Progress in sanitation among poor households in Kenya: evidence from demographic and health surveys.

BACKGROUND: An estimated 14% of Kenyans practice open defecation. Poverty has been associated with open defecation. Kenya aims to achieve 100% open defecation free status by 2030 in line with sustainable development goal number 6. Using data from 3 national household surveys, this study sought to explore progress made in attaining this at the household level with a focus on poor households. METHODS: Kenya demographic and health survey for 2003, 2008 and 2014 respectively were analysed. Descriptive analysis and bivariate logistic regression was done with open defecation status as the dependent variable. Independent variables were poverty status, place of residence, region where household was located, absence of farm animals, gender and educational level of household head. RESULTS: The most common sanitation method nationally is a pit latrine without a slab. This ranged from 35.9-37.9%. Open defecation was 16.2, 12.1 and 9.9% in 2003, 2008 and 2014 respectively. Among households practicing open defecation, 81.8, 86 and 96% were classified as poor in 2003, 2008 and 2014 respectively. Poverty, educational level of household head and residing in a rural area were the most significant predictors of open defecation. Odds ratio for poverty was 9.4 (7-12.6 95% CI), 9.4(6.6-13.5 95% CI) and 29.2 (23.3-36.8 95% CI) for 2003, 2008 and 2014 respectively. The majority of richest households transitioned from using a pit latrine with a slab in 2003 to using a flush toilet connected to a sewer in 2008 and 2014. The majority of richer households transitioned from using a pit latrine without a slab in 2003 and 2008 to using a pit latrine with a slab in 2014. The majority of middle and poorer households stagnated at using a pit latrine without a slab across the similar period. The poorest households stagnated at the open defecation stage. CONCLUSION: The burden of open defecation has increased among poor households, more so among the poorest. This may be attributed to non-poor households exiting the open defecation stage at a higher rate compared to poor households. Poor households may need to be targeted more if Kenya is to attain open defecation free status by 2030.

Impact of free delivery policy on utilization of maternal health services in county referral hospitals in Kenya.

BACKGROUND: Kenya has a high maternal mortality rate. Provision of skilled delivery plays a major role in reducing maternal mortality. Cost is a hindrance to the utilization of skilled delivery. The Government of Kenya introduced a policy of free delivery services in government facilities beginning June 2013. We sought to determine the impact of this intervention on facility based deliveries in Kenya. METHODS: We compared deliveries and antenatal attendance in 47 county referral hospitals and 30 low cost private hospitals not participating in the free delivery policy for 2013 and 2014 respectively. The data was extracted from the Kenya Health Information System. Multiple regression was done to assess factors influencing increase in number of deliveries among the county referral hospitals. RESULTS: The number of deliveries and antenatal attendance increased by 26.8% and 16.2% in county referral hospitals and decreased by 11.9% and 5.4% respectively in low cost private hospitals. Increase in deliveries among county referral hospitals was influenced by population size of county and type of county referral hospital. Counties with level 5 hospitals recorded more deliveries compared to those with level 4 hospitals. CONCLUSION: This intervention increased the number of facility based deliveries. Policy makers may consider incorporating low cost private hospitals so as to increase the coverage of this intervention.

Effect of eliminating open defecation on diarrhoeal morbidity: an ecological study of Nyando and Nambale sub-counties, Kenya.

BACKGROUND: Defecating in the open predisposes people to soil transmitted helminthes and diarrhoeal diseases. An estimated 5.6 million Kenyans defecate in the open. Kenya launched a program to eradicate open defecation by 2013 in the rural areas. By end of 2013, only two sub-counties had eliminated open defecation. These are Nambale and Nyando. The study looked at the impact of eradicating open defecation on diarrhea prevalence among children in these two sub-counties. METHODS: Data on diarrhoea morbidity among children under 5 years was extracted from the Kenya Health Information System for all the sub-counties in Busia and Kisumu counties for 2012, 2013 and 2014 respectively. Prevalence was calculated for each sub-county in Kisumu for comparison with Nyando's. Prevalence was also calculated for each sub-county in Busia County and compared to that of Nambale sub-county. A Mann-Whitney U Test was done to test the null hypothesis that diarrhoea prevalence was similar in both open defecation and open defecation free sub-counties. RESULTS: A Mann-Whitney U Test revealed significant difference in diarrhoeal prevalence of open defecation sub-counties (Md = 18.4, n = 34) and open defecation free sub-counties (Md = 9.8, n = 5), U = 9, z = -3.2, p = .001. Among the two Counties, Nambale had the lowest prevalence. It recorded a decline from 9.8 to 5.7 % across the three years. Prevalence for diarrhoea cases in Nyando declined from 19.1 to 15.2 % across the three years. Nyando initially had the second highest prevalence in Kisumu County and by 2014 it had the lowest prevalence. CONCLUSIONS: The two sub-counties with open defecation free status had lower prevalence of diarrhoea cases compared to sub-counties which were yet to attain open defecation free status. This suggests that elimination of open defecation may reduce the number of diarrhoea cases.

Khat consumption in Masalani town, northeastern Kenya.

Khat is widely consumed in Kenya. It contains cathinone, a psychoactive alkaloid, whose health effects are similar to those of amphetamine. A descriptive study was done among men in a remote Kenyan town on consumption of khat. We administered semi-structured questionnaires. Of those interviewed, 68% chewed khat, and of those who chewed, half did so on a daily basis. Most prefer to chew it in the company of their friends and age mates, accompanied by soda, sweet tea, and cigarettes. Those employed were three times more likely to chew khat compared to those unemployed (OR = 2.8, 95% CI 1.03-7.6). A plausible reason is that they have regular sources of income to buy khat. Most respondents were knowledgeable about the health effects of khat, with a third reporting mental health problems. The major social consequences of khat chewing reported were negligence of responsibility by men, family break-up, promiscuity, and impotence. The consumption of khat may increase in the near future, given that a high proportion of the males in this district are below 19 years. This cohort will gradually finish school and gain employment. There may be need to put in place health education programs and provide recreational facilities targeting this group and those already chewing khat in this resource-limited setting.

The Effect of the COVID-19 Pandemic on Use of Select Child Health Services in Kenyan Hospitals.

INTRODUCTION: Kenya reported its first case of coronavirus disease (COVID-19) in March 2020. Pandemics may disrupt provision of essential health services. This study sought to find out if the COVID-19 outbreak had any effect on reported paediatric workload in Kenya. METHODS: Aggregate workload data for 12 months before COVID-19 outbreak and 12 months of the COVID-19 outbreak were extracted from the Kenya Health Information System and negative binomial regression conducted. RESULTS: A significant decline was observed across all indicators. Paediatric clinics attendance declined by 36%, paediatric admissions by 31.4%, outpatient attendance by 28.7%, and child wellness clinics attendance by 10.3%. In outpatient attendance, the five conditions with the highest attendance reported a decline ranging from 17.3% to 33.8%. CONCLUSION: COVID-19 partially disrupted essential health services among children in Kenya. Children in need of specialized treatment were more disadvantaged.

The effect of a pilot universal health coverage program on hospital workload: A comparative study of two counties in Kenya.

Aim: Universal health coverage (UHC) aims to provide individuals with the healthcare they need without predisposing them to catastrophic health expenditures. The Kenyan government piloted UHC in four select counties in 2019. Nyeri County was one of the selected counties. Area residents accessed health services from government-owned health facilities at no cost. This study assessed the effect of this pilot on the workload of major health facilities in Nyeri. Material and methods: The monthly workload of six health facilities in Nyeri was compared with that of similar facilities in the non-participating county of Embu. A difference-in - differences analysis was done for workload indicators. Workload was downloaded from the Kenya health information system. The level 5 hospital recorded an increase in eight workload indicators with four having statistically significant increases. Three indicators recorded non-significant declines. The level 4 and 3 health facilities also recorded an increase in outpatient workload. Conclusion: The pilot UHC program increased workload and by extension utilization of healthcare among major health facilities in Nyeri.

Malaria morbidity and temperature variation in a low risk Kenyan district: a case of overdiagnosis?

Diagnosis of malaria using only clinical means leads to overdiagnosis. This has implications due to safety concerns and the recent introduction of more expensive drugs. Temperature is a major climatic factor influencing the transmission dynamics of malaria. This study looked at trends in malaria morbidity in the low risk Kenyan district of Nyandarua, coupled with data on temperature and precipitation for the years 2003-2006. July had the highest number of cases (12.2% of all cases) followed by August (10.2% of all cases). July and August also had the lowest mean maximum temperatures, 20.1 and 20.2 degrees C respectively. April, July and August had the highest rainfall, with daily means of 4.0, 4.3 and 4.9 mm, respectively. Observation showed that the coldest months experienced the highest number of cases of malaria. Despite the high rainfall, transmission of malaria tends to be limited by low temperatures due to the long duration required for sporogony, with fewer vectors surviving. These cold months also tend to have the highest number of cases of respiratory infections. There is a possibility that some of these were misdiagnosed as malaria based on the fact that only a small proportion of malaria cases were diagnosed using microscopy or rapid diagnostic tests. We conclude that overdiagnosis may be prevalent in this district and there may be a need to design an intervention to minimise it.

Impact of a Conditional Cash Transfer Program Aimed at Promoting Maternal and Child Health Services in Kakamega County, Kenya.

INTRODUCTION: The Kenyan government launched a free maternity program in 2013. Kakamega County Government supplemented this through a conditional cash transfer program targeting poor women. This was to facilitate their access to maternal and child health services. This study looked at the impact of this intervention. METHODS: Deliveries, four antenatal attendances, and general antenatal attendance were analysed for level 4 hospitals in Kakamega, Bungoma, and Busia counties. Difference-in-differences treatment effects methods were used with Busia and Bungoma acting as controls. Population and poverty were controlled for. RESULTS: Monthly deliveries increased by 57, though this was not significant. Monthly antenatal clinic attendance and four antenatal clinic attendance increased significantly by 539 and 144 respectively. Poverty was a significant factor in influencing utilization of deliveries and antenatal clinic attendance. CONCLUSION: This conditional cash transfer may have improved use of maternal health services, with greatest impact on antenatal attendance.

Impact of Nurses' Strike in Kenya on Number of Fully Immunized Infants in 18 County Referral Hospitals.

INTRODUCTION: Nurses in Kenya provide significant health care including immunization in government-run health facilities. Nurses' went on strike for 150 days in 2017. This study sought to determine the strike's effect on immunization services. METHODS: Data on number of fully immunized infants reported in 18 county referral hospitals was extracted from the Kenya Health Information System and analyzed for strike and similar non-strike months. A similar analysis was conducted for 14 faith-based health facilities that were not affected by the strike. RESULTS: A Mann-Whitney U Test revealed significant difference in the mean number of fully immunized infants during the strike period (Md= 111, n=18) and non-strike period (Md=289, n=18), U=37, z= -4.0, p= .000, r=.6. A decline of 56.9% was reported during the strike. Faith-based health facilities reported an increase of 251.6% during the strike periodConclusion. This nurses' strike may have adversely affected immunization services.

Open Defecation in Newly Created Kenyan Counties: A Situational Analysis.

INTRODUCTION: An estimated 5.6 million Kenyans defecate in the open. This exposes them to sanitation related diseases. This study analysed open defecation trends among the 47 counties in Kenya, newly created in 2013. METHODS: The study used four data sets on open defecation, unimproved water supply coverage, poverty levels, and population density. RESULTS: Mean open defecation rate across the 47 counties was 23.5% and the median rate 6.9%. The lowest rate was 0.1% and the highest 88.4%. Fifteen counties had open defecation rates of 40% and above. Another 21 counties had open defecation rates of less than 5%. Poverty was the most significant predictor accounting for 68.4% of the variance in open defecation after controlling for unimproved water supply and population density. CONCLUSION: Some counties have unacceptably high open defecation rates. Alleviating poverty may reduce open defecation in Kenya.

Impact of Health Workers' Strike in August 2014 on Health Services in Mombasa County Referral Hospital, Kenya.

INTRODUCTION: Health workers are an essential part of the health system. Health workers in Mombasa County went on strike for two weeks in August 2014 due to nonpayment of salaries. This study analysed the impact of this strike. METHODS: Monthly utilization of health services was accessed from the Kenya Health Information website. This was for general outpatient, special clinics, maternal and child health, inpatient services, maternity services, dental, and radiological services. For each indicator, monthly mean was calculated for January to July 2014. This was compared with the August monthly mean. RESULTS: Outpatient attendance declined by 64.4%, special clinics attendance by 74.2%, and deliveries by 53.5%. Inpatient admissions declined by 57.8 % and inpatient deaths by 26.3%. CONCLUSION: The August 2014 strike adversely affected health services. County governments should put in place mechanisms to avert future health workers' strike. The national government should also disburse funds to the counties on time.

Impact of an Intervention to Minimize Overdiagnosis of Malaria Cases in a Low Risk Kenyan sub-County.

INTRODUCTION: Overdiagnosis of malaria cases hampers malaria control in developing countries. Due to lack of diagnostics, febrile cases are treated using signs and symptoms. We evaluated an intervention to minimize overdiagnosis in Ijara sub-County, Kenya. METHODS: Health workers were trained on case management and rapid diagnostic tests provided in late 2011. Malaria outpatient morbidity was assessed a year before and after the intervention coupled with data on rapid diagnostic tests consumption. RESULTS: The number of diagnosed malaria cases decreased from 15,615 in 2011 to 1,892 in 2012. This represents an 87.8% decrease. There was a significant difference in number of diagnosed monthly malaria cases during the pre-intervention (Mean = 1,299, SD = 550.4) and post-intervention periods (Mean = 158, SD = 160.9, t (12.9) = 6.9, p =.000, two tailed). Mean monthly consumption of rapid diagnostic tests was 730, with 5.2% testing positive. CONCLUSION: This intervention reduced overdiagnosis and overtreatment of malaria cases.

Incentives among health workers in a remote Kenyan district: implications for proposed county health system.

INTRODUCTION: Attracting and retaining health workers in remote rural areas is a challenge in Kenya. Devolution of the Kenyan health system may negatively affect worker retention; incentives may play a role in retaining health workers. METHODS: Semi-structured questionnaires were administered to health workers and human resource data reviewed. Analysis was for descriptive and emerging themes. RESULTS: Health workers were employed under three different terms of service. The majority receive a monthly hardship allowance in the range of $7.5-94. Only five percent of health workers were able to engage in private practice. Available housing, water supply, electricity supply, and educational facilities were cited as inadequate. With the proposed devolution to county governments, 97.3% of respondents preferred to work in a different county. CONCLUSION: There may be need to harmonize the terms of service, improve the incentives, and amenities available to health workers in remote Kenyan counties in order to improve retention.

An assessment of malaria curative services in Ijara district, a remote community in the North-Eastern province of Kenya.

INTRODUCTION: Malaria is a major public health problem in Kenya and there is need to strengthen malaria control activities at the district level. METHODS: As part of this, an assessment of malaria curative services offered in health facilities in terms of health care material availability and the case management skills of the health workers was conducted in Ijara district. A questionnaire was administered to the health workers. Observation and physical inspection of malaria health care material and perusal of relevant documents were also carried out in all health facilities in 2011. RESULTS: All health facilities had the recommended drugs, though only 90% of facilities had quinine injection. All facilities lacked Rapid Diagnostic Tests, Adverse Drug Reaction reporting forms, and poor quality medicine forms. CONCLUSIONS: There is need to equip the health workers with up-to-date case management skills and to provide rapid diagnostic tests.