Implementing and evaluating group interpersonal therapy for postnatal depression in Lebanon and Kenya-individually randomised superiority trial.

BACKGROUND: Depression ranks as the foremost mental health concern among childbearing women. Within low- and middle-income countries (LMICs), between 20 and 25% of women encounter depression during pregnancy or soon after delivery. This condition impacts not only the mothers but also their offspring. Offspring of women suffering from postnatal depression (PND) exhibit suboptimal cognitive development and increased emotional and behavioural issues throughout their growth. This scenario becomes more pronounced in LMICs, where numerous adversities further jeopardise children's developmental progress. Despite antenatal services providing a pivotal platform to address women's mental health needs, PND treatment remains inaccessible in many LMICs. The World Health Organization advocates interpersonal psychotherapy (IPT) for treating depression. While research from high-income countries has established the efficacy of IPT and group-IPT (g-IPT) for PND, its effectiveness within the LMIC context and its potential benefits for child development remain uncharted. This study seeks to gauge the potency of g-IPT for women with PND in two LMICs. METHODS: This multi-site randomised controlled trial is a continuation of two preceding phases-conceptual mapping and a feasibility study executed in Lebanon and Kenya. Insights gleaned from these phases underpin this comprehensive RCT, which contrasts the efficacy and cost-effectiveness of high-quality standard care (HQ-SC) augmented with g-IPT against HQ-SC in isolation. The trial, characterised as an individually randomised superiority assessment, targets women with postnatal depression in Beirut, Lebanon, and Nairobi, Kenya. It aims to determine if culturally tailored g-IPT, administered within community settings in both countries, outperforms HQ-SC in influencing child developmental outcomes, maternal depression, and the quality of the mother-child bond. DISCUSSION: The SUMMIT trial, designed with pragmatism, possesses the magnitude to evaluate g-IPT within two LMIC frameworks. It seeks to enlighten policymakers, service commissioners, professionals, and users about g-IPT's potential to alleviate maternal PND and bolster child developmental outcomes in LMICs. Additionally, the trial will generate valuable data on the clinical and economic merits of high-quality standard care. TRIAL REGISTRATION: ISRCTN, ISRCTN15154316. Registered on 27 September 2023, https://doi.org/10.1186/ISRCTN15154316.

Inadequacies in service delivery for the diagnosis and treatment of vaginitis and vaginosis in Nairobi, Kenya.

Vulvovaginal candidiasis (VVC), a common cause of vaginitis, affects 75% of women in their lifetime. In Kenya, vaginitis/VVC is managed using the vaginal discharge syndrome guidelines. We assessed how frequently healthcare workers consider the diagnosis of vaginitis/VVC in symptomatic women, and adherence to the syndromic guidelines, outpatient records at Nairobi City County health facilities, of non-pregnant symptomatic females aged ≥15 years were abstracted. Descriptive statistics were applied, and analysis of determinants of practice determined using multivariable logistic regression models. Of 6,516 patients, 4,236 (65%) (inter-facility range 11-92%) had vaginitis of which 1,554 (37%) were considered VVC (inter-facility range 0-99%). Vaginitis was associated with facility, adjusted odds ratio (aOR) 2.80 (95% confidence interval (CI) 1.64-4.76) and aOR 0.03 (95% CI 0.02-0.04); and month, aOR 0.33 (95% CI 0.25-0.43). Vaginal examination was in 53% (inter-facility range 0-98%). Adherence to syndromic treatment was 56% (inter-facility range 0-83%), better with older patients (aOR 7.73, 95% CI 3.31-18.07). Vaginitis and VVC are commonly diagnosed in symptomatic patients in Nairobi; adherence to the syndromic guidelines is low and differs across the health facilities. Interventions to improve adherence are needed.

Knowledge of Nairobi East District Community Health Workers concerning HIV-related orofacial lesions and other common oral lesions.

BACKGROUND: Human immunodeficiency virus (HIV) related orofacial lesions (HROLs) impact negatively on the health of patients and could be managed at primary healthcare (PHC) level. Community health workers (CHWs) are crucial in optimal patient management through patient identification, education and early referral for professional care. The study objective was to assess knowledge of Nairobi East district CHWs regarding HROLs and other common oral diseases. METHODS: Of the total population of CHWs, 815 [94.5%] completed a 56-item questionnaire covering 5 topics: general dental knowledge, knowledge about HROLs, past encounters with HROLs, current care at community level, opinions regarding oral health problems; and items concerning background characteristics and past training activities. Confirmatory factor analysis revealed Cronbach's alpha coefficient values of 0.45, 0.59, 0.79, 0.50 and 0.09 respectively. The first four topics were confirmed as domains. Mean minimum score was 0 and mean maximum score was 1 for each variable. However, for 'past encounters with HROLs, the minimum score was 0 and maximum score was 5. RESULTS: CHWs had moderate knowledge about general oral health (mean = 0.47) and HROLs (mean = 0.43). None had been formally trained in oral health aspects. Although they had high opinions regarding their role in identifying, educating and referring patients with HROLs (mean = 0.80) to the health facilities, they actually rarely referred such patients. CONCLUSIONS: CHWs need training for building competence in promoting oral health among general and HIV patients in their communities and in early identification and management of non-HIV oral lesions.

Oral health training programs for community and professional health care workers in Nairobi East District increases identification of HIV-infected patients.

BACKGROUND: Better knowledge and skills for diagnosis and management of human immunodeficiency virus (HIV) related oral lesions by primary healthcare workers (PHWs) may increase recognition of HIV-related oral lesions (HROLs) and may improve implementation of HIV testing in Kenya. For this purpose training programs at health facility and community level were evaluated. DESIGN AND METHODS: A pre-post control-test group design in two administrative divisions of Nairobi East District was used. Clinical competencies of PHWs (n = 32 intervention, and n = 27 control) at health facility level were assessed 9 months after training, and after 6 months for community health workers, (CHWs) (n = 411 intervention and n = 404 control) using written questionnaires, clinical data and patient interviews. Effects on referral for HIV testing and actual HIV testing were assessed by comparing laboratory registries pre- and post training. RESULTS: PHWs in intervention (n = 27; 84%) and control (n = 15; 60%) divisions, and CHWs in intervention (n = 330; 80%) and control (189; 47%) divisions, completed all questionnaires. Trained PHWs significantly increased their knowledge of HROLs (p<0.02), frequency of oral examinations, diagnosis of HROLs and referral of patients with HROLs for HIV testing. Trained CHWs significantly gained knowledge about HROLs (p<0.02) and referred more patients with HROLs to health facilities. Overall percentage of HIV-positive test results was three-fold for HROLs compared to non-HROLs. Specifically, 70% of patients with oro pharyngeal candidiasis (OPC), the most commonly diagnosed HROL, were confirmed as being HIV-positive. Increase in overall HIV testing rates (1.6% pre-, 1.2% post training) and overall percentage of HIV-positive results (13% pre-, 16% post-intervention) was not significant. CONCLUSION: Training programs significantly increased PHW and CHW knowledge, recognition and management of HROLs but increased neither overall HIV testing rates nor overall percentage of positive tests. Speculation is that the health system and patient-related barriers seriously limit HIV testing. TRIAL REGISTRATION: Netherlands Trial Register NTR2627 (date registered 22nd November 2010), and NTR2697 (date registered 13th January 2011).

A Community-based Oral Health Promotion Model for HIV Patients in Nairobi, East District in Kenya: a Study Protocol.

BACKGROUND: General HIV-related orofacial lesions, most commonly oropharyngeal candidiasis, have a typical clinical appearance and can be recognised by members of the community. Although affected patients often experience pain leading to compromised eating and swallowing, barriers such as social stigma and lack of knowledge regarding available services may prevent them from seeking early care. Educating the community about these lesions through community health workers (CHWs) who are democratically elected community members may encourage individuals affected to seek early oral healthcare in the health facilities. A health facility (HF) is a health centre mainly run by clinical officers (CO), i.e. personnel with a 3-year medical training, and nurses. This study aims to evaluate the effect of a CHW training programme on: i) their knowledge and recognition of HIV-related oral-facial lesions at a community level; and ii) referral of affected patients from the community to the HFs. DESIGN AND METHODS: All 800 CHWs in 2 administrative divisions of Nairobi East District (test group n=400; control group n=400) will be selected. The test group will receive training. CHWs in both groups will be assessed at 4 time points: -3, 0, +3 and +6 months with reference to the training on: i) their knowledge of HIV-related orofacial lesions (using a written questionnaire); and ii) their performance in referring affected patients to the HFs (using clinical data). EXPECTED IMPACT: Early recognition of HIV-related orofacial lesions at a community level will prompt community members to seek early oral care, leading to early HIV testing and counselling regarding failure of antiretroviral therapy, while treatment outcomes are still favourable.

Attitudes, subjective norms, and intention to perform routine oral examination for oropharyngeal candidiasis as perceived by primary health-care providers in Nairobi Province.

OBJECTIVES: To assess attitudes, subjective norms, and intentions of primary health-care (PHC) providers in performing routine oral examination for oropharyngeal candidiasis (OPC) during outpatient consultations. METHODS: A 47-item Theory of Planned Behaviour-based questionnaire was developed and administered, in a cross-sectional survey, to 216 PHC providers (clinical officers and nurses) working in 54 clinics, dispensaries, and health centers in Nairobi Province in January 2010. The constructs - attitudes, subjective norms, and perceived behavioral control (dependent variables) - and their individual indirect (direct) items were analyzed for scores, internal validity, independent variables (district, gender, years of service, profession, and age), and contribution to intentions. Perceived behavioral control had low construct validity and was therefore removed from subsequent analyses. RESULTS: The questionnaire was completed by 195 participants (90 percent response rate). PHC provider's attitudes, subjective norms, and intentions to perform an oral examination during outpatient consultations were highly positive, with mean scores of 6.30 (0.82), 6.06 (1.07), and 5.6 (1.33), respectively, regardless of sociodemographic characteristics. Indirect attitude and subjective norms were strongly correlated to their individual items (r=0.63-0.79, P<0.05 and r=0.78-0.87, P<0.05) and moderately to their direct items (r=0.44, P<0.0001 and r=0.52, P<0.0001). Attitudes (P=0.0026) and subjective norms (P<0.0001) were both predictive of intentions. CONCLUSIONS: PHC providers were willing to integrate patients' oral health care into their routine medical consultations. Emphasizing the importance of detecting other oral problems and of the fact that routine oral examination for OPC is likely to give patients' fulfillment will enhance PHC providers' morale in performing routine oral examinations. Winning support from policy makers, their supervisors, specialists, and colleagues is important for motivating PHC providers to perform routine oral examinations for OPC at their workplaces.

Effect of Education of Primary Health Care Workers on HIV-related Oral Lesions in Nairobi East District.

BACKGROUND: An estimated 90% of HIV-infected people are likely to develop oral lesions in the course of HIV infection. Oro-pharyngeal candidiasis (OPC), an early marker for HIV-infection, can be diagnosed during an oral examination (OE). Primary healthcare (PHC) providers in Kenya are neither trained nor sufficiently equipped to perform this simple, cheap and non-invasive examination. The PHC system in Kenya offers an opportunity to integrate early recognition and management of oral lesions into general health care. This study aims to estimate the effect of a multifaceted intervention for PHC providers in training them to perform an OE. Specifically, our primary objective is to establish whether the intervention is effective in increasing: i) the frequency of early detection of HIV-related oral lesions; and ii) referral rates for HIV-testing. DESIGN AND METHODS: THE STUDY HAS BEEN DESIGNED IN TWO PARTS: a retrospective clinical data record study and a prospective cohort study with pre-post control group design, carried out in 2 administrative divisions in Nairobi East district. The intervention group will receive one day of training on recognition of HIV-related oral lesions and other common oral conditions. Reminder sessions will be held at individual health facilities. Routine tally sheets will be used to record all patients with HIV-related oral lesions, dental caries and periodontal disease. A convenience sample of all the PHC in a division will be used. It will not be possible to blind investigators or assessors. Expected impact of the study for Public Health. Early recognition and treatment of HIV infection influences long-term survival rates and will reduce healthcare expenditure. ACKNOWLEDGMENTS: The project is funded by the Netherlands organisation for international cooperation in higher education (NUFFIC). We would like to thank all participating health facilities and health care workers for their willingness to take part in this study. LNK also thanks the Kenya Ministry of Public Health and Sanitation for permission to carry out this study. We also thank Mr. J Mulder from Radboud University Nijmegen Medical Centre, Department of Methodology, Information Management and Statistics, Nijmegen, The Netherlands for statistical advice. FUNDING: THIS STUDY IS FUNDED BY A RESEARCH GRANT FROM THE NETHERLANDS ORGANIZATION FOR INTERNATIONAL COOPERATION IN HIGHER EDUCATION (NUFFIC, GRANT NR: C&B-NFP-PHD.10/110), The Hague, The Netherlands. TRIAL REGISTRATION: Netherlands Trial Register NTR2627 (date registered 22(nd) November 2010). ETHICS APPROVAL: Kenyatta National Hospital/University of Nairobi Ethics and Research Committee (approval number KNH-ERC/A/474), and The Ministry of Public Health and Sanitation (Ref. N. MPHS/IB/1/14 Vol. III).