Healthcare provider perspectives on managing sexually transmitted infections in HIV care settings in Kenya: A qualitative thematic analysis.

BACKGROUND: The burden of sexually transmitted infections (STIs) has been increasing in Kenya, as is the case elsewhere in sub-Saharan Africa, while measures for control and prevention are weak. The objectives of this study were to (1) describe healthcare provider (HCP) knowledge and practices, (2) explore HCP attitudes and beliefs, (3) identify structural and environmental factors affecting STI management, and (4) seek recommendations to improve the STI program in Kenya. METHODS AND FINDINGS: Using individual in-depth interviews (IDIs), data were obtained from 87 HCPs working in 21 high-volume comprehensive HIV care centers (CCCs) in 7 of Kenya's 8 regions. Transcript coding was performed through an inductive and iterative process, and the data were analyzed using NVivo 10.0. Overall, HCPs were knowledgeable about STIs, saw STIs as a priority, reported high STI co-infection amongst people living with HIV (PLHIV), and believed STIs in PLHIV facilitate HIV transmission. Most used the syndromic approach for STI management. Condoms and counseling were available in most of the clinics. HCPs believed that having an STI increased stigma in the community, that there was STI antimicrobial drug resistance, and that STIs were not prioritized by the authorities. HCPs had positive attitudes toward managing STIs, but were uncomfortable discussing sexual issues with patients in general, and profoundly for anal sex. The main barriers to the management of STIs reported were low commitment by higher levels of management, few recent STI-focused trainings, high stigma and low community participation, and STI drug stock-outs. Solutions recommended by HCPs included formulation of new STI policies that would increase access, availability, and quality of STI services; integrated STI/HIV management; improved STI training; increased supervision; standardized reporting; and community involvement in STI prevention. The key limitations of our study were that (1) participant experience and how much of their workload was devoted to managing STIs was not considered, (2) some responses may have been subject to recall and social desirability bias, and (3) patients or clients of STI services were not interviewed, and therefore their inputs were not obtained. While considering these limitations, the number and variety of facilities sampled, the mix of staff cadres interviewed, the use of a standardized instrument, and the consistency of responses add strength to our findings. CONCLUSIONS: This study showed that HCPs understood the challenges of, and solutions for, improving the management of STIs in Kenya. Commitment by higher management, training in the management of STIs, measures for reducing stigma, and introducing new policies of STI management should be considered by health authorities in Kenya.

Unintended pregnancy and subsequent use of modern contraceptive among slum and non-slum women in Nairobi, Kenya.

BACKGROUND: In spite of major gains in contraceptive prevalence over the last few decades, many women in most parts of the developing world who would like to delay or avoid pregnancy do not use any method of contraception. This paper seeks to: a) examine whether experiencing an unintended pregnancy is associated with future use of contraception controlling for a number factors including poverty at the household and community levels; and b) investigate the mechanisms through which experiencing an unintended pregnancy leads to uptake of contraception. METHODS: Quantitative and qualitative data from a cross-sectional research project conducted in 2009/10 in two slum settlements and two non-slum settings of Nairobi, Kenya are used. The quantitative component of the project was based on a random sample of 1,259 women aged 15-49 years. Logistic regression models were used to assess the effect of unintended pregnancy on future contraceptive use. The qualitative component of the project successfully interviewed a total of 80 women randomly selected from survey participants who had reported having at least one unintended pregnancy. RESULTS: Women whose last pregnancy was unintended were more likely to be using a modern method of contraception, compared to their peers whose last pregnancy was intended, especially among the wealthier group as shown in the interaction model. Among poor women, unintended pregnancy was not associated with subsequent use of contraception. The qualitative investigation with women who had an unplanned pregnancy reveals that experiencing an unintended pregnancy seems to have served as a "wake-up call", resulting in greater attention to personal risks, including increased interest in pregnancy prevention. For some women, unintended pregnancy was a consequence of strong opposition by their partners to family planning, while others reported they started using contraceptives following their unintended pregnancy, but discontinued after experiencing side effects. CONCLUSION: This study provides quantitative and qualitative evidence that women who have had an unintended pregnancy are "ready for change". Family planning programs may use the contacts with antenatal, delivery and post-delivery care system as an opportunity to identify women whose pregnancy is unplanned, and target them with information and services.

The state of emergency obstetric care services in Nairobi informal settlements and environs: results from a maternity health facility survey.

BACKGROUND: Maternal mortality in Sub-Saharan Africa remains a challenge with estimates exceeding 1,000 maternal deaths per 100,000 live births in some countries. Successful prevention of maternal deaths hinges on adequate and quality emergency obstetric care. In addition to skilled personnel, there is need for a supportive environment in terms of essential drugs and supplies, equipment, and a referral system. Many household surveys report a reasonably high proportion of women delivering in health facilities. However, the quality and adequacy of facilities and personnel are often not assessed. The three delay model; 1) delay in making the decision to seek care; 2) delay in reaching an appropriate obstetric facility; and 3) delay in receiving appropriate care once at the facility guided this project. This paper examines aspects of the third delay by assessing quality of emergency obstetric care in terms of staffing, skills equipment and supplies. METHODS: We used data from a survey of 25 maternity health facilities within or near two slums in Nairobi that were mentioned by women in a household survey as places that they delivered. Ethical clearance was obtained from the Kenya Medical Research Institute. Permission was also sought from the Ministry of Health and the Medical Officer of Health. Data collection included interviews with the staff in-charge of maternity wards using structured questionnaires. We collected information on staffing levels, obstetric procedures performed, availability of equipment and supplies, referral system and health management information system. RESULTS: Out of the 25 health facilities, only two met the criteria for comprehensive emergency obstetric care (both located outside the two slums) while the others provided less than basic emergency obstetric care. Lack of obstetric skills, equipment, and supplies hamper many facilities from providing lifesaving emergency obstetric procedures. Accurate estimation of burden of morbidity and mortality was a challenge due to poor and incomplete medical records. CONCLUSION: The quality of emergency obstetric care services in Nairobi slums is poor and needs improvement. Specific areas that require attention include supervision, regulation of maternity facilities; and ensuring that basic equipment, supplies, and trained personnel are available in order to handle obstetric complications in both public and private facilities.