Knowledge, attitudes, and perceptions of Kenyan healthcare workers regarding pediatric discharge from hospital

Objective
To assess attitudes, perceptions, and practices of healthcare workers regarding hospital discharge and follow-up care for children under age five in Migori and Homa Bay, Kenya.

Methods
This mixed-methods study included surveys and semi-structured telephone interviews with healthcare workers delivering inpatient pediatric care at eight hospitals between November 2017 and December 2018.

Results
The survey was completed by 111 (85%) eligible HCWs. Ninety-seven of the surveyed HCWs were invited for interviews and 39 (40%) participated. Discharge tasks were reported to be “very important” to patient outcomes by over 80% of respondents, but only 37 (33%) perceived their hospital to deliver this care “very well” and 23 (21%) believed their facility provides sufficient resources for its provision. The vast majority (97%) of participants underestimated the risk of pediatric post-discharge mortality. Inadequate training, understaffing, stock-outs of take-home therapeutics, and user fees were commonly reported health systems barriers to adequate discharge care while poverty was seen as limiting caregiver adherence to discharge and follow-up care. Respondents endorsed the importance of follow-up care, but reported supportive mechanisms to be lacking. They requested enhanced guidelines on discharge and follow-up care.

Conclusion
Kenyan healthcare workers substantially underestimated the risk of pediatric post-discharge mortality. Pre- and in-service training should incorporate instruction on discharge and follow-up care. Improved post-discharge deaths tracking–e.g., through vital registry systems, child mortality surveillance studies, and community health worker feedback loops–is needed, alongside dissemination which could leverage platforms such as routine hospital-based mortality reports. Finally, further interventional trials are needed to assess the efficacy and cost-effectiveness of novel packages to improve discharge and follow-up care.

Exploring women’s childbirth experiences and perceptions of delivery care in peri-urban settings in Nairobi, Kenya

Kenya continues to have a high maternal mortality rate that is showing slow progress in improving. Peri-urban settings in Kenya have been reported to exhibit higher rates of maternal death during labor and childbirth as compared to the general Kenyan population. Although research indicates that women in Kenya have increased access to facility-based birth in recent years, a small percentage still give birth outside of the health facility due to access challenges and poor maternal health service quality. Most studies assessing facility-based births have focused on the sociodemographic determinants of birthing location. Few studies have assessed women’s user experiences and perceptions of quality of care during childbirth. Understanding women’s experiences can provide different stakeholders with strategies to structure the provision of maternity care to be person-centered and to contribute to improvements in women’s satisfaction with health services and maternal health outcomes.

Methods
A qualitative study was conducted, whereby 70 women from the peri-urban area of Embakasi in the East side of Nairobi City in Kenya were interviewed. Respondents were aged 18 to 49 years and had delivered in a health facility in the preceding six weeks. We conducted in-depth interviews with women who gave birth at both public and private health facilities. The interviews were recorded, transcribed, and translated for analysis. Braune and Clarke’s guidelines for thematic analysis were used to generate themes from the interview data.

Results
Four main themes emerged from the analysis. Women had positive experiences when care was person-centered—i.e. responsive, dignified, supportive, and with respectful communication. They had negative experiences when they were mistreated, which was manifested as non-responsive care (including poor reception and long wait times), non-dignified care (including verbal and physical abuse lack of privacy and confidentiality), lack of respectful communication, and lack of supportive care (including being denied companions, neglect and abandonment, and poor facility environment).

Conclusion
To sustain the gains in increased access to facility-based births, there is a need to improve person-centered care to ensure women have positive facility-based childbirth experiences.

Neurosurgery in Sub-Saharan Africa – Historical Background and Development of Training Programs in East Africa.

1 INTRODUCTION
Modern Neurosurgery in Sub-Saharan Africa (SSA) has its roots in the 1960s when Neurosurgeons from Europe set up Units in West Africa and East Africa. While it would be unfair to give credit to some individuals, and inadvertently not naming others, Prof Abdeslam El Khamlichi (1) in his book, “Emerging Neurosurgery in Africa,” quoting Professor Adelola Adeloye (2), provided a valuable account: A French Neurosurgeon, Dr. Courson, set up the first neurosurgical unit in West Africa in Senegal in 1967. He was joined by two other French neurosurgeons, Dr. Claude Cournil and Dr. Alliez, in 1972 and 1975. They trained the first Senegalese Neurosurgeon, Dr. Mamadou Gueye, who joined as a trainee in 1977. Dr. Gueye was to become the first Senegalese Professor and Chairman of the Neurosurgery Department.

2 | REGIONS BEGINS

In Ivory Coast, the first unit was set up by Dr. Claude Cournil in Abidjan in 1976, having left Dakar. He joined the first Ivorian Neurosurgeon, Dr. Kanga, who set up practice in 1974 in Abidjan. In Ghana, the first Neurosurgical Unit was set up by Ghanaian Neurosurgeon Dr. Osman Mustaffah in 1969. In Nigeria, the first units were set up by Nigerian Neurosurgeon Dr. Latunde Odeku started the service in Ibadan in 1962. He was joined by two other pioneer neurosurgeons, Dr. Adelola Adeloye in 1967 and Dr. Adebayo Ajayi Olumide in 1974. A second department was set up in Lagos by Dr. de Silva and Dr. Nosiru Ojikutu; in 1968, Dr. Samuel C. Ohaegbulam started the third service in Enugu in 1974 (2). In East Africa, Neurosurgical procedures had been carried out by Dr. Peter Clifford, an ENT surgeon, in 1955 (3).
In Kenya, modern Neurosurgery was introduced by Dr. Renato Ruberti, an Italian Neurosurgeon from Napoli, who set up Private practice in the European hospital in Nairobi in 1967 part-time at the King George V Hospital, which served as the National Hospital. He was joined in 1972 by Dr. Jawahar Dar, from New Delhi. The Indian Dr. Jawahar Dar set up the First Neurosurgery Unit at the King George V hospital, renamed Kenyatta National Hospital while teaching at the University of Nairobi. They were joined by Dr. Gerishom Sande, the first Kenyan Neurosurgeon following his training in Belfast, in 1979 (3).
In Uganda, on advice and recommendation of the renowned British Neurosurgeon, Professor Valentine Logue of the Hospital for Nervous Diseases, Queen Square, London, was invited by the government in 1968 to advise the establishment of neurosurgery at Mulago Hospital, Dr. Ian Bailey moved to Uganda. He was instrumental in establishing the first neurosurgical unit in Uganda at Mulago Hospital in 1969, equipped with 54 beds for the department of neurosurgery and cardiothoracic surgery (4). He was joined by the first Ugandan Neurosurgeon, Dr. Jovan Kiryabirwe, in 1971, who became the first indigenous Ugandan Neurosurgeon and the first African Neurosurgeon in East and Central Africa. He attended medical school at Makerere University School of Medicine in Kampala and subsequently completed postgraduate training at the Royal College of Surgeons in Ireland and Scotland; he also trained at Queens Square with Professor Logue (5).
In Tanzania, the first step towards modern neurosurgery was the establishment of orthopedic and trauma services in 1971 at the
Muhimbili Medical Center (MMC) by Professor Philemon Sarangi (6). At the time, orthopedic surgeons treated most of the cranial and spinal trauma. Over the next few years, several foreign neurosurgeons from Cuba, China, and the Soviet Union spent short stints practicing neurosurgery at MMC. Dr. Reulen, Professor and Chairman of Neurosurgery at University Hospital in Inselspital, Bern, Switzerland, and later in Munich, Germany, provided the impetus for the establishment of a neurosurgery program at MMC teaching in hospital of the University of Dar-es-Salaam and creating a “sandwich” program with training split between national and international centers. He trained Dr. Simpert Kinunda, a plastic surgeon who later became the first Tanzanian with any neurosurgical training.
Peter Kadyanji was the first fully trained Tanzanian neurosurgeon, and he joined MMC in 1985 after completing his training in the Soviet Union. Yadon M. Kohi followed in Kadyanji’s footsteps, graduating from Makerere University and the Faculty of Medicine at the University of Dar-es-Salaam. He obtained his FRCS in Ireland and Glasgow and later was appointed as the General Director of the National Commission for Science and Technology. Dr. Mlay was the third neurosurgeon to join MMC in 1989, with a specialty in pediatric neurosurgery. Professor Sarungi was essential to establish the Muhimbili Orthopedic Institute (MOI), which was opened in 1993 and later combined with MMC to become Muhimbili National Hospital, the national institute of neurosurgery, orthopedics, and traumatology.
Several neurosurgeons have practiced at MOI since its founding, including Dr. Abednego Kinasha and Dr. Joseph Kahamba. They, along with Professor Laurence Museru, the Medical Director of MOI, played a pivotal role in laying the foundation for training the current generation of neurosurgeons in Tanzania (6). Contemporary, locally trained neurosurgeons form the core of the specialized expertise in the country. They provide neurosurgical training and care at MOI at several healthcare institutions around the country. There are currently 20 neurosurgeons in the country, 18 of whom are in public service, one at a Mission hospital in Moshi, one in a private hospital (the Aga Khan University Hospital) Dar-es-salaam, and one at the Mnazi Mmoja/NED Institute in Zanzibar. No dedicated neuroscience nurses or beds are available in the country; however, currently, there are eight neurosurgical intensive care unit beds at MOI. An additional 14 at the new hospital within the Muhimbili hospital complex in Dar-es-Salaam opened in 2018. There are 5 CT scanners and 3 MRI scanners available across the country, mainly in Dar-es-Salaam, the largest city in Tanzania.
In Zimbabwe, Dr. Lawrence Frazer Levy, a British neurosurgeon, started in 1956 (Zimbabwe was called Rhodesia). He set up the Neurosurgery Department at the Central Hospital in Harare (Salisbury), becoming its first Professor and Chairman in 1971. He was joined by a young Scottish neurosurgeon, Dr. Carol Auchtertonie, responsible for starting the second unit at the European Hospital in Harare. The two served patients from Zimbabwe and neighboring Zambia, Malawi, and others for quite a long time (2). From these early beginnings, progress in neurosurgery remained slow, with only a handful of neurosurgeons available in SSA. In 1959, Professor Adelola Adeloye noted that there were only 20 neurosurgeons all across Africa, the majority practicing in South Africa (2). It is against this backdrop that the need to develop neurosurgical care in Sub-Saharan Africa came into focus.

Predictors of Five-Year Overall Survival in Women Treated for Cervical Cancer at the Kenyatta National Hospital in 2008

Cervical cancer is the fourth most commonly diagnosed and the fourth leading cause of cancer death among women worldwide. In many low- and middle-income countries (LMICs) including Kenya cervical cancer remains the leading cause of cancer death among women. This situation is due to the fact that despite the existence of effective preventive and early detection programs, lack of implementation in LMICs leads many women suffering from the disease to premature death. This study was aimed at estimating the five-year overall survival rates for women with cervical cancer in Kenya. To achieve this, the study employed a retrospective cohort design where medical records of all patients who commenced treatment for cervical cancer in 2008 were reviewed retrospectively over a period of five years from 2008- 2013. Data analysis involved the use of Stata v14.2 to generate descriptive statistics and conduct survival analysis. The five-year overall survival estimate for women with cervical cancer at Kenyatta National Hospital (KNH) in 2008 was found to be 59%. Stage of disease at diagnosis, type of treatment received and whether or not treatment was initiated and completed are the three factors revealed to have the strongest influence on patient survival. Occupation which was used as a proxy for socio-economic status (SES) did not reflect the financial burden imposed on patients seeking treatment. However, the loss to follow up was significantly high at a rate of 82.3%; with no deaths observed after the first year, the overall survival estimate is only accurate over the first year. The results of this study provided insight on the relationship between various socio-demographic and clinical factors and patient outcomes of cervical cancer treatments at KNH. Moreover, it highlighted the ongoing health system challenges surrounding provision of and access to cancer treatment. The results will inform policy makers and health service providers on the quality and accessibility of available cervical cancer treatments as delivered within our healthcare setting

Implementing an intrapartum package of interventions to improve quality of care to reduce the burden of preterm birth in Kenya and Uganda

Abstract
Background
Quality of care during the intrapartum and immediate postnatal period for maternal and newborn health remains a major challenge due to the multiple health system bottlenecks in low-income countries. Reports of complex interventions that have been effective in reducing maternal and newborn mortality in these settings are usually limited in description, which inhibits learning and replication. We present a detailed account of the Preterm Birth Initiative (PTBi) implementation process, experiences and lessons learnt to inform scale-up and replication.

Methods
Using the TiDieR framework, we detail how the PTBi implemented an integrated package of interventions through a pair-matched cluster randomized control trial in 20 health facilities in Migori County, Kenya, and the Busoga region in east central Uganda from 2016 to 2019. The package aimed to improve quality of care during the intrapartum and immediate postnatal period with a focus on preterm birth. The package included data strengthening (DS) and introduction of a modified WHO Safe Childbirth Checklist (mSCC), simulation-based training and mentoring (PRONTO), and a Quality Improvement (QI) Collaborative.

Results
In 2016, DS and mSCC were introduced to improve existing data processes and increase the quality of data for measures needed to evaluate study impact. PRONTO and QI interventions were then rolled out sequentially. While package components were implemented with fidelity, some implementation processes required contextual adaptation to allow alignment with national priorities and guidelines, and flexibility to optimize uptake.

Conclusion
Lessons learned included the importance of synergy between interventions, the need for local leadership engagement, and the value of strengthening local systems and resources. Adaptations of individual elements of the package to suit the local context were important for effective implementation, and the TIDieR framework provides the guidance needed in detailed description to replicate such a complex intervention in other settings. Detailed documentation of the implementation process of a complex intervention with mutually synergistic components can help contextualize trial results and potential for scale-up. The trial is registered at ClinicalTrials.govNCT03112018, registered December 2016, posted April 2017.

Cost of hospital care of women with postpartum haemorrhage in India, Kenya, Nigeria and Uganda: a financial case for improved prevention

Objective
Access to quality, effective lifesaving uterotonics in low and middle-income countries (LMICs) remains a major barrier to reducing maternal deaths from postpartum haemorrhage (PPH). Our objective was to assess the costs of care for women who receive different preventative uterotonics, and with PPH and no-PPH so that the differences, if significant, can inform better resource allocation for maternal health care.

Methods
The costs of direct hospital care of women who received oxytocin or heat-stable carbetocin for prevention of PPH in selected tertiary care facilities in India, Kenya, Nigeria, and Uganda were assessed. We collected data from all women who had PPH, as well as a random sample of women without PPH. Cost data was collected for the cost of stay, PPH interventions, transfusions and medications for 2966 women. We analyzed the difference in cost of care at a facility level between women who experienced a PPH event and those who did not.

Key findings

The mean cost of care of a woman experiencing PPH in the study sites in India, Kenya, Nigeria, and Uganda exceeded the cost of care of a woman who did not experience PPH by between 21% and 309%. There was a large variation in cost across hospitals within a country and across countries.

Conclusion
Our results quantify the increased cost of PPH of up to 4.1 times that for a birth without PPH. PPH cost information can help countries to evaluate options across different conditions and in the formulation of appropriate guidelines for intrapartum care, including rational selection of quality-assured, effective medicines. This information can be applied to national assessment and adaptation of international recommendations such as the World Health Organization’s recommendations on uterotonics for the prevention of PPH or other interventions used to treat PPH.

Epidemiological patterns of patients managed for cleft lip and palate during free outreach camps at a peripheral hospital in Kenya

Context: Clefts involving lip and palate are the most common craniofacial anomalies. The prevalence varies widely according to various factors. There is a paucity of epidemiological data on cleft deformities in African populations. Aims: The aim was to determine the epidemiological patterns of patients managed for cleft lip and palate during free outreach camps in Kenya and subsequently compare it with other studies done nationally, regionally, and internationally. Design: Prospective Cohort Study. Subjects and Methods: This was a prospective cohort study. Data were collected during five cleft surgery outreach camps held at Kitale County Referral Hospital in Trans-Nzoia County, Kenya, between January 2016 and January 2018. Statistical Analysis Used: The study was statistically analyzed by the Statistical Package for the Social Sciences Windows version 21 software for descriptive characteristics. Results: A total of 84 patients were reviewed, of which 74 underwent surgical management. The study population included nine different Counties in Kenya (with one patient from Uganda) and were reported to have traveled between 3 and 450 km. The age range was from 5 weeks to 35 years with patients below 2 years of age making up the majority (58.3%). There was a male preponderance (61.9%). The most common cleft deformities were cleft lip (46.4%), cleft lip and palate (34.6%), and cleft palate (15.5%). Unilateral clefts were commonly left-sided (62%). Sex distribution varied with clinical diagnosis, and familial and syndromic association was rare. Conclusions: More initiative programs are recommended to address the unmet medical and surgical needs of the cleft deformities in various parts of the region.

A baseline review of the ability of hospitals in Kenya to provide emergency and critical care services for COVID-19 patients

Introduction
As the Coronavirus Disease 2019 (COVID-19) cases in Kenya begin to rise, the number of severe and critical COVID-19 patients has the potential to quickly overload the local healthcare system beyond its capacity to treat people.

Objective
The purpose of this study was to gather information about the ability of hospitals in Kenya to provide emergency and critical care services and to identify priority actions for use by policymakers and other stakeholders as a roadmap toward strengthening the COVID-19 response in the country.

Methods
This was a comprehensive review of the published and grey literature on emergency and critical care services in Kenya published in the last three years through April 2020. Screening of articles was conducted independently by the authors and the final decision for inclusion was made collaboratively. A total of 15 papers and documents were included in the review.

Key recommendations.

There is an urgent need to strengthen prehospital emergency care in Kenya by establishing a single toll-free ambulance access number and an integrated public Emergency Medical Services (EMS) system to respond to severe and critical COVID-19 patients in the community and other emergency cases. Functional 24-h emergency departments (EDs) need to be established in all the level 4, 5 and 6 hospitals in the country to ensure these patients receive immediate lifesaving emergency care when they arrive at the hospitals. The EDs should be equipped with pulse oximeters and functioning oxygen systems and have the necessary resources and skills to perform endotracheal intubation to manage COVID-19-induced respiratory distress and hypoxia. Additional intensive care unit (ICU) beds and ventilators are also needed to ensure continuity of care for the critically ill patients seen in the ED. Appropriate practical interventions should be instituted to limit the spread of COVID-19 to healthcare personnel and other patients within the healthcare system. Further research with individual facility levels of assessment around infrastructure and service provision is necessary to more narrowly define areas with significant shortfalls in emergency and critical care services as the number of COVID-19 cases in the country increase.

Mortality during and following hospital admission among school-aged children: a cohort study

Background: Far less is known about the reasons for hospitalization or mortality during and after hospitalization among school-aged children than among under-fives in low- and middle-income countries. This study aimed to describe common types of illness causing hospitalisation; inpatient mortality and post-discharge mortality among school-age children at Kilifi County Hospital (KCH), Kenya.
Methods: A retrospective cohort study of children 5−12 years old admitted at KCH, 2007 to 2016, and resident within the Kilifi Health Demographic Surveillance System (KHDSS). Children discharged alive were followed up for one year by quarterly census. Outcomes were inpatient and one-year post-discharge mortality.
Results: We included 3,907 admissions among 3,196 children with a median age of 7 years 8 months (IQR 74−116 months). Severe anaemia (792, 20%), malaria (749, 19%), sickle cell disease (408, 10%), trauma (408, 10%), and severe pneumonia (340, 8.7%) were the commonest reasons for admission. Comorbidities included 623 (16%) with severe wasting, 386 (10%) with severe stunting, 90 (2.3%) with oedematous malnutrition and 194 (5.0%) with HIV infection. 132 (3.4%) children died during hospitalisation. Inpatient death was associated with signs of disease severity, age, bacteraemia, HIV infection and severe stunting. After discharge, 89/2,997 (3.0%) children died within one year during 2,853 child-years observed (31.2 deaths [95%CI, 25.3−38.4] per 1,000 child-years). 63/89 (71%) of post-discharge deaths occurred within three months and 45% of deaths occurred outside hospital. Post-discharge mortality was positively associated with weak pulse, tachypnoea, severe anaemia, HIV infection and severe wasting and negatively associated with malaria.
Conclusions: Reasons for admissions are markedly different from those reported in under-fives. There was significant post-discharge mortality, suggesting hospitalisation is a marker of risk in this population. Our findings inform guideline development to include risk stratification, targeted post-discharge care and facilitate access to healthcare to improve survival in the early months post-discharge in school-aged children.

Changing the face of global health: short-term surgical trips

With the growth of global health awareness, global surgery has emerged as a key focus area. This article examines short-term surgical trips (STSTs) as one of the ways used to address some of the gaps in global surgery. It demonstrates the Kenyan experience in organising and participating in a short-term surgical trip with a 10-year history. Their experience has been that STSTs should be co-organised between the regional hosting surgeons and the visiting surgical team, with an emphasis on education rather that the ‘number of surgeries’ performed during each camp.