Understanding Women's Preferences for Prevention of Mother-to-Child HIV Transmission Services in Kenya.

Background and Objective: Understanding the preferences of women living with HIV (WLH) for the prevention of mother-to-child HIV transmission (PMTCT) services is important to ensure such services are person-centered. Methods: From April to December 2022, we surveyed pregnant and postpartum WLH enrolled at five health facilities in western Kenya to understand their preferences for PMTCT services. WLH were stratified based on the timing of HIV diagnosis: known HIV-positive (KHP; before antenatal clinic [ANC] enrollment), newly HIV-positive (NHP; on/after ANC enrollment). Multivariable logistic regression was used to determine associations between various service preferences and NHP (vs. KHP) status, controlling for age, facility, gravidity, retention status, and pregnancy status. Results: Among 250 participants (median age 31 years, 31% NHP, 69% KHP), 93% preferred integrated versus non-integrated HIV and maternal-child health (MCH) services; 37% preferred male partners attend at least one ANC appointment (vs. no attendance/no preference); 54% preferred support groups (vs. no groups; 96% preferred facility - over community-based groups); and, preferences for groups was lower among NHP (42%) versus KHP (60%). NHP had lower odds of preferring support groups versus KHP (aOR 0.45, 95% CI 0.25-0.82), but not the other services. Conclusion and Global Health Implications: Integrated services were highly preferred by WLH, supporting the current PMTCT service model in Kenya. Further research is needed to explore the implementation of facility-based support groups for WLH as well as the reasons underlying women's preferences.

Post-intervention perceptions on the antiretroviral therapy community group model in Trans Nzoia County, Kenya.

Introduction: the increasing number of people receiving antiretroviral therapy (ART) in sub-Saharan Africa has stressed already overburdened health systems. A care model utilizing community-based peer-groups (ART Co-ops) facilitated by community health workers (CHW) was implemented (2016-2018) to address these challenges. In 2018, a post-intervention study assessed perceptions of the intervention. Methods: forty participants were engaged in focus group discussions consisting of ART Co-op clients, study staff, and health care providers from Kitale HIV clinic. Data were analyzed thematically for content on the intervention, challenges, and recommendations for improvement. Results: all participants liked the intervention. However, some reported traveling long distances to attend ART Co-op meetings and experiencing stigma with ART Co-ops participation. The ART Co-op inclusion criteria were considered appropriate; however, additional outreach to deliberately include spouses living with HIV, the disabled, the poor, and HIV pregnant women was recommended. Participants liked CHW-directed quarterly group meetings which included ART distribution, adherence review, and illness identification. The inability of the CHW to provide full clinical care, inconvenient meeting venues, poor timekeeping, and non-attendance behaviors were noted as issues. Participants indicated that program continuation, regular CHW training, rotating meetings at group members´ homes, training ART Co-ops leaders to assume CHW tasks, use of pill diaries to check adherence, nutritional support, and economically empowering members through income generation projects would be beneficial. Conclusion: the intervention was viewed positively by both clinic staff and clients. They identified specific challenges and generated actionable key considerations to improve access and acceptability of the community-based model of care.

Impact of patient-centered communication on patient satisfaction scores in patients with chronic life-limiting illnesses: an experience from Kenya.

Background: Patient satisfaction remains a key area of interest worldwide; utilizing a patient-centered communication approach, particularly with patients with chronic life-limiting illnesses may be one way to achieve this. However, there is a dearth of empirical information on the effect of patient-centered communication strategies in patients with chronic life-limiting illnesses in Kenya on patient satisfaction. Objectives: The objective of this study was to assess the impact of patient-centered communication on patient satisfaction. Methods: We conducted our study at a tertiary teaching and referral hospital in Kenya. We utilized a quasi-experimental pre-test post-test study design and engaged 301 adult medical in-patients with chronic life limiting conditions. We randomized them to receive patient-centered communication, and evaluated the change in patient satisfaction scores using an adapted Medical Interview satisfaction Scale 21 (MISS 21). Results: Two hundred and seventy-eight out of 301 recruited participants completed the study. The baseline characteristics of the participants randomized to the control and intervention arms were similar. Although both the control and intervention arms had a decline in the mean difference scores, the intervention arm recorded a larger decline, -15.04 (-20.6, -9.47) compared to -7.87 (-13.63, -2.12), with a statistically significant mean difference between the two groups at -7.16 (-9.67, -4.46). Participants in the intervention arm were less likely to: understand the cause of their illness (p < 0.001), understand aspects of their illness (p < 0.001), understand the management plan (p < 0.001), receive all the relevant information on their health (p < 0.001), and to receive adequate self-care information (p < 0.001). They were also less likely to acknowledge a good interpersonal relationship with the healthcare providers (p < 0.001), to feel comfortable discussing private issues (p < 0.004), and to feel that the consultation time was adequate (p < 0.001). Conclusion and recommendation: Contrary to expectation, patient-centered communication did not result in improved patient satisfaction scores. Further studies can evaluate factors affecting and explaining this relationship and assess intermediate and long-term effects of provision of a patient-centered communication in diverse global contexts.

Ketogenic dietary therapy utilization in Kenya: A qualitative exploration of dietitian's perceptions.

This study utilized a qualitative design to explore dietitians' perceptions regarding Ketogenic Diet Therapy (KDT) for patients with drug-resistant epilepsy in Kenya. Dietitians from Kenya were selected and consented. Audio-recorded interviews were conducted, followed by thematic analysis of verbatim transcripts to identify recurring patterns. The study enrolled 18 dietitians, fourteen of whom correctly described their understanding of KDT for managing drug-resistant epilepsy. There was a lack of confidence in their capacity to initiate the KDT with all expressing the need for further training and facilitation. Only one dietitian reported having initiated and maintained KDT. There was an overall positive view regarding KDT and willingness to implement KDT for patients with drug-resistant epilepsy. Dietitians expressed concerns regarding the availability of national policies, inadequate staffing to support families who require KDT, and the cost of implementing this intervention. Dietitians expressed interest in virtual training to enhance their understanding of KDT. Dietitians in Kenya are mostly aware of KDT utilization for the management of drug-resistant epilepsy. However, they cited poor capability and various barriers to implementation. There is a need for policies to facilitate KDT as a treatment option for the benefit of patients with drug-resistant epilepsy.

Challenges and opportunities for improving access to adolescent and youth sexual and reproductive health services and information in the coastal counties of Kenya: a qualitative study.

BACKGROUND: Globally, adolescents and youth experience high unmet need for sexual and reproductive health (SRH) information and services. In Kenya, evidence shows that more than half of teenage pregnancies are unintended and that half of all new HIV infections occur in people ages 15-24-year-olds, with the majority of those being female. The coastal counties in Kenya record a relatively high adolescent pregnancy rate and higher rates of unmet need for contraception for all women of reproductive age compared to the national average. This study focused on gaining a deeper understanding of the existing challenges to and opportunities for accessing SRH information and services among adolescents and youth (AY) at the Kenyan coast. METHODS: Using qualitative methods, this study conducted thirty-six focus group discussions with adolescents, youth, and community health volunteers across all the six coastal counties in Kenya. The sample included adolescents aged 10-14 years in school (male and female), adolescents aged 15-19 years not in education (male and female), youths aged 20-24 years (mix of both male and female), and community health volunteers who were conveniently sampled. Thematic analysis was used to examine the data and report the study results. RESULTS: The barriers to accessing AYSRH identified in the study are individual factors (feelings of shame, lack of information, and fear of being judged) parental factors, healthcare worker and health institution factors, teacher/educators factors, and broader contextual factors such as culture, religion, poverty, and illiteracy. Factors that facilitate access to AYSRH information and services included, supportive parenting and culture, AYSRH sessions in schools, peer support, supportive health institutions, gender inclusivity, and digital technology. CONCLUSIONS: AYSRH information and services at the Kenyan coast is strongly influenced by a range of individual, social, cultural, and economic factors. Improving access to AYSHR necessitates meaningful AY engagement, provision of youth-friendly services, use of digital technology as alternative pathways for sharing SRH information, strengthening parent-AY relationships, embracing peer-to-peer support, and the adoption of gender-inclusive approaches in AYSRH programming.

Reducing Barriers to COVID-19 Vaccination Uptake: Community Ideas from Urban and Rural Kenya.

Following the rapid development of COVID-19 vaccines, addressing vaccine hesitancy and optimizing uptake have emerged as critical challenges, emphasizing the importance of reducing barriers toward COVID-19 vaccination. This study investigates ideas on ways to reduce barriers to COVID-19 vaccination uptake. It explores methods that can overcome COVID-19 vaccination barriers through qualitative research: interviews and group discussions involving healthcare providers, administration personnel, teachers, and individuals with chronic conditions across urban (Mombasa) and rural (Kilifi) Kenya. Audio-recorded discussions were transcribed and thematically analyzed across locations. Five themes emerged in our results regarding the reduction in barriers to COVID-19 vaccination in the context of Kenya, including awareness campaigns, engaging diverse stakeholders, using various communication techniques, capacity building to increase vaccination centers and trained staff, and lastly, revising relevant government health policies and guidelines. These results indicate the importance of adopting multiple approaches, as no single strategy can boost vaccine acceptance. Moreover, this study provides recommendations for conceiving actionable interventions to potentially boost vaccine demand and maintain routine immunization in Kenya.

Preferences of Pregnant and Postpartum Women for Differentiated Service Delivery in Kenya.

BACKGROUND: Differentiated service delivery models are implemented by HIV care programs globally, but models for pregnant and postpartum women living with HIV (PPWH) are lacking. We conducted a discrete choice experiment to determine women's preferences for differentiated service delivery. SETTING: Five public health facilities in western Kenya. METHODS: PPWH were enrolled from April to December 2022 and asked to choose between pairs of hypothetical clinics that differed across 5 attributes: clinic visit frequency during pregnancy (monthly vs. every 2 months), postpartum visit frequency (monthly vs. only with routine infant immunizations), seeing a mentor mother (each visit vs. as needed), seeing a clinician (each visit vs. as needed), and basic consultation cost (0, 50, or 100 Kenya Shillings [KSh]). We used multinomial logit modeling to determine the relative effects (ß) of each attribute on clinic choice. RESULTS: Among 250 PPWH (median age 31 years, 42% pregnant, 58% postpartum, 20% with a gap in care), preferences were for pregnancy visits every 2 months (ß = 0.15), postpartum visits with infant immunizations (ß = 0.36), seeing a mentor mother and clinician each visit (ß = 0.05 and 0.08, respectively), and 0 KSh cost (ß = 0.39). Preferences were similar when stratified by age, pregnancy, and retention status. At the same cost, predicted market choice for a clinic model with fewer pregnant/postpartum visits was 75% versus 25% for the standard of care (ie, monthly visits during pregnancy/postpartum). CONCLUSION: PPWH prefer fewer clinic visits than currently provided within the standard of care in Kenya, supporting the need for implementation of differentiated service delivery for this population.

Ethical Considerations for Engaging Children and Adolescents Living with HIV in Research in African Countries: A Systematic Review.

Research engaging children and adolescents living with HIV (CALWH) is critical for youth-friendly services and HIV care, and researchers need to ensure that such engagement is ethical. We conducted a systematic review to identify key ethical considerations for the engagement of CALWH in research. The review focused on primary research articles conducted in African countries that examined ethical issues in CALWH engaged in research. Ten studies met the inclusion criteria; the following seven key domains were extracted: 1) justifications for engaging CALWH in research; 2) community involvement; 3) informed consent/assent; 4) caregiver involvement; 5) perceptions of benefits; 6) perception of the risks of involvement; and 7) confidentiality. These domains can inform the ethical engagement of CALWH in research.

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.

Ethical Considerations for Engaging Youth Living with HIV in Research: Perspectives from Youth, Their Caregivers and Subject Matter Experts in Kenya.

Introduction: Engaging youth living with HIV (YLWH) in research is critical to improving HIV-related outcomes, but their involvement raises unaddressed bioethical questions. Methods: This study used qualitative inquiry with Kenyan YLWH, caregivers, and subject matter experts (SMEs) to evaluate ethical considerations and strategies for research involving YLWH. Results: Interviews were conducted with 99 participants: 40 YLWH (median age 17.5, 50% female), 20 caregivers (70% female), and 39 SMEs (44% female). All participant groups discussed the need for HIV disclosure status assessment, confidentiality, and engagement of caregivers. Youth participants discussed the importance of clear protocol explanations and developing good rapport. All participant groups perceived youth under 18 to be harder to recruit due to a number of identified barriers. Clinic settings were the most acceptable place for recruitment. Conclusion: Participants provided perspectives on engaging YLWH in research that can be incorporated into protocols and regulatory guidelines.

Institutional capacity to prevent and manage research misconduct: perspectives from Kenyan research regulators.

BACKGROUND: Research misconduct i.e. fabrication, falsification, and plagiarism is associated with individual, institutional, national, and global factors. Researchers' perceptions of weak or non-existent institutional guidelines on the prevention and management of research misconduct can encourage these practices. Few countries in Africa have clear guidance on research misconduct. In Kenya, the capacity to prevent or manage research misconduct in academic and research institutions has not been documented. The objective of this study was to explore the perceptions of Kenyan research regulators on the occurrence of and institutional capacity to prevent or manage research misconduct. METHODS: Interviews with open-ended questions were conducted with 27 research regulators (chairs and secretaries of ethics committees, research directors of academic and research institutions, and national regulatory bodies). Among other questions, participants were asked: (1) How common is research misconduct in your view? (2) Does your institution have the capacity to prevent research misconduct? (3) Does your institution have the capacity to manage research misconduct? Their responses were audiotaped, transcribed, and coded using NVivo software. Deductive coding covered predefined themes including perceptions on occurrence, prevention detection, investigation, and management of research misconduct. Results are presented with illustrative quotes. RESULTS: Respondents perceived research misconduct to be very common among students developing thesis reports. Their responses suggested there was no dedicated capacity to prevent or manage research misconduct at the institutional and national levels. There were no specific national guidelines on research misconduct. At the institutional level, the only capacity/efforts mentioned were directed at reducing, detecting, and managing student plagiarism. There was no direct mention of the capacity to manage fabrication and falsification or misconduct by faculty researchers. We recommend the development of Kenya code of conduct or research integrity guidelines that would cover misconduct.

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.

Perceptions of Global Health Engagements in Relation to the COVID-19 Pandemic Among Health Care Workers and Administrators in Western Kenya: Protocol for a Multistage Qualitative Study.

BACKGROUND: There has been significant interest in global health in low- and middle-income countries (LMICs) among individuals living in high-income countries (HICs) over the past 30 years. Much of the literature on global health engagements (GHEs) has been presented from the perspective of individuals from high-income countries. Local stakeholders such as health care workers and health care administrators represent critical constituencies for global health activities, yet their perspectives are underrepresented in the literature. The purpose of this study is to examine the experiences of local health care workers and administrators with GHEs in Kenya. We will explore the perceived role GHEs play in preparing the health system to address a public health crisis, as well as their role in pandemic recovery and its aftermath. OBJECTIVE: The aims of this study are to (1) examine how Kenyan health care workers and administrators interpret experiences with GHEs as having advantaged or hindered them and the local health system to provide care during an acute public health crisis and (2) to explore recommendations to reimagine GHEs in a postpandemic Kenya. METHODS: This study will be conducted at a large teaching and referral hospital in western Kenya with a long history of hosting GHEs in support of its tripartite mission of providing care, training, and research. This qualitative study will be conducted in 3 phases. In phase 1, in-depth interviews will be conducted to capture participants' lived experience in relation to their unique understandings of the pandemic, GHEs, and the local health system. In phase 2, group discussions using nominal group techniques will be conducted to determine potential priority areas to reimagine future GHEs. In phase 3, in-depth interviews will be conducted to explore these priority areas in greater detail to explore recommendations for potential strategies, policies, and other actions that might be used to achieve the priorities determined to be of highest importance. RESULTS: The study activities commenced in late summer 2022, with findings to be published in 2023. It is anticipated that the findings from this study will provide insight into the role GHEs play in a local health system in Kenya and provide critical stakeholder and partner input from persons hitherto ignored in the design, implementation, and management of GHEs. CONCLUSIONS: This qualitative study will examine the perspectives of GHEs in relation to the COVID-19 pandemic among Kenyan health care workers and health care administrators in western Kenya using a multistage protocol. Using a combination of in-depth interviews and nominal group techniques, this study aims to shed light on the roles global health activities are perceived to play in preparing health care professionals and the health system to address an acute public health crisis. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/41836.

HIV-Related Stigma Shapes Research Participation for Youth Living With HIV in Kenya.

Introduction: HIV stigma affects medication adherence, psychosocial outcomes, and clinical management for youth living with HIV (YLWH). We explored the impact of HIV stigma on research participation, to inform the ethical engagement of this vulnerable group. Methods: We interviewed 40 YLWH, 20 caregivers, and 39 subject matter experts (SMEs); transcripts were analyzed by HK and EG, with emerging themes confirmed by JA and AC. Results: All categories of participants identified the impacts of stigma on YLWH research participation, suggesting implementing privacy protections, considering recruitment locations carefully, and developing supportive relationships with YLWH. SMEs suggested that YLWH experience uniquely high risks from stigma due to the compounding effects of developmental challenges and transitionary life period. Accidental HIV disclosure and subsequent stigma were identified as a risk of research participation; some viewed the creation of community through research as a benefit. Conclusion: Participants provided insights into stigma-related considerations for research with YLWH, which may guide engagement protocols.

Understanding the treatment burden of people with chronic conditions in Kenya: A cross-sectional analysis using the Patient Experience with Treatment and Self-Management (PETS) questionnaire.

In Kenya, non-communicable diseases (NCDs) are an increasingly important cause of morbidity and mortality, requiring both better access to health care services and self-care support. Evidence suggests that treatment burdens can negatively affect adherence to treatment and quality of life. In this study, we explored the treatment and self-management burden among people with NCDs in in two counties in Western Kenya. We conducted a cross-sectional survey of people newly diagnosed with diabetes and/or hypertension, using the Patient Experience with Treatment and Self-Management (PETS) instrument. A total of 301 people with diabetes and/or hypertension completed the survey (63% female, mean age = 57 years). They reported the highest treatment burdens in the domains of medical and health care expenses, monitoring health, exhaustion related to self-management, diet and exercise/physical therapy. Treatment burden scores differed by county, age, gender, education, income and number of chronic conditions. Younger respondents (<60 years) reported higher burden for medication side effects (p<0.05), diet (p<0.05), and medical appointments (p = 0.075). Those with no formal education or low income also reported higher burden for diet and for medical expenses. People with health insurance cover reported lower (albeit still comparatively high) burden for medical expenses compared to those without it. Our findings provide important insights for Kenya and similar settings where governments are working to achieve universal health coverage by highlighting the importance of financial protection not only to prevent the economic burden of seeking health care for chronic conditions but also to reduce the associated treatment burden.

Acceptability and feasibility of community-based provision of urine pregnancy tests to support linkages to reproductive health services in Western Kenya: a qualitative analysis.

BACKGROUND: The majority of women living in rural Kenya access antenatal care (ANC) late in pregnancy, and approximately 20% have an unmet need for family planning (FP). This study aimed to determine whether training community health volunteers (CHVs) to deliver urine pregnancy testing (UPT), post-test counselling, and referral to care was an acceptable and feasible intervention to support timely initiation of ANC and uptake of FP. METHODS: We applied community-based participatory methods to design and implement the pilot intervention between July 2018 and May 2019. We conducted qualitative content analysis of 12 pre-intervention focus group discussions (FGDs) with women, men, and CHVs, and of 4 post-intervention FGDs with CHVs, each with 7-9 participants per FGD group. Using a pragmatic approach, we conducted inductive line-by-line coding to generate themes and subthemes describing factors that positively or negatively contributed to the intervention's acceptability and feasibility, in terms of participants' views and the intervention aims. RESULTS: We found that CHV-delivered point of care UPT, post-test counselling, and referral to care was an acceptable and feasible intervention to increase uptake of ANC, FP, and other reproductive healthcare services. Factors that contributed to acceptability were: (1) CHV-delivery made UPT more accessible; (2) UPT and counselling supported women and men to build knowledge and make informed choices, although not necessarily for women with unwanted pregnancies interested in abortion; (3) CHVs were generally trusted to provide counselling, and alternative counselling providers were available according to participant preference. A factor that enhanced the feasibility of CHV delivering UPT and counselling was CHV's access to appropriate supplies (e.g. carrying bags). However, factors that detracted from the feasibility of women actually accessing referral services after UPT and counselling included (1) downstream barriers like cost of travel, and (2) some male community members' negative attitudes toward FP. Finally, improved financial, educational, and professional supports for CHVs would be needed to make the intervention acceptable and feasible in the long-term. CONCLUSION: Training CHVs in rural western Kenya to deliver UPT, post-test counselling, and referral to care was acceptable and feasible to men, women, and CHVs in this context, and may promote early initiation of ANC and uptake of FP. Additional qualitative work is needed to explore implementation challenges, including issues related to unwanted pregnancies and abortion, the financial burden of volunteerism on CHVs, and educational and professional supports for CHVs.

Exploring the impact of health worker strikes on maternal and child health in a Kenyan county.

BACKGROUND: Studies of the impact of health care workers' strikes tend to look at facility-level activity rather than populations, with evidence from low and middle-income countries relatively sparse. This study explored the effect of national strikes on maternal and child health. It looked at the impact on health system activity in both public and non-public sectors (e.g. private, faith-based), on health promotion investments like immunisation, and on disease detection like post-partum haemorrhage (PPH). A 100 day doctors' strike started in December 2016, a 150 day nurses strike from June 2017 and then the clinical officers for 21 days that September. METHODS: Time series descriptive analysis of attendance data from the Kenyan Health Management Information System (public, non-public sector facilities). The setting was Kilifi, a coastal county in Kenya with a population of about 1.5 million. RESULTS: Along the care pathway from antenatal, postnatal and out-patient child health clinics, activity levels dropped markedly in the public sector with only partial compensatory increases in non-public sector activity. The number of fully immunised children fell during the nurses strike as did women seen with PPH during all strikes. These health care strikes caused significant adverse health impacts at the time and potentially inter-generationally as exemplified by the fall in antenatal haematinics supplementation and syphilis testing. Some post-strike ''catch-up" activity occurred, however this may have been too late in some instances. CONCLUSIONS: Policy-makers at national and county level need to ensure population health is protected at times of strikes and ideally resolve disputes without such action. Not to do so risks major negative effects on maternal and child health. Increased use of the non-public health sector could be done by the authorities in mitigation should strikes occur again.

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.