From home deliveries to health care facilities: establishing a traditional birth attendant referral program in Kenya.

OBJECTIVE: To assess the effectiveness of a traditional birth attendant (TBA) referral program on increasing the number of deliveries overseen by skilled birth attendants (SBA) in rural Kenyan health facilities before and after the implementation of a free maternity care policy. METHODS: In a rural region of Kenya, TBAs were recruited to educate pregnant women about the importance of delivering in healthcare facilities and were offered a stipend for every pregnant woman whom they brought to the healthcare facility. We evaluated the percentage of prenatal care (PNC) patients who delivered at the intervention site compared with the percentage of PNC patients who delivered at rural control facilities, before and after the referral program was implemented, and before and after the Kenya government implemented a policy of free maternity care. The window period of the study was from July of 2011 through September 2013, with a TBA referral intervention conducted from March to September 2013. RESULTS: The absolute increases from the pre-intervention period to the TBA referral intervention period in SBA deliveries were 5.7 and 24.0% in the control and intervention groups, respectively (p < 0.001). The absolute increases in SBA delivery rates from the pre-intervention period to the intervention period before the implementation of the free maternity care policy were 4.7 and 17.2% in the control and intervention groups, respectively (p < 0.001). After the policy implementation the absolute increases from pre-intervention to post-intervention were 1.8 and 11.6% in the control and intervention groups, respectively (p < 0.001). CONCLUSION: The percentage of SBA deliveries at the intervention health facility significantly increased compared to control health facilities when TBAs educated women about the need to deliver with a SBA and when TBAs received a stipend for bringing women to local health facilities to deliver. Furthermore, this TBA referral program proved to be far more effective in the target region of Kenya than a policy change to provide free obstetric care.

The promise of home visitation by community health workers in rural Kenya: A protective effect that reduces neonatal illness.

BACKGROUND: Nearly three million neonates die each year, largely from preventable illnesses in developing countries. Sub-Saharan Africa has disproportionately high neonatal mortality. Community health worker (CHW) programs are a promising intervention to reduce mortality rates. This research evaluates a CHW newborn home visitation program in rural Kenya by assessing the frequency of health service utilization and overnight hospitalization. METHODS: This quasi-experimental study encompassed two consecutive years and compared the rate of medical service utilization for neonatal illness in an intervention group with that of a control group using a household survey. Severity of neonatal illness was assessed by need for overnight hospitalization. Household, maternal, and child characteristics were collected. RESULTS: A total of 489 surveys were completed and showed that 35% of not-visited families reported taking their infant to a healthcare facility, compared with 21% of CHW-visited families (P < 0.01). Rates of overnight hospitalization were 6% for not-visited infants and 1% for visited infants (P < 0.01). Few significant differences were found in household, maternal, and child characteristics. DISCUSSION: This study found that a CHW newborn home visitation program in rural Kenya significantly decreased rates of health service utilization and overnight hospitalization, but did not have the power to detect an effect on neonatal mortality.

Economic empowerment and AIDS-related stigma in rural Kenya: a double-edged sword?

Economic empowerment, HIV risk and AIDS-related stigma appear intricately intertwined for women in Kenya. Their interaction must be understood in order to implement effective economic interventions that also decrease HIV risk and stigma. We conducted a qualitative study amongst women in a rural Kamba-speaking community of southeastern Kenya to pursue whether engagement in an economic empowerment initiative (a basket weaving cooperative) influences women's perspectives and experiences with HIV risk and AIDS-related stigma. We conducted seven women's focus groups: participants in the local basket-weaving cooperative comprised four focus groups and non-participants comprised the remaining three groups. The HIV status of the women was not known. Three dominant themes emerged from the focus groups: empowerment, pervasive vulnerability and unanticipated social paradoxes. Contradictions found in these themes suggest that economic empowerment can become a double-edged sword. Economic empowerment enhanced perceived individual, domestic and social community status. However, this enhancement was not protective of domestic violence and perceived HIV risk. Social perceptions may have paradoxically contributed barriers to HIV testing and treatment putting women at greater HIV risk. In conclusion, economic empowerment initiatives for women in developing countries in the context of the HIV epidemic should be coupled with peer mediated support and HIV-risk education.

A community health worker home visitation project to prevent neonatal deaths in Kenya.

Neonatal deaths account for 43% of under-5 childhood deaths in Kenya. Most infants are born at home, and many of them die at home unaccounted for, often during the first week of life. Previous studies in which community health workers (CHWs) were trained to provide neonatal care reported reductions in neonatal mortality. These programmes required more resources than may be available in some resource-poor settings. We implemented a brief and inexpensive programme to train rural Kenyan CHWs to evaluate newborn infants for signs of severe illness during the first week of life and refer the ill infants to a health facility. During the first 12 months, 20 CHWs visited 702 infants, and all three visits were completed for 93% of the infants. There were five neonatal deaths, none after the first week of life. A brief low-cost training programme for CHW home visitation of newborns is feasible for rural Kenya and the larger African setting.

A strategy to increase the number of deliveries with skilled birth attendants in Kenya.

OBJECTIVE: To increase the number of deliveries with skilled birth attendants (SBAs) in Kenyan health facilities, with assistance from traditional birth attendants (TBAs). METHODS: In the Yatta district of Kenya, TBAs were recruited to attend meetings in which they were encouraged to educate pregnant women about the importance of delivering in health facilities; they were offered a small stipend for each pregnant woman they brought to a facility for SBA delivery. The primary outcome was the percentage of prenatal care patients who delivered at intervention health facilities compared with control facilities. RESULTS: During the year preceding the intervention, 102/524 (19.5%) and 413/2068 (20.0%) prenatal care patients had SBA deliveries at intervention and control facilities, respectively. During the 1-year study period, 217/440 (49.3%) prenatal care patients delivered at intervention health facilities and 415/1995 (20.8%) delivered at control facilities (P<0.001). Deliveries at intervention facilities increased 113% in the study year compared with the preceding year. CONCLUSION: The rate of SBA births in health facilities increased when TBAs were recruited and compensated for bringing women to local health facilities to deliver.

Blood lead levels and potental environmental exposures among children under five years in Kibera slums, Nairobi.

OBJECTIVE: Lead exposure has been associated with intellectual impairment in children in a number of international studies. Prevalence of elevated blood lead levels (eBLL > or = 10ug/dL) of between 5 - 15% has been reported among in Nairobi (UNEP, 2006). However, little is known about potential environmental exposure for eBLLs among children in Kibera, Nairobi. METHODS: A descriptive, cross-sectional study of children drawn from Kibera slums who presented at Yes to kids (Y2K) programme of VIPS Health Services at Woodley, Nairobi between June and August 2007 was carried out. The study assessed potential correlates of eBLLs in 387 children aged 6 to 59 months and had lived in Kibera slums since birth. Sampling was purposive. The factors examined were age, sex, breastfeeding history, respondent's education and occupation, type of house walls, sources of drinking water and kales, and awareness of lead poisoning among respondents. Potential risk factors such exposure to paint, contaminated playgrounds, glazed pottery, cosmetics and para-occupational as well as living near lead industry and pica behavior were also examined. Potential environmental sources of lead such as drinking water, soil and kales were analyzed for lead levels. RESULTS: Seven percent (n = 27, N = 387) had BLLs above 10ug/dl. BLL > or = 10ug/dl was associated with non-permanent housing (p = 0.812), playing on potentially lead contaminated grounds (p = 0.627) and pica behavior (p = 0.439). Low risk parental occupation (p = 0.001) and Kales sourced from the market/kiosks (p = 0.001) were significantly associated with BLL > or = 10ug/dl. Soil lead levels (Soil Pb) ranged from 3,000 to 90,000ug/kg, which was very high compared to WHO acceptable range of 100 - 200ug/kg. There was weak linear association (r2 = 0.0160) between Soil Pb and mean BLLs for a given village. There were no detectable levels of lead in kales and tap water. CONCLUSIONS: The study found about 7% (N = 387) of the children tested had eBLL > or = 10ug/dl in an area with very high soil lead levels (range in Kibera slums: 3,365 - 89,570ug/kg; WHO allowable range: 100 - 120ug/kg), raising a health flag that must be addressed using the multi-sectoral approach and further studies. It's important to note that the study design and its inherent limitations could have masked true picture of childhood lead poisoning in Kibera slums, Nairobi.

Prevalence of intestinal worm infections among primary school children in Nairobi City, kenyA.

OBJECTIVE: The main objective of the study was to determine the prevalence of total, single and multiple intestinal worm infections among the primary school children in Nairobi City. METHODS: A cross-sectional descriptive study was used to determine the status of intestinal worm infections whose subjects were drawn from eight city administrative divisions. Proportional random sampling method to select forty five (45) schools out of 320 public, private and non-formal schools was used. Using the school enrolment register for standard 3 and 4, fifty (50) pupils per school were selected to participate in the study. Quantitative data from the study subjects were collected by use of a structured questionnaire. In addition, stool specimens were collected from each study subject and examined by Kato-Katz laboratory method. RESULTS: The four intestinal worms investigated constituted a total prevalence of 12.9%. This prevalence was found to be lower than that in two other previous studies. A. lumbricoides had the highest prevalence and S. mansoni had the lowest. Prevalence of single worm infections constituted 8.6% of the total prevalence. Differences in prevalence between males and females were observed only with respect to T. trichiura and hookworm species. Fourteen to sixteen (14-16) and 11-13 years of age groups had the highest total prevalence of 47% and 30.6% respectively. Differences in prevalence were not found among the school categories with exception of T. trichiura infections. CONCLUSION: Prevalence of total, single ahd multiple infections showed a downward trend when compared to the previous studies with Ascaris lumbricoides persisting with the highest prevalence.

Role of governmental and non-governmental organizations in mitigation of stigma and discrimination among HIV/AIDS persons in Kibera, Kenya.

OBJECTIVE: This study assessed the role of governmental and non-governmental organizations in mitigation of stigma and discrimination among people infected and affected by HIV/AIDS in informal settlements of Kibera. METHODS: This was a descriptive cross-sectional study and used a multi stage stratified sampling method. The study was conducted in Kibera, an informal settlement with a population of over one million people which makes it the largest slum not only in Kenya but in sub-Saharan Africa. The study targeted infected individuals, non-infected community members, managers of the organizations implementing HIV/AIDS programmes and service providers. In the process 1331 households were interviewed using qualitative and quantitative data collection instruments. Statistical Package for Social Sciences (SPSS) and Nudist 4 packages were used to analyze the quantitative and qualitative data respectively. RESULTS: More than 61% of the respondents had patients in their households. Fifty five percent (55%) of the households received assistance from governmental and non-governmental organizations in taking care of the sick. Services provided included awareness, outreach, counseling, testing, treatment, advocacy, home based care, assistance to the orphans and legal issues. About 90% of the respondents perceived health education, counseling services and formation of post counseling support groups to combat stigma and discrimination to be helpful. CONCLUSION: Stigma and discrimination affects the rights of People Living with HIV/AIDS (PLWHAs). Such stigmatization and discrimination goes beyond and affects those who care for the PLWHAs, and remains the biggest impediment in the fight against HIV/AIDS in Kibera. Governmental and non-governmental organizations continue to provide key services in the mitigation of stigma and discrimination in Kibera. However, personal testimonies by PLWHAs showed that HIV positive persons still suffer from stigma and discrimination. Approximately 43% of the study population experienced stigma and discrimination.