Addressing Possible Serious Bacterial infection among sick young infants in Kenya where referral is not feasible

1. ADDRESSING POSSIBLE SERIOUS
BACTERIAL INFECTION AMONG SICK
YOUNG INFANTS IN KENYA WHERE
REFERRAL IS NOT FEASIBLE:
WHERE ARE WE NOW?
Jesse Gitaka –Mount Kenya University
Wilson Liambila and Timothy Abuya-Population
Council
Fred Were and Kezia K’Oduol- KEPRECON

2.  Kenya has high NNM rate (22 per 1000 live births) with sepsis
contributing up to 20% of deaths
 Poor care seeking, dysfunctional referral pathways and
negative cultural beliefs worsen situation
 Reducing this burden requires timely case identification &
initiation of suitable antibiotic treatment
 Clinical trials of simplified treatment regimens in Asia
and Africa (2011-2013) showed:
high refusal rates for referral by caregivers (Kenya 89%)
simplified antibiotic regimens for SYIs provided at PHC level when
referral is not feasible are effective and can save lives.

5. PROJECT UPDATES

6. Revision of concept
and full proposal
development
August-October 2017
Addis Ababa advocacy
meeting
Jan 2018
Co creation workshop
Jan 2017 Update of IMNCI and
newborn protocols
Jan-may 2018
Formative phase
June-July 2018
Dissemination
and revision of
work county plans
Sept-Oct 2018
Development of job
aids/pamphlets
Jan-March 2019
IMNCI Induction
Jan-March 2019
Dissemination of Job
aids/follow up forms
March 2019
Provider induction on
IMNCI/PSBI
Six monthly follow
up
Quarterly follow up &
tracking
2 3 4 5 6 7 8 9 10 11 12 131
National level
advocacy
Oct 2017

7. • Create foundation for learning
• Generate evidence for action
• Develop a measurement
framework through periodic
monitoring of performance or
implementation activities

8.  Formative assessment in
project sites, June – July 2018
 Technical Advisory Group
meeting, August 2018
 Establishment of Community
of Practice (CoP), October
2018.
 Join CoP at:
psbi@communities.harpnet.org
 Ongoing establishment of local
CoP.
 Quarterly monitoring system

9. Formative assessment activity Sample Sizes
Capacity assessment with CHMTs 4
Capacity assessment with SCHMTs 8
Health facility assessment 48
Partner mapping 8
IDI young mothers (15-18 yrs) 11
IDI young mothers 19-24 yrs 12
IDI with providers & facility managers 14
FGD young mothers (15-18 yrs) 7
FGD young mothers (19-24 yrs) 12
FGD Older mothers (25-45 yrs) 6
FGD married men (>35 yrs) 7
FGD with active CHVs 7

10. RESULTS OF THE FORMATIVE ASSESSMENT:
ORGANIZATIONAL CAPACITY INDEX (OCI)
SCORES BY HEALTH SYSTEM DOMAINS
OCI Bungoma Turkana Mombasa Kilifi
Health Policy and Financing 69.5 64.8 68.6 66.7
Leadership and Governance 53.8 53.8 54.5 61.3
Human Resource for Health 54.5 48.5 57.6 60.6
Health Products and Technologies 61.1 41.7 55.6 62.5
Service delivery 67.1 71.3 74.3 70.7
Infrastructure 65 51.1 53.3 53.3
HMIS 70 72.5 80 70
M&E 40 49.1 50.9 54.5
Key Status Score Action needed
<=50 Red Poor Extensive support
51-69 Amber Average Medium level support
>=70 Green Good Minimal support

11. OVERALL ORGANIZATIONAL
CAPACITY INDEX

12. Cultural practices
 Infants rejecting the allocated names
 Witchcraft or sorcery
 Bad omen
 Bad/ evil eye or
 Statements made about the infant
 Presence of an owl in the homestead
Myths and misconceptions
 Infants born out of wedlock
 Use of family planning
 Eating foods such as wild fruits
 Overworking during pregnancy
 Mother sleeping outdoors during
pregnancy
Harmful practices
• Delayed breastfeeding while waiting for naming ceremony (religious or cultural)
• Placing exposed young infant outside the home to prevent them from dying like
other siblings
• Use of cultural practices to protect against the evil eye

13. • Germs from people and dirty
surroundings
- Failing to observe hygiene
(unwashed hands, unclean
breast)
- Exposing umbilical cord to
dirty razor, string, grass,
ash, dung, soot
- Cutting baby’s skin and
applying herbs or other
traditional treatment
• Exposing the young infant to
cold
• Complications during
childbirth
• Some birth defects or
abnormalities
• Delaying
breastfeeding
• Giving other foods
other than BF
• Missing
immunization
• Delivery outside a
health facility
• Delivery by unskilled
persons
• Poor diet during or
after pregnancy

14. Poor
breastfeeding,
sunken eyes & eye
discharges
Changes in body
temperature ,
convulsions &
change of skin
color
Excessive crying,
inability to pass
urine or fecal
matter, not
sleeping well, and
or restlessness
Difficulty in
breathing,
diarrhea and
vomiting
Care seeking is
preceded by
seeking a second
opinion due to
persistence of the
condition or
severity then the
action is taken
based on
understanding of
cause of illness

15. Bungoma
Perception that referral may mean severity of illness and thus
possible deaths
Transportation costs and logistics of referral
Lack of funds for in patient care esp. money for food/drugs
Social roles in supporting family at home & Lack of support from
spouses to provide money
Timing of referral

16. CHVs across all counties create
awareness, educate the community on
newborn care, link the community to the
health facilities, serve as referral agents.
“P: When we get into the house that we visit, there are a few
things that we normally ask. Like if there is a sick person or if
there is an expectant mother who has not yet started clinic, or if
there are those who started the clinic and defaulted, then I teach
them and refer them to go to the hospital. And if there is a sick
person, we check on the symptoms and if there is a sign of malaria,
…and if not malaria I refer them to the hospital to be treated”
Bungoma FGD CHVs.
Inadequate number of CHVs, capacity
gaps makes it hard for them to reach
newborns and mothers
Transport and logistics affect service
delivery at community level

17. 0
1
2
3
4
5
6
7
8
Total number
of facilities
(HC)
Functional
maternity
unit
Functional
new born
unit/area
Newborn
resuscitation
space/table
Functional
kangaroo
mother care
beds
Functional
pediatric unit
Turkana Kilifi Bungoma Mombasa

18. 0
1
2
3
4
5
6
7
SC
Hosp
(n=3)
H/C
(n=4)
Disp
(n=6)
SC
Hosp
(n=3)
H/C
(n=4)
Disp
(n=5)
SC
Hosp
(n=3)
H/C
(n=3)
Disp
(n=5)
SC
Hosp
(n=3)
H/C
(n=7)
Disp
(n=2)
Turkana Kilifi Bungoma Mombasa
Ampicillin 125MG/5ML Gentamicin
No. of
facilitie
s
Amoxicillin Dispersible
Tab

19. 0 1 2 3 4 5 6 7
IMNCI
Essential newborn care
CPAP
Helping babies breathe
Newborn care at PHC
Management of preterm babies
Kangaroo mother care
Breast feeding/newborn feeding
PNC for mother and baby
ETAT+
Mombasa
Bungoma
Kilifi
Turkana

20. IMPLEMENTATION
ACTIONS BASED ON
FORMATIVE DATA

23.  IMNCI training materials
have been revised/ updated
to incorporate PSBI
 In Bungoma-IMNCI
training for TOTs has just
been completed and plans
are underway to train the
providers

24.  Quarterly routine monitoring.
 Project team working with County, Sub-county and
Facility quality improvement teams to assess the quality
of care.

25.  IR data collection cycles involve
conducting case narratives with
women who use PSBI and those
referred from the community by
CHVs, and in-depth interviews
with active CHVs and frontline
providers.
 Project team will continuously
document the number of PSBI
cases seen and the treatment given
as well as referral practices for
purposes of generating additional
evidence to guide scale up and
future revisions of national
IMNCI/PSBI guidelines.

26.  Shortage of staff especially in lower HFs
 Barriers such as negative cultural practices contribute
to delays in care seeking for SYIs with PSBI
 Weak linkage between HFs/providers & CHV activities
contribute to poor follow up of SYIs with PSBI
 Some HFs do not have community health units (CUs) -
hence no active CHVs to assist in following up SYIs.
 Erratic supply of some key antibiotics such as
Gentamycin, Amoxicillin dispersible tablets, etc
NB: There is need for the MOH/C&sub county teams to
involve the private sector providers in the training of
IMNCI/PSBI

27. Population
Council
 Wilson Liambila
 Timothy Abuya
 Charity Ndwiga
 George Odwe
 Charlotte Warren
Institutions
• Newborn, Child & Adolescent Health Unit - MOH
• County and Sub-County Health Management Teams –
Bungoma
• Health Facility Management Teams – Project Counties
• USAID-for providing financial resources
Kenya Paediatric
Research
Consortium
• Fred Were
• David Githanga
• Joe Mbuthia
• Doris Kinuthia
• Kezia K’Oduol
Mount Kenya
University
• Jesse Gitaka
• Alice Natecho
• Samuel Mungai
• Peter Mwaura
• Jackline Nyaberi