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Background:Despite the widespread application of the community health strategy (CHS) in Kenya and evidence of its effectiveness in reducing health outcomes at the household level, data from Kakamega County, of which Lurambi sub-county is part of, still showed that skilled birth delivery was at 47% against the national estimateof 62% and a target of 90%. However, there was limited evidence on the level of CHS implementation and its association with the uptake of skilled delivery.Methods:The study employed a cross-sectional analytic design. A structured validated community unit (CU) scorecard and a household questionnaire were used to collect quantitative data from the CUs through Community Health Extension Workers (CHEWs) and at the household level through mothers with children below 1 year. A random sample of 436 mothers from all the 38 Community Units (CUs) was included. CU functionality was assessed using 17 binary indicators (scored as 1 for a positive response, 0 otherwise) and total scores were expressed as percentages. Fully functional CUs scored ≥80% and semi-functional CU scored >50 to

The strategic aim of universal health coverage (UHC) is to ensure that everyone can use health services they need without risk of financial impoverishment. Linda mama (Taking care of the mother) initiative focuses on the most vulnerable women, newborns and infants in offering free health services. Financial risk protection is one element in the package of measures that provides overall social protection, as well as protection against severe financial difficulties in the event of pregnancy, childbirth, neonatal and perinatal health care for mothers and their children. Purpose of study was to find out the extent of awareness, and involvement among managers, service providers and consumers of “Linda mama” supported services and benefits of the initiative from the perspectives of consumers, providers and managers Methods We carried out cross sectional study in four sub counties in western Kenya: Rachuonyo East, Nyando, Nyakach, and Alego Usonga. We used qualitative techniques to collect data from purposively selected knowledge rich individuals, managers, service providers and service consumers. Findings From the perspectives of managers, service providers and consumers of the “Linda Mama” scheme emerge concepts, principles and pathways of successful health interventions. Managers and service providers were well aware of the initiative and were involved in it. Participation in “Linda Mama” seemed to be more prominent among managers and service providers. Routine household visits by community health volunteers to sensitize mothers and community engagement was core to the initiative. The managers and providers of services displayed profound awareness of how requiring identification cards and telephone numbers had the potential to undermine equity by excluding those in greater need of care such as under-age pregnant adolescents.Maternity and mother child health services improved as a result of the funds received by health facilities. “Linda Mama” reimbursements helped to purchase drug and reduced workload in the facility by hiring extra hands. Conclusion The initiative seems to have influenced attitudes on health facility delivery through: Partnership among key stakeholders and highlighting the need for enhanced partnership with the communities. It enhanced the capacity of health facilities to deliver high quality comprehensive, essential care package and easing economic burden.

Background: Globally, the COVID-19 pandemic has had broad consequences on health outcomes with significant morbidity and mortality. Rural health systems face more challenges in the availability of a workforce, adequate infrastructure and equipment. We completed a baseline assessment of the health system in Siaya at the beginning stages of the COVID-19 pandemic and designed an integrated intervention to maximize the prevention of COVID-19 cases and optimize case management at community and health facility levels. Methods: In partnership with the Ministry of Health (MOH), we trained health care workers in COVID-19 infection prevention, control, and case management at community and health facility levels. We strengthened the diagnostic and monitoring capacity of healthcare workers with thermometers and pulse oximeters, and we trained clinicians in basic critical care. In addition, we addressed leadership skills and psychological first aid. Youth were included during implementation to promote the uptake of digital tools by health care workers. Primary outcome measures were the total number of confirmed COVID-19 cases and the total number of COVID-19 related deaths in Siaya. Secondary outcome measures were related to hand hygiene practices and use of essential health services; specifically, the incidence of diarrheal diseases and respiratory infections not related to COVID-19, and the number of facility based deliveries. Findings: The incidence of confirmed COVID-19 cases was low compared to neighboring counties (with risk reduction ratios up to 7.8, CI 6.85-8.89). The total number of COVID-19 cases was 266 and the total number of COVID-19 related deaths was 7 at the time of the analysis in November 2020. The incidences of diarrheal diseases and respiratory infections (URTIs) not related to COVID-19 were lower in 2020 compared to 2019 and use of essential maternal health services was maintained during the COVID-19 response: specifically, the mean number of diarrheal cases was 3’033 in 2020 and 4’795 in 2019 (p=0.001); the mean number of URTIs not related to COVID-19 was 19’683 in 2020 and 27’567 in 2019 (p=0.015); and the mean number of facility based deliveries was 2’402 in 2020 and 2’322 in 2019 (p=0.2). Interpretation: An integrated and comprehensive intervention with capacity building at community and health facility levels results in the reduction of COVID-19 infections, and the reduction in the number of diarrheal and non COVID-19 related respiratory infections. Furthermore, the intervention resulted in the maintained use of maternal health services during the COVID-19 response. Trial Registration: Clinicaltrials.gov NCT04501458 Funding Statement: Wellcome Trust Declaration of Interests: None to declare. Ethics Approval Statement: Ethical review approvals received from the University of Nairobi Ethics Review Committee and Jaramogi Oginga Odinga Teaching and Referral Hospital Ethics Review Committee (approval number IERC/JOOTR/219/20)

Globally, the number of COVID-19 infections is approaching 63 million; more than 1 million individuals have lost their lives. In Kenya, the number of infections has surpassed 80,000 and 1469 people have lost their lives. In Kenya, the community health strategy has been used to deliver essential health services since 2007. Furthermore, the population in Kenya is young (the median age is 21 years old) and Kenya is recognized as a technology hub in the East African region. Community-based health care, youth, and technology, are assets within the Kenyan context that can be leveraged to respond to the COVID-19 pandemic with concurrent strengthening of the critical care capacity at the health system level. This is a quasi-experimental study with quantitative and qualitative methods of data collection to complete a baseline assessment of community health unit and health facility service readiness in the study site of Siaya County in western Kenya. Following the baseline assessment, service ready community health units and health facilities with oxygen capacity will form intervention groups. At the community level, the intervention will consist of training youth, community health assistants and community health workers in screening, case detection, prevention, management and referral of COVID-19 cases with maintenance of essential health services. The community intervention will be enhanced by youth and use of digital tools. At the health facility level, the intervention will consist of training health care workers in basic critical care and caring for severe COVID-19 patients with maintenance of essential health services. The primary outcome measure will be mortality related to COVID-19 infection both at community and health facility levels. This study would be the first study to evaluate the effectiveness of an integrated approach in preparing for and implementing a robust pandemic response. Registration: ClinicalTrials.gov ID NCT04501458; registered on 6 August 2020.

In Kenya, Maternal Mortality Rate remains high at 488 deaths per 100,000 live births and the scenario is even worse in rural areas. Community Health Workers (CHWs) are integral in community mobilization to reduce maternal mortality, which is far more dependent on specific facility based interventions. This study's main objective was to determine effectiveness of CHWs in promotion of maternal health services in Butere District (intervention site) and Mumias District (non intervention site) in Kenya. This was a quantitative nested study with quasi-experimental study design for the secondary data collected in 2011. Statistical Package for Social Sciences 16 was used for data analysis. Inferential Statistics were used to estimate effectiveness of CHWs. There was a significant increase in the proportion of women who had Focused Antenatal Care (FANC) from 53% to 66% and Health Facility delivery from 35% to 48% and a moderate positive relationship between these indicators in Butere District. A woman in Butere was three times likely to deliver in a Health Facility with higher odds as compared to a woman in Mumias. CHWs are effective in promotion of maternal health services and their utilization should be up scaled especially in rural population with poor health seeking behaviours.

Information should form the backbone of decisions that effect change in all areas. It is therefore paramount in health, for information to be used for decision making. In effect this will bring about equity in health resource allocation. The development of comprehensive community based health information systems is increasingly becoming important for measuring and improving the quality of health services. Many developing countries including Kenya have made efforts to strengthen their national health information systems to provide information for decision-making in managing health care services. The purpose of this paper is to explore how data collected at the community level is utilised by various stakeholders within the community in order to produce actionable information for decision making. This was a descriptive, cross sectional study. The qualitative aspects of data collection involved key informant interviews and focused group discussions with the health service providers; potential health services users, and community health workers. Findings indicated that strong local ownership of data developed at the community. The main perspectives of service providers included joint ownership of health intervention programs at the community level, the community owned their health and aimed to improve it and community health workers to champion on health and development issues to bring about change.

Background Many low and middle income countries have developed community health strategies involving lay health workers, to complement and strengthen public health services. This study explores variations in costing parameters pertinent to deployment of community health volunteers across different contexts outlining considerations for costing program scale-up. Methods The study used quasi experimental study design and employed both quantitative and qualitative methods to explore community health unit implementation activities and costs and compare costs across purposively selected sites that differed socially, economically and ecologically. Data were collected from November 2010 to December 2013 through key informant interviews and focus group discussions. We interviewed 16 key informants (eight District community health strategy focal persons, eight frontline field officers), and eight focus group discussions (four with community health volunteers and four with community health committee) and 560 sets of monthly cost data. Cost data were tabulated using Microsoft Excel. Qualitative data were transcribed and coded using a content analysis framework. Results Four critical elements: attrition rates for community health volunteers, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits, drove cost variations across the three sites. Attrition rate was highest in peri-urban site where population is highly mobile and lowest in nomadic site. More households were covered by community health workers in the peri-urban area making per capita costs considerably less than in the nomadic settings where long distances had to be covered to reach sparsely distributed households. Livelihood opportunity costs for Community Health Volunteers were highest in nomadic setting, while peri-urban ones reported substantial employability benefits resulting from training. Social opportunity benefits were highest in rural site. Conclusions Results show that costs of implementing community health strategy varied due to different area contextual factors in Kenya. This study identified four critical elements that drive cost variations: attrition rates for community health volunteers, geography and population density, livelihood opportunity costs and benefits, and social opportunity benefits. Health programme managers and policy-makers need to pay attention to details of contextual factors in costing for effective implementation of community health strategies. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4140-z) contains supplementary material, which is available to authorized users.

Cost-effectiveness analysis is a type of economic evaluation used to determine the best use of money available for medical care for informed decision making. This study carried out a cost-effectiveness analysis of using Community Health Workers (CHWs) as an integral part of Community Health Strategy implementation to promote uptake of maternal health services in Butere District, rural western Kenya. The main objective was to determine incremental cost-effectiveness ratio of utilization of CHWs in promotion of maternal health services in Butere District (intervention site) in selected Community Health Units. The costs and consequences of promoting maternal health services at the community level with CHWs were identified, measured, valued while using a quasi experimental study design. Annual cost incurred in utilizing CHWs to promote maternal health services in Butere District in 2011 was US$ 30,124, effectiveness of utilization of CHWs was 1,205 yearly DALY averted. The incremental cost-effectiveness ratio was US$25 per yearly DALY averted.Utilization of CHWs to promote maternal health services is a cost effective strategy in Butere District. Community Health Strategy should be up scaled as it is a cost effective intervention to promote uptake of maternal health services especially in the rural population where health seeking behaviours are low.

We studied the effect of using Motivational Interviewing Intervention (MII) on health facility delivery and newborn care practices among pregnant women receiving Care of the Mother and Newborn at Home (CNH) visits by Community Health Workers (CHWs). Near-Term women who had received at least one CHW home visit, were randomly assigned to one session of MII (intervention) or no MII (Control). Fifty five (55%) of intervention women, compared to 35% of control women delivered in health facilities. Intervention women also understood the need to breastfeed exclusively for 6 months better than controls (P = 0.000), and had a p-value of 0.07 for breastfeeding within one hour after birth. We concluded in the context of CHW Home visit program, adding may improve perinatal care.

Background The enormous impact of HIV on communities and health services in Sub-Saharan Africa and the Caribbean has especially affected nurses, who comprise the largest proportion of the health workforce in low- and middle-income countries (LMICs). Strengthening action-based leadership for and by nurses is a means to improve the uptake of evidence-informed practices for HIV care. Methods A prospective quasi-experimental study in Jamaica, Kenya, Uganda and South Africa examined the impact of establishing multi-stakeholder leadership hubs on evidence-informed HIV care practices. Hub members were engaged through a participatory action research (PAR) approach. Three intervention districts were purposefully selected in each country, and three control districts were chosen in Jamaica, Kenya and Uganda. WHO level 3, 4 and 5 health care institutions and their employed nurses were randomly sampled. Self-administered, validated instruments measured clinical practices (reports of self and peers), quality assurance, work place policies and stigma at baseline and follow-up. Standardised average scores ranging from 0 to 1 were computed for clinical practices, quality assurance and work place policies. Stigma scores were summarised as 0 (no reports) versus 1 (one or more reports). Pre-post differences in outcomes between intervention and control groups were compared using the Mantel Haenszel chi-square for dichotomised stigma scores, and independent t tests for other measures. For South Africa, which had no control group, pre-post differences were compared using a Pearson chi-square and independent t test. Multivariate analysis was completed for Jamaica and Kenya. Hub members in all countries self-assessed changes in their capacity at follow-up; these were examined using a paired t test. Results Response rates among health care institutions were 90.2 and 80.4 % at baseline and follow-up, respectively. Results were mixed. There were small but statistically significant pre-post, intervention versus control district improvements in workplace policies and quality assurance in Jamaica, but these were primarily due to a decline in scores in the control group. There were modest improvements in clinical practices, workplace policies and quality assurance in South Africa (pre-post) (clinical practices of self—pre 0.67 (95 % CI, 0.62, 0.72) versus post 0.78 (95 % CI, 0.73–0.82), p = 0.002; workplace policies—pre 0.82 (95 % CI, 0.70, 0.85) versus post 0.87 (95 % CI, 0.84, 0.90), p = 0.001; quality assurance—pre 0.72 (95 % CI, 0.67, 0.77) versus post 0.84 (95 % CI, 0.80, 0.88)). There were statistically significant improvements in scores for nurses stigmatising patients (Jamaica reports of not stigmatising—pre-post intervention 33.9 versus 62.4 %, pre-post control 54.7 versus 64.4 %, p = 0.002—and Kenya pre-post intervention 35 versus 51.6 %, pre-post control 34.2 versus 47.8 %, p = 0.006) and for nurses being stigmatised (Kenya reports of no stigmatisation—pre-post intervention 23 versus 37.3 %, pre-post control 15.4 versus 27 %, p = 0.004). Multivariate results for Kenya and Jamaica were non-significant. Twelve hubs were established; 11 were active at follow-up. Hub members (n = 34) reported significant improvements in their capacity to address care gaps. Conclusions Leadership hubs, comprising nurses and other stakeholders committed to change and provided with capacity building can collectively identify issues and act on strategies that may improve practice and policy. Overall, hubs did not provide the necessary force to improve the uptake of evidence-informed HIV care in their districts. If hubs are to succeed, they must be integrated within district health authorities and become part of formal, legal organisations that can regularise and sustain them. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0478-3) contains supplementary material, which is available to authorized users.

Background: Children from nomadic pastoralist communities might not receive all the recommended doses of vaccines at age-appropriate times due to limited access to immunization services. Skipped, delayed or missed vaccination doses result in under vaccination which in turn make children vulnerable to preventable diseases. The purpose of present study was to establish completion timeliness and under-vaccination of all the recommended childhood vaccinations in a nomadic pastoralist community.Methods: Authors used a cluster sampling technique to identify children aged 0 to 24 months at the household level. Vaccine completion was the accumulation of the required number of doses by infants irrespective of the timing. Timeliness was vaccines administered within the recommended age range. Under vaccination was the sum total of days a delayed vaccine was given after the recommended age range.Results: Completion of all individual antigens did not meet the target of 90%. The mean number of days a child remained under-vaccinated in days was: OPV0, 20 days; BCG, 39 days; measles vaccine, 47 days; PVC3, 121 days; pentavalent, 117 days, and rotavirus, 103 days. Approximately 42% were severely under-vaccinated for more than six months. Vaccine-specific under-vaccination of more than six months was: pentavalent 3, 20%; PCV 3, 14%; OPV 3, 9.5%; BCG, 3%, and measles vaccine 20%. Overall children remained under-vaccinated for 185 days.Conclusions: A significant proportion of children remained under vaccinated for extended periods leaving them at risk during a vulnerable period of their life.

The main objective of the study was to assess the utilisation of prevention of mother-to-child transmission (PMTCT) services among mothers registered for services at Nyanza Provincial Hospital in Kenya. A crosssectional exploratory study was conducted, using both quantitative and qualitative approaches to collect primary and secondary data. The study population was 133 clients registered for PMTCT services. The study revealed that 52.4% of clients received PMTCT information at the health facility without prior knowledge about intervention, 96% waited for more than 90 minutes, and 89% took less than 10 minutes for post-test counselling. Knowledge of MTCT and PMTCT was inadequate even after counselling, as participants could not recall the information divulged during counselling. In addition, 80% of clients did not present for follow-up counselling irrespective of HIV status, and 95%, did not disclose positive HIV status to spouses/relatives for fear of stigma, discrimination and violence. Inadequate counselling services delivered to clients affected service utilisation, in that significant dropout occurred at the stages of HIV result (31.5%), enrollment (53.6%), and delivery (80.7%). Reasons for dropout included fear of positive HIV result, chronic illness, stigma and discrimination, unsupportive spouse and inability to pay for the services.

Africa is behind in all Millennium Development Goals (MDGs) indicators and are unlikely to achieve them by 2015. This calls for innovations to accelerate progress. Community Based Volunteerism (CBV) is one such innovation. Volunteers are people who work on behalf of others without pay or tangible gain, (Decker 2003). Volunteerism exists in all cultures and religions. It enhances solidarity and reciprocity among people. It is valued as a means of responding to human resource needs, most urgent in Africa because of limited resources (Smith, 1998b). This paper presents results of a study on the contribution of CBVs to efforts towards the MDGs in Nyakach District, Western Kenya. The study was cross sectional, descriptive and exploratory in design. The objective was to describe the contribution of volunteers in services relevant to the achievement of the MDGs in the study area, using quantitative and qualitative data collection methods.Results: Services rendered by volunteers were relevant to MDGs 1, 2, 4, 5, 6, and 7. Majority of volunteers spent 6-10 hours in a week offering voluntary services. This is equivalent to $20 per person per month, for 40 volunteers serving 5,000 people. Thus they contribute USD 9,600 per year, which is 4% budget of $170,000 the population at recommended $34 per capita per year. Majority of volunteers (70%) in study area had served for more than five years, indicating a reasonable retention rate. Conclusion: The study concluded that volunteers make substantial contribution to efforts, and budget towards the MDG relevant services, and are vital if MDGs are to be achieved. Due to the budgetary strains and human resource crisis, volunteerism presents an alternative of providing services. It should become a way of life for every citizen, as it is the only way most governments could progress towards the MDGs.

Background The appropriate use of anti-malarial drugs determines therapeutic efficacy and the emergence and spread of drug-resistant malaria. Strategies for improving drug compliance require accurate information about current practices at the consumer level. This is to ascertain that the currently applied new combination therapy to malaria treatment will achieve sustained cure rates and protection against parasite resistance. Therefore, this cross-sectional study was designed to determine knowledge and behaviour of the consumers in households (n = 397) in peri-urban location in a malaria holoendemic region of western Kenya. Methods The knowledge and behaviour associated with anti-malarial use were evaluated. Using clusters, a questionnaire was administered to a particular household member who had the most recent malaria episode (within Results Consumers' knowledge on dosage and duration/frequency demonstrated that only 29.4% used the correct artemisinin-based combination therapy (ACT) dosage. Most respondents who used quinine identified the correct duration of use (96.4%) since its administration was entirely at health facilities. To assess behaviours during use of anti-malarial drugs, respondents were stratified into those who took drugs with prescription (39.4%) and without prescription (61.6%). For those without prescription, the reasons given were; procedure of acquisition less costly (39.0%), took same drug for similar symptoms (23.0%), not satisfied with health services (15.5%), neighbour/friend/relative previously taken the same drug (12.5%) and health institution was far from their location (10%). Conclusion Majority of consumers in the study area were knowledgeable on the symptoms of malaria. In addition, majority acquired ineffective anti-malarial drugs for treatment and reported sub-optimal treatment regimens with the currently recommended drugs. Furthermore, behaviours which constrain the successful up-scaling of ACT were common, creating a challenge in the desire to turn efficacy to effectiveness of the combination therapy programme. It will be important to direct and focus interventions in creating awareness on the importance of using recommended drugs to lessen the use of less efficacious anti-malarials. In addition, the consumers need to be educated on the importance of drug adherence in such areas to reduce the emergence and spread of drug-resistant malaria.

Despite focused health policies and a reform agenda Kenya has not made a breakthrough in improving the situations of households entrapped in the vicious cycle of poverty and ill health. Consequently, Great Lakes University of Kisumu developed and tested a model for facilitating improvement in the performance of the District Health System (DHS) and, hence, the health status of poor households served. The model consisted of evidence-based dialogue between the communities and service providers, working with service consumers as partners in improving service delivery and outcomes. The study was undertaken in partnership with the Ministry of Health (MOH) and the Communities. The model was tested by introducing it in selected sites and carrying out health facility and household sample surveys at the beginning of the intervention and two years later in both intervention and control sites. Among the key improvements noted were: governance and management of the health system; service delivery and health outcomes in terms of immunisation coverage; usage of insecticide treated nets; and utilisation of skilled attendance at childbirth. Based on the results, the Kenyan MOH adopted the model as a strategy for the implementation of the Kenya Essential Package for Health countrywide. The University developed the implementation guidelines and training materials for rolling out the strategy countrywide.

Summary Background There is little information on country trends in the complete distributions of children's anthropometric status, which are needed to assess all levels of mild to severe undernutrition. We aimed to estimate trends in the distributions of children's anthropometric status and assess progress towards the Millennium Development Goal 1 (MDG 1) target of halving the prevalence of weight-for-age Z score (WAZ) below −2 between 1990 and 2015 or reaching a prevalence of 2·3% or lower. Methods We collated population-representative data on height-for-age Z score (HAZ) and WAZ calculated with the 2006 WHO child growth standards. Our data sources were health and nutrition surveys, summary statistics from the WHO Global Database on Child Growth and Malnutrition, and summary statistics from reports of other national and international agencies. We used a Bayesian hierarchical mixture model to estimate Z-score distributions. We quantified the uncertainty of our estimates, assessed their validity, compared their performance to alternative models, and assessed sensitivity to key modelling choices. Findings In developing countries, mean HAZ improved from −1·86 (95% uncertainty interval −2·01 to −1·72) in 1985 to −1·16 (–1·29 to −1·04) in 2011; mean WAZ improved from −1·31 (–1·41 to −1·20) to −0·84 (–0·93 to −0·74). Over this period, prevalences of moderate-and-severe stunting declined from 47·2% (44·0 to 50·3) to 29·9% (27·1 to 32·9) and underweight from 30·1% (26·7 to 33·3) to 19·4% (16·5 to 22·2). The largest absolute improvements were in Asia and the largest relative reductions in prevalence in southern and tropical Latin America. Anthropometric status worsened in sub-Saharan Africa until the late 1990s and improved thereafter. In 2011, 314 (296 to 331) million children younger than 5 years were mildly, moderately, or severely stunted and 258 (240 to 274) million were mildly, moderately, or severely underweight. Developing countries as a whole have less than a 5% chance of meeting the MDG 1 target; but 61 of these 141 countries have a 50–100% chance. Interpretation Macroeconomic shocks, structural adjustment, and trade policy reforms in the 1980s and 1990s might have been responsible for worsening child nutritional status in sub-Saharan Africa. Further progress in the improvement of children's growth and nutrition needs equitable economic growth and investment in pro-poor food and primary care programmes, especially relevant in the context of the global economic crisis. Funding The Bill & Melinda Gates Foundation and the UK Medical Research Council.

A pragmatic cluster randomised controlled trial. Participants: Clusters were primary health care clinics on the Ministry of Health list. Clients were eligible if they were aged 18 and over. Interventions: Two members of staff from each intervention clinic received the training programme. Clients in both intervention and control clinics subsequently received normal routine care from their health workers. Objective: To examine the impact of a mental health inservice training on routine detection of mental disorder in the clinics and on client outcomes. Outcomes: The primary outcome was the rate of accurate routine clinic detection of mental disorder and the secondary outcome was client recovery over a twelve week follow up period. Randomisation: clinics were randomised to intervention and control groups using a table of random numbers. Blinding: researchers and clients were blind to group assignment. Numbers randomised: 49 and 50 clinics were assigned to intervention and control groups respectively. 12 GHQ positive clients per clinic were identified for follow up. Numbers analysed: 468 and 478 clients were followed up for three months in intervention and control groups respectively. Outcome: At twelve weeks after training of the intervention group, the rate of accurate routine clinic detection of mental disorder was greater than 0 in 5% versus 0% of the intervention and control groups respectively, in both the intention to treat analysis (p = 0.50) and the per protocol analysis (p =0.50). Standardised effect sizes for client improvement were 0.34 (95% CI = (0.01,0.68)) for the General Health Questionnaire, 0.39 ((95% CI = (0.22, 0.61)) for the EQ and 0.49 (95% CI = (0.11,0.87)) for WHODAS (using ITT analysis); and 0.43 (95% CI = (0.09,0.76)) for the GHQ, 0.44 (95% CI = (0.22,0.65)) for the EQ and 0.58 (95% CI = (0.18,0.97)) for WHODAS (using per protocol analysis). Harms: None identified. The training programme did not result in significantly improved recorded diagnostic rates of mental disorders in the routine clinic consultation register, but did have significant effects on patient outcomes in routine clinical practice. International Standard Randomised Controlled Trial Number Register ISRCTN53515024 .

Background Despite focused health policies and reform agenda, Kenya has challenges in improving households’ situation in poverty and ill health; interventions to address the Millennium Development Goals in maternal and child health, such as focused antenatal care and immunization of children, are yet to achieve success. Research has shown that addressing the demand side is critical in improving health outcomes. This paper presents a model for health systems performance improvement using a strategy that bridges the interface between the community and the health system. Methods The study employed quasi-experimental design, using pre- and post-intervention surveys in intervention and control sites. The intervention was the implementation of all components of the Kenyan Community Health Strategy, guided by policy. The two year intervention (2011 and 2012) saw the strategy introduced to selected district health management teams, service providers, and communities through a series of three-day training workshops that were held three times during the intervention period. Baseline and endline surveys were conducted in intervention and control sites where community unit assessment was undertaken to determine the status of health service utilization before and after the intervention. A community health unit consists of 1000 households, a population of about 5000, served by trained community health workers, each supporting about 20 to 50 households. Data was organized and analyzed using Excel, SPSS, Epi info, Stata Cal, and SAS. Results A number of health indicators, such as health facility delivery, antenatal care, water treatment, latrine use, and insecticide treated nets, improved in the intervention sites compared to non-interventions sites. The difference between intervention and control sites was statistically significant (p