Essential surgery delivery in the Northern Kivu Province of the Democratic Republic of the Congo.

INTRODUCTION: Surgical services are an essential part of a functional healthcare system, but the Lancet Commission of Global Surgery (LCoGS) indicators of surgical capacity such as perioperative workforce and surgical volume are unknown in many low- and middle-income countries (LMICs) including the Democratic Republic of Congo (DRC). We aimed to determine the surgical capacity and its associated factors within the DRC. METHODS: Hospitals were assessed in the North Kivu province of the DRC. Hospital characteristics and surgical rates were determined using the WHO-PGSSC hospital assessment tool and operating room (OR) registries. The primary outcome of interest was the number of Bellwether operations (i.e. Caesarean sections, laparotomies, and external fixation for bone fractures) per 100,000 people. Univariate and multiple linear regressions were performed. Primary predictors were the number of trained surgeons, anaesthesiologists, and obstetricians (SAOs) and the number of perioperative providers (including clinical officers and nurse anaesthetists) per 100,000 people. RESULTS: Twenty-eight hospitals in North Kivu were assessed over one year in 2021; 24 (86%) were first-level referral health centres while 4 (14%) were second-level referral hospitals. In total, 11,176 Bellwether procedures were performed in the region in one year. Rates per 100,000 people were 1,461 Bellwether surgical interventions, 1.05 SAOs, and 13.1 perioperative providers. In univariate linear regression analysis, each additional SAO added 239 additional cases annually (p = 0.023), while each additional perioperative provider added 110 cases annually (p < 0.001). In our multiple regression analysis adjusting for other hospital services, the association between workforce and Bellwether surgeries was no longer significant. CONCLUSIONS: The surgical workforce in DRC did not meet the LCoGS benchmark of 20 SAOs per 100,000 people but was not an independent predictor of surgical capacity. Major investment is needed to simultaneously bolster healthcare facilities and increase surgical workforce training.

Determinants of Access to Essential Surgery in the Democratic Republic of Congo.

INTRODUCTION: In the Democratic Republic of Congo (DRC), the determinants and barriers of essential surgical care are not well described, hindering efforts to improve national surgical programs and access. METHODS: A cross-sectional study evaluated access to essential surgery in the Butembo and Katwa health zones in the North Kivu province of DRC. A double-clustered random sample of community members was surveyed using questions derived from the Surgeons OverSeas Surgical Needs Assessment Survey, a validated tool to determine the reasons for not seeking, reaching, or receiving a Bellwether surgery (i.e., caesarean delivery, laparotomy, and external fixation of a fracture) when needed. RESULTS: Overall, 887 households comprising 5944 community members were surveyed from April to August 2022. Six percent (n = 363/5944) of the study population involving 35% (n = 309/887) households needed a Bellwether surgery in the previous year, 30% (n = 108/363) of whom died. Of those who needed surgery, 25% (n = 78) did not go to the hospital to seek care and were more likely to find transportation unaffordable (P = 0.042). The most common reasons for not seeking care were lack of funds for hospitalization, prior poor hospital experience, and fear of hospital care. CONCLUSIONS: Access and delivery of essential surgery are drastically limited in the North Kivu province of the DRC, such that a quarter of households needing surgery fails to seek surgical care. Poor access was predominantly driven by households' inability to pay for surgery and community distrust of the hospital system.

Determinants of parents' intention to vaccinate their children aged 12-17 years against COVID-19 in North Kivu (Democratic Republic of Congo).

Parents are facing tremendous stress in relation to the COVID-19 pandemic and the effectiveness of the COVID-19 vaccination program for children. We aimed to investigate parents' willingness to vaccinate their children against COVID-19 in North Kivu province, (Democratic Republic of Congo). A cross-sectional survey between 1 December 2021 to 20 January 2022 in six health zones (Goma, Karisimbi, Butembo, Beni, Kamango, and Katwa) was conducted in the province of North Kivu. In each health zone, we selected five clusters (Health area) using the method of probabilistic selection proportional to population size. In total, 522 parents participated in our study. Results: Overall, 32.8% of parents intended to vaccinate their children. In the multivariate analysis, a younger age of parents (aOR: 2.40, CI: [1.50-3.83]), a higher level of fear that "a member of my family" could contract COVID-19 (aOR: 2.35, CI: [1.38-4.02]), a higher level of perceived vulnerability to COVID-19 within the family (aOR: 1.70, CI: [1.005-2.2881]), a higher level of perceived susceptibility to COVID-19 within the family (aOR: 3.07, CI: [1.80-5.23]), and a history of vaccination against COVID-19 among parents (aOR: 16.47, CI: [8.39-32.33]), were all significantly associated with the intention of parents to have their children or adolescents vaccinated. According to the different explanatory factors of the will to have their children vaccinated, an emphasis on the health education of parents who are prone to refusal or hesitation of the vaccine, by addressing the common reasons for the refusal of the vaccine and highlight the vaccine's benefits.

Effect of A Community Health Worker led Intervention on Skilled Birth Care in Rural Mwingi West Sub-County, Kenya: A Quasi Experimental Study.

Despite strong evidence that skilled birth care (SBC) significantly reduces maternal deaths, one in four babies worldwide are delivered without SBC. This has kept maternal mortality rates (MMR) high in sub-Saharan Africa and Kenya in particular. Kenya adopted Community Health Strategy (CHS) with the aim of improving community health services. The aim of this study was to evaluate the effect of CHS on SBC in Mwingi west sub-county, Kenya. A quasi experimental study design was conducted with 1 pretest and 2 post-test household surveys done in intervention and control sites. Sample size in each survey was 422 households. Women with a child aged 9-12 months were main respondents. Binary logistic regression analysis was used to estimate the odds of SBC utilization before and after the intervention In intervention site; SBC utilization significantly improved by 12.9% (57.9% vs. 70.5%) and women in end term survey were 1.6 times (Adj. OR=1.556, P <0.0001; 95%CI: 1.295-1.868) more likely to deliver under SBC compared to baseline. Compared to control, the proportion of women delivering under SBC in intervention site increased by 8.6%. To improve maternal and child health outcomes in Kenya, implementation of CHS should be fast tracked in all counties.

Community health worker interventions are key to optimal infant immunization coverage, evidence from a pretest-posttest experiment in Mwingi, Kenya.

INTRODUCTION: Immunization is a powerful and cost-effective health intervention which averts an estimated 2 to 3 million deaths every year. Kenya has a high infant and under five mortality and morbidity rates. Increasing routine child immunization coverage is one way of reducing child morbidity and mortality rates in Kenya. Community Health Workers (CHWs) have emerged as critical human resources for health in developing countries. The Community Strategy (CS) is one of the CHW led interventions promoting Maternal and Child Health (MCH) in Kenya. This study sought to establish the effect of CS on infant vaccination Coverage (IVC) in Mwingi west sub-county; Kenya. METHODS: This was a pretest - posttest experimental study design with 1 pretest and 2 post-test surveys conducted in intervention and control sites. Mwingi west and Mwingi north sub-counties where intervention and control sites respectively. Sample size in each survey was 422 households. Women with a child aged 9-12 months were main respondents. RESULTS: Intervention site end-term evaluation indicated that; the CS increased IVC by 10.1% (Z =6.0241, P <0.0001), from a suboptimal level of 88.7% at baseline survey to optimal level of 98.8% at end term survey. Infants in intervention site were 2.5 times more likely to receive all recommended immunizations within their first year of life [(crude OR= 2.475, P<0.0001; 95%CI: 1.794-3.414) (adj. OR=2.516, P<0.0001; 95%CI: 1.796-3.5240)]. CONCLUSION: CS increased IVC in intervention site to optimal level (98.8%). To improve child health outcomes through immunization coverage, Kenya needs to fast-track nationwide implementation of the CS intervention.

Efficiency and factors influencing efficiency of Community Health Strategy in providing Maternal and Child Health services in Mwingi District, Kenya: an expert opinion perspective.

INTRODUCTION: Community Health Strategy (CHS) is a new Primary Health Care (PHC) model in Kenya, designed to provide PHC services in Kenya. In 2011, CHS was initiated in Mwingi district as one of the components of APHIA plus kamili program. The objectives of this study was to evaluate the efficiency of the CHS in providing MCH services in Mwingi district and to establish the factors influencing efficiency of the CHS in providing MCH services in the district. METHODS: This was a qualitative study. Fifteen Key informants were sampled from key stakeholders. Sampling was done using purposive and maximum variation sampling methods. Semi-structured in-depth interviews were used for data collection. Data was managed and analyzed using NVIVO. Framework analysis and quasi statistics were used in data analysis. RESULTS: Expert opinion data indicated that the CHS was efficient in providing MCH services. Factors influencing efficiency of the CHS in provision of MCH services were: challenges facing Community Health Workers (CHWs), Social cultural and economic factors influencing MCH in the district, and motivation among CHWs. CONCLUSION: Though CHS was found to be efficient in providing MCH services, this was an expert opinion perspective, a quantitative Cost Effectiveness Analysis (CEA) to confirm these findings is recommended. To improve efficiency of the CHS in the district, challenges facing CHWs and Social cultural and economic factors that influence efficiency of the CHS in the district need to be addressed.

Voluntary medical male circumcision scale-up in Nyanza, Kenya: evaluating technical efficiency and productivity of service delivery.

BACKGROUND: Voluntary medical male circumcision (VMMC) service delivery is complex and resource-intensive. In Kenya's context there is still paucity of information on resource use vis-à-vis outputs as programs scale up. Knowledge of technical efficiency, productivity and potential sources of constraints is desirable to improve decision-making. OBJECTIVE: To evaluate technical efficiency and productivity of VMMC service delivery in Nyanza in 2011/2012 using data envelopment analysis. DESIGN: Comparative process evaluation of facilities providing VMMC in Nyanza in 2011/2012 using output orientated data envelopment analysis. RESULTS: Twenty one facilities were evaluated. Only 1 of 7 variables considered (total elapsed operation time) significantly improved from 32.8 minutes (SD 8.8) in 2011 to 30 minutes (SD 6.6) in 2012 (95%CI = 0.0350-5.2488; p = 0.047). Mean scale technical efficiency significantly improved from 91% (SD 19.8) in 2011 to 99% (SD 4.0) in 2012 particularly among outreach compared to fixed service delivery facilities (CI -31.47959-4.698508; p = 0.005). Increase in mean VRS technical efficiency from 84% (SD 25.3) in 2011 and 89% (SD 25.1) in 2012 was not statistically significant. Benchmark facilities were #119 and #125 in 2011 and #103 in 2012. Malmquist Productivity Index (MPI) at fixed facilities declined by 2.5% but gained by 4.9% at outreach ones by 2012. Total factor productivity improved by 83% (p = 0.032) in 2012, largely due to progress in technological efficiency by 79% (p = 0.008). CONCLUSIONS: Significant improvement in scale technical efficiency among outreach facilities in 2012 was attributable to accelerated activities. However, ongoing pure technical inefficiency requires concerted attention. Technological progress was the key driver of service productivity growth in Nyanza. Incorporating service-quality dimensions and using stepwise-multiple criteria in performance evaluation enhances comprehensiveness and validity. These findings highlight site-level resource use and sources of variations in VMMC service productivity, which are important for program planning.

Determinants of cervical screening services uptake among 18-49 year old women seeking services at the Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya.

BACKGROUND: Kenyan women aged ≥ 15 years are at risk of developing cervical cancer. Currently, cervical cytology reduces cervical cancer incidence, since it allows for early diagnosis and treatment. Uptake of cervical screening services is a priority research area in Kenya. Central to the success of any screening programme is its ability to identify, reach out and screen the defined target population. Cervical screening coverage in Kenya is currently at 3.2%. In Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) in Nyanza, the number screened for cervical cancer is low (averagely 3/day). Thus the current study sought to identify factors influencing uptake of cervical screening services at the facility. METHODS: In a cross-sectional study, knowledge, perceptions and cues for action associated with self-reported cervical screening uptake were explored. The targeted population (n = 424), purposively selected were women of child-bearing age (18-49 years) visiting JOOTRH. Data on socio-demographic status (age, level of education, marital status, job status, income level), knowledge of cervical cancer, perceptions on severity and susceptibility to the disease were collected using self-administered structured questionnaires. Statistical significance of differences in proportions were determined by chi-square analyses while logistic regression analyses were used to identify determinants of self-reported uptake of the service. RESULTS: Self-reported screening uptake was 17.5%. There was a strong positive association between age (P < 0.0001), level of education (P < 0.0001) and income levels (P = 0.005) with the uptake of the service. Knowledge level on the signs and symptoms of cervical cancer was an important determinant for being screened for cervical cancer (P < 0.0001). Furthermore, those who said they didn't know about the disease (OR, 26.84, 95% CI, 6.07-118.61, P < 0.0001) or were not aware about susceptibility to it (OR, 2.37, 95% CI, 1.10-5.08, P = 0.02) had a higher likelihood of not being screened. On cues for action, those who attended the child welfare clinic were more likely to be screened (OR, 2.31, 95% CI, 1.17-3.93, P = 0.03). CONCLUSION: Knowledge, perception of higher susceptibility and attending child welfare clinic are key determinants of self-reported uptake of cervical screening. Increasing knowledge, enhancing health education and providing free services may increase uptake among women population in such settings.

Systematic monitoring of male circumcision scale-up in Nyanza, Kenya: exploratory factor analysis of service quality instrument and performance ranking.

BACKGROUND: Considerable conceptual and operational complexities related to service quality measurements and variability in delivery contexts of scaled-up medical male circumcision, pose real challenges to monitoring implementation of quality and safety. Clarifying latent factors of the quality instruments can enhance contextual applicability and the likelihood that observed service outcomes are appropriately assessed. OBJECTIVE: To explore factors underlying SYMMACS service quality assessment tool (adopted from the WHO VMMC quality toolkit) and; determine service quality performance using composite quality index derived from the latent factors. STUDY DESIGN: Using a comparative process evaluation of Voluntary Medical Male Circumcision Scale-Up in Kenya site level data was collected among health facilities providing VMMC over two years. Systematic Monitoring of the Medical Male Circumcision Scale-Up quality instrument was used to assess availability of guidelines, supplies and equipment, infection control, and continuity of care services. Exploratory factor analysis was performed to clarify quality structure. RESULTS: Fifty four items and 246 responses were analyzed. Based on Eigenvalue >1.00 cut-off, factors 1, 2 & 3 were retained each respectively having eigenvalues of 5.78; 4.29; 2.99. These cumulatively accounted for 29.1% of the total variance (12.9%; 9.5%; 6.7%) with final communality estimates being 13.06. Using a cut-off factor loading value of ≥0.4, fifteen items loading on factor 1, five on factor 2 and one on factor 3 were retained. Factor 1 closely relates to preparedness to deliver safe male circumcisions while factor two depicts skilled task performance and compliance with protocols. Of the 28 facilities, 32% attained between 90th and 95th percentile (excellent); 45% between 50th and 75th percentiles (average) and 14.3% below 25th percentile (poor). CONCLUSION: the service quality assessment instrument may be simplified to have nearly 20 items that relate more closely to service outcomes. Ranking of facilities and circumcision procedure using a composite index based on these items indicates that majority performed above average.

Low levels of awareness despite high prevalence of schistosomiasis among communities in Nyalenda informal settlement, Kisumu city, western Kenya.

INTRODUCTION: Intestinal schistosomiasis is widely distributed around Lake Victoria in Kenya where about 16 million people in 56 districts are at risk of the infection with over 9.1 million infected. Its existence in rural settings has been extensively studied compared to urban settings where there is limited information about the disease coupled with low level of awareness. This study therefore assessed community awareness on existence, signs and symptoms, causes, transmission, control and risk factors for contracting schistosomiasis as well as attitudes, health seeking behaviour and environmental antecedents that affect its control so as to identify knowledge gaps that need to be addressed in order to strengthen schistosomiasis control interventions in informal urban settings. METHODS: The study was carried out in an informal urban settlement where the prevalence of intestinal schistosomiasis was previously reported to be the highest (36%) among the eight informal settlements of Kisumu city. The study adopted cross-sectional design and purposive sampling technique. Eight focus group discussions were conducted with adult community members and eight key informant interviews with opinion leaders. Data was audio recorded transcribed, coded and thematically analyzed using ATLAS.ti version 6 software. RESULTS: Most respondents stated having heard about schistosomiasis but very few had the correct knowledge of signs and symptoms, causes, transmission and control of schistosomiasis. However, there was moderate knowledge of risk factors and at high risk groups. Their attitudes towards schistosomiasis and its control were generally indifferent with a general belief that they had no control over their environmental circumstances to reduce transmission. DISCUSSION/CONCLUSION: Although schistosomiasis was prevalent in the study area, majority of the people in the community had low awareness. This study, therefore, stresses the need for health education to raise community's awareness on schistosomiasis in such settings in order to augment prevention, control and elimination efforts.

Provider knowledge of treatment policy and dosing regimen with artemether-lumefantrine and quinine in malaria-endemic areas of western Kenya.

BACKGROUND: Due to widespread anti-malarial drug resistance in many countries, Kenya included, artemisinin-based Combination Therapy (ACT) has been adopted as the most effective treatment option against malaria. Artemether-lumefantrine (AL) is the first-line ACT for treatment of uncomplicated malaria in Kenya, while quinine is preferred for complicated and severe malaria. Information on the providers' knowledge and practices prior to or during AL and quinine implementation is scanty. The current study evaluated providers' knowledge and practices of treatment policy and dosing regimens with AL and quinine in the public, private and not-for-profit drug outlets. METHODS: A cross-sectional survey using three-stage sampling of 288 (126 public, 96 private and 66 not-for-profits) providers in drug outlets was conducted in western Kenya in two Plasmodium falciparum-endemic regions with varying malarial risk. Information on provider in-service training, knowledge (qualification, treatment policy, dosing regimen, recently banned anti-malarials) and on practices (request for written prescription, prescription of AL, selling partial packs and advice given to patients after prescription), was collected. RESULTS: Only 15.6% of providers in private outlets had received any in-service training on AL use. All (100%) in public and majority (98.4%) in not-for-profit outlets mentioned AL as first line-treatment drug. Quinine was mentioned as second-line drug by 47.9% in private outlets. A total of 92.0% in public, 57.3% in private and 78.8% in not-for-profit outlets stated correct AL dose for adults. A total of 85.7% of providers in public, 30.2% in private and 41.0% in not-for-profit outlets were aware that SP recommendations changed from treatment for mild malaria to IPTp in high risk areas. In-service training influenced treatment regimen for uncomplicated malaria (P = 0.039 and P = 0.039) and severe malaria (P < 0.0001 and P = 0.002) in children and adults, respectively. Most (82.3%) of private outlets sell partial packs of AL while 72.4% do not request for written prescription for AL. In-service training influenced request for written prescription (P = 0.001), AL prescription (P < 0.0001) and selling of partial packs (P < 0.0001). CONCLUSION: Public-sector providers have higher knowledge on treatment policy and dosing regimen on recommended anti-malarials. Changes in treatment guidelines should be accompanied by subsequent implementation activities involving all sector players in unbiased strategies.

Home-based Health Care(HBHC): are women caregivers at risk? A study of Busia and Teso districts in Western Kenya.

CONTEXT: Most caregivers of people living with HIV/AIDS (PLWHA) in rural Kenya are women. In resource-limited situations, this can be a challenging and risky responsibility. OBJECTIVE: Assess the risk factors to which home-based caregivers are exposed. SETTING: Study of Home-based Health Care (HBHC) activities done in the Busia and Teso Districts of Western Kenya, with 824 patients under HBHC, from April 2004-April 2005. The Ministry of Health HBHC Policy in 2000 reduced bed-occupancy in Government Health facilities. Consequently, many AIDS-Related-Infections (ARI) patients, upon discharge, were nursed by relatives. METHODS: Relevant information reviewed and data collected using: questionnaires; personal and key informant interviews (KII); and observation of caregivers' working conditions and protective measures. RESULTS: The majority of home caregivers were women. Most caregivers (85%) were unaware of risks involved in PLWHA caregiving. Fifty-two percent had chest pains and coughs, 55% skin infections and 24% tuberculosis. Over 8% were found to be HIV+ upon testing at the Voluntary Counselling and Testing (VCT) clinic. CONCLUSIONS: Women, and sometimes young children, assume the caregiving burden. Ignorance of risks and non-use of protection may predispose these caregivers to infections. Results point to the need for advocacy to improve the working conditions of home-based caregivers by primary health care policy makers. Finally, because the caregivers were sexually inactive, the caregivers that were HIV+ attributed their infections to nursing PLWHA.