COBES REPORT
1
A REPORT OF COMMUNITY EXPERIENCE IN AINAMOI SUBCOUNTY FROM
26th SEPTEMBER, 2022, AND COMMUNITY HEALTH FIELD TRIPS FROM 6th
OCTOBER, 2022
PRESENTED
BY
BENARD OKOTH WERE
COURSE CODE: NUS 400
NUR/K/0032/2018
SCHOOL OF HEALTH SCIENCES
DEPARTMENT OF NURSING SCIENCES
A REPORT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE AWARD OF THE BACHELORS DEGREE (NURSING) IN THE SCHOOL
OF SCIENCES AND TECHNOLOGY, OF THE UNIVERSITY OF KABIANGA.
@OCTOBER2022
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DECLARATION
This report is my original work and has not been presented for any degree or any other
institution.
Signature ....................................
Date .......................................
BENARD OKOTH WERE
NUR/K/0032/2018
SUPPERVISORS
SIGNATURE
Dr. Simon K. Macharia
……………….
Madam Irene Lumonje
……………….
Madam Rose Rotich
………………..
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ACKNOWLEDGEMENT
I would like to acknowledge the following for their support during my COBES experience:
I am thanking God for the good health He granted me throughout the entire period of COBES
placement.
The Dean School of Health Sciences, Dr. Erick Mibei, the Head of the Department, Mrs. Lily
Ng'eno for ensuring that the community health nursing activities take place.
The Course Supervisor Mrs. Rose Rotich, Mr. Macharia Simon and Madam Irene Lumonje
for their guidance in the community health trips and the clinical instructor Mr. Keitany and
Madam Emily for the support and guidance during the community health nursing practice.
The SCPHN Ainamoi sub-county Mrs. Hellen Rotich for the mentorship during the entire period.
The PHO Kericho County Referral, Mr. Dennis Ngeno for his mentorship during the entire
period of placement.
The nursing officer in charge, Mrs.Ednah Maiyo GK prison-Kericho Dispensary for her time and
support during the entire period.
The Leprosy and Tuberculosis Coordinator Alupe Hospital Mr. Amukang for the mentorship.
The PHO in Budalangi, Mr. Edward for his mentorship.
My fellow classmates for the teamwork and moral support during the entire period.
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FORWARD
The nurse is present at all levels of health services from basic to the complex services in a
hospital and community setting. Nursing is acknowledged as an essential component of health
care delivery systems from primary health care to all deliveries at all levels and more especially
in the tertiary level in Kenya as well as in the primary level.
A COBES experience is meant to produce professional competences that is achieved in the
training process with formative and summative evaluation both in standard and elective
curriculum overall.
The University of Kabianga, department of Nursing (BScN training) 4th year in the end has
COBES unit (NUS 400) aimed at providing an opportunity to a student to improve on
knowledge, skills, competency and attitude towards offering essential nursing services in the
country and more especially in the community setting.
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LIST OF ABBREVIATIONS
AEFD – Adverse events following Immunization.
CHEW- Community Health Extension Workers.
CECM –County Executive Member Committee.
CCC – Comprehensive Care Centre.
CHMST- County Health Management System Team.
COBES- Community Based Education Services.
COVID-19- Corona virus.
CORPs -Communities Own Resource Persons.
CHVs - Community Health Volunteers.
CHWs -Community Health Workers.
CS- Cabinet Secretary.
DHIS-District Health Information System.
FP- Family Planning.
HBC - Home Based Care.
KEMSA- Kenya Medical Supplies Authority.
KEPI -Kenya Expanded Programme on Immunization.
KDHS -Kenya Disease Health Survey.
MOH -Ministry of Health.
MOH 333 -Maternal Services Register.
MOH 406 -Postnatal Register.
MOH 710 – Immunization.
MOH 514 - CHEW Service delivery logbook.
MOH 515 - CHEW Summary.
MCH- Mother Child Health.
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MDGs- Millennium Developmental Goals.
NGO - Non-Governmental Organization.
NHIF - National Health Insurance Funds.
IEC- Information, Education and Communication.
PHC - Primary Health Care.
PHOs - Public Health Officers.
SDGs -Sustainable Developmental Goals.
SCPHN- Sub County Public Health Nurse.
SHMT - Sub County Health Management Team.
SCHRIO -Sub County Human Resource and Information Officer.
UNICEF- United Nations International Children's Emergency Fund.
VVM - Vaccine Vial Monitor.
WHO - World Health Organization.
KCRH- Kericho County Referral Hospital.
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DEFINITION OF TERMS
Anemia - A condition in which the Hemoglobin concentration is lower than normal. As a result,
the amount of oxygen delivered to body tissue is diminished.
Epidemiology- A branch of medicine that focuses with the incidence, distribution and possible
control of diseases and other factors relating to health.
Health- A state of complete physical, mental and social well-being and not merely the absence
of disease and infirmity (WHO).
Immunization- A process by which a person becomes protected against a disease through
vaccination.
Malnourished- State of lack of sufficient nutrients in the body.
Primary Health Care - Essential Health care based on practical, scientifically sound and
socially acceptable methods and technology, made universally accessible to individuals and
families.
Public Health - Science and art of preventing diseases, prolonging life and promoting health
through the organized efforts and informed choices of the society, organizations, public and
private, communities and individuals.
Community diagnosis - It is a process through which health workers together with members of
the community identify the community's priority health problems and implement them.
Disease Surveillance- An epidemiological practice by which the spread of disease is monitored
in order to establish patterns of progression.
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ABSTRACT
When working towards a degree in Nursing there are many required prerequisites that are taken
both in classroom setup, hospital clinical placements and some research conduction.
Understanding how human an important aspect any nursing profession.
COBES is designed to build on nurses on the aspect of conducting proper community diagnosis,
identify the health problems as well as address the problems. It provides opportunities to build on
nursing skills, attitude and knowledge on different areas within the community.
COBES enriches nurses with enough competence to face the challenges in the community,
identify their needs and use appropriate resources allocated within the community to meet the
needs that the community faces. It also involves participating jointly with other stakeholders to
include, CHWs, CHVs, CHEW, organizations such as WHO and UNICEF and other health
care providers to include Public Health Officers, Medical Officers for the good of people in the
community.
This report entails various objectives that i was able to achieve during my COBES placement. I
worked under the guidance of the SCPHN, Mrs. Hellen Rotich, at the KEPI department which
entailed giving and distributing and recording supplies issued at Ainamoi South Sub County
health centers staff, maintaining and monitoring cold chain and administering vaccines which
included as the COVID -19 vaccines such as AstraZeneca, Pfizer and Moderna first and second
doses. Also shown the organizations structure of the Ministry of Health as well as health
indicators identification that include Immunization and viral load besides identification of gaps
within the health facilities with possible ways to addressing them.
There was also support from the PHO , Mr. Dennis Ng'eno, who took me around inspecting
premises to include homesteads ,slaughter house, roles of CHVs and CHEWS and we had a
hospital inspection under His guidance at KCRH.I also familiarized myself with the flagship
projects of vision 2030 available in the community such as beyond zero campaign and Linda
mama at the KCRH Mother and Child Health Departments above 18 years for accorded
commitment in the fight against Corona virus in the rise towards achievement of Herd
immunity. Health education on curbing the COVID 19 virus such as hand washing, putting on
face masks and maintaining social distancing was sensitized.
We also went for field trips at Kisumu international airport where we learnt about port health,
Alupe hospital where we learnt about leprosy, port Victoria where we learnt about disaster
management and Children’s home in where we learnt about the steps of admission of children to
the home.
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Contents
CHAPTER TWO ............................................................................................................................................ 12
2.1 ACTIVITIES PERFORMED AS PER OBJECTIVES ................................................................................... 12
Level 1: COMMUNITY FACILITIES ............................................................................................................ 12
LEVEL 2: DISPENSARIES ....................................................................................................................... 12
LEVEL 3: HEALTH CENTERS. ................................................................................................................. 12
LEVEL 4:
SUBCOUNTY HOSPITALS .................................................................................................... 13
LEVEL 5: COUNTY REFFERRAL HOSPITALS ........................................................................................... 13
LEVEL 6: NATIONAL REFFERAL HOSPITALS.......................................................................................... 13
2.2 Organization structure of ministry of Health in Kenya ..................................................................... 13
2.3 Sub County Health Management team (SHMT) ............................................................................... 14
Members of the SHMT ........................................................................................................................ 14
Functions of SHMT .............................................................................................................................. 15
REPORT FROM PORT VICTORIA................................................................................................................... 15
REPORT FROM ALUPE SUB COUNTY HOSPITAL. ......................................................................................... 16
Management of leprosy .......................................................................................................................... 17
CONCLUSION............................................................................................................................................... 17
RECOMMENDATIONS. ................................................................................................................................ 18
REFFERENCES .............................................................................................................................................. 20
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CHAPTER ONE
1.1 Introduction
A community is a group of people living in a certain geographical area either small or large and
are working together for a common purpose. The members of the community share resource
such as water, health services and schools. Health is a state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity (WHO definition).
Therefore, Community health is a systematic way of studying the health and diseases present in a
community and patterns of delivery of care.
I was placed at Kericho County Referral Hospital which is a level 4 hospital located in Kericho
County, Ainamoi Sub- County in Kericho Town. The hospital served as central meeting point for
all level 1 to level 3 community health personnel in Ainamoi Sub- County so as to discuss
emerging health issues, give monthly health reports and identify gaps in the sub county so as to
improve the quality and delivery of health care in the sub county. The KEPI store of the hospital
is where the health facilities of the sub-county obtained vaccines. During the placement the
COVID 19 vaccines were already dispensed to the facility from Nakuru regional stores as the
COVID 19 immunization campaign was already on. There were already three sets of vaccines
that is AstraZeneca, Moderna and Pfizer in addition to the other vaccines. The health centers in
Ainamoi Sub County include which serves estimated population of 182 312 persons,
1.2 Objectives of the study
1.2.1 Broad Objective
Acquire knowledge, skills and attitude in offering health services to the people at the community
level.
1.2.2 Specific Objectives
1. Familiarize with the organization and structure of Health care delivery system in Kenya.
The role and functions of community health team for example the CHVs.
2. Provide comprehensive promotive, preventive, curative care services to clients seeking
health services in the community.
3. Analyze and demonstrate the role of a nurse in the provision of services at the community
level
4. Assessing the needs of the people living in the community to help in identifying possible
solutions to their problems.
5. Adapt nursing care documentation at the community level
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6. Participate in Rural Health Management Team meetings.
7. Log into and submit reports using the health information system (online or stand- alone)
e.g. Fun soft, Open Data Kit, District Health Information System (DHIS) 1 and 2.
8. Participate in supportive supervision of rural health facilities within a County or
Sub-County.
1.3 Roles of Community Health Nurse

Carry out a community diagnosis to identify the health needs of the people in the
community.

Use the available resources within the community to provide the necessary health needs
and concerns of the people within the society.

Partner with other stakeholders and organizations such as the NGOs, WHO and
UNICEF in the provision of essential health services within the community.

Provide promotive, preventive, curative and rehabilitative services to the people within
the community.

Proper documentation of incidences and activities in the respective document to monitor
the progress of health services being offered to individuals at the community level. This
also assist for future references in case.

Identify health issues that require urgency for treatment in order to conduct referral to
reduce the morbidity and mortality cases, more especially for the sick pregnant mother
and infants/children.

Assist epidemiologist in conducting a proper disease surveillance and report to the
appropriate department to allow for appropriate measures to be taken.
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CHAPTER TWO
2.1 ACTIVITIES PERFORMED AS PER OBJECTIVES
1) Health care delivery system structure hierarchy in Kenya
During the experience I familiarized with the organization of Kenya’s health structure and the
Sub County health management team (SHMT). The health docket of Kenya was devolved in the
2010 constitution. It’s managed at both the national level and county level. There are six levels
of health care facilities in which the first five levels are managed by the county government and
the sixth level managed by the national government. The levels are as follows;
Level 1: COMMUNITY FACILITIES
These are community facilities in the community set-up. They are always managed by CHVs and
CHEWs. They provide services such as: HIV testing, home visits, contact tracing, blood pressure
testing, Malaria rapid test, offer health talks to people at the community level. and issue referral
letters to other facilities for management of patients.
LEVEL 2: DISPENSARIES
These are health centers in the community which have out-patient services. They are always run
by clinical officers and nurses. They provide outpatient services such as laboratory services,
antenatal services, HIV testing services, pharmacy services, counselling services, they issue
referral letters to other facilities for further management of patients and generally offer primary
health care services.
LEVEL 3: HEALTH CENTERS.
This are small hospitals with limited facilities but offer services to patients. They have at least 1
doctor, clinical officers and nurses. They offer services such as laboratory services, in patient
maternity services, antenatal and postnatal services, Comprehensive care clinics for HIV
patients, special clinics such as dental clinic, diabetic clinics and also issue referral letters to
other health care facilities
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LEVEL 4:
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SUBCOUNTY HOSPITALS
These are hospitals at the sub-county level. They offer Level 3 health services plus radiology
services and inpatient services. They serve as meeting places for Level 1-level 4 community
health personnel where they give monthly health reports and take supplies of vaccines, essential
drugs and non-pharmaceuticals such as vaccine solo shots, masks, gloves among others. They
also issue referral letters to other health facilities. They are run by a director. They have more
doctors, nurses and clinical officers.
LEVEL 5: COUNTY REFFERRAL HOSPITALS.
These are hospitals that are run by the chief executive officer at the county. They offer level 4
services plus other services such as orthopedics, physiotherapy. They issue referral letters to
other hospitals on the national level like Kenyatta National Hospital and Moi Teaching and
Referral Hospital
LEVEL 6: NATIONAL REFFERAL HOSPITALS.
These are teaching and research hospitals that are managed by the national government example
Kenyatta National Hospital, Moi Teaching and Referral Hospital and Mathari Teaching and
Referral Hospital. These hospitals offer specialized services other than the ones offered by level
5 hospitals.
2.2 Organization structure of ministry of Health in Kenya
The ministry of Health is run by the Cabinet secretary (CS) for health currently whose
headquarters are at Afya House in Nairobi. After the CS there is Chief Administrative secretary
(CAS) and then there is the principal secretary (PS) who is the accounting officer and Chief
executive officer of the ministry of Health. Then there is the acting director general of medical
services in the ministry of health after the PS (DMS). From the DMS there are various
departmental heads in the ministry of health at the national level such as Chief Nursing Officer
who foresees nursing activities in the country, Head of finance, Chief Pharmacist, Chief public
health officer, chief clinical officer among others.
From the national level, we then go to the 47 counties in Kenya. The health docket is headed by
the County Executive Member Committee (CECM) who is appointed by the governor. He
oversees and plans for various departments in the county. Then the Chief Officer of health is the
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accounting officer for health in the county. After the Chief Officer is the County director of
health. After the County director of Health are various departmental heads in the county such as
county nursing officer, county pharmacist, county nutritionist, county public health officer,
county disease surveillance.
After the Counties we then go to the Sub County level in which there is the Sub County medical
officer of health (SCMOH) who foresees health activities of the Sub County. Then follows Sub
County departmental heads such as the sub county public health officer, sub county medical lad,
sub county disease surveillance officer among others.
From the Sub County level, we then go to the primary health care level which consists of health
facilities that are run by health facility in charge. Then the community level that contains
CHEWS and CHVS.
2.3 Sub County Health Management team (SHMT)
These are a team of health workers that manage the district health office. The team is chaired by
the Sub County medical officer of health.
Members of the SHMT

Sub county Public Health Nurse.

Sub County Health Records and information officer

Sub County Nutrition officer

Sub County Clinical officer

Sub County Disease Surveillance Coordinator

Sub County STI and HIV coordinator

Sub County Public Health Officer

Sub County Health administrative officer Sub County Pharmacist

Sub County Reproductive Health Coordinator.

Sub County Infection Prevention and control Officer.
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Sub County health promotion officer.

Sub County Medical Laboratory Officer
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Functions of SHMT

Monitoring and supervision of all health activities and personnel. This is achieved
through support supervision and routine supervision of health facilities, inspection of
health facilities.

Collect and use health information for planning, monitoring and evaluation. This is
achieved through various reporting tools such as MOH 710 for immunization

Ensure efficient management of both human and material resources. This is achieved
through monthly reports such as consumption report, daily workload reports, S11 forms.

Plan and execute health services in the district. This involves community participation,
local government and inter-sectoral coordination and collaboration in health.

Capacity building through training of health personnel. This is through CMEs,
Sensitization of personnel in case of new drugs, new vaccines, new diseases example
COVID 19, workshops and Conferences.
REPORT FROM PORT VICTORIA.
We went to port Victoria on .... of October 2022 to gain experience on disaster management. The
area is mostly affected by floods from River Nzoia which usually breaks its banks in march,
April or May according to the area meteorological department. The area also has a swampy area
which is flat. There are increased diarrheal diseases in the area, water borne diseases such as
cholera, Typhoid and water related diseases and vector borne diseases especially malaria. The
floods occur in the rainy season whereby river Nzoia bursts its banks. The people economic
activity in the area includes fishing, sand harvesting from river Nzoia.
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The area has increased diarrhea cases due to the residents drinking contaminated Water is
contaminated by human and animal waste. A wide area of Budalangi lacks toilets since the water
table is high and floods sweep away the toilets. There is increased open defecation by the
residents and the boys harvesting sand in the river also defecate in the rivers and consume the
water. When floods begin, there is increased waterborne diseases such as cholera, typhoid due to
consuming contaminated water and water-based diseases that come as a result of the effect of the
water such as schistosomiasis that comes when the people walk bare footed. The residents
consume the water from river Nzoia, do not treat it hence causing the above diseases. During the
floods the residents are always evacuated but some deny to move away from their homes due to
the culture of the Nyala people who try to remain in their ancestral land. They stay on the dykes
which creates a risk to injury, drowning, lack of food to feed their livestock and unavailable safe
water for domestic uses and drinking. Measures that have been put in place due to floods include
construction of dykes, moving people to safe camps, river trimming so as to prevent formation of
ox-bow lakes by the river. River Nzoia has a meteorological department a gauge placed in a
certain level usually to detect water levels rising up to 5 meters which is an indication of a
possibility of floods occurring. When water levels rise to a particular level of the river, it sends
signals to the meteorological department and the meteorological department communicates to the
residents through a local radio station called Bulala FM for the residents to evacuate to safe
places. In the camps there are CHVs who refer people and aid in primary health care. Some of
the top ten diseases in the area include: Malaria, upper respiratory tract infections, other diseases,
skin diseases, hypertension, urinary tract infections.
REPORT FROM ALUPE SUB COUNTY HOSPITAL.
We went to Alupe Sub County hospital which is a leprosy and tuberculosis center. It also has a
Kenya medical research institute (KEMRI). We had sessions with Mr. Amukanga who took us
through leprosy. We had to see a patient who had recovered from leprosy which was diagnosed
in 2013 took medications for a year and healed. Leprosy is a chronic infectious disease caused by
Mycobacterium liprae which are rod-shaped acid-fast bacilli. It is characterized by lesions of
peripheral nerves; the natural host is Armadillo an animal in Brazil the mode of transmission is
by droplet infection it’s also called Hansen's disease. It damages mostly the facial nerve cervical
nerves, medial nerve, sciatic nerves. Leprosy is also called Hansen’s disease. It was discovered
in 1873 by Hansen. The natural host of leprosy is an animal called Armadillo which is found in
Amazon in Brazil. Leprosy can be classified as either paucibacillary or multibacillary.
Paucibacillary leprosy has 1-5 patches, produces negative skin smear on biopsy, and leads to
type 1 reaction which damages one or more peripheral nerves. Examples of paucibacillary
include; true tuberculoid and borderline leprosy. Multibacillary leprosy on the other hand ha got
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more than 6 patches, has a positive skin smear on biopsy, produces type one and type two
reaction and disability develops at a later stage. Examples of multibacillary leprosy include;
neural leprosy, indeterminate leprosy and lepromatous leprosy. Clinical manifestations include;
presence of hypo pigmented skin patches with loss of sensation, presence of one or more
enlarged nerves, nodules, scars, dryness where there are patches, tingling sensation, numbness,
burning sensation, loss of hair and positive skin smear on biopsy.
Management of leprosy
Includes health education on managing the wounds, multi drug therapy with dapsone, rifampicin
and clofazimine, 6 months for paucibacillary and 12 months for multibacillary leprosy. The
patients are also given special foot ware called elephant boots since they have a wide base so as
to prevent trauma to the patient. There is no vaccine for leprosy. Unmanaged leprosy leads to
deformities due to nerve damage. These deformities include; wrist drop, wrinkling of face due to
facial nerve damage, foot drop and lagophthalmia. some complications after treatment include
type I and type 2 immunological reactions due to the presence of dead mycobacterial granuloma
in the body which is usually excreted slowly out of the body with time.
CONCLUSION
It has been a good experience personally to learn activities taking place in community health
nursing in relation to occupational health, environmental health, disaster management. Moreover,
I have gained nursing education in management of Kenya programme of expanded immunization
programme in Ainamoi sub-county level, health information management systems, conducting a
support supervision among others stated in the learning objectives in this unit which could help
me become a competent nurse I the future I thank God and all who participated in achieving my
community health nursing practicum objectives.
Challenges we faced during the clinical placement with my colleagues

I missed at some point or reported late to the clinical stations I was placed due to transport
issues with the bus we were using

Unavailability of the SCPHN in the last week of our rotations since she was occupied and
busy elsewhere
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I wasn’t able to meet some of the objectives due to the timeline of the clinical placement
such as participating I rural health management team meetings, inspection of pharmacy and
management of disasters such as floods and cholera.
RECOMMENDATIONS.
To the University of Kabianga

Each placement of community health should have at least one instructor to ensure the
students learn and achieve their objectives.

The students should be allowed to live close to their areas of clinical placement to save on
time and avoid transport challenges.
To Kericho county referral hospital.

Improve the KEPI store, increase its space and de-congest it.

Do more CMEs on flagship projects of Vision 2030.
To the Ainamoi sub-county

Employ one more nurse in the KEPI store to aid the SCPHN when he is away.

Do regular routine supervision to check on data quality audit so as to ensure data
accuracy, consistency from the registers and the KHIS.Educate the nurses on the different
registers and reporting tools through CMEs and seminars to avoid confusion of staff.
To the county government of Kericho.

Allocate funds to motivate CHVs so as to prevent some of them from leaving their jobs
due to lack of remuneration.

Employ more staff to aid in community health services.

Make a strategic plan to achieve vision 2030 flagship projects in the sub county.

Support Bethel Children’s home financially and its infrastructure.
To the Government of Kenya

Mobilize funds for construction of permanent dykes made of concrete so as to control
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floods in Budalangi.

Do land reclamation of the swamps in Budalangi by setting up irrigation schemes such as
rice.

Mobilize funds to ensure attainment of universal health coverage.
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REFFERENCES
Draft for National Policy of Disaster Management in Kenya (2009).
National Tuberculosis and Leprosy control programme TB MANUAL, REPUBLIC OF ZAMBIA 5th ed.
(2017) pg.39-56.
Peter Ngatia,Tiberry Nyakwana,Bon Oirere,Betty Rabar and Peter M.
Waithaka.(2008).Community Health (3rd edition). AMREF.