Unlike in the UK, health care in Kenya is not an automatic right. Similar to other low-to-middle income countries, provision is sketchy across much of the country. However, there have been exciting new developments in Makueni County in Kenya. There is now a scheme offering health care coverage for whole families for 500 Kenyan Shillings (about £3.70) per year, with free care for the over-65s. Coverage is still poor however, especially in rural areas. Too many people remain uninsured and face huge bills for their care, deterring many from seeking help.
Health care in many rural and remote areas relies heavily on Community Health Volunteers (CHV). They work at the local level and provide a screening and advisory service. Although they are volunteers, they are trained to detect significant health problems. CHVs can refer people to confirm whether or not they have diabetes to the nearest hospital. There is often a reluctance to go, due to the large distances to reach the nearest hospital and the anticipated cost if they do not have health care insurance.
Due to the long distances that CHVs have to travel, motorbikes are provided for them. A system is in development for their referrals to be sent to them via a mobile app. Despite a number of innovative identification and referral initiatives using mobile technology, hospital facilities are severely under-resourced and can be overwhelmed with the number of people coming in to be treated, as I found out during my research in Kenya.
Kenya is not alone in terms of the increased prevalence of diabetes. As people live longer and lifestyles change, conditions such as diabetes are on the increase. This applies in both high income countries like the UK and in low-to-middle income countries such as Kenya. The International Diabetes Federation (IDF) has estimated that 1 in 10 people have diabetes worldwide. They have predicted that by 2024, there will be 47 million people in Africa alone with diabetes, a 143% increase on 2019 figures (IDF Atlas, 2019).
In addition to the rise in physical illnesses, the prevalence of mental health problems is growing. Evidence has shown that people with diabetes are significantly more likely than those without diabetes to have depression or other mental health problems, creating in effect a ‘double whammy’. In Kenya, this places an even greater burden on the CHVs in terms of referrals to services, but also in terms of identification. This is often difficult due to the stigma surrounding disclosing a mental health problem.
As part of the Community Intervention for Diabetes and Depression (CoIN-DD) network, which I jointly lead with Professor David Ndetei from the African Mental Health Research and Training Foundation, a research project is underway in Makueni County. This is being facilitated by our mental health nurse researcher Christine Musyimi and aims to address this stigma and increase understanding of both diabetes and depression.
Working alongside people from local rural communities, CHVs, public health officers and other health care workers, we have co-created educational materials designed to be used extensively in both communities and health care settings to increase knowledge and understanding of depression and other mental health problems. The focus of these materials addresses the negative and stigmatising language used to talk about these conditions. We anticipate this will help with both identification and treatment of diabetes and depression – our next step is to formally evaluate these materials before distributing them more widely.
The COIN-DD network extends well beyond Kenya. Since the network’s launch in 2018, it has gone from strength to strength, training early career researchers, developing protocols for research and participating in projects including the International Prevalence and Treatment of Diabetes and Depression (INTERPRET-DD) study. This is now taking place in 14 countries across the globe, including Kenya. The study has found that stressful life events, as well as the emotional distress related to diabetes significantly increase the risk of depression for adults with diabetes across all the nations studied.
We are now closely following a sub-sample of the INTERPRET-DD cohort in order to examine the country-specific treatment pathways, which will assist in shaping the best treatment options specific to each country’s context. We continue to work with our colleagues in Makueni county, to both enhance the recognition of health problems and support improvements in clinical care and will be reporting the results of our research soon.
The TV series that inspired this article