Effects of selected socio-demographic characteristics of community health workers on performance of home visits during pregnancy: a cross-sectional study in Busia District, Kenya.

OBJECTIVE: Appropriate performance of home visits facilitates adoption of best practices at home and increased demand for facility based services. METHODS: It was a cross-sectional study in which community health workers were observed conducting home visits during pregnancy.  Data was collected using a structured questionnaire and the Consultant Quality Index (CQI-2 tool) on record keeping, use of job aids, counselling, client satisfaction and client enablement. Descriptive and inferential statistics were used. Relationships were determined using chi square and odds ratios. RESULTS: The study showed significant relationships of age with good record keeping (p = 0.0001), appropriate use of job aids (p=0.0001), client satisfaction (p = 0.018) and client enablement (p = 0.001). Male CHWs were 1.6 times more likely to keep better records than females (OR 1.64 CI (1.02-2.63), while females were more likely to counsel and enable their clients OR 0.42 CI (0.25-0.71) and OR 0.29 CI (012-070) respectively when compared to men. Moreover, higher levels of education were associated with good record keeping OR 0.30 CI (0.19-0.49), p=0.0001; appropriate use of job aids OR 0.30 CI (0.15-0.61) and to appropriately counsel their clients OR 0.34 CI (0.20-0.58) than their lower literacy level counterparts. Experience of CHWs was associated with appropriate use of job aids (p = 0.049); client satisfaction (p = 0.0001) and client enablement (p = 0.032). CONCLUSIONS: Socio-demographic characteristics of community health workers affect the performance of home visits in various ways. The study also confirmed that CHWs with lower literacy levels satisfy and enable their clients effectively.

Determinants of male partner involvement in promoting deliveries by skilled attendants in Busia, Kenya.

A cross-sectional study covering 380 male partners and their spouses was conducted in Busia district in Western Kenya to establish demographic, socio-economic and cultural factors that affect male partner participation in promoting deliveries by skilled attendants. The study showed a significant relationship between level of education (P=0.0000) and level of income (P=0.0004) of the male partner and his support for skilled delivery. Lack of knowledge by male partners of complications associated with delivery, cultural beliefs, high fees charged for deliveries at health facilities and "un-cooperative" health workers are major contributing factors to low male partner involvement in child birth activities. Improving the levels of education and income of male partners, addressing the cultural beliefs and practices, improving health care provider-client relationship and sensitizing men on complications associated with pregnancy and child birth can contribute significantly in enhancing male partner involvement in promoting deliveries by skilled attendants.

Effectiveness of Kenya's Community Health Strategy in delivering community-based maternal and newborn health care in Busia County, Kenya: non-randomized pre-test post test study.

BACKGROUND: Maternal mortality ratio and neonatal mortality rate trends in Kenya have remained unacceptably high in a decade. In 2007, the Ministry of Public Health and Sanitation adopted a community health strategy to reverse the poor health outcomes in order to meet Millennium Development Goals 4 and 5. It aims at strengthening community participation and its ability to take action towards health. The study aimed at evaluating the effectiveness of the strategy in improving maternal and neonatal health outcomes in Kenya. METHODS: Between 2008 and 2010, the African Medical and Research Foundation implemented a community-based maternal and newborn care intervention package in Busia County using the community health strategy approach. An interventional, non-randomized pre-test post test study design was used to evaluate change in essential maternal and neonatal care practices among mothers with children aged 0 - 23 months. RESULTS: There was statistically significant (p < 0.05) increase in attendance of at least four antenatal care visits (39% to 62%), deliveries by skilled birth attendants (31% to 57%), receiving intermittent preventive treatment (23% to 57%), testing for HIV during pregnancy (73% to 90%) and exclusive breastfeeding (20% to 52%). CONCLUSION: The significant increase in essential maternal and neonatal care practices demonstrates that, community health strategy is an appropriate platform to deliver community based interventions. The findings will be used by actors in the child survival community to improve current approaches, policies and practice in maternal and neonatal care.

Reasoning and deciding PMTCT-adherence during pregnancy among women living with HIV in Kenya.

This study explores type identities among rural and urban slum women on antiretroviral therapies who become pregnant. Narrative structuring was chosen to develop type narratives that illustrate how rural and urban women handle their HIV-infection and how they reason and decide about PMTCT-adherence during pregnancy and childbirth. Women in rural areas described their lives as 'secure and family controlled'. This gave the women security and predictability in life, but also meant that it was difficult to keep secrets about HIV infection. For women in the urban slum area the narratives were a tale of the uncertain and hard to predict reality in the slum, but also about self-reliance and decisiveness. They portrayed themselves as 'vulnerable and striving to survive' thus managing a tough situation without long-term solutions. We conclude that pregnancy poses different social challenges in rural and urban areas affecting how women choose to manage their adherence to PMTCT, which is also affected by HIV stigma and lack of disclosure.

Is 'Opt-Out HIV Testing' a real option among pregnant women in rural districts in Kenya?

BACKGROUND: An 'opt-out' policy of routine HIV counseling and testing (HCT) is being implemented across sub-Saharan Africa to expand prevention of mother-to-child transmission (PMTCT). Although the underlying assumption is that pregnant women in rural Africa are able to voluntarily consent to HIV testing, little is known about the reality and whether 'opt-out' HCT leads to higher completion rates of PMTCT. Factors associated with consent to HIV testing under the 'opt-out' approach were investigated through a large cross-sectional study in Kenya. METHODS: Observations during HIV pre-test information sessions were followed by a cross-sectional survey of 900 pregnant women in three public district hospitals carrying out PMTCT in the Busia district. Women on their first antenatal care (ANC) visit during the current pregnancy were interviewed after giving blood for HIV testing but before learning their test results. Descriptive statistics and multivariate regression analysis were performed. RESULTS: Of the 900 women participating, 97% tested for HIV. Lack of testing kits was the only reason for women not being tested, i.e. nobody declined HIV testing. Despite the fact that 96% had more than four earlier pregnancies and 37% had been tested for HIV at ANC previously, only 17% of the women surveyed knew that testing was optional. Only 20% of those surveyed felt they could make an informed decision to decline HIV testing. Making an informed decision to decline HIV testing was associated with knowing that testing was optional (OR = 5.44, 95%CI 3.44-8.59), not having a stable relationship with the child's father (OR = 1.76, 95%CI 1.02-3.03), and not having discussed HIV testing with a partner before the ANC visit (OR = 2.64 95%CI 1.79-3.86). CONCLUSION: High coverage of HIV testing appears to be achieved at the cost of pregnant women not understanding that testing is optional. Good quality HIV pre-test information is central to ensure that pregnant women understand and accept the reasons for testing and will thus come back to collect their test results, an important prerequisite for completing PMTCT for those who test HIV-positive.

'Keeping healthy in the backseat': How motherhood interrupted HIV treatment in recently delivered women in Kenya.

Although there is a large body of literature related to the experiences of motherhood and aspects of the change that it brings about, how the experience of motherhood affects the healthcare of women with chronic illness is less documented. This study explores how motherhood in newly delivered HIV-infected mothers in Kenya interrupted their antiretroviral treatment (ART). Qualitative interviews were performed with 26 mothers on ART in a rural or urban area. The data were organised and interpreted using content analysis. The study found that adherence to ART was influenced by contextual differences in socio-cultural expectations and family relationships. Urban life enabled women to make decisions on their own and to negotiate challenges that were often unpredictable. Women in rural areas knew what was expected of them and decisions were normally not for them to make alone. The women in Busia and Kibera had difficulties combining adherence with attaining the socio-cultural definition of good mothering. Lack of support from health providers and weak healthcare systems contributed to inadequate stocks of HIV drugs and inaccessibility of HIV-related care. From the data, we developed the main theme 'keeping healthy in the backseat' and the two sub-themes 'regaining self-worth through motherhood' and 'mother first - patient later.' We suggest that motherhood is context-specific and follows socio-cultural practises, which made it difficult for the women in Kenya to follow ART instructions. There is a need to reassess HIV-related services for mothers on ART in order to give them a better chance to stay on treatment and satisfy their aspiration to be 'good mothers.' Context-specific HIV-treatment policies are necessary for ensuring adherence and successful treatment outcomes.