises, and key informant interviews (KII) among key populations in Kiambu County, Kenya. Adolescent girls and young women (AGYW), female sex workers (FSW), and men who have sex with men (MSM) assessed the usability and acceptability of a MAP prototype. Male partners of AGYW/FSW assessed MAP acceptability as partners of likely users. We analyzed data using NVivo, applying an inductive approach. Health service providers and policymakers assessed programmatic fit. Usability exercise participants applied a no-drug, no-microneedle MAP prototype and assessed MAP features.ResultsWe implemented 10 FGD (4 AGYW; 2 FSW; 2 MSM; 2 male partners); 47 mock use exercises (19 AGYW; 9 FSW; 8 MSM; 11 HSP); and 6 policymaker KII. Participants reported high interest in MAPs due to discreet and easy use, long-term protection, and potential for self-administration. MAP size and duration of protection were key characteristics influencing acceptability. Most AGYW preferred the MPT MAP over an HIV PrEP-only MAP. FSW saw value in both MAP indications and voiced need for MPTs that protect from other infections. Preferred duration of protection was 1–3 months. Some participants would accept a larger MAP if it provided longer protection. Participants suggested revisions to the feedback indicator to improve confidence. Policymakers described the MPT MAP as “killing two birds with one stone,” in addressing AGYW needs for both HIV protection and contraception. An MPT MAP is aligned with Kenya's policy of integrating health care programs.ConclusionsMAPs for HIV PrEP and as an MPT both were acceptable across participant groups. Some groups valued an MPT MAP over an HIV PrEP MAP. Prototype refinements will improve usability and confidence

Safeguarding in practice: anticipating, minimising and mitigating risk in teenage pregnancy research in urban informal settlements in Nairobi, Kenya

Safeguarding challenges in global health research include sexual abuse and exploitation, physical and psychological abuse, financial exploitation and neglect. Intersecting individual identities (such as gender and age) shape vulnerability to risk. Adolescents, who are widely included in sexual and reproductive health research, may be particularly vulnerable. Sensitive topics like teenage pregnancy may lead to multiple risks. We explored potential safeguarding risks and mitigation strategies when studying teenage pregnancies in informal urban settlements in Nairobi, Kenya. Risk mapping was initiated by the research team that had prolonged engagement with adolescent girls and teen mothers. The team mapped potential safeguarding risks for both research participants and research staff due to, and unrelated to, the research activity. Mitigation measures were agreed for each risk. The draft risk map was validated by community members and coresearchers in a workshop. During implementation, safeguarding risks emerged across the risk map areas and are presented as case studies. Risks to the girls included intimate partner violence because of a phone provided by the study; male participants faced potential disclosure of their perceived criminal activity (impregnating teenage girls); and researchers faced psychological and physical risks due to the nature of the research. These cases shed further light on safeguarding as a key priority area for research ethics and implementation. Our experience illustrates the importance of mapping safeguarding risks and strengthening safeguarding measures throughout the research lifecycle. We recommend co-developing and continuously updating a safeguarding map to enhance safety, equity and trust between the participants, community and researchers

Intra-urban variation of intimate partner violence against women and men in Kenya: Evidence from the 2014 Kenya Demographic and Health Survey

Although urban areas are diverse and urban inequities are well documented, surveys commonly differentiate intimate partner violence (IPV) rates only by urban versus rural residence. This study compared rates of current IPV victimization among women and men by urban residence (informal and formal settlements). Data from the 2014 Kenya Demographic and Health Survey, consisting of an ever-married sample of 1,613 women (age 15-49 years) and 1,321 men (age 15-54), were analyzed. Multilevel logistic regression was applied to female and male data separately to quantify the associations between residence and any current IPV while controlling for regional variation and other factors. Results show gendered patterns of intra-urban variation in IPV occurrence, with the greatest burden of IPV identified among women in informal settlements (across all types of violence). Unadjusted analyses suggest residing in informal settlements is associated with any current IPV against women, but not men, compared with their counterparts in formal urban settlements. This correlation is not statistically significant when adjusting for women’s education level in multivariate analysis. In addition, reporting father beat mother, use of current physical violence against partner, partner’s alcohol use, and marital status are associated with any current IPV against women and men. IPV gets marginal attention in urban violence and urban health research and our results highlight the importance of spatially disaggregate IPV data – beyond the rural-urban divide – to inform policy and programming. Future research may utilize intersectional and syndemic approaches to investigate the complexity of IPV and clustering with other forms of violence and other health issues in different urban settings, especially among marginalized residents in informal urban settings

Power and poverty: A participatory study on the complexities of HIV and intimate partner violence in an informal urban settlement in Nairobi, Kenya

People in informal urban settlements in Kenya face multiple inequalities, yet researchers investigate issues such as HIV or intimate partner violence (IPV) in isolation, targeting single populations and focusing on individual behaviour, without involving informal settlement dwellers. We formed a study team of researchers (n = 4) and lay investigators (n = 11) from an informal settlement in Nairobi, Kenya to understand the power dynamics in the informal urban settlement that influence vulnerability to IPV and HIV among women and men from key populations in this context. We facilitated participatory workshops with 56 women and 32 men from different marginalised groups and interviewed 10 key informants. We used a participatory data analysis approach. Our findings suggest the IPV and HIV nexus is rooted in the daily struggle for cash and survival in the informal settlement where lucrative livelihoods are scarce and a few gatekeepers regulate access to opportunities. Power is gendered and used to exercise control over people and resources. Common coping strategies applied to mitigate against the effects of poverty and powerlessness amplify vulnerabilities to HIV and IPV. These complex power relations create and sustain an environment conducive to IPV and HIV. Prevention interventions thus need to address underlying structural drivers, uphold human rights, create safe environments, and promote participation to maximise and sustain the positive effects of biomedical, behavioural, and empowerment strategies

Leaving No One Behind: A Photovoice Case Study on Vulnerability and Wellbeing of Children Heading Households in Two Informal Settlements in Nairobi

Children heading households (CHH) in urban informal settlements face specific vulnerabilities shaped by limitations on their opportunities and capabilities within the context of urban inequities, which affect their wellbeing. We implemented photovoice research with CHHs to explore the intersections between their vulnerabilities and the social and environmental context of Nairobi’s informal settlements. We enrolled and trained four CHHs living in two urban informal settlements—Korogocho and Viwandani—to utilise smartphones to take photos that reflected their experiences of marginalisation and what can be done to address their vulnerabilities. Further, we conducted in-depth interviews with eight more CHHs. We applied White’s wellbeing framework to analyse data. We observed intersections between the different dimensions of wellbeing, which caused the CHHs tremendous stress that affected their mental health, social interactions, school performance and attendance. Key experiences of marginalisation were lack of adequate food and nutrition, hazardous living conditions and stigma from peers due to the limited livelihood opportunities available to them. Despite the hardships, we documented resilience among CHH. Policy action is required to take action to intervene in the generational transfer of poverty, both to improve the life chances of CHHs who have inherited their parents’ marginalisation, and to prevent further transfer of vulnerabilities to their children. This calls for investing in CHHs’ capacity for sustaining livelihoods to support their current and future independence and wellbeing

“It’s like these CHCs don’t exist, are they featured anywhere?”: Social network analysis of community health committees in a rural and urban setting in Kenya

Background In Kenya, Community Health Committees (CHC) were established to enhance community participation in health services. Their role is to provide leadership, oversight in delivery of community health services, promote social accountability and mobilize resources for community health. CHCs form social networks with other actors, with whom they exchange health information for decision-making and accountability. This case study aimed to explore the structure of a rural and an urban CHC network and to analyze how health-related information flowed in these networks. Understanding the pathways of information in community settings may provide recommendations for strategies to improve the role and functioning of CHCs. Methods In 2017, we conducted 4 focus group discussions with 27 community discussants and 10 semi-structured interviews with health professionals in a rural area and an urban slum. Using social network analysis, we determined the structure of their social networks and how health related information flowed in these networks. Results Both CHCs were composed of respected persons nominated by their communities. Each social network had 12 actors that represented both community and government institutions. CHCs were not central actors in the exchange of health-related information. Health workers, community health volunteers and local Chiefs in the urban slum often passed information between the different groups of actors, while CHCs hardly did this. Therefore, CHCs had little control over the flow of health-related information. Although CHC members were respected persons who served in multiple roles within their communities, this did not enhance their centrality. It emerged that CHCs were often left out in the flow of health-related information and decision-making, which led to demotivation. Community health volunteers were more involved by other actors such as health managers and non-governmental organizations as a conduit for health-related information. Conclusion Social network analysis demonstrated how CHCs played a peripheral role in the flow of health-related information. Their perception of being left out of the information flow led to demotivation, which hampered their ability to facilitate community participation in community health services; hence challenging effective participation through CHCs

Limits and opportunities to community health worker empowerment: A multi-country comparative study.

BACKGROUND In LMICs, Community Health Workers (CHW) increasingly play health promotion related roles involving 'Empowerment of communities'. To be able to empower the communities they serve, we argue, it is essential that CHWs themselves be, and feel, empowered. We present here a critique of how diverse national CHW programs affect CHW's empowerment experience. METHODS We present an analysis of findings from a systematic review of literature on CHW programs in LMICs and 6 country case studies (Bangladesh, Ethiopia, Indonesia, Kenya, Malawi, Mozambique). Lee & Koh's analytical framework (4 dimensions of empowerment: meaningfulness, competence, self-determination and impact), is used. RESULTS CHW programs empower CHWs by providing CHWs, access to privileged medical knowledge, linking CHWs to the formal health system, and providing them an opportunity to do meaningful and impactful work. However, these empowering influences are constantly frustrated by - the sense of lack/absence of control over one's work environment, and the feelings of being unsupported, unappreciated, and undervalued. CHWs expressed feelings of powerlessness, and frustrations about how organisational processual and relational arrangements hindered them from achieving the desired impact. CONCLUSIONS While increasingly the onus is on CHWs and CHW programs to solve the problem of health access, attention should be given to the experiences of CHWs themselves. CHW programs need to move beyond an instrumentalist approach to CHWs, and take a developmental and empowerment perspective when engaging with CHWs. CHW programs should systematically identify disempowering organisational arrangements and take steps to remedy these. Doing so will not only improve CHW performance, it will pave the way for CHWs to meet their potential as agents of social change, beyond perhaps their role as health promoters