Guiding the Implementation of Wastewater-based Surveillance for Carceral Infection Control with Perspectives from People with Lived Experience of Incarceration during the COVID-19 Pandemic.

Background: Little guidance exists on best practices for implementing and sustaining wastewater-based surveillance (WBS) for SARS-CoV-2 in carceral settings. To ensure alignment with priorities of stakeholders, we aimed to understand the perspectives of persons with lived experience (PLE) of jail who were incarcerated during the height of the COVID-19 pandemic on infection control. Methods: We recruited two PLE at each of four jails: Cook County (IL), Fulton County (GA), Middlesex County (MA), and Washington DC. Focus Group Discussion (FGD) guides followed the Consolidated Framework for Implementation Research (CFIR). Two FGDs focusing on lived experience with jail infection control protocol and WBS were conducted, and six Key Informant (KI) interviews followed to gain insights on communicating WBS results. We used a combination of deductive thematic analysis based on CFIR constructs and inductive analysis to capture emergent themes. Results: Themes from FGDs included: (1) variable experiences with COVID-19 infection control protocols including intake processes, individual testing, isolation and quarantine, (2) the perceived attitudes of fellow residents and staff surrounding COVID-19 mitigation in a carceral setting; and (3) perceived benefits and challenges involving WBS implementation and messaging. KIs emphasized 1) The importance of straightforward health messaging and trustworthiness in the communication of WBS results, 2) Support for enhanced health education around outbreaks, and 3) Receptiveness to WBS being used as a tool to measure common infectious agents (i.e., influenza) but hesitancy regarding its application to conditions such as HIV and illicit drug use. PLE articulated support of robust infection control programs and receptiveness to expanding WBS if conducted in a non-stigmatizing manner. Conclusion: Perspectives from PLE can help shape the infection control programs for future outbreaks and inform the expansion of WBS implementation in carceral facilities. It will be important to consider the voices of current and former residents, as receivers of care, to promote an environment conducive to comprehensive infection control. In addition to having infection control programs consistently execute set protocols and educate all stakeholders, PLE identified collaboration between jail staff and residents, and clear communication around program expectations as priorities. Findings from this qualitative study can be shared with jail decision makers and the perceived engagement of stakeholders can be measured.

The state of reporting context and implementation in peer-reviewed evaluations of water, sanitation, and hygiene interventions: A scoping review.

INTRODUCTION: To accurately assess evidence from environmental and public health field trials, context and implementation details of the intervention must be weighed with trial results; yet these details are under and inconsistently reported for water, sanitation, and hygiene (WASH), limiting the external validity of the evidence. METHODS: To quantify the level of reporting of context and implementation in WASH evaluations, we conducted a scoping review of the 40 most cited evaluations of WASH interventions published in the last 10 years (2012-2022). We applied criteria derived from a review of existing reporting guidance from other sectors including healthcare and implementation science. We subsequently reviewed main articles, supplements, protocols, and other associated resources to assess thoroughness of context and implementation reporting. RESULTS: Of the final 25 reporting items we searched for, four-intervention name, approach, location, and temporality-were reported by all studies. Five items-theory, implementer qualifications, dose intensity, targeting, and measured fidelity-were not reported in over a third of reviewed articles. Only two studies (5%) reported all items in our checklist. Only 74% of items were found in the main article, while the rest were found in separate papers (7%) or not at all (19%). DISCUSSION: Inconsistent reporting of WASH implementation illustrates a major challenge in the sector. It is difficult to know what interventions are actually being evaluated and how to compare evaluation results. This inconsistent and incomplete implementation reporting limits the ability of programmers and policy makers to apply the available evidence to their contexts. Standardized reporting guidelines would improve the application of the evidence for WASH field evaluations.

Success in vaccination programming through community health workers: a qualitative analysis of interviews and focus group discussions from Nepal, Senegal and Zambia.

OBJECTIVES: Community health workers are essential to front-line health outreach throughout low-income and middle-income countries, including programming for early childhood immunisation. Understanding how community health workers are engaged for successful early childhood vaccination among countries who showed success in immunisation coverage would support evidence-based policy guidance across contexts. DESIGN: We employed a multiple case study design using qualitative research methods. SETTING: We conducted research in Nepal, Senegal and Zambia. PARTICIPANTS: We conducted 207 interviews and 71 focus group discussions with 678 participants at the national, regional, district, health facility and community levels of the health systems of Nepal, Senegal and Zambia, from October 2019 to April 2021. We used thematic analysis to investigate contributing factors of community health worker programming that supported early childhood immunisation within each country and across contexts. RESULTS: Implementation of vaccination programming relied principally on the (1) organisation, (2) motivation and (3) trust of community health workers. Organisation was accomplished by expanding cadres of community health workers to carry out their roles and responsibilities related to vaccination. Motivation was supported by intrinsic and extrinsic incentives. Trust was expressed by communities due to community health worker respect and value placed on their work. CONCLUSION: Improvements in immunisation coverage was facilitated by community health worker organisation, motivation and trust. With the continued projection of health worker shortages, especially in low-income countries, community health workers bridged the equity gap in access to vaccination services by enabling wider reach to underserved populations. Although improvements in vaccination programming were seen in all three countries-including government commitment to addressing human resource deficits, training and remuneration; workload, inconsistency in compensation, training duration and scope, and supervision remain major challenges to immunisation programming. Health decision-makers should consider organisation, motivation and trust of community health workers to improve the implementation of immunisation programming.

Evidence-based complementary feeding recipe book for Kenyan caregivers: A novel approach.

The Kenyan Ministry of Health (MOH) and a consortium of nutritionists, researchers and communication, and design specialists developed a novel approach to create an evidence-based recipe book promoting complementary feeding (CF) in Kenya. The ADAPT approach includes five steps: applied research (A), dialogue with stakeholders (D), adapted behaviour change communication (BCC) theories (A), purpose-driven visual communication (P), and tailoring to priority audiences (T). Through this approach, the recipe book addresses key knowledge gaps using behaviour change theories and visual communication best practice to increase accessibility, acceptability, retention and motivation for behaviour change. The book addresses barriers to CF identified through formative applied research. Dialogue with stakeholders helped ensure cultural appropriateness and the book's alignment with MOH recommendations and key messages. The book uses behaviour change theories to approach the reader in a respectful way that motivates behaviour change. The use of consistent, purpose-driven visuals helps ensure key messages are easily understood and accessible to all caregivers regardless of literacy level. The book's tone and content are tailored to its audiences' attributes, needs and preferences. This five-step process inspired the development of ADAPT, a novel approach that integrates behaviour change and visual communication for greater impact. This paper outlines how the consortium used the ADAPT approach to develop an evidence-based book that thoughtfully and holistically addresses a wide range of barriers, provides practical solutions and increases self-efficacy around CF. It offers a blueprint for public health practitioners from any field who are interested in using visual behaviour change communication to promote healthy behaviour.

Critical success factors for high routine immunisation performance: a qualitative analysis of interviews and focus groups from Nepal, Senegal, and Zambia.

OBJECTIVES: Vaccination averts an estimated 2-3 million deaths annually. Although vaccine coverage improvements across Africa and South Asia have remained below global targets, several countries have outperformed their peers with significant increases in coverage. The objective of this study was to examine these countries' vaccination programmes and to identify and describe critical success factors that may have supported these improvements. DESIGN: Multiple case study design using qualitative research methods. SETTING: Three countries with high routine immunisation rates: Nepal, Senegal, and Zambia. PARTICIPANTS: We conducted 207 key informant interviews and 71 focus group discussions with a total of 678 participants. Participants were recruited from all levels, including government officials, health facility staff, frontline workers, community health workers, and parents. Participants were recruited from both urban and rural districts in Nepal, Senegal, and Zambia. RESULTS: Our data revealed that the critical success factors for vaccination programmes relied on the cultural, historical, and statutory context in which the interventions were delivered. In Nepal, Senegal, and Zambia, high immunisation coverage was driven by (1) strong governance structures and healthy policy environments; (2) adjacent successes in health system strengthening; (3) government-led community engagement initiatives, and (4) adaptation considering contextual factors at all levels of the health system. CONCLUSIONS: Throughout this project, our analysis returned to the importance of defining and understanding the context, governance, financing, and health systems within a country, rather than focusing on any one intervention. This paper augments findings from existing literature by highlighting how contextual factors impact implementation decisions that have led to improvements in childhood vaccine delivery. Findings from this research may help identify transferable lessons and support actionable recommendations to improve national immunisation coverage in other settings.

Drivers of early childhood vaccination success in Nepal, Senegal, and Zambia: a multiple case study analysis using the Consolidated Framework for Implementation Research.

INTRODUCTION: The fundamental components of a vaccine delivery system are well-documented, but robust evidence is needed on how the related processes and implementation strategies - including the facilitators and barriers - contribute to improvements in childhood vaccination coverage. The purpose of this study was to identify critical facilitators and barriers to the implementation of common interventions across three countries that have dramatically increased coverage of early childhood vaccination over the past 20 years, and to qualify common or divergent themes in their success. METHODS: We conducted 278 key informant interviews and focus group discussions with public health leaders at the regional, district, and local levels and community members in Nepal, Senegal, and Zambia to identify intervention activities and the facilitators and barriers to implementation. We used thematic analysis grounded in the Consolidated Framework for Implementation Research (CFIR) constructs of inner and outer settings to identify immunization program key facilitators and barriers. RESULTS: We found that the common facilitators to program implementation across the countries were the CFIR inner setting constructs of (1) networks and communications, (2) goals and feedback, (3) relative priority, and (4) readiness for implementation and outer setting constructs of (5) cosmopolitanism and (6) external policies and mandates. The common barriers were incentives and rewards, available resources, access to knowledge and information, and patients' needs and resources. Critical to the success of these national immunization programs were prioritization and codification of health as a human right, clear chain of command and shared ownership of immunization, communication of program goals and feedback, offering of incentives at multiple levels, training of staff central to vaccination education, the provision of resources to support the program, key partnerships and guidance on implementation and adoption of vaccination policies. CONCLUSION: Adequate organizational commitment, resources, communication, training, and partnerships were the most critical facilitators for these countries to improve childhood vaccination.

Critical interventions for demand generation in Zambia, Nepal, and Senegal with regards to the 5C psychological antecedents of vaccination.

Introduction: Childhood vaccination is an effective intervention for lowering the burden of infectious disease. Vaccine coverage has increased globally, but vaccine hesitancy and refusal threatens these gains. The 5C psychological antecedents of vaccination ("5C") provides a validated measure of "vaccine hesitancy or confidence" to assess individual thoughts and behaviors behind vaccination. We investigated population-level factors that contributed to high and sustained vaccination coverage in Zambia, Nepal, and Senegal, and alignment with the 5Cs. Methods: Data was collected in the larger Exemplars in Vaccine Delivery study, from focus group discussions (FDGs) and key informant interviews (KIIs) at the national, regional, district, health facility, and community levels of health systems in Zambia, Nepal, and Senegal. We assessed the demand environment, as relayed by participants, and identified interventions reported as successful for demand generation, then retroactively aligned the interventions with the 5C constructs. Results: Demand was positively correlated with high confidence and collective responsibility. Psychological constraints sometimes impacted demand. Physical constraints created barriers in some communities, particularly difficult to access (i.e., mountainous). Occasionally, physical constraints did not affect vaccination behavior - parents believed the benefits of vaccination worth pursuing. Factors negatively correlated with demand and intent, complacency and calculation, had limited impact. Critical interventions were: targeted and tailored health education activities (media partnerships, school outreach); community engagement; community ownership; and community involvement (community health workers, leaders, religious figures). Conclusion: We found similar interventions used to generate demand, with strategies aligned with the 5C constructs. Categorizing interventions by drivers of demand may help strategic planning and the division of resources; decision makers may choose to implement our suggested interventions. Assessing the 5Cs allows decision-makers to operationalize demand generation into concrete interventions and policies, and determine the individual impact of these constructs on the population and focus efforts on interventions tailored to a specific need.

Critical success factors for high routine immunization performance: A case study of Senegal.

Background: The essential components of a vaccine delivery system are well-documented, but robust evidence is lacking on how policies and implementation strategies are operationalized to drive catalytic improvements in coverage. To address this gap, we identified success factors that supported improvements in routine immunization coverage in Senegal, especially from 2000 to 2019. Methods: We identified Senegal as an exemplar in the delivery of childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health facility, and community-level, we investigated factors that contributed to high and sustained vaccination coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results: The following success factors emerged: 1) Strong political will and prioritization of resources for immunization programming supported urgent allocation of funding and supplies; 2) Collaboration between the Ministry of Health and Social Action and external partners fostered innovation, capacity building, and efficiency; 3) Improved surveillance, monitoring, and evaluation allowed for timely and evidence-based decision making; 4) Community ownership of vaccine service delivery supported tailored programming and response to local needs; and 5) Community health workers spearheaded vaccine promotion and demand generation for vaccines. Conclusion: The vaccination program in Senegal was supported by evidence-based decision making at the national-level, alignment of priorities between governmental entities and external partners, and strong community engagement initiatives that fostered local ownership of vaccine delivery and uptake. High routine immunization coverage was likely driven by prioritization of immunization programming, improved surveillance systems, a mature and reliable community health worker program, and tailored strategies for addressing geographical, social, and cultural barriers.

Determinants of food preparation and hygiene practices among caregivers of children under two in Western Kenya: a formative research study.

INTRODUCTION: Diarrhea is a leading cause of child morbidity and mortality worldwide and is linked to early childhood stunting. Food contamination from improper preparation and hygiene practices is an important transmission pathway for exposure to enteric pathogens. Understanding the barriers and facilitators to hygienic food preparation can inform interventions to improve food hygiene. We explored food preparation and hygiene determinants including food-related handwashing habits, meal preparation, cooking practices, and food storage among caregivers of children under age two in Western Kenya. METHODS: We used the Capabilities, Opportunities, and Motivations model for Behavior Change (COM-B) framework in tool development and analysis. We conducted 24 focus group discussions with mothers (N = 12), fathers (N = 6), and grandmothers (N = 6); 29 key informant interviews with community stakeholders including implementing partners and religious and community leaders; and 24 household observations. We mapped the qualitative and observational data onto the COM-B framework to understand caregivers' facilitators and barriers to food preparation and hygiene practices. RESULTS: Facilitators and barriers to food hygiene and preparation practices were found across the COM-B domains. Caregivers had the capability to wash their hands at critical times; wash, cook, and cover food; and clean and dry utensils. Barriers to food hygiene and preparation practices included lack of psychological capability, for instance, caregivers' lack of knowledge of critical times for handwashing, lack of perceived importance of washing some foods before eating, and not knowing the risks of storing food for more than four hours without refrigerating and reheating. Other barriers were opportunity-related, including lack of resources (soap, water, firewood) and an enabling environment (monetary decision-making power, social support). Competing priorities, socio-cultural norms, religion, and time constraints due to work hindered the practice of optimal food hygiene and preparation behaviors. CONCLUSION: Food hygiene is an underexplored, but potentially critical, behavior to mitigate fecal pathogen exposure for young children. Our study revealed several knowledge and opportunity barriers that could be integrated into interventions to enhance food hygiene.

Critical success factors for high routine immunization performance: A case study of Nepal.

Introduction: The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies drive catalytic improvements in vaccination coverage are not well established. To address this gap, we identified critical success factors that may have led to substantial improvements in routine childhood immunization coverage in Nepal from 2000 through 2019. Methods: We identified Nepal as an exemplar in the delivery of early childhood immunization through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national, regional, district, health post, and community level, we investigated factors that contributed to high and sustained vaccine coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results: The following success factors emerged: 1) Codification of health as a human right, - along with other vaccine-specific legislation - ensured the stability of vaccination programming; 2) National and multi-national partnerships supported information sharing, division of labor, and mutual capacity building; 3) Pro-vaccine messaging through various mediums, which was tailored to local needs, generated public awareness; 4) Female Community Health Volunteers educated community members as trusted and compassionate neighbors; and 5) Cultural values fostered collective responsibility and community ownership of vaccine coverage. Conclusion: This case study of Nepal suggests that the success of its national immunization program relied on the engagement and understanding of the beneficiaries. The immunization program was supported by consistent and reliable commitment, collaboration, awareness, and collective responsibility between the government, community, and partners. These networks are strengthened through a collective dedication to vaccination programming and a universal belief in health as a human right.

Application of the Capabilities, Opportunities, Motivations, and Behavior (COM-B) Change Model to Formative Research for Child Nutrition in Western Kenya.

Background: Interventions aimed at improving dietary intake and feeding practices have alone proven insufficient for combatting stunting resulting from poor nutrition and repeated infections. Objectives: To support the development of an integrated water, sanitation, and hygiene (WASH) and nutrition, social, and behavior change strategy aimed at reducing stunting, formative research was conducted in 2 program sites in western Kenya. Methods: Twenty-nine key informant interviews were conducted with community leaders, health workers, and project staff, and 24 focus group discussions with caregivers of children under 2 y on topics related to feeding, sanitation, and hygiene behaviors. Three frameworks informed the study design and analysis of our formative research: the Capabilities, Opportunities, and Motivations model for behavior change, which identifies what needs to change in order for behavior change interventions to be effective; the Grandmother Project's Change Through Culture Approach, which values the important role of influential household and community members in producing household health; and Starr and Fornoff's approach to Theory of Change development. Results: Caregivers exhibited sufficient psychological capabilities (knowledge and skills) for many of the key maternal and infant nutrition behaviors. However, reflective motivation to perform optimal behaviors was undermined by limitations in physical and social opportunities, including limited time and competing priorities for mothers, limited accessibility and availability of diverse foods, low self-efficacy for exclusive breastfeeding, and fears of negative consequences related to specific foods and recommended practices. Conclusions: Interventions that aim to improve maternal and child diets should address the underlying social, cultural, and environmental determinants that contribute to motivations and opportunities to perform recommended practices.

Providing "a beam of light to see the gaps": determinants of implementation of the Systems Analysis and Improvement Approach applied to the pediatric and adolescent HIV cascade in Kenya.

BACKGROUND: Children and adolescents living with HIV have poorer rates of HIV testing, treatment, and virologic suppression than adults. Strategies that use a systems approach to optimize these multiple, linked steps simultaneously are critical to close these gaps. METHODS: The Systems Analysis and Improvement Approach (SAIA) was adapted and piloted for the pediatric and adolescent HIV care and treatment cascade (SAIA-PEDS) at 6 facilities in Kenya. SAIA-PEDS includes three tools: continuous quality improvement (CQI), flow mapping, and pediatric cascade analysis (PedCAT). A predominately qualitative evaluation utilizing focus group discussions (N = 6) and in-depth interviews (N = 19) was conducted with healthcare workers after implementation to identify determinants of implementation. Data collection and analysis were grounded in the Consolidated Framework for Implementation Research (CFIR). RESULTS: Overall, the adapted SAIA-PEDS strategy was acceptable, and the three tools complemented one another and provided a relative advantage over existing processes. The flow mapping and CQI tools were compatible with existing workflows and resonated with team priorities and goals while providing a structure for group problem solving that transcended a single department's focus. The PedCAT was overly complex, making it difficult to use. Leadership and hierarchy were complex determinants. All teams reported supportive leadership, with some describing in detail how their leadership was engaged and enthusiastic about the SAIA-PEDS process, by providing recognition, time, and resources. Hierarchy was similarly complex: in some facilities, leadership stifled rapid innovation by insisting on approving each change, while at other facilities, leadership had strong and supportive oversight of processes, checking on the progress frequently and empowering teams to test innovative ideas. CONCLUSION: CQI and flow mapping were core components of SAIA-PEDS, with high acceptability and consistent use, but the PedCAT was too complex. Leadership and hierarchy had a nuanced role in implementation. Future SAIA-PEDS testing should address PedCAT complexity and further explore the modifiability of leadership engagement to maximize implementation.

Critical success factors for routine immunization performance: A case study of Zambia 2000 to 2018.

Introduction: The essential components of a vaccine delivery system are well-documented, but robust evidence on how and why the related processes and implementation strategies prove effective at driving coverage is not well-established. To address this gap, we identified critical success factors associated with advancing key policies and programs that may have led to the substantial changes in routine childhood immunization coverage in Zambia between 2000 and 2018. Methods: We identified Zambia as an exemplar in the delivery of childhood vaccines through analysis of DTP1 and DTP3 coverage data. Through interviews and focus group discussions at the national and subnational levels, we investigated factors that contributed to high and sustained vaccination coverage. We conducted a thematic analysis through application of implementation science frameworks to determine critical success factors. We triangulated these findings with quantitative analyses using publicly available data. Results: The following success factors emerged: 1) the Inter-agency Coordinating Committee was strengthened for long-term engagement which, complemented by the Zambia Immunization Technical Advisory Group, is valued by the government and integrated into national-level decision-making; 2) the Ministry of Health improved the coordination of data collection and review for informed decision-making across all levels; 3) Regional multi-actor committees identified development priorities, strategies, and funding, and iteratively adjusted policies to account for facilitators, barriers, and lessons learned; 4) Vaccine messaging was disseminated through multiple channels, including the media and community leaders, increasing trust in the government by community members; 5) The Zambia Ministry of Health and Churches Health Association of Zambia formalized a long-term organizational relationship to leverage the strengths of faith-based organizations; and 6) Neighborhood Health Committees spearheaded community-driven strategies via community action planning and ultimately strengthened the link between communities and health facilities. Conclusion: Broader health systems strengthening and strong partnerships between various levels of the government, communities, and external organizations were critical factors that accelerated vaccine coverage in Zambia. These partnerships were leveraged to strengthen the overall health system and healthcare governance.

Brief Report: Pediatric Saliva-Based HIV Testing: Health care Worker and Caregiver Acceptability.

BACKGROUND: Pediatric HIV testing remains suboptimal. The OraQuick test [saliva-based test (SBT)] is validated in pediatric populations ≥18 months. Understanding caregiver and health care worker (HCW) acceptability of pediatric SBT is critical for implementation. METHODS: A trained qualitative interviewer conducted 8 focus group discussions (FGDs): 4 with HCWs and 4 with caregivers of children seeking health services in western Kenya. FGDs explored acceptability of pediatric SBT and home- and facility-based SBT use. Two reviewers conducted consensus coding and thematic analyses of transcripts using Dedoose. RESULTS: Most HCWs but few caregivers had heard of SBT. Before seeing SBT instructions, both had concerns about potential HIV transmission through saliva, which were mostly alleviated after kit demonstration. Noted benefits of SBT included usability and avoiding finger pricks. Benefits of facility-based pediatric SBT included shorter client waiting and service time, higher testing coverage, and access to HCWs, while noted challenges included ensuring confidentiality. Benefits of caregivers using home-based SBT included convenience, privacy, decreased travel costs, increased testing, easier administration, and child comfort. Perceived challenges included not receiving counseling, disagreements with partners, child neglect, and negative emotional response to a positive test result. Overall, HCWs felt that SBT could be used for pediatric HIV testing but saw limited utility for caregivers performing SBT without an HCW present. Caregivers saw utility in home-based SBT but wanted easy access to counseling in case of a positive test result. CONCLUSIONS: SBT was generally acceptable to HCWs and caregivers and is a promising strategy to expand testing coverage.

Impact of a demand-side integrated WASH and nutrition community-based care group intervention on behavioural change: a randomised controlled trial in western Kenya.

INTRODUCTION: Growth shortfalls and diarrhoeal diseases remain a major cause of morbidity and mortality in low-income settings. Due to the multifaceted causes of undernutrition and the identified limitations of siloed nutrition programmes, improving the delivery of integrated water, sanitation, hygiene (WASH) and nutrition programming could improve child health. METHODS: We conducted a cluster randomised trial in western Kenya to assess the impact on household behaviours of a novel, theory-informed and integrated WASH and nutrition intervention delivered through care groups as compared with the standard care group approach. We developed an intervention targeting practices relating to food hygiene, mealtime and feeding, and compound cleanliness, each using various behavioural change techniques to influence the uptake of targeted behaviours. Prespecified behavioural outcomes were verified through direct observation, 24 hours recall, and self-reported picture-based methods. RESULTS: Compared with control households, a greater proportion of intervention households had a hygienic food preparation area (Risk double difference (RDD) 0.81, 95% CI 0.68 to 0.96), had stored food hygienically (RDD 0.76, 95% CI 0.58 to 1.00), had a functional handwashing station (RDD 0.64, 95% CI 0.56 to 0.74), provided a safe space for their child to play (RDD 0.73, 95% CI 0.56 to 0.96), and who fed their children thickened porridge (RDD 0.56, 95% CI 0.51 to 0.63) at endline. The proportion of children 6-24 months in intervention households consuming a sufficient diversity of foods (RDD 0.81, 95% CI 0.64 to 1.04) was higher than in control households; however, there was a non-significant increase in the percentage of pregnant and lactating women receiving an adequate diversity of foods in their diets (RDD 0.86, 95% CI 0.70 to 1.05) among intervention compared with control households at endline. CONCLUSION: Our integrated WASH and nutrition intervention resulted in important changes in behaviours. This theory-informed intervention could be added to existing care group programmes to considerable advantage.

Designing integrated interventions to improve nutrition and WASH behaviors in Kenya.

BACKGROUND: Child stunting, an indicator of chronic malnutrition, is a global public health problem. Malnutrition during pregnancy and the first 2 years of life undermines the survival, growth, and development of children. Exposure to fecal pathogens vis-à-vis inadequate water, sanitation, and hygiene (WASH) has been implicated in the etiology of child stunting, highlighting the need to integrate WASH with nutrition-sensitive interventions to comprehensively address this complex problem. The aim of this study was to describe a systematic, theoretically informed approach (that drew from the Starr and Fornoff approach to the Theory of Change development and the Behavior Change Wheel approach) to design a multi-component and integrated social and behavior change intervention to improve WASH and nutrition-related behaviors in western Kenya. METHODS: This intervention was developed to be integrated into an existing project that utilized the care group model and aimed to create a culture of care and support for HIV/AIDS-affected children under two and their caregivers and was executed by local partners. We tested the newly created intervention packages in user-testing trials using an adapted Trials of Improved Practices approach to pilot acceptability and feasibility. RESULTS: Using authentic stakeholder engagement and relevant theories, we conducted an 8-step process: (1) conduct mixed methods formative research, (2) prioritize target behaviors, (3) use causal analysis to create problem trees, (4) develop solution trees and articulate assumptions and rationales for change, (5) link solution trees to intervention functions, (6) develop the intervention plan, (7) create the intervention packages, and (8) test and refine the intervention packages. CONCLUSIONS: This study highlights the need to take a multi-sectorial, integrated approach that integrates contextually relevant behavior change theories with the experiential knowledge gleaned from stakeholders into the design of interventions that seek to reduce child stunting. This process resulted in the creation of intervention packages that grouped behaviors thematically to be most relevant and responsive to the population context. This work has the potential to make important contributions towards achievement of the United Nations' sustainable development goals.

Development and Application of Novel Caregiver Hygiene Behavior Measures Relating to Food Preparation, Handwashing, and Play Environments in Rural Kenya.

Exposure to fecal pathogens results in both acute and chronic sequalae in young children. Diarrhea causes nearly 20% of all under-five mortality, while even sub-clinical enteric infections may lead to growth shortfalls. Stunting affects nearly 165 million children globally and results in lifelong and intergenerational effects for the world's poorest populations. Caregiver hygiene behaviors, such as those surrounding handwashing and food preparation, play a critical role in exposure to fecal pathogens; standard metrics to assess these behaviors are warranted to provide a means of quantifying the impact these behaviors have on enteric infections and to evaluate the success or failure of interventions and programs. This paper documents the development of three novel caregiver hygiene behavior measures: hygienic food preparation and storage, handwashing at key times, and provision of a safe play environment for children under two years. We developed these measures using formative qualitative work, survey creation and deployment theoretically underpinned by the COM-B model of behavior change, and exploratory and confirmatory factor analysis. The final measure for hygienic food preparation and storage includes 10 items across two factors; the final measure for handwashing at key times includes 15 items across three factors; and the final measure for safe play environment contains 13 items across three factors. Future researchers may employ these measures to assess caregiver behaviors in other populations, identify specific behavioral dimensions that should be the focus of interventions, and evaluate interventions and programs.

'The girl with her period is the one to hang her head' Reflections on menstrual management among schoolgirls in rural Kenya.

BACKGROUND: The onset of menstruation is a landmark event in the life of a young woman. Yet the complications and challenges that can accompany such an event have been understudied, specifically in resource-poor settings. As interventions aim to improve female attendance in schools, it is important to explore how menstruation is perceived and navigated by girls in the school setting. This research conveys rural Kenyan schoolgirls' perceptions and practices related to menstruation METHODS: Data were collected at six rural schools in the Nyanza Province of Western Kenya. Using focus group discussions, in-depth interviews, and field notes from observations, researchers collected information from 48 primary schoolgirls and nine teachers. Systematic analysis began with a reading of transcripts and debriefing notes, followed by manual coding of the narratives. RESULTS: Focus group discussions became opportunities for girls to share thoughts on menstruation, instruct one another on management practices and advise one another on coping mechanisms. Girls expressed fear, shame, distraction and confusion as feelings associated with menstruation. These feelings are largely linked to a sense of embarrassment, concerns about being stigmatized by fellow students and, as teachers explained, a perception that the onset of menstruation signals the advent of a girl's sexual status. Among the many methods for managing their periods, girls most frequently said they folded, bunched up or sewed cloth, including cloth from shirts or dresses, scraps of old cloth, or strips of an old blanket. Cloth was reported to frequently leak and cause chafing, which made school attendance difficult particularly as the day progressed. Attitudes and practices of girls toward menstruation have been arranged into personal, environmental and behavioural factors. CONCLUSION: Further research on menstrual management options that are practical, sustainable and culturally acceptable must be conducted to inform future programs and policies that aim to empower young girls as they transition into womanhood. Stakeholders working within this and similar contexts must consider systematic mechanisms to explain to young girls what menstruation is and how to manage it. Providing sanitary supplies or guiding girls on how to create supplies serve as critical components for future interventions.

Nurses' impoliteness as an impediment to patients' rights in selected Kenyan hospitals.

The institutionalization of patients' rights is a recent phenomenon in Kenya. In 2006, Kenya's Ministry of Health initiated policy measures to improve patient satisfaction through a charter of patients' rights. The aim was to change the longstanding public perception that nurses in public hospitals routinely ignored patients' right to respectful treatment. This paper focuses on linguistic indicators of violation or promotion of patients' rights in the health care context. We examine the extent to which patients' rights to dignity, respect, and humaneness are observed or denied, and we argue that impolite utterances impede rather than promote the realization of other fundamental human rights. It appears that nurses' impoliteness does not merely constitute rudeness, but encodes a violation of dignity which, in turn, hampers the chances of enjoyment of broader human rights such as the right to autonomy, free expression, self-determination, information, personalized attention, and non-discrimination. We argue that, for patients to enjoy their rights in the hospital setting, a clear definition of roles and relationships and public education on strategies of asserting their rights without intimidation are necessary. It emerges that when patients' rights are denied, patients resort to retaliation by violating the dignity of the nurses. This jeopardizes the envisaged mutual support in the nurse-patient relationship and compromises patient satisfaction.