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.

Perceived competency deficits and challenges of family medicine trainees in sub-Saharan Africa.

BACKGROUND: A competency-based approach to family medicine (FM) post graduate (PG) training falls short of a holistic process if it focuses only on patients' needs without eliciting those of trainees. AIM: To identify perceived competency deficits of trainees and challenges hindering achievement of learning outcomes. SETTING: PG FM programmes in sub-Saharan Africa. METHODS: We conducted a cross-sectional survey using a web-based questionnaire with a list of competency items and challenges. Common Factor Analysis was used to ascertain which competency items and challenges accounted for the highest shared variability. A perceived competency deficit was assumed for any item with a component loading of <0.5. For challenges, higher component loadings denoted higher levels of agreement with the annotated item. Data were analysed using SPSS (version 16). RESULTS: A total of 150 trainees took the survey. Appraising and utilising scientific knowledge was the item with a perceived competency deficit, while poor mentor-mentee relationship was considered the foremost challenge that hindered learning outcomes. CONCLUSION: Critical appraisal and utilisation of scientific knowledge should be part of every stage of the African FM trainee's learning experience. To achieve this and other learning outcomes, improving mentor-mentee relationships are essential.

The quality of primary care performance in private sector facilities in Nairobi, Kenya: a cross-sectional descriptive survey.

BACKGROUND: Integrated health services with an emphasis on primary care are needed for effective primary health care and achievement of universal health coverage. The key elements of high quality primary care are first-contact access, continuity, comprehensiveness, coordination, and person-centredness. In Kenya, there is paucity of information on the performance of these key elements and such information is needed to improve service delivery. Therefore, the study aimed to evaluate the quality of primary care performance in private sector facilities in Nairobi, Kenya. METHODS: A cross-sectional descriptive study using an adapted Primary Care Assessment Tool for the Kenyan context and surveyed 412 systematically sampled primary care users, from 13 PC clinics. Data were analysed to measure 11 domains of primary care performance and two aggregated primary care scores using the Statistical Package for Social Sciences. RESULTS: Mean primary care score was 2.64 (SD=0.23) and the mean expanded primary care score was 2.68 (SD=0.19), implying an overall low performance. The domains of first contact-utilisation, coordination (information system), family-centredness and cultural competence had mean scores of >3.0 (acceptable to good performance). The domains of first contact-access, coordination, comprehensiveness (provided and available), ongoing care and community-orientation had mean scores of < 3.0 (poor performance). Older respondents (p=0.05) and those with higher affiliation to the clinics (p=0.01) were more likely to rate primary care as acceptable to good. CONCLUSION: These primary care clinics in Nairobi showed gaps in performance. Performance was rated as acceptable-to-good for first-contact utilisation, the information systems, family-centredness and cultural competence. However, patients rated low performance related to first-contact access, ongoing care, coordination of care, comprehensiveness of services, community orientation and availability of a complete primary health care team. Performance could be improved by deploying family physicians, increasing the scope of practice to become more comprehensive, incentivising use of these PC clinics rather than the tertiary hospital, improving access after-hours and marketing the use of the clinics to the practice population.

Communication skills of general practitioners in Nairobi, Kenya: a descriptive observational study.

BACKGROUND: High-quality primary care needs to be person-centred, and GPs must communicate effectively to ensure continuity and coordination of care. In Kenya, there is little knowledge about the quality of communication in consultations by GPs. AIM: To evaluate the quality of communication in consultations by GPs. DESIGN & SETTING: Descriptive, observational study of 23 GP consultations in 13 private sector primary care facilities in Nairobi, Kenya. METHOD: One consultation with a randomly selected adult patient was recorded per GP, and 16 communication skills evaluated with the Stellenbosch University Observation Tool (SUOT). A total percentage score was calculated per consultation, and compared with the GPs' demographics and the consultation complexity and duration using the Statistical Package for Social Sciences (SPSS, version 25). RESULTS: The GPs' median age was 30.0 years (interquartile range [IQR] 29.0-32.0) and median consultation time was 7.0 minutes (IQR 3.0-9.0). Median overall score was 64.3% (IQR 48.4-75.7). GPs demonstrated skills in gathering information, making and explaining the diagnosis, and suggesting appropriate management. GPs did not make an appropriate introduction, explore the context or patients' perspectives, allow shared decision making, or provide adequate safety netting. There was a positive correlation between the scores and duration of the consultations (r = 0.680; P = 0.001). The score was higher in consultations of moderate complexity (78.1, IQR 57.1-86.7) versus low complexity (52.2, IQR 45.1-66.6) (P = 0.012). CONCLUSION: Consultations were brief and biomedical by young GPs. GPs need further training in communication skills, particularly with regard to delivering person-centred consultations. Deploying family physicians to the primary care setting would also improve the overall quality of service delivery.

Clinical skills of general practitioners in Nairobi, Kenya: a cross-sectional study.

BACKGROUND: Quality service delivery in primary care requires motivated and competent health professionals. In the Kenyan private sector, GPs with no postgraduate training in family medicine offer primary care. There is a paucity of evidence on the ability of primary care providers to deliver comprehensive care and no such evidence is available for GPs practising in the private sector in Kenya. AIM: To evaluate GPs' training and experience in the skills required for comprehensive primary care. DESIGN AND SETTING: A cross-sectional descriptive survey in 13 primary care clinics in the private sector of Nairobi, Kenya. METHOD: A questionnaire, originally designed for a national survey of primary care doctors in South Africa, was adapted. The study collected self-reported data on performance of clinical skills by 25 GPs. Data were analysed using the Statistical Package for Social Sciences (SPSS, version 25). RESULTS: GPs were mostly aged <40 years, with ≤10 years of experience, and there was an equal sex distribution. GPs reported moderate performance with adult health, communication and consultation, and clinical administration; and weak performance with emergencies, child health, surgery, ear, nose, and throat (ENT) and eyes, women's health, and orthopaedics. The GPs lacked training in specific skills such as proctoscopies, contraceptive devices, skin procedures, intra-articular injections, red reflex tests, and use of genograms. CONCLUSION: GPs lacked training and performed poorly in some of the essential skills required in primary care. Continuing professional development, training in family medicine, broadening the model of care, and deployment of family physicians to the clinics could improve care comprehensiveness.

Evaluation of the quality of service delivery in private sector, primary care clinics in Kenya: A descriptive patient survey.

BACKGROUND: The quality of service delivery in primary care (PC) is an important determinant of clinical outcomes. The patients' perspective is one significant predictor of this quality. Little is known of the quality of such service delivery in the private sector in Kenya. The aim of the study was to evaluate the quality of service delivery in private sector, PC clinics in Nairobi, Kenya. METHODS: The study employed a descriptive cross-sectional survey by using the General Practice Assessment Questionnaire in 378 randomly selected patients from 13 PC clinics. Data were analysed using the Statistical Package for Social Sciences. RESULTS: Overall, 76% were below 45 years, 74% employed and 73% without chronic diseases. Majority (97%) were happy to see the general practitioner (GP) again, 99% were satisfied with their consultation and 83% likely to recommend the GP to others. Participants (97%) found in receptionist helpful and the majority were happy with the opening hours (73%) and waiting times (85%). Although 84% thought appointments were important, only 48% felt this was easy to make, and only 44% were able to access a particular GP on the same day. Overall satisfaction was higher in employed (98%) versus those unemployed (95%), studying (93%) or retired (94%) (p 0.001). CONCLUSION: Patients reported a high quality of service delivery. Utilisation was skewed towards younger, employed adults, without chronic conditions, suggesting that PC was not fully comprehensive. Services were easily accessible, although with little expectation of relational continuity. Further studies should continue to evaluate the quality of service delivery from other perspectives and tools.

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.

Lifestyle, cardiovascular risk knowledge and patient counselling among selected sub-Saharan African family physicians and trainees.

BACKGROUND:  Cardiovascular disease (CVD)-related deaths in sub-Saharan Africa (SSA) are on the rise, and primary care physicians could facilitate the reversal of this trend through treatment and prevention strategies. AIM:  The aim of this study was to determine the relationship between physician lifestyle practices, CVD prevention knowledge and patient CVD counselling practices among family physicians (FPs) and family medicine (FM) trainees affiliated to FM colleges and organisations in SSA. SETTING:  FPs and FM trainees affiliated to FM colleges and organisations in Anglophone SSA. METHODS:  A web-based cross-sectional analytical study was conducted using validated, self-administered questionnaires. Following collation of responses, the relationship between the participants' CVD prevention knowledge, lifestyle practices and CVD counselling rates was assessed. RESULTS:  Of the 174 participants (53% response rate), 83% were married, 51% were females and the mean age was 39.2 (standard deviation [SD] 7.6) years. Most of the participants responded accurately to the CVD prevention knowledge items, but few had accurate responses on prioritising care by 10-year risk. Most participants had less than optimal lifestyle practices except for smoking, vegetable or fruit ingestion and sleep habits. Most participants (65%) usually counselled patients on nutrition, but less frequently on weight management, exercise, smoking and alcohol. The region of practice and physicians with poor lifestyle were predictive of patient counselling rates. CONCLUSION:  Training on patient counselling and self-awareness for CVD prevention may influence patient counselling practice. Promoting quality training on patient counselling among FPs as well as a healthy self-awareness for CVD prevention is thus needed. The complex relationship between physician lifestyle and patient counselling warrants further study.

Perceptions regarding the scope of practice of family doctors amongst patients in primary care settings in Nairobi.

BACKGROUND:  Primary care (PC) is the foundation of the Kenyan health care system, providing comprehensive care, health promotion and managing all illnesses across the lifecycle. In the private sector in Nairobi, PC is principally offered by the general practitioners, also known as family doctors (FDs). The majority have no postgraduate training. Little is known about how patients perceive their capability. AIM:  To assess patients' perceptions of the scope of practice of FDs working in private sector PC clinics in Nairobi and their awareness of the new category of family physicians (FPs) and the discipline of family medicine. SETTING:  Private sector PC clinics in Nairobi. METHODS:  A descriptive survey using a structured, self-administered questionnaire. Simple random sampling was used to recruit 162 patient participants. RESULTS:  Of the participants, 30% knew the difference between FPs and FDs. There was a high to moderate confidence that FDs could treat common illnesses; provide lifestyle advice; family planning (66%) and childhood immunisations (64%). In adolescents and adults, low confidence was expressed in their ability to manage tuberculosis (58%), human immunodeficiency virus (55%) and cancer (33%). In the elderly, there was low confidence in their ability to manage depression (55%), anxiety (57%), urinary incontinence (57%) and diabetes (59%). There was low confidence in their ability to provide antenatal care (55%) and Pap smears (42%). CONCLUSION:  Patients did not perceive that FDs could offer fully comprehensive PC services. These perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing FPs.

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.