BackgroundThe World Health Organization (WHO) and the Government of Kenya alike identify a well-performing health workforce as key to attaining better health. Nevertheless, the motivation and retention of health care workers (HCWs) persist as challenges. This study investigated factors influencing motivation and retention of HCWs at primary health care facilities in three different settings in Kenya - the remote area of Turkana, the relatively accessible region of Machakos, and the disadvantaged informal urban settlement of Kibera in Nairobi.MethodsA cross-sectional cluster sample design was used to select 59 health facilities that yielded interviews with 404 health care workers, grouped into 10 different types of service providers. Data were collected in November 2011 using structured questionnaires and a Focus Group Discussion guide. Findings were analyzed using bivariate and multivariate methods of the associations and determinants of health worker motivation and retention.ResultsThe levels of education and gender factors were lowest in Turkana with female HCWs representing only 30% of the workers against a national average of 53%. A smaller proportion of HCWs in Turkana feel that they have adequate training for their jobs. Overall, 13% of the HCWs indicated that they had changed their job in the last 12 months and 20% indicated that they could leave their current job within the next two years. In terms of work environment, inadequate access to electricity, equipment, transport, housing, and the physical state of the health facility were cited as most critical, particularly in Turkana. The working environment is rated as better in private facilities. Adequate training, job security, salary, supervisor support, and manageable workload were identified as critical satisfaction factors. Family health care, salary, and terminal benefits were rated as important compensatory factors.ConclusionsThere are distinct motivational and retention factors that affect HCWs in the three regions. Findings and policy implications from this study point to a set of recommendations to be implemented at national and county levels. These include gender mainstreaming, development of appropriate retention schemes, competitive compensation packages, strategies for career growth, establishment of a model HRH community, and the conduct of a discrete choice experiment.

Many people newly diagnosed with HIV are lost to follow-up before timely initiation of antiretroviral therapy (ART). A randomised controlled trial (RCT), WelTel Kenya1, demonstrated the effectiveness of the WelTel text messaging intervention to improve clinical outcomes among patients initiating ART. In preparation for WelTel Retain, an RCT that will evaluate the effect of the intervention to retain patients in care immediately following HIV diagnosis, we conducted an informative qualitative study with people living with HIV (n = 15) and healthcare providers (HCP) (n = 5) in October 2012. Study objectives included exploring the experiences of people living with HIV who have attempted to engage in HIV care, the use of cell phones in everyday life, and perceptions of communicating via text message with HCP. Participants were recruited through convenience sampling. Semi-structured, qualitative interviews were conducted and recorded, transcribed verbatim and analysed using NVivo software. Analysis was guided by the Theory of Reasoned Action and the Technology Acceptance Model. Results indicate that while individuals have many motivators for engaging in care after diagnosis, structural and individual barriers including poverty, depression and fear of stigma prevent them from doing so. All participants had access to a mobile phone, and most were comfortable communicating through text messages, or were willing to learn. Both people living with HIV and HCP felt that increased communication via the text messaging intervention has the potential to enable early identification of problems, leading to timely problem solving that may improve retention and engagement in care during the first year after diagnosis.

BackgroundIn response to poor maternal, newborn, and child health indicators in Magadi sub-county, the “Boma” model was launched to promote health facility delivery by establishing community health units and training community health volunteers (CHVs) and traditional birth attendants (TBAs) as safe motherhood promoters. As a result, health facility delivery increased from 14% to 24%, still considerably below the national average (61%). We therefore conducted this study to determine factors influencing health facility delivery and describe barriers and motivators to the same.MethodsA mixed methods cross-sectional study involving a survey with 200 women who had delivered in the last 24 months, 3 focus group discussions with health providers, chiefs and CHVs and 26 in-depth interviews with mothers, key decision influencers and TBAs. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) using logistic regression were calculated to identify predictive factors for health facility delivery. Thematic analysis was done to describe barriers and motivators to the same.ResultsOf the women interviewed, 39% delivered at the health facility. Factors positively associated with health facility deliveries included belonging to the highest wealth quintiles [aOR 4.9 (95%CI 1.5–16.5)], currently not married [aOR 2.4 (95%CI 1.1–5.4)] and living near the health facility [aOR 2.2 (95%CI 1.1 = 4.4)]. High parity [aOR 0.7 (95%CI 0.5–0.9)] was negatively associated with health facility delivery. Barriers to health facility delivery included women not being final decision makers on place of birth, lack of a birth plan, gender of health provider, unfamiliar birthing position, disrespect and/or abuse, distance, attitude of health providers and lack of essential drugs and supplies. Motivators included proximity to health facility, mother’s health condition, integration of TBAs into the health system, and health education/advice received.ConclusionBelonging to the highest wealth quintile, currently not married and living near a health facility were positively associated with health facility delivery. Gender inequity and cultural practices such as lack of birth preparedness should be addressed. Transport mechanisms need to be established to avoid delay in reaching a health facility. The health systems also need to be functional with adequate supplies and motivated staff.Electronic supplementary materialThe online version of this article (10.1186/s12884-017-1632-x) contains supplementary material, which is available to authorized users.

SummaryBackgroundRetention of patients in HIV care is crucial to ensure timely treatment initiation, viral suppression, and to avert AIDS-related deaths. We did a randomised trial to determine whether a text-messaging intervention improved retention during the first year of HIV care.MethodsThis unmasked, randomised parallel-group study was done at two clinics in informal settlements in Nairobi, Kenya. Eligible participants were aged 18 years or older, HIV-positive, had their own mobile phone or access to one, and were able to use simple text messaging (or have somebody who could text message on their behalf). Participants were randomly assigned (1:1), with random block sizes of 2, 4, and 6, to the intervention or control group. Participants in the intervention group received a weekly text message from the automated WelTel service for 1 year and were asked to respond within 48 h. Participants in the control group did not receive text messages. Participants in both groups received usual care, which comprised psychosocial support and counselling; patient education; CD4 cell count; treatment; screening for tuberculosis, opportunistic infections, and sexually transmitted infections; prevention of mother-to-child transmission and family planning services; and up to two telephone calls for missed appointments. The primary outcome was retention in care at 12 months (ie, clinic attendance 10–14 months after the first visit). Participants who did not attend this 12-month appointment were traced, and we considered as retained those who were confirmed to be active in care elsewhere. The data analyst and clinic staff were masked to the group assignment, whereas participants and research nurses were not. We analysed the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01630304.FindingsBetween April 4, 2013, and June 4, 2015, we screened 1068 individuals, of whom 700 were recruited. 349 people were allocated to the intervention group and 351 to the control group. Participants were followed up for a median of 55 weeks (IQR 51–60). At 12 months, 277 (79%) of 349 participants in the intervention group were retained, compared with 285 (81%) of 351 participants in the control group (risk ratio 0·98, 95% CI 0·91–1·05; p=0·54). There was one mild adverse event related to the intervention, a domestic dispute that occurred when a participant’s partner became suspicious of the weekly messages and follow-up calls.InterpretationThis weekly text-messaging service did not improve retention of people in early HIV care. The intervention might have a modest role in improving self-perceived health-related quality of life in individuals in HIV care in similar settings.

BackgroundMalaria is a leading cause of morbidity and mortality in children younger than 5 years in Kenya. Within the context of planning for a vaccine to be used alongside existing malaria control methods, this study explores sociocultural and health communications issues among individuals who are responsible for or influence decisions on childhood vaccination at the community level.MethodsThis qualitative study was conducted in two malaria-endemic regions of Kenya--South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted.ResultsParticipants understand that malaria is a serious problem that no single tool can defeat. Communities would welcome a malaria vaccine, although they would have questions and concerns about the intervention. While support for local child immunization programs exists, limited understanding about vaccines and what they do is evident among younger and older people, particularly men. Even as health care providers are frustrated when parents do not have their children vaccinated, some parents have concerns about access to and the quality of vaccination services. Some women, including older mothers and those less economically privileged, see themselves as the focus of health workers' negative comments associated with either their parenting choices or their children's appearance. In general, parents and caregivers weigh several factors--such as personal opportunity costs, resource constraints, and perceived benefits--when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers.ConclusionsThe study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunization focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender. It should involve influential community members and provide needed information and reassurances about immunization. Efforts also should be made to address concerns about the quality of immunization services--including health workers' interpersonal communication skills.