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Item Level of User Satisfaction with Electronic Medical Records System among Health Workers in Kakamega County Teaching and Referral Hospital, Kenya(Kenyatta University, 2024-02) Okumu, Olivia BukachiStudies have reported low adoption of Electronic Medical Records (EMR) mainly because of lack of EMR use by end users. The main objective of this study was to establish the level of satisfaction by users with electronic medical records system among health workers in Kakamega County Referral Hospital by determining the level of user satisfaction levels with the EMR system by examining the influence of user characteristics and system factors on the level of user satisfaction with EMR system. A descriptive cross-sectional research design was adopted. The study targeted health care workers who had ever used the EMRS system in the hospital before and during the time of the study. The respondents were stratified into homogeneous groups according to cadre and randomly sampled. Fisher et al. (1998) formula was used to determine a sample size of 252 respondents. Structured questionnaires and Key informant interviews were used to collect data. Instrument reliability was by use of Cronbach Alpha coefficient (0.743) and content and construct validity was verified by field experts. Data analysis was both descriptive and inferential analysis. Response rate was 98.01% and the average satisfaction index of EMRS was 54.5%. Key informant (KI) 1“Generally Satisfied with the system because it is easy to use and there is faster and easier retrieval of patient information…” Majority of user characteristics and system factors did influence the level of satisfaction of health workers on the use of ERMS. Age (𝝌𝟐 11.66(p value 0.03) Gender (𝝌𝟐15.566 (p value <0.001) Profession ((Fisher exact) <0.001) Computer Literacy 𝝌𝟐 15.159(p value < 0.001), Training 𝝌𝟐 5.955(p value 0.015) Attitude 𝝌𝟐 95.675(p value < 0.001), significantly associated with overall satisfaction of EMR system. Years worked in hospital were not associated with user satisfaction (p value of 4).KI3 “All staff are required to have a certificate in basic IT this enables the staff to use the system but regular trainings on the EMRs would be appreciated to increase competency of the staff on the system...” The system factors were Information quality 𝝌𝟐 39.314(p value < 0.001), 𝝌𝟐 6.352(p value < 0.012) System quality 𝝌𝟐 8.062(p value < 0.005) 𝝌𝟐 4.452(p value < 0.033) were all associated with user satisfaction while Service quality 𝝌𝟐 2.047(p value < 0.153) 𝝌𝟐 3.333(p value 0.068) was not associated with user satisfaction. KII “The system is secure you cannot access the Emr without a password. Though Users can easily manipulate the system thus the Information Is not taken as being 100% truthful e.g. you can be able to change past patient information...” The binary logistic regression model of overall satisfaction (Omnibus test χ2= 141.055, p < 0.001) and could correctly predict 84.1% of the users who were satisfied with EMRS systems.The study recommendations included a periodical review of user satisfaction levels plus frequent trainings on the system by users and lastly system developers should upgrade system factors such as security, clinical decision support and ability to generate end month reports. A study can be conducted to check why different healthcare professional’s level of user satisfaction differs.Item Patients Health Information and Hypertension Management at Kenyatta National Hospital; Kenya(Kenyatta University, 2023-05) Alembi, Osanya Ayub; Joyce C. Kirui; Eliphas GitongaAbstractItem Livelihood Diversification Strategies and Livelihood Outcomes among Agro-Pastoral Households in Laikipia North Sub-County, Kenya(Kenyatta University, 2022) Irungu, Martin Waithaka; Joan Kabaria- Muriithi; Jane Rose NjueDespite the existing efforts by the agro-pastoral communities to seek livelihood alternatives, they still encounter persistent livelihood insecurity. The growing burden of the need to address food scarcity, among other crises, reflects Arid and Semi-Arid Lands communities' inability to survive without external aid. This study aimed to investigate livelihood diversification strategies and the subsequent livelihood outcomes among agro-pastoral households in Laikipia North Sub-County, Kenya. The specific objectives of the study were; to establish the demographic characteristics of the agro-pastoral households; to investigate the livelihood outcomes; to explore the influence of assets on livelihood outcomes; to establish the relationship between livelihood challenges and livelihood outcomes among agro-pastoralists and to establish the relationship between livelihood diversification and livelihood outcomes in Laikipia North Sub-County. The study adopted a cross-sectional survey design where a sample of the population was selected, and from these individuals, data was collected to help answer the research questions. A total of 422 households were systematically sampled. Data was collected from household heads using household questionnaires and key informant interview guide with County Agriculture and Livestock Officer. Analysis of data was done using SPSS (version 20). Pie charts, frequency tables, and bar graphs present study findings. Significant correlations between variables were tested using the Chi-square test and Spearman rank correlation coefficient at a significance level of 0.05. The study realized a response rate of 90.3% of whom 55.9% were household heads. The average years the respondents had lived in the area was 43. The study found that climate change was a major cause of disparity between the past and current livelihood diversification strategies at 40.7%. Assets (physical, financial and social) were found to significantly influence livelihood outcomes. However, the challenges the respondents faced were found to have no significant influence on the livelihood outcomes (χ=1.017, df =1, p=0.313). Finally, there was a significant relationship between the adopted livelihood strategies and livelihood outcomes (χ2=14.730, df =1, p=0.000, r=-0.197). The study made recommendations to the relevant entities to strengthen extension services, improve infrastructure and provide a conducive business environment.Item Referral for Health Services among Outpatients at Nyeri County Referral Hospital, Kenya(Kenyatta University, 2022) Murithi, Gatwiri; Kenneth RuchaOne of the fundamental human rights is right to health. To achieve this within a health system with different levels of care there is need for a functional referral system that enables continued uninterrupted care across different levels. Data available in Nyeri county health department however shows that clients bypass the primary level facilities and present themselves to referral facilities thus placing huge demands for health services on tertiary facilities. This research therefore sought to establish factors associated with referral for health care services at the County Referral hospital during (Universal Health Coverage) UHC implementation in Nyeri County. The study employed a cross-sectional study design targeting patient, health care professionals and managers at the County Referral hospital in Nyeri. Administration of structured questionnaires and key informant interviews were carried out to acquire qualitative and quantitative data. A sample size of 402 respondents was estimated proportionate to the population from a sampling frame of patients seeking outpatient services at the County Referral hospital. Purposive sampling was used to pick key informant respondents while patient respondents were picked by systematic random sampling. Acquired data was analyzed by use of SPSS version 23 and MS excel. Inferential statistics included Chi-Square tests done at a confidence interval of 95% to ascertain association between the study variables while thematic analysis was applied for qualitative data. The study found that majority of respondents were female, young, self-employed, had low income and lived in rural areas. Chi-square tests showed that sex (p=0.004), level education (p=0.000) and residence (p=0.000) were significant. Majority of the respondents said that they had never been given information about the referral process. Even among those who had received information, majority reported information given was not clear. Lack of awareness was also highlighted as a factor influencing referral during key informant interview. Awareness (p=0.000) was significant. Slightly less than half responded they were dissatisfied with health care services they received Chi-square results showed that distance (p=0.000), infrastructure (p=0.004) and general satisfaction (p=0.000) were significant. The odds of females practicing referral as compared to males (OR= 0.54;95% CI 0.35-0.82), awareness (OR=0.21;95% CI 0.13-0.34) residence (OR=23.47 95% CI 13.54-40.69) remained significant in the logistic regression analysis. Descriptive results showed that respondents were dissatisfied with waiting time and patient-doctor relationship. Lack of medicine and lack of information were other factors cited for dissatisfaction. The study therefore concluded that referral for health care services among outpatients was predicted by socio-demographics, awareness and health system factors with awareness being the most important predictor. The findings of this study therefore call for a public sensitization campaign to enhance the utilization of primary healthcare facility with the ultimate goal of having a smooth referral process. The county governments also need to ensure that primary health facilities are adequately staffed and well equipped especially with medicines.Item Tuberculosis Treatment Adherence among Patients Taking Anti-TB Drugs in Kilifi County, Kenya.(Kenyatta University, 2022) Chebet, Nancy Auguct; Joyce KiruiTuberculosis is a still global public health problem, despite numerous interventions in place to reduce its spread and burden among the poor. Despite TB being a treatable, curable and preventable disease, there has been very minimal decline of below 2% to TB incidence in the past years, with over 4 million cases neither diagnosed nor treated. TB has no empirical measure for treatment adherence. WHO, defines treatment adherence as either process or outcome oriented. Process oriented include the use of pill count and appointment date keeping, whilst outcome orient includes use of cure rate as a measure of success. Kilifi County has case notification rate of 189/100000 which are higher than the national standing of 154/100000. Malindi subcounty reported low treatment success rate and cure are of 68% and 68% respectively which are way below the national target of 90% cure rate, less than 5% loss to follow-up (LTFU), <5% TB deaths and 0% patients not accounted for. Further in the recent years there has been increasing loss to follow up cases of 8% in 2017, to 42% in 2018 as reported by TIBU. The study adopted a descriptive cross-sectional study to determine individual factors, behavioural factor, societal factors and health facility factors that influence TB patients into adhering to treatment in Malindi subcounty, Kilifi County. The data was collected from structured questionnaire from Morisky adherence scale and focused group discussion. The study was pretested in Kilifi County Referral Hospital-TB clinic for Validity and reliability. The findings were analysed using SPSS version 20.0, further analysed through using Odd Ratio to measure the strength of variables to treatment adherence. The findings indicated TB treatment adherence in Kilifi County was at 75% which was below the National target of 90%. Sociodemographic factors like living with family and level of knowledge on TB specifically what causes TB, who can get TB and duration of treatment were associated with TB treatment adherence. Behavioural factors of perceived severity, perceived susceptibility, Societal factors like stigma and health facility factors like patients’ satisfaction were factors associated to TB treatment adherence. We recommend the Ministry of Health increase health advocacy on TB at the community to increase knowledge and reduce stigma. Secondly, Policy makers should recommend regular patient trainings on behaviour change campaigns to increase perceived severity and perceived susceptibility during treatment regime. Thirdly, refresher trainings for health care workers on service delivery to patient satisfactionsItem Utilization of Free Maternity Services among Mothers Aged 18- 49 Years in Nakuru County, Kenya(2022-04) Najoli, Priscilla Jemeli; Dr. Joyce KiruiIn response to sustainable development goal (SDG) 3,all countries were expected by 2030 to have improved maternal and neonatal health indicators.In Kenya,the hope of free maternity services (FMS) was to increase the demand for maternity health care services offered by certified health professionals.This,inturn would contribute to reversing MMR and neonatal mortality and improve the uptake of skilled birth attendance(SBA).Nakuru County has indicated poor maternal child health indicators as demonstrated by increased MMR,neonatal mortality and low SBA.Thus,this study aimed to determine and understand the utilization level of FMS among mothers aged 18-49 living in Naivasha Sub-County,Kenya.The research employed a crosssectional and descriptive design that involved 392 women who utilized FMS 2018- 2019.A mixed-methods approach collected quantitative and qualitative data through structured questionnaires,health records reviews,focus group discussions, and key informant interviews.The quantitative and qualitative data were analyzed by use of SPSS 20 and content analysis respectively.The results were further subjected to multiple regression analysis.The findings showed that over 80% utilized antenatal care, facility deliveries and postnatal care, but 68% of respondents utilized family planning. The mothers were found active in their first, second and third pregnancies in utilizing FMS followed by a sudden decline.The mothers preferred the public health facilities to the private, mission and NGOs.The significant findings influencing the utilization of FMS among the mothers were age (P=.004), the number of children (P=.000), age at first birth (P=.025), household income (P=.008) and residential area (P=000).The mothers in rural and periurban settings utilized the FMS than their counterparts in the urban areas.The mothers' level of knowledge on FMS was notably at 80%.The radio, television,health facility and community sources were significant with (P=.000) as effective sources of information for the mothers in the community.The decision makers consider age, the number of children, age at first birth, household income and residential area in formulation of FMS policies.Further,utilize relevant sources of information on FMS in the community.Item Determinants of Elimination of Mother to Child Transmission of Hiv among Patients at the Nakuru County Referral Hospital, Kenya(Kenyatta University, 2022) Isindu, Boniface Ambani; Alloys Orago; Joachim OsurGlobally, 37.6 million people living with HIV around the world, 67% live in sub-Saharan Africa. Out of the 200,000 new diagnoses of HIV in Africa in 2021, young women and adolescent girls aged 15-24 made up 27% of those new cases. The United Nations reported 1,000 new infections per week in this group. Regionally, out of the 20.7 million adults living with HIV in the region in 2018, 12 million were women: young women (aged 15–24 years) account for 26% of new HIV infections: In Kenya, tremendous progress in slowing down spread of HIV has been made with new infections declining by 68.4% between 2013 and 2021.Deaths attributed to HIV/AIDS had dipped by 67% from 58,446 people in 2013 to 19,486 in 2021.Increased number of people on life-saving antiretroviral treatment ;Rise by 83%, from 656,369 in 2013 to 1,199,101 in 2021 adults prevalence stands at 4.9%;Women at 6.6% twice that of men (3.1%) as per Kenya Population-based HIV Impact Assessment (KENPHIA) 2018 survey Mother to child transmission (MTCT) of HIV, is the main route of HIV infection among infants born by HIV positive mothers. An estimated 50,000 to 60,000 infants contract HIV infection annually in Kenya through their mothers .Kenya rolled out a countrywide Prevention of Mother to Child Transmission (PMTCT) programme to reduce the HIV infection in children because the main route for HIV transmission among children is through birth .In Kenya, an estimated 37,000 to 42,000 infants are infected with HIV annually due to MTCT.During pregnancy, about 5 to 8 percent of HIV-exposed babies become infected through transmission across the placenta. In Kenya, the national MTCT rate for the year 2021 was 3.2% while the rate in Nakuru County was reported to be 4..9% with the highest reported rate being in the month of march 2021 at 9.4%.Currently the MTCT rate reported in Nakuru county (4.9%) is much higher than the National rate (3.2%).The causes of this sustained high MTCT rate are not well documented hence this study at Nakuru County Referral Hospital to investigate these determinants. The Study objective was to investigate the determinants of eMTCT among patients at Nakuru county Level 6 Referral Hospital, Kenya. A cross sectional analytical research study was carried out with data collected from ANC mothers, key informants and FGD participants using structured questioners, key informant interview guides and FGD guides. The analysis of the data collected from the ANC clients revealed that nearly seventy percent of mothers had no knowledge of services provided to seropositive pregnant mothers to reduce the risk of transmission to unborn child. Further analysis revealed that low male involvement and participation, Stigma, and discrimination, peer pressure, social groups, religious sects, ceremonies (funerals), visiting sick people in the community were key social determinants that sustained high transmission rates in the county. Cultural beliefs, practices and taboos had a significant contribution to the high MTCT rates that were reported in the county. Low level of knowledge contributes significantly to the high MTCT rate reported in Nakuru Referral Hospital as were social cultural factors. It was recommended that Ministry of Health in collaboration with Health implementing partners and all health actors to develop promotional messages and information on eMTCT and disseminate them to all pregnant women attending ANC at all health facilities in the country. Socio mobilization and awareness on Prevention of Mother to Child Transmission program to be scaled up to empower women with knowledge on PMTCT. Community and political leaders to be enlightened by health implementing partners on good health practices to discourage pregnant women from their negative cultural beliefs and practices to promote health seeking behavior among these women. Health education and health talks to pregnant women to focus more on the importance of adherence to clinic appointments during their pregnancy life to benefit from services provided.Item Use of Routine Health Information for Decision Making among Health Care Workers in Marsabit County, Kenya(Kenyatta University, 2021) Asafa Aila, Mohamed; Peter KithukaGlobally, health agencies have delved in strengthening health systems as a means of improving health outcomes. In Kenya today, the management of the public health facilities at different levels is more concerned about the collection and reporting of routine health data through District Health Information Software (DHIS2) but little is known on how individual facilities analyze report and disseminate the same for use in making informed decisions at the facility level. Yet in spite of the introduction of DHIS2, recent evidence has shown very low levels of data demand and use by the targeted stockholders in Kenya. Generally, there is a concerted effort by both the government and the international bodies to accelerate the collection of health data, but little efforts have been made to ensure its utilization at facility levels. The current study assessed the factors associated with the use of routine health information for decision making among health care workers. The study employed descriptive cross-sectional design. Researchers purposively stratified 201 health workers by cadre, and then probability proportionate sampling was applied to get the required number from every cadre. Both qualitative and quantitative data were collected. Quantitative data was entered into the SPSS software, descriptive statistics and Chi-square tests were used to analyze the data. Whereas qualitative data was analyzed thematically. The study found that the overall Routine Health Information (RHI) used was evidently below average at 47.1% in decision-making across six management functions. However, RHI was above averagely used for medical supply at 54%, service delivery at 57%, and identification of gaps at 56%. It was below averagely used for the formulation of plans, budgeting, and staffing decisions. It was also found that the health facilities lacked sufficient IT accessories. Nevertheless, internet access was at 71 % and electricity supply at 84 % implying access was not limited. The type of software use had a significant association with the frequent use of RHI at a p-value (0.028<0.05). The majority 74% of respondents had basic computer skills but 80% of respondents lacked training in health information management. The study concluded that the use of RHI in decision-making was below average and training increases the likelihoods of healthcare workers utilizing RHI. Also, computers and the types of software were likely to influence the use of RHI. The study recommends that the County government of Marsabit should embrace the adoption of the electronic medical record system in all health facilities to strengthen the practice of RHI use in decision-making across all health system blocks. In addition, the County government should increase the availability of IT accessories in health facilities to enhance data management practices. Further, the study recommends that the County should provide continuous training for HCWs by focusing computer literacy and data management through on-job training, and refresher courses.Item Assessment of Anti-Female Genital Mutilation Program in Garissa County, Kenya(Kenyatta University, 2021) Derow, Yasmin Hassan; Eliphas GitongaFemale genital mutilation (FGM), is a social traditional practice performed by cutting parts of the external female genitalia. Globally, over three million women take part in the practice each year. The practise of this rite was made illegal in Kenya in 2011 and a board established to spearhead its abandonment in a program referred to as AntiFGM campaign. Garissa County in north eastern Kenya has the highest practise of FGM with a prevalence of 94%. This study aimed to investigate the success of the antiFGM programs in Garissa County with specific objectives being to determining the level of knowledge of adolescents/youth of Garissa County towards the anti FGM law, to determine the attitude of area residents towards the anti FGM law and to determine factors that influenced the implementation of the antiFGM law in Garissa County. Mixed methods study design was used in this study. A cross-sectional design using interviewer guided questionnaires to collect data was conducted among 108 randomly selected participants and results used to answer objectives one to three. Desktop review of previous studies was use to answer objective four. Data was analyzed using SPSS version 25. Chi-square and Fishers exact were used to compare participants characteristics against study outcome variable. Of the 108 participants, 53.7% were female. The median age of participants was 23 years (Interquartile range [IQR] 15-40). The prevalence of FGM was 62% with the mean age of circumcision being 8.3 years (SD 2.7 years). There was a statistically significant association between practicing Islam and FGM (p=0.001). There was an improvement on the level of awareness of the antiFGM law among youth in Garissa at 84%. Two thirds of participants did not support FGM. Mothers were the main influencers and decision makers on having FGM practiced. Excision was the main type of FGM practiced with traditional circumcizers being the preferred circumcizers followed by trained nurses and midwives. Introduction of the antiFGM law and advocacy by NGOs focused on combating FGM has led to a reduction in the prevalence of FGM and a reduction in the support of the act. There is an increase in the medicalization of FGM in Garissa with evidence of the practice going underground. This study recommends NGOs to have a clearer focus on the method chosen in advocating for abandonment of FGM.Item Preparedness for Ebola amongst Healthcare Workers in Public Health Facilities in Nairobi City County, Kenya(2021) Elyas, Mohamed Ali; Andrew YitambeEbola virus disease, a highly infectious viral condition, has caused the worst epidemics in the West African countries of Guinea Bissau, Sierra Leone and Liberia in 2014-2016.In 2018 the virus re-emerged in Democratic Republic of Congo prompting WHO to declare it a public health emergency of international concern with the most recent outbreak in Guinea Bissau in 2021. Kenya is at high risk due to its proximity to the affected countries of DRC and Uganda, its porous borders and its high volume of international flights. Thus, Kenya’s preparedness mode is heightened with measures including reactivation of Ebola Contingency Plan, conducting simulation exercise at Kenyatta National Hospital and mapping of the counties based on their Ebola risk levels instituted albeit at the national level. However, less attention has been given in terms of preparedness to the healthcare workers at critical service delivery points at the Public health facilities in high risky Nairobi City County. This prompted the need to identify the organizational support for healthcare workers, their risk perceptions and socio-demographic characteristics associated with Ebola preparedness amongst healthcare workers in Public health facilities in Kibra sub-county. A cross-sectional descriptive study design was adopted and 165 established as the sample size. Response rate stood at 95% with 157 of the 165 health care workers fully participating. Probability proportionate to size together with simple random sampling was used. Data was analysed using statistical packages for social sciences (SPSS) version 23, where both descriptive frequencies and inferential statistics generated. Chi-square was used to establish associations between variables. Ebola preparedness was assessed using three criteria of capacity to detect Ebola case, protect staffs and notify for action. Majority of the healthcare workers felt unprepared (66%). Socio-demographic characteristic was found to be associated with healthcare workers’ Ebola preparedness with age (χ2=21.; df=3; P<0.001) and professional cadre (χ2=28.901; df=7,P<0.001) emerging significant predictors. Younger respondents were found to be less prepared for Ebola. It further revealed that healthcare workers with low perceived risk were more prepared for Ebola (χ2=6.854, df=1, P=0.009). Besides, several organizational support factors such as access to hand sanitizers (χ2 =13.893,df=1,P<0.001), pairs of gloves (χ2=11.863,df=1,P=0.001), holding Ebola related briefs (χ2=11.144,df=1,P=0.001), risk alert sharing (χ2=27.081,df=1,P<0.001) having participated in Ebola training (χ2 =11.144,df=1, P=0.001) and whether contents of the preparedness plan was availed (χ2 =7.303,df=1,P=0.007) were established to be associated with Ebola preparedness. Conclusively, the study established socio-demographic characteristics, risk perceptions and organizational support to be significantly associated with Ebola preparedness. To fill the limitation of this study, there is need to undertake similar study on healthcare workers preparedness for Ebola in both Public and private health facilities across counties with a view to increase sample size for wider generalizability of the findings.Item Compliance with the Medical Records Documentation Standard Operating Procedure among Health Workers in Bungoma Hospital County, Kenya(Kenyatta University, 2021) Omoit, David Franklin Opudi; George O. Otieno; Kenneth Kibaara RuchaImproving medical records documentation among the health workers remains a major challenge to achieving compliance to medical records documentation SOP in many developing countries. Compliance to medical records documentation SOP can be used to improve health care and protect people against catastrophic health care risks and expenses. Most developing countries have low compliance to medical records documentation SOP and rely on manual systems for documentation. Despite having automated systems in some private and public health facilities, compliance to medical records documentation is still below the acceptable standards. The main objective of this study was to establish compliance with medical records documentation SOP among health workers in Bungoma level 4 hospital, Kenya, with specific objective of determining association between socio-demographic characteristics and compliance with medical records documentation SOP, influence of institutional characteristics and, influence of health workers' IT Proficiency on compliance with medical records documentation SOP among health workers in Bungoma level 4 hospital. The current study adopted an analytical cross-sectional design and quantitative data was collected using self-administered questionnaires, stratified proportionate and simple random sampling techniques were both employed to select 197 health workers sampled from a target population of 400 in Bungoma level 4 hospital. Chi-square, fishers exact, and Binary logistic regression analyses were used to test the association and the relationships between dependent (compliance with medical records documentation SOP) and independent variables (sociodemographic, institutional, and IT proficiency) respectively, albeit at a 95% confidence interval (CI), frequency tables, pie charts, and bar graphs were used to summarize and present the results. The current analysis confirmed that the compliance level to medical records documentation SOP was indeed very low at 47.2%. Socio-demographic factors such as Cadre (Fisher‟s exact test =24.52; p=0.002), level of education (Fisher‟s exact test =11.26; p=0.042), and work experience χ2 (8.75, df=5, N =195) p=0.047 were significantly associated with compliance to medical records documentation SOP. On both Institutional characteristics (P=0.023, exp(B)=1.454) and healthcare worker‟s Information Technology proficiency (P=0.027, exp(B)=2.156), positively influenced compliance to medical records documentation SOP. The current study concludes that, cadre, level of education, and work experience were significantly associated with compliance to medical records documentation SOP, Institutional characteristics like technical support, requisite documents, staff training and, health worker‟s information technology proficiency, positively influenced compliance to medical records documentation SOP respectively. The study therefore, recommends an urgent need for the County Government to channel additional funding towards employing more technical staff, procuring the requisite documentation tools, and training of staff on the documentation tools. Otherwise, the facility health management team needs to factor in periodic Information Technology refresher training for health workers, since the majority of health workers in Bungoma level 4 facility seem to have at least an intermediate level of IT proficiency. Future research should incorporate more robust data collection methods like observation checklists, and also consider qualitative methods like Key Informant Interviews to establish better insight on the compliance with medical records documentation SOP across all level 4 health facilities in Bungoma County and beyond.Item Administration of Informed Consent for Medical Imaging Services among Patients in Government Hospitals in Nairobi City County, Kenya(Kenyatta University, 2021) Koi, Victoria Otysula; Andrea Yitambe; Peterson WarutereInformed consent is a requirement by law to allow patients to make decisions with respect to their health and well-being. It is an ethical and legal requirement that patients seeking medical imaging services should give an informed consent prior to seeking treatment with respect from healthcare providers. However, the extent of usage of the informed consent process varies across medical procedures. The study therefore sought to assess informed consent process in medical imaging procedures for patients in government hospitals in Nairobi City County, Kenya. The study adopted a descriptive cross-sectional study design. The study specifically focused on administration of informed consent, contents of the patients Informed Consent Forms and modes of informed consent used among patients for medical imaging services. Imaging departments in Kenyatta National hospital, Mbagathi, Mama Lucy, National spinal injury and National Mathare Hospitals in Nairobi City County were chosen as the area of study. The patients in the imaging departments of the selected hospitals were recruited for the study. The sample size selected was 307 respondents. The respondents were selected using systematic random sampling at a predetermined interval of 3. Collected data was coded for analysis by use of Statistical Package for Social Sciences. Analysis was conducted on descriptive and inferential statistics. Frequency tables, pie-charts and graphs were used to present the quantitative data. Inferential statistics were done using Chi Square tests to determine the association between study variables at 95% confidence interval (p<0.05). The ethical considerations were strictly followed during data collection. The study results revealed that majority 222(75.0%) of respondents were administered with informed consent with 79(75.2%) of respondents in Kenyatta National Hospital reporting to have adequately administered with informed consent before a medical imaging procedure. It was established that most 181(61.1%) patients sought for X-ray services compared to other imaging procedures for treatment. Verbal informed consent was the most used mode of informed consent with 123(55.0%) respondents having administered to it. It was further revealed that age (χ2=3.782; df= 4; p=0.016;), level of education (χ2=3.89; df= 4; p=0.030), revelation of reason for referral (χ2=26.081; df=1; p=0.001), provision of right to refuse or defer imaging (χ2=33.468; df= 1; p=0.001), giving consent for treatment (χ2=70.733; df=1; p=0.001), decision making for wellbeing (χ2=12.056; df=1; p=0.001), pre-operative counseling (χ2=9.533; df=1; p=0.002), cases of negligence from clinicians (χ2=22.414; df=1; p=0.001), understanding information provided by clinicians (χ2=4.394; df=1; p=0.036), adaptation of informed consent doctrine meeting physicians and patients (χ2=7.648; df=1; p=0.006), performance of diagnosis from patients’ past medical history (χ2=9.788; df=1; p=0.002), advice on alternative treatment options available (χ2=8.065; df=1; p=0.005), disclosure of information by practitioners (χ2=19.406; df=1; p=0.001) and physical examination done before medication (χ2=9.006; df=1; p=0.003) were significantly associated with informed consent administration among respondents. The study concludes that informed consent was administered to majority of respondents in Public Hospitals in Nairobi City County. Most of the domains of the contents of informed consent were adhered to. The study further concludes that verbal informed consent was the most prevalent mode administered with most of the respondents utilizing X-ray medical imaging services. These research findings provide a great insights and information to leaders, managers, law makers, governing and oversight authorities in decision making, policy formulation, strategic planning and regulation in a context specific to provide a conducive environment for practicing medical imaging procedures in an ethical and legal manner.Item Management of Diabetes Mellitus at the Household Level Using Community Health Strategy in Embu County, Kenya.(Kenyatta University, 2021) Hussein, Salim Ali; Peter M. KithukaThe community health strategy (CHS) focuses on empowering the communities to take control of and over their health. This approach aims to improve the health status of Kenyan communities by initiating and implementing health care actions that focus on the whole life cycle. Globally Diabetes Mellitus (DM) causes a mortality of 1.6 million each year and morbidity of about 422 million people. DM causes 1% of the mortality in Kenya and 2% of the population in Kenya has DM. In 2019 Embu County was the 5th leading County in DM morbidity and the 6th leading county in DM mortality in Kenya. Kenya adopted the Community Health Strategy in 2006 as an approach to reduce the worsening health indicators. This study assessed the management of Diabetes Mellitus at the household level using the community health strategy in Embu County. It was a cross sectional study using 422 household participants in Embu County. The 60 households sampled in each location was equally distributed among villages in each location Purposive sampling was used to select all the 30 Community Health Volunteers (CHVs) that had been trained on DM management at the household level and were interviewed. CHVs’ knowledge on management of DM was tested. Interviewer administered questionnaires and assessment questions were used to collect data. Key informant interviews were used on CHS managers. Data was analyzed using SPSS version 25. The results showed that CHVs in Embu County had poor scores in managing diabetes in the study area. The health system factors that were positively associated with performance of CHVs were leadership and governance with (adjusted odds ratio [AOR] 5.0; 95% confidence interval [CI] 1.20.7.89), financial support AOR 2.23; 95% Confidence interval [CI] 0.20, 6.00) and availability of kits and commodities [AOR 4.00, (Odd ratio=4.00; 95% CI=1.21, 7.8) Level of knowledge of CHVs on Diabetes Management was also positively associated with DM management at household level in particular level of knowledge of prevention and treatment of DM by CHVs increases the odd of DM management at (Adjusted Odd ratio [AOR] 12.0; 95% Confidence Interval [CI]0.901, 33.3) as well as level of knowledge of CHVs to define and classify Diabetes (Odd ratio=13.9; 95% CI=2.00, 23.9) At the same knowledge of CHVs to identify signs and symptoms of diabetes was found to increases the odd of DM management by (Adjusted Odd ratio [AOR] =8.90; Confidence Interval [CI] 4.56, 33.00). The qualitative findings reinforced the quantitative results by indicating that refresher training, workload, and in-kind incentives were important determinants of performance. Major recommendation was as follows; that there is a need for continued use of CHVs to be the focal point for diabetes management, improved staffing of the facilities where community units are linked in order to strengthen referrals and linkage systems especially taking into consideration the spatial distribution and population density. This will improve support supervision from Community Health Extension Workers (CHEWs) to CHVs during their community work.Item Clinician Workload Determinants at Paediatric Wards of Selected Private and Public Hospitals in Nairobi City County, Kenya(Kenyatta University, 2020) Kiura, Daniel Munyi; Andrew Yitambe; Goretti OfafaHuman Resources for Health is a key pillar of healthcare provision necessitating prudent staffing norms to meet workload demands of health facilities. Uniform staffing norms across health systems based solely on policy guidelines can no longer be used at facility level without adjusting for facility specific trends of workload determinants such as occupancy the omission of which results in poor outcomes or wasted resources due to inadequate staffing mix. The study utilized a cross sectional design & sought to confirm or disapprove the correlation between bed occupancy and patient care activity time with clinician workload at paediatric wards of selected public & private hospitals in Nairobi County, Kenya and drive for determinant informed application of staffing norms in the different settings of the health sector. A validated staffing standardization model was used to estimate Clinician Workload. The different types of activities that clinicians carry out in their daily work were determined through key informant interviews. Results of the interviews helped design a work sampling data collection tool through which observations were made on the frequency of patient care activities carried out by the clinicians and thus established activity times. Activity time data collected from the survey was analyzed using Statistical Package for Social Sciences (SPSS) version 22 and factored into the validated model so as to derive workload and the corresponding clinician staffing level. Multivariate linear regression analysis was used to correlate the various independent variables and clinician workload followed by test of significance for each variable. A sample of 6188 observations were made among 115 clinicians with a distribution of 4,890 (79.0 %) observations for direct patient care activities, 771(12.5 %) observations for indirect patient care activities and 527(8.5%) observations on allowance activities. Differences were observed between public & private facilities in average bed occupancy (2= -0.505, df= 53, p = 0.000) and proportion of time spent by clinicians in direct patient care activities (2= -10.995, df=53 p = < 0.05) but no significant difference in workload required (t=- 1.415, df=53, p= 0.163). There was varied but significant correlation between various variables and workload including direct patient activities (r=.743, P< .000), indirect patient activities (r=-.311, P< .021) and bed occupancy (r=.314, P< .020). The study concluded that workload increases by one unit with every 8.8% change in direct patient care activities volume, every 5% change in indirect patient care activities and 14.3% change in bed occupancy with the three factors accounting for 54.4%, 9.7%, and 9.8% of the determinants of workload respectively. Multivariate regression of the combined factors of patient care activities, allowance activity, ward occupancy and facility owner found these factors to account for 85.9% of the variation in clinician workload (p-value <0.001). The study recommends that the magnitude of direct patient care activities should be considered when determining clinician workload, that strategies of reducing the effect of indirect patient care activities on clinician workload should be devised and that bed occupancy trends should be studied and factored into workload determination derivation of staffing norms.Item Determinants of Utilization of Electronic Medical Records Systems in Clinical Management in Public Healthcare Facilities in Mombasa County, Kenya(Kenyatta University, 2021) Mwang’ombe, Alice; Andrea Yitambe; Stephen Titus WaithakaThe adoption of information and communication technology (ICT) in the medical field in the form of electronic medical records (EMR) systems had been promoted as a way to reduce cost, increase effectiveness and improve the quality of care. In Kenya, the EMR is being rapidly implemented in both public and private sector healthcare facilities. However, the implementation of the EMR system has been met with partial success, for example, while the patient billing component is being fully utilized, the patient clinical data capture of the system remains underperforming leading to questions about its useability and usefulness in holistic healthcare management functions. Therefore, the study sought to find out the determinants of utilization of electronic medical records systems in clinical management in public healthcare facilities in Mombasa County, Kenya. Specifically, it sought to establish how perceived usefulness of EMR, staff ICT knowledge and staff attitudes influence the use of electronic medical records systems in clinical management in public healthcare facilities in Mombasa County. It also sought to establish the moderating effect of internet connectivity on determinants of utilization of electronic medical records systems in clinical management in public healthcare facilities in Mombasa County. The study was guided by the Technological Acceptance Model. Cross-sectional study design was adopted which targeted healthcare professional drawn from various public healthcare facilities in the County. Stratified random sampling was used to acquire a sample size of 215 respondents. Data was collected using structured questionnaires. Data was analyzed using both descriptive and inferential statistical techniques with the aid of Statistical Package for Social Scientists (SPSS) version 21. The findings of multiple regression analysis revealed that two variables: staff attitudes (β = 0.221, p < 0.05) and staff ICT knowledge knowledge (β = -. 161, p < 0.05) significantly influenced the use of EMR in clinical management in public healthcare facilities in Mombasa County. However, perceived usefulness of EMR (β = 0.121, p > 0.05), and was found not to significantly influence the use of EMR in clinical management in public healthcare facilities in Mombasa County. Further, Internet Connectivity (R-square change before (β = 0.3387; P = 0.011 and after β = 0.2777; P = 0.020) had a significant moderating effect on utilization of electronic medical records systems in clinical management in public healthcare facilities in Mombasa County. The study, therefore, recommends, the EMR system designers to involve the medical staff substantially in the design of the system so as to fully capture their views and working requirements and also help domesticate the system to improve its implementation rate in the area. In addition, the Mombasa County government ought to increase funding in the health sector for acquisition of ICT resources needed to increase EMR use in the hospitals as well as sponsor regular training on EMR to encourage hospital staffs to participate in the program and also improve on their computer skills.There is need for the County health management team to organize seminars or conferences to bring together academicians, clinicians, hospital administrators and other policy makers to convince the medical staff on the advantages of using EMR in clinical management of patients. Finally, the hospitals‘ management together with other stakeholders need to re-engage the communications networks service providers to improve the network performance of the stystem to provide full coverage and access even from remote locations.Item Level of Information and Communication Technology Adoption among Information Technology Managers in Selected Health Facilities in Nairobi City County, Kenya(Kenyatta University, 2021) Sudi, Collins Adego; George Ochieng Otieno; Kenneth Kibaara RuchaInformation Communication and Technologies (ICTs) have the potential of improving the quality of service delivery in Health Facilities. The broad objective of the study was to establish the factors influencing the level of ICT adoption in Health facilities in Nairobi City County. The specific objectives were: to determine the current level of ICT adoption in Health facilities, to determine the factors that influence adoption of ICT in Health facilities, and to determine the influence of Health workers attitude on adoption of ICT in Nairobi City County. A cross sectional descriptive study design was adopted. Participant (N=270) consisted of IT managers drawn using the proportional stratification sampling method to represent health facilities at different levels of categorization as per the Kenya Master Facility list. Questionnaires from 220 (81%) of the respondents were filled and returned. The collected data was analyzed quantitatively and qualitatively. Descriptive (frequencies and percentages) and inferential statistics (chi-square results) were computed. The green ICT maturity model theoretical framework tool was used to establish the overall level of ICT adoption. The study found that 1) the overall level of ICT adoption in Nairobi County Hospitals is at level two. Specifically, the level of ICT adoption as assessed at different levels showed that the ICT functional sophistication is 27%, technological sophistication is 7%, and system integration is 3% of sampled hospitals; 2) various factors influence ICT adoption at various levels. Specifically technological (χ² = 1.7915; df = 2; p = 0.008), organizational (χ²= 1.6534; df = 2; p = 0.037), and financial (χ² = 2.1944; df = 2; p=0.034) factors were significantly associated with functional sophistication; technological (χ²= 1.7915; df = 4; p = 0.008) and financial (χ² = 2.1944; df = 4; p=0.034) factors were significantly associated with level of technological sophistication while technological (χ² = 7.3827; df = 2; p=0.025), environmental (χ² = 15.5053; df = 2; p=0.000), organizational (χ² = 7.2298; df = 2; p=0.027) , and financial (χ² = 2.1944; df = 2; p=0.027) factors were significantly associated with ICT integration 3). Staff attitudes were significantly associated with technological sophistication (χ²= 3.6675, df = 2; p=0.453) and service integration (χ²= 6.5463, df =2; p=0.038). The study found sufficient evidence to reject the null hypothesis that ICT adoption in health facilities is not influenced by organizational, technological, financial and environmental factors. Additionally, with regards to the second null hypothesis, the study also found sufficient evidence to reject the null hypothesis that health workers attitudes do not significantly influence ICT adoption. The study recommends allocation of more resources and support of ICT related management by the Ministry of Health both at the National and County level; that the health workers to be involved in decision making regarding the types of technologies and systems to adopt this enhances acceptability .Item Job Satisfaction among Healthcare Professionals in Selected Public Hospitals in tTans-Nzoia County, Kenya(Kenyatta University, 2021) Nyang’ori, Fred Wangila; Kenneth Bucha Kibaara; Peter KithukaThe major challenge facing hospitals worldwide is dissatisfaction among Healthcare Professionals. Job dissatisfaction can lead to an increase in the spate of industrial actions and poor quality service delivery. This research sought to assess the determinants of job satisfaction among Healthcare professionals in selected public hospitals in Trans Nzoia County, Kenya. The hospitals were Cherangany, Kwanza, Endebes, Saboti Sub-county hospitals, and Kitale County Referral hospital. The specific objectives included; to determine the level of job satisfaction, to determine whether there was a statistically significant relationship between socio demographic characteristics, work environment factors and job satisfaction, to explore the mediating effect of government policy on the relationship between work environment factors and job satisfaction and to explore determinants of job satisfaction among healthcare professionals in selected public hospitals in Trans-Nzoia County, Kenya. A facility-based cross-sectional study was conducted among 263 randomly selected healthcare professionals from all health cadres. Quantitative data were collected using self-administered questionnaires and analyzed SPSS v24 software. The bivariate analysis used a chi-square test for association at 95% CI. Significant factors (p<0.05) at bivariate analysis were subjected to Logistic regression (LR) to identify the predictors of job satisfaction. Chi-square analysis was used to determine the association between dependent and independent variables. Content analysis was done on the qualitative data and findings integrated into the report. The study established a 47.5% job satisfaction rate. From the Key informant interview, 80% of respondents stated that healthcare professionals in their institutions were dissatisfied with their jobs. There was a significant statistical association between socio-demographic characteristics, work environment factors, and job satisfaction. The variables that independently predicted overall job satisfaction were found to be year of service in the hospital (AOR= 0.132, 95% CI= 0.020-0.867, p= 0.035), designation (AOR= 1.411, 95% CI= 1.411-1.02, p= 0.037), contingent reward (AOR= 0.007, 95% CI= 0.000-0.87, p= 0.043), pay (AOR= 419.558, 95% CI= 2.005-87803.14, p= 0.027), fringe benefit reward (AOR= 459.68, 95% CI= 2.206-95792.65, p= 0.024) time off (AOR= 9587.84 95% CI= 10.206-9007324.44, p= 0.009), Job evaluation (AOR= 719.589, 95% CI= 3.587-144363.23, p=0.015), training (AOR=2193.54, 95% CI= 9.224-521630.56, p=0.006), staff competence (AOR= 275.586, 95% CI= 2.472-30723.09, p=0.019), appreciation (AOR=2193.54, 95% CI= 9.224-521630.56, p=0.032), supervision (AOR=118.826, 95% CI= 2.255-6260.744, p=0.018), communication (AOR=681.22, 95% CI= 3.270-141920.08, p=0.017), relationship with co-workers (AOR=1069.194, 95% CI= 3.818-299442.63, p=0.015), equipment and resources (AOR=1829.65, 95% CI= 6.809-491653.31, p=0.008) lighting and ventilation (AOR=476.53, 95% CI= 8.321-27289.24, p=0.003), nature of work (AOR=779.035, 95% CI= 8.548-71001.15, (p=0.004) and operating procedures (AOR=268.155, 95% CI= 2.537-28343.457, p=0.019). The key informants identified poor compensation, inadequate training and development opportunities, and occupational health and safety as the key determinants of job satisfaction. The study recommends that `Trans Nzoia County should adopt processes and tools for assessing the work environment, including satisfaction levels and comparing them, and identifying the best practices to apply across the system. The study proposes a comparative study on determinants of job satisfaction among healthcare professionals in private and public facilities to understand the dynamics and variations.Item Adherence to Data Protection Guidelines among Health Researchers at Kenya Medical Research Institute(Kenyatta University, 2021) Kipchirchir, Kebenei Enock; George O. Otieno; Kenneth RuchaResearchers are expected to keep participants’ data in a highly confidential and private manner. A study conducted in Kenya in 2014 revealed that the research stakeholders face different challenges relating to the sharing of public health data. The exposure of data occurs through stigmatization, invasion of privacy, disrespecting autonomy and unfair competition either intentionally or unintentional 'misuse' of data. The general research objective of this study was to examine the adherence to the data protection guidelines in health research in KEMRI, Kenya. Cross-sectional study design was used and it employed quantitative methods of data collection and analysis. The sample size for this study was 128 research participants, however an extra 10% was added to cover for non-respondence. The study targeted the KEMRI’s scientists who have participated in any research project. Stratified sampling method and the “Probability Proportional to Size” (PPS) was used to get the desired sample in each of the KEMRI center. The data analysis was done using SPSS Version 23. Descriptive statistics and chi-square test were done to determine significant association and results presented in tables, graphs and charts. A total of nine questions were asked to determine the adherence to the national guidelines. A respondent is considered to have adhered if he/she has agreed to all the 9 items. The neutral respondents were considered as non-adherence. The findings reveal that 18 (12.6%) of the respondents adhered to data protection guidelines in health research while the majority did not adhere 121 (87.4%). P-values <0.05 were considered significant. Results further showed that guidelines or policies on data protection within the institute are the organizational factor which highly influences adherence to data protection (p-value of 0.01). Restricting access to the authorized persons and use of codes to conceal participant’s identity (p-value of 0.04) are the best ways of protecting health research data. In conclusion, most researchers do not comply with all aspects of national guidelines on data protection which may lead to the exposure and leakage of participant’s data. In view of the findings, the researcher recommends the creation of awareness through workshops and trainings as well as the development of institutional guidelines as the best ways of adhering to data protection guidelines.Item Utilization of Disease Classification Systems among Health Information Professionals in ‘Selected Public Hospitals’ in Kiambu County, Kenya(Kenyatta University, 2021) Maina, Duncan Mutongu; George Ochieng Otieno; Kenneth Kibaara RuchaDespite the globally acclaimed efficacy of the disease classification systems as a tool for health planning, reporting and reimbursement, not enough emphasis is laid on the quality of disease coding by the forerunners in the field. The starting point to sustaining the quality of disease coding is establishing its utilization. The purpose of the study is to establish the utilization of disease classification systems in Kiambu County, Kenya. Specifically, the study aims to determine health professionals' factors, health system factors and technological factors affecting utilization of disease classification systems (DCS) in Public Hospitals. This study was conducted in Kiambu County, Kenya, with a focus on public hospitals. Cross-sectional descriptive study design was used by employing total population sampling of the target population. The population of interest was the health records and information management professionals within the study area; as well as the key opinion leaders. Complete enumeration and purposive sampling designs were used to select the study participants, which included all 119 HRIOs in Kiambu County. Data was collected using self-administered questionnaires and key informant guides with the help of two research assistants. Data entry and analysis was done using SPSS v22. Data analysis included both descriptive (frequencies, means, percentages) and inferential statistics (Pearson chi-square with degrees of freedom), with the alpha level of significance set at 5%. Out of the 112 respondents, 75 (67%) indicated that the systems were utilized either frequently or always on average for the functions studied. Clinical coding was done at various locations within the hospitals and broadly depended on the layout of each facility. The study also found that greater age (X2= 7.719; p=0.003), increase in length of coding experience (X2= 3.7; p=0.027), and better DCS perception (X2= 9.74; p=0.00) were significantly associated with frequent use of DCS utilization. Additionally, from the qualitative findings, resource allocation for health, and consequently for DCS was inadequate; International coding guidelines and policies were present as availed through the World Health Organization (WHO), although local or national guidelines were missing. The study found sufficient evidence to reject the null hypothesis that health professionals age, duration of disease classification experience, and perception of DCS were not statistically significantly associated with DCS utilization. The study concludes that, based on these findings, coding experience, positive perception, health facility budget and availability of disease classification technology were central to the success of utilization of DCS. The study recommends 1) County Health Management Team (CHMT) and Sub-CHMT to increase exploitation of the various uses of DCSs at facility level so as to improve the perception of the staff; 2) The HRIOs to emphasize on importance of DCS technology in the health facilities to increase utilization of the DCSs; and 3) The MOH should increase resource allocation for health, and consequently for DCS at all levels: national and county.Item Correlates of HIV Viral Load Suppression Among HIV Positive Adults on Care in Nakuru County, Kenya(Kenyatta University, 2020) Nakazea, Rocky JumapiliAcross the entire globe, 75% of people are aware of their HIV Status, at the same time 79% of the people living with HIV are now accessing anti-retroviral therapy while 81% of those people are at the same time accessing the treatment and have suppressed viral loads. Nakuru County viral suppression stands at 88.3 % (30,407) below the UNAIDS target and National target (2020). The purpose of the study was to determine the correlates of Viral Suppression in Naivasha Sub-County Hospital, Nakuru County. Specific objectives were to determine the socio-demographic characteristics associated with viral suppression in Nakuru County, to establish the patient health related correlates associated with viral suppression in Nakuru County and determine the health system correlates associated with viral suppression. A descriptive cross-sectional study was carried out in Naivasha Sub-District Hospital. The study focussed on Naivasha SubCounty Hospital which currently has 2986 clients on care. The study focused on Naivasha Sub-County Hospital which currently has 2986 clients on care with 2586 virally suppressed which is 85.0%. A Sample size of 192 clients was selected using systematic random sampling. Data was collected using questionnaires for patients and key informant interviews who managed HIV clients in Naivasha Sub-County Hospital. Analysis was analysed using SPSS (Version 24. 0): Descriptive statistics and inferential statistics (Measures of association and correlation was applied) inferential statistics which was done using logistic regression where likelihood or odd ratio was used to predict the correlates of viral suppression. The study response rate was 100.0% whereby out of 192 cohort’s under study, 125 (65.0%) clients had viral load suppression below 1000 viral copies/ microliter of blood and 67 (35.0%) clients with viral load suppression above 1000 viral copies/microliter of blood. The study found the following factors to be critical predictors associated with viral load suppression; distance to facility, occupation, adherence, and co-morbidity, leadership of facility and ARV regimen. The study made the following recommendations; there is need of policy makers at County Level to develop policies that focus on client’s centred management of viral load suppression. The county level should advocate to the facilities on proper use of guidelines and come up with new innovations of patient’s management through evidence based approach on the existing policies. There should be improved coordination and programs ownership at facility and County level that will foster continuity of services and facilities should develop protocols on drugs sensitivity testing before changing regimen especially clients with high viral load.