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Nding'ori D, Spitzer RF, Songok J, Buitendyk M, Mishra P, Kosgei W, Kipchumba B, Kakuti M, Tonui P, Fung-Kee-Fung K, Leftwich H, Gardner A, Nyongesa P, Okun N. Improving health equity through sustained academic partnership: development of a maternal-fetal medicine fellowship training program in Western Kenya. AJOG GLOBAL REPORTS 2024; 4:100362. [PMID: 39072337 PMCID: PMC11278782 DOI: 10.1016/j.xagr.2024.100362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024] Open
Abstract
Low- and middle-income countries are underresourced in subspecialist care. This study describes a unique maternal-fetal medicine clinical fellowship training program at Moi University School of Medicine and Moi Teaching and Referral Hospital in Eldoret, Western Kenya. The first of its kind in Eastern Africa, it has met with success in the retention of highly qualified practitioners providing complex pregnancy care to a population that has been heretofore underserved.
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Affiliation(s)
- David Nding'ori
- Department of Obstetrics and Gynecology, Kitale County Referral Hospital, Kitale, Kenya (Nding'ori)
| | - Rachel F. Spitzer
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto Canada, Toronto, Ontario (Spitzer)
| | - Julia Songok
- Department of Child health and Pediatrics, Moi University, Eldoret, Kenya (Songok)
| | - Marie Buitendyk
- Department of Obstetrics and Gynecology, St Joseph's Health Centre, University of Toronto, Toronto, Canada (Buitendyk)
| | - Pallavi Mishra
- Department of Reproductive Health, Mediheal Group of Hospitals, Nairobi, Kenya (Pallavi)
| | - Wycliffe Kosgei
- Department of Reproductive Health, Moi Teaching and Referral Hospital, Moi University, Eldoret, Kenya (Kosgei, Kipchumba, Kakuti, Tonui, and Nyongesa)
| | - Bett Kipchumba
- Department of Reproductive Health, Moi Teaching and Referral Hospital, Moi University, Eldoret, Kenya (Kosgei, Kipchumba, Kakuti, Tonui, and Nyongesa)
| | - Mutindi Kakuti
- Department of Reproductive Health, Moi Teaching and Referral Hospital, Moi University, Eldoret, Kenya (Kosgei, Kipchumba, Kakuti, Tonui, and Nyongesa)
| | - Philip Tonui
- Department of Reproductive Health, Moi Teaching and Referral Hospital, Moi University, Eldoret, Kenya (Kosgei, Kipchumba, Kakuti, Tonui, and Nyongesa)
| | - Karen Fung-Kee-Fung
- Department of Obstetrics and Gynecology, The Ottawa Hospital, University of Ottawa, Ottawa, Canada (Fung-Kee-Fung)
| | - Heidi Leftwich
- University of Massachusetts Chan Medical School/UMass Memorial Health, Worcester, MA (Leftwich)
| | - Adrian Gardner
- Center for Global Health, Indiana University, Indianapolis, IN (Gardiner)
| | - Paul Nyongesa
- Department of Reproductive Health, Moi Teaching and Referral Hospital, Moi University, Eldoret, Kenya (Kosgei, Kipchumba, Kakuti, Tonui, and Nyongesa)
| | - Nanette Okun
- Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada (Okun)
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Wilson-Barthes M, Steingrimsson J, Lee Y, Tran DN, Wachira J, Kafu C, Pastakia SD, Vedanthan R, Said JA, Genberg BL, Galárraga O. Economic outcomes among microfinance group members receiving community-based chronic disease care: Cluster randomized trial evidence from Kenya. Soc Sci Med 2024; 351:116993. [PMID: 38781744 PMCID: PMC11180555 DOI: 10.1016/j.socscimed.2024.116993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/15/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Poverty can be a robust barrier to HIV care engagement. We assessed the extent to which delivering care for HIV, diabetes and hypertension within community-based microfinance groups increased savings and reduced loan defaults among microfinance members living with HIV. METHODS We analyzed cluster randomized trial data ascertained during November 2020-May 2023 from 57 self-formed microfinance groups in western Kenya. Groups were randomized 1:1 to receive care for HIV and non-communicable diseases in the community during regular microfinance meetings (intervention) or at a health facility during routine appointments (standard care). Community and facility care provided clinical evaluations, medications, and point-of-care testing. The trial enrolled 900 microfinance members, with data collected quarterly for 18-months. We used a two-part model to estimate intervention effects on microfinance shares purchased, and a negative binomial regression model to estimate differences in loan default rates between trial arms. We estimated effects overall and by participant characteristics. RESULTS Participants' median age and distance from a health facility was 52 years and 5.6 km, respectively, and 50% reported earning less than $50 per month. The probability of saving any amount (>$0) through purchasing microfinance shares was 2.7 percentage points higher among microfinance group members receiving community vs. facility care. Community care recipients and facility care patients saved $44.90 and $25.24 over 18-months, respectively, and the additional amount saved by community care recipients was statistically significant (p = 0.036). Overall and in stratified analyses, loan defaults rates were not statistically significantly different between community and facility care patients. CONCLUSIONS Receiving integrated care in the community was significantly associated with modest increases in savings. We did not find any significant association between community-delivered care and reductions in loan defaults among HIV-positive microfinance group members. Longer follow up examination and formal mediation analyses are warranted.
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Affiliation(s)
- M Wilson-Barthes
- Brown University School of Public Health, International Health Institute, Providence, RI, USA.
| | - J Steingrimsson
- Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA
| | - Y Lee
- Brown University School of Public Health, Department of Biostatistics, Providence, RI, USA
| | - D N Tran
- Temple University, School of Pharmacy, Philadelphia, PA, USA
| | - J Wachira
- Moi University College of Health Sciences, School of Medicine, Department of Behavioral Science, Eldoret, Kenya
| | - C Kafu
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - S D Pastakia
- Purdue University College of Pharmacy, Center for Health Equity and Innovation, Indianapolis, IN, USA
| | - R Vedanthan
- New York University Grossman School of Medicine, Department of Population Health, New York, NY, USA
| | - J A Said
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - B L Genberg
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - O Galárraga
- Brown University School of Public Health, Department of Health Services, Policy and Practice; and International Institute, Providence, RI, USA
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Ogugu EG, Bidwell JT, Ruark A, Butterfield RM, Weiser SD, Neilands TB, Mulauzi N, Rambiki E, Mkandawire J, Conroy AA. Barriers to accessing care for cardiometabolic disorders in Malawi: partners as a source of resilience for people living with HIV. Int J Equity Health 2024; 23:83. [PMID: 38678232 PMCID: PMC11055364 DOI: 10.1186/s12939-024-02181-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND People living with HIV (PLWH) are at increased risk of cardiometabolic disorders (CMD). Adequate access to care for both HIV and CMD is crucial to improving health outcomes; however, there is limited research that have examined couples' experiences accessing such care in resource-constrained settings. We aimed to identify barriers to accessing CMD care among PLWH in Malawi and the role of partners in mitigating these barriers. METHODS We conducted a qualitative investigation of barriers to CMD care among 25 couples in Malawi. Couples were eligible if at least one partner was living with HIV and had hypertension or diabetes (i.e., the index patient). Index patients were recruited from HIV care clinics in the Zomba district, and their partners were enrolled thereafter. Interviews were conducted separately with both partners to determine barriers to CMD care access and how partners were involved in care. RESULTS Participants framed their experiences with CMD care by making comparisons to HIV treatment, which was free and consistently available. The main barriers to accessing CMD care included shortage of medications, cost of tests and treatments, high cost of transportation to health facilities, lengthy wait times at health facilities, faulty or unavailable medical equipment and supplies, inadequate monitoring of patients' health conditions, some cultural beliefs about causes of illness, use of herbal therapies as an alternative to prescribed medicine, and inadequate knowledge about CMD treatments. Partners provided support through decision-making on accessing medical care, assisting partners in navigating the healthcare system, and providing financial assistance with transportation and treatment expenses. Partners also helped manage care for CMD, including communicating health information to their partners, providing appointment reminders, supporting medication adherence, and supporting recommended lifestyle behaviors. CONCLUSIONS Couples identified many barriers to CMD care access, which were perceived as greater challenges than HIV care. Partners provided critical forms of support in navigating these barriers. With the rise of CMD among PLWH, improving access to CMD care should be prioritized, using lessons learned from HIV and integrated care approaches. Partner involvement in CMD care may help mitigate most barriers to CMD care.
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Affiliation(s)
- Everlyne G Ogugu
- Betty Irene Moore School of Nursing, University of California Davis, Davis, CA, USA.
- Betty Irene Moore School of Nursing, University of California Davis, 2570 48th Street, Sacramento, CA, 95817, USA.
| | - Julie T Bidwell
- Betty Irene Moore School of Nursing, University of California Davis, Davis, CA, USA
| | - Allison Ruark
- Wheaton College, Biological and Health Sciences, Wheaton, IL, USA
| | - Rita M Butterfield
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sheri D Weiser
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Torsten B Neilands
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Amy A Conroy
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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Maritim B, Koon AD, Kimaina A, Goudge J. Citizen engagement in national health insurance in rural western Kenya. Health Policy Plan 2024; 39:387-399. [PMID: 38334694 PMCID: PMC11005831 DOI: 10.1093/heapol/czae007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 11/01/2023] [Accepted: 02/06/2024] [Indexed: 02/10/2024] Open
Abstract
Effective citizen engagement is crucial for the success of social health insurance, yet little is known about the mechanisms used to involve citizens in low- and middle-income countries. This paper explores citizen engagement efforts by the National Health Insurance Fund (NHIF) and their impact on health insurance coverage within rural informal worker households in western Kenya. Our study employed a mixed methods design, including a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), six focus group discussions with community stakeholders and key informant interviews (n = 11) with policymakers. The findings reveal that NHIF is widely recognized, but knowledge of its services, feedback mechanisms and accountability systems is limited. NHIF enrolment among respondents is low (11%). The majority (63%) are aware of NHIF, but only 32% know about the benefit package. There was higher awareness of the benefit package (60%) among those with NHIF compared to those without (28%). Satisfaction with the NHIF benefit package was expressed by only 48% of the insured. Nearly all respondents (93%) are unaware of mechanisms to provide feedback or raise complaints with NHIF. Of those who are aware, the majority (57%) mention visiting NHIF offices for assistance. Most respondents (97%) lack awareness of NHIF's performance reporting mechanisms and express a desire to learn. Negative media reports about NHIF's performance erode trust, contributing to low enrolment and member attrition. Our study underscores the urgency of prioritizing citizen engagement to address low enrolment and attrition rates. We recommend evaluating current citizen engagement procedures to enhance citizen accountability and incorporate their voices. Equally important is the need to build the capacity of health facility staff handling NHIF clients in providing information and addressing complaints. Transparency and information accessibility, including the sharing of performance reports, will foster trust in the insurer. Lastly, standardizing messaging and translations for diverse audiences, particularly rural informal workers, is crucial.
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Affiliation(s)
- Beryl Maritim
- Consortium for Advanced Research Training in Africa (CARTA), P.O. Box 10787, Nairobi 00100, Kenya
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 51 2193, 60 York Rd, Parktown, Johannesburg 2193, South Africa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, 00100, Nairobi 00100, Kenya
| | - Adam D Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E8143, Baltimore, MD 21205, USA
| | - Allan Kimaina
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, 00100, Nairobi 00100, Kenya
| | - Jane Goudge
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 51 2193, 60 York Rd, Parktown, Johannesburg 2193, South Africa
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Sinnott C, Vedanthan R, van Olmen J. Elusive but hopefully not illusive: coordinating care for patients with heart failure with preserved ejection fraction. BMJ Qual Saf 2024; 33:212-215. [PMID: 38195252 DOI: 10.1136/bmjqs-2023-016754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2024] [Indexed: 01/11/2024]
Affiliation(s)
- Carol Sinnott
- THIS Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Josefien van Olmen
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
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Bhatia MB, Kisilu N, Kiptoo S, Limenik I, Adaniya E, Kibiwot S, Wabende LN, Jepkirui S, Awuor DA, Morgan J, Loehrer PJ, Hunter-Squires JL, Busakhala N. Breast Health Awareness: Understanding Health-Seeking Behavior in Western Kenya. Ann Surg Oncol 2024; 31:1190-1199. [PMID: 38044347 DOI: 10.1245/s10434-023-14575-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/25/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION In Kenya, patients with breast cancer predominantly present with late-stage disease and experience poor outcomes. To promote early-stage diagnosis, we implemented the Academic Model Providing Access to Healthcare (AMPATH) Breast and Cervical Cancer Control Program (ABCCCP) in Western Kenya. OBJECTIVE The aim of this study was to assess differences between patients presenting to health facilities and health fairs. METHODS This was an institutional Review and Ethics Commitee-approved retrospective cohort study of all individuals who underwent clinical breast examination (CBE) via local healthcare workers in Western Kenya. From 2017 to 2021, the program hosted health fairs, and trained healthcare providers at health facilities to complete CBEs. Results were analyzed using the Chi-square and Kruskal-Wallis tests, with an α < 0.05. RESULTS Over a 5-year period, the ABCCCP completed 61,812 CBEs with 75.9% (n = 46,902) performed at a health facility. Patients presenting to health fairs were older (44 vs. 38 years; p < 0.0001) and had higher risk factor rates including early menarche, family history of breast and ovarian cancer, and use of alcohol or smoking. Only 27.6% of patients with an abnormal CBE underwent core needle biopsy, and only 5.2% underwent repeat CBE over the 5-year period, of whom 90.3% presented to health facilities. CONCLUSIONS Successful uptake of CBE through the ABCCCP is the first step to introduce breast health awareness (BHA). Benefits of broad advertisements for health fairs in promoting BHA may be limited to a single event. Poor rates of repeat examinations and diagnostic testing of abnormal CBEs indicate additional resources should be allocated to educating patients, including about possible treatment trajectories for breast cancer.
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Affiliation(s)
| | | | - Stephen Kiptoo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ivan Limenik
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Emily Adaniya
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Silvanus Kibiwot
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Sally Jepkirui
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Jennifer Morgan
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - JoAnna L Hunter-Squires
- Indiana University School of Medicine, Indianapolis, IN, USA
- Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
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Kibel M, Nyambura M, Embleton L, Kiptui R, Galárraga O, Apondi E, Ayuku D, Braitstein P. Enabling Adherence to Treatment (EAT): a pilot study of a combination intervention to improve HIV treatment outcomes among street-connected individuals in western Kenya. BMC Health Serv Res 2023; 23:1331. [PMID: 38037045 PMCID: PMC10691070 DOI: 10.1186/s12913-023-10215-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 10/26/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya. METHODS This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention. RESULTS Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant. CONCLUSIONS This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.
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Affiliation(s)
- Mia Kibel
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Monicah Nyambura
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Lonnie Embleton
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Global Health and Health System Design, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - Reuben Kiptui
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Omar Galárraga
- Department of Health Services Policy and Practice, and International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
- Department of Child Health and Paediatrics, College of Health Sciences, Moi University, Eldoret, Kenya
| | - David Ayuku
- Department of Mental Health and Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Paula Braitstein
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
- Department of Epidemiology and Medical Statistics, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
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Nessle CN, Njuguna F, Dettinger J, Koima R, Nyamusi L, Kisembe E, Kinja S, Ndung'u M, Njenga D, Langat S, Olbara G, Moyer C, Vik T. Barriers to and facilitators of effective management of fever episodes in hospitalised Kenyan children with cancer: protocol for convergent mixed methods study. BMJ Open 2023; 13:e078124. [PMID: 37918936 PMCID: PMC10626801 DOI: 10.1136/bmjopen-2023-078124] [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: 07/25/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023] Open
Abstract
INTRODUCTION Febrile neutropenia is an oncological emergency in children with cancer, associated with serious infections and complications. In low-resourced settings, death from infections in children with cancer is 20 times higher than in high-resourced treatment settings, thought to be related to delays in antibiotic administration and management. The barriers to effective management of fever episodes in children with cancer have not previously been described. This convergent mixed-methods study will provide the evidence to develop fever treatment guidelines and to inform their effective implementation in children with cancer at Moi Teaching and Referral Hospital (MTRH), a level 6 referral hospital in western Kenya. METHODS AND ANALYSIS Prospective data collection of paediatric patients with cancer with new fever episodes admitted to MTRH will be performed during routine treatment. Clinical variables will be collected from 50 fever episodes, including cancer diagnosis and infectious characteristics of the fever episode, and elapsed time from fever onset to various milestones in the management workflow. Semistructured qualitative interviews with healthcare providers (estimated 20 to reach saturation) will explore the barriers to and facilitators of appropriate management of fever episodes in children with cancer. The interview guide was informed by a theoretical framework and Consolidated Framework for Implementation Research. A mixed-methods analysis use of joint display tables and process mapping will link and integrate the two types of data with meta-inferences. ETHICS AND DISSEMINATION Institutional review board approval was obtained from the MTRH (0004273) and the University of Michigan (HUM0225674), and the study was registered with National Commission for Science Technology and Innovation (P/23/22885). Written consent will be obtained from all participants. Results will be formally shared with local and national policy leadership and local end users, presented at relevant national academic conferences and submitted for publication in a peer-reviewed journal.
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Affiliation(s)
- Charles Nathaniel Nessle
- Department of Pediatrics, Division of Hematology-Oncology, University of Michigan, Ann Arbor, Michigan, USA
- Fogarty International Center, National Institute of Health, Bethesda, Maryland, USA
| | - Festus Njuguna
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Julia Dettinger
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Raphael Koima
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Lenah Nyamusi
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Evelynn Kisembe
- School of Arts and Social Sciences, Moi University, Eldoret, Kenya
- Behavioral and Social Science Research, Moi University, Eldoret, Kenya
| | - Sarah Kinja
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Mercy Ndung'u
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Dennis Njenga
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Sandra Langat
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Gilbert Olbara
- Department of Child Health and Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Cheryl Moyer
- Medical School, Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Terry Vik
- Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
- Department of Pediatrics, Division of Hematology-Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Ruhl LJ, Kiplagat J, O'Brien R, Wools-Kaloustian K, Scanlon M, Plater D, Thomas MR, Pastakia S, Gopal-Srivastava R, Morales-Soto N, Nyandiko W, Vreeman RC, Litzelman DK, Laktabai J. A Global Health Reciprocal Innovation grant programme: 5-year review with lessons learnt. BMJ Glob Health 2023; 8:e013585. [PMID: 37977589 PMCID: PMC10660845 DOI: 10.1136/bmjgh-2023-013585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/16/2023] [Indexed: 11/19/2023] Open
Abstract
Unilateral approaches to global health innovations can be transformed into cocreative, uniquely collaborative relationships between low-income and middle-income countries (LMICs) and high-income countries (HIC), constituted as 'reciprocal innovation' (RI). Since 2018, the Indiana Clinical and Translational Sciences Institute (CTSI) and Indiana University (IU) Center for Global Health Equity have led a grants programme sculpted from the core elements of RI, a concept informed by a 30-year partnership started between IU (Indiana) and Moi University (Kenya), which leverages knowledge sharing, transformational learning and translational innovations to address shared health challenges. In this paper, we describe the evolution and implementation of an RI grants programme, as well as the challenges faced. We aim to share the successes of our RI engagement and encourage further funding opportunities to promote innovations grounded in the RI core elements. From the complex series of challenges encountered, three major lessons have been learnt: dedicating extensive time and resources to bring different settings together; establishing local linkages across investigators; and addressing longstanding inequities in global health research. We describe our efforts to address these challenges through educational materials and an online library of resources for RI projects. Using perspectives from RI investigators funded by this programme, we offer future directions resulting from our 5-year experience in applying this RI-focused approach. As the understanding and implementation of RI grow, global health investigators can share resources, knowledge and innovations that have the potential to significantly change the face of collaborative international research and address long-standing health inequities across diverse settings.
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Affiliation(s)
- Laura J Ruhl
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- AMPATH, Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | - Rishika O'Brien
- Center for Global Health Equity, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kara Wools-Kaloustian
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- AMPATH, Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Michael Scanlon
- AMPATH, Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Center for Global Health Equity, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - David Plater
- AMPATH, Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Health Systems Design, Icahn School of Medicine at Mount Sinai Arnhold Institute for Global Health, New York, New York, USA
| | - Melissa R Thomas
- Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
| | - Sonak Pastakia
- AMPATH, Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Center for Health Equity and Innovation, Purdue University College of Pharmacy Nursing and Health Sciences, West Lafayette, Indiana, USA
| | - Rashmi Gopal-Srivastava
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, Maryland, USA
| | - Nydia Morales-Soto
- Eck Institute for Global Health, University of Notre Dame, Notre Dame, Indiana, USA
| | - Winstone Nyandiko
- AMPATH, Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Rachel C Vreeman
- AMPATH, Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Health Systems Design, Icahn School of Medicine at Mount Sinai Arnhold Institute for Global Health, New York, New York, USA
| | - Debra K Litzelman
- Center for Global Health Equity, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Center for Health Services Research, Regenstrief Institute Inc, Indianapolis, Indiana, USA
| | - Jeremiah Laktabai
- AMPATH, Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Family Medicine, Moi University School of Medicine, Eldoret, Kenya
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10
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Gala P, Kamano JH, Vazquez Sanchez M, Mugo R, Orango V, Pastakia S, Horowitz C, Hogan JW, Vedanthan R. Cross-sectional analysis of factors associated with medication adherence in western Kenya. BMJ Open 2023; 13:e072358. [PMID: 37669842 PMCID: PMC10481848 DOI: 10.1136/bmjopen-2023-072358] [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: 02/28/2023] [Accepted: 08/14/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVES Poor medication adherence in low-income and middle-income countries is a major cause of suboptimal hypertension and diabetes control. We aimed to identify key factors associated with medication adherence in western Kenya, with a focus on cost-related and economic wealth factors. SETTING We conducted a cross-sectional analysis of baseline data of participants enrolled in the Bridging Income Generation with Group Integrated Care study in western Kenya. PARTICIPANTS All participants were ≥35 years old with either diabetes or hypertension who had been prescribed medications in the past 3 months. PRIMARY AND SECONDARY OUTCOME MEASURES Baseline data included sociodemographic characteristics, wealth and economic status and medication adherence information. Predictors of medication adherence were separated into the five WHO dimensions of medication adherence: condition-related factors (comorbidities), patient-related factors (psychological factors, alcohol use), therapy-related factors (number of prescription medications), economic-related factors (monthly income, cost of transportation, monthly cost of medications) and health system-related factors (health insurance, time to travel to the health facility). A multivariable analysis, controlling for age and sex, was conducted to determine drivers of suboptimal medication adherence in each overarching category. RESULTS The analysis included 1496 participants (73.7% women) with a mean age of 60 years (range 35-97). The majority of participants had hypertension (69.2%), 8.8% had diabetes and 22.1% had both hypertension and diabetes. Suboptimal medication adherence was reported by 71.2% of participants. Economic factors were associated with medication adherence. In multivariable analysis that investigated specific subtypes of costs, transportation costs were found to be associated with worse medication adherence. In contrast, we found no evidence of association between monthly medication costs and medication adherence. CONCLUSION Suboptimal medication adherence is highly prevalent in Kenya, and primary-associated factors include costs, particularly indirect costs of transportation. Addressing all economic factors associated with medication adherence will be important to improve outcomes for non-communicable diseases. TRIAL REGISTRATION NUMBER NCT02501746.
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Affiliation(s)
- Pooja Gala
- Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | | | - Manuel Vazquez Sanchez
- Population Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Richard Mugo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Vitalis Orango
- Medicine, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Sonak Pastakia
- Center for Health Equity and Innovation, Purdue University College of Pharmacy Nursing and Health Sciences, West Lafayette, Indiana, USA
| | - Carol Horowitz
- Medicine and Population Health Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joseph W Hogan
- Biostatistics, Brown University, Providence, Rhode Island, USA
| | - Rajesh Vedanthan
- Medicine and Population Health, New York University Grossman School of Medicine, New York, New York, USA
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11
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Goldstein D, Salvatore M, Ferris R, Phelps BR, Minior T. Integrating global HIV services with primary health care: a key step in sustainable HIV epidemic control. Lancet Glob Health 2023; 11:e1120-e1124. [PMID: 37349037 DOI: 10.1016/s2214-109x(23)00156-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/27/2023] [Accepted: 03/06/2023] [Indexed: 06/24/2023]
Abstract
Ending the HIV epidemic relies in part on integrating stand-alone HIV programming with primary health-care platforms to improve population-level health and ensure sustainability. Integration of HIV and primary health care services in sub-Saharan Africa improves both outcomes. Existing models support both integrating primary health care services into existing HIV services, and incorporating HIV services into primary health care platforms, with optimal programming based on local contexts and local epidemic factors. Person-centred differentiated service delivery, community-based interventions, and a well supported health workforce form the backbone of successful integration. Strategic financing to optimise HIV and primary health care integration requires well-coordinated partnerships with host governments, private sector companies, multilateral stakeholders, development banks, and non-government organisations. Programme success will require increased flexibility of international donors' implementation guidance as well as involvement of local communities and civil society organisations. As we seek to end the HIV epidemic by 2030 amidst a constrained global economic climate, integration of HIV programming with primary health care offers an avenue of opportunity and hope.
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Affiliation(s)
- Deborah Goldstein
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA.
| | | | - Robert Ferris
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Benjamin Ryan Phelps
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Thomas Minior
- Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
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12
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Amick E, Naanyu V, Bucher S, Henry BW. Perceptions of Global Health Engagements in Relation to the COVID-19 Pandemic Among Kenyan Health Care Workers and Administrators in Western Kenya: Protocol for Multi-stage Qualitative Study. JMIR Res Protoc 2023. [PMID: 37315197 PMCID: PMC10365599 DOI: 10.2196/41836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND There has been significant interest in global health in low- and middle-income countries (LMICs) among individuals living in high-income countries (HICs) over the past 30 years. Much of the literature on global health engagements (GHEs) has been presented from the perspective of individuals from HIC participants. Local stakeholders such as health care workers and health care administrators represent critical constituencies for global health activities, yet their perspectives are under-represented in the literature. The purpose of this study is to examine local health worker and administrator experiences with GHEs in Kenya. We will explore the perceived role GHEs play in preparing the health system to address a public health crisis, as well as their role in pandemic recovery and its aftermath. OBJECTIVE The aim of this study is to 1) examine how Kenyan health care workers and administrators interpret experiences with global health engagements as having advantaged or hindered them and the local health system to provide care during an acute public health crisis and 2) to explore recommendations to reimagine GHEs in a post-pandemic Kenya. METHODS This study will be conducted at a large teaching and referral hospital in western Kenya, with a long history of hosting GHEs in support of its tripartite mission of providing care, training, and research. This qualitative study will be conducted in three phases. In Phase 1, in-depth interviews (IDIs) will be conducted to capture participants' lived experience in relation to their unique understandings of the pandemic, GHEs, and the local health system. In Phase 2, group discussions, using nominal group technique (NGTs) will be conducted to determine potential priority areas to reimagine future GHEs. In Phase 3, IDIs will be conducted to explore these priority areas in greater detail to explore potential recommendations for potential strategies, policies, and other actions that might be employed to achieve the priorities determined to be of highest importance. RESULTS Study activities will commence late summer 2022, with findings to be published in 2023. It is anticipated that findings from this study will provide insight into the role GHEs play in a local health system in Kenya, and provide critical stakeholder and partner input, from persons hitherto ignored in the design, implementation, and management of GHEs. CONCLUSIONS This qualitative study will examine perspectives of global health engagements in relation to the COVID-19 pandemic among Kenyan health care workers and health care administrators in western Kenya using a multi-stage protocol. Using a combination of in-depth interviews and nominal group techniques this study aims to shed light on the roles global health activities are perceived to play in preparing health care professionals and the health system to address an acute public health crisis. CLINICALTRIAL INTERNATIONAL REGISTERED REPORT PRR1-10.2196/41836.
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Affiliation(s)
- Erick Amick
- College of Health and Human Sciences, Northern Illinois University, DeKalb, US
- Susan and Richard Kiphart Center for Global Health and Social Development, Crown Family School of Social Work, Policy, and Practice, University of Chicago, 969 E 60th st, Chicago, US
| | - Violet Naanyu
- School of Public Health, Moi University, Eldoret, KE
| | - Sherri Bucher
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, US
| | - Beverly W Henry
- College of Health and Human Sciences, Northern Illinois University, DeKalb, US
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13
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Karwa R, Miller ML, Schellhase E, Crowe S, Manji I, Albertson S, Frauhiger M, Pastakia S. Comparison of Clinical Interventions between Student Pharmacists on Advanced Pharmacy Practice Experiences in Indianapolis, Indiana versus Eldoret, Kenya. PHARMACY 2023; 11:92. [PMID: 37368418 DOI: 10.3390/pharmacy11030092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/07/2023] [Accepted: 05/13/2023] [Indexed: 06/28/2023] Open
Abstract
Student pharmacists can have a positive impact on patient care. The objective of this research was to compare clinical interventions made by Purdue University College of Pharmacy (PUCOP) student pharmacists completing internal medicine Advanced Pharmacy Practice Experiences (APPE) in Kenya and the US. A retrospective analysis of interventions made by PUCOP student pharmacists participating in either the 8-week global health APPE at Moi Teaching and Referral Hospital (MTRH-Kenya) or the 4-week adult medicine APPE at the Sydney & Lois Eskenazi Hospital (SLEH-US) was completed. Twenty-nine students (94%) documented interventions from the MTRH-Kenya cohort and 23 (82%) from the SLEH-US cohort. The median number of patients cared for per day was similar between the MTRH-Kenya (6.98 patients per day, interquartile range [IQR] = 5.75 to 8.15) and SLEH-US students (6.47 patients per day, IQR = 5.58 to 7.83). MTRH-Kenya students made a median number of 25.44 interventions per day (IQR = 20.80 to 28.95), while SLEH-US students made 14.77 (IQR = 9.80 to 17.72). The most common interventions were medication reconciliation/t-sheet rewrite and patient chart reviews for MTRH-Kenya and the SLEH-US, respectively. This research highlights how student pharmacists, supported in a well-designed, location-appropriate learning environment, can positively impact patient care.
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Affiliation(s)
- Rakhi Karwa
- The Academic Model Providing Access to Healthcare, Moi Teaching and Referral Hospital, Eldoret 30100, Kenya
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN 47906, USA
| | - Monica L Miller
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN 47906, USA
| | - Ellen Schellhase
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN 47906, USA
| | - Susie Crowe
- The Academic Model Providing Access to Healthcare, Moi Teaching and Referral Hospital, Eldoret 30100, Kenya
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN 47906, USA
| | - Imran Manji
- The Academic Model Providing Access to Healthcare, Moi Teaching and Referral Hospital, Eldoret 30100, Kenya
| | | | | | - Sonak Pastakia
- The Academic Model Providing Access to Healthcare, Moi Teaching and Referral Hospital, Eldoret 30100, Kenya
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, IN 47906, USA
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14
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Somani NA, Marshall K, Durrani H, Tang K, Mogilevskii R, Bhutta Z. Evaluation of frameworks demonstrating the role of private sector in non-communicable disease management and control: a systematic review and thematic synthesis. BMJ Open 2023; 13:e061370. [PMID: 36868600 PMCID: PMC9990678 DOI: 10.1136/bmjopen-2022-061370] [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] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVES Conduct a systematic review of existing frameworks to understand the for-profit private sector's roles in non-communicable disease (NCD) control and management. Control includes population-level control measures that prevent NCDs and mitigate the magnitude of the NCD pandemic, and management includes treatment and management of NCDs. The for-profit private sector was defined as any private entities that make profit from their activities (ie, pharmaceutical companies, unhealthy commodity industries, distinct from not-for-profit trusts or charitable organisations). DESIGN A systematic review and inductive thematic synthesis was performed. Comprehensive searches of PubMed, EMBASE, Cochrane Library, Web of Science, Business Source Premier and Proquest/ABI Inform were conducted on 15 January 2021. Grey literature searches were conducted on 2 February 2021 using the websites of 24 relevant organisations. Searches were filtered to only include articles published from the year 2000 onwards, in English. Articles that included frameworks, models or theories and the for-profit private sector's role in NCD control and management were included. Two reviewers performed the screening, data extraction and quality assessment. Quality was assessed using the tool developed by Hawker et al for qualitative studies. SETTING The for-profit private sector. RESULTS There were 2148 articles initially identified. Following removal of duplicates, 1383 articles remained, and 174 articles underwent full-text screening. Thirty-one articles were included and used to develop a framework including six themes that outlined the roles that the for-profit private sector plays in NCD management and control. The themes that emerged included healthcare provision, innovation, knowledge educator, investment and financing, public-private partnerships, and governance and policy. CONCLUSION This study provides an updated insight on literature that explores the role of the private sector in controlling and monitoring NCDs. The findings suggest that the private sector could contribute, through various functions, to effectively manage and control NCDs globally.
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Affiliation(s)
- Nadia Amin Somani
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Keiko Marshall
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hammad Durrani
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kun Tang
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Roman Mogilevskii
- Institute of Public Policy and Administration, University of Central Asia, Bishkek, Kyrgyzstan
| | - Zulfiqar Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
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15
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Raciti CG, Marsha J, Nafiseh AA, Masese ER, Apondi E, McHenry MS. "If it benefits someone, it will be good:" perspectives on research participation from pregnant women living with HIV. AIDS Care 2023; 35:366-373. [PMID: 35341423 PMCID: PMC10775893 DOI: 10.1080/09540121.2022.2057411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
Pregnant women living with HIV (PWLHIV) are becoming increasingly involved in HIV research; however, the ethical concerns regarding their decision-making related to research participation are understudied. This qualitative study aimed to understand the perspectives and lived research experiences of PWLHIV, intending to identify important considerations to inform best practices. This study used semi-structured interviews (SSIs) of PWLHIV who participated in research studies in Eldoret, Kenya. All interviews were audio-recorded, transcribed, and translated. Qualitative analyses were performed, with line-by-line coding, constant comparison, axial coding, and triangulation to identify central concepts. Twelve PWLHIV participated. Overall, participants had positive experiences with HIV research. Most participants had difficulty distinguishing the differences between the research process and enhanced clinical care. They reported a willingness to participate in future HIV research studies and indicated altruism as the primary motivator. Participants identified their preferences and experiences with recruitment, consenting, reimbursement, and enrolment of infants in HIV research. The largest barrier for participating in HIV research was identified as a concern that participation would lead to HIV disclosure. By understanding the lived experiences of PWLHIV who participate in HIV research, future researchers can design studies and consenting processes to optimize ethical research practices.
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Affiliation(s)
- Catherine G Raciti
- Richard M. Fairbanks School of Public Health, Indiana University Purdue University- Indianapolis
| | - Joy Marsha
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Eric R Masese
- Department of Sociology, Psychology and Anthropology, Moi University School of Arts and Social Sciences, Eldoret, Kenya
| | - Edith Apondi
- Department of Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Megan S. McHenry
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Pediatrics, Indiana University School of Medicine
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16
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Maritim B, Koon AD, Kimaina A, Lagat C, Riungu E, Laktabai J, Ruhl LJ, Kibiwot M, Scanlon ML, Goudge J. "It is like an umbrella covering you, yet it does not protect you from the rain": a mixed methods study of insurance affordability, coverage, and financial protection in rural western Kenya. Int J Equity Health 2023; 22:27. [PMID: 36747182 PMCID: PMC9901092 DOI: 10.1186/s12939-023-01837-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/21/2023] [Indexed: 02/08/2023] Open
Abstract
Countries in Sub-Saharan Africa are increasingly adopting mandatory social health insurance programs. In Kenya, mandatory social health insurance is being implemented through the national health insurer, the National Hospital Insurance Fund (NHIF), but the level of coverage, affordability and financial risk protection provided by health insurance, especially for rural informal households, is unclear. This study provides as assessment of affordability of NHIF premiums, the need for financial risk protection, and the extent of financial protection provided by NHIF among rural informal workers in western Kenya.Methods We conducted a mixed methods study with a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), and 6 focus group discussions (FGDs) with community stakeholders in rural western Kenya. Health insurance status was self-reported and households were categorized into insured and uninsured. Using survey data, we calculated the affordability of health insurance (unaffordability was defined as the monthly premium being > 5% of total household expenditures), out of pocket expenditures (OOP) on healthcare and its impact on impoverishment, and incidence of catastrophic health expenditures (CHE). Logistic regression was used to assess household characteristics associated with CHE.Results Only 12% of households reported having health insurance and was unaffordable for the majority of households, both insured (60%) and uninsured (80%). Rural households spent an average of 12% of their household budget on OOP, with both insured and uninsured households reporting high OOP spending and similar levels of impoverishment due to OOP. Overall, 12% of households experienced CHE, with uninsured households more likely to experience CHE. Participants expressed concerns about value of health insurance given its cost, availability and quality of services, and financial protection relative to other social and economic household needs. Households resulted to borrowing, fundraising, taking short term loans and selling family assets to meet healthcare costs.Conclusion Health insurance coverage was low among rural informal sector households in western Kenya, with health insurance premiums being unaffordable to most households. Even among insured households, we found high levels of OOP and CHE. Our results suggest that significant reforms of NHIF and health system are required to provide adequate health services and financial risk protection for rural informal households in Kenya.
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Affiliation(s)
- Beryl Maritim
- Consortium for Advanced Research Training in Africa (CARTA), Nairobi, Kenya.
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
| | - Adam D Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Allan Kimaina
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Cornelius Lagat
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Elvira Riungu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jeremiah Laktabai
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, Moi University, Eldoret, Kenya
| | - Laura J Ruhl
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, Indiana University, Indianapolis, USA
| | - Michael Kibiwot
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Michael L Scanlon
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Medicine, Indiana University, Indianapolis, USA
| | - Jane Goudge
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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17
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Sors TG, Chauhan O’Brien R, Scanlon ML, Yuan Bermel L, Chikowe I, Gardner A, Kiplagat J, Lieberman M, Moe SM, Morales-Soto N, Nyandiko WM, Plater D, Cheriro Rono B, Tierney WM, Vreeman RC, Wiehe SE, Wools-Kaloustian K, Litzelman DK. Reciprocal innovation: A new approach to equitable and mutually beneficial global health partnerships. Glob Public Health 2023; 18:2102202. [PMID: 35877989 PMCID: PMC9873831 DOI: 10.1080/17441692.2022.2102202] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 07/08/2022] [Indexed: 01/27/2023]
Abstract
Global health researchers often discount mutual learning and benefit to address shared health challenges across high and low- and middle-income settings. Drawing from a 30-year partnership called AMPATH that started between Indiana University in the US and Moi University in Kenya, we describe an innovative approach and program for mutual learning and benefit coined 'reciprocal innovation.' Reciprocal innovation harnesses a bidirectional, co-constituted, and iterative exchange of ideas, resources, and innovations to address shared health challenges across diverse global settings. The success of AMPATH in Kenya, particularly in HIV/AIDS and community health, resulted in several innovations being 'brought back' to the US. To promote the bidirectional flow of learning and innovations, the Indiana CTSI reciprocal innovation program hosts annual meetings of multinational researchers and practitioners to identify shared health challenges, supports pilot grants for projects with reciprocal exchange and benefit, and produces educational and training materials for investigators. The transformative power of global health to address systemic health inequities embraces equitable and reciprocal partnerships with mutual benefit across countries and communities of academics, practitioners, and policymakers. Leveraging a long-standing partnership, the Indiana CTSI has built a reciprocal innovation program with promise to redefine global health for shared wellbeing at a global scale.
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Affiliation(s)
- Thomas G Sors
- Purdue Institute of Inflammation, Immunology and Infectious Disease, Purdue University. Address: Discovery Park, 207 S. Martin Jischke Drive, West Lafayette, Indiana, 47907, USA
| | - Rishika Chauhan O’Brien
- Indiana University Center for Global Health. Address: 702 Rotary Circle, Suite RO 101, Indianapolis, Indiana, 46202, USA
| | - Michael L Scanlon
- Indiana University Center for Global Health. Address: 702 Rotary Circle, Suite RO 101, Indianapolis, Indiana, 46202, USA
| | - Li Yuan Bermel
- Women’s Global Health Institute, Purdue University. Address: Discovery Park, 207 S. Martin Jischke Drive, West Lafayette, Indiana, 47907, USA
| | - Ibrahim Chikowe
- Pharmacy Department, Kamuzu University of Health Sciences. Address: Private Bag 1, Lilongwe, Malawi
| | - Adrian Gardner
- Indiana University Center for Global Health. Address: 702 Rotary Circle, Suite RO 101, Indianapolis, Indiana, 46202, USA
| | - Jepchirchir Kiplagat
- Academic Model Providing Access to Healthcare (AMPATH). Address: AMPATH, P.O. Box 4606 030100, Eldoret, Kenya
| | - Marya Lieberman
- Department of Chemistry and Biochemistry, University of Notre Dame. Address: 251 Nieuwland Science Hall, Notre Dame, Indiana, 46556, USA
| | - Sharon M Moe
- Clinical and Translational Research Institute, Indiana University School of Medicine. Address: 950 W. Walnut Street, R2-202, Indianapolis, Indiana, 46202, USA
| | - Nydia Morales-Soto
- Eck Institute for Global Health, University of Notre Dame. Address: 4143 Jenkins Nanovic Halls, Notre Dame, Indiana, 46556, USA
| | - Winstone M. Nyandiko
- Department of Child Health and Paediatrics, School of Medicine, College of Health Sciences, Moi University. Address: Moi University, P.O. Box 4606 030100, Eldoret, Kenya
| | - David Plater
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai. Address: Arnhold Institute for Global Health, 1 Gustave L. Levy Place, New York, New York, 10029-5674, USA
| | - Betsy Cheriro Rono
- Jomo Kenyatta University of Agriculture and Technology. Address: Juja Kwale Rd, Juja, Kenya
| | - William M Tierney
- Richard M. Fairbanks School of Public Health, Indiana University Purdue University Indianapolis. Address: 1050 Wishard Blvd, Indianapolis, Indiana, 46202, USA
| | - Rachel C Vreeman
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai. Address: Arnhold Institute for Global Health, 1 Gustave L. Levy Place, New York, New York, 10029-5674, USA
| | - Sarah E Wiehe
- Clinical and Translational Research Institute, Indiana University School of Medicine. Address: 950 W. Walnut Street, R2-202, Indianapolis, Indiana, 46202, USA
| | - Kara Wools-Kaloustian
- Indiana University Center for Global Health. Address: 702 Rotary Circle, Suite RO 101, Indianapolis, Indiana, 46202, USA
| | - Debra K Litzelman
- Indiana University Center for Global Health. Address: 702 Rotary Circle, Suite RO 101, Indianapolis, Indiana, 46202, USA
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18
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Tran DN, Ching J, Kafu C, Wachira J, Koros H, Venkataramani M, Said J, Pastakia SD, Galárraga O, Genberg BL. Interruptions to HIV Care Delivery During Pandemics and Natural Disasters: A Qualitative Study of Challenges and Opportunities From Frontline Healthcare Providers in Western Kenya. J Int Assoc Provid AIDS Care 2023; 22:23259582231152041. [PMID: 36718505 PMCID: PMC9893388 DOI: 10.1177/23259582231152041] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
During public health crises, people living with HIV (PLWH) may become disengaged from care. The goal of this study was to understand the impact of the COVID-19 pandemic and recent flooding disasters on HIV care delivery in western Kenya. We conducted ten individual in-depth interviews with HIV providers across four health facilities. We used an iterative and integrated inductive and deductive data analysis approach to generate four themes. First, increased structural interruptions created exacerbating strain on health facilities. Second, there was increased physical and psychosocial burnout among providers. Third, patient uptake of services along the HIV continuum decreased, particularly among vulnerable patients. Finally, existing community-based programs and teleconsultations could be adapted to provide differentiated HIV care. Community-centric care programs, with an emphasis on overcoming the social, economic, and structural barriers will be crucial to ensure optimal care and limit the impact of public health disruptions on HIV care globally.
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Affiliation(s)
- Dan N Tran
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA, USA.,The 430902Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Jennifer Ching
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
| | - Catherine Kafu
- The 430902Academic Model Providing Access to Healthcare, Eldoret, Kenya.,Department of Media Studies, University of Witwatersrand School of Literature, Language and Media, Johannesburg, South Africa
| | - Juddy Wachira
- Department of Mental Health & Behavioral Sciences, 130188Moi University School of Medicine, Eldoret, Kenya
| | - Hillary Koros
- The 430902Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Maya Venkataramani
- Department of Medicine, 1500Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jamil Said
- The 430902Academic Model Providing Access to Healthcare, Eldoret, Kenya.,Department of Human Anatomy, 130188Moi University School of Medicine, Eldoret, Kenya
| | - Sonak D Pastakia
- The 430902Academic Model Providing Access to Healthcare, Eldoret, Kenya.,Center for Health Equity and Innovation, Purdue University School of Pharmacy, Indianapolis, IN, USA
| | - Omar Galárraga
- Department of Health Services, Policy & Practice, 174610Brown University School of Public Health, Providence, RI, USA
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MA, USA
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19
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Kafu C, Wachira J, Omodi V, Said J, Pastakia SD, Tran DN, Onyango JA, Aburi D, Wilson-Barthes M, Galárraga O, Genberg BL. Integrating community-based HIV and non-communicable disease care with microfinance groups: a feasibility study in Western Kenya. Pilot Feasibility Stud 2022; 8:266. [PMID: 36578093 PMCID: PMC9795156 DOI: 10.1186/s40814-022-01218-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 11/29/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The Harambee study is a cluster randomized trial in Western Kenya that tests the effect, mechanisms, and cost-effectiveness of integrating community-based HIV and non-communicable disease care within microfinance groups on chronic disease treatment outcomes. This paper documents the stages of our feasibility study conducted in preparation for the Harambee trial, which include (1) characterizing the target population and gauging recruitment capacity, (2) determining community acceptability of the integrated intervention and study procedures, and (3) identifying key implementation considerations prior to study start. METHODS Feasibility research took place between November 2019 and February 2020 in Western Kenya. Mixed methods data collection included surveys administered to 115 leaders of 105 community-based microfinance groups, 7 in-person meetings and two workshops with stakeholders from multiple sectors of the health system, and ascertainment of field notes and geographic coordinates for group meeting locations and HIV healthcare facilities. Quantitative survey data were analyzed using STATA IC/13. Longitude and latitude coordinates were mapped to county boundaries using Esri ArcMap. Qualitative data obtained from stakeholder meetings and field notes were analyzed thematically. RESULTS Of the 105 surveyed microfinance groups, 77 met eligibility criteria. Eligible groups had been in existence from 6 months to 18 years and had an average of 22 members. The majority (64%) of groups had at least one member who owned a smartphone. The definition of "active" membership and model of saving and lending differed across groups. Stakeholders perceived the community-based intervention and trial procedures to be acceptable given the minimal risks to participants and the potential to improve HIV treatment outcomes while facilitating care integration. Potential challenges identified by stakeholders included possible conflicts between the trial and existing community-based interventions, fear of group disintegration prior to trial end, clinicians' inability to draw blood for viral load testing in the community, and deviations from standard care protocols. CONCLUSIONS This study revealed that it was feasible to recruit the number of microfinance groups necessary to ensure that our clinical trial was sufficient powered. Elicitation of stakeholder feedback confirmed that the planned intervention was largely acceptable and was critical to identifying challenges prior to implementation. TRIAL REGISTRATION The original trial was prospectively registered with ClinicalTrials.gov (NCT04417127) on 4 June 2020.
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Affiliation(s)
- Catherine Kafu
- Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya. .,School of Literature, Language and Media, Department of Media Studies, University of Witwatersrand, 1 Jan Smuts Avenue, Braamfontein, Johannesburg, 2000, South Africa.
| | - Juddy Wachira
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.79730.3a0000 0001 0495 4256School of Medicine, Department of Behavioral Science, Moi University College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - Victor Omodi
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya
| | - Jamil Said
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.79730.3a0000 0001 0495 4256School of Medicine, Department of Human Anatomy, Moi University College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - Sonak D. Pastakia
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.169077.e0000 0004 1937 2197Center for Health Equity and Innovation, Purdue University College of Pharmacy, 640 Eskenazi Ave, Indianapolis, IN 46202 USA
| | - Dan N. Tran
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.264727.20000 0001 2248 3398Department of Pharmacy Practice, Temple University School of Pharmacy, 3307 N Broad St, Philadelphia, PA 19140 USA
| | - Jael Adongo Onyango
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya
| | - Dan Aburi
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya
| | - Marta Wilson-Barthes
- grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02912 USA
| | - Omar Galárraga
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI 02912 USA
| | - Becky Lynn Genberg
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
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20
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Maritim B, Koon AD, Kimaina A, Goudge J. Acceptability of prepayment, social solidarity and cross-subsidies in national health insurance: A mixed methods study in Western Kenya. Front Public Health 2022; 10:957528. [PMID: 36311602 PMCID: PMC9614422 DOI: 10.3389/fpubh.2022.957528] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/20/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Many low- and middle-income countries are attempting to finance healthcare through voluntary membership of insurance schemes. This study examined willingness to prepay for health care, social solidarity as well as the acceptability of subsidies for the poor as factors that determine enrolment in western Kenya. Methods This study employed a sequential mixed method design. We conducted a cross-sectional household survey (n = 1,746), in-depth household interviews (n = 36), 6 FGDs with community stakeholders and key informant interviews (n = 11) with policy makers and implementers in a single county in western Kenya. Social solidarity was defined by willingness to make contributions that would benefit people who were sicker ("risk cross-subsidization") and poorer ("income cross-subsidization"). We also explored participants' preferences related to contribution cost structure - e.g., flat, proportional, progressive, and exemptions for the poor. Results Our study found high willingness to prepay for healthcare among those without insurance (87.1%) with competing priorities, low incomes, poor access, and quality of health services, lack of awareness of flexible payment options cited as barriers to enrolment. More than half of respondents expressed willingness to tolerate risk and income cross-subsidization suggesting strong social solidarity, which increased with socio-economic status (SES). Higher SES was also associated with preference for a proportional payment while lower SES with a progressive payment. Few participants, even the poor themselves, felt the poor should be exempt from any payment, due to stigma (being accused of laziness) and fear of losing power in the process of receiving care (having the right to demand care). Conclusion Although there was a high willingness to prepay for healthcare, numerous barriers hindered voluntary health insurance enrolment in Kenya. Our findings highlight the importance of fostering and leveraging existing social solidarity to move away from flat rate contributions to allow for fairer risk and income cross-subsidization. Finally, governments should invest in robust strategies to effectively identify subsidy beneficiaries.
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Affiliation(s)
- Beryl Maritim
- Consortium for Advanced Research Training in Africa (CARTA), Nairobi, Kenya
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Adam D. Koon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Allan Kimaina
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jane Goudge
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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21
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Severance TS, Njuguna F, Olbara G, Kugo M, Langat S, Mostert S, Klootwijk L, Skiles J, Coven SL, Overholt KM, Kaspers G, Vik TA. An evaluation of the disparities affecting the underdiagnosis of pediatric cancer in Western Kenya. Pediatr Blood Cancer 2022; 69:e29768. [PMID: 35593641 DOI: 10.1002/pbc.29768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/22/2022] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Western Kenya is home to approximately 24 million people, with 10 million children under the age of 15 years.1 Based on estimates of cancer incidence in similar populations from around the world, approximately 1500 patients should be diagnosed with pediatric cancer each year. This article describes the international collaboration that investigates potential barriers preventing the effective diagnosis of pediatric patients with cancer. METHODS Here, we describe a multidisciplinary and sequential approach to better evaluate the complex factors affecting the lack of appropriate diagnosis of pediatric cancer in Western Kenya. RESULTS Internal review at a large tertiary hospital noted 200-250 patients were diagnosed annually, suggesting the remaining 75%-80% of patients go undiagnosed and do not receive treatment. Following our screening process at a local referring hospital, 41 malaria slides demonstrated both morphologic and genetic evidence of leukemia. Knowledge assessments of local providers at referring institutions suggested a lack of education and training as the factors that contribute to lower rates of diagnosis. DISCUSSION Through a multi-step approach, our teams were better able to isolate potential issues impeding the appropriate and timely diagnosis of pediatric cancer in Kenya.
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Affiliation(s)
- Tyler S Severance
- Department of Pediatrics, Riley Hospital for Children, Indianapolis, Indiana, USA.,Indiana University School of Medicine, Indianapolis, USA.,Riley Hospital Division of Pediatric Hematology Oncology, Indianapolis, Indiana, USA
| | | | | | - Maureen Kugo
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | | | - Saskia Mostert
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Larissa Klootwijk
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jodi Skiles
- Department of Pediatrics, Riley Hospital for Children, Indianapolis, Indiana, USA.,Indiana University School of Medicine, Indianapolis, USA.,Riley Hospital Division of Pediatric Hematology Oncology, Indianapolis, Indiana, USA
| | - Scott L Coven
- Department of Pediatrics, Riley Hospital for Children, Indianapolis, Indiana, USA.,Indiana University School of Medicine, Indianapolis, USA.,Riley Hospital Division of Pediatric Hematology Oncology, Indianapolis, Indiana, USA
| | - Kathleen M Overholt
- Department of Pediatrics, Riley Hospital for Children, Indianapolis, Indiana, USA.,Indiana University School of Medicine, Indianapolis, USA.,Riley Hospital Division of Pediatric Hematology Oncology, Indianapolis, Indiana, USA
| | - Gertjan Kaspers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.,Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, Pediatric Oncology, Amsterdam, The Netherlands
| | - Terry A Vik
- Department of Pediatrics, Riley Hospital for Children, Indianapolis, Indiana, USA.,Indiana University School of Medicine, Indianapolis, USA.,Riley Hospital Division of Pediatric Hematology Oncology, Indianapolis, Indiana, USA.,Moi Teaching and Referral Hospital, Eldoret, Kenya
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22
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Toromo JJ, Apondi E, Nyandiko WM, Omollo M, Bakari S, Aluoch J, Kantor R, Fortenberry JD, Wools-Kaloustian K, Elul B, Vreeman RC, Enane LA. "I have never talked to anyone to free my mind" - challenges surrounding status disclosure to adolescents contribute to their disengagement from HIV care: a qualitative study in western Kenya. BMC Public Health 2022; 22:1122. [PMID: 35658924 PMCID: PMC9167528 DOI: 10.1186/s12889-022-13519-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 05/25/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Adolescents living with HIV (ALHIV, ages 10–19) experience complex barriers to care engagement. Challenges surrounding HIV status disclosure or non-disclosure to adolescents may contribute to adolescent disengagement from HIV care or non-adherence to ART. We performed a qualitative study to investigate the contribution of disclosure challenges to adolescent disengagement from HIV care. Methods This was a qualitative study performed with disengaged ALHIV and their caregivers, and with healthcare workers (HCW) in the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya. Inclusion criteria for ALHIV were ≥1 visit within the 18 months prior to data collection at one of two clinical sites and nonattendance ≥60 days following their last scheduled appointment. HCW were recruited from 10 clinics. Analysis was conducted by multiple independent coders, and narratives of disclosure and care disengagement were closely interrogated. Overarching themes were elucidated and summarized. Results Interviews were conducted with 42 disengaged ALHIV, 32 caregivers, and 28 HCW. ALHIV were average age 17.0 (range 12.9–20.9), and 95% indicated awareness of their HIV diagnosis. Issues surrounding disclosure to ALHIV presented important barriers to HIV care engagement. Themes centered on delays in HIV status disclosure; hesitancy and reluctance among caregivers to disclose; struggles for adolescents to cope with feelings of having been deceived prior to full disclosure; pervasive HIV stigma internalized in school and community settings prior to disclosure; and inadequate and unstructured support after disclosure, including for adolescent mental health burdens and for adolescent-caregiver relationships and communication. Both HCW and caregivers described feeling inadequately prepared to optimally handle disclosure and to manage challenges that may arise after disclosure. Conclusions Complex challenges surrounding HIV status disclosure to adolescents contribute to care disengagement. There is need to enhance training and resources for HCW, and to empower caregivers to support children and adolescents before, during, and after HIV status disclosure. This should include counseling caregivers on how to provide children with developmentally-appropriate and accurate information about their health from an early age, and to support adolescent-caregiver communication and relationships. Optimally integrating peer support can further promote ALHIV wellbeing and retention in care. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13519-9.
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Affiliation(s)
- Judith J Toromo
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA
| | - Edith Apondi
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Winstone M Nyandiko
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Department of Child Health and Paediatrics, School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Mark Omollo
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
| | - Salim Bakari
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
| | - Josephine Aluoch
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya
| | - Rami Kantor
- Division of Infectious Diseases, Department of Medicine, Brown University Apert Medical School, Providence, RI, USA
| | - J Dennis Fortenberry
- Section of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kara Wools-Kaloustian
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Batya Elul
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Rachel C Vreeman
- Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.,Department of Child Health and Paediatrics, School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya.,Department of Health System Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Arnhold Institute for Global Health, New York, NY, USA
| | - Leslie A Enane
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA. .,Academic Model Providing Access To Healthcare (AMPATH), Eldoret, Kenya.
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23
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Bernard C, Jakait B, Fadel WF, Mocello AR, Onono MA, Bukusi EA, Wools-Kaloustian KK, Cohen CR, Patel RC. Preferences for Multipurpose Technology and Non-oral Methods of Antiretroviral Therapy Among Women Living With HIV in Western Kenya: A Survey Study. Front Glob Womens Health 2022; 3:869623. [PMID: 35663925 PMCID: PMC9160913 DOI: 10.3389/fgwh.2022.869623] [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: 02/04/2022] [Accepted: 04/27/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Understanding interests in and preferences for multipurpose technology (MPT) for the co-administration of contraception and antiretroviral therapy (ART) and alternative, non-oral ART methods among women living with HIV (WLHIV) is vital to successful implementation of future treatment options, such as long-acting injectable ART. Methods Between May 2016 and March 2017 we conducted a cross-sectional telephone survey of 1,132 WLHIV of reproductive potential with prior experience using intermediate- or long-acting contraceptive methods in western Kenya. We present descriptive statistics and multinomial logistic regression to evaluate predictors of interest in specific MPT and non-oral ART methods. Results Two-thirds (67%) reported interest in MPT, with the most common reason for interest being ease of using a single medication for both purposes of HIV treatment and pregnancy prevention (26%). Main reasons for lack of interest in MPT were need to stop/not use contraception while continuing ART (21%) and risk of side effects (16%). Important characteristics of MPT were effectiveness for pregnancy prevention (26%) and HIV treatment (24%) and less than daily dosing (19%). Important characteristics of non-oral ART methods were less than daily dosing (47%), saving time accessing ART (16%), and effectiveness of HIV treatment (15%). The leading preferred methods for both MPT and non-oral ART were injectables (50 and 54%) and implants (32 and 31%). Prior use of a contraceptive implant or injectable predicted interest in similar methods for both MPT and non-oral ART methods, while this relationship did not appear to vary between younger vs. older WLHIV. Discussion Most WLHIV in western Kenya are interested in MPT for HIV treatment and contraception. Prior exposure to contraceptive implants or injectables appears to predict interest in similar methods of MPT and non-oral ART. Developers of MPT and non-oral ART methods should strongly consider WLHIV's preferences, including their changing reproductive desires.
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Affiliation(s)
- Caitlin Bernard
- Department of Obstetrics & Gynecology, Division of Family Planning, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Beatrice Jakait
- Moi Teaching & Referral Hospital/Moi University & Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - William F. Fadel
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - A. Rain Mocello
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Health, University of California San Francisco, CA, United States
| | - Maricianah A. Onono
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Craig R. Cohen
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Health, University of California San Francisco, CA, United States
| | - Rena C. Patel
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, United States
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Larson CP, Plamondon KM, Dubent L, Bicaba F, Bicaba A, Minh TH, Nguyen A, Girard JE, Ramdé J, Gyorkos TW. The Equity Tool for Valuing Global Health Partnerships. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00316. [PMID: 35487557 PMCID: PMC9053142 DOI: 10.9745/ghsp-d-21-00316] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/15/2022] [Indexed: 11/15/2022]
Abstract
There is a need to more comprehensively identify and respond to equity in global health partnerships. The Equity Tool can support dialogue at any stage of a partnership, by individuals at any level. This assists partnerships to embrace ways of recognizing, understanding, and advancing equity in all their processes. Global health partnerships (GHPs) involve complex relationships between individuals and organizations, often joining partners from high-income and low- or middle-income countries around work that is carried out in the latter. Therefore, GHPs are situated in the context of global inequities and their underlying sociopolitical and historical causes, such as colonization. Equity is a core principle that should guide GHPs from start to end. How equity is embedded and nurtured throughout a partnership has remained a constant challenge. We have developed a user-friendly tool for valuing a GHP throughout its lifespan using an equity lens. The development of the EQT was informed by 5 distinct elements: a scoping review of scientific published peer-reviewed literature; an online survey and follow-up telephone interviews; workshops in Canada, Burkina Faso, and Vietnam; a critical interpretive synthesis; and a content validation exercise. Findings suggest GHPs generate experiences of equity or inequity yet provide little guidance on how to identify and respond to these experiences. The EQT can guide people involved in partnering to consider the equity implications of all their actions, from inception, through implementation and completion of a partnership. When used to guide reflective dialogue with a clear intention to advance equity in and through partnering, this tool offers a new approach to valuing global health partnerships. Global health practitioners, among others, can apply the EQT in their partnerships to learning together about how to cultivate equity in their unique contexts within what is becoming an increasingly diverse, vibrant, and responsive global health community.
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Affiliation(s)
- Charles P Larson
- Canadian Association for Global Health (formerly Canadian Coalition for Global Health Research), Ottawa, Canada.
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
| | - Katrina M Plamondon
- Canadian Association for Global Health (formerly Canadian Coalition for Global Health Research), Ottawa, Canada
- School of Nursing, Faculty of Health and Social Development, University of British Columbia, Okanagan, Canada
| | - Leslie Dubent
- Canadian Association for Global Health (formerly Canadian Coalition for Global Health Research), Ottawa, Canada
| | - Frank Bicaba
- Société d'Études et de Recherche en Santé Publique, Ouagadougou, Burkina Faso
| | - Abel Bicaba
- Société d'Études et de Recherche en Santé Publique, Ouagadougou, Burkina Faso
| | - Tran Hung Minh
- Center for Creative Initiatives in Health and Population, Hanoi, Vietnam
| | - An Nguyen
- HealthBridge Vietnam, Hanoi, Vietnam
| | - Jacques E Girard
- Canadian Association for Global Health (formerly Canadian Coalition for Global Health Research), Ottawa, Canada
- Direction en Santé Mondiale, Faculté de Médecine, Université Laval, Québec, Canada
| | - Jean Ramdé
- Canadian Association for Global Health (formerly Canadian Coalition for Global Health Research), Ottawa, Canada
- HealthBridge Vietnam, Hanoi, Vietnam
| | - Theresa W Gyorkos
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, Faculty of Medicine and Health Sciences, McGill University, Montréal, Canada
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Lessons learned from academic medical centers’ response to the COVID-19 pandemic in partnership with the Navajo Nation. PLoS One 2022; 17:e0265945. [PMID: 35381019 PMCID: PMC8982841 DOI: 10.1371/journal.pone.0265945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 03/10/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction Structural forces that drive health inequalities are magnified in crises. This was especially true during the COVID-19 pandemic, and minority communities were particularly affected. The University of California San Francisco and Health, Equity, Action, Leadership Initiative jointly sent volunteer teams of nurses and doctors to work in the Navajo Nation during the COVID-19 pandemic. This presented an opportunity to explore how academic medical centers (AMCs) could effectively partner with vulnerable communities to provide support during healthcare crises. Therefore, the aims of this study were to describe volunteers’ perspectives of academic-community partnerships by exploring their personal, professional and societal insights and lessons learned based on their time in the Navajo Nation during COVID-19. Methods We recruited key informants using purposeful sampling of physicians and nurses who volunteered to go to the Navajo Nation during the spring 2020 COVID-19 surge, as well as hospital administrators and leaders involved in organizing the COVID-19 efforts. We used in-depth qualitative interviews to explore key informants’ experiences pre-departure, during their stay, and after their return, as well as perspectives of the partnership between an AMC and the Navajo Nation. We used thematic analysis to systematically identify, analyze and report patterns (themes) within the data. Results In total, 37 clinicians and hospital administrators were interviewed including 14 physicians, 16 nurses, and 7 health system leaders. Overall, we found 4 main themes each with several subthemes that defined the partnership between the AMC and the Navajo Nation. Mission and values incorporated civic duty, community engagement, leadership commitment and employee dedication. Solidarity, trust and humility encompassed pre-existing trust, workforce sustainability, humility and erasure of ‘savior narratives.’ Coordination included logistical coordination, flexibility, selectivity of who and what traveled to the response and coordination around media response. Workforce preparation and support encompassed understanding of historical context and providing healthcare in limited settings, dangers of inadequate preparation and the need for emotional support. Conclusion This study provides guidelines which AMCs might use to develop and improve partnerships they have or would like to develop with vulnerable communities. These guidelines may even be broadly applied to partnerships outside of a pandemic response. Importantly, such partnerships need to be built with trust and with an eye towards sustainability and long-term relationships as opposed to ‘medical missions’.
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Kiplagat J, Tran DN, Barber T, Njuguna B, Vedanthan R, Triant VA, Pastakia SD. How health systems can adapt to a population ageing with HIV and comorbid disease. Lancet HIV 2022; 9:e281-e292. [PMID: 35218734 DOI: 10.1016/s2352-3018(22)00009-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 06/14/2023]
Abstract
As people age with HIV, their needs increase beyond solely managing HIV care. Ageing people with HIV, defined as people with HIV who are 50 years or older, face increased risk of both age-regulated comorbidities and ageing-related issues. Globally, health-care systems have struggled to meet these changing needs of ageing people with HIV. We argue that health systems need to rethink care strategies to meet the growing needs of this population and propose models of care that meet these needs using the WHO health system building blocks. We focus on care provision for ageing people with HIV in the three different funding mechanisms: President's Emergency Plan for AIDS Relief and Global Fund funded nations, the USA, and single-payer government health-care systems. Although our categorisation is necessarily incomplete, our efforts provide a valuable contribution to the debate on health systems strengthening as the need for integrated, people-centred, health services increase.
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Affiliation(s)
| | - Dan N Tran
- Academic Model Providing Access to Healthcare, Eldoret, Kenya; Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA, USA
| | - Tristan Barber
- Department of HIV Medicine, Ian Charleson Day Centre, Royal Free Hospital, London, UK
| | - Benson Njuguna
- Academic Model Providing Access to Healthcare, Eldoret, Kenya; Department of Clinical Pharmacy and Practice, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Rajesh Vedanthan
- Academic Model Providing Access to Healthcare, Eldoret, Kenya; Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Virginia A Triant
- Divisions of Infectious Diseases and General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sonak D Pastakia
- Academic Model Providing Access to Healthcare, Eldoret, Kenya; Center for Health Equity and Innovation, College of Pharmacy, Purdue University, Indianapolis, IN, USA.
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27
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Enane LA, Apondi E, Liepmann C, Toromo JJ, Omollo M, Bakari S, Scanlon M, Wools-Kaloustian K, Vreeman RC. 'We are not going anywhere': a qualitative study of Kenyan healthcare worker perspectives on adolescent HIV care engagement during the COVID-19 pandemic. BMJ Open 2022; 12:e055948. [PMID: 35354627 PMCID: PMC8968109 DOI: 10.1136/bmjopen-2021-055948] [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] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Adolescents living with HIV (ALHIV) may be vulnerable to widescale impacts of the COVID-19 pandemic and to health system responses which impact HIV care. We assessed healthcare worker (HCW) perspectives on impacts of the COVID-19 pandemic on adolescent HIV care delivery and engagement in western Kenya. METHODS We performed in-depth qualitative interviews with HCW at 10 clinical sites in the Academic Model Providing Access to Healthcare in Kenya, from January to March, 2021. Semistructured interviews ascertained pandemic-related impacts on adolescent HIV care delivery and retention. RESULTS Interviews were conducted with 22 HCWs from 10 clinics. HCWs observed adolescent financial hardships, unmet basic needs and school dropouts during the pandemic, with some adolescents relocating to rural homes, to partners or to the street. Marked increases in adolescent pregnancies and pregnancy complications were described, as well as barriers to family planning and antenatal care. Transportation challenges and restrictions limited access to care and prompted provision of multi-month refills, refills at local dispensaries or transfer to local facilities. Adolescent-friendly services were compromised, resulting in care challenges and disengagement from care. Clinic capacities to respond to adolescent needs were limited by funding cuts to multidisciplinary staff and resources. HCW and youth peer mentors (YPMs) demonstrated resilience, by adapting services, taking on expanded roles and leveraging available resources to support adolescent retention and access to care. CONCLUSIONS ALHIV are uniquely vulnerable, and adolescent-friendly services are essential to their treatment. The combined effects of the pandemic, health system changes and funding cuts compromised adolescent-friendly care and limited capacity to respond to adolescent needs. There is a need to reinforce adolescent-friendly services within programmes and funding structures. Support for expanded YPM roles may facilitate dedicated, scalable and effective adolescent-friendly services, which are resilient and sustainable in times of crisis.
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Affiliation(s)
- Leslie A Enane
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Indiana University Center for Global Health, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Claire Liepmann
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Judith J Toromo
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mark Omollo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Salim Bakari
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Michael Scanlon
- Indiana University Center for Global Health, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA
| | - Kara Wools-Kaloustian
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Indiana University Center for Global Health, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel C Vreeman
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Global Health and Health Systems Design, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Arnhold Institute for Global Health, New York City, New York, USA
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Thakkar A, Valente T, Andesia J, Njuguna B, Miheso J, Mercer T, Mugo R, Mwangi A, Mwangi E, Pastakia SD, Pathak S, Pillsbury MKM, Kamano J, Naanyu V, Williams M, Vedanthan R, Akwanalo C, Bloomfield GS. Network characteristics of a referral system for patients with hypertension in Western Kenya: results from the Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) study. BMC Health Serv Res 2022; 22:315. [PMID: 35255913 PMCID: PMC8903732 DOI: 10.1186/s12913-022-07699-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 02/25/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Health system approaches to improve hypertension control require an effective referral network. A national referral strategy exists in Kenya; however, a number of barriers to referral completion persist. This paper is a baseline assessment of a hypertension referral network for a cluster-randomized trial to improve hypertension control and reduce cardiovascular disease risk. METHODS We used sociometric network analysis to understand the relationships between providers within a network of nine geographic clusters in western Kenya, including primary, secondary, and tertiary care facilities. We conducted a survey which asked providers to nominate individuals and facilities to which they refer patients with controlled and uncontrolled hypertension. Degree centrality measures were used to identify providers in prominent positions, while mixed-effect regression models were used to determine provider characteristics related to the likelihood of receiving referrals. We calculated core-periphery correlation scores (CP) for each cluster (ideal CP score = 1.0). RESULTS We surveyed 152 providers (physicians, nurses, medical officers, and clinical officers), range 10-36 per cluster. Median number of hypertensive patients seen per month was 40 (range 1-600). While 97% of providers reported referring patients up to a more specialized health facility, only 55% reported referring down to lower level facilities. Individuals were more likely to receive a referral if they had higher level of training, worked at a higher level facility, were male, or had more job experience. CP scores for provider networks range from 0.335 to 0.693, while the CP scores for the facility networks range from 0.707 to 0.949. CONCLUSIONS This analysis highlights several points of weakness in this referral network including cluster variability, poor provider linkages, and the lack of down referrals. Facility networks were stronger than provider networks. These shortcomings represent opportunities to focus interventions to improve referral networks for hypertension. TRIAL REGISTRATION Trial Registered on ClinicalTrials.gov NCT03543787 , June 1, 2018.
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Affiliation(s)
- Aarti Thakkar
- Duke University School of Medicine, 300 West Morgan Street, Durham, NC, 27701, USA
| | | | - Josephine Andesia
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Juliet Miheso
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Tim Mercer
- The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Richard Mugo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ann Mwangi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- College of Health Sciences, Moi University, Eldoret, Kenya
| | - Eunice Mwangi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | | | | | - Jemima Kamano
- Moi Teaching and Referral Hospital, Eldoret, Kenya
- College of Health Sciences, Moi University, Eldoret, Kenya
| | - Violet Naanyu
- College of Health Sciences, Moi University, Eldoret, Kenya
| | | | - Rajesh Vedanthan
- New York University, Grossman School of Medicine, New York, NY, USA
| | | | - Gerald S Bloomfield
- Duke University School of Medicine, 300 West Morgan Street, Durham, NC, 27701, USA.
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Myers C, Apondi E, Toromo JJ, Omollo M, Bakari S, Aluoch J, Sang F, Njoroge T, Morris Z, Kantor R, Braitstein P, Nyandiko WM, Wools-Kaloustian K, Elul B, Vreeman RC, Enane LA. "Who am I going to stay with? Who will accept me?": family-level domains influencing HIV care engagement among disengaged adolescents in Kenya. J Int AIDS Soc 2022; 25:e25890. [PMID: 35192747 PMCID: PMC8863355 DOI: 10.1002/jia2.25890] [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: 08/27/2021] [Accepted: 02/01/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Adolescents living with HIV (ALHIV, ages 10-19) have developmentally specific needs in care, and have lower retention compared to other age groups. Family-level contexts may be critical to adolescent HIV outcomes, but have often been overlooked. We investigated family-level factors underlying disengagement and supporting re-engagement among adolescents disengaged from HIV care. METHODS Semi-structured interviews were performed with 42 disengaged ALHIV, 32 of their caregivers and 28 healthcare workers (HCW) in the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya, from 2018 to 2020. Disengaged ALHIV had ≥1 visit within the 18 months prior to data collection at one of two sites and nonattendance ≥60 days following their last scheduled appointment. HCW were recruited from 10 clinics. Transcripts were analysed through thematic analysis. A conceptual model for family-level domains influencing adolescent HIV care engagement was developed from these themes. RESULTS Family-level factors emerged as central to disengagement. ALHIV-particularly those orphaned by the loss of one or both parents-experienced challenges when new caregivers or unstable living situations limited support for HIV care. These challenges were compounded by anticipated stigma; resultant non-disclosure of HIV status to household members; enacted stigma in the household, with overwhelming effects on adolescents; or experiences of multiple forms of trauma, which undermined HIV care engagement. Some caregivers lacked finances or social support to facilitate care. Others did not feel equipped to support adolescent engagement or adherence. Regarding facilitators to re-engagement, participants described roles for household disclosure; and solidarity from caregivers, especially those also living with HIV. Family-level domains influencing HIV care engagement were conceptualized as follows: (1) adolescent living situation and contexts; (2) household material resources or poverty; (3) caregiver capacities and skills to support adolescent HIV care; and (4) HIV stigma or solidarity at the household level. CONCLUSIONS Family-level factors are integral to retention in care for ALHIV. The conceptual model developed in this study for family-level influences on care engagement may inform holistic approaches to promote healthy outcomes for ALHIV. Developmentally appropriate interventions targeting household relationships, disclosure, HIV stigma reduction, HIV care skills and resources, and economic empowerment may promote adolescent engagement in HIV care.
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Affiliation(s)
- Courtney Myers
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Judith J Toromo
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mark Omollo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Salim Bakari
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Josephine Aluoch
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Festus Sang
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Tabitha Njoroge
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Zariel Morris
- Indiana University-Purdue University-Indianapolis, Indiana University, Indianapolis, Indiana, USA
| | - Rami Kantor
- Division of Infectious Diseases, Department of Medicine, Brown University Apert Medical School, Providence, Rhode Island, USA
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Epidemiology, Indiana University Fairbanks School of Public Health, Indianapolis, Indiana, USA.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Winstone M Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Child Health and Pediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Kara Wools-Kaloustian
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Indiana University Center for Global Health, Indianapolis, Indiana, USA
| | - Batya Elul
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Rachel C Vreeman
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Child Health and Pediatrics, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.,Department of Health System Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Arnhold Institute for Global Health, New York, New York, USA
| | - Leslie A Enane
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Global Health, Indianapolis, Indiana, USA
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Bünder T, Karekezi C, Wirtz V. Governing industry involvement in the non-communicable disease response in Kenya. Global Health 2021; 17:123. [PMID: 34670570 PMCID: PMC8527303 DOI: 10.1186/s12992-021-00776-3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In low- and middle-income countries (LMICs), multinational companies have become increasingly involved in addressing public health challenges. Dealing with companies as partners in health sector development creates new challenges for governments. We sought to develop an approach to assess the existence and effectiveness of governance structures that can ensure that industry-led public health initiatives contribute to development. METHODS We developed a governance assessment tool based on the principles of the Paris Declaration for Aid Effectiveness and other related agreements. We applied it to the case of pharmaceutical companies' involvement in the Kenyan response to non-communicable diseases (NCDs). We gathered data for analysis through 46 stakeholder interviews and reviewing documents. RESULTS The Kenyan government has informal norms in place regarding program governance and strategy, but it has yet to issue formal regulations. While enabling elements exist that support initiatives to develop in alignment with these norms, implementation is often hindered by a lack of resources. Currently, broad stakeholder support for filling these gaps has created a window of opportunity for action. CONCLUSION The application of the proposed assessment tool illustrates its viability for assisting companies and governments alike in defining governance needs for industry-led public health initiatives. Our findings in Kenya provide example considerations for LMICs working to integrate industry-led public health programs into the health system. Bilateral and multilateral donors also have important roles in strengthening LMICs' capacities to govern multinational corporations' contributions to NCDs in particular, and development in general.
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Affiliation(s)
- Tobias Bünder
- Hertie School, Friedrichstraße 180, Berlin, 10117, Germany.
| | - Catherine Karekezi
- Non-communicable Diseases Alliance Kenya (NCDAK), KMA Plaza Apartments, Block C Unit 5.2, Mara Road - Upper Hill, P. O Box 5337, Nairobi, Kenya
- Kenya Diabetes Management & Information Centre, Jadala Place, 2nd Floor Office 2.1, Ngong Lane, Ngong Road, P. O. Box 45099 -, Nairobi, 00100, Kenya
| | - Veronika Wirtz
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA
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Genberg BL, Wilson-Barthes MG, Omodi V, Hogan JW, Steingrimsson J, Wachira J, Pastakia S, Tran DN, Kiragu ZW, Ruhl LJ, Rosenberg M, Kimaiyo S, Galárraga O. Microfinance, retention in care, and mortality among patients enrolled in HIV care in East Africa. AIDS 2021; 35:1997-2005. [PMID: 34115646 PMCID: PMC8963387 DOI: 10.1097/qad.0000000000002987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To measure associations between participation in community-based microfinance groups, retention in HIV care, and death among people with HIV (PWH) in low-resource settings. DESIGN AND METHODS We prospectively analyzed data from 3609 patients enrolled in an HIV care program in western Kenya. HIV patients who were eligible and chose to participate in a Group Integrated Savings for Health Empowerment (GISHE) microfinance group were matched 1 : 2 on age, sex, year of enrollment in HIV care, and location of initial HIV clinic visit to patients not participating in GISHE. Follow-up data were abstracted from medical records from January 2018 through February 2020. Logistic regression analysis examined associations between GISHE participation and two outcomes: retention in HIV care (i.e. >1 HIV care visit attended within 6 months prior to the end of follow-up) and death. Socioeconomic factors associated with HIV outcomes were included in adjusted models. RESULTS The study population was majority women (78.3%) with a median age of 37.4 years. Microfinance group participants were more likely to be retained in care relative to HIV patients not participating in a microfinance group [adjusted odds ratio (aOR) = 1.31, 95% confidence interval (CI) 1.01-1.71; P = 0.046]. Participation in group microfinance was associated with a reduced odds of death during the follow-up period (aOR = 0.57, 95% CI 0.28-1.09; P = 0.105). CONCLUSION Participation in group-based microfinance appears to be associated with better HIV treatment outcomes. A randomized trial is needed to assess whether microfinance groups can improve clinical and socioeconomic outcomes among PWH in similar settings.
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Affiliation(s)
- Becky L. Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Marta G. Wilson-Barthes
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Victor Omodi
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Joseph W. Hogan
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jon Steingrimsson
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Behavioral Science, Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Sonak Pastakia
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Purdue University College of Pharmacy, Center for Health Equity and Innovation, Indianapolis, Indiana
| | - Dan N. Tran
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, Pennsylvania
| | - Zana W. Kiragu
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Laura J. Ruhl
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Molly Rosenberg
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, Indiana
| | | | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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Pillsbury MKM, Mwangi E, Andesia J, Njuguna B, Bloomfield GS, Chepchumba A, Kamano J, Mercer T, Miheso J, Pastakia SD, Pathak S, Thakkar A, Naanyu V, Akwanalo C, Vedanthan R. Human-centered implementation research: a new approach to develop and evaluate implementation strategies for strengthening referral networks for hypertension in western Kenya. BMC Health Serv Res 2021; 21:910. [PMID: 34479556 PMCID: PMC8414706 DOI: 10.1186/s12913-021-06930-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022] Open
Abstract
Background Human-centered design (HCD) is an increasingly recognized approach for engaging stakeholders and developing contextually appropriate health interventions. As a component of the ongoing STRENGTHS study (Strengthening Referral Networks for Management of Hypertension Across the Health System), we report on the process and outcomes of utilizing HCD to develop the implementation strategy prior to a cluster-randomized controlled trial. Methods We organized a design team of 15 local stakeholders to participate in an HCD process to develop implementation strategies. We tested prototypes for acceptability, appropriateness, and feasibility through focus group discussions (FGDs) with various community stakeholder groups and a pilot study among patients with hypertension. FGD transcripts underwent content analysis, and pilot study data were analyzed for referral completion and reported barriers to referral. Based on this community feedback, the design team iteratively updated the implementation strategy. During each round of updates, the design team reflected on their experience through FGDs and a Likert-scale survey. Results The design team developed an implementation strategy consisting of a combined peer navigator and a health information technology (HIT) package. Overall, community participants felt that the strategy was acceptable, appropriate, and feasible. During the pilot study, 93% of referrals were completed. FGD participants felt that the implementation strategy facilitated referral completion through active peer engagement; enhanced communication between clinicians, patients, and health administrators; and integrated referral data into clinical records. Challenges included referral barriers that were not directly addressed by the strategy (e.g. transportation costs) and implementation of the HIT package across multiple health record systems. The design team reflected that all members contributed significantly to the design process, but emphasized the need for more transparency in how input from study investigators was incorporated into design team discussions. Conclusions The adaptive process of co-creation, prototyping, community feedback, and iterative redesign aligned our implementation strategy with community stakeholder priorities. We propose a new framework of human-centered implementation research that promotes collaboration between community stakeholders, study investigators, and the design team to develop, implement, and evaluate HCD products for implementation research. Our experience provides a feasible and replicable approach for implementation research in other settings. Trial registration Clinicaltrials.gov, NCT02501746, registration date: July 17, 2015, Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06930-2.
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Affiliation(s)
- Mc Kinsey M Pillsbury
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Eunice Mwangi
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Josephine Andesia
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | | | - Agneta Chepchumba
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jemima Kamano
- Moi Teaching and Referral Hospital, Eldoret, Kenya.,College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Tim Mercer
- Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Juliet Miheso
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Sonak D Pastakia
- Center for Health Equity and Innovation, Purdue University, West Lafayette, IN, USA
| | | | | | - Violet Naanyu
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | | | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 8th floor, New York, NY, 10016, USA.
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Tran DN, Manji I, Njuguna B, Kamano J, Laktabai J, Tonui E, Vedanthan R, Pastakia S. Solving the problem of access to cardiovascular medicines: revolving fund pharmacy models in rural western Kenya. BMJ Glob Health 2021; 5:bmjgh-2020-003116. [PMID: 33214173 PMCID: PMC7678234 DOI: 10.1136/bmjgh-2020-003116] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/17/2020] [Accepted: 09/20/2020] [Indexed: 12/13/2022] Open
Abstract
Availability of medicines for treatment of cardiovascular disease (CVD) is low in low-income and middle-income countries (LMIC). Supply chain models to improve the availability of quality CVD medicines in LMIC communities are urgently required. Our team established contextualised revolving fund pharmacies (RFPs) in rural western Kenya, whereby an initial stock of essential medicines was obtained through donations or purchase and then sold at a small mark-up price sufficient to replenish drug stock and ensure sustainability. In response to different contexts and levels of the public health system in Kenya (eg, primary versus tertiary), we developed and implemented three contextualised models of RFPs over the past decade, creating a network of 72 RFPs across western Kenya, that supplied 22 categories of CVD medicines and increased availability of essential CVD medications from <30% to 90% or higher. In one representative year, we were able to successfully supply 5 793 981 units of CVD and diabetes medicines to patients in western Kenya. The estimated programme running cost was US$6.5–25 per patient, serving as a useful benchmark for public governments to invest in medication supply chain systems in LMICs going forward. One important lesson that we have learnt from implementing three different RFP models over the past 10 years has been that each model has its own advantages and disadvantages, and we must continue to stay nimble and modify as needed to determine the optimal supply chain model while ensuring consistent access to essential CVD medications for patients living in these settings.
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Affiliation(s)
- Dan N Tran
- Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, IN, USA .,Pharmacology and Toxicology, Moi University College of Health Sciences, Eldoret, Kenya.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Imran Manji
- Pharmacy, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Benson Njuguna
- Pharmacy, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Jemima Kamano
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Medicine, Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Jeremiah Laktabai
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Family Medicine, Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Edith Tonui
- Pharmacy, Kericho County Referral Hospital, Kericho, Kenya
| | - Rajesh Vedanthan
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Sonak Pastakia
- Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis, IN, USA.,Pharmacology and Toxicology, Moi University College of Health Sciences, Eldoret, Kenya.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
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Kamano J, Naanyu V, Ayah R, Limo O, Gathecha G, Saenyi E, Jefwa P, Too K, Manji I, Gala P, Vedanthan R. Maintaining care delivery for non-communicable diseases in the face of the COVID-19 pandemic in western Kenya. Pan Afr Med J 2021; 39:143. [PMID: 34527159 PMCID: PMC8418157 DOI: 10.11604/pamj.2021.39.143.29708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/19/2021] [Indexed: 11/24/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has disrupted health systems worldwide, gravely threatening continuity of care for non-communicable diseases (NCDs), particularly in low-resource settings. We describe our efforts to maintain the continuity of care for patients with NCDs in rural western Kenya during the COVID-19 pandemic, using a five-component approach: 1) Protect: protect staff and patients; 2) Preserve: ensure medication availability and clinical services; 3) Promote: conduct health education and screenings for NCDs and COVID-19; 4) Process: collect process indicators and implement iterative quality improvement; and 5) Plan: plan for the future and ensure financial risk protection in the face of a potentially overwhelming health and economic catastrophe. As the pandemic continues to evolve, we must continue to pursue new avenues for improvement and expansion. We anticipate continuing to learn from the evolving local context and our global partners as we proceed with our efforts.
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Affiliation(s)
- Jemima Kamano
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Violet Naanyu
- Academic Model Providing Access to Health Care, Eldoret, Kenya
- Department of Sociology Psychology and Anthropology, School of Arts and Social Sciences, Moi University, Eldoret, Kenya
| | - Richard Ayah
- School of Public Health, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Obed Limo
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Gladwell Gathecha
- Division of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
| | - Eugene Saenyi
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Pendo Jefwa
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Kenneth Too
- Academic Model Providing Access to Health Care, Eldoret, Kenya
| | - Imran Manji
- Directorate of Pharmacy and Nutrition, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Pooja Gala
- Department of Medicine, NYU Grossman School of Medicine, New York, USA
| | - Rajesh Vedanthan
- Department of Medicine, NYU Grossman School of Medicine, New York, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, USA
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Sikka N, DeLong A, Kamano J, Kimaiyo S, Orango V, Andesia J, Fuster V, Hogan J, Vedanthan R. Sex differences in health status, healthcare utilization, and costs among individuals with elevated blood pressure: the LARK study from Western Kenya. BMC Public Health 2021; 21:948. [PMID: 34011345 PMCID: PMC8136119 DOI: 10.1186/s12889-021-10995-3] [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] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 05/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Elevated blood pressure is the leading risk factor for global mortality. While it is known that there exist differences between men and women with respect to socioeconomic status, self-reported health, and healthcare utilization, there are few published studies from Africa. This study therefore aims to characterize differences in self-reported health status, healthcare utilization, and costs between men and women with elevated blood pressure in Kenya. METHODS Data from 1447 participants enrolled in the LARK Hypertension study in western Kenya were analyzed. Latent class analysis based on five dependent variables was performed to describe patterns of healthcare utilization and costs in the study population. Regression analysis was then performed to describe the relationship between different demographics and each outcome. RESULTS Women in our study had higher rates of unemployment (28% vs 12%), were more likely to report lower monthly earnings (72% vs 51%), and had more outpatient visits (39% vs 28%) and pharmacy prescriptions (42% vs 30%). Women were also more likely to report lower quality-of-life and functional health status, including pain, mobility, self-care, and ability to perform usual activities. Three patterns of healthcare utilization were described: (1) individuals with low healthcare utilization, (2) individuals who utilized care and paid high out-of-pocket costs, and (3) individuals who utilized care but had lower out-of-pocket costs. Women and those with health insurance were more likely to be in the high-cost utilizer group. CONCLUSIONS Men and women with elevated blood pressure in Kenya have different health care utilization behaviors, cost and economic burdens, and self-perceived health status. Awareness of these sex differences can help inform targeted interventions in these populations.
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Affiliation(s)
- Neha Sikka
- Icahn School of Medicine at Mount Sinai, New York, USA
| | - Allison DeLong
- Center for Statistical Sciences, School of Public Health, Brown University, Providence, RI, USA
| | - Jemima Kamano
- Department of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Sylvester Kimaiyo
- Department of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Vitalis Orango
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Josephine Andesia
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Joseph Hogan
- Center for Statistical Sciences, School of Public Health, Brown University, Providence, RI, USA
- Department of Biostatistics, Brown University School of Public Health, Providence, RI, USA
| | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.
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Genberg BL, Wachira J, Steingrimsson JA, Pastakia S, Tran DNT, Said JA, Braitstein P, Hogan JW, Vedanthan R, Goodrich S, Kafu C, Wilson-Barthes M, Galárraga O. Integrated community-based HIV and non-communicable disease care within microfinance groups in Kenya: study protocol for the Harambee cluster randomised trial. BMJ Open 2021; 11:e042662. [PMID: 34006540 PMCID: PMC8137246 DOI: 10.1136/bmjopen-2020-042662] [Citation(s) in RCA: 6] [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] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION In Kenya, distance to health facilities, inefficient vertical care delivery and limited financial means are barriers to retention in HIV care. Furthermore, the increasing burden of non-communicable diseases (NCDs) among people living with HIV complicates chronic disease treatment and strains traditional care delivery models. Potential strategies for improving HIV/NCD treatment outcomes are differentiated care, community-based care and microfinance (MF). METHODS AND ANALYSIS We will use a cluster randomised trial to evaluate integrated community-based (ICB) care incorporated into MF groups in medium and high HIV prevalence areas in western Kenya. We will conduct baseline assessments with n=900 HIV positive members of 40 existing MF groups. Group clusters will be randomised to receive either (1) ICB or (2) standard of care (SOC). The ICB intervention will include: (1) clinical care visits during MF group meetings inclusive of medical consultations, NCD management, distribution of antiretroviral therapy (ART) and NCD medications, and point-of-care laboratory testing; (2) peer support for ART adherence and (3) facility referrals as needed. MF groups randomised to SOC will receive regularly scheduled care at a health facility. Findings from the two trial arms will be compared with follow-up data from n=300 matched controls. The primary outcome will be VS at 18 months. Secondary outcomes will be retention in care, absolute mean change in systolic blood pressure and absolute mean change in HbA1c level at 18 months. We will use mediation analysis to evaluate mechanisms through which MF and ICB care impact outcomes and analyse incremental cost-effectiveness of the intervention in terms of cost per HIV suppressed person-time, cost per patient retained in care and cost per disability-adjusted life-year saved. ETHICS AND DISSEMINATION The Moi University Institutional Research and Ethics Committee approved this study (IREC#0003054). We will share data via the Brown University Digital Repository and disseminate findings via publication. TRIAL REGISTRATION NUMBER NCT04417127.
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Affiliation(s)
- Becky L Genberg
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Juddy Wachira
- Behavioral Sciences, Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Jon A Steingrimsson
- Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Sonak Pastakia
- Center for Health Equity and Innovation, Purdue University College of Pharmacy, Indianapolis, Indiana, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Dan N Tina Tran
- Center for Health Equity and Innovation, Purdue University College of Pharmacy, Indianapolis, Indiana, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jamil AbdulKadir Said
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Internal Medicine, Moi University School of Medicine, Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Epidemiology, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Joseph W Hogan
- Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Rajesh Vedanthan
- Global Health, New York University Grossman School of Medicine, New York, New York, USA
| | - Suzanne Goodrich
- Division of Infectious Diseases, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Catherine Kafu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Marta Wilson-Barthes
- Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Omar Galárraga
- Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main St. Box G-S121-2 Providence, Rhode Island, USA
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Enane LA, Apondi E, Omollo M, Toromo JJ, Bakari S, Aluoch J, Morris C, Kantor R, Braitstein P, Fortenberry JD, Nyandiko WM, Wools‐Kaloustian K, Elul B, Vreeman RC. "I just keep quiet about it and act as if everything is alright" - The cascade from trauma to disengagement among adolescents living with HIV in western Kenya. J Int AIDS Soc 2021; 24:e25695. [PMID: 33838007 PMCID: PMC8035676 DOI: 10.1002/jia2.25695] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 02/22/2021] [Accepted: 03/02/2021] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION There are approximately 1.7 million adolescents living with HIV (ALHIV, ages 10 to 19) globally, including 110,000 in Kenya. While ALHIV experience poor retention in care, limited data exist on factors underlying disengagement. We investigated the burden of trauma among disengaged ALHIV in western Kenya, and its potential role in HIV care disengagement. METHODS We performed in-depth qualitative interviews with ALHIV who had disengaged from care at two sites, their caregivers and healthcare workers (HCW) at 10 sites, from 2018 to 2020. Disengagement was defined as not attending clinic ≥60 days past a missed scheduled visit. ALHIV and their caregivers were traced through phone calls and home visits. Interviews ascertained barriers and facilitators to adolescent retention in HIV care. Dedicated questions elicited narratives surrounding traumatic experiences, and the ways in which these did or did not impact retention in care. Through thematic analysis, a conceptual model emerged for a cascade from adolescent experience of trauma to disengagement from HIV care. RESULTS Interviews were conducted with 42 disengaged ALHIV, 34 caregivers and 28 HCW. ALHIV experienced a high burden of trauma from a range of stressors, including experiences at HIV disclosure or diagnosis, the loss of parents, enacted stigma and physical or sexual violence. A confluence of factors - trauma, stigma and isolation, and lack of social support - led to hopelessness and depression. These factors compounded each other, and resulted in complex mental health burdens, poor antiretroviral adherence and care disengagement. HCW approaches aligned with the factors in this model, suggesting that these areas represent targets for intervention and provision of trauma-informed care. CONCLUSIONS Trauma is a major factor underlying disengagement from HIV care among Kenyan adolescents. We describe a cascade of factors representing areas for intervention to support mental health and retention in HIV care. These include not only the provision of mental healthcare, but also preventing or addressing violence, trauma and stigma, and reinforcing social and familial support surrounding vulnerable adolescents. In this conceptualization, supporting retention in HIV care requires a trauma-informed approach, both in the individualized care of ALHIV and in the development of strategies and policies to support adolescent health outcomes.
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Affiliation(s)
- Leslie A Enane
- The Ryan White Center for Pediatric Infectious Disease and Global HealthDepartment of PediatricsIndiana University School of MedicineIndianapolisINUSA
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Moi Teaching and Referral HospitalEldoretKenya
| | - Mark Omollo
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Judith J Toromo
- The Ryan White Center for Pediatric Infectious Disease and Global HealthDepartment of PediatricsIndiana University School of MedicineIndianapolisINUSA
| | - Salim Bakari
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Josephine Aluoch
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Clemette Morris
- Indiana University‐Purdue University‐IndianapolisIndiana UniversityIndianapolisINUSA
| | - Rami Kantor
- Division of Infectious DiseasesDepartment of MedicineBrown University Apert Medical SchoolProvidenceRIUSA
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Department of EpidemiologyIndiana University Fairbanks School of Public HealthIndianapolisINUSA
- Dalla Lana School of Public HealthDivision of EpidemiologyUniversity of TorontoTorontoONCanada
- Department of MedicineCollege of Health SciencesSchool of MedicineMoi UniversityEldoretKenya
| | - J Dennis Fortenberry
- Division of Adolescent MedicineDepartment of PediatricsIndiana University School of MedicineIndianapolisINUSA
| | - Winstone M Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Department of Child Health and PediatricsCollege of Health SciencesSchool of MedicineMoi UniversityEldoretKenya
| | - Kara Wools‐Kaloustian
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Division of Infectious DiseasesDepartment of MedicineIndiana University School of MedicineIndianapolisINUSA
| | - Batya Elul
- Department of EpidemiologyMailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Rachel C Vreeman
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Division of Infectious DiseasesDepartment of MedicineIndiana University School of MedicineIndianapolisINUSA
- Department of Health System Design and Global HealthIcahn School of Medicine at Mount SinaiNew YorkNYUSA
- Arnhold Institute for Global HealthNew YorkNYUSA
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Tran DN, Were PM, Kangogo K, Amisi JA, Manji I, Pastakia SD, Vedanthan R. Supply-chain strategies for essential medicines in rural western Kenya during COVID-19. Bull World Health Organ 2021; 99:388-392. [PMID: 33958827 PMCID: PMC8061666 DOI: 10.2471/blt.20.271593] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 12/12/2022] Open
Abstract
Problem The coronavirus disease 2019 (COVID-19) pandemic has disrupted health systems worldwide and threatened the supply of essential medicines. Especially affected are vulnerable patients in low- and middle-income countries who can only afford access to public health systems. Approach Soon after physical distancing and curfew orders began on 15 March 2020 in Kenya, we rapidly implemented three supply-chain strategies to ensure a continuous supply of essential medicines while minimizing patients’ COVID-19 exposure risks. We redistributed central stocks of medicines to peripheral health facilities to ensure local availability for several months. We equipped smaller, remote health facilities with medicine tackle boxes. We also made deliveries of medicines to patients with difficulty reaching facilities. Local setting Τo implement these strategies we leveraged our 30-year partnership with local health authorities in rural western Kenya and the existing revolving fund pharmacy scheme serving 85 peripheral health centres. Relevant changes In April 2020, stocks of essential chronic and non-chronic disease medicines redistributed to peripheral health facilities increased to 835 140 units, as compared with 316 330 units in April 2019. We provided medicine tackle boxes to an additional 46 health facilities. Our team successfully delivered medications to 264 out of 311 patients (84.9%) with noncommunicable diseases whom we were able to reach. Lessons learnt Our revolving fund pharmacy model has ensured that patients’ access to essential medicines has not been interrupted during the pandemic. Success was built on a community approach to extend pharmaceutical services, adapting our current supply-chain infrastructure and working quickly in partnership with local health authorities.
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Affiliation(s)
- Dan N Tran
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, United States of America (USA)
| | - Phelix M Were
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Kibet Kangogo
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - James A Amisi
- Department of Family Medicine, Moi University School of Medicine, Eldoret, Kenya
| | - Imran Manji
- Department of Pharmacy, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Sonak D Pastakia
- Department of Pharmacy Practice, Purdue University College of Pharmacy, 640 Eskenazi Ave, West Lafayette, IN 46202, USA
| | - Rajesh Vedanthan
- Department of Population Health, New York University Grossman School of Medicine, New York, USA
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Miller ML, Schellhase E, Whicker H, Manji I, Karwa R, Pastakia SD, Kimani S. Global service learning: A unique educational pathway for community engagement and student scholarship development. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Monica L. Miller
- Department of Pharmacy Practice, Purdue University College of Pharmacy West Lafayette Indiana USA
- Pharmacy Department, Academic Model Providing Access to Healthcare Eldoret Kenya
| | - Ellen Schellhase
- Department of Pharmacy Practice, Purdue University College of Pharmacy West Lafayette Indiana USA
- Pharmacy Department, Academic Model Providing Access to Healthcare Eldoret Kenya
| | - Hadley Whicker
- Department of Pharmacy Practice, Purdue University College of Pharmacy West Lafayette Indiana USA
| | - Imran Manji
- Department of Pharmacy, Moi Teaching and Referral Hospital Eldoret Kenya
| | - Rakhi Karwa
- Department of Pharmacy Practice, Purdue University College of Pharmacy West Lafayette Indiana USA
- Pharmacy Department, Academic Model Providing Access to Healthcare Eldoret Kenya
- Department of Pharmacology and Toxicology, Moi University College of Health Sciences Eldoret Kenya
| | - Sonak D. Pastakia
- Department of Pharmacy Practice, Purdue University College of Pharmacy West Lafayette Indiana USA
- Pharmacy Department, Academic Model Providing Access to Healthcare Eldoret Kenya
- Department of Pharmacology and Toxicology, Moi University College of Health Sciences Eldoret Kenya
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Vedanthan R, Kumar A, Kamano JH, Chang H, Raymond S, Too K, Tulienge D, Wambui C, Bagiella E, Fuster V, Kimaiyo S. Effect of Nurse-Based Management of Hypertension in Rural Western Kenya. Glob Heart 2020; 15:77. [PMID: 33299773 PMCID: PMC7716784 DOI: 10.5334/gh.856] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/06/2020] [Indexed: 01/23/2023] Open
Abstract
Background Elevated blood pressure is the leading cause of death worldwide; however, treatment and control rates remain very low. An expanding literature supports the strategy of task redistribution of hypertension care to nurses. Objective We aimed to evaluate the effect of a nurse-based hypertension management program in Kenya. Methods We conducted a retrospective data analysis of patients with hypertension who initiated nurse-based hypertension management care between January 1, 2011, and October 31, 2013. The primary outcome measure was change in systolic blood pressure (SBP) over one year, analyzed using piecewise linear mixed-effect models with a cut point at 3 months. The primary comparison of interest was care provided by nurses versus clinical officers. Secondary outcomes were change in diastolic blood pressure (DBP) over one year, and blood pressure control analyzed using a zero-inflated Poisson model. Results The cohort consisted of 1051 adult patients (mean age 61 years; 65% women). SBP decreased significantly from baseline to three months (nurse-managed patients: slope -4.95 mmHg/month; clinical officer-managed patients: slope -5.28), with no significant difference between groups. DBP also significantly decreased from baseline to three months with no difference between provider groups. Retention in care at 12 months was 42%. Conclusions Nurse-managed hypertension care can significantly improve blood pressure. However, retention in care remains a challenge. If these results are reproduced in prospective trial settings with improvements in retention in care, this could be an effective strategy for hypertension care worldwide.
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Affiliation(s)
- Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, New York, US
| | - Anirudh Kumar
- Department of Medicine, NYU Grossman School of Medicine, New York, US
| | - Jemima H. Kamano
- Department of Medicine, School of Medicine, Moi University College of Health Sciences, Eldoret, KE
- Chronic Disease Management, Academic Model Providing Access to Healthcare, Eldoret, KE
| | - Helena Chang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, US
| | - Samantha Raymond
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, US
| | - Kenneth Too
- Chronic Disease Management, Academic Model Providing Access to Healthcare, Eldoret, KE
| | - Deborah Tulienge
- Chronic Disease Management, Academic Model Providing Access to Healthcare, Eldoret, KE
| | - Charity Wambui
- Chronic Disease Management, Academic Model Providing Access to Healthcare, Eldoret, KE
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, US
| | - Valentin Fuster
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, US
| | - Sylvester Kimaiyo
- Department of Medicine, School of Medicine, Moi University College of Health Sciences, Eldoret, KE
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Developing Ethical and Sustainable Global Health Educational Exchanges for Clinical Trainees: Implementation and Lessons Learned from the 30-Year Academic Model Providing Access to Healthcare (AMPATH) Partnership. Ann Glob Health 2020; 86:137. [PMID: 33178558 PMCID: PMC7597575 DOI: 10.5334/aogh.2782] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: There is strong interest among healthcare trainees and academic institutions in global health rotations. There are a number of guidelines detailing the ethical principles for equitable and ethical global health rotations and bilateral exchanges, but it is often challenging to know to implement those principles and develop longstanding partnerships. Objectives: The Academic Model Providing Access to Healthcare (AMPATH) is a 30-year continuous partnership between a consortium of 12 universities in North America and Moi University in Kenya. The AMPATH bilateral educational exchange has had 1,871 North American and over 400 Kenyan clinical trainees participate to date. The article describes the bilateral exchange of trainees including curriculum, housing, and costs and discusses how each is an application of the principles of ethical global engagement. Findings: The article takes the experiences of the AMPATH partnership and offers practical strategies for implementing similar partnerships based on previously published ethical principles. Conclusions: AMPATH provides a model for developing an institutional partnership for a bilateral educational exchange grounded in cultural humility, bidirectional relationships, and longitudinal, sustainable engagement.
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Abstract
: As coronavirus disease 2019 (Covid-19) restrictions upend the community bonds that have enabled African communities to thrive in the face of numerous challenges, it is vital that the gains made in community-based healthcare are preserved by adapting our approaches. Instead of reversing the many gains made through locally driven development partnerships with international funding agencies for other viral diseases like HIV, we must use this opportunity to adapt the many lessons learned to address the burden of Covid-19. Programs like the Academic Model Providing Access to Healthcare are currently leveraging widely available technologies in Africa to prevent patients from experiencing significant interruptions in care as the healthcare system adjusts to the challenges presented by Covid-19. These approaches are designed to preserve social contact while incorporating physical distancing. The gains and successes made through approaches like group-based medical care must not only continue but can help expand upon the extraordinary success of programs like President's Emergency Plan for AIDS Relief.
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Karwa R, Miller ML, Schellhase E, Tran D, Manji I, Njuguna B, Fletcher S, Kanyi J, Maina M, Jakait B, Kigen G, Kipyegon V, Aruasa W, Crowe S, Pastakia SD. Evaluating the impact of a 15‐year academic partnership to promote sustainable engagement, education, and scholarship in global health. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1249] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Rakhi Karwa
- Department of Pharmacy Practice, Purdue University College of Pharmacy West Lafayette Indiana United States
- Academic Model Providing Access to Healthcare Eldoret Kenya
| | - Monica L. Miller
- Department of Pharmacy Practice, Purdue University College of Pharmacy West Lafayette Indiana United States
- Academic Model Providing Access to Healthcare Eldoret Kenya
| | - Ellen Schellhase
- Department of Pharmacy Practice, Purdue University College of Pharmacy West Lafayette Indiana United States
- Academic Model Providing Access to Healthcare Eldoret Kenya
| | - Dan Tran
- Department of Pharmacy Practice, Purdue University College of Pharmacy West Lafayette Indiana United States
- Academic Model Providing Access to Healthcare Eldoret Kenya
| | - Imran Manji
- Moi Teaching and Referral Hospital Eldoret Kenya
- Academic Model Providing Access to Healthcare Eldoret Kenya
| | | | - Sara Fletcher
- Department of Drug Use Research and Management, Oregon State University College of Pharmacy Corvallis Oregon USA
| | - John Kanyi
- Moi Teaching and Referral Hospital Eldoret Kenya
| | - Mercy Maina
- Moi Teaching and Referral Hospital Eldoret Kenya
| | | | - Gabriel Kigen
- Department of Pharmacology & Therapeutics, Moi University College of Health Sciences Eldoret Kenya
| | | | - Wilson Aruasa
- Moi Teaching and Referral Hospital Eldoret Kenya
- Academic Model Providing Access to Healthcare Eldoret Kenya
| | - Susie Crowe
- Department of Pharmacy Practice, Bill Gatton College of Pharmacy East Tennessee State University Johnson Tennessee USA
| | - Sonak D. Pastakia
- Department of Pharmacy Practice, Purdue University College of Pharmacy West Lafayette Indiana United States
- Academic Model Providing Access to Healthcare Eldoret Kenya
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Pastakia SD. Past, present, and future journeys in clinical pharmacy around the world. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Sonak D. Pastakia
- College of Pharmacy, Center for Health Equity and Innovation Purdue University Indianapolis Indiana USA
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Pastakia SD, Tran DN, Manji I, Schellhase E, Karwa R, Miller ML, Aruasa W, Khan ZM. Framework and case study for establishing impactful global health programs through academia - biopharmaceutical industry partnerships. Res Social Adm Pharm 2020; 16:1519-1525. [PMID: 32792324 DOI: 10.1016/j.sapharm.2020.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/06/2020] [Accepted: 07/17/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The field of global health has grown with multiple different public and private stakeholders engaging in the effort to improve health outcomes for underserved populations around the world. There is, however, only limited published guidance on how to promote successful partnerships between academia and the biopharmaceutical industry. OBJECTIVE This analysis will provide a framework for developing successful partnerships around five central principles. This framework will then be applied to two representative pharmacy collaboration case studies focused on training and donations. FRAMEWORK DESCRIPTION AND CASE STUDY FINDINGS Within the Academic Model Providing Access to Healthcare (AMPATH), successful collaborations between the biopharmaceutical industry philanthropic entities and academic partners have consistently prioritized 1) contextualization, 2) collaboration, 3) local priorities, 4) institutional commitment, and 5) integration. In the first case study, the application of this framework to clinical pharmacy training activities sponsored by Celgene and implemented by the Purdue Kenya Partnership has helped the program transition from an entirely donor dependent training program to a revenue generating, locally administered program which is now recognized and accredited by the Kenyan government. In the second case study, medication donations from Eli Lilly and Company have been converted from a traditional donation program in one Kenyan health facility to a replicable and sustainable supply chain model which has been expanded to more than 70 public sector facilities across western Kenya. CONCLUSION Adherence to the five core principles of the proposed framework can help guide partnerships between academic institutions and the biopharmaceutical industry to advance healthcare services for underserved populations around the world. As large-scale government-based development agencies continue to primarily focus on specific disease states, biopharmaceutical industry-based collaborations can help initiate activities in underfunded therapeutic areas such as non-communicable diseases.
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Affiliation(s)
- Sonak D Pastakia
- Purdue University College of Pharmacy, West Lafayette, IN, USA; Moi University College of Health Sciences, Eldoret, Kenya; Academic Model Providing Access to Healthcare, Eldoret, Kenya.
| | - Dan N Tran
- Purdue University College of Pharmacy, West Lafayette, IN, USA; Moi University College of Health Sciences, Eldoret, Kenya; Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Imran Manji
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Ellen Schellhase
- Purdue University College of Pharmacy, West Lafayette, IN, USA; Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Rakhi Karwa
- Purdue University College of Pharmacy, West Lafayette, IN, USA; Moi University College of Health Sciences, Eldoret, Kenya; Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Monica L Miller
- Purdue University College of Pharmacy, West Lafayette, IN, USA; Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | | | - Zeba M Khan
- Celgene (Now Part of Bristol Myers Squibb), USA
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Osetinsky B, Mwangi A, Pastakia S, Wilson‐Barthes M, Kimetto J, Rono K, Laktabai J, Galárraga O. Layering and scaling up chronic non-communicable disease care on existing HIV care systems and acute care settings in Kenya: a cost and budget impact analysis. J Int AIDS Soc 2020; 23 Suppl 1:e25496. [PMID: 32562355 PMCID: PMC7305417 DOI: 10.1002/jia2.25496] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 03/03/2020] [Accepted: 04/01/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Like many countries in sub-Saharan Africa, Kenya is experiencing a rapid rise in the burden of non-communicable diseases (NCDs): NCDs now contribute to over 50% of inpatient admissions and 40% of hospital deaths in the country. The Academic Model Providing Access to Healthcare (AMPATH) Chronic Disease Management (CDM) programme builds on lessons and capacity of HIV care to deliver chronic NCD care layered into both HIV and primary care platforms to over 24,000 patients across 69 health facilities in western Kenya. We conducted a cost and budget impact analysis of scaling up the AMPATH CDM programme in western Kenya using the International Society for Pharmacoeconomics and Outcomes Research guidelines. METHODS Costs of the CDM programme for the health system were measured retrospectively for 69 AMPATH clinics from 2014 to 2018 using programmatic records and clinic schedules to assign per clinic monthly costs. We quantified the additional costs to provide NCD care above those associated with existing HIV or acute care services, including clinician, staff, training, travel and equipment costs, but do not include drugs or consumables as they would be paid by the patient. We projected the budget impact of increasing CDM coverage to 50% of the eligible population from 2021 to 2025, and compared it with the county budgets from 2019. RESULTS The per visit cost of providing CDM care was $10.42 (SD $2.26), with costs at facilities added to HIV clinics $1.00 (95% CI: -$2:11 to $0.11) lower than at primary care facilities. The budget impact of adding 26,765 patients from 2021 to 2025 to the CDM programme was 3,088,928 under constant percent growth, and 3,451,732 under steady-state enrolment. Scaling up under the constant percent growth scenario resulted in 12% cost savings in the budget impact. The county programmatic CDM cost in 2025 was <1% of the county healthcare budgets from 2019. CONCLUSIONS The budget impact of scaling up AMPATH's CDM programme will be driven by annual growth scenarios, and facility/provider mix. By leveraging task shifting, referral systems and partnering with public and non-profit clinics without NCD services, AMPATH's CDM programme can provide critical NCD care to new, rural populations with minimal financial impact.
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Affiliation(s)
- Brianna Osetinsky
- Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRIUSA
- Health Systems and PolicySwiss Tropical and Public Health InstituteBaselSwitzerland
| | - Ann Mwangi
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Department of Behavioral ScienceSchool of MedicineMoi UniversityEldoretKenya
| | - Sonak Pastakia
- Department of Pharmacy PracticePurdue Kenya PartnershipPurdue University College of PharmacyEldoretKenya
| | - Marta Wilson‐Barthes
- Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRIUSA
| | - Joan Kimetto
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Kimutai Rono
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
| | - Jeremiah Laktabai
- Academic Model Providing Access to Healthcare (AMPATH)EldoretKenya
- Department of Behavioral ScienceSchool of MedicineMoi UniversityEldoretKenya
| | - Omar Galárraga
- Health Services, Policy, and PracticeBrown University School of Public HealthProvidenceRIUSA
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Leung CL, Naert M, Andama B, Dong R, Edelman D, Horowitz C, Kiptoo P, Manyara S, Matelong W, Matini E, Naanyu V, Nyariki S, Pastakia S, Valente T, Fuster V, Bloomfield GS, Kamano J, Vedanthan R. Human-centered design as a guide to intervention planning for non-communicable diseases: the BIGPIC study from Western Kenya. BMC Health Serv Res 2020; 20:415. [PMID: 32398131 PMCID: PMC7218487 DOI: 10.1186/s12913-020-05199-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 04/07/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Non-communicable disease (NCD) care in Sub-Saharan Africa is challenging due to barriers including poverty and insufficient health system resources. Local culture and context can impact the success of interventions and should be integrated early in intervention design. Human-centered design (HCD) is a methodology that can be used to engage stakeholders in intervention design and evaluation to tailor-make interventions to meet their specific needs. METHODS We created a Design Team of health professionals, patients, microfinance officers, community health workers, and village leaders. Over 6 weeks, the Design Team utilized a four-step approach of synthesis, idea generation, prototyping, and creation to develop an integrated microfinance-group medical visit model for NCD. We tested the intervention with a 6-month pilot and conducted a feasibility evaluation using focus group discussions with pilot participants and community members. RESULTS Using human-centered design methodology, we designed a model for NCD delivery that consisted of microfinance coupled with monthly group medical visits led by a community health educator and a rural clinician. Benefits of the intervention included medication availability, financial resources, peer support, and reduced caregiver burden. Critical concerns elicited through iterative feedback informed subsequent modifications that resulted in an intervention model tailored to the local context. CONCLUSIONS Contextualized interventions are important in settings with multiple barriers to care. We demonstrate the use of HCD to guide the development and evaluation of an innovative care delivery model for NCDs in rural Kenya. HCD can be used as a framework to engage local stakeholders to optimize intervention design and implementation. This approach can facilitate the development of contextually relevant interventions in other low-resource settings. TRIAL REGISTRATION Clinicaltrials.gov, NCT02501746, registration date: July 17, 2015.
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Affiliation(s)
- Claudia L. Leung
- Duke University Medical Center, 10 Duke Medicine Circle, Durham, NC 27710 USA
- Division of General Internal Medicine, Duke University School of Medicine, 200 Morris St. 3rd floor, Durham, NC 27701 USA
| | - Mackenzie Naert
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - Benjamin Andama
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Rae Dong
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - David Edelman
- Division of General Internal Medicine, Duke University School of Medicine, 200 Morris St. 3rd floor, Durham, NC 27701 USA
| | - Carol Horowitz
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - Peninah Kiptoo
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Simon Manyara
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Winnie Matelong
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Esther Matini
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Violet Naanyu
- Department of Behavioral Sciences, School of Medicine, College of Health Science, Moi University College of Health Sciences, Eldoret, Kenya
| | - Sarah Nyariki
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, Eldoret, 30100 Kenya
| | - Sonak Pastakia
- Purdue University, Purdue University College of Pharmacy, Purdue-Kenya Partnership, West Lafayette, IN, PO Box 5760, Eldoret, 30100 Kenya
| | - Thomas Valente
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | - Valentin Fuster
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - Gerald S. Bloomfield
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY 10029 USA
| | - Jemima Kamano
- Department of Behavioral Sciences, School of Medicine, College of Health Science, Moi University College of Health Sciences, Eldoret, Kenya
| | - Rajesh Vedanthan
- New York University Grossman School of Medicine, 180 Madison Avenue, 8th Floor, New York, NY 10016 USA
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Were LP, Hogan JW, Galárraga O, Wamai R. Predictors of Health Insurance Enrollment among HIV Positive Pregnant Women in Kenya: Potential for Adverse Selection and Implications for HIV Treatment and Prevention. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2892. [PMID: 32331351 PMCID: PMC7216063 DOI: 10.3390/ijerph17082892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/17/2022]
Abstract
Background: The global push to achieve the 90-90-90 targets designed to end the HIV epidemic has called for the removing of policy barriers to prevention and treatment, and ensuring financial sustainability of HIV programs. Universal health insurance is one tool that can be used to this end. In sub-Saharan Africa, where HIV prevalence and incidence remain high, the use of health insurance to provide comprehensive HIV care is limited. This study looked at the factors that best predict social health insurance enrollment among HIV positive pregnant women using data from the Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. Methods: Cross-sectional clinical encounter data were extracted from the electronic medical records (EMR) at AMPATH. We used univariate and multivariate logistic regressions to estimate the predictors of health insurance enrollment among HIV positive pregnant women. The analysis was further stratified by HIV disease severity (based on CD4 cell count <350 and 350>) to test the possibility of differential enrollment given HIV disease state. Results: Approximately 7% of HIV infected women delivering at a healthcare facility had health insurance. HIV positive pregnant women who deliver at a health facility had twice the odds of enrolling in insurance [2.46 Adjusted Odds Ratio (AOR), Confidence Interval (CI) 1.24-4.87]. They were 10 times more likely to have insurance if they were lost to follow-up to HIV care during pregnancy [9.90 AOR; CI 3.42-28.67], and three times more likely to enroll if they sought care at an urban clinic [2.50 AOR; 95% CI 1.53-4.12]. Being on HIV treatment was negatively associated with health insurance enrollment [0.22 AOR; CI 0.10-0.49]. Stratifying the analysis by HIV disease severity while statistically significant did not change these results. Conclusions: The findings indicated that health insurance enrollment among HIV positive pregnant women was low mirroring national levels. Additionally, structural factors, such as access to institutional delivery and location of healthcare facilities, increased the likelihood of health insurance enrollment within this population. However, behavioral aspects, such as being lost to follow-up to HIV care during pregnancy and being on HIV treatment, had an ambiguous effect on insurance enrollment. This may potentially be because of adverse selection and information asymmetries. Further understanding of the relationship between insurance and HIV is needed if health insurance is to be utilized for HIV treatment and prevention in limited resource settings.
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Affiliation(s)
- Lawrence P.O. Were
- Department of Health Sciences, Boston University’s College of Health and Rehabilitation Sciences: Sargent College & Department of Global Health, Boston University School of Public Health, Boston, MA 02215, USA
| | - Joseph W Hogan
- School of Public Health, Brown University, Providence, RI 02912, USA; (J.W.H.); (O.G.)
| | - Omar Galárraga
- School of Public Health, Brown University, Providence, RI 02912, USA; (J.W.H.); (O.G.)
| | - Richard Wamai
- Department of Cultures, Societies and Global Studies, Northeastern University, Boston, MA 02115, USA;
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Craveiro I, Carvalho A, Ferrinho P. "Get us partnerships!" - a qualitative study of Angolan and Mozambican health academics' experiences with North/South partnerships. Global Health 2020; 16:33. [PMID: 32295611 PMCID: PMC7161017 DOI: 10.1186/s12992-020-00562-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 03/27/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Sustainable Development Goal (SDG) 17 focuses on North/South partnerships for sustainable development. Literature on research partnerships and capacity -building often neglects how these processes are carried out in practice, their social impacts and participants' subjective experiences. Recognizing the increasingly global dimensions of Higher Education Institutions, the University Development and Innovation - Africa project (UDI-A) was designed to train lecturers and administrative staff of Angolan and Mozambican Universities through collaborations with European institutions, aiming at strengthening African academic and social landscapes through knowledge translation and dissemination. This paper examines potential outcomes of UDI-A on participants' academic pathways, investigating the conflict between different imaginaries of capacity-building and partnerships, focusing on how Angolan and Mozambican health sciences researchers experience international collaborations. METHODS Semi-structured interviews were conducted with seven health academics, as well as a focus group discussion involving all participants. These were recorded, fully transcribed, anonymized and coded to identify common themes. A consent form was signed by all participants. RESULTS AND DISCUSSION UDI-A was considered innovative, fostering the improvement of pedagogical skills and increasing social entrepreneurship activities. Participants arrived with a specific institutional mandate and believed that the training received should be incorporated into institutional practices to "modernize" these specific Portuguese speaking African Universities and the health sector. The institutional mechanisms put in place to attain this goal, Centres for Academic Development and Innovation ("CADIs"), were considered potential research and development hubs and drivers of academic and societal transformation. Nevertheless, participants shared a sense of asymmetry (infrastructural, financial, in terms of access to information) between them and European trainers. Although this asymmetry was the underlying basis of this capacity-building project, they argued that UDI-A did not fully acknowledge their local contexts, compromising the prospective development of partnerships in the health field. CONCLUSIONS More attention should be devoted to understanding how participants experience capacity building processes, integrating the diversity of their aspirations and perceptions into subsequent phases of the project, requiring the development of methodological innovations to increase the impact of these programs.
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Affiliation(s)
- Isabel Craveiro
- Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Rua da Junqueira 100, 1349-008 Lisbon, Portugal
| | - António Carvalho
- Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Rua da Junqueira 100, 1349-008 Lisbon, Portugal
- Centre for Social Studies, University of Coimbra, Praça Dom Dinis, 3000-104 Coimbra, Portugal
| | - Paulo Ferrinho
- Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Rua da Junqueira 100, 1349-008 Lisbon, Portugal
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Cancedda C, Adams LV, Powderly W. Adopting locally the lessons learned globally: a call to action for academic medical centres in the USA. BMJ Glob Health 2020; 5:e002238. [PMID: 32399257 PMCID: PMC7204932 DOI: 10.1136/bmjgh-2019-002238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/16/2020] [Accepted: 03/27/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Corrado Cancedda
- Center for Global Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lisa V Adams
- Center for Global Health Equity, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - William Powderly
- Institute for Public Health, Washington University in St Louis, St Louis, Missouri, USA
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