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

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

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

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

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

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

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

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

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

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

The 'heat' goes away: sexual disorders of married women with female genital mutilation/cutting in Kenya.

BACKGROUND: Female genital mutilation/cutting (FGM/C) has been implicated in sexual complications among women, although there is paucity of research evidence on sexual experiences among married women who have undergone this cultural practice. The aim of this study was to investigate the sexual experiences among married women in Mauche Ward, Nakuru County. METHODS: Quantitative and qualitative data collection methods were used. Quantitative data were obtained from 318 married women selected through multistage sampling. The women were categorized into: cut before marriage, cut after marriage and the uncut. A questionnaire was used to collect demographic information while psychometric data were obtained using a female sexual functioning index (FSFI) tool. The resulting quantitative data were analyzed using SPSS® Version 22. Qualitative data were obtained from five FGDs and two case narratives. The data were organized into themes, analyzed and interpreted. Ethical approval for the study was granted by Kenyatta National Hospital-University of Nairobi Ethics and Research Committee. RESULTS: The mean age of the respondents was 30.59 ± 7.36 years. The majority (74.2%) had primary education and 76.1% were farmers. Age (p = 0.008), number of children (p = 0.035) and education (p = 0.038) were found to be associated with sexual functioning. The cut women reported lower sexual functioning compared to the uncut. ANOVA results show the reported overall sexual functioning to be significantly (p = 0.019) different across the three groups. Women cut after marriage (mean = 22.81 ± 4.87) scored significantly lower (p = 0.056) than the uncut (mean = 25.35 ± 3.56). However, in comparison to the cut before marriage there was no significant difference (mean = 23.99 ± 6.63). Among the sexual functioning domains, lubrication (p = 0.008), orgasm (p = 0.019) and satisfaction (p = 0.042) were significantly different across the three groups. However, desire, arousal and pain were not statistically different. CONCLUSION: Generally, cut women had negative sexual experiences and specifically adverse changes in desire, arousal and satisfaction were experienced among cut after marriage. FGM/C mitigating strategies need to routinely provide sexual complications management to safeguard women's sexual right to pleasure subsequently improving their general well-being.

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

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

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

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

Effectiveness of a community-centered Newcastle disease vaccine delivery model under paid and free vaccination frameworks in southeastern Kenya.

In the absence of effective drugs, vaccines constitute the cornerstone for the prevention of Newcastle disease (ND). Different strategies have been implemented to increase vaccination, but uptake remains low, underscoring the need for novel vaccine delivery methods. We designed and assessed the effectiveness of a community-centered ND vaccine delivery model in southeastern Kenya. Under the model, we sensitized smallholder chicken farmers (SCFs) through structured training on chicken husbandry, biosecurity, ND, and its vaccination, among other aspects. We subsequently engaged trained community vaccinators (CVs) to deliver vaccines and/or provide vaccination services to SCFs at a cost on one hand and, at no cost on the other, in selected sites to address challenges of inadequate service providers, vaccine unavailability, and inaccessibility. We tested this model under paid and free vaccination frameworks over one year and assessed the model's effect on vaccine uptake, ND-related deaths, and vaccine accessibility, among other aspects. Overall, we vaccinated more chickens at free sites compared to paid sites. However, we vaccinated a significantly higher mean number of chickens per household at paid (49.4±38.5) compared to free (28.4±25.9) sites (t = 8.4, p<0.0001). We recorded a significant increase in the proportion of SCFs who vaccinated their chickens from 31.3% to 68.4% (χ2(1, N = 399) = 58.3, p<0.0001) in paid and from 19.9% to 74.9% (χ2(1, N = 403) = 115.7, p<0.0001) in free sites pre- and post-intervention, respectively. The mean number of ND-related deaths reported per household decreased from 18.1±31.6 pre-intervention to 7.5±22.3 post-intervention (t = 5.4, p = 0.000), with higher reductions recorded in paid sites (20.9±37.7 to 4.5±11.2) compared to free sites (15.0±22.6 to 10.7±29.7) pre- and post-intervention, respectively. Farmers with access to vaccines increased significantly from 61.1% to 85.4% (χ2(1, N = 399) = 31.7, p<0.0001) in paid and 43.6% to 74.9% (χ2(1, N = 403) = 38.4, p = 0.0001) in free sites pre- and post-intervention, respectively. We established that type of intervention framework, gender of household head, if the household head attended training on chicken production in the last 12 months, access to information on ND vaccination, and the number of chickens lost to the previous ND outbreak were significant predictors of ND vaccine uptake. Our findings indicate the model has a broader reach and benefits for SCFs. However, policies should be enacted to regulate the integration of CVs into the formal animal health sector.

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

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

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

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

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

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

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

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

Practicing provider-initiated HIV testing in high prevalence settings: consent concerns and missed preventive opportunities.

BACKGROUND: Counselling is considered a prerequisite for the proper handling of testing and for ensuring effective HIV preventive efforts. HIV testing services have recently been scaled up substantially with a particular focus on provider-initiated models. Increasing HIV test rates have been attributed to the rapid scale-up of the provider-initiated testing model, but there is limited documentation of experiences with this new service model. The aim of this study was to determine the use of different types of HIV testing services and to investigate perceptions and experiences of these services with a particular emphasis on the provider initiated testing in three selected districts in Kenya, Tanzania, and, Zambia. METHODS: A concurrent triangulation mixed methods design was applied using quantitative and qualitative approaches. A population-based survey was conducted among adults in the three study districts, and qualitative data were obtained from 34 focus group discussions and 18 in-depth interviews. The data originates from the ongoing EU funded research project "REsponse to ACountable Priority Setting for Trust in Health Systems" (REACT) implemented in the three countries which has a research component linked to HIV and testing, and from an additional study focusing on HIV testing, counselling perceptions and experiences in Kenya. RESULTS: Proportions of the population formerly tested for HIV differed sharply between the study districts and particularly among women (54% Malindi, 34% Kapiri Mposhi and 27% Mbarali) (p < 0.001). Women were much more likely to be tested than men in the districts that had scaled-up programmes for preventing mother to child transmission of HIV (PMTCT). Only minor gender differences appeared for voluntary counselling and testing. In places where, the provider-initiated model in PMTCT programmes had been rolled out extensively testing was accompanied by very limited pre- and post-test counselling and by a related neglect of preventative measures. Informants expressed frustration related to their experienced inability to 'opt-out' or decline from the provider-initiated HIV testing services. CONCLUSION: Counselling emerged as a highly valued process during HIV testing. However, counselling efforts were limited in the implementation of the provider-initiated opt-out HIV testing model. The approach was moreover not perceived as voluntary. This raises serious ethical concerns and implies missed preventive opportunities inherent in the counselling concept. Moreover, implementation of the new testing approach seem to add a burden to pregnant women as disproportionate numbers of women get to know their HIV status, reveal their HIV status to their spouse and recruit their spouses to go for a test. We argue that there is an urgent need to reconsider the manner in which the provider initiated HIV testing model is implemented in order to protect the client's autonomy and to maximise access to HIV prevention.

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

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

Factors influencing tuberculosis management in rural south-west Kenya.

SETTING: The Abagusii people in rural south-west Kenya. OBJECTIVE: To investigate tuberculosis (TB) treatment pathways and factors associated with treatment-seeking behaviour. METHOD: Quantitative data were obtained using a structured questionnaire administered to 100 household heads, while qualitative data were obtained from three focus group discussions (FGDs), six key informant interviews and seven case histories that focused on experiences of TB. RESULTS: Data reveal that patients follow oscillatory pathways in treatment seeking. Treatment-seeking behaviour is influenced by socio-structural and superstructural forces such as beliefs and perceptions regarding treatment and disease-causing factors. CONCLUSION: To improve TB treatment, these socio-structural and superstructural factors should be addressed.

A critical assessment of the WHO responsiveness tool: lessons from voluntary HIV testing and counselling services in Kenya.

BACKGROUND: Health, fair financing and responsiveness to the user's needs and expectations are seen as the essential objectives of health systems. Efforts have been made to conceptualise and measure responsiveness as a basis for evaluating the non-health aspects of health systems performance. This study assesses the applicability of the responsiveness tool developed by WHO when applied in the context of voluntary HIV counselling and testing services (VCT) at a district level in Kenya. METHODS: A mixed method study was conducted employing a combination of quantitative and qualitative research methods concurrently. The questionnaire proposed by WHO was administered to 328 VCT users and 36 VCT counsellors (health providers). In addition to the questionnaire, qualitative interviews were carried out among a total of 300 participants. Observational field notes were also written. RESULTS: A majority of the health providers and users indicated that the responsiveness elements were very important, e.g. confidentiality and autonomy were regarded by most users and health providers as very important and were also reported as being highly observed in the VCT room. However, the qualitative findings revealed other important aspects related to confidentiality, autonomy and other responsiveness elements that were not captured by the WHO tool. Striking examples were inappropriate location of the VCT centre, limited information provided, language problems, and concern about the quality of counselling. CONCLUSION: The results indicate that the WHO developed responsiveness elements are relevant and important in measuring the performance of voluntary HIV counselling and testing. However, the tool needs substantial revision in order to capture other important dimensions or perspectives. The findings also confirm the importance of careful assessment and recognition of locally specific aspects when conducting comparative studies on responsiveness of HIV testing services.

Accountable priority setting for trust in health systems--the need for research into a new approach for strengthening sustainable health action in developing countries.

Despite multiple efforts to strengthen health systems in low and middle income countries, intended sustainable improvements in health outcomes have not been shown. To date most priority setting initiatives in health systems have mainly focused on technical approaches involving information derived from burden of disease statistics, cost effectiveness analysis, and published clinical trials. However, priority setting involves value-laden choices and these technical approaches do not equip decision-makers to address a broader range of relevant values - such as trust, equity, accountability and fairness - that are of concern to other partners and, not least, the populations concerned. A new focus for priority setting is needed.Accountability for Reasonableness (AFR) is an explicit ethical framework for legitimate and fair priority setting that provides guidance for decision-makers who must identify and consider the full range of relevant values. AFR consists of four conditions: i) relevance to the local setting, decided by agreed criteria; ii) publicizing priority-setting decisions and the reasons behind them; iii) the establishment of revisions/appeal mechanisms for challenging and revising decisions; iv) the provision of leadership to ensure that the first three conditions are met.REACT - "REsponse to ACcountable priority setting for Trust in health systems" is an EU-funded five-year intervention study started in 2006, which is testing the application and effects of the AFR approach in one district each in Kenya, Tanzania and Zambia. The objectives of REACT are to describe and evaluate district-level priority setting, to develop and implement improvement strategies guided by AFR and to measure their effect on quality, equity and trust indicators. Effects are monitored within selected disease and programme interventions and services and within human resources and health systems management. Qualitative and quantitative methods are being applied in an action research framework to examine the potential of AFR to support sustainable improvements to health systems performance.This paper reports on the project design and progress and argues that there is a high need for research into legitimate and fair priority setting to improve the knowledge base for achieving sustainable improvements in health outcomes.

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

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

Understanding acceptance of and adherence to a new formulation of paediatric antiretroviral treatment in the form of pellets (LPV/r)-A realist evaluation.

BACKGROUND: Improving access to paediatric HIV treatment requires large-scale antiretroviral treatment programmes and medication adapted to infants and children's needs. The World Health Organisation recommends lopinavir/ritonavir plus two nucleoside reverse transcriptase inhibitors as first-line treatment for all HIV-infected children younger than three years, usually given as a syrup. A pellet formulation (i.e. tiny cylinders of compressed medication put in capsules) was developed to overcome the syrup formulation's disadvantages such as bitterness, toxicity and cold storage. This study assessed multi-level factors influencing caregivers' acceptance of and adherence to lopinavir/ritonavir pellets as well as their underlying mechanisms. METHODS: A realist evaluation (a theory-driven evaluation method considering the social context and mechanisms of change), embedded in a clinical trial was carried out in three hospital settings in Kenya. Data were collected through document review, observations (n = 34) in home and clinic settings and semi-structured interviews (n = 44) with caregivers and providers. Data analysis was based on realist principles. RESULTS: High levels of treatment initiation and adherence were observed. Taste masking, neutral packaging and easy storage made the new formulation highly acceptable. Caregivers developed individual strategies to deliver the treatment, particularly to overcome specific problems e.g. in case of just-weaned babies or food shortage. A refined program theory emerged from the triangulated findings showing that ease of administration combined with increased self-efficacy and competences of the caregivers, and effective provider support contributed to high levels of adherence. CONCLUSIONS: Formulating combined antiretroviral treatment in the form of pellets is clearly a more acceptable solution for infants and children and their caregivers compared to the syrup. Further research in non-trial settings may shed light on factors related to providers, services and the health system that contribute to better adherence of such formulations.