Are outpatient costs for hypertension and diabetes care affordable? Evidence from Western Kenya

BACKGROUND

Diabetes and hypertension pose a significant socio-economic burden in developing countries such as Kenya, where financial risk-protection mechanisms remain inadequate. This proves to be a great barrier towards achieving universal health care in such settings unless mechanisms are put in place to ensure greater access and affordability to non-communicable disease (NCD) management services.

AIM

This article aims to examine outpatient management services costs for patients with diabetes and hypertension attending public primary healthcare facilities.

SETTING

The study was conducted in Busia and Trans-Nzoia counties in Western Kenya in facilities supported by the PIC4C project, between August 2020 and December 2020.

METHODS

This cross-sectional survey included 719 adult participants. Structured interviewer-administered questionnaires were used to collect information on healthcare-seeking behaviour and associated costs. The annual direct and indirect costs borne by patients were computed by disease type and level of healthcare facility visited.

RESULTS

Patients with both diabetes and hypertension incurred higher annual costs (KES 13 149) compared to those with either diabetes (KES 8408) or hypertension (KES 7458). Patients attending dispensaries and other public healthcare facilities incurred less direct costs compared to those who visited private clinics. Furthermore, a higher proportionate catastrophic healthcare expenditure of 41.83% was noted among uninsured patients.

CONCLUSION

Despite this study being conducted in facilities that had an ongoing NCDs care project that increased access to subsidised medication, we still reported a substantially high cost of managing diabetes and hypertension among patients attending primary healthcare facilities in Western Kenya, with a greater burden among those with comorbidities.Contribution: Evidenced by the results that there is enormous financial burden borne by patients with chronic diseases such as hypertension and diabetes; we recommend that universal healthcare coverage that offers comprehensive care for NCDs be urgently rolled out alongside strengthening of lower-level public healthcare systems.

A Protocol on Using the RE-AIM Framework in the Process Evaluation of the Primary Health Integrated Care Project for Four Chronic Conditions in Kenya

Background: There has been a rapid increase in morbidity and mortality arising from non-communicable diseases (NCDs). The Academic Model Providing Access to Healthcare (AMPATH) program has established a chronic disease management program in collaboration with the Ministry of Health (MoH) in Kenya at over 150 health facilities in western Kenya. The primary health integrated care for chronic (PIC4C) disease project seeks to deliver preventive, promotive, and curative care for diabetes, hypertension, cervical and breast cancers at the primary health care level. We apply the RE-AIM framework to conduct a process evaluation of the integrated PIC4C model. This paper describes the protocol we are using in the PIC4C process evaluation planning and activities.

Methods and Analysis: This evaluation utilizes clinic reports as well as primary data collected in two waves. Using mixed methods (secondary data, observation, semi-structured interviews, and focus group discussions), the process evaluation assesses the reach, effectiveness, adoption, implementation and maintenance of the PIC4C model in Busia and Trans Nzoia Kenya. The evaluation captures the PIC4C process, experiences of implementers and users, and the wishes of those using the PIC4C services. We will analyse our data across the RE-AIM dimensions using descriptive statistics and two-sample t-test to compare the mean scores for baseline and end line. Qualitative data will be analyzed thematically.

Discussion: The process evaluation of the PIC4C model in Kenya allows implementers and users to reflect and question its implementation, uptake and maintenance. Our experiences thus far suggest practicable strategies to facilitate primary health care can benefit extensively from deliberate process evaluation of the programs undertaken. Furthermore, integrating the RE-AIM framework in the process evaluation of health programs is valuable due to its pragmatic and reporting usefulness.

Maintaining care delivery for non-communicable diseases in the face of the COVID-19 pandemic in western Kenya

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.

Effect of Nurse-Based Management of Hypertension in Rural Western Kenya

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.

Reference data on the anatomy, hematology and biochemistry of 9-month-old silver foxes

Anthropometric, anatomical, hematological and biochemical reference values were estimated in clinically healthy male and female 9-month-old silver foxes. The coefficients of variation of anthropometric and anatomical measurements for 9-month-old silver foxes were as low as previously reported for adult foxes. However, in relation to body size, all measurements were smaller. Compared with adult silver foxes, higher values were observed in serum levels of triglyceride, phospholipid, beta-lipoprotein, blood urea nitrogen and total protein. Similarly, higher levels were obtained for serum enzymes, especially aspartate aminotransferase (AST), lactate dehydrogenase (LDH) and creatine kinase (CK). The high levels of these serum enzymes may be due to handling stress. Inorganic phosphorus and calcium concentrations in the young foxes were also high. The alkaline phosphatase (ALP) level, reflecting the level of bone growth, was higher than that of adults. Biochemical values of beta-lipoprotein glucose and calcium in male 9-month-old silver foxes were lower than those of females, whereas those of total cholesterol, total protein, fructosamine, iron, albumin and beta-globulin were higher.

Cardiopathological observation on a case of persistent ventricular tachycardia in a pony mare

A 20-year-old pony mare with persistent ventricular tachycardia (VT) was examined cardiopathologically. At necropsy, the heart was enlarged and rounded with both ventricular dilatation. In a longitudinal section of the ventricular septum, a large grayish white patchy lesion (5 x 25 mm) was detected in the relatively higher portion. Microscopically, the lesion was extensive myocardial fibrosis located in the vicinity of the proximal part of the left bundle branch. Partially the fibrotic lesion was in contact with the branch. Such a lesion might play an important role in creating a suitable background for the development of VT via automaticity or reentry mechanism.

Arrhythmias in newborn thoroughbred foals

Foetal electrocardiograms (ECG) were obtained from 39 of 50 Thoroughbred foaling mares close to delivery. The 50 newborn foals were studied electrocardiographically during their adaptive period, immediately after birth. In 48 foals there were paroxysmal arrhythmias or mixed arrhythmias. The most common arrhythmias were sinus arrhythmias including wandering pacemaker (32/50) and atrial premature contraction (30/50). The others observed were atrial fibrillation (15/50), ventricular premature contraction (10/50), partial atrioventricular block (7/50), ventricular tachycardia (4/50), atrial tachycardia (3/50) and idioventricular rhythm (1/50). The duration of the arrhythmias was approximately 5 min, and in all cases the arrhythmia disappeared within 15 min of birth. From foetal ECG recordings, no indication of the likelihood of neonatal arrhythmias was detected. With the exception of 2 cases, all foals have continued to grow and develop normally. These arrhythmias are considered normal physiological processes in newborn Thoroughbred foals during the adaptive period to extra-uterine life. High vagal tone and hypoxaemia at birth are probably the main contributing factors.

Electrocardiographic findings during parturition and blood gas tensions immediately after birth in thoroughbred foals

In 101 newborn Thoroughbred foals and foaling mares, 45 fetal (FECGs) and 101 neonatal electrocardiograms (NECGs) were obtained to investigate neonatal arrhythmias and other parameters including changes in fetal (FHR) and neonatal heart rate (NHR). Moreover, umbilical arterial, venous and jugular venous blood gas tensions and pH immediately after birth were analyzed to compare with the type and the degree of neonatal arrhythmias. Before delivery, in 37 fetuses FHR gradually decreased while in 8 cases it increased after rupture of the chorio-allantois. Abnormal deliveries were related in 5 of the 8 cases. In foals born with sinus rhythm, NHR at birth was 22 beats per minute higher than the FHR immediately before birth, gradually decreased for 1-2 min and then increased. Various types of neonatal arrhythmias and their combinations were recorded in 92 of the 101 NECGs. No arrhythmias demonstrated in NECGs were detected in the FECGs. The mean values for umbilical arterial pH, PCO2 and PO2 indicated that newborn foals at birth were exposed to hypoxemic, hypercapnic and acidemic conditions. The relationship between the umbilical arterial PO2 value as an indicator of the degree of hypoxemia of the foal and the type of arrhythmias was not apparent. However, the PO2 value in the group with severe arrhythmias was comparatively lower than that in the group with mild arrhythmias. It was suggested that hypoxemia played an important role in neonatal arrhythmias.

Reference data on the anatomy and serum biochemistry of the silver fox

Clinically healthy silver foxes obtained from a closed colony were investigated for the purpose of establishing base-line data for this species. The anthropometry (body weight; body length; length and width of the head; width, depth, and circumference of the chest; length of the tail), anatomical measurements (weight; longitudinal and transverse length; thickness of the main organs) and serum biochemical assays (AST, ALT, ALP, LDH, CK, lipase, GGT, T-Cho, beta-Lipo, TG, Phos-Lip, Tp, T-Bil, UA, BUN, Crea, Glu, Ca, IP, Mg, Fe, Na, K, Cl, LDH and CK isoenzymes) were carried out. The data were presented as mean values with standard deviations, and compared with those of the dog. The coefficient of variation (CV) for each of the anthropometric parameters was low, except for that of female body weight for which the CV was 17%. The body size of the male was larger than the female, and the weights of the main organs, corresponding to body size, were greater than the female. The results were equivalent to those for a Beagle dog aged between 3 and 5 months. Significant differences between the sexes were detected in the following parameters: concentrations of BUN, beta-Lipo and T-Bil (p less than 0.01); concentration of Mg and Glu (p less than 0.05); activity of LDH and lipase (p less than 0.05). The biochemical data ware uniform with some exceptions. These were AST (142 IU/l) and ALP (122 IU/l) in a 5-year-old male fox, Glu (over 200 mg/dl) in four 2-year-old female foxes, CK (629 IU/l) in a 2-year-old female fox, and finally CK (366 IU/l) and lipase (428 IU/l) in an 8-year-old female fox, all of which were elevated. These data were similar to the reference values for the dog previously reported. The reference values presented in this report for the silver fox will be valuable as a guide for clinical diagnosis and research.

Lactate dehydrogenase and creatine phosphokinase isoenzymes in tissues of laboratory animals

The lactate dehydrogenase (LDH) and creatine phosphokinase (CPK) isoenzyme distributions in tissues of the ICR mouse, Wistar rat, guinea pig and golden hamster were analyzed by histoelectrophoresis. Tissues obtained were as follows: liver, pancreas, stomach, small intestine, heart, femoral muscle, uterus, kidney, spleen, lymph node, cerebrum, spinal cord and erythrocyte. Histoelectrophoresis was for the direct analysis of LDH and CPK isoenzymes in the tissues and had high practical value compared with previous tissue-extraction methods. In tissues of the mouse, guinea pig and golden hamster, LDH isoenzymes showed five bands. In the rat, LDH isoenzyme was separated into four fractions. CPK isoenzyme showed three bands; BB, MB and MM. In some tissues, the MM band was separated into two sub fractions.

Lactate dehydrogenase isoenzyme patterns in bovine liver tissue

Liver lactate dehydrogenase (LDH) isoenzymes in normal and diseased cows were analyzed electrophoretically. This method (histoelectrophoresis) was improved for the direct analysis of tissue LDH isoenzymes. The mean values of LDH 1 through LDH 5 in the livers of normal cows were 31.7, 24.8, 27.3, 12.8, and 3.3%, respectively. In cases with hydropic degeneration of the liver, the patterns revealed increases of LDH 1 and LDH 2 as compared to normal cows. The patterns showed a decrease of LDH 1 and an increase of LDH 2 in fatty change of the liver. Congestion of the liver alone decreased LDH 1 and increased LDH 3, LDH 4 and LDH 5. Necrosis of the liver decreased LDH 1 and LDH 2, and increased LDH 3, LDH 4 and LDH 5. It was suggested that the functional hepatocellular damage due to anoxia might be a important factor of the change of liver LDH isoenzyme patterns. We have attempted to standardize the LDH isoenzyme patterns by using a computer under various conditions. In cases with hydropic lesions, the diagnostic sensitivity (DS) was 53% (28 of 53 cases) and the predictive value of positive tests (PVPT) was 100% (28 cases of 28 cases selected). In cases with congestive or necrotic lesions, DS was 41% (9 of 22 cases) and PVPT was 69% (9 cases of 13 cases selected).

Electrocardiogram studies in llamas

Electrocardiograms (ECG) of 3 captive llamas (Lama glama) were recorded by a telemeter at a farm in Japan. The pattern of the ECGs was similar to the ruminant pattern in the AB lead position. QRS and T-waves were discordant in polarity except in one llama, where the polarity of the T wave changed according to the HR. In the quiet state, the HR varied between 60-80/min depending on the nervousness of the llama. After running and after being held, the HR increased to more than 100/min. During the recordings there were some variations of the HR which could be due to respiratory arrhythmia. Second-degree AV block and supraventricular premature complexes were also found in two llamas.

A morphometric study of foetal and newborn cardiac growth in the horse

A morphometric study of hearts in 81 equine foetuses, ranging in age from 190 to 330 days of foetal age, and in 26 newborn foals is reported. The mean weight, external dimensions, ventricular wall thickness and circumference of the atrio-ventricular orifice were measured. Features of the main associated vessels of the heart were also recorded. All cardiac measurements of foetuses increased linearly throughout the latter half of pregnancy and were highly correlated with foetal age. This linear growth pattern was also found in the parameters of the associated arterial trunks. The ratio of the right ventricular weight to the total ventricular weight in the equine foetuses increased gradually from 0.27 (Day 190) to 0.34 (full term), but in newborn foals, this ratio began to decrease soon after birth, declining from 0.32 to 0.28 by 11 days of age. The interventricular septum was thickest followed by the right ventricular wall, and the left ventricular wall was thinnest during the period of gestation studied. The right ventricle was 3.2 per cent to 31.5 per cent thicker than the left ventricle.

A morphological study on the obliteration processes of the ductus arteriosus in the horse

The obliteration processes of the ductus arteriosus of equine foetuses and newborn foals were studied morphometrically and histologically. The length, internal and external diameters and circumference of the ductus in equine foetuses increased progressively and linearly up to 310 days with advancing foetal age, but the values, especially the internal diameter, decreased from 320 to 330 days. After birth, the ductal measurements decreased gradually and ductal closure was found in three of 14 foals examined on the first day post partum, in two of six on the second day and in nine of nine on the third day or later, suggesting that the ductus arteriosus closes physiologically within three days after birth. Microscopical findings of the ductus arteriosus were characterised by the rearrangement of smooth muscle cells in the inner media and intimal thickening in foetuses, and by the central displacement of the intima in newborn foals. It was concluded that the ductus arteriosus begins to undergo preparatory modifications during intrauterine life, when the vessel is still functional, and that the most significant starting point of change in the obliteration processes is the rearrangement of smooth muscle cells in the inner media, which occurs during pre- and post natal life.

Detection of antibodies to leptospiral genus-specific antigen in human and animal sera by indirect hemagglutination test with a partially purified genus-specific protein antigen

Antibodies against leptospiral genus-specific antigen were detected in the sera from clinically diagnosed human leptospirosis and suspected animal leptospirosis by indirect hemagglutination (IHA) test with a partially purified genus-specific protein antigen (GP-Ag). The reaction was positive in the infected humans and animals irrespective of the leptospiral serovars. No significant correlation was found between IHA titer against GP-Ag and microscopic agglutination (MA) titer. IHA titer did not always develop in parallel with MA titers. Sera obtained from healthy individuals were negative in both IHA and MA tests.