-
David Gathara,
Newton Opiyo,
John Wagai,
Stephen Ntoburi,
Philip Ayieko,
Charles Opondo,
Annah Wamae,
Santau Migiro,
Wycliffe Mogoa, Aggrey Wasunna,
Fred Were,
Grace Irimu,
Mike English
[show abstract]
[hide abstract]
ABSTRACT: 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.
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.
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.
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.
BMC Health Services Research 11/2011; 11:307. · 1.66 Impact Factor
-
Philip Ayieko,
Stephen Ntoburi,
John Wagai,
Charles Opondo,
Newton Opiyo,
Santau Migiro,
Annah Wamae,
Wycliffe Mogoa,
Fred Were, Aggrey Wasunna,
Greg Fegan,
Grace Irimu,
Mike English
[show abstract]
[hide abstract]
ABSTRACT: 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.
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%]).
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.
PLoS Medicine 04/2011; 8(4):e1001018. · 16.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To assess the availability of resources that support the provision of basic neonatal care in eight first-referral level (district) hospitals in Kenya.
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.
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.
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.
Tropical Medicine & International Health 09/2009; 14(10):1165-72. · 2.80 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To evaluate final year medical students' access to new medical information.
Cross-sectional survey of final year medical students at the University of Nairobi using anonymous, self-administered questionnaires.
Questionnaires were distributed to 85% of a possible 343 students and returned by 44% (152). Half reported having accessed some form of new medical information within the previous 12 months, most commonly from books and the internet. Few students reported regular access; and specific, new journal articles were rarely accessed. Absence of internet facilities, slow internet speed and cost impeded access to literature; and current training seems rarely to encourage students to seek new information.
Almost half the students had not accessed any new medical information in their final year in medical school. This means they are ill prepared for a career that may increasingly demand life-long, self-learning.
Tropical Medicine & International Health 02/2009; 14(1):118-22. · 2.80 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Objectives To evaluate final year medical students’ access to new medical information.Method Cross-sectional survey of final year medical students at the University of Nairobi using anonymous, self-administered questionnaires.Results Questionnaires were distributed to 85% of a possible 343 students and returned by 44% (152). Half reported having accessed some form of new medical information within the previous 12 months, most commonly from books and the internet. Few students reported regular access; and specific, new journal articles were rarely accessed. Absence of internet facilities, slow internet speed and cost impeded access to literature; and current training seems rarely to encourage students to seek new information.Conclusion Almost half the students had not accessed any new medical information in their final year in medical school. This means they are ill prepared for a career that may increasingly demand life-long, self-learning.Objectifs: Évaluer l’accès à de nouvelles informations médicales pour les étudiants en dernière année de médecine.Méthode: Etude transversale sur les étudiants de dernière année de médecine à l’Université de Nairobi en utilisant questionnaires anonymes auto-administrés.Résultats: Les questionnaires ont été distribués à 85% de 343 étudiants et retournés par 44% (152) d’entre eux. La moitié ont déclaré avoir eu accès à une certaine forme de nouvelle information médicale au cours des 12 précédents mois, le plus souvent à partir de livres et de l’Internet. Peu d’étudiants ont rapporté un accès régulier et de nouveaux articles de revues spécifiques sont rarement accessibles. L’absence de services Internet, la lenteur du débit Internet et le coût entravaient l’accès à la littérature et la formation actuelle semble rarement encourager les étudiants à rechercher de nouvelles informations.Conclusion: Près de la moitié des étudiants n’avaient pas accédéà une nouvelle information médicale au cours de leur dernière année à la faculté de médecine. Cela signifie qu’ils sont mal préparés à une carrière qui pourrait requérir de plus en plus l’auto apprentissage au long de la vie.Objetivos: Evaluar el acceso de estudiantes de último año de medicina a nueva información médica.Método: Estudio croseccional entre estudiantes de ultimo año de medicina de la Universidad de Nairobi utilizando cuestionarios anónimos, auto-administrados.Resultados: Se distribuyeron cuestionarios al 85% de los posibles 343 estudiantes y un 44% (152) los devolvió. La mitad reportaron haber tenido acceso a algún tipo de información médica nueva dentro de los 12 meses anteriores, principalmente a través de libros y de Internet. Algunos estudiantes reportaron tener acceso regular; los nuevos artículos de revistas científicas específicas eran raramente accedidos. La ausencia de instalaciones con Internet, una velocidad de conexión a Internet lenta y los costes, impedían el acceso a literatura. Adicionalmente la educación recibida en la actualidad parecería raramente fomentar a los estudiantes a buscar información nueva y reciente.Conclusión: Casi la mitad de los estudiantes no habían accedido a ningún tipo de información médica nueva durante su último año de medicina. Esto quiere decir que su preparación deja mucho que desear en una profesión que requiere cada vez más de un auto-aprendizaje contínuo durante toda la vida.
Tropical Medicine & International Health 12/2008; 14(1):118 - 122. · 2.80 Impact Factor
-
Archives of Disease in Childhood 10/2008; 93(9):799-804. · 2.88 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Small hospitals sit at the apex of the pyramid of primary care in the health systems of many low-income countries. If the Millennium Development Goal for child survival is to be achieved, hospital care for referred severely ill children will need to be improved considerably in parallel with primary care in many countries. Yet little is known about how to achieve this. This article describes the evolution and final design of an intervention study that is attempting to improve hospital care for children in Kenyan district hospitals. It illustrates many of the difficulties involved in reconciling epidemiological rigour and feasibility in studies at a health system, rather than an individual, level and the importance of the depth and breadth of analysis when trying to provide a plausible answer to the question: does it work? Although there are increasing calls for more health systems research in low-income countries, the importance of strong, broadly based local partnerships and long-term commitment even to initiate projects is not always appreciated.
Archives of Disease in Childhood 07/2008; 93(6):540-4. · 2.88 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Birth asphyxia kills 0.7 to 1.6 million newborns a year globally with 99% of deaths in developing countries. Effective newborn resuscitation could reduce this burden of disease but the training of health-care providers in low income settings is often outdated. Our aim was to determine if a simple one day newborn resuscitation training (NRT) alters health worker resuscitation practices in a public hospital setting in Kenya.
We conducted a randomised, controlled trial with health workers receiving early training with NRT (n = 28) or late training (the control group, n = 55). The training was adapted locally from the approach of the UK Resuscitation Council. The primary outcome was the proportion of appropriate initial resuscitation steps with the frequency of inappropriate practices as a secondary outcome. Data were collected on 97 and 115 resuscitation episodes over 7 weeks after early training in the intervention and control groups respectively. Trained providers demonstrated a higher proportion of adequate initial resuscitation steps compared to the control group (trained 66% vs control 27%; risk ratio 2.45, [95% CI 1.75-3.42], p<0.001, adjusted for clustering). In addition, there was a statistically significant reduction in the frequency of inappropriate and potentially harmful practices per resuscitation in the trained group (trained 0.53 vs control 0.92; mean difference 0.40, [95% CI 0.13-0.66], p = 0.004).
Implementation of a simple, one day newborn resuscitation training can be followed immediately by significant improvement in health workers' practices. However, evidence of the effects on long term performance or clinical outcomes can only be established by larger cluster randomised trials.
Controlled-Trials.com ISRCTN92218092.
PLoS ONE 01/2008; 3(2):e1599. · 4.09 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The structured admission form is an apparently simple measure to improve data quality. Poor motivation, lack of supervision, lack of resources and other factors are conceivably major barriers to their successful use in a Kenyan public hospital setting. Here we have examined the feasibility and acceptability of a structured paediatric admission record (PAR) for district hospitals as a means of improving documentation of illness.
The PAR was primarily based on symptoms and signs included in the Integrated Management of Childhood Illness (IMCI) diagnostic algorithms. It was introduced with a three-hour training session, repeated subsequently for those absent, aiming for complete coverage of admitting clinical staff. Data from consecutive records before (n = 163) and from a 60% random sample of dates after intervention (n = 705) were then collected to evaluate record quality. The post-intervention period was further divided into four 2-month blocks by open, feedback meetings for hospital staff on the uptake and completeness of the PAR.
The frequency of use of the PAR increased from 50% in the first 2 months to 84% in the final 2 months, although there was significant variation in use among clinicians. The quality of documentation also improved considerably over time. For example documentation of skin turgor in cases of diarrhoea improved from 2% pre-intervention to 83% in the final 2 months of observation. Even in the area of preventive care documentation of immunization status improved from 1% of children before intervention to 21% in the final 2 months.
The PAR was well accepted by most clinicians and greatly improved documentation of features recommended by IMCI for identifying and classifying severity of common diseases. The PAR could provide a useful platform for implementing standard referral care treatment guidelines.
BMC International Health and Human Rights 02/2006; 6:9. · 1.44 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The district hospital is considered essential for delivering basic, cost-effective health care to children in resource poor countries. We aimed to investigate the performance of these facilities in Kenya.
Government hospitals providing first referral level care were prospectively sampled from 13 Kenyan districts. Workload statistics and data documenting the management and care of admitted children were obtained by specially trained health workers.
Data from 14 hospitals were surveyed with routine statistics showing considerable variation in inpatient paediatric mortality (range 4-15%) and specific case fatality rates (eg, anaemia 3-46%). The value of these routine data is seriously undermined by missing data, apparent avoidance of a diagnosis of HIV/AIDS, and absence of standard definitions. Case management practices are often not in line with national or international guidelines. For malaria, signs defining severity such as the level of consciousness and degree of respiratory distress are often not documented (range per hospital 0-100% and 9-77%, respectively), loading doses of quinine are rarely given (3% of cases) and dose errors are not uncommon. Resource constraints such as a lack of nutritional supplements for malnourished children also restrict the provision of basic, effective care.
Even crude performance measures suggest there is a great need to improve care and data quality, and to identify and tackle key health system constraints at the first referral level in Kenya. Appropriate intervention might lead to more effective use of health workers' efforts in such hospitals.
The Lancet 07/2004; 363(9425):1948-53. · 38.28 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We aimed to investigate provision of paediatric care in government district hospitals in Kenya. We surveyed 14 first-referral level hospitals from seven of Kenya's eight provinces and obtained data for workload, outcome of admission, infrastructure, and resources and the views of hospital staff and caretakers of admitted children. Paediatric admission rates varied almost ten-fold. Basic anti-infective drugs, clinical supplies, and laboratory tests were available in at least 12 hospitals, although these might be charged for on discharge. In at least 11 hospitals, antistaphylococcal drugs, appropriate treatment for malnutrition, newborn feeds, and measurement of bilirubin were rarely or never available. Staff highlighted infrastructure and human and consumable resources as problems. However, a strong sense of commitment, support for the work of the hospital, and a desire for improvement were expressed. Caretakers' views were generally positive, although dissatisfaction with the physical environment in which care took place was common. The capacity of the district hospital in Kenya needs strengthening by comprehensive policies that address real needs if current or new interventions and services at this level of care are to enhance child survival.
The Lancet 364(9445):1622-9. · 38.28 Impact Factor
