Unmet need for primary healthcare and associated individual and household-level factors in Kenya: results from a national survey

OBJECTIVE

To determine the prevalence of unmet need for primary healthcare and associated individual and household-level factors in Kenya.

DESIGN

The data for this study are drawn from the 2016 Kenya Integrated Household Budget Survey (KIHBS). A multistage sampling technique involving a systematic selection of clusters at the national level and final selection of households was used.

SETTING

This study was conducted in Kenya. The KIHBS is a nationally representative survey on a wide range of indicators to assess the progress made in improving the living standards of the population at the national level.

PARTICIPANTS

A total of 9447 households comprising 15 539 household members who reported a sickness or injury over the 4 weeks preceding this survey were included in this study. The study respondents comprised of the household heads.

PRIMARY OUTCOME MEASURE

The primary outcome of this study is unmet need for primary healthcare defined as an unexpressed demand for primary healthcare following a reported sickness or injury over the 4 weeks preceding this survey.

RESULTS

About one in every five study participants experienced an unexpressed demand for primary care. The odds of having unmet need for primary healthcare were 68% higher among participants without health insurance coverage compared with those with health insurance (adjusted OR 1.68; p<0.001; 95% CI 1.34 to 2.09) and 45% higher among households headed by single or unmarried persons compared with the those who were in a marital union (adjusted OR 1.45; p<0.05; 95% CI 1.06 to 1.98).

CONCLUSIONS

Our findings show that there is still a considerable unexpressed demand for primary care services despite widespread implementation of Universal Health Coverage (UHC) in Kenya, with households without a health insurance cover bearing the highest burden. Therefore, the design of UHC reforms in Kenya should focus on embedding social health protection to escalate the demand for primary healthcare services.

Patterns and predictors of private and public health care utilization among residents of an informal settlement in Nairobi, Kenya: a cross-sectional study

BACKGROUND

Knowledge of health care utilization is important in low-and middle-income countries where inequalities in the burden of diseases and access to primary health care exist. Limited evidence exists on health seeking and utilization in the informal settlements in Kenya. This study assessed the patterns and predictors of private and public health care utilization in an urban informal settlement in Kenya.

METHODS

This study used data from the Lown scholars study conducted between June and July 2018. A total of 300 households were randomly selected and data collected from 364 household members who reported having sought care for an illness in the 12 months preceding the study. Data were collected on health-seeking behaviour and explanatory variables (predisposing, enabling, and need factors). Health care utilization patterns were described using proportions. Predictors of private or public health care use were identified using multinomial logistic regression with the reference group being other providers.

RESULTS

Majority of the participants used private (47%) and public facilities (33%) with 20% using other providers including local pharmacies/drug shops and traditional healers. In the model comparing public facilities vs other facilities, members who were satisfied with the quality of health care (vs not satisfied) were less likely to use public facilities (adjusted relative risk ratio (aRRR) 0.29; CI 0.11-0.76) while members who reported an acute infection (vs no acute infection) were more likely to use public facilities (aRRR 2.31; 95% CI 1.13-4.99) compared to other facilities. In the second model comparing private facilities to other facilities, having health insurance coverage (aRRR 2.95; 95% CI 1.53-5.69), satisfaction with cost of care (aRRR 2.08; CI 1.00-4.36), and having an acute infection (aRRR 2.97; 95% CI 1.50-5.86) were significantly associated with private facility use compared to other facilities.

CONCLUSIONS

The majority of urban informal settlement dwellers seek care from private health facilities. As Kenya commits to achieving universal health coverage, interventions that improve health care access in informal and low-resource settlements are needed and should be modelled around enabling and need factors, particularly health care financing and quality of health care.

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya

Background

Access to primary healthcare is crucial for the delivery of Kenya’s universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya.

Methods

The data were drawn from the Lown scholars’ study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas’ model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations.

Results

The odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47–6.37]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18–0.74]; p < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67–12.01]; p < .001).

Conclusion

In Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.

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.

Polychlorinated biphenyls and hexachlorocyclohexanes in sediments and fish species from the Napoleon Gulf of Lake Victoria, Uganda

Polychlorinated biphenyls (PCBs) and hexachlorocyclohexanes (HCHs) were analyzed in surface sediments (<30 cm depth) and two fish species: Nile perch (Lates niloticus) and Nile tilapia (Oreochromis niloticus). The samples were collected from the Napoleon Gulf on the northern shore of Lake Victoria. The analysis was done using a gas chromatograph (GC) coupled to a high resolution mass spectrometer for PCBs and a GC equipped with an electron capture detector for HCHs. Total (Σ) PCBs in the muscles of fish varied widely with mean values ranging from 41 to 670 pg g(-1) lipid weight (lw). The PCB levels in L. niloticus were significantly greater than those in O. niloticus. The large variability observed in the data was attributed to differences in feeding habits and trophic levels. While O. niloticus is a filter-eating fish species feeding mainly on phytoplankton and zooplankton, L. niloticus have predatory feeding behaviors and prefer a diet of live fish and, therefore, are more prone to bio-accumulate contaminants. The mean PCB concentrations in the sediments varied from 362 to 848 pg g(-1) dry weight. Variations in PCB levels were observed from one study site to another, this was attributed to the nature and particle size of the sediments. HCH isomers were detected in fish at mean concentrations of up to 45,900 pg g(-1) lw. The PCB and HCH concentrations were lower than those from previous studies elsewhere in literature and were below the maximum residue limits set by the European Commission and FAO/WHO Codex Alimentarius Commission, implying that the fish was fit for human consumption.

Impacts of climate-induced changes on the distribution of pesticides residues in water and sediment of Lake Naivasha, Kenya

This study reports evidence of increased chlorpyrifos contamination in sediment and water in Lake Naivasha following its intensive application in the horticultural farms in the catchment area. Analytical results show that levels of chlorpyrifos residues were influenced by climate-induced rainfall pattern with higher levels reported during period of heavy precipitation with significant decrease during low rainfall. On average, the levels ranged between 14.8 and 32.8 ng g(-1) in sediment during rainy season compared to a range of 8.5-16.6 ng g(-1) in the dry season. Additionally, the mean concentration of chlorpyrifos in water ranged between 8.61 and 22.4 μg L(-1) during rainy season and below detection limit (bdl) -13.6 μg L(-1) in dry season as quantified by enzyme-linked immunosorbent assay. Meanwhile, independent t test analysis indicated that there was significant difference in concentration at p ≤ 0.05 between the seasons with respect to sediment and water samples. This demonstrated that climate-induced variations had considerable influence on contamination. While diazinon and carbofuran were equally applied intensively, their levels were below the detection limit in the all the samples analyzed. ELISA results were validated by the capillary-HPLC photodiode-array detector instrument analysis, and statistical comparison showed no significant difference between them. It was evident that chlorpyrifos residues determination in water and sediment by ELISA can be a useful strategy in environmental management and monitoring program, and a complimentary analytical tool to high performance liquid chromatography. Levels of chlorpyrifos detected in sediment and water were found to exceed recommended criteria for protection of aquatic life and preservation of water quality and may be hazardous if not regularly monitored.

Spatial distribution and temporal trend in concentration of carbofuran, diazinon and chlorpyrifos ethyl residues in sediment and water in Lake Naivasha, Kenya

Chlorpyrifos ethyl was found to be widely distributed in water and sediment in Lake Naivasha. Higher levels were reported in sediment (11.2-30.0 ng g(-1) dry weight (dw) in wet season than in dry season (4.7-17.4 ng g(-1) dw). The mean concentration of chlorpyrifos ethyl in water in wet season ranged between 8.8 and 26.6 μg L(-1) and decreased to between below detection limit to 14.0 μg L(-1) in dry season. On average, higher concentrations of chlorpyrifos ethyl were observed in sediment than water samples. Statistical analysis revealed a significant difference in concentration between the seasons, and a significant interaction between seasons and mean concentrations at p ≤ 0.05. However, levels of diazinon and carbofuran were below the detection limit in all the samples analyzed. Notably, levels of chlorpyrifos ethyl were higher than the maximum allowable limits (0.1 μg L(-1)) recommended by European Union for drinking water and general water quality criterion for protection of freshwater water organisms (0.083 μg L(-1)).

Carbofuran and its toxic metabolites provide forensic evidence for furadan exposure in vultures (Gyps africanus) in Kenya

Forensic analysis of carbofuran residues in weathered tissue samples for evidence of Furadan exposure in vultures (Gps africanus) by HPLC gave concentration (mg/Kg dry tissue weight) ranges of bdl - 0.07 (carbofuran), bdl - 0.499 (3-ketocarbofuran) and 0.013-0.147 (3-hydroxycarbofuran) in beaks, bdl-0.65 (carbofuran), 0.024-0.190 (3-ketocarbofuran) and 0.017-0.098 (3-hydroxycarbofuran) in feet, 0.179-0.219 (3-ketocarbofuran) and 0.081-0.093 (3-hydroxycarbofuran) in crop content, 0.078-0.082 (3-ketocarbofuran) and 0.091-0.101 (3-hydroxycarbofuran) in muscle of a laced carcass and 0.006-0.014 (carbofuran), 0.590-1.010 (3-ketocarbofuran) and 0.095-0.135 (3-hydroxycarbofuran) in soil sampled from a poisoning site. These compounds were confirmed by GC-MS. The results showed that HPLC combined with GC-MS is suitable for forensic analysis of carbofuran residues in bird tissue samples and that forensic investigation should include its two toxic metabolites, 3-hydroxycarbofuran and 3-ketocarbofuran.

Soil and water contamination with carbofuran residues in agricultural farmlands in Kenya following the application of the technical formulation Furadan

This study was undertaken to determine the concentrations of carbofuran residues in water, soil and plant samples from selected sites in the farmlands in Kenya and to demonstrate the impact of Furadan use on the local environment. Soil, water and plant samples obtained from agricultural farmlands where the technical formulation Furadan has been used extensively showed high environmental contamination with concentrations of carbofuran and its two toxic metabolites 3-hydroxycarbofuran and 3-ketocarbofuran, separately, ranging from 0.010-1.009 mg/kg of dry surface soil, 0.005-0.495 mg/L in water samples from two rivers flowing through the farms and bdl-2.301 mg/L in water samples from ponds and dams located close to the farms. Maize plant samples contained these residues in concentrations ranging from 0.04-1.328 mg/kg of dry plant tissue. The significantly high concentration levels of carbofuran and its metabolites, 3-ketocarbofuran and 3-hydroxycarbofuran, found in various matrices demonstrate that Furadan was used extensively in the two areas and that there was environmental distribution and exposure of residues in water which posed risks when used for domestic purposes or as drinking water for animals in two wildlife conservancies where the dams and ponds are located. Surface soil contamination was also high and posed risks through run-off into the dams and rivers as well as through secondary exposure to small birds and mammals.

Risk factor profile and the occurrence of microvascular complications in short-term type 2 diabetes mellitus at Kenyatta National Hospital, Nairobi

BACKGROUND

Type 2 diabetes has a long pre-clinical period before diagnosis, during which there may be development of complications, both of microvascular and macrovascular types.

OBJECTIVE

To determine the risk factor profile of hyperglycaemia, hypertension and dyslipidaemia in patients with short-term (=/ < 2 years) type 2 diabetes.

DESIGN

Cross-sectional descriptive study over six months.

SETTING

Outpatient diabetic clinic of Kenyatta National Hospital.

SUBJECTS

Ambulatory patients with type 2 diabetes.

RESULTS

One hundred patients were included. The mean (SD) duration of diabetes was 10.3 (7.5) months. There were 66% of the study subjects with obesity, 50% with hypertension, 29% had ideal glucose control and less than 40% had high LDL-cholesterol. Twenty eight (28%) who had polyneuropathy had significant differences in their older age, higher total and LDL-cholesterol compared with those who did not have polyneuropathy. Twenty five (25%) of the study patients had micro-albuminuria and only 1% had macro-albuminuria. There were no significant differences in the selected characteristics between study patients with and those without albuminuria. Only 7% of the study patients had retinopathy on direct ophthalmoscopy.

CONCLUSION

Microvascular complications occurred in patients with type 2 diabetes of short duration of not more than two years. The risk factors of hypertension, poor glycaemic control, dyslipidaemia and cigarette smoking were present in a fair proportion of the study patients. Patients with type 2 diabetes should be actively screened for complications and the risk factors thereof, even if the diabetes was of recent onset.

Household based treatment of drinking water with flocculant-disinfectant for preventing diarrhoea in areas with turbid source water in rural western Kenya: cluster randomised controlled trial

OBJECTIVE

To compare the effect on prevalence of diarrhoea and mortality of household based treatment of drinking water with flocculant-disinfectant, sodium hypochlorite, and standard practices in areas with turbid water source in Africa.

DESIGN

Cluster randomised controlled trial over 20 weeks.

SETTING

Family compounds, each containing several houses, in rural western Kenya.

PARTICIPANTS

6650 people in 605 family compounds.

INTERVENTION

Water treatment: flocculant-disinfectant, sodium hypochlorite, and usual practice (control).

MAIN OUTCOME MEASURES

Prevalence of diarrhoea and all cause mortality. Escherichia coli concentration, free residual chlorine concentration, and turbidity in household drinking water as surrogates for effectiveness of water treatment.

RESULTS

In children < 2 years old, compared with those in the control compounds, the absolute difference in prevalence of diarrhoea was -25% in the flocculant-disinfectant arm (95% confidence interval -40 to -5) and -17% in the sodium hypochlorite arm (-34 to 4). In all age groups compared with control, the absolute difference in prevalence was -19% in the flocculant-disinfectant arm (-34 to -2) and -26% in the sodium hypochlorite arm (-39 to -9). There were significantly fewer deaths in the intervention compounds than in the control compounds (relative risk of death 0.58, P = 0.036). Fourteen per cent of water samples from control compounds had E coli concentrations < 1 CFU/100 ml compared with 82% in flocculant-disinfectant and 78% in sodium hypochlorite compounds. The mean turbidity of drinking water was 8 nephelometric turbidity units (NTU) in flocculant-disinfectant households, compared with 55 NTU in the two other compounds (P < 0.001).

CONCLUSIONS

In areas of turbid water, flocculant-disinfectant was associated with a significant reduction in diarrhoea among children < 2 years. This health benefit, combined with a significant reduction in turbidity, suggests that the flocculant-disinfectant is well suited to areas with highly contaminated and turbid water.

Household based treatment of drinking water with flocculant-disinfectant for preventing diarrhoea in areas with turbid source water in rural western Kenya: cluster randomised controlled trial

OBJECTIVE

To compare the effect on prevalence of diarrhoea and mortality of household based treatment of drinking water with flocculant-disinfectant, sodium hypochlorite, and standard practices in areas with turbid water source in Africa.

DESIGN

Cluster randomised controlled trial over 20 weeks.

SETTING

Family compounds, each containing several houses, in rural western Kenya.

PARTICIPANTS

6650 people in 605 family compounds.

INTERVENTION

Water treatment: flocculant-disinfectant, sodium hypochlorite, and usual practice (control).

MAIN OUTCOME MEASURES

Prevalence of diarrhoea and all cause mortality. Escherichia coli concentration, free residual chlorine concentration, and turbidity in household drinking water as surrogates for effectiveness of water treatment.

RESULTS

In children < 2 years old, compared with those in the control compounds, the absolute difference in prevalence of diarrhoea was -25% in the flocculant-disinfectant arm (95% confidence interval -40 to -5) and -17% in the sodium hypochlorite arm (-34 to 4). In all age groups compared with control, the absolute difference in prevalence was -19% in the flocculant-disinfectant arm (-34 to -2) and -26% in the sodium hypochlorite arm (-39 to -9). There were significantly fewer deaths in the intervention compounds than in the control compounds (relative risk of death 0.58, P = 0.036). Fourteen per cent of water samples from control compounds had E coli concentrations < 1 CFU/100 ml compared with 82% in flocculant-disinfectant and 78% in sodium hypochlorite compounds. The mean turbidity of drinking water was 8 nephelometric turbidity units (NTU) in flocculant-disinfectant households, compared with 55 NTU in the two other compounds (P < 0.001).

CONCLUSIONS

In areas of turbid water, flocculant-disinfectant was associated with a significant reduction in diarrhoea among children < 2 years. This health benefit, combined with a significant reduction in turbidity, suggests that the flocculant-disinfectant is well suited to areas with highly contaminated and turbid water.