The promise of home visitation by community health workers in rural Kenya: A protective effect that reduces neonatal illness.

BACKGROUND: Nearly three million neonates die each year, largely from preventable illnesses in developing countries. Sub-Saharan Africa has disproportionately high neonatal mortality. Community health worker (CHW) programs are a promising intervention to reduce mortality rates. This research evaluates a CHW newborn home visitation program in rural Kenya by assessing the frequency of health service utilization and overnight hospitalization. METHODS: This quasi-experimental study encompassed two consecutive years and compared the rate of medical service utilization for neonatal illness in an intervention group with that of a control group using a household survey. Severity of neonatal illness was assessed by need for overnight hospitalization. Household, maternal, and child characteristics were collected. RESULTS: A total of 489 surveys were completed and showed that 35% of not-visited families reported taking their infant to a healthcare facility, compared with 21% of CHW-visited families (P < 0.01). Rates of overnight hospitalization were 6% for not-visited infants and 1% for visited infants (P < 0.01). Few significant differences were found in household, maternal, and child characteristics. DISCUSSION: This study found that a CHW newborn home visitation program in rural Kenya significantly decreased rates of health service utilization and overnight hospitalization, but did not have the power to detect an effect on neonatal mortality.

Economic empowerment and AIDS-related stigma in rural Kenya: a double-edged sword?

Economic empowerment, HIV risk and AIDS-related stigma appear intricately intertwined for women in Kenya. Their interaction must be understood in order to implement effective economic interventions that also decrease HIV risk and stigma. We conducted a qualitative study amongst women in a rural Kamba-speaking community of southeastern Kenya to pursue whether engagement in an economic empowerment initiative (a basket weaving cooperative) influences women's perspectives and experiences with HIV risk and AIDS-related stigma. We conducted seven women's focus groups: participants in the local basket-weaving cooperative comprised four focus groups and non-participants comprised the remaining three groups. The HIV status of the women was not known. Three dominant themes emerged from the focus groups: empowerment, pervasive vulnerability and unanticipated social paradoxes. Contradictions found in these themes suggest that economic empowerment can become a double-edged sword. Economic empowerment enhanced perceived individual, domestic and social community status. However, this enhancement was not protective of domestic violence and perceived HIV risk. Social perceptions may have paradoxically contributed barriers to HIV testing and treatment putting women at greater HIV risk. In conclusion, economic empowerment initiatives for women in developing countries in the context of the HIV epidemic should be coupled with peer mediated support and HIV-risk education.

A community health worker home visitation project to prevent neonatal deaths in Kenya.

Neonatal deaths account for 43% of under-5 childhood deaths in Kenya. Most infants are born at home, and many of them die at home unaccounted for, often during the first week of life. Previous studies in which community health workers (CHWs) were trained to provide neonatal care reported reductions in neonatal mortality. These programmes required more resources than may be available in some resource-poor settings. We implemented a brief and inexpensive programme to train rural Kenyan CHWs to evaluate newborn infants for signs of severe illness during the first week of life and refer the ill infants to a health facility. During the first 12 months, 20 CHWs visited 702 infants, and all three visits were completed for 93% of the infants. There were five neonatal deaths, none after the first week of life. A brief low-cost training programme for CHW home visitation of newborns is feasible for rural Kenya and the larger African setting.

Feasibility and effectiveness of supplementation with locally available foods in prevention of child malnutrition in Kenya.

OBJECTIVE: To establish the operational feasibility and effectiveness of using locally available foods to prevent malnutrition and improve child growth in Kenyan children. DESIGN: Quasi-experimental design with an intervention group of children in all villages in one region and a non-intervention group of children in all villages in an adjacent region. The intervention was the distribution of a monthly food ration for the index child, a separate family ration, and group education on appropriate complementary feeding and hygiene. SETTING: Rural villages in the arid lands of eastern Kenya with a high prevalence of child malnutrition. SUBJECTS: All children in the target villages aged 6-20 months with weight-for-length Z-score (WHZ) greater than -2 at baseline. RESULTS: Children in the intervention and non-intervention groups had similar baseline anthropometric measures. The caregivers in the intervention group confirmed that the intended amounts of food supplements were received and child nutrient intake improved. During the 7-month intervention period there were significant group differences in pre-post Z-score changes between the intervention and non-intervention groups for weight-for-age (0·82, P < 0·001) and weight-for-height (1·19, P < 0·001), but not for height-for-age (-0·20, P = 0·09), after adjusting for multiple covariates. Compared with the non-intervention group, the intervention group had a lower prevalence of wasting (0% v. 8·9%, P = 0·0002) and underweight (6·3% v. 23·0%, P < 0·0001). Infectious morbidity was similar in both groups. CONCLUSIONS: The findings suggest that the distribution of locally available foods is operationally feasible and improves child weight gain and decreases acute malnutrition in Kenyan children.

The Health Commons and care of New Mexico's uninsured.

PURPOSE: A seamless system of social, behavioral, and medical services for the uninsured was created to address the social determinants of disease, reduce health disparities, and foster local economic development in 2 inner-city neighborhoods and 2 rural counties in New Mexico. METHODS: Our family medicine department helped urban and rural communities that had large uninsured, minority populations create Health Commons models. These models of care are characterized by health planning shared by community stakeholders; 1-stop shopping for medical, behavioral, and social services; employment of community health workers bridging the clinic and the community; and job creation. RESULTS: Outcomes of the Health Commons included creation of a Web-based assignment of uninsured emergency department patients to primary care homes, reducing return visits by 31%; creation of a Web-based interface allowing partner organizations with incompatible information systems to share medical information; and creation of a statewide telephone Health Advice Line offering rural and urban uninsured individuals access to health and social service information and referrals 24 hours a day, 7 days a week. The Health Commons created jobs and has been sustained by attracting local investment and external public and private funding for its products. Our department's role in developing the Health Commons helped the academic health center (AHC) form mutually beneficial community partnerships with surrounding and distant urban and rural communities. CONCLUSIONS: Broad stakeholder participation built trust and investment in the Health Commons, expanding services for the uninsured. This participation also fostered marketable innovations applicable to all Health Commons' sites. Family medicine can promote the Health Commons as a venue for linking complementary strengths of the AHC and the community, while addressing the unique needs of each. Overall, our experience suggests that family medicine can play a leadership role in building collaborative approaches to seemingly intractable health problems among the uninsured, benefiting not only the community, but also the AHC.

From home deliveries to health care facilities: establishing a traditional birth attendant referral program in Kenya.

OBJECTIVE: To assess the effectiveness of a traditional birth attendant (TBA) referral program on increasing the number of deliveries overseen by skilled birth attendants (SBA) in rural Kenyan health facilities before and after the implementation of a free maternity care policy. METHODS: In a rural region of Kenya, TBAs were recruited to educate pregnant women about the importance of delivering in healthcare facilities and were offered a stipend for every pregnant woman whom they brought to the healthcare facility. We evaluated the percentage of prenatal care (PNC) patients who delivered at the intervention site compared with the percentage of PNC patients who delivered at rural control facilities, before and after the referral program was implemented, and before and after the Kenya government implemented a policy of free maternity care. The window period of the study was from July of 2011 through September 2013, with a TBA referral intervention conducted from March to September 2013. RESULTS: The absolute increases from the pre-intervention period to the TBA referral intervention period in SBA deliveries were 5.7 and 24.0% in the control and intervention groups, respectively (p < 0.001). The absolute increases in SBA delivery rates from the pre-intervention period to the intervention period before the implementation of the free maternity care policy were 4.7 and 17.2% in the control and intervention groups, respectively (p < 0.001). After the policy implementation the absolute increases from pre-intervention to post-intervention were 1.8 and 11.6% in the control and intervention groups, respectively (p < 0.001). CONCLUSION: The percentage of SBA deliveries at the intervention health facility significantly increased compared to control health facilities when TBAs educated women about the need to deliver with a SBA and when TBAs received a stipend for bringing women to local health facilities to deliver. Furthermore, this TBA referral program proved to be far more effective in the target region of Kenya than a policy change to provide free obstetric care.

Integrating population health into a family medicine clerkship: 7 years of evolution.

A population health curriculum using methodologies from community-oriented primary care (COPC) was developed in 1994 as part of a required third-year family medicine clerkship at the University of New Mexico. The curriculum integrates population health/community medicine projects and problem-based tutorials into a community-based, ambulatory clinical experience. By combining a required population health experience with relevant clinical training, student careers have the opportunity to be influenced during the critical third year. Results over a 7-year period describe a three-phase evolution of the curriculum, within the context of changes in medical education and in health care delivery systems in that same period of time. Early evaluation revealed that students viewed the curricular experience as time consuming and peripheral to their training. Later comments on the revised curriculum showed a higher regard for the experience that was described as important for student learning.

A strategy to increase the number of deliveries with skilled birth attendants in Kenya.

OBJECTIVE: To increase the number of deliveries with skilled birth attendants (SBAs) in Kenyan health facilities, with assistance from traditional birth attendants (TBAs). METHODS: In the Yatta district of Kenya, TBAs were recruited to attend meetings in which they were encouraged to educate pregnant women about the importance of delivering in health facilities; they were offered a small stipend for each pregnant woman they brought to a facility for SBA delivery. The primary outcome was the percentage of prenatal care patients who delivered at intervention health facilities compared with control facilities. RESULTS: During the year preceding the intervention, 102/524 (19.5%) and 413/2068 (20.0%) prenatal care patients had SBA deliveries at intervention and control facilities, respectively. During the 1-year study period, 217/440 (49.3%) prenatal care patients delivered at intervention health facilities and 415/1995 (20.8%) delivered at control facilities (P<0.001). Deliveries at intervention facilities increased 113% in the study year compared with the preceding year. CONCLUSION: The rate of SBA births in health facilities increased when TBAs were recruited and compensated for bringing women to local health facilities to deliver.