Maternal and child health indicators in primary healthcare facilities: Findings in a health systems quasi-experimental study in western Kenya.

Background and purpose: Maternal and infant mortality are higher in low-income than in high-income countries due to weak health systems. The objective of this study was to improve access, utilization and quality of Maternal and Child Health care through a predesigned Enhanced Health Care System (EHC) that embodies the World Health Organization (WHO) pillars of the health system. Design and methodology: This study was conducted in two dispensaries in the Counties of Busia and Bungoma in Kenya as intervention sites and in four control clusters in Kakamega, Uasin Gishu, Trans Nzoia and Elgeyo Marakwet Counties. The study population was pregnant women and their children delivered over the study period in the intervention and control clusters.A quasi-experimental study design was used to conduct the study between 2015 and 2020 to compare the outcomes of the implementation of the EHC using the Find Link Treat and Retain (FLTR) strategy in one cluster, community owned initiatives in the other cluster and four control clusters at baseline and at the end of the study. A baseline survey was conducted in year one and an end line survey in the fifth year. Continuous data collection on maternal and childhood health indicators was done in all the six clusters and comparison made at the end of the study between the clusters. Results: We found a 26%, 10.3% and 0.8% increase in antenatal care (ANC) attendance in the intervention clusters of Obekai, Kabula and control clusters respectively. There was a 28.2%, 5.8% and 17.0% increase in attendance of 4+ ANC clinics of Obekai, Kabula and control clusters respectively. There was a 24% and 13% increase in Obekai and Kabula respectively in contraceptive use and a 2% decrease in contraceptive use in the control locations. There was a 38.2%, 25.6% and 34.7% increase in facility deliveries over the study period in Obekai, Kabula and control clusters respectively. There was a marked increase in immunization coverage in the intervention clusters of Obekai and Kabula compared to a significant decrease in control clusters for BCG, polio, pentavalent and measles. Conclusions and recommendations: In conclusion, use of the health systems approach in health care provision provides a holistic improvement in access and utilization of health services and in the improvement of health indicators.We do recommend that a systems approach be used in health services delivery to improve access, utilization and quality of health care provision at community and primary care levels.

Improving maternal and child health outcomes through a community involvement strategy in Kabula location, Bungoma County, Kenya.

Background: Maternal, fetal and neonatal mortality are higher in low-income compared to high-income countries due to weak health systems including poor access and utilization of health services. Despite enormous recent improvements in maternal, neonatal and under five children health indicators, more rapid progress is needed to meet the targets including the Sustainable Development Goal 3(SDG). In Kenya these indicators are still high and comprehensive systems are needed to attain these goals. Objective: To facilitate innovative partnerships in health care provision and to assess trends in access, utilization and quality of Maternal and Child Health care through the health systems approach using community owned initiatives including use of community owned resourse persons (CORPs), establishment of Community Based Organisations (CBOs) and Income Generating Activities(IGAs). Study site: This was implemented in Kabula location, Bungoma County, Kenya between January 2016 and April 2019. Study population: Pregnant women, newborns and under-five children living in Kabula location identified by Community Owned Resource Persons (CORPs). Methods: A prospective study to show trends in maternal, neonatal and infant outcomes through the implementation of community owned initiatives. Findings: General, under five and antenatal clinic attendance increased four fold in 2016,2017 and 2018. There was a 76% full immunization coverage with 97% BCG and 84% Polio coverage respectively among children studied. There was an 87% facility delivery rate among the pregnant women enrolled in the study. Conclusions: Trends in Maternal and under-five health indicators in Kabula showed improvements over the study period following the implementation of the community owned initiatives and community participation. Recommendations: The community owned initiatives as implemented in this study is useful in primary care and universal health coverage programs in health care delivery systems in LMICs.

A system approach to improving maternal and child health care delivery in Kenyan communities and primary care facilities: baseline survey on maternal health.

BACKGROUND: Maternal, fetal and neonatal mortality are 10 to 100 fold higher in many low-income compared to high-income countries. Reasons for these discrepancies include limited antenatal care and delivery outside health facilities. OBJECTIVES: The study aimed at conducting a baseline survey to assess the current levels of maternal health indicators in six counties in Western Kenya. METHODS: This was a cross sectional study conducted targeting women residing in Uasin-Gishu, ElgeyoMarakwet, TransNzoia, Bungoma, Busia and Kakamega counties who had given birth five years prior to the interview. Socio-demographic and maternal indicators were collected using forms adopted from KDHS 2009. Interviews were conducted in the homesteads between December 2015 and June 2016. RESULTS: A total of 6257 women participated in the study, median age 27 years IQR 23-32. Majority of the women had post-primary level of education, were married and 40% were members of an income-generating activity. 56.8% were using modern family planning method, 49% attended WHO recommended four plus antenatal clinic visits and only 20% attended in the first trimester. Majority, 85% had their most recent delivery in a health facility. CONCLUSION: Findings suggest that women are not attending recommended four plus antenatal clinic visits and even those that attend are few are during the first trimester.

Potential benefits of triage for the trauma patient in a Kenyan emergency department.

BACKGROUND: Improved trauma management can reduce the time between injury and medical interventions, thus decreasing morbidity and mortality. Triage at the emergency department is essential to ensure prioritization and timely assessment of injured patients. The aim of the present study was to investigate how a lack of formal triage system impacts timely intervention and mortality in a sub-Saharan referral hospital. Further, the study attempts to assess potential benefits of triage towards efficient management of trauma patients in one middle income country. METHODS: A prospective descriptive study was conducted. Adult trauma patients admitted to the emergency department during an 8-month period at Moi Teaching and Referral Hospital in Eldoret, Kenya, were included. Mode of arrival and vital parameters were registered. Variables included in the analysis were Injury Severity Score, time before physician's assessment, length of hospital stay, and mortality. The patients were retrospectively categorized according to the Rapid Emergency Triage and Treatment System (RETTS) from patient records. RESULTS: A total of 571 patients were analyzed, with a mean Injury Severity Score of 12.2 (SD 7.7) with a mean length of stay of 11.6 (SD 18.3) days. The mortality rate was 1.8%. The results obtained in this study illustrate that trauma patients admitted to the emergency department at Eldoret are not assessed in a timely fashion, and the time frame recommendations postulated by RETTS are not adhered to. Assessment of patients according to the triage algorithm used revealed a significantly higher average Injury Severity Score in the red category than in the other color categories. CONCLUSION: The results from this study clearly illustrate a lack of correct prioritization of patients in relation to the need for timely assessment. This is further demonstrated by the retrospective triage classification of patients, which identified patients with high ISS as in urgent need of care. Since no significant difference in to time to assessment regardless of injury severity was observed, the need for a well-functioning triage system is apparent.

A system approach to improving maternal and child health care delivery in Kenya: innovations at the community and primary care facilities (a protocol).

BACKGROUND: Maternal, fetal and neonatal mortality are higher in low-income compared to high-income countries due to weak health systems including poor access and utilization of health services. Despite enormous recent improvements in maternal, neonatal and under 5 health indicators, more rapid progress is needed to meet the targets including the Development Goal 3(SDG). In Kenya these indicators are still high and comprehensive systems are needed to attain the targets of the SDG 3 by 2030. We describe the structure and methods of a study to assess the impact of an innovative system approach on maternal, neonatal and under-five children outcomes. This will be implemented in two clusters in the Counties of Busia and Bungoma in Kenya. There will be 4 control clusters in Kakamega, UasinGishu, Trans Nzoia and Elgeyo Marakwet Counties in Kenya. The study population will be pregnant women, newborns and under-five children identified over the study period. The objective of the study is to improve access, utilization and quality of Maternal and Child Health care through a predesigned Enhanced Health Care System (EHC) that embodies six WHO pillars of the health system and community owned initiatives including Community Based Organisations and Income Generating Activities. METHODS/DESIGN: A five year quasi-experimental design will be used to compare the outcomes of the implementation of the EHC using the Find Link Treat and retain (FLTR) strategy in one cluster, community owned initiatives in one cluster and four control clusters at baseline and at the end of the study. A Baseline survey will be conducted in year one and an endline in the fifth year in which maternal, neonatal and underfive childhood outcomes will be compared. DISCUSSION: The expected findings from the study include showing trends in improvement in the intervention clusters for morbidity, mortality, health service utilization and access indicators. Use of the health systems approach in health care provision is expected to provide a holistic improvement in the quality of care in the study populations in the intervention clusters that will lead to improved health indicators including morbidity and mortality. It is expected that the findings will inform health policy of the national and county governments in Kenya and worldwide.

Assessing the impact of an emergency trauma course for senior medical students in Kenya.

INTRODUCTION: Ninety percent of all injury-related deaths occur in low- and middle-income countries. The WHO recommends short, resource-specific trauma courses for healthcare providers. Studies show that teaching trauma courses to medical students in developed countries leads to significant increases in knowledge and skill. High costs hinder widespread and sustained teaching of these courses in low-income countries. METHODS: A two-day trauma course was designed for students at Moi College of Health Sciences in Eldoret, Kenya. Participants underwent pre- and post-course written and simulation testing and rated their confidence in 21 clinical scenarios and 15 procedures pre- and post-course using a five point Likert scale. A subset of the students was re-evaluated nine months post-course. Using the paired t-test, mean written, simulation and confidence scores were compared pre-course, immediately post-course and nine months post-course. RESULTS: Twenty-two students were enrolled. Written test score means were 61.5% pre-course and 76.9% post-course, mean difference 15.5% (p < 0.001). Simulation test score means were 36.7% pre-course and 82.2% post-course, mean difference 45.5% (p < 0.001). Aggregate confidence scores were 3.21 pre-course and 4.72 post-course (scale 1-5). Ten out of 22 (45.5%) students were re-evaluated nine months post-course. Results showed written test score mean of 75%, simulation score mean of 61.7%, and aggregate confidence score of 4.59 (scale 1-5). Mean differences between immediate post- and nine months post-course were 1.6% (p = 0.75) and 8.7% (p = 0.10) for the written and simulation tests, respectively. CONCLUSION: Senior Kenyan medical students demonstrated statistically significant increases in knowledge, skills and confidence after participating in a novel student trauma course. Nine months post-course, improvements in knowledge skills and confidence were sustained.

Assessing the impact of an emergency trauma course for senior medical students in Kenya

Introduction:Ninety percent of all injury-related deaths occur in low- and middle-income countries. The WHO recommends short, resource-specific trauma courses for healthcare providers.Studies show that teaching trauma courses to medical students in developed countries leads to significant increases in knowledge and skill. High costs hinder widespread and sustained teaching of these courses in low-income countries.Methods:A two-day trauma course was designed for students at Moi College of Health Sciences in Eldoret,Kenya. Participants underwent pre- and post-course written and simulation testing and rated their confidence in 21 clinical scenarios and 15 procedures pre- and post-course using a five point Likert scale. A subset of the students was re-evaluated nine months post-course. Using the pairedt-test, mean written, simulation and confidence scores were compared pre-course,immediately post-course and nine months post-course.Results:Twenty-two students were enrolled. Written test score means were 61.5% pre-course and 76.9%post-course, mean difference 15.5% (p < 0.001). Simulation test score means were 36.7% pre-course and 82.2% post-course, mean difference 45.5% (p < 0.001). Aggregate confidence scores were 3.21 pre-course and 4.72 post-course (scale 1­5). Ten out of 22 (45.5%) students were re-evaluated nine months post- course. Results showed written test score mean of 75%, simulation score mean of 61.7%, and aggregate confidence score of 4.59 (scale 1­5). Mean differences between immediate post- and nine months post-course were 1.6% (p = 0.75) and 8.7% (p = 0.10) for the written and simulation tests, respectively.Conclusion: Senior Kenyan medical students demonstrated statistically significant increases in knowledge, skills and confidence after participating in a novel student trauma course. Nine months post-course, improvements in knowledge skills and confidence were sustained