Rethinking our Rigor Mortis: Creating space for more adaptive and inclusive truth-seeking in community-based global health research in Kenya

As global health researchers, we have long embraced the conviction that the answers to complex problems of poverty and disease will reveal themselves if only we apply enough scientific rigor. Yet, at the community level, our group of American and Kenyan investigators has begun to question whether our veneration of rigor is itself contributing to the intractability of certain types of global health problems. Here, we illustrate examples from our experience among the remote island communities of Lake Victoria, Kenya, and join a chorus of emerging voices, to examine how our culture of control as global health scientists may marginalise truth-seekers and change-makers within communities we seek to serve. More broadly, we seek to acknowledge the limitations of control over truth that rigorous academic research affords. We suggest that by relinquishing this pervasive illusion of control, we can more fully appreciate complementary modes of answering important questions that rely upon the intrinsic resourcefulness and creativity of community-based enterprises taking place across sub-Saharan Africa. While such inquiries may never solve all problems facing the diverse populations of the continent, we advocate for a deeper appreciation of the inherent capacity of adaptive, locally contextualised investigations to identify meaningful and enduring solutions

Antiretroviral Concentrations in Small Hair Samples as a Feasible Marker of Adherence in Rural Kenya

Antiretroviral hair levels objectively quantify drug exposure over time and predict virologic responses. We assessed the acceptability and feasibility of collecting small hair samples in a rural Kenyan cohort. Ninety-five percentage of participants (354/373) donated hair. Although median self-reported adherence was 100% (interquartile range, 96%-100%), a wide range of hair concentrations likely indicates overestimation of self-reported adherence and the advantages of a pharmacologic adherence measure. Higher nevirapine hair concentrations observed in women and older adults require further study to unravel behavioral versus pharmacokinetic contributors. In resource-limited settings, hair antiretroviral levels may serve as a low-cost quantitative biomarker of adherence

The MOMENTUM study: Putting the ‘Three Delays’ to work to evaluate access to emergency obstetric and neonatal care in a remote island community in Western Kenya

Despite worldwide improvements in maternal and infant mortality, mothers and babies in remote, low-resource communities remain disproportionately vulnerable to adverse health outcomes. In these settings, delays in accessing emergency care are a major driver of poor outcomes. The ‘Three Delays’ model is now widely utilised to conceptualise these delays. However, in out-of-hospital contexts, operational and methodological constraints present major obstacles in practically quantifying the ‘Three Delays’. Here, we describe a novel protocol for the MOMENTUM study (Monitoring of Maternal Emergency Navigation and Triage on Mfangano), a 12-month cohort design to assess delays during obstetric and neonatal emergencies within the remote villages of Mfangano Island Division, Lake Victoria, Kenya. This study also evaluates the preliminary impact of a community-based intervention called the ‘Mfangano Health Navigation’ programme. Utilising participatory case audits and contextually specific chronological reference strategies, this study combines quantitative tools with deeper-digging qualitative inquiry. This pragmatic design was developed to empower local research staff and study participants themselves as assets in unravelling the complex socio-economic, cultural, and logistical dynamics that contribute to delays, while providing real-time feedback for locally driven intervention. We present our methods as an adaptive framework for researchers grappling with similar challenges across fragmented, rural health landscapes

Implementation and Operational Research

BackgroundDespite progress in the global scale-up of antiretroviral therapy, sustained engagement in HIV care remains challenging. Social capital is an important factor for sustained engagement, but interventions designed to harness this powerful social force are uncommon.MethodsWe conducted a quasiexperimental study evaluating the impact of the Microclinic Social Network intervention on engagement in HIV care and medication adherence on Mfangano Island, Kenya. The intervention was introduced into 1 of 4 similar communities served by this clinic; comparisons were made between communities using an intention-to-treat analysis. Microclinics, composed of patient-defined support networks, participated in 10 biweekly discussion sessions covering topics ranging from HIV biology to group support and group HIV status disclosure. Nevirapine concentrations in hair were measured before and after study.ResultsOne hundred thirteen (74%) intervention community participants joined a microclinic group, 86% of whom participated in group HIV status disclosure. Over 22-month follow-up, intervention community participants experienced one-half the rate of ≥ 90-day clinic absence as those in control communities (adjusted hazard ratio: 0.48; 95% confidence interval: 0.25 to 0.92). Nevirapine hair levels declined in both study arms; in adjusted linear regression analysis, the decline was 6.7 ng/mg less severe in the intervention arm than control arm (95% confidence interval: -2.7 to 16.1).ConclusionsThe microclinic intervention is a promising and feasible community-based strategy to improve long-term engagement in HIV care and possibly medication adherence. Reducing treatment interruptions using a social network approach has important implications for individual patient virologic suppression, morbidity, and mortality and for broader community empowerment and engagement in healthcare

Around the Table: Food Insecurity, Socioeconomic Status, and Instrumental Social Support among Women Living in a Rural Kenyan Island Community.

The objective of this study was to investigate the relationship among socioeconomic status, social support, and food insecurity in a rural Kenyan island community. A cross-sectional random sample of 111 female heads of households representing 583 household members were surveyed in Mfangano Island, Kenya from August to October 2010 using adaptations of the Household Food Insecurity Access Scale and the Medical Outcomes Study Social Support Survey. In multiple linear regression models, less instrumental social support, defined as concrete direct ways people help others (B = -0.81; 95% confidence interval [CI] -1.45 to -0.17), and decreased ownership scale based on owning material assets (B = -2.93; 95% CI -4.99 to -0.86) were significantly associated with increased food insecurity, controlling for age, education, marital status, and household size. Social support interventions geared at group capacity and resilience may be crucial adjuncts to improve and maintain the long term food security and health of persons living in low-resource regions

Fishing for food? Analyzing links between fishing livelihoods and food security around Lake Victoria, Kenya

Food-producing livelihoods have the potential to improve food security and nutrition through direct consumption or indirectly through income. To better understand these pathways, we examined if fishing households ate more fish and had higher food security than non-fishing households around Lake Victoria, Kenya. In 2010, we randomly sampled 111 households containing 583 individuals for a cross-sectional household survey in a rural fishing community. We modeled the associations between fish consumption and food security and fishing household status, as well as socio-economic variables (asset index, monthly income, household size) for all households and also for a subset of households with adult male household members (76% of households). Participating in fishing as a livelihood was not associated with household fish consumption or food security. Higher household fish consumption was associated with higher household income and food security, and was weakly associated with lower household morbidity. Household food security was associated with higher incomes and asset index scores. Our results suggest socioeconomic factors may be more important than participation in food-producing livelihoods for predicting household consumption of high quality foods

Movement between facilities for HIV care among a mobile population in Kenya: transfer, loss to follow-up, and reengagement

HIV treatment is life-long, yet many patients travel or migrate for their livelihoods, risking treatment interruption. We examine timely reengagement in care among patients who transferred-out or were lost-to-follow-up (LTFU) from a rural HIV facility. We conducted a cohort study among 369 adult patients on antiretroviral therapy between November 2011 and November 2013 on Mfangano Island, Kenya. Patients who transferred or were LTFU (i.e., missed a scheduled appointment by ≥90 days) were traced to determine if they reengaged or accessed care at another clinic. We report cumulative incidence and time to reengagement using Cox proportional hazards models adjusted for patient demographic and clinical characteristics. Among 369 patients at the clinic, 23(6%) requested an official transfer and 78(21%) were LTFU. Among official transfers, cumulative incidence of linkage to their destination facility was 91% at three months (95%CI (confidence intervals) 69-98%). Among LTFU, cumulative incidence of reengagement in care at the original or a new clinic was 14% at three months (95%CI 7-23%) and 60% at six months (95%CI 48-69%). In the adjusted Cox model, patients who left with an official transfer reengaged in care six times faster than those who did not (adjusted hazard ratio 6.2, 95%CI 3.4-11.0). Patients who left an island-based HIV clinic in Kenya with an official transfer letter reengaged in care faster than those who were LTFU, although many in both groups had treatment gaps long enough to risk viral rebound. Better coordination of transfers between clinics, such as assisting patients with navigating the process or improving inter-clinic communication surrounding transfers, may reduce delays in treatment during transfer and improve overall clinical outcomes

Human health alters the sustainability of fishing practices in East Africa

Understanding feedbacks between human and environmental health is critical for the millions who cope with recurrent illness and rely directly on natural resources for sustenance. Although studies have examined how environmental degradation exacerbates infectious disease, the effects of human health on our use of the environment remains unexplored. Human illness is often tacitly assumed to reduce human impacts on the environment. By this logic, ill people reduce the time and effort that they put into extractive livelihoods and, thereby, their impact on natural resources. We followed 303 households living on Lake Victoria, Kenya over four time points to examine how illness influenced fishing. Using fixed effect conditional logit models to control for individual-level and time-invariant factors, we analyzed the effect of illness on fishing effort and methods. Illness among individuals who listed fishing as their primary occupation affected their participation in fishing. However, among active fishers, we found limited evidence that illness reduced fishing effort. Instead, ill fishers shifted their fishing methods. When ill, fishers were more likely to use methods that were illegal, destructive, and concentrated in inshore areas but required less travel and energy. Ill fishers were also less likely to fish using legal methods that are physically demanding, require travel to deep waters, and are considered more sustainable. By altering the physical capacity and outlook of fishers, human illness shifted their effort, their engagement with natural resources, and the sustainability of their actions. These findings show a previously unexplored pathway through which poor human health may negatively impact the environment

Characteristics of Pica Behavior among Mothers around Lake Victoria, Kenya: A Cross-Sectional Study.

Background: Pica, the craving and purposeful consumption of nonfoods, is poorly understood. We described the prevalence of pica among women on Mfangano Island, Kenya, and examined sociodemographic and health correlates. Methods: Our cross-sectional study included 299 pregnant or postpartum women in 2012. We used a 24-h recall to assess pica, defined as consumption of earth (geophagy), charcoal/ash, or raw starches (amylophagy) and built multivariable logistic regression models to examine sociodemographic and health correlates of pica. Results: Eighty-one women (27.1%) engaged in pica in the previous 24 h, with 59.3% reporting amylophagy and 56.8% reporting geophagy, charcoal, and/or ash consumption. The most common substances consumed were raw cassava (n = 30, 36.6%), odowa, a chalky, soft rock-like earth (n = 21, 25.6%), and soil (n = 17, 20.7%). Geophagy, charcoal, and/or ash consumption was negatively associated with breastfeeding (OR = 0.38, 95% CI: 0.18-0.81), and amylophagy was associated with pregnancy (OR = 4.31, 95% CI: 1.24-14.96). Pica was more common within one of six study regions (OR = 3.64, 95% CI: 1.39-9.51). We found no evidence of an association between food insecurity and pica. Conclusion: Pica was a common behavior among women, and the prevalence underscores the need to uncover its dietary, environmental, and cultural etiologies

Characteristics of Pica Behavior among Mothers around Lake Victoria, Kenya: A Cross-Sectional Study

Background: Pica, the craving and purposeful consumption of nonfoods, is poorly understood. We described the prevalence of pica among women on Mfangano Island, Kenya, and examined sociodemographic and health correlates. Methods: Our cross-sectional study included 299 pregnant or postpartum women in 2012. We used a 24-h recall to assess pica, defined as consumption of earth (geophagy), charcoal/ash, or raw starches (amylophagy) and built multivariable logistic regression models to examine sociodemographic and health correlates of pica. Results: Eighty-one women (27.1%) engaged in pica in the previous 24 h, with 59.3% reporting amylophagy and 56.8% reporting geophagy, charcoal, and/or ash consumption. The most common substances consumed were raw cassava (n = 30, 36.6%), odowa, a chalky, soft rock-like earth (n = 21, 25.6%), and soil (n = 17, 20.7%). Geophagy, charcoal, and/or ash consumption was negatively associated with breastfeeding (OR = 0.38, 95% CI: 0.18–0.81), and amylophagy was associated with pregnancy (OR = 4.31, 95% CI: 1.24–14.96). Pica was more common within one of six study regions (OR = 3.64, 95% CI: 1.39–9.51). We found no evidence of an association between food insecurity and pica. Conclusion: Pica was a common behavior among women, and the prevalence underscores the need to uncover its dietary, environmental, and cultural etiologies