Anne Njeri’s research while affiliated with African Population and Health Research Center and other places

Background Experience of care is typically measured through client exit surveys administered in the facility. Evidence suggests that such measures suffer from courtesy reporting bias whereby respondents do not accurately report on their experiences while in the facility. We explored the presence of courtesy bias by comparing women’s reported experience of person-centred maternity care (PCMC) from facility-based client exit surveys to mobile phone-based surveys out of the facility in Nairobi and Lusaka’s urban informal settlements. Methods We randomly and independently sampled women in the facilities for either a facility-based survey (n = 233 in Lusaka and n = 112 in Nairobi) or a mobile phone-based survey (n = 203 in Lusaka and n = 300 in Nairobi) within one to two weeks of facility discharge. The questionnaire included a validated PCMC scale. After adjusting for differences in women’s characteristics across groups, we compared PCMC scores between facility and phone-based samples. We ran multilevel linear regression models to assess PCMC by survey modality in each city. Results In both cities, over 70.0% of women were aged 20–34 years and were married, at least two thirds had secondary education, and over 95.0% were unaccompanied during labour/delivery. The overall PCMC score was 69.3% among women surveyed on the phone compared to 70.2% among those surveyed in the facility in Nairobi. In Lusaka, it was 57.5% on the phone compared to 56.8% in-facility. We found no statistically significant differences in PCMC scores between survey modalities in both cities, after adjusting for differences in women’s characteristics. Conclusions We did not detect significant courtesy reporting bias in PCMC in facility-based client exit surveys in the context of urban informal settlements in Nairobi and Lusaka. Experience of PCMC can be measured through in-facility client exit surveys or mobile phone surveys. However, it is critical to address challenges related to a mobile phone-based approach.

Background Sub-Saharan Africa’s rapid urbanisation has led to the sprawling of urban informal settlements. The urban poorest women are more likely to experience worse health outcomes and poor treatment during childbirth. This study measures levels of person-centred maternity care (PCMC) and identifies determinants of PCMC among women living in urban informal settlements in Nairobi, Lusaka and Ouagadougou. Methods We conducted phone, home-based or facility-based exit surveys of women discharged from childbirth care in facilities serving urban informal settlements. We estimated overall and domain-specific PCMC scores covering dignity and respect, communication and autonomy, and supportive care. We ran multilevel linear regression models to identify structural, intermediary and health systems factors associated with PCMC. Results We included 1249 women discharged from childbirth care: the majority were aged 20–34 years and were unemployed. In Lusaka and Nairobi, over 65% of women had secondary education, and over half gave birth in a hospital, whereas in Ouagadougou one-third had secondary education and 30.4% gave birth in a hospital. The mean PCMC score ranged from 57.1% in Lusaka to 73.8% in Ouagadougou. Across cities, women reported high dignity and respect mean scores (73.5%–84.3%), whereas communication and autonomy mean scores were consistently poor (47.6%–63.2%). In Ouagadougou, women with formal employment, those who delivered in a private for-profit facility, and whose newborn received postnatal care before discharge reported significantly higher PCMC. In Nairobi and Lusaka, women who were attended by a physician during childbirth, and those whose newborn was checked before discharge reported significantly higher PCMC. Conclusions Women living in urban informal settlements experience inadequate PCMC and report poor communication with health providers. Select health systems and provision of care factors are associated with PCMC in this context. Quality improvement efforts are needed to enhance PCMC and ensure women’s continuity in care seeking.

Background: In sub-Saharan Africa, maternal and newborn deaths remain disproportionately higher among low-income populations, and they are associated with delivery in poorly equipped facilities and a shortage of staff to manage birth complications. We measured facility readiness to provide essential maternal and newborn health services and its association with women's experience of person-centered maternity care (PCMC), and we compared facilities serving and not serving informal settlements in Nairobi, Lusaka and Ouagadougou cities. Methods: We conducted a health facility assessment in public and private facilities serving select urban informal settlements in Nairobi, and we used existing data in Lusaka and Ouagadougou. We computed readiness indices for labor and delivery care, and small and/or sick newborn care (SSNC) in each city, and used t-tests to compare them across facilities serving and not serving informal settlements. We linked women's self-reported PCMC scores to the labor and delivery readiness score of the facility they attended and ran 2-level linear regression models testing the association between facility readiness and PCMC scores. Results: Facility readiness scores were computed among 18, 38 and 138 facilities offering delivery services in Nairobi, Lusaka and Ouagadougou respectively. Mean labor and delivery readiness scores in facilities serving informal settlements ranged from 55.9% in Ouagadougou to 73.6% in Lusaka; SSNC readiness ranged from 37.2% in Ouagadougou to 61.3% in Nairobi. While facilities serving informal settlements had statistically significantly poorer readiness in Lusaka and Ouagadougou, key items such as newborn caps, registers, guidelines, and staff trained in Kangaroo Mother Care were lacking across both areas. We found no significant association between facility readiness and PCMC. Conclusions: All facilities have substandard readiness for essential maternal and newborn health services, but those serving informal settlements are more disadvantaged. Investments in service readiness and quality of care remain critical.

Background: Sub-Saharan Africa's rapid urbanization has led to the sprawling of urban informal settlements. The urban poorest women are more likely to experience worse health outcomes and poor treatment during childbirth. This study measures levels of person-centered maternity care (PCMC) and identifies determinants of PCMC among women living in urban informal settlements in Nairobi, Lusaka and Ouagadougou. Methods: We conducted phone, home-based or facility-based exit surveys of women discharged from childbirth care in facilities serving urban informal settlements. We estimated overall and domain-specific PCMC scores covering dignity and respect, communication and autonomy, and supportive care. We ran multilevel linear regression models to identify structural, intermediary and health systems factors associated with PCMC. Results: We included 1,249 women discharged from childbirth care: the majority were aged 20-34 years and were unemployed. In Lusaka and Nairobi, over 65% of women had secondary education, and over half gave birth in a hospital, whereas in Ouagadougou a third had secondary education and 30.4% gave birth in a hospital. The mean PCMC score ranged from 57.1% in Lusaka to 73.8% in Ouagadougou. Across cities, women reported high dignity and respect mean scores (73.5% - 84.3%), whereas communication and autonomy mean scores were consistently poor (47.6% - 63.2%). In Ouagadougou, women with formal employment, those who delivered in a private for-profit facility, and whose newborn received postnatal care before discharge reported significantly higher PCMC. In Nairobi and Lusaka, women who were attended by a physician during childbirth, and those whose newborn was checked before discharge reported significantly higher PCMC. Conclusion: Women living in urban informal settlements experience inadequate PCMC and report poor communication with health providers. Select health systems and provision of care factors are associated with PCMC in this context. Quality improvement efforts are needed to enhance PCMC and ensure women's continuity in care seeking.

Background: This paper explores the evolving digital landscape in Africa, focusing on its challenges and opportunities for promoting data governance and sharing in Africa. As the region integrates digital technology into health systems and adopts artificial intelligence (AI), the need for collaborative data sharing becomes crucial. The African Union has established cybersecurity policies and data protection measures but the progress to their implementation has been slow, with only a fraction of countries signing and ratifying the Malabo Convention of 2014 as of March 2023. To contribute to these efforts, the African Population and Health Research Center (APHRC) organized a data governance policy dialogue convening in September 2023, in Naivasha, Kenya, involving diverse stakeholders to discuss the challenges and opportunities in the African data ecosystem. Methods: Participants (n=46) were drawn from the office of the data protection, ministry of health, national statistics bureau, population and health research, data producers including health and demographic surveillance system (HDSS), data managers and data scientists. Sessions included technical presentations, round table and panel discussions, and breakout sessions. Findings: We found that the key gaps to data sharing in African included lack of standardized data management and sharing principles, administrative and bureaucratic barriers, mistrust resulting from fear of data misrepresentation, misuse and breach of privacy, and data systems that are not interoperable. To navigate this, the academia has a crucial role to play. First, in strengthening capacity and creating awareness about data privacy and protection, and second, in contributing to research on best practices. This includes working with research community to develop training curricula on data governance and sharing. Further, there was emphasis on development of comprehensive data governance frameworks at institutional, national and regional levels. The data governance framework should be tailored to the unique challenges and opportunities in Africa, and leverage the power of AI in its implementation and research. Conclusion: Policy makers should focus on creating more awareness, foster collaboration and trust to enhance data sharing aligning with national and regional data protection laws. There is need for the data protection laws to be interoperable across different jurisdictions. Capacity strengthening on responsible data management and sharing is key to unlocking the potential of data use and re-use for decision making.

Background We sought to estimate SARS‐CoV‐2 antibody seroprevalence within representative samples of the Kenyan population during the third year of the COVID‐19 pandemic and the second year of COVID‐19 vaccine use. Methods We conducted cross‐sectional serosurveys among randomly selected, age‐stratified samples of Health and Demographic Surveillance System (HDSS) residents in Kilifi and Nairobi. Anti‐spike (anti‐S) immunoglobulin G (IgG) serostatus was measured using a validated in‐house ELISA and antibody concentrations estimated with reference to the WHO International Standard for anti‐SARS‐CoV‐2 immunoglobulin. Results HDSS residents were sampled in February–June 2022 (Kilifi HDSS N = 852; Nairobi Urban HDSS N = 851) and in August–December 2022 ( N = 850 for both sites). Population‐weighted coverage for ≥1 doses of COVID‐19 vaccine were 11.1% (9.1–13.2%) among Kilifi HDSS residents by November 2022 and 34.2% (30.7–37.6%) among Nairobi Urban HDSS residents by December 2022. Population‐weighted anti‐S IgG seroprevalence among Kilifi HDSS residents increased from 69.1% (65.8–72.3%) by May 2022 to 77.4% (74.4–80.2%) by November 2022. Within the Nairobi Urban HDSS, seroprevalence by June 2022 was 88.5% (86.1–90.6%), comparable with seroprevalence by December 2022 (92.2%; 90.2–93.9%). For both surveys, seroprevalence was significantly lower among Kilifi HDSS residents than among Nairobi Urban HDSS residents, as were antibody concentrations ( p < 0.001). Conclusion More than 70% of Kilifi residents and 90% of Nairobi residents were seropositive for anti‐S IgG by the end of 2022. There is a potential immunity gap in rural Kenya; implementation of interventions to improve COVID‐19 vaccine uptake among sub‐groups at increased risk of severe COVID‐19 in rural settings is recommended.

Background Up-to-date SARS-CoV-2 antibody seroprevalence estimates are important for informing public health planning, including priorities for Coronavirus disease 2019 (COVID-19) vaccination programs. We sought to estimate infection- and vaccination-induced SARS-CoV-2 antibody seroprevalence within representative samples of the Kenyan population approximately two years into the COVID-19 pandemic and approximately one year after rollout of the national COVID-19 vaccination program. Methods We conducted cross-sectional serosurveys within random, age-stratified samples of Kilifi Health and Demographic Surveillance System (HDSS) and Nairobi Urban HDSS residents. Anti-spike (anti-S) immunoglobulin G (IgG) and anti-nucleoprotein (anti-N) IgG were measured using validated in-house ELISAs. Target-specific Bayesian population-weighted seroprevalence was calculated overall, by sex and by age, with adjustment for test performance as appropriate. Anti-S IgG concentrations were estimated with reference to the WHO International Standard (IS) for anti-SARS-CoV-2 immunoglobulin and their reverse cumulative distributions plotted. Results Between February and June 2022, 852 and 851 individuals within the Kilifi HDSS and the Nairobi Urban HDSS, respectively, were sampled. Only 11.0% (95% confidence interval [CI] 9.0-13.3) of all Kilifi HDSS participants and 33.4% (95%CI 30.2-36.6) of all Nairobi Urban HDSS participants had received any doses of COVID-19 vaccine. Population-weighted anti-S IgG seroprevalence was 69.1% (95% credible interval [CrI] 65.8-72.3) within the Kilifi HDSS and 88.5% (95%CrI 86.1-90.6) within the Nairobi Urban HDSS. Among COVID-unvaccinated residents of the Kilifi HDSS and Nairobi Urban HDSS, it was 66.7% (95%CrI 63.3-70.0) and 85.3% (95%CrI 82.1-88.2), respectively. Population-weighted, test-adjusted anti-N IgG seroprevalence within the Kilifi HDSS was 53.5% (95%CrI 46.5-61.1) and 65.5% (95%CrI 56.0-75.6) within the Nairobi Urban HDSS. The prevalence of anti-N antibodies was similar in vaccinated and unvaccinated subgroups in both HDSS populations. Anti-S IgG concentrations were significantly lower among Kilifi HDSS residents than among Nairobi Urban HDSS residents (p< 0.001). Conclusions Approximately, 7 in 10 Kilifi residents and 9 in 10 Nairobi residents were seropositive for anti-S IgG by May 2022 and June 2022, respectively. Given COVID-19 vaccination coverage, anti-S IgG seropositivity among COVID-unvaccinated individuals, and anti-N IgG seroprevalence, population-level anti-S IgG seroprevalence was predominantly derived from infection. Interventions to improve COVID-19 vaccination uptake should be targeted to individuals in rural Kenya who are at high risk of severe COVID-19.

Background Slums or informal settlements characterize most large cities in LMIC. Previous evidence suggests pharmacies may be the most frequently used source of primary care in LMICs but that pharmacy services are of variable quality. However, evidence on pharmacy use and availability is very limited for slum populations. Methods We conducted household, individual, and healthcare provider surveys and qualitative observations on pharmacies and pharmacy use in seven slum sites in four countries (Nigeria, Kenya, Pakistan, and Bangladesh). All pharmacies and up to 1200 households in each site were sampled. Adults and children were surveyed about their use of healthcare services and pharmacies were observed and their services, equipment, and stock documented. Results We completed 7692 household and 7451 individual adults, 2633 individual child surveys, and 157 surveys of pharmacies located within the seven sites. Visit rates to pharmacies and drug sellers varied from 0.1 (Nigeria) to 3.0 (Bangladesh) visits per person-year, almost all of which were for new conditions. We found highly variable conditions in what constituted a “pharmacy” across the sites and most pharmacies did not employ a qualified pharmacist. Analgesics and antibiotics were widely available but other categories of medications, particularly those for chronic illness were often not available anywhere. The majority of pharmacies lacked basic equipment such as a thermometer and weighing scales. Conclusions Pharmacies are locally and widely available to residents of slums. However, the conditions of the facilities and availability of medicines were poor and prices relatively high. Pharmacies may represent a large untapped resource to improving access to primary care for the urban poor.