Understanding different positions on female genital cutting among Maasai and Samburu communities in Kenya: a cultural psychological perspective.

This paper presents an analysis of different positions on female genital cutting, either legitimising the practice or challenging it. The framework it offers has been developed from cultural psychological theory and qualitative data collected in Maasai communities around Loitokitok and Magadi, Kajiado County, and Samburu communities around Wamba, Samburu County, in Kenya. Over the course of one month, 94 respondents were interviewed using maximum variation sampling. Triangulation took place by means of participant observation of significant events, such as alternative rites, participation in daily activities and informal talks while staying at traditional homesteads and kraals. The framework adds to understanding of why more contextual approaches and holistic interventions are required to bring an end to female genital cutting.

Factors influencing deliveries at health facilities in a rural Maasai Community in Magadi sub-County, Kenya.

BACKGROUND: In response to poor maternal, newborn, and child health indicators in Magadi sub-county, the "Boma" model was launched to promote health facility delivery by establishing community health units and training community health volunteers (CHVs) and traditional birth attendants (TBAs) as safe motherhood promoters. As a result, health facility delivery increased from 14% to 24%, still considerably below the national average (61%). We therefore conducted this study to determine factors influencing health facility delivery and describe barriers and motivators to the same. METHODS: A mixed methods cross-sectional study involving a survey with 200 women who had delivered in the last 24 months, 3 focus group discussions with health providers, chiefs and CHVs and 26 in-depth interviews with mothers, key decision influencers and TBAs. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) using logistic regression were calculated to identify predictive factors for health facility delivery. Thematic analysis was done to describe barriers and motivators to the same. RESULTS: Of the women interviewed, 39% delivered at the health facility. Factors positively associated with health facility deliveries included belonging to the highest wealth quintiles [aOR 4.9 (95%CI 1.5-16.5)], currently not married [aOR 2.4 (95%CI 1.1-5.4)] and living near the health facility [aOR 2.2 (95%CI 1.1 = 4.4)]. High parity [aOR 0.7 (95%CI 0.5-0.9)] was negatively associated with health facility delivery. Barriers to health facility delivery included women not being final decision makers on place of birth, lack of a birth plan, gender of health provider, unfamiliar birthing position, disrespect and/or abuse, distance, attitude of health providers and lack of essential drugs and supplies. Motivators included proximity to health facility, mother's health condition, integration of TBAs into the health system, and health education/advice received. CONCLUSION: Belonging to the highest wealth quintile, currently not married and living near a health facility were positively associated with health facility delivery. Gender inequity and cultural practices such as lack of birth preparedness should be addressed. Transport mechanisms need to be established to avoid delay in reaching a health facility. The health systems also need to be functional with adequate supplies and motivated staff.

Determinants of use of skilled birth attendant at delivery in Makueni, Kenya: a cross sectional study.

BACKGROUND: Kenya has a maternal mortality ratio of 488 per 100,000 live births. Preventing maternal deaths depends significantly on the presence of a skilled birth attendant at delivery. Kenyan national statistics estimate that the proportion of births attended by a skilled health professional have remained below 50% for over a decade; currently at 44%, according to Kenya's demographic health survey 2008/09 against the national target of 65%. This study examines the association of mother's characteristics, access to reproductive health services, and the use of skilled birth attendants in Makueni County, Kenya. METHODS: We carried out secondary data analysis of a cross sectional cluster survey that was conducted in August 2012. Interviews were conducted with 1,205 eligible female respondents (15-49 years), who had children less than five years (0-59 months) at the time of the study. Data was analysed using SPSS version 17. Multicollinearity of the independent variables was assessed. Chi-square tests were used and results that were statistically significant with p-values, p < 0.25 were further included into the multivariable logistic regression model. Adjusted odds ratio (AOR) and their 95% confidence intervals were (95%) calculated. P value less than 0.05 were considered significant. RESULTS: Among the mothers who were interviewed, 40.3% (489) were delivered by a skilled birth attendant while 59.7% (723) were delivered by unskilled birth attendants. Mothers with tertiary/university education were more likely to use a skilled birth attendant during delivery, adjusted OR 8.657, 95% CI, (1.445- 51.853) compared to those with no education. A woman whose partner had secondary education was 2.9 times more likely to seek skilled delivery, adjusted odds ratio 2.913, 95% CI, (1.337- 6.348). Attending ANC was equally significant, adjusted OR 11.938, 95% CI, (4.086- 34.88). Living within a distance of 1- 5 kilometers from a facility increased the likelihood of skilled birth attendance, adjusted OR 95% CI, 1.594 (1.071- 2.371). CONCLUSIONS: The woman's level of education, her partner's level of education, attending ANC and living within 5kms from a health facility are associated with being assisted by skilled birth attendants. Health education and behaviour change communication strategies can be enhanced to increase demand for skilled delivery.

Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya.

BACKGROUND: Malaria is a leading cause of morbidity and mortality in children younger than 5 years in Kenya. Within the context of planning for a vaccine to be used alongside existing malaria control methods, this study explores sociocultural and health communications issues among individuals who are responsible for or influence decisions on childhood vaccination at the community level. METHODS: This qualitative study was conducted in two malaria-endemic regions of Kenya--South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted. RESULTS: Participants understand that malaria is a serious problem that no single tool can defeat. Communities would welcome a malaria vaccine, although they would have questions and concerns about the intervention. While support for local child immunization programs exists, limited understanding about vaccines and what they do is evident among younger and older people, particularly men. Even as health care providers are frustrated when parents do not have their children vaccinated, some parents have concerns about access to and the quality of vaccination services. Some women, including older mothers and those less economically privileged, see themselves as the focus of health workers' negative comments associated with either their parenting choices or their children's appearance. In general, parents and caregivers weigh several factors--such as personal opportunity costs, resource constraints, and perceived benefits--when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers. CONCLUSIONS: The study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunization focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender. It should involve influential community members and provide needed information and reassurances about immunization. Efforts also should be made to address concerns about the quality of immunization services--including health workers' interpersonal communication skills.

A scorecard for assessing functionality of community health unit in Kenya.

INTRODUCTION: In 2005, Kenya's Ministry of Health (MOH) in its quest to improve health outcomes developed the Community Health Strategy (CHS) as a key approach. The MOH and partners grappled with the challenge of managing the functionality of the Community Health Units (CHUs). Amref Health Africa in Kenya developed a replicable CHUs Functionality Scorecard for measuring and managing the functionality of CHUs. METHODS: We designed and piloted the CHU Functionality Scorecard at 114 CHUs in Rift valley province in Kenya. The scorecard categorized CHUs as Functional, Semi-functional, or Non-Functional. We used before and after design to assess the functionality of the CUs. RESULTS: Over seven quarters (January 2012 to September 2013). The proportion of functional CHU increased from 3.5% to 82.9%, Semi-Functional reduced from 39% to 13% while Non-Functional reduced from 58% to 4%. The greatest improvements were noted in Community Health Volunteers (CHVs) receiving stipends, CHVs with referral booklets, monthly dialogue days, actions planning, chalk boards, and CHVs reporting rates. CONCLUSION: The CHU functionality scorecard is a valuable tool for the management of performance, resource allocation, and decision making. We recommend the adoption of the Functionality Scorecard by the Kenya Government for country-wide application. We recommend: further work in defining Advanced Functionality and incorporating the same into the scorecard; and implementation research on long term sustainability of CHUs.

Health and demographic surveillance in rural western Kenya: a platform for evaluating interventions to reduce morbidity and mortality from infectious diseases.

We established a health and demographic surveillance system in a rural area of western Kenya to measure the burden of infectious diseases and evaluate public health interventions. After a baseline census, all 33,990 households were visited every four months. We collected data on educational attainment, socioeconomic status, pediatric outpatient visits, causes of death in children, and malaria transmission. The life expectancy at birth was 38 years, the infant mortality rate was 125 per 1000 live births, and the under-five mortality rate was 227 per 1,000 live births. The increased mortality rate in younger men and women suggests high human immunodeficiency virus/acquired immunodeficiency syndrome-related mortality in the population. Of 5,879 sick child visits, the most frequent diagnosis was malaria (71.5%). Verbal autopsy results for 661 child deaths (1 month to <12 years) implicated malaria (28.9%) and anemia (19.8%) as the most common causes of death in children. These data will provide a basis for generating further research questions, developing targeted interventions, and evaluating their impact.

Effectiveness of Ng'adakarin Bamocha model in improving access to ante-natal and delivery services among nomadic pastoralist communities of Turkana West and Turkana North Sub-Counties of Kenya.

INTRODUCTION: Access to maternal and child health care services among the nomadic pastoralists community in Kenya and African continent in general is unacceptably low. In Turkana, only 18.1% of the women had seen a nurse or a midwife for antenatal care during pregnancy while only 1.3% of pregnant women reported delivery at health facilities in 2005. Ng'adakarin BAMOCHA model, based on migratory routes of the Turkana pastoralists and container clinics was adopted in 2007 to improve access to maternal and child health services by the nomads. METHODS: A cross-sectional study design was used to establish the effectiveness of Ng'adakarin BAMOCHA model on accessibility and uptake of ante-natal care and delivery services. A total of 360 households and 400 households were interviewed for pre-intervention and post-intervention respectively. The study compared the pre-intervention and post-intervention findings. Structured questionnaires and focus group discussion were used for data collection. RESULTS: There was no improvement in the fourth ante-natal care visits between pre-intervention and post-intervention groups at 119(51.5%) and 111(41.9%) respectively (p < 0.05). Knowledge of the community on the importance of ANC visits improved from 60%-72% with significance level of p < 0.05. There was a significant increase 6%-17% of deliveries under a skilled health worker (p < 0.05). TBA assisted deliveries increased from 7.5%- 20.2% with a p < 0.05. There was significant reduction in home deliveries from 89.5%-79.5% with a p < 0.05. CONCLUSION: The Ng'adakarin Bamocha model had a positive effect on the improving maternal health care among the nomadic pastoralist community in Turkana.

Health care utilization and access to human immunodeficiency virus (HIV) testing and care and treatment services in a rural area with high HIV prevalence, Nyanza Province, Kenya, 2007.

We present health and demographic surveillance system data to assess associations with health care utilization and human immunodeficiency virus (HIV) service receipt in a high HIV prevalence area of western Kenya. Eighty-six percent of 15,302 residents indicated a facility/clinician for routine medical services; 60% reported active (within the past year) attendance. Only 34% reported a previous HIV test, and self-reported HIV prevalence was 6%. Active attendees lived only slightly closer to their reported service site (2.8 versus 3.1 km; P < 0.001) compared with inactive attendees. Multivariate analysis showed that younger respondents (< 30 years of age) and active and inactive attendees were more likely to report an HIV test compared with non-attendees; men were less likely to report HIV testing. Despite traveling farther for HIV services (median distance = 4.4 km), 77% of those disclosing HIV infection reported HIV care enrollment. Men and younger respondents were less likely to enroll in HIV care. Socioeconomic status was not associated with HIV service use. Distance did not appear to be the major barrier to service receipt. The health and demographic surveillance system data identified patterns of service use that are useful for future program planning.

Effectiveness of Kenya's Community Health Strategy in delivering community-based maternal and newborn health care in Busia County, Kenya: non-randomized pre-test post test study.

BACKGROUND: Maternal mortality ratio and neonatal mortality rate trends in Kenya have remained unacceptably high in a decade. In 2007, the Ministry of Public Health and Sanitation adopted a community health strategy to reverse the poor health outcomes in order to meet Millennium Development Goals 4 and 5. It aims at strengthening community participation and its ability to take action towards health. The study aimed at evaluating the effectiveness of the strategy in improving maternal and neonatal health outcomes in Kenya. METHODS: Between 2008 and 2010, the African Medical and Research Foundation implemented a community-based maternal and newborn care intervention package in Busia County using the community health strategy approach. An interventional, non-randomized pre-test post test study design was used to evaluate change in essential maternal and neonatal care practices among mothers with children aged 0 - 23 months. RESULTS: There was statistically significant (p < 0.05) increase in attendance of at least four antenatal care visits (39% to 62%), deliveries by skilled birth attendants (31% to 57%), receiving intermittent preventive treatment (23% to 57%), testing for HIV during pregnancy (73% to 90%) and exclusive breastfeeding (20% to 52%). CONCLUSION: The significant increase in essential maternal and neonatal care practices demonstrates that, community health strategy is an appropriate platform to deliver community based interventions. The findings will be used by actors in the child survival community to improve current approaches, policies and practice in maternal and neonatal care.

Profile: the KEMRI/CDC Health and Demographic Surveillance System--Western Kenya.

The KEMRI/Centers for Disease Control and Prevention (CDC) Health and Demographic Surveillance System (HDSS) is located in Rarieda, Siaya and Gem Districts (Siaya County), lying northeast of Lake Victoria in Nyanza Province, western Kenya. The KEMRI/CDC HDSS, with approximately 220 000 inhabitants, has been the foundation for a variety of studies, including evaluations of insecticide-treated bed nets, burden of diarrhoeal disease and tuberculosis, malaria parasitaemia and anaemia, treatment strategies and immunological correlates of malaria infection, and numerous HIV, tuberculosis, malaria and diarrhoeal disease treatment and vaccine efficacy and effectiveness trials for more than a decade. Current studies include operations research to measure the uptake and effectiveness of the programmatic implementation of integrated malaria control strategies, HIV services, newly introduced vaccines and clinical trials. The HDSS provides general demographic and health information (such as population age structure and density, fertility rates, birth and death rates, in- and out-migrations, patterns of health care access and utilization and the local economics of health care) as well as disease- or intervention-specific information. The HDSS also collects verbal autopsy information on all deaths. Studies take advantage of the sampling frame inherent in the HDSS, whether at individual, household/compound or neighbourhood level.