Health services availability and readiness moderate cash transfer impacts on health insurance enrolment: evidence from the LEAP 1000 cash transfer program in Ghana.

BACKGROUND: Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services. METHODS: We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities' service availability and readiness. RESULTS: We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points). CONCLUSIONS: We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors. TRIAL REGISTRATION: This study is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations ( RIDIE-STUDY-ID-55942496d53af ).

Readiness of health facilities to deliver non-communicable diseases services in Kenya: a national cross-sectional survey.

BACKGROUND: Non-communicable diseases (NCDs) account for an estimated 71% of all global deaths annually and nearly 80% of these deaths occur in low- and middle-income countries. This study aimed to assess the readiness of existing healthcare systems at different levels of health care in delivering NCDs management and prevention services in Kenya. METHODS: A cross-sectional survey of 258 facilities was conducted between June 2019 and December 2020 using multistage sampling, examining facility readiness based on the availability of indicators such as equipment, diagnostic capacity, medicines and commodities, trained staff and guidelines for NCDs management. Readiness scores were calculated as the mean availability of tracer items expressed as a percentage and a cut-off threshold of ≥ 70% was used to classify facilities as "ready" to manage NCDs. Descriptive and bivariate analyses were performed to assess the readiness of facilities by type, level, and location settings. Logistic regressions were used to identify factors associated with the readiness of facilities to provide disease-specific services. RESULTS: Of the surveyed facilities, 93.8% offered chronic respiratory disease (CRD) diagnosis and/or management services, 82.2% diabetes mellitus, 65.1% cardiovascular disease (CVD), and only 24.4% cervical cancer screening services. The mean readiness scores for diabetes mellitus (71%; 95% CI: 67-74) and CVD (69%; 95% CI: 66-72) were relatively high. Although CRD services were reportedly the most widely available, its mean readiness score was low (48%; 95% CI: 45-50). The majority of facilities offering cervical cancer services had all the necessary tracer items available to provide these services. Modeling results revealed that private facilities were more likely to be "ready" to offer NCDs services than public facilities. Similarly, hospitals were more likely "ready" to provide NCDs services than primary health facilities. These disparities in service readiness extended to the regional and urban/rural divide. CONCLUSIONS: Important gaps in the current readiness of facilities to manage NCDs in Kenya at different levels of health care were revealed, showing variations by disease and healthcare facility type. A collective approach is therefore needed to bridge the gap between resource availability and population healthcare needs.

Patterns and predictors of private and public health care utilization among residents of an informal settlement in Nairobi, Kenya: a cross-sectional study.

BACKGROUND: Knowledge of health care utilization is important in low-and middle-income countries where inequalities in the burden of diseases and access to primary health care exist. Limited evidence exists on health seeking and utilization in the informal settlements in Kenya. This study assessed the patterns and predictors of private and public health care utilization in an urban informal settlement in Kenya. METHODS: This study used data from the Lown scholars study conducted between June and July 2018. A total of 300 households were randomly selected and data collected from 364 household members who reported having sought care for an illness in the 12 months preceding the study. Data were collected on health-seeking behaviour and explanatory variables (predisposing, enabling, and need factors). Health care utilization patterns were described using proportions. Predictors of private or public health care use were identified using multinomial logistic regression with the reference group being other providers. RESULTS: Majority of the participants used private (47%) and public facilities (33%) with 20% using other providers including local pharmacies/drug shops and traditional healers. In the model comparing public facilities vs other facilities, members who were satisfied with the quality of health care (vs not satisfied) were less likely to use public facilities (adjusted relative risk ratio (aRRR) 0.29; CI 0.11-0.76) while members who reported an acute infection (vs no acute infection) were more likely to use public facilities (aRRR 2.31; 95% CI 1.13-4.99) compared to other facilities. In the second model comparing private facilities to other facilities, having health insurance coverage (aRRR 2.95; 95% CI 1.53-5.69), satisfaction with cost of care (aRRR 2.08; CI 1.00-4.36), and having an acute infection (aRRR 2.97; 95% CI 1.50-5.86) were significantly associated with private facility use compared to other facilities. CONCLUSIONS: The majority of urban informal settlement dwellers seek care from private health facilities. As Kenya commits to achieving universal health coverage, interventions that improve health care access in informal and low-resource settlements are needed and should be modelled around enabling and need factors, particularly health care financing and quality of health care.

Persistent barriers to the use of maternal, newborn and child health services in Garissa sub-county, Kenya: a qualitative study.

BACKGROUND: North Eastern Kenya has persistently had poor maternal, new-born and child health (MNCH) indicators. Barriers to access and utilisation of MNCH services are structural, individual and community-level factors rooted in sociocultural norms. A package of interventions was designed and implemented in Garissa sub-County aimed at creating demand for services. Community Health Volunteers (CHVs) were trained to generate demand for and facilitate access to MNCH care in communities, while health care providers were trained on providing culturally acceptable and sensitive services. Minor structural improvements were made in the control areas of two facilities to absorb the demand created. Community leaders and other social actors were engaged as influencers for demand creation as well as to hold service providers accountable. This qualitative research was part of a larger mixed methods study and only the qualitative results are presented. In this paper, we explore the barriers to health care seeking that were deemed persistent by the end of the intervention period following a similar assessment at baseline. METHODS: An exploratory qualitative research design with participatory approach was undertaken as part of an impact evaluation of an innovation project in three sites (two interventions and one control). Semi-structured interviews were conducted with women who had given birth during the intervention period. Focus group discussions were conducted among the wider community members and key informant interviews among healthcare managers and other stakeholders. Participants were purposively selected. Data were analysed using content analysis by reading through transcripts. Interview data from different sources on a single event were triangulated to increase the internal validity and analysis of multiple cases strengthened external validity. RESULTS: Three themes were pre-established: 1) barriers and solutions to MNCH use at the community and health system level; 2) perceptions about women delivering in health facilities and 3) community/social norms on using health facilities. Generally, participants reported satisfaction with services offered in the intervention health facilities and many indicated that they would use the services again. There were notable differences between the intervention and control site in attitudes towards use of services (skilled birth attendance, postnatal care). Despite the apparent improvements, there still exist barriers to MNCH services use. Persistent barriers identified were gender of service provider, insecurity, poverty, lack of transport, distance from health facilities, lack of information, absence of staff especially at night-time and quality of maternity care. CONCLUSION: Attitudes towards MNCH services are generally positive, however some barriers still hinder utilization. The County health department and community leaders need to sustain the momentum gained by ensuring that service access and quality challenges are continually addressed.

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya.

BACKGROUND: Access to primary healthcare is crucial for the delivery of Kenya's universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. METHODS: The data were drawn from the Lown scholars' study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas' model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations. RESULTS: The odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47-6.37]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18-0.74]; p < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67-12.01]; p < .001). CONCLUSION: In Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.

Using Participatory Workshops to Assess Alignment or Tension in the Community for Minimally Invasive Tissue Sampling Prior to Start of Child Mortality Surveillance: Lessons From 5 Sites Across the CHAMPS Network.

The Child Health and Mortality Prevention Surveillance (CHAMPS) program is a 7-country network (as of December 2018) established by the Bill & Melinda Gates Foundation to identify the causes of death in children in communities with high rates of under-5 mortality. The program carries out both mortality and pregnancy surveillance, and mortality surveillance employs minimally invasive tissue sampling (MITS) to gather small samples of body fluids and tissue from the bodies of children who have died. While this method will lead to greater knowledge of the specific causes of childhood mortality, the procedure is in tension with cultural and religious norms in many of the countries where CHAMPS works-Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa. Participatory Inquiry Into Community Knowledge of Child Health and Mortality Prevention (PICK-CHAMP) is a community entry activity designed to introduce CHAMPS to communities and gather initial perspectives on alignments and tensions between CHAMPS activities and community perceptions and priorities. Participants' responses revealed medium levels of overall alignment in all sites (with the exception of South Africa, where alignment was high) and medium levels of tension (with the exception of Ethiopia, where tension was high). Alignment was high and tension was low for pregnancy surveillance across all sites, whereas Ethiopia reflected low alignment and high tension for MITS. Participants across all sites indicated that support for MITS was possible only if the procedure did not interfere with burial practices and rituals.

Effectiveness of the delivery of interventions to prevent malaria in pregnancy in Kenya.

BACKGROUND: Coverage with malaria in pregnancy interventions remains unacceptably low. Implementation research is needed to identify and quantify the bottlenecks for the delivery and use of these life-saving interventions through antenatal clinics (ANC). METHODS: A cross-sectional study was carried out in ANC across nine health facilities in western Kenya. Data were collected for an individual ANC visit through structured observations and exit interviews with the same ANC clients. The cumulative and intermediate systems effectiveness for the delivery of intermittent preventive treatment (IPTp) and insecticide-treated nets (ITNs) to eligible pregnant women on this one specific visit to ANC were estimated. RESULTS: Overall the ANC systems effectiveness for delivering malaria in pregnancy interventions was suboptimal. Only 40 and 53 % of eligible women received IPTp by directly observed therapy as per policy in hospitals and health centres/dispensaries respectively. The overall systems effectiveness for the receipt of IPTp disregarding directly observed therapy was 62 and 72 % for hospitals and lower level health facilities, respectively. The overall systems effectiveness for ITNs for first ANC visit was 63 and 67 % for hospitals and lower level facilities, respectively. CONCLUSION: This study found that delivery of IPTp and ITNs through ANC was ineffective and more so for higher-level facilities. This illustrates missed opportunities and provider level bottlenecks to the scale up and use of interventions to control malaria in pregnancy delivered through ANC. The high level of clustering within health facilities suggest that future studies should assess the feasibility of implementing interventions to improve systems effectiveness tailored to the health facility level.

Assessment of submicroscopic infections and gametocyte carriage of Plasmodium falciparum during peak malaria transmission season in a community-based cross-sectional survey in western Kenya, 2012.

BACKGROUND: Although malaria control intervention has greatly decreased malaria morbidity and mortality in many African countries, further decline in parasite prevalence has stagnated in western Kenya. In order to assess if malaria transmission reservoir is associated with this stagnation, submicroscopic infection and gametocyte carriage was estimated. Risk factors and associations between malaria control interventions and gametocyte carriage were further investigated in this study. METHODS: A total of 996 dried blood spot samples were used from two strata, all smear-positives (516 samples) and randomly selected smear-negatives (480 samples), from a community cross-sectional survey conducted at peak transmission season in 2012 in Siaya County, western Kenya. Plasmodium falciparum parasite presence and density were determined by stained blood smear and by 18S mRNA transcripts using nucleic acid sequence-based amplification assay (NASBA), gametocyte presence and density were determined by blood smear and by Pfs25 mRNA-NASBA, and gametocyte diversity by Pfg377 mRNA RT-PCR and RT-qPCR. RESULTS: Of the randomly selected smear-negative samples, 69.6 % (334/480) were positive by 18S-NASBA while 18S-NASBA detected 99.6 % (514/516) smear positive samples. Overall, 80.2 % of the weighted population was parasite positive by 18S-NASBA vs 30.6 % by smear diagnosis and 44.0 % of the weighted population was gametocyte positive by Pfs25-NASBA vs 2.6 % by smear diagnosis. Children 5-15 years old were more likely to be parasitaemic and gametocytaemic by NASBA than individuals >15 years old or children <5 years old while gametocyte density decreased with age. Anaemia and self-reported fever within the past 24 h were associated with increased odds of gametocytaemia. Fever was also positively associated with parasite density, but not with gametocyte density. Anti-malarial use within the past 2 weeks decreased the odds of gametocytaemia, but not the odds of parasitaemia. In contrast, recent anti-malarial use was associated with lowered parasite density, but not the gametocyte density. Use of ITNs was associated with lower odds for parasitaemia in part of the study area with a longer history of ITN interventions. In the same part of study area, the odds of having multiple gametocyte alleles were also lower in individuals using ITNs than in those not using ITNs and parasite density was positively associated with gametocyte diversity. CONCLUSION: A large proportion of submicroscopic parasites and gametocytes in western Kenya might contribute to the stagnation in malaria prevalence, suggesting that additional interventions targeting the infectious reservoir are needed. As school aged children and persons with anaemia and fever were major sources for gametocyte reservoir, these groups should be targeted for intervention and prevention to reduce malaria transmission. Anti-malarial use was associated with lower parasite density and odds of gametocytaemia, but not the gametocyte density, indicating a limitation of anti-malarial impact on the transmission reservoir. ITN use had a protective role against parasitaemia and gametocyte diversity in western Kenya.

Greenhouse gas emission and its potential mitigation process from the waste sector in a large-scale exhibition.

As one of the largest human activities, World Expo is an important source of anthropogenic Greenhouse Gas emission (GHG), and the GHG emission and other environmental impacts of the Expo Shanghai 2010, where around 59,397 tons of waste was generated during 184 Expo running days, were assessed by life cycle assessment (LCA). Two scenarios, i.e., the actual and expected figures of the waste sector, were assessed and compared, and 124.01 kg CO2-equivalent (CO2-eq.), 4.43 kg SO2-eq., 4.88 kg NO3--eq., and 3509 m3 water per ton tourist waste were found to be released in terms of global warming (GW), acidification (AC), nutrient enrichment (NE) and spoiled groundwater resources (SGWR), respectively. The total GHG emission was around 3499 ton CO2-eq. from the waste sector in Expo Park, among which 86.47% was generated during the waste landfilling at the rate of 107.24 kg CO2-eq., and CH4, CO and other hydrocarbons (HC) were the main contributors. If the waste sorting process had been implemented according to the plan scenario, around 497 ton CO2-eq. savings could have been attained. Unlike municipal solid waste, with more organic matter content, an incineration plant is more suitable for tourist waste disposal due to its high heating value, from the GHG reduction perspective.

Serological markers for monitoring historical changes in malaria transmission intensity in a highly endemic region of Western Kenya, 1994-2009.

BACKGROUND: Monitoring local malaria transmission intensity is essential for planning evidence-based control strategies and evaluating their impact over time. Anti-malarial antibodies provide information on cumulative exposure and have proven useful, in areas where transmission has dropped to low sustained levels, for retrospectively reconstructing the timing and magnitude of transmission reduction. It is unclear whether serological markers are also informative in high transmission settings, where interventions may reduce transmission, but to a level where considerable exposure continues. METHODS: This study was conducted through ongoing KEMRI and CDC collaboration. Asembo, in Western Kenya, is an area where intense malaria transmission was drastically reduced during a 1997-1999 community-randomized, controlled insecticide-treated net (ITN) trial. Two approaches were taken to reconstruct malaria transmission history during the period from 1994 to 2009. First, point measurements were calculated for seroprevalence, mean antibody titre, and seroconversion rate (SCR) against three Plasmodium falciparum antigens (AMA-1, MSP-119, and CSP) at five time points for comparison against traditional malaria indices (parasite prevalence and entomological inoculation rate). Second, within individual post-ITN years, age-stratified seroprevalence data were analysed retrospectively for an abrupt drop in SCR by fitting alternative reversible catalytic conversion models that allowed for change in SCR. RESULTS: Generally, point measurements of seroprevalence, antibody titres and SCR produced consistent patterns indicating that a gradual but substantial drop in malaria transmission (46-70%) occurred from 1994 to 2007, followed by a marginal increase beginning in 2008 or 2009. In particular, proportionate changes in seroprevalence and SCR point estimates (relative to 1994 baseline values) for AMA-1 and CSP, but not MSP-119, correlated closely with trends in parasite prevalence throughout the entire 15-year study period. However, retrospective analyses using datasets from 2007, 2008 and 2009 failed to detect any abrupt drop in transmission coinciding with the timing of the 1997-1999 ITN trial. CONCLUSIONS: In this highly endemic area, serological markers were useful for generating accurate point estimates of malaria transmission intensity, but not for retrospective analysis of historical changes. Further investigation, including exploration of different malaria antigens and/or alternative models of population seroconversion, may yield serological tools that are more informative in high transmission settings.

Prevalence of all epilepsies in urban informal settlements in Nairobi, Kenya: a two-stage population-based study.

BACKGROUND: WHO estimates that more than 50 million people worldwide have epilepsy and 80% of cases are in low-income and middle-income countries. Most studies in Africa have focused on active convulsive epilepsy in rural areas, but there are few data in urban settings. We aimed to estimate the prevalence and spatial distribution of all epilepsies in two urban informal settlements in Nairobi, Kenya. METHODS: We did a two-stage population-based cross-sectional study of residents in a demographic surveillance system covering two informal settlements in Nairobi, Kenya (Korogocho and Viwandani). Stage 1 screened all household members using a validated epilepsy screening questionnaire to detect possible cases. In stage 2, those identified with possible seizures and a proportion of those screening negative were invited to local clinics for clinical and neurological assessments by a neurologist. Seizures were classified following the International League Against Epilepsy recommendations. We adjusted for attrition between the two stages using multiple imputations and for sensitivity by dividing estimates by the sensitivity value of the screening tool. Complementary log-log regression was used to assess prevalence differences by participant socio-demographics. FINDINGS: A total of 56 425 individuals were screened during stage 1 (between Sept 17 and Dec 23, 2021) during which 1126 were classified as potential epilepsy cases. A total of 873 were assessed by a neurologist in stage 2 (between April 12 and Aug 6, 2022) during which 528 were confirmed as epilepsy cases. 253 potential cases were not assessed by a neurologist due to attrition. 30 179 (53·5%) of the 56 425 individuals were male and 26 246 (46·5%) were female. The median age was 24 years (IQR 11-35). Attrition-adjusted and sensitivity-adjusted prevalence for all types of epilepsy was 11·9 cases per 1000 people (95% CI 11·0-12·8), convulsive epilepsy was 8·7 cases per 1000 people (8·0-9·6), and non-convulsive epilepsy was 3·2 cases per 1000 people (2·7-3·7). Overall prevalence was highest among separated or divorced individuals at 20·3 cases per 1000 people (95% CI 15·9-24·7), unemployed people at 18·8 cases per 1000 people (16·2-21·4), those with no formal education at 18·5 cases per 1000 people (16·3-20·7), and adolescents aged 13-18 years at 15·2 cases per 1000 people (12·0-18·5). The epilepsy diagnostic gap was 80%. INTERPRETATION: Epilepsy is common in urban informal settlements of Nairobi, with large diagnostic gaps. Targeted interventions are needed to increase early epilepsy detection, particularly among vulnerable groups, to enable prompt treatment and prevention of adverse social consequences. FUNDING: National Institute for Health Research using Official Development Assistance.

Impacts of climate-induced changes on the distribution of pesticides residues in water and sediment of Lake Naivasha, Kenya.

This study reports evidence of increased chlorpyrifos contamination in sediment and water in Lake Naivasha following its intensive application in the horticultural farms in the catchment area. Analytical results show that levels of chlorpyrifos residues were influenced by climate-induced rainfall pattern with higher levels reported during period of heavy precipitation with significant decrease during low rainfall. On average, the levels ranged between 14.8 and 32.8 ng g(-1) in sediment during rainy season compared to a range of 8.5-16.6 ng g(-1) in the dry season. Additionally, the mean concentration of chlorpyrifos in water ranged between 8.61 and 22.4 µg L(-1) during rainy season and below detection limit (bdl) -13.6 µg L(-1) in dry season as quantified by enzyme-linked immunosorbent assay. Meanwhile, independent t test analysis indicated that there was significant difference in concentration at p ≤ 0.05 between the seasons with respect to sediment and water samples. This demonstrated that climate-induced variations had considerable influence on contamination. While diazinon and carbofuran were equally applied intensively, their levels were below the detection limit in the all the samples analyzed. ELISA results were validated by the capillary-HPLC photodiode-array detector instrument analysis, and statistical comparison showed no significant difference between them. It was evident that chlorpyrifos residues determination in water and sediment by ELISA can be a useful strategy in environmental management and monitoring program, and a complimentary analytical tool to high performance liquid chromatography. Levels of chlorpyrifos detected in sediment and water were found to exceed recommended criteria for protection of aquatic life and preservation of water quality and may be hazardous if not regularly monitored.

Cardiometabolic multimorbidity and associated patterns of healthcare utilization and quality of life: Results from the Study on Global AGEing and Adult Health (SAGE) Wave 2 in Ghana.

Understanding the patterns of multimorbidity, defined as the co-occurrence of more than one chronic condition, is important for planning health system capacity and response. This study assessed the association of different cardiometabolic multimorbidity combinations with healthcare utilization and quality of life (QoL). Data were from the World Health Organization (WHO) study on global AGEing and adult health Wave 2 (2015) conducted in Ghana. We analysed the clustering of cardiometabolic diseases including angina, stroke, type 2 diabetes, and hypertension with unrelated conditions such as asthma, chronic lung disease, arthritis, cataract and depression. The clusters of adults with cardiometabolic multimorbidity were identified using latent class analysis and agglomerative hierarchical clustering algorithms. We used negative binomial regression to determine the association of multimorbidity combinations with outpatient visits. The association of multimorbidity clusters with hospitalization and QoL were assessed using multivariable logistic and linear regressions. Data from 3,128 adults aged over 50 years were analysed. We identified four distinct classes of multimorbidity: relatively "healthy class" with no multimorbidity (47.9%): abdominal obesity only (40.7%): cardiometabolic and arthritis class comprising participants with hypertension, type 2 diabetes, stroke, abdominal and general obesity, arthritis and cataract (5.7%); and cardiopulmonary and depression class including participants with angina, chronic lung disease, asthma, and depression (5.7%). Relative to the class with no multimorbidity, the cardiopulmonary and depression class was associated with a higher frequency of outpatient visits [ß = 0.3; 95% CI 0.1 to 0.6] and higher odds of hospitalization [aOR = 1.9; 95% CI 1.0 to 3.7]. However, cardiometabolic and arthritis class was associated with a higher frequency of outpatient visits [ß = 0.8; 95% CI 0.3 to 1.2] and not hospitalization [aOR = 1.1; 95% CI 0.5 to 2.9]. The mean QoL scores was lowest among participants in the cardiopulmonary and depression class [ß = -4.8; 95% CI -7.3 to -2.3] followed by the cardiometabolic and arthritis class [ß = -3.9; 95% CI -6.4 to -1.4]. Our findings show that cardiometabolic multimorbidity among older persons in Ghana cluster together in distinct patterns that differ in healthcare utilization. This evidence may be used in healthcare planning to optimize treatment and care.

Multimorbidity of cardiometabolic diseases: a cross-sectional study of patterns, clusters and associated risk factors in sub-Saharan Africa.

OBJECTIVE: To determine the patterns of cardiometabolic multimorbidity and associated risk factors in sub-Saharan Africa (SSA). DESIGN: We used data from the WHO STEPwise approach to non-communicable disease risk factor surveillance cross-sectional surveys conducted between 2014 and 2017. PARTICIPANTS: The participants comprised 39, 658 respondents aged 15-69 years randomly selected from nine SSA countries using a multistage stratified sampling design. PRIMARY OUTCOME MEASURE: Using latent class analysis and agglomerative hierarchical clustering algorithms, we analysed the clustering of cardiometabolic diseases (CMDs) including high blood sugar, hypercholesterolaemia, hypertension and cardiovascular diseases (CVDs) such as heart attack, angina and stroke. Clusters of lifestyle risk factors: harmful salt intake, physical inactivity, obesity, tobacco and alcohol use were also computed. Prevalence ratios (PR) from modified Poisson regression were used to assess the association of cardiometabolic multimorbidity with sociodemographic and lifestyle risk factors. RESULTS: Two distinct classes of CMDs were identified: relatively healthy group with minimal CMDs (95.2%) and cardiometabolic multimorbidity class comprising participants with high blood sugar, hypercholesterolaemia, hypertension and CVDs (4.8%). The clusters of lifestyle risk factors included alcohol, tobacco and harmful salt consumption (27.0%), and physical inactivity and obesity (5.8%). The cardiometabolic multimorbidity cluster exhibited unique sociodemographic and lifestyle risk profiles. Being female (PR=1.7, 95% CI (1.5 to 2.0), middle-aged (35-54 years) (3.9 (95% CI 3.2 to 4.8)), compared with age 15-34 years, employed (1.2 (95% CI 1.1 to 1.4)), having tertiary education (2.5 (95% CI 2.0 to 3.3)), vs no formal education and clustering of physical inactivity and obesity (2.4 (95% CI 2.0 to 2.8)) were associated with a higher likelihood of cardiometabolic multimorbidity. CONCLUSION: Our findings show that cardiometabolic multimorbidity and lifestyle risk factors cluster in distinct patterns with a disproportionate burden among women, middle-aged, persons in high socioeconomic positions, and those with sedentary lifestyles and obesity. These results provide insights for health systems response in SSA to focus on these clusters as potential targets for integrated care.

Assessing the Readiness to Provide Integrated Management of Cardiovascular Diseases and Type 2 Diabetes in Kenya: Results from a National Survey.

Introduction: Integrated chronic disease management is the desired core function of a responsive healthcare system. However, many challenges surround its implementation in Sub-Saharan Africa. The current study assessed the readiness of healthcare facilities to provide integrated management of cardiovascular diseases (CVDs) and type 2 diabetes in Kenya. Methods: We used data from a nationally representative cross-sectional survey of 258 public and private health facilities conducted in Kenya between 2019 and 2020. Data were collected using a standardised facility assessment questionnaire and observation checklists modified from the World Health Organization Package of Essential Non-communicable Diseases. The primary outcome was the readiness to provide integrated care for CVDs and diabetes-defined as the mean availability of tracer items comprising trained staff and clinical guidelines, diagnostic equipment, essential medicines, diagnosis, treatment and follow-up. A cut-off threshold of ≥70% was used to classify facilities as 'ready'. Gardner-Altman plots and modified Poisson regression were used to examine the facility characteristics associated with care integration readiness. Results: Of the surveyed facilities, only a quarter (24.1%) were ready to provide integrated care for CVDs and type 2 diabetes. Care integration readiness was lower in public versus private facilities [aPR = 0.6; 95% CI 0.4 to 0.9], and primary healthcare facilities were less likely to be ready compared to hospitals [aPR = 0.2; 95% CI 0.1 to 0.4]. Facilities located in Central Kenya [aPR = 0.3; 95% CI 0.1 to 0.9], and the Rift Valley region [aPR = 0.4; 95% CI 0.1 to 0.9], were less likely to be ready compared to the capital Nairobi. Conclusions: There are gaps in the readiness of healthcare facilities particularly primary healthcare facilities in Kenya to provide integrated care services for CVDs and diabetes. Our findings inform the review of current supply-side interventions for integrated management of CVDs and type 2 diabetes, especially in lower-level public health facilities in Kenya.

Cardiometabolic Multimorbidity Associated with Moderate and Severe Disabilities: Results from the Study on Global AGEing and Adult Health (SAGE) Wave 2 in Ghana and South Africa.

Background: Integrated management of cardiometabolic diseases is crucial in improving the quality of life of older persons. The objective of the study was to identify clusters of cardiometabolic multimorbidity associated with moderate and severe disabilities in Ghana and South Africa. Methods: Data were from the World Health Organization (WHO) study on global AGEing and adult health (SAGE) Wave-2 (2015) conducted in Ghana and South Africa. We analysed the clustering of cardiometabolic diseases including angina, stroke, diabetes, obesity, and hypertension with unrelated conditions such as asthma, chronic lung disease, arthritis, cataracts, and depression. The WHO Disability Assessment Instrument version 2.0 was used to assess functional disability. We used latent class analysis to calculate the multimorbidity classes and disability severity levels. Ordinal logistic regression was used to identify the clusters of multimorbidity associated with moderate and severe disabilities. Results: Data from 4,190 adults aged over 50 years were analysed. The prevalence of moderate and severe disabilities was 27.0% and 8.9% respectively. Four latent classes of multimorbidity were identified. These included a relatively healthy group with minimal cardiometabolic multimorbidity (63.5%), general and abdominal obesity (20.5%), hypertension, abdominal obesity, diabetes, cataracts, and arthritis (10.0%), and angina, chronic lung disease, asthma, and depression (6.0%). Compared to the participants with minimal cardiometabolic multimorbidity, the odds of moderate and severe disabilities were higher among participants with multimorbidity comprising hypertension, abdominal obesity, diabetes, cataract and arthritis [aOR = 3.0; 95% CI 1.6 to 5.6], and those with angina, chronic lung disease, asthma and depression [aOR = 2.7; 95% CI 1.6 to 4.5]. Conclusions: Cardiometabolic diseases among older persons in Ghana and South Africa cluster in distinct multimorbidity patterns that are significant predictors of functional disabilities. This evidence may be useful for defining disability prevention strategies and long-term care for older persons living with or at risk of cardiometabolic multimorbidity in sub-Saharan Africa.

Perceived health system facilitators and barriers to integrated management of hypertension and type 2 diabetes in Kenya: a qualitative study.

OBJECTIVE: Understanding the facilitators and barriers to managing hypertension and type 2 diabetes (T2D) will inform the design of a contextually appropriate integrated chronic care model in Kenya. We explored the perceived facilitators and barriers to the integrated management of hypertension and T2D in Kenya using the Rainbow Model of Integrated Care. DESIGN: This was a qualitative study using data from a larger mixed-methods study on the health system response to chronic disease management in Kenya, conducted between July 2019 and February 2020. Data were collected through 44 key informant interviews (KIIs) and eight focus group discussions (FGDs). SETTING: Multistage sampling procedures were used to select a random sample of 12 study counties in Kenya. PARTICIPANTS: The participants for the KIIs comprised purposively selected healthcare providers, county health managers, policy experts and representatives from non-state organisations. The participants for the FGDs included patients with hypertension and T2D. OUTCOME MEASURES: Patients' and providers' perspectives of the health system facilitators and barriers to the integrated management of hypertension and T2D in Kenya. RESULTS: The clinical integration facilitators included patient peer support groups for hypertension and T2D. The major professional integration facilitators included task shifting, continuous medical education and integration of community resource persons. The national referral system, hospital insurance fund and health management information system emerged as the major facilitators for organisational and functional integration. The system integration facilitators included decentralisation of services and multisectoral partnerships. The major barriers comprised vertical healthcare services characterised by service unavailability, unresponsiveness and unaffordability. Others included a shortage of skilled personnel, a lack of interoperable e-health platforms and care integration policy implementation gaps. CONCLUSIONS: Our study identified barriers and facilitators that may be harnessed to improve the integrated management of hypertension and T2D. The facilitators should be strengthened, and barriers to care integration redressed.

Effectiveness of integrated chronic care models for cardiometabolic multimorbidity in sub-Saharan Africa: a systematic review and meta-analysis.

OBJECTIVES: This review aimed at identifying the elements of integrated care models for cardiometabolic multimorbidity in sub-Saharan Africa (SSA) and their effects on clinical or mental health outcomes including systolic blood pressure (SBP), blood sugar, depression scores and other patient-reported outcomes such as quality of life and medication adherence. DESIGN: Systematic review and meta-analysis using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. DATA SOURCES: We systematically searched PubMed, Embase, Scopus, Web of Science, Global Health CINAHL, African Journals Online, Informit, PsycINFO, ClinicalTrials.gov, Pan African Clinical Trials Registry and grey literature from OpenSIGLE for studies published between 1999 and 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included randomised controlled trial studies featuring integrated care models with two or more elements of Wagner's chronic care model. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers used standardised methods to search and screen included studies. Publication bias was assessed using the Doi plot and Luis Furuya Kanamori Index. Meta-analysis was conducted using random effects models. RESULTS: In all, we included 10 randomised controlled trials from 11 publications with 4864 participants from six SSA countries (South Africa, Kenya, Nigeria, Eswatini, Ghana and Uganda). The overall quality of evidence based on GRADE criteria was moderate. A random-effects meta-analysis of six studies involving 1754 participants shows that integrated compared with standard care conferred a moderately lower mean SBP (mean difference=-4.85 mm Hg, 95% CI -7.37 to -2.34) for people with cardiometabolic multimorbidity; Hedges' g effect size (g=-0.25, (-0.39 to -0.11). However, integrated care compared with usual care showed mixed results for glycated haemoglobin, depression, medication adherence and quality of life. CONCLUSION: Integrated care improved SBP among patients living with cardiometabolic multimorbidity in SSA. More studies on integrated care are required to improve the evidence pool on chronic care models for multimorbidity in SSA. These include implementation studies and cost-effectiveness studies. PROSPERO REGISTRATION NUMBER: CRD42020187756.

Effect of Patient Support Groups for Hypertension on Blood Pressure among Patients with and Without Multimorbidity: Findings from a Cohort Study of Patients on a Home-Based Self-Management Program in Kenya.

Introduction: Patient support group interventions have been widely used to manage chronic diseases in Kenya. However, the potential benefits of these groups on patient health outcomes, and how this is influenced by multimorbidity, have not been rigorously evaluated. Objective: We assessed the effect of a patient support group intervention on blood pressure (BP) management and the potential moderating effect of multimorbidity among low- and middle-income patients with hypertension in Kenya. Methods: We analysed data from a non-randomized, quasi-experimental study of 410 patients with hypertension on a home-based self-management program conducted from September 2019 to September 2020. The program included the formation and participation in patient support groups. Using a modified STEPS questionnaire, data were collected on BP, anthropometry and other measurements at enrolment and after 12 months of follow-up. Multimorbidity was defined as the simultaneous presence of hypertension and at least one or more related conditions with similar pathophysiology (concordant multimorbidity) or unrelated chronic conditions (discordant multimorbidity). Propensity score (PS) weighting was used to adjust for baseline differences among 243 patients who participated in the support groups and 167 who did not. We estimated the effects of patient support groups and moderating effects of multimorbidity on BP management using multivariable ordinary linear regression weighted by PS. Findings: Participation in support groups significantly reduced systolic BP by 5.4 mmHg compared to non-participation in the groups [ß = -5.4; 95% CI -1.9 to -8.8]. However, among participants in the support group intervention, the mean systolic BP at follow-up assessment for those with concordant multimorbidity was 8.8 mmHg higher than those with no multimorbidity [ß = 8.8; 95% CI 0.8 to 16.8]. Conclusion: Although patient support groups are potentially important adjuncts to home-based self-care, multimorbidity attenuates their effectiveness. There is a need to tailor patient support group interventions to match the needs of the people living with multimorbidity in low- and middle-income settings in Kenya.

Acceptability of minimally invasive autopsy by community members and healthcare workers in Siaya and Kisumu counties, western Kenya, 2017-2018.

Worldwide, nearly six million children under the age of five (<5s) die annually, a substantial proportion of which are due to preventable and treatable diseases. Efforts to reduce child mortality indicators in the most affected regions are often undermined by a lack of accurate cause of death data. To generate timely and more accurate causes of death data for <5s, the Child Health and Mortality Prevention Surveillance (CHAMPS) Network established mortality surveillance in multiple countries using Minimally Invasive Tissue Sampling (MITS) in <5 deaths. Here we present acceptability of MITS by community members and healthcare workers in Siaya and Kisumu counties, western Kenya. From April 2017 to February 2018, we conducted 40 in-depth interviews and five focus group discussions with healthcare workers and community members, before and during CHAMPS implementation. Participants were purposively selected. Field observations to understand traditional death-related practices were also performed. Interviews were transcribed into Nvivo 11.0 for data organization and management. Analysis was guided by the grounded theory approach. Facilitators of acceptability were desire to understand why death occurred, timely performance of MITS procedures, potential for MITS results in improving clinical practice and specific assistance provided to families by the CHAMPS program. However, cultural and religious beliefs highlighted important challenges to acceptability, including CHAMPS teams recruiting after a child's death, rumours and myths, unmet expectations from families, and fear by healthcare workers that some families could use MITS results to sue for negligence. Increasing MITS uptake requires sustained strategies to strengthen the identified facilitators of acceptability and simultaneously address the barriers. MITS acceptance will contribute to better characterization of causes of death and support the development of improved interventions aimed at reducing <5 mortality.