Cost-effectiveness of One Health intervention to reduce risk of human exposure and infection with non-typhoidal salmonellosis (NTS) in Nigeria

Background

Non-typhoidal Salmonella infection (NTS) is an important foodborne zoonosis with underappreciated health and economic burdens, and low case fatality. It has global prevalence, with more burdens in under-resourced countries with poor health infrastructures. Using a cohort study, we determined the cost-effectiveness of NTS in humans in Nigeria for the year 2020.

Methods

Using a customized Excel-based cost-effectiveness analysis tool, structured (One Health) and unstructured (episodic intervention against NTS) in Nigeria were evaluated. Input data on the disease burdens, costs surveillance, response and control of NTS were obtained from validated sources and the public health system.

Results

The non-complicated and complicated cases were 309,444 (95%) and 16,287 (5%) respectively, and the overall programme cost was US$ 31,375,434.38. The current non-systematic episodic intervention costed US$ 14,913,480.36, indicating an additional US$ 16,461,954 to introduce the proposed intervention. The intervention will avert 4036.98 NTS DALYs in a single year. The non-complicated NTS case was US$ 60/person with significant rise in complicated cases. The cumulative costs of NTS with and without complications far outweighed the program cost for One Health intervention with an incremental cost-effectiveness ratio (ICER) of -US$ 221.30).

Conclusions

Utilising structured One Health intervention is cost-effective against NTS in Nigeria, it carries additional mitigative benefits for other diseases and is less costly and more effective, indicative of a superior health system approach. Identified limitations must be improved to optimize benefits associated and facilitate policy discussions and resource allocation.

Barley MLA3 recognizes the host-specificity effector Pwl2 from Magnaporthe oryzae

Plant nucleotide-binding leucine-rich repeat (NLRs) immune receptors directly or indirectly recognize pathogen-secreted effector molecules to initiate plant defense. Recognition of multiple pathogens by a single NLR is rare and usually occurs via monitoring for changes to host proteins; few characterized NLRs have been shown to recognize multiple effectors. The barley (Hordeum vulgare) NLR gene Mildew locus a (Mla) has undergone functional diversification, and the proteins encoded by different Mla alleles recognize host-adapted isolates of barley powdery mildew (Blumeria graminis f. sp. hordei [Bgh]). Here, we show that Mla3 also confers resistance to the rice blast fungus Magnaporthe oryzae in a dosage-dependent manner. Using a forward genetic screen, we discovered that the recognized effector from M. oryzae is Pathogenicity toward Weeping Lovegrass 2 (Pwl2), a host range determinant factor that prevents M. oryzae from infecting weeping lovegrass (Eragrostis curvula). Mla3 has therefore convergently evolved the capacity to recognize effectors from diverse pathogens.

Pattern and determinants of contraceptive use among the muslim women in Wajir and Lamu counties in Kenya: a cross-sectional study

BACKGROUND

Improving access to family planning (FP) is associated with positive health benefits that includes averting nearly a third of all maternal deaths and 10% of childhood deaths. Kenya has made great strides in improving access to family planning services. However, amid this considerable progress, regional variation has been noted which begs the need for a clearer understanding of the the patterns and determinants that drive these inconsistencies.

METHODS

We conducted a cross-sectional study that involved 663 Muslim women of reproductive age (15-49 years) from Wajir and Lamu counties in Kenya between March and October 2018.The objective of this study was to understand patterns and determinants of contraceptive use in two predominantly Muslim settings of Lamu and Wajir counties that have varying contraceptive uptake. Eligible women were interviewed using a semi-structured questionnaire containing socio-demographic information and history of family planning use. Simple and multiple logistic regression were used to identify determinants of family planning use. The results were presented as Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) ratios at 95% confidence interval. A p-value of 0.05 was considered statistically significant.

RESULTS

Of the 663 Muslim women of reproductive age consenting to participate in the study, 51.5%, n = 342 and 48.5%, n = 321 were from Lamu and Wajir County, respectively. The prevalence of women currently using contraceptive was 18.6% (n = 123). In Lamu, the prevalence was 32.8%, while in Wajir, it was 3.4%. The determinants of current contraceptive use in Lamu include; marital status, age at marriage, employment status, discussion with a partner on FP, acceptability of FP in culture, and willingness to obtain information on FP. While in Wajir, determinants of current contraceptive use were education, and the belief that family planning is allowed in Islam.

CONCLUSIONS

Our study found moderately high use of contraceptives among Muslim women of reproductive age in Lamu county and very low contraceptive use among women in Wajir. Given the role of men in decision making, it is critical to design male involvement strategy particularly in Wajir where the male influence is very prominent. It is critical for the government to invest in women and girls' education to enhance their ability to make informed decisions; particularly in Wajir where FP uptake is low with low education attainment. Further, our findings highlight the need for culturally appropriate messages and involvement of religious leaders to demystify the myths and misconception around family planning and Islam particularly in Wajir.

The effectiveness of combined approaches towards improving utilisation of adolescent sexual and reproductive health services in Kenya: a quasi-experimental evaluation

Adolescent sexual and reproductive health (ASRH) services are key to improving the health of adolescents. This study aimed to establish the effectiveness of an intervention that combined activities in health facilities and communities in Kenya to increase utilisation of ASRH services. A quasi-experimental evaluation design was used to assess the effectiveness of the intervention. Using a stratified cluster sampling approach, two cross-sectional household surveys targeting girls aged 15-19 were conducted at baseline (September 2019) and endline (December 2020) in intervention and comparison. We combined the difference-in-difference approach to analyse the net change in outcomes between intervention and comparison arms of the study at baseline and endline and coarsened exact matching for variables that were significantly different to address the imbalance. There were a total of 1011 participants in the intervention arm and 880 in the comparison arm. Descriptive results showed a net increase of 12.7% in intervention sites in the knowledge of misconceptions about sex, pregnancy, and contraception, compared to 10.4% in the control site. In the multivariate regression analysis, two outcomes remained significant: decreases in adolescents' discomfort when seeking ASRH services because of either fear of parents (aPR = 0.58, 95% CI = 0.42-0.79, P = 0.001) or a lack of support from their partner (aPR = 0.25, 95% CI = 0.08-0.82, P = 0.023). The intervention combining a facility and community approach was not effective in increasing the use of ASRH information and services. Possible reasons for this are explored.

Quality of life and factors associated among caregivers of adolescent and young adult Ebola survivors in Democratic Republic of the Congo, a cross-sectional study

BACKGROUND

Ebola virus disease is a medical condition whose consequent effects on quality of life of patients. In the history of infectious diseases, there have been pathologies that have had significant repercussions for caregivers, healthcare providers and the community.

OBJECTIVES

This study investigate determinants of quality of life among caregivers of adolescent and young adult Ebola survivors in Democratic Republic of the Congo.

METHODS

This was a cross sectional study. The study sites were the two health districts of Beni and Katwa, in North-Kivu province in the Eastern part of Democratic Republic of the Congo. The study period was from April to August 2022. Participants of the study were caregivers of adolescents and young adult Ebola virus survivors. Simple random sampling technique was used to select the 68 study participants. A questionnaire was administered. Data was collected using pretested questionnaire of WHO quality of life Bref (WHOQOL-BREF) and CommCare by Dimagi.Inc. lastest Version 2.52.1 and  a sum of score of 78 or higher indicated a high level of life quality. To determine the quality of life of caregivers of adolescents and young adult EVD survivors, descriptive analysis was used. The Pearson correlation coefficient was utilized to check whether the predictor variables are multicollinear. The regression analysis produced the crude odds ratio (COR), adjusted odds ratio (aOR), 95% confidence interval (CI), and p-value. Statistical significance was defined as a p-value 0.05. The final multivariate model contained variables that were significant in the bivariate analysis. Prior to data collection, a research permit from National Ethical Committee of Research in Democratic Republic of the Congo was obtained. Written informed consents from literate or illiterate caregivers of adolescent and young adult Ebola survivors were obtained. Throughout the study, participants' privacy and confidentiality were respected.

RESULTS

A total of 68 care givers participated in the study, with a majority 54/68(79.41%) having poor quality of life. Men were 3.17 times more likely to record good quality of life than women (p = 0.02); OR:(95% CI), 3.17: (1.2 - 8.36), With regards to place of residence, caregivers who lived in town were less likely to have good quality of life compared to those in rural (p = 0.01); OR: (95%CI), 0.25: (0.09 - 0.72).

CONCLUSION

The quality of life of caregivers of adolescent and young adult Ebola survivors in Democratic Republic of the Congo is poor. To be woman caregiver and to live in town are determinants associated with poor quality of life among caregivers of adolescent and young adult Ebola survivors.

Childhood mortality and associated factors in Migori County, Kenya: evidence from a cross-sectional survey

OBJECTIVES

The under-five mortality (U5M) rate in Kenya (41 per 1000 live births) remains significantly above international goals (25 per 1000 live births). This is further exacerbated by regional inequalities in mortality. We aimed to describe U5M in Migori County, Kenya, and identify associated factors that can serve as programming targets.

DESIGN

Cross-sectional observational survey.

SETTING

Areas served by the Lwala Community Alliance and control areas in Migori County, Kenya.

PARTICIPANTS

This study included 15 199 children born to respondents during the 18 years preceding the survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was mortality in the first 5 years of life. The survey was powered to detect a 10% change in various health metrics over time with 80% power.

RESULTS

A total of 15 199 children were included in the primary analyses, and 230 (1.5%) were deceased before the fifth birthday. The U5M rate from 2016 to 2021 was 32.2 per 1000 live births. Factors associated with U5M included year of birth (HR 0.926, p<0.001), female sex (HR 0.702, p=0.01), parental marriage (HR 0.642, p=0.036), multiple gestation pregnancy (HR 2.776, p<0.001), birth spacing less than 18 months (HR 1.894, p=0.005), indoor smoke exposure (HR 1.916, p=0.027) and previous familial contribution to the National Hospital Insurance Fund (HR 0.553, p=0.009). The most common cause of death was malaria.

CONCLUSIONS

We describe factors associated with childhood mortality in a Kenyan community using survival analyses of complete birth histories. Mortality rates will serve as the baseline for future programme evaluation as a part of a 10-year study design. This provides both the hyperlocal information needed to improve programming and generalisable conclusions for other organisations working in similar environments.

Examining the responsiveness of the National Health Insurance Fund to people living with hypertension and diabetes in Kenya: a qualitative study

OBJECTIVES

To assess the responsiveness of the National Health Insurance Fund (NHIF) Supa Cover benefit package to the needs of individuals with diabetes and hypertension in Kenya.

DESIGN, SETTING AND PARTICIPANTS

We carried out a qualitative study and collected data using key informant interviews (n=39) and focus group discussions (n=4) in two purposively selected counties in Western Kenya. Study participants were drawn from NHIF officials, county government officials, health facility managers, healthcare workers and individuals with hypertension and diabetes who were enrolled in NHIF. We analysed data using a thematic approach.

RESULTS

Study participants reported that the NHIF Supa Cover benefit package expanded access to services for people living with hypertension and diabetes. However, the NHIF members and healthcare workers had inadequate awareness of the NHIF service entitlements. The NHIF benefit package inadequately covered the range of services needed by people living with hypertension and diabetes and the benefits package did not prioritise preventive and promotive services. Sometimes patients were discriminated against by healthcare providers who preferred cash-paying patients, and some NHIF-empanelled health facilities had inadequate structural inputs essential for quality of care. Study participants felt that the NHIF premium for the general scheme was unaffordable, and NHIF members faced additional out-of-pocket costs because of additional payments for services not available or covered.

CONCLUSION

Whereas NHIF has reduced financial barriers for hypertension and diabetes patients, to enhance its responsiveness to patient needs, NHIF should implement mechanisms to increase benefit package awareness among members and providers. In addition, preventive and promotive services should be included in NHIF's benefits package and mechanisms to monitor and hold contracted providers accountable should be strengthened.

Impact, cost-effectiveness, and budget implications of HPV vaccination in Kenya: A modelling study

BACKGROUND

Sub-Saharan Africa has the highest rate of cervical cancer cases and deaths worldwide. Kenya introduced a quadrivalent HPV vaccine (GARDASIL, hereafter referred to as GARDASIL-4) for ten-year-old girls in late 2019 with donor support from Gavi, the Vaccine Alliance. As Kenya may soon graduate from Gavi support, it is important to evaluate the potential cost-effectiveness and budget impact of the current HPV vaccine, and potential alternatives.

METHODS

We used a proportionate outcomes static cohort model to evaluate the annual budget impact and lifetime cost-effectiveness of vaccinating ten-year-old girls over the period 2020-2029. We included a catch-up campaign for girls aged 11-14 years in 2020. We estimated cervical cancer cases, deaths, disability adjusted life years (DALYs), and healthcare costs (government and societal perspective) expected to occur with and without vaccination over the lifetimes of each cohort of vaccinated girls. For each of the four products available globally (CECOLIN©, CERVARIX©, GARDASIL-4©, and GARDASIL-9 ©), we estimated the cost (2021 US$) per DALY averted compared to no vaccine and to each other. Model inputs were obtained from published sources, as well as local stakeholders.

RESULTS

We estimated 320,000 cases and 225,000 deaths attributed to cervical cancer over the lifetimes of the 14 evaluated birth cohorts. HPV vaccination could reduce this burden by 42-60 %. Without cross-protection, CECOLIN had the lowest net cost and most attractive cost-effectiveness. With cross-protection, CERVARIX was the most cost-effective. Under either scenario the most cost-effective vaccine had a 100 % probability of being cost-effective at a willingness-to-pay threshold of US$ 100 (5 % of Kenya's national gross domestic product per capita) compared to no vaccination. Should Kenya reach its target of 90 % coverage and graduate from Gavi support, the undiscounted annual vaccine program cost could exceed US$ 10 million per year. For all three vaccines currently supported by Gavi, a single-dose strategy would be cost-saving compared to no vaccination.

CONCLUSION

HPV vaccination for girls is highly cost-effective in Kenya. Compared to GARDASIL-4, alternative products could provide similar or greater health benefits at lower net costs. Substantial government funding will be required to reach and sustain coverage targets as Kenya graduates from Gavi support. A single dose strategy is likely to have similar benefits for less cost.

Comparing travel behaviour characteristics and correlates between large and small Kenyan cities (Nairobi versus Kisumu)

Understanding urban travel behaviour is crucial for planning healthy and sustainable cities. Africa is urbanising at one of the fastest rates in the world and urgently needs this knowledge. However, the data and literature on urban travel behaviour, their correlates, and their variation across African cities are limited. We aimed to describe and compare travel behaviour characteristics and correlates of two Kenyan cities (Nairobi and Kisumu). We analysed data from 16,793 participants (10,000 households) in a 2013 Japan International Cooperation Agency (JICA) household travel survey in Nairobi and 5790 participants (2760 households) in a 2016 Institute for Transportation and Development Policy (ITDP) household travel survey in Kisumu. We used the Heckman selection model to explore correlations of travel duration by trip mode. The proportion of individuals reporting no trips was far higher in Kisumu (47% vs 5%). For participants with trips, the mean number [lower - upper quartiles] of daily trips was similar (Kisumu (2.2 [2-2] versus 2.4 [2-2] trips), but total daily travel durations were lower in Kisumu (65 [30-80] versus 116 [60-150] minutes). Walking was the most common trip mode in both cities (61% in Kisumu and 42% in Nairobi), followed by motorcycles (17%), matatus (minibuses) (11%), and cars (5%) in Kisumu; and matatus (28%), cars (12%) and buses (12%) in Nairobi. In both cities, females were less likely to make trips, and when they did, they travelled for shorter durations; people living in households with higher incomes were more likely to travel and did so for longer durations. Gender, income, occupation, and household vehicle ownership were associated differently with trip making, use of transport modes and daily travel times in cities. These findings illustrate marked differences in reported travel behaviour characteristics and correlates within the same country, indicating setting-dependent influences on travel behaviour. More sub-national data collection and harmonisation are needed to build a more nuanced understanding of patterns and drivers of travel behaviour in African cities.

Prevalence and determinants of contraception utilization over time in Migori County, Kenya: Repeated cross-sectional household surveys

Contraception use and family planning have been shown to save lives and benefit women, their families, and their communities. We conducted a cross-sectional study analyzing data from a 2021 survey that was conducted across eight different regions in Migori County, Kenya to examine the potential role that different factors play in meeting family planning targets. Comparisons are made to data collected in 2018/2019 in order to estimate the change over time of contraception uptake. Descriptive statistics were calculated, the Cochran-Mantel-Haenszel test was used to compare contraception use over time, and multivariable logistic regression was used to model determinants of contraceptive use. Sixty-four percent of respondents in 2021 reported that they currently use some form of contraception, and implants are the most popular contraceptive method. Factors associated with higher contraception usage were region, ages 25-34 years, and marital status. Contraception uptake increased significantly in East Kamagambo following a community-driven sexual and reproductive health intervention by the Lwala Community Alliance, suggesting that increased investment in family planning may be influential. We recommend targeted outreach to population groups with low uptake of contraception and investment in both demand- and supply-side interventions to increase contraceptive uptake. Additional research, especially for populations under 18, is needed to further inform effective investment and policy.

Evaluating the effectiveness of the National Health Insurance Fund in providing financial protection to households with hypertension and diabetes patients in Kenya

BACKGROUND

Non-communicable diseases (NCDs) can impose a substantial financial burden to households in the absence of an effective financial risk protection mechanism. The national health insurance fund (NHIF) has included NCD services in its national scheme. We evaluated the effectiveness of NHIF in providing financial risk protection to households with persons living with hypertension and/or diabetes in Kenya.

METHODS

We carried out a prospective cohort study, following 888 households with at least one individual living with hypertension and/or diabetes for 12 months. The exposure arm comprised households that are enrolled in the NHIF national scheme, while the control arm comprised households that were not enrolled in the NHIF. Study participants were drawn from two counties in Kenya. We used the incidence of catastrophic health expenditure (CHE) as the outcome of interest. We used coarsened exact matching and a conditional logistic regression model to analyse the odds of CHE among households enrolled in the NHIF compared with unenrolled households. Socioeconomic inequality in CHE was examined using concentration curves and indices.

RESULTS

We found strong evidence that NHIF-enrolled households spent a lower share (12.4%) of their household budget on healthcare compared with unenrolled households (23.2%) (p = 0.004). While households that were enrolled in NHIF were less likely to incur CHE, we did not find strong evidence that they are better protected from CHE compared with households without NHIF (OR = 0.67; p = 0.47). The concentration index (CI) for CHE showed a pro-poor distribution (CI: -0.190, p < 0.001). Almost half (46.9%) of households reported active NHIF enrolment at baseline but this reduced to 10.9% after one year, indicating an NHIF attrition rate of 76.7%. The depth of NHIF cover (i.e., the share of out-of-pocket healthcare costs paid by NHIF) among households with active NHIF was 29.6%.

CONCLUSION

We did not find strong evidence that the NHIF national scheme is effective in providing financial risk protection to households with individuals living with hypertension and/diabetes in Kenya. This could partly be explained by the low depth of cover of the NHIF national scheme, and the high attrition rate. To enhance NHIF effectiveness, there is a need to revise the NHIF benefit package to include essential hypertension and/diabetes services, review existing provider payment mechanisms to explicitly reimburse these services, and extend the existing insurance subsidy programme to include individuals in the informal labour market.

Cost Effectiveness of Strategies for Caring for Critically Ill Patients with COVID-19 in Tanzania

BACKGROUND

The resources for critical care are limited in many settings, exacerbating the significant morbidity and mortality associated with critical illness. Budget constraints can lead to choices between investing in advanced critical care (e.g. mechanical ventilators in intensive care units) or more basic critical care such as Essential Emergency and Critical Care (EECC; e.g. vital signs monitoring, oxygen therapy, and intravenous fluids).

METHODS

We investigated the cost effectiveness of providing EECC and advanced critical care in Tanzania in comparison with providing 'no critical care' or 'district hospital-level critical care' using coronavirus disease 2019 (COVID-19) as a tracer condition. We developed an open-source Markov model ( https://github.com/EECCnetwork/POETIC_CEA ) to estimate costs and disability-adjusted life-years (DALYs) averted, using a provider perspective, a 28-day time horizon, patient outcomes obtained from an elicitation method involving a seven-member expert group, a normative costing study, and published literature. We performed a univariate and probabilistic sensitivity analysis to assess the robustness of our results.

, RESULTS

EECC is cost effective 94% and 99% of the time when compared with no critical care (incremental cost-effectiveness ratio [ICER] $37 [-$9 to $790] per DALY averted) and district hospital-level critical care (ICER $14 [-$200 to $263] per DALY averted), respectively, relative to the lowest identified estimate of the willingness-to-pay threshold for Tanzania ($101 per DALY averted). Advanced critical care is cost effective 27% and 40% of the time, when compared with the no critical care or district hospital-level critical care scenarios, respectively.

CONCLUSION

For settings where there is limited or no critical care delivery, implementation of EECC could be a highly cost-effective investment. It could reduce mortality and morbidity for critically ill COVID-19 patients, and its cost effectiveness falls within the range considered 'highly cost effective'. Further research is needed to explore the potential of EECC to generate even greater benefits and value for money when patients with diagnoses other than COVID-19 are accounted for.

Essential emergency and critical care as a health system response to critical illness and the COVID19 pandemic: what does it cost?

Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, effective, low-cost, life-saving care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in Tanzania and Kenya.The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.The costs per patient day of EECC is estimated to be 1 USD, 11 USD and 33 USD in Tanzania and 2 USD, 14 USD and 37 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13 USD and 294 USD in Tanzania and USD 17 USD and 345 USD in Kenya for severe and critical COVID-19 patients, respectively.EECC is a novel approach for providing the essential care to all critically ill patients. The low costs and lower tech approach inherent in delivering EECC mean that EECC could be provided to many and suggests that prioritizing EECC over ACC may be a rational approach when resources are limited.

Socioeconomic inequalities in food purchasing practices and expenditure patterns: Results from a cross-sectional household survey in western Kenya

Introduction

Socioeconomic inequalities contribute to poor health. Inequitable access to diverse and healthy foods can be a risk factor for non-communicable diseases, especially in individuals of low socioeconomic status. We examined the extent of socioeconomic inequalities in food purchasing practices, expenditure, and consumption in a resource-poor setting in Kenya.

Methods

We conducted a secondary analysis of baseline cross-sectional data from a natural experimental study with a sample size of 512 individuals from 376 households in western Kenya. Data were collected on household food sources, expenditure and food consumption. Household socioeconomic status (SES) was assessed using the multiple correspondence analysis (MCA) model. Concentration indices (Ci) and multivariable linear regression models were used to establish socioeconomic inequalities.

Results

About half (47.9%) of individuals achieved a minimum level of dietary diversity with the majority coming from wealthier households. The two most consumed food groups were grains and roots (97.5%, n = 499) and dark green leafy vegetables (73.8%, n = 378), but these did not vary by SES. The consumption of dark green leafy vegetables was similar across wealth quantiles (Ci = 0.014, p = 0.314). Overall, the wealthier households spent significantly more money on food purchases with a median of USD 50 (IQR = 60) in a month compared to the poorest who spent a median of USD 40 (IQR = 40). Of all the sources of food, the highest amount was spent at open-air markets median of USD 20 (IQR = 30) and the expenditure did not vary significantly by SES (Ci = 0.4, p = 0.684). The higher the socioeconomic status the higher the total amount spent on food purchases. In multivariable regression analysis, household SES was a significant determinant of food expenditure [Adjusted coefficient = 6.09 (95%confidence interval CI = 2.19, 9.99)].

Conclusion

Wealthier households spent more money on food compared to the poorest households, especially on buying food at supermarkets. Individuals from the poorest households were dominant in eating grains and roots and less likely to consume a variety of food groups, including pulses, dairy, eggs and fruits, and vegetables. Individuals from the poorest households were also less likely to achieve adequate dietary diversity. Deliberate policies on diet and nutrition are required to address socioeconomic inequalities in food purchasing practices.

Foodscapes, finance, and faith: Multi-sectoral stakeholder perspectives on the local population health and wellbeing in an urbanizing area in Kenya

Introduction

Rapid urbanization (growth of cities) can upset the local population's health and wellbeing by creating obesogenic environments which increase the burden of non-communicable diseases (NCDs). It is important to understand how stakeholders perceive the impact of urbanizing interventions (such as the construction of a new hypermarket) on the health and wellbeing of local populations. Because low- and middle-income countries (LMICs) lack the reliable infrastructure to mitigate the effects of obesogenic environments, so engaging stakeholders who influence dietary habits is one population-level strategy for reducing the burden of NCDs caused by newly built developments.

Methods

We conducted key informant interviews with 36 stakeholders (25 regulatory and 11 local community stakeholders) from Kisumu and Homa Bay Counties of Western Kenya in June 2019. We collected stakeholders' perspectives on the impacts of a new Mall and supermarket in Kisumu, and existing supermarkets in Homa Bay on the health and wellbeing of local populations.

Results

Through thematic discourse analysis, we noted that some stakeholders thought supermarkets enabled access to unhealthy food items despite these outlets being also reliable food sources for discerning shoppers. Others linked the changing physical environment to both an increase in pollution and different types of diseases. Stakeholders were unsure if the pricing and convenience of supermarkets would stop local populations from buying from their usual small-scale food vendors. The key finding of this study was that engaging relevant stakeholders as part of population health impact assessments of new developments in cities are important as it directs focus on health equity and prevention in instances of resource constraints. The findings highlight, also, that community members have a strong awareness of the potential for interventions that would improve the health and wellbeing of local populations.

Trends and determinants of adolescent pregnancy: Results from Kenya demographic health surveys 2003-2014

Background

Adolescent pregnancy increases the risk of disability and death due to unsafe abortion, prolonged labour and delivery, and complications after birth. Availability of accurate data is important to guide decision-making related to adolescent sexual reproductive health (ASRH). This study analyses the trends in prevalence and factors associated with adolescent pregnancy in Kenya using data from three national Demographic Health Surveys (2003, 2008/2009, 2014).

Methods

Our analysis focused on a subsample of data collected from women aged 20 to 24 years. A trend analysis was performed to establish a change in the rate of adolescent pregnancy in 2003, 2008/2009, and 2014 survey data points. Binary Logistic regression and pooled regression analysis were used to explore factors associated with adolescent pregnancy.

Results

The percentage of women aged 20 to 24 years who reported their first pregnancy between ages 15 and 19 years was 42% in 2003 and 42.2% in 2009 but declined to 38.9% in 2014. Using regression analyses, we established that education status, marital status, religion and wealth quintile were associated with adolescent pregnancy. Trend analysis shows that there was an overall decreasing trend in adolescent pregnancy between 2003 and 2014.

Conclusion

Although Kenya has made strides in reducing the prevalence of adolescent pregnancy in the last decade, much more needs to be done to further reduce the burden, which remains high.

Definition

Adolescents: Although WHO defines the adolescence period as being 10–19 years, this paper focuses on the late adolescent period, 15–19 years, here in referred to as adolescents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01986-6.

Revealing the extent of the first wave of the COVID-19 pandemic in Kenya based on serological and PCR-test data

Policymakers in Africa need robust estimates of the current and future spread of SARS-CoV-2. We used national surveillance PCR test, serological survey and mobility data to develop and fit a county-specific transmission model for Kenya up to the end of September 2020, which encompasses the first wave of SARS-CoV-2 transmission in the country. We estimate that the first wave of the SARS-CoV-2 pandemic peaked before the end of July 2020 in the major urban counties, with 30-50% of residents infected. Our analysis suggests, first, that the reported low COVID-19 disease burden in Kenya cannot be explained solely by limited spread of the virus, and second, that a 30-50% attack rate was not sufficient to avoid a further wave of transmission.

Reducing Sugar Intake in South Africa: Learnings from a Multilevel Policy Analysis on Diet and Noncommunicable Disease Prevention

High sugar intake contributes to diet-related excess weight and obesity and is a key determinant for noncommunicable diseases (NCDs) in low- and middle-income countries (LMICs). The World Health Organization (WHO) gives specific advice on limiting sugar intake in adults and children. Yet, to what extent have policy ideas on sugar intake reduction originating at the global level found expression at lower levels of policymaking? A systematic policy document analysis identified policies issued at the African regional, South African national and Western Cape provincial levels between 2000 and 2020 using search terms related to sugar, sugar-sweetened beverages (SSBs), and NCDs. Forty-eight policy documents were included in the review, most were global and national policies and thus the focus of analysis. A policy transfer conceptual framework was applied. Global recommendations for effectively tackling unhealthy diets and NCDs advise implementing a mix of cost-effective policy options that employ a multisectoral approach. South African country-level policy action has followed the explicit global guidance, and ideas on reducing sugar intake have found expression in sectors outside of health, to a limited extent. As proposed in this paper, with the adoption of the SSB health tax and other policy measures, South Africa's experience offers several learnings for other LMICs.

Prevalence, types, patterns and risk factors associated with drugs and substances of use and abuse: A cross-sectional study of selected counties in Kenya

Background

The increasing trend of drugs and substances abuse (DSA) by different age groups and gender in parts of Kenya is not only a socio-economic problem but a public health concern. There is a need to determine prevalence, types and patterns of DSA by age and gender in order to develop all-inclusive and long-term strategies to prevent and manage the DSA within different communities. In this study we determined the prevalence of DSA, types and patterns of drugs and substances being abused and risk factors associated with this abuse.

Methods

A descriptive cross-sectional mixed methods study was conducted in four counties; Isiolo, Kajiado, Murang’a and Nyamira, all purposively selected from the 47 counties of Kenya based on the review reports of the Kenya Medical Research Institute’s County Cluster Coordinators which indicated that DSA was a priority health concern in the selected counties. From each county, two sub-locations each from two locations in one sub-county were purposively selected. In each sub-location, 225 households were systematically selected. Hence, a total of 3,600 participants were systematically sampled for quantitative data collection using an interviewer-based questionnaire to gather information on magnitude and causes of DSA. Additionally, in each county, qualitative data through in-depth interviews (IDIs) with 16 opinion leaders, 16 healthcare personnel, 16 previous DSAs, at least 5 county personnel, 32 current DSAs; and through 16 focus group discussions (FGDs) were concurrently collected to elicit more information on types, patterns and causes of DSA. The observed overall prevalence of DSA was calculated using binomial logistic regression model and factors associated with DSA analyzed using multilevel logistic regression model. Qualitative data was analyzed using QSR NVIVO version 10, thematically by types, patterns and causes of DSA by age and gender.

Results

Prevalence of DSA was 86.0% (95%CI: 84.9–87.2) with the highest prevalence being observed in Nyamira County, 89.8% (95%CI: 87.9–91.7). Age-wise, the highest prevalence was observed in persons aged between 45 to 53 years, 89.4% (95%CI: 86.9–92.0), followed by those aged 36 to 44 years, 88.0% (95%CI: 85.4–90.6). Majority of those who abuse drugs and substances were males; 94.5% (95%CI: 93.6–95.4). The most abused drugs or substances were packaged/legal alcohol at 25.2% (745), cigarettes 20.3% (600), local brew (chang’aa) 16.3% (482), and khat (miraa) 10.5% (311). Risk factors analysis revealed that DSA was significantly higher among males (adjusted odds ratio (aOR) = 7.02 (95%CI: 5.21–9.45), p<0.001), government employees (aOR = 2.27 (95%CI: 1.05–4.91), p = 0.036) and unmarried (aOR = 1.71 (95%CI: 1.06–2.77), p = 0.028).

Conclusions

These study findings are useful in informing development of specific control programmes which will address age, gender and county needs of DSA in Kenya in order to comprehensively respond to this public health problem. This study was conducted in line with the Kenya National Authority for the Campaign against Alcohol and Drug Abuse (NACADA) mandate to promote use of research on drugs and substances abuse.

Navigating the local foodscape: qualitative investigation of food retail and dietary preferences in Kisumu and Homa Bay Counties, western Kenya

Introduction

Non-communicable diseases have risen markedly over the last decade. A phenomenon that was mainly endemic in high-income countries has now visibly encroached on low and middle-income settings. A major contributor to this is a shift towards unhealthy dietary behavior. This study aimed to examine the complex interplay between people’s characteristics and the environment to understand how these influenced food choices and practices in Western Kenya.

Methods

This study used semi-structured guides to conduct in-depth interviews and focus group discussions with both male and female members of the community, across various socioeconomic groups, from Kisumu and Homa Bay Counties to further understand their perspectives on the influences of dietary behavior. Voice data was captured using digital voice recorders, transcribed verbatim, and translated to English. Data analysis adopted an exploratory and inductive analysis approach. Coded responses were analyzed using NVIVO 12 PRO software.

Results

Intrapersonal levels of influence included: Age, the nutritional value of food, occupation, perceived satiety of some foods as opposed to others, religion, and medical reasons. The majority of the participants mentioned location as the main source of influence at the community level reflected by the regional staple foodscape. Others include seasonality of produce, social pressure, and availability of food in the market. Pricing of food and distance to food markets was mentioned as the major macro-level influence. This was followed by an increase in population and road infrastructure.

Conclusion

This study demonstrated that understanding dietary preferences are complex. Future interventions should not only consider intrapersonal and interpersonal influences when aiming to promote healthy eating among communities but also need to target the community and macro environments. This means that nutrition promotion strategies should focus on multiple levels of influence that broaden options for interventions. However, government interventions in addressing food access, affordability, and marketing remain essential to any significant change.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13580-4.

Reduction in malaria burden following the introduction of indoor residual spraying in areas protected by long-lasting insecticidal nets in Western Kenya, 2016-2018

Background

Long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) are the main malaria vector control measures deployed in Kenya. Widespread pyrethroid resistance among the primary vectors in Western Kenya has necessitated the re-introduction of IRS using an organophosphate insecticide, pirimiphos-methyl (Actellic® 300CS), as a pyrethroid resistance management strategy. Evaluation of the effectiveness of the combined use of non-pyrethroid IRS and LLINs has yielded varied results. We aimed to evaluate the effect of non-pyrethroid IRS and LLINs on malaria indicators in a high malaria transmission area.

Methods

We reviewed records and tallied monthly aggregate of outpatient department (OPD) attendance, suspected malaria cases, those tested for malaria and those testing positive for malaria at two health facilities, one from Nyatike, an intervention sub-county, and one from Suba, a comparison sub-county, both located in Western Kenya, from February 1, 2016, through March 31, 2018. The first round of IRS was conducted in February–March 2017 in Nyatike sub-county and the second round one year later in both Nyatike and Suba sub-counties. The mass distribution of LLINs has been conducted in both locations. We performed descriptive analysis and estimated the effect of the interventions and temporal changes of malaria indicators using Poisson regression for a period before and after the first round of IRS.

Results

A higher reduction in the intervention area in total OPD, the proportion of OPD visits due to suspected malaria, testing positivity rate and annual malaria incidences were observed except for the total OPD visits among the under 5 children (59% decrease observed in the comparison area vs 33% decrease in the intervention area, net change -27%, P <0.001). The percentage decline in annual malaria incidence observed in the intervention area was more than twice the observed percentage decline in the comparison area across all the age groups. A marked decline in the monthly testing positivity rate (TPR) was noticed in the intervention area, while no major changes were observed in the comparison area. The monthly TPR reduced from 46% in February 2016 to 11% in February 2018, representing a 76% absolute decrease in TPR among all ages (RR = 0.24, 95% CI 0.12–0.46). In the comparison area, TPR was 16% in both February 2016 and February 2018 (RR = 1.0, 95% CI 0.52–2.09). A month-by-month comparison revealed lower TPR in Year 2 compared to Year 1 in the intervention area for most of the one year after the introduction of the IRS.

Conclusions

Our findings demonstrated a reduced malaria burden among populations protected by both non-pyrethroid IRS and LLINs implying a possible additional benefit afforded by the combined intervention in the malaria-endemic zone.

Comparison of household socioeconomic status classification methods and effects on risk estimation: lessons from a natural experimental study, Kisumu, Western Kenya

Introduction

Low household socioeconomic status is associated with unhealthy behaviours including poor diet and adverse health outcomes. Different methods leading to variations in SES classification has the potential to generate spurious research findings or misinform policy. In low and middle-income countries, there are additional complexities in defining household SES, a need for fieldwork to be conducted efficiently, and a dearth of information on how classification could impact estimation of disease risk.

Methods

Using cross-sectional data from 200 households in Kisumu County, Western Kenya, we compared three approaches of classifying households into low, middle, or high SES: fieldworkers (FWs), Community Health Volunteers (CHVs), and a Multiple Correspondence Analysis econometric model (MCA). We estimated the sensitivity, specificity, inter-rater reliability and misclassification of the three methods using MCA as a comparator. We applied an unadjusted generalized linear model to determine prevalence ratios to assess the association of household SES status with a self-reported diagnosis of diabetes or hypertension for one household member.

Results

Compared with MCA, FWs successfully classified 21.7% (95%CI = 14.4%-31.4%) of low SES households, 32.8% (95%CI = 23.2–44.3) of middle SES households, and no high SES households. CHVs successfully classified 22.5% (95%CI = 14.5%-33.1%) of low SES households, 32.8% (95%CI = 23.2%-44.3%) of middle SES households, and no high SES households. The level of agreement in SES classification was similar between FWs and CHVs but poor compared to MCA, particularly for high SES. None of the three methods differed in estimating the risk of hypertension or diabetes.

Conclusions

FW and CHV assessments are community-driven methods for SES classification. Compared to MCA, these approaches appeared biased towards low or middle SES households and not sensitive to high household SES. The three methods did not differ in risk estimation for diabetes and hypertension. A mix of approaches and further evaluation to refine SES classification methodology is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01652-1.

Scaling up the primary health integrated care project for chronic conditions in Kenya: study protocol for an implementation research project

INTRODUCTION

Amid the rising number of people with non-communicable diseases (NCDs), Kenya has invested in strengthening primary care and in efforts to expand existing service delivery platforms to integrate NCD care. One such approach is the AMPATH (Academic Model Providing Access to Healthcare) model in western Kenya, which provides the platform for the Primary Health Integrated Care Project for Chronic Conditions (PIC4C), launched in 2018 to further strengthen primary care services for the prevention and control of hypertension, diabetes, breast and cervical cancer. This study seeks to understand how well PIC4C delivers on its intended aims and to inform and support scale up of the PIC4C model for integrated care for people with NCDs in Kenya.

METHODS AND ANALYSIS

The study is guided by a conceptual framework on implementing, sustaining and spreading innovation in health service delivery. We use a multimethod design combining qualitative and quantitative approaches, involving: (1) in-depth interviews with health workers and decision-makers to explore experiences of delivering PIC4C; (2) a cross-sectional survey of patients with diabetes or hypertension and in-depth interviews to understand how well PIC4C meets patients' needs; (3) a cohort study with an interrupted time series analysis to evaluate the degree to which PIC4C leads to health benefits such as improved management of hypertension or diabetes; and (4) a cohort study of households to examine the extent to which the national hospital insurance chronic care package provides financial risk protection to people with hypertension or diabetes within PIC4C.

ETHICS AND DISSEMINATION

The study has received approvals from Moi University Institutional Research and Ethics Committee (FAN:0003586) and the London School of Hygiene & Tropical Medicine (17940). Workshops with key stakeholders at local, county, national and international levels will ensure early and wide dissemination of our findings to inform scale up of this model of care. We will also publish findings in peer-reviewed journals.

Haematological consequences of acute uncomplicated falciparum malaria: a WorldWide Antimalarial Resistance Network pooled analysis of individual patient data

BACKGROUND

Plasmodium falciparum malaria is associated with anaemia-related morbidity, attributable to host, parasite and drug factors. We quantified the haematological response following treatment of uncomplicated P. falciparum malaria to identify the factors associated with malarial anaemia.

METHODS

Individual patient data from eligible antimalarial efficacy studies of uncomplicated P. falciparum malaria, available through the WorldWide Antimalarial Resistance Network data repository prior to August 2015, were pooled using standardised methodology. The haematological response over time was quantified using a multivariable linear mixed effects model with nonlinear terms for time, and the model was then used to estimate the mean haemoglobin at day of nadir and day 7. Multivariable logistic regression quantified risk factors for moderately severe anaemia (haemoglobin < 7 g/dL) at day 0, day 3 and day 7 as well as a fractional fall ≥ 25% at day 3 and day 7.

RESULTS

A total of 70,226 patients, recruited into 200 studies between 1991 and 2013, were included in the analysis: 50,859 (72.4%) enrolled in Africa, 18,451 (26.3%) in Asia and 916 (1.3%) in South America. The median haemoglobin concentration at presentation was 9.9 g/dL (range 5.0-19.7 g/dL) in Africa, 11.6 g/dL (range 5.0-20.0 g/dL) in Asia and 12.3 g/dL (range 6.9-17.9 g/dL) in South America. Moderately severe anaemia (Hb < 7g/dl) was present in 8.4% (4284/50,859) of patients from Africa, 3.3% (606/18,451) from Asia and 0.1% (1/916) from South America. The nadir haemoglobin occurred on day 2 post treatment with a mean fall from baseline of 0.57 g/dL in Africa and 1.13 g/dL in Asia. Independent risk factors for moderately severe anaemia on day 7, in both Africa and Asia, included moderately severe anaemia at baseline (adjusted odds ratio (AOR) = 16.10 and AOR = 23.00, respectively), young age (age < 1 compared to ≥ 12 years AOR = 12.81 and AOR = 6.79, respectively), high parasitaemia (AOR = 1.78 and AOR = 1.58, respectively) and delayed parasite clearance (AOR = 2.44 and AOR = 2.59, respectively). In Asia, patients treated with an artemisinin-based regimen were at significantly greater risk of moderately severe anaemia on day 7 compared to those treated with a non-artemisinin-based regimen (AOR = 2.06 [95%CI 1.39-3.05], p < 0.001).

CONCLUSIONS

In patients with uncomplicated P. falciparum malaria, the nadir haemoglobin occurs 2 days after starting treatment. Although artemisinin-based treatments increase the rate of parasite clearance, in Asia they are associated with a greater risk of anaemia during recovery.

Revealing the extent of the first wave of the COVID-19 pandemic in Kenya based on serological and PCR-test data

Policymakers in Africa need robust estimates of the current and future spread of SARS-CoV-2. We used national surveillance PCR test, serological survey and mobility data to develop and fit a county-specific transmission model for Kenya up to the end of September 2020, which encompasses the first wave of SARS-CoV-2 transmission in the country. We estimate that the first wave of the SARS-CoV-2 pandemic peaked before the end of July 2020 in the major urban counties, with 30-50% of residents infected. Our analysis suggests, first, that the reported low COVID-19 disease burden in Kenya cannot be explained solely by limited spread of the virus, and second, that a 30-50% attack rate was not sufficient to avoid a further wave of transmission.

Effectiveness of interactive text messaging and structured psychosocial support groups on developmental milestones of children from adolescent pregnancies in Kenya: a quasi-experimental study (Preprint)

BACKGROUND

In sub-Saharan Africa, one-quarter of all pregnancies occur in adolescents. Children born to adolescent mothers have poorer physical and socio-cognitive development. One reason may be inadequate knowledge on childcare and psychosocial support during pregnancy and post partum, since adolescent mothers have less antenatal care attendance and overall interaction with the health care system. Mobile health technology has been used to relay health information to special groups; however, psychosocial support commonly requires physical interaction.

OBJECTIVE

We aimed to assess the efficacy of an interactive mobile text messaging platform and support groups in improving adolescent mothers' knowledge and practices as well as infant growth and development.

METHODS

This was a quasi-experimental study, conducted among adolescent mothers with infants younger than 3 months, in Homa Bay County, Kenya. Five of the 8 subcounties in Homa Bay County were purposively selected as study clusters. Four subcounties were assigned as intervention clusters and 1 as a control cluster. Adolescent mothers from 2 intervention subcounties received interactive text messaging only (limited package), whereas those from the other 2 subcounties received text messaging and weekly support groups, moderated by a community health extension worker and a counselor (full package); the control cluster only received the end-line evaluation (posttest-only control). The follow-up period was 9 months. Key outcomes were maternal knowledge on childcare and infant development milestones assessed using the Developmental Milestones Checklist (DMC III). Knowledge and DMC III scores were compared between the intervention and control groups, as well as between the 2 intervention groups.

RESULTS

We recruited 791 mother-infant pairs into the intervention groups (full package: n=375; limited package: n=416) at baseline and 220 controls at end line. Attrition from the intervention groups was 15.8% (125/791). Compared with the control group, adolescent mothers receiving the full package had a higher knowledge score on infant care and development (9.02 vs 8.01; P<.001) and higher exclusive breastfeeding rates (238/375, 63.5% vs 112/220, 50.9%; P=.004), and their infants had higher average DMC III scores (53.09 vs 48.59; P=.01). The limited package group also had higher knowledge score than the control group (8.73 vs 8.01; P<.001); this group performed better than the full package group on exclusive breastfeeding (297/416, 71.4% vs 112/220, 50.9%; P<.001) and DMC III scores (58.29 vs 48.59; P<.001) when compared with the control group. We found a marginal difference in knowledge scores between full and limited package groups (9.02 vs 8.73; P=.048) but no difference in DMC III scores between the 2 groups (53.09 vs 58.29; P>.99).

CONCLUSIONS

An interactive text messaging platform improved adolescent mothers' knowledge on nurturing infant care and the development of their children, even without physical support groups. Such platforms offer a convenient avenue for providing reproductive health information to adolescents.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201806003369302; https://tinyurl.com/kkxvzjse.

Cross-Sectional Association of Food Source with Food Insecurity, Dietary Diversity and Body Mass Index in Western Kenya

The triple burden of malnutrition in many low- and middle-income countries (LMICs) is partly a result of changing food environments and a shift from traditional diets to high-calorie Western-style diets. Exploring the relationship between food sources and food- and nutrition-related outcomes is important to understanding how changes in food environments may affect nutrition in LMICs. This study examined associations of household food source with household food insecurity, individual dietary diversity and individual body mass index in Western Kenya. Interview-administered questionnaire and anthropometric data from 493 adults living in 376 randomly-selected households were collected in 2019. Adjusted regression analyses were used to assess the association of food source with measures of food insecurity, dietary diversity and body mass index. Notably, participants that reported rearing domesticated animals for consumption (‘own livestock’) had lower odds of moderate or severe household food insecurity (odds ratio (OR) = 0.29 (95% CI: 0.09, 0.96)) and those that reported buying food from supermarkets had lower odds of moderate or severe household food insecurity (borderline significant, OR = 0.37 (95% CI: 0.14, 1.00)), increased dietary diversity scores (Poisson coefficient = 0.17 (95% CI: 0.10, 0.24)) and higher odds of achieving minimum dietary diversity (OR = 2.84 (95% CI: 1.79, 4.49)). Our findings provide insight into the relationship between food environments, dietary patterns and nutrition in Kenya, and suggest that interventions that influence household food source may impact the malnutrition burden in this context.

Modelling the cost-effectiveness of essential and advanced critical care for COVID-19 patients in Kenya

BACKGROUND

Case management of symptomatic COVID-19 patients is a key health system intervention. The Kenyan government embarked to fill capacity gaps in essential and advanced critical care (ACC) needed for the management of severe and critical COVID-19. However, given scarce resources, gaps in both essential and ACC persist. This study assessed the cost-effectiveness of investments in essential and ACC to inform the prioritisation of investment decisions.

METHODS

We employed a decision tree model to assess the incremental cost-effectiveness of investment in essential care (EC) and investment in both essential and ACC (EC +ACC) compared with current healthcare provision capacity (status quo) for COVID-19 patients in Kenya. We used a health system perspective, and an inpatient care episode time horizon. Cost data were obtained from primary empirical analysis while outcomes data were obtained from epidemiological model estimates. We used univariate and probabilistic sensitivity analysis to assess the robustness of the results.

RESULTS

The status quo option is more costly and less effective compared with investment in EC and is thus dominated by the later. The incremental cost-effectiveness ratio of investment in essential and ACC (EC+ACC) was US$1378.21 per disability-adjusted life-year averted and hence not a cost-effective strategy when compared with Kenya's cost-effectiveness threshold (US$908).

CONCLUSION

When the criterion of cost-effectiveness is considered, and within the context of resource scarcity, Kenya will achieve better value for money if it prioritises investments in EC before investments in ACC. This information on cost-effectiveness will however need to be considered as part of a multicriteria decision-making framework that uses a range of criteria that reflect societal values of the Kenyan society.

COVID-19 transmission dynamics underlying epidemic waves in Kenya

Policy decisions on COVID-19 interventions should be informed by a local, regional and national understanding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission. Epidemic waves may result when restrictions are lifted or poorly adhered to, variants with new phenotypic properties successfully invade, or infection spreads to susceptible subpopulations. Three COVID-19 epidemic waves have been observed in Kenya. Using a mechanistic mathematical model, we explain the first two distinct waves by differences in contact rates in high and low social-economic groups, and the third wave by the introduction of higher-transmissibility variants. Reopening schools led to a minor increase in transmission between the second and third waves. Socioeconomic and urban–rural population structure are critical determinants of viral transmission in Kenya.

Appressorium-mediated plant infection by Magnaporthe oryzae is regulated by a Pmk1-dependent hierarchical transcriptional network

Rice blast is a devastating disease caused by the fungal pathogen Magnaporthe oryzae that threatens rice production around the world. The fungus produces a specialized infection cell, called the appressorium, that enables penetration through the plant cell wall in response to surface signals from the rice leaf. The underlying biology of plant infection, including the regulation of appressorium formation, is not completely understood. Here we report the identification of a network of temporally coregulated transcription factors that act downstream of the Pmk1 mitogen-activated protein kinase pathway to regulate gene expression during appressorium-mediated plant infection. We show that this tiered regulatory mechanism involves Pmk1-dependent phosphorylation of the Hox7 homeobox transcription factor, which regulates genes associated with induction of major physiological changes required for appressorium development-including cell-cycle control, autophagic cell death, turgor generation and melanin biosynthesis-as well as controlling a additional set of virulence-associated transcription factor-encoding genes. Pmk1-dependent phosphorylation of Mst12 then regulates gene functions involved in septin-dependent cytoskeletal re-organization, polarized exocytosis and effector gene expression, which are necessary for plant tissue invasion. Identification of this regulatory cascade provides new potential targets for disease intervention.

Intersectoral Action for Addressing NCDs through the Food Environment: An Analysis of NCD Framing in Global Policies and Its Relevance for the African Context

Noncommunicable diseases contribute the greatest to global mortality. Unhealthy diet-a prominent risk factor-is intricately linked to urban built and food environments and requires intersectoral efforts to address. Framings of the noncommunicable disease problem and proposed solutions within global and African regional diet-related policy documents can reveal how amenable the policy landscape is for supporting intersectoral action for health in low-income to middle-income countries. This study applied a document analysis approach to undertake policy analysis on global and African regional policies related to noncommunicable disease and diet. A total of 62 global and 29 African regional policy documents were analysed. Three problem frames relating to noncommunicable disease and diet were identified at the global and regional level, namely evidence-based, development, and socioeconomic frames. Health promotion, intersectoral and multisectoral action, and evidence-based monitoring and assessment underpinned proposed interventions to improve education and awareness, support structural changes, and improve disease surveillance and monitoring. African policies insufficiently considered associations between food security and noncommunicable disease. In order to effectively address the noncommunicable disease burden, a paradigm shift from 'health for development' to 'development for health' is required across non-health sectors. Noncommunicable disease considerations should be included within African food security agendas, using malnutrition as a possible intermediary concept to motivate intersectoral action to improve access to nutritious food in African low-income to middle-income countries.

Examining the cost-effectiveness of personal protective equipment for formal healthcare workers in Kenya during the COVID-19 pandemic

BACKGROUND

Healthcare workers are at a higher risk of COVID-19 infection during care encounters compared to the general population. Personal Protective Equipment (PPE) have been shown to protect COVID-19 among healthcare workers, however, Kenya has faced PPE shortages that can adequately protect all healthcare workers. We, therefore, examined the health and economic consequences of investing in PPE for healthcare workers in Kenya.

METHODS

We conducted a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model following the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines. We examined two outcomes: 1) the incremental cost per healthcare worker death averted, and 2) the incremental cost per healthcare worker COVID-19 case averted. We performed a multivariate sensitivity analysis using 10,000 Monte Carlo simulations.

RESULTS

Kenya would need to invest $3.12 million (95% CI: 2.65-3.59) to adequately protect healthcare workers against COVID-19. This investment would avert 416 (IQR: 330-517) and 30,041 (IQR: 7243 - 102,480) healthcare worker deaths and COVID-19 cases respectively. Additionally, such an investment would result in a healthcare system ROI of $170.64 million (IQR: 138-209) - equivalent to an 11.04 times return.

CONCLUSION

Despite other nationwide COVID-19 prevention measures such as social distancing, over 70% of healthcare workers will still be infected if the availability of PPE remains scarce. As part of the COVID-19 response strategy, the government should consider adequate investment in PPE for all healthcare workers in the country as it provides a large return on investment and it is value for money.

Population-based socio-demographic household assessment of livelihoods and health among communities in Migori County, Kenya over multiple timepoints (2021, 2024, 2027): A study protocol

Migori County is located in western Kenya bordering Lake Victoria and has traditionally performed poorly on important health metrics, including child mortality and HIV prevalence. The Lwala Community Alliance is a non-governmental organization that serves to promote the health and well-being of communities in Migori County through an innovative model utilizing community health workers, community committees, and high-quality facility-based care. This has led to improved outcomes in areas served, including improvements in childhood mortality. As the Lwala Community Alliance expands to new programming areas, it has partnered with multiple academic institutions to rigorously evaluate outcomes. We describe a repeated cross-sectional survey study to evaluate key health metrics in both areas served by the Lwala Community Alliance and comparison areas. This will allow for longitudinal evaluation of changes in metrics over time. Surveys will be administered by trained enumerators on a tablet-based platform to maintain high data quality.

Adolescent Levers for a Diet and Physical Activity Intervention Across Socioecological Levels in Kenya, South Africa, Cameroon, and Jamaica: Mixed Methods Study Protocol

Background

The increasing burden of noncommunicable diseases that are prevalent in low- and middle-income countries (LMICs) is largely attributed to modifiable behavioral risk factors such as unhealthy diets and insufficient physical activity (PA). The adolescent stage, defined as 10 to 24 years of age, is an important formative phase of life and offers an opportunity to reduce the risk of noncommunicable diseases across the life course and for future generations.

Objective

The aim of this paper is to describe a protocol for a study using a convergent mixed methods design to explore exposures in the household, neighborhood, school, and the journey from home to school that may influence diet and PA behaviors in adolescents from LMICs.

Methods

Male and female adolescents (n≥150) aged between 13 and 24 years will be recruited from selected high schools or households in project site countries to ensure the socioeconomic diversity of perspectives and experiences at the individual, home, and neighborhood levels. The project will be conducted at 5 sites in 4 countries: Kenya, Cameroon, Jamaica, and South Africa (Cape Town and Johannesburg). Data on anthropometric measures, food intake, and PA knowledge and behavior will be collected using self-report questionnaires. In addition, a small number of learners (n=30-45) from each site will be selected as citizen scientists to capture data (photographs, audio notes, text, and geolocations) on their lived experiences in relation to food and PA in their homes, the journey to and from school, and the school and neighborhood environments using a mobile app, and for objective PA measurements. In-depth interviews will be conducted with the citizen scientists and their caregivers to explore household experiences and determinants of food intake and foodways, as well as the PA of household members.

Results

The study described in this protocol paper was primarily funded through a UK National Institute for Health Research grant in 2017 and approved by the relevant institutional ethics review boards in the country sites (South Africa, Cameroun, and Jamaica in 2019, and Kenya in 2020). As of December 23, 2020, we had completed data collection from adolescents (n≥150) in all the country sites, except Kenya, and data collection for the subgroup (n=30-45) is ongoing. Data analysis is ongoing and the output of findings from the study described in this protocol is expected to be published by 2022.

Conclusions

This project protocol contributes to research that focuses on adolescents and the socioecological determinants of food intake and PA in LMIC settings. It includes innovative methodologies to interrogate and map the contexts of these determinants and will generate much-needed data to understand the multilevel system of factors that can be leveraged through upstream and downstream strategies and interventions to improve health outcomes.

International Registered Report Identifier (IRRID)

DERR1-10.2196/26739

Impact of Community-Based Mass Testing and Treatment on Malaria Infection Prevalence in a High-Transmission Area of Western Kenya: A Cluster Randomized Controlled Trial

BACKGROUND

Global gains toward malaria elimination have been heterogeneous and have recently stalled. Interventions targeting afebrile malaria infections may be needed to address residual transmission. We studied the efficacy of repeated rounds of community-based mass testing and treatment (MTaT) on malaria infection prevalence in western Kenya.

METHODS

Twenty clusters were randomly assigned to 3 rounds of MTaT per year for 2 years or control (standard of care for testing and treatment at public health facilities along with government-sponsored mass long-lasting insecticidal net [LLIN] distributions). During rounds, community health volunteers visited all households in intervention clusters and tested all consenting individuals with a rapid diagnostic test. Those positive were treated with dihydroartemisinin-piperaquine. Cross-sectional community infection prevalence surveys were performed in both study arms at baseline and each year after 3 rounds of MTaT. The primary outcome was the effect size of MTaT on parasite prevalence by microscopy between arms by year, adjusted for age, reported LLIN use, enhanced vegetative index, and socioeconomic status.

RESULTS

Demographic and behavioral characteristics, including LLIN usage, were similar between arms at each survey. MTaT coverage across the 3 annual rounds ranged between 75.0% and 77.5% in year 1, and between 81.9% and 94.3% in year 2. The adjusted effect size of MTaT on the prevalence of parasitemia between arms was 0.93 (95% confidence interval [CI], .79-1.08) and 0.92 (95% CI, .76-1.10) after year 1 and year 2, respectively.

CONCLUSIONS

MTaT performed 3 times per year over 2 years did not reduce malaria parasite prevalence in this high-transmission area.

CLINICAL TRIALS REGISTRATION

NCT02987270.

Revealing the extent of the first wave of the COVID-19 pandemic in Kenya based on serological and PCR-test data

Policymakers in Africa need robust estimates of the current and future spread of SARS-CoV-2. We used national surveillance PCR test, serological survey and mobility data to develop and fit a county-specific transmission model for Kenya up to the end of September 2020, which encompasses the first wave of SARS-CoV-2 transmission in the country. We estimate that the first wave of the SARS-CoV-2 pandemic peaked before the end of July 2020 in the major urban counties, with 30-50% of residents infected. Our analysis suggests, first, that the reported low COVID-19 disease burden in Kenya cannot be explained solely by limited spread of the virus, and second, that a 30-50% attack rate was not sufficient to avoid a further wave of transmission.

Willingness to pay for improvements in rural sanitation: Evidence from a cross-sectional survey of three rural counties in Kenya

Poor sanitation worldwide leads to an annual loss of approximately $222.9 billion and is the second leading cause of Disability-Adjusted Life Years (DALY’s) lost due to diarrhoea. Yet in Kenya, the slow rate and levels at which the household’s access improved sanitation facilities remain a concern, and it is unknown if the cost of new technologies is a barrier to access. This study assessed the maximum willingness to pay (WTP) for SAFI and SATO sanitation products and identified those factors that affect the willingness to pay (WTP) valuation estimates by households in three counties in Kenya. It used quantitative economic evaluation research integrated within a cross-sectional survey. Contingent valuation method (CVM) was used to determine the maximum WTP for sanitation in households. We used the logistic regression model in data analysis. A total of 211 households were interviewed in each county, giving a total sample size of 633 households. The mean WTP for SAFI latrines was $153.39 per household, while the mean WTP for SATO pans and SATO stools was $11.49 and $14.77 respectively. For SAFI latrines, households in Kakamega were willing to pay $6.6 more than average while in Siaya, the households were willing to pay $5.1 less than the average. The main determinants of households WTP for the two sanitation products included household’s proximity to the toilet (p = 0.0001), household income (β = .2245741, p = 0.004), sanitation product (β = -2968.091; p = 0.004), socioeconomic status (β = -3305.728, p = 0.004) and a household’s satisfaction level with the current toilet (β = -4570.602; p = 0.0001). Increased proximity of households to the toilet, higher incomes, and providing loan facilities or subsidy to poor households could increase the demand for these sanitation technologies.

Examining unit costs for COVID-19 case management in Kenya

Introduction

We estimated unit costs for COVID-19 case management for patients with asymptomatic, mild-to-moderate, severe and critical COVID-19 disease in Kenya.

Methods

We estimated per-day unit costs of COVID-19 case management for patients. We used a bottom-up approach to estimate full economic costs and adopted a health system perspective and patient episode of care as our time horizon. We obtained data on inputs and their quantities from data provided by three public COVID-19 treatment hospitals in Kenya and augmented this with guidelines. We obtained input prices from a recent costing survey of 20 hospitals in Kenya and from market prices for Kenya.

Results

Per-day, per-patient unit costs for asymptomatic patients and patients with mild-to-moderate COVID-19 disease under home-based care are 1993.01 Kenyan shilling (KES) (US$18.89) and 1995.17 KES (US$18.991), respectively. When these patients are managed in an isolation centre or hospital, the same unit costs for asymptomatic patients and patients with mild-to-moderate disease are 6717.74 KES (US$63.68) and 6719.90 KES (US$63.70), respectively. Per-day unit costs for patients with severe COVID-19 disease managed in general hospital wards and those with critical COVID-19 disease admitted in intensive care units are 13 137.07 KES (US$124.53) and 63 243.11 KES (US$599.51).

Conclusion

COVID-19 case management costs are substantial, ranging between two and four times the average claims value reported by Kenya’s public health insurer. Kenya will need to mobilise substantial resources and explore service delivery adaptations that will reduce unit costs.

Impacts of a New Supermarket on Dietary Behavior and the Local Foodscape in Kisumu, Kenya: Protocol for a Mixed Methods, Natural Experimental Study

Background

Access to healthy food is considered a key determinant of dietary behavior, and there is mixed evidence that living near a supermarket is associated with a healthier diet. In Africa, supermarkets may contribute to the nutrition transition by offering both healthy and unhealthy foods and by replacing traditional food sellers. In Kisumu, Kenya, a planned hypermarket (ie, a supermarket combined with a department store) will form the basis for a natural experimental evaluation.

Objective

The aim of this study is to explore the impacts of a new hypermarket on food shopping practices, dietary behaviors, physical activity patterns, and body composition among local residents and to identify concurrent changes in the local foodscape. We also aim to explore how impacts and associations vary by socioeconomic status.

Methods

We employ a mixed methods, longitudinal study design. Two study areas were defined: the hypermarket intervention area (ie, Kisumu) and a comparison area with no hypermarket (ie, Homabay). The study is comprised of 4 pieces of primary data collection: a quantitative household survey with local residents, a qualitative study consisting of focus group discussions with local residents and semistructured interviews with government and private sector stakeholders, an audit of the local foodscape using on-the-ground data collection, and an intercept survey of shoppers in the hypermarket. Assessments will be undertaken at baseline and approximately 1 year after the hypermarket opens.

Results

Baseline assessments were conducted from March 2019 to June 2019. From a total sampling frame of 400 households, we recruited 376 of these households, giving an overall response rate of 94.0%. The household survey was completed by 516 individuals within these households. Across the two study areas, 8 focus groups and 44 stakeholder interviews were conducted, and 1920 food outlets were geocoded.

Conclusions

This study aims to further the understanding of the relationship between food retail and dietary behaviors in Kenya. Baseline assessments for the study have been completed.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17814

Coverage outcomes (effects), costs, cost-effectiveness, and equity of two combinations of long-lasting insecticidal net (LLIN) distribution channels in Kenya: a two-arm study under operational conditions

BACKGROUND

Malaria-endemic countries distribute long-lasting insecticidal nets (LLINs) through combined channels with ambitious, universal coverage (UC) targets. Kenya has used eight channels with variable results. To inform national decision-makers, this two-arm study compares coverage (effects), costs, cost-effectiveness, and equity of two combinations of LLIN distribution channels in Kenya.

METHODS

Two combinations of five delivery channels were compared as 'intervention' and 'control' arms. The intervention arm comprised four channels: community health volunteer (CHV), antenatal and child health clinics (ANCC), social marketing (SM) and commercial outlets (CO). The control arm consisted of the intervention arm channels except mass campaign (MC) replaced CHV. Primary analysis used random sample household survey data, service-provider costs, and voucher or LLIN distribution data to compare between-arm effects, costs, cost-effectiveness, and equity. Secondary analyses compared costs and equity by channel.

RESULTS

The multiple distribution channels used in both arms of the study achieved high LLIN ownership and use. The intervention arm had significantly lower reported LLIN use the night before the survey (84·8% [95% CI 83·0-86·4%] versus 89·2% [95% CI 87·8-90·5%], p < 0·0001), higher unit costs ($10·56 versus $7·17), was less cost-effective ($86·44, 95% range $75·77-$102·77 versus $69·20, 95% range $63·66-$77·23) and more inequitable (Concentration index [C.Ind] = 0·076 [95% CI 0·057 to 0·095 versus C.Ind = 0.049 [95% CI 0·030 to 0·067]) than the control arm. Unit cost per LLIN distributed was lowest for MC ($3·10) followed by CHV ($10·81) with both channels being moderately inequitable in favour of least-poor households.

CONCLUSION

In line with best practices, the multiple distribution channel model achieved high LLIN ownership and use in this Kenyan study setting. The control-arm combination, which included MC, was the most cost-effective way to increase UC at household level. Mass campaigns, combined with continuous distribution channels, are an effective and cost-effective way to achieve UC in Kenya. The findings are relevant to other countries and donors seeking to optimise LLIN distribution.

TRIAL REGISTRATION

The assignment of the intervention was not at the discretion of the investigators; therefore, this study did not require registration.

Patterns and determinants of modern contraceptive discontinuation among women of reproductive age: Analysis of Kenya Demographic Health Surveys, 2003-2014

Objectives

This study aimed to examine patterns and determinants of modern contraceptive discontinuation among women in Kenya.

Methods

Secondary analysis was conducted using national representative Kenya Demographic and Health Surveys of 2003, 2008/9, and 2014. These household cross-sectional surveys targeted women of reproductive age from 15 to 49 years who had experienced an episode of modern contraceptive use within five years preceding the surveys from 2003 (n = 2686), 2008/9 (n = 2992), and 2014 (5919). The contraceptive discontinuation rate was defined as the number of episodes discontinued divided by the total number of episodes. Weighted descriptive statistics, multivariable logistic regression analysis, and Cox proportional hazards analysis were used to examine the determinants of contraceptive discontinuation.

Results

The 12-month contraceptive discontinuation rate for all methods declined from 37.5% in 2003 and 36.7% in 2008/9 to 30.5% in 2014. Consistently across the three surveys, intrauterine devices had the lowest 12-month discontinuation rate (6.4% in 2014) followed by implants (8.0%, in 2014). In 2014, higher rates were seen for pills (44.9%) and male condoms (42.9%). The determinants of contraceptive discontinuation among women of reproductive age in the 2003 survey included users of short-term contraception methods, specifically for those who used male condoms (hazard ratio [HR] = 3.30, 95% confidence interval [CI] = 2.13–5.11) and pills (HR = 2.68; 95CI = 1.79–4.00); and younger women aged 15–19 year (HR = 2.07; 95% CI = 1.49–2.87) and 20–24 years (HR = 1.94; 95% CI = 1.61–2.35). The trends in the most common reasons for discontinuation from 2003 to 2014 revealed an increase among those reporting side effects (p = 0.0002) and those wanting a more effective method (p<0.0001). A decrease was noted among those indicating method failure (p<0.0001) and husband disapproval (p<0.0001).

Conclusions

Family planning programs should focus on improving service quality to strengthen the continuation of contraceptive use among those in need. Women should be informed about potential side effects and reassured on health concerns, including being provided options for method switching. The health system should avail a wider range of contraceptive methods and ensure a constant supply of commodities for women to choose from. Short-term contraceptive method users and younger women may need greater support for continued use.

Cost-effectiveness of intermittent preventive treatment with dihydroartemisinin-piperaquine for malaria during pregnancy: an analysis using efficacy results from Uganda and Kenya, and pooled data

BACKGROUND

Prevention of malaria infection during pregnancy in HIV-negative women currently relies on the use of long-lasting insecticidal nets together with intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). Increasing sulfadoxine-pyrimethamine resistance in Africa threatens current prevention of malaria during pregnancy. Thus, a replacement for IPTp-SP is urgently needed, especially for locations with high sulfadoxine-pyrimethamine resistance. Dihydroartemisinin-piperaquine is a promising candidate. We aimed to estimate the cost-effectiveness of intermittent preventive treatment in pregnancy with dihydroartemisinin-piperaquine (IPTp-DP) versus IPTp-SP to prevent clinical malaria infection (and its sequelae) during pregnancy.

METHODS

We did a cost-effectiveness analysis using meta-analysis and individual trial results from three clinical trials done in Kenya and Uganda. We calculated disability-adjusted life-years (DALYs) arising from stillbirths, neonatal death, low birthweight, mild and moderate maternal anaemia, and clinical malaria infection, associated with malaria during pregnancy. Cost estimates were obtained from data collected in observational studies, health-facility costings, and from international drug procurement databases. The cost-effectiveness analyses were done from a health-care provider perspective using a decision tree model with a lifetime horizon. Deterministic and probabilistic sensitivity analyses using appropriate parameter ranges and distributions were also done. Results are presented as the incremental cost per DALY averted and the likelihood that an intervention is cost-effective for different cost-effectiveness thresholds.

FINDINGS

Compared with three doses of sulfadoxine-pyrimethamine, three doses of dihydroartemisinin-piperaquine, delivered to a hypothetical cohort of 1000 pregnant women, averted 892 DALYs (95% credibility interval 274 to 1517) at an incremental cost of US$7051 (2653 to 13 038) generating an incremental cost-effectiveness ratio (ICER) of $8 (2 to 29) per DALY averted. Compared with monthly doses of sulfadoxine-pyrimethamine, monthly doses of dihydroartemisinin-piperaquine averted 534 DALYS (-141 to 1233) at a cost of $13 427 (4994 to 22 895), resulting in an ICER of $25 (-151 to 224) per DALY averted. Both results were highly robust to most or all variations in the deterministic sensitivity analysis.

INTERPRETATION

Our findings suggest that among HIV-negative pregnant women with high uptake of long-lasting insecticidal nets, IPTp-DP is cost-effective in areas with high malaria transmission and high sulfadoxine-pyrimethamine resistance. These data provide a comprehensive overview of the current evidence on the cost-effectiveness of IPTp-DP. Nevertheless, before a policy change is advocated, we recommend further research into the effectiveness and costs of different regimens of IPTp-DP in settings with different underlying sulfadoxine-pyrimethamine resistance.

FUNDING

Malaria in Pregnancy Consortium, which is funded through a grant from the Bill & Melinda Gates Foundation to the Liverpool School of Hygiene and Tropical Medicine.

Evaluation of Implementation Level of Community Health Strategy and Its Influence on Uptake of Skilled Delivery in Lurambi Sub County-Kenya

BACKGROUND

Despite the widespread application of the community health strategy (CHS) in Kenya and evidence of its effectiveness in reducing health outcomes at the household level, data from Kakamega County, of which Lurambi sub-county is part of, still showed that skilled birth delivery was at 47% against the national estimateof 62% and a target of 90%. However, there was limited evidence on the level of CHS implementation and its association with the uptake of skilled delivery.

METHODS

The study employed a cross-sectional analytic design. A structured validated community unit (CU) scorecard and a household questionnaire were used to collect quantitative data from the CUs through Community Health Extension Workers (CHEWs) and at the household level through mothers with children below 1 year. A random sample of 436 mothers from all the 38 Community Units (CUs) was included. CU functionality was assessed using 17 binary indicators (scored as 1 for a positive response, 0 otherwise) and total scores were expressed as percentages. Fully functional CUs scored ≥80% and semi-functional CU scored >50 to <80%. No CU was non-functional (scored ≤50%). Data from the CUs were merged with data at the household level. Association between CU functionality and skilled delivery was assessed using multivariable binary logistic regression controlling for socio-demographic variables. Adjusted Odds Ratios (OR) and 95% Confidence Intervals (95%CI) are reported.

RESULTS

A total of 38 CUs were assessed and of these, 26(68.6%) were fully functional and 12(31.4%) were semi-functional, 18(47.4%) had both household registers (MOH 513) and service delivery logbooks (MOH 514). Overall, 387(80.0%) of mothers had skilled birth deliveries, 263(68%) were from functional CUs and 124(32%) were from semi-functional CUs. Pregnant women were more likely to have skilled deliveries in fully functional CUs than semi-functional CUs (OR=1.3; 95% CI=1.1-2.4; p-value<.001). Other factors significantly associated with uptake of skilled delivery included receiving health education(OR=2.9;95%CI =1.4-6.1, p=.005), being visited at least twice by Community Health Volunteers, CHVs(OR=1.9;95%CI=1.1-3.5, p=.045), attending antenatal care clinics, ANC (OR=3.4;95%CI=1.3-3.5, p=.012), receiving advice where to deliver (OR=4.1;95%CI=1.8-9.4, p=.001).

CONCLUSION

2 out of 3 community units were fully functional, and functionality was associated with increased uptake of skilled delivery. In a fully functional CUs, Community Health Volunteers provided health education through regular visits and they were able to provide a referral to health facilities for the pregnant women. To achieve national targets for skilled deliveries and universal health coverage, there is a need to ensure CUs are fully functional.

The Costs of Implementing Vaccination With the RTS,S Malaria Vaccine in Five Sub-Saharan African Countries

Background. The World Health Organization has recommended pilot implementation of a candidate vaccine against malaria (RTS,S/AS01) in selected sub-Saharan African countries. This exploratory study aimed to estimate the costs of implementing RTS,S in Burkina Faso, Ghana, Kenya, Mozambique, and Tanzania. Methods. Key informants of the expanded program on immunization at all levels in each country were interviewed on the resources required for implementing RTS,S for routine vaccination. Unit prices were derived from the same sources or from international price lists. Incremental costs in 2015 US dollars were aggregated per fully vaccinated child (FVC). It was assumed the four vaccine doses were either all delivered at health facilities or the fourth dose was delivered in an outreach setting. Results. The costs per FVC ranged from US$25 (Burkina Faso) to US$37 (Kenya) assuming a vaccine price of US$5 per dose. Across countries, recurrent costs represented the largest share dominated by vaccines (including wastage) and supply costs. Non-recurrent costs varied substantially across countries, mainly because of differences in needs for hiring personnel, in wages, in cold-room space, and equipment. Recent vaccine introductions in the countries may have had an impact on resource availability for a new vaccine implementation. Delivering the fourth dose in outreach settings raised the costs, mostly fuel, per FVC by less than US$1 regardless of the country. Conclusions. This study provides relevant information for donors and decision makers about the cost of implementing RTS,S. Variations within and across countries are important and the unknown future price per dose and wastage rate for this candidate vaccine adds substantially to the uncertainty about the actual costs of implementation.

Trends in malaria prevalence and health related socioeconomic inequality in rural western Kenya: results from repeated household malaria cross-sectional surveys from 2006 to 2013

OBJECTIVE

The objective of this analysis was to examine trends in malaria parasite prevalence and related socioeconomic inequalities in malaria indicators from 2006 to 2013 during a period of intensification of malaria control interventions in Siaya County, western Kenya.

METHODS

Data were analysed from eight independent annual cross-sectional surveys from a combined sample of 19 315 individuals selected from 7253 households. Study setting was a health and demographic surveillance area of western Kenya. Data collected included demographic factors, household assets, fever and medication use, malaria parasitaemia by microscopy, insecticide-treated bed net (ITN) use and care-seeking behaviour. Households were classified into five socioeconomic status and dichotomised into poorest households (poorest 60%) and less poor households (richest 40%). Adjusted prevalence ratios (aPR) were calculated using a multivariate generalised linear model accounting for clustering and cox proportional hazard for pooled data assuming constant follow-up time.

RESULTS

Overall, malaria infection prevalence was 36.5% and was significantly higher among poorest individuals compared with the less poor (39.9% vs 33.5%, aPR=1.17; 95% CI 1.11 to 1.23) but no change in prevalence over time (trend p value <0.256). Care-seeking (61.1% vs 62.5%, aPR=0.99; 95% CI 0.95 to 1.03) and use of any medication were similar among the poorest and less poor. Poorest individuals were less likely to use Artemether-Lumefantrine or quinine for malaria treatment (18.8% vs 22.1%, aPR=0.81, 95% CI 0.72 to 0.91) while use of ITNs was lower among the poorest individuals compared with less poor (54.8% vs 57.9%; aPR=0.95; 95% CI 0.91 to 0.99), but the difference was negligible.

CONCLUSIONS

Despite attainment of equity in ITN use over time, socioeconomic inequalities still existed in the distribution of malaria. This might be due to a lower likelihood of treatment with an effective antimalarial and lower use of ITNs by poorest individuals. Additional strategies are necessary to reduce socioeconomic inequities in prevention and control of malaria in endemic areas in order to achieve universal health coverage and sustainable development goals.

Community-based intermittent mass testing and treatment for malaria in an area of high transmission intensity, western Kenya: development of study site infrastructure and lessons learned

Background

Malaria transmission is high in western Kenya and the asymptomatic infected population plays a significant role in driving the transmission. Mathematical modelling and simulation programs suggest that interventions targeting asymptomatic infections through mass testing and treatment (MTaT) or mass drug administration (MDA) have the potential to reduce malaria transmission when combined with existing interventions.

Objective

This paper describes the study site, capacity development efforts required, and lessons learned for implementing a multi-year community-based cluster-randomized controlled trial to evaluate the impact of MTaT for malaria transmission reduction in an area of high transmission in western Kenya.

Methods

The study partnered with Kenya’s Ministry of Health (MOH) and other organizations on community sensitization and engagement to mobilize, train and deploy community health volunteers (CHVs) to deliver MTaT in the community. Within the health facilities, the study availed staff, medical and laboratory supplies and strengthened health information management system to monitor progress and evaluate impact of intervention.

Results

More than 80 Kenya MOH CHVs, 13 clinical officers, field workers, data and logistical staff were trained to carry out MTaT three times a year for 2 years in a population of approximately 90,000 individuals. A supply chain management was adapted to meet daily demands for large volumes of commodities despite the limitation of few MOH facilities having ideal storage conditions. Modern technology was adapted more to meet the needs of the high daily volume of collected data.

Conclusions

In resource-constrained settings, large interventions require capacity building and logistical planning. This study found that investing in relationships with the communities, local governments, and other partners, and identifying and equipping the appropriate staff with the skills and technology to perform tasks are important factors for success in delivering an intervention like MTaT.

Modelling the relationship between malaria prevalence as a measure of transmission and mortality across age groups

Background

Parasite prevalence has been used widely as a measure of malaria transmission, especially in malaria endemic areas. However, its contribution and relationship to malaria mortality across different age groups has not been well investigated. Previous studies in a health and demographic surveillance systems (HDSS) platform in western Kenya quantified the contribution of incidence and entomological inoculation rates (EIR) to mortality. The study assessed the relationship between outcomes of malaria parasitaemia surveys and mortality across age groups.

Methods

Parasitological data from annual cross-sectional surveys from the Kisumu HDSS between 2007 and 2015 were used to determine malaria parasite prevalence (PP) and clinical malaria (parasites plus reported fever within 24 h or temperature above 37.5 °C). Household surveys and verbal autopsy (VA) were used to obtain data on all-cause and malaria-specific mortality. Bayesian negative binomial geo-statistical regression models were used to investigate the association of PP/clinical malaria with mortality across different age groups. Estimates based on yearly data were compared with those from aggregated data over 4 to 5-year periods, which is the typical period that mortality data are available from national demographic and health surveys.

Results

Using 5-year aggregated data, associations were established between parasite prevalence and malaria-specific mortality in the whole population (RR_malaria = 1.66; 95% Bayesian Credible Intervals: 1.07–2.54) and children 1–4 years (RR_malaria = 2.29; 1.17–4.29). While clinical malaria was associated with both all-cause and malaria-specific mortality in combined ages (RR_all-cause = 1.32; 1.01–1.74); (RR_malaria = 2.50; 1.27–4.81), children 1–4 years (RR_all-cause = 1.89; 1.00–3.51); (RR_malaria = 3.37; 1.23–8.93) and in older children 5–14 years (RR_all-cause = 3.94; 1.34–11.10); (RR_malaria = 7.56; 1.20–39.54), no association was found among neonates, adults (15–59 years) and the elderly (60+ years). Distance to health facilities, socioeconomic status, elevation and survey year were important factors for all-cause and malaria-specific mortality.

Conclusion

Malaria parasitaemia from cross-sectional surveys was associated with mortality across age groups over 4 to 5 year periods with clinical malaria more strongly associated with mortality than parasite prevalence. This effect was stronger in children 5–14 years compared to other age-groups. Further analyses of data from other HDSS sites or similar platforms would be useful in investigating the relationship between malaria and mortality across different endemicity levels.

Electronic supplementary material

The online version of this article (10.1186/s12936-019-2869-9) contains supplementary material, which is available to authorized users.