Leading from the bottom: The clinical leaders roles in an HIV primary care facility in Eldoret, Kenya.

BACKGROUND: Clinical leaders in health systems play critical roles in making decisions that impact patient care and health system performance. Current literature has focused on the importance of clinical leaders' roles in healthcare settings and has not addressed the leadership aspect that clinical leaders engage in day-to-day decision-making in HIV facilities while providing HIV patient care. Therefore, identifying the leadership roles that wclinical leaders perform at HIV primary facilities is of critical importance. PURPOSE: The study explored the views of healthcare providers working in AMPATH-MTRH HIV facility on what they perceived as the roles of clinical leaders at the HIV primary care facility. METHODS: We conducted a qualitative exploratory study between December 2019 to May 2020, involving in-depth interviews with (n = 22) healthcare providers working in AMPATH-MTRH HIV facility, who were purposively and conveniently sampled to participate in in-depth interviews to explore perceptions regarding the leadership roles of clinical leaders. The collected data were analyzed thematically and Nvivo vs.12 software was used for data management. RESULTS: The following themes were identified from the analysis regarding perceived clinical leaders' roles in an HIV primary care facility: 1) Strategic roles: providing direction and guidance, ensuring goals and objectives of the department are achieved within the set timelines, planning, and budgeting for adequate resources to support patient HIV care 2) Interconnecting health systems levels and supervisory oversight roles: a link between management, staff, and patients, solving problems, organizing and attending departmental meetings, facilitate staff training, accountable, collaborating with other departments and leaders, defines and assigns responsibilities, ensure quality patient service, coordination, and management of daily activities 3) Research roles: data collation, analysis, generation, review and reporting to the management. CONCLUSION: Clinical leaders in the HIV care system perform leadership roles that are characterized by strategic, middle-level, supervisorial and research which reflects the model of the leadership and management style of the HIV care system. The understanding of these roles contributes valuable insights to HIV leaders and managers to recognize the important contribution of clinical leaders and consider reviewing Standard Operating Procedures to include these leadership roles and strengthen their capacity to maximize clinicians' contribution to improve HIV care and enhance responsive health systems.

Integrated community-based HIV and non-communicable disease care within microfinance groups in Kenya: study protocol for the Harambee cluster randomised trial.

INTRODUCTION: In Kenya, distance to health facilities, inefficient vertical care delivery and limited financial means are barriers to retention in HIV care. Furthermore, the increasing burden of non-communicable diseases (NCDs) among people living with HIV complicates chronic disease treatment and strains traditional care delivery models. Potential strategies for improving HIV/NCD treatment outcomes are differentiated care, community-based care and microfinance (MF). METHODS AND ANALYSIS: We will use a cluster randomised trial to evaluate integrated community-based (ICB) care incorporated into MF groups in medium and high HIV prevalence areas in western Kenya. We will conduct baseline assessments with n=900 HIV positive members of 40 existing MF groups. Group clusters will be randomised to receive either (1) ICB or (2) standard of care (SOC). The ICB intervention will include: (1) clinical care visits during MF group meetings inclusive of medical consultations, NCD management, distribution of antiretroviral therapy (ART) and NCD medications, and point-of-care laboratory testing; (2) peer support for ART adherence and (3) facility referrals as needed. MF groups randomised to SOC will receive regularly scheduled care at a health facility. Findings from the two trial arms will be compared with follow-up data from n=300 matched controls. The primary outcome will be VS at 18 months. Secondary outcomes will be retention in care, absolute mean change in systolic blood pressure and absolute mean change in HbA1c level at 18 months. We will use mediation analysis to evaluate mechanisms through which MF and ICB care impact outcomes and analyse incremental cost-effectiveness of the intervention in terms of cost per HIV suppressed person-time, cost per patient retained in care and cost per disability-adjusted life-year saved. ETHICS AND DISSEMINATION: The Moi University Institutional Research and Ethics Committee approved this study (IREC#0003054). We will share data via the Brown University Digital Repository and disseminate findings via publication. TRIAL REGISTRATION NUMBER: NCT04417127.

Needs assessment of community health workers to enhance efficient delivery of their services for community case management of malaria in Kenya.

BACKGROUND: Malaria continues to be the leading cause of morbidity and mortality in Africa. Community Case Management of malaria (CCMm) which is undertaken by engaging Community Health Workers (CHWs) to effectively address management of malaria cases in some endemic communities was explored in this study. The aim was to assess the needs of CHWs that would help sustain and retain their services to enhance the efficient delivery of CCMm. METHODS: Using semi-structured questionnaires, data on the needs of CHWs was gathered through a qualitative study consisting of in-depth interviews and focus group discussions (FGDs) conducted among study participants in five districts in western Kenya. The study participants comprised of 100 CHWs, 100 mothers of children under five years and 25 key informants made up of public health officers and clinicians involved in the CCMm. The interviews were conducted in English and Swahili or Dholuo, the local language. The recorded audio interviews were transcribed later. The analysis was done using NVivo version 7 software and transcripts were coded after which themes related to the objectives of the study were identified. RESULTS: All the study participants recognized the need to train and update CHWs on their work as well as remunerating them for their services to enhance efficient delivery of services. The CHWs on their part perceived the provision of gloves, rapid diagnostic test kits (RDTs), lancets, cotton wool and ethanol, bins (to dispose of RDTs and lancets), together with drugs for treating clients as the essential needs to undertake CCMm in the communities. Other logistical needs and incentives mentioned by CHWs and key informants for the successful delivery of CCMm included: gumboots, raincoats, torch lights, mobile phones, means of transportation (bicycles and motorbikes), uniforms and ID cards for identification. CONCLUSIONS: CHWs would perform tasks better and their services retained for a sustainable CCMm if: properly incentivized; offered refresher trainings (and updates) on malaria; and equipped with the requisite tools identified in this study.

Exploring media framing of abortion content on Kenyan television: a qualitative study protocol.

BACKGROUND: Media framing of abortion messages is an emerging field of research. However, little is known about how the news media frames abortion messages aimed at influencing adolescents' reproductive health choices. This study therefore seeks to investigate the framing of abortion in TV news items on three leading Kenyan TV outlets over a period of 3 years, understand Kenyan journalists' perceptions and experiences with abortion coverage, and to examine adolescents' perceptions and experiences with abortion coverage on Kenyan televised news media. METHODS: This qualitative study which will be conducted in two sites-Nairobi and Uasin Gishu counties-in Kenya will purposively sample abortion news items from three leading media outlets aired between January 2016 to December 2019, for content analysis. Additionally, 12 journalists (9 reporters, 3 news editors) will be purposively sampled for Key Informant Interviews (KIIs) on journalist framing of abortion messages. Finally, convenience sampling will be used to select approximately 48 university-going adolescents for four Focus Group Discussions (FGDs)-2 female, 2 male- aimed at examining adolescents' perceptions and experiences with abortion coverage in the broadcast news media. The KIIs and FGDs will be audio-recorded, transcribed and translated. These data will be analyzed thematically. DISCUSSION: This study moves beyond interrogating only media items to further exploring framing from the perspectives of media consumers and investigations in the process behind production of abortion messages. The study interrogates abortion messages aimed at younger demographics such as adolescents as well as the gendered differences of the effects of these abortion messages, an area barely explored. The study findings will be informative to those who wish to develop media that could be used to promote safe abortion as well as advocate for sexual reproductive health rights, especially among adolescents.

Challenges of achieving sustainable community health services for community case management of malaria.

BACKGROUND: Community Case Management of malaria (CCMm) using Community Health Workers (CHWs) is an approach to improve access to timely and effective malaria case management in malaria endemic countries. So far the programme has been shown to be effective in many communities in sub-Saharan Africa. However, questions remain on the sustainability of this programme due to the high dropout cases of CHWs given their modest remuneration. The aim of the study was to identify challenges of achieving sustainable community health services for CCMm. METHODS: A community based qualitative study was conducted in five districts in western Kenya where CCMm was being undertaken. In-depth interviews and focus group discussions were conducted with the CHWs, mothers of children under-five years and key informants such as public health officers and clinicians involved in the CCMm. The interviews were audio recorded and conducted in English, Swahili and the local language. Recorded interviews were transcribed. Analysis was conducted using NVivo version 7 software, where transcripts were coded after which themes related to the objectives of the study were identified. RESULTS: The community members, the CHWs and stakeholders perceived CCMm as an important approach for reducing the burden of malaria. Key informants perceived lack of basic supplies (RDTs, gloves), drugs, inadequate remuneration of CHWs and lack of basic working equipment as challenges for CCM. CHWs highlighted that lack of drugs and basic supplies such as gloves at the health facilities, inadequate community sensitization by health workers, inadequate stipend to meet basic needs, as challenges of achieving sustainable CCMm. Some clinicians perceived that CHWs should not be given Artemisinin-based combination therapy (ACT) as part of the CCMm since they might misuse them. CONCLUSION: This study shows that for CCMm to be sustainable, concerted efforts from stakeholders are needed to boost the programme. Commodities needed for implementation of the programme need to be readily available and the morale of the CHWs who undertake CCMm needs boosting.

Psychometric Assessment of a Physician-Patient Communication Behaviors Scale: The Perspective of Adult HIV Patients in Kenya.

Introduction. There have been no scales specifically developed to assess physician-patient communication behaviors (PPCB) in the sub-Saharan population. Aim. We revised an existing PPCB scale and tested its psychometric properties for HIV patients in Kenya. Methods. 17 items (five-point scale) measuring PPCB were initially adopted from the Matched Pair Instrument (MPI). Between July and August 2011, we surveyed a convenient sample of 400 HIV adult patients, attending three Academic Model Providing Healthcare program (AMPATH) clinics in Eldoret, Kenya. Of these 400, eight also participated in cognitive interviews, and 200 were invited to return after one week for follow-up interviews; 134 (67%) returned and were interviewed. Construct and content validity were established using an exploratory factor analysis, bivariate analyses, internal consistency, test-retest reliability and cognitive interviews. Results. Construct and content validity supported a one-dimensional measure of 13 PPCB items. Items assessed physicians' effort to promote a favorable atmosphere for interaction with HIV patients. Biases associated with encoding and comprehension of specific terms, such as "discussion, involvement or concerns," were noted. Internal consistency (Cronbach's alpha = .81) and one-week retest reliability scores (.82) supported the reliability of the 13-item scale. Discussion. The revised PPCB scale showed acceptable validity and reliability in Kenya.