A process evaluation of the Communication for Healthy Communities adolescent health program in Uganda.

This study is a process evaluation of an adolescent-focused intervention of the USAID Communication for Healthy Communities program, in Uganda. We used mixed methods including observation, consultations and review of program documents to collect data on program coverage, reach and factors influencing implementation. Findings show that program activities were successfully implemented through collaborative partnerships with service partners and the community. Interpersonal communication complemented by mass-media messaging was effective in reaching and empowering adolescents with health information to make informed choices for behavior change. The program used theoretical frameworks to guide targeted interventions through audience segmentation and community empowerment. Targeted mass-media messaging and placement was found to be pertinent for program reach. Working through existing community structures is important for an effective reach of health promotion programs. Lessons identified for scaling-up adolescent health programs include the need to harmonize training and deployment of community champions by development partners, recruit audience-specific influential champions and link income-generating activities to health education interventions. There is thus need to collaboratively develop and institutionalize effective monitoring and evaluation strategies during program inception and design phases for appropriate accountability, ownership and a continuation of gains.

A Qualitative Description of Community Participation in Water and Sanitation Activities in the Control of Schistosomiasis in Nyalenda B, an Informal Settlement in Kisumu City, Western Kenya.

BACKGROUND: Community participation is central to the success of primary health care. However, over 30 years since the Alma Ata declaration, the absence of universal community participation remains a major obstacle to combating all types of diseases. This study investigated community participation in water and sanitation activities towards schistosomiasis control in Nyalenda B, an informal settlement in Kisumu City. METHODS: Eight key informant interviews (KIIs) and 8 focus group discussions (FGDs) were conducted. Additionally, data on NGOs dealing with water and sanitation activities in Kisumu was collected from the local NGO registration Board. Qualitative data was organised into themes and concepts and analyzed using Atlas.ti. RESULTS: Most participants felt that project implementers did not involve them in key levels of project implementation, leading to unsustainable projects and unacceptance from the community. Community structures identified that could be used as avenues of engaging the community in improving water and sanitation situation included the use of organised groups, such as youth, gender-based, farmers and HIV support groups, and merry-go-rounds. Factors mentioned that hindered community participation included negative attitude from community members, poor monitoring and evaluation strategies, limited disclosure of project details, and overdependence from the community. CONCLUSION: Effective community participation in water and sanitation activities requires a multipronged paradigm that incorporates a change of attitude from the community, information sharing and consultation, improved monitoring and evaluation, transparency and accountability.

Options for sustaining solar-powered mosquito trapping systems on Rusinga Island, Western Kenya: a social dilemma analysis.

BACKGROUND: In 2012, a donor-supported proof of principle study was launched to eliminate malaria from Rusinga Island, western Kenya, using solar-powered mosquito trapping systems (SMoTS). SMoTS, which also provided power for room lighting and charging mobile telephones, were installed in houses. In view of the involvement of individual and collective benefits, as well as individual and collective maintenance solutions, this study qualitatively examined preferences of some project stakeholders towards SMoTS sustainability components to see if and how they related to social dilemma factors. METHODS: The data were collected through participant observation, semi-structured interviews and focus group discussions. RESULTS: The results show that respondents largely preferred individual solutions to various aspects of maintenance. Selective collective solutions such as table banking groups were considered positively for mobilising financial resources for maintenance, but respondents were hardly willing to contribute financially to a collective entity. Few people saw a meaningful role for a collective governing body; people preferred to rely on individual household responsibility and private service delivery for repairs and stocking spare parts. An overriding concern was that people lacked trust in other community members, leaders and/or technicians who would be employed by a governing body. Respondents also had little confidence that a governing body or saving group could effectively impose sanctions to misappropriation of funds, poor leadership, defecting group members or technicians that might abuse a salaried position. CONCLUSION: There seemed to be linkages between preferences towards organising various components of SMoTS sustainability and known hindrances to addressing social dilemmas. This posed considerable challenges to organising the sustainability of this innovative malaria control strategy. TRIAL REGISTRATION: NTR3496 .

Application of Core Processes for Understanding Multiple Concurrent Sexual Partnerships Among Adolescents in Uganda.

Introduction: Adolescents in Uganda, as in other sub-Saharan countries, engage in sex with multiple concurrent partners, thus placing them at risk for HIV and unplanned pregnancies, but it is not clear why. This study explored why adolescents in Uganda engage in multiple concurrent sexual partnerships (MCSP). Methods: This study used a Core Processes methodology. We used the processes of brainstorming, and identification of evidence and theoretical support, in various phases/steps of intervention planning, to provide possible explanations for adolescent MCSP. Results: Adolescents were found to have limited knowledge of the risks associated with MCSP and perceived a low risk for HIV. Peer influence to engage in MCSP exacerbated the problem among adolescents. Poor communication with sexual partners and parents and societal indifference to multiple sexual partnerships increased permissive attitudes toward infidelity. The unclear adolescent sexual and reproductive health policies hampered access to services, and transactional sexual relationships with older (polygamous) sexual partners increased the HIV risk. Adolescents were found to be more concerned about unplanned pregnancies than HIV risk. Discussion: From the empirical evidence, adolescent health programs in Uganda should incorporate comprehensive sexual health education on HIV and teenage pregnancy risk-reduction strategies. Programs should strengthen parental and community support through enhanced collaborative training on communication with and for adolescents. Forming strategic partnerships with various stakeholders for concerted efforts to address the MCSP problem among adolescents is critical.

Community-based biological control of malaria mosquitoes using Bacillus thuringiensis var. israelensis (Bti) in Rwanda: community awareness, acceptance and participation.

BACKGROUND: Targeting the aquatic stages of malaria vectors via larval source management (LSM) in collaboration with local communities could accelerate progress towards malaria elimination when deployed in addition to existing vector control strategies. However, the precise role that communities can assume in implementing such an intervention has not been fully investigated. This study investigated community awareness, acceptance and participation in a study that incorporated the socio-economic and entomological impact of LSM using Bacillus thuringiensis var. israelensis (Bti) in eastern Rwanda, and identified challenges and recommendations for future scale-up. METHODS: The implementation of the community-based LSM intervention took place in Ruhuha, Rwanda, from February to July 2015. The intervention included three arms: control, community-based (CB) and project-supervised (PS). Mixed methods were used to collect baseline and endline socio-economic data in January and October 2015. RESULTS: A high perceived safety and effectiveness of Bti was reported at the start of the intervention. Being aware of malaria symptoms and perceiving Bti as safe on other living organisms increased the likelihood of community participation through investment of labour time for Bti application. On the other hand, the likelihood for community participation was lower if respondents: (1) perceived rice farming as very profitable; (2) provided more money to the cooperative as a capital; and, (3) were already involved in rice farming for more than 6 years. After 6 months of implementation, an increase in knowledge and skills regarding Bti application was reported. The community perceived a reduction in mosquito density and nuisance biting on treated arms. Main operational, seasonal and geographical challenges included manual application of Bti, long working hours, and need for transportation for reaching the fields. Recommendations were made for future scale-up, including addressing above-mentioned concerns and government adoption of LSM as part of its vector control strategies. CONCLUSIONS: Community awareness and support for LSM increased following Bti application. A high effectiveness of Bti in terms of reduction of mosquito abundance and nuisance biting was perceived. The study confirmed the feasibility of community-based LSM interventions and served as evidence for future scale-up of Bti application and adoption into Rwandan malaria vector control strategies.

Using an intervention mapping approach for planning, implementing and assessing a community-led project towards malaria elimination in the Eastern Province of Rwanda.

BACKGROUND: Active community participation in malaria control is key to achieving malaria pre-elimination in Rwanda. This paper describes development, implementation and evaluation of a community-based malaria elimination project in Ruhuha sector, Bugesera district, Eastern province of Rwanda. METHODS: Guided by an intervention mapping approach, a needs assessment was conducted using household and entomological surveys and focus group interviews. Data related to behavioural, epidemiological, entomological and economical aspects were collected. Desired behavioural and environmental outcomes were identified concurrently with behavioural and environmental determinants. Theoretical methods and their practical applications were enumerated to guide programme development and implementation. An operational plan including the scope and sequence as well as programme materials was developed. Two project components were subsequently implemented following community trainings: (1) community malaria action teams (CMATs) were initiated in mid-2014 as platforms to deliver malaria preventive messages at village level, and (2) a mosquito larval source control programme using biological substances was deployed for a duration of 6 months, implemented from January to July 2015. Process and outcome evaluation has been conducted for both programme components to inform future scale up. RESULTS: The project highlighted malaria patterns in the area and underpinned behavioural and environmental factors contributing to malaria transmission. Active involvement of the community in collaboration with CMATs contributed to health literacy, particularly increasing ability to make knowledgeable decisions in regards to malaria prevention and control. A follow up survey conducted six months following the establishment of CMATs reported a reduction of presumed malaria cases at the end of 2014. The changes were related to an increase in the acceptance and use of available preventive measures, such as indoor residual spraying and increase in community-based health insurance membership, also considered as a predictor of prompt and adequate care. The innovative larval source control intervention contributed to reduction in mosquito density and nuisance bites, increased knowledge and skills for malaria control as well as programme ownership. CONCLUSION: This community-based programme demonstrated the feasibility and effectiveness of active community participation in malaria control activities, which largely contributed to community empowerment and reduction of presumed malaria in the area. Further studies should explore how gains may be sustained to achieve the goal of malaria pre-elimination.

The effect of mass mosquito trapping on malaria transmission and disease burden (SolarMal): a stepped-wedge cluster-randomised trial.

BACKGROUND: Odour baits can attract host-seeking Anopheles mosquitoes indoors and outdoors. We assessed the effects of mass deployment of odour-baited traps on malaria transmission and disease burden. METHODS: We installed solar-powered odour-baited mosquito trapping systems (SMoTS) to households on Rusinga Island, Lake Victoria, western Kenya (mean population 24 879), in a stepped-wedge cluster-randomised trial. All residents in the completed health and demographic surveillance system were eligible to participate. We used the travelling salesman algorithm to assign all households to a cluster (50 or 51 geographically contiguous households); nine contiguous clusters formed a metacluster. Initially, no cluster had SMoTS (non-intervened). During the course of the intervention roll-out SMoTS were gradually installed cluster by cluster until all clusters had SMoTS installed (intervened). We generated 27 cluster randomisations, with the cluster as unit of randomisation, to establish the order to install the traps in the clusters until all had a SMoTS installed. Field workers and participants were not masked to group allocation. The primary outcome of clinical malaria was monitored through repeated household visits covering the entire population, once before roll-out (baseline) and five times throughout the 2-year roll-out. We measured clinical malaria as fever plus a positive result with a rapid diagnostic test. The SolarMal project was registered on the Dutch Trial Register (NTR 3496). FINDINGS: We enrolled 34 041 participants between April 25, 2012, and March 23, 2015, to 81 clusters and nine metaclusters. 4358 households were provided with SMoTS during roll-out between June 3, 2013, and May 16, 2015. 23 clinical malaria episodes were recorded in intervened clusters and 33 episodes in non-intervened clusters (adjusted effectiveness 40·8% [95% CI -172·8 to 87·1], p=0·5) during the roll-out. Malaria prevalence measured by rapid diagnostic test was 29·8% (95% CI 20·9-38·0) lower in SMoTS clusters (prevalence 23·7%; 1552 of 6550 people) than in non-intervened clusters (prevalence 34·5%; 2002 of 5795 people). INTERPRETATION: The unexpectedly low clinical incidence of malaria during roll-out led to an imprecise estimate of effectiveness from the clinical incidence data. The substantial effect on malaria prevalence is explained by reduction in densities of Anopheles funestus. Odour-baited traps might be an effective malaria intervention. FUNDING: COmON Foundation.

Mass mosquito trapping for malaria control in western Kenya: study protocol for a stepped wedge cluster-randomised trial.

BACKGROUND: Increasing levels of insecticide resistance as well as outdoor, residual transmission of malaria threaten the efficacy of existing vector control tools used against malaria mosquitoes. The development of odour-baited mosquito traps has led to the possibility of controlling malaria through mass trapping of malaria vectors. Through daily removal trapping against a background of continued bed net use it is anticipated that vector populations could be suppressed to a level where continued transmission of malaria will no longer be possible. METHODS/DESIGN: A stepped wedge cluster-randomised trial design was used for the implementation of mass mosquito trapping on Rusinga Island, western Kenya (the SolarMal project). Over the course of 2 years (2013-2015) all households on the island were provided with a solar-powered mosquito trapping system. A continuous health and demographic surveillance system combined with parasitological surveys three times a year, successive rounds of mosquito monitoring and regular sociological studies allowed measurement of intervention outcomes before, during and at completion of the rollout of traps. Data collection continued after achieving mass coverage with traps in order to estimate the longer term effectiveness of this novel intervention. Solar energy was exploited to provide electric light and mobile phone charging for each household, and the impacts of these immediate tangible benefits upon acceptability of and adherence to the use of the intervention are being measured. DISCUSSION: This study will be the first to evaluate whether the principle of solar-powered mass mosquito trapping could be an effective tool for elimination of malaria. If proven to be effective, this novel approach to malaria control would be a valuable addition to the existing strategies of long-lasting insecticide-treated nets and case management. Sociological studies provide a knowledge base for understanding the usage of this novel tool. TRIAL REGISTRATION: Trialregister.nl: NTR3496 - SolarMal. Registered on 20 June 2012.

Determinants of prompt and adequate care among presumed malaria cases in a community in eastern Rwanda: a cross sectional study.

BACKGROUND: In order to understand factors influencing fever/malaria management practices among community-based individuals, the study evaluated psychosocial, socio-demographic and environmental determinants of prompt and adequate healthcare-seeking behaviours. METHODS: A quantitative household (HH) survey was conducted from December 2014 to February 2015 in Ruhuha sector, Bugesera district in the Eastern province of Rwanda. HHs that reported having had at least one member who experienced a fever and/or malaria episode in the previous 3 months prior to the study were included in the analysis. Healthcare-seeking behaviours associated with the last episode of illness were analysed. Socio-demographic, health facility access, long-lasting insecticidal-treated nets (LLINs), data on malaria knowledge, data and theory of planned behaviour (TPB) related variables (attitudes, subjective norms, perceived behavioural control) with regard to fever/malaria healthcare seeking, were collected. The primary outcome was prompt and adequate care defined as: (1) seeking advice or treatment at a health facility (health centre or hospital) or from a community health worker (CHW); (2) advice or treatment seeking within same/next day of symptoms onset; (3) received a laboratory diagnosis; (4) received advice or treatment; and, (5) reported completing the prescribed dose of medication. Determinants of prompt and adequate care among presumed malaria cases were evaluated using a logistic regression analysis. RESULTS: Overall, 302 (21 %) of the 1410 interviewed HHs reported at least one member as having experienced a fever or malaria within the 3 months prior to the survey. The number of HHs (where at least one member reported fever/malaria) that reported seeking advice or treatment at a health facility (health centre or hospital) or from a CHW was 249 (82.4 %). Of those who sought advice or treatment, 87.3 % had done so on same/next day of symptoms developing, 82.8 % received a laboratory diagnosis, and more than 90 % who received treatment reported completing the prescribed dosage. Prompt and adequate care was reported from 162 of the 302 HHs (53.6 %) that experienced fever or malaria for one or more HH members. Bivariate analyses showed that head of household (HoH)-related characteristics including reported knowledge of three or more malaria symptoms, having health insurance, being able to pay for medical services, use of LLINs the night before the survey, having a positive attitude, perceiving social support, as well as a high-perceived behavioural control with regard to healthcare seeking, were all significantly associated with prompt and adequate care. In the final logistic regression model, a high-perceived behavioural control (odds ratio (OR) 5.068, p = 0.042), having a health insurance (OR 2.410, p = 0.044) and having knowledge of malaria symptoms (OR 1.654, p = 0.049) significantly predicted prompt and adequate care. CONCLUSIONS: To promote prompt and adequate care seeking for malaria in the area, particular emphasis should be placed on community-focused strategies that promote early malaria symptom recognition, increased health insurance coverage and enhanced perceived behavioural control with regard to healthcare-seeking.

Factors impeding the acceptability and use of malaria preventive measures: implications for malaria elimination in eastern Rwanda.

BACKGROUND: Long-lasting insecticidal nets (LLIN), indoor residual spraying (IRS) and malaria case treatment with artemisinin-based combination therapy (ACT) have been proven to significantly reduce malaria, but may not necessarily lead to malaria elimination. This study explored factors hindering the acceptability and use of available malaria preventive measures to better inform area specific strategies that can lead to malaria elimination. METHODS: Nine focus group discussions (FGD) covering a cross-section of 81 lay community members and local leaders were conducted in Ruhuha, Southern Eastern Rwanda in December 2013 to determine: community perceptions on malaria disease, acceptability of LLIN and IRS, health care-seeking behaviours and other malaria elimination strategies deployed at household and environmental levels. Discussions were recorded in Kinyarwanda, transcribed into English and coded using Nvivo 10 software. RESULTS: Participants ranked malaria as the top among five common diseases in the Ruhuha sector. Participants expressed comprehensive knowledge and understanding of malaria transmission and symptoms. The concept of malaria elimination was acknowledged, but challenges were reported. Sleeping under a bed net was negatively affected by increase of bedbugs (and the associated irritability) as well as discomfortable warmness particularly during the dry season. These two factors were reported as common hindrances of the use of LLIN. Also, widespread use of LLIN in constructing chicken pens or as fences around vegetable gardens was reported. Participants also reported that IRS appeared to lead to an increase in number of mosquitoes and other household bugs rather than kill them. Prompt health centre utilization among participants with presumed malaria was reported to be common particularly among subscribers to the subsidized community-based health insurance (CBHI) scheme. In contrast, the lack of CBHI and/or perceptions that health centre visits were time consuming were common reasons for the use of over-the-counter medicines for malaria management. CONCLUSION: In this study, identification of behavioural determinants in relation to LLIN use, IRS acceptability and health care seeking is a critical step in the development of effective, targeted interventions aiming to further reduce malaria transmission and elimination in the area.

Combining malaria control with house electrification: adherence to recommended behaviours for proper deployment of solar-powered mosquito trapping systems, Rusinga Island, western Kenya.

OBJECTIVE: To investigate community adherence to recommended behaviours for proper deployment of solar-powered mosquito trapping systems (SMoTS) after 3- to 10-week use. METHODS: Solar-powered mosquito trapping system, which also provided power for room lighting and charging mobile phones, were installed in houses in Rusinga Island, western Kenya. We used a structured checklist for observations and a semi-structured questionnaire for interviews in 24 homesteads. We also analysed the subject of 224 community calls to the project team for technical maintenance of SMoTS. RESULTS: Most respondents cared for SMoTS by fencing, emptying and cleaning the trap. Our observations revealed that most traps were fenced, clean and in good working condition. A significantly higher proportion of community calls was lighting-related. Lighting was the main reason respondents liked SMoTS because it reduced or eliminated expenditure on kerosene. However, some respondents observed they no longer heard sounds of mosquitoes inside their houses. All respondents reportedly slept under insecticide-treated nets (ITNs) before receiving SMoTS. After receiving SMoTS, most respondents reportedly continued to use ITNs citing that the project advised them to do so. Some beach residents stopped using ITNs because they no longer heard mosquitoes or due to heat discomfort caused by lights. CONCLUSION: Electricity-related incentives played a greater role in encouraging adherence to recommended behaviours for proper deployment of SMoTS than the potential health benefits in the early stages of the intervention. Although energy-related financial incentives may play a role, they are insufficient to ensure adherence to health advice, even in the short term. Ongoing community engagement and research monitors and addresses adherence to recommended behaviours including continuation of current malaria control strategies.

Tracking the mutual shaping of the technical and social dimensions of solar-powered mosquito trapping systems (SMoTS) for malaria control on Rusinga Island, western Kenya.

BACKGROUND: There has been increasing effort in recent years to incorporate user needs in technology design and re-design. This project employed a bottom-up approach that engaged end users from the outset. Bottom-up approaches have the potential to bolster novel interventions and move them towards adaptive and evidence-based strategies. The present study concerns an innovative use of solar-powered mosquito trapping systems (SMoTS) to control malaria in western Kenya. Our paper highlights the co-dependence of research associated with the development of the SMoTS technology on one hand and research for enhancing the sustainable uptake of that very same intervention within the community on the other. METHODS: During the pre-intervention year, we examined the design, re-design and piloting of a novel technology to generate lessons for malaria elimination on Rusinga Island. Initial ideas about many technological necessities were evaluated and re-designed following feedback from various sources, including technical and social research as well as broader interactions with the social environment. We documented the interlocking of the multiple processes and activities that took place through process observation and document reviews. We analysed the data within the conceptual framework of system innovation by identifying mutual shaping between technical and social factors. RESULTS: Our findings illustrate how various project stakeholders including project staff, collaborators, donor, and community members simultaneously pursued interdependent technological transformations and social interests. In the ongoing process, we observed how partial outcomes in the technological domain influenced social events at a later phase and vice versa. CONCLUSIONS: Looking at malaria intervention projects employing novel technologies as niches that may evolve towards system innovation, helps to reveal interrelations between the various technical and social aspects. Revealing these interrelations requires a different role for research and different perspective on innovation where innovation is more than the technical aspects. This approach therefore requires that research is designed in a way that enables obtaining feedback from both aspects.

Community mobilization for malaria elimination: application of an open space methodology in Ruhuha sector, Rwanda.

BACKGROUND: Despite the significant reduction of malaria transmission in Rwanda, Ruhuha sector is still a highly endemic area for malaria. The objective of this activity was to explore and brainstorm the potential roles of various community stakeholders in malaria elimination. METHODS: Horizontal participatory approaches such as 'open space' have been deployed to explore local priorities, stimulate community contribution to project planning, and to promote local capacity to manage programmes. Two open space meetings were conducted with 62 and 82 participants in years 1 and 2, respectively. Participants included purposively selected community and local organizations' representatives. RESULTS: Malaria was perceived as a health concern by the respondents despite the reported reduction in prevalence from 60 to 20% for cases at the local health centre. Some misconceptions of the cause of malaria and misuse of preventive strategies were noted. Poverty was deemed to be a contributing factor to malaria transmission, with suggestions that improvement of living conditions for poor families might help malaria reduction. Participants expressed willingness to contribute to malaria elimination and underscored the need for constant education, sensitization and mobilization towards malaria control in general. Active diagnosis, preventative strategies and prompt treatment of malaria cases were all mentioned by participants as ways to reduce malaria. Participants suggested that partnership of stakeholders at various levels could speed up programme activities. A community rewards system was deemed important to motivate engaged participants, i.e., community health workers and households. Establishment of malaria clubs in schools settings was also suggested as crucial to speed up community awareness and increase skills towards further malaria reduction. CONCLUSIONS: This bottom-up approach was found useful in engaging the local community, enabling them to explore issues related to malaria in the area and suggest solutions for sustainable malaria elimination gains.

Low levels of awareness despite high prevalence of schistosomiasis among communities in Nyalenda informal settlement, Kisumu city, western Kenya.

INTRODUCTION: Intestinal schistosomiasis is widely distributed around Lake Victoria in Kenya where about 16 million people in 56 districts are at risk of the infection with over 9.1 million infected. Its existence in rural settings has been extensively studied compared to urban settings where there is limited information about the disease coupled with low level of awareness. This study therefore assessed community awareness on existence, signs and symptoms, causes, transmission, control and risk factors for contracting schistosomiasis as well as attitudes, health seeking behaviour and environmental antecedents that affect its control so as to identify knowledge gaps that need to be addressed in order to strengthen schistosomiasis control interventions in informal urban settings. METHODS: The study was carried out in an informal urban settlement where the prevalence of intestinal schistosomiasis was previously reported to be the highest (36%) among the eight informal settlements of Kisumu city. The study adopted cross-sectional design and purposive sampling technique. Eight focus group discussions were conducted with adult community members and eight key informant interviews with opinion leaders. Data was audio recorded transcribed, coded and thematically analyzed using ATLAS.ti version 6 software. RESULTS: Most respondents stated having heard about schistosomiasis but very few had the correct knowledge of signs and symptoms, causes, transmission and control of schistosomiasis. However, there was moderate knowledge of risk factors and at high risk groups. Their attitudes towards schistosomiasis and its control were generally indifferent with a general belief that they had no control over their environmental circumstances to reduce transmission. DISCUSSION/CONCLUSION: Although schistosomiasis was prevalent in the study area, majority of the people in the community had low awareness. This study, therefore, stresses the need for health education to raise community's awareness on schistosomiasis in such settings in order to augment prevention, control and elimination efforts.

Community knowledge, attitudes and practices on schistosomiasis in western Kenya--the SCORE Project.

In an effort to improve intervention strategies, community knowledge, attitudes, and practices on schistosomiasis were evaluated using focus group discussions involving 237 participants, in eight Schistosoma mansoni high prevalence districts in rural Nyanza Province, Kenya. The majority of participants reported having heard about schistosomiasis through schools, posters, radio announcements, and community gatherings. Participants had a variety of beliefs about contracting schistosomiasis, including associating it with dirty drinking water and uncooked or contaminated food. Avenues for seeking treatment included health centers, spiritual intervention, herbal treatments, and medicine shops, with health centers receiving the most mention. Barriers to schistosomiasis control included attitudes of community members toward the infection, especially misconceptions that lead to stigma and the perception that diagnosis and treatment are expensive. Schools were the most common avenue for receiving information, suggesting that the existing education infrastructure can be used for health education and improved sensitization about schistosomiasis control programs.

Cultural practices and sexual risk behaviour among adolescent orphans and non-orphans: a qualitative study on perceptions from a community in Western Kenya.

BACKGROUND: This study explored community perceptions of cultural beliefs and practices that may increase sexual risk behaviour of adolescents, to understand more about meaning they hold within the culture and how they expose adolescent orphans and non-orphans to higher risks in a high HIV and teenage pregnancy prevalence context. METHODS: Using a qualitative descriptive cross-sectional design 14 focus group discussions were conducted with 78 adolescents and 68 parents/guardians purposively selected to represent their communities. Thirteen key informant interviews were also conducted with community leaders, health care and child welfare workers, and adolescents who were also selected purposively. The two methods were used to explore how cultural beliefs and practices predispose adolescent orphans and non- orphans to risky sexual behaviours. Data were analysed through line-by-line coding, grouped into families and retrieved as themes and sub-themes. RESULTS: Identified cultural practices that predisposed adolescents orphans and non-orphans to risky sexual behaviours included: adolescent sleeping arrangements, funeral ceremonies, replacing a deceased married daughter with her younger sister in marriage, widow inheritance among boys, early marriage among girls, and preference for boys/sons. Cultural risks perceived to equally affect both orphans and non-orphans were sleeping arrangements, funeral ceremonies, and sister replacement. Factors associated more with orphans than non-orphans were widow inheritance among boys and a preference for boy over girl children. CONCLUSIONS: Adolescent sexual risk reduction programs should be developed considering the specific cultural context, using strategies that empower communities to challenge the widely accepted cultural norms that may predispose young people in general to sexual risks while targeting those that unequally influence orphans.

Understanding orphan and non-orphan adolescents' sexual risks in the context of poverty: a qualitative study in Nyanza Province, Kenya.

BACKGROUND: Some studies show orphanhood to be associated with increased sexual risk-taking while others have not established this relationship, but have found factors other than orphanhood as predictors of sexual risk behaviours and outcomes among adolescents. This study examines community members' perceptions of how poverty influences adolescent sexual behaviour and outcomes in four districts of Nyanza Province, Kenya. METHODS: Eight study sites within the four districts were randomly selected. Focus group discussions were conducted with a purposive sample of adolescents, parents and caregivers. Key informant interviews were undertaken with a purposive sample of community leaders, child welfare and healthcare workers, and adolescents. The two methods elicited information on factors perceived to predispose adolescent orphans and non-orphans to sexual risks. Data were analysed through line-by-line coding, grouped into families and retrieved as themes and sub-themes. RESULTS: Participants included 147 adolescents and parents/caregivers in 14 focus groups and 13 key informants. Poverty emerged as a key predisposing factor to sexual risk behaviour among orphans and non-orphans. Poverty was associated with lack of food, poor housing, school dropout, and engaging in income generating activities, all of which increase their vulnerability to transactional sex, early marriage, sexual experimentation, and the eventual consequences of increased risk of unintended pregnancies and STI/HIV. CONCLUSION: Poverty was perceived to contribute to increasing sexual risks among orphan and non-orphan adolescents through survival strategies adopted to be able to meet their basic needs. Policies for prevention and intervention that target adolescents in a generalized poverty and HIV epidemic should integrate economic empowerment for caregivers and life skills for adolescents to reduce vulnerabilities of orphan and non-orphan adolescents to sexual risk behaviour.

Risky sexual behavior among orphan and non-orphan adolescents in Nyanza Province, Western Kenya.

A household survey of male and female adolescents was conducted to establish whether orphanhood or other factors contribute to risky sexual behavior. Results show that orphanhood was not associated with risky sexual behavior. Sleeping in a different house from the household head and attending social activities at night were positively associated with sexual activity and transactional sex among boys and girls. Older adolescents were more likely to be sexually active while urban residents, and those who perceived their caregivers as able to provide for their basic needs, were less likely to have ever engaged in sex. Condom use at last sex was associated with older age and having talked with parents/caregivers about sexual risks. Interventions should address these predictors, promote risk reduction among all adolescents irrespective of orphan status, and strengthen parents'/guardians' capacity to discuss sexuality with adolescents and to provide for their basic needs.

Community health workers' experiences and perspectives on mass drug administration for schistosomiasis control in western Kenya: the SCORE Project.

Abstract. The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) includes communitywide treatment in areas with ≥ 25% prevalence of schistosomiasis along the shores of Lake Victoria using community health workers (CHWs). The CHWs are key drivers in community-owned mass drug administration (MDA) intervention programs. We explored their experiences and perceptions after initial MDA participation. Unstructured open-ended group discussions were conducted after completion of MDA activities. Narratives were obtained from CHWs using a digital audio recorder during the group discussion, transcribed verbatim and translated into English where applicable. Thematic decomposition of data was done using ATLAS.t.i. software. From the perspective of the CHWs, factors influencing MDA compliance included drug side effects, food supply stability, and conspiracy theories about the "real" purpose of treatment. The interest of CHWs to serve as community drug distributors stemmed from both intrinsic and extrinsic factors. Feedback from CHWs can promote more effective MDA in rural Kenyan communities.

Healthcare-seeking behaviour for common infectious disease-related illnesses in rural Kenya: a community-based house-to-house survey.

Community surveys of healthcare-use determine the proportion of illness episodes not captured by health facility-based surveillance, the methodology used most commonly to estimate the burden of disease in Africa. A cross-sectional survey of households with children aged less than five years was conducted in 35 of 686 census enumeration areas in rural Bondo district, western Kenya. Healthcare sought for acute episodes of diarrhoea or fever in the past two weeks or pneumonia in the past year was evaluated. Factors associated with healthcare-seeking were analyzed by logistic regression accounting for sample design. In total, 6,223 residents of 981 households were interviewed. Of 1,679 children aged less than five years, 233 (14%) had diarrhoea, and 736 (44%) had fever during the past two weeks; care at health facilities was sought for one-third of these episodes. Pneumonia in the past year was reported for 64 (4%) children aged less than five years; 88% sought healthcare at any health facility and 48% at hospitals. Seeking healthcare at health facilities was more likely for children from households with higher socioeconomic status and with more symptoms of severe illness. Health facility and hospital-based surveillance would underestimate the burden of disease substantially in rural western Kenya. Seeking healthcare at health facilities and hospitals varied by syndrome, severity of illness, and characteristics of the patient.