Towards elimination of Lymphatic Filariasis in Kenya: improving advocacy, communication and social mobilization activities for mass drug administration, a qualitative study.

INTRODUCTION: The Kenya Breaking Transmission Strategy for Neglected Tropical Diseases (NTD) from 2019 to 2023 intensifies advocacy, coordination, and partnerships. The purpose of this study was to explore views and experiences of stakeholders and health workers on ways of improving the Advocacy, Communication and Social Mobilization (ACSM) activities of Mass Drug Administration (MDA) for Lymphatic Filariasis (LF) programs through participatory approaches in Kilifi County, Kenya. METHODS: Two wards were purposely selected in the Kaloleni sub-county, Kilifi County, where there was an average treatment coverage of 56% in 2015, 50.5% in 2016. Qualitative data collection methods were employed, which included participatory meetings with county stakeholders to understand their views, experiences, and suggestions on how ACSM strategies can be improved in MDA for LF. Twelve In-Depth Interviews (IDIs) were conducted (six with opinion leaders and six with Community Health Extension Workers (CHEWs) and two semi-structured interviews (SSIs) were held with county and sub-county coordinators involved in MDA administration. The aim was to better to understand their perceptions of the NTD program about ACSM, challenges to ACSM strategies, and ways to improve the strategies for ACSM in MDA for LF. The Data was organized and classified into codes and themes using QSR NVIVO version 12. RESULTS: The study observed the low participation of stakeholders in the ACSM activities of MDA for LF and identified potential areas for stakeholders' involvement to strengthen the activities. Challenges hindering effective implementation of ACSM activities include late delivery of Information, Educational and Communication (IEC) and few IEC materials, insufficient funding, inadequate time allocated to reach the assigned households with messages, messaging, and packaging of information for dissemination due to the vastness of the area. The stakeholders recommended innovative strategies and techniques to improve ACSM activities. DISCUSSION AND CONCLUSION: The results of this study show key challenges to ACSM implementation of MDA for LF. Implementers need to pay attention to these challenges to enhance the effectiveness of MDA per the Kenya NTD Breaking Transmission Strategy. ACSM efforts in MDA for LF control and elimination should be linked with overarching efforts to mainstream partnerships and coordination in control and elimination.

Larval source reduction with a purpose: Designing and evaluating a household- and school-based intervention in coastal Kenya.

BACKGROUND: Since Aedes aegypti mosquitoes preferentially breed in domestic containers, control efforts focus on larval source reduction. Our objectives were to design and test the effectiveness of a source reduction intervention to improve caregiver knowledge and behaviors in coastal Kenya. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a cluster-randomized controlled trial with 261 households from 5 control villages and 259 households from 5 intervention villages. From each household, one child (10-16 years old) and his or her primary caregiver participated in the intervention. We assessed caregiver knowledge and behavior at baseline, as well as 3 and 12 months after the intervention. We assessed household entomological indices at baseline and 12 months after the intervention to avoid seasonal interference. We conducted qualitative interviews with 34 caregivers to understand barriers and facilitators to change. We counted and weighed containers collected by children and parents during a community container clean-up and recycling event. After 12 months, caregiver knowledge about and self-reported behavior related to at least one source reduction technique was more than 50 percentage points higher in the intervention compared to control arm (adjusted risk differences for knowledge: 0.69, 95% CI [0.56 to 0.82], and behavior: 0.58 [0.43 to 0.73]). Respondents stated that other family members' actions were the primary barriers to proper container management. The number of containers at households did not differ significantly across arms even though children and parents collected 17,200 containers (1 ton of plastics) which were used to planted 4,000 native trees as part of the community event. CONCLUSIONS/SIGNIFICANCE: Our study demonstrates that source reduction interventions can be effective if designed with an understanding of the social and entomological context. Further, source reduction is not an individual issue, but rather a social/communal issue, requiring the participation of other household and community members to be sustained.

Implementation challenges and opportunities for improved mass treatment uptake for lymphatic filariasis elimination: Perceptions and experiences of community drug distributors of coastal Kenya.

Community drug distributors (CDDs) who are volunteers have the responsibility of awareness creation, household census, drug distribution and record-keeping and are thus key stakeholders in the campaign for Lymphatic Filariasis (LF) elimination. Taking into account their experiences and perceptions is important for a successful elimination campaign. We conducted a qualitative study in 2018 to identify implementation challenges and opportunities for improved mass drug administration (MDA) uptake based on the CDDs perceptions and experiences. Within a larger study that used mixed methods quasi-experimental design, we collected qualitative data from two wards in Kaloleni Sub-County of Kilifi County which was purposively selected owing to its low, 56% and 50.5% treatment coverage in 2015 and 2016 respectively. Focus group discussions (FGDs) (n = 8) and in-depth interviews (IDIs) (n = 8) with CDDs, IDIs (n = 22) with opinion leaders and IDIs (n = 8) with health workers were conducted and the data analyzed by QSR NVIVO version 10 according to thematic areas. The results showed that based on the perceptions and experiences of the CDDs, several challenges: communities' refusal to take the drugs; absenteeism during MDA; non-adherence to CDDs selection criteria; inadequacy in number of CDDs engaged during the campaign and training provided; insufficiency of drugs issued to CDDs; lack of CDDs supervision and low motivation negatively impact on MDA uptake. Opportunities to address the challenges included: awareness creation on MDA, health education on LF and observation of hygiene during drug administration, increased duration of awareness creation and drug administration, adherence to CDDs selection criteria and putting into consideration the vastness of an area and population density while deploying CDDs. Other opportunities include: improved CDDs training and scheduling; issuing of enough drugs to CDDs to meet the communities' demand and improved supervision and motivation of CDDs. Addressing the challenges highlighted is an important step of maximizing MDA uptake. The opportunities presented need to be considered by the NTD program personnel, the county health personnel and the community while planning the implementation of MDA campaigns.

Addressing barriers of community participation and access to mass drug administration for lymphatic filariasis elimination in Coastal Kenya using a participatory approach.

Since the prioritization of Lymphatic Filariasis (LF) elimination in 1997, progress has been made in reducing disease transmission and burden. Validation of elimination through Transmission Assessment Surveys (TAS) in implementation units (IUs) that have received at least 5 rounds of mass drug administration (MDA) and achieved minimum threshold of 65% treatment coverage is required. There are IUs that do not qualify for TAS due to achievement of low treatment coverage. This study sought to identify barriers of community participation and access to MDA, develop and test strategies to be recommended for improved uptake. Two wards in Kaloleni sub-county, Kilifi county with an average treatment coverage of 56% in 2015, 50.5% in 2016 were purposively sampled and a quasi-experimental study conducted. Through systematic random sampling, 350 (pre-intervention) and 338 (post-intervention) household heads were selected and interviewed for quantitative data. For qualitative data, 16 Focus Group Discussions (FGDs) with purposively selected community groups were conducted. Participatory meetings were held with county stakeholders to agree on strategies for improved community participation in MDA. The quantitative data were analyzed using STATA version 14.1, statistical significance assessed by chi square test and qualitative data by QSR NVIVO version 10. The identified strategies were tested in experimental sites during the 2018 MDA and the usual MDA strategies applied in control sites. The results showed an increase in community participation and access to MDA in both sites 80.6% (pre-intervention), 82.9% (post-intervention). The proportion of participants who considered the treatment as necessary significantly (p = 0.001) increased to 96.2% from 88.3% and significantly dropped for those with drug swallowing problems associated with: size (p<0.001), number (p<0.027) and taste (p = 0.001). The implemented strategies may have contributed to increased participation and access to MDA and should be applied for improved treatment uptake. Health education on disease aetiology and importance of drug uptake in all rounds is key to program's success.

Source reduction with a purpose: Mosquito ecology and community perspectives offer insights for improving household mosquito management in coastal Kenya.

Understanding mosquito breeding behavior as well as human perspectives and practices are crucial for designing interventions to control Aedes aegypti mosquito-borne diseases as these mosquitoes primarily breed in water-holding containers around people's homes. The objectives of this study were to identify productive mosquito breeding habitats in coastal Kenya and to understand household mosquito management behaviors and their behavioral determinants. The field team conducted entomological surveys in 444 households and semi-structured interviews with 35 female caregivers and 37 children in Kwale County, coastal Kenya, between May and December 2016. All potential mosquito habitats with or without water were located, abundances of mosquito immatures measured and their characteristics recorded. Interviews explored household mosquito management behaviors and their behavioral determinants. 2,452 container mosquito habitats were counted containing 1,077 larvae and 390 pupae, predominantly Aedes species. More than one-third of the positive containers were found outside houses in 1 of the 10 villages. Containers holding water with no intended purpose contained 55.2% of all immature mosquitoes. Containers filled with rainwater held 95.8% of all immature mosquitoes. Interviews indicated that households prioritize sleeping under bednets as a primary protection against mosquito-borne disease because of concern about night-time biting, malaria-transmitting Anopheles mosquitoes. Respondents had limited knowledge about the mosquito life cycle, especially with respect to day-time biting, container-breeding Aedes mosquitoes. Therefore, respondents did not prioritize source reduction. Most mosquitoes breed in containers that have no direct or immediate purpose ("no-purpose containers"). These containers may be left unattended for several days allowing rainwater to collect, and creating ideal conditions for mosquito breeding. An intervention that requires little effort and targets only the most productive containers could effectively reduce mosquito indices and, relatedly, mosquito-borne disease risk.

Exploring communities' and health workers' perceptions of indicators and drivers of malaria decline in Malindi, Kenya.

BACKGROUND: Since 2000, a decrease in malaria burden has been observed in most endemic countries. Declining infection rates and disease burden and reduction in asymptomatic carriers are the outcome of improved quality of care and related health system factors. These include improved case management through better diagnosis, implementation of highly effective antimalarial drugs and increased use of bednets. We studied communities' and health workers' perceptions of indicators and drivers in the context of decreasing malaria transmission in Malindi, Kenya. MATERIALS AND METHODS: A variety of qualitative methods that included participatory rural appraisal (PRA) tools such as community river of life and trend lines, focus group discussions (FGDs) and key informant interviews were used. Studies took place between November 2013 and April 2014. RESULTS: Providing residents with bednets contributed to malaria reduction, and increasing community awareness on the causes and symptoms of malaria and improved malaria treatment were also perceived to contribute to the decline of malaria. The study identified three perceived drivers to the reported decline in malaria: a) community health workers' enhanced awareness creation towards household owners regarding malaria-related activities through visitations and awareness sessions, b) Women involvement in Savings Internal Lending Community was perceived to have increased their financial base, thereby improving their decision-making power towards the care of their sick child(ren), c) Non Governmental Organizations (NGOs) and partners played a promoter part in health and general economic development initiatives. CONCLUSIONS: To achieve the goal of malaria elimination, collaboration between governmental and NGOs will be crucial when improving the financial base of women and enhancing participation of community health workers.

A formative study of disposal and re-use of old mosquito nets by communities in Malindi, Kenya.

BACKGROUND: About 30 million insecticide treated mosquito nets have been distributed in Kenya since 2001 and ownership is approaching full coverage. As a consequence of this achievement, Kenya is faced with the challenge of disposing old mosquito nets that are no longer in use. The study aimed at investigating ways of disposal and re-use of old and torn nets by end users. MATERIALS AND METHODS: A formative study was conducted in the former Malindi District, which is comprised of Malindi and Magarini sub-counties of Kilifi County in Coastal Kenya. A total of 6 Focus Group Discussions, 10 Key Informant Interviews and 9 transect walks/drives were undertaken. Data from the different sources were analysed separately and triangulated for similarities and differences. RESULTS: There were variations in disposal and re-use of old nets between urban and rural or peri-urban residents. In all settings, people adopted innovative and beneficial ways of re-using old, expired nets, and those that were damaged beyond repair. Common causes of damage were fire, children, domestic animals sharing the sleeping room and friction from the bed poles while hanging or tacking it in under a sleeping mat. Re-use was most prominent in farming activities (78%) and less to for use in mosquito control, like window screening (15%). The remaining 8% was related to making ropes, swings, footballs, goal posts and fishing nets. Advantageous texture and nature of the netting material, perceived economic benefit and lack of guidelines for disposal were the main reasons cited by residents for re-using old nets. CONCLUSIONS: It is important that re-use and disposal of old mosquito nets is distinguished from misuse of newly distributed mosquito nets. Alternative uses of old nets as opposed to misuse of new nets was found to be common in our study.

Understanding the context of HIV risk behavior among HIV-positive and HIV-negative female sex workers and male bar clients following antiretroviral therapy rollout in Mombasa, Kenya.

This study explored perceptions of HIV following local introduction of antiretroviral therapy (ART), among 30 HIV-positive and -negative female sex workers (FSWs) and 10 male bar patrons in Mombasa, Kenya. Semi-structured interviews were analyzed qualitatively to identify determinants of sexual risk behaviors. ART was not perceived as a barrier to safer sex and in some cases led to decreased high-risk behaviors. Barriers to safer sex included economic pressure and sexual partnership types. Many women reported that negotiating condom use is more difficult in long-term partnerships. These women favored short-term partnerships to minimize risk through consistent condom use. For women living with HIV, concern about maintaining health and avoiding HIV superinfection was a strong motivator of protective behaviors. For HIV-negative women, a negative HIV test was a powerful motivator. Incorporation of context- and serostatus-specific factors (e.g., self-protection for HIV-positive women) into tailored prevention counseling may support high-risk women to reduce risk behaviors.

Wide-scale application of Bti/Bs biolarvicide in different aquatic habitat types in urban and peri-urban Malindi, Kenya.

Larval control is a major component in mosquito control programs. This study evaluated the wide-scale application of Bti/Bs biolarvicide (Bacillus thuringiensis var. israelensis [Bti] and Bacillus sphaericus [Bs]) in different aquatic habitats in urban and peri-urban Malindi, Kenya. This study was done from June 2006 to December 2007. The urban and peri-urban area of Malindi town was mapped and categorized in grid cells of 1 km(2). A total of 16 1-km(2) cells were selected based on presence Community Based Organization dealing with malaria control within the cells. Each of the 16 1-km(2) cells was thoroughly searched for the presence of potential larval habitats. All habitats, whether positive or negative for larvae, were treated and rechecked 24 h (1 day), 6 days, and 10 days later for the efficacy of Bti/Bs. Weekly larval sampling was done to determine the mosquito larval dynamics in the aquatic habitats during the study period. Morphological identification of the mosquito larvae showed that Anopheles gambiae s.l. Giles was the most predominant species of the Anopheles and while in the culicines, Cx. quinquefasciatus Say was the predominant species. Anopheles larvae were all eliminated in habitats within a day post-application. For culicine larvae, 38.1% (n=8) of the habitat types responded within day 1 post-treatment and all the larvae were killed, they turned negative during the days of follow-up. Another 38.1% (n=8) of the habitat types had culicine larvae but turned negative by day 6, while three habitats (14.3%) had larvae by 6th day but turned negative by 10th day. However during this Bti/Bs application studies, two habitat types, house drainage and cesspits (9.5%), remained positive during the follow-up although the mosquito larvae were significantly reduced. Both early and late instars of Anopheles larvae immediately responded to Bti/Bs application and reached 100% mortality. The early and late instars of culicine responded to the Bti/Bs application but not as fast as the Anopheles larval instars. The early instars Culex, responded with 90.8% mortality at day 1 post-treatment, and the mortality was 99.9% at day 10. Similarly, the late instars Culex followed the same trend and exhibited same mortalities. The weekly sampling in the aquatic habitats showed that there was a 36.3% mosquito larval reduction in the aquatic habitats over the 18-months study period. In conclusion, Bti/Bs biolarvicide are useful in reducing the mosquito larval densities in a wide range of habitats which have a direct impact of adult mosquito populations.

Efficacy of vectobac DT and culinexcombi against mosquito larvae in unused swimming pools in Malindi, Kenya.

The efficacy and persistence of 2 bacterial larvicides, Vectobac-DT (Bacillus thuringiensis israelensis [Bti]) and CulinexCombi (Bti and Bacillus sphaericus [Bs]), were tested against Anopheles gambiae and Culex quinquefasciatus in temporarily unused swimming pools with rainwater in Malindi, Kenya. Pre- and posttreatment larval densities were recorded by sampling with the standard WHO dipping technique for 8 consecutive days. The larvicides were applied to the pools with a knapsack sprayer. The data showed that Vectobac-DT was highly effective against early instars of An. gambiae with 89% reduction within 24 h but not as effective against the early stages of Cx. quinquefasciatus with reduction of only 46%. CulinexCombi resulted in high mortalities to early instars of both species with over 97% reduction within 24 h, but showed a drastic reduction 48 h after application. Both Vectobac-DT and CulinexCombi were highly effective against late instars of both species, whereby Vectobac-DT persisted much longer than CulinexCombi. Anopheles gambiae was found to be more susceptible to both larvicides than Cx. quinquefasciatus. By their high efficacy and good persistence against mosquito larvae, both Vectobac-DT and CulinexCombi can be recommended for use in integrated mosquito control programs.

Comparison of mosquito control programs in seven urban sites in Africa, the Middle East, and the Americas

Mosquito control programs at seven urban sites in Kenya, Egypt, Israel, Costa Rica, and Trinidad are described and compared. Site-specific urban and disease characteristics, organizational diagrams, and strengths, weaknesses, obstacles and threats (SWOT) analysis tools are used to provide a descriptive assessment of each mosquito control program, and provide a comparison of the factors affecting mosquito abatement. The information for SWOT analysis is collected from surveys, focus-group discussions, and personal communication. SWOT analysis identified various issues affecting the efficiency and sustainability of mosquito control operations. The main outcome of our work was the description and comparison of mosquito control operations within the context of each study site's biological, social, political, management, and economic conditions. The issues identified in this study ranged from lack of inter-sector collaboration to operational issues of mosquito control efforts. A lack of sustainable funding for mosquito control was a common problem for most sites. Many unique problems were also identified, which included lack of mosquito surveillance, lack of law enforcement, and negative consequences of human behavior. Identifying common virtues and shortcomings of mosquito control operations is useful in identifying "best practices" for mosquito control operations, thus leading to better control of mosquito biting and mosquito-borne disease transmission.

Comparison of mosquito control programs in seven urban sites in Africa, the Middle East, and the Americas.

Mosquito control programs at seven urban sites in Kenya, Egypt, Israel, Costa Rica, and Trinidad are described and compared. Site-specific urban and disease characteristics, organizational diagrams, and strengths, weaknesses, obstacles and threats (SWOT) analysis tools are used to provide a descriptive assessment of each mosquito control program, and provide a comparison of the factors affecting mosquito abatement. The information for SWOT analysis is collected from surveys, focus-group discussions, and personal communication. SWOT analysis identified various issues affecting the efficiency and sustainability of mosquito control operations. The main outcome of our work was the description and comparison of mosquito control operations within the context of each study site's biological, social, political, management, and economic conditions. The issues identified in this study ranged from lack of inter-sector collaboration to operational issues of mosquito control efforts. A lack of sustainable funding for mosquito control was a common problem for most sites. Many unique problems were also identified, which included lack of mosquito surveillance, lack of law enforcement, and negative consequences of human behavior. Identifying common virtues and shortcomings of mosquito control operations is useful in identifying "best practices" for mosquito control operations, thus leading to better control of mosquito biting and mosquito-borne disease transmission.

Community based vector control in Malindi, Kenya.

BACKGROUND: Community involvement has become an important component of the National Malaria Control Strategy in Kenya, resulting in the organization of groups charged with addressing mosquito and malaria-related concerns within the community. OBJECTIVES: The purpose of this study was to identify community groups involved with intended malaria vector control activity in Malindi, Kenya. METHODS: Information was obtained from key informant interviews, focus group discussions, and a stakeholder meeting. The objectives were to determine the roles of community groups, identify examples of past successes and obstacles to successful implementation of vector control, and assess the level of knowledge about malaria and mosquitoes among the groups. RESULTS: Nineteen of 34 community groups (56%) registered at social services reported intended malaria vector control activities such as treating ditches, making and selling insecticide-treated mosquito nets, draining stagnant water, organizing clean-ups, making and selling neem soap, and the organization of campaigns such as the "Malaria Mosquito Day". Major challenges facing these groups include volunteerism, lack of technical expertise, supervision, and maintaining control activities in the absence of funds. Most groups reported limited knowledge about malaria vectors, and thus targeted all water bodies for control activities. CONCLUSIONS: We found that community groups are willing to participate in control operations, but lack government and technical support. We highlight the importance of strengthening organizational efforts and capacity building, as well as the need to clarify government policy on malaria vector control responsibilities within the communities.

A geographic sampling strategy for studying relationships between human activity and malaria vectors in urban Africa.

This paper describes a geographic sampling strategy for ecologic studies and describes the relationship between human activities and anopheline larval ecology in urban areas. Kisumu and Malindi, Kenya were mapped using global positioning systems, and a geographic information system was used to overlay a measured grid, which served as a sampling frame. Grid cells were stratified and randomly selected according to levels of planning and drainage. A cross-sectional survey was conducted in April and May 2001 to collect entomologic and human ecologic data. Multivariate regression analysis was used to test the relationship between the abundance of potential larval habitats, and house density, socioeconomic status, and planning and drainage. In Kisumu, 98 aquatic habitats were identified, 65% of which were human made and 39% were positive for anopheline larvae. In Malindi, 91 aquatic habitats were identified, of which, 93% were human made and 65% were harboring anopheline larvae. The regression model explains 82% of the variance associated with the abundance of potential larval habitats in Kisumu. In Malindi, 59% of the variance was explained. As the number of households increased, the number of larval habitats increased correspondingly to a point. Beyond a critical threshold, the density of households appeared to suppress the development of aquatic habitats. The proportion of high-income households and the planning and drainage variables tested insignificant in both locations. The integration of social and biologic sciences will allow local mosquito and malaria control groups an opportunity to assess the risk of encountering potentially infectious mosquitoes in a given area, and concentrate resources accordingly.

Examining the determinants of mosquito-avoidance practices in two Kenyan cities.

BACKGROUND: This study assesses the behavioural and socio-economic factors associated with avoiding mosquitoes and preventing malaria in urban environments in Kenya. METHODS: Data from two cities in Kenya were gathered using a household survey and a two-stage cluster sample design. The cities were stratified based on planning and drainage observed across the urban areas. This helped control for the strong environmental and topographical variation that we assumed influences mosquito ecology. Individual interviews given to each household included questions on socio-economic status, education, housing type, water source, rubbish disposal, mosquito-prevention practices and knowledge of mosquitoes. In multivariate regression, factors measuring wealth, education level, and the communities' level of planning and drainage were used to estimate the probability that a household engages in multiple mosquito-avoidance activities, or has all members sleeping under a bed net. RESULTS: Our analysis shows that people from wealthier, more educated households were more likely to sleep under a net, in Kisumu (OR = 6.88; 95% CI = 2.56,18.49) and Malindi (OR = 3.80; 95% CI = 1.91,7.55). Similarly, the probability that households use several mosquito-prevention activities was highest among the wealthiest, best-educated households in Kisumu (OR = 5.15; 95% CI = 2.04,12.98), while in Malindi household wealth alone is the major determinant. CONCLUSION: We demonstrate the importance of examining human-mosquito interaction in terms of how access to resources may enhance human activities. The findings illustrate that the poorest segments of society are already doing many things to protect themselves from being bitten, but they are doing less than their richer neighbours.