Migration and primary healthcare in sub-Saharan Africa: A scoping review.

BACKGROUND:  Migration in Africa is increasing and driven by a variety of inter-related socio-economic, conflict and climate-related causes. Primary healthcare (PHC) migration on PHC service will be in the forefront of responding to the associated health issues. AIM:  This study aimed to review the literature on the effect of migration on PHC service delivery in Africa and the challenges facing migrants in accessing PHC. METHOD:  A systematic approach (Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews) was applied across six databases and grey literature from African universities (2010 to 2021). Data were extracted and analysed quantitatively and qualitatively. RESULTS:  A total of 3628 studies were identified and 50 were included. Most studies were descriptive or used mixed methods. Publications came from 25 countries, with 52% of studies from South Africa, Uganda and Kenya. Most migrants originated from Zimbabwe, the Democratic Republic of Congo and Somalia. Population health management for migrant communities was challenging. Migration impacted PHC services through an increase in infectious diseases, mental health disorders, reproductive health issues and malnutrition. Primary healthcare services were poorly prepared for handling displaced populations in disaster situations. Access to PHC services was compromised by factors related to migrants, health services and healthcare workers. CONCLUSION:  Several countries in Africa need to better prepare their PHC services and providers to handle the increasing number of migrants in the African context.Contribution: The review points to the need for a focus on policy, reducing barriers to access and upskilling primary care providers to handle diversity and complexity.

Reimagining nutrition education for pregnant adolescents in the face of climate change: a community approach.

Objectives: To explore challenges with current nutrition education for teenage pregnant women in a drought-prone community in Kenya and to elicit the communities' suggestions on how to best adapt it in the face of climate change. Design: Nine serial focus group discussions (four with adolescents, two with their parents, two with community health volunteers and one with healthcare workers) were conducted on a purposively selected study population in Kaloleni, Kilifi County, Kenya. Data collection took place between March and November 2022, with a total of 73 participants. An inductive approach was used, and interpretive thematic coding was done as the primary analytic strategy to allow themes derived from participants' reflections. Results: First, participants reported that unpredictable rainfall patterns had affected nutrition intake and variety due to reduced yield from farmland, diseases in livestock and insufficient income. Second, participants reported barriers to accessing nutrition education, as it was mainly given in clinics and not targeted at adolescents or men. Third, they experienced challenges in applying nutrition education in daily life due to a mismatch between available foods and cultural practices. Recommendations for the future encompassed equipping individuals with practical cooking skills tailored to available nutrients, initiatives aimed at water conservation and addressing animal health concerns, enhancing accessibility through community-based training programmes and fostering collaborative efforts to ensure the provision of essential nutrients. Conclusion: Food choices in Kilifi County are getting more limited due to unpredicted rainfall patterns. Therefore, a reorientation of nutrition education is needed in order to build resilience in the community. Strengthening community action, including developing skills to increase long-term local support, would be needed to ensure the adequate nutrition status of vulnerable groups like pregnant adolescent women.

Knowledge, attitudes and beliefs toward polypharmacy among older people attending Family Medicine Clinic, Nairobi, Kenya.

BACKGROUND: Life expectancy has increased over the last century among older people, particularly those aged over 60 years. Aging is associated with increased disability, multiple chronic conditions, and increased use of health services managed with polypharmacy. There are few studies on polypharmacy and aging in sub-Saharan Africa, and it is unclear what older people know and their attitudes toward polypharmacy. This paper presents findings from a study that aimed to understand older people's knowledge, attitudes and beliefs about polypharmacy. METHODS: A qualitative study using in-depth interviews of 15 patients aged 60 years and older who were taking more than five medications per day. The study was conducted at the Family Medicine Clinic (FMC), Aga Khan University Hospital, Nairobi. Data were analyzed using NVivo 12 software. RESULT: Majority of participants had a good understanding of their underlying health conditions, but they did not know the specific names of the medications they were taking. Participants had diverse attitudes toward polypharmacy, with both positive and negative perceptions. Although adverse side effects were reported, participants remained positive because they believed these medicines were beneficial. Religion, faith and living healthy lifestyles were perceived to contribute to their positive attitude toward polypharmacy. Stigma and the cost of medication were reported as barriers. CONCLUSION: This study provides valuable insights into the complexities of polypharmacy in older people. It highlights the importance of patient education, fostering strong patient-provider relationships, de-stigmatization, and improving medication affordability and accessibility. Further research could explore the polypharmacy of older people attending public institutions in rural Kenya.

Associated Factors and Outcomes of Acute Kidney Injury in COVID-19 Patients in Kenya.

Background: Corona Virus Disease 2019 (COVID-19), an infection caused by the SARS-CoV-2 virus, has been the largest global pandemic since the turn of the 21st century. With emerging research on this novel virus, studies from the African continent have been few. Corona Virus Disease 2019 has been shown to affect various organs including the lungs, gut, nervous system, and the kidneys. Acute kidney injury (AKI) is an independent risk factor for mortality and increases the health care burden for patients with persistent kidney dysfunction and maintenance dialysis. Sub-Saharan Africa has a high number of poorly controlled chronic illnesses, economic inequalities, and health system strains that may contribute to higher cases of kidney injury in patients with COVID-19 disease. Objectives: The objective of this study was to determine the incidence, associated factors, and outcomes of AKI in patients hospitalized with COVID-19 in Kenya. Methods: This retrospective cohort study included 1366 patients with confirmed COVID-19 illness hospitalized at the Aga Khan University Hospital in Nairobi, Kenya, between April 1, 2020 and October 31, 2021. Data were collected on age, sex, the severity of COVID-19 illness, existing pregnancy and comorbid conditions including human immunodeficiency virus (HIV), diabetes mellitus, hypertension, and functioning kidney transplant patients. Univariate analysis was carried out to determine the association of clinical and demographic factors with AKI. To determine independent associations with AKI incidence, a logistic regression model was used and the relationship was reported as odds ratios (ORs) with a 95% confidence interval (CI). The outcomes of AKI including the in-hospital mortality rate, renal recovery rate at hospital discharge, and the duration of hospital stay were reported and stratified based on the stage of AKI. Results: The median age of study patients was 56 years (interquartile range [IQR] = 45-68 years), with 67% of them being male (914 of 1366). The AKI incidence rate was 21.6% (n = 295). Patients with AKI were older (median age = 64 years vs 54 years; P < .001), majority male (79% of men with AKI vs 63.6% without AKI; P < .001), and likely to have a critical COVID-19 (OR = 8.03, 95% CI = 5.56-11.60; P < .001). Diabetes and hypertension, with an adjusted OR of 1.75 (95% CI = 1.34-2.30; P < .001) and 1.68 (95% CI = 1.27-2.23; P < .001), respectively, were associated with AKI occurrence in COVID-19. Human immunodeficiency virus, pregnancy, and a history of renal transplant were not significantly associated with increased AKI risk in this study. Patients with AKI had significantly higher odds of mortality, and this effect was proportional to the stage of AKI (OR = 11.35, 95% CI = 7.56-17.03; P < .001). 95% of patients with stage 1 AKI had complete renal recovery vs 33% of patients with stage 3 AKI. Of the patients with stage 3 AKI (n = 64), 10 underwent hemodialysis, with 1 recovery in renal function and 3 patients requiring ongoing dialysis after discharge. Conclusions: This study was conducted at a single private tertiary-level health care facility in Kenya and only up to the time of hospital discharge. It is one of the first large studies from sub-Saharan Africa looking at the associated factors and outcomes of AKI in COVID-19 and forms a foundation for further analysis on the long-term consequences of COVID-19 on the kidneys. A major limitation of the study is the lack of baseline pre-admission creatinine values for most patients; thus, the impact of chronic kidney disease/baseline creatinine values on the incidence of AKI could not be established.

Factors associated with depressive symptoms in patients with benign prostatic enlargement.

BACKGROUND: Depression is a common condition that may lead to suicide at its worst. It is considered one of the primary causes of morbidity globally. Among the urological causes of depression is benign prostatic enlargement (BPE). AIM: To determine the prevalence and factors associated with depressive symptoms among BPE patients. SETTING: This study was conducted in the Urology and Family Medicine Clinic at the Aga Khan University Hospital, Nairobi and Urology clinic at the Aga Khan Hospital Mombasa. METHODS: The study was a cross-sectional design recruiting 308 males above the age of 40. Patient Health Questionnaire-9 and International Prostate Symptom Score (IPSS) were used to assess depressive symptoms and lower urinary tract symptoms (LUTS), respectively. Association between depressive symptoms and LUTS was determined. Factors associated with depressive symptoms were analysed by logistic regression. RESULTS: Prevalence of depressive symptoms among patients with symptomatic benign prostatic enlargement (sBPE) was 42.90%. Factors associated with depressive symptoms included comorbid conditions, medication side effects, reduced libido, alcohol use, disturbed sleep at night and anxiety in regard to the prostate condition. CONCLUSION: There is a high prevalence of depressive symptoms among men with BPE. Assessment and early intervention for depressive symptoms among men with BPE should be initiated before clinical depression sets in.Contribution: The study has created a knowledge base on factors associated with depressive symptoms among men with sBPE in the African context.

Climate change poses a threat to nutrition and food security in Kilifi County, Kenya.

Over the last decades, increased emission of greenhouse gases has led to hot weather extremes, heavy precipitation and worsening of agricultural and ecological droughts. Although Africa's contribution to climate change is minimal, the continent is especially vulnerable to its effects. This report aims to describe the effect of climate change leading to drought in Kilifi County, Kenya, and the communities' experiences of this effect on food availability. During their community rotation, residents from a university in Nairobi, Kenya, evaluated changes in weather patterns and nutrition indicators in Kilifi County and conducted focus group discussions (FGDs) with community members and health care stakeholders to explore challenges in access to adequate nutrition and possible local solutions. Kilifi County has one of the highest rates of undernutrition in Kenya, with one in five under-5 children being underweight. County data showed that rainfall in the last 4 years has become increasingly unpredictable, resulting in reduced household milk production, one of the indicators of nutrition security. Three major themes emerged from the FGDs: lack of food variety, collapse of drought mitigating projects and increasing poverty levels. Possible solutions to these problems include promoting alternatives to the current diet that are culturally sensitive and adaptable to recent climate changes, ensuring continuity of agricultural and financial support projects and improved local leadership and governance.

Burden of upper respiratory tract infections in primary care facilities and excessive antimicrobial over-prescription: A community-oriented primary care project in rural Kenya.

During their community oriented primary care (COPC) rotation in rural coastal Kenya, residents of the Family Medicine programme at the Aga Khan University-Nairobi, identified a high burden of upper respiratory tract infections (URTI) in the dispensaries with high prescription of antimicrobials (AMs) in over 80% of the patients presenting with URTI. An interactive participatory education intervention, designed based on principles of community participation and capacity building, reduced AM prescription in the under 5-year age group with 44% in the 2 weeks after the intervention, and with 18% at week 8 and 9. In the over 5-year age group, this was reduced with 18% and 8%, respectively. Key challenges for upholding AM stewardship after the intervention included the high patient workload in the clinics, difficulties in addressing patient's concerns regarding the prognosis, inaccessibility to ingredients for home therapies, and easy availability of AMs without prescription at local chemists. Interventions addressing improper prescription at the facility level should include provision of continuous training, including communication training, for health facility staff, as well as audits on prescription practices. Collaboration with Community Health Volunteers (CHVs) can help in increasing community awareness on antimicrobial resistance (AMR). This study demonstrates the value of family physicians in clinical governance and improving the quality of care through implementation of guidelines and training. Joint action with the Kilifi county Ministry of Health and the private sector is needed to address mal-regulated access to AMs beyond health facility control.

Prevalence of and factors associated with female sexual dysfunction among women using hormonal and non-hormonal contraception at the AGA Khan University Hospital Nairobi.

BACKGROUND: Female sexual function (FSD) is a complex phenomenon. It integrates all body systems and is influenced by a variety of factors. Contraceptives have shown to have variable effects on FSD. In Kenya, the majority of women use hormonal contraception with high rates of discontinuation of use, attributed to related side effects such as weight loss and loss of libido. AIM: To determine the prevalence of and the factors affecting FSD among women using contraception in our setting. SETTING: The study was carried out at the Aga Khan University Hospital, Nairobi, at various clinical sites. METHODS: A cross-sectional study was conducted. Consecutive sampling of women of reproductive age using either hormonal or non-hormonal contraception was conducted. Two questionnaires were completed after obtaining informed consent. Independent associations of factors with the outcome variables were assessed using the chi-square test of association, and variables with a p 0.25 were used in the multivariate analysis. Factors associated with FSD were determined using binary logistic regression. RESULTS: A total of 566 participants were included. The prevalence of FSD among those using hormonal and those using non-hormonal contraception was 51.5% and 29.6%, respectively (p 0.0001). We found that the factors associated with FSD were presence of chronic illness and use of chronic medication, being self-employed or unemployed, alcohol intake and history of miscarriage(s). CONCLUSION: There was a high prevalence of and a strong association between hormonal contraception and FSD. More studies on this topic in different settings are recommended to investigate the effect of each type of hormonal method on FSD.

Effect of diabetes self-management education on glycaemic control among type 2 diabetic patients at a family medicine clinic in Kenya: A randomised controlled trial.

BACKGROUND:  Diabetes self-management education (DSME) is a key component of diabetes care aimed at delaying complications. Unlike usual care, DSME is a more structured educational approach provided by trained, certified diabetes educators (CDE). In Kenya, many diabetic patients are yet to receive this integral component of care. At the family medicine clinic of the Aga Khan University Hospital (AKUH), Nairobi, the case is no different; most patients lack education by CDE. AIM:  This study sought to assess effects of DSME in comparison to usual diabetes care by family physicians. SETTING:  Family Medicine Clinic, AKUH, Nairobi. METHODS:  Non-blinded randomised clinical trial among sub-optimally controlled (glycated haemoglobin (HbA1c) ≥ 8%) type 2 diabetes patients. The intervention was DSME by CDE plus usual care versus usual care from family physicians. Primary outcome was mean difference in HbA1c after six months of follow-up. Secondary outcomes included blood pressure and body mass index. RESULTS:  A total of 220 diabetes patients were screened out of which 140 met the eligibility criteria and were randomised. Around 96 patients (69%) completed the study; 55 (79%) in the DSME group and 41 (59%) in the usual care group. The baseline mean age and HbA1c of all patients were 48.8 (standard deviation [SD]: 9.8) years and 9.9% (SD: 1.76%), respectively. After a 6-month follow-up, no significant difference was noted in the primary outcome (HbA1c) between the two groups, with a mean difference of 0.37 (95% confidence interval: -0.45 to 1.19; p = 0.37). DSME also made no remarkable change in any of the secondary outcome measures. CONCLUSION:  From this study, short-term biomedical benefits of a structured educational approach seemed to be limited. This suggested that offering a short, intensified education programme might have limited additional benefit above and beyond the family physicians' comprehensive approach in managing chronic conditions like diabetes.

An assessment of implementation of CommunityOriented Primary Care in Kenyan family medicine postgraduate medical education programmes.

BACKGROUND AND OBJECTIVES: Family medicine postgraduate programmes in Kenya are examining the benefits of Community-Oriented Primary Care (COPC) curriculum, as a method to train residents in population-based approaches to health care delivery. Whilst COPC is an established part of family medicine training in the United States, little is known about its application in Kenya. We sought to conduct a qualitative study to explore the development and implementation of COPC curriculum in the first two family medicine postgraduate programmes in Kenya. METHOD: Semi-structured interviews of COPC educators, practitioners, and academic stakeholders and focus groups of postgraduate students were conducted with COPC educators, practitioners and academic stakeholders in two family medicine postgraduate programmes in Kenya. Discussions were transcribed, inductively coded and thematically analysed. RESULTS: Two focus groups with eight family medicine postgraduate students and interviews with five faculty members at two universities were conducted. Two broad themes emerged from the analysis: expected learning outcomes and important community-based enablers. Three learning outcomes were (1) making a community diagnosis, (2) understanding social determinants of health and (3) training in participatory research. Three community-based enablers for sustainability of COPC were (1) partnerships with community health workers, (2) community empowerment and engagement and (3) institutional financial support. CONCLUSIONS: Our findings illustrate the expected learning outcomes and important communitybased enablers associated with the successful implementation of COPC projects in Kenya and will help to inform future curriculum development in Kenya.