The double burden of both non-communicable and communicable conditions is becoming a reality in developing counties. Changes in lifestyle patterns and longer survival rates in HIV positive patients have led to an increased risk of developing non-communicable diseases like hypertension and other cardiovascular conditions. Hypertension contributes to a greater extend of the heart disease, which may be led to increased rate of sickness and death in HIV positive patients. High blood pressure in Kenya has been on the increase based on data from studies. Available data shows an increase in the prevalence of hypertension in people living with HIV in Kenya, but the research was done in tier three and four health facilities. It is not known if the prevalence and distribution of determinants is similar to that in the tier 2 facilities. Tier two health facilities like Mathare North health centre do not routinely screen HIV positive patients for hypertension. The objective of this study was to assess the prevalence and determinants of hypertension among HIV positive patients at Mathare North health centre, Nairobi. A cross-sectional, mixed method study was conducted in Mathare North Health Centre located in Nairobi – Kenya, Ruaraka Sub County, Mathare North ward. A random sample of 148 participants was drawn from the study population. A questionnaire (modified from the WHO STEPs tool) was used to collect quantitative data from the participants and the registers available at the clinic while focus group discussions and key informant interviews were used for qualitative data. Data was collected on social, economic, demographic, behavioural, physiological and biomedical factors. Measurements of height, weight, blood pressure and blood glucose were taken for all respondents. Descriptive, univariable and multivariable analysis was done using Stata software, version 11 to show which determinants were statistically significant. The qualitative data from the focus group discussions and Key informant interviews was transcribed then analysed using NVivo, 2020. Ethical approval was sought from the KNH-UoN ERC and Nairobi Metropolitan Services (NMS) –Health department before proceeding with the research. Only the patients who gave written approval by signing the consent forms were included in the study. Of the 148 participants included in the analysis, 17.5% were classified as hypertensive. Male respondents represented 51.4%. The participants’ ages ranged between 25 and 73 years with a median age of 40 and an IQR of 15 years. In terms of physiological and behavioural factors, 4.7% and 1.3% of the participants reported current alcohol and harmful alcohol consumption respectively. Majority of the participants (57.4%) reported insufficient physical activity while all had insufficient daily intake of fruits and vegetables. From the multivariable analysis after controlling for other factors, current use of alcohol (aOR 6.78; 95% CI 1.13-40.50) and current regimen – EFV based (aOR 7.48; 95% CI 1.02-55.05) were associated with hypertension in HIV positive patients on ART. Stress and unhealthy diet were reported as the most significant factors associated with hypertension from the qualitative data collected through the focus group discussions and key informant interviews. Therefore, Nairobi Metropolitan services health department, the facility health management team and the implementing partners needs to put in place proper structures for patient health education on predisposing factors (with a focus on modifiable risk factors), blood pressure screening for all patients, proper diagnostic systems and support groups for the hypertensive patients at the clinic to help mitigate stress.

Breast cancer is the most commonly diagnosed cancer among women in both developed and developing countries. Studies have shown several risk factors including viral agents especially high risk HPV which can be diagnosed by studying p16 INK4A expression on formalin fixed, paraffin wax embedded tissue blocks. p16Immunohistochemistry is considered the best candidate for initial diagnosis of high risk HPV related lesions because of its availability, easy interpretation and its high sensitivity and specificity. This study examined p16 INK4A expression in series of invasive breast carcinoma at Kenyatta National Hospital in order to determine its utility in identifying high risk HPV related invasive breast carcinomas. Objectives The primary objective was to establish the p16 INK4A expression as a marker of high risk HPV infection in women invasive breast carcinomas at Kenyatta National Hospital. Design: Our study was retrospective laboratory based. ixSetting: The study was conducted at University of Nairobi, anatomic pathology laboratory at Kenyatta National Hospital. Study population: Ninety-six (96) formalin fixed, paraffin wax embedded tissue blocks from breast biopsies reported as invasive breast carcinomas in women who attended KNH from January 2013 to February 2016. Results: Our study demonstrated that 25 years old patient was the youngest while the oldest patient was 96 years old. The mean age was 46 years. The most affected age group was 41-50 age group (37.5%) followed by 31-40 age group (27%). The predominant histological type was invasive ductal carcinoma NOS (82.2%). Invasive breast carcinoma grade II were predominant (47.3 %) and majority of the patients presented with stage III invasive breast carcinomas (65.6 %). Positivity was considered when there is nuclear and cytoplasmic staining or expression for p16INK4A. Positivity was noted in 11.4% of our cases and majority of the positive cases were noted among grade III breast carcinoma cases. There was no statistically significant association between invasive breast carcinoma stage or grade to p16INK4A expression. Conclusion: High risk HPV infection has been identified in a series of high grade and advanced stageinvasive breast carcinomas in Kenyatta National Hospital. Women aged from 40-50 years are the most affected by invasive breast carcinoma. Mastectomy was most common specimen. P16INK4A expression is not associated with breast tumor stage or grade

Background Breast density is a well-known and proven independent risk factor for breast cancer and can significantly affect the sensitivity of screening mammograms. Mammographic breast density is thus great importance in the evaluation of a mammogram because increased breast density is known to increase the risk of individual breast cancer (1) Analysis of breast density is done through the ACR- Birads lexicon 2013, which categorizes breast density into four categories A-D A- Almost entirely fatty, B- scattered areas of fibroglandular density, C- heterogeneously dense, which may obscure small masses and Dextremely dense, which lowers the sensitivity of mammography. Due to the subjective nature of the visual assessment during categorization, differences may arise when assessing the breast density between two observers. It is important to assess the degree of agreement or variability as this affects the reproducibility of the report. Aim The study aimed to evaluate and record the degree of inter and intra observer variability when assessing the mammographic breast density using the Breast Imaging Reporting and Data System (BIRADS), as defined by American College of Radiology. Methodology Cross-sectional study was carried out at Kenyatta National Hospital, mammography department of Radiology over a period of one year. Four radiologists were required to review mammograms that were of diagnostic value and classify the breast density based on the ACR classification 5th edition. After an interval of one month, they were asked to review the same mammograms again. Mammographic density category for each mammogram by each radiologist was recorded. Statistical Analysis The intra-observer variability was calculated for each radiologist and reported as weighted kappa values and 95% confidence intervals. Fleiss-Cohen Kappa coefficients and their corresponding 95% confidence intervals were used to calculate the inter-observer variability. The levels of agreement were assigned a kappa value between 0.0-1.0 where 0.0 was considered as no agreement and 1.0 was considered perfect agreement. Results ixThere was moderate overall inter-observer variability both at baseline and after the onemonth review with kappa values being 0.49(95% CI 0.43,0.59) and 0.43 ( 95% CI 0.38,0.61)) respectively when using the ACR BI-RADS 2013 lexicon to assess breast density. The intraobserver variability was substantial with kappa values ranging from 0.61(95% CI 0.48- 0.72) to 0.77 (95% CI 0.67-0.87). Conclusion There was a moderate level of inter- and intra- observer variability demonstrated when assessing mammographic breast density but a substantial level of individual intra-observer variability.

This research sought to evaluate the relationship between the NG-CDF project management structure and the performance of NG-CDF projects in Kenya with a focused study of public secondary schools in North Mugirango constituency in Nyamira county. The research adopted a descriptive survey design targeting a population of 387 board of management members in the 42 public secondary schools and the NG-CDF constituency committee in North Mugirango constituency. A sample of 172 members were targeted from the schools’ boards and constituency committee. Of the 172 members who received the questionnaires, 139 (80.81%) members responded. From the results obtained, it was noted that there was a lack of construction management knowledge and skills in most of school boards of management at 61.15%. Secondly, it was noted that a majority of the stakeholders at 59.71%, were not involved in the implementation of the projects. Consequently, it was established that there arose difficulties in monitoring and evaluation of the projects which resulted in overpricing, stalling and eventual dissatisfaction. The results of the findings indicated that the NG-CDF project management structure adopted in the implementation of NG-CDF projects is negatively affecting the performance of NG-CDF projects. The study recommended a policy formulation where the project implementation teams especially NG-CDF constituency committee and school boards of management would have one fifth of their members being building construction specialists. The specialists will enrich the teams with skills and knowledge that is vital in the running of the construction projects in those schools. The research equally recommended mandatory involvement of all project implementation team members in the process of proposing and prioritization of projects that are important to the community in order to guarantee fairness, openness and transparency in resource management.

Background: Sickle cell disease has contributed significantly to mortality rate in children; pain is a regular problem during painful crises. Studies have shown that it is the most common cause for admission in children with sickle cell disease. Pain has significant physiological effects on the body during a painful crisis, and severe painful crises are associated with severe disease complications. There is minimal evidence on the level of knowledge among health care workers regarding pain assessment, use of pain scales/tools, and treatment. Some existing evidence suggests that healthcare workers (HCWs) have misconceptions about opioid use to manage pain. Study Objective: To assess knowledge, attitude, and practice of health care workers, regarding assessment and treatment of acute pain crisis in children with sickle cell disease in Homabay County Hospital. Study design and setting: Two-phase study – phase A, observational cross-sectional design, and phase B, a retrospective abstraction of medical records. Data collection methods were concurrent mixed method in phase A where quantitative followed by qualitative data collection (FGDs and KII) was done. Phase B - quantitative data abstracted from medical records. It was conducted in Homabay County Teaching and Referral Hospital (Homabay CH) a county referral hospital in Western Kenya. Study Methods: Phase A: pretested questionnaire was administered to HCWs. The study used both knowledge and attitude (K&A) questionnaire (Appendix II). Two FGDS conducted one for clinicians and one for nurses, KII done with four Hcws. The study included HCWs in the paediatrics and medical ward attending to children hospitalized with acute pain crisis (n = 50).Inclusion criteria mentioned HCWs in paediatrics and medical wards, pharmacists and pharmaceutical technologists working in main pharmacy. Exclusion criteria HCWs with less than 6 months of experience and pharmacist/pharmaceutical technologist not working in the main pharmacy. 15Phase B: Retrospective evaluation of pain management in children over preceding two years by reviewing medical records. This was done by use of a structured audit tool (Appendix I). To abstract data from patient files and treatment sheets retrospectively. The study population comprises of children diagnosed with and hospitalized with acute pain crisis in the paediatrics ward and medical ward of HCTRH (N=67). Inclusion criteria Children and adolescents with a diagnosis of aged 6 months to 18 years old hospitalized with acute pain crisis from March 2018 to March 2020 with available medical records. Exclusion criteria children with a diagnosis of SCD hospitalized with other complications, outside the study period, children with missing medical record. Data Analysis Phase A: One point was awarded for each correct/appropriate answer and zero for incorrect/unclear response. Total scores were therefore analysed for each HCW, and HCWs who score between 80-100% were considered to have good knowledge, between 60-79% were regarded as a medium/moderate, while those below 60% were deemed to have poor knowledge. This was applied to knowledge on pain assessment, and on treatment of pain. To explore challenges that HCWs face in implementing optimal pain management for children presenting with acute pain crisis, the study collected qualitative data guided by FGDS and KII. This data was analysed using inductive thematic analysis with the help of NVivo software. Phase B: For each analgesics that was given morphine, tramadol, ibuprofen, and paracetamol, dosage, route, duration and any inconsistency that occurred in administration was analysed and based on WHO analgesic ladder NSAIDS/paracetamol for mild pain, weak opioid for mild to moderate pain, strong opioid for moderate to severe pain it was decided if it was optimal or suboptimal practice. Results: Phase A - We enrolled 50 HCWs, 42 % male and 58% female, by cadre nurses 48%, clinical officers 46% and doctors 6%.70 % of the participants were aged between 21-30 years. Diploma holders 78% and degree being the highest level of education at 22%. By department 56 % medicine department and 44% paediatrics department. 16HCWs knowledge regarding pain assessment during acute pain crisis was good as Majority of clinicians 58% and nurses 54% had a good score. Regarding knowledge on pain treatment during acute pain crisis HCWS had a fair knowledge, 88% of nurses had a fair score while 54% of clinician had a fair score. HCWs had a negative attitude on opiate use for treatment of pain in children experiencing an acute painful crisis, specifically fear of side effects such as addiction, respiratory distress, difficulty in weaning off morphine and constipation. Challenges that were facing HWCs included opiate drug stock outs, difficulty in accessing morphine when it was available due to administrative barriers, and inadequate pre-service training regarding management of painful SCD crisis. Phase B - We retrieved files for 67 children for phase B to assess pain practices for children treated for SCD acute pain crisis at the hospital during the preceding two years. HCWs practice was found to be suboptimal no assessment of pain was documented and 60% of children were started on morphine (strong opioid) as initial analgesic weak opioid was not used and NSAID was used as an escalation or combination analgesic rather than initial analgesic. Conclusions Health care workers had good knowledge regarding pain assessment during acute painful crisis. HCW's knowledge on pharmacological pain treatment was fair for both the nurses and clinicians, as the majority had a moderate score. Healthcare workers’ had a fearful attitude towards use of opiate analgesics during acute pain crisis. Health care workers' practice regarding pharmacologic treatment of acute pain crisis management was suboptimal, despite having good knowledge on treatment. Challenges that HCWs face during acute pain crisis management are stock outs and limited access to stronger analgesics, and inadequate pre service training in management of acute pain crisis.

Somalia and the Horn of Africa region are bound to be tested to the limits as foreign forces withdraw from the country over the next year. The African Mission on Somalia (AMISOM) will withdraw all its troops from Somalia by end of December 2021 upon the expiry of its mandate.1 Other countries with contingents not part of AMISOM are also withdrawing their troops for domestic reasons. The United States, pursuing reduced overseas military engagement under President Donald J. Trump, has already begun its troop withdrawals. Ethiopia is said to have already withdrawn at least 3,000 troops from Somalia as it faces internal disturbances, particularly in the Tigray region 2 Critically, the troops are not just leaving a country. They leave behind millions of victims of the Al-Shabab terrorist group who have not been accorded justice and who face grim chances of ever attaining criminal justice. States, whether individually or collectively, have a duty to investigate, prosecute and punish criminals for human rights violations. Failure to do so amounts to a breach of the victims’ right of access to justice. The international community has always attached immense value to criminal justice. First, numerous regional and international human rights instruments recognise and define cardinal fundamental rights and freedoms, and spell out the obligations of States in observing, fulfilling, and protecting such rights. Beyond the treaties, under customary international law, there are certain crimes that the community of States has deemed an affront to humankind, and the perpetrators must be punished whether their States have ratified treaties prohibiting the crimes or not. Second, the international community has over the years established elaborate enforcement mechanisms designed to ensure States comply with obligations. The Human Rights Committee monitors the compliance of States with the International Covenant on Civil and Political Rights (ICCPR). The Committee against Torture monitors compliance with the United Nations Convention Against Torture, Inhuman or Degrading Treatment or Punishment. Moreover, the international community has always established accountability mechanisms for perpetrators of 1 UNSC Res 2520 (29 May 2020) UN Doc S/RES/2520; Vincent Achuka, ‘East Africa: Tough Times Ahead for Somalia as Troops Start Pulling Out’ (AllAfrica 22 December 2020) <https://allafrica.com/stories/202012220086.html> accessed 22 December 2020 2 Ibid Vincent Achukagrave crimes. Such mechanisms have ranged from international and regional courts as well as specialised international and hybrid tribunals. Third, there is rich jurisprudence emphasizing that victims of violations of human rights must be accorded justice by their State. Further, States have a legal duty to take reasonable steps to prevent human rights violations and to use the means at their disposal to seriously investigate violations committed within their jurisdiction, identify those responsible, punish them, and adequately compensate the victims.3 Where States are unable to undertake those duties, the international community must intervene to punish perpetrators and accord justice to victims. There has not been any hope for victims of Somalia’s armed conflict. Despite prima facie evidence that Al-Shabab is committing the gravest crimes of terrorism and even crimes against humanity and war crimes, there is a complete lack of accountability for perpetrators. This study focuses on the two later crimes whose prohibition constitutes a peremptory (jus cogens) norm in international law. Somalia is itself hampered by a lack of a functional government and weak institutions since 1991 when the government of Siad Barre fell at least until 2012 when the country managed to install its first permanent government post-Barre. With international support, Somalia has managed to establish a police force and a fairly remunerated, independent, and professional judiciary. However, challenges of deeply embedded corruption, clannism, and weak institutions persist. Somali institutions have still yielded limited results when it comes to holding Al-Shabab fighters accountable for their crimes in and around Somalia. There is a need to examine the available accountability mechanisms to ascertain how they can be improved or how mechanisms not being applied can be applied and in the process deliver justice to millions of AlShabab victims.

Introduction: District Health Information System (DHIS2) is a platform designed to collect, process, and report data and trends regarding health to aid the health decision-makers in making health-related decisions. It is pertinent that decision-makers such as county government health managers, departments, non-government organisations, and stakeholders utilise credible information from Routine Health Information Systems DHIS2 for Enhancing health-related outcomes and addressing inequities. A quality decision is particularly crucial in Wajir county, one of the country's poorest counties and the top 15 counties ranking on the maternal and perinatal burden. There exist low accessibility and utilisation of the health information collected in DHIS2. Most health decision-makers such as public health, policymakers, and healthcare organisations do not often consider the DHIS2 data appropriate for guiding their decisions. The low utilisation of DHIS2 has been a challenge in improving the health sector performance. Broad Objective: To establish the factors affecting access and utilization of the DHIS2 in Wajir County. Specific objectives: The study focused on influence of data infrastructure, staff technical capacity, available resources, and county health organizational support and how they influence the access and utilization of the DHIS2. Methodology:A cross-sectional study was carried out among the Wajir County health sector managers from June to August 2021. The study adopted a convergent mixed-method research design that blended quantitative and qualitative data collection and analysis approaches. The target population was managers from the Wajir County health department. A sample size of 95 was drawn from 125 managers of Wajir Health departments. Additionally, the study also inquired from 10 key informants(KIs) drawn from the health sector. Systematic sampling was employed to select managers from the various health departments. Self-administered questionnaires and an interview guide collected the primary data to determine the factors influencing access and utilization of DHIS2 in Wajir County. The Quantitative data were analysed using STATA version 11.2 to make descriptive and inferential statistics to understand the data and further presented in bar charts and tables. Descriptive statistics produced mean, standard deviation and frequencies of the responses, while inferential statistics, namely correlation and linear regression, showed the relationship between independent and dependent variables. The qualitative data was organized using themes and content analysis and discussed in narratives. Results: According to descriptive study results, there was varying perceptions or views regarding the quality of data infrastructure. From inferential analysis, data infrastructure has beneficial effects on DHIS2 access and utilization. In addition, descriptive statistics revealed that staff technical capacity limits the utilization of DHIS2. Some areas lacking quality include the employee ability to handle and interpret health data and DHIS2 customization despite many of them having a high level of education. The regression results showed that staff technical capacity positively influences access and utilization of DHIS2. Similarly, few available resources limit the use and utilization of DHIS2. According to inferential analysis, available resources positively influence utilization and access of DHIS2. Finally, the study revealed that county health organizational support has positive effect on access and utilization of DHIS2. xiiiConclusion: The study concludes that DHIS2 data infrastructure, staff technical capacity, available resources and county health organizational support are key determinants of access and utilization of DHIS2. Recommendation: To facilitate the use of DHIS2, this study recommends the departments of health at Wajir County conduct more training and workshops to impact all the health workers with knowledge and skills needed to operate DHIS2 and make use of it in decision making.Besides, Wajir County should allocate appropriate funding to all health departments, as well as partner with non-governmental organizations to help in funding some health functions.

A majority of market sensing capabilities studies have either been carried out in different contexts or the conceptualizations were different. The current study was focused on establishing the relationship between market sensing practices and performance of fintech companies in Kenya. The main underlying theories in the study were the technology acceptance model and the dynamic capabilities. A cross-sectional survey together with a census approach were the choice design. The study focused on the 38 registered Fintech firms. Primary data was collected using structured questionnaire from senior managers. Simple regression technique was used to evaluate the relationship between the independent variables, Learning Orientation, Organizational System, Market Information and Organizational communication and firm performance as the dependent variable. The results include analyses of the model summary, ANOVA and regression coefficients. The findings indicated that 62% of the variation in firm performance was explained by learning orientation, organizational system, market information, and organizational communication which is a significant outcome in spite of the observation that learning orientation and organizational system are inversely related to firm performance. However, it was found that the overall effect of market sensing capability on firm performance was positive and statistically significant. This means that Fintech companies in Kenya are likely to realize increased performance if they develop and apply market sensing capabilities as a market facing strategy. The study concluded that market sensing influences firm performance in the Fintech industry in Kenya. As such, firms that have robust market sensing practices are likely to register better outcomes.

The goal of this project, is to compare the AFT model and Cox PH model using the employee attrition data set. Survival analysis examines the desired outcome until the occurrence ofthe event. Although Cox PH together with AFT models have been widely utilized in survival time predictions, AFT models are least used in employee attrition. Therefore, the goal of this research is to conduct survival analysis on the employee attrition data set to narrow down on the specific factors that will benefit the employer using both models and the best method to use. Using R, the Accelerated Failure Time model gave favourable outcome compared to the Cox PH model. The main factors that have a significant impact on the survival attrition include, the job role(Research Scientist, Sales Executive), home to job distance, work life balance, level of satisfaction in job and nature of travel. Furthermore, the Generalized Gamma AFT model offers the most outstanding fit for the observed data. The research will serve as a focal point for surviving analysis models in predicting employee attrition, enlightenment in the analysis and deepen the context of survival analysis.

This study sought to determine how school-based factors influenced students discipline in public secondary schools in Seme Sub-county, Kisumu County. The study was guided by the following objectives: to examine the influence of peer pressure on students’ discipline, to establish the influence of principals’ democratic leadership style on students’ discipline, to determine the influence of school population on students’ discipline and to establish the influence of Teachers’ drunkenness behavior on students’ discipline. The study employed descriptive survey research design and targeted 281 teachers, 34 principals and1451 form four students. The sample size included 141 teachers,17 principals and 290 form four students. Two sets of instruments were used to collect data. These included the teachers’ and students’ questionnaire and the head teachers’ interview guide which were self-delivered by the researcher and filled. They were analyzed using descriptive statistics including frequencies and percentages which were presented in form of tables. The findings of the study revealed that Principals and teachers warns students against joining peer bad company as shown by (97.9%) of students and (94.8%) of teachers. Peers in the same groups go against the set school rules and regulation as marked by (68.8%) of students and (84.4%) of teachers’ responses. The study further established that defiance to authority is commonly associated with bad peer group among the students It was further established that principals democratic style minimized indiscipline cases in schools as shown by (79.9%) of students, (87.6%) of teachers’ and (70.6%) of principals’ responses. Highly congested class rooms contributed to disorder in classroom cases in school as shown by (67.5%) of students and (71.9%) of teachers’ responses. A large number of teachers 94 (69.6%) agreed that high students’ population in school overwhelmed them thus little attention was paid on discipline. Students school absenteeism (23.7%) and students’ defiance to authority (23.7%) were identified as the most common indiscipline cases in schools. drunkard teachers are always unprepared for lessons and teachers’ ill preparedness for lesson encouraged indiscipline in school as shown by (54.6%) of teachers’ responses it was affirmed that drunkard teachers cause indiscipline in schools by humiliating and intimidating the students as shown by (54.2%) of teachers, (82.3%) of students and principals’ responses. The principals, teachers, guidance and counseling department should conduct constantly guide students on importance of having a good peer company, principals should embrace democratic style of leadership in the management of schools, school management should build spacious classrooms and facilities to cater for high students’ population and the Teachers Service Commission should ensure teachers adhere to teachers ’code of conduct and other legal instruments guiding education. The researcher recommended a similar study in private schools and other areas to establish the cases in the regions.