IMPLEMENTING TOOLS TO PROMOTE ADHERENCE TO ANTIRETROVIRAL THERAPY AT FACILITIES IN KENYA.

BACKGROUND: Lack of effective systems and tools to identify and track defaulters are some of the factors that pose challenges in adherence monitoring for patients on anti-retroviral treatment (ART). An intervention was performed to introduce a facility-based appointment keeping system, and a revised clinic form to monitor patients' adherence to ART. OBJECTIVE: To assess facility staff perceptions of, motivation for and self-reported practice in the implementation, and on the use of adherence-based indicators to inform decisions for performance improvement. DESIGN: Qualitative explorative study aiming to evaluate a quasi-experimental intervention. SETTINGS: Six conveniently sampled health facilities in Kenya located in Central, Eastern and Rift Valley provinces. SUBJECTS: Thirty-six clinic staff members were interviewed, six at each facility, including facility managers, clinicians, nursing and pharmacy staff, counsellors, health records information officers and social workers. Analysis was performed in line with the Pettigrew and Whipp framework. RESULTS: Providers perceived that the intervention had empowered them to assess their clinic's daily workload and to identify those patients who missed their appointments. Factors enhancing the positive uptake of the intervention included the availability of tools to monitor appointment keeping, training on adherence principles and supervisory support. Early detection of treatment defaulters helped the providers design targeted patient support to enhance appointment keeping. CONCLUSION: The effect of the intervention led to implementation of changes within the clinic to enhance patients' appointment keeping and improve adherence to treatment. We expect the reported and observed changes to be sustainable as data generation and calculation of indicators to inform decision-making were performed by the providers themselves.

Quality of care provided to febrile children presenting in rural private clinics on the Kenyan coast.

BACKGROUND: Private sector health facilities are diverse in nature, and offer widely varying quality of care (QOC). OBJECTIVES: The study aimed to describe the QOC provided to febrile children at rural private clinics on the Kenyan coast and stakeholder perspectives on standards of practice and opportunities for change. METHODS: Data collection methods were structured observations of consultations; interviews with users on exit from clinic and at home and in depth interviews with private practitioners (PP) and district health managers. FINDINGS: Private clinics have basic structural features for health care delivery. The majority of the clinics in this study were owned and run by single-handed trained medical practitioners. Amongst 92 observed consultations, 62% of diagnoses made were consistent with the history, examinations and tests performed. 74% of childhood fevers were diagnosed as malaria, and 88% of all prescriptions contained an antimalarial drug. Blood slides for malaria parasites were performed in 55 children (60%). Of those whose blood slide was positive (n=27), 52% and 48% were treated with a nationally recommended first or second line antimalarial drug, respectively. Where no blood slide was done (n=37), 73% were prescribed a nationally recommended first line and 27% received a second line antimalarial drug. Overall, 68 % of antimalarial drugs were prescribed in an appropriate dose and regime. Both private practitioners and district health managers expressed the view that existing linkages between the public and private health sectors within the district are haphazard and inadequate. CONCLUSIONS: Although rural PPs are potentially well placed for treatment of febrile cases in remote settings, they exhibit varying QOC. Practitioners, users and district managers supported the need to develop interventions to improve QOC. The study identifies the need to consider involvement of the for-profit providers in the implementation of the IMCI guidelines in Kenya.