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Objective: To develop and assess an alternative care model using community-based groups for people living with HIV and facilitate by lay personnel., Methods: Geographic locations in the Academic Model Providing Access to Healthcare Kitale clinic catchment were randomized to standard of care versus a community-based care group (ART Co-op). Adults stable on antiretroviral therapy and virally suppressed were eligible. Research Assistant-led ART Co-ops met in the community every 3 months. Participants were seen in the HIV clinic only if referred. CD4 count and viral load were measured in clinic at enrollment and after 12 months. Retention, viral suppression, and clinic utilization were compared between groups using χ2, Fisher exact, and Wilcoxon rank sum tests., Results: At 12 months, there were no significant differences in mean CD4 count or viral load suppression. There was a significant difference in patient retention in assigned study group between the intervention and control group (81.6% vs 98.6%; P < 0.001), with a number of intervention patients withdrawing because of stigma, relocation, pregnancy, and work conflicts. All participants, however, were retained in an HIV care program for the study duration. The median number of clinic visits was lower for the intervention group than that for the control group (0 vs 3; P < 0.001)., Conclusions: Individuals retained in a community-based HIV care model had clinical outcomes equivalent to those receiving clinic-based care. This innovative model of HIV care addresses the problems of insufficient health care personnel and patient retention barriers, including time, distance, and cost to attend clinic, and has the potential for wider implementation., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a“work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Purpose: The purpose of this article is to provide a general review of the health-care needs in Kenya which focuses on the role of community engagement in facilitating access and diminishing barriers to quality care services. Health-care concerns throughout Kenya and the culture of Kenyan's health-care practices care are considered. Design/methodology/approach: A comprehensive review covered studies of community engagement from 2000 till present. Studies are collected using Google Scholar, PubMed, EBSCOhost and JSTOR and from government and nongovernment agency websites. The approach focuses on why various populations seek health care and how they seek health care, and on some current health-care delivery models. Findings: Suggestions for community engagement, including defining the community, are proposed. A model for improved health-care delivery introduces community health workers (CHWs), mHealth technologies and the use of mobile clinics to engage the community and improve health and quality of care in low-income settings. Practical implications: The results emphasize the importance of community engagement in building a sustainable health-care delivery model. This model highlights the importance of defining the community, setting goals for the community and integrating CHWs and mobile clinics to improve health status and decrease long-term health-care costs. The implementation of these strategies contributes to an environment that promotes health and wellness for all. Originality/value: This paper evaluates health-care quality and access issues in Kenya and provides sustainable solutions that are linked to effective community engagement. In addition, this paper adds to the limited number of studies that explore health-care quality and access alongside community engagement in low-income settings.

Background: Removing user fees in primary health care services is one of the most critical policy issues being considered in Africa. User fees were introduced in many African countries during the 1980s and their impacts are well documented. Concerns regarding the negative impacts of user fees have led to a recent shift in health financing debates in Africa. Kenya is one of the countries that have implemented a user fees reduction policy. Like in many other settings, the new policy was evaluated less that one year after implementation, the period when expected positive impacts are likely to be highest. This early evaluation showed that the policy was widely implemented, that levels of utilization increased and that it was popular among patients. Whether or not the positive impacts of user fees removal policies are sustained has hardly been explored. We conducted this study to document the extent to which primary health care facilities in Kenya continue to adhere to a 'new' charging policy 3 years after its implementation. Methods: Data were collected in two districts (Kwale and Makueni). Multiple methods of data collection were applied including a cross-sectional survey (n = 184 households Kwale; 141 Makueni), Focus Group Discussions (n = 12) and patient exit interviews (n = 175 Kwale; 184 Makueni). Results: Approximately one third of the survey respondents could not correctly state the recommended charges for dispensaries, while half did not know what the official charges for health centres were. Adherence to the policy was poor in both districts, but facilities in Makueni were more likely to adhere than those in Kwale. Only 4 facilities in Kwale adhered to the policy compared to 10 in Makueni. Drug shortage, declining revenue, poor policy design and implementation processes were the main reasons given for poor adherence to the policy. Conclusion: We conclude that reducing user fees in primary health care in Kenya is a policy on paper that is yet to be implemented fully. We recommend that caution be taken when deciding on how to reduce or abolish user fees and that all potential consequences are carefully considered. [ABSTRACT FROM AUTHOR]

Purpose: This paper aims to present a literature review of the health workforce, hospital and clinic systems, infrastructure, primary care, regulatory climate, the pharmaceutical industry and community health behavior of the Kenyan health-care system with the purpose of providing a thorough background on the health-care environment in Kenya. Design/methodology/approach: A systematic literature review was conducted using Pub Med, searching for "Kenya" in the title of articles published from January 1, 2015 to February 24, 2016; this provided a broad overview of the type of research being conducted in Kenya. Other data provided by governmental agencies and non-governmental agencies was also reviewed to describe the current state of population health in Kenya. Findings: An initial review of 615 Pubmed articles included 455 relevant articles. A complete review of these studies was conducted, resulting in a final sample of 389 articles. These articles were categorized into three main subject areas with 14 secondary subject areas (Figure 1). Research limitations/implications: The narrow scope of the search parameters set for the systematic review was a necessary limitation to focus on the most relevant literature. The findings of this study provide a thorough background on health care in Kenya to researchers and practitioners. Originality/value: This compilation of data specific to Kenya provides a detailed summary of both the country's health-care services and health status, focusing on potential means of realizing increased quality and length of life.

Kenyan sex worker-led organisations (SWLOs) often play a key role in the national HIV response. Accounts of these organisations frequently focus on their community-led approaches to promote sexual health. This paper addresses sensitisation, an underexplored but significant activity in the political agency of sex workers (SWs). Drawing on ethnographic fieldwork in a male SWLO in Nairobi, we examine how male SWs strategically use their position in the national HIV response to create spaces of police sensitisation. Taking police sensitisation as a manifestation of community-led advocacy and a 'politics of small steps', we examine how SWs respond to, resist and remake the political landscape of police violence. The strategy supports SWs in changing existing power relationships between themselves and the police, albeit within the confines of a criminalising legal system. The analysis of sensitisation practices supports a reimagining of SWLOs that stresses their political agency in the production of new political spaces and expands the focus on African SWLOs beyond HIV work to their political activities, which advance SWs' health, rights and social justice. [ABSTRACT FROM AUTHOR]

Purpose: This paper is a commentary which aims to address themes arising from the article by Bunning et al. entitled "Empowering caregivers of children with learning and developmental disabilities: from situation analysis to community-based inclusive development in Kilifi, Kenya". Design/methodology/approach: This commentary provides discussion stimulated by the paper by Bunning et al., including important areas for consideration when developing and evaluating care pathways or solutions to providing support to families of children with disabilities in low- and middle-income countries. Findings: This commentary highlights issues such as: the value of transported and home-grown approaches; the importance of empowerment and advocacy; and the benefits of equitable collaborative partnerships between researchers in low- and middle-income countries and those in high-income countries. Originality/value: This is the personal perspective of two collaborators who have been working in the field of service delivery of complex interventions for children with developmental disabilities in high- and low-income country settings. [ABSTRACT FROM AUTHOR]

Since the 1990s, researchers have used community-based participatory approaches to achieve outcomes relevant to local communities, to build collaborative and sustainable research infrastructures, and to address disparities in knowledge production. Notwithstanding these strengths, communities and researchers have questioned its success in addressing power imbalances inherent in collaborative research encounters. In this methodological paper, we describe a novel community-based program science approach to guide an interdisciplinary research project on HIV self-testing among men who have sex with men in three Kenyan counties. Drawing on ethnographic field notes, we detail how community researchers and their academic and programmatic partners collaborated through all phases of the research process, including research design and data collection. Importantly, community researchers also played an integral role in data analysis and dissemination, going well beyond the conventional role of 'community engagement' in global health research. We also present findings from qualitative interviews conducted by community researchers with their peers to inform the rollout of HIV self-testing kits in their respective county-contexts. Our approach highlights that engaging community directly in evidence production allows research findings – owned and generated by communities on their own behalf – to be fed more swiftly and effectively into community-led program delivery. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this paper is to explore the views of orphans and vulnerable children (OVC) on the kind of psychosocial support they receive in a community-based organization (CBO) in Kenya. Design/methodology/approach: This is a mixed approach study that utilized a qualitative approach through individual interviews and quantitative approach through the use of unstructured and structured questionnaire for data collection. This mixed approach was selected since rich information could be obtained from individual interviews and was validated through quantitative data. Qualitative data were collected through individual interviews for OVC, social workers and child counseling psychologist. The items used in the individual interview guide were generated based on three areas of research interests, namely, psychological, educational and social interventions. The individual interview questions focused on what was currently being offered to OVC, their views about such services, the challenges they might be facing and suggestions for improvement. The unstructured questionnaire was designed in an open-ended manner to allow the respondents to express their views freely on the kind of psychosocial support they were receiving within the CBO. The unstructured questionnaire was divided into thematic areas, namely, psychological support, social support and educational support. The structured questionnaire was used to collect data on psychosocial support that children receive within the CBO. The items were in form of a "YES/NO" format since the children could be able to understand them so easily and respond accordingly. Both methods of data collection were selected to allow triangulation of data and improve the credibility and generalizability of data. Findings: The findings of this study revealed that the psychosocial support for the OVC was taken care of within the CBO. The OVC get psychological support through the counseling and peer-group support, while educational intervention was done through the provision of school uniforms and educational materials. But there is a need to encourage the families to engage in income generating activities so as to help them become independent instead of overburdening the CBO which is already straining in terms of resources. The OVC also get health care support as well as shelter and accommodation. Research limitations/implications: The study had few limitations just like any other study. One of the limitations was the few numbers of participants who took part in the study. A larger sample could have provided more information that can easily be generalized to other OVC within any given organization. But despite this limitation, the information obtained was useful in shedding light on the kind of psychosocial support that the OVC is receiving within the CBO. Practical implications: Resources are required for an extensive research to establish the effectiveness of such services on improving the lives of OVC within the society rather than the superficial way of care without considering their psychosocial well-being. This study recommends that more support is required from the governments, the donors and other international bodies to support the escalating numbers of OVC within the society. Social implications: Since the numbers of OVC are escalating globally, the findings of this study could add value to the importance of psychosocial support that the OVC receive within the CBO. It also gives directions for policy and program development that targets OVC in Kenya and in other parts of the world. Originality/value: This is a research paper whereby the data were collected from the OVC and analyzed to generate first-hand information. [ABSTRACT FROM AUTHOR]

A significant burden and treatment gap associated with serious mental illness (SMI) exists in low- and middle-income countries (LMIC). In order to address these issues, a range of community-based rehabilitation models in alignment with the Capabilities Approach is necessary, including opportunities for people with SMI to be rapidly engaged in meaningful work within their communities. This paper outlines the development processes and evaluation of the proof of concept for the Community REcovery Achieved Through Entrepreneurship (CREATE) strategy in Kenya. The CREATE strategy pairs Work Integration Social Enterprises (WISE) with a focused, low-cost, recovery-oriented Psychosocial Rehabilitation (PSR) toolkit within a peer involvement/support model as a means of addressing marginalization and fostering health, wellbeing, and participation of people living with SMI. Qualitative research methods were used to understand the experiences of a range of stakeholders involved in CREATE implementation in Kenya. Three overarching themes explicated the experiences of the various stakeholders involved: (1) experiencing a business like other businesses – yet different; (2) expanding capacities, opportunities, and networks through meaningful work; and (3) promoting knowledge and empowerment through education. Within each theme, there was evidence of the attenuation of central elements of marginalization. The CREATE strategy demonstrated acceptability and a variety of potential positive impacts in a low resource setting in Kenya. Application of the CREATE strategy to other low resource settings within Kenya and other LMIC merits further exploration. [ABSTRACT FROM AUTHOR]

Rampant levels of AIDS and poverty have made many children in sub-Saharan Africa the primary caregivers of their ageing or ailing guardians. This paper reports on a social action fund initiative that brought caregiving children together to set-up and run income generating activities as a group with the aim of strengthening their coping capabilities. To further our understanding of child-led microfinance activities, this paper explores how intra-community relations can both facilitate and undermine child-led activities, and how these activities in turn can further strengthen some intra-community relations. Twenty-one children (aged 12–17) and six guardians participated in this study. Data included draw-and-write compositions (n=21), essays (n=16), workshop notes and proposals (n=8) and in-depth interviews (n=16). A thematic analysis revealed that the children actively drew on the expertise and involvement of some guardians in the project as well as on each other, developing supportive peer relations that helped strengthen their coping capabilities. However, the children's disenfranchised position in the community meant that some adults took advantage of the child-led activities for their own personal gain. Some children also showed a lack of commitment to collective work, undermining the morale of their more active peers. Nevertheless, both guardians and the children themselves began to look at caregiving children differently as their engagement in the project began to earn them respect from the community – changing guardian/child relations. The paper concludes that microfinance interventions targeting children and young people must consider children's relationships with each other and with adults as key determinants of Project success. [ABSTRACT FROM PUBLISHER]

Birth registration and obtaining physical birth certificates impose major challenges in developing countries, with impact on child and community health, education, planning, and all levels of development. However despite initiatives, universal registration is elusive, leading to calls for new approaches to understanding the decisions of parents. In this paper, we report results of a survey of students in grades six to eight (age ~12–16) in an under-registered area of Kenya regarding their own understanding of registration issues and their suggestions for improvement. These students were selected because they themselves were also nearing the age for high school enrollment/entrance examinations, which specifically requires possession of a birth certificate. This assessment was also a companion to our previous representative survey of adults in the same Kenyan region, allowing for parent-child comparison. Results supported previous research, showing that only 43% had birth certificates. At the same time, despite these low totals, students were themselves quite aware of registration factors and purposes. The students also made quite prescient sources for understanding their households’ motivations, with many of their suggestions—for focus on communication of pragmatic benefits, or automatic measures shifting responsibility from parents—mirroring our own previous suggestions, and showing a level of pragmatism not witnessed when surveying their parents. This paper therefore adds evidence to the discussion of registration policy planning. More generally, it also builds on an important trend regarding the treatment of children as stakeholders and important sources of information, and raising an intriguing new avenue for future research. [ABSTRACT FROM AUTHOR]

Background: There is a global emphasis on engaging community health volunteers (CHVs) in low- to middle-income countries (LMICs) to reach to the vast underserved populations that live in rural areas. Retention of CHVs in most countries has however been difficult and turnover in many settings has been reported to be high with profound negative effects on continuity of community health services. In rural Kenya, high attrition among CHVs remains a concern. Understanding challenges faced by CHVs in rural settings and how to reduce attrition rates with sustainable income-generating activities (IGAs) is key to informing the implementation of contextual measures that can minimise high turnover. This paper presents findings on the challenges of volunteerism in community health and the preferred IGAs in rural Kilifi county, Kenya.Methods: The study employed qualitative methods. We conducted 8 key informant interviews (KIIs) with a variety of stakeholders and 10 focus group discussions (FGDs) with CHVs. NVIVO software was used to organise and analyse our data thematically.Results: Community Health Volunteers work is not remunerated and it conflicts with their economic activities, child care and other community expectations. In addition, lack of supervision, work plans and relevant training is a barrier to delivering CHVs' work to the communities. There is a need to remunerate CHVs work as well as provide support in the form of basic training and capital on entrepreneurship to implement the identified income generating activities such as farming and events management.Conclusions: Strategies to support the livelihoods of CHVs through context relevant income generating activities should be identified and co-developed by the ministry of health and other stakeholders in consultation with the CHVs. [ABSTRACT FROM AUTHOR]

Background: Elevated blood pressure (BP) is the leading global risk factor for mortality. Delay in seeking hypertension care is associated with increased mortality., Objectives: This study investigated whether community health workers, equipped with behavioral communication strategies and smartphone technology, can increase linkage of individuals with elevated BP to a hypertension care program in western Kenya and significantly reduce BP., Methods: The study was a cluster randomized trial with 3 arms: 1) usual care (standard training); 2) "paper-based" (tailored behavioral communication, using paper-based tools); and 3) "smartphone" (tailored behavioral communication, using smartphone technology). The co-primary outcomes were: 1) linkage to care; and 2) change in systolic BP (SBP). A covariate-adjusted mixed-effects model was used, adjusting for differential time to follow-up. Bootstrap and multiple imputation were used to handle missing data., Results: A total of 1,460 individuals (58% women) were enrolled (491 usual care, 500 paper-based, 469 smartphone). Average baseline SBP was 159.4 mm Hg. Follow-up measures of linkage were available for 1,128 (77%) and BP for 1,106 (76%). Linkage to care was 49% overall, with significantly greater linkage in the usual care and smartphone arms of the trial. Average overall follow-up SBP was 149.9 mm Hg. Participants in the smartphone arm experienced a modestly greater reduction in SBP versus usual care (-13.1 mm Hg vs. -9.7 mm Hg), but this difference was not statistically significant. Mediation analysis revealed that linkage to care contributed to SBP change., Conclusions: A strategy combining tailored behavioral communication and mobile health (mHealth) for community health workers led to improved linkage to care, but not statistically significant improvement in SBP reduction. Further innovations to improve hypertension control are needed. (Optimizing Linkage and Retention to Hypertension Care in Rural Kenya [LARK]; NCT01844596)., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

In Kenyan communities, religious leaders are important gatekeepers in matters of health and public morality. In a context that is generally homophobic, religious leaders may aggravate or reduce stigmatization of sexual minorities such as gay and bisexual men, and other men who have sex with men (GBMSM). Literature indicates mixed results in efforts to encourage religious leaders to work effectively and sensitively with issues regarding HIV and sexuality. This paper describes the implementation of an engagement intervention with religious leaders from different denominations, which took place following a homophobic hate attack that was led by local religious leaders, at an HIV research clinic for GBMSM on the Kenyan coast. After the homophobic attack, tailored engagement activities, including a comprehensive four-day online sensitivity training course took place between June 2015 and October 2016 in the Kenyan coast. HIV researchers, together with trained GBMSM activists, organized the series of engagement activities for religious leaders which unfolded iteratively, with each subsequent activity informed by the results of the previous one. Facilitated conversations were used to explore differences and disagreements in relation to questions of scripture, mission, HIV, and human sexuality. As a result, researchers noted that many religious leaders, who initially expressed exceedingly negative attitudes towards GBMSM, started to express far more accepting and supportive views of sexuality, sexual identities, and same-sex relations. This paper describes the changes in religious leaders’ discourses relating to GBMSM, and highlights the possibility of using engagement interventions to build trust between research institutes, religious leaders, and GBMSM. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this article is to provide a general review of the health-care needs in Kenya which focuses on the role of community engagement in facilitating access and diminishing barriers to quality care services. Health-care concerns throughout Kenya and the culture of Kenyan’s health-care practices care are considered.Design/methodology/approach A comprehensive review covered studies of community engagement from 2000 till present. Studies are collected using Google Scholar, PubMed, EBSCOhost and JSTOR and from government and nongovernment agency websites. The approach focuses on why various populations seek health care and how they seek health care, and on some current health-care delivery models.Findings Suggestions for community engagement, including defining the community, are proposed. A model for improved health-care delivery introduces community health workers (CHWs), mHealth technologies and the use of mobile clinics to engage the community and improve health and quality of care in low-income settings.Practical implications The results emphasize the importance of community engagement in building a sustainable health-care delivery model. This model highlights the importance of defining the community, setting goals for the community and integrating CHWs and mobile clinics to improve health status and decrease long-term health-care costs. The implementation of these strategies contributes to an environment that promotes health and wellness for all.Originality/value This paper evaluates health-care quality and access issues in Kenya and provides sustainable solutions that are linked to effective community engagement. In addition, this paper adds to the limited number of studies that explore health-care quality and access alongside community engagement in low-income settings. [ABSTRACT FROM AUTHOR]

The Baby-Friendly Community Initiative (BFCI) is an extension of the 10th step of the Ten Steps of Successful Breastfeeding and the Baby-Friendly Hospital Initiative (BFHI) and provides continued breastfeeding support to communities upon facility discharge after birth. BFCI creates a comprehensive support system at the community level through the establishment of mother-to-mother and community support groups to improve breastfeeding. The Government of Kenya has prioritized community-based programming in the country, including the development of the first national BFCI guidelines, which inform national and subnational level implementation. This paper describes the process of BFCI implementation within the Kenyan health system, as well as successes, challenges, and opportunities for integration of BFCI into health and other sectors. In Maternal and Child Survival Program (MCSP) and UNICEF areas, 685 community leaders were oriented to BFCI, 475 health providers trained, 249 support groups established, and 3,065 children 0-12 months of age reached (MCSP only). Though difficult to attribute to our programme, improvements in infant and young child feeding practices were observed from routine health data following the programme, with dramatic declines in prelacteal feeding (19% to 11%) in Kisumu County and (37.6% to 5.1%) in Migori County from 2016 to 2017. Improvements in initiation and exclusive breastfeeding in Migori were also noted-from 85.9% to 89.3% and 75.2% to 92.3%, respectively. Large gains in consumption of iron-rich complementary foods were also seen (69.6% to 90.0% in Migori, 78% to 90.9% in Kisumu) as well as introduction of complementary foods (42.0-83.3% in Migori). Coverage for BFCI activities varied across counties, from 20% to 60% throughout programme implementation and were largely sustained 3 months postimplementation in Migori, whereas coverage declined in Kisumu. BFCI is a promising platform to integrate into other sectors, such as early child development, agriculture, and water, sanitation, and hygiene., (© 2019 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Maternal and neonatal mortality are unacceptably high in developing countries. Essential nutrition interventions contribute to reducing this mortality burden, although nutrition is poorly integrated into health systems. Universal health coverage is an essential prerequisite to decreasing mortality indices. However, provision and utilization of nutrition and health services for pregnant women and their newborns are poor and the potential for improvement is limited where health systems are weak. The Community-Based Maternal and Neonatal Health and Nutrition project was established as a set of demonstration projects in 4 countries in Africa with varied health system contexts where there were barriers to safe maternal health care at individual, community and facility levels. We selected project designs based on the need, context, and policies under consideration. A theory driven approach to programme implementation and evaluation was used involving developing of contextual project logic models that linked inputs to address gaps in quality and uptake of antenatal care; essential nutrition actions in antenatal care, delivery, and postnatal care; delivery with skilled and trained birth attendant; and postnatal care to outcomes related to improvements in maternal health service utilization and reduction in maternal and neonatal morbidity and mortality. Routine monitoring and impact evaluations were included in the design. The objective of this paper is to describe the rationale and methods used in setting up a multi-country study that aimed at designing the key maternal and neonatal health interventions and identifying indicators related to inputs, outcomes, and impact that were measured to track change associated with our interventions., (© 2018 John Wiley & Sons Ltd.)

The availability of free antiretroviral treatment in public health facilities since 2004 has contributed to the increasing biomedicalization of AIDS care in Kenya. This has been accompanied by a reduction of funding for community-based care and support organizations since the 2008 global economic crisis and a consequent donor divestment from HIV projects in Africa. This paper explores the ways that HIV interventions, including support groups, home-based care and antiretroviral treatments have shaped expectations regarding relations of care in the low-income area of Kibera in Nairobi, Kenya, over the last decade. Findings are based on 20 months of ethnographic research conducted in Nairobi between January 2011 and August 2013. By focusing on three eras of HIV treatment – pre-treatment, treatment scale-up, and post-crisis – the authors illustrate how family and community-based care have changed with shifts in funding. Many support groups that previously provided HIV care in Kibera, where the state is largely absent and family networks are thin, have been forced to cut services. Large-scale HIV treatment programmes may allow the urban poor in Nairobi to survive, but they are unlikely to thrive. Many care needs continue to go unmet in the age of treatment, and many economically marginal people who had found work in care-oriented community-based organizations now find themselves jobless or engaged in work not related to HIV. [ABSTRACT FROM AUTHOR]

Context: The Kenya Partnership for Health (KPH) program began in 1999, and is currently one of the 12 field projects participating in the WHO's 'Towards Unity for Health initiative' implemented to develop partnership synergies in support of the Primary Health Care (PHC) approach [1]. Content: This paper illustrates how Program-linked Information Management by Integrative-participatory Research Approach (PIMIRA) as practised under KPH has been implemented within Trans-Nzoia District, Kenya to enhance community-based health initiatives. It shows how this model is strategically being scaled-up from one community to another in the management of political, social, cultural and economic determinants (barriers and enhancers) of health. Objective: Target rural communities in the development of a community-based health information management and feedback initiatives that can provide insights on the social, cultural, political and economic determinants of health for utilization in informed health service management. Key Findings and Achievements: 1. Cues for health seeking and health service utilization are determined by the social, cultural, political and economic factors as seen by the individual and as defined by the community but not due to the pathological nature of the illness. 2. Establishment of community-based health surveillance and health action initiatives as the best practices in transferring health as a resource that can be 'owned and guarded' by the community. 3. Establishment of Healthy Villages Initiative (HVI) through which health service delivery and scale-up can be sustained at the community level. 4. Provision of actionable health information necessary for health planning and evaluation of preventive health programs thorough PIMIRA. Conclusion: It has been realized that for every one person who visits a health facility for medication, there are nine others who had the same condition but sought health care from other sources including self-medication and five others who never sought health care. Innovative means of involving the community in health information management and utilization such as PIMIRA are hence the best ways of guaranteeing equitable delivery of health services that are accessible and sustainable by the community. [ABSTRACT FROM AUTHOR]

This is one of the few studies that explores preferences of and experiences with integrated sexual and reproductive health (SRH)-HIV care among users of mainstream family planning and postnatal care services who are women living with HIV (WLWH). This paper reports on the quantitative data from 179 clients attending public sector clinics and from 30 qualitative in-depth interviews with WLHIV in Kenya. Quantitative data show that integration is happening for the vast majority of these clients at their last HIV visit. However, qualitative data show that very often the care received by WLWH is fragmented as providers do not offer multiple same-day appointments for FP and ARV refills. Our study has shown factors that could either prevent or enable receipt of integrated SRH and HIV care for WLWH. To address these factors, management systems need to be able to support providers to make flexible decisions and facilitate better coordination and communication across clinics within facilities. [ABSTRACT FROM AUTHOR]

Background: Community health committees (CHCs) are mechanisms for community participation in decision-making and overseeing health services in several low-and middle-income countries (LMICs). There is little research that examines teamwork and internal team relationships between members of these committees in LMICs. We aimed to assess teamwork and factors that affected teamwork of CHCs in an urban slum setting in Nairobi, Kenya. Methods: Using a qualitative case-study design, we explored teamwork of two CHCs based in two urban informal settlements in Nairobi. We used semi-structured interviews (n = 16) to explore the factors that influenced teamwork and triangulated responses using three group discussions (n = 14). We assessed the interpersonal and contextual factors that influenced teamwork using a framework for assessing teamwork of teams involved in delivering community health services. Results: Committee members perceived the relationships with each other as trusting and respectful. They had regular interaction with each other as friends, neighbors and lay health workers. CHC members looked to the Community Health Assistants (CHAs) as their supervisor and "boss", despite CHAs being CHC members themselves. The lay-community members in both CHCs expressed different goals for the committee. Some viewed the committee as informal savings group and community-based organization, while others viewed the committee as a structure for supervising Community Health Promoters (CHPs). Some members doubled up as both CHPs and CHC members. Complaints of favoritism arose from CHC members who were not CHPs whenever CHC members who were CHPs received stipends after being assigned health promotion tasks in the community. Underlying factors such as influence by elites, power imbalances and capacity strengthening had an influence on teamwork in CHCs. Conclusion: In the absence of direction and support from the health system, CHCs morph into groups that prioritize the interests of the members. This redirects the teamwork that would have benefited community health services to other common interests of the team. Teamwork can be harnessed by strengthening the capacity of CHC members, CHAs, and health managers in team building and incorporating content on teamwork in the curriculum for training CHCs. [ABSTRACT FROM AUTHOR]

Background: The advancement of universal health coverage (UHC) is largely based on identifying and addressing barriers to accessing community health services. Traditional qualitative research approaches provide excellent insights but have unfeasibly high resource requirements for most care providers. Aim: To identify, categorise, and evaluate methods that have been used to identify barriers to and/or solutions for improving access to community-based health services, grounded in engagement with affected communities, excluding approaches that take >14 days. Design & setting: This was a scoping review. Method: Following Joanna Briggs Institute (JBI) guidelines, a search was undertaken using the Cochrane Library, Ovid MEDLINE, Ovid Embase, Ovid Global Health, and Google Scholar. An information specialist designed the search, and dual independent review and data charting were used. Results: In total, 44 studies were included from 30 countries, reporting on 18 different clinical services. Thirty studies used self-described 'rapid' approaches; however, the majority of these did not justify what they meant by this term. Nearly half of the studies used mixed- or multi-methods and triangulation to verify early findings. All of the qualitative studies used interviews and/or focus groups, which were often supplemented with observations, document review, and mapping activities. The use of in situ snowball and convenience sampling; community members as data collectors and cultural guides; collaborative summarisation (review of findings with community members and end-users); and deductive framework analysis expedited the research processes. There were no data on costs. Conclusion: There are a wide range of methods that can be used to deliver timely information about barriers to access. The methods employed in the articles reviewed tended to use traditional data collection approaches in innovative ways. [ABSTRACT FROM AUTHOR]

Background: Despite focused health policies and reform agenda, Kenya has challenges in improving households' situation in poverty and ill health; interventions to address the Millennium Development Goals in maternal and child health, such as focused antenatal care and immunization of children, are yet to achieve success. Research has shown that addressing the demand side is critical in improving health outcomes. This paper presents a model for health systems performance improvement using a strategy that bridges the interface between the community and the health system., Methods: The study employed quasi-experimental design, using pre- and post-intervention surveys in intervention and control sites. The intervention was the implementation of all components of the Kenyan Community Health Strategy, guided by policy. The two year intervention (2011 and 2012) saw the strategy introduced to selected district health management teams, service providers, and communities through a series of three-day training workshops that were held three times during the intervention period., Results: A number of health indicators, such as health facility delivery, antenatal care, water treatment, latrine use, and insecticide treated nets, improved in the intervention sites compared to non-interventions sites. The difference between intervention and control sites was statistically significant (p<0.0001) for antenatal care, health facility delivery, water treatment, latrine use, use of insecticide treated nets, presence of clinic card, and measles vaccination. Degree of improvement across the various indicators measured differed by socio-demographic contexts. The changes were greatest in the rural agrarian sites, compared to peri-urban and nomadic sites., Conclusion: The study showed that most of the components of the strategy were implemented and sustained in different socio-demographic contexts, while participatory community planning based on household information drives improvement of health indicators.

INNOVATIVE EDUCATION: The FHS, Moi University has been an active member of Community Based Education and Service (COBES) network. To achieve this, FHS uses innovative educational strategies that encourage active learning and self-directed learning. However, since these educational strategies are very resource intensive, the faculty has been forced to establish links with health programs. SUSTAINABILITY OF INNOVATIONS: Although higher learning institutions have been urged to become more innovative and responsive to a globally competitive knowledge market, support from governments has been declining. This has forced institutions to develop new links with service systems to enable them to sustain innovations. It is undisputable that investments in higher learning generate major community benefits through returns from research, technology application and service provision. Collaboration, which is a mechanism of working together in a harmonious and supportive way with other agencies, is vital for sustaining innovations. POTENTIAL HEALTH PROGRAMS FOR COLLABORATION: In Kenya, where programs such as Health Education and Maternal Child Health that undertake outreach health services exist, Higher Learning Institutions need to collaborate with these programs to enable them make best use of resources and increase efficiency. In this paper, a framework for collaboration in developing countries where resources are meager is suggested.

Setting: A rural district, Machakos, in Kenya, facing decreasing national resources for health and an increasing tuberculosis (TB) caseload fuelled by the human immunodeficiency virus (HIV)., Objective: To evaluate the impact on district TB programme performance of decentralising TB treatment by providing ambulatory care in the hospital and peripheral health units and in the community., Methods: A comparative study of district TB programme performance before and after the decentralisation of TB services at the end of 1997. To facilitate ambulatory care, ethambutol replaced streptomycin in the new treatment regimen., Findings: The number of patients registered in the control period (1996) was 1141, of whom almost 100% were admitted during the intensive phase of TB treatment, and in the intervention period (1998 and 1999), it was 3244, of whom only 153 (4.7%) required admission in the intensive phase. Of 3244 TB patients (all forms) registered in the intervention period, the number (%) choosing the different options for directly observed treatment (DOT) supervision were: hospital clinic 1618 (49.9%), peripheral health unit 904 (27.9%), community volunteer 569 (17.5%) and hospitalisation 153 (4.7%). The options were found to be acceptable to patients, their families and health staff. The treatment outcomes among new sputum smear-positive pulmonary TB patients were similar in the intervention and control cohorts, with treatment success rates of 88% vs. 85% and death rates of 4% vs. 6%, respectively. Treatment completion was significantly higher among new sputum smear-negative and extra-pulmonary TB patients in the intervention than in the control cohort (79% vs. 48%, respectively)., Conclusion: The decentralisation of the intensive phase of TB treatment resulted in maintenance of good TB programme performance, while Machakos hospital closed its TB wards. A separate paper describes the cost-effectiveness of this approach. The National Tuberculosis Control Programme plans to adopt this approach as national policy.

The relative cost of indoor residual house-spraying (IRS) versus insecticide-treated bednets (ITNs) forms part of decisions regarding selective malaria prevention. This paper presents a cost comparison of these two approaches as recently implemented by Merlin, a UK emergency relief organization funded through international donor support and working in the highland districts of Gucha and Kisii in Kenya. The financial costs (cash expenditures) and the economic costs (including the opportunity costs of using existing staff and volunteers, and an annualized cost for capital items) were assessed. The financial cost for IRS was US dollars 0.86 per person protected, compared with 4.21 dollars for ITNs (reducing to 3.42 dollars to the provider assuming cost recovery). The economic cost per person protected for IRS was 0.88 dollars, compared with 2.34 dollars for ITNs. The costs for ITNs were sensitive to the number of nets sold per community group ('efficiency'), as the delivery costs constituted upwards of 40% of the total cost. However, even marked increases in efficiency of these groups could not reduce the costs of ITNs to that comparable with IRS, except if more than one cycle of IRS was needed. The implications of predicted reductions in the cost of insecticide for both IRS and ITNs are also explored. The provision of itemized cost data allows predictions to be made on changes in the design of these programmes. Under almost all design scenarios, IRS would appear to be a more cost-efficient means of vector control in the Kenyan highlands.

Introduction: Traditional male circumcision (TMC) inculcates masculine-dominance norms in young men. Early infant male circumcision (EIMC) and medical male circumcision (MMC) can potentially minimise these adverse gender norms. We explored the perceptions about EIMC and MMC among communities practising TMC in Kenya. Method: We conducted focus group discussions with men and women and councils of elders, and key informant interviews with traditional circumcisers. Data were analysed using NVivo 10. Results: Most participants described MC as a rite of passage into adulthood, with the preferred age for MC to occur at 10 to 15 years old. Interestingly, awareness of the advantages of EIMC, especially among younger men and women, was high. Participants acknowledged that TMC reinforces hegemonic masculinity that undermines gender equality. Except among traditional circumcisers and some members of councils of elders, MMC and female providers were largely deemed acceptable. Conclusion: EIMC and MMC are slowly gaining acceptance, providing important tools to challenge adverse gender norms associated with TMC. [ABSTRACT FROM AUTHOR]

Increased interest in the potential contribution of insecticide-impregnated bed nets (ITBN) to malaria control has led to research efforts to determine the impact and sustainability of ITBN programmes in differing environments. There is a need to develop effective, feasible educational strategies that will both inform and motivate community members, and thus maximize the correct usage of ITBN. This is especially true in communities where indigenous usage of bed nets is low. This paper describes the educational component of a randomized controlled community intervention trial of ITBN, with childhood malaria morbidity as an outcome. The educational approach and messages for the ITBN trial were developed from anthropological survey data collected 4 years before the trial, and from community surveys conducted by project researchers. Low levels of understanding amongst mothers of the aetiological link between mosquitos and malaria led to the exclusion of the term 'malaria' from the initial educational messages promoting the use of ITBN. Appropriate individuals within the existing district health care structure were trained as community educators in the project. These educators conducted intensive teaching in the community through public meetings and group teaching in the first 6 months of the trial. The impact of these initial activities was assessed through interviews with a random sample of 100 mothers and 50 household heads. This allowed the identification of messages which had not been well understood and further educational methods were chosen to address the areas pinpointed. The community assessment also demonstrated that, in 1994, over 90% of mothers understood a protective role for bed nets against malaria and the ITBN education messages were changed to take account of this. The school programme was evaluated through determining outreach (the number of households accessed), changes in participant children's knowledge, post-teaching assessment of mothers' knowledge and discussions with parent-teacher associations. It was shown that 40% of intervention homes with children in the target group were accessed, participant children learned the educational messages well (scores increased from a pre-teaching mean of 59% to a post-teaching mean of 92%) and a high level of awareness of the ITBN trial was achieved in these homes (75%). However, specific messages of the education programmed were not well transferred to the home (30%). The discussion emphasises the need for allocation of adequate resources for education in programmes dependent on achieving a change in community practices. We also describe the value of ongoing communication between programme planners and a target population in maximizing the effectiveness of messages and methods used.

High fertility is the major demographic problem presently affecting rural Kenya. Chogoria Hospital has attempted to provide a community based family planning service to address this issue. This paper describes the intervention used and analyses the current contraceptive practice in the area. It is concluded that community based distribution of family planning commodities may be associated with a marked decrease in fertility rate and family size within a relatively short period. Family planning initiatives in Africa may be remarkably cost-effective interventions in the development of a nation and be associated with well spaced and healthy children.

Urban refugees often face tremendous adversities during displacement that exacerbate mental health and psychosocial outcomes. Given the lack of research on how extended displacement affects mental health in urban refugee youth, this study examines the differential effects of country of birth on trauma exposure and psychosocial factors that influence mental health experiences among Somali refugee youth in urban Kenya (n = 303). Findings reveals that childhood trauma and impeded social functioning predicted mental health outcomes. Being born in Kenya was a significant predictor of poor mental health despite there being no significant difference in trauma exposures and psychosocial factors between Somali-born and Kenya-born youth. This difference can be attributed to prolonged displacement, disrupted development of cultural identity, and discrimination experienced in the host country. Given the widely devastating effects of childhood trauma and community violence, mental health interventions need to be two-prolonged: addressing and preventing intergenerational trauma sequelae through family-based interventions; and community-level programs and advocacy for safety and protection for the displaced. Our findings also emphasize that future interventions for urban refugee communities should be inclusive to all community members, considering shared vulnerability to community violence as well as intergenerational transmission of traumas through childhood adversities and lacking support. [ABSTRACT FROM AUTHOR]

Social capital predicts many positive health outcomes, including food and water access and sufficiency. Hence, increasing social capital has emerged as one potential strategy to improve food and water security. In this study, we investigate whether social capital generated through participation in a community-based microlending programme based in semi-rural Kenya is associated with water and food insecurity, and explore the interconnectedness of water and food insecurity through mediation analysis. Randomly-selected women participants of the community-based programme (n = 400) were interviewed in June 2018 and again in June 2019. Survey measures included water insecurity, food insecurity and an index of social capital constructs, namely group cohesion, trust, expectations of mutual support, sense of belonging and frequency of attendance in the programme. Random effects linear regression showed that an increase the social capital index was associated with lower water and food insecurity. The mediation analysis indicated that the association between social capital and food insecurity was completely mediated by water insecurity. This study demonstrates the need for further investigation into how social capital-generating programmes can contribute to systems approaches for collaborative food and water security programmes, especially among rural communities in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Understanding the link between health and place can strengthen the design of health interventions, particularly in the context of HIV prevention. Individuals who might one day participate in such interventions – including youth – may further improve the design if engaged in a meaningful way in the formative research process. Increasingly, participatory mapping methods are being used to achieve both aims. We describe the development of three innovative mapping methods for engaging youth in formative community-based research: ‘dot map’ focus groups, geocaching games, and satellite imagery-assisted daily activity logs. We demonstrate that these methods are feasible and acceptable in a low-resource, rural African setting. The discussion outlines the merits of each method and considers possible limitations. [ABSTRACT FROM AUTHOR]

Palliative care should not be seen as a luxury, but as a necessary essential service. It should not be only for the few who can afford it, or for those living in better socioeconomic conditions. The Kenya Hospice and Palliative Care Association works together with its stakeholders such as the Ministry of Health, government hospitals, mission hospitals, hospices, and community-based organizations, and training institutions to ensure that there is greater awareness of and access to palliative care across the country. In the past 7 years, there has been a significant improvement in palliative care in Kenya focusing on availability, accessibility, and affordability of services through scaling up existing services as well as integrating palliative care into the public health care system. This paper briefly outlines this development while highlighting the challenges faced in the geographical context of sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Evidence suggests an overlap between intimate partner violence (IPV) experience and perpetration. However, few studies in sub-Saharan Africa have investigated experience and perpetration of IPV among women and men within the same community. This study reports prevalence of past-year IPV experience and perpetration among women and men living in an informal settlement in Nairobi, Kenya, and factors associated with IPV. Data analyzed for this study involved a geographically distributed random sample of 273 women and 429 men who participated in a community survey. We approximated prevalence of IPV experience and perpetration and used logistic regression for estimating associations between individual-level factors and IPV. Women and men experienced similar levels of IPV, but a significantly higher proportion of men reported physical and sexual IPV perpetration. Witnessing violence between parents in childhood was associated with women's physical and sexual, and men's sexual IPV experience; and with women perpetrating emotional, and men perpetrating sexual IPV. Less equitable gender attitudes were associated with men's perpetration of physical IPV. More equitable gender knowledge was associated with women's experience of sexual IPV, and with men perpetrating IPV. Perceived skills to challenge gender inequitable practices were negatively associated with men perpetrating sexual IPV. In conclusion, we found IPV experience and perpetration were highly correlated, and that, contrary to commonly reported gender gaps, men and women experienced similar rates of IPV. We make suggestions for future research, including on IPV prevention interventions in areas with such IPV prevalence that would be beneficial for women and men and future generations. [ABSTRACT FROM AUTHOR]

A primary health care community development programme was initiated in 1979 by people living in Saradidi, Kenya. The community was involved in planning, organization, setting of priorities and objectives, implementation, evaluation and benefits. This paper describes the developmental process that occurred including how the programme began, how it was organized and what it attempted to accomplish.

This paper identifies implications for community-based health care (CBHC). Sustainability of CBHC depends on effective community involvement, power sharing, adequate resources and, above all else careful planning with the community expected to benefit from CBHC.

Background Global gains toward malaria elimination have been heterogeneous and have recently stalled. Interventions targeting afebrile malaria infections may be needed to address residual transmission. We studied the efficacy of repeated rounds of community-based mass testing and treatment (MTaT) on malaria infection prevalence in western Kenya. Methods Twenty clusters were randomly assigned to 3 rounds of MTaT per year for 2 years or control (standard of care for testing and treatment at public health facilities along with government-sponsored mass long-lasting insecticidal net [LLIN] distributions). During rounds, community health volunteers visited all households in intervention clusters and tested all consenting individuals with a rapid diagnostic test. Those positive were treated with dihydroartemisinin-piperaquine. Cross-sectional community infection prevalence surveys were performed in both study arms at baseline and each year after 3 rounds of MTaT. The primary outcome was the effect size of MTaT on parasite prevalence by microscopy between arms by year, adjusted for age, reported LLIN use, enhanced vegetative index, and socioeconomic status. Results Demographic and behavioral characteristics, including LLIN usage, were similar between arms at each survey. MTaT coverage across the 3 annual rounds ranged between 75.0% and 77.5% in year 1, and between 81.9% and 94.3% in year 2. The adjusted effect size of MTaT on the prevalence of parasitemia between arms was 0.93 (95% confidence interval [CI],.79–1.08) and 0.92 (95% CI,.76–1.10) after year 1 and year 2, respectively. Conclusions MTaT performed 3 times per year over 2 years did not reduce malaria parasite prevalence in this high-transmission area. Clinical Trials Registration NCT02987270. [ABSTRACT FROM AUTHOR]

Introduction: Community participation in the governance of health services is an important component in engaging stakeholders (patients, public and partners) in decision-making and related activities in health care. Community participation is assumed to contribute to quality improvement and goal attainment but remains elusive. We examined the implementation of community participation, through collaborative governance in primary health care facilities in Uasin Gishu County, Western Kenya, under the policy of devolved governance of 2013. Methods: Utilizing a multiple case study methodology, five primary health care facilities were purposively selected. Study participants were individuals involved in the collaborative governance of primary health care facilities (from health service providers and community members), including in decision-making, management, oversight, service provision and problem solving. Data were collected through document review, key informant interviews and observations undertaken from 2017 to 2018. Audio recording, notetaking and a reflective journal aided data collection. Data were transcribed, cleaned, coded and analysed iteratively into emerging themes using a governance attributes framework. Findings: A total of 60 participants representing individual service providers and community members participated in interviews and observations. The minutes of all meetings of five primary health care facilities were reviewed for three years (2014–2016) and eight health facility committee meetings were observed. Findings indicate that in some cases, structures for collaborative community engagement exist but functioning is ineffective for a number of reasons. Health facility committee meetings were most frequent when there were project funds, with discussions focusing mainly on construction projects as opposed to the day-to-day functioning of the facility. Committee members with the strongest influence and power had political connections or were retired government workers. There were no formal mechanisms for stakeholder forums and how these worked were unclear. Drug stock outs, funding delays and unclear operational guidelines affected collaborative governance performance. Conclusion: Implementing collaborative governance effectively requires that the scope of focus for collaboration include both specific projects and the routine functioning of the primary health care facility by the health facility committee. In the study area, structures are required to manage effective stakeholder engagement. [ABSTRACT FROM AUTHOR]

The author discusses the health care needs and the delivery of health care in Kenya, emphasizing in particular the role and contribution of traditional health practitioners. She also identifies the knowledge and continuous education needed by professional nurses and indicates how they should relate with the community at large. The nurse, it is argued, should be clear about her identity and maintain it without depriving the community and others of their rights and privileges. [ABSTRACT FROM AUTHOR]

Despite worldwide improvements in maternal and infant mortality, mothers and babies in remote, low-resource communities remain disproportionately vulnerable to adverse health outcomes. In these settings, delays in accessing emergency care are a major driver of poor outcomes. The 'Three Delays' model is now widely utilised to conceptualise these delays. However, in out-of-hospital contexts, operational and methodological constraints present major obstacles in practically quantifying the 'Three Delays'. Here, we describe a novel protocol for the MOMENTUM study (Monitoring of Maternal Emergency Navigation and Triage on Mfangano), a 12-month cohort design to assess delays during obstetric and neonatal emergencies within the remote villages of Mfangano Island Division, Lake Victoria, Kenya. This study also evaluates the preliminary impact of a community-based intervention called the 'Mfangano Health Navigation' programme. Utilising participatory case audits and contextually specific chronological reference strategies, this study combines quantitative tools with deeper-digging qualitative inquiry. This pragmatic design was developed to empower local research staff and study participants themselves as assets in unravelling the complex socio-economic, cultural, and logistical dynamics that contribute to delays, while providing real-time feedback for locally driven intervention. We present our methods as an adaptive framework for researchers grappling with similar challenges across fragmented, rural health landscapes. [ABSTRACT FROM AUTHOR]

Background: Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality. Methods: We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach. Results: The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery. Conclusion: While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals. [ABSTRACT FROM AUTHOR]

Background: Kaposi's sarcoma (KS) is one of the most common HIV-associated malignancies in sub-Saharan Africa. Worldwide, the availability of antiretroviral therapy (ART) has improved KS survival. In resource-rich settings, survival has also benefited from chemotherapy, which is widely available. Little is known, however, about the epidemiology of chemotherapy use for HIV-associated KS in resource-limited regions such as sub-Saharan Africa.Methods: We identified all patients newly diagnosed with HIV-related KS from 2009 to 2012 in the 26-clinic AMPATH network, a large community-based care network in Kenya. We ascertained disease severity at diagnosis, frequency of initiation of chemotherapy, and distribution of chemotherapeutic regimens used. Indications for chemotherapy included AIDS Clinical Trial Group T1 stage and/or "severe" disease defined by WHO KS treatment guidelines.Results: Of 674 patients diagnosed with KS, charts were available for 588; 61% were men, median age was 35 years, and median CD4 at KS diagnosis was 185 cells/μl. At time of diagnosis, 58% had at least one chemotherapy indication, and 22% had more than one indication. For patients with a chemotherapy indication, cumulative incidence of chemotherapy initiation (with death as a competing event) was 37% by 1 month and 56% by 1 year. Median time from diagnosis to chemotherapy initiation was 25 days (IQR 1-50 days). In multivariable regression, patients with > 3 chemotherapy indications at time of diagnosis had a 2.30 (95% CI 1.46-3.60) increased risk of rapid chemotherapy initiation (within 30 days of diagnosis) compared to those with only one chemotherapy indication (p < 0.001). Initial regimens were bleomycin-vincristine (78%), adriamycin-bleomycin-vincristine (11%), etoposide (7%), and gemcitabine (4%).Conclusions: A substantial fraction of patients with KS in East Africa are diagnosed at advanced disease stage. For patients with chemotherapy indications, nearly half did not receive chemotherapy by one year. Liposomal anthracyclines, often used in resource-rich settings, were not first line. These findings emphasize challenges in East Africa cancer care, and highlight the need for further advocacy for improved access to higher quality chemotherapy in this setting. [ABSTRACT FROM AUTHOR]

Greater male partner involvement in Prevention of Mother to Child Transmission (PMTCT) and Early Infant Diagnosis (EID) is associated with improved outcomes. Perceived low social support for the mother can negatively impact the uptake of PMTCT/EID services. Most research relies on women's reports of the types and quality of male partner support received versus what is desired. This qualitative study examines Kenyan male partners' reported social support provision pre- and post-partum from their own perspective. The study was embedded within intervention development studies in Kenya designed to develop and pilot a PMTCT module of a web based system to improve EID. Focus groups were conducted with male partners of pregnant women with HIV and elicited feedback on male partner involvement in maternal and child care and factors affecting participation. Interviews were analyzed within a theoretical social support framework. Participants described providing tangible support (financial resources), informational support (appointment reminders) and emotional support (stress alleviation in the face of HIV-related adversity). African conceptualizations of masculinity and gender norms influenced the types of support provided. Challenges included economic hardship; insufficient social support from providers, peers and bosses; and HIV stigma. Collaboration among providers, mothers and partners; a community-based social support system; and recasting notions of traditional masculinity were identified as ways to foster male partner support. [ABSTRACT FROM AUTHOR]

Reducing child mortality is a key global health challenge. We examined reasons for greater or lesser success in meeting under-five mortality rate reductions, i.e. Millennium Development Goal #4, between 1990 and 2015 in Sub-Saharan Africa where child mortality remains high. We first examined factors associated with child mortality from all World Health Organization African Region nations during the Millennium Development Goal period. This analysis was followed by case studies of the facilitators and barriers to Millennium Development Goal #4 in four countries – Kenya, Liberia, Zambia, and Zimbabwe. Quantitative indicators, policy documents, and qualitative interviews and focus groups were collected from each country to examine factors within and across countries related to child mortality. We found familiar themes that highlighted the need for both specific services (e.g. primary care access, emergency obstetric and neonatal care) and general management (e.g. strong health governance and leadership, increasing community health workers, quality of care). We also identified methodological opportunities and challenges to assessing progress in child health, which can provide insights to similar efforts during the Sustainable Development Goal period. Specifically, it is important for countries to adapt general international goals and measurements to their national context, considering baseline mortality rates and health information systems, to develop country-specific goals. It will also be critical to develop more rigorous measurement tools and indicators to accurately characterize maternal, neonatal, and child health systems, particularly in the area of governance and leadership. Valuable lessons can be learned from Millennium Development Goal successes and failures, as well as how they are evaluated. As countries seek to lower child mortality further during the Sustainable Development Goal period, it will be necessary to prioritize and support countries in quantitative and qualitative data collection to assess and contextualize progress, identifying areas needing improvement. [ABSTRACT FROM AUTHOR]

Sexual health and rights are a core feature of human development. Yet, most work on sexual health and wellbeing in the Global South and elsewhere has historically focused on heterosexual, cisgender people, as well as sexual minority cisgender men and transgender women. This exploratory study includes an analysis of comments made during a facilitated community forum and an examination of the sociopolitical and legal environment relevant to sexual minority women's health in Kenya. Through analysis of the group discussion hosted by a sexual minority women's group, we identified multiple sexual health-related issues, including concerns related to healthcare access, healthy sexual relationships, economic instability, and freedom from violence. Based on issues identified by the forum, we conducted an analysis of law and policy in the areas of community need. The legal and policy analysis indicated that the public policy and health policy context is complicated by the presence of hostile laws regarding same-sex sexuality, an absence of economic policies to protect women, and yet some existing health policy inclusive of sexual and gender minorities that nonetheless render sexual minority women invisible. The findings indicate a need for focus on public opinion, health services, legislation, and health policy as sites of intervention. [ABSTRACT FROM AUTHOR]

Background: Close-to-community (CTC) providers of health care are a crucial workforce for delivery of high-quality and universal health coverage. There is limited evidence on the effect of training supervisors of this cadre in supportive supervision. Our study aimed to demonstrate the effects of a training intervention on the approach to and frequency of supervision of CTC providers of health care. Methods: We conducted a context analysis in 2013 in two Kenyan counties to assess factors that influenced delivery of community health services. Supervision was identified a priority factor that needed to be addressed to improve community health services. Supervision was inadequate due to lack of supervisor capacity in supportive approaches and lack of supervision guidelines. We designed a six-day training intervention and trained 48 purposively selected CTC supervisors on the educative, administrative and supportive components of supportive supervision, problem solving and advocacy and provided them with checklists to guide supervision sessions. We administered quantitative questionnaires to supervisors to assess changes in supervision frequency before and after the training and then explored perspectives on the intervention with community health volunteers (CHVs) and their supervisors using qualitative in-depth interviews. Results: Six months after the intervention, we observed that supervisors had shifted the supervision approach from being controlling and administrative to coaching, mentorship and problem solving. Changes in the frequency of supervision were found in Kitui only, whereby significant decreases in group supervision were met with increases in accompanied home visit supervision. Supervisors and CHVs reported the intervention was helpful and it responded to capacity gaps in supervision of CHVs. Conclusion: Our intervention responded to capacity gaps in supervision and contributed to enhanced supervision capacity among supervisors. Supervisors found the curriculum acceptable and useful in improving supervision skills. [ABSTRACT FROM AUTHOR]

Many gaps in care exist for provision of antiretroviral therapy (ART) in sub-Saharan Africa. Differentiated HIV care tailors provision of ART for patients based on their level of acuity, providing alternatives for where, by whom, and how often care occurs. We conducted a scoping review to assess novel differentiated care models for ART provision for stable HIV-infected adults in sub-Saharan Africa, and how these models can be used to guide differentiated care implementation in Kenya. A systematic search was conducted using PubMed, Embase, Web of Science, Popline, Cochrane Library, and African Index Medicus between January 2006 and January 2017. Grey literature searches and handsearching were also used. We included articles that quantitatively assessed the health, acceptability, and cost-effectiveness of differentiated HIV care. Two reviewers independently performed article screening, data extraction and determination of inclusion for analysis. We included 40 publications involving over 240,000 participants spanning nine countries in sub-Saharan Africa - 54.4% evaluated clinical outcomes, 23.5% evaluated acceptability outcomes, and 22.1% evaluated cost outcomes. Differentiated care models included: facility fast-track drug refills and appointment spacing, facility or community-based ART groups, community ART distribution points or home-based care, and task-shifting or decentralization of care. Studies suggest that these approaches had similar outcomes in viral load suppression and retention in care and were acceptable alternatives to standard HIV care. No clear results could be inferred for studies investigating task shifting and those reporting cost-effectiveness outcomes. Kenya has started to scale up differentiated care models, but further evaluation, quality improvement and research studies should be performed as different models are rolled out. [ABSTRACT FROM AUTHOR]

Until recently, HIV in Africa was presumed to be driven by poverty, gender inequality and poor governance. The last decade has seen a shift in global and national public health discourses, especially in eastern Africa where new statistical evidence is used to justify prevention efforts to target Key Populations, i.e. men who have sex with men (MSM), injecting drug users, and sex workers. In this article, we focus on Kenya to examine state, NGO and community HIV treatment and prevention efforts targeting MSM, specifically male sex workers. We combine ethnographic fieldwork with a critical analysis of policy(making) and implementation practices to sketch the contours of the global, national and local forces that have combined to (re)make male homosexual sex to be understood as a practice that contributes to HIV incidence in Kenya. We also show that HIV-related MSM programmes in Kenya primarily enrol male sex workers in HIV treatment programmes, which focus on mainly on treatment adherence and pay insufficient attention to the economic and psycho-social problems experienced by male sex workers. Although upper and middle class MSM are involved in running LGTBI rights-based interventions and in mobilising male sex workers for HIV interventions, they are rarely targeted by those interventions. [ABSTRACT FROM AUTHOR]

Introduction: Appropriate demand for, and supply of, high quality essential neonatal care is key to improving newborn survival but evaluating such provision has received limited attention in low- and middle-income countries. Moreover, specific local data are needed to support healthcare planning for this vulnerable population. Methods: We conducted health facility assessments between July 2015-April 2016, with retrospective review of admission events between 1st July 2014 and 30th June 2015, and used estimates of population-based incidence of neonatal conditions in Nairobi to explore access and evaluate readiness of public, private not-for-profit (mission), and private-for-profit (private) sector facilities providing 24/7 inpatient neonatal care in Nairobi City County. Results: In total, 33 (4 public, 6 mission, and 23 private) facilities providing 24/7 inpatient neonatal care in Nairobi City County were identified, 31 were studied in detail. Four public sector facilities, including the only three facilities in which services were free, accounted for 71% (8,630/12,202) of all neonatal admissions. Large facilities (>900 annual admissions) with adequate infrastructure tended to have high bed occupancy (over 100% in two facilities), high mortality (15%), and high patient to nurse ratios (7–15 patients per nurse). Twenty-one smaller, predominantly private, facilities were judged insufficiently resourced to provide adequate care. In many of these, nurses provided newborn and maternity care simultaneously using resources shared across settings, newborn care experience was likely to be limited (<50 cases per year), there was often no resident clinician, and sick babies were often referred onwards. Results suggest 44% (9,764/21,966) of Nairobi’s small and sick newborns may not access any of the identified facilities and a further 9% (2,026/21,966) access facilities judged to be inadequately equipped. Conclusion: Over 50% of Nairobi’s sick newborns may not access a facility with adequate resources to provide essential care. A very high proportion of care accessed is provided by four public and one low cost mission facility; these face major challenges of high patient acuity (high mortality), high patient to nurse ratios, and often overcrowding. Reducing high neonatal mortality in this urban, predominantly poor, population will require effective long-term, multi-sectoral planning and investment. [ABSTRACT FROM AUTHOR]