"For a man to go to hospital, then that would be his last option": A qualitative study exploring men's experiences, perceptions and healthcare needs in the implementation of Universal Health Coverage in Kenya.

The achievement of Universal Health Coverage (UHC) requires equitable access and utilization of healthcare services across all population groups, including men. However, men often face unique barriers that impede their engagement with health systems which are influenced by a myriad of socio-cultural, economic, and systemic factors. Therefore, understanding men's perspectives and experiences is crucial to identifying barriers and facilitators to their healthcare-seeking behaviour under UHC initiatives. This qualitative study sought to explore men's perceptions, experiences, healthcare needs and potential strategies to inform an impartial implementation of Universal Health Coverage (UHC) in Kenya. The study employed a qualitative research design to investigate men's healthcare experiences in 12 counties across Kenya. Thirty focus group discussions involving 296 male participants were conducted. Men were purposively selected and mobilized through the support of health facility-in-charges, public health officers, and community health extension workers. Data was coded according to emergent views and further categorized thematically into three main domains (1) Perspectives and experiences of healthcare access (2) Socio-cultural beliefs and societal expectations (3) Desires and expectations of health systems. Findings revealed complex sociocultural, economic, and health system factors that influenced men's healthcare experiences and needs which included: masculinity norms and gender roles, financial constraints and perceived unaffordability of services, lack of male-friendly and gender-responsive healthcare services, confidentiality concerns, and limited health literacy and awareness about available UHC services. Our study has revealed a disconnect between men's needs and the current healthcare system. The expectations concerning masculinity further exacerbate the problem and exclude men further hindering men's ability to receive appropriate care. This data provides important considerations for the development of comprehensive and gender-transformative approaches challenging harmful masculine norms, pushing for financial risk protection mechanisms and gender-responsive healthcare delivery attuned to the unique needs and preferences of men.

Pairwise fitting of piecewise mixed models for the joint modeling of multivariate longitudinal outcomes, in a randomized crossover trial.

Many statistical models have been proposed in the literature for the analysis of longitudinal data. One may propose to model two or more correlated longitudinal processes simultaneously, with a goal of understanding their association over time. Joint modeling is then required to carefully study the association structure among the outcomes as well as drawing joint inferences about the different outcomes. In this study, we sought to model the associations among six nutrition outcomes while circumventing the computational challenge posed by their clustered and high-dimensional nature. We analyzed data from a 2 × $\times$ 2 randomized crossover trial conducted in Kenya, to compare the effect of high-dose and low-dose iodine in household salt on systolic blood pressure (SBP) and diastolic blood pressure (DBP) in women of reproductive age and their household matching pair of school-aged children. Two additional outcomes, namely, urinary iodine concentration (UIC) in women and children were measured repeatedly to monitor the amount of iodine excreted through urine. We extended the model proposed by Mwangi et al. (2021, Communications in Statistics: Case Studies, Data Analysis and Applications, 7(3), 413-431) allowing flexible piecewise joint models for six outcomes to depend on separate random effects, which are themselves correlated. This entailed fitting 15 bivariate general linear mixed models and deriving inference for the joint model using pseudo-likelihood theory. We analyzed the outcomes separately and jointly using piecewise linear mixed-effects (PLME) model and further validated the results using current state-of-the-art Jones and Kenward methodology (JKME model) used for analyzing randomized crossover trials. The results indicate that high-dose iodine in salt significantly reduced blood pressure (BP) compared to low-dose iodine in salt. Estimates for the random effects and residual error components showed that SBP and DBP had strong positive correlation, with effect of the random slope indicating that significantly related outcomes are strongly associated in their evolution. There was a moderately strong inverse relationship between evolutions of UIC and BP both in women and children. These findings confirmed the original hypothesis that high-dose iodine salt has significant lowering effect on BP. We further sought to evaluate the performance of our proposed PLME model against the widely used JKME model, within the multivariate joint modeling framework through a simulation study mimicking a 2 × 2 $2\times 2$ crossover design. From our findings, the multivariate joint PLME model performed exceptionally well both in estimation of random-effects matrix (G) and Hessian matrix (H), allowing satisfactory model convergence during estimation. It allowed a more complex fit to the data with both random intercepts and slopes effects compared to the multivariate joint JKME model that allowed for random intercepts only. When a hierarchical viewpoint is adopted, in the sense that outcomes are specified conditionally upon random effects, the variance-covariance matrix of the random effects must be positive definite. In some cases, additional random effects could explain much variability in the data, thus improving precision in estimation of the estimands (effect size) parameters. The key highlight in this evaluation shows that multivariate joint JKME model is a powerful tool especially while fitting mixed models with random intercepts only, in crossover design settings. Addition of random slopes may lead to model complexities in most cases, resulting in unsatisfactory model convergence during estimation. To circumvent convergence pitfalls, extention of JKME model to PLME model allows a more flexible fit to the data (generated from crossover design settings), especially in the multivariate joint modeling framework.

Health systems' capacity in availability of human resource for health towards implementation of Universal Health Coverage in Kenya.

INTRODUCTION: Kenya faces significant challenges related to health worker shortages, low retention rates, and the equitable distribution of Human Resource for Health (HRH). The Ministry of Health (MOH) in Kenya has established HRH norms and standards that define the minimum requirements for healthcare providers and infrastructure at various levels of the health system. The study assessed on the progress of Universal Health Coverage (UHC) piloting on Human Resource for Health in the country. METHODS: The study utilized a Convergent-Parallel-Mixed-Methods design, incorporating both quantitative and qualitative approaches. The study sampled diverse population groups and randomly selected health facilities. Four UHC pilot counties are paired with two non-UHC pilot counties, one neighboring county and the second county with a geographically distant and does not share a border with any UHC pilot counties. Stratification based on ownership and level was performed, and the required number of facilities per stratum was determined using the square root allocation method. Data on the availability of human resources for health was collected using a customized Kenya Service Availability and Readiness Assessment Mapping (SARAM) tool facilitated by KoBo ToolKitTM open-source software. Data quality checks and validation were conducted, and the HRH general service availability index was measured on availability of Nurses, Clinician, Nutritionist, Laboratory technologist and Pharmacist which is a minimum requirement across all levels of health facilities. Statistical analyses were performed using IBM SPSS version 27 and comparisons between UHC pilot counties and non-UHC counties where significance threshold was established at p < 0.05. Qualitative data collected using focus group discussions and in-depth interview guides. Ethical approval and research permits were obtained, and written informed consent was obtained from all participants. RESULTS: The study assessed 746 health facilities with a response rate of 94.3%. Public health facilities accounted for 75% of the sample. The overall healthcare professional availability index score was 17.2%. There was no significant difference in health workers' availability between UHC pilot counties and non-UHC pilot counties at P = 0.834. Public health facilities had a lower index score of 14.7% compared to non-public facilities at 27.0%. Rural areas had the highest staffing shortages, with only 11.1% meeting staffing norms, compared to 31.8% in urban areas and 30.4% in peri-urban areas. Availability of health workers increased with the advancement of The Kenya Essential Package for Health (KEPH Level), with all Level 2 facilities across counties failing to meet MOH staffing norms (0.0%) except Taita Taveta at 8.3%. Among specific cadres, nursing had the highest availability index at 93.2%, followed by clinical officers at 52.3% and laboratory professionals at 55.2%. The least available professions were nutritionists at 21.6% and pharmacist personnel at 33.0%. This result is corroborated by qualitative verbatim. CONCLUSION: The study findings highlight crucial challenges in healthcare professional availability and distribution in Kenya. The UHC pilot program has not effectively enhanced healthcare facilities to meet the standards for staffing, calling for additional interventions. Rural areas face a pronounced shortage of healthcare workers, necessitating efforts to attract and retain professionals in these regions. Public facilities have lower availability compared to private facilities, raising concerns about accessibility and quality of care provided. Primary healthcare facilities have lower availability than secondary facilities, emphasizing the need to address shortages at the community level. Disparities in the availability of different healthcare cadres must be addressed to meet diverse healthcare needs. Overall, comprehensive interventions are urgently needed to improve access to quality healthcare services and address workforce challenges.

Evaluation of a flexible piecewise linear mixed-effects model in the analysis of randomized cross-over trials.

Cross-over designs are commonly used in randomized clinical trials to estimate efficacy of a new treatment. They have received a lot of attention, particularly in connection with regulatory requirements for new drugs. The main advantage of using cross-over designs over conventional parallel designs is increased precision, thanks to within-subject comparisons. In the statistical literature, more recent developments are discussed in the analysis of cross-over trials, in particular regarding repeated measures. A piecewise linear model within the framework of mixed effects has been proposed in the analysis of cross-over trials. In this article, we report on a simulation study comparing performance of a piecewise linear mixed-effects (PLME) model against two commonly cited models-Grizzle's mixed-effects (GME) and Jones & Kenward's mixed-effects (JKME) models-used in the analysis of cross-over trials. Our simulation study tried to mirror real-life situation by deriving true underlying parameters from empirical data. The findings from real-life data confirmed the original hypothesis that high-dose iodine salt have significantly lowering effect on diastolic blood pressure (DBP). We further sought to evaluate the performance of PLME model against GME and JKME models, within univariate modeling framework through a simulation study mimicking a 2 × 2 cross-over design. The fixed-effects, random-effects and residual error parameters used in the simulation process were estimated from DBP data, using a PLME model. The initial results with full specification of random intercept and slope(s), showed that the univariate PLME model performed better than the GME and JKME models in estimation of variance-covariance matrix (G) governing the random effects, allowing satisfactory model convergence during estimation. When a hierarchical view-point is adopted, in the sense that outcomes are specified conditionally upon random effects, the variance-covariance matrix of the random effects must be positive-definite. The PLME model is preferred especially in modeling an increased number of random effects, compared to the GME and JKME models that work equally well with random intercepts only. In some cases, additional random effects could explain much variability in the data, thus improving precision in estimation of the estimands (effect size) parameters.

The Livestock for Health Study: A Field Trial on Livestock Interventions to Prevent Acute Malnutrition Among Women and Children in Pastoralist Communities in Northern Kenya.

BACKGROUND: Livestock-dependent communities in Africa's drylands disproportionately experience acute malnutrition, especially during drought seasons. We detail the design and implementation of the Livestock for Health (L4H) study aimed at determining the effect of providing livestock feed and nutritional counselling to prevent seasonal spikes of acute malnutrition. METHODS: The L4H study employed a 3-arm cluster randomized controlled trial to compare households in pastoralist settings in northern Kenya receiving livestock feeds during critical dry periods, with or without nutritional counseling, with control households. Over 4 dry seasons, 2019 to 2021, the study collected data on household milk production, consumption patterns, mothers'/children's nutritional status, household socioeconomic status, herd dynamics, and human and animal health status every 6 weeks. RESULTS: L4H recruited 1734 households, with 639, 585, and 510 households assigned to intervention arms 1 and 2 and control arm 3, respectively. From these households, 1734 women and 1748 children younger than 3 years were recruited. In total, 19 419 household visits were completed, obtaining anthropometric measures 9 times on average for each child and mother. Eighty-one households (5%) were lost from the study due to the mother's death, child's death, migration, and withdrawal for other reasons. DISCUSSION: L4H's success in a challenging environment was possible due to strong community engagement, formative studies to inform trial design, collaboration with local authorities, and effective interdisciplinary collaboration. Subsequent manuscripts will report the study findings. TRIAL REGISTRATION: The study was registered October 29, 2020, and is online at ClinicalTrials.gov (ID: NCT04608656).

Diabetes health care specific services readiness and availability in Kenya: Implications for Universal Health Coverage.

Diabetes is a major cause of morbidity and mortality worldwide yet preventable. Complications of undetected and untreated diabetes result in serious human suffering and disability. It negatively impacts on individual's social economic status threatening economic prosperity. There is a scarcity of data on health system diabetes service readiness and availability in Kenya which necessitated an investigation into the specific availability and readiness of diabetes services. A cross sectional descriptive study was carried out using the Kenya service availability and readiness mapping tool in 598 randomly selected public health facilities in 12 purposively selected counties. Ethical standards outlined in the 1964 Declaration of Helsinki and its later amendments were upheld throughout the study. Health facilities were classified into primary and secondary level facilities prior to statistical analysis using IBM SPSS version 25. Exploratory data analysis techniques were employed to uncover the distribution structure of continuous study variables. For categorical variables, descriptive statistics in terms of proportions, frequency distributions and percentages were used. Of the 598 facilities visited, 83.3% were classified as primary while 16.6% as secondary. A variation in specific diabetes service availability and readiness was depicted in the 12 counties and between primary and secondary level facilities. Human resource for health reported a low mean availability (46%; 95% CI 44%-48%) with any NCDs specialist and nutritionist the least carder available. Basic equipment and diagnostic capacity reported a fairly high mean readiness (73%; 95% CI 71%-75%) and (64%; 95%CI 60%-68%) respectively. Generally, primary health facilities had low diabetic specific service availability and readiness compared to secondary facilities: capacity to cope with diabetes increased as the level of care ascended to higher levels. Significant gaps were identified in overall availability and readiness in both primary and secondary levels facilities particularly in terms of human resource for health specifically nutrition and laboratory profession.

The impact of livestock interventions on nutritional outcomes of children younger than 5 years old and women in Africa: a systematic review and meta-analysis.

Background: Nutrition-sensitive livestock interventions have the potential to improve the nutrition of communities that are dependent on livestock for their livelihoods by increasing the availability and access to animal-source foods. These interventions can also boost household income, improving purchasing power for other foods, as well as enhance determinants of health. However, there is a lack of synthesized empirical evidence of the impact and effect of livestock interventions on diets and human nutritional status in Africa. Objective: To review evidence of the effectiveness of nutrition-sensitive livestock interventions in improving diets and nutritional status in children younger than 5 years old and in pregnant and lactating women. Methods: Following PRISMA guidelines, we conducted a systematic review and meta-analysis of published studies reporting on the effect of livestock interventions on maternal and child nutrition in Africa. Data were extracted, synthesized, and summarized qualitatively. Key outcomes were presented in summary tables alongside a narrative summary. Estimation of pooled effects was undertaken for experimental studies with nutritional outcomes of consumption of animal-source foods (ASFs) and minimum dietary diversity (MDD). Fixed effects regression models and pooled effect sizes were computed and reported as odds ratios (ORs) together with their 95% confidence intervals (CI). Results: After the screening, 29 research papers were included in the review, and of these, only 4 were included in the meta-analysis. We found that nutrition-sensitive livestock interventions have a significant positive impact on the consumption of ASFs for children < 5 years (OR = 5.39; 95% CI: 4.43-6.56) and on the likelihood of meeting minimum dietary diversity (OR = 1.89; 95% CI: 1.51-2.37). Additionally, the impact of livestock interventions on stunting, wasting, and being underweight varied depending on the type of intervention and duration of the program/intervention implementation. Therefore, because of this heterogeneity in reporting metrics, the pooled estimates could not be computed. Conclusion: Nutrition-sensitive livestock interventions showed a positive effect in increasing the consumption of ASFs, leading to improved dietary diversity. However, the quality of the evidence is low, and therefore, more randomized controlled studies with consistent and similar reporting metrics are needed to increase the evidence base on how nutrition-sensitive livestock interventions affect child growth outcomes.

Analysis of user interactions with a digital health wallet for enabling care continuity in the context of an ongoing pandemic.

BACKGROUND: The onset of COVID-19 and related policy responses made it difficult to study interactive health informatics solutions in clinical study settings. Instrumented log and event data from interactive systems capture temporal details that can be used to generate insights about care continuity during ongoing pandemics. OBJECTIVE: To investigate user interactions with a digital health wallet (DHW) system for addressing care continuity challenges in chronic disease management in the context of an ongoing pandemic. MATERIALS AND METHODS: We analyzed user interaction log data generated by clinicians, nurses, and patients from the deployment of a DHW in a feasibility study conducted during the COVID-19 pandemic in Kenya. We used the Hamming distance from Information Theory to quantify deviations of usage patterns extracted from the events data from predetermined workflow sequences supported by the platform. RESULTS: Nurses interacted with all the user interface elements relevant to triage. Clinicians interacted with only 43% of elements relevant to consultation, while patients interacted with 67% of the relevant user interface elements. Nurses and clinicians deviated from the predetermined workflow sequences by 42% and 36%, respectively. Most deviations pertained to users going back to previous steps in their usage workflow. CONCLUSIONS: User interaction log analysis is a valuable alternative method for generating and quantifying user experiences in the context of ongoing pandemics. However, researchers should mitigate the potential disruptions of the actual use of the studied technologies as well as use multiple approaches to investigate user experiences of health technology during pandemics.

Sero - epidemiology of brucellosis in people and their livestock: A linked human - animal cross-sectional study in a pastoralist community in Kenya.

Background: Brucellosis is associated with massive livestock production losses and human morbidity worldwide. Efforts to control brucellosis among pastoralist communities are limited by scarce data on the prevalence and risk factors for exposure despite the high human-animal interactions in these communities. This study simultaneously assessed the seroprevalence of brucellosis and associated factors of exposure among pastoralists and their livestock in same households. Methods: We conducted a cross-sectional study in pastoralist communities in Marsabit County - Kenya. A total of 1,074 women and 225 children participated and provided blood samples. Blood was also drawn from 1,876 goats, 322 sheep and 189 camels. Blood samples were collected to be screened for the presence of anti-Brucella IgG antibodies using indirect IgG Enzyme-Linked Immunosorbent Assay (ELISA) kits. Further, Individual, household and herd-level epidemiological information were captured using a structured questionnaire. Group differences were compared using the Pearson's Chi-square test, and p-values < 0.05 considered statistically significant. Generalized mixed-effects multivariable logistic human and animal models using administrative ward as the random effect was used to determine variables correlated to the outcome. Results: Household-level seropositivity was 12.7% (95% CI: 10.7-14.8). The individual human seroprevalence was 10.8% (9.1-12.6) with higher seroprevalence among women than children (12.4 vs. 3.1%, p < 0.001). Herd-level seroprevalence was 26.1% (23.7-28.7) and 19.2% (17.6-20.8) among individual animals. Goats had the highest seroprevalence 23.1% (21.2 - 25.1), followed by sheep 6.8% (4.3-10.2) and camels 1.1% (0.1-3.8). Goats and sheep had a higher risk of exposure OR = 3.8 (95% CI 2.4-6.7, p < 0.001) and 2.8 (1.2-5.6, p < 0.007), respectively relative to camels. Human and animal seroprevalence were significantly associated (OR = 1.8, [95%CI: 1.23-2.58], p = 0.002). Herd seroprevalence varied by household head education (OR = 2.45, [1.67-3.61, p < 0.001]) and herd size (1.01, [1.00-1.01], p < 0.001). Conclusions: The current study showed evidence that brucellosis is endemic in this pastoralist setting and there is a significant association between animal and human brucellosis seropositivity at household level representing a potential occupational risk. Public health sensitization and sustained human and animal brucellosis screening are required.

Mid-term evaluation of Maternal and Child Nutrition Programme (MCNP II) in Kenya.

BACKGROUND: Kenya is faced with a triple burden of malnutrition which is multi-faceted with health and socio-economic implications. Huge geographical disparities exist, especially, in the arid and semi-arid lands exacerbated by inadequate resource allocation to the nutrition sector and challenges in multi-sectoral coordination and nutrition governance. UNICEF's Maternal and Child Nutrition Programme is a four-year (2018-2022) resilience-building, multi-sectoral program focused on pregnant and lactating women, mothers of children under five years and children under five years. The objective of the mid-term evaluation was to establish the relevance, effectiveness, efficiency, and sustainability of the programme. METHODS: The field evaluation conducted between June and July 2021, adopted a concurrent mixed-methods approach, where qualitative information was gathered through 29 key informant interviews and 18 focus group discussions (6 FGDs per population group; women of reproductive age, adolescent girls and men). Quantitatively, data were obtained through desk review of secondary data from programme reports, budgets, and project outputs where descriptive analysis was undertaken using Excel software. Qualitative information was organized using Nvivo software and analyzed thematically. RESULTS: The findings provide evidence of the relevance of the Maternal and Child Nutrition Programme II to the nutrition situation in Kenya and its alignment with the Government of Kenya and donor priorities. Most planned programme targets were achieved despite operating in a COVID-19 pandemic environment. The use of innovative approaches such as family mid-upper arm circumference, integrated management of acute malnutrition surge model, Malezi bora and Logistic Management Information Management System contributed to the realization of effective outputs and outcomes. Stringent financial management strategies contributed toward programme efficiencies; however, optimal utilization of the resources needs further strengthening. The programme adopted strategies for strengthening local capacity and promoting ownership and long-term sustainability. CONCLUSION: The programme is on track across the four evaluation criteria. However, a few suggestions are recommended to improve relevance, effectiveness, efficiency, and sustainability. A formal transition strategy needs to be developed in consultation with multi-stakeholder groups and implemented in phases. UNICEF Nutrition section should explore a more integrated  programming mode of delivery through joint initiatives with other agencies under the Delivery as One UN agenda, along the more gender transformative approaches with more systematic involvement of males and females in gender-based discussions.

Endemicity of Coxiella burnetii infection among people and their livestock in pastoral communities in northern Kenya.

Background: Coxiella burnetti can be transmitted to humans primarily through inhaling contaminated droplets released from infected animals or consumption of contaminated dairy products. Despite its zoonotic nature and the close association pastoralist communities have with their livestock, studies reporting simultaneous assessment of C. burnetti exposure and risk-factors among people and their livestock are scarce. Objective: This study therefore estimated the seroprevalence of Q-fever and associated risk factors of exposure in people and their livestock. Materials and methods: We conducted a cross-sectional study in pastoralist communities in Marsabit County in northern Kenya. A total of 1,074 women and 225 children were enrolled and provided blood samples for Q-fever testing. Additionally, 1,876 goats, 322 sheep and 189 camels from the same households were sampled. A structured questionnaire was administered to collect individual- and household/herd-level data. Indirect IgG ELISA kits were used to test the samples. Results: Household-level seropositivity was 13.2% [95% CI: 11.2-15.3]; differences in seropositivity levels among women and children were statistically insignificant (p = 0.8531). Lactating women had higher odds of exposure, odds ratio (OR) = 2.4 [1.3-5.3], while the odds of exposure among children increased with age OR = 1.1 [1.0-1.1]. Herd-level seroprevalence was 83.7% [81.7-85.6]. Seropositivity among goats was 74.7% [72.7-76.7], while that among sheep and camels was 56.8% [51.2-62.3] and 38.6% [31.6-45.9], respectively. Goats and sheep had a higher risk of exposure OR = 5.4 [3.7-7.3] and 2.6 [1.8-3.4], respectively relative to camels. There was no statistically significant association between Q-fever seropositivity and nutrition status in women, p = 0.900 and children, p = 1.000. We found no significant association between exposure in people and their livestock at household level (p = 0.724) despite high animal exposure levels, suggesting that Q-fever exposure in humans may be occurring at a scale larger than households. Conclusion: The one health approach used in this study revealed that Q-fever is endemic in this setting. Longitudinal studies of Q-fever burden and risk factors simultaneously assessed in human and animal populations as well as the socioeconomic impacts of the disease and further explore the role of environmental factors in Q-fever epidemiology are required. Such evidence may form the basis for designing Q-fever prevention and control strategies.

Impact of livestock interventions on maternal and child nutrition outcomes in Africa: A systematic review and meta-analysis protocol.

The challenge of undernutrition (stunting and wasting) still remains a major health concern in children below 5 years of age in Africa, with the continent accounting for more than one third of all stunted children and more than one quarter of all wasted children globally. Despite the growing evidence on the role of agriculture interventions in improving nutrition, empirical evidence on the impact of livestock intervention on nutrition in Africa is scant. This review is aimed at determining whether livestock interventions are effective in reducing undernutrition in children below five years of age and in pregnant and lactating women in Africa. The review will be conducted according to PRISMA guidelines. Major electronic databases will be searched and complemented with grey and non-indexed literature from google and google scholar, and expert consultation for additional articles and reports. PICO criteria will be used while employing search strategies including MeSH, Boolean search operators and truncation/wildcard symbol to narrow or broaden the search. Articles on effect of livestock interventions on maternal and child nutrition conducted in Africa that meet the set inclusion criteria will be included in the review after critical appraisal by two independent reviewers. A standardized form will be used to extract data from included studies. The extracted data will be summarized and synthesized both qualitatively and quantitatively and key outcomes presented. Evidence generated from the systematic review and meta-analysis will be important for guiding nutrition sensitive livestock interventions and policies on nutrition programming, specifically on how to leverage on livestock interventions to reduce the burden of undernutrition.

Perceptions on Adherence to Dietary Prescriptions for Adults with Chronic Kidney Disease on Hemodialysis: A Qualitative Study.

Diet is one of the modifiable lifestyle factors in management of kidney disease. We explored perceptions on adherence to dietary prescriptions for adults with chronic kidney disease on hemodialysis. This was a qualitative descriptive study. Participants were purposively selected at renal clinics/dialysis units at national referral hospitals in Kenya. Data were collected using in-depth interviews, note-taking and voice-recording. The data were managed and analyzed thematically in NVIV0-12 computer software. Study participants were 52 patients and 40 family caregivers (42 males and 50 females) aged 20 to 69 years. Six sub-themes emerged in this study: "perceived health benefits"; "ease in implementing prescribed diets"; "cost of prescribed renal diets"; "nutrition information and messages"; "transition to new diets" and "fear of complications/severity of disease". Both patients and caregivers acknowledged the health benefits of adherence to diet prescriptions. However, there are mixed messages to the patients and caregivers who have challenges with management and acceptability of the prescriptions. Most of them make un-informed dietary decisions that lead to consumption of unhealthy foods with negative outcomes such as metabolic waste accumulation in the patients' bodies negating the effects of dialysis and undermining the efforts of healthcare system in management of patients with chronic kidney disease.

Patient costs of diabetes mellitus care in public health care facilities in Kenya.

OBJECTIVE: To estimate the direct and indirect costs of diabetes mellitus care at five public health facilities in Kenya. METHODS: We conducted a cross-sectional study in two counties where diabetes patients aged 18 years and above were interviewed. Data on care-seeking costs were obtained from 163 patients seeking diabetes care at five public facilities using the cost-of-illness approach. Medicines and user charges were classified as direct health care costs while expenses on transport, food, and accommodation were classified as direct non-health care costs. Productivity losses due to diabetes were classified as indirect costs. We computed annual direct and indirect costs borne by these patients. RESULTS: More than half (57.7%) of sampled patients had hypertension comorbidity. Overall, the mean annual direct patient cost was KES 53 907 (95% CI, 43 625.4-64 188.6) (US$ 528.5 [95% CI, 427.7-629.3]). Medicines accounted for 52.4%, transport 22.6%, user charges 17.5%, and food 7.5% of total direct costs. Overall mean annual indirect cost was KES 23 174 (95% CI, 20 910-25 438.8) (US$ 227.2 [95% CI, 205-249.4]). Patients reporting hypertension comorbidity incurred higher costs compared with diabetes-only patients. The incidence of catastrophic costs was 63.1% (95% CI, 55.7-70.7) and increased to 75.4% (95% CI, 68.3-82.1) when transport costs were included. CONCLUSION: There are substantial direct and indirect costs borne by diabetic patients in seeking care from public facilities in Kenya. High incidence of catastrophic costs suggests diabetes services are unaffordable to majority of diabetic patients and illustrate the urgent need to improve financial risk protection to ensure access to care.

Diagnostic Accuracy of Unattended Automated Office Blood Pressure Measurement in Screening for Hypertension in Kenya.

Despite increasing adoption of unattended automated office blood pressure (uAOBP) measurement for determining clinic blood pressure (BP), its diagnostic performance in screening for hypertension in low-income settings has not been determined. We determined the validity of uAOBP in screening for hypertension, using 24-hour ambulatory BP monitoring as the reference standard. We studied a random population sample of 982 Kenyan adults; mean age, 42 years; 60% women; 2% with diabetes mellitus; none taking antihypertensive medications. We calculated sensitivity using 3 different screen positivity cutoffs (≥130/80, ≥135/85, and ≥140/90 mm Hg) and other measures of validity/agreement. Mean 24-hour ambulatory BP monitoring systolic BP was similar to mean uAOBP systolic BP (mean difference, 0.6 mm Hg; 95% CI, -0.6 to 1.9), but the 95% limits of agreement were wide (-39 to 40 mm Hg). Overall discriminatory accuracy of uAOBP was the same (area under receiver operating characteristic curves, 0.66-0.68; 95% CI range, 0.64-0.71) irrespective of uAOBP cutoffs used. Sensitivity of uAOBP displayed an inverse association (P<0.001) with the cutoff selected, progressively decreasing from 67% (95% CI, 62-72) when using a cutoff of ≥130/80 mm Hg to 55% (95% CI, 49-60) at ≥135/85 mm Hg to 44% (95% CI, 39-49) at ≥140/90 mm Hg. Diagnostic performance was significantly better (P<0.001) in overweight and obese individuals (body mass index, >25 kg/m2). No differences in results were present in other subanalyses. uAOBP misclassifies significant proportions of individuals undergoing screening for hypertension in Kenya. Additional studies on how to improve screening strategies in this setting are needed.

Patient costs of hypertension care in public health care facilities in Kenya.

BACKGROUND: Hypertension in low- and middle-income countries, including Kenya, is of economic importance due to its increasing prevalence and its potential to present an economic burden to households. In this study, we examined the patient costs associated with obtaining care for hypertension in public health care facilities in Kenya. METHODS: We conducted a cross-sectional study among adult respondents above 18 years of age, with at least 6 months of treatment in two counties. A total of 212 patients seeking hypertension care at five public facilities were interviewed, and information on care seeking and the associated costs was obtained. We computed both annual direct and indirect costs borne by these patients. RESULTS: Overall, the mean annual direct cost to patients was US$ 304.8 (95% CI, 235.7-374.0). Medicines (mean annual cost, US$ 168.9; 95% CI, 132.5-205.4), transport (mean annual cost, US$ 126.7; 95% CI, 77.6-175.9), and user charges (mean annual cost, US$ 57.7; 95% CI, 43.7-71.6) were the highest direct cost categories. Overall mean annual indirect cost was US$ 171.7 (95% CI, 152.8-190.5). The incidence of catastrophic health care costs was 43.3% (95% CI, 36.8-50.2) and increased to 59.0% (95% CI, 52.2-65.4) when transport costs were included. CONCLUSIONS: Hypertensive patients incur substantial direct and indirect costs. High rates of catastrophic costs illustrate the urgency of improving financial risk protection for these patients and strengthening primary care to ensure affordability of hypertension care.

New Statistical Approach to Apportion Dietary Sources of Iodine Intake: Findings from Kenya, Senegal and India.

Progress of national Universal Salt Iodization (USI) strategies is typically assessed by household coverage of adequately iodized salt and median urinary iodine concentration (UIC) in spot urine collections. However, household coverage does not inform on the iodized salt used in preparation of processed foods outside homes, nor does the total UIC reflect the portion of population iodine intake attributable to the USI strategy. This study used data from three population-representative surveys of women of reproductive age (WRA) in Kenya, Senegal and India to develop and illustrate a new approach to apportion the population UIC levels by the principal dietary sources of iodine intake, namely native iodine, iodine in processed food salt and iodine in household salt. The technique requires measurement of urinary sodium concentrations (UNaC) in the same spot urine samples collected for iodine status assessment. Taking into account the different complex survey designs of each survey, generalized linear regression (GLR) analyses were performed in which the UIC data of WRA was set as the outcome variable that depends on their UNaC and household salt iodine (SI) data as explanatory variables. Estimates of the UIC portions that correspond to iodine intake sources were calculated with use of the intercept and regression coefficients for the UNaC and SI variables in each country's regression equation. GLR coefficients for UNaC and SI were significant in all country-specific models. Rural location did not show a significant association in any country when controlled for other explanatory variables. The estimated UIC portion from native dietary iodine intake in each country fell below the minimum threshold for iodine sufficiency. The UIC portion arising from processed food salt in Kenya was substantially higher than in Senegal and India, while the UIC portions from household salt use varied in accordance with the mean level of household SI content in the country surveys. The UIC portions and all-salt-derived iodine intakes found in this study were illustrative of existing differences in national USI legislative frameworks and national salt supply situations between countries. The approach of apportioning the population UIC from spot urine collections may be useful for future monitoring of change in iodine nutrition from reduced salt use in processed foods and in households.

Nutritional status of cancer outpatients using scored patient generated subjective global assessment in two cancer treatment centers, Nairobi, Kenya.

BACKGROUND: Malnutrition is a universal problem in cancer patients renowned as an important factor for increased morbidity, decreased quality of life and high mortality. Early diagnosis of malnutrition risk through nutrition screening followed by comprehensive and timely interventions reduces mortality associated with malnutrition. The Scored Patient-Generated Subjective Global Assessment (PGSGA) method has been proved efficient in identifying cancer patients with nutrition challenges and guiding appropriate interventions. However this tool has not been adopted in management of cancer patients in Kenya. The aim of the study was to assess and describe nutrition status of cancer outpatients receiving treatment at Kenyatta National Hospital Hospital (KNH) and Texas Cancer Centre (TCC). METHODS: The study adopted a hospital based descriptive cross sectional study. Cancer outpatients with confirmed stage 1-4 cancers, physically stable, aged 18 years and above and receiving cancer treatment were recruited and assessed using Scored PGSGA tool. Proportions, measures of central tendency and pearsons' chi-square test were used in statistical analysis. RESULTS: Among the 471 participants assessed, 71.8% were female and 28.2% male. Most participants had stage 2, 3 and 4 cancers at 27.2%, 27.2% and 24.3% respectively. Highest proportion of participants had breast (29.7%) and female genital cancers (22.9%). Sixty nine percent of participants were well nourished (SGA-A), 19.7% moderately malnourished (SGA-B) and 11.3% severely malnourished (SGA-C) and this difference was statistically significant. The mean PGSGA score was 6.76 (SD 5.17). Based on the score, 33.8% of participants required critical nutrition care, 34.8% symptoms management, 14.2% constant nutrition education and pharmacological intervention while 17.2% required routine assessments and reassurance. More (m;54.7%, f; 45.3%) males than females were severely malnourished(SGA-C) and this was statistically significant (P < 0.001).Prevalence of severe malnutrition was highest among participants with digestive organ cancers (49.1%) followed by those with lip cancer (17%) and the least prevalence reported in those with Karposi Sarcoma (0%). Most of stage 4 participants were moderately (37.5%) and severely (29.4%) malnourished. CONCLUSIONS: The Scored Patient-Generated Subjective Global Assessment is able to identify cancer patients both at risk of malnutrition and those severely malnourished. It also provides a guideline on the appropriate nutrition intervention hence an important tool in nutrition management of cancer patients.

Food Insecurity and Not Dietary Diversity Is a Predictor of Nutrition Status in Children within Semiarid Agro-Ecological Zones in Eastern Kenya.

Machakos and Makueni counties in Kenya are associated with historical land degradation, climate change, and food insecurity. Both counties lie in lower midland (LM) lower humidity to semiarid (LM4), and semiarid (LM5) agroecological zones (AEZ). We assessed food security, dietary diversity, and nutritional status of children and women. Materials and Methods. A total of 277 woman-child pairs aged 15-46 years and 6-36 months respectively, were recruited from farmer households. Food security and dietary diversity were assessed using standard tools. Weight and height, or length in children, were used for computation of nutritional status. Findings. No significant difference (P > 0.05) was observed in food security and dietary diversity score (DDS) between LM4 and LM5. Stunting, wasting, and underweight levels among children in LM4 and LM5 were comparable as were BMI scores among women. However, significant associations (P = 0.023) were found between severe food insecurity and nutritional status of children but not of their caregivers. Stunting was significantly higher in older children (>2 years) and among children whose caregivers were older. Conclusion. Differences in AEZ may not affect dietary diversity and nutritional status of farmer households. Consequently use of DDS may lead to underestimation of food insecurity in semiarid settings.

Prevalence of metabolic syndrome among an urban population in Kenya.

OBJECTIVE: Developing countries are undergoing an epidemiologic transition accompanied by increasing burden of cardiovascular disease (CVD) linked to urbanization and lifestyle modifications. Metabolic syndrome is a cluster of CVD risk factors whose extent in Kenya remains unknown. The aim of this study was to determine the prevalence of metabolic syndrome and factors associated with its occurrence among an urban population in Kenya. RESEARCH DESIGN AND METHODS: This was a household cross-sectional survey comprising 539 adults (aged ≥18 years) living in Nairobi, drawn from 30 clusters across five socioeconomic classes. Measurements included waist circumference, HDL cholesterol, triacylglycerides (TAGs), fasting glucose, and blood pressure. RESULTS: The prevalence of metabolic syndrome was 34.6% and was higher in women than in men (40.2 vs. 29%; P < 0.001). The most frequently observed features were raised blood pressure, a higher waist circumference, and low HDL cholesterol (men: 96.2, 80.8, and 80%; women: 89.8, 97.2, and 96.3%, respectively), whereas raised fasting glucose and TAGs were observed less frequently (men: 26.9 and 63.3%; women: 26.9 and 30.6%, respectively). The main factors associated with the presence of metabolic syndrome were increasing age, socioeconomic status, and education. CONCLUSIONS: Metabolic syndrome is prevalent in this urban population, especially among women, but the incidence of individual factors suggests that poor glycemic control is not the major contributor. Longitudinal studies are required to establish true causes of metabolic syndrome in Kenya. The Kenyan government needs to create awareness, develop prevention strategies, and strengthen the health care system to accommodate screening and management of CVDs.