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Aims and Objectives Neonatal inpatient care is reliant on experienced nursing care, yet little is known about how Kenyan hospitals foster the development of newborn nursing experience in newborn units. Design A Qualitative ethnographic design. Methods Face to face 29 in depth interviews were conducted with nurses providing neonatal care in one private, one faith based and one public hospital in Nairobi, Kenya between January 2017 and March 2018. All data were transcribed verbatim, coded in the original language and analysed using a framework approach. Results Across the sectors, nurses perceived experience as important to the provision of quality care. They noted that hospitals could foster experience through recruitment, orientation, continuous learning and retention. However, while the private hospital facilitated experience building the public and faith‐based hospitals experienced challenges due to human resource management practices and nursing shortages. Conclusion Health sector context influenced how experience was developed among nurses. Implications Nurturing experience will require that different health sectors adopt better recruitment for people interested in NBU work, better orientation and fewer rotations even without specialist nurse training.

Recent global commitments to shift responsibility for Neglected Tropical Disease (NTD) control to affected countries reflect a renewed emphasis on sustainability, away from aid-dependency. This calls for a better understanding of how domestic stakeholders perceive investments in different strategies for NTD control. Soil transmitted helminths (STH) are among the NTDs targeted for elimination as a public health problem by international agencies through mass drug administration, provided periodically to at-risk population groups, often using drugs donated by pharmaceutical companies. This study was conducted in Kenya at a time when responsibilities for long running STH programmes were transitioning from external to national and sub-national agencies. Following an initial assessment in which we identified key domestic stakeholders and reviewed relevant scientific and government documents, the perspectives of stakeholders working in health, education, community engagement and sanitation were investigated through semi-structured interviews with national level policymakers, county level policymakers, and frontline implementers in one high-STH burden county, Kwale. Our conceptual framework on sustainability traced a progression in thinking, from ensuring financial stability through the technical ability to adapt to changing circumstances, and ultimately to a situation where a programme is prioritised by domestic policymakers because empowered communities demand it. It was clear from our interviews that most Kenyan stakeholders sought to be at the final stage in this progression. Interviewees criticised long-term investment in mass drug administration, the approach favoured predominantly by external agencies, for failing to address underlying causes of STH. Instead they identified three synergistic priority areas for investment: changes in institutional structures and culture to reduce working in silos; building community demand for and ownership; and increased policymaker engagement on underlying socioeconomic and environmental causes of STH. Although challenging to implement, the shift in responsibility from external agencies to domestic stakeholders may lead to emergence of new strategic directions.

This reflective opinion article arises from our experience conducting interviews with refugee women attending ante-natal and post-natal services in an urban setting in Kenya in the context of COVID‑19. First, we explain the research context in light of the study objectives. We reflect on the methodological challenges we faced, including researcher’s positionality, and argue that conducting research within the refugee context during the pandemic is unique, therefore research design must reconsider inclusive methodologies tailored to the uniqueness of refugees’ experience in order to obtain useful data. Second, we discuss these challenges in light of our experiences and the implications for addressing the gaps we identified, with particular emphasis on the ways in which professionals working with refugee communities in the context of a pandemic can build trust and obtain meaningful and uncompromised data. Lastly, we provide recommendations for researchers conducting similar research.

Background:Kenya has one of the highest rates of neonatal mortality in the world at 22/1,000 live births. Improving the quality of newborn care would greatly improve survival rates. There is an increasing consensus that strong health systems are key to achieving improved health outcomes. However, there is significantly less agreement on what to strengthen in low and middle-income countries such as Kenya. As nurses are the main caregivers in many inpatient settings, efforts aimed at improving the quality of facility care for sick newborn babies need to take into account nurses views and opinions. Our intent in this paper is to describe the current state of the nursing environment and what would be required to improve the quality of those environs from nurses’ perspectives.Methods: Between January 2017 and March 2018, we collected data through non-participant observations, unsolicited conversations and review of admission registers. We also conducted 29 individual in-depth interviews with nurses working in the newborn units (NBU) of a public sector hospital (n=10), a private sector hospital (n=11) and a faith-based hospital (n=8). The interviews were digitally audio recorded, transcribed verbatim and, together with observation notes, analysed using thematic content analysis.Results:Nurses as frontline care givers and intervention intermediaries, irrespective of their work contexts, have similar aspirations, needs and expectations from the health systems of how they should be supported to provide quality inpatient care for newborns. These are about the structure of the work environment, especially human resources for health, and the consequences of inadequate structure. They are also about how care is organised and systems that respond to emergencies.Conclusion:Interventions and investments to improve quality need to be directed towards experienced based co-design where we listen to the problems that nurses experience.

Background In March 2013, Kenya transitioned from a centralized to a devolved system of governance. Within the health sector, this entailed the transfer of service provision functions to 47 newly formed semi-autonomous counties, while policy and regulatory functions were retained at the national level. The devolution process was rapid rather than progressive. Methods We conducted qualitative research within one county to examine the early experiences of devolution in the health sector. We specifically focused on the experience of change from the perspective of sub-county managers, who form the link between county level managers and health facility managers. We collected data by observing a diverse range of management meetings, support supervision visits and outreach activities involving sub-county managers between May 2013 and June 2015, conducting informal interviews wherever we could. Informal observations and interviews were supplemented by fifteen tape recorded in depth interviews with purposively selected sub-county managers from three sub-counties. Results We found that sub county managers as with many other health system actors were anxious about and ill-prepared for the unexpectedly rapid devolution of health functions to the newly created county government. They experienced loss of autonomy and resources in addition to confused lines of accountability within the health system. However, they harnessed individual, team and stakeholder resources to maintain their jobs, and continued to play a central role in supporting peripheral facility managers to cope with change. Conclusions Our study illustrates the importance in accelerated devolution contexts for: 1) mid-level managers to adopt new ways of working and engagement with higher and lower levels in the system; 2) clear lines of communication during reforms to these actors and 3) anticipating and managing the effect of change on intangible software issues such as trust and motivation. More broadly, we show the value of examining organisational change from the perspective of key actors within the system, and highlight the importance in times of rapid change of drawing upon and working with those already in the system. These actors have valuable tacit knowledge, but tapping into and building on this knowledge to enable positive response in times of health system shocks requires greater attention to sustained software capacity building within the health system.

Recruitment of couples is important for study success. The multi-centered HPTN 052 clinical trial was designed to evaluate whether immediate versus delayed use of ART by HIV-infected individuals would reduce transmission of HIV to their HIV-uninfected partners. The objective of this study was to retrospectively compare several approaches for community recruitment at our site in Kisumu, Kenya based on a) feedback from recruitment staff, b) associated cost, and c) number of eligible couples enrolled. A secondary objective was to assess the discordant couples’ acceptability of the community recruitment approaches relative to the a) main recruitment venues, b) educational materials, and c) local language best suited for explaining the trial. 241 couples were screened for eligibility using nine recruitment approaches. We compared the approaches used for the 60 couples found to be eligible to those used for the 56 ineligible couples for whom that information was available. Analyses for association were carried out. In-depth interviews were conducted with 20 staff and 29 discordant couples. Records were kept of the costs associated with each approach. Overall, staff interviews revealed that acceptability of the approaches was high. Challenges were present with all approaches ranging from one member of the couple not wanting to reveal their positive HIV status to their partner (Patient Support Center or PSC approach), to not finding people at home (home based counseling and testing or HBCT approach). The PSC and the HBCT recruitment approaches were the most effective in terms of recruiting eligible participants. There was an overall significant difference between the proportion of eligible and ineligible participants among the 9 approaches (χ (8) =33.5; p

Men who have sex with men are an important yet marginalised population for HIV prevention in Africa. We conducted a two-phase study (individual qualitative interviews and a survey) of men who have sex with men, aged 18-34 years of age and living in Kisumu, Kenya. Approximately half (27/51) of survey respondents reported belonging to a support group. The odds of belonging to support groups were greater for older men (aged 24-34 versus 18-23 years [OR = 5.20; 95% CI = 1.27-26.66]). More than two-thirds (68.6%) of survey respondents were categorised as having high knowledge of HIV-risk factors. Most respondents (94.1%) correctly reported lack of condom use during vaginal sex as a risk factor for HIV, but slightly fewer (82.4%) recognised lack of condom use during anal sex as an HIV risk factor. Among the 15 interviewees, the following were included as greatest needs: health information (n = 5), safe lubricants (n = 5), condoms (n = 4), healthcare facility or men-who-have-sex-with-men-friendly health services (n = 3) and advocacy (n = 2). Kenyan men who have sex with men have developed support groups and have unmet needs for information, lubricants and condoms and services. Partnering with support groups offers an opportunity for organisations to reach men who have sex with men with accurate health information, provision of safe sexual lubricants, condoms and other health and social services.

A combination of in-depth interviews ( n = 38) and surveys ( n = 203) were used to (1) identify strategies to recruit persons at high risk for HIV infection; (2) determine whether one strategy was more successful than others; and (3) describe motivators and barriers to participation in HIV-prevention studies. From in-depth interviews, four main recruitment strategies were identified: (1) use of a person with specific knowledge of a target population (link person mobilization); (2) use of co-workers or contemporaries (peer mobilization); (3) use of group or association leaders (leader mobilization); and (4) contacting persons by study staff directly (staff contact mobilization). The odds of inconsistently using condoms during sex were greater among those recruited using the peer mobilization (adjusted odds ratio [AOR] = 3.59; 95% confidence interval [CI] = 1.35–9.54) and the leader mobilization strategies (AOR = 2.76; 95% CI = 1.04–7.38) compared with the link person mobilization strategy. The main motivators for taking part in an HIV research study were receiving HIV-prevention education, HIV information or counselling, and receiving compensation for study participation. The main barriers were fear of lack of confidentiality and HIV testing concerns. Using evaluated strategies to recruit persons at high risk for HIV infection and addressing barriers to participation will improve the conduct and outcome of HIV-prevention studies.

In the Kisumu Breastfeeding Study (KiBS), prevention of mother-to-child HIV transmission study, highly active antiretroviral therapy (HAART) is provided from 34 weeks gestation, through delivery to six months postpartum. The study recommends that women practice exclusive breastfeeding for six months, then wean abruptly. We sought to explore factors such as, education, family support, cultural norms, and sources of information about perinatal HIV transmission, which may influence a mother's decision to comply or not comply with the study's recommendation to stop breastfeeding when HAART is discontinued. We used semi-structured interviews of a purposive sample of 18 mothers participating in the KiBS. By interviewing 10 mothers who stopped breastfeeding and eight mothers who continued, it was possible to examine how different factors may have affected the groups of participants. All participants stated that it was not traditional to stop breastfeeding at six months. Participants who stopped breastfeeding reported more family support, were more educated, and were more likely to disclose their HIV status. Participants who continued breastfeeding more often expressed concern about stigma. Participants learned about mother-to-child transmission from clinics, churches, community groups, and other HIV-positive mothers. This substudy suggests that family support, education, and cultural norms are important factors that may influence a mother's decision regarding breastfeeding cessation. Thus, counseling and family support may play integral roles in the promotion of early breastfeeding cessation.