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Zhao Y, Nzekwu S, Boga M, Mbuthia D, Nzinga J, English M, Molyneux S, McGivern G. Examining liminality in professional practice, relational identities, and career prospects in resource-constrained health systems: Findings from an empirical study of medical and nurse interns in Kenya. Soc Sci Med 2024; 357:117226. [PMID: 39146903 DOI: 10.1016/j.socscimed.2024.117226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 06/12/2024] [Accepted: 08/09/2024] [Indexed: 08/17/2024]
Abstract
We examine new doctors' and nurses' experiences of transitioning from training to practising as health professionals, drawing on the concept of liminality. Liminality is a stage of 'in-betweenness', involving uncertainty and ambiguity as people leave one social context and reintegrate into a new one. Surprisingly little research has explored new health professionals' experiences of liminality during role and career transitions, particularly in precarious and resource-constrained settings. Drawing on 146 qualitative interviews and seven focus groups, involving 121 new graduate medical doctors and nurses transitioning through internship training in Kenya, we describe three aspects of liminality. First, liminal professional practice, where interns realise that best practices learned during medical and nursing schools are often impossible to implement in resource constrained health care settings; instead they learn workarounds and practical norms. Second, liminal relational identities, where interns leave behind being students and adopt the identities and responsibilities of qualified professionals within pre-existing professional hierarchies of status and expertise. We explain how these new doctors and graduate nurses negotiate their liminal status, including in relation to more experienced but less qualified professional colleagues. We also discuss how interns cope with liminality due to disappointing and inadequate supervision and role modelling from senior colleagues but then find peer support and their place within their own professions. Finally, we discuss how new doctors and nurses come to terms with the precarity of working in resource constrained health systems, abandon expectations of secure, permanent employment and careers, and accept the realities of liminal professional careers. We explain how all three forms of liminality influence professionals' developing practices, identities, and careers. We call for further studies with a specific liminality lens to explore this critical period in health workers' careers, to inform policy and practice responding to global transformations in healthcare professions and practice.
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Affiliation(s)
- Yingxi Zhao
- NDM Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | | | | | | | | | - Mike English
- NDM Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK; KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Sassy Molyneux
- NDM Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK; KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Gerry McGivern
- King's Business School, King's College London, London, UK
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2
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Ogero M, Ndiritu J, Sarguta R, Tuti T, Aluvaala J, Akech S. Recalibrating prognostic models to improve predictions of in-hospital child mortality in resource-limited settings. Paediatr Perinat Epidemiol 2023; 37:313-321. [PMID: 36745113 PMCID: PMC10946771 DOI: 10.1111/ppe.12948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND In an external validation study, model recalibration is suggested once there is evidence of poor model calibration but with acceptable discriminatory abilities. We identified four models, namely RISC-Malawi (Respiratory Index of Severity in Children) developed in Malawi, and three other predictive models developed in Uganda by Lowlaavar et al. (2016). These prognostic models exhibited poor calibration performance in the recent external validation study, hence the need for recalibration. OBJECTIVE In this study, we aim to recalibrate these models using regression coefficients updating strategy and determine how much their performances improve. METHODS We used data collected by the Clinical Information Network from paediatric wards of 20 public county referral hospitals. Missing data were multiply imputed using chained equations. Model updating entailed adjustment of the model's calibration performance while the discriminatory ability remained unaltered. We used two strategies to adjust the model: intercept-only and the logistic recalibration method. RESULTS Eligibility criteria for the RISC-Malawi model were met in 50,669 patients, split into two sets: a model-recalibrating set (n = 30,343) and a test set (n = 20,326). For the Lowlaavar models, 10,782 patients met the eligibility criteria, of whom 6175 were used to recalibrate the models and 4607 were used to test the performance of the adjusted model. The intercept of the recalibrated RISC-Malawi model was 0.12 (95% CI 0.07, 0.17), while the slope of the same model was 1.08 (95% CI 1.03, 1.13). The performance of the recalibrated models on the test set suggested that no model met the threshold of a perfectly calibrated model, which includes a calibration slope of 1 and a calibration-in-the-large/intercept of 0. CONCLUSIONS Even after model adjustment, the calibration performances of the 4 models did not meet the recommended threshold for perfect calibration. This finding is suggestive of models over/underestimating the predicted risk of in-hospital mortality, potentially harmful clinically. Therefore, researchers may consider other alternatives, such as ensemble techniques to combine these models into a meta-model to improve out-of-sample predictive performance.
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Affiliation(s)
- Morris Ogero
- Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeNairobiKenya
- School of MathematicsUniversity of NairobiNairobiKenya
| | - John Ndiritu
- School of MathematicsUniversity of NairobiNairobiKenya
| | | | - Timothy Tuti
- Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeNairobiKenya
| | - Jalemba Aluvaala
- Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeNairobiKenya
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)‐Wellcome Trust Research ProgrammeNairobiKenya
- School of MedicineUniversity of NairobiNairobiKenya
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English M, Nzinga J, Oliwa J, Maina M, Oluoch D, Barasa E, Irimu G, Muinga N, Vincent C, McKnight J. Improving facility-based care: eliciting tacit knowledge to advance intervention design. BMJ Glob Health 2022; 7:e009410. [PMID: 35985694 PMCID: PMC9396143 DOI: 10.1136/bmjgh-2022-009410] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/16/2022] [Indexed: 12/23/2022] Open
Abstract
Attention has turned to improving the quality and safety of healthcare within health facilities to reduce avoidable mortality and morbidity. Interventions should be tested in health system environments that can support their adoption if successful. To be successful, interventions often require changes in multiple behaviours making their consequences unpredictable. Here, we focus on this challenge of change at the mesolevel or microlevel. Drawing on multiple insights from theory and our own empirical work, we highlight the importance of engaging managers, senior and frontline staff and potentially patients to explore foundational questions examining three core resource areas. These span the physical or material resources available, workforce capacity and capability and team and organisational relationships. Deficits in all these resource areas may need to be addressed to achieve success. We also argue that as inertia is built into the complex social and human systems characterising healthcare facilities that thought on how to mobilise five motive forces is needed to help achieve change. These span goal alignment and ownership, leadership for change, empowering key actors, promoting responsive planning and procurement and learning for transformation. Our aim is to bridge the theory-practice gap and offer an entry point for practical discussions to elicit the critical tacit and contextual knowledge needed to design interventions. We hope that this may improve the chances that interventions are successful and so contribute to better facility-based care and outcomes while contributing to the development of learning health systems.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, Oxford, UK
| | - Jacinta Nzinga
- Health Economics Research Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi College of Health Sciences, Nairobi, Kenya
| | - Michuki Maina
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dorothy Oluoch
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
| | - Grace Irimu
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi College of Health Sciences, Nairobi, Kenya
| | - Naomi Muinga
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Jacob McKnight
- Health Systems Collaborative, Nuffield Department of Medicine, Oxford, UK
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Hildenwall H. Paediatric early warning systems in low-income settings-Putting the pieces together. Acta Paediatr 2022; 111:1658-1659. [PMID: 35822532 DOI: 10.1111/apa.16478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/23/2022] [Accepted: 07/04/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Helena Hildenwall
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Tuti T, Aluvaala J, Malla L, Irimu G, Mbevi G, Wainaina J, Mumelo L, Wairoto K, Mochache D, Hagel C, Maina M, English M. Evaluation of an audit and feedback intervention to reduce gentamicin prescription errors in newborn treatment (ReGENT) in neonatal inpatient care in Kenya: a controlled interrupted time series study protocol. Implement Sci 2022; 17:32. [PMID: 35578243 PMCID: PMC9109356 DOI: 10.1186/s13012-022-01203-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/10/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Medication errors are likely common in low- and middle-income countries (LMICs). In neonatal hospital care where the population with severe illness has a high mortality rate, around 14.9% of drug prescriptions have errors in LMICs settings. However, there is scant research on interventions to improve medication safety to mitigate such errors. Our objective is to improve routine neonatal care particularly focusing on effective prescribing practices with the aim of achieving reduced gentamicin medication errors. METHODS We propose to conduct an audit and feedback (A&F) study over 12 months in 20 hospitals with 12 months of baseline data. The medical and nursing leaders on their newborn units had been organised into a network that facilitates evaluating intervention approaches for improving quality of neonatal care in these hospitals and are receiving basic feedback generated from the baseline data. In this study, the network will (1) be expanded to include all hospital pharmacists, (2) include a pharmacist-only professional WhatsApp discussion group for discussing prescription practices, and (3) support all hospitals to facilitate pharmacist-led continuous medical education seminars on prescription practices at hospital level, i.e. default intervention package. A subset of these hospitals (n = 10) will additionally (1) have an additional hospital-specific WhatsApp group for the pharmacists to discuss local performance with their local clinical team, (2) receive detailed A&F prescription error reports delivered through mobile-based dashboard, and (3) receive a PDF infographic summarising prescribing performance circulated to the clinicians through the hospital-specific WhatsApp group, i.e. an extended package. Using interrupted time series analysis modelling changes in prescribing errors over time, coupled with process fidelity evaluation, and WhatsApp sentiment analysis, we will evaluate the success with which the A&F interventions are delivered, received, and acted upon to reduce prescribing error while exploring the extended package's success/failure relative to the default intervention package. DISCUSSION If effective, these theory-informed A&F strategies that carefully consider the challenges of LMICs settings will support the improvement of medication prescribing practices with the insights gained adapted for other clinical behavioural targets of a similar nature. TRIAL REGISTRATION PACTR, PACTR202203869312307 . Registered 17th March 2022.
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Affiliation(s)
- Timothy Tuti
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
| | - Jalemba Aluvaala
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Lucas Malla
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- London School of Hygiene and Tropical Medicine, London, UK
| | - Grace Irimu
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - George Mbevi
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - John Wainaina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Kefa Wairoto
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Christiane Hagel
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Michuki Maina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Zhao Y, Osano B, Were F, Kiarie H, Nicodemo C, Gathara D, English M. Characterising Kenyan hospitals' suitability for medical officer internship training: a secondary data analysis of a cross-sectional study. BMJ Open 2022; 12:e056426. [PMID: 35523483 PMCID: PMC9083393 DOI: 10.1136/bmjopen-2021-056426] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 04/08/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To characterise the capacity of Kenya internship hospitals to understand whether they are suitable to provide internship training for medical doctors. DESIGN A secondary data analysis of a cross-sectional health facility assessment (Kenya Harmonized Health Facility Assessment (KHFA) 2018). SETTING AND POPULATION We analysed 61 out of all 74 Kenyan hospitals that provide internship training for medical doctors. OUTCOME MEASURES Comparing against the minimum requirement outlined in the national guidelines for medical officer interns, we filtered and identified 166 indicators from the KHFA survey questionnaire and grouped them into 12 domains. An overall capacity index was calculated as the mean of 12 domain-specific scores for each facility. RESULTS The average overall capacity index is 69% (95% CI 66% to 72%) for all internship training centres. Hospitals have moderate capacity (over 60%) for most of the general domains, although there is huge variation between hospitals and only 29 out of 61 hospitals have five or more specialists assigned, employed, seconded or part-time-as required by the national guideline. Quality and safety score was low across all hospitals with an average score of 40%. As for major specialties, all hospitals have good capacity for surgery and obstetrics-gynaecology, while mental health was poorest in comparison. Level 5 and 6 facilities (provincial and national hospitals) have higher capacity scores in all domains when compared with level 4 hospitals (equivalent to district hospitals). CONCLUSION Major gaps exist in staffing, equipment and service availability of Kenya internship hospitals. Level 4 hospitals (equivalent to district hospitals) are more likely to have a lower capacity index, leading to low quality of care, and should be reviewed and improved to provide appropriate and well-resourced training for interns and to use appropriate resources to avoid improvising.
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Affiliation(s)
- Yingxi Zhao
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Boniface Osano
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
- Kenya Paediatric Research Consortium (KEPRECON), Nairob, Kenya
| | - Fred Were
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Helen Kiarie
- Division of Monitoring & Evaluation, Ministry of Health, Nairobi, Kenya
| | - Catia Nicodemo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Gathara
- Wellcome Trust Research Program, Kenya Medical Research Institute, Nairobi, Kenya
| | - Mike English
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
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Ogero M, Orwa J, Odhiambo R, Agoi F, Lusambili A, Obure J, Temmerman M, Luchters S, Ngugi A. Pentavalent vaccination in Kenya: coverage and geographical accessibility to health facilities using data from a community demographic and health surveillance system in Kilifi County. BMC Public Health 2022; 22:826. [PMID: 35468754 PMCID: PMC9040218 DOI: 10.1186/s12889-022-12570-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background There is substantial evidence that immunization is one of the most significant and cost-effective pillars of preventive and promotive health interventions. Effective childhood immunization coverage is thus essential in stemming persistent childhood illnesses. The third dose of pentavalent vaccine for children is an important indicator for assessing performance of the immunisation programme because it mirrors the completeness of a child’s immunisation schedule. Spatial access to an immunizing health facility, especially in sub-Sahara African (SSA) countries, is a significant determinant of Pentavalent 3 vaccination coverage, as the vaccine is mainly administered during routine immunisation schedules at health facilities. Rural areas and densely populated informal settlements are most affected by poor access to healthcare services. We therefore sought to determine vaccination coverage of Pentavalent 3, estimate the travel time to health facilities offering immunisation services, and explore its effect on immunisation coverage in one of the predominantly rural counties on the coast of Kenya. Methods We used longitudinal survey data from the health demographic surveillance system implemented in Kaloleni and Rabai Sub-counties in Kenya. To compute the geographical accessibility, we used coordinates of health facilities offering immunisation services, information on land cover, digital elevation models, and road networks of the study area. We then fitted a hierarchical Bayesian multivariable model to explore the effect of travel time on pentavalent vaccine coverage adjusting for confounding factors identified a priori. Results Overall coverage of pentavalent vaccine was at 77.3%. The median travel time to a health facility was 41 min (IQR = 18–65) and a total of 1266 (28.5%) children lived more than one-hour of travel-time to a health facility. Geographical access to health facilities significantly affected pentavalent vaccination coverage, with travel times of more than one hour being significantly associated with reduced odds of vaccination (AOR = 0.84 (95% CI 0.74 – 0.94). Conclusion Increased travel time significantly affects immunization in this rural community. Improving road networks, establishing new health centres and/or stepping up health outreach activities that include vaccinations in hard-to-reach areas within the county could improve immunisation coverage. These data may be useful in guiding the local department of health on appropriate location of planned immunization centres.
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Affiliation(s)
- Morris Ogero
- Department of Population Health, Aga Khan University, Nairobi, Kenya. .,School of Mathematics, University of Nairobi, Nairobi, Kenya. .,Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
| | - James Orwa
- Department of Population Health, Aga Khan University, Nairobi, Kenya
| | - Rachael Odhiambo
- Department of Population Health, Aga Khan University, Nairobi, Kenya.,Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Felix Agoi
- Department of Population Health, Aga Khan University, Nairobi, Kenya
| | | | - Jerim Obure
- Centre of Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Marleen Temmerman
- Centre of Excellence for Women and Child Health, Aga Khan University, Nairobi, Kenya.,Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya.,International Centre for Reproductive Health, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Stanley Luchters
- Department of Population Health, Aga Khan University, Nairobi, Kenya.,International Centre for Reproductive Health, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Burnet Institute, Melbourne, Australia
| | - Anthony Ngugi
- Department of Population Health, Aga Khan University, Nairobi, Kenya
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Sibande GT, Banda NPK, Moya T, Siwinda S, Lester R. Antibiotic guideline adherence by Clinicians in medical wards at Queen Elizabeth Central Hospital (QECH), Blantyre Malawi. Malawi Med J 2022; 34:3-8. [PMID: 37265826 PMCID: PMC10230578 DOI: 10.4314/mmj.v34i1.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
Antimicrobial resistance (AMR) is a major concern in health care worldwide. In Malawi rates of AMR, in particular third-generation cephalosporin-resistant (3GC-R) Enterobacterales have rapidly increased since 2003. Antibiotic guidelines are a key component of antimicrobial stewardship (AMS). As part of stewardship, Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi developed an antibiotic guideline in the form of a smart phone application in June 2016. Aim We conducted a study to assess clinicians adherence to the local antibiotic guideline on the adult medical wards, two years after it was introduced. Specifically assessing choice of antibiotic, time of blood culture collection and 48-hour review. Methods A cross-sectional study was carried out using purposive sampling method. 230 case files of adult patients were audited against the antibiotic guideline. Adherence to the guideline in terms of indication for antibiotic, choice of antibiotic and antibiotic review time was reviewed. Statistical analysis was done using IBM SPSS and presented with descriptive statistics. Results 194 (84% [95% CI 79.0-88.8]) antibiotic prescriptions were adherent to the guideline, 28 (12% [95% CI 8.2-17.1]) non-adherent and 8 (3.5% [95% CI 1.5-6.7]) antibiotic indication was not clear. The most common indication for antibiotic prescriptions was pneumonia, as documented in 89 (39% [95 % CI 32.4-45.3]) case files. 191(76% [95% CI 70.3-81.2]) of prescriptions were for ceftriaxone. There was evidence of utilising blood culture to adjust therapy as 88/230 (38% [95% CI 32.0-44.9]) had culture taken. 175(76% [95 % CI 70.0-81.4]) of files had antibiotics reviewed within 48 hours. Conclusion There is still need to work on rational prescribing of antibiotics as ceftriaxone usage was high during this study period. Scheduled audits and point prevalence surveys should be implemented quickly to reduce the impact of antibiotic resistance and improve individual patient care.
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Affiliation(s)
| | - Ndaziona Peter Kwanjo Banda
- University of Malawi, College of Medicine, Blantyre, Malawi
- Department of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Thandizo Moya
- University of Malawi, College of Medicine, Blantyre, Malawi
| | - Sylvia Siwinda
- University of Malawi, College of Medicine, Blantyre, Malawi
| | - Rebecca Lester
- Malawi Liverpool Wellcome Trust Research Programme, Blantyre, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Gachau S, Njagi EN, Molenberghs G, Owuor N, Sarguta R, English M, Ayieko P. Pairwise joint modeling of clustered and high-dimensional outcomes with covariate missingness in pediatric pneumonia care. Pharm Stat 2022; 21:845-864. [PMID: 35199938 PMCID: PMC7613603 DOI: 10.1002/pst.2197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 12/17/2021] [Accepted: 01/31/2022] [Indexed: 11/09/2022]
Abstract
Multiple outcomes reflecting different aspects of routine care are a common phenomenon in health care research. A common approach of handling such outcomes is multiple univariate analyses, an approach which does not allow for answering research questions pertaining to joint inference. In this study, we sought to study associations among nine pediatric pneumonia care outcomes spanning assessment, diagnosis and treatment domains of care, while circumventing the computational challenge posed by their clustered and high-dimensional nature and incompletely recorded covariates. We analyzed data from a cluster randomized trial conducted in 12 Kenyan hospitals. There were varying degrees of missingness in the covariates of interest, and these were multiply imputed using latent normal joint modeling. We used the pairwise joint modeling strategy to fit a correlated random effects joint model for the nine outcomes. This entailed fitting 36 bivariate generalized linear mixed models and deriving inference for the joint model using pseudo-likelihood theory. We also analyzed the nine outcomes separately before and after multiple imputation. We observed joint effects of patient-, clinician- and hospital-level factors on pneumonia care indicators before and after multiple imputation of missing covariates. In both pairwise joint modeling and separate univariate analysis methods, enhanced audit and feedback improved documentation and adherence to recommended clinical guidelines over time in six and five pneumonia care indicators, respectively. Additionally, multiple imputation improved precision of parameter estimates compared to complete case analysis. The strength and direction of association among pneumonia outcomes varied within and across the three domains of pneumonia care.
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Affiliation(s)
- Susan Gachau
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,School of Mathematics, University of Nairobi, Nairobi, Kenya
| | - Edmund Njeru Njagi
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Geert Molenberghs
- Center for Statistics, Universiteit Hasselt, Hasselt, Belgium.,Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Katholieke Universiteit, Leuven, Belgium
| | - Nelson Owuor
- School of Mathematics, University of Nairobi, Nairobi, Kenya
| | - Rachel Sarguta
- School of Mathematics, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Philip Ayieko
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.,Mwanza Intervention Trials Unit, Mwanza, Tanzania
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Wanyama C, Nagraj S, Muinga N, Tuti T, Edgcombe H, Geniets A, Winters N, English M, Rossner J, Paton C. Lessons from the design, development and implementation of a three-dimensional (3D) neonatal resuscitation training smartphone application: Life-saving Instruction for Emergencies (LIFE app). Adv Simul (Lond) 2022; 7:2. [PMID: 35012665 PMCID: PMC8744048 DOI: 10.1186/s41077-021-00197-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/22/2021] [Indexed: 11/16/2022] Open
Abstract
Neonatal mortality remains disproportionately high in sub-Saharan Africa partly due to insufficient numbers of adequately trained and skilled front-line health workers. Opportunities for improving neonatal care may result from upskilling frontline health workers using innovative technological approaches. This practice paper describes the key steps involved in the design, development and implementation of an innovative smartphone-based training application using an agile, human-centred design approach. The Life-saving Instruction for Emergencies (LIFE) app is a three-dimension (3D) scenario-based mobile app for smartphones and is free to download. Two clinical modules are currently included with further scenarios planned. Whilst the focus of the practice paper is on the lessons learned during the design and development process, we also share key learning related to project management and sustainability plans, which we hope will help researchers working on similar projects.
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Affiliation(s)
- Conrad Wanyama
- KEMRI/Wellcome Trust Research Programme, Kenya Medical Research Institute, 197 Lenana Place, P.O Box 43640-00100, Nairobi, Kenya.
| | - Shobhana Nagraj
- Nuffield Department of Women's & Reproductive Health, Oxford, England
- The George Institute for Global Health, London, UK
| | - Naomi Muinga
- KEMRI/Wellcome Trust Research Programme, Kenya Medical Research Institute, 197 Lenana Place, P.O Box 43640-00100, Nairobi, Kenya
| | - Timothy Tuti
- KEMRI/Wellcome Trust Research Programme, Kenya Medical Research Institute, 197 Lenana Place, P.O Box 43640-00100, Nairobi, Kenya
| | | | - Anne Geniets
- Department of Education, University of Oxford, Oxford, UK
| | - Niall Winters
- Department of Education, University of Oxford, Oxford, UK
| | - Mike English
- KEMRI/Wellcome Trust Research Programme, Kenya Medical Research Institute, 197 Lenana Place, P.O Box 43640-00100, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jakob Rossner
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chris Paton
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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11
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Tuti T, Aluvaala J, Chelangat D, Mbevi G, Wainaina J, Mumelo L, Wairoto K, Mochache D, Irimu G, Maina M, English M. Improving in-patient neonatal data quality as a pre-requisite for monitoring and improving quality of care at scale: A multisite retrospective cohort study in Kenya. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000673. [PMID: 36962543 PMCID: PMC10021237 DOI: 10.1371/journal.pgph.0000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/20/2022] [Indexed: 03/11/2023]
Abstract
The objectives of this study were to (1)explore the quality of clinical data generated from hospitals providing in-patient neonatal care participating in a clinical information network (CIN) and whether data improved over time, and if data are adequate, (2)characterise accuracy of prescribing for basic treatments provided to neonatal in-patients over time. This was a retrospective cohort study involving neonates ≤28 days admitted between January 2018 and December 2021 in 20 government hospitals with an interquartile range of annual neonatal inpatient admissions between 550 and 1640 in Kenya. These hospitals participated in routine audit and feedback processes on quality of documentation and care over the study period. The study's outcomes were the number of patients as a proportion of all eligible patients over time with (1)complete domain-specific documentation scores, and (2)accurate domain-specific treatment prescription scores at admission, reported as incidence rate ratios. 80,060 neonatal admissions were eligible for inclusion. Upon joining CIN, documentation scores in the monitoring, other physical examination and bedside testing, discharge information, and maternal history domains demonstrated a statistically significant month-to-month relative improvement in number of patients with complete documentation of 7.6%, 2.9%, 2.4%, and 2.0% respectively. There was also statistically significant month-to-month improvement in prescribing accuracy after joining the CIN of 2.8% and 1.4% for feeds and fluids but not for Antibiotic prescriptions. Findings suggest that much of the variation observed is due to hospital-level factors. It is possible to introduce tools that capture important clinical data at least 80% of the time in routine African hospital settings but analyses of such data will need to account for missingness using appropriate statistical techniques. These data allow exploration of trends in performance and could support better impact evaluation, exploration of links between health system inputs and outcomes and scrutiny of variation in quality and outcomes of hospital care.
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Affiliation(s)
- Timothy Tuti
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | | | - George Mbevi
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - John Wainaina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Kefa Wairoto
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Grace Irimu
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Michuki Maina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Muinga N, Paton C, Gicheha E, Omoke S, Abejirinde IOO, Benova L, English M, Zweekhorst M. Using a human-centred design approach to develop a comprehensive newborn monitoring chart for inpatient care in Kenya. BMC Health Serv Res 2021; 21:1010. [PMID: 34556098 PMCID: PMC8461871 DOI: 10.1186/s12913-021-07030-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 09/09/2021] [Indexed: 01/25/2023] Open
Abstract
Introduction Job aids such as observation charts are commonly used to record inpatient nursing observations. For sick newborns, it is important to provide critical information, intervene, and tailor treatment to improve health outcomes, as countries work towards reducing neonatal mortality. However, inpatient vital sign readings are often poorly documented and little attention has been paid to the process of chart design as a method of improving care quality. Poorly designed charts do not meet user needs leading to increased mental effort, duplication, suboptimal documentation and fragmentation. We provide a detailed account of a process of designing a monitoring chart. Methods We used a Human-Centred Design (HCD) approach to co-design a newborn monitoring chart between March and May 2019 in three workshops attended by 16–21 participants each (nurses and doctors) drawn from 14 hospitals in Kenya. We used personas, user story mapping during the workshops and observed chart completion to identify challenges with current charts and design requirements. Two new charts were piloted in four hospitals between June 2019 and February 2020 and revised in a cyclical manner. Results Challenges were identified regarding the chart design and supply, and how staff used existing charts. Challenges to use included limited staffing, a knowledge deficit among junior staff, poor interprofessional communication, and lack of appropriate and working equipment. We identified a strong preference from participants for one chart to capture vital signs, assessment of the baby, and feed and fluid prescription and monitoring; data that were previously captured on several charts. Discussion Adopting a Human-Centred Design approach, we designed a new comprehensive newborn monitoring chart that is unlike observation charts in the literature that only focus on vital signs. While the new chart does not address all needs, we believe that once implemented, it can help build a clearer picture of the care given to newborns. Conclusion The chart was co-designed and piloted with the user and context in mind resulting in a unique monitoring chart that can be adopted in similar settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07030-x.
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Affiliation(s)
- Naomi Muinga
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands. .,KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya. .,Sexual and Reproductive Health Group, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Chris Paton
- Centre for Tropical medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, GB, England.,Department of Information Science, University of Otago, Dunedin, New Zealand
| | | | - Sylvia Omoke
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Lenka Benova
- Sexual and Reproductive Health Group, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Mike English
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, GB, England
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13
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Tuti T, Aluvaala J, Akech S, Agweyu A, Irimu G, English M. Pulse oximetry adoption and oxygen orders at paediatric admission over 7 years in Kenya: a multihospital retrospective cohort study. BMJ Open 2021; 11:e050995. [PMID: 34493522 PMCID: PMC8424839 DOI: 10.1136/bmjopen-2021-050995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/13/2021] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES To characterise adoption and explore specific clinical and patient factors that might influence pulse oximetry and oxygen use in low-income and middle-income countries (LMICs) over time; to highlight useful considerations for entities working on programmes to improve access to pulse oximetry and oxygen. DESIGN A multihospital retrospective cohort study. SETTINGS All admissions (n=132 737) to paediatric wards of 18 purposely selected public hospitals in Kenya that joined a Clinical Information Network (CIN) between March 2014 and December 2020. OUTCOMES Pulse oximetry use and oxygen prescription on admission; we performed growth-curve modelling to investigate the association of patient factors with study outcomes over time while adjusting for hospital factors. RESULTS Overall, pulse oximetry was used in 48.8% (64 722/132 737) of all admission cases. Use rose on average with each month of participation in the CIN (OR: 1.11, 95% CI 1.05 to 1.18) but patterns of adoption were highly variable across hospitals suggesting important factors at hospital level influence use of pulse oximetry. Of those with pulse oximetry measurement, 7% (4510/64 722) had hypoxaemia (SpO2 <90%). Across the same period, 8.6% (11 428/132 737) had oxygen prescribed but in 87%, pulse oximetry was either not done or the hypoxaemia threshold (SpO2 <90%) was not met. Lower chest-wall indrawing and other respiratory symptoms were associated with pulse oximetry use at admission and were also associated with oxygen prescription in the absence of pulse oximetry or hypoxaemia. CONCLUSION The adoption of pulse oximetry recommended in international guidelines for assessing children with severe illness has been slow and erratic, reflecting system and organisational weaknesses. Most oxygen orders at admission seem driven by clinical and situational factors other than the presence of hypoxaemia. Programmes aiming to implement pulse oximetry and oxygen systems will likely need a long-term vision to promote adoption, guideline development and adherence and continuously examine impact.
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Affiliation(s)
- Timothy Tuti
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine and Department of Paediatrics, University of Oxford, Oxford, UK
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14
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Omoke S, English M, Aluvaala J, Gathara D, Agweyu A, Akech S. Prevalence and fluid management of dehydration in children without diarrhoea admitted to Kenyan hospitals: a multisite observational study. BMJ Open 2021; 11:e042079. [PMID: 34145005 PMCID: PMC8215254 DOI: 10.1136/bmjopen-2020-042079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To examine the prevalence of dehydration without diarrhoea among admitted children aged 1-59 months and to describe fluid management practices in such cases. DESIGN A multisite observational study that used routine in-patient data collected prospectively between October 2013 and December 2018. SETTINGS Study conducted in 13 county referral hospitals in Kenya. PARTICIPANTS Children aged 1-59 months with admission or discharge diagnosis of dehydration but had no diarrhoea as a symptom or diagnosis. Children aged <28 days and those with severe acute malnutrition were excluded. RESULTS The prevalence of dehydration in children without diarrhoea was 3.0% (2019/68 204) and comprised 15.9% (2019/12 702) of all dehydration cases. Only 55.8% (1127/2019) of affected children received either oral or intravenous fluid therapy. Where fluid treatment was given, the volumes, type of fluid, duration of fluid therapy and route of administration were similar to those used in the treatment of dehydration secondary to diarrhoea. Pneumonia (1021/2019, 50.6%) and malaria (715/2019, 35.4%) were the two most common comorbid diagnoses. Overall case fatality in the study population was 12.9% (260/2019). CONCLUSION Sixteen per cent of children hospitalised with dehydration do not have diarrhoea but other common illnesses. Two-fifths do not receive fluid therapy; a regimen similar to that used in diarrhoeal cases is used in cases where fluid is administered. Efforts to promote compliance with guidance in routine clinical settings should recognise special circumstances where guidelines do not apply, and further studies on appropriate management for dehydration in the absence of diarrhoea are required.
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Affiliation(s)
- Sylvia Omoke
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Clinical Medicine, Nuffield, Oxford, UK
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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English M, Ogola M, Aluvaala J, Gicheha E, Irimu G, McKnight J, Vincent CA. First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality. Arch Dis Child 2021; 106:326-332. [PMID: 33361068 PMCID: PMC7982941 DOI: 10.1136/archdischild-2020-320630] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the technical and relational skills needed to perform these system diagnostic roles. Some safety challenges need leadership from professional associations to provide important resources, peer support and mentorship to sustain safety work.
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Affiliation(s)
- Mike English
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK .,Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Muthoni Ogola
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Edith Gicheha
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya,Kenya Paediatric Research Consortium, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya,Kenya Paediatric Research Consortium, Nairobi, Kenya
| | - Jacob McKnight
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
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16
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English M, Irimu G, Akech S, Aluvaala J, Ogero M, Isaaka L, Malla L, Tuti T, Gathara D, Oliwa J, Agweyu A. Employing learning health system principles to advance research on severe neonatal and paediatric illness in Kenya. BMJ Glob Health 2021; 6:e005300. [PMID: 33758014 PMCID: PMC7993294 DOI: 10.1136/bmjgh-2021-005300] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/03/2021] [Accepted: 03/07/2021] [Indexed: 11/03/2022] Open
Abstract
We have worked to develop a Clinical Information Network (CIN) in Kenya as an early form of learning health systems (LHS) focused on paediatric and neonatal care that now spans 22 hospitals. CIN's aim was to examine important outcomes of hospitalisation at scale, identify and ultimately solve practical problems of service delivery, drive improvements in quality and test interventions. By including multiple routine settings in research, we aimed to promote generalisability of findings and demonstrate potential efficiencies derived from LHS. We illustrate the nature and range of research CIN has supported over the past 7 years as a form of LHS. Clinically, this has largely focused on common, serious paediatric illnesses such as pneumonia, malaria and diarrhoea with dehydration with recent extensions to neonatal illnesses. CIN also enables examination of the quality of care, for example that provided to children with severe malnutrition and the challenges encountered in routine settings in adopting simple technologies (pulse oximetry) and more advanced diagnostics (eg, Xpert MTB/RIF). Although regular feedback to hospitals has been associated with some improvements in quality data continue to highlight system challenges that undermine provision of basic, quality care (eg, poor access to blood glucose testing and routine microbiology). These challenges include those associated with increased mortality risk (eg, delays in blood transfusion). Using the same data the CIN platform has enabled conduct of randomised trials and supports malaria vaccine and most recently COVID-19 surveillance. Employing LHS principles has meant engaging front-line workers, clinical managers and national stakeholders throughout. Our experience suggests LHS can be developed in low and middle-income countries that efficiently enable contextually appropriate research and contribute to strengthening of health services and research systems.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Oxford Centre for Global Health Research, Nuffield Department of Clinical Medicine, Oxford, UK
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Morris Ogero
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Lynda Isaaka
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Timothy Tuti
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jacquie Oliwa
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Ambrose Agweyu
- Epidemiology and Demography, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
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17
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Zhao Y, Musitia P, Boga M, Gathara D, Nicodemo C, English M. Tools for measuring medical internship experience: a scoping review. HUMAN RESOURCES FOR HEALTH 2021; 19:10. [PMID: 33446218 PMCID: PMC7809831 DOI: 10.1186/s12960-021-00554-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/02/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Appropriate and well-resourced medical internship training is important to ensure psychological health and well-being of doctors in training and also to recruit and retain these doctors. However, most reviews focused on clinical competency of medical interns instead of the non-clinical aspects of training. In this scoping review, we aim to review what tools exist to measure medical internship experience and summarize the major domains assessed. METHOD The authors searched MEDLINE, Embase, PsycINFO, ERIC, and the Cochrane Library for peer-reviewed studies that provided quantitative data on medical intern's (house officer, foundation year doctor, etc.) internship experience and published between 2000 and 2019. Three reviewers screened studies for eligibility with inclusion criteria. Data including tools used, key themes examined, and psychometric properties within the study population were charted, collated, and summarized. Tools that were used in multiple studies, and tools with internal validity or reliability assessed directed in their intern population were reported. RESULTS The authors identified 92 studies that were included in the analysis. The majority of studies were conducted in the US (n = 30, 32.6%) and the UK (n = 20, 21.7%), and only 14 studies (15.2%) were conducted in low- and middle-income countries. Major themes examined for internship experience included well-being, educational environment, and work condition and environment. For measuring well-being, standardized tools like the Maslach Burnout Inventory (for measuring burnout), Patient Health Questionnaire-9 (depression), General Health Questionnaire-12 or 30 (psychological distress) and Perceived Stress Scale (stress) were used multiple times. For educational environment and work condition and environment, there is a lack of widely used tools for interns that have undergone psychometric testing in this population other than the Postgraduate Hospital Educational Environment Measure, which has been used in four different countries. CONCLUSIONS There are a large number of tools designed for measuring medical internship experience. International comparability of results from future studies would benefit if tools that have been more widely used are employed in studies on medical interns with further testing of their psychometric properties in different contexts.
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Affiliation(s)
- Yingxi Zhao
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, S Parks Rd, Oxford, OX1 3SY, United Kingdom.
| | - Peris Musitia
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - David Gathara
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Catia Nicodemo
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Mike English
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, S Parks Rd, Oxford, OX1 3SY, United Kingdom
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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18
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/24/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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19
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 01/25/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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20
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Ogero M, Sarguta RJ, Malla L, Aluvaala J, Agweyu A, English M, Onyango NO, Akech S. Prognostic models for predicting in-hospital paediatric mortality in resource-limited countries: a systematic review. BMJ Open 2020; 10:e035045. [PMID: 33077558 PMCID: PMC7574949 DOI: 10.1136/bmjopen-2019-035045] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 09/03/2020] [Accepted: 09/09/2020] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To identify and appraise the methodological rigour of multivariable prognostic models predicting in-hospital paediatric mortality in low-income and middle-income countries (LMICs). DESIGN Systematic review of peer-reviewed journals. DATA SOURCES MEDLINE, CINAHL, Google Scholar and Web of Science electronic databases since inception to August 2019. ELIGIBILITY CRITERIA We included model development studies predicting in-hospital paediatric mortality in LMIC. DATA EXTRACTION AND SYNTHESIS This systematic review followed the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies framework. The risk of bias assessment was conducted using Prediction model Risk of Bias Assessment Tool (PROBAST). No quantitative summary was conducted due to substantial heterogeneity that was observed after assessing the studies included. RESULTS Our search strategy identified a total of 4054 unique articles. Among these, 3545 articles were excluded after review of titles and abstracts as they covered non-relevant topics. Full texts of 509 articles were screened for eligibility, of which 15 studies reporting 21 models met the eligibility criteria. Based on the PROBAST tool, risk of bias was assessed in four domains; participant, predictors, outcome and analyses. The domain of statistical analyses was the main area of concern where none of the included models was judged to be of low risk of bias. CONCLUSION This review identified 21 models predicting in-hospital paediatric mortality in LMIC. However, most reports characterising these models are of poor quality when judged against recent reporting standards due to a high risk of bias. Future studies should adhere to standardised methodological criteria and progress from identifying new risk scores to validating or adapting existing scores. PROSPERO REGISTRATION NUMBER CRD42018088599.
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Affiliation(s)
- Morris Ogero
- School of Mathematics, University of Nairobi College of Biological and Physical Sciences, Nairobi, Kenya
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Rachel Jelagat Sarguta
- School of Mathematics, University of Nairobi College of Biological and Physical Sciences, Nairobi, Kenya
| | - Lucas Malla
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine and Department of Paediatrics, Oxford University, Oxford, UK
| | - Nelson Owuor Onyango
- School of Mathematics, University of Nairobi College of Biological and Physical Sciences, Nairobi, Kenya
| | - Samuel Akech
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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21
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English M, Strachan B, Esamai F, Ngwiri T, Warfa O, Mburugu P, Nalwa G, Gitaka J, Ngugi J, Zhao Y, Ouma P, Were F. The paediatrician workforce and its role in addressing neonatal, child and adolescent healthcare in Kenya. Arch Dis Child 2020; 105:927-931. [PMID: 32554508 PMCID: PMC7513261 DOI: 10.1136/archdischild-2019-318434] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine the availability of paediatricians in Kenya and plans for their development. DESIGN Review of policies and data from multiple sources combined with local expert insight. SETTING Kenya with a focus on the public, non-tertiary care sector as an example of a low-income and middle-income country aiming to improve the survival and long-term health of newborns, children and adolescents. RESULTS There are 305 practising paediatricians, 1.33 per 100 000 individuals of the population aged <19 years which in total numbers approximately 25 million. Only 94 are in public sector, non-tertiary county hospitals. There is either no paediatrician at all or only one paediatrician in 21/47 Kenyan counties that are home to over a quarter of a million under 19 years of age. Government policy is to achieve employment of 1416 paediatricians in the public sector by 2030, however this remains aspirational as there is no comprehensive training or financing plan to reach this target and health workforce recruitment, financing and management is now devolved to 47 counties. The vast majority of paediatric care is therefore provided by non-specialist healthcare workers. DISCUSSION The scale of the paediatric workforce challenge seriously undermines the ability of the Kenyan health system to deliver on the emerging survive, thrive and transform agenda that encompasses more complex health needs. Addressing this challenge may require innovative workforce solutions such as task-sharing, these may in turn require the role of paediatricians to be redefined. Professional paediatric communities in countries like Kenya could play a leadership role in developing such solutions.
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Affiliation(s)
- Mike English
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya .,Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | | | - Fabian Esamai
- Department of Paediatrics and Child Health, College of Health Sciences, Moi University, Kenya, Eldoret, Kenya
| | | | | | - Patrick Mburugu
- Department of Paediatrics and Child Health, School of Medicine, Jomo Kenyatta University of Africulture and Technology, Nairobi, Kenya
| | - Grace Nalwa
- Department of Paediatrics and Child Health, Maseno University, Maseno, Nyanza, Kenya
| | - Jesse Gitaka
- Directorate of Research and Innovation, School of Medicine, Mount Kenya University, Thika, Kenya
| | - John Ngugi
- Department of Paediatrics and Child Health, Kenyatta University, Nairobi, Kenya
| | - Yingxi Zhao
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Paul Ouma
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Fred Were
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Antibiotic use in Kenyan public hospitals: Prevalence, appropriateness and link to guideline availability. Int J Infect Dis 2020; 99:10-18. [PMID: 32781162 PMCID: PMC7562818 DOI: 10.1016/j.ijid.2020.07.084] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/18/2020] [Accepted: 07/26/2020] [Indexed: 11/28/2022] Open
Abstract
We report findings from a point prevalence survey across 14 Kenyan public hospitals. About half of the hospitalised patients received appropriate antibiotic therapy. Laboratory investigations supported less than 1% of the antibiotic prescriptions. Physical availability of treatment guidelines influenced treatment appropriateness. There is need for context-specific, up-to-date, and accessible treatment guidelines.
Objective To examine prescription patterns and explore to what extent guidelines are available and how they might influence treatment appropriateness among hospitalised patients in Kenyan hospitals. Methods Data on antimicrobial usage were collected from hospitalised patients across 14 Kenyan public hospitals. For each prescription, appropriateness of treatment was defined using available local and international treatment guidelines and through consensus with local medical specialists. Association between appropriate treatment, guideline availability and other possible explanatory factors was explored using univariate and multiple regression analysis. Results There were 1675 (46.7%) of the 3590 hospitalised patients on antimicrobials with 3145(94%) of the 3363 antimicrobial prescriptions being antibiotics. Two patients (0.1%), had treatment based on available antibiotic susceptibility tests. Appropriate treatment was assessed in 1502 patients who had a single diagnosis. Of these, 805 (53.6%) received appropriate treatment. Physical availability of treatment guidelines increased the odds of receiving appropriate treatment Odds Ratio 6.44[95% CI 4.81–8.64]. Conclusion Appropriate antibiotic prescription remains a challenge in Kenyan public hospitals. This may be improved by the availability of context-specific, up-to-date, and readily accessible treatment guidelines across all the departments, and by providing better diagnostic support.
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