"I Am Now Five Steps Ahead": How Co-design Platforms Sustain Kenyan Community Health Volunteer Engagement.

OBJECTIVES: The aim of this study is to examine how humancentered design (HCD) as a platform for co-production might function to explain community health volunteer (CHV) motivation in self-directed and self-funded community health activities. Sustaining engagement has been difficult for CHVs who lack monetary incentives, expense reimbursement, and are rarely given opportunity to give their own voice to local health priorities. DESIGN: Qualitative study utilized focus group discussions 12 months post intervention and included both an inductive and deductive level of analysis. SETTING: Three community health units (CHU) representing Kenya's diversity were selected with the local Ministry of Health including peri-urban slum, rural agrarian, and a unit where informal day labor and rented housing was the norm. PARTICIPANTS: The participants were selected according to Kenya's community health strategy norms and had previously had the standard basic community health training. INTERVENTION: A 3-day training rooted in HCD utilized multiple quality improvement tools (asset mapping, root cause analysis, key drivers) in order to help CHVs uncover unarticulated community needs and assumptions and encourage behavior change. Action plans with Plan-Do-Study-Act cycles were tracked longitudinally. RESULTS: Key themes were self-interest, common goal, gratitude/indebtedness. Additional thematic analysis identified altruism as supporting sustained engagement. CONCLUSIONS: This study supports HCD as a platform for sustained CHV engagement. It builds the evidence for self-interest, common goal, and gratitude/indebtedness as sustaining factors. These factors are also seen in process-based theories that operationalize and measure trust building reciprocity cycles that mirror the iterative P-D-S-A cycles seen in HCD.

Outpatient management of urinary tract infections by medical officers in Nairobi, Kenya: lack of benefit from audit and feedback on adherence to treatment guidelines.

INTRODUCTION: Acute uncomplicated urinary tract infections are common in outpatient settings but are not treated optimally. Few studies of the outpatient use of antibiotics for specific diagnoses have been done in sub-Saharan Africa, so little is known about the prescribing patterns of medical officers in the region. METHODS: Aga Khan University has 16 outpatient clinics throughout the Nairobi metro area with a medical officer specifically assigned to that clinic. A baseline assessment of evaluation and treatment of suspected UTI was performed from medical records in these clinics. Then the medical officer from each of the 16 clinics was recruited from each clinic was recruited with eight each randomized to control vs. feedback groups. Both groups were given a multimodal educational session including locally adapted UTI guidelines and emphasis on problems identified in the baseline assessment Each record was scored using a scoring system that was developed for the study according to adequacy of history, physical examination, clinical diagnosis matching recorded data, diagnostic workup and treatment. Three audits were done for both groups; baseline (audit 1), post-CME (audit 2), and a final audit, which was after feedback for the feedback group (audit 3). The primary analysis assessed overall guideline adherence in the feedback group versus the CME only group. RESULTS: The overall scores in both groups showed significant improvement after the CME in comparison to baseline and for each group, the scores in most domains also improved. However, audit 3 showed persistence of the gains attained after the CME but no additional benefit from the feedback. Some deficiencies that persisted throughout the study included lack of workup of possible STI and excess use of non-UTI laboratory tests such as CBC, stool culture and H. pylori Ag. After the CME, the use of nitrofurantoin rose from only 4% to 8% and cephalosporin use increased from 49 to 67%, accompanied by a drop in quinolone use. CONCLUSION: The CME led to modest improvements in patient care in the categories of history taking, treatment and investigations, but feedback had no additional effect. Future studies should consider an enforcement element or a more intensive feedback approach.

Moving beyond audit: driving system learning using a novel mortality classification system in a tertiary training hospital in Kenya.

Clinical classification systems have proliferated since the APGAR score was introduced in 1953. Numerical scores and classification systems enable qualitative clinical descriptors to be transformed into categorical data, with both clinical utility and ability to provide a common language for learning. The clarity of classification rubrics embedded in a mortality classification system provides the shared basis for discussion and comparison of results. Mortality audits have been long seen as learning tools, but have tended to be siloed within a department and driven by individual learner need. We suggest that the learning needs of the system are also important. Therefore, the ability to learn from small mistakes and problems, rather than just from serious adverse events, remains facilitated.We describe a mortality classification system developed for use in the low-resource context and how it is 'fit for purpose,' able to drive both individual trainee, departmental and system learning. The utility of this classification system is that it addresses the low-resource context, including relevant factors such as limited prehospital emergency care, delayed presentation, and resource constraints. We describe five categories: (1) anticipated death or complication following terminal illness; (2) expected death or complication given clinical situation, despite taking preventive measures; (3) unexpected death or complication, not reasonably preventable; (4) potentially preventable death or complication: quality or systems issues identified and (5) unexpected death or complication resulting from medical intervention. We document how this classification system has driven learning at the individual trainee level, the departmental level, supported cross learning between departments and is being integrated into a comprehensive system-wide learning tool.

Living on the Edge of Possibility: Ethical Issues in the Care of Critically Ill Patients in Resource-Limited Settings.

The birth, expansion, and sustenance of critical care medicine as a specialty have often presented ethical challenges and dilemmas to health care workers in diverse settings. In addition to critical services being provided at the extreme end of a disease process, they are often in limited supply. The authors present patterns of inception and development of this crucial service as they have witnessed in rural Africa. Furthermore, they present the ethical challenges, both typical and unique, as they have experienced them in a tertiary referral center in Kenya.

Understanding intra- and interprofessional team and teamwork processes by exploring facility-based neonatal care in kenyan hospitals.

BACKGROUND: Within intensive care settings such as neonatal intensive care units, effective intra- and interprofessional teamwork has been linked to a significant reduction of errors and overall improvement in the quality of care. In Kenya, previous studies suggest that coordination of care among healthcare teams providing newborn care is poor. Initiatives aimed at improving intra- and interprofessional teamwork in healthcare settings largely draw on studies conducted in high-income countries, with those from resource-constrained low and middle countries, particularly in the context of newborn care lacking. In this study, we explored the nature of intra- and interprofessional teamwork among health care providers in newborn units (NBUs) of three hospitals in Kenya, and the professional and contextual dynamics that shaped their interactions. METHODS: This exploratory qualitative study was conducted in three hospitals in Nairobi and Muranga Counties in Kenya. We adopted an ethnographic approach, utilizing both in-depth interviews (17) and non-participant observation of routine care provision in NBUs (250 observation hours). The study participants included: nurses, nursing students, doctors, and trainee doctors. All the data were thematically coded in NVIVO 12. RESULTS: The nature of intra- and interprofessional teamwork among healthcare providers in the study newborn units is primarily shaped by broader contextual factors and varying institutional contexts. As a result, several team types emerged, loosely categorized as the 'core' team which involves providers physically present in the unit most times during the work shift; the emergency team and the temporary ad-hoc teams which involved the 'core' team, support staff students and mothers. The emergence of these team types influenced relationships among providers. Overall, institutionalized routines and rituals shaped team relations and overall functioning. CONCLUSIONS: Poor coordination and the sub-optimal nature of intra-and interprofessional teamwork in NBUs are attributed to broader contextual challenges that include low staff to patient ratios and institutionalized routines and rituals that influenced team norming, relationships, and team leadership. Therefore, mechanisms to improve coordination and collaboration among healthcare teams in these settings need to consider contextual dynamics including institutional cultures while also targeting improvement of team-level processes including leadership development and widening spaces for more interaction and better communication.

Exploring healthcare workers' perceptions on the use of morbidity and mortality audits as an avenue for learning and care improvement in Kenyan hospitals' newborn units.

BACKGROUND: In many sub-Saharan African countries, including Kenya, the use of mortality and morbidity audits in maternal and perinatal/neonatal care as an avenue for learning and improving care delivery is sub-optimal due to structural, organizational, and human barriers. While attempts to address these barriers have been reported, lots of emphasis has been paid to addressing the role of tangible inputs (e.g., availing guidelines and training staff in the success of mortality and morbidity audits), while process-related factors (i.e., the role of the people, their experiences, relationships, and motivations) remain inadequately explored. We examined the processes of neonatal audits, their potential in promoting learning from gaps in care and improving care delivery, with a deliberate focus on process-related factors that generally influence mortality and morbidity (M&M) audits. METHODS: This was an exploratory qualitative study, conducted in three hospitals, in Nairobi and Muranga counties. We employed a mix of in-depth interviews (17) and observation of 12 mortality and morbidity audit meetings. Our study participants included: nurses, doctors, trainee clinicians (i.e., junior doctors on internships), and nursing students involved in providing newborn care. These data were coded using NVivo12 employing a thematic content analysis approach. RESULTS: Perceived shortcomings in the conduct of M&M audits such as unclear structure was reported to have contributed to its sub-optimal nature in promoting learning. These shortcomings, in addition to hierarchy and power dynamics, poor implementation of audit recommendations, and negative experiences, (e.g., blame) also demotivated health workers from attendance and participation in audits. Despite these, positive outcomes linked to audit recommendations, such as revision of care protocols, were reported. Overall, leadership and a blame-free culture enabled positive changes and promoted learning from audit-identified modifiable factors. CONCLUSION: Our findings indicate that M&M audits provide a space for meaningful discussions, which may lead to learning and improvement in care delivery processes. However, a lack of participation, lack of observed positive outcomes, and negative experiences may reduce their usefulness. An enabling environment characterized by minimized effects of hierarchy and positive use of power and a blame-free culture may promote active participation, enhancing positive relationships and interactions thus promoting team learning.

Understanding Women's Choices: How Women's Perceptions of Quality of Care Influences Place of Delivery in a Rural Sub-County in Kenya. A Qualitative Study.

BACKGROUND: Maternal mortality is still unacceptably high in Kenya. The Kenyan Government introduced a free maternity service to overcome financial barriers to access. This policy led to a substantial increase in women's delivery options. This increase in coverage might have led to a reduction in quality of care. This study explores women's perceptions of quality of delivery services in the context of the free policy and how the perceptions lead to the choice of a place for delivery. METHODS: Our study site was Naivasha sub-County in Kenya, a rural context, whose geography encompasses pastoralists, rural agrarian, and high population density informal settlements near flower farms. Women from this area are from the lowest wealth quintile in Kenya. We conducted a qualitative study to explore the women's perceptions of quality of care based on their experiences during maternity care. The participants were women of reproductive age (18-49 years) attending antenatal care clinics at six health facilities in the sub-county. Six focus group discussions with 55 respondents were used. For inclusion, the women needed to have delivered a baby within the six months preceding the study. Interviews were recorded with consent, translated and transcribed. The interviews were analyzed using a thematic content approach. RESULTS: Four broad themes that determined the choice of health facility for delivery were identified: women's perceptions of clinical quality of care; the cost of delivery; distance to the health facility and management of primary health facilities. An unexpected theme was the presence of home deliveries amongst pastoralist women. These findings suggest that in this setting both process and structural dimensions of quality of care and financial and physical accessibility influence women's choices for place of delivery. CONCLUSION: This study expands our understanding of how women make choices regarding place of delivery. Understanding women's perceptions can provide useful insights to policy makers and facility managers on providing high quality patient centered maternity care necessary to sustain the increased utilization of maternity services at health facilities under the free maternity policy and further reductions in maternal mortality.

Coping with COVID: Developing a Rapid-cycle Frontline Quality-improvement Process to Support Employee Well-being and Drive Institutional Responsiveness in a Tertiary Care Faith-based Hospital in Rural Kenya.

The coronavirus disease 2019 (COVID-19) pandemic has demanded rapid institutional responses to meet the needs of patients and employees in the face of a serious new disease. To support the well-being of frontline staff, a series of debriefing sessions was used to drive a rapid-cycle quality-improvement process. The goals were to confidentially determine personal coping strategies used by staff, provide an opportunity for staff cross-learning, identify what staff needed most, and provide a real-time feedback loop for decision-makers to create rapid changes to support staff safety and coping. Data were collected via sticky notes on flip charts to protect confidentiality. Management reviewed the data daily. Institutional responses to problems identified during debrief sessions were tracked, visualized, addressed, and shared with staff. More than 10% of staff participated over a 2-week period. Feedback influenced institutional decisions to improve staff schedules, transportation, and COVID-19 training.

Eliciting women's preferences for place of child birth at a peri-urban setting in Nairobi, Kenya: A discrete choice experiment.

OBJECTIVE: Maternal and newborn mortality rates are high in peri-urban areas in cities in Kenya, yet little is known about what drives women's decisions on where to deliver. This study aimed at understanding women's preferences on place of childbirth and how sociodemographic factors shape these preferences. METHODS: This study used a Discrete Choice Experiment (DCE) to quantify the relative importance of attributes on women's choice of place of childbirth within a peri-urban setting in Nairobi, Kenya. Participants were women aged 18-49 years, who had delivered at six health facilities. The DCE consisted of six attributes: cleanliness, availability of medical equipment and drug supplies, attitude of healthcare worker, cost of delivery services, the quality of clinical services, distance and an opt-out alternative. Each woman received eight questions. A conditional logit model established the relative strength of preferences. A mixed logit model was used to assess how women's preferences for selected attributes changed based on their sociodemographic characteristics. RESULTS: 411 women participated in the Discrete Choice Experiment, a response rate of 97.6% and completed 20,080 choice tasks. Health facility cleanliness was found to have the strongest association with choice of health facility (ß = 1.488 p<0.001) followed respectively by medical equipment and supplies availability (ß = 1.435 p<0.001). The opt-out alternative (ß = 1.424 p<0.001) came third. The attitude of the health care workers (ß = 1.347, p<0.001), quality of clinical services (ß = 0.385, p<0.001), distance (ß = 0.339, p<0.001) and cost (ß = 0.0002 p<0.001) were ranked 4th to 7th respectively. Women who were younger and were the main income earners having a stronger preference for clean health facilities. Older married women had stronger preference for availability of medical equipment and kind healthcare workers. CONCLUSIONS: Women preferred both technical and process indicators of quality of care. DCE's can lead to the development of person-centered strategies that take into account the preferences of women to improve maternal and newborn health outcomes.

Understanding what women want: eliciting preference for delivery health facility in a rural subcounty in Kenya, a discrete choice experiment.

OBJECTIVE: To identify what women want in a delivery health facility and how they rank the attributes that influence the choice of a place of delivery. DESIGN: A discrete choice experiment (DCE) was conducted to elicit rural women's preferences for choice of delivery health facility. Data were analysed using a conditional logit model to evaluate the relative importance of the selected attributes. A mixed multinomial model evaluated how interactions with sociodemographic variables influence the choice of the selected attributes. SETTING: Six health facilities in a rural subcounty. PARTICIPANTS: Women aged 18-49 years who had delivered within 6 weeks. PRIMARY OUTCOME: The DCE required women to select from hypothetical health facility A or B or opt-out alternative. RESULTS: A total of 474 participants were sampled, 466 participants completed the survey (response rate 98%). The attribute with the strongest association with health facility preference was having a kind and supportive healthcare worker (ß=1.184, p<0.001), second availability of medical equipment and drug supplies (ß=1.073, p<0.001) and third quality of clinical services (ß=0.826, p<0.001). Distance, availability of referral services and costs were ranked fourth, fifth and sixth, respectively (ß=0.457, p<0.001; ß=0.266, p<0.001; and ß=0.000018, p<0.001). The opt-out alternative ranked last suggesting a disutility for home delivery (ß=-0.849, p<0.001). CONCLUSION: The most highly valued attribute was a process indicator of quality of care followed by technical indicators. Policymakers need to consider women's preferences to inform strategies that are person centred and lead to improvements in quality of care during delivery.

Implementation research and human-centred design: how theory driven human-centred design can sustain trust in complex health systems, support measurement and drive sustained community health volunteer engagement.

Human-centred design (HCD) can support complex health system interventions by navigating thorny implementation problems that often derail population health efforts. HCD is a pragmatic, 'practice framework', not an intervention protocol. It can build empathy by bringing patient voice, user perspective and innovation to construct and repair pieces of the intervention or health system. However, its emphasis on product development and process change with fixed end points has left it as an approach lacking explanatory power and reproducible measurement. Yet when informed by theory, the tremendous innovation potential of HCD can be harnessed to drive sustainability, mediate implementation problems, frame measurement constructs and ultimately improve population-level health outcomes. In attempting to mine, the potential of HCD we move beyond the pragmatic 'how it works', to the theoretical question, 'why it works'. In doing so, we explore a more fundamental human question, 'How can participation and engagement be sustained for impact in close to the community health systems?' In this exploration, we illustrate the power of HCD by linking it to our theory of trust building. The research method we utilize is that of a longitudinal process evaluation. We leverage the heterogeneity of five community health units from the diverse setting (rural, peri-urban slum) to better understand what works for whom and in what context by tracking 21 groups of community health volunteers (CHVs) over 12 months. We report results with a focus on the outlier case failure to illustrate the contrast with common features of sustained CHV engagement, where recurrent reciprocal cycles of trust building are demonstrated in the successful implementation of action plans in plan-do-study-act cycles for improvement. All was accomplished by CHVs with no external funding. We conclude by discussing how HCD could be unleashed if linked to theoretical frameworks, increasing ability to address implementation challenges in complex health systems.

'We just look at the well-being of the baby and not the money required': a qualitative study exploring experiences of quality of maternity care among women in Nairobi's informal settlements in Kenya.

OBJECTIVE: To examine how women living in an informal settlement in Nairobi perceive the quality of maternity care and how it influences their choice of a delivery health facility. DESIGN: Qualitative study. SETTINGS: Dandora, an informal settlement, Nairobi City in Kenya. PARTICIPANTS: Six focus group discussions with 40 purposively selected women aged 18-49 years at six health facilities. RESULTS: Four broad themes were identified: (1) perceived quality of the delivery services, (2) financial access to delivery service, (3) physical amenities at the health facility, and (4) the 2017 health workers' strike.The four facilitators that influenced women to choose a private health facility were: (1) interpersonal treatment at health facilities, (2) perceived quality of clinical services, (3) financial access to health services at the facility, and (4) the physical amenities at the health facility. The three barriers to choosing a private facility were: (1) poor quality clinical services at low-cost health facilities, (2) shortage of specialist doctors, and (3) referral to public health facilities during emergencies.The facilitators that influenced women to choose a public facility were: (1) physical amenities for dealing with obstetric emergencies and (2) early referral to public maternity during antenatal care services. Barriers to choosing a public facility were: (1) perception of poor quality clinical services, (2) concerns over security for newborns at tertiary health facilities, (3) fear of mistreatment during delivery, (4) use of unsupervised trainee doctors for deliveries, (5) poor quality of physical amenities, and (6) inadequate staffing. CONCLUSION: The study provides insights into decision-making processes for women when choosing a delivery facility by identifying critical attributes that they value and how perceptions of quality influence their choices.

Health and disease among Somali primary school children in Hargeisa.

BACKGROUND AND OBJECTIVE: Limited data exist on health conditions of school children in Somaliland. School Health Intervention Pilot Program (SHIPP) was conducted through Edna Adan University Hospital to screen children and offer interventions. We present the results of the general health screening of the school children, and also describe the association between nutritional status and other variables. METHODS: In this cross-sectional study children from two public primary schools in Hargeisa were assessed for general health by nursing students. Nutritional status was assessed by BMI-for-age z-scores and visual acuity by Paediatric Snellen Chart. RESULTS: We screened 2,093 children aged 4-19 years; 58% were boys. Very low BMI-for-age (z-score < -3) was detected in 5%; 6% had visual acuity below 0.7; 26% had dental caries. Children reported low exposure to health services: 33% reported no prior vaccination; 46% reported they had never visited a health clinic or hospital. CONCLUSION: A significant number of children were malnourished, had reduced visual acuity or treatable infections which could impact their ability to learn. Public schools are a feasible entry point for public health action including screening, treatment, and referral in fragile countries.

Improving maternal and newborn health: effectiveness of a community health worker program in rural Kenya.

BACKGROUND: Volunteer community health workers (CHWs) form an important element of many health systems, and in Kenya these volunteers are the foundation for promoting behavior change through health education, earlier case identification, and timely referral to trained health care providers. This study examines the effectiveness of a community health worker project conducted in rural Kenya that sought to promote improved knowledge of maternal newborn health and to increase deliveries under skilled attendance. METHODS: The study utilized a quasi-experimental nonequivalent design that examined relevant demographic items and knowledge about maternal and newborn health combined with a comprehensive retrospective birth history of women's children using oral interviews of women who were exposed to health messages delivered by CHWs and those who were not exposed. The project trained CHWs in three geographically distinct areas. RESULTS: Mean knowledge scores were higher in those women who reported being exposed to the health messages from CHWs, Eburru 32.3 versus 29.2, Kinale 21.8 vs 20.7, Nyakio 26.6 vs 23.8. The number of women delivering under skilled attendance was higher for those mothers who reported exposure to one or more health messages, compared to those who did not. The percentage of facility deliveries for women exposed to health messages by CHWs versus non-exposed was: Eburru 46% versus 19%; Kinale 94% versus 73%: and Nyakio 80% versus 78%. CONCLUSION: The delivery of health messages by CHWs increased knowledge of maternal and newborn care among women in the local community and encouraged deliveries under skilled attendance.

Effectiveness trial of community-based I Choose Life-Africa human immunodeficiency virus prevention program in Kenya.

We measured the effectiveness of a human immunodeficiency virus (HIV) prevention program developed in Kenya and carried out among university students. A total of 182 student volunteers were randomized into an intervention group who received a 32-hour training course as HIV prevention peer educators and a control group who received no training. Repeated measures assessed HIV-related attitudes, intentions, knowledge, and behaviors four times over six months. Data were analyzed by using linear mixed models to compare the rate of change on 13 dependent variables that examined sexual risk behavior. Based on multi-level models, the slope coefficients for four variables showed reliable change in the hoped for direction: abstinence from oral, vaginal, or anal sex in the last two months, condom attitudes, HIV testing, and refusal skill. The intervention demonstrated evidence of non-zero slope coefficients in the hoped for direction on 12 of 13 dependent variables. The intervention reduced sexual risk behavior.

Acculturation as a predictor of the onset of sexual intercourse among Hispanic and white teens.

OBJECTIVE: To investigate ethnic differences in onset of sexual intercourse among Hispanic/Mexican American and white adolescents based on acculturation. DESIGN/METHODS: Preprogram survey data from 7270 Hispanic or white teens in 7th to 12th grade involved in the Arizona Abstinence-Only Education Program were used to predict the probability of onset of sexual intercourse based on age, sex, family structure, program location, religiosity, free school lunch, grades, rural residence, acculturation, and ethnicity. Specific attention was given to the influence of acculturation among Hispanic teens. The primary language spoken by the respondents (English, Spanish, or both) was used as a proxy measure for acculturation. RESULTS: Hispanic youth were at a greater risk for experiencing onset of intercourse than white youth, while controlling for all other predictors (odds ratio [OR], 1.40 [95% confidence interval (CI), 1.21-1.63]). This risk was amplified for highly acculturated Hispanic teens (OR, 1.69 [95% CI, 1.43-1.99]). However, less acculturated Hispanic youth were actually less likely to have experienced first intercourse than white youth (OR, 0.59 [95% CI, 0.42-0.82]), English-speaking Hispanic youth (OR, 0.35 [95% CI, 0.25-0.49]), or bilingual Hispanic youth (OR, 0.45 [95% CI, 0.31-0.64]). CONCLUSIONS: Low acculturation emerges as a significant protective factor while controlling for other social and cultural factors, in spite of the increased risk of initiating sexual intercourse for Hispanic teens overall. Hispanic Spanish speakers were least likely to have initiated intercourse, while Hispanic English speakers were the most likely.