George Otieno

Measuring effectiveness of electronic medical records systems: Towards building a composite index for benchmarking hospitals

INTRODUCTION Many hospitals are currently in the process of developing and implementing electronic medical records (EMR) systems. This is a critical time for developing a framework that can measure and allow for comparison the effectiveness of EMR systems across hospitals that have implemented these systems. The motivation for this study comes from the realization that there is limited research on the understanding of the effectiveness of EMR systems, and a lack of appropriate reference theoretical framework for measuring the effectiveness of EMR systems. In this paper, we propose a conceptual framework for generating a composite index (CI) for measuring the effectiveness of EMR systems in hospitals. METHODS Data used to test the framework and associated research objectives were derived from a cross-sectional survey of five stakeholders of EMR systems including chief medical officers, chief nursing officers, chief information officers, doctors and nurses in 20 Japanese hospitals. Using statistical means of standardization and principal component analysis (PCA) procedure, CI was developed by summing up the scores of four dimensions-system quality, information quality, use and user satisfaction. The process included formulating items for each dimension, condensing the data into factors relevant to the dimension and calculating the CI by summing up the product of each dimension with its respective principal component score coefficient. RESULTS The Cronbachs alpha for the four dimensions used in developing CI was .843. Validation of CI revealed that it was correlated to internal dimensions (system quality, R=.828; information quality, R=.909; use, R=.969; and user satisfaction, R=.679) and to external factors (JAHIS level, R=.832 and patient safety culture, R=.585). These results suggest that CI could be a reliable and valid measure of the effectiveness of EMR systems in the responding hospitals. On benchmarking of hospitals, 30.0% (6/20) of the responding hospitals performed less than satisfactory on CI and that majority of the hospitals performed poorly on user satisfaction. CONCLUSIONS CI has provided a standard way, through quantitative means, of measuring, comparing and categorizing the effectiveness of EMR systems in hospitals. CI can be a powerful tool for benchmarking the effectiveness of EMR systems in hospitals in ways that can guide hospitals in computerization process as well as benchmark their systems against other hospitals.

Menstrual Needs and Associations with Sexual and Reproductive Risks in Rural Kenyan Females: A Cross-Sectional Behavioral Survey Linked with HIV Prevalence

Abstract Background: Females in low and middle income countries (LMICs) have difficulty coping with menstrual needs, but few studies have examined the social or health implications of these needs. Methods: Responses from 3418 menstruating females aged 13–29 years were extracted from an HIV and behavioral risks cross-sectional survey conducted in rural western Kenya. We examined sanitary products used, provision of products from sexual partners or from transactional sex, and demographic and sexual exposures. Results: Overall, 75% of females reported using commercial pads and 25% used traditional materials such as cloth or items like paper or tissue, with 10% of girls <15 years old depending on makeshift items. Two-thirds of females with no education relied on traditional items. Having attended secondary school increased the odds of using commercial pads among married (adjusted odds ratios [AOR] 4.8, 95% confidence interval [CI] 3.25–7.12) and single females (AOR 2.17, 95% CI 1.04–4.55). Married females had lower odds of pad use if they reported early (<12 years of age) compared with later (≥18 years) sexual debut (64% vs. 78%, AOR 0.45, 95% CI 0.21–0.97). Two-thirds of pad users received them from sexual partners. Receipt was lower among married females if partners were violent (AOR 0.67, 95% CI 0.53–0.85). Receipt among single females was higher if they had two or more sexual partners in the past year (AOR 2.11, 95% CI 1.04–4.29). Prevalence of engaging in sex for money to buy pads was low (1.3%); however, 10% of 15-year-olds reported this, with girls ≤15 having significantly higher odds compared with females over 15 (AOR 2.84, 95% CI 0.89–9.11). The odds of having transactional sex for pads was higher among females having two or more partners in the past 12 months (AOR 4.86, 95% CI 2.06–11.43). Conclusions: Menstrual needs of impoverished females in rural LMICs settings likely leads to increased physical and sexual harms. Studies are required to strengthen knowledge and to evaluate interventions to reduce these harms.

Early biting of the Anopheles gambiae s.s. and its challenges to vector control using insecticide treated nets in western Kenya highlands

Long term use of insecticides in malaria vector control has been shown to alter the behavior of vectors. Such behavioral shifts have the potential of undermining the effectiveness of insecticide-based control interventions. The effects of insecticide treated nets (ITNs) use on the composition, biting/feeding and sporozoite rates of Anopheles gambiae s.l. mosquitoes in Musilongo village, Vihiga County of western Kenya highlands were investigated. Adult mosquitoes were collected in selected sleeping spaces inside six randomly selected houses using miniature Centre for Disease Control and Prevention (CDC) light traps. Mosquito sampling in each house was conducted twice every week for 16 consecutive months (May 2010-August 2012). At each sampling a single trap was set in the selected space inside each house such that it collected mosquitoes alternatively from 18:00 to 21:00h and 21:00 to 06:00h every week. All collected mosquitoes were morphologically identified. Female Anopheles mosquitoes were classified according to their physiological status as unfed, fed, partially gravid and gravid, sorted and counted. Members of the A. gambiae complex were identified using a Polymerase chain reaction (PCR) method. Enzyme-linked-immunosorbent assay (ELISA) was used to determine blood meal sources and Plasmodium infection rates in A. gambiae s.l. mosquitoes. Blood meal tests were conducted on DNA extracted from gut contents of blood fed A. gambiae s.l. The head and thorax section of dried samples of A. gambiae s.l. were used in testing for the presence of Plasmodium falciparum (Pf) sporozoites. Overall, 735 adult female Anopheles comprising 708 [96.3%] A. gambiae s.l. and 27 [3.7%] Anopheles funestus mosquitoes were collected. A. gambiae s.l. population collected comprised, 615 [86.9%] unfed and 38 [5.4%] fed adult mosquitoes. The rest were either partially or fully gravid. The proportion of A. gambiae s.l. biting indoors within 18:00-21:00h was 15.8% (103/653) at a rate of 3.2bites per person per hour compared to 84.2% biting from 21:00-06:00h at a rate of 3.8 bites/per/h. An estimated 97.7% A. gambiae ss and 2.3% A. arabiensis constituted the indoor biting A. gambiae s.l. The population of An. gambiae s.l. biting from 18:00 to 21:00h had a Plasmodium faciparum (pf) sporozoite rate of 3.8% compared to 3.5% observed in populations biting within 21:00-06:00h. Human blood constituted 89% of An. gambiae s.l. blood meal sources. The risk of malaria transmission from 21:00 to 06:00h was approximately 5 fold the risk within 18:00-21:00h. Majority of the infective female A. gambiae s.l. adults were biting deep into the night than in the early hours of the night. Humans remain the preferred source of blood meal for A. gambiae s.s. the dominant malaria vector in the highlands. ITNs remain a fundamental control intervention against malaria transmission since female blood seekers were more during bed time than pre-bed time. Advocacy on enhanced net availability, integrity and usage in Kenyan highlands can reduce Pf transmission. Additional complementary interventions are required to control the biting and parasite transmission encountered before bed-time.

HIV incidence in western Kenya during scale-up of antiretroviral therapy and voluntary medical male circumcision: a population-based cohort analysis

BACKGROUND In Kenya, coverage of antiretroviral therapy (ART) among people with HIV infection has increased from 7% in 2006, to 57% in 2016; and, in western Kenya, coverage of voluntary medical male circumcision (VMMC) increased from 45% in 2008, to 72% in 2014. We investigated trends in HIV prevalence and incidence in a high burden area in western Kenya in 2011-16. METHODS In 2011, 2012, and 2016, population-based surveys were done via a health and demographic surveillance system and home-based counselling and testing in Gem, Siaya County, Kenya, including 28 688, 17 021, and 16 772 individuals aged 15-64 years. Data on demographic variables, self-reported HIV status, and risk factors were collected. Rapid HIV testing was offered to survey participants. Participants were tracked between surveys by use of health and demographic surveillance system identification numbers. HIV prevalence was calculated as a proportion, and HIV incidence was expressed as number of new infections per 1000 person-years of follow-up. FINDINGS HIV prevalence was stable in participants aged 15-64 years: 15% (4300/28 532) in 2011, 12% (2051/16 875) in 2012, and 15% (2312/15 626) in 2016. Crude prevalences in participants aged 15-34 years were 11% (1893/17 197) in 2011, 10% (1015/10 118) in 2012, and 9% (848/9125) in 2016; adjusted for age and sex these prevalences were 11%, 9%, and 8%. 12 606 (41%) of the 30 520 non-HIV-infected individuals enrolled were seen again in at least one more survey round, and were included in the analysis of HIV incidence. HIV incidence was 11·1 (95% CI 9·1-13·1) per 1000 person-years from 2011 to 2012, and 5·7 (4·6-6·9) per 1000 person-years from 2012 to 2016. INTERPRETATION With increasing coverage of ART and VMMC, HIV incidence declined substantially in Siaya County between 2011 and 2016. VMMC, but not ART, was suggested to have a direct protective effect, presumably because ART tended to be given to individuals with advanced HIV infection. HIV incidence is still high and not close to the elimination target of one per 1000 person-years. The effect of further scale-up of ART and VMMC needs to be monitored. FUNDING Data were collected under Cooperative Agreements with the US Centers for Disease Control and Prevention, with funding from the Presidents Emergency Fund for AIDS Relief.

Participant satisfaction with clinical trial experience and post-trial transitioning to HIV care in Kenya

We conducted an exploratory analysis of former HIV Prevention Trials Network 052 (HPTN 052) clinical trial participants in 2016 to assess their (1) satisfaction with the HPTN 052 clinical trial care and treatment, and reasons for joining the trial; and (2) perspectives about the post-trial transition to public HIV care centers. Quantitative data showed that, of the 70 survey participants, 94.3% (n = 66) reported being very satisfied with the care and treatment they received while participating in the clinical trial and 51.4% (n = 36) reported they joined the study because they would receive information to improve their own or their partner’s health. Qualitative data (five in-depth interviews and two focus group discussions) analysis revealed the following themes: transition experiences; perceived superior clinical trial care; study benefits not offered at public HIV care centers; and the public HIV care centers’ indifference to the uninfected partner. For some HPTN 052 participants, transition to HIV care clinics was disappointing. Clinical trial investigators and local Institutional Review Boards should consider the need for safeguards and oversight of post-trial health care for trial participants after the trial ends, especially in resource-constrained settings, to avoid negative health outcomes.

High prevalence of sexually transmitted infections among women screened for a contraceptive intravaginal ring study, Kisumu, Kenya, 2014

We assessed prevalence and correlates of bacterial vaginosis (BV) and sexually transmitted infections (STIs) including herpes simplex virus type 2 (HSV-2), gonorrhoea (GC), syphilis (SYP), Chlamydia (CT) and HIV among Kenyan women aged 18–34 years who were screened for a contraceptive intravaginal ring study. Women provided demographic, behavioural and medical information, and underwent medical evaluation, including a pelvic exam. We computed crude and adjusted prevalence ratio (aPR) and 95% confidence interval (CI) using log-binomial regression. Of 463 women screened, 457 provided laboratory specimens and were included in the analysis. The median age was 25 years, interquartile range (21–28), and 68.5% had completed primary or lower education. Overall, 72.2% tested positive for any STI or BV. Point prevalence was 55.6, 38.5, 3.9, 2.0, 4.6, and 14.7% for HSV-2, BV, GC, SYP, CT, and HIV, respectively. Co-infection with HSV-2, BV, and HIV occurred in 28 (6.1%) participants. Having ≥1 STI/BV was associated with younger age at first sex (≤13 versus 17–19 years, aPR=1.27, 95% CI 1.07–1.51), history of exchange sex (aPR = 2.05, 95% CI 1.07–3.92), sexual intercourse in the past seven days (aPR = 1.17, 95% CI 1.01–1.36), and older age (30–34 versus 18–24 years, aPR = 1.26, 95% CI 1.06–1.48). STI/BV diagnosis was less likely for women reporting one lifetime sexual partner compared to women with ≥4 lifetime sexual partners (aPR = 0.70, 95% CI 0.54–0.92). Combination prevention approaches (biomedical, behavioural, social, and structural) tailored to women with diverse risk profiles may help mitigate STI/BV prevalence in this setting.

Community perceptions and personal accounts of HIV discordance in rural western Kenya

Among HIV-discordant couples, the literature is sparse regarding issues related to stigma, relationships and coping. Objectives were to explore: 1) perceptions about discordant HIV status; 2) understanding of HIV discordancy; 3) effects of discordancy on couples; and 4) adaptation and coping strategies for discordant HIV status. A survey was administered to 202 members of heterosexual discordant couples in rural western Kenya. In addition, to understand the community perspective, in-depth interviews (IDI) (n = 26) and focus group discussions (FGD) (n = 10) were conducted with community opinion leaders, healthcare workers and members of discordant couples. More than 70% of men (73.4%) and women (80.4%) surveyed agreed that their relationship changed for the worse when they disclosed their HIV status to their partner. Participants of IDIs and FGDs provided several explanations for discordancy including the perception that discordancy is a lie, the negative partner has “thick blood”, HIV infection is a punishment for sexual promiscuity or cultural disobedience, and that HIV is a punishment from God. Members of discordant couples reported experiencing tension and fear, stigma and rejection, and changes in partner support. Adaptation and coping strategies included counselling, sero-sorting and pursuing concordancy with the uninfected partner. HIV discordancy in a relationship can potentially cause long-term negative emotional and physical consequences. There is an acute need to develop and disseminate locally sensitive HIV-discordant couple counselling messages, and to provide couple-centred HIV care and treatment. Communication can help couples rebuild and rebalance their relationship and adjust to a new normal.

Factors associated with physical violence by a sexual partner among girls and women in rural Kenya

Background Intimate partner physical violence increases women’s risk for negative health outcomes and is an important public health concern. The purpose of the present study was to determine 1) the proportion of girls (≤18 years) and women (>18 years) who experienced physical violence by a sexual partner, and 2) factors (including self–reported HIV infection) associated with girls and women who experienced physical violence by a sexual partner. Methods Cross–sectional surveys conducted in the Gem Health and Demographic Surveillance System (HDSS) area in Siaya County, western Kenya in 2011–2012 (Round 1) and 2013–2014 (Round 2). Findings Among 8003 unique participants (582 girls and 7421 women), 11.6% reported physical violence by a sexual partner in the last 12 months (girls: 8.4%, women: 11.8%). Three factors were associated with physical violence by a sexual partner among girls: being married or cohabiting (nearly 5–fold higher risk), low education, and reporting forced sex in the last 12 months (both with an approximate 2–fold higher risk). Predictive factors were similar for women, with the addition of partner alcohol/drug use and deliberately terminating a pregnancy. Self–reported HIV status was not associated with recent physical violence by a sexual partner among girls or women. Conclusions Gender–based physical violence is prevalent in this rural setting and has a strong relationship with marital status, low education level, and forced sex among girls and women. Concerted efforts to prevent child marriage and retain girls in school as well as implementation of school and community–based anti–violence programs may help mitigate this risk.

Teen pregnancy in rural western Kenya: a public health issue

Abstract Rates of teenage pregnancy remain high in sub-Saharan Africa. The KEMRI Health and Demographic Surveillance System provided the sampling frame for a survey. Analysis focused on 1,952 girls aged 13–19 years. Over a third (37.2%; n = 727) were sexually active and 23.3% (n = 454) had ever been pregnant. Adjusted odds of reporting a history of pregnancy were greater for older compared to younger teens, teens who were ever married or cohabiting compared to those who were single, teens with a primary education or less compared to those with a higher level of education, and teens who experienced partner violence in the last 12 months. Three-quarters of teens pregnant in the last 12 months did not want to get pregnant (n = 190); only 64.2% (n = 122) answered yes to using any family planning method. Teen pregnancy and its consequences are serious public health issues. Higher education levels are a crucial component to address the problem.

Viral and Host Characteristics of Recent and Established HIV-1 Infections in Kisumu based on a Multiassay Approach

Integrated approaches provide better understanding of HIV/AIDS epidemics. We optimised a multiassay algorithm (MAA) and assessed HIV incidence, correlates of recent infections, viral diversity, plus transmission clusters among participants screened for Kisumu Incidence Cohort Study (KICoS1) (2007–2009). We performed BED-CEIA, Limiting antigen (LAg) avidity, Biorad avidity, and viral load (VL) tests on HIV-positive samples. Genotypic analyses focused on HIV-1 pol gene. Correlates of testing recent by MAA were assessed using logistic regression model. Overall, 133 (12%, 95% CI: 10.2–14.1) participants were HIV-positive, of whom 11 tested recent by MAA (BED-CEIA OD-n < 0.8 + LAg avidity OD-n < 1.5 + VL > 1000 copies/mL), giving an incidence of 1.46% (95% CI: 0.58–2.35) per year. This MAA-based incidence was similar to longitudinal KICoS1 incidence. Correlates of testing recent included sexually transmitted infection (STI) treatment history (OR = 3.94, 95% CI: 1.03–15.07) and syphilis seropositivity (OR = 10.15, 95% CI: 1.51–68.22). Overall, HIV-1 subtype A (63%), D (15%), C (3%), G (1%) and recombinants (18%), two monophyletic dyads and intrinsic viral mutations (V81I, V81I/V, V108I/V and K101Q) were observed. Viral diversity mirrored known patterns in this region, while resistance mutations reflected likely non-exposure to antiretroviral drugs. Management of STIs may help address ongoing HIV transmission in this region.