Community engagement to inform development of strategies to improve referral for hypertension: perspectives of patients, providers and local community members in western Kenya.

BACKGROUND: Hypertension is the leading cause of death and disability. Clinical care for patients with hypertension in Kenya leverages referral networks to provide basic and specialized healthcare services. However, referrals are characterized by non-adherence and delays in completion. An integrated health information technology (HIT) and peer-based support strategy to improve adherence to referrals and blood pressure control was proposed. A formative assessment gathered perspectives on barriers to referral completion and garnered thoughts on the proposed intervention. METHODS: We conducted a qualitative study in Kitale, Webuye, Kocholya, Turbo, Mosoriot and Burnt Forest areas of Western Kenya. We utilized the PRECEDE-PROCEED framework to understand the behavioral, environmental and ecological factors that would influence uptake and success of our intervention. We conducted four mabaraza (customary heterogenous community assemblies), eighteen key informant interviews, and twelve focus group discussions among clinicians, patients and community members. The data obtained was audio recorded alongside field note taking. Audio recordings were transcribed and translated for onward coding and thematic analysis using NVivo 12. RESULTS: Specific supply-side and demand-side barriers influenced completion of referral for hypertension. Key demand-side barriers included lack of money for care and inadequate referral knowledge. On the supply-side, long distance to health facilities, low availability of services, unaffordable services, and poor referral management were reported. All participants felt that the proposed strategies could improve delivery of care and expressed much enthusiasm for them. Participants appreciated benefits of the peer component, saying it would motivate positive patient behavior, and provide health education, psychosocial support, and assistance in navigating care. The HIT component was seen as reducing paper work, easing communication between providers, and facilitating tracking of patient information. Participants also shared concerns that could influence implementation of the two strategies including consent, confidentiality, and reduction in patient-provider interaction. CONCLUSIONS: Appreciation of local realities and patients' experiences is critical to development and implementation of sustainable strategies to improve effectiveness of hypertension referral networks. Incorporating concerns from patients, health care workers, and local leaders facilitates adaptation of interventions to respond to real needs. This approach is ethical and also allows research teams to harness benefits of participatory community-involved research. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03543787, Registered June 1, 2018. https://clinicaltrials.gov/ct2/show/NCT03543787.

Examining the responsiveness of the National Health Insurance Fund to people living with hypertension and diabetes in Kenya: a qualitative study.

OBJECTIVES: To assess the responsiveness of the National Health Insurance Fund (NHIF) Supa Cover benefit package to the needs of individuals with diabetes and hypertension in Kenya. DESIGN, SETTING AND PARTICIPANTS: We carried out a qualitative study and collected data using key informant interviews (n=39) and focus group discussions (n=4) in two purposively selected counties in Western Kenya. Study participants were drawn from NHIF officials, county government officials, health facility managers, healthcare workers and individuals with hypertension and diabetes who were enrolled in NHIF. We analysed data using a thematic approach. RESULTS: Study participants reported that the NHIF Supa Cover benefit package expanded access to services for people living with hypertension and diabetes. However, the NHIF members and healthcare workers had inadequate awareness of the NHIF service entitlements. The NHIF benefit package inadequately covered the range of services needed by people living with hypertension and diabetes and the benefits package did not prioritise preventive and promotive services. Sometimes patients were discriminated against by healthcare providers who preferred cash-paying patients, and some NHIF-empanelled health facilities had inadequate structural inputs essential for quality of care. Study participants felt that the NHIF premium for the general scheme was unaffordable, and NHIF members faced additional out-of-pocket costs because of additional payments for services not available or covered. CONCLUSION: Whereas NHIF has reduced financial barriers for hypertension and diabetes patients, to enhance its responsiveness to patient needs, NHIF should implement mechanisms to increase benefit package awareness among members and providers. In addition, preventive and promotive services should be included in NHIF's benefits package and mechanisms to monitor and hold contracted providers accountable should be strengthened.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study.

INTRODUCTION: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions. METHODS AND ANALYSIS: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks. ETHICS AND DISSEMINATION: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Scaling up the primary health integrated care project for chronic conditions in Kenya: study protocol for an implementation research project.

INTRODUCTION: Amid the rising number of people with non-communicable diseases (NCDs), Kenya has invested in strengthening primary care and in efforts to expand existing service delivery platforms to integrate NCD care. One such approach is the AMPATH (Academic Model Providing Access to Healthcare) model in western Kenya, which provides the platform for the Primary Health Integrated Care Project for Chronic Conditions (PIC4C), launched in 2018 to further strengthen primary care services for the prevention and control of hypertension, diabetes, breast and cervical cancer. This study seeks to understand how well PIC4C delivers on its intended aims and to inform and support scale up of the PIC4C model for integrated care for people with NCDs in Kenya. METHODS AND ANALYSIS: The study is guided by a conceptual framework on implementing, sustaining and spreading innovation in health service delivery. We use a multimethod design combining qualitative and quantitative approaches, involving: (1) in-depth interviews with health workers and decision-makers to explore experiences of delivering PIC4C; (2) a cross-sectional survey of patients with diabetes or hypertension and in-depth interviews to understand how well PIC4C meets patients' needs; (3) a cohort study with an interrupted time series analysis to evaluate the degree to which PIC4C leads to health benefits such as improved management of hypertension or diabetes; and (4) a cohort study of households to examine the extent to which the national hospital insurance chronic care package provides financial risk protection to people with hypertension or diabetes within PIC4C. ETHICS AND DISSEMINATION: The study has received approvals from Moi University Institutional Research and Ethics Committee (FAN:0003586) and the London School of Hygiene & Tropical Medicine (17940). Workshops with key stakeholders at local, county, national and international levels will ensure early and wide dissemination of our findings to inform scale up of this model of care. We will also publish findings in peer-reviewed journals.

A Protocol on Using the RE-AIM Framework in the Process Evaluation of the Primary Health Integrated Care Project for Four Chronic Conditions in Kenya.

Background: There has been a rapid increase in morbidity and mortality arising from non-communicable diseases (NCDs). The Academic Model Providing Access to Healthcare (AMPATH) program has established a chronic disease management program in collaboration with the Ministry of Health (MoH) in Kenya at over 150 health facilities in western Kenya. The primary health integrated care for chronic (PIC4C) disease project seeks to deliver preventive, promotive, and curative care for diabetes, hypertension, cervical and breast cancers at the primary health care level. We apply the RE-AIM framework to conduct a process evaluation of the integrated PIC4C model. This paper describes the protocol we are using in the PIC4C process evaluation planning and activities. Methods and Analysis: This evaluation utilizes clinic reports as well as primary data collected in two waves. Using mixed methods (secondary data, observation, semi-structured interviews, and focus group discussions), the process evaluation assesses the reach, effectiveness, adoption, implementation and maintenance of the PIC4C model in Busia and Trans Nzoia Kenya. The evaluation captures the PIC4C process, experiences of implementers and users, and the wishes of those using the PIC4C services. We will analyse our data across the RE-AIM dimensions using descriptive statistics and two-sample t-test to compare the mean scores for baseline and end line. Qualitative data will be analyzed thematically. Discussion: The process evaluation of the PIC4C model in Kenya allows implementers and users to reflect and question its implementation, uptake and maintenance. Our experiences thus far suggest practicable strategies to facilitate primary health care can benefit extensively from deliberate process evaluation of the programs undertaken. Furthermore, integrating the RE-AIM framework in the process evaluation of health programs is valuable due to its pragmatic and reporting usefulness.

Knowledge and Perceptions Regarding Palliative Care Among Religious Leaders in Uasin Gishu County, Kenya: Survey and Focus Group Analysis.

Spirituality and religion are at the core of Kenyan life. Pastoral leaders play a key role in shaping the individual and community's response to living with chronic and life-threatening illnesses. Involvement of religious leaders would therefore be critical in advocacy and education efforts in palliative care (PC) to address the needs of this population. The goal of this study was to evaluate the knowledge and perceptions of religious leaders in Western Kenya regarding PC. This was a mixed-methods study with 86 religious leaders utilizing a 25-question survey followed by 5-person focus group discussions. Eighty-one percent of participants agreed that pastors should encourage members with life-threatening illnesses to talk about death and dying. However, almost a third of participants (29%) also agreed with the statement that full use of PC can hasten death. The pastors underscored challenges in end-of-life spiritual preparation as well as the importance of traditional beliefs in shaping cultural norms. Pastors supported the need for community-based PC education and additional training in PC for religious leaders. The results of this study confirm the dominant role of religion and spirituality in PC in Kenya. This dominant role in shaping PC is tied closely to Kenyan attitudes and norms surrounding death and dying.

Deliver on Your Own: Disrespectful Maternity Care in rural Kenya.

BACKGROUND: Under the Free Maternity Policy (FMP), Kenya has witnessed an increase in health facility deliveries rather than home deliveries with Traditional Birth Attendants (TBA) resulting in improved maternal and neonatal outcomes. Despite these gains, maternal and infant mortality and morbidity rates in Kenya remain unacceptably high indicating that more needs to be done. AIM: Using data from the Access to Quality Care through Extending and Strengthening Health Systems (AQCESS) project's qualitative gender assessment, this paper examines women's experience of disrespectful care during pregnancy, labour, and delivery. The goal is to promote an improved understanding of the actual care conditions to inform the development of interventions that can lift the standard of care, increase maternity facility use, and improve health outcomes for both women and newborns. METHODOLOGY: We conducted sixteen focus group discussions (FGDs), two each for adolescent females, adult females, adult males, and community health committee members. As well, twenty-four key Informants interviews (KII) were also conducted including religious leaders, and persons from local government representatives, Ministry of Health (MOH), and local women's organizations. Data were captured through audio recordings and reflective field notes. RESEARCH SITE: Kisii and Kilifi Counties in Kenya. FINDINGS: Findings show nursing and medical care during labour and delivery were at times disrespectful, humiliating, uncompassionate, neglectful, or abusive. In both counties, male health workers were preferred by women giving birth, as they were perceived as more friendly and sensitive. Adolescent females were more likely to report abuse during maternity care while women with disabled children reported being stigmatized. Structural barriers related to transportation and available resources at facilities associated with disrespectful care were identified. CONCLUSIONS: A focus on quality and compassionate care as well as more facility resources will lead to increased, successful, and sustainable use of facility care. Interpreting these results within a systems perspective, Kenya needs to implement, enforce, and monitor quality of care guidelines for pregnancy and delivery including respectful maternity care of pregnant women. To ensure these procedures are enforced, measurable benchmarks for maternity care need to be established, and hospitals need to be regularly monitored to ensure these benchmarks are achieved.

"Childbirth is not a Sickness; A Woman Should Struggle to Give Birth": Exploring Continuing Popularity of Home Births in Western Kenya.

More than 95% of Kenyan women receive antenatal care (ANC) and only 62% access skilled delivery. To explore women's opinion on delivery location, 20 focus group discussions were conducted at an urban and rural setting in western Kenya. Participants included health care workers, traditional birth attendants (TBAs), and women who attended at least four ANC visits and delivered. Six in-depth interviews were also conducted with a combination of women who gave birth in a facility and at home. Discussions were digitally recorded and transcribed for analysis. Data was subjected to content analysis for deductive and inductive codes. Emergent themes were logically organized to address the study topic. Findings revealed that delivery services were sought from both skilled attendants and TBAs. TBAs remain popular despite lack of acknowledgement from mainstream health care. Choice of delivery is influenced by financial access, availability and quality of skilled delivery services, physical access, culture, ignorance about childbirth processes, easy access to familiar TBAs, fear of hospitals and hospital procedures, and social stigma. Appreciation of TBA referral role, quality maternity service, and reproductive health education can encourage facility deliveries. Formal and informal health workers should cooperate in innovative ways and ensure safe motherhood in Kenya.

Bridging Income Generation with Group Integrated Care for cardiovascular risk reduction: Rationale and design of the BIGPIC study.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with >80% of CVD deaths occurring in low and middle income countries (LMICs). Diabetes mellitus and pre-diabetes are risk factors for CVD, and CVD is the major cause of morbidity and mortality among individuals with DM. There is a critical period now during which reducing CVD risk among individuals with diabetes and pre-diabetes may have a major impact. Cost-effective, culturally appropriate, and context-specific approaches are required. Two promising strategies to improve health outcomes are group medical visits and microfinance. METHODS/DESIGN: This study tests whether group medical visits integrated into microfinance groups are effective and cost-effective in reducing CVD risk among individuals with diabetes or at increased risk for diabetes in western Kenya. An initial phase of qualitative inquiry will assess contextual factors, facilitators, and barriers that may impact integration of group medical visits and microfinance for CVD risk reduction. Subsequently, we will conduct a four-arm cluster randomized trial comparing: (1) usual clinical care, (2) usual clinical care plus microfinance groups only, (3) group medical visits only, and (4) group medical visits integrated into microfinance groups. The primary outcome measure will be 1-year change in systolic blood pressure, and a key secondary outcome measure is 1-year change in overall CVD risk as measured by the QRISK2 score. We will conduct mediation analysis to evaluate the influence of changes in social network characteristics on intervention outcomes, as well as moderation analysis to evaluate the influence of baseline social network characteristics on effectiveness of the interventions. Cost-effectiveness analysis will be conducted in terms of cost per unit change in systolic blood pressure, percent change in CVD risk score, and per disability-adjusted life year saved. DISCUSSION: This study will provide evidence regarding effectiveness and cost-effectiveness of interventions to reduce CVD risk. We aim to produce generalizable methods and results that can provide a model for adoption in low-resource settings worldwide.

Barriers Influencing Linkage to Hypertension Care in Kenya: Qualitative Analysis from the LARK Hypertension Study.

BACKGROUND: Hypertension, the leading global risk factor for mortality, is characterized by low treatment and control rates in low- and middle-income countries. Poor linkage to hypertension care contributes to poor outcomes for patients. However, specific factors influencing linkage to hypertension care are not well known. OBJECTIVE: To evaluate factors influencing linkage to hypertension care in rural western Kenya. DESIGN: Qualitative research study using a modified Health Belief Model that incorporates the impact of emotional and environmental factors on behavior. PARTICIPANTS: Mabaraza (traditional community assembly) participants (n = 242) responded to an open invitation to residents in their respective communities. Focus groups, formed by purposive sampling, consisted of hypertensive individuals, at-large community members, and community health workers (n = 169). APPROACH: We performed content analysis of the transcripts with NVivo 10 software, using both deductive and inductive codes. We used a two-round Delphi method to rank the barriers identified in the content analysis. We selected factors using triangulation of frequency of codes and themes from the transcripts, in addition to the results of the Delphi exercise. Sociodemographic characteristics of participants were summarized using descriptive statistics. KEY RESULTS: We identified 27 barriers to linkage to hypertension care, grouped into individual (cognitive and emotional) and environmental factors. Cognitive factors included the asymptomatic nature of hypertension and limited information. Emotional factors included fear of being a burden to the family and fear of being screened for stigmatized diseases such as HIV. Environmental factors were divided into physical (e.g. distance), socioeconomic (e.g. poverty), and health system factors (e.g. popularity of alternative therapies). The Delphi results were generally consistent with the findings from the content analysis. CONCLUSIONS: Individual and environmental factors are barriers to linkage to hypertension care in rural western Kenya. Our analysis provides new insights and methodological approaches that may be relevant to other low-resource settings worldwide.

Lay perceptions of breast cancer in Western Kenya.

AIM: To explore lay perceptions of causes, severity, presenting symptoms and treatment of breast cancer. METHODS: In October-November 2012, we recruited men and women (18 years and older) from households and health facilities in three different parts of Western Kenya, chosen for variations in their documented burdens of breast cancer. A standardized and validated tool, the breast cancer awareness measure (BCAM), was administered in face-to-face interviews. Survey domains covered included socio-demographics, opinions about causes, symptoms, severity, and treatment of breast cancer. Descriptive analyses were done on quantitative data while open-ended answers were coded, and emerging themes were integrated into larger categories in a qualitative analysis. The open-ended questions had been added to the standard BCAM for the purposes of learning as much as the investigators could about underlying lay beliefs and perceptions. RESULTS: Most respondents were female, middle-aged (mean age 36.9 years), married, and poorly educated. Misconceptions and lack of knowledge about causes of breast cancer were reported. The following (in order of higher to lower prevalence) were cited as potential causes of the condition: Genetic factors or heredity (n = 193, 12.3%); types of food consumed (n = 187, 11.9%); witchcraft and curses (n = 108, 6.9%); some family planning methods (n = 56, 3.6%); and use of alcohol and tobacco (n = 46, 2.9%). When asked what they thought of breast cancer's severity, the most popular response was "it is a killer disease" (n = 266, 19.7%) a lethal condition about which little or nothing can be done. While opinions about presenting symptoms and signs of breast cancer were able to be elicited, such as an increase in breast size and painful breasts, early-stage symptoms and signs were not widely recognized. Some respondents (14%) were ignorant of available treatment altogether while others felt breast cancer treatment is both dangerous and expensive. A minority reported alternative medicine as providing relief to patients. CONCLUSION: The impoverished knowledge in these surveys suggests that lay education as well as better screening and treatment should be part of breast cancer control in Kenya.

Implementation and operational research: evaluating outcomes of patients lost to follow-up in a large comprehensive care treatment program in western Kenya.

BACKGROUND: Academic Model Providing Access To Healthcare (AMPATH) program provides comprehensive HIV care and treatment services. Approximately, 30% of patients have become lost to follow-up (LTFU). We sought to actively trace and identify outcomes for a sample of these patients. METHODS: LTFU was defined as missing a scheduled visit by ≥3 months. A randomly selected sample of 17% of patients identified as LTFU between January 2009 and June 2011 was generated, with sample stratification on age, antiretroviral therapy (ART) status at last visit, and facility. Chart reviews were conducted followed by active tracing. Tracing was completed by trained HIV-positive outreach workers July 2011 to February 2012. Outcomes were compared between adults and children and by ART status. RESULTS: Of 14,811 LTFU patients, 2540 were randomly selected for tracing (2179 adults, 1071 on ART). The chart reviews indicated that 326 (12.8%) patients were not actually LTFU. Outcomes for 71% of sampled patients were determined including 85% of those physically traced. Of those with known outcomes, 21% had died, whereas 29% had disengaged from care for various reasons. The remaining patients had moved away (n = 458, 25%) or were still receiving HIV care (n = 443 total, 25%). CONCLUSIONS: Our findings demonstrate the feasibility of a large-scale sampling-based approach. A significant proportion of patients were found not to be LTFU, and further, high numbers of patients who were LTFU could not be located. Over a quarter of patients disengaged from care for various reasons including access challenges and familial influences.

An examination of postpartum family planning in western Kenya: "I want to use contraception but I have not been told how to do so".

Postpartum family planning (FP) in Kenya is low due to inadequate sensitization and awareness among women, particularly in rural areas. This paper identifies most widely used types of FP, intent and unmet needs among women, FP counseling and barriers to FP uptake. Focus group discussions with providers, traditional birth attendants (TBAs) and mothers, as well as in-depth interviews identify key themes including preferred postpartum FP, limits to existing FP counseling and barriers to FP uptake. Postpartum FP is common including injectable contraceptives, oral contraceptives, coils, condoms, and calendar methods. FP counseling is provided by peers, friends, TBAs and formal health providers. FP practices are associated with family support, literacy, access to FP information, side effects, costs and religion. In conclusion, changes in service provision and education could encourage increase in postpartum FP use in Kenya.