Perceived health system facilitators and barriers to integrated management of hypertension and type 2 diabetes in Kenya: a qualitative study

OBJECTIVE

Understanding the facilitators and barriers to managing hypertension and type 2 diabetes (T2D) will inform the design of a contextually appropriate integrated chronic care model in Kenya. We explored the perceived facilitators and barriers to the integrated management of hypertension and T2D in Kenya using the Rainbow Model of Integrated Care.

DESIGN

This was a qualitative study using data from a larger mixed-methods study on the health system response to chronic disease management in Kenya, conducted between July 2019 and February 2020. Data were collected through 44 key informant interviews (KIIs) and eight focus group discussions (FGDs).

SETTING

Multistage sampling procedures were used to select a random sample of 12 study counties in Kenya.

PARTICIPANTS

The participants for the KIIs comprised purposively selected healthcare providers, county health managers, policy experts and representatives from non-state organisations. The participants for the FGDs included patients with hypertension and T2D.

OUTCOME MEASURES

Patients' and providers' perspectives of the health system facilitators and barriers to the integrated management of hypertension and T2D in Kenya.

RESULTS

The clinical integration facilitators included patient peer support groups for hypertension and T2D. The major professional integration facilitators included task shifting, continuous medical education and integration of community resource persons. The national referral system, hospital insurance fund and health management information system emerged as the major facilitators for organisational and functional integration. The system integration facilitators included decentralisation of services and multisectoral partnerships. The major barriers comprised vertical healthcare services characterised by service unavailability, unresponsiveness and unaffordability. Others included a shortage of skilled personnel, a lack of interoperable e-health platforms and care integration policy implementation gaps.

CONCLUSIONS

Our study identified barriers and facilitators that may be harnessed to improve the integrated management of hypertension and T2D. The facilitators should be strengthened, and barriers to care integration redressed.

Impact of DREAMS interventions on experiences of violence among adolescent girls and young women: Findings from population-based cohort studies in Kenya and South Africa

DREAMS aims to reduce HIV incidence among adolescent girls and young women (AGYW) by tackling drivers of HIV risk including gender-based violence. We evaluate the impact of DREAMS on recent experiences of violence perpetuated by men against AGYW. AGYW cohorts were randomly selected from demographic platforms in South Africa (rural KwaZulu-Natal) and Kenya (Nairobi informal settlements and rural Gem sub-county). AGYW aged 13-22 years were enrolled in 2017 (Nairobi, KwaZulu-Natal) or 2018 (Gem), with annual follow-up to 2019. We described proportions of AGYW who self-reported experiences of violence perpetrated by males in the 12 months preceding the interview, overall and by form (physical, sexual, emotional). We investigated associations with DREAMS (invitation to participate during 2017-2018) through multivariable propensity score-adjusted logistic regression and estimated the causal effect of DREAMS on experiences of violence, under counter-factual scenarios in which all versus no AGYW were DREAMS beneficiaries. Among 852, 1018 and 1712 AGYW followed-up in 2019 in Nairobi, Gem and KZN, respectively, proportions reporting any violence in 2019 were higher in Nairobi (29%) than Gem (18%) and KwaZulu-Natal (19%). By sub-type, emotional and physical violence were more frequently reported than sexual violence. We found no evidence of an impact attributable to DREAMS on overall levels of violence, in any setting. Nor was there evidence of impact on sub-types of violence, with one exception: an increase in physical violence in Nairobi if all, versus no, AGYW were DREAMS beneficiaries (16% vs 11%; +5% difference [95% CI: +0.2%, +10.0%]). Experiences of gender-based violence were common among AGYW, especially in urban settings, and DREAMS had no measurable impact on reducing violence within three years of implementation. Violence prevention programming that reaches more men and the broader community, sustained for longer periods, may yield greater gains in violence reduction than AGYW-focused programming. Additionally, more investment in implementation research is needed to bridge trial-based study findings from efficacy to population-level effectiveness.

1075Patterns, determinants and socioeconomic inequalities in eating healthy in Kenya

Background

Kenya is undergoing an epidemiological transition marked by an increase in the burden of non-communicable diseases (NCDs) with unhealthy diet being a key risk factor. This study sought to identify patterns, determinants and socioeconomic inequalities in healthy food consumption in Kenya.

Methods

A secondary analysis of the Kenya Integrated Household Budget Survey 2015/2016 (KIHBS) data was conducted. A healthy diet indicator (HDI) was computed from food consumption information using principal component analysis (PCA) based on WHO and FAO recommendations. Multivariable probit regression was used to identify determinants of eating healthy. The concentration index (CI) method was used to identify socioeconomic inequalities in eating healthy overall, by gender and residence using household aggregate consumption per adult equivalent.

Results

The final sample consisted of 21, 512 households. Two thirds of them were rural and majority were male-headed (66%). 49% of households were eating healthy countrywide. HDI scores increased with increasing socioeconomic status overall, by gender and residence. Households with higher socioeconomic status (0.30, p < 0.01), rural (0.20, p < 0.01), in union (0.07, p < 0.01) and Christian (0.16, p < 0.01) were more likely to eat healthy while male-headed (-0.04, p < 0.01), Muslim (-0.07, p < 0.05) and households whose household-heads had lower education status (-0.09, p < 0.01) were less likely to eat healthy. Eating healthy was concentrated among the rich overall, by gender and residence.

Conclusions

A large proportion of Kenyans are consuming unhealthy foods with the rich eating healthier than the poor.

Key messages

Interventions are required to promote healthy dietary patterns and reduce socioeconomic inequality in eating healthy.

Prevalence and factors associated with health insurance coverage in resource-poor urban settings in Nairobi, Kenya: a cross-sectional study

OBJECTIVE

To determine the prevalence of health insurance and associated factors among households in urban slum settings in Nairobi, Kenya.

DESIGN

The data for this study are from a cross-sectional survey of adults aged 18 years or older from randomly selected households in Viwandani slums (Nairobi, Kenya). Respondents participated in the Lown scholars' study conducted between June and July 2018.

SETTING

The Lown scholars' survey was nested in the Nairobi Urban Health and Demographic Surveillance System in Viwandani slums in Nairobi, Kenya.

PARTICIPANTS

A total of 300 randomly sampled households participated in the survey. The study respondents comprised of either the household head, their spouses or credible adult household members.

PRIMARY OUTCOME MEASURE

The primary outcome of this study was enrolment in a health insurance programme. The households were classified into two groups: those having at least one member covered by health insurance and those without any health insurance cover.

RESULTS

The prevalence of health insurance in the sample was 43%. Being unemployed (adjusted OR (aOR) 0.17; p<0.05; 95% CI 0.06 to 0.47) and seeking care from a public health facility (aOR 0.50; p<0.05; 95% CI 0.28 to 0.89) was significantly associated with lower odds of having a health insurance cover. The odds of having a health insurance cover were significantly lower among respondents who perceived their health status as good (aOR 0.62; p<0.05; 95% CI 1.17 to 5.66) and those who were unsatisfied with the cost of seeking primary care (aOR 0.34; p<0.05; 95% CI 0.17 to 0.69).

CONCLUSIONS

Health insurance coverage in Viwandani slums in Nairobi, Kenya, is low. As universal health coverage becomes the growing focus of Kenya's 'Big Four Agenda' for socioeconomic transformation, integrating enabling and need factors in the design of the national health insurance package may scale-up social health protection.

Factors affecting the acceptability of isoniazid preventive therapy among healthcare providers in selected HIV clinics in Nairobi County, Kenya: a qualitative study

OBJECTIVE

Despite being globally recommended as an effective intervention in tuberculosis (TB) prevention among people living with HIV, isoniazid preventive therapy (IPT) implementation remains suboptimal, especially in sub-Saharan Africa. This study explored the factors influencing the acceptability of IPT among healthcare providers in selected HIV clinics in Nairobi County, Kenya, a high HIV/TB burden country.

DESIGN

A qualitative study was conducted using in-depth interviews with healthcare providers in selected HIV clinics. All conversations were audio recorded, transcribed verbatim and analysed using a thematic approach.

SETTING

The study was conducted in the HIV clinics of three purposefully selected public healthcare facilities in Nairobi County, Kenya between February 2017 and April 2017.

PARTICIPANTS

Eighteen purposefully selected healthcare providers (clinicians, nurses, pharmacists and counsellors) working in the HIV clinics participated in the study.

RESULTS

Provider acceptability of IPT was influenced by factors relating to the organisational context, provider training on IPT and their perception on its efficacy, length and clarity of IPT guidelines and standard operation procedures, as well as structural factors (policy, physical and work environment). Inadequate high-level commitment and support for the IPT programme by programme managers and policy-makers were found to be the major barriers to successful IPT implementation in our study context.

CONCLUSION

This study provides insight into the complexity of factors affecting the IPT implementation in Kenya. Ensuring optimal acceptability of IPT among healthcare providers will require an expanded depth of engagement by policy-makers and IPT programme managers with both providers and patients, as well as on-the-job design specific actions to support providers in implementation. Such high-level commitment and support are consequently essential for quality delivery of the intervention.