Impact of training on knowledge, confidence and attitude amongst community health volunteers in the provision of community-based palliative care in rural Kenya.

OBJECTIVES: Existing literature suggests multiple potential roles for community health volunteers (CHVs) in the provision of palliative care (PC) in low- and middle-income countries. In Kenya the role of CHV in the provision of PC has not been reported. The objective of this study was to assess knowledge, confidence, attitude, and clinical practice of community health volunteers after attending a novel palliative care (PC) training program. METHODS: A total of 105 CHVs participated in a 3-day in person training followed by a 1-month in person and telephone observation period of the palliative care activities in the community. Structured questionnaires were used pre- and post-training to assess knowledge acquisition, impact on practice, and content delivery. A mixed method study design was conducted 12-month post training to assess impact on clinical practice. RESULTS: Immediately after training, CHV provided positive ratings on relevance and content delivery. In the month following training, CHVs evaluated 1,443 patients, referred 154, and conducted 110 and 129 tele consults with the patients and PC providers respectively. The follow up survey at 12 months revealed improved knowledge and confidence in various domains of palliative care including symptom and spiritual assessment and provision of basic nursing and bereavement care. Focus group discussions revealed the CHVs ability to interpret symptoms, make referrals, improved communication/ interpersonal relationships, spiritual intervention, patient comfort measures and health care practices as newly learned and practiced skills. CONCLUSIONS: We noted improved knowledge, new skills and change in practice after CHVs participation in a novel training curriculum. CHVs can make important contributions to the PC work force and be first line PC providers in the community as part of larger hub and spoke care model.

A pragmatic approach to equitable global health partnerships in academic health sciences.

Global partnerships offer opportunities for academic departments in the health sciences to achieve mutual benefits. However, they are often challenged by inequities in power, privilege and finances between partners that have plagued the discipline of global health since its founding. In this article, a group of global health practitioners in academic medicine offer a pragmatic framework and practical examples for designing more ethical, equitable and effective collaborative global relationships between academic health science departments, building on the principles laid out by the coalition Advocacy for Global Health Partnerships in the Brocher declaration.

Community-based medication delivery program for antihypertensive medications improves adherence and reduces blood pressure.

Non-adherence to antihypertensive medications is a major cause of uncontrolled hypertension, leading to cardiovascular morbidity and mortality. Ensuring consistent medication possession is crucial in addressing non-adherence. Community-based medication delivery is a strategy that may improve medication possession, adherence, and blood pressure (BP) reduction. Our program in Kenya piloted a community medication delivery program, coupled with blood pressure monitoring and adherence evaluation. Between September 2019 and March 2020, patients who received hypertension care from our chronic disease management program also received community-based delivery of antihypertensive medications. We calculated number of days during which each patient had possession of medications and analyzed the relationship between successful medication delivery and self-reported medication adherence and BP. A total of 128 patient records (80.5% female) were reviewed. At baseline, mean systolic blood pressure (SBP) was 155.7 mmHg and mean self-reported adherence score was 2.7. Sixty-eight (53.1%) patients received at least 1 successful medication delivery. Our pharmacy dispensing records demonstrated that medication possession was greater among patients receiving medication deliveries. Change in self-reported medication adherence from baseline worsened in patients who did not receive any medication delivery (+0.5), but improved in patients receiving 1 delivery (-0.3) and 2 or more deliveries (-0.8). There was an SBP reduction of 1.9, 6.1, and 15.5 mmHg among patients who did not receive any deliveries, those who received 1 delivery, and those who received 2 or more medication deliveries, respectively. Adjusted mixed-effect model estimates revealed that mean SBP reduction and self-reported medication adherence were improved among individuals who successfully received medication deliveries, compared to those who did not. A community medication delivery program in western Kenya was shown to be implementable and enhanced medication possession, reduced SBP, and significantly improved self-reported adherence. This is a promising strategy to improve health outcomes for patients with uncontrolled hypertension that warrants further investigation.

The Relationship Between Household Microfinance Group Participation and Vaccine Adherence Among Children in Rural Western Kenya.

INTRODUCTION: High childhood vaccine adherence is critical for disease prevention, and poverty is a key barrier to vaccine uptake. Interventions like microfinance programs that aim to lift individuals out of poverty could thus improve vaccine adherence of the children in the household. BIGPIC Family Program in rural Western Kenya provides group-based microfinance services while working to improve access to healthcare and health screenings for the local community. The aim of the present paper is to evaluate the association between household participation in BIGPIC's microfinance program and vaccine adherence among children in the household. We hypothesize that microfinance group participation will have a positive impact on vaccine adherence among children in the household. METHODS: From 2018 to 2019, we surveyed a sample of 300 participants from two rural communities in Western Kenya, some of whom were participants in the BIGPIC Family's microfinance program. The primary outcome of interest was vaccine adherence of children in the household. Log-binomial models were used to estimate the relationship between microfinance group participation and vaccine adherence, adjusted for key covariates. We also assessed whether the relationship differed by gender of the adult respondent. RESULTS: Microfinance group members were more likely to have all children in their households fully vaccinated [aPR (95% CI): 1.68 (1.20,2.35)] compared to non-microfinance group members. Further, the association was stronger when women were the microfinance members [PR (95% CI): 1.87 (1.27,2.76)] compared to men [PR (95% CI): 1.24 (0.81,1.90)]. CONCLUSIONS: Microfinance participation was associated with higher childhood vaccine adherence in rural Western Kenya. Microfinance interventions should be further explored as strategies to improve child health and well-being in low- and middle-income countries.

Supply-chain strategies for essential medicines in rural western Kenya during COVID-19.

PROBLEM: The coronavirus disease 2019 (COVID-19) pandemic has disrupted health systems worldwide and threatened the supply of essential medicines. Especially affected are vulnerable patients in low- and middle-income countries who can only afford access to public health systems. APPROACH: Soon after physical distancing and curfew orders began on 15 March 2020 in Kenya, we rapidly implemented three supply-chain strategies to ensure a continuous supply of essential medicines while minimizing patients' COVID-19 exposure risks. We redistributed central stocks of medicines to peripheral health facilities to ensure local availability for several months. We equipped smaller, remote health facilities with medicine tackle boxes. We also made deliveries of medicines to patients with difficulty reaching facilities. LOCAL SETTING: Τo implement these strategies we leveraged our 30-year partnership with local health authorities in rural western Kenya and the existing revolving fund pharmacy scheme serving 85 peripheral health centres. RELEVANT CHANGES: In April 2020, stocks of essential chronic and non-chronic disease medicines redistributed to peripheral health facilities increased to 835 140 units, as compared with 316 330 units in April 2019. We provided medicine tackle boxes to an additional 46 health facilities. Our team successfully delivered medications to 264 out of 311 patients (84.9%) with noncommunicable diseases whom we were able to reach. LESSONS LEARNT: Our revolving fund pharmacy model has ensured that patients' access to essential medicines has not been interrupted during the pandemic. Success was built on a community approach to extend pharmaceutical services, adapting our current supply-chain infrastructure and working quickly in partnership with local health authorities.

Closing the loop in child TB contact management: completion of TB preventive therapy outcomes in western Kenya.

SETTING: Children especially those <5 years of age exposed to pulmonary tuberculosis (TB) are at a high risk of severe TB disease and death. Isoniazid preventive therapy (IPT) has been shown to decrease disease progression by up to 90%. Kenya, a high TB burden country experiences numerous operational challenges that limit implementation of TB preventive services. IPT completion in child contacts is not routinely reported in Kenya. OBJECTIVE: This study aims to review the child contact management (CCM) cascade and present IPT outcomes across 10 clinics in western Kenya. DESIGN: A retrospective chart review of programmatic data of a TB Reach-funded active, clinic-based CCM strategy. RESULTS: Of 553 child contacts screened, 231 (42%) were reported symptomatic. 74 (13%) of the child contacts were diagnosed with active TB disease. Of those eligible for IPT, 427 (90%) initiated IPT according to TB REACH project data while 249 (58%) were recorded in the IPT register with 49 (11%) recorded as a transfer to other facilities. Of the 249 recorded in the IPT register, 205 (82%) were documented to complete therapy (48% of project initiation children). CONCLUSION: Our evaluation shows gaps in the routine CCM care cascade related to completeness of documentation that require further programmatic monitoring and evaluation to improve CCM outcomes.

The relationship between a microfinance-based healthcare delivery platform, health insurance coverage, health screenings, and disease management in rural Western Kenya.

BACKGROUND: Structural barriers often prevent rural Kenyans from receiving healthcare and diagnostic testing. The Bridging Income Generation through grouP Integrated Care (BIGPIC) Family intervention facilitates microfinance groups, provides health screenings and treatment, and delivers education about health insurance coverage to address some of these barriers. This study evaluated the association between participation in BIGPIC microfinance groups and health screening/disease management outcomes. METHODS: From November 2018 to March 2019, we interviewed a sample of 300 members of two rural communities in Western Kenya, 100 of whom were BIGPIC microfinance members. We queried participants about their experiences with health screening and disease management for HIV, diabetes, hypertension, tuberculosis, and cervical cancer. We used log-binomial regression models to estimate the association between microfinance membership and each health outcome, adjusting for key covariates. RESULTS: Microfinance members were more likely to be screened for most of the health conditions we queried, including those provided by BIGPIC [e.g. diabetes: aPR (95% CI): 3.46 (2.60, 4.60)] and those not provided [e.g. cervical cancer: aPR (95% CI): 2.43 (1.21, 4.86)]. Microfinance membership was not significantly associated with health insurance uptake and disease management outcomes. CONCLUSIONS: In rural Kenya, a microfinance program integrated with healthcare delivery may be effective at increasing health screening. Interventions designed to thoughtfully and sustainably address structural barriers to healthcare will be critical to improving the health of those living in low-resource settings.

Twin pregnancy in a bicornuate uterus in rural Kenya: A case report for accidental discovery and successful delivery.

INTRODUCTION: Uterine anomalies are often identified during pregnancy, during infertility evaluation or pregnancy miscarriage and have been associated with an increased risk of adverse pregnancy outcomes. Although some studies have documented the rare occurrence of spontaneous twin pregnancy in each horn of a bicornuate uterus, this is the first time this is being documented in Kenya, to the best of our knowledge. This is a rare occurrence and reporting of this case adds to the documentation of such cases. PATIENT PRESENTATION: This is a case report for a 30-year-old female, para 2+0 at 34 weeks 4 days by dates, who presented with features of labour. Upon examination, she had normal vital signs and a fundal height of 38 weeks with multiple foetal parts both in cephalic presentation and two foetal heart rates within normal range. Her antenatal profile was non-contributory and had undergone two ultrasounds that confirmed twin gestation with no other notable findings.Management and outcome: The patient had a spontaneous vertex delivery of the first twin with a good outcome. There was a delay in the delivery of the second twin and a caesarean section was done with an indication of non-reassuring foetal status and low-lying placenta. The bicornuate uterus was accidentally identified during the surgery. The outcome was good, with an APGAR score of 6 in the first minute and 9 at 10 min. CONCLUSION: Although this is a rare occurrence, we would like to sensitise healthcare workers in rural low- to middle-income countries that this can occur, and they should attempt to increase antenatal diagnosis as it can influence the mode of delivery.

Expanding Point-of-Care Ultrasound Training in a Low- and Middle-Income Country: Experiences From a Collaborative Short-Training Workshop in Kenya.

BACKGROUND AND OBJECTIVES: In Kenya, little data exists on point-of-care ultrasound (POCUS) training and use for family medicine physicians. In 2017, a 3-day POCUS workshop assembled most of the family medicine physicians in Kenya. Through surveys, we assessed how this workshop could affect the level of POCUS use, skill, and confidence in family medicine practitioners in the long term. METHODS: Structured surveys, distributed before, after, and 10 months postworkshop assessed demographics, POCUS use, barriers, comfort, and skills based on attendee self-assessment. We compared data from the preworkshop surveys to postsurveys and post-postsurveys to assess immediate and long-term differences. Wilcoxon signed-rank test was used to evaluate continuous data, and significance was based on a P value of <.05. RESULTS: The proportion of participants who self-reported using POCUS increased significantly between presurvey and post-postsurvey (29.7% to 63.2%, P=.0161). Mean confidence scores increased significantly from presurvey to postsurvey and post-postsurvey. For all body systems, self-reported mean skill scores increased significantly from presurvey to postsurvey and post-postsurvey. Lack of access to machines and mentorship are substantial barriers to increasing POCUS use. CONCLUSIONS: This study highlights the utility of one-time POCUS training in increasing long-term POCUS uptake by participants. While encouraging, our findings also show barriers to increasing POCUS use. These barriers must be addressed, potentially through intradepartmental and interorganizational exchanges of resources to ensure that future POCUS workshops are successful in supporting POCUS use in Kenya.