Multisystemic Resilience and Psychosocial Wellbeing among Older Refugees: A Systematic Review with Implications for Mental Health and Psychosocial Support (MHPSS).

Older refugees experience poor mental and emotional health outcomes compared to younger counterparts. Although older adults are instrumental in family/community adjustment in postmigration settings, little is known about how to enhance psychosocial resilience in this population. The aim of this systematic review is to glean deeper insight into the protective factors and processes associated with older refugees' resilience and positive psychosocial health in postmigration settings. We searched eight electronic health and social science databases. Twenty-three articles met the criteria for inclusion; we analyzed these using a multisystemic resilience lens. Studies spanned 1991 to 2022; importantly, 15 of the 23 articles were published in the past decade, indicating growing attention to the mental and psychosocial health of older refugees. Only six of the included articles focused on older refugees living in low- and middle-income countries, revealing a contrast between where most of the world's refugees reside and where the majority of mental health and psychosocial support (MHPSS) research is conducted. We found tremendous variation in determinants of psychosocial resilience based on the politico-historical contexts of migration; sociocultural backgrounds of refugees; and distinct postmigration needs, resources, and settings. Broadly, macrosystem determinants of resilience included security, access to basic services, and maintenance of culture and spirituality. Mesosystem factors were related to social support from families, ethnic communities, religious networks, and host country nationals. Finally, microsystem determinants of older refugees' resilience included language acquisition, cognitive reappraisal, and sense of optimism. Our findings suggest the importance of interdisciplinary, multilevel research designs to highlight how multiple ecosystems interact to promote psychosocial resilience among older refugees. Taken together, this systematic review offers important insight into multilevel protective factors and processes to enhance culturally and contextually meaningful MHPSS for older refugees.

Analysing 3429 digital supervisory interactions between Community Health Workers in Uganda and Kenya: the development, testing and validation of an open access predictive machine learning web app.

BACKGROUND: Despite the growth in mobile technologies (mHealth) to support Community Health Worker (CHW) supervision, the nature of mHealth-facilitated supervision remains underexplored. One strategy to support supervision at scale could be artificial intelligence (AI) modalities, including machine learning. We developed an open access, machine learning web application (CHWsupervisor) to predictively code instant messages exchanged between CHWs based on supervisory interaction codes. We document the development and validation of the web app and report its predictive accuracy. METHODS: CHWsupervisor was developed using 2187 instant messages exchanged between CHWs and their supervisors in Uganda. The app was then validated on 1242 instant messages from a separate digital CHW supervisory network in Kenya. All messages from the training and validation data sets were manually coded by two independent human coders. The predictive performance of CHWsupervisor was determined by comparing the primary supervisory codes assigned by the web app, against those assigned by the human coders and calculating observed percentage agreement and Cohen's kappa coefficients. RESULTS: Human inter-coder reliability for the primary supervisory category of messages across the training and validation datasets was 'substantial' to 'almost perfect', as suggested by observed percentage agreements of 88-95% and Cohen's kappa values of 0.7-0.91. In comparison to the human coders, the predictive accuracy of the CHWsupervisor web app was 'moderate', suggested by observed percentage agreements of 73-78% and Cohen's kappa values of 0.51-0.56. CONCLUSIONS: Augmenting human coding is challenging because of the complexity of supervisory exchanges, which often require nuanced interpretation. A realistic understanding of the potential of machine learning approaches should be kept in mind by practitioners, as although they hold promise, supportive supervision still requires a level of human expertise. Scaling-up digital CHW supervision may therefore prove challenging. TRIAL REGISTRATION: This was not a clinical trial and was therefore not registered as such.

Enhancing the Supervision of Community Health Workers With WhatsApp Mobile Messaging: Qualitative Findings From 2 Low-Resource Settings in Kenya.

An estimated half of all mobile phone users in Kenya use WhatsApp, an instant messaging platform that provides users an affordable way to send and receive text messages, photos, and other media at the one-to-one, one-to-many, many-to-one, or many-to-many levels. A mobile learning intervention aimed at strengthening supervisory support for community health workers (CHWs) in Kibera and Makueni, Kenya, created a WhatsApp group for CHWs and their supervisors to support supervision, professional development, and team building. We analyzed 6 months of WhatsApp chat logs (from August 19, 2014, to March 1, 2015) and conducted interviews with CHWs and their supervisors to understand how they used this instant messaging tool. During the study period, 1,830 posts were made by 41participants. Photos were a key component of the communication among CHWs and their supervisors: 430 (23.4%) of all posts contained photos or other media. Of the remaining 1,400 text-based posts, 87.6% (n = 1,227) related to at least 1 of 3 defined supervision objectives: (1) quality assurance, (2) communication and information, or (3) supportive environment. This supervision took place in the context of posts about the roll out of the new mobile learning intervention and the delivery of routine health care services, as well as team-building efforts and community development. Our preliminary investigation demonstrates that with minimal training, CHWs and their supervisors tailored the multi-way communication features of this mobile instant messaging technology to enact virtual one-to-one, group, and peer-to-peer forms of supervision and support, and they switched channels of communication depending on the supervisory objectives. We encourage additional research on how health workers incorporate mobile technologies into their practices to develop and implement effective supervisory systems that will safeguard patient privacy, strengthen the formal health system, and create innovative forms of community-based, digitally supported professional development for CHWs.

Determinants of use of skilled birth attendant at delivery in Makueni, Kenya: a cross sectional study.

BACKGROUND: Kenya has a maternal mortality ratio of 488 per 100,000 live births. Preventing maternal deaths depends significantly on the presence of a skilled birth attendant at delivery. Kenyan national statistics estimate that the proportion of births attended by a skilled health professional have remained below 50% for over a decade; currently at 44%, according to Kenya's demographic health survey 2008/09 against the national target of 65%. This study examines the association of mother's characteristics, access to reproductive health services, and the use of skilled birth attendants in Makueni County, Kenya. METHODS: We carried out secondary data analysis of a cross sectional cluster survey that was conducted in August 2012. Interviews were conducted with 1,205 eligible female respondents (15-49 years), who had children less than five years (0-59 months) at the time of the study. Data was analysed using SPSS version 17. Multicollinearity of the independent variables was assessed. Chi-square tests were used and results that were statistically significant with p-values, p < 0.25 were further included into the multivariable logistic regression model. Adjusted odds ratio (AOR) and their 95% confidence intervals were (95%) calculated. P value less than 0.05 were considered significant. RESULTS: Among the mothers who were interviewed, 40.3% (489) were delivered by a skilled birth attendant while 59.7% (723) were delivered by unskilled birth attendants. Mothers with tertiary/university education were more likely to use a skilled birth attendant during delivery, adjusted OR 8.657, 95% CI, (1.445- 51.853) compared to those with no education. A woman whose partner had secondary education was 2.9 times more likely to seek skilled delivery, adjusted odds ratio 2.913, 95% CI, (1.337- 6.348). Attending ANC was equally significant, adjusted OR 11.938, 95% CI, (4.086- 34.88). Living within a distance of 1- 5 kilometers from a facility increased the likelihood of skilled birth attendance, adjusted OR 95% CI, 1.594 (1.071- 2.371). CONCLUSIONS: The woman's level of education, her partner's level of education, attending ANC and living within 5kms from a health facility are associated with being assisted by skilled birth attendants. Health education and behaviour change communication strategies can be enhanced to increase demand for skilled delivery.

Situational analysis and expert evaluation of the nutrition and health status of infants and young children in five countries in sub-Saharan Africa.

BACKGROUND: The poor feeding practices of pregnant women, infants, and young children contribute to the burden of malnutrition and subsequently to childhood morbidity and mortality in sub-Saharan Africa. Gaining insight into the nutritional and health status of infants and young children will help to focus future nutrition programs and actions. OBJECTIVE: To assess the nutrition and health status of infants and young children in five sub-Saharan African countries: Ivory Coast, Senegal, Cameroon, Kenya, and Nigeria. METHODS: Published and gray literature was critically reviewed and enriched with the views of local experts from academia, hospitals, and institutions to assess infants' and children's diet and health in the five sub-Saharan African countries. Subsequently, the Africa Nutriday Conference was held in Senegal in November 2011 to further discuss key challenges, action plans, and recommendations for future research. RESULTS: This review highlighted the need for education of parents and healthcare professionals in order to increase their knowledge of breastfeeding, vaccination programs, and over- and undernutrition. An integrated health and nutrition surveillance is needed both to identify micronutrient deficiencies and to recognize early signs of overweight. These data will help to adapt nutrition education and food fortification programs to the target populations. CONCLUSIONS: Different countries in sub-Saharan Africa face similar nutrition and health issues and are currently not sharing best practices, nutrition programs, and scientific studies optimally. There is a need for closer collaboration among scientists within and between countries.

Utilization rates and perceptions of (VCT) services in Kisii Central District, Kenya.

Voluntary counseling and testing (VCT) services have been set up in most Districts in Kenya due to the rising surge of HIV/AIDS. However, the use of these services among married persons has not been fully explored. In Kissi, the issue of VCT is pressing as the rate of HIV prevalence is close to 3%. In 2006, about 20 000 clients came for VCT services in Kenya yet only 165 of these were married persons. In the Keumbu sub-district hospital, of the more than 1000 clients that came for VCT services, approximately 29% were married persons. This paper therefore aims at determining the utilization of VCT services by married persons in the study area. The qualitative data was obtained principally through two focus group discussions (FGDs) in which the respondents were asked to comment on their use of VCT services while the quantitative data was obtained from interviews with 245 respondents. The qualitative data was analyzed through verbatim transcription while for the quantitative data; the responses were coded and populated into SPSS from which the frequencies and percentages were calculated. The results show that actual use of the VCT services is low (28.1%) but slightly higher among female respondents than males. The low usage may be attributed to (a) fear of results, (b) death anxiety, (c) lack of confidentiality and lastly, (d) fear of stigmatization. Female respondents were found to have a greater awareness of VCT and thus its potential use.

Barriers to enrolment into a professional upgrading programme for enrolled nurses in Kenya.

INTRODUCTION: Nurses play a key role in the provision of health care. Over 70% of the nurses in Kenya are Enrolled Community Health Nurses (ECHNs). AMREF in partnership with Nursing Council of Kenya and the Ministry of Health pioneered an eLearning Nurse Upgrading Programme. The purpose of this study was to identify barriers that hindered enrolment into the programme. METHODS: A descriptive cross-sectional design was used. A sample of 532 ECHNs was interviewed from four provinces. Data was collected using a pre-tested self administered questionnaire. Analysis was done using SPSS computer software. Descriptive statistics were calculated for all variables and chi-square tests used to determine variables that were associated with enrolment. Mann Whitney U-test was used for continuous variables. RESULTS: A third (29.7%) of the nurses were from Rift Valley province and 17.9% from Coast. Majority (75%) were from public health facilities. The mean age of the nurses was 40.6 years. The average monthly income was KES 22,497.68 (USD 294). Awareness of the upgrading programme was high (97%) among the nurses. The cost of fees was the main (74.1%) barrier to enrolment in all the provinces and across all the health facilities. The type of health facility was significantly (p < 0.05) associated with enrolment. Nurses from faith-based health facilities were less likely to have enrolled. CONCLUSION: Awareness of the upgrading programme is high. The cost of upgrading programme, age and working in a faith-based health facility are the main barriers to enrolment. Intervention that fund nurses to upgrade would increase nurse enrolment.

The effect of work status on exclusive breastfeeding in Nairobi.

For many women today work is essential for the economic survival of their families while they also fulfil their role of providing optimum nutrition to their babies through breastfeeding. The objective of the study is to document the effect of returning to work on exclusive breastfeeding by mothers in Kenya. A cross-sectional study of 444 working mothers was undertaken in Nairobi, Kenya. About one half of the mothers were in formal paid employment and the rest were self-employed. The mean number of hours the mothers were away from home due to work was 46.2 hours per week. The prevalence of exclusive breastfeeding was 13.3% at three months. Early introduction of complementary foods was high, with 46.4% of the mothers introducing other foods before one month. Breast milk insufficiency and return to work were the main reasons cited for the cessation of exclusive breastfeeding. In a logistic regression analysis the mode of work (fixed working hours versus shift working hours) was associated with exclusive breastfeeding at one month (OR=0.45) and two months (OR=0.39). Working mothers were able to continue breastfeeding, although the exclusive breastfeeding rates were low. The early introduction of other foods is of public health importance as it exposes infants to increased risk of infection and poor nutrition, particularly diarrhoeal diseases and may lead to flattening of the growth curve. Shift work makes it impossible for some mothers to exclusively breastfeed their infants.

Breast-feeding and the working mother in Nairobi.

OBJECTIVE: In the fast growing city of Nairobi, women often combine the roles of mother and worker in trying to achieve better standards of living. The objective of this study was to document the effect of returning to work on breast-feeding by mothers in Kenya. DESIGN: A cross-sectional survey. SETTING: Outpatient clinics of two major hospitals in Nairobi, one government hospital in an economically deprived area and one high-fee private hospital. SUBJECTS: Four hundred and forty-four working mothers from low and higher socio-economic areas in Nairobi. All working mothers with infants aged 4 to 12 months attending during the survey period were invited to participate. RESULTS: The prevalence of breast-feeding at the time of interview was found to be 94.1%. The lower socio-economic group exhibited a higher prevalence of breast-feeding (99%), 10% greater than the higher socio-economic group. The mean number of hours the mothers were away from home due to work was 46.2 hours each week. The majority (54.4%) of the mothers employed a 'house-girl' to care for their infant while they were at work, while 28.4% were able to take their infants to work. Most of the breast-feeding mothers (95%) breast-fed their infants at least three times a day and only 23 mothers reported not being able to breast-feed their infants during the day. The lower socio-economic group had a mean of 5.09 breast-feeding times per day while the higher socio-economic group had a mean of 3 times a day. In a logistic regression analysis the mode of work (fixed working hours vs. shift working hours) was associated with exclusive breast-feeding at one month (odds ratio (OR)=0.45) and two months (OR=0.39). CONCLUSION: In Western countries 'return to work' is often cited as the reason that breast-feeding is discontinued prematurely. In this study we have shown how mothers in Kenya are able to successfully continue breast-feeding after they have returned to work, often for very long hours.