Socio-economic and structural barriers in Newcastle disease vaccines uptake by smallholder women farmers in Southeastern Kenya.

The exploitation of the full benefits of chicken rearing by smallholder farmers in Sub-Saharan (SSA) Africa is often impeded by poultry diseases which is compounded by limited uptake of vaccination. We interrogate the structural and socioeconomic factors associated with vaccine uptake by women farmers in Southeastern Kenya. A mixed methods design with a convergent approach for comparison of quantitative and qualitative findings was adopted. This involved the administration of a cross section survey to 1274 households, conduct of 23 Focus Groups Discussions (FGDs) and 7 Key informant Interviews (KIIs). Chi Square and t-tests were used to identify factors associated with vaccine uptake. Logistics regression analysis was used to identify the influence of the structural and socioeconomic barriers to vaccine uptake. Findings indicate that having knowledge of Newcastle disease (ND) vaccine increases the likelihood of farmers vaccinating their chicken by up to 32.5 times (95% CI [8.46-124.53]) with a 1 unit increase in vaccine knowledge. A farmer's distance away from the nearest ND vaccine vendor was found to reduce the likelihood of farmers vaccinating their chicken by up to 4% (95% CI ([0.93-1.00]) for every 1-kilometre increase in distance away from the vaccine vendors. Farmers who considered vaccines to be effective in preventing ND were 39 times (95% CI [6.23-239.8]) more likely to use ND vaccines than those that did not consider ND vaccine to effective. We surmise that a comprehensive approach that addresses increased ND vaccine knowledge among smallholder women chicken farmers, proximity of ND vendors, as well as cost holds the potential for regular and increased ND vaccine uptake.

Women's empowerment and intra-household gender dynamics and practices around sheep and goat production in South East Kenya.

Small ruminant production facets like decision-making, ownership, labour allocation, access to- and control over assets are gendered. This study investigates intra-household gender dynamics and practices around sheep and goat production among smallholder farmers in South East region of Kenya. A quantitative study was conducted on 358 dual-headed (married) households to generate gender-disaggregated data on ownership, decision-making and labour allocation around small ruminant production. Qualitative data was collected through focused group discussions to bring out the community perspectives. From the findings, the average number of small ruminants owned by the households as reported by men was slightly higher than women. The average number of small ruminants solely owned by men was significantly higher than by women. Men reported a relatively higher number of jointly owned small ruminants compared to women. More women than men reported that they could give as a gift, sell-off and slaughter jointly owned small ruminants without consulting their spouses. Small ruminants were considered the most important livestock asset in supporting a household's livelihood by relatively more women than men. Men had more decision-making autonomy over jointly owned small ruminants compared to women. Production tasks around small ruminants such as feeding, watering, selling milk and cleaning housing structures were mostly performed by the women. Qualitative data identified men as the de facto owners of small ruminants with a higher power position in making the important production decisions. The study offers three implications on the design of livestock interventions to empower women, the interventions should ensure that; 1) women are not just owners of livestock assets but also share power and decision-making rights in all aspects of production, 2) production labour is shared equitably between men and women and, 3) women access benefits from livestock production even when animals are owned by men.

From policy to practice: An assessment of biosecurity practices in cattle, sheep and goats production, marketing and slaughter in Baringo County, Kenya.

Globally, biosecurity is instrumental in prevention, control and management of livestock diseases and protection of human health. It is defined, prescribed, adopted and enforced through global, regional and national frameworks, laws, policies and strategies. There is more biosecurity practice research conducted in developed countries than developing ones. Consequently, the gap between the ideals recommended in biosecurity frameworks and what is practical in under-resourced rural settings is poorly understood. This anthropological study sought to assess adoption of biosecurity practices across a cattle, sheep and goat value chains continuum to demonstrate where risks lie. The cross-sectional mixed-methods study took place in Baringo County, Kenya. Qualitatively, it utilized 26 focus group discussions with community members and 10 observational interviews with slaughter facility workers. Quantitatively, it included a household survey with 560 community members and a separate survey with 231 livestock traders. Results show that producers, traders and slaughter facility workers did observe some biosecurity practices but not others due but not limited to personal preference, limitations in veterinary service delivery and enforcement of some biosecurity measures, and lack of requisite infrastructure. The study concludes that the implementation of biosecurity measures in rural settings is more complex than envisioned in biosecurity policies and frameworks. It can be hampered by resource limitations, poor enforcement, and contestations with cultural practices. The study recommends that further studies on willingness to adopt biosecurity measures targeting community members in under-resourced settings be conducted to identify possible critical points of intervention at county and national levels.

Institutional-level drivers of gender-inequitable scientific career progression in sub-Saharan Africa.

BACKGROUND: This study sought to determine how institutional environments, including values, policies, and their implementation, shape inequities in scientific career progression for women and men, and their disadvantages in relation to their multiple social identities in sub-Saharan Africa (SSA). The findings are drawn from a wider research study that was aimed at gaining an in-depth understanding of the barriers and enablers of gender-equitable scientific career progression for researchers in SSA. This was nested within the context of the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme-a health-based scientific research capacity-strengthening initiative. METHODS: The study adopted an exploratory qualitative cross-sectional study design. In-depth interviews (IDIs) with trainees/research fellows at various career stages supported and/or affiliated to three purposively selected DELTAS Africa Research Consortia were the main method of data collection. In addition, key informant interviews (KIIs) with consortia research leaders/directors, co-investigators, and the consortia management team were also conducted to corroborate information gathered from the IDIs, and also to provide additional insights on the drivers of intersectional gender-inequitable career progression. In total, 58 IDIs (32 female and 26 male) and 20 KIIs (4 female and 16 male) were conducted. The interviews were carried out in English between May and December 2018. The data were analysed inductively based on emergent themes. RESULTS: Three interrelated themes were identified: first, characterization of the institutional environment as highly complex and competitive with regard to advancement opportunities and funding structure; second, inequitable access to support systems within institutions; third, informal rules-everyday experiences of negative practices and culture at the workplace, characterized by negative stereotypical attitudes, gender biases, sexual harassment, and bullying and intimidation. CONCLUSIONS: We contend that understanding and addressing the social power relations at the meso-institutional environment and macro-level contexts could benefit career progression of both female and male researchers by improving work culture and practices, resource allocation, and better rules and policies, thus fostering positive avenues for systemic and structural policy changes.

An intersectional gender analysis of familial and socio-cultural drivers of inequitable scientific career progression of researchers in Sub-Saharan Africa.

BACKGROUND: Sub-Saharan Africa (SSA) suffers from a dearth of concrete information on the causes of women's under-representation in scientific research workforce particularly at higher levels compared with the wealth of information that exists in the global north. The goal of this study was to illuminate familial and socio-cultural drivers that contribute to intersectional gender inequities in scientific career progression in SSA to inform strategies that could promote career equity for African scientific researchers. METHODS: This study was nested within the context of 'Developing Excellence in Leadership, Training and Science in Africa' (DELTAS Africa)-a health-based scientific research capacity strengthening initiative. It adopted an exploratory qualitative cross-sectional study design. In-depth interviews were conducted among 58 (32 Female and 26 Male) trainees/research fellows at various career stages, affiliated to three purposively selected African Research Consortia. The interviews were conducted between May and December 2018 in English. The data were analysed inductively based on emergent themes. RESULTS: The study participants were nationals of thirteen SSA countries. More female than male participants had young children. Four themes were identified. They illustrate women's and men's characterisation of the normative career pathway and progression requirements which calls for significant 'time' commitments (theme 1), and how social power relations of gender within the family and wider society shapes their participation in scientific research activities (theme 2). This culminates in researchers'' differential experiences of navigating between the 'two different lives'-family and career, and the resultant implications for their career progression and personal well-being (theme 3). Women researchers made different and conscious trade-offs for navigating the 'two different lives' by utilising various metaphors such as the 'biological clock and career clock', the 'glass ball and rubber ball', and the concept of 'sacrifice' (theme 4). CONCLUSIONS: This study is the first of its kind to demonstrate how intersectional gender analysis through use of qualitative research methods may provide novel insights into the hidden familial and socio-cultural drivers of gender inequitable scientific research career progression. It offers important policy and practice measures and approaches for fostering career equity for women and men scientists within research capacity strengthening initiatives in SSA.

Larval species diversity, seasonal occurrence and larval habitat preference of mosquitoes transmitting Rift Valley fever and malaria in Baringo County, Kenya.

BACKGROUND: Baseline information that is essential for determining the areas to target with larval control includes estimates of vector diversity and larval habitat preferences. Due to a lack of such information in Baringo County, Kenya, this study assessed species diversity and larval habitat preference of potential mosquito vectors of Rift Valley fever (RVF) and malaria. METHODS: Mosquito larvae were sampled from nine types of larval habitats and were identified morphologically. Species diversity was estimated by the Shannon's diversity index while larval habitat preference by RVF and malaria vectors was determined by ANOVA. RESULTS: A total of 7724 immature mosquitoes comprising 17 species belonging to four genera, namely Anopheles, Culex, Aedes and Mansonia, were identified. Among the 17 species, three Anopheles species are responsible for malaria transmission: An. gambiae (s.l.), An. funestus (s.l.) and An. pharoensis. Rift Valley fever vectors included Mansonia spp. and Culex spp. The highest Shannon's diversity index was observed during the cold dry season (H = 2.487) and in the highland zone (H = 2.539) while the lowest diversity was recorded during the long rain season (H = 2.354) and in the riverine zone (H = 2.085). Ditches had the highest mean number of Anopheles larvae (16.6 larvae per sample) followed by swamp (12.4) and seasonal riverbed (10.7). Water pit and water pan had low mean numbers of Anopheles larvae (1.4 and 1.8, respectively) but relatively high mean numbers of culicines (16.9 and 13.7, respectively). Concrete tank was the least sampled type of habitat but had highest mean number of culicine larvae (333.7 l) followed distantly by water spring (38.9) and swamp (23.5). Overall, larval habitats were significantly different in terms of larval density (F(8,334) = 2.090, P = 0.036). CONCLUSIONS: To our knowledge, the present study reports culicine larval species diversity in Baringo for the first time and the most preferred habitats were concrete tanks, water springs and swamps. Habitats preferred by Anopheles were mainly riverbed pools, ditches and swamps. Environmental management targeting the habitats most preferred by potential vectors can be part of integrated vector control in Baringo, especially during dry seasons.

A grounded theory of regaining normalcy and reintegration of women with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula is a reproductive health problem causing immense suffering to 1% of women in Kenya that is formed as sequelae of prolonged obstructed labour. It is a chronic illness that disrupts women lives, causing stigma and isolation. Fistula illness often introduces a crisis in women's life begetting feelings of shame and serious disruption to their social, psychological, physical and economic lives, in addition to dealing with moral and hygiene challenges. Currently, women undergo free of charge surgery at vesicovaginal fistula (VVF) camps held in national referral hospitals and dedicated fistula centres generating a significant pool of women who have undergone surgery and are ready to regain normal lives. OBJECTIVE: The purpose of this study was to explore experiences of women immersing back into communities and their return to normalcy after surgery in three VVF repair centres in Kenya. We set out to answer the question: what strategies improve obstetric fistula patients' reintegration process? METHODS: We used grounded theory methodology to capture the reintegration and regaining normalcy experiences of women after surgery. Narrative interviews were held with 60 women during community follow-up visits in their homes after 6-19 months postoperatively. Grounded theory processes of theoretical sampling, repeated measurement; constant comparative coding in three stage open, axial and selective coding; memoing, reflexivity and positionality were applied. Emergent themes helped generate a grounded theory of reintegration and regaining normalcy for fistula patients. RESULTS: To regain normal healthy lives, women respond to fistula illness by seeking surgery.. After surgery, four possible outcomes of the reintegration process present; reintegration fully or partially back into their previous communities, not reintegrated or newly integrating away from previous social and family settings. The reintegration statuses point to the diversity outcomes of care for fistula patients and the necessity of tailoring treatment programs to cater for individual patient needs. CONCLUSION: The emerging substantive theory on the process of reintegration and regaining normalcy for fistula patients is presented. The study findings have implications for fistula care, training and policy regarding women's health, suggesting a model of care that encompasses physical, social, economic and psychological aspects of care after surgery and discharge.

Sensitivity of vegetation to climate variability and its implications for malaria risk in Baringo, Kenya.

The global increase in vector borne diseases has been linked to climate change. Seasonal vegetation changes are known to influence disease vector population. However, the relationship is more theoretical than quantitatively defined. There is a growing demand for understanding and prediction of climate sensitive vector borne disease risks especially in regions where meteorological data are lacking. This study aimed at analyzing and quantitatively assessing the seasonal and year-to-year association between climatic factors (rainfall and temperature) and vegetation cover, and its implications for malaria risks in Baringo County, Kenya. Remotely sensed temperature, rainfall, and vegetation data for the period 2004-2015 were used. Poisson regression was used to model the association between malaria cases and climatic and environmental factors for the period 2009-2012, this being the period for which all datasets overlapped. A strong positive relationship was observed between the Normalized Difference Vegetation Index (NDVI) and monthly total precipitation. There was a strong negative relationship between NDVI and minimum temperature. The total monthly rainfall (between 94 -181mm), average monthly minimum temperatures (between 16-21°C) and mean monthly NDVI values lower than 0.35 were significantly associated with malaria incidence rates. Results suggests that a combination of climatic and vegetation greenness thresholds need to be met for malaria incidence to be significantly increased in the county. Planning for malaria control can therefore be enhanced by incorporating these factors in malaria risk mapping.

Malaria vector abundance is associated with house structures in Baringo County, Kenya.

Malaria, a major cause of morbidity and mortality, is the most prevalent vector borne disease in Baringo County; a region which has varied house designs in arid and semi-arid areas. This study investigated the association between house structures and indoor-malaria vector abundance in Baringo County. The density of malaria vectors in houses with open eaves was higher than that for houses with closed eaves. Grass thatched roof houses had higher density of malaria vectors than corrugated iron sheet roofs. Similarly, mud walled houses had higher vector density than other wall types. Houses in the riverine zone were significantly associated with malaria vector abundance (p<0.000) possibly due to more varied house structures. In Kamnarok village within riverine zone, a house made of grass thatched roof and mud wall but raised on stilts with domestic animals (sheep/goats) kept at the lower level had lower mosquito density (5.8 per collection) than ordinary houses made of same materials but at ground level (30.5 mosquitoes per collection), suggestive of a change in behavior of mosquito feeding and resting. House modifications such as screening of eaves, improvement of construction material and building stilted houses can be incorporated in the integrated vector management (IVM) strategy to complement insecticide treated bed nets and indoor residual spray to reduce indoor malaria vector density.

"We don't want our clothes to smell smoke": changing malaria control practices and opportunities for integrated community-based management in Baringo, Kenya.

BACKGROUND: The decline in global malaria cases is attributed to intensified utilization of primary vector control interventions and artemisinin-based combination therapies (ACTs). These strategies are inadequate in many rural areas, thus adopting locally appropriate integrated malaria control strategies is imperative in these heterogeneous settings. This study aimed at investigating trends and local knowledge on malaria and to develop a framework for malaria control for communities in Baringo, Kenya. METHODS: Clinical malaria cases obtained from four health facilities in the riverine and lowland zones were used to analyse malaria trends for the 2005-2014 period. A mixed method approach integrating eight focus group discussions, 12 key informant interviews, 300 survey questionnaires and two stakeholders' consultative forums were used to assess local knowledge on malaria risk and develop a framework for malaria reduction. RESULTS: Malaria cases increased significantly during the 2005-2014 period (tau = 0.352; p < 0.001) in the riverine zone. March, April, May, June and October showed significant increases compared to other months. Misconceptions about the cause and mode of malaria transmission existed. Gender-segregated outdoor occupation such as social drinking, farm activities, herding, and circumcision events increased the risk of mosquito bites. A positive relationship occurred between education level and opinion on exposure to malaria risk after dusk (χ2 = 2.70, p < 0.05). There was over-reliance on bed nets, yet only 68% (204/300) of respondents owned at least one net. Complementary malaria control measures were under-utilized, with 90% of respondents denying having used either sprays, repellents or burnt cow dung or plant leaves over the last one year before the study was conducted. Baraza, radios, and mobile phone messages were identified as effective media for malaria information exchange. Supplementary strategies identified included unblocking canals, clearing Prosopis bushes, and use of community volunteers and school clubs to promote social behaviour change. CONCLUSIONS: The knowledge gap on malaria transmission should be addressed to minimize the impacts and enhance uptake of appropriate malaria management mechanisms. Implementing community-based framework can support significant reductions in malaria prevalence by minimizing both indoor and outdoor malaria transmissions.

The socio-economic burden of human African trypanosomiasis and the coping strategies of households in the South Western Kenya foci.

INTRODUCTION: Human African Trypanosomiasis (HAT), a disease caused by protozoan parasites transmitted by tsetse flies, is an important neglected tropical disease endemic in remote regions of sub-Saharan Africa. Although the determination of the burden of HAT has been based on incidence, mortality and morbidity rates, the true burden of HAT goes beyond these metrics. This study sought to establish the socio-economic burden that households with HAT faced and the coping strategies they employed to deal with the increased burden. MATERIALS AND METHODS: A mixed methods approach was used and data were obtained through: review of hospital records; structured interviews (152); key informant interviews (11); case narratives (12) and focus group discussions (15) with participants drawn from sleeping sickness patients in the south western HAT foci in Kenya. Quantitative data were analysed using descriptive statistics while qualitative data was analysed based on emerging themes. RESULTS: Socio-economic impacts included, disruption of daily activities, food insecurity, neglect of homestead, poor academic performance/school drop-outs and death. Delayed diagnosis of HAT caused 93% of the affected households to experience an increase in financial expenditure (ranging from US$ 60-170) in seeking treatment. Out of these, 81.5% experienced difficulties in raising money for treatment resorting to various ways of raising it. The coping strategies employed to deal with the increased financial expenditure included: sale of agricultural produce (64%); seeking assistance from family and friends (54%); sale/lease of family assets (22%); seeking credit (22%) and use of personal savings (17%). CONCLUSION AND RECOMMENDATION: Coping strategies outlined in this study impacted negatively on the affected households leading to further food insecurity and impoverishment. Calculation of the true burden of disease needs to go beyond incidence, mortality and morbidity rates to capture socio-economic variables entailed in seeking treatment and coping strategies of HAT affected households.

'I stayed with my illness': a grounded theory study of health seeking behaviour and treatment pathways of patients with obstetric fistula in Kenya.

BACKGROUND: Obstetric fistula classic symptoms of faecal and urinary incontinence cause women to live with social stigma, isolation, psychological trauma and lose their source of livelihoods. There is a paucity of studies on the health seeking behaviour trajectories of women with fistula illness although women live with the illness for decades before surgery. We set out to establish the complete picture of women's health seeking behaviour using qualitative research. We sought to answer the question: what patterns of health seeking do women with obstetric fistula display in their quest for healing? METHODS: We used grounded theory methodology to analyse data from narratives of women during inpatient stay after fistula surgery in 3 hospitals in Kenya. Emergent themes contributed to generation of substantive theory and a conceptual framework on the health seeking behaviour of fistula patients. RESULTS: We recruited 121 participants aged 17 to 62 years whose treatment pathways are presented. Participants delayed health seeking, living with fistula illness after their first encounter with unresponsive hospitals. The health seeking trajectory is characterized by long episodes of staying home with illness for decades and consulting multiple actors. Staying with fistula illness entailed health seeking through seven key actions of staying home, trying home remedies, consulting with private health care providers, Non-Governmental organisations, prayer, traditional medicine and formal hospitals and clinics. Long treatment trajectories at hospital resulted from multiple hospital visits and surgeries. Seeking treatment at hospital is the most popular step for most women after recognizing fistula symptoms. CONCLUSIONS: We conclude that the formal health system is not responsive to women's needs during fistula illness. Women suffer an illness with a chronic trajectory and seek alternative forms of care that are not ideally placed to treat fistula illness. The results suggest that a robust health system be provided with expertise and facilities to treat obstetric fistula to shorten women's treatment pathways.

"We do not bury dead livestock like human beings": Community behaviors and risk of Rift Valley Fever virus infection in Baringo County, Kenya.

BACKGROUND: Rift Valley Fever (RVF), is a viral zoonotic disease transmitted by Aedes and Culex mosquitoes. In Kenya, its occurrence is associated with increased rains. In Baringo County, RVF was first reported in 2006-2007 resulting in 85 human cases and 5 human deaths, besides livestock losses and livelihood disruptions. This study sought to investigate the county's current RVF risk status. METHODOLOGY AND PRINCIPAL FINDINGS: A cross-sectional study on the knowledge, attitudes and practices of RVF was conducted through a mixed methods approach utilizing a questionnaire survey (n = 560) and 26 focus group discussions (n = 231). Results indicate that study participants had little knowledge of RVF causes, its signs and symptoms and transmission mechanisms to humans and livestock. However, most of them indicated that a person could be infected with zoonotic diseases through consumption of meat (79.2%) and milk (73.7%) or contact with blood (40%) from sick animals. There was a statistically significant relationship between being male and milking sick animals, consumption of milk from sick animals, consuming raw or cooked blood, slaughtering sick livestock or dead animals for consumption (all at p≤0.001), and handling sick livestock with bare hands (p = 0.025) with more men than women engaging in the risky practices. Only a few respondents relied on trained personnel or local experts to inspect meat for safety of consumption every time they slaughtered an animal at home. Sick livestock were treated using conventional and herbal medicines often without consulting veterinary officers. CONCLUSIONS: Communities in Baringo County engage in behaviour that may increase their risk to RVF infections during an outbreak. The authors recommend community education to improve their response during outbreaks.

Effect of climatic variability on malaria trends in Baringo County, Kenya.

BACKGROUND: Malaria transmission in arid and semi-arid regions of Kenya such as Baringo County, is seasonal and often influenced by climatic factors. Unravelling the relationship between climate variables and malaria transmission dynamics is therefore instrumental in developing effective malaria control strategies. The main aim of this study was to describe the effects of variability of rainfall, maximum temperature and vegetation indices on seasonal trends of malaria in selected health facilities within Baringo County, Kenya. METHODS: Climate variables sourced from the International Research Institute (IRI)/Lamont-Doherty Earth Observatory (LDEO) climate database and malaria cases reported in 10 health facilities spread across four ecological zones (riverine, lowland, mid-altitude and highland) between 2004 and 2014 were subjected to a time series analysis. A negative binomial regression model with lagged climate variables was used to model long-term monthly malaria cases. The seasonal Mann-Kendall trend test was then used to detect overall monotonic trends in malaria cases. RESULTS: Malaria cases increased significantly in the highland and midland zones over the study period. Changes in malaria prevalence corresponded to variations in rainfall and maximum temperature. Rainfall at a time lag of 2 months resulted in an increase in malaria transmission across the four zones while an increase in temperature at time lags of 0 and 1 month resulted in an increase in malaria cases in the riverine and highland zones, respectively. CONCLUSION: Given the existence of a time lag between climatic variables more so rainfall and peak malaria transmission, appropriate control measures can be initiated at the onset of short and after long rains seasons.

Ecological niche modelling of Rift Valley fever virus vectors in Baringo, Kenya.

BACKGROUND: Rift Valley fever (RVF) is a vector-borne zoonotic disease that has an impact on human health and animal productivity. Here, we explore the use of vector presence modelling to predict the distribution of RVF vector species under climate change scenario to demonstrate the potential for geographic spread of Rift Valley fever virus (RVFV). OBJECTIVES: To evaluate the effect of climate change on RVF vector distribution in Baringo County, Kenya, with an aim of developing a risk map for spatial prediction of RVF outbreaks. METHODOLOGY: The study used data on vector presence and ecological niche modelling (MaxEnt) algorithm to predict the effect of climatic change on habitat suitability and the spatial distribution of RVF vectors in Baringo County. Data on species occurrence were obtained from longitudinal sampling of adult mosquitoes and larvae in the study area. We used present (2000) and future (2050) Bioclim climate databases to model the vector distribution. RESULTS: Model results predicted potential suitable areas with high success rates for Culex quinquefasciatus, Culex univitattus, Mansonia africana, and Mansonia uniformis. Under the present climatic conditions, the lowlands were found to be highly suitable for all the species. Future climatic conditions indicate an increase in the spatial distribution of Cx. quinquefasciatus and M. africana. Model performance was statistically significant. CONCLUSION: Soil types, precipitation in the driest quarter, precipitation seasonality, and isothermality showed the highest predictive potential for the four species.

Lay knowledge and management of malaria in Baringo county, Kenya.

BACKGROUND: Malaria, a disease caused by protozoan parasites of the genus Plasmodium and transmitted by female anopheline mosquitoes, is a major cause of morbidity, mortality and loss in productivity in humans. Baringo County is prone to seasonal transmissions of malaria mostly in the rainy seasons. METHODS: This cross-sectional study used a mixed methods approach to collect data on knowledge and lay management of malaria. A questionnaire survey was administered to 560 respondents while qualitative data was collected through 20 focus group discussions in four ecological zones covering Baringo North, Baringo South and Marigat sub-Counties of Baringo County. Analyses were done through summary and inferential statistics for quantitative data and content analysis for qualitative data. RESULTS: The study communities were knowledgeable of malaria signs, symptoms, cause and seasonality but this biomedical knowledge co-existed with other local perceptions. This knowledge, however, did not influence their first (p = 0.77) or second choice treatments (p = 0.49) and compliance to medication (p = 0.84). Up to 88 % of respondents reported having suffered from malaria. At the onset of a suspected malaria case community members reported the following: 28.9 % visited a health facility, 37.2 % used analgesics, 26.6 % herbal treatments, 2.2 % remnant malaria medicines, 2.2 % over the counter malaria medicines, 1 % traditional healers and 1.8 % other treatments. Nearly all respondents (97.8 %) reported visiting a health facility for subsequent treatments. Herbal treatments comprised of infusions and decoctions derived from roots, barks and leaves of plants believed to have medicinal value. Compliance to conventional malaria treatment regime was, however, identified as a challenge in malaria management. Quick relief from symptoms, undesirable qualities like drug bitterness and bad smell, undesirable side-effects, such as nausea and long regimen of treatment were some of the contributors to non-compliance. Men and women exhibited different health-seeking behaviours based on the cultural expectations of masculinity, femininity, gender roles and acceptability of health services. CONCLUSIONS: While knowledge of malaria is important in identifying the disease, it does not necessarily lead to good management practice. Treatment-seeking behaviour is also influenced by perceived cause, severity of disease, timing, anticipated cost of seeking treatment and gender, besides the availability of both traditional and conventional medicines.

Exploring the barriers to health care and psychosocial challenges in cervical cancer management in Kenya.

Cervical cancer is the most frequent cancer among women aged between 15 years and 44 years in Kenya, resulting in an estimated 4,802 women being diagnosed with cervical cancer and 2,451 dying from the disease annually. It is often detected at its advanced invasive stages, resulting in a protracted illness upon diagnosis. This qualitative study looked at the illness trajectories of women living with cervical cancer enrolled for follow-up care at Kenyatta National Hospital cancer treatment center and the Nairobi Hospice, both in Nairobi county, Kenya. Using the qualitative phenomenological approach, data were collected through 18 in-depth interviews with women living with cervical cancer between April and July 2011. In-depth interviews with their caregivers, key informant interviews with health care workers, and participant observation field notes were used to provide additional qualitative data. These data were analyzed based on grounded theory's inductive approach. Two key themes on which the data analysis was then anchored were identified, namely, psychosocial challenges of cervical cancer and structural barriers to quality health care. Findings indicated a prolonged illness trajectory with psychosocial challenges, fueled by structural barriers that women were faced with after a cervical cancer diagnosis. To address issues relevant to the increasing numbers of women with cervical cancer, research studies need to include larger samples of these women. Also important are studies that allow in-depth understanding of the experiences of women living with cervical cancer.

Healthcare priority setting in Kenya: a gap analysis applying the accountability for reasonableness framework.

In resource-poor settings, the accountability for reasonableness (A4R) has been identified as an important advance in priority setting that helps to operationalize fair priority setting in specific contexts. The four conditions of A4R are backed by theory, not evidence, that conformance with them improves the priority setting decisions. This paper describes the healthcare priority setting processes in Malindi district, Kenya, prior to the implementation of A4R in 2008 and evaluates the process for its conformance with the conditions for A4R. In-depth interviews and focus group discussions with key players in the Malindi district health system and a review of key policy documents and national guidelines show that the priority setting process in the district relies heavily on guidelines from the national level, making it more of a vertical, top-down orientation. Multilateral and donor agencies, national government, budgetary requirements, traditions and local culture influence the process. The four conditions of A4R are present within the priority setting process, albeit to varying degrees and referred to by different terms. There exists an opportunity for A4R to provide a guiding approach within which its four conditions can be strengthened and assessed to establish whether conformance helps improve on the priority setting process.

Still living with fistula: an exploratory study of the experience of women with obstetric fistula following corrective surgery in West Pokot, Kenya.

Obstetric fistula is a complication of pregnancy that affects women following prolonged obstructed labour. Although there have been achievements in the surgical treatment of obstetric fistula, the long-term emotional, psychological, social and economic experiences of women after surgical repair have received less attention. This paper documents the challenges faced by women following corrective surgery and discusses their needs within the broader context of women's health. We interviewed a small sample of women in West Pokot, Kenya, during a two-month period in 2010, including eight in-depth interviews with fistula survivors and two focus group discussions, one each with fistula survivors and community members. The women reported continuing problems following corrective surgery, including separation and divorce, infertility, stigma, isolation, shame, reduced sense of worth, psychological trauma, misperceptions of others, and unemployment. Programmes focusing on the needs of the women should address their social, economic and psychological needs, and include their husbands, families and the community at large as key actors. Nonetheless, a weak health system, poor infrastructure, lack of focus, few resources and weak political emphasis on women's reproductive health do not currently offer enough support for an already disempowered group.

Children as caregivers of older relatives living with HIV and AIDS in Nyang'oma division of western Kenya.

There is growing debate about the situations of children who care for a relative with HIV-related illness, especially in developing countries with high HIV prevalence. In particular, there is inadequate information on the long-term consequences of children taking on this caregiving role. The article reanalyses data collected between January and November 2006 in a rural setting in western Kenya where 19 children caring for a total of 15 people living with HIV or AIDS (PLHIV) participated. Data were collected through in-depth interviews, participant observation, focus group discussions and narratives. The findings show that children regularly become involved in caregiving due to lack of a responsible adult to perform the role, which may be as a result of HIV stigma and rejection of the care recipient by extended family members and neighbours or because of cultural barriers. Fulfilling the responsibilities of caregiving had profound repercussions for the children's lives, including psychological distress, physical burden, dropping out of school, participation in wage labour, and forced early marriage. Financial needs pushed some girls into transactional sexual relations, predisposing them to the risks of unwanted pregnancy or sexually transmitted infections. Since the children providing care for PLHIV are themselves vulnerable, we recommend that they should be targeted with support.