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Background: Health system responsiveness to public priorities and needs is a broad, multi-faceted and complex health system goal thought to be important in promoting inclusivity and reducing system inequity in participation. Power dynamics underlie the complexity of responsiveness but are rarely considered. This paper presents an analysis of various manifestations of power within the responsiveness practices of Health Facility Committees (HFCs) and Sub-county Health Management Teams (SCHMTs) operating at the subnational level in Kenya. Kenyan policy documents identify responsiveness as an important policy goal. Methods: Our analysis draws on qualitative data (35 interviews with health managers and local politicians, four focus group discussions with HFC members, observations of SCHMT meetings, and document review) from a study conducted at the Kenyan Coast. We applied a combination of two power frameworks to interpret our findings: Gaventa's power cube and Long's actor interface analysis. Results: We observed a weakly responsive health system in which system-wide and equity in responsiveness were frequently undermined by varied forms and practices of power. The public were commonly dominated in their interactions with other health system actors: invisible and hidden power interacted to limit their sharing of feedback; while the visible power of organisational hierarchy constrained HFCs' and SCHMTs' capacity both to support public feedback mechanisms and to respond to concerns raised. These power practices were underpinned by positional power relationships, personal characteristics, and world views. Nonetheless, HFCs, SCHMTs and the public creatively exercised some power to influence responsiveness, for example through collaborations with political actors. However, most resulting responses were unsustainable, and sometimes undermined equity as politicians sought unfair advantage for their constituents. Conclusion: Our findings illuminate the structures and mechanisms that contribute to weak health system responsiveness even in contexts where it is prioritised in policy documents. Supporting inclusion and participation of the public in feedback mechanisms can strengthen receipt of public feedback; however, measures to enhance public agency to participate are also needed. In addition, an organisational environment and culture that empowers health managers to respond to public inputs is required. [ABSTRACT FROM AUTHOR]

Background: As a disease characterised by non-motor and very visible motor symptoms, Parkinson's disease has been associated with multiple forms of stigma, while awareness about the disease globally remains low. The experience of stigma relating to Parkinson's disease from high-income nations is well-documented, while less is known about low- and middle-income countries (LMICs). Literature on stigma and disease from Africa and the Global South has described the added complexities people face resulting from structural violence, as well as perceptions about symptoms and disease associated with supernatural beliefs, which can have significant implications for access to healthcare and support. Stigma is a recognised barrier to health-seeking behaviour and a social determinant of population health. Methods: This study draws on qualitative data collected as part of a wider ethnographic study to explore the lived experience of Parkinson's disease in Kenya. Participants include 55 people diagnosed with Parkinson's and 23 caregivers. The paper draws on the Health Stigma and Discrimination Framework as a tool to understand stigma as a process. Results: Data from interviews identified the drivers and facilitators of stigma, including poor awareness of Parkinson's, lack of clinical capacity, supernatural beliefs, stereotypes, fear of contagion and blame. Participants reported their lived realities of stigma, and experiences of stigma practices, which had significant negative health and social outcomes, including social isolation and difficulty accessing treatment. Ultimately, stigma had a negative and corrosive effect on the health and wellbeing of patients. Conclusion: This paper highlights the interplay of structural constraints and the negative consequences of stigma experienced by people living with Parkinson's in Kenya. The deep understanding of stigma made possible through this ethnographic research leads us to see stigma as a process, something that is embodied and enacted. Targeted and nuanced ways of tackling stigma are suggested, including educational and awareness campaigns, training, and the development of support groups. Importantly, the paper shows that awareness of, and advocacy for the recognition of, Parkinson's globally needs to improve. This recommendation is in line with the World Health Organization's Technical Brief on Parkinson disease, which responds to the growing public health challenge posed by Parkinson's. [ABSTRACT FROM AUTHOR]

Background: The social determinants of health (SDH) play a key role in the health of individuals, communities, and populations. Academic institutions and clinical licensing bodies increasingly recognize the need for healthcare professionals to understand the importance of considering the SDH to engage with patients and manage their care effectively. However, incorporating relevant skills, knowledge, and attitudes relating to the SDH into curricula must be more consistent. This scoping review explores the integration of the SDH into graduate medical education training programs. Methods: A systematic search was performed of PubMed, Ovid MEDLINE, ERIC, and Scopus databases for articles published between January 2010 and March 2023. A scoping review methodology was employed, and articles related to training in medical or surgical specialties for registrars and residents were included. Pilot programs, non-SDH-related programs, and studies published in languages other than English were excluded. Results: The initial search produced 829 articles after removing duplicates. The total number of articles included in the review was 24. Most articles were from developed countries such as the USA (22), one from Canada, and only one from a low- and middle-income country, Kenya. The most highly represented discipline was pediatrics. Five papers explored the inclusion of SDH in internal medicine training, with the remaining articles covering family medicine, obstetrics, gynecology, or a combination of disciplines. Longitudinal programs are the most effective and frequently employed educational method regarding SDH in graduate training. Most programs utilize combined teaching methods and rely on participant surveys to evaluate their curriculum. Conclusion: Applying standardized educational and evaluation strategies for SDH training programs can pose a challenge due to the diversity of the techniques reported in the literature. Exploring the most effective educational strategy in delivering these concepts and evaluating the downstream impacts on patient care, particularly in surgical and non-clinical specialties and low- and middle-income countries, can be essential in integrating and creating a sustainable healthcare force. [ABSTRACT FROM AUTHOR]

Background: Understanding the impact of disease associations is becoming a priority in Kenya and other countries bearing the load of infectious diseases. With the increased incidences of non-communicable diseases and the endemicity of infectious diseases in Sub-Saharan Africa, their co-existence poses significant challenges to patients, health workers and an overwhelmed health sector. Classical risk factors for diabetes such as physical inactivity and unhealthy diet may not solely explain the current trends, suggesting the role of novel risk factors including infections/inflammation. HIV and its treatment have been identified as potential contributors especially to patients with family history of confirmed diabetes cases. Co-infections frequently observed during HIV infection also significantly influence both the epidemiological and pathophysiological of the link between HIV and diabetes. Understanding the correlates of HIV and diabetes is crucial to inform management and prevention strategies of the twin infections. We therefore aimed to determine the prevalence of diabetes mellitus and risk factors in a population of HIV infected patients on HAART. This study determined the association of diabetes/impaired glucose regulation in the context of HIV-1. A cross-sectional study was conducted at a comprehensive care clinic in Nairobi (Kenya). Participants were screened for diabetes and impaired glucose regulation using random blood glucose and glycated haemoglobin (HbA1c) This paper describes the prevalence of diabetes mellitus in Human Immunodeficiency Virus positive individuals and the associated risk factors. We have demonstrated that family history is a risk factor for diabetes. While age and BMI are known risk factors, they were not associated with diabetes in this study. [ABSTRACT FROM AUTHOR]

Background: Life expectancy has increased over the last century among older people, particularly those aged over 60 years. Aging is associated with increased disability, multiple chronic conditions, and increased use of health services managed with polypharmacy. There are few studies on polypharmacy and aging in sub-Saharan Africa, and it is unclear what older people know and their attitudes toward polypharmacy. This paper presents findings from a study that aimed to understand older people's knowledge, attitudes and beliefs about polypharmacy. Methods: A qualitative study using in-depth interviews of 15 patients aged 60 years and older who were taking more than five medications per day. The study was conducted at the Family Medicine Clinic (FMC), Aga Khan University Hospital, Nairobi. Data were analyzed using NVivo 12 software. Result: Majority of participants had a good understanding of their underlying health conditions, but they did not know the specific names of the medications they were taking. Participants had diverse attitudes toward polypharmacy, with both positive and negative perceptions. Although adverse side effects were reported, participants remained positive because they believed these medicines were beneficial. Religion, faith and living healthy lifestyles were perceived to contribute to their positive attitude toward polypharmacy. Stigma and the cost of medication were reported as barriers. Conclusion: This study provides valuable insights into the complexities of polypharmacy in older people. It highlights the importance of patient education, fostering strong patient-provider relationships, de-stigmatization, and improving medication affordability and accessibility. Further research could explore the polypharmacy of older people attending public institutions in rural Kenya. [ABSTRACT FROM AUTHOR]

Background: Malaria remains a public health problem in Kenya despite several concerted control efforts. Empirical evidence regarding malaria effects in Kenya suggests that the disease imposes substantial economic costs, jeopardizing the achievement of sustainable development goals. The Kenya Malaria Strategy (2019–2023), which is currently being implemented, is one of several sequential malaria control and elimination strategies. The strategy targets reducing malaria incidences and deaths by 75% of the 2016 levels by 2023 through spending around Kenyan Shillings 61.9 billion over 5 years. This paper assesses the economy-wide implications of implementing this strategy. Methods: An economy-wide simulation model is calibrated to a comprehensive 2019 database for Kenya, considering different epidemiological zones. Two scenarios are simulated with the model. The first scenario (GOVT) simulates the annual costs of implementing the Kenya Malaria Strategy by increasing government expenditure on malaria control and elimination programmes. The second scenario (LABOR) reduces malaria incidences by 75% in all epidemiological malaria zones without accounting for the changes in government expenditure, which translates into rising the household labour endowment (benefits of the strategy). Results: Implementing the Kenya Malaria Strategy (2019–2023) enhances gross domestic product at the end of the strategy implementation period due to more available labour. In the short term, government health expenditure (direct malaria costs) increases significantly, which is critical in controlling and eliminating malaria. Expanding the health sector raises the demand for production factors, such as labour and capital. The prices for these factors rise, boosting producer and consumer prices of non-health-related products. Consequently, household welfare decreases during the strategy implementation period. In the long run, household labour endowment increases due to reduced malaria incidences and deaths (indirect malaria costs). However, the size of the effects varies across malaria epidemiological and agroecological zones depending on malaria prevalence and factor ownership. Conclusions: This paper provides policymakers with an ex-ante assessment of the implications of malaria control and elimination on household welfare across various malaria epidemiological zones. These insights assist in developing and implementing related policy measures that reduce the undesirable effects in the short run. Besides, the paper supports an economically beneficial long-term malaria control and elimination effect. [ABSTRACT FROM AUTHOR]

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Background: Parental stress often arises when parenting demands exceed the expected and actual resources available for parents to succeed in the parenting role. Parental stress is an important contributor to parent-child relationships. This, in turn, affects opportunities to engage their children in stimulating activities which could improve their development outcomes. However, limited evidence exists from sub-Saharan Africa (SSA) on the association between parental stress, caregiving practices, and child developmental outcomes. Methods: The findings reported in this paper were derived from data collected through previous longitudinal work on nurturing care evaluation studies in Kisumu and Nairobi Counties in Kenya, and Chisamba District in Zambia. A total of 341 caregivers and their children who participated in the three rounds of data collection were included in this study. The children's mean age was 9.3 (SD = 8.2) months pre-intervention, 25.5 (SD = 8.6) months in mid-intervention, and 36 (SD = 10.0) months post-intervention. The Ages and Stages Questionnaire (ASQ), Parental Stress Scale (PSS), and caregiving tools were used to assess children's developmental outcomes, parental stress, and stimulation practices, respectively. A Random Intercept Cross-Lagged Panel model (RI-CLPM) was used to determine the association between caregivers' parenting stress, child stimulation practices, and child developmental outcomes. Results: The findings showed that caregiver stimulation practices were positively associated with developmental outcomes. Findings on the associations between parental stress and caregivers' stimulation practices and children's developmental outcomes were not universally supported. Conclusion: The findings show that improved caregiver stimulation practices are likely to improve children's developmental outcomes. The policy implications of the findings from this study focus on improving parenting practices by addressing the predictors of parental stress. This includes subsidising childcare services to reduce costs. Trial registration: Pan African Clinical Trials Registry (https://pactr.samrc.ac.za/) database (ID number: PACTR20180774832663 Date: 26/July/2018. [ABSTRACT FROM AUTHOR]

Background: Despite major improvements in child survival over the past decade, many children in low and middle-income countries (LMICs) remain at risk of not reaching their developmental potential due to malnutrition, poor health, and a lack of stimulation. Maternal engagement and stimulation have been identified as some of the most critical inputs for healthy development of children. However, relatively little evidence exists on the links between maternal stimulation and child development exists in sub-Saharan Africa (SSA). This current paper aims to identify the associations between maternal stimulation and child development in Kenya and Zambia, as well as the activities that are most predictive of developmental outcomes in these settings. Methods: We conducted a descriptive study using data from a prospective study in Kenya and Zambia. The study included three rounds of data collection. Children were on average 10 months old in round one, 25 months old in round two, and 36 months old in round three. The primary exposure variable of interest was maternal stimulation activities, which we grouped into cognitive, language, motor, and socio-emotional activities. The outcome of interest was child development measured through the Third Edition of the Ages and Stages Questionnaire (ASQ-3). Linear regression models were used to estimate the associations between overall maternal stimulation and domain-specific maternal stimulation and child development across the three rounds of the survey. Results: Higher maternal stimulation scores were associated with higher ASQ scores (effect size = 0.25; 95% CI: 0.19, 0.31) after adjusting for other confounders. For domain specific and child development (ASQ scores), the largest effect size (ES) was found for language stimulation (ES = 0.15) while weakest associations were found for socio-emotional domain activities (ES= -0.05). Overall maternal stimulation was most strongly associated with gross motor development (ES = 0.21) and the least associated with problem-solving (ES = 0.16). Conclusion: Our study findings suggest a strong positive link between maternal stimulation activities and children's developmental outcomes among communities in poor rural settings. Trial registration: NA (not a clinical trial). [ABSTRACT FROM AUTHOR]

Background: High-quality neonatal care requires sufficient functional medical devices, furniture, fixtures, and use by trained healthcare workers, however there is lack of publicly available tools for quantification and costing. This paper describes development and use of a planning and costing tool regarding furniture, fixtures and devices to support scale-up of WHO level-2 neonatal care, for national and global newborn survival targets. Methods: We followed a systematic process. First, we reviewed planning and costing tools of relevance. Second, we co-designed a new tool to estimate furniture and device set-up costs for a default 40-bed level-2 neonatal unit, incorporating input from multi-disciplinary experts and newborn care guidelines. Furniture and device lists were based off WHO guidelines/norms, UNICEF and national manuals/guides. Due to lack of evidence-based quantification, ratios were based on operational manuals, multi-country facility assessment data, and expert opinion. Default unit costs were from government procurement agency costs in Kenya, Nigeria, and Tanzania. Third, we refined the tool by national use in Tanzania. Results: The tool adapts activity-based costing (ABC) to estimate quantities and costs to equip a level-2 neonatal unit based on three components: (1) furniture/fixtures (18 default but editable items); (2) neonatal medical devices (16 product categories with minimum specifications for use in low-resource settings); (3) user training at device installation. The tool was used in Tanzania to generate procurement lists and cost estimates for level-2 scale-up in 171 hospitals (146 District and 25 Regional Referral). Total incremental cost of all new furniture and equipment acquisition, installation, and user training were US$93,000 per District hospital (level-2 care) and US$346,000 per Regional Referral hospital. Estimated cost per capita for whole-country district coverage was US$0.23, representing 0.57% increase in government health expenditure per capita and additional 0.35% for all Regional Referral hospitals. Conclusion: Given 2.3 million neonatal deaths and potential impact of level-2 newborn care, rational and efficient planning of devices linked to systems change is foundational. In future iterations, we aim to include consumables, spare parts, and maintenance cost options. More rigorous implementation research data are crucial to formulating evidence-based ratios for devices numbers per baby. Use of this tool could help overcome gaps in devices numbers, advance efficiency and quality of neonatal care. [ABSTRACT FROM AUTHOR]

Background: A birth companion is a simple and low-cost intervention that can improve both maternal and newborn health outcomes. The evidence that birth companionship improves labor outcomes and experiences of care has been available for many years. Global and national policies exist in support of birth companions. Many countries including Ethiopia, Kenya, and Nigeria have not yet incorporated birth companions into routine practice in health facilities. This paper presents the protocol for a trial that aims to assess if a package of interventions that addresses known barriers can increase the coverage of birth companions. Methods: This two parallel arm cluster randomized controlled trial will evaluate the impact of a targeted intervention package on scale-up of birth companionship at public sector health facilities in Ethiopia (five study sites encompassing 12 facilities), Kenya (two sites encompassing 12 facilities in Murang'a and 12 facilities in Machakos counties), and Nigeria (two sites encompassing 12 facilities in Kano and 12 facilities in Nasarawa states). Baseline and endline assessments at each site will include 744 women who have recently given birth in the quantitative component. We will interview a maximum of 16 birth companions, 48 health care providers, and eight unit managers quarterly for the qualitative component in each country. Discussion: Ample evidence supports the contribution of birth companions to positive health outcomes for mothers and newborns. However, limited data are available on effective strategies to improve birth companion coverage and inform scale-up efforts. This trial tests a birth companion intervention package in diverse clinical settings and cultures to identify possible barriers and considerations to increasing uptake of birth companions. Findings from this study may provide valuable evidence for scaling up birth companionship in similar settings. Trial registration: Trial is registered with ClinicalTrials.gov with identifier: NCT05565196, first posted 04/10/ 2022. [ABSTRACT FROM AUTHOR]

Background: Ivermectin (IVM) mass drug administration is a candidate complementary malaria vector control tool. Ingestion of blood from IVM treated hosts results in reduced survival in mosquitoes. Estimating bio-efficacy of IVM on wild-caught mosquitoes requires they ingest the drug in a blood meal either through a membrane or direct feeding on a treated host. The latter, has ethical implications, and the former results in low feeding rates. Therefore, there is a need to develop a safe and effective method for IVM bio-efficacy monitoring in wild mosquitoes. Methods: Insectary-reared Anopheles gambiae s.s. were exposed to four IVM doses: 85, 64, 43, 21 ng/ml, and control group (0 ng/ml) in three different solutions: (i) blood, (ii) 10% glucose, (iii) four ratios (1:1, 1:2, 1:4, 1:8) of blood in 10% glucose, and fed through filter paper. Wild-caught An. gambiae s.l. were exposed to 85, 43 and 21 ng/ml IVM in blood and 1:4 ratio of blood-10% glucose mixture. Survival was monitored for 28 days and a pool of mosquitoes from each cohort sacrificed immediately after feeding and weighed to determine mean weight of each meal type. Results: When administered in glucose solution, mosquitocidal effect of IVM was not comparable to the observed effects when similar concentrations were administered in blood. Equal concentrations of IVM administered in blood resulted in pronounced reductions in mosquito survival compared to glucose solution only. However, by adding small amounts of blood to glucose solution, mosquito mortality rates increased resulting in similar effects to what was observed during blood feeding. Conclusion: Bio-efficacy of ivermectin is strongly dependent on mode of drug delivery to the mosquito and likely influenced by digestive processes. The assay developed in this study is a good candidate for field-based bio-efficacy monitoring: wild mosquitoes readily feed on the solution, the assay can be standardized using pre-selected concentrations and by not involving treated blood hosts (human or animal) variation in individual pharmacokinetic profiles as well as ethical issues are bypassed. Meal volumes did not explain the difference in the lethality of IVM across the different meal types necessitating further research on the underlying mechanisms. [ABSTRACT FROM AUTHOR]

Background: This document describes two qualitative programmatic case studies documenting experiences implementing digital financial services (DFS) for health with a focus on expanding access to universal health coverage (UHC). The CBHI 3MS system in Rwanda and the i-PUSH and Medical Credit Fund programs in Kenya were selected because they represent innovative use of digital financing technologies to support UHC programs at scale. Methods: These studies were conducted from April-August 2021 as part of a broader digital financial services landscape assessment that used a mixed methods process evaluation to answer three questions: 1) what was the experience implementing the program, 2) how was it perceived to influence health systems performance, and 3) what was the client/beneficiary experience? Qualitative interviews involved a range of engaged stakeholders, including implementers, developers, and clients/users from the examined programs in both countries. Secondary data were used to describe key program trends. Results: Respondents agreed that DFS contributed to health system performance by making systems more responsive, enabling programs to implement changes to digital services based on new laws or client-proposed features, and improving access to quality data for better management and improved quality of services. Key informants and secondary data confirmed that both implementations likely contributed to increasing health insurance coverage; however, other changes in market dynamics were also likely to influence these changes. Program managers and some beneficiaries praised the utility of digital functions, compared to paper-based systems, and noted their effect on individual savings behavior to contribute to household resilience. Discussion/Conclusions: Several implementation considerations emerged as facilitators or barriers to successful implementation of DFS for health, including the importance of multisectoral investments in general ICT infrastructure, the value of leveraging existing community resources (CHWs and mobile money agents) to boost enrollment and help overcome the digital divide, and the significance of developing trust across government and private sector organizations. The studies led to the development of five main recommendations for the design and implementation of health programs incorporating DFS. [ABSTRACT FROM AUTHOR]

Objective: This study proposes to identify and validate weighted sensor stream signatures that predict near-term risk of a major depressive episode and future mood among healthcare workers in Kenya. Approach: The study will deploy a mobile application (app) platform and use novel data science analytic approaches (Artificial Intelligence and Machine Learning) to identifying predictors of mental health disorders among 500 randomly sampled healthcare workers from five healthcare facilities in Nairobi, Kenya. Expectation: This study will lay the basis for creating agile and scalable systems for rapid diagnostics that could inform precise interventions for mitigating depression and ensure a healthy, resilient healthcare workforce to develop sustainable economic growth in Kenya, East Africa, and ultimately neighboring countries in sub-Saharan Africa. This protocol paper provides an opportunity to share the planned study implementation methods and approaches. Conclusion: A mobile technology platform that is scalable and can be used to understand and improve mental health outcomes is of critical importance. [ABSTRACT FROM AUTHOR]

Background: The global increase in mean body mass index has resulted in a substantial increase of non-communicable diseases (NCDs), including in many low- and middle-income countries such as Kenya. This paper assesses four interventions for the prevention and control of overweight and obesity in Kenya to determine their potential health and economic impact and cost effectiveness. Methods: We reviewed the literature to identify evidence of effect, determine the intervention costs, disease costs and total healthcare costs. We used a proportional multistate life table model to quantify the potential impacts on health conditions and healthcare costs, modelling the 2019 Kenya population over their remaining lifetime. Considering a health system perspective, two interventions were assessed for cost-effectiveness. In addition, we used the Human Capital Approach to estimate productivity gains. Results: Over the lifetime of the 2019 population, impacts were estimated at 203,266 health-adjusted life years (HALYs) (95% uncertainty interval [UI] 163,752 − 249,621) for a 20% tax on sugar-sweetened beverages, 151,718 HALYs (95% UI 55,257 − 250,412) for mandatory kilojoule menu labelling, 3.7 million HALYs (95% UI 2,661,365–4,789,915) for a change in consumption levels related to supermarket food purchase patterns and 13.1 million HALYs (95% UI 11,404,317 − 15,152,341) for a change in national consumption back to the 1975 average levels of energy intake. This translates to 4, 3, 73 and 261 HALYs per 1,000 persons. Lifetime healthcare cost savings were approximately United States Dollar (USD) 0.14 billion (USD 3 per capita), USD 0.08 billion (USD 2 per capita), USD 1.9 billion (USD 38 per capita) and USD 6.2 billion (USD 124 per capita), respectively. Lifetime productivity gains were approximately USD 1.8 billion, USD 1.2 billion, USD 28 billion and USD 92 billion. Both the 20% tax on sugar sweetened beverages and the mandatory kilojoule menu labelling were assessed for cost effectiveness and found dominant (health promoting and cost-saving). Conclusion: All interventions evaluated yielded substantive health gains and economic benefits and should be considered for implementation in Kenya. [ABSTRACT FROM AUTHOR]

Background: Aggregate electronic data repositories and population-level cross-sectional surveys play a critical role in HIV programme monitoring and surveillance for data-driven decision-making. However, these data sources have inherent limitations including inability to respond to public health priorities in real-time and to longitudinally follow up clients for ascertainment of long-term outcomes. Electronic medical records (EMRs) have tremendous potential to bridge these gaps when harnessed into a centralised data repository. We describe the evolution of EMRs and the development of a centralised national data warehouse (NDW) repository. Further, we describe the distribution and representativeness of data from the NDW and explore its potential for population-level surveillance of HIV testing, care and treatment in Kenya. Main body: Health information systems in Kenya have evolved from simple paper records to web-based EMRs with features that support data transmission to the NDW. The NDW design includes four layers: data warehouse application programming interface (DWAPI), central staging, integration service, and data visualization application. The number of health facilities uploading individual-level data to the NDW increased from 666 in 2016 to 1,516 in 2020, covering 41 of 47 counties in Kenya. By the end of 2020, the NDW hosted longitudinal data from 1,928,458 individuals ever started on antiretroviral therapy (ART). In 2020, there were 936,869 individuals who were active on ART in the NDW, compared to 1,219,276 individuals on ART reported in the aggregate-level Kenya Health Information System (KHIS), suggesting 77% coverage. The proportional distribution of individuals on ART by counties in the NDW was consistent with that from KHIS, suggesting representativeness and generalizability at the population level. Conclusion: The NDW presents opportunities for individual-level HIV programme monitoring and surveillance because of its longitudinal design and its ability to respond to public health priorities in real-time. A comparison with estimates from KHIS demonstrates that the NDW has high coverage and that the data maybe representative and generalizable at the population-level. The NDW is therefore a unique and complementary resource for HIV programme monitoring and surveillance with potential to strengthen timely data driven decision-making towards HIV epidemic control in Kenya. Database link: (https://dwh.nascop.org/). [ABSTRACT FROM AUTHOR]

Background: Hypertension is the leading cause of death and disability. Clinical care for patients with hypertension in Kenya leverages referral networks to provide basic and specialized healthcare services. However, referrals are characterized by non-adherence and delays in completion. An integrated health information technology (HIT) and peer-based support strategy to improve adherence to referrals and blood pressure control was proposed. A formative assessment gathered perspectives on barriers to referral completion and garnered thoughts on the proposed intervention. Methods: We conducted a qualitative study in Kitale, Webuye, Kocholya, Turbo, Mosoriot and Burnt Forest areas of Western Kenya. We utilized the PRECEDE-PROCEED framework to understand the behavioral, environmental and ecological factors that would influence uptake and success of our intervention. We conducted four mabaraza (customary heterogenous community assemblies), eighteen key informant interviews, and twelve focus group discussions among clinicians, patients and community members. The data obtained was audio recorded alongside field note taking. Audio recordings were transcribed and translated for onward coding and thematic analysis using NVivo 12. Results: Specific supply-side and demand-side barriers influenced completion of referral for hypertension. Key demand-side barriers included lack of money for care and inadequate referral knowledge. On the supply-side, long distance to health facilities, low availability of services, unaffordable services, and poor referral management were reported. All participants felt that the proposed strategies could improve delivery of care and expressed much enthusiasm for them. Participants appreciated benefits of the peer component, saying it would motivate positive patient behavior, and provide health education, psychosocial support, and assistance in navigating care. The HIT component was seen as reducing paper work, easing communication between providers, and facilitating tracking of patient information. Participants also shared concerns that could influence implementation of the two strategies including consent, confidentiality, and reduction in patient-provider interaction. Conclusions: Appreciation of local realities and patients' experiences is critical to development and implementation of sustainable strategies to improve effectiveness of hypertension referral networks. Incorporating concerns from patients, health care workers, and local leaders facilitates adaptation of interventions to respond to real needs. This approach is ethical and also allows research teams to harness benefits of participatory community-involved research. Trial registration: Clinicaltrials.gov, NCT03543787, Registered June 1, 2018. https://clinicaltrials.gov/ct2/show/NCT03543787 [ABSTRACT FROM AUTHOR]

Background: Lack of dependable morbidity and mortality data complicates efforts to measure the demographic or population-level impact of the global HIV/AIDS epidemic. Mortuary-based mortality surveillance can address gaps in vital statistics in low-resource settings by improving accuracy of measuring HIV-associated mortality and indicators of access to treatment services among decedents. This paper describes the process and considerations taken in conducting mortuary and hospital-based HIV mortality surveillance among decedents in Kenya.Main Text: We conducted HIV mortuary and hospital-based mortality surveillance at two of the largest mortuaries in Kisumu County, Kenya (April 16-July 12, 2019). Medical charts were reviewed for documentation of HIV status among eligible decedents. HIV testing was done on blood and oral fluid samples from decedents with undocumented HIV status and those whose medical records indicated HIV-negative test results > 3 months before death. A panel of experts established the cause of death according to the International Classification of Diseases, 10th Revision rules. Civil registry data for the year 2017 were abstracted and coded to corresponding ICD-10 codes. Of the 1004 decedents admitted to the two mortuaries during the study period, 49 (4.9%) were unavailable because they had been transferred to other facilities or dispatched for burial before enrolment. Of the 955 available decedents, 104 (10.9%) were ineligible for the study. Blood samples were collected from 659 (77.4%) decedents, and 654 (99.2%) were tested for HIV. Of the 564 decedents eligible for the OraQuick® validation sub-study, 154 were eligible for oral sample collection, and 132 (85.7%) matched pre- and post-embalming oral samples were collected and tested. Of the 851 eligible decedents, 241 (28.3%) had evidence of HIV infection: 119 had a diagnosis of HIV infection recorded in their patient files, and 122 had serological evidence of HIV infection.Conclusion: This study shows that in low-resource settings, conducting hospital and mortuary-based surveillance is feasible and can be an alternative source of mortality data when civil registry data are inadequate. [ABSTRACT FROM AUTHOR]

Background : A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals' use of antibiotics (ABs) to treat illness. To better understand motivations and context for antibiotic use we use the concept of a patient treatment-seeking pathway: a treatment journey encompassing where patients go when they are unwell, what motivates their choices, and how they obtain antibiotics. This paper investigates patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high. Methods: The Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda between February 2019- September 2020, and conducted qualitative in-depth patient interviews with a subset (n = 116). We described patterns of treatment-seeking visually using Sankey plots and explored explanations and motivations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three factors related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs. Results: Although most patients (86%) sought help from medical facilities in the first instance, many (56%) described multi-step, repetitive treatment-seeking pathways, which further increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and have multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as hybrid healthcare systems and AB availability. Conclusion: There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR. A focus on individual antibiotic use as the key intervention point in this cycle ignores the contextual challenges patients face when treatment seeking, which include inadequate access to diagnostics, perceived inefficient public healthcare and ease of purchasing antibiotics without prescription. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend further attention to healthcare system factors, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers). [ABSTRACT FROM AUTHOR]

Background: Currently, chemotherapy stands out as the major malaria intervention strategy, however, anti-malarial resistance may hamper global elimination programs. Artemisinin-based combination therapy (ACT) stands as the drug of choice for the treatment of Plasmodium falciparum malaria. Plasmodium falciparum kelch13 gene mutations are associated with artemisinin resistance. Thus, this study was aimed at evaluating the circulation of P. falciparum k13 gene polymorphisms from Kisii County, Kenya during an era of ACT deployment. Methods: Participants suspected to have malaria were recruited. Plasmodium falciparum was confirmed using the microscopy method. Malaria-positive patients were treated with artemether-lumefantrine (AL). Blood from participants who tested positive for parasites after day 3 was kept on filter papers. DNA was extracted using chelex-suspension method. A nested polymerase chain reaction (PCR) was conducted and the second-round products were sequenced using the Sanger method. Sequenced products were analysed using DNAsp 5.10.01 software and then blasted on the NCBI for k13 propeller gene sequence identity using the Basic Local Alignment Search Tool (BLAST). To assess the selection pressure in P. falciparum parasite population, Tajima' D statistic and Fu & Li's D test in DnaSP software 5.10.01 was used. Results: Out of 275 enrolled participants, 231 completed the follow-up schedule. 13 (5.6%) had parasites on day 28 hence characterized for recrudescence. Out of the 13 samples suspected of recrudescence, 5 (38%) samples were positively amplified as P. falciparum, with polymorphisms in the k13-propeller gene detected. Polymorphisms detected in this study includes R539T, N458T, R561H, N431S and A671V, respectively. The sequences have been deposited in NCBI with bio-project number PRJNA885380 and accession numbers SAMN31087434, SAMN31087433, SAMN31087432, SAMN31087431 and SAMN31087430 respectively. Conclusions: WHO validated polymorphisms in the k13-propeller gene previously reported to be associated with ACT resistance were not detected in the P. falciparum isolates from Kisii County, Kenya. However, some previously reported un-validated k13 resistant single nucleotide polymorphisms were reported in this study but with limited occurrences. The study has also reported new SNPs. More studies need to be carried out in the entire country to understand the association of reported mutations if any, with ACT resistance. [ABSTRACT FROM AUTHOR]

Background: Contraceptive use among young women in Nairobi remains low despite high general knowledge of family planning (FP) methods. This paper draws on social norms theory to explore the role of key influencers (partners, parents and friends) in women's FP use and how women anticipate normative reactions or sanctions. Methods: A qualitative study with 16 women, 10 men and 14 key influencers across 7 peri-urban wards in Nairobi, Kenya. Interviews were conducted during the COVID-19 pandemic in 2020 by phone. A thematic analysis was conducted. Results: Women identified parents, specifically mothers, aunts, partners, friends and healthcare workers as key influencers on FP. Their interactions with these key influencers varied based on trust, the information they needed about FP, and whether they perceived a key influencer to perpetuate or challenge existing social norms on FP. Mothers were perceived to understand the social risks of using FP and thus could advise on discreet FP use, and aunts were trusted and approachable sources to impartially describe the benefits and drawbacks of FP. Although women identified partners as key FP decision makers, they were cognisant of possible power imbalances affecting a final FP choice. Conclusions: FP interventions should consider the normative influence key actors have on women's FP choices. Opportunities to design and deliver network-level interventions which seek to engage with social norms surrounding FP in order to challenge misconceptions and misinformation among key influencers should be explored. Intervention design should consider dynamics of secrecy, trust and emotional closeness that mediate discussions of FP to address changing norms. Further training to change norms held by healthcare providers about why women, in particular unmarried young women, access FP should be provided to reduce barriers for FP access. Plain language summary: Women's decisions to use family planning (FP) are influenced by social norms, the unwritten rules of appropriate actions within social networks, and are shaped by advice and information received from key influencers—important individuals who shape what is acceptable within social networks. The aim of this study was to understand how key influencers uphold and transmit information and norms about FP, and explore who women consult as they make FP decisions and why they consult these key influencers. We interviewed 16 women, 10 partners and 14 key influencers in peri-urban Nairobi, Kenya. We found that key influencers for decisions about FP included mothers, aunts, partners, friends and healthcare providers. In making a decision about FP use, women consulted key influencers based on who they deemed trustworthy to keep their FP use secret and described less trust to speak with men about FP in their social networks. Mothers understood the social risks of using FP and so could advise on its discreet use, and aunts were approachable sources of impartial information about FP. Although women identified partners as key decision makers, they were aware that power imbalances might affect final FP choices. Our findings underscore the importance of FP interventions working with women's social networks and to address social norms influencing women's decisions in using FP. Interventions to change FP norms should consider dynamics of secrecy, trust and emotional closeness that affect FP discussions among women's networks. [ABSTRACT FROM AUTHOR]

Background: Alcohol use disorder is prevalent globally and in Kenya, and is associated with significant health and socio-economic consequences. Despite this, available pharmacological treatment options are limited. Recent evidence indicates that intravenous (IV) ketamine can be beneficial for the treatment of alcohol use disorder, but is yet to be approved for this indication. Further, little has been done to describe the use of IV ketamine for alcohol use disorder in Africa. The goal of this paper, is to: 1) describe the steps we took to obtain approval and prepare for off-label use of IV ketamine for patients with alcohol use disorder at the second largest hospital in Kenya, and 2) describe the presentation and outcomes of the first patient who received IV ketamine for severe alcohol use disorder at the hospital. Case presentation: In preparing for the off-label use of ketamine for alcohol use disorder, we brought together a multi-disciplinary team of clinicians including psychiatrists, pharmacists, ethicists, anesthetists, and members of the drug and therapeutics committee, to spearhead the process. The team developed a protocol for administering IV ketamine for alcohol use disorder that took into account ethical and safety issues. The national drug regulatory authority, the Pharmacy and Poison's Board, reviewed and approved the protocol. Our first patient was a 39-year-old African male with severe alcohol use disorder and comorbid tobacco use disorder and bipolar disorder. The patient had attended in-patient treatment for alcohol use disorder six times and each time had relapsed between one to four months after discharge. On two occasions, the patient had relapsed while on optimal doses of oral and implant naltrexone. The patient received IV ketamine infusion at a dose of 0.71 mg/kg. The patient relapsed within one week of receiving IV ketamine while on naltrexone, mood stabilizers, and nicotine replacement therapy. Discussion & conclusions: This case report describes for the first time the use of IV ketamine for alcohol use disorder in Africa. Findings will be useful in informing future research and in guiding other clinicians interested in administering IV ketamine for patients with alcohol use disorder. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The Harambee study is a cluster randomized trial in Western Kenya that tests the effect, mechanisms, and cost-effectiveness of integrating community-based HIV and non-communicable disease care within microfinance groups on chronic disease treatment outcomes. This paper documents the stages of our feasibility study conducted in preparation for the Harambee trial, which include (1) characterizing the target population and gauging recruitment capacity, (2) determining community acceptability of the integrated intervention and study procedures, and (3) identifying key implementation considerations prior to study start. Methods: Feasibility research took place between November 2019 and February 2020 in Western Kenya. Mixed methods data collection included surveys administered to 115 leaders of 105 community-based microfinance groups, 7 in-person meetings and two workshops with stakeholders from multiple sectors of the health system, and ascertainment of field notes and geographic coordinates for group meeting locations and HIV healthcare facilities. Quantitative survey data were analyzed using STATA IC/13. Longitude and latitude coordinates were mapped to county boundaries using Esri ArcMap. Qualitative data obtained from stakeholder meetings and field notes were analyzed thematically. Results: Of the 105 surveyed microfinance groups, 77 met eligibility criteria. Eligible groups had been in existence from 6 months to 18 years and had an average of 22 members. The majority (64%) of groups had at least one member who owned a smartphone. The definition of "active" membership and model of saving and lending differed across groups. Stakeholders perceived the community-based intervention and trial procedures to be acceptable given the minimal risks to participants and the potential to improve HIV treatment outcomes while facilitating care integration. Potential challenges identified by stakeholders included possible conflicts between the trial and existing community-based interventions, fear of group disintegration prior to trial end, clinicians' inability to draw blood for viral load testing in the community, and deviations from standard care protocols. Conclusions: This study revealed that it was feasible to recruit the number of microfinance groups necessary to ensure that our clinical trial was sufficient powered. Elicitation of stakeholder feedback confirmed that the planned intervention was largely acceptable and was critical to identifying challenges prior to implementation. Trial registration: The original trial was prospectively registered with ClinicalTrials.gov (NCT04417127) on 4 June 2020. [ABSTRACT FROM AUTHOR]

Background: Peripartum adolescents experience significant interpersonal transitions in their lives. Depression and emotional distress are often exacerbated by adolescents' responses to these interpersonal changes. Improved understanding of pregnancy-related social changes and maladaptive responses to these shifts may inform novel approaches to addressing the mental health needs of adolescents during the perinatal period. The paper aims to understand the sources of psychological distress in peripartum adolescents and map these to Interpersonal Psychotherapy's (IPT) problem areas as a framework to understand depression. Method: We conducted interviews in two Nairobi primary care clinics with peripartum adolescents ages 16–18 years (n = 23) with experiences of depression, keeping interpersonal psychotherapy framework of problem areas in mind. We explored the nature of their distress, triggers, antecedents of distress associated with an unplanned pregnancy, quality of their relationships with their partner, parents, and other family members, perceived needs, and sources of support. Results: We found that the interpersonal psychotherapy (IPT) framework of interpersonal problems covering grief and loss, role transitions, interpersonal disputes, and social isolation was instrumental in conceptualizing adolescent depression, anxiety, and stress in the perinatal period. Conclusion: Our interviews deepened understanding of peripartum adolescent mental health focusing on four IPT problem areas. The interpersonal framework yields meaningful information about adolescent depression and could help in identifying strategies for addressing their distress. [ABSTRACT FROM AUTHOR]

To most indigenous communities, livestock plays important socio-cultural roles in addition to sustenance. Like many other communities in the world, the Borana people regard livestock and livestock products not only as nourishment but as an integral part of their cultural identity and social construct. The Borana are Cushitic-speaking people who reside in northern Kenya and southern Ethiopia and practise pastoralism as the primary way of livelihood. Livestock is reared by Borana people to obtain meat, milk and other by-products further to socio-cultural roles that were important for communal prosperity and resilience. The aim of this paper was therefore, to describe the various role of cattle and its significance to Borana people. For data collection, qualitative methods such as key informant interviews and focus group discussions were used. The interviews were audio recorded, transcribed and analysed. The results showed that cattle and particularly bulls were slaughtered for meat consumption, rituals and high-value ceremonial purposes. Moreover, as a desired form of wealth, cattle provide numerous resources to the owners and the prestige associated with herd of cattle accelerates social status and identity among the Borana community. Thus, according to participants' discussions and views, cattle are highly symbolic and have cultural meaning not only as the primary source of food but also in shaping social–cultural values embedded in their social structure. The various role of cattle and its products had significant implications on food security; the traditional practice of livestock wealth sharing shielded the Borana community in times of need and the practice of commensality led to greater social bonds. However, the changing socio-cultural environment caused by recurrent droughts has affected the traditional coping mechanism and led to alternative forms of livelihood. [ABSTRACT FROM AUTHOR]

Background: Female sex workers (FSWs) in Kenya are at an increased risk of violence, poverty, police arrest, and problematic alcohol and other substance use, all of which are linked to poor mental health and suicidal ideation. Despite the psychological stressors experienced by FSWs, there is no published qualitative methods research investigating their mental health experiences in Kenya. In this paper, we draw on data from in-depth interviews to examine FSWs' lifetime mental health experiences and perceived risk factors.Methods: We used baseline in-depth interviews of the Maisha Fiti longitudinal study of FSWs in Nairobi. We randomly selected 40 FSWs from 1003 FSWs who attended a baseline behavioural-biological interview as part of the Maisha Fiti study. The interview guide was semi-structured, and participants were asked to detail their life stories, including narrating specific events such as entry into sex work, experiences of violence, mental health experiences, and use of alcohol and other substances. Interviews were recorded in Kiswahili/ English and transcribed in English. Data were coded and thematically analysed in Nvivo (v.12).Results: Results indicated that the majority of participants understood 'mental health' as 'insanity', 'stress', 'depression', and 'suicide'; nevertheless, a number described mental health symptomatically, while a few believed that mental health problems were caused by witchcraft. Interestingly, poverty, low levels of education, poor job opportunities, a lack of family support, harmful gender norms, intimate partner violence and subsequent relationship breakdowns, and family bereavement all contributed to poor mental health and subsequent entry into sex work. In addition, the consequences of sex work such as sexual risks, and ongoing violence from police and clients, further exacerbated poor mental health.Conclusions: There is a need for both micro- and macro interventions to address poverty and violence against FSWs in Kenya, thereby reducing mental health problems. Addressing violence against women and girls may also reduce entry into sex work. Improving mental health literacy and providing mental health intervention services for 'at-risk' populations such as FSWs should enhance coping strategies and help-seeking efficacy. [ABSTRACT FROM AUTHOR]

Background: Every Newborn Action Plan (ENAP) coverage target 4 necessitates national scale-up of Level-2 Small and Sick Newborn Care (SSNC) (with Continuous Positive Airway Pressure (CPAP)) in 80% of districts by 2025. Routine neonatal inpatient data is important for improving quality of care, targeting equity gaps, and enabling data-driven decision-making at individual, district, and national-levels. Existing neonatal inpatient datasets vary in purpose, size, definitions, and collection processes. We describe the co-design and operationalisation of a core inpatient dataset for use to track outcomes and improve quality of care for small and sick newborns in high-mortality settings. Methods: A three-step systematic framework was used to review, co-design, and operationalise this novel neonatal inpatient dataset in four countries (Malawi, Kenya, Tanzania, and Nigeria) implementing with the Newborn Essential Solutions and Technologies (NEST360) Alliance. Existing global and national datasets were identified, and variables were mapped according to categories. A priori considerations for variable inclusion were determined by clinicians and policymakers from the four African governments by facilitated group discussions. These included prioritising clinical care and newborn outcomes data, a parsimonious variable list, and electronic data entry. The tool was designed and refined by > 40 implementers and policymakers during a multi-stakeholder workshop and online interactions. Results: Identified national and international datasets (n = 6) contained a median of 89 (IQR:61–154) variables, with many relating to research-specific initiatives. Maternal antenatal/intrapartum history was the largest variable category (21, 23.3%). The Neonatal Inpatient Dataset (NID) includes 60 core variables organised in six categories: (1) birth details/maternal history; (2) admission details/identifiers; (3) clinical complications/observations; (4) interventions/investigations; (5) discharge outcomes; and (6) diagnosis/cause-of-death. Categories were informed through the mapping process. The NID has been implemented at 69 neonatal units in four African countries and links to a facility-level quality improvement (QI) dashboard used in real-time by facility staff. Conclusion: The NEST360 NID is a novel, parsimonious tool for use in routine information systems to inform inpatient SSNC quality. Available on the NEST360/United Nations Children's Fund (UNICEF) Implementation Toolkit for SSNC, this adaptable tool enables facility and country-level comparisons to accelerate progress toward ENAP targets. Additional linked modules could include neonatal at-risk follow-up, retinopathy of prematurity, and Level-3 intensive care. [ABSTRACT FROM AUTHOR]

Background: Fathers are often perceived to be mainly responsible for the provision of the family's economic needs. However, past studies have demonstrated that fathers' involvement in parenting has great significance for the child's holistic growth and development. Few studies have investigated fathers' roles in the nurturing care of young children, particularly responsive care and stimulation, in sub-Saharan Africa. The study reported here was carried out as part of a larger study that sought to evaluate the effectiveness of the Moments That Matter (MTM) program in improving the nurturing care of young children in rural communities in Zambia and Kenya. The MTM program uses a parenting empowerment approach to promote bonding and interactions between caregivers and their children within the home, focusing on responsive care, early learning, and security and safety so that children reach their full developmental potential. Trained volunteers facilitated monthly primary caregiver support and learning groups and ECD home visits. Fathers were encouraged to participate in the home visits and to attend some of the group meetings on specific topics. The study reported in this paper aimed to establish the impact of the parenting empowerment program in promoting more gender-equal attitudes and practices on parenting among fathers (who were not the primary caregivers). Methods: Qualitative data were collected at three time points (pre-intervention before the implementation began; mid-intervention after 6 months of implementation; and post-intervention, after 24 months). We conducted focused group discussions with primary caregivers (n = 72) and fathers (n = 24) with children below 3 years. In-depth interviews were conducted with ECD Promoters (n = 43) and faith leaders (= 20). We also conducted key informant interviews with the MTM program implementers (n = 8) and government officials (n = 5) involved in the program implementation. We employed thematic analysis to analyse the qualitative data. Results: The findings showed that the MTM program resulted in improved gender-equal parenting attitudes and practices among mothers/other primary caregivers and fathers. Study participants reported that most fathers spent more time playing and interacting with their children and were more involved in household chores due to their participation in the MTM program. Conclusion: The study findings provide evidence for policy formulation and a guide for implementation of policies that can influence changes in perceived gender roles in parenting. [ABSTRACT FROM AUTHOR]

Background: Health system approaches to improve hypertension control require an effective referral network. A national referral strategy exists in Kenya; however, a number of barriers to referral completion persist. This paper is a baseline assessment of a hypertension referral network for a cluster-randomized trial to improve hypertension control and reduce cardiovascular disease risk.Methods: We used sociometric network analysis to understand the relationships between providers within a network of nine geographic clusters in western Kenya, including primary, secondary, and tertiary care facilities. We conducted a survey which asked providers to nominate individuals and facilities to which they refer patients with controlled and uncontrolled hypertension. Degree centrality measures were used to identify providers in prominent positions, while mixed-effect regression models were used to determine provider characteristics related to the likelihood of receiving referrals. We calculated core-periphery correlation scores (CP) for each cluster (ideal CP score = 1.0).Results: We surveyed 152 providers (physicians, nurses, medical officers, and clinical officers), range 10-36 per cluster. Median number of hypertensive patients seen per month was 40 (range 1-600). While 97% of providers reported referring patients up to a more specialized health facility, only 55% reported referring down to lower level facilities. Individuals were more likely to receive a referral if they had higher level of training, worked at a higher level facility, were male, or had more job experience. CP scores for provider networks range from 0.335 to 0.693, while the CP scores for the facility networks range from 0.707 to 0.949.Conclusions: This analysis highlights several points of weakness in this referral network including cluster variability, poor provider linkages, and the lack of down referrals. Facility networks were stronger than provider networks. These shortcomings represent opportunities to focus interventions to improve referral networks for hypertension.Trial Registration: Trial Registered on ClinicalTrials.gov NCT03543787 , June 1, 2018. [ABSTRACT FROM AUTHOR]

Background: Men's depression, alcohol use, and family problems commonly co-occur to create of cluster of mental health problems. Yet, few treatments exist to address these problems, especially in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel task-shifted intervention to address this cluster of men's mental health problems with a focus on engaging and retaining men in treatment. Methods: The intervention, Learn, Engage, Act, Dedicate (LEAD), is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop LEAD, we engaged in a community-engaged multi-step, collaborative process with local Kenyan stakeholders. LEAD was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated given engagement of men was key for proof of concept. Semi-structured interviews were conducted with participants and analyzed using thematic content analysis. Results: The development process resulted in a weekly 5-session intervention rooted in behavioral activation, motivational interviewing, and masculinity discussion strategies. These approaches were combined and adapted to fit contextually salient constructs, such as the importance of the man as provider, and streamlined for lay providers. Feasibility and acceptability results were promising with high attendance, acceptability of delivery and intervention content, and perceived intervention helpfulness. Conclusion: Results describe an acceptable task-shifted treatment that may engage men in care and addresses a cluster of common mental health problems among men in ways that consider social determinants like masculinity. Findings set the stage for a larger trial. Trial registration ISRCTN, ISRCTN130380278. Registered 7 October 2019—Retrospectively registered, http://www.isrctn.com/ISRCTN13038027 [ABSTRACT FROM AUTHOR]

Background: Undernourished children in low- and middle-income countries remain at elevated risk of death following hospital discharge, even when treated during hospitalisation using World Health Organisation recommended guidelines. The role of community health workers (CHWs) in supporting post-discharge recovery to improve outcomes has not been adequately explored.Methods: This paper draws on qualitative research conducted as part of the Childhood Acute Illnesses and Nutrition (CHAIN) Network in Bangladesh and Kenya. We interviewed family members of 64 acutely ill children admitted across four hospitals (a rural and urban hospital in each country). 27 children had severe wasting or kwashiorkor on admission. Family members were interviewed in their homes soon after discharge, and up to three further times over the following six to fourteen months. These data were supplemented by observations in facilities and homes, key informant interviews with CHWs and policy makers, and a review of relevant guidelines.Results: Guidelines suggest that CHWs could play a role in supporting recovery of undernourished children post-discharge, but the mechanisms to link CHWs into post-discharge support processes are not specified. Few families we interviewed reported any interactions with CHWs post-discharge, especially in Kenya, despite our data suggesting that opportunities for CHWs to assist families post-discharge include providing context sensitive information and education, identification of danger signs, and supporting linkages with community-based services and interventions. Although CHWs are generally present in communities, challenges they face in conducting their roles include unmanageable workloads, few incentives, lack of equipment and supplies and inadequate support from supervisors and some community members.Conclusion: A multi-pronged approach before or on discharge is needed to strengthen linkages between CHWs and children vulnerable to poor outcomes, supported by clear guidance. To encourage scale-ability and cost-effectiveness of interventions, the most vulnerable, high-risk children, should be targeted, including undernourished children. Intervention designs must also take into account existing health worker shortages and training levels, including for CHWs, and how any new tasks or personnel are incorporated into hospital and broader health system hierarchies and systems. Any such interventions will need to be evaluated in carefully designed studies, including tracking for unintended consequences. [ABSTRACT FROM AUTHOR]

Background: In this evaluation, we aim to strengthen Routine Health Information Systems (RHIS) through the digitization of data quality assessment (DQA) processes. We leverage electronic data from the Kenya Health Information System (KHIS) which is based on the District Health Information System version 2 (DHIS2) to perform DQAs at scale. We provide a systematic guide to developing composite data quality scores and use these scores to assess data quality in Kenya. Methods: We evaluated 187 HIV care facilities with electronic medical records across Kenya. Using quarterly, longitudinal KHIS data from January 2011 to June 2018 (total N = 30 quarters), we extracted indicators encompassing general HIV services including services to prevent mother-to-child transmission (PMTCT). We assessed the accuracy (the extent to which data were correct and free of error) of these data using three data-driven composite scores: 1) completeness score; 2) consistency score; and 3) discrepancy score. Completeness refers to the presence of the appropriate amount of data. Consistency refers to uniformity of data across multiple indicators. Discrepancy (measured on a Z-scale) refers to the degree of alignment (or lack thereof) of data with rules that defined the possible valid values for the data. Results: A total of 5,610 unique facility-quarters were extracted from KHIS. The mean completeness score was 61.1% [standard deviation (SD) = 27%]. The mean consistency score was 80% (SD = 16.4%). The mean discrepancy score was 0.07 (SD = 0.22). A strong and positive correlation was identified between the consistency score and discrepancy score (correlation coefficient = 0.77), whereas the correlation of either score with the completeness score was low with a correlation coefficient of -0.12 (with consistency score) and -0.36 (with discrepancy score). General HIV indicators were more complete, but less consistent, and less plausible than PMTCT indicators. Conclusion: We observed a lack of correlation between the completeness score and the other two scores. As such, for a holistic DQA, completeness assessment should be paired with the measurement of either consistency or discrepancy to reflect distinct dimensions of data quality. Given the complexity of the discrepancy score, we recommend the simpler consistency score, since they were highly correlated. Routine use of composite scores on KHIS data could enhance efficiencies in DQA at scale as digitization of health information expands and could be applied to other health sectors beyondHIV clinics. [ABSTRACT FROM AUTHOR]

Background: Current prostate cancer treatments are associated with life-threatening side effects, prompting the search for effective and safer alternatives. Aspilia pluriseta Schweinf. ex Engl. has previously shown anticancer activity in lung and liver cancer cell lines. This study investigated its potential for prostate cancer. Methods: A crude extract of A. pluriseta root was prepared using dichloromethane/methanol (1:1 v/v) and partitioned into hexane, ethyl acetate, and water fractions. The MTT assay was used to assess the antiproliferative activity of the fractions. The active fractions were tested at 6.25–200 µg/ml on human prostate cancer DU-145 cells and non-cancerous Vero E6 cells. Qualitative phytochemical and gas chromatography-mass spectrometry (GC-MS) analyses were conducted to identify chemical compounds. Network pharmacology was employed to predict molecular targets and modes of action of the identified chemical compounds, with subsequent validation through molecular docking and real-time PCR. Results: Active extracts included crude dichloromethane/methanol, hexane, and ethyl acetate fractions, inhibiting DU-145 cell proliferation with IC50 values of 16.94, 20.06, and 24.14 µg/ml, respectively. Selectivity indices were determined to be 6.04 (crude), 3.62 (hexane), and 6.68 (ethyl acetate). Identified phytochemicals comprised phenols, terpenoids, flavonoids, tannins, sterols, and saponins. GC-MS analysis revealed seventy-nine (79) compounds, with seven (7) meeting ideal drug candidate parameters; their hub gene targets included MAPK3, MAPK1, IL6, TP53, ESR1, PTGS2, MMP9, MDM2, AR, and MAP2K1, implicating regulation of PI3K/Akt, MAPK, and p53 signaling pathways as potential modes of action. Core compounds such as 1-heneicosanol, lanosterol, andrographolide, and retinoic acid exhibited strong binding activities, particularly lanosterol with MAPK21 (-9.7 kcal/mol), ESR1 (-8.9 kcal/mol), and MAPK3 (-8.8 kcal/mol). Treatment with A. pluriseta downregulated AR expression and upregulated p53, while also downregulating CDK1 and BCL-2 and upregulating caspase-3. Conclusions: A. pluriseta extracts inhibited DU-145 cell growth without causing cellular toxicity, suggesting great potential for development as an anti-prostate cancer agent. However, further in vitro and in vivo experiments are recommended. [ABSTRACT FROM AUTHOR]

Background: Improving maternal healthcare services is crucial to achieving the Sustainable Development Goal (SDG-3), which aims to reduce maternal mortality and morbidity. There is a consensus among different researchers that proper utilization of maternal healthcare services can improve the reproductive health of women, and this can be achieved by providing Antenatal Care (ANC) during pregnancy, Health Facility Delivery (HFD), and Postnatal Care (PNC) to all pregnant women. The main aim of this study was to investigate the utilization and factors associated with maternal and child healthcare services among women of reproductive age in the pastoralist communities in Kenya. Methods: A cross-sectional survey was conducted among 180 pastoralist women who gave birth in the past two years across ten mobile villages in Marsabit County between 2nd January and 29th February 2019. Three key outcomes were analyzed, whether they attended ANC 4+ visits, delivered at HF, and received PNC. Pearson χ2 test and multivariate logistic regression analysis were conducted by IBM SPSS27.0 following Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The significance level was set at p < 0.05. Results: Of the 180 eligible pastoralist women (mean age 27.44 ± 5.13 years), 92.2% were illiterate, 93.9% were married, 33.3% were in polygamy, and 14.4% had mobile phones. The median commuting distance was 15.00 (10–74) km, 41.7% attended ANC 4+, 33.3% HFD, and 42.8% PNC. Those women residing close (≤ 15 km) to a health facility had a threefold higher ANC 4+ (OR 3.10, 95% CI 1.47–6.53), 2.8-fold higher HFD (OR 2.80, 95% CI 1.34–5.84), and 2.5-fold higher PNC (OR 2.49, 95% CI 1.19–5.22) probability. The likelihood was 30-fold higher for ANC 4+ (OR 29.88, 95% CI 6.68–133.62), 2.5-fold higher for HFD (OR 2.56, 95% CI 0.99–6.63), and 60-fold higher for PNC (OR 60.46, 95% CI 10.43–350.55) in women with mobile phones. A monogamous marriage meant a fivefold higher ANC 4+ (OR 5.17, 95% CI 1.88–14.23), 1.6-fold higher HFD (OR 1.67, 95% CI 0.77–3.62), and a sevenfold higher PNC (OR 7.05, 95% CI 2.35–21.19) likelihood. Hosmer Lemeshow test indicated a good-fitting model for ANC 4+, HFD, and PNC (p = 0.790, p = 0.441, p = 0.937, respectively). Conclusion: In conclusion, the utilization of three essential maternal health services is low. Geographic proximity, monogamous marriage, and possession of mobile phones were significant predictors. Therefore, it is recommended that stakeholders take the initiative to bring this service closer to the pastoralist community by providing mobile health outreach and health education. Plain Language Summary: Attending maternal healthcare clinics is essential to reduce maternal deaths and infections. This can be achieved by receiving antenatal care, delivering at health facilities, and checkups after delivery. We investigated the utilization and factors associated with maternal and child healthcare services among pastoralist women of reproductive age who have given birth in the past two years. Of one hundred and eighty women who participated, most of them were illiterate; the majority were married, of which almost a quarter were in polygamous marriages. This population's uptake of antenatal care, delivery in health facilities, and checkups after delivery is low. This means, that walking distance to the health facility was more than 15 km, almost half of women attended antenatal care and received checkups after delivery but only thirty-three percent delivered at a health facility. Geographic proximity, monogamy, and possession of mobile phones for communication were significant in determining the usage of maternal health care. Living close to a health facility means almost three times more antenatal care, two times more health facility delivery, and checkups after delivery. Women with mobile phones showed twenty-seven more times chances to attend antenatal care, more than four times chances to deliver in a health facility and sixty times more chances of having checkups after delivery. Monogamous marriage showed five times higher odds to attend ANC 4+ visits, and seven times having checkups after delivery. Therefore, it is recommended that stakeholders take the initiative to bring this service closer to the pastoralist community. [ABSTRACT FROM AUTHOR]

Introduction: COVID-19 has become a public health concern globally with increased numbers of cases of the disease and deaths reported daily. The key strategy for the prevention of COVID-19 disease is to enhance mass COVID-19 vaccination. However, mass vaccination faces challenges of hesitation to acceptance of the vaccine in the community. The youth may not be among the vulnerable population to severe COVID-19 disease but are highly susceptible to contracting the virus and spreading it. The aim of the study was to assess COVID-19 vaccine youth behavior intentions and their determinants in Kenya. Methods: The study used a mixed method design, employing a cross-sectional survey and focused group discussions across 47 counties in Urban, Peri-Urban and Rural settings of Kenya. The interviewees were youths aged 18–35, registered in online platforms/peer groups that included Shujaaz, Brck Moja, Aiffluence, Y Act and Heroes for Change. Quantitative data was collected using Google forms. A total of 665 interviews were conducted. Quantitative data was analysed using STATA version 16. In this paper we report quantitative study findings. Results: The findings of the study indicated that only 42% of the youth were ready to be vaccinated, with 52% adopting a wait and see approach to what happens to those who had received the vaccine and 6% totally unwilling to be vaccinated. The determinants of these behavior intentions included: the perceived adverse effects of the vaccine on health, inadequate information about the COVID-19 vaccine, conflicting information about COVID-19 vaccine from the social media, religious implications of the vaccine, impact of education level on understanding of the vaccine, perceived risk of contracting the COVID-19 disease, efficacy of the COVID-19 vaccine, COVID-19 affecting women than men and trust in the ministry of health to lead COVID-19 interventions. Significantly it was found that hesitancy is higher among females, protestants and those with post-secondary education. Lack of information and concerns around vaccine safety and effectiveness were main cause of COVID-19 vaccine hesitancy. Social media was the major source of information contributing to hesitancy. Other contributors to hesitancy included low trust in the MoH and belief that mass vaccination is not helpful. Conclusion: Vaccine hesitancy remains high among the youth but the causes of it are modifiable and health systems need to have evidence based engagements with the youth to reduce vaccine hesitancy. [ABSTRACT FROM AUTHOR]

Background: Prognosis of DKA has improved over time with the availability of evidence-based protocols and resources. However, in Kenya, there are limited resources for the appropriate diagnosis and management of DKA, mostly limited to tertiary-level referral facilities. This study aimed to review the clinical presentation, management, and outcomes of adult patients admitted with DKA and assess differences in these parameters before and during the COVID-19 pandemic. Methods: This was a retrospective study of DKA admissions from January 2017 to December 2021. Patient data were retrieved from the medical records department using ICD-10 codes, and individual details were abstracted on clinical presentation, management, and outcomes of DKA. Comparisons were made between pre-COVID-19 and during COVID-19 durations. Results: 150 patients admitted with DKA were included (n = 48 pre- COVID-19, n = 102 during COVID-19 (n = 23 COVID-19 positive, n = 79 COVID-19 negative)). Median age was 47 years (IQR 33.0, 59.0), median HbA1C was 12.4% [IQR 10.8, 14.6]), and most patients had severe DKA (46%). Most common DKA precipitants were infections (40.7%), newly diagnosed diabetes (33.3%) and missed medication (25.3%). There was a significant difference in pulmonary infections as a DKA precipitant, between the pre- COVID and during COVID-19 pandemic (21.6% during COVID-19 versus 6.3% pre- COVID-19; p = 0.012). Median total insulin dose used was 110.0 units [IQR 76.0, 173.0], and a 100% of patients received basal insulin. Median length of hospital stay was 4.0 days [IQR 3.0, 6.0] and time to DKA resolution was 30.0 h [IQR 24.0, 48.0]. There were 2 deaths (1.3%), none directly attributable to DKA. Severity of DKA significantly differed between pre- COVID-19, COVID-19 positive and COVID-19 negative DKA (52.2% of COVID-19 positive had moderate DKA compared to 26.6% of COVID-19 negative and 22.9% of Pre-COVID-19 (p = 0.006)). Conclusion: Even in developing regions, good outcomes can be achieved with the appropriate facilities for DKA management. Clinician and patient education is necessary to ensure early detection and prompt referral to avoid patients presenting with severe DKA. Exploratory studies are needed to assess reasons for prolonged time to DKA resolution found in this study. [ABSTRACT FROM AUTHOR]

Several studies have reported on the association between parental and childhood psychopathologies. Despite this, little is known about the psychopathologies between parents and children in a non-clinical population. We present such a study, the first in a Kenyan setting in an attempt to fill this gap. The objective of this study was to determine the association between self-rating psychopathology in children, parent-rating psychopathology in their children and self-rating psychopathology in parents in a non-clinical population of children attending schools in Kenya. We identified 113 participants, comprising children and their parents in 10 randomly sampled primary schools in South East Kenya. The children completed the Youth Self-Report (YSR) scale and parents completed the Child Behavior Check List (CBCL) on their children and the Adult Self-Reports (ASR) on themselves. These instruments are part of the Achenbach System of Empirically Based Assessment (ASEBA), developed in the USA for a comprehensive approach to assessing adaptation and maladaptive behavior in children and adolescents. There was back and forth translation of the instruments from English to Swahili and the local dialect, Kamba. Every revision of the English translation was sent to the instrument author who sent back comments until the revised version was in sync with the version developed by the author. We used the ASEBA in-built algorithm for scoring to determine cut-off points for problematic and non-problematic behavior. Correlations, linear regression and independent sample t-test were used to explore these associations. The mean age of the children was 12.7. While there was no significant association between child problems as measured by YSR (self-reported) and parent problems as measured by ASR and CBCL in the overall correlations, there was a significant association when examining specific groups (clinical range vs. non-clinical). Moreover, significant association existed between total problems on YSR and ASR internalizing problems (t=-2.3,p = 0.023), with clinical range having a higher mean than the normal range. In addition, a significant relationship (p < 0.05) was found between psychopathology in children as reported by both parents (CBCL) and psychopathology in parents as self-reported (ASR). Mothers were more likely to report lower syndrome scores of their children as compared to fathers. Our findings indicate discrepancies between children self-rating and parent ratings, suggesting that one cannot manage psychopathology in children without reference to psychopathology in their parents. We suggest broad-based psycho-education to include children and parents to enhance shared awareness of psychopathology and uptake of treatment. [ABSTRACT FROM AUTHOR]

Background: When caring for critically ill patients, health workers often need to 'call-for-help' to get assistance from colleagues in the hospital. Systems are required to facilitate calling-for-help and enable the timely provision of care for critically ill patients. Evidence around calling-for-help systems is mostly from high income countries and the state of calling-for-help in hospitals in Tanzania and Kenya has not been formally studied. This study aims to describe health workers' experiences about calling-for-help when taking care of critically ill patients in hospitals in Tanzania and Kenya. Methods: Ten hospitals across Kenya and Tanzania were visited and in-depth interviews conducted with 30 health workers who had experience of caring for critically ill patients. The interviews were transcribed, translated and the data thematically analyzed. Results: The study identified three thematic areas concerning the systems for calling-for-help when taking care of critically ill patients: 1) Calling-for-help structures: there is lack of functioning structures for calling-for-help; 2) Calling-for-help processes: the calling-for-help processes are innovative and improvised; and 3) Calling-for-help outcomes: the help that is provided is not as requested. Conclusion: Calling-for-help when taking care of a critically ill patient is a necessary life-saving part of care, but health workers in Tanzanian and Kenyan hospitals experience a range of significant challenges. Hospitals lack functioning structures, processes for calling-for-help are improvised and help that is provided is not as requested. These challenges likely cause delays and decrease the quality of care, potentially resulting in unnecessary mortality and morbidity. [ABSTRACT FROM AUTHOR]

Background: Comprehensive sexual reproductive health (SRH) programs for female sex workers (FSW) offering clinical, behavioural, and structural interventions have contributed to declining rates of HIV in this population. However, data on costs and cost drivers is needed to support programs and their donors to better allocate resources, make an investment case for continued funding, and to identify areas of improvement in program design and implementation. We aimed to estimate the annual per-FSW costs of comprehensive services for a standalone FSW program in Kenya. Methods: We implemented a top–bottom and activity-based costing study of comprehensive FSW services at two drop-in centres (DICs), Mtwapa and Kilifi town, in Kilifi County, Kenya. Service costs were obtained from routinely collected patient data during FSW scheduled and unscheduled visits using Kenyan Ministry of Health records. Costing data were from the program and organization's expenditure reports, cross checked against bank documents and supported by information from in-depth interviews. Data were collected retrospectively for the fiscal year 2019. We obtained approval from the AMREF Research Ethics Committee (AMREF-ESRC P862/2020). Results: In 2019, the unit cost of comprehensive services was 105.93 USD per FSW per year, roughly equivalent to 10,593 Kenya shillings. Costs were higher at Mtwapa DICs compared to Kilifi town DIC; 121.90 USD and 89.90 USD respectively. HIV counselling and testing cost 63.90 USD per person, PrEP was 34.20 USD and family planning was 9.93 USD. Of the total costs, staff salaries accounted for about 60%. Adjusted for inflation, costs in 2024 would be approximately 146.60. Conclusion: Programs should strive to maximize the number of FSW served to benefit from economies of scale. Given that personnel costs contribute most to the unit costs, programs should consider alternative designs which reduce personnel and other costs. [ABSTRACT FROM AUTHOR]

Introduction: The United Nations established the Sustainable Development Goals (SDGs) in 2015 to enhance global development. In this study, we examine an SDG indicator: the percentage of women aged 15–49 whose family planning needs are met by modern contraception (mDFPS). We evaluate both the factors influencing its coverage and its progress since 2015. Methods: We used nationally representative surveys data (Demographic and Health Surveys (DHS) and Performance Monitoring for Action (PMA)) from Ethiopia, Kenya, and Nigeria. We assessed predictors of mDFPS. We also computed mDFPS coverage across countries and subnational areas, assessing coverage changes from the SDGs onset to the most recent period, using a Bayesian model-based geostatistical approach. We assessed whether the subnational areas exceeded the minimum recommended WHO mDFPS coverage of 75%. Results: Varied individual and community-level determinants emerged, highlighting the countries' uniqueness. Factors such as being part of a female-headed household, and low household wealth, lowered the odds of mDFPS, while rural-residence had low odds only in Ethiopia and Nigeria. The results indicate mDFPS stagnation in most administrative areas across the three countries. Geographic disparities persisted over time, favouring affluent regions. The predicted posterior proportion of mDFPS and exceedance probability (EP) for WHO target for Ethiopia was 39.85% (95% CI: [4.51, 83.01], EP = 0.08) in 2016 and 46.28% (95% CI: [7.15, 85.99], EP = 0.13) in 2019. In Kenya, the adjusted predicted proportion for 2014 was 30.19% (95% CI: [2.59, 80.24], EP = 0.06) and 44.16% (95%CI: [9.35, 80.24], EP = 0.13) in 2022. In Nigeria, the predicted posterior proportion of mDFPS was 17.91% (95% CI: [1.24, 61.29], EP = 0.00) in 2013, and it was 23.08% (95% CI: [1.80, 56.24], EP = 0.00) in 2018. None of the sub-national areas in Ethiopia and Nigeria exceeded the WHO target. While 9 out of 47 counties in Kenya in 2022 exceeded the WHO mDFPS target. Conclusion: The study unveils demographic, geographic, and socioeconomic mDFPS disparities, signalling progress and stagnation across administrative areas. The findings offer policymakers and governments insights into targeting interventions for enhanced mDFPS coverage. Context-specific strategies can address local needs, aiding SDG attainment. [ABSTRACT FROM AUTHOR]

Background: The emergence of COVID-19 precipitated containment policies (e.g., lockdowns, school closures, etc.). These policies disrupted healthcare, potentially eroding gains for Sustainable Development Goals including for neonatal mortality. Our analysis aimed to evaluate indirect effects of COVID-19 containment policies on neonatal admissions and mortality in 67 neonatal units across Kenya, Malawi, Nigeria, and Tanzania between January 2019 and December 2021. Methods: The Oxford Stringency Index was applied to quantify COVID-19 policy stringency over time for Kenya, Malawi, Nigeria, and Tanzania. Stringency increased markedly between March and April 2020 for these four countries (although less so in Tanzania), therefore defining the point of interruption. We used March as the primary interruption month, with April for sensitivity analysis. Additional sensitivity analysis excluded data for March and April 2020, modelled the index as a continuous exposure, and examined models for each country. To evaluate changes in neonatal admissions and mortality based on this interruption period, a mixed effects segmented regression was applied. The unit of analysis was the neonatal unit (n = 67), with a total of 266,741 neonatal admissions (January 2019 to December 2021). Results: Admission to neonatal units decreased by 15% overall from February to March 2020, with half of the 67 neonatal units showing a decline in admissions. Of the 34 neonatal units with a decline in admissions, 19 (28%) had a significant decrease of ≥ 20%. The month-to-month decrease in admissions was approximately 2% on average from March 2020 to December 2021. Despite the decline in admissions, we found no significant changes in overall inpatient neonatal mortality. The three sensitivity analyses provided consistent findings. Conclusion: COVID-19 containment measures had an impact on neonatal admissions, but no significant change in overall inpatient neonatal mortality was detected. Additional qualitative research in these facilities has explored possible reasons. Strengthening healthcare systems to endure unexpected events, such as pandemics, is critical in continuing progress towards achieving Sustainable Development Goals, including reducing neonatal deaths to less than 12 per 1000 live births by 2030. [ABSTRACT FROM AUTHOR]

Background: Stress during pregnancy can lead to adverse maternal and infant health outcomes through epigenetic changes in the hypothalamic–pituitary–adrenal axis. Among farmers in low-income countries, one important stressor is food insecurity, which can be reduced using hermetic storage bags. This study aimed to determine, for the first time, whether a hermetic storage bag intervention during pregnancy positively affects maternal and infant DNA methylation of the hypothalamic–pituitary–adrenal axis-related genes FKBP5 and NR3C1. We further analyzed whether anthropometrics, stress, and mental health were associated with DNA methylation. Methods: This study was part of a larger matched-pair randomized controlled trial focusing on the impact of improved on-farm storage on food security, poverty, and net income of smallholder farming households. A total of N = 149 mothers were recruited by telephone and invited to attend a study appointment at health facilities in Kakamega County, Western Kenya, with their infants in April or May 2021. During the appointment, anthropometric measurements were taken, questionnaires on stress and mental health were administered, and saliva samples were collected. Logistic and multiple linear regression were used to examine the effect of the intervention and related measures on DNA methylation. Results: Mothers in the intervention group showed higher mean NR3C1 methylation levels than those in the control group, corrected for multiple testing. Maternal postpartum body mass index was positively associated with infant NR3C1 CpG3 DNA methylation. The more stressful life events a mother had experienced in the previous 12 months (including during pregnancy), the lower her FKBP5 CpG3 methylation levels. Conclusions: Food insecurity and stressful life events during pregnancy seem to exert significant effects on maternal DNA methylation. While these stressors did not appear to impact infant DNA methylation in the present study, maternal postpartum body mass index was significantly related to infant methylation. These findings suggest that while infants may be protected from excessive maternal glucocorticoids by placental barrier activity, maternal metabolic status is still reflected in their epigenetic make-up. Trial registration This study was part of a larger matched-pair randomized controlled trial on the impact of improved on-farm crop storage on welfare, nutrition, and human health. Registration can be found in the American Economic Association (AEA) RCT Registry, RCT ID: AEARCTR-0005845. [ABSTRACT FROM AUTHOR]

Indoor residual spraying (IRS) and insecticide-treated nets (ITNs) are the main methods used to control mosquito populations for malaria prevention. The efficacy of these strategies is threatened by the spread of insecticide resistance (IR), limiting the success of malaria control. Studies of the genetic evolution leading to insecticide resistance could enable the identification of molecular markers that can be used for IR surveillance and an improved understanding of the molecular mechanisms associated with IR. This study used a weighted gene co-expression network analysis (WGCNA) algorithm, a systems biology approach, to identify genes with similar co-expression patterns (modules) and hub genes that are potential molecular markers for insecticide resistance surveillance in Kenya and Benin. A total of 20 and 26 gene co-expression modules were identified via average linkage hierarchical clustering from Anopheles arabiensis and An. gambiae, respectively, and hub genes (highly connected genes) were identified within each module. Three specific genes stood out: serine protease, E3 ubiquitin-protein ligase, and cuticular proteins, which were top hub genes in both species and could serve as potential markers and targets for monitoring IR in these malaria vectors. In addition to the identified markers, we explored molecular mechanisms using enrichment maps that revealed a complex process involving multiple steps, from odorant binding and neuronal signaling to cellular responses, immune modulation, cellular metabolism, and gene regulation. Incorporation of these dynamics into the development of new insecticides and the tracking of insecticide resistance could improve the sustainable and cost-effective deployment of interventions. [ABSTRACT FROM AUTHOR]

Background: Reliance on praziquantel for the treatment and control of schistosomiasis is likely to facilitate the emergence of drug resistance. Combination therapy targeting adult and juvenile schistosome worms is urgently needed to improve praziquantel efficacy and delay the potential development of drug resistance. We assessed the efficacy and safety of single-dose praziquantel combined with single-dose artesunate plus sulfalene-pyrimethamine in the treatment of Kenyan children with schistosomiasis. Methods: This was an open-label, randomised clinical trial involving 426 school-aged children (7–15 years old) diagnosed with Schistosoma mansoni (by Kato-Katz) or S. haematobium (by urine filtration). They were randomly assigned (1:1:1) to receive a single dose of praziquantel (40 mg/kg), a single dose of artesunate plus sulfalene-pyrimethamine (12 mg/kg artesunate) or combination therapy using a single dose of praziquantel (40 mg/kg) combined with a single dose of artesunate plus sulfalene-pyrimethamine (12 mg/kg artesunate). The primary outcome was cure and egg reduction rates at 6 weeks post-treatment in the available case population. Adverse events were assessed within 3 h after treatment. Results: Of the 426 children enrolled, 135 received praziquantel, 150 received artesunate plus sulfalene-pyrimethamine, and 141 received combination therapy. Outcome data were available for 348 (81.7%) children. For S. mansoni-infected children (n = 335), the cure rates were 75.6%, 60.7%, and 77.8%, and the egg reduction rates were 80.1%, 85.0%, and 88.4% for praziquantel, artesunate plus sulfalene-pyrimethamine, and combination therapy, respectively. For S. haematobium-infected children (n = 145), the corresponding cure rates were 81.4%, 71.1%, and 82.2%, and the egg reduction rates were 95.6%, 97.1%, and 97.7%, respectively. Seventy-one (16.7%) children reported mild-intensity adverse events. The drugs were well tolerated and no serious adverse events were reported. Conclusions: A single oral dose of praziquantel combined with artesunate plus sulfalene-pyrimethamine cured a high proportion of children with S. haematobium but did not significantly improve the treatment efficacy for either urinary or intestinal schistosomiasis. Sequential administration of praziquantel and artesunate plus sulfalene-pyrimethamine may enhance the efficacy and safety outcomes. [ABSTRACT FROM AUTHOR]

Background: Exclusive breastfeeding (EBF) in the first six months remains low globally, despite known benefits of lower morbidity and mortality among breastfed infants. It is important to understand factors associated with breastfeeding to support optimal breastfeeding practices, particularly in settings with a high burden of HIV. Methods: We analyzed data from a population-level survey of mother-infant pairs attending 6-week or 9-month immunizations at 141 clinics across Kenya. Primary outcomes included maternal report of (1) EBF at 6-week visit, defined as currently feeding the infant breast milk only, (2) EBF for the first 6-months of life, defined as breastfeeding or feeding the infant breast milk only with no introduction of other liquids or solid foods until 6 months, and (3) continued breastfeeding with complementary feeding at 9-months. Correlates of breastfeeding practices were assessed using generalized Poisson regression models accounting for facility-level clustering. Results: Among 1662 mothers at 6-weeks, nearly all self-reported breastfeeding of whom 93% were EBF. Among 1180 mothers at 9-months, 99% had ever breastfed, 94% were currently breastfeeding and 73% reported 6-month EBF. At 6-weeks, younger age (< 25 years) (adjusted Prevalence Ratio (aPR) 0.96; 95% CI 0.93, 0.99), lower education (aPR 0.96; 95% CI 0.93, 0.99) and recent infant illness (aPR 0.97; 95% CI 0.94, 1.00) were associated with lower EBF prevalence while women living with HIV (WLWH) had higher EBF prevalence (aPR 1.06; 95% CI 1.02, 1.10) than women without HIV. 6-month EBF prevalence was 26% higher in WLWH (aPR 1.26; 95% CI 1.15, 1.35) than women without HIV, 14% lower in women reporting mild or above depressive symptoms (aPR 0.86; 95% CI 0.76, 0.99) than those with none or minimal depressive symptoms, and 15% lower in women with versus without history of intimate partner violence (aPR 0.85; 95% CI 0.74, 0.98). At 9-months, WLWH had a lower prevalence of continued breastfeeding with complementary feeding (aPR 0.73; 95% CI 0.64, 0.84) than women without HIV. Conclusion: WLWH had higher EBF prevalence in the first 6-months, but lower prevalence of continued breastfeeding at 9-months. Strategies to support EBF and continued breastfeeding beyond 6-months postpartum, particularly among WLWH, are needed. [ABSTRACT FROM AUTHOR]

Background: Addressing attitudes is central to achieving sexual and reproductive health and rights (SRHR) and Agenda 2030. We aimed to develop a comprehensive index to measure attitudinal support for SRHR, expanding opportunities for global trend analyses and tailored interventions. Methods: We designed a new module capturing attitudes towards different dimensions of SRHR, collected via the nationally representative World Values Survey in Ethiopia, Kenya, and Zimbabwe during 2020–2021 (n = 3,711). We used exploratory factor analysis of 58 items to identify sub-scales and an overall index. Adjusted regression models were used to evaluate the index according to sociodemographic characteristics, stratified by country and sex. Results: A 23-item, five-factor solution was identified and used to construct sub-indices reflecting support for: (1) sexual and reproductive rights, (2) neighborhood sexual safety, (3) gender-equitable relationships, (4) equitable masculinity norms, and (5) SRHR interventions. These five sub-indices performed well across countries and socioeconomic subgroups and were combined into a comprehensive "SRHR Support Index", standardized on a 1–100 scale (mean = 39.19, SD = 15.27, Cronbach's alpha = 0.80) with higher values indicating more support for SRHR. Mean values were highest in Kenya (45.48, SD = 16.78) followed by Ethiopia (40.2, SD = 13.63), and lowest in Zimbabwe (32.65, SD = 13.77), with no differences by sex. Higher education and being single were associated with more support, except in Ethiopia. Younger age and urban residence correlated with more support among males only. Conclusion: The SRHR Support Index has the potential to broaden SRHR attitude research from a comprehensive perspective – addressing the need for a common measure to track progress over time. Plain language summary: Sexual and reproductive health and rights (SRHR) are becoming increasingly polarized worldwide, but researchers have previously not been able to fully measure what people think about SRHR. More research about this topic is needed to address discriminatory norms and advance SRHR for all. In this study, we added new questions to the World Values Survey collected in Ethiopia, Kenya, and Zimbabwe during 2020–2021. We used statistical methods to develop an index capturing to what extent individuals' attitudes were supportive of SRHR. This index, which we call the SRHR Support Index, included 23 survey questions reflecting support for five related dimensions of SRHR. Those dimensions were (1) sexual and reproductive rights, (2) neighborhood sexual safety, (3) gender-equitable relationships, (4) equitable masculinity norms, and (5) SRHR interventions. We found that individuals in Kenya were more supportive of SRHR, followed by Ethiopia and then Zimbabwe. There were no differences in support of SRHR between men and women, but individuals who were single and those with higher education were more supportive of SRHR, except in Ethiopia. Younger men living in urban areas were also more supportive. Our SRHR Support Index enables researchers, policymakers, and others to measure attitudes to SRHR in countries across the world and over time, based on new data from the World Values Survey that are readily available online. If combined with other sources of data, researchers can also investigate how people's support of SRHR is linked to, for example, health and policy. [ABSTRACT FROM AUTHOR]

Background: In Kenya, 65% of sexually active unmarried women use modern contraceptives, a population at increased risk of HIV acquisition compared to other populations. Anchoring HIV prevention services, including pre-exposure prophylaxis (PrEP), to trusted contraceptive delivery settings offers opportunities to efficiently reach this important population. In Kenya, almost half (40%) of women accessing contraception services do so outside traditional healthcare facilities, such as retail pharmacies. Thus, integrating PrEP services into retail pharmacies may increase options for reaching adolescent girls and young women (AGYW) who could benefit from PrEP. Efforts are underway to define care pathways for pharmacy-delivered PrEP services in Kenya, including unsupported and supported models with nurse navigators. Methods: The AGYW Pharmacy PrEP study is an unblinded 2-arm cluster-randomized controlled trial in Kisumu, Kenya. The objective is to determine the effect that unsupported versus supported pharmacy-delivered PrEP services has on PrEP initiation, persistence, and adherence among AGYW seeking contraception. Twenty retail pharmacies offering pharmacy provider-led PrEP delivery will be randomized 1:1 to either receive or not receive a nurse navigator to support PrEP delivery. Eligible AGYW (n = 1900 total, n = 950/arm) will be ≥ 15 years old, purchasing a method of contraception at the pharmacy. Trained pharmacy provider will offer eligible AGYW either daily oral PrEP or the monthly DPV vaginal ring. The primary trial outcomes are PrEP initiation (use of PrEP at 1 month), persistence (use of PrEP at 10 months), and adherence (quantified by levels of TFV or DPV in hair samples). Additionally, several secondary (STI incidence, PrEP method selection, predictors of PrEP adherence) and exploratory outcomes (HIV incidence, quality of care, contraceptive method mix) will be explored. Discussion: We hypothesize pharmacy-delivered PrEP services supported with nurse navigator, versus delivered by pharmacy providers alone, will improve PrEP outcomes among AGYW seeking contraception. Our results will help policy makers better understand how to potentially implement this novel differentiated service model for PrEP and prime pharmacies for the delivery of new PrEP agents in the pipeline (e.g., long-acting injectables and multi-purpose technologies). The study was initiated on May 13, 2023, and is expected to be completed by February 2025. Trial Registration: ClinicalTrials.gov (NCT05467306), with registration on July 20, 2022. [ABSTRACT FROM AUTHOR]

Background: Cervical cancer remains the second most common cause of death in women and poses a growing public health challenge. It is urgent to increase cervical cancer screening rates in Kenya as per the 2018 Kenya National Cancer Screening Guidelines. Addressing access to care may serve as a target to achieve this goal; however, how individual dimensions of access to care are associated with the utilization of cervical cancer screening services in low- and middle-income countries, including Kenya, remains unclear. This study aimed to examine how different aspects of access to care (affordability, availability, geographical access, and social influence) were associated with cervical cancer screening among Kenyan women of reproductive age. Methods: This cross-sectional study used data from the 2014 Kenya Demographic and Health Survey and the 2010 Kenya Service Provision Assessment. The final sample included 5,563 women aged 25–49 years. Logistic regression models were used to examine the association between different aspects of access to care and the uptake of cervical cancer screening. Results: Factors such as being in the poorest wealth quintile, lacking health insurance, having difficulty obtaining funds for treatment (affordability), limited availability of screening services at nearby facilities (availability), living in rural areas (geographical access), and having healthcare decisions made solely by husbands/partners or others (social influence) were associated with a decreased likelihood of the uptake of cervical cancer screening. Conclusions: Increasing health insurance coverage, enhancing the availability of screening services at health facilities, expanding mobile screening health facilities in rural areas, and empowering women to make their own healthcare decisions are crucial steps for increasing cervical cancer screening uptake in Kenya. [ABSTRACT FROM AUTHOR]

Background: Self-monitoring of glucose is an essential component of type 1 diabetes (T1D) management. In recent years, continuous glucose monitoring (CGM) has provided an alternative to daily fingerstick testing for the optimisation of insulin dosing and general glucose management in people with T1D. While studies have been conducted to evaluate the impact of CGM on clinical outcomes in the US, Europe and Australia, there are limited data available for low- and middle-income countries (LMICs) and further empirical evidence is needed to inform policy decision around their use in these countries. Methods: This trial was designed as a pragmatic, parallel-group, open-label, multicentre, three-arm, randomised (1:1:1) controlled trial of continuous or periodic CGM device use versus standard of care in people with T1D in South Africa and Kenya. The primary objective of this trial will be to assess the impact of continuous or periodic CGM device use on glycaemic control as measured by change from baseline glycosylated haemoglobin (HbA1c). Additional assessments will include clinical outcomes (glucose variation, time in/below/above range), safety (adverse events, hospitalisations), quality of life (EQ-5D, T1D distress score, Glucose Monitoring Satisfaction Survey for T1D), and health economic measures (incremental cost-effectiveness ratios, quality adjusted life years). Discussion: This trial aims to address the substantial evidence gap on the impact of CGM device use on clinical outcomes in LMICs, specifically South Africa and Kenya. The trial results will provide evidence to inform policy and treatment decisions in these countries. Trial registration: NCT05944731 (Kenya), July 6, 2023; NCT05944718 (South Africa), July 13, 2023. [ABSTRACT FROM AUTHOR]