Economic outcomes among microfinance group members receiving community-based chronic disease care: Cluster randomized trial evidence from Kenya.

BACKGROUND: Poverty can be a robust barrier to HIV care engagement. We assessed the extent to which delivering care for HIV, diabetes and hypertension within community-based microfinance groups increased savings and reduced loan defaults among microfinance members living with HIV. METHODS: We analyzed cluster randomized trial data ascertained during November 2020-May 2023 from 57 self-formed microfinance groups in western Kenya. Groups were randomized 1:1 to receive care for HIV and non-communicable diseases in the community during regular microfinance meetings (intervention) or at a health facility during routine appointments (standard care). Community and facility care provided clinical evaluations, medications, and point-of-care testing. The trial enrolled 900 microfinance members, with data collected quarterly for 18-months. We used a two-part model to estimate intervention effects on microfinance shares purchased, and a negative binomial regression model to estimate differences in loan default rates between trial arms. We estimated effects overall and by participant characteristics. RESULTS: Participants' median age and distance from a health facility was 52 years and 5.6 km, respectively, and 50% reported earning less than $50 per month. The probability of saving any amount (>$0) through purchasing microfinance shares was 2.7 percentage points higher among microfinance group members receiving community vs. facility care. Community care recipients and facility care patients saved $44.90 and $25.24 over 18-months, respectively, and the additional amount saved by community care recipients was statistically significant (p = 0.036). Overall and in stratified analyses, loan defaults rates were not statistically significantly different between community and facility care patients. CONCLUSIONS: Receiving integrated care in the community was significantly associated with modest increases in savings. We did not find any significant association between community-delivered care and reductions in loan defaults among HIV-positive microfinance group members. Longer follow up examination and formal mediation analyses are warranted.

Properties of activated blended cement containing high content of calcined clay.

This paper presents findings of an experimental investigation on sodium sulphate (Na2SO4) activated calcined clay - Portland cement blends in sulphuric acid media. Calcined clays were blended with Ordinary Portland Cement (OPC) at replacement levels of 40% 45% and 50 % by mass of OPC to make blended cement labelled PCC40, PCC45 and PCC50 respectively. Initially, pozzolanicity and setting time tests were conducted. Mortar prisms measuring 40 mm × 40 mm × 160 mm were cast using 0.5M Na2SO4 solution and their compressive strengths determined on the 2nd, 7th, 28th and 90 th day of curing. The 28th day cured mortar prisms were subjected to porosity test. Moreover, 5 × 5 × 5 cm mortar cubes were also prepared and their weight and strength loss was taken as a measure of their acid resistivity after an immersion time of 7, 14, 28, 56, 84 and 120 days in 3 % of sulphuric acid at 23 ± 1 °C. OPC, commercial Portland Pozzolana Cement (PPC) and PCC40, PCC45 and PCC50 cement were cast using water and similarly investigated for comparison purposes. The results obtained showed that chemically activated cements exhibited higher pozzolanic activity, lower porosity, shorter setting times and higher resistance to acid attack compared to non-activated cements. However, OPC was found to be non-pozzolanic.

Cystic echinococcosis in Turkana, Kenya: 30 years of imaging in an endemic region.

Cystic echinococcosis (CE), a widespread, complex zoonosis, causes chronic disease associated with high morbidity. The pastoral Turkana people of Kenya have one of the highest prevalence rates of CE in the world. Between 1983 and 2015, a CE control program in the Turkana region used ultrasound (US) screening surveys and surgical outreach visits to evaluate CE prevalence and treat those with the disease. As the gold standard modality for diagnosing CE, US reveals a great deal of information about the disease in affected populations. The aim of this study is to discuss the characteristics of untreated CE in the Turkana people as revealed by US data collected during the CE control program and evaluate disease presentation, factors influencing the risk of transmission, and the timeline of disease progression. Data were obtained from written patient notes from US screenings and images; cysts were classified using the World Health Organization (WHO) standardized US classification of CE. Findings include greater prevalence of cysts, later stages of cysts, and multiple cysts in older age groups, with no multiple cysts occurring in patients under six years of age, which are consistent with the assertion that rates of exposure, transmission, and infection increase with age in endemic regions. Findings also raise questions regarding the timeline of disease progression, and factors potentially influencing disease transmission within this and other endemic populations. A comprehensive survey focusing on cultural and community observations (e.g., changing behaviors, hygienic practices, etc.) may provide more detailed information regarding factors that facilitate transmission.

Refining a questionnaire to assess breast cancer knowledge and barriers to screening in Kenya: Psychometric assessment of the BCAM.

BACKGROUND: Our study objective was to determine the validity and reliability of the breast module of a cancer awareness measure (BCAM) among adult women in western Kenya. METHODS: The study was conducted between October and November 2012, following three breast cancer screening events. Purposive and systematic random sampling methods were used to identity 48 women for cognitive focus group discussions, and 1061 (594 who attended vs. 467 who did not attend screening events) for surveys, respectively. Face and psychometric validity of the BCAM survey was assessed using cognitive testing, factor analysis of survey data, and correlations. Internal reliability was assessed using Cronbach's alpha. RESULTS: Among survey participants, the overall median age was 34 (IQR: 26-44) years. Compared to those women who did not attend the screening events, women attendees were older (median: 35 vs. 32 years, p = 0.001) more often married (79% vs. 72%, p = 0.006), more educated (52% vs. 46% with more than an elementary level of education, p = 0.001), more unemployed (59% vs. 11%, p = 0.001), more likely to report doing breast self-examination (56% vs. 40%, p = 0.001) and more likely to report having felt a breast lump (16% vs. 7%, p = 0.001). For domain 1 on knowledge of breast cancer symptoms, one factor (three items) with Eigen value of 1.76 emerged for the group that did not attend screening, and 1.50 for the group that attended screening. For both groups two factors (factor 1 "internal influences" and factor 2 "external influences") emerged among domain 4 on barriers to screening, with varied item loadings and Eigen values. There were no statistically significant differences in the factor scores between attendees and non-attendees. There were significant associations between factor scores and other attributes of the surveyed population, including associations with occupation, transportation type, and training for and practice of breast self-examination. Cronbach's alpha showed an acceptable internal consistency. CONCLUSION: Certain subpopulations are less likely than others to attend breast screening in Kenya. A survey measure of breast cancer knowledge and perceived barriers to screening shows promise for use in Kenya for characterizing clinical and community population beliefs, but needs adaptation for setting, language and culture.

Adapting ethical guidelines for adolescent health research to street-connected children and youth in low- and middle-income countries: a case study from western Kenya.

BACKGROUND: Street-connected children and youth (SCCY) in low- and middle-income countries (LMIC) have multiple vulnerabilities in relation to participation in research. These require additional considerations that are responsive to their needs and the social, cultural, and economic context, while upholding core ethical principles of respect for persons, beneficence, and justice. The objective of this paper is to describe processes and outcomes of adapting ethical guidelines for SCCY's specific vulnerabilities in LMIC. METHODS: As part of three interrelated research projects in western Kenya, we created procedures to address SCCY's vulnerabilities related to research participation within the local context. These consisted of identifying ethical considerations and solutions in relation to community engagement, equitable recruitment, informed consent, vulnerability to coercion, and responsibility to report. RESULTS: Substantial community engagement provided input on SCCY's participation in research, recruitment, and consent processes. We designed an assent process to support SCCY to make an informed decision regarding their participation in the research that respected their autonomy and their right to dissent, while safeguarding them in situations where their capacity to make an informed decision was diminished. To address issues related to coercion and access to care, we worked to reduce the unequal power dynamic through street outreach, and provided access to care regardless of research participation. CONCLUSIONS: Although a vulnerable population, the specific vulnerabilities of SCCY can to some extent be managed using innovative procedures. Engaging SCCY in ethical research is a matter of justice and will assist in reducing inequities and advancing their health and human dignity.

Impact of an educational intervention on breast cancer knowledge in western Kenya.

Our objective was to assess the effectiveness of educational sessions that accompanied breast cancer screening events in three communities in western Kenya between October and November 2013. Five hundred and thirty-two women were recruited to complete a test of breast cancer-relevant knowledge and randomly allocated to 'pre-test' or 'post-test' groups that immediately preceded or followed participation in the educational sessions. The education was organized as a presentation by health professionals and focused mainly on causes of breast cancer, early and late cancer presentation signs, high-risk groups, screening methods to find early-stage breast cancer, self-breast exam procedures and treatment options for this disease. Participants were invited to ask questions and practice finding nodules in silicone breast models. The median age was 35 years (interquartile range: 28-45), and 86% had not undergone breast cancer screening previously. Many individual items in our test of knowledge showed statistically significant shifts to better-informed responses. When all items in the assessment questionnaire were scored as a 'test', on average there was a 2.80 point (95% CI: 2.38, 3.22) significant improvement in knowledge about breast cancer after the educational session. Our study provides evidence for the effectiveness of an educational strategy carefully tailored for women in these communities in Kenya.

BARRIERS TO UPTAKE OF BREAST CANCER SCREENING IN KENYA.

OBJECTIVES: To conduct clinical breast cancer screening in three sites in Western Kenya and explore community barriers to screening uptake. DESIGN: Cross-sectional study. SETTING: Western Kenya specifically, Mosoriot, Turbo, and Kapsokwony. SUBJECTS: Community members (18 years and older) who did not attend the screening events. OUTCOME MEASURE: The outcome measure was having heard about the breast cancer screening events. Both structured and open-ended questions were used for data collection. Item frequency, correlations, and content analyses were performed. RESULTS: A total of 733 community members were surveyed (63% women, median age 33 years, IQR = 26-43). More than half (55%) of respondents had heard about the screening but did not attend. The majority of those who had heard about this particular screening had knowledge of screening availability in general (45% vs. 25%, p < 0.001). Only 8.0% of those who heard and 6.0% of those who had not heard of the screening event had previously undergone clinical breast exam (p = 0.20). Reasons for not attending the screening event were personal factors, including busy schedule (41.0%), perceived low personal risk (12.7%), lack of transport (4.2%), as well as health facility factors such as poor publicity (14.4%) and long queues (8.7%). CONCLUSION: Barriers to breast cancer screening uptake were associated with inadequate publicity, perceived long waits at event and busy lives among community women.

Profile of the female athlete triad among elite Kenyan endurance athletes and non-athletes

Women participating in endurance sports are at risk of presenting with low energy availability (EA), menstrual dysfunction (MD), and low bone mineral density (BMD), collectively termed the female athlete triad (FAT or TRIAD). Therefore, the purpose of the study was to determine the profile of the TRIAD among elite Kenyan female athletes and among non-athletes. There were 39 participants (athletes: 25, non-athletes:14) who provided the data for this study. Exercise energy expenditure (EEE) was deducted from energy intake (EI), and the remnant energy normalized to fat free mass (FFM) to determine energy availability (EA). Weight of all food and liquid consumed during three consecutive days determined EI. EEE was determined after isolating and deducting energy expended in exercise or physical activity above lifestyle from the total energy expenditure output as measured by Actigraph GT3X+. Dual energy x-ray absorptiometry (DXA) determined both FFM and BMD. Menstrual function was determined from a daily temperature-menstrual log kept by each participant for nine continuous months. Low EA (<45 kcal/kgFFM.d-1) was evident in 61.53% of the participants (athletes: 28.07 ±11.45 kcal/kgFFM.d-1, non-athletes: 56.97 ±21.38 kcal/kgFFM.d-1). The overall 36% MD seen among all participants was distributed as 40% among the athletes, and 29% among non-athletes. None of the athletes was amenorrheic. Low BMD was seen in 79% of the participants (athletes: 76%, non-athletes:86%). Overall, 10% of the participants (athletes: 4, non-athletes: 0) showed simultaneous presence of all three components of the TRIAD. The Independent sample t-test showed significant difference (t=5.860; p< 0.001) in prevalence of the TRIAD between athletes and non-athletes. The hypothesized higher prevalence of the TRIAD among athletes compared to non-athletes was partially accepted. To alleviate conditions arising from low EA, both athletes and their coaches need regular education on how to ensure they adequately meet specific dietary and nutritional requirements for their competition events

Association between energy availability and menstrual function in elite Kenyan runners

Low energy availability (EA) has been recognized as an instigator of menstrual dysfunction and subsequent hypoestrogenism that leads to deterioration in bone health. Elite Kenyan male athletes have been reported to often function under low energy balance. Therefore, the purpose of this study was to determine EA and menstrual function (MF) among elite Kenyan female athletes; and to explore the association between EA and MF in the athletes. The data were collected from 25 elite Kenyan runners and 14 non-athletes. Energy intake (EI) minus exercise energy expenditure (EEE) normalized to fat free mass (FFM) determined EA. EI was determined through weight of all food and liquid consumed over three consecutive days. EEE was determined after isolating and deducting energy expended in exercise or physical activity above lifestyle level from the total energy expenditure output as measured by Actigraph GT3X+. FFM was assessed using DXA. A daily temperature-menstrual log kept for nine continuous months was used to establish menstrual function. Overall, EA below 45 kcal/kgFFM.d-1 was seen in 61.53% of the participants (athletes: 28.07 ±11.45 kcal/kgFFM.d-1, non-athletes:56.97 ±21.38 kcal/kgFFM.d-1). Results on menstrual dysfunction were as follows: oligomenorrhea (athletes: 40%; non-athletes: 14.3%) and amenorrhea (non-athletes: 14.3%). None of the athletes were amenorrheic. Results did not show any significant association between EA and MF, but the low to sub-optimal EA among elite Kenyan female athletes raises concern for their future menstrual and bone health. . Educating the athletes and coaches will enhance achievement of the specific dietary and nutritional needs appropriate to their competition events

Factors Underlying Taking a Child to HIV Care: Implications for Reducing Loss to Follow-up among HIV-Infected and Exposed Children

Objective: With the aim of reducing pediatric loss to follow-up (LTFU) from HIV clinical care programs in sub-Saharan Africa; we sought to understand the personal and socio-cultural factors associated with the behavior of caregivers taking HIV-infected and -exposed children for care in western Kenya.Methods: Between Mayand August; 2010; in-depth interviews were conducted with 26 purposively sampled caregivers caring for HIVinfected(7); HIV-exposed (17) and HIV-unknown status (2) children; documented as LTFU from an urban and rural HIV care clinic. All were women with a majority (77) being biological parents. Interviews were audio-recorded; transcribed and content analyzed.Results: Thematic content analysis of the women's perceptions revealed that their decision about routinely taking their children to HIV care involved multiple levels of factors including: (1) intrapersonal: transport costs; food availability; time constraints due to work commitment; disclosure of HIV status for both mother and child; perception that child is healthy and religious beliefs; (2) interpersonal: unsupportive male partner; stigma by the family and family conflicts; (3) community: cultural norms; changing community dynamics and perceived stigma; (4) health care system: clinic location; lack of patient-centered care; delays at the clinic and different appointment schedules (mother and child). Furthermore; the factors across these different levels interacted with each other in a complex way; illustrating the challenges women face in taking their children to HIV care.Conclusion: The complexity and interconnectedness of the factors underlying retention of children in HIV care perceived by these women caregivers suggests that interventions to reduce pediatric LTFU need to be holistic and address multiple socio-ecological levels. Patient-centered care that integrates a family-centered approach to HIV pediatric care is recommended

Assessment of knowledge, attitudes and practices of infant feeding in the context of HIV: a case study from western Kenya.

Guidelines for infant feeding options among HIV-positive mothers are changing with informative research. Cultural factors, socialisation processes, gender dimensions and socio-economic status within communities should be considered in recommending feasible and sustainable options. The objective of this study was to assess the knowledge, attitudes and practices with regards to infant feeding in the context of HIV. A cross-sectional study was conducted between November 2003 and January 2004. The study was carried out in Kosirai Division, Nandi-North District, in western Kenya. The target population was community members aged 18 - 45 years and key informants aged 18 years and above. Structured questionnaires and in-depth interviews were used to collect data. Multistage and snowball sampling methods were used to identify study participants. Quantitative data were analysed using the SPSS statistical package for social scientists (Version 12). Cross-tabulations were calculated and Pearson's chi-square test used to test significance of relationships between categorical variables. Recorded qualitative data were transcribed and coded. Themes were developed and integrated. A generation of concepts was used to organise the presentation into summaries, interpretations and text. A total of 385 individuals participated in the survey, 50% of whom were women. There were 30 key informants. Farming was the main source of income but half of the women (49.7% ) had no income. Most of the respondents (85.5% ) knew of breastfeeding as a route of HIV transmission with sex (p=0.003) and age (p=0.000) being highly associated with this knowledge. Breastfeeding was the norm although exclusive breastfeeding was not practised. Cow's milk, the main breast milk substitute, was reported as being given to infants as early as two weeks. It was the most popular (93.5% ) infant feeding option in the context of HIV/AIDS. Heating expressed milk, wet nursing and milk banks were least preferred. Thus, the social, cultural and psychological complexity of infant feeding practices should be taken into account when advocating appropriate infant feeding options. Further research is required to determine the safety of using cow's milk as an infant feeding option. Community engagement, including education and awareness strategies, specific to the benefits of exclusive breastfeeding as a mechanism to reduce the risk of HIV transmission is urgently needed.

Partial involvement of c-jun protooncogene in growth enhancing and cytotoxic effects of lithium in vitro.

The AP-1 transcription factor is comprised of homo- and heterodimers of the Fos and Jun families of proteins. Literature reports indicate that AP-1 is activated in lithium treated mammalian cells suggesting a role in lithium induced growth stimulation and apoptosis. In these studies, an antisense c-jun plasmid blocked the stimulation of HL-60 cell growth by lithium. Furthermore, antisense c-jun caused a 60% reduction in cell viability at 48 hr post-transfection but did not influence DNA fragmentation in the presence of lithium. The levels of c-jun mRNA, as determined by RT-PCR, were not affected by lithium treatment. Nevertheless, 12-O-tetradecanoyl-phorbol-13-acetate (TPA) blocked the induction of apoptosis by lithium suggesting the involvement of the protein kinase C (PKC) signaling pathway. In RAJI cells, antisense c-jun mimicked lithium by inhibiting cell proliferation with only a marginal loss in cell viability. This study therefore suggests that PKC is involved in the effects of lithium on cells in culture and provides evidence for differential effects of antisense c-jun on hemotopoietic lineages.

Cytotoxicity of novel trifluoromethylquinoline derivatives on human leukemia cells.

This report is a comparative study of the in vitro cell-growth inhibitory activity of six new trifluoromethylquinoline derivatives on human promyelocytic leukemic cells and the evaluation of their DNA binding characteristics. 2,8-Bis(trifluoromethyl)quinoline-4-(N(4)-ethyl-5-nitroimidazolo)methylene ketone shows the highest cell-growth inhibitory activity with IC(50) of 10+/-2.5 microM, causes extensive changes in the morphology of the HL-60 cells and appears to induce apoptosis. The other compounds are only moderately growth-inhibitory, while 8-trifluoromethylquinoline-4-(N(4)-ethyl-5-nitroimidazolo)methylene ketone is actually stimulatory to cell growth. Except for the latter, the cell growth inhibitory activity of these compounds appears to be due their ability to bind to and intercalate DNA.

Hepatic cyst in a Turkana woman - case report.

An unusual case of hepatic hydatid cyst in a 27-year old female is reported. The patient had abdominal distention of 10-year duration, pain, pallor of mucous membranes, and was grossly wasted. Ultrasonography revealed a large hydatid cyst that covered most of the abdomen. A successful surgical intervention was performed and 24 litres of hydatid fluid drained.

Airborne surgical outreach services in eastern Africa.

BACKGROUND: African Medical and Research Foundation (AMREF) has for forty years offered airborne specialist surgeons or surgical teams to supplement the major surgery conducted by local hospital staff, particularly in Kenya and Tanzania. OBJECTIVE: To quantify and qualitatively describe the contribution of airborne surgical outreach services in relation to the total surgical output of remote rural hospitals in Kenya and Tanzania. DATA SOURCES: Surgical theatre registration books of one government and two church/mission owned hospitals in Kenya and Tanzania from 1994 to 1995; and service records kept by the surgeons during outreach trips in the same period. RESULTS: AMREF contributed 15.1% of all major operations, and operations performed by AMREF were relatively complex. The average number of AMREF's major operations performed per visit was 17 and per visit day 4.3. Numerous minor operations and examinations, ward rounds and an average of 10 patient consultations per day were done during the visits. CONCLUSIONS: Total population-based operation rates, and rates by sex and age, are useful indicators for monitoring and comparison. Every hospital should report, annually, major operations performed by type and by age and sex of patients, with special mention of operations and consultations performed by visiting teams, if any. Each hospital should also state the estimated population of its current catchment area.

Cellular immunity to Echinococcus granulosus cysts

A fundamental feature of Echinococcus granulosus infection is its chronicity. There are many reasons for this; including weak natural immunity and the ability of the larval stages to evade or resist elimination by the hosts' specific immune responses. To identify the types of hosts' cellular immune response; a series of ultrastructral studies of hydatid cysts surgically removed from Turkana patients was conducted based on transmission electron microscopy. Ultrastructurally; the ectocyst (adventitial layer) is organised into three layers; an inner layer containing mainly the infiltrating mononuclear leukocytes; a middle; loose connective tissue layer with inflammatory cells mainly plasma cells; fibroblasts; scant neutrophils; eosinophils and lymphocytes; and an outer loose connective tissue layer that blends with the surrounding host tissue. The mast cells and basophils were not observed. This study has showm that the adventitial layer of hydatid cysts infiltrated by leukocytes; principally by macrophages and plasma cells

Echinococcus granulosus: ultrastructural effect of albendazole therapy.

The effects of the anthelmintic Albendazole against Echinococcus granulosus hydatid cysts in Turkana patients given orally were studied by means of ultrasound as well as light microscopy, scanning and transmission electron microscopy. The treatment generally reduced the size of the cyst mass, making the patients feel well. The drug therapy caused collapse of the cyst wall and daughter cyst. The pathological changes on the germinal layer of Albendazole-treatment cysts differed widely from the untreated control hydatid tissue. The effects included morphological changes of the protoscolices, presence of lamellated bodies, necrosis with detachment of the germinal layer from the laminated layer. However, some parts of the Albendazole-treated hydatid tissue remained unaffected.