Sustainability drivers and inhibitors for the health system performance improvement projects in selected health facilities in Kenya: a qualitative study.

OBJECTIVES: To investigate the health managers perceived sustainability status of the health facilities institutional improvement projects and their experiences on factors that facilitated or constrained their maintenance, with intentions of informing relevant strategies or policies in Kenya's health sector. METHODS: A qualitative study, nested within a quasi-experimental study. Thirty-three project-teams of health managers were purposively selected and interviewed based on their project implementation success rates post-training. The managers had previously undergone a 9-month leadership training, complimented with facility-based team coaching around the chosen projects. The training was funded by the US Agency for International Development; however, the implementation of the projects was based on how the participants could innovatively use the existing resource to create a positive change. The projects were housed within 20 public, 9 faith-based and 4 private health facilities in 19 counties in Kenya. The interviews explored the manager's experiences in sustaining the successfully implemented projects within the (24-60 months post-training period). We asked managers to describe factors they perceived enabled or hindered the sustainability of the successfully implemented institutional improvement project. The digitally audio-recorded interviews were transcribed verbatim. Data on barriers and enablers were thematically analysed. RESULTS: Twenty-nine out of the 33 successfully implemented projects reported sustainability within periods ranging from 24 to 60 months post-training. Seven themes related to drivers of sustainability emerged, namely; programme design, stakeholder's buy-in, board members, communication, coaching, presence of change champion, devolution and political good-will. Four sustainability inhibitors identified were: human resources constraints, policy implementation, misalignment of projects with daily operations, devolution and political interference. CONCLUSIONS: The sustainability of institutional improvement strategies such as projects implemented post-leadership training in public and private health facilities depends on the quality of board members, communication management and institutionalisation of coaching culture. These findings are pertinent for planning and implementing similar health systems strengthening intervention in low-income countries.

Kidney recipients with allograft failure, transition of kidney care (KRAFT): A survey of contemporary practices of transplant providers.

Kidney allograft failure and return to dialysis carry a high risk of morbidity. A practice survey was developed by the AST Kidney Pancreas Community of Practice workgroup and distributed electronically to the AST members. There were 104 respondents who represented 92 kidney transplant centers. Most survey respondents were transplant nephrologists at academic centers. The most common approach to immunosuppression management was to withdraw the antimetabolite first (73%), while only 12% responded they would withdraw calcineurin inhibitor (CNI) first. More than 60% reported that the availability of a living donor is the most important factor in their decision to taper immunosuppression, followed by risk of infection, risk of sensitization, frailty, and side effects of medications. More than half of respondents reported that embolization was either not available or offered to less than 10% as an option for surgical intervention. Majority reported that ≤50% of failed allograft patients were re-listed before dialysis, and less than a quarter of transplant nephrologists performed frequent visits with their patients with failed kidney allograft after they return to dialysis. This survey demonstrates heterogeneity in the care of patients with a failing allograft and the need for more evidence to guide improvements in clinical practice related to transition of care.

Pathology findings and correlation with body condition index in stranded killer whales (Orcinus orca) in the northeastern Pacific and Hawaii from 2004 to 2013.

Understanding health and mortality in killer whales (Orcinus orca) is crucial for management and conservation actions. We reviewed pathology reports from 53 animals that stranded in the eastern Pacific Ocean and Hawaii between 2004 and 2013 and used data from 35 animals that stranded from 2001 to 2017 to assess association with morphometrics, blubber thickness, body condition and cause of death. Of the 53 cases, cause of death was determined for 22 (42%) and nine additional animals demonstrated findings of significant importance for population health. Causes of calf mortalities included infectious disease, nutritional, and congenital malformations. Mortalities in sub-adults were due to trauma, malnutrition, and infectious disease and in adults due to bacterial infections, emaciation and blunt force trauma. Death related to human interaction was found in every age class. Important incidental findings included concurrent sarcocystosis and toxoplasmosis, uterine leiomyoma, vertebral periosteal proliferations, cookiecutter shark (Isistius sp.) bite wounds, excessive tooth wear and an ingested fish hook. Blubber thickness increased significantly with body length (all p < 0.001). In contrast, there was no relationship between body length and an index of body condition (BCI). BCI was higher in animals that died from trauma. This study establishes a baseline for understanding health, nutritional status and causes of mortality in stranded killer whales. Given the evidence of direct human interactions on all age classes, in order to be most successful recovery efforts should address the threat of human interactions, especially for small endangered groups of killer whales that occur in close proximity to large human populations, interact with recreational and commercial fishers and transit established shipping lanes.

From strategy to action: a qualitative study on salient factors influencing knowledge transfer in project-based experiential learning in healthcare organisations in Kenya.

OBJECTIVES: Knowledge transfer is recognised as a key determinant of organisational competitiveness. Existing literature on the transfer of knowledge and skills imply diminutive return on investment in training and development due to the low application of learnt knowledge. Following devolution of health services provision to new counties in Kenya in 2013, Strathmore Business School designed an experiential facility improvement project-based leadership training programme for healthcare managers in the new counties. Selected healthcare management teams participated in the leadership training to improve health systems performance in the devolved counties in Kenya. Despite similar training, the projects implementation contexts were different, leading to different implementation completion rates. The aim of this study was to investigate the reasons for this disparity and then recommend solutions. DESIGN: A qualitative study using semi-structured interviews. A thematic framework approach was used in data analysis. SETTING AND PARTICIPANTS: Thirty-nine projects teams constituting; 33 successful and 6 unsuccessful project teams, were purposively selected based on their project implementation success rates at the end of the leadership training. The managers had undertaken a team-based institutional improvement project. The prioritised projects were housed within; 23 public, 10 faith-based and 6 private health facilities in 19 counties in Kenya. RESULTS: Our findings indicate projects completion rates were influenced by (training design, work environment climate, trainee characteristics, team-based coaching and leveraging on occurring opportunities). Transfer barriers were (inadequate management support, inadequate team and staff support, high staff turnover, misalignment of board's verses manager's priorities, missing technical expertise, endemic strikes, negative politics and poor communication). Recommendations were (need-driven curriculum, effective allocation and efficient utilisation of resources, proper prioritisation, effective communication, longitudinal coaching and work-teams recruitment). CONCLUSION: The findings reveal that unless training interventions are informed by a need-driven curriculum customised to real-world work teams, the potential knowledge and skill transfer can be thwarted.

Characteristics of Recurrent Large-for-Gestational-Age Infants in Obese Women.

Objective The objective of this study was to identify characteristics associated with recurrent large-for-gestational-age (LGA) infants in obese women and to explore the relationship between interpregnancy weight change and gestational weight gain (GWG) on risk of recurrence. Study Design We conducted a population-based historical cohort study of 1,190 obese women in Missouri who delivered LGA infants in their first pregnancy with two consecutive pregnancies resulting in singleton live births during 1998 to 2005. Adjusted odds ratios (aORs) for recurrent LGA infants were calculated with multiple logistic regression. Population-attributable risk assessed the relative importance of specific characteristics. Results A second LGA infant was delivered by 501 women (42%). Recurrence of LGA infants was associated with GWG (aOR, 1.03 [per pound]; 95% confidence interval [CI], 1.02-1.04), maternal age (aOR, 1.05 [per year]; 95% CI, 1.02-1.08), birth weight of the first LGA infant (aOR, 1.001 [per gram]; 95% CI, 1.000-1.001), being married (aOR, 1.71; 95% CI, 1.02-2.49), diabetes (aOR, 1.79; 95% CI, 1.24-2.59), and pre-pregnancy body mass index (BMI) (aOR, 1.04 [per unit BMI]; 95% CI, 1.02-1.06). Excessive GWG contributed the most to LGA infant recurrence (13%). Interpregnancy weight change was not significantly associated with LGA infant recurrence. Conclusion Lower pre-pregnancy BMI and reduced GWG may mitigate the risk of recurrent LGA infants in obese women.

Tracking the Development of Muscular Myoglobin Stores in Mysticete Calves.

For marine mammals, the ability to tolerate apnea and make extended dives is a defining adaptive trait, facilitating the exploitation of marine food resources. Elevated levels of myoglobin within the muscles are a consistent hallmark of this trait, allowing oxygen collected at the surface to be stored in the muscles and subsequently used to support extended dives. In mysticetes, the largest of marine predators, details on muscular myoglobin levels are limited. The developmental trajectory of muscular myoglobin stores has yet to be documented and any physiological links between early behavior and the development of muscular myoglobin stores remain unknown. In this study, we used muscle tissue samples from stranded mysticetes to investigate these issues. Samples from three different age cohorts and three species of mysticetes were included (total sample size = 18). Results indicate that in mysticete calves, muscle myoglobin stores comprise only a small percentage (17-23%) of conspecific adult myoglobin complements. Development of elevated myoglobin levels is protracted over the course of extended maturation in mysticetes. Additionally, comparisons of myoglobin levels between and within muscles, along with details of interspecific differences in rates of accumulation of myoglobin in very young mysticetes, suggest that levels of exercise may influence the rate of development of myoglobin stores in young mysticetes. This new information infers a close interplay between the physiology, ontogeny and early life history of young mysticetes and provides new insight into the pressures that may shape adaptive strategies in migratory mysticetes. Furthermore, the study highlights the vulnerability of specific age cohorts to impending changes in the availability of foraging habitat and marine resources.

The impact of interpregnancy weight change on birthweight in obese women.

OBJECTIVE: The purpose of this study was to estimate the impact of interpregnancy weight change from first to second pregnancies in obese women on the risk of large-for-gestational-age (LGA) and small-for-gestational-age (SGA) infants. STUDY DESIGN: A population-based historical cohort analysis of 10,444 obese women in Missouri who delivered their first 2 singleton live infants from 1998-2005. Interpregnancy weight change was calculated as the difference between prepregnancy body mass index (BMI) of the first and second pregnancies. LGA and SGA births were compared among 3 interpregnancy weight change groups: (1) weight loss (≥2 BMI units), (2) weight gain (≥2 BMI units), and (3) reference group (BMI maintained within 2 units). Adjusted odds ratios (aOR) were calculated for LGA and SGA births with the use of multiple logistic regression. A dose-response relationship was assessed with a linear-by-linear χ(2) test. RESULTS: Compared with the reference group, interpregnancy weight loss was associated with lower risk of an LGA infant (aOR, 0.61; 95% confidence interval, 0.52-0.73), whereas interpregnancy weight gain was associated with increased risk of an LGA infant (aOR, 1.37; 95% confidence interval, 1.21-1.54). Interpregnancy BMI change was not related to SGA infant risk, except for weight loss of >8 BMI units. A significant dose-response relationship was observed for LGA infant risk (P < .001), but not SGA infant risk (P = .840). CONCLUSION: Mild-to-moderate interpregnancy weight loss in obese women reduced the risk of subsequent birth of LGA infants without increasing the risk of SGA infants. The interpregnancy interval may be a crucial period for targeting weight loss in obese women.