A cross-sectional survey on the effectiveness of public health campaigns for changing knowledge, attitudes, and practices in Kenyan informal settlements during the COVID-19 pandemic.

We performed two cross-sectional surveys across three informal settlements in Kenya (within Kisii county, Nairobi, and Nakuru county) to study the effectiveness of public health interventions during the COVID-19 pandemic. A total of 720 participants were surveyed from 120 randomly selected geographical locations (240 participants/settlement/survey), and a coordinated health promotion campaign was delivered between the two surveys by trained staff. Information relating to knowledge, attitudes, and practices (KAP) were collected by trained field workers using a validated questionnaire. The main outcomes showed improvements in: (i) mask-wearing (% of participants 'Always' using their mask increased from 71 to 74%, and the percentage using their masks 'Sometimes' decreased from 15% to 6%; p<0.001); (ii) practices related to face mask usage (% of subjects covering the mouth and nose increased from 91 to 95%, and those covering only part of their face decreased from around 2.5% to <1%; p<0.001). Significant improvements were also seen in the attitudes and expectations relating to mask wearing, and in the understanding of government directives. Over 50% of subjects in the post-campaign survey reported that social distancing was not possible in their communities and fears associated with COVID-19 testing were resistant to change (unchanged at 10%). Access to COVID-19 testing facilities was limited, leaving a large proportion of people unable to test. As willingness to take a COVID-19 test did not change between surveys (69 vs 70%; p = 0.57), despite increased availability, we recommend that policy level interventions are needed, aimed at mitigating adverse consequences of a positive test. Improvements of KAPs in the more crowded urban environment (Nairobi) were less than at settlements in rural or semi-urban settings (Nakuru and Kisii). We conclude that coordinated public health campaigns are effective in facilitating the change of KAPs amongst people living amidst challenging socio-economic conditions in informal settlements.

Sub-Standard Pharmaceutical Services in Private Healthcare Facilities Serving Low-Income Settlements in Nairobi County, Kenya.

Background: Quality pharmaceutical services are an integral part of primary healthcare and a key determinant of patient outcomes. The study focuses on pharmaceutical service delivery among private healthcare facilities serving informal settlements within Nairobi County, Kenya and aims at understanding the drug procurement practices, task-shifting and ethical issues associated with drug brand preference, competition and disposal of expired drugs. Methods: Forty-five private facilities comprising of hospitals, nursing homes, health centres, medical centres, clinics and pharmacies were recruited through purposive sampling. Structured electronic questionnaires were administered to 45 respondents working within the study facilities over an 8-week period. Results: About 50% of personnel carrying out drug procurement belonged to non-pharmaceutical cadres namely; doctors, clinical officers, nurses and pharmacy assistants. Drug brand preferences among healthcare facilities and patients were mainly pegged on perceived quality and price. Unethical business competition practices were recorded, including poor professional demeanour and waiver of consultation fees veiled to undercut colleagues. Government subsidized drugs were sold at 100% profit in fifty percent of the facilities stocking them. In 44% of the facilities, the disposal of expired drugs was not in conformity to existing government regulatory guidelines. Conclusions: There is extensive task-shifting and delegation of pharmaceutical services to non-pharmaceutical cadres and poor observance of ethical guidelines in private facilities. Strict enforcement of regulations is required for optimal practices.

Medicine Prices, Availability, and Affordability in Private Health Facilities in Low-Income Settlements in Nairobi County, Kenya.

Medicine prices are a major determinant of access to healthcare. Owing to low availability of medicines in the public health facilities and poor accessibility to these facilities, most low-income residents pay out-of-pocket for health services and transport to the private health facilities. In low-income settlements, high retail prices are likely to push the population further into poverty and ill health. This study assessed the retail pricing, availability, and affordability of medicines in private health facilities in low-income settlements within Nairobi County. Medicine prices and availability data were collected between September and December 2016 at 45 private healthcare facilities in 14 of Nairobi's low-income settlements using electronic questionnaires. The International Medical Products Price Guide provided international medicine reference prices for comparison. Affordability and availability proxies were calculated according to existing methods. Innovator brands were 13.8 times more expensive than generic brands. The lowest priced generics and innovator brands were, on average, sold at 2.9 and 32.6 times the median international reference prices of corresponding medicines. Assuming a 100% disposable income, it would take 0.03 to 1.33 days' wages for the lowest paid government employee to pay for treatment courses of selected single generic medicines. Medicine availability in the facilities ranged between 2% and 76% (mean 43%) for indicator medicines. Prices of selected medicines varied within the 14 study regions. Retail medicine prices in the low-income settlements studied were generally higher than corresponding international reference prices. Price variations were observed across different regions although the regions comprise similar socioeconomic populations. These factors are likely to impact negatively on healthcare access.

The quality of anti-malarial medicines in Embu County, Kenya.

BACKGROUND: Malaria is a major health problem in sub-Saharan Africa where over 90% of the world's malaria cases occur. Artemisinin-based combination therapy (ACT) is recommended by the World Health Organization as first-line and second-line treatments for uncomplicated falciparum malaria. However, there are a growing number of reports of sub-standard and falsified anti-malarial medicines in sub-Saharan Africa. METHODS: A cross-sectional study was conducted in Embu County, Kenya on the quality of anti-malarial medicines available in public and private facilities. Sampling of anti-malarial medicines from public and private hospitals, health centers and pharmacies was conducted between May and June 2014. Quality control tests were performed at the Drug Analysis and Research Unit, University of Nairobi, using ultraviolet spectrophotometry and high-performance liquid chromatography. A test for microbial load was also conducted for suspension formulations. RESULTS: A total of 39 samples were collected from public and private facilities across the Embu County. A visual inspection of the medicines showed no signs of sub-standard or falsification. All ACT passed identification, assay and dissolution tests. Of 11 suspension samples collected, none failed the microbial load test although one sample had 50 colony forming units (cfu). No oral artemisinin monotherapy medicines were encountered during the survey. Amodiaquine and chloroquine monotherapy products accounted for 5% of the collected samples, despite their ban in Kenya. Two herbal anti-malarial formulations were collected during the survey. Sulfadoxine/pyrimethamine (SP) was also found to be available use for malaria treatment, not in accordance with malaria treatment guidelines. CONCLUSION: All the anti-malarial drugs analysed in this study passed the quality control tests. This is encouraging given the high malaria burden in Kenya. Regulatory actions are required to counter SP and herbal products for malaria treatment.

The Medical Education Partnership Initiative (MEPI): Innovations and Lessons for Health Professions Training and Research in Africa.

MEPI was a $130 million competitively awarded grant by President's Emergency Plan for AIDS Relief (PEPFAR) and National Institutes of Health (NIH) to 13 Medical Schools in 12 Sub-Saharan African countries and a Coordinating Centre (CC). Implementation was led by Principal investigators (PIs) from the grantee institutions supported by Health Resources and Services Administration (HRSA), NIH and the CC from September, 2010 to August, 2015. The goals were to increase the capacity of the awardees to produce more and better doctors, strengthen locally relevant research, promote retention of the graduates within their countries and ensure sustainability. MEPI ignited excitement and stimulated a broad range of improvements in the grantee schools and countries. Through in-country consortium arrangements African PIs expanded the programme from the 13 grantees to over 60 medical schools in Africa, creating vibrant South-South and South-North partnerships in medical education, and research. Grantees revised curricular to competency based models, created medical education units to upgrade the quality of education and established research support centres to promote institutional and collaborative research. MEPI stimulated the establishment of ten new schools, doubling of the students' intake, in some schools, a three-fold increase in post graduate student numbers, and faculty expansion and retention.Sustainability of the MEPI innovations was assured by enlisting the support of universities and ministries of education and health in the countries thus enabling integration of the new programs into the regular national budgets. The vibrant MEPI annual symposia are now the largest medical education events in Africa attracting global participation. These symposia and innovations will be carried forward by the successor of MEPI, the African Forum for Research and Education in Health (AFREhealth). AFREhealth promises to be more inclusive and transformative bringing together other health professionals including nurses, pharmacists, and dentists.

Detection of counterfeit brand spirits using 1H NMR fingerprints in comparison to sensory analysis.

Beverage fraud involving counterfeiting of brand spirits is an increasing problem not only due to deception of the consumer but also because it poses health risks e.g. from possible methanol admixture. Suspicious spirit samples from Russia and Kenya were analysed using 1H nuclear magnetic resonance (NMR) spectroscopy in comparison to authentic products. Using linear regression analysis of spectral integral values, 4 counterfeited samples from Russia and 2 from Kenya were easily identifiable with R2 < 0.7. Sensory analysis using triangle test methodology confirmed significant taste differences between counterfeited and authentic samples but the assessors were unable to correctly identify the counterfeited product in the majority of cases. An important conclusion is that consumers cannot assumed to be self-responsible when consuming counterfeit alcohol because there is no general ability to organoleptically detect counterfeit alcohol.

High Ethanol Contents of Spirit Drinks in Kibera Slums, Kenya: Implications for Public Health.

Cheap licit and artisanal illicit spirit drinks have been associated with numerous outbreaks of alcohol poisoning especially with methanol. This study aimed to evaluate the quality of cheap spirit drinks in Kibera slums in Nairobi County, Kenya. The samples consisted of cheap licit spirits (n = 11) and the artisanal spirit drink, 'chang'aa', (n = 28). The parameters of alcoholic strength and volatile composition were used as indicators of quality and were determined using gas chromatography with flame ionization detection (GC-FID) and gas chromatography-mass spectrometry (GC-MS) respectively. The ranges for alcoholic strength were 42.8-85.8% vol and 28.3-56.7% vol for chang'aa and licit spirit drinks respectively, while the pH ranges were 3.3-4.2 and 4.4-4.8 for chang'aa and licit spirit drinks respectively. The majority of volatiles were found in artisanal spirits and they included higher alcohols, ethyl esters and carbonyl compounds. The alcoholic strength of all the artisanal spirits (100%) and 91% of the licit spirits was above the 40% vol of standard spirits such as vodka. The high ethanol content of the alcohol products was the only element of public health significance in this study.

Building capacity in implementation science research training at the University of Nairobi.

BACKGROUND: Health care systems in sub-Saharan Africa, and globally, grapple with the problem of closing the gap between evidence-based health interventions and actual practice in health service settings. It is essential for health care systems, especially in low-resource settings, to increase capacity to implement evidence-based practices, by training professionals in implementation science. With support from the Medical Education Partnership Initiative, the University of Nairobi has developed a training program to build local capacity for implementation science. METHODS: This paper describes how the University of Nairobi leveraged resources from the Medical Education Partnership to develop an institutional program that provides training and mentoring in implementation science, builds relationships between researchers and implementers, and identifies local research priorities for implementation science. RESULTS: The curriculum content includes core material in implementation science theory, methods, and experiences. The program adopts a team mentoring and supervision approach, in which fellows are matched with mentors at the University of Nairobi and partnering institutions: University of Washington, Seattle, and University of Maryland, Baltimore. A survey of program participants showed a high degree satisfaction with most aspects of the program, including the content, duration, and attachment sites. A key strength of the fellowship program is the partnership approach, which leverages innovative use of information technology to offer diverse perspectives, and a team model for mentorship and supervision. CONCLUSIONS: As health care systems and training institutions seek new approaches to increase capacity in implementation science, the University of Nairobi Implementation Science Fellowship program can be a model for health educators and administrators who wish to develop their program and curricula.

Use of mobile learning technology among final year medical students in Kenya.

INTRODUCTION: Mobile phone penetration has increased exponentially over the last decade as has its application in nearly all spheres of life including health and medical education. This study aimed at assessing the use of mobile learning technology and its challenges among final year undergraduate students in the College of Health sciences, University of Nairobi. METHODS: This was a cross-sectional descriptive study conducted among final year undergraduate students at the University of Nairobi, College of Health Sciences. Self-administered, anonymous questionnaires were issued to all final year students in their lecture rooms after obtaining informed consent. Data on demographics, mobile device ownership and mobile learning technology use and its challenges was collected. Data entry and analysis was done using SPSS(®). Chi-square and t-test were used for bivariate analysis. RESULTS: We had 292 respondents; 62% were medical students, 16% were nursing students, 13% were pharmacy students and 9% were dental surgery students. The majority were female (59%) and the average age was 24 years. Eighty eight percent (88%) of the respondents owned a smart device and nearly all of them used it for learning. 64% of the respondents used medical mobile applications. The main challenges were lack of a smart device, lack of technical know-how in accessing or using apps, sub-optimal internet access, cost of acquiring apps and limited device memory. CONCLUSION: Mobile learning is increasingly popular among medical students and should be leveraged in promoting access and quality of medical education.

A strategy to improve skills in pharmaceutical supply management in East Africa: the regional technical resource collaboration for pharmaceutical management.

BACKGROUND: International initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the President's Emergency Plan for AIDS Relief and the President's Malaria Initiative have significantly increased availability and access to medicines in some parts of the developing world. Despite this, however, skills remain limited on quantifying needs for medications and ordering, receiving and storing medications appropriately; recording medications inventories accurately; distributing medications for use appropriately; and advising patients on how to use medications appropriately. The Regional Technical Resource Collaboration for Pharmaceutical Management (RTRC) has been established to help address the problem of skills shortage in pharmaceutical management in East Africa. METHODS: The initiative brings together academic institutions from four East African countries to participate in skills-building activities in pharmaceutical supply management. The initiative targeted the institutions' ability to conduct assessments of pharmaceutical supply management systems and to develop and implement effective skills-building programmes for pharmaceutical supply chain management. RESULTS: Over a two-year period, the RTRC succeeded in conducting assessments of pharmaceutical supply management systems and practices in Kenya, Rwanda, Tanzania and Uganda. In 2006, the RTRC participated in a materials-development workshop in Kampala, Uganda, and contributed to the development of comprehensive HIV/AIDS pharmaceutical management training materials; these materials are now widely available in all four countries. In Tanzania and Uganda the RTRC has been involved with the training of health care workers in HIV/AIDS pharmaceutical management. In Kenya, Tanzania and Uganda the RTRC has been conducting operations research to find solutions to their countries' skills-shortage problems. Some of the interventions tested include applying and evaluating the effectiveness of a novel skills-building approach for pharmaceutical supply management. CONCLUSION: Nurturing collaboration between regional institutions in resource-limited countries to build in-country skills in pharmaceutical supply management appears to be an effective intervention. Support from local programmes and technical assistance from organizations and institutions with the necessary expertise is critical for success, particularly at inception. The skills acquired by local institutions can be incorporated into both pre-service and in-service teaching curricula. This ensures long-term availability of skills in-country. The ability of trained institutions to mobilize their own resources for skills-building activities is crucial for the success and sustainability of these programmes.