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Tesfaye B, Sowe A, Kisangau N, Ogange J, Ntoburi S, Nekar I, Muitherero C, Camara Y, Gathenji C, Langat D, Sergon K, Limo H, Nzunza R, Kiptoon S, Kareko D, Onuekwusi I. An epidemiological analysis of Acute Flaccid Paralysis (AFP) surveillance in Kenya, 2016 to 2018. BMC Infect Dis 2020; 20:611. [PMID: 32811467 PMCID: PMC7437168 DOI: 10.1186/s12879-020-05319-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 08/03/2020] [Indexed: 12/02/2022] Open
Abstract
Background The poliovirus has been targeted for eradication since 1988. Kenya reported its last case of indigenous Wild Poliovirus (WPV) in 1984 but suffered from an outbreak of circulating Vaccine-derived Poliovirus type 2 (cVDPV2) in 2018. We aimed to describe Kenya’s polio surveillance performance 2016–2018 using WHO recommended polio surveillance standards. Methods Retrospective secondary data analysis was conducted using Kenyan AFP surveillance case-based database from 2016 to 2018. Analyses were carried out using Epi-Info statistical software (version 7) and mapping was done using Quantum Geographic Information System (GIS) (version 3.4.1). Results Kenya reported 1706 cases of AFP from 2016 to 2018. None of the cases were confirmed as poliomyelitis. However, 23 (1.35%) were classified as polio compatible. Children under 5 years accounted for 1085 (63.6%) cases, 937 (55.0%) cases were boys, and 1503 (88.1%) cases had received three or more doses of Oral Polio Vaccine (OPV). AFP detection rate substantially increased over the years; however, the prolonged health workers strike in 2017 negatively affected key surveillance activities. The mean Non-Polio (NP-AFP) rate during the study period was 2.87/ 100,000 children under 15 years, and two adequate specimens were collected for 1512 (88.6%) AFP cases. Cumulatively, 31 (66.0%) counties surpassed target for both WHO recommended AFP quality indicators. Conclusions The performance of Kenya’s AFP surveillance system surpassed the minimum WHO recommended targets for both non-polio AFP rate and stool adequacy during the period studied. In order to strengthen the country’s polio free status, health worker’s awareness on AFP surveillance and active case search should be strengthened in least performing counties to improve case detection. Similar analyses should be done at the sub-county level to uncover underperformance that might have been hidden by county level analysis.
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Affiliation(s)
- Brook Tesfaye
- World Health Organization, Kenya Country Office, United Nations Office in Nairobi (UNON), Gigiri Complex, Block U, Nairobi, Kenya.
| | - Alieu Sowe
- World Health Organization, Kenya Country Office, United Nations Office in Nairobi (UNON), Gigiri Complex, Block U, Nairobi, Kenya
| | - Ngina Kisangau
- World Health Organization, Kenya Country Office, United Nations Office in Nairobi (UNON), Gigiri Complex, Block U, Nairobi, Kenya
| | - John Ogange
- World Health Organization, Kenya Country Office, United Nations Office in Nairobi (UNON), Gigiri Complex, Block U, Nairobi, Kenya
| | - Stephen Ntoburi
- World Health Organization, Kenya Country Office, United Nations Office in Nairobi (UNON), Gigiri Complex, Block U, Nairobi, Kenya
| | - Irene Nekar
- Polio Surge Consultant, African Field Epidemiology Network, Nairobi, Kenya
| | - Charles Muitherero
- World Health Organization, Kenya Country Office, United Nations Office in Nairobi (UNON), Gigiri Complex, Block U, Nairobi, Kenya
| | - Yaya Camara
- World Health Organization, Kenya Country Office, United Nations Office in Nairobi (UNON), Gigiri Complex, Block U, Nairobi, Kenya
| | - Carolyne Gathenji
- Horn of Africa Polio Eradication Coordination Office, Nairobi, Kenya
| | - Daniel Langat
- Division of Disease Surveillance and Response, Ministry of Health, Nairobi, Kenya
| | - Kibet Sergon
- World Health Organization, Kenya Country Office, United Nations Office in Nairobi (UNON), Gigiri Complex, Block U, Nairobi, Kenya
| | - Hilary Limo
- Division of Disease Surveillance and Response, Ministry of Health, Nairobi, Kenya
| | - Rosemary Nzunza
- Kenya Medical Research Institute, Center for Virus Research, Ministry of Health, Nairobi, Kenya
| | - Shem Kiptoon
- World Health Organization, Kenya Country Office, United Nations Office in Nairobi (UNON), Gigiri Complex, Block U, Nairobi, Kenya
| | - David Kareko
- Division of Disease Surveillance and Response, Ministry of Health, Nairobi, Kenya
| | - Iheoma Onuekwusi
- World Health Organization, Kenya Country Office, United Nations Office in Nairobi (UNON), Gigiri Complex, Block U, Nairobi, Kenya
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Muinga N, Ayieko P, Opondo C, Ntoburi S, Todd J, Allen E, English M. Using health worker opinions to assess changes in structural components of quality in a Cluster Randomized Trial. BMC Health Serv Res 2014; 14:282. [PMID: 24974166 PMCID: PMC4082497 DOI: 10.1186/1472-6963-14-282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 06/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The 'resource readiness' of health facilities to provide effective services is captured in the structure component of the classical Donabedian paradigm often used for assessment of the quality of care in the health sector. Periodic inventories are commonly used to confirm the presence (or absence) of equipment or drugs by physical observation or by asking those in charge to indicate whether an item is present or not. It is then assumed that this point observation is representative of the everyday status. However the availability of an item (consumables) may vary. Arguably therefore a more useful assessment for resources would be one that captures this fluctuation in time. Here we report an approach that may circumvent these difficulties. METHODS We used self-administered questionnaires (SAQ) to seek health worker views of availability of key resources supporting paediatric care linked to a cluster randomized trial of a multifaceted intervention aimed at improving this care conducted in eight rural Kenyan district hospitals. Four hospitals received a full intervention and four a partial intervention. Data were collected pre-intervention and after 6 and 18 months from health workers in three clinical areas asked to score item availability using an 11-point scale. Mean scores for items common to all 3 areas and mean scores for items allocated to domains identified using exploratory factor analysis (EFA) were used to describe availability and explore changes over time. RESULTS SAQ were collected from 1,156 health workers. EFA identified 11 item domains across the three departments. Mean availability scores for these domains were often <5/10 at baseline reflecting lack of basic resources such as oxygen, nutrition and second line drugs. An improvement in mean scores occurred in 8 out of 11 domains in both control and intervention groups. A calculation of difference in difference of means for intervention vs. control suggested an intervention effect resulting in greater changes in 5 out of 11 domains. CONCLUSION Using SAQ data to assess resource availability experienced by health workers provides an alternative to direct observations that provide point prevalence estimates. Further the approach was able to demonstrate poor access to resources, change over time and variability across place.
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Affiliation(s)
- Naomi Muinga
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya.
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Opondo C, Ayieko P, Ntoburi S, Wagai J, Opiyo N, Irimu G, Allen E, Carpenter J, English M. Effect of a multi-faceted quality improvement intervention on inappropriate antibiotic use in children with non-bloody diarrhoea admitted to district hospitals in Kenya. BMC Pediatr 2011; 11:109. [PMID: 22117602 PMCID: PMC3314405 DOI: 10.1186/1471-2431-11-109] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 11/25/2011] [Indexed: 11/23/2022] Open
Abstract
Background There are few reports of interventions to reduce the common but irrational use of antibiotics for acute non-bloody diarrhoea amongst hospitalised children in low-income settings. We undertook a secondary analysis of data from an intervention comprising training of health workers, facilitation, supervision and face-to-face feedback, to assess whether it reduced inappropriate use of antibiotics in children with non-bloody diarrhoea and no co-morbidities requiring antibiotics, compared to a partial intervention comprising didactic training and written feedback only. This outcome was not a pre-specified end-point of the main trial. Methods Repeated cross-sectional survey data from a cluster-randomised controlled trial of an intervention to improve management of common childhood illnesses in Kenya were used to describe the prevalence of inappropriate antibiotic use in a 7-day period in children aged 2-59 months with acute non-bloody diarrhoea. Logistic regression models with random effects for hospital were then used to identify patient and clinician level factors associated with inappropriate antibiotic use and to assess the effect of the intervention. Results 9, 459 admission records of children were reviewed for this outcome. Of these, 4, 232 (44.7%) were diagnosed with diarrhoea, with 130 of these being bloody (dysentery) therefore requiring antibiotics. 1, 160 children had non-bloody diarrhoea and no co-morbidities requiring antibiotics-these were the focus of the analysis. 750 (64.7%) of them received antibiotics inappropriately, 313 of these being in the intervention hospitals vs. 437 in the controls. The adjusted logistic regression model showed the baseline-adjusted odds of inappropriate antibiotic prescription to children admitted to the intervention hospitals was 0.30 times that in the control hospitals (95%CI 0.09-1.02). Conclusion We found some evidence that the multi-faceted, sustained intervention described in this paper led to a reduction in the inappropriate use of antibiotics in treating children with non-bloody diarrhoea. Trial registration International Standard Randomised Controlled Trial Number Register ISRCTN42996612
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Affiliation(s)
- Charles Opondo
- Child and Newborn Health Group, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
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Gathara D, Opiyo N, Wagai J, Ntoburi S, Ayieko P, Opondo C, Wamae A, Migiro S, Mogoa W, Wasunna A, Were F, Irimu G, English M. Quality of hospital care for sick newborns and severely malnourished children in Kenya: a two-year descriptive study in 8 hospitals. BMC Health Serv Res 2011; 11:307. [PMID: 22078071 PMCID: PMC3236590 DOI: 10.1186/1472-6963-11-307] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 11/11/2011] [Indexed: 11/24/2022] Open
Abstract
Background Given the high mortality associated with neonatal illnesses and severe malnutrition and the development of packages of interventions that provide similar challenges for service delivery mechanisms we set out to explore how well such services are provided in Kenya. Methods As a sub-component of a larger study we evaluated care during surveys conducted in 8 rural district hospitals using convenience samples of case records. After baseline hospitals received either a full multifaceted intervention (intervention hospitals) or a partial intervention (control hospitals) aimed largely at improving inpatient paediatric care for malaria, pneumonia and diarrhea/dehydration. Additional data were collected to: i) examine the availability of routine information at baseline and their value for morbidity, mortality and quality of care reporting, and ii) compare the care received against national guidelines disseminated to all hospitals. Results Clinical documentation for neonatal and malnutrition admissions was often very poor at baseline with case records often entirely missing. Introducing a standard newborn admission record (NAR) form was associated with an increase in median assessment (IQR) score to 25/28 (22-27) from 2/28 (1-4) at baseline. Inadequate and incorrect prescribing of penicillin and gentamicin were common at baseline. For newborns considerable improvements in prescribing in the post baseline period were seen for penicillin but potentially serious errors persisted when prescribing gentamicin, particularly to low-birth weight newborns in the first week of life. Prescribing essential feeds appeared almost universally inadequate at baseline and showed limited improvement after guideline dissemination. Conclusion Routine records are inadequate to assess newborn care and thus for monitoring newborn survival interventions. Quality of documented inpatient care for neonates and severely malnourished children is poor with limited improvement after the dissemination of clinical practice guidelines. Further research evaluating approaches to improving care for these vulnerable groups is urgently needed. We also suggest pre-service training curricula should be better aligned to help improve newborn survival particularly.
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Affiliation(s)
- David Gathara
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya.
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Ayieko P, Ntoburi S, Wagai J, Opondo C, Opiyo N, Migiro S, Wamae A, Mogoa W, Were F, Wasunna A, Fegan G, Irimu G, English M. A multifaceted intervention to implement guidelines and improve admission paediatric care in Kenyan district hospitals: a cluster randomised trial. PLoS Med 2011; 8:e1001018. [PMID: 21483712 PMCID: PMC3071366 DOI: 10.1371/journal.pmed.1001018] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 03/01/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In developing countries referral of severely ill children from primary care to district hospitals is common, but hospital care is often of poor quality. However, strategies to change multiple paediatric care practices in rural hospitals have rarely been evaluated. METHODS AND FINDINGS This cluster randomized trial was conducted in eight rural Kenyan district hospitals, four of which were randomly assigned to a full intervention aimed at improving quality of clinical care (evidence-based guidelines, training, job aides, local facilitation, supervision, and face-to-face feedback; n = 4) and the remaining four to control intervention (guidelines, didactic training, job aides, and written feedback; n = 4). Prespecified structure, process, and outcome indicators were measured at baseline and during three and five 6-monthly surveys in control and intervention hospitals, respectively. Primary outcomes were process of care measures, assessed at 18 months postbaseline. In both groups performance improved from baseline. Completion of admission assessment tasks was higher in intervention sites at 18 months (mean = 0.94 versus 0.65, adjusted difference 0.54 [95% confidence interval 0.05-0.29]). Uptake of guideline recommended therapeutic practices was also higher within intervention hospitals: adoption of once daily gentamicin (89.2% versus 74.4%; 17.1% [8.04%-26.1%]); loading dose quinine (91.9% versus 66.7%, 26.3% [-3.66% to 56.3%]); and adequate prescriptions of intravenous fluids for severe dehydration (67.2% versus 40.6%; 29.9% [10.9%-48.9%]). The proportion of children receiving inappropriate doses of drugs in intervention hospitals was lower (quinine dose >40 mg/kg/day; 1.0% versus 7.5%; -6.5% [-12.9% to 0.20%]), and inadequate gentamicin dose (2.2% versus 9.0%; -6.8% [-11.9% to -1.6%]). CONCLUSIONS Specific efforts are needed to improve hospital care in developing countries. A full, multifaceted intervention was associated with greater changes in practice spanning multiple, high mortality conditions in rural Kenyan hospitals than a partial intervention, providing one model for bridging the evidence to practice gap and improving admission care in similar settings.
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Affiliation(s)
- Philip Ayieko
- KEMRI-Wellcome Trust Research Programme,
Nairobi, Kenya
| | | | - John Wagai
- KEMRI-Wellcome Trust Research Programme,
Nairobi, Kenya
| | | | - Newton Opiyo
- KEMRI-Wellcome Trust Research Programme,
Nairobi, Kenya
| | - Santau Migiro
- Division of Child Health, Ministry of Public
Health and Sanitation, Nairobi, Kenya
| | - Annah Wamae
- Division of Child Health, Ministry of Public
Health and Sanitation, Nairobi, Kenya
| | | | - Fred Were
- Department of Paediatrics and Child Health,
University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Aggrey Wasunna
- Department of Paediatrics and Child Health,
University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Greg Fegan
- KEMRI-Wellcome Trust Research Programme,
Nairobi, Kenya
- Infectious Disease Epidemiology Unit,
Department of Epidemiology and Population Health, London School of Hygiene and
Tropical Medicine, London, United Kingdom
| | - Grace Irimu
- KEMRI-Wellcome Trust Research Programme,
Nairobi, Kenya
- Department of Paediatrics and Child Health,
University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | - Mike English
- KEMRI-Wellcome Trust Research Programme,
Nairobi, Kenya
- Department of Paediatrics, University of
Oxford and John Radcliffe Hospital, Headington, Oxford, United
Kingdom
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Ntoburi S, Hutchings A, Sanderson C, Carpenter J, Weber M, English M. Development of paediatric quality of inpatient care indicators for low-income countries - A Delphi study. BMC Pediatr 2010; 10:90. [PMID: 21144065 PMCID: PMC3022793 DOI: 10.1186/1471-2431-10-90] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 12/14/2010] [Indexed: 11/16/2022] Open
Abstract
Background Indicators of quality of care for children in hospitals in low-income countries have been proposed, but information on their perceived validity and acceptability is lacking. Methods Potential indicators representing structural and process aspects of care for six common conditions were selected from existing, largely qualitative WHO assessment tools and guidelines. We employed the Delphi technique, which combines expert opinion and existing scientific information, to assess their perceived validity and acceptability. Panels of experts, one representing an international panel and one a national (Kenyan) panel, were asked to rate the indicators over 3 rounds and 2 rounds respectively according to a variety of attributes. Results Based on a pre-specified consensus criteria most of the indicators presented to the experts were accepted: 112/137(82%) and 94/133(71%) for the international and local panels respectively. For the other indicators there was no consensus; none were rejected. Most indicators were rated highly on link to outcomes, reliability, relevance, actionability and priority but rated more poorly on feasibility of data collection under routine conditions. There was moderate to substantial agreement between the two panels of experts. Conclusions This Delphi study provided evidence for the perceived usefulness of most of a set of measures of quality of hospital care for children proposed for use in low-income countries. However, both international and local experts expressed concerns that data for many process-based indicators may not currently be available. The feasibility of widespread quality assessment and responsiveness of indicators to intervention should be examined as part of continued efforts to improve approaches to informative hospital quality assessment.
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Affiliation(s)
- Stephen Ntoburi
- Kenya Medical Research Institute/Wellcome Trust Centre for Geographic Medicine Research, Kilifi, Kenya.
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Opondo C, Ntoburi S, Wagai J, Wafula J, Wasunna A, Were F, Wamae A, Migiro S, Irimu G, English M. Are hospitals prepared to support newborn survival? - An evaluation of eight first-referral level hospitals in Kenya. Trop Med Int Health 2009; 14:1165-72. [PMID: 19695001 PMCID: PMC2751740 DOI: 10.1111/j.1365-3156.2009.02358.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective To assess the availability of resources that support the provision of basic neonatal care in eight first-referral level (district) hospitals in Kenya. Methods We selected two hospitals each from four of Kenya’s eight provinces with the aim of representing the diversity of this part of the health system in Kenya. We created a checklist of 53 indicator items necessary for providing essential basic care to newborns and assessed their availability at each of the eight hospitals by direct observation, and then compared our observations with the opinions of health workers providing care to newborns on recent availability for some items, using a self-administered structured questionnaire. Results The hospitals surveyed were often unable to maintain a safe hygienic environment for patients and health care workers; staffing was insufficient and sometimes poorly organised to support the provision of care; some key equipment, laboratory tests, drugs and consumables were not available while patient management guidelines were missing in all sites. Conclusion Hospitals appear relatively poorly prepared to fill their proposed role in ensuring newborn survival. More effective interventions are needed to improve them to meet the special needs of this at-risk group.
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Affiliation(s)
- Charles Opondo
- KEMRI Centre for Geographic Medicine Research - Coast, and Wellcome Trust Research Programme, Nairobi, Kenya.
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English M, Ntoburi S, Wagai J, Mbindyo P, Opiyo N, Ayieko P, Opondo C, Migiro S, Wamae A, Irimu G. An intervention to improve paediatric and newborn care in Kenyan district hospitals: understanding the context. Implement Sci 2009; 4:42. [PMID: 19627588 PMCID: PMC2724481 DOI: 10.1186/1748-5908-4-42] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 07/23/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is increasingly appreciated that the interpretation of health systems research studies is greatly facilitated by detailed descriptions of study context and the process of intervention. We have undertaken an 18-month hospital-based intervention study in Kenya aiming to improve care for admitted children and newborn infants. Here we describe the baseline characteristics of the eight hospitals as environments receiving the intervention, as well as the general and local health system context and its evolution over the 18 months. METHODS Hospital characteristics were assessed using previously developed tools assessing the broad structure, process, and outcome of health service provision for children and newborns. Major health system or policy developments over the period of the intervention at a national level were documented prospectively by monitoring government policy announcements, the media, and through informal contacts with policy makers. At the hospital level, a structured, open questionnaire was used in face-to-face meetings with senior hospital staff every six months to identify major local developments that might influence implementation. These data provide an essential background for those seeking to understand the generalisability of reports describing the intervention's effects, and whether the intervention plausibly resulted in these effects. RESULTS Hospitals had only modest capacity, in terms of infrastructure, equipment, supplies, and human resources available to provide high-quality care at baseline. For example, hospitals were lacking between 30 to 56% of items considered necessary for the provision of care to the seriously ill child or newborn. An increase in spending on hospital renovations, attempts to introduce performance contracts for health workers, and post-election violence were recorded as examples of national level factors that might influence implementation success generally. Examples of factors that might influence success locally included frequent and sometimes numerous staff changes, movements of senior departmental or administrative staff, and the presence of local 'donor' partners with alternative priorities. CONCLUSION The effectiveness of interventions delivered at hospital level over periods realistically required to achieve change may be influenced by a wide variety of factors at national and local levels. We have demonstrated how dynamic such contexts are, and therefore the need to consider context when interpreting an intervention's effectiveness.
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Affiliation(s)
- Mike English
- KEMRI Centre for Geographic Medicine Research - Coast, & Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya.
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Nzinga J, Ntoburi S, Wagai J, Mbindyo P, Mbaabu L, Migiro S, Wamae A, Irimu G, English M. Implementation experience during an eighteen month intervention to improve paediatric and newborn care in Kenyan district hospitals. Implement Sci 2009; 4:45. [PMID: 19627594 PMCID: PMC2724482 DOI: 10.1186/1748-5908-4-45] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 07/23/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We have conducted an intervention study aiming to improve hospital care for children and newborns in Kenya. In judging whether an intervention achieves its aims, an understanding of how it is delivered is essential. Here, we describe how the implementation team delivered the intervention over 18 months and provide some insight into how health workers, the primary targets of the intervention, received it. METHODS We used two approaches. First, a description of the intervention is based on an analysis of records of training, supervisory and feedback visits to hospitals, and brief logs of key topics discussed during telephone calls with local hospital facilitators. Record keeping was established at the start of the study for this purpose with analyses conducted at the end of the intervention period. Second, we planned a qualitative study nested within the intervention project and used in-depth interviews and small group discussions to explore health worker and facilitators' perceptions of implementation. After thematic analysis of all interview data, findings were presented, discussed, and revised with the help of hospital facilitators. RESULTS Four hospitals received the full intervention including guidelines, training and two to three monthly support supervision and six monthly performance feedback visits. Supervisor visits, as well as providing an opportunity for interaction with administrators, health workers, and facilitators, were often used for impromptu, limited refresher training or orientation of new staff. The personal links that evolved with senior staff seemed to encourage local commitment to the aims of the intervention. Feedback seemed best provided as open meetings and discussions with administrators and staff. Supervision, although sometimes perceived as fault finding, helped local facilitators become the focal point of much activity including key roles in liaison, local monitoring and feedback, problem solving, and orientation of new staff to guidelines. In four control hospitals receiving a minimal intervention, local supervision and leadership to implement new guidelines, despite their official introduction, were largely absent. CONCLUSION The actual content of an intervention and how it is implemented and received may be critical determinants of whether it achieves its aims. We have carefully described our intervention approach to facilitate appraisal of the quantitative results of the intervention's effect on quality of care. Our findings suggest ongoing training, external supportive supervision, open feedback, and local facilitation may be valuable additions to more typical in-service training approaches, and may be feasible.
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Affiliation(s)
- Jacinta Nzinga
- KEMRI Centre for Geographic Medicine Research - Coast, and Wellcome Trust Research Programme, P.O. Box 43640, Nairobi, Kenya.
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Irimu G, Wamae A, Wasunna A, Were F, Ntoburi S, Opiyo N, Ayieko P, Peshu N, English M. Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya. Arch Dis Child 2008; 93:799-804. [PMID: 18719161 PMCID: PMC2654066 DOI: 10.1136/adc.2007.126508] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The under-5 mortality rate in most developing countries remains high yet many deaths could be averted if available knowledge was put into practice. For seriously ill children in hospital investigations in low-income countries commonly demonstrate incorrect diagnosis and treatment and frequent prescribing errors. To help improve hospital management of the major causes of inpatient childhood mortality we developed simple clinical guidelines for use in Kenya, a low-income setting. The participatory process we used to adapt existing WHO materials and further develop and build support for such guidelines is discussed. To facilitate use of the guidelines we also developed job-aides and a 5.5 days training programme for their dissemination and implementation. We attempted to base our training on modern theories around adult learning and deliberately attempted to train a ‘critical mass’ of health workers within each institution at low cost. Our experience suggests that with sustained effort it is possible to develop locally owned, appropriate clinical practice guidelines for emergency and initial hospital care for seriously ill children with involvement of pertinent stake holders throughout. Early experience suggests that the training developed to support the guidelines, despite the fact that it challenges many established practices, is well received, appropriate to the needs of front line health workers in Kenya and feasible. To our knowledge the process described in Kenya is among a handful of attempts globally to implement inpatient or referral care components of WHO / UNICEF’s Integrated Management of Childhood Illness approach. However, whether guideline dissemination and implementation result in improved quality of care in our environment remains to be seen.
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Affiliation(s)
- Grace Irimu
- Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, Republic of Kenya.
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Ntoburi S, Wagai J, Irimu G, English M. Debating the quality and performance of health systems at a global level is not enough, national debates are essential for progress. Trop Med Int Health 2008; 13:444-7. [PMID: 18346030 PMCID: PMC2592478 DOI: 10.1111/j.1365-3156.2008.02073.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Stephen Ntoburi
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobi, Kenya
| | - John Wagai
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobi, Kenya
| | - Grace Irimu
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobi, Kenya
- Department of Paediatrics and Child Health, University of NairobiNairobi, Kenya
| | - Mike English
- Kenya Medical Research Institute/Wellcome Trust Research ProgrammeNairobi, Kenya
- Department of Paediatrics, University of OxfordOxford, UK
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