The development of task sharing policy and guidelines in Kenya.

BACKGROUND: The global critical shortage of health workers prevents expansion of healthcare services and universal health coverage. Like most countries in sub-Saharan Africa, Kenya's healthcare workforce density of 13.8 health workers per 10,000 population falls below the World Health Organization (WHO) recommendation of at least 44.5 doctors, nurses, and midwives per 10,000 population. In response to the health worker shortage, the WHO recommends task sharing, a strategy that can increase access to quality health services. To improve the utilization of human and financial health resources in Kenya for HIV and other essential health services, the Kenya Ministry of Health (MOH) in collaboration with various institutions developed national task sharing policy and guidelines (TSP). To advance task sharing, this article describes the process of developing, adopting, and implementing the Kenya TSP. CASE PRESENTATION: The development and approval of Kenya's TSP occurred from February 2015 to May 2017. The U.S. Centers for Disease Control and Prevention (CDC) allocated funding to Emory University through the United States President's Emergency Plan for AIDS Relief (PEPFAR) Advancing Children's Treatment initiative. After obtaining support from leadership in Kenya's MOH and health professional institutions, the TSP team conducted a desk review of policies, guidelines, scopes of practice, task analyses, grey literature, and peer-reviewed research. Subsequently, a Policy Advisory Committee was established to guide the process and worked collaboratively to form technical working groups that arrived at consensus and drafted the policy. The collaborative, multidisciplinary process led to the identification of gaps in service delivery resulting from health workforce shortages. This facilitated the development of the Kenya TSP, which provides a general orientation of task sharing in Kenya. The guidelines list priority tasks for sharing by various cadres as informed by evidence, such as HIV testing and counseling tasks. The TSP documents were disseminated to all county healthcare facilities in Kenya, yet implementation was stopped by order of the judiciary in 2019 after a legal challenge from an association of medical laboratorians. CONCLUSIONS: Task sharing may increase access to healthcare services in resource-limited settings. To advance task sharing, TSP and clinical practice could be harmonized, and necessary adjustments made to other policies that regulate practice (e.g., scopes of practice). Revisions to pre-service training curricula could be conducted to ensure health professionals have the requisite competencies to perform shared tasks. Monitoring and evaluation can help ensure that task sharing is implemented appropriately to ensure quality outcomes.

Lessons learned from a corporate manufacturer on driving the adoption of nature-based solutions.

Companies are increasingly focused on driving the adoption of nature-based solutions across their organizations. Yet, implementing nature-based solutions within existing regulatory frameworks poses a unique set of challenges. In this paper, we present three nature-based solution case studies from The Dow Chemical Company and The Nature Conservancy's nearly 10-year collaboration. In the first case study, we focus on the potential benefits of reforestation to support the state's air quality improvement efforts. Ultimately, federal and state authorities did not approve of the reforestation project. Following this early setback, the collaboration team developed a suite of science-based tools that could be used to better advocate for government approval for the implementation of nature-based solutions. In the second case study, we highlight how one of these tools, the Ecosystem Services Identification & Inventory Tool, was used to improve communications about the benefits of nature-based solutions with regulatory agencies. In this case, Dow ultimately received approval for the restoration of a wetland to remediate an existing ash pond. Finally, the third case study highlights how engaging the right expertise through collaboration between the private sector and conservationists can improve land management strategies. Overall, this paper emphasizes the importance of robust conservation science, tools and expertise, and thoughtful collaboration as necessary means of driving the adoption of nature-based solutions both within a company and by its regulating entities. Integr Environ Assess Manag 2022;18:74-81. © 2021 SETAC.

The Emory-Addis Ababa PhD in Nursing Program: A sustainable model for strengthening nursing research capacity in Ethiopia.

In 2015, Ethiopia's first PhD in nursing program was established in collaboration between the Addis Ababa University (AAU) and Emory University Schools of Nursing. Eleven students have entered the program since its inception, six have successfully defended their proposals, one has graduated, and two have received Fogarty Global Health Fellowships. This paper describes the evolution of this international partnership and the innovative processes and mechanisms involved in program implementation; the authors address the description of the program, central implementation challenges, notable outcomes, and student achievements. One key implementation challenge has been that, although nursing is one of the largest healthcare workforces in Ethiopia, nurses remain underutilized and undervalued in the workplace. This treatment is due, in part, to limited professional regulations, leading some of the PhD students to apply their leadership skills to advocate for national practice reform. According to students, the PhD program has been a means not only to improve nursing research capacity and education in Ethiopia, but also to generate the regulations necessary for graduates to practice according to their degree. While the opportunity to generate knowledge is vitally important, students also value the chance to transform the profession of nursing.

Reducing exposure to high levels of perfluorinated compounds in drinking water improves reproductive outcomes: evidence from an intervention in Minnesota.

BACKGROUND: Per- and polyfluoroalkyl substances (PFASs) have been detected in drinking water supplies around the world and are the subject of intense regulatory debate. While they have been associated with several illnesses, their effects on reproductive outcomes remains uncertain. METHODS: We analyzed birth outcomes in the east Minneapolis-St. Paul metropolitan area from 2002 to 2011, where a portion of the population faced elevated exposure to PFASs due to long-term contamination of drinking water supplies from industrial waste disposal. Installation of a water filtration facility in the highly contaminated city of Oakdale, MN at the end of 2006 resulted in a sharp decrease in exposure to PFASs, creating a "natural experiment". Using a difference-in-differences approach, we compare the changes in birth outcomes before and after water filtration in Oakdale to the changes over the same period in neighboring communities where the treatment of municipal water remained constant. RESULTS: Average birth weight and average gestational age were statistically significantly lower in the highly exposed population than in the control area prior to filtration of municipal water supply. The highly exposed population faced increased odds of low birth weight (adjusted odds ratio 1.36, 95% CI 1.25-1.48) and pre-term birth (adjusted odds ratio 1.14, 95% CI 1.09-1.19) relative to the control before filtration, and these differences moderated after filtration. The general fertility rate was also significantly lower in the exposed population (incidence rate ratio 0.73, 95% CI 0.69-0.77) prior to filtration and appeared to be rebounding post-2006. CONCLUSIONS: Our findings provide evidence of a causal relationship between filtration of drinking water containing high levels of exposure to PFASs and improved reproductive outcomes.

From ash pond to Riverside Wetlands: Making the business case for engineered natural technologies.

The 2015 announcement of The Dow Chemical Company's (Dow) Valuing Nature Goal, which aims to identify $1 billion in business value from projects that are better for nature, gives nature a spot at the project design table. To support this goal, Dow and The Nature Conservancy have extended their long-standing collaboration and are now working to develop a defensible methodology to support the implementation of the goal. This paper reviews the nature valuation methodology framework developed by the Collaboration in support of the goal. The nature valuation methodology is a three-step process that engages Dow project managers at multiple stages in the project design and capital allocation processes. The three-step process identifies projects that may have a large impact on nature and then promotes the use of ecosystem service tools, such as the Ecosystem Services Identification and Inventory Tool, to enhance the project design so that it better supports ecosystem health. After reviewing the nature valuation methodology, we describe the results from a case study of redevelopment plans for a 23-acre site adjacent to Dow's Michigan Operations plant along the Tittabawassee River.

Relationship between pregnancy experience and the development of certain neuropsychiatric disorders in childhood.

A continuum of reproductive causality is postulated, extending from fetal deaths - abortion, stillbirth, and neonatal - through a descending gradient of brain damage manifested in neuropsychiatric disorders. The research and administrative public health implications of these findings and the concept of the continuum are briefly but provocatively discussed.

Informing the scale-up of Kenya's nursing workforce: a mixed methods study of factors affecting pre-service training capacity and production.

BACKGROUND: Given the global nursing shortage and investments to scale-up the workforce, this study evaluated trends in annual student nurse enrolment, pre-service attrition between enrolment and registration, and factors that influence nurse production in Kenya. METHODS: This study used a mixed methods approach with data from the Regulatory Human Resources Information System (tracks initial student enrolment through registration) and the Kenya Health Workforce Information System (tracks deployment and demographic information on licensed nurses) for the quantitative analyses and qualitative data from key informant interviews with nurse training institution educators and/or administrators. Trends in annual student nurse enrolment from 1999 to 2010 were analyzed using regulatory and demographic data. To assess pre-service attrition between training enrolment and registration with the nursing council, data for a cohort that enrolled in training from 1999 to 2004 and completed training by 2010 was analyzed. Multivariate logistic regression was used to test for factors that significantly affected attrition. To assess the capacity of nurse training institutions for scale-up, qualitative data was obtained through key informant interviews. RESULTS: From 1999 to 2010, 23,350 students enrolled in nurse training in Kenya. While annual new student enrolment doubled between 1999 (1,493) and 2010 (3,030), training institutions reported challenges in their capacity to accommodate the increased numbers. Key factors identified by the nursing faculty included congestion at clinical placement sites, limited clinical mentorship by qualified nurses, challenges with faculty recruitment and retention, and inadequate student housing, transportation and classroom space. Pre-service attrition among the cohort that enrolled between 1999 and 2004 and completed training by 2010 was found to be low (6%). CONCLUSION: To scale-up the nursing workforce in Kenya, concurrent investments in expanding the number of student nurse clinical placement sites, utilizing alternate forms of skills training, hiring more faculty and clinical instructors, and expanding the dormitory and classroom space to accommodate new students are needed to ensure that increases in student enrolment are not at the cost of quality nursing education. Student attrition does not appear to be a concern in Kenya compared to other African countries (10 to 40%).

Kenya's emergency-hire nursing programme: a pilot evaluation of health service delivery in two districts.

OBJECTIVE: To assess the feasibility of utilizing a small-scale, low-cost, pilot evaluation in assessing the short-term impact of Kenya's emergency-hire nursing programme (EHP) on the delivery of health services (outpatient visits and maternal-child health indicators) in two underserved health districts with high HIV/AIDS prevalence. METHODS: Six primary outcomes were assessed through the collection of data from facility-level health management forms-total general outpatient visits, vaginal deliveries, caesarean sections, antenatal care (ANC) attendance, ANC clients tested for HIV, and deliveries to HIV-positive women. Data on outcome measures were assessed both pre-and post-emergency-hire nurse placement. Informal discussions were also conducted to obtain supporting qualitative data. FINDINGS: The majority of EHP nurses were placed in Suba (15.5%) and Siaya (13%) districts. At the time of the intervention, we describe an increase in total general outpatient visits, vaginal deliveries and caesarean sections within both districts. Similar significant increases were seen with ANC attendance and deliveries to HIV-positive women. Despite increases in the quantity of health services immediately following nurse placement, these levels were often not sustained. We identify several factors that challenge the long-term sustainability of these staffing enhancements. CONCLUSIONS: There are multiple factors beyond increasing the supply of nurses that affect the delivery of health services. We believe this pilot evaluation sets the foundation for future, larger and more comprehensive studies further elaborating on the interface between interventions to alleviate nursing shortages and promote enhanced health service delivery. We also stress the importance of strong national and local relationships in conducting future studies.

The public sector nursing workforce in Kenya: a county-level analysis.

BACKGROUND: Kenya's human resources for health shortage is well documented, yet in line with the new constitution, responsibility for health service delivery will be devolved to 47 new county administrations. This work describes the public sector nursing workforce likely to be inherited by the counties, and examines the relationships between nursing workforce density and key indicators. METHODS: National nursing deployment data linked to nursing supply data were used and analyzed using statistical and geographical analysis software. Data on nurses deployed in national referral hospitals and on nurses deployed in non-public sector facilities were excluded from main analyses. The densities and characteristics of the public sector nurses across the counties were obtained and examined against an index of county remoteness, and the nursing densities were correlated with five key indicators. RESULTS: Of the 16,371 nurses in the public non-tertiary sector, 76% are women and 53% are registered nurses, with 35% of the nurses aged 40 to 49 years. The nursing densities across counties range from 1.2 to 0.08 per 1,000 population. There are statistically significant associations of the nursing densities with a measure of health spending per capita (P value = 0.0028) and immunization rates (P value = 0.0018). A higher county remoteness index is associated with explaining lower female to male ratio of public sector nurses across counties (P value <0.0001). CONCLUSIONS: An overall shortage of nurses (range of 1.2 to 0.08 per 1,000) in the public sector countrywide is complicated by mal-distribution and varying workforce characteristics (for example, age profile) across counties. All stakeholders should support improvements in human resources information systems and help address personnel shortages and mal-distribution if equitable, quality health-care delivery in the counties is to be achieved.

The impact of out-migration on the nursing workforce in Kenya.

OBJECTIVE: To examine the impact of out-migration on Kenya's nursing workforce. STUDY SETTING: This study analyzed deidentified nursing data from the Kenya Health Workforce Informatics System, collected by the Nursing Council of Kenya and the Department of Nursing in the Ministry of Medical Services. STUDY DESIGN: We analyzed trends in Kenya's nursing workforce from 1999 to 2007, including supply, deployment, and intent to out-migrate, measured by requests for verification of credentials from destination countries. PRINCIPLE FINDINGS: From 1999 to 2007, 6 percent of Kenya's nursing workforce of 41,367 nurses applied to out-migrate. Eighty-five percent of applicants were registered or B.Sc.N. prepared nurses, 49 percent applied within 10 years of their initial registration as a nurse, and 82 percent of first-time applications were for the United States or United Kingdom. For every 4.5 nurses that Kenya adds to its nursing workforce through training, 1 nurse from the workforce applies to out-migrate, potentially reducing by 22 percent Kenya's ability to increase its nursing workforce through training. CONCLUSIONS: Nurse out-migration depletes Kenya's nursing workforce of its most highly educated nurses, reduces the percentage of younger nurses in an aging nursing stock, decreases Kenya's ability to increase its nursing workforce through training, and represents a substantial economic loss to the country.

Reducing the risk of mother-to-child human immunodeficiency virus transmission: past successes, current progress and challenges, and future directions.

Prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) in the United States and Europe has been a tremendous success, such that transmission rates of less than 2% have been achieved. Some key successes have also been demonstrated in resource-poor countries; however, the translation of successful interventions into public health policy has been slow because of a variety of factors such as inadequate funding and cultural, social, and institutional barriers. The issue of HIV and infant feeding in settings that lack culturally acceptable, feasible, affordable, safe, and sustainable nutritional substitutes for breast milk is a continuing dilemma. An effective preventive infant HIV vaccine would be an optimal approach to reduce HIV acquisition in the first year of life among breast-feeding infants. The challenges to eliminate new perinatal HIV infections worldwide will depend on both sustaining and expanding PMTCT interventions and effective primary HIV prevention for women, adolescents, and young adults.

Developing a nursing database system in Kenya.

OBJECTIVE: To describe the development, initial findings, and implications of a national nursing workforce database system in Kenya. PRINCIPAL FINDINGS: Creating a national electronic nursing workforce database provides more reliable information on nurse demographics, migration patterns, and workforce capacity. Data analyses are most useful for human resources for health (HRH) planning when workforce capacity data can be linked to worksite staffing requirements. As a result of establishing this database, the Kenya Ministry of Health has improved capability to assess its nursing workforce and document important workforce trends, such as out-migration. Current data identify the United States as the leading recipient country of Kenyan nurses. The overwhelming majority of Kenyan nurses who elect to out-migrate are among Kenya's most qualified. CONCLUSIONS: The Kenya nursing database is a first step toward facilitating evidence-based decision making in HRH. This database is unique to developing countries in sub-Saharan Africa. Establishing an electronic workforce database requires long-term investment and sustained support by national and global stakeholders.

Global and planetary health: teaching as if the future matters.

If nursing, along with other health professions, is to be able to critique national and international health policy and be equipped to address the global and planetary dimensions of health, the conceptual horizons of our educational and research enterprises will need to be expanded. Not only are nursing curricula needed that address such concepts as "health for all" and "environmental sustainability," but new pedagogies are required that engage students deeply and call them to socially and globally responsible ways-of-being. This article describes teaching and learning in a course that situates health in a global and environmental context and calls forth new personal and professional meanings.

Detecting deception in children: an experimental study of the effect of event familiarity on CBCA ratings.

The CBCA is the most commonly used deception detection. technique worldwide. Pezdek et al. (2004) used a quasi-experimental design to assess children's accounts of a traumatic medical procedure; CBCA ratings were higher for descriptions of familiar than unfamiliar events. This study tested this effect using an experimental design and assessed the joint effect of familiarity and veracity on CBCA ratings. Children described a true or a fabricated event. Half described a familiar event; half described an unfamiliar event. Two CBCA-trained judges rated transcripts of the descriptions. CBCA scores were more strongly influenced by the familiarity than the actual veracity of the event, and CBCA scores were significantly correlated with age. CBCA results were compared with results from other measures. Together with the results of K. Pezdek et al. (2004) these findings suggest that in its current form, CBCA is of limited utility as a credibility assessment tool.

Detecting deception in children: event familiarity affects criterion-based content analysis ratings.

Statement Validity Assessment (SVA) is a comprehensive credibility assessment system, with the Criterion-Based Content Analysis (CBCA) as a core component. Worldwide, the CBCA is reported to be the most widely used veracity assessment instrument. We tested and confirmed the hypothesis that CBCA scores are affected by event familiarity; descriptions of familiar events are more likely to be judged true than are descriptions of unfamiliar events. CBCA scores were applied to transcripts of 114 children who recalled a routine medical procedure (control) or a traumatic medical procedure that they had experienced one time (relatively unfamiliar) or multiple times (relatively familiar). CBCA scores were higher for children in the relatively familiar than the relatively unfamiliar condition, and CBCA scores were significantly correlated with age. Results raise serious questions regarding the forensic suitability of the CBCA for assessing the veracity of children's accounts.