INVESTIGATING THE DETERMINANTS OF THE QUALITY OF HEALTHCARE IN NAIROBI COUNTY, KENYA

This study examines whether women in face gender-based discrimination when they seek care and collects data in 250 primary care facilities in Naiorbi county Kenya. The proposed study has two main objectives. First, it uses male and female standardised patients (SPs) – healthy people pretending to be ill and visiting healthcare providers under-cover – to examine whether women with symptoms of coronary heart disease (i.e. chest pain) receive worse healthcare than men. Second, it provides evidence on how any potential gender-based discrimination might be remedied and tests the short-term effect of a provider training intervention. The training workshop will be based on a course developed by the WHO and will be evaluated with a randomised experiment. Providers working in half of the study facilities will be invited to the training. We will evaluate the effect of the training by comparing quality of care received by male and female SPs before and after the intervention.

Providers working in a random sample of 125 (of 250) primary care facilities will be invited to take part in the training workshop. During the provider survey, we aim to collect contact information for all facility managers as well as healthcare providers who saw SPs. The training workshop will be conducted virtually.

We will organise up to five virtual training sessions, for which providers can sign up depending on convenience. After the workshop, providers will complete a brief quiz summarising the key points of the training and will be issued a training certificate upon completion. Providers who complete their training certificate will receive 1,000 KES as a token of appreciation, as well as to offset mobile data usage costs.

The content of the training workshop will closely follow the WHO HEARTS technical package, materials for which are freely available online (WHO 2024). The two-hour session will focus on two of the six components of WHO HEARTS, which are most relevant for the study: healthy lifestyle counselling and cardiovascular disease management in primary care. Training workshops will be held by local healthcare professionals.

2024-06-24

2024-06-28

The primary outcome of interest is the clinical quality of care received by SPs, which can be measured in a variety of ways.

The clinical quality of care received by SPs is usually captured via a binary variable that indicates the quality of case management. Based on previous studies using the same SP case of stable angina in primary care, patients who either received an ECG (electrocardiogram) or were referred will be coded as having received clinically indicated treatments. The main point of interest will be variations in quality between male and female SPs.

Although important, a binary outcome of the quality of case management hides a lot of important variation, particularly in relation to how intensely patients were treated. Studies from high-income countries for instance suggest that women are often treated less intensively than men with the same symptoms. For this reason, we will also consider:
• The urgency of the received referral (when were patients told they should attend the referral facility)
• To which level patients were referred and if referrals were to specialists (for instance, a secondary care facility compared to a specialist cardiology centre)
• The proportion of relevant questions asked and examinations done, as well as the duration of the consultation – to capture general provider effort

To investigate whether providers seemed less likely to consider heart disease with female patients, we will consider:
• Whether the diagnosis given to patients was non-cardiac
• Whether the diagnosis focused on stress of mental health issues
• Whether a diagnosis was given at all

Since healthy lifestyle counselling is a key component of cardiovascular care management in primary care based both on Kenyan clinical guidelines as well as WHO HEARTS, we will consider:
• Whether patients received lifestyle counselling (nutrition, exercise, smoking and alcohol)
• The proportion of relevant recommendations covered

Providers working in a random sample of 125 (of 250) primary care facilities will be invited to take part in the training workshop. All providers who usually deliver general primary care to adult patients in selected facilities will be invited to take part.

Providers working in a random sample of 125 (of 250) primary care facilities will be invited to take part in the training workshop. During the provider survey (third phase of data collection), we aim to collect contact information for all facility managers as well as healthcare providers who saw SPs. We will contact providers telephonically or via email to invite them to the workshop. If feasible, we will also send written invitations. All providers who usually deliver general primary care to adult patients will be invited to take part.

The training workshop will be conducted virtually. Our sense it that a virtual workshop is preferable to in-person training because virtual activities are easier to implement at scale and are less disruptive to day-to-day healthcare provision. In addition, virtual training is also increasingly common for providers in Kenya.

We will organise up to five virtual training sessions, for which providers can sign up depending on convenience. After the workshop, providers will complete a brief quiz summarising the key points of the training and will be issued a training certificate upon completion. Providers who complete their training certificate will receive 1,000 KES as a token of appreciation, as well as to offset mobile data usage costs.

The content of the training workshop will closely follow the WHO HEARTS technical package, materials for which are freely available online (WHO 2024). The two-hour session will focus on two of the six components of WHO HEARTS, which are most relevant for the study: healthy lifestyle counselling and cardiovascular disease management in primary care. Training workshops will be held by local healthcare professionals. Trainers will receive some prior training on WHO HEARTS – although the individuals delivering the training will work within cardiovascular care. The aim is to have the same individuals conduct all sessions and to use the same slide deck. After the virtual training, providers will complete a brief quiz on the content of training and, if successful, receive 1,000 KES as a token of appreciation (which will be paid via mobile money).

There are two main threats to the internal validity of the evaluation. The first is that not all providers who will have consulted SPs will take part in the workshop and that not all providers who will take part in the workshop will see SPs for a follow-up consultation. We will do our best to ensure that all interested providers have the opportunity to take part in the workshop – by providing multiple sessions at convenient times and following up with providers if needed. Whenever possible we will aim to make appointments with healthcare providers seen at baseline when the follow-up is conducted. In the provider survey, providers working in selected facilities will also be asked about their usual working hours or days, as well as about potential holidays. We will use this information to try and time SP visits at endline and ensure that our sample size is sufficiently large. Nonetheless, despite these efforts and the relatively short time between baseline and endline assessment, we will not be able to match baseline and endline data for all providers. We will however be able to assess the facility-level effect of the training, given that facilities will have been randomly selected to take part.

Another issue for the internal validity of the study is potential contamination. It is possible that healthcare providers work in multiple facilities and that some work in treatment and control facilities. As we know the identity of healthcare providers seen by SPs, as well as the identity of providers who attended the training, and will have the list of all providers working in study facilities, as well as the reported workplace of each provider – hence, we will be able to verify cases of cross-contamination. However, it is still possible that some providers will not disclose secondary employers and that some contamination will occur.

Randomisation done by the PI (in office by a computer).

All of the 250 facilities will be visited by male and female SPs with symptoms of angina. Enumerators will be randomly attributed to specific health facilities. Every SP will have to visit a specific facility on a specific day and timing will be based on logistical considerations only – and will be set by the PI before fieldwork commences.

The randomisation of the training intervention will happen at facility-level, as half of the 250 study facilities will be selected into the treatment group. Randomisation will be done by the PI.

Yes

The study will be conducted in 250 primary care facilities in Nairobi. Half of which will be randomly assigned to the treatment group (where providers are invited to take part in the training workshop).

There will be roughly 1,000 observations, assuming 500 SP visits at baseline and 500 at endline. At each stage, half of the observations are from consultations between providers and male SPs and the other half from consultations between providers and female SPs.

There will be 500 observations in the treatment group (in 125 facilities) and 500 in the control group (in 125 facilities).