Antiretroviral drug adherence by HIV infected children attending Kericho District Hospital, Kenya.

OBJECTIVE: To determine ARV drug adherence levels in children (aged 3 to 14 years) attending Kericho District Hospital (KDH), Kenya. METHODS: A cross-sectional design was used to collect data from a random sample of caregivers of 230 children on ARVs for a study period of six months (i.e. 1st August 2010 to 31st January 2011). The study population comprised HIV infected children on ARVs and their caregivers. The caregivers whose children met the selection criteria were selected. A structured pre-tested, interviewer-administered questionnaire was used to interview the caregivers of the HIV infected children who were selected from among those who took the children for treatment. The interview was continued on the consecutive caregivers until the sample of 230 children was attained. The key variables examined were; demographic information of caregivers and children and drug adherence levels. Measures of adherence included; drug/pill counting and estimate of volumes of syrup remaining from the last prescription, caregiver reports (on keeping clinic appointments and timing of taking ARVs by the child), and drug refill data (from pharmacy records). Data was analyzed using SPSS version 12.0.1 with statistical significance set at P < 0.05. RESULTS: The adherence levels based on time of taking ARV drugs was 56.1%, keeping clinic appointments 45.7%, No ARVs returned (i.e. took all drugs assessed through pill counts) 27%, and pharmacy drug refill was 47.8%. The overall average adherence level was suboptimal at 44.2%. It was recommended that caregivers of the HIV infected children should be educated on importance of strict adherence to prescribed doses of ARVs to the children. Future research should explore using multiple measures of adherence and reasons for non-adherence among HIV infecting children. CONCLUSION: The drug adherence level was sub-optimal.

Injuries from interpersonal violence presenting to a rural health center in Western Kenya: characteristics and correlates.

OBJECTIVE: To define the scope of injury due to interpersonal violence in a medium-sized town in Western Kenya. DESIGN: Prospective, cross-sectional data collection and analysis. SETTING/SUBJECTS: Data were prospectively collected on all injured patients (n = 562) presenting to a health center in Western Kenya, 2002-2004. Age, gender, type, and severity of injury, relationship to assailant, disposition, and clinician's suspicion of alcohol use were recorded. MAIN OUTCOME MEASURES: Number of injuries due to interpersonal violence; correlation of gender, alcohol use, relationship to assailant, and type of injury. RESULTS: Interpersonal violence caused 43% of all injuries. Men and women were equally likely to suffer violent injuries (42% vs 45%); however, women were more likely to suffer injury from domestic violence (4.7% vs 7.0%) and sexual assault (0% vs 3.5%). Men and women were equally likely to know their assailant. Women were more likely to be injured by a spouse/partner (19% vs 1.3%), whereas men were more likely to be injured by an acquaintance (29% vs 16%). Alcohol use was more often suspected for victims of violent, as opposed to unintentional, injury (45% vs 16%). Men with violent injuries were more likely than women to be suspected of having used alcohol (51% vs 35%). CONCLUSIONS: Interpersonal violence is a leading cause of injury in Western Kenya. Although men and women are equally likely to be assaulted, women are more likely to be injured by a spouse, and men by an acquaintance. Alcohol use is common among those who suffer violent injuries in this population.

Characteristics of injuries presenting to a rural health centre in western Kenya.

OBJECTIVES: To describe characteristics of injuries among patients presenting to a rural health centre in western Kenya, and identify the associated risk factors. DESIGN: A retrospective descriptive study. SETTING: A primary care Ministry of Health Rural Health Centre in western Kenya. RESULTS: Of the 315 injured patients, 62% were males and 38% females. Young adults aged 15-44 years were the most affected, comprising 63.5%. The five most common causes of injury were struck by object (36.6%), assault (34.4%), falls (11.6%), burns (6.2%) and road traffic accidents (4.7%). Quarrels and fights were the leading reasons for assaults among males (69.5%) and females (44.4%). Most injuries occurred at work (36.2%), when subjects were engaged in vital activities (19.5%) or during play/leisure time (19.2%). A third of injured adults aged 15 years and above had consumed alcohol prior to the injury event. Alcohol use was significantly associated with assaults (51.3%) than all other causes of injury (OR=4.51, p<0.0001). CONCLUSION: The pattern and certain risk factors for non-fatal injuries among patients attending a rural health centre, such as place of occurrence, activity and alcohol use, can be identified through a facility-based electronic injury surveillance system. The information can be used to develop context-specific injury prevention interventions in the community.

Alcohol abuse among patients with and without HIV infection attending public clinics in western Kenya.

OBJECTIVE: To evaluate the prevalence of hazardous drinking among persons with and without HIV/AIDS attending both urban/hospital-based and rural clinics in western Kenya. DESIGN: Cross sectional survey. SETTING: The Moi Teaching and Referral Hospital and the Mosoriot rural health care Centre. SUBJECTS: Two hundred and ninety nine adults with and without HIV/AIDS at a teaching and referral hospital and rural health centre. MAIN OUTCOME MEASURES: Results of the World Health Organization's Alcohol Use Disorders Identification Test (AUDIT) where a score of > 8 is indicative of hazardous alcohol consumption. Independent correlates of hazardous drinking were identified using logistic regression analysis including adjustment for common covariables. RESULTS: Study participants were relatively young (38 +/- 9 years) with 55% being male and 54% completing the AUDIT in Kiswahili. Home-made alcohol was more commonly drunk by patients attending the rural health centre while commercial beer was more commonly drunk by patients attending the teaching and referral hospital clinics. Approximately half (54%) of participants reported hazardous drinking behaviour (AUDIT score=9.9 +/- 9.4). Hazardous drinking was most prevalent among men attending the rural health centre (83% hazardous drinkers, AUDIT score=16.0 +/- 9.1). In multivariable analyses adjusting for age, sex and site of care, men remained more than nine times (odds ratio=9.3, 95% C.I.=5.1-16.9) likely to report hazardous drinking behaviour compared to women. CONCLUSIONS: Hazardous drinking is common among patients with and without HIV/ AIDS in western Kenya and is dramatically more common among rural men than women. Effective interventions for HIV/AIDS in this setting must include a concetrated effort to reduce hazardous drinking.

Knowledge, attitudes, and practices of private medical practitioners on tuberculosis among HIV/AIDS patients in Eldoret, Kenya.

BACKGROUND: Tuberculosis (TB) is one of the major communicable diseases afflicting mankind today. Its prevalence is increasing with increase in HIV infection. It is important that doctors be able to correctly diagnose and institute proper management of patients with TB. OBJECTIVES: To determine the knowledge, attitudes, and practices (KAP) of private medical practitioners in Eldoret on the management of TB. DESIGN: Cross-sectional descriptive qualitative study. SETTING: Private medical practitioners' clinics and the outpatient departments of private hospitals in Eldoret town, western, Kenya. Eldoret is a cosmopolitan town 350-km north west of Nairobi. It is the main town in the north Rift Valley with such infrastructure as roads, international airport, and banks. SUBJECTS: Private medical practitioners in Eldoret. RESULTS: Fifty three out of 70 private doctors were interviewed. Of these 84.9% were male. Only 5.7% knew that sputum for AAFBs is collected on spot, early morning, and spot, whereas 69.8% and 13.2% said it should be collected on three and six consecutive early mornings respectively. Sputum and chest X-ray were the most common investigations used to diagnose TB. Few doctors knew that the clinical features considered as suspicious for TB in children were failure to thrive (FTT) (20.6%), contact with open TB case (12.8%), and cough for more than two or more weeks (7.8%). Others wrongly considered cough for four or more weeks (9.2%). Features correctly considered of diagnostic value by a few of the private doctors in paediatric TB were: chest X-ray (19.8%), FTT (8.7%), positive sputum for AAFBs (8.7%), and history of contact with TB case (8.7%). A small number of doctors based their diagnosis on chest X-ray (38%), AAFBs (19%), and Keith-Jones criteria (6.3%). There were 16 regimes mentioned and used for the treatment of TB. The NLTP recommended regimes such as 2RHZ/4RH, 2RHZE/6HE, 2RHZ/6HE and 2SHRZE/1RHZE/5HRE, were used by 9(19.6%), 2(4.3%), 0% and 0% of the doctors respectively. The rest used unrecommended regimes and no doctor used the re-treatment regime of 2SHRZE/1RHZE/5RHE. Similar regimes were used for the HIV as for the non-HIV-infected patients. None of the interviewees had appropriate knowledge on all the areas of diagnosis, treatment, case recording, and follow up. CONCLUSION: Most doctors were not aware of the correct diagnosis and treatment of TB and many used unrecommended treatment regimes. They were generally unfamiliar with the recording system of TB cases. Most doctors did not know the definitions of the various re-treatment cases. Continuing medical education on clinical management of TB patients is needed for doctors in private practice.

The MOSORIOT medical record system (MMRS) phase I to phase II implementation: an outpatient computer-based medical record system in rural Kenya.

The authors of this paper describe the second phase of the implementation of the Mosoriot Medical Record System (MMRS) in a remote health care facility on the outskirts of Eldoret, Kenya, located in sub-Saharan Africa. We describe of the collaboration between Indiana University (IU) and the Moi University (MU), and the process that led to the development of the computer-based Mosoriot Medical Record System (MMRS) is provided. We then provide the conceptualization and initial implementation of this basic electronic medical record system. We also describe the different processes for assessing the MMRS' effects on health care, including time-motion studies and a strict implementation plan that is necessary for the successful implementation of the system. The MMRS project has many features that make it significant in the domain of CBPR systems. It may serve as a model for establishing similar, basic electronic record systems in the developed and developing world. In developing countries there are few (if any) projects that have attempted to implement such a system. This paper describes the planning, end-user education to new technologies, and time-motion studies necessary for the successful implementation of the MMRS. The system will be used to improve the quality of health data collection and subsequently patient care. It will also be used to link data from ongoing public health surveys and this can be used in public health research programs of the Moi University.

Major obstetric interventions among encamped refugees and the local population in Turkana District, Kenya.

BACKGROUND: Maternal mortality in developing countries remains high due to lack of appropriate emergency obstetric care. Major obstetric intervention (MOI) rate can be used as an indicator of unmet obstetric needs and quality of care. OBJECTIVES: Identify indications for major obstetric interventions, determine MOI rates and assess extent of unmet obstetric need for women in Turkana district, Kenya. DESIGN: Descriptive bi-directional study. SETTING: Turkana district: Kakuma Refugee Camp, Kakuma Catholic Mission and Lodwar District Hospitals. SUBJECTS: Four thousand two hundred and eighty encamped refugee women and 7,630 women from the host population delivering in Turkana district between January 1995 and September 1999. DATA SOURCES: Maternity registers, inpatient case notes and theatre registers. MAIN OUTCOME MEASURES: Maternal mortality, perinatal mortality, major obstetric interventions, unmet obstetric need and length of stay. RESULTS: The subjects from the two study populations were similar with respect to age, parity and indications for surgical intervention. Caesarean section was the only major obstetric intervention. Overall, caesarean section rate was significantly higher among refugees than in the host population (3.1% versus 2.1%, p<0.01; CI 1.4-2.1). Maternal indications were the main reasons for c/s in both populations, with the c/s rate being higher for refugees than for local women (2.5% versus 1.7%). At least 0.8% of parturient women from the host population had unmet obstetric needs: this translates to 61 pregnant women who may have died or experienced birth-related complications over the study period. The mean length of hospital stay was much less for refugee women than for the host population (8.1 days versus 11.3 days). CONCLUSION: Encamped refugee women in Kakuma have better obstetric care than those from the host population, and the level of unmet obstetric needs in the district is high. This imbalance could be reduced through resource sharing and integration of refugee health care services with that for the host population.

The Mosoriot medical record system: design and initial implementation of an outpatient electronic record system in rural Kenya.

Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Kenya in sub-Saharan Africa. The region is characterised by widespread poverty and a very poor technology infrastructure. Many houses do not have electricity, telephones or tap water. The health center does have electricity and tap water. In a collaborative project between Indiana University and the Moi University Faculty of Health Sciences (MUFHS), we designed a core electronic medical record system within the Mosoriot Health Center, with the intention of improving the quality of health data collection and, subsequently, patient care. The electronic medical record system will also be used to link clinical data from the health center to information collected from the public health surveys performed by medical students participating in the public health research programs of Moi University. This paper describes the processes involved in the development of the computer-based Mosoriot medical record system (MMRS) up to the point of implementation. It particularly focuses on the decisions and trade-offs that must be made when introducing this technology into an established health care system in a developing country.

An evaluation of sensitivity and specificity of blood alcohol concentrations obtained by a breathalyser survey in a casualty department in Kenya.

Whereas breathalysers have been shown to provide blood alcohol concentration (BAC) measurements comparable to those obtained by gas chromatography, such evidence has not been reported in low and middle income countries where measures for preventing alcohol-related injuries are virtually non-existent. Before promoting any method of blood alcohol evaluation, as a routine procedure for monitoring the association of alcohol with different types of injuries in Kenya, we sought to assess the reliability and validity of blood alcohol results obtained by a breathalyser, using gas chromatography analysis values as the reference, in a sample of 179 trauma-affected adults presenting to casualty departments. No differences in proportions of subjects with high levels of blood alcohol (equal to or greater than 50 mg%) were detected by breath and blood test procedures (58.7 vs 60.3%). Breathalyser readings yielded high levels of sensitivity and specificity (97.2 and 100%, respectively) with optimal positive and negative predictive values (100 and 95.9%, respectively) at higher BACs (> or = 50 mg%). The study thus reaffirms that breathalyser tests are of value in detecting high blood alcohol levels and can be used to rapidly identify intoxicated subjects. The procedure is easy to perform and can be used for monitoring the association between blood alcohol level and driving in low-income developing countries.

Alcohol-related road traffic injuries in Eldoret, Kenya.

OBJECTIVE: To establish the extent of alcohol involvement in motor vehicle crashes occurring in Eldoret in western Kenya. DESIGN: A descriptive hospital-based study. SETTING AND SUBJECTS: Crash-involved patients aged 16 years and above presenting for treatment in all hospitals located in Eldoret town over a period of six months. METHODS: Casualties were enrolled consecutively. A questionnaire eliciting demographics and crash circumstances was administered. Blood alcohol concentration (BAC) was evaluated either by breath tests or venous blood sample analysis in consenting casualties presenting within 10 hours of the crash. BAC levels of 5 mg% and greater were taken as a positive test; patients registering BAC levels equal to or greater than 50 mg% were considered as being intoxicated. RESULTS: Of the 188 patients evaluated, 23.4% were BAC positive and 12.2% were intoxicated. Males were twice as likely as females to have been drinking prior to the crash (26.4% versus 13.6%; p = 0.08). Significantly greater proportions of night-time and weekend crashes involved intoxicated subjects (p = 0.02 and p = 0.03, respectively). Motor vehicle drives were the most affected by alcohol (60%), whereas pedestrians (33.3%), passengers (16%) and pedal cyclists (8.3%) were involved to a lesser extent. In comparison to passengers, drivers were eight times more likely to have been drinking (OR = 7.9, p = 0.04). CONCLUSIONS: Alcohol is a contributing factor in a substantial proportion of traffic crashes occurring in western Kenya. Policy response and specific interventions for discouraging driving under the influence of alcohol, including the establishment and enforcement of a legal BAC limit are needed.

Road traffic injuries in developing countries: a comprehensive review of epidemiological studies.

Motor vehicle accidents are the leading cause of death in adolescents and young adults worldwide. Nearly three-quarters of road deaths occur in developing countries and men comprise a mean 80% of casualties. This review summarizes studies on the epidemiology of motor vehicle accidents in developing countries and examines the evidence for association with alcohol.

Drinking and driving in an urban setting in Kenya.

A roadside alcohol prevalence survey of drivers randomly selected from the general traffic was conducted in Eldoret, Kenya. Blood alcohol concentration (BAC) data obtained by a breath test in 90% of the sample (n = 479) was analysed by demographic and travel characteristics. 19.9% had a positive breath test (BAC > or = 5 mg%), 8.4% had BACs greater than 50 mg%, and 4% exceeded 80 mg%. A greater proportion of males (20%) had been drinking compared to females (12.5%): all drivers with high BACs (> or = 50 mg%) were males. The likelihood of having consumed alcohol was greater in motorists aged 25 years and above (20.4%) than in younger drivers aged 16-24 years (15.4%), their mean BACs were also more elevated (57 mg% versus 31 mg%). In comparison to operators of public service vehicles (PSV), people driving personal cars were more than twice as likely to have been drinking: with 21.9% being BAC positive against 10.8% (OR = 2.3; 95% CI, 1.0 to 6.3, p = 0.05). Educated individuals with skilled careers tended to indulge in drink-driving to a greater extent than professional drivers (operators of public transport, taxi and heavy goods vehicles), with BAC prevalence rates of 23.7% and 15.5%, respectively. Other circumstances influencing the probability of drink-driving were number of vehicle occupants, distance to destination, road location, time of the night and whether it was a weekend or weekday. These findings are discussed in relation to the potential for promotion of relevant deterrent measures, including the establishment of an appropriate BAC legal limit for drivers in Kenya.

Incidence and characteristics of injuries in Eldoret, Kenya.

Injuries are a major cause of mortality, morbidity and disability. They have been recognized worldwide as a serious public health problem. The epidemiology of injuries in Kenya is however poorly documented and specific programmes for their surveillance and prevention have not been established. This study aimed at examining the incidence and causes of trauma, their relationships with demographic characteristics as well as hospital utilization. It was a prospective hospital based survey over a three month period in which trauma victims presenting to hospitals located within Eldoret town were enrolled. A total of 1304 casualties were registered of whom 71% were males and 29% females. The most vulnerable groups were males and young adults aged between 20 and 30 years. Exposure during night-time and weekends in addition to alcohol intoxication all had a significant influence on the incidence. Assaults were the leading cause of injuries being responsible for 40%. Road traffic accidents (RTAs) accounted for 18%, falls 17%, burns 3% and dog bites 3%. 16.5% of the victims aged above 15 years, who were examined within 12 hours of injury had taken alcohol. 25% of the assault victims were alcohol related while this was 10% amongst road traffic casualties. Passengers in public transport vehicles were most involved in RTAs. They comprised 56% whereas bicyclists, pedestrians and drivers accounted for 15%, 14%, 8% respectively. 80% of the casualties were treated as outpatients while 20% were admitted. The mean length of stay was seven days. Twelve patients died. The use of operating theatres was required in only eleven cases, while X-rays were indicated in nearly one third of the victims. The implications of these findings, with regard to the formulation of injury prevention strategies are discussed.

Road traffic accidents in Kenya: an epidemiological appraisal.

A descriptive analysis of road traffic accident (RTA) and injury data in Kenya was done using routine accident reports, official statistical abstracts, published and unpublished surveys. The characteristics of injury-producing accidents examined included trends, distribution patterns, risk factors, types of vehicles involved, and road-users injured or killed. The numbers killed increased by 578%, while non-fatal casualties rose by 506% between 1962 and 1992. Fatality rate per 10,000 vehicles increased from 50.7 to 64.2, while fatality per 100,000 population ranged between 7.3 and 8.6. 66% of the accidents occurred during daytime. 60% of the reported RTAs occurred on rural roads and had a higher case fatality rate (CFR) of 16% compared to those occurring in urban areas (11%). Human factors were responsible for 85% of all causes. Vehicle-pedestrian collisions were most severe and had the highest CFR of 24%, while only 12% of injuries resulting from vehicle-vehicle accidents were fatal. Utility vehicles, 'matatus' and buses were involved in 62% of the injury producing accidents. Of all traffic fatalities reported, pedestrians comprised 42%, passengers 38%, drivers 12%, and cyclists 8%. The high pedestrian and passenger deaths imply the need to investigate the underlying risk factors, operational and policy issues involved in the transport system, and to develop and implement appropriate responsive road safety interventions.