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Kamau M, Nyanja N, Lusambili AM, Shabani J, Mohamoud G. Knowledge, attitudes and beliefs toward polypharmacy among older people attending Family Medicine Clinic, Nairobi, Kenya. BMC Geriatr 2024; 24:132. [PMID: 38317102 PMCID: PMC10845745 DOI: 10.1186/s12877-024-04697-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 01/10/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Life expectancy has increased over the last century among older people, particularly those aged over 60 years. Aging is associated with increased disability, multiple chronic conditions, and increased use of health services managed with polypharmacy. There are few studies on polypharmacy and aging in sub-Saharan Africa, and it is unclear what older people know and their attitudes toward polypharmacy. This paper presents findings from a study that aimed to understand older people's knowledge, attitudes and beliefs about polypharmacy. METHODS A qualitative study using in-depth interviews of 15 patients aged 60 years and older who were taking more than five medications per day. The study was conducted at the Family Medicine Clinic (FMC), Aga Khan University Hospital, Nairobi. Data were analyzed using NVivo 12 software. RESULT Majority of participants had a good understanding of their underlying health conditions, but they did not know the specific names of the medications they were taking. Participants had diverse attitudes toward polypharmacy, with both positive and negative perceptions. Although adverse side effects were reported, participants remained positive because they believed these medicines were beneficial. Religion, faith and living healthy lifestyles were perceived to contribute to their positive attitude toward polypharmacy. Stigma and the cost of medication were reported as barriers. CONCLUSION This study provides valuable insights into the complexities of polypharmacy in older people. It highlights the importance of patient education, fostering strong patient-provider relationships, de-stigmatization, and improving medication affordability and accessibility. Further research could explore the polypharmacy of older people attending public institutions in rural Kenya.
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Affiliation(s)
- Maureen Kamau
- Department of Family Medicine, Aga Khan University Hospital, Nairobi, Kenya.
| | - Njeri Nyanja
- Department of Family Medicine, Aga Khan University Hospital, Nairobi, Kenya
| | | | - Jacob Shabani
- Department of Family Medicine, Aga Khan University Hospital, Nairobi, Kenya
| | - Gulnaz Mohamoud
- Department of Family Medicine, Aga Khan University Hospital, Nairobi, Kenya
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Lusambili AM, Wisofschi S, Wade TJ, Temmerman M, Obure J. A qualitative enquiry of health care workers' narratives on knowledge and sources of information on principles of Respectful Maternity Care (RMC). PLOS Glob Public Health 2023; 3:e0000157. [PMID: 36962732 PMCID: PMC10021807 DOI: 10.1371/journal.pgph.0000157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 12/12/2022] [Indexed: 06/18/2023]
Abstract
Research from sub-Saharan Africa indicate that many women experience varied forms of disrespectful maternity care, which amount to a violation of their rights and dignity. Notably, there is little research that sheds light on health care workers (HCWs) training and knowledge of principles of respectful maternity care (RMC). Formulating appropriate interventional strategies to promote the respectful provision of services for women during pregnancy, childbirth, and postpartum period requires an understanding of the current state of knowledge and sources of information on respectful maternity care among HCWs. This paper reports findings from a qualitative study that examined the knowledge and sources of information on the Respectful Maternity Care Charter among HCWs in rural Kisii and Kilifi counties in Kenya. Between January and March 2020, we conducted 24 in-depth interviews among HCWs in rural Kisii and Kilifi health facilities. Data were analyzed using a mixed deductive and inductive thematic analysis guided by Braun's [2006] six stages of analysis. We found that from the seven globally accepted principles of respectful maternity care, at least half of the HCWs were aware of patients right to consented care, confidentiality and privacy, and the right to non-discriminatory care based on specific attributes. Knowledge of the right to no physical and emotional abuse, abandonment of care, and detentions in the facilities was limited to a minority of health care workers but only after prompting. Sources of information on respectful maternity care were largely limited to continuous medical and professional training and clinical mentorship. The existing gap shows the need for training and mentorship of HCWs on the Respectful Maternity Care Charter as part of pre-service medical and nursing curricula and continuing clinical education to bridge this gap. At the policy level, strategies are necessary to support the integration of respectful maternity care into pre-service training curricula.
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Affiliation(s)
- Adelaide M. Lusambili
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
- School of Business, African International University, Nairobi, Kenya
| | - Stefania Wisofschi
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Terrance J. Wade
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
- Department of Health Sciences, Brock University, St. Catharines, Canada
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Medical College, Aga Khan University, Nairobi, Kenya
| | - Jerim Obure
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
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Lusambili AM, Martini M, Abdirahaman F, Abena A, Guni JN, Ochieng S, Luchters S. 'It is a disease which comes and kills directly': What refugees know about COVID-19 and key influences of compliance with preventive measures. PLoS One 2021; 16:e0261359. [PMID: 34932556 PMCID: PMC8691645 DOI: 10.1371/journal.pone.0261359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 11/30/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Refugees are at increased risk for COVID-19 infection in part due to their living conditions, which make it harder to adopt and adhere to widely accepted preventive measures. Little empirical evidence exists about what refugees know about COVID-19 and what they do to prevent infection. This study explored what refugee women and their health care workers understand about COVID-19 prevention, the extent of their compliance to public health recommendations, and what influences the adoption of these measures. METHODS In October 2020, we conducted 25 in-depth interviews with facility and community health care staff (n = 10) and refugee women attending antenatal and postnatal care services (n = 15) in Eastleigh, Nairobi. FINDINGS While researchers found a high level of awareness about COVID-19 and related prevention and control measures among refugee women, various barriers affected compliance with such measures, due in part to poverty and in part to rampant misconceptions informed by religious beliefs and political narratives about the virus. CONCLUSIONS These findings indicated that Kenya's Ministry of Health needs to institute a concerted and continuous education program to bring refugee communities up to speed about COVID-19 and its prevention. In addition to disseminating information about the need to wear masks and repeatedly wash hands, supplies-masks, soap and access to water-need to be made available to poor refugee communities. Future research could explore which measures for disseminating factual information work best in refugee populations with different cultural norms and how best to target interventions to these groups.
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Affiliation(s)
- Adelaide M. Lusambili
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Michela Martini
- International Organisation of Migration (IOM), United Nations, Nairobi, Kenya
| | - Faiza Abdirahaman
- International Organisation of Migration (IOM), United Nations, Nairobi, Kenya
| | - Asante Abena
- International Organisation of Migration (IOM), United Nations, Nairobi, Kenya
| | - Joseph N. Guni
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Sharon Ochieng
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Stanley Luchters
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya
- Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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Lusambili AM, Martini M, Abdirahman F, Asante A, Ochieng S, Guni JN, Maina R, Luchters S. "We have a lot of home deliveries" A qualitative study on the impact of COVID-19 on access to and utilization of reproductive, maternal, newborn and child health care among refugee women in urban Eastleigh, Kenya. J Migr Health 2021; 1-2:100025. [PMID: 34405176 PMCID: PMC8352096 DOI: 10.1016/j.jmh.2020.100025] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 11/16/2022] Open
Abstract
Background Little is known about how pregnant refugee women, and the frontline health care workers who serve them, are affected by the COVID-19 pandemic in terms of health, and health service access. Women refugees are classified as a vulnerable group with regard to pregnancy outcomes and access to maternal care, and may be disproportionally at risk for COVID-19 infection as they are likely to face unique barriers to information and access to reproductive health services during the pandemic. Few studies identify gaps that could inform potential interventions to improve service uptake for refugee women, particularly in the context of COVID-19. Yet, understanding how pregnant refugees are impacted in the context of the pandemic is critical to developing and implementing strategies and measures that can help in their care and the delivery of health services. Aims This study aimed to improve understanding of the impact of COVID-19 on women refugees' access to and utilisation of antenatal care, delivery and postnatal care in Eastleigh, Kenya. Methods The study was conducted in Eastleigh, a semi-urban centre in Nairobi. We conducted 25 in-depth interviews with facility and community health care staff (n = 10) and women attending antenatal (n = 10) and postnatal care services (n = 5) in October 2020. Data was analysed using NVIVO 12 software. Findings Our findings suggest that within the first eight months of COVID-19, preferences for home deliveries by refugee women increased and health care workers reported having observed reduced utilisation of services and delayed care. Fear, economic challenges and lack of migrant-inclusive health system policies were key factors influencing home deliveries and delayed and low uptake of facility-based care. Conclusions The findings highlight the need to mitigate and lower barriers that prevent refugee women from seeking care at health facilities. One approach includes the development of refugee-inclusive public health policies, particularly during a pandemic, and the need to tailor health care services for refugees at facilities and in the communities.
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Key Words
- AKU, Aga Khan University
- ANC, ante-natal care
- Antenatal care
- CHV, community health volunteer
- COVID-19
- FP, family planning
- HCW, health care workers
- HIC, high-income country
- HIV, Human Immunodeficiency Virus
- Home deliveries
- IOM, International Organisation of Migration
- Kenya
- LMIC, low- to middle-income country
- MNCH, maternal, new-born and child health
- Migrants
- NACOSTI, National Commission for Science, Technology and Innovation
- PI, principal investigator
- PNC, post-natal care
- Postnatal care
- Qualitative Inquiry
- RMNCH, reproductive, maternal, new-born and child health
- Refugees
- SSA, sub-Saharan Africa
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Affiliation(s)
| | - Michela Martini
- International Organisation of Migration (IOM), United Nations Migration, Kenya
| | - Faiza Abdirahman
- International Organisation of Migration (IOM), United Nations Migration, Kenya
| | - Abena Asante
- International Organisation of Migration (IOM), United Nations Migration, Kenya
| | - Sharon Ochieng
- Department of Population Health, Medical College, Aga Khan University, Kenya
| | - Joseph N Guni
- Department of Population Health, Medical College, Aga Khan University, Kenya
| | - Rose Maina
- School of Nursing and Midwifery, Aga Khan University, Kenya
| | - Stanley Luchters
- Department of Population Health, Medical College, Aga Khan University, Kenya.,International Centre for Reproductive Health, Department of Public Health and Primary Care, Ghent University, Belgium.,Department of Epidemiology and Preventive Medicine, Monash University, Australia.,Burnet Institute, Melbourne, Australia
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Lusambili AM, Wisofschi S, Shumba C, Muriuki P, Obure J, Mantel M, Mossman L, Pell R, Nyaga L, Ngugi A, Orwa J, Luchters S, Mulama K, Wade TJ, Temmerman M. A Qualitative Endline Evaluation Study of Male Engagement in Promoting Reproductive, Maternal, Newborn, and Child Health Services in Rural Kenya. Front Public Health 2021; 9:670239. [PMID: 34307276 PMCID: PMC8296463 DOI: 10.3389/fpubh.2021.670239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Globally, male involvement in reproductive, maternal, newborn, and child health (RMNCH) is associated with increased benefits for women, their children, and their communities. Between 2016 and 2020, the Aga Khan University implemented the Access to Quality of Care through Extending and Strengthening Health Systems (AQCESS), project funded by the Government of Canada and Aga Khan Foundation Canada (AKFC). A key component of the project was to encourage greater male engagement in RMNCH in rural Kisii and Kilifi, two predominantly patriarchal communities in Kenya, through a wide range of interventions. Toward the end of the project, we conducted a qualitative evaluation to explore how male engagement strategies influenced access to and utilization of RMNCH services. This paper presents the endline evaluative study findings on how male engagement influenced RMNCH in rural Kisii and Kilifi. Methods: The study used complementing qualitative methods in the AQCESS intervention areas. We conducted 10 focus group discussions (FGDs) with 82 community members across four groups including adult women, adult men, adolescent girls, and adolescent boys. We also conducted 11 key informant interviews (KIIs) with facility health managers, and sub-county and county officials who were aware of the AQCESS project. Results: Male engagement activities in Kisii and Kilifi counties were linked to improved knowledge and uptake of family planning (FP), spousal/partner accompaniment to facility care, and defeminization of social and gender roles. Conclusion: This study supports the importance of male involvement in RMNCH in facilitating decisions on women and children's health as well as in improving spousal support for use of FP methods.
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Affiliation(s)
- Adelaide M Lusambili
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Stefania Wisofschi
- Centre of Excellence in Women and Child Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Constance Shumba
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Peter Muriuki
- Centre of Excellence in Women and Child Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Jerim Obure
- Centre of Excellence in Women and Child Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Michaela Mantel
- Centre of Excellence in Women and Child Health, Medical College, Aga Khan University, Nairobi, Kenya
| | | | - Rachel Pell
- Aga Khan Foundation, Canada, Ottawa, ON, Canada
| | - Lucy Nyaga
- Centre of Excellence in Women and Child Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Anthony Ngugi
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - James Orwa
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Stanley Luchters
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya.,Aga Khan Foundation, Canada, Ottawa, ON, Canada.,Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | - Kennedy Mulama
- Centre of Excellence in Women and Child Health, Medical College, Aga Khan University, Nairobi, Kenya
| | - Terrance J Wade
- Centre of Excellence in Women and Child Health, Medical College, Aga Khan University, Nairobi, Kenya.,Department of Health Sciences, Brock University, St. Catharines, ON, Canada
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Medical College, Aga Khan University, Nairobi, Kenya.,Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,Department of Obstetrics and Gynaecology, Medical College, Aga Khan University, Nairobi, Kenya
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Lusambili AM, Muriuki P, Wisofschi S, Shumba CS, Mantel M, Obure J, Nyaga L, Mulama K, Ngugi A, Orwa J, Luchters S, Temmerman M. Male Involvement in Reproductive and Maternal and New Child Health: An Evaluative Qualitative Study on Facilitators and Barriers From Rural Kenya. Front Public Health 2021; 9:644293. [PMID: 33968883 PMCID: PMC8096930 DOI: 10.3389/fpubh.2021.644293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/08/2021] [Indexed: 11/17/2022] Open
Abstract
Male involvement in reproductive, maternal, newborn and child health (RMNCH) is known to improve maternal and child health outcomes. However, there is sub-optimal adoption of male involvement strategies in several low- and middle-income countries such as Kenya. Aga Khan University implemented Access to Quality of Care through Extending and Strengthening Health Systems (AQCESS), a project funded by the Government of Canada and Aga Khan Foundation Canada (AKFC), between 2016 and 2020 in rural Kisii and Kilifi counties, Kenya. A central element in the interventions was increasing male engagement in RMNCH. Between January and March 2020, we conducted an endline qualitative study to examine the perspectives of different community stakeholders, who were aware of the AQCESS project, on the facilitators and barriers to male involvement in RMNCH. We found that targeted information sessions for men on RMNCH are a major facilitator to effective male engagement, particularly when delivered by male authority figures such as church leaders, male champions and teachers. Sub-optimal male engagement arises from tensions men face in directly contributing to the household economy and participating in RMNCH activities. Social-cultural factors such as the feminization of RMNCH and the associated stigma that non-conforming men experience also discourage male engagement.
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Affiliation(s)
| | - Peter Muriuki
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Stefania Wisofschi
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Constance S Shumba
- Department of Population Health (DPH), Aga Khan University, Nairobi, Kenya
| | - Michaela Mantel
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Jerim Obure
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Lucy Nyaga
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Kennedy Mulama
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Anthony Ngugi
- Department of Population Health (DPH), Aga Khan University, Nairobi, Kenya
| | - James Orwa
- Department of Population Health (DPH), Aga Khan University, Nairobi, Kenya
| | - Stanley Luchters
- Department of Population Health (DPH), Aga Khan University, Nairobi, Kenya.,Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Marleen Temmerman
- Centre of Excellence in Women and Child Health, Aga Khan University, Nairobi, Kenya.,Department of Public Health and Primary Care, International Centre for Reproductive Health, Ghent University, Ghent, Belgium.,Department of Obstetrics and Gynaecology, Medical College, Aga Khan University, Nairobi, Kenya
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Lusambili AM, Naanyu V, Wade TJ, Mossman L, Mantel M, Pell R, Ngetich A, Mulama K, Nyaga L, Obure J, Temmerman M. Deliver on Your Own: Disrespectful Maternity Care in rural Kenya. PLoS One 2020; 15:e0214836. [PMID: 31910210 PMCID: PMC6946164 DOI: 10.1371/journal.pone.0214836] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 12/06/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Under the Free Maternity Policy (FMP), Kenya has witnessed an increase in health facility deliveries rather than home deliveries with Traditional Birth Attendants (TBA) resulting in improved maternal and neonatal outcomes. Despite these gains, maternal and infant mortality and morbidity rates in Kenya remain unacceptably high indicating that more needs to be done. AIM Using data from the Access to Quality Care through Extending and Strengthening Health Systems (AQCESS) project's qualitative gender assessment, this paper examines women's experience of disrespectful care during pregnancy, labour, and delivery. The goal is to promote an improved understanding of the actual care conditions to inform the development of interventions that can lift the standard of care, increase maternity facility use, and improve health outcomes for both women and newborns. METHODOLOGY We conducted sixteen focus group discussions (FGDs), two each for adolescent females, adult females, adult males, and community health committee members. As well, twenty-four key Informants interviews (KII) were also conducted including religious leaders, and persons from local government representatives, Ministry of Health (MOH), and local women's organizations. Data were captured through audio recordings and reflective field notes. RESEARCH SITE Kisii and Kilifi Counties in Kenya. FINDINGS Findings show nursing and medical care during labour and delivery were at times disrespectful, humiliating, uncompassionate, neglectful, or abusive. In both counties, male health workers were preferred by women giving birth, as they were perceived as more friendly and sensitive. Adolescent females were more likely to report abuse during maternity care while women with disabled children reported being stigmatized. Structural barriers related to transportation and available resources at facilities associated with disrespectful care were identified. CONCLUSIONS A focus on quality and compassionate care as well as more facility resources will lead to increased, successful, and sustainable use of facility care. Interpreting these results within a systems perspective, Kenya needs to implement, enforce, and monitor quality of care guidelines for pregnancy and delivery including respectful maternity care of pregnant women. To ensure these procedures are enforced, measurable benchmarks for maternity care need to be established, and hospitals need to be regularly monitored to ensure these benchmarks are achieved.
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Affiliation(s)
- Adelaide M. Lusambili
- Centre for Excellence in Women and Child Health, Aga Khan University, Nairobi, East Africa, Kenya
| | - Violet Naanyu
- Centre for Excellence in Women and Child Health, Aga Khan University, Nairobi, East Africa, Kenya
| | - Terrance J. Wade
- Department of Health Sciences, Brock University, St Catharines, Ontario, Canada
| | | | - Michaela Mantel
- Centre for Excellence in Women and Child Health, Aga Khan University, Nairobi, East Africa, Kenya
| | - Rachel Pell
- Aga Khan Foundation, Canada Ottawa, ON, Canada
| | | | | | - Lucy Nyaga
- Centre for Excellence in Women and Child Health, Aga Khan University, Nairobi, East Africa, Kenya
| | - Jerim Obure
- Centre for Excellence in Women and Child Health, Aga Khan University, Nairobi, East Africa, Kenya
| | - Marleen Temmerman
- Centre for Excellence in Women and Child Health, Aga Khan University, Nairobi, East Africa, Kenya
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Lusambili AM, Tod AM, Homer C, Abbott J, Cooke J, McDaid KA. Keeping Warm: Social Connectedness and Technology - A Case Study of Rotherham, England ‘Technology and Health in the Elderly’. ACTA ACUST UNITED AC 2011. [DOI: 10.18848/2156-8960/cgp/v01i03/41174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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