Socioeconomic inequalities, equity effect, and cost-effectiveness of malaria control interventions in an endemic area of western Kenya

Background Malaria control in endemic areas still faces the challenge of ensuring that scale-up of interventions is sustainable, cost-effective and equitable. However, there have not been adequate studies monitoring equity effects or changes in socioeconomic inequalities of these Interventions over time even. The existence of socioeconomic health inequalities is a barrier to achieve universal health coverage and sustainable development goals. Methods: Secondary datasets have been used in these microeconomic evaluations including eight years of repeated annual cross-sectional surveys from 2006 to 2013 involving 19,000 individuals in Siaya County, western Kenya. Data from a two-year cluster randomized Mass Test and Treat (MTAT) study conducted between 2013 and 2015 were also used. Further, malaria-related mortality and morbidity data from health and demographic surveillance system (HDSS) surveys from 2006 to 2014 have been used. Lastly, data on costs and effects of Long-Lasting Insecticide Nets (LLIN) distribution channels were collected from national to local levels in Busia County, western Kenya to assess the cost-effectiveness of LLIN distribution channels from a provider and household perspectives. Household socioeconomic status (SES) was established using multiple correspondence analysis (MCA), socioeconomic inequalities were assessed using concentration indices, and multi-level mixed-effects generalized linear regression models (GLM) were used to compare prevalence ratios with 95% confidence intervals. Disability-adjusted life years and cost-effectiveness ratios were calculated to answer research questions. Data were compared between the poorest and less poor individuals at the household and population level. 12 Results: The poorest individuals, children, and women, bore the greatest burden of malaria measured in terms of morbidity, mortalities and disability-adjusted life years but the health inequality gap between the poor and less poor has reduced over time. There were no significant inequalities in medication use and care-seeking for fever between the poorest and less poor which represents equity gains for the poorest individuals. The MTAT intervention resulted in equity gains amongst the socio-economic groups in terms of access to medication, care-seeking, use of LLINs and averting malaria deaths in the participating communities. Mass distribution of LLINs combined with the use of community health volunteers remains the most cost-effective and equitable method of achieving universal coverage. Discussion. Malaria remains a disease of poor individuals across age groups and gender but is mostly concentrated amongst children and women. While intensification of malaria control activities has resulted in a reduction of socioeconomic inequalities in rates of infections, mortality, care seeking and medication for fever, pro-poor and mass campaigns for control interventions should be to be integrated to reduce inequalities and inequities. The results from these studies are vital for monitoring socioeconomic inequalities and equity trends towards achieving universal health coverage and sustainable development goals

Investigating the role of effector proteins in the rice blast fungus Magnaporthe oryzae

To cause disease in plants, microbial pathogens secrete effector proteins that can suppress basal plant immunity mechanisms and help facilitate proliferation of the pathogen in plant tissue. The rice blast fungus, Magnaporthe oryzae, causes the most serious disease of cultivated rice. During early biotrophic colonisation, this fungus evades the plant immune system via the action of secreted effector proteins, allowing penetration of individual rice cells by invasive hyphae. The ability of the Magnaporthe isolates to infect weeping lovegrass (Eragrostis curvula) is controlled by a single gene, PWL2. Pwl2, like other effector proteins and several biotrophy-associated secreted (Bas) proteins, is secreted into a structure referred to as the biotrophic interfacial complex (BIC) before translocating into the cytoplasm [1-3]. In this study, I have used comparative genomics to analyse the relationship between the effector repertoire of M. oryzae and their potential recognition as avirulence determinants in rice blast populations in Sub-Saharan Africa (SSA). During effector-triggered immunity, effectors can be recognised as avirulence gene products by rice resistance (R) proteins. Currently, 25 rice blast resistance genes have been cloned along with 10 cognate avirulence genes [4]. I have used third-generation Pacbio RSII sequencing technology to generate improved genome assemblies of two M. oryzae strains, wild type Guy11, and KE002, a Kenyan isolate that is avirulent on selected rice monogenic lines and is thought to carry many avirulence genes. I show that by using improved contiguous genomes, in combination with RNA-sequencing data, it is possible to establish a gene prediction pipeline that can identify isolate-specific or novel 2 small secreted protein encoding genes. With this approach, I have identified additional 49 and 590 genes in Guy11 and KE002 genomes respectively. Three of them, MEP13, MEP15 and MEP14, have been confirmed to encode secreted effector proteins. I also provide new insight into how effectors are secreted and delivered across the fungal plasma membrane. I report the use of high resolution microscopy and fluorescently labelled effector proteins to show that the biotrophy interfacial complex (BIC) is a plant derived structure through which the fungus continually secretes effectors in one direction into the targeted plant organelles. Using fluorescently labelled Pwl2 and Bas1, I present results suggesting that effectors translocate across the plasma membrane packaged in vesicles which are visible in the BIC, and that these effectors are sorted into distinct vesicles before crossing the plasma membrane. I then use CRISPR/Cas9 gene editing to generate pwl2 mutants in M. oryzae strain Guy11 which has three copies of the gene resulting in deletion of all copies of the effector gene and gain of virulence towards weeping lovegrass. This confirmed the function of PWL2 as a host range determinant that is conserved in most rice blast isolates. These results show that genes with multiple copies in the genome can be functionally characterised through either disruption or replacement using CRISPR/Cas9 in M. oryzae.BBSRCBill and Melinda Gates Foundation Halpin Trust Scholarshi

Hotel facilities’ management practices and employee performance in Kenya

This study investigated the efficacy of hotel facilities’ management practices on employee performance. A descriptive research survey was applied, while  the study area was Nairobi County. The sampling techniques applied were a census, stratified, purposive and simple random sampling which gave a  sample size of 144 employees. Study results show that sufficient lighting to allow ease of working and moving around safely gave the highest mean value  among maintenance management factors (3.95), while work surfaces and head-height beams yielded the highest mean (3.95) among hotel  workplace design factors. Nonetheless, health and safety had the majority (40%) of respondents among the hotel facilities regulations and standards.  Finally, hotel maintenance management gave the greatest contribution in the relationship between hotel facilities management practices and employee  performance (Β = 0.572, t = 4.637, p < 0.001), while hotel workplace design gave the least contribution (B = −0.299, t = −2.576, p = 0.011).&nbsp

Cassava breeding through complementary conventional and participatory approaches in western Kenya.

Thesis (Ph.D.)-University of KwaZulu-Natal, Pietermaritzburg, 2011.Participation of farmers in plant breeding programmes has been reported to increase breeding efficiency. Farmers’ participation bridges the gap between variety development and dissemination and provides an opportunity for farmers to select varieties they prefer. The breeders on the others hand learn more about the farmers’ preferences and the environment in which the new varieties will be grown. However, the advantages of participatory breeding can best be realized when farmers’ indigenous technical knowledge (ITK) and experience complement the breeder’s scientific knowledge and skills. Cassava (Manihot esculenta Crantz) is a clonally propagated crop grown in diverse environments by small scale farmers for subsistence. Information on the roles of farmers and breeders at various stages of breeding and their ability to effectively participate in breeding programmes is limited. The objectives of this study were to determine: (1) cassava farmers’ preferences, production constraints and systems; (2) farmers’ selection criteria of cassava varieties; (3) genetic inheritance of farmer preferred traits; (4) how farmers and breeders complement each other at all stages and activities of cassava breeding. Participatory rural appraisal was conducted in three purposefully sampled districts of western Kenya based on ethnicity and agro-ecology. The results reveal that cassava is predominantly grown by small scale farmers with mean land size of 1.6 ha mainly under mixed cropping system for subsistence. The storage roots are eaten either after boiling or processing to flour. The majority of farmers (over 60%) are aware of the improved varieties but adoption rate is low (18% in some districts). The effects of pests and diseases, and the lack of high yielding varieties, capital, land, and disease free planting material are the most important constraints to cassava production. Farmers prefer tall, high yielding varieties that are resistant to diseases and pests, early maturing and long underground storability of harvestable storage roots. The districts surveyed significantly differed in popularity of utilization methods, traits preferences and relative ranking of the production constraints indicative of differences in ethnicity and agro-ecology. Three farmer groups from the three districts selected in western Kenya were used to study farmers’ variety selection criteria based on their own indigenous technical knowledge (ITK). The groups evaluated 15 (10 landraces and five improved) popular cassava varieties with concealed identities on their farms. The results revealed that farmers have effective methods of selecting varieties for most of their preferred traits. However, ITK alone cannot be used to evaluate all the important traits, such as cyanide content. The genetic inheritance of farmer preferred traits was determined through a genetic study. Six landraces and four improved varieties popular in western Kenya were crossed using the North Carolina mating design II to generate 24 full-sib families. The 24 families, represented by 40 siblings each, were evaluated at two sites, Kakamega and Alupe research station farms, in a 24 x 40 a-lattice design. General combining ability (GCA) and specific combining ability (SCA) mean squares were significant (P<0.05) for all traits evaluated except dry matter content and cyanide content. However, non-additive gene action predominated over additive gene for cassava mosaic disease (CMD) resistance, height to first branching, total number of storage roots per plant and fresh storage root yield in all environments. The best crosses were not necessarily obtained from parents with high general combining ability confirming the presence of non-additive gene action. The best performing parents per se did not necessarily have high GCA effects implying that selection based on the per se performance of parents may not always lead to development of superior hybrids. The clonal evaluation trial (CET) was established at Alupe research station and evaluated by the breeder and farmers from two districts independently. Three selection criteria were tested to determine the most appropriate approach to selection of varieties that meet both farmers’ and breeder’s preferences. The selection criteria were; farmers’ independent selection index (SI) derived from farmers’ selection criteria from each district, breeder’s negative selection and independent SI, and a participatory SI which combines farmers’ and breeder’s selection criteria. There was 14% overlap among the top 100 varieties selected by farmers from all districts and the breeder when independent SI were used. However, there was 49% overlap among the top 100 varieties selected by farmers using participatory SI and the breeder’s SI. The farmers and the breeder have a role to play in the variety development process. Varieties with traits preferred by both the farmers and the breeder are likely to enhance breeding efficiency and effectiveness

Evaluation of Implementation Level of Community Health Strategy and Its Influence on Uptake of Skilled Delivery in Lurambi Sub County- Kenya

Background:&nbsp;Despite the widespread application of the community health strategy (CHS) in Kenya and evidence of its effectiveness in reducing health outcomes at the household level, data from Kakamega County, of which Lurambi sub-county is part of, still showed that skilled birth delivery was at 47% against the national estimateof 62% and a target of 90%. However, there was limited evidence on the level of CHS implementation and its association with the uptake of skilled delivery.Methods:&nbsp;The study employed a cross-sectional analytic design. A structured validated community unit (CU) scorecard and a household questionnaire were used to collect quantitative data from the CUs through Community Health Extension Workers (CHEWs) and at the household level through mothers with children below 1 year. A random sample of 436 mothers from all the 38 Community Units (CUs) was included. CU functionality was assessed using 17 binary indicators (scored as 1 for a positive response, 0 otherwise) and total scores were expressed as percentages. Fully functional CUs scored ≥80% and semi-functional CU scored &gt;50 to &lt;80%. No CU was non-functional (scored ≤50%). Data from the CUs were merged with data at the household level. Association between CU functionality and skilled delivery was assessed using multivariable binary logistic regression controlling for socio-demographic variables. Adjusted Odds Ratios (OR) and 95% Confidence Intervals (95%CI) are reported.Results:&nbsp;A total of 38 CUs were assessed and of these, 26(68.6%) were fully functional and 12(31.4%) were semi-functional, 18(47.4%) had both household registers (MOH 513) and service delivery logbooks (MOH 514). Overall, 387(80.0%) of mothers had skilled birth deliveries, 263(68%) were from functional CUs and 124(32%) were from semi-functional CUs. Pregnant women were more likely to have skilled deliveries in fully functional CUs than semi-functional CUs (OR=1.3; 95% CI=1.1-2.4; p-value&lt;.001). Other factors significantly associated with uptake of skilled delivery included receiving health education(OR=2.9;95%CI=1.4-6.1,p=.005), being visited at least twice by Community Health Volunteers, CHVs(OR=1.9;95%CI=1.1-3.5,p=.045), attending antenatal care clinics, ANC (OR=3.4;95%CI=1.3-3.5,p=.012), receiving advice where to deliver (OR=4.1;95%CI=1.8-9.4,p=.001).Conclusion: 2 out of 3 community units were fully functional, and functionality was associated with increased uptake of skilled delivery. In a fully functional CUs, Community Health Volunteers provided health education through regular visits and they were able to provide a referral to health facilities for the pregnant women. To achieve national targets for skilled deliveries and universal health coverage, there is a need to ensure CUs are fully functional

Assessing Capacity and Performance of Health Systems Using Principal Component Analysis: Results from Cross Sectional Survey in Kakamega County, Western Kenya

Background: Strong health systems are fundamental if countries are to improve health outcomes and accelerate the attainment of the Sustainable Development Goal (SDGs) number 3 ‘Ensure healthy lives and promote well-being for all at all ages.’ Despite the strong consensus on need to strengthen health systems, many health systems lack the capacity to measure or understand their own weakness and constraints which effectively leaves policy makers without ideas of what they should actually strengthen. Methods: Principal Component Analysis (PCA) was used to factor weights which were used to assess individual contribution of indicators to the health system performance.  PCA is a type of a multivariable linear regression of all indicators in one model. PCA index was classify variables from heighted to the lowest indicator and further used to rank the indicator. Indicators of individual health system building block were weighted independently to measure the amount of contribution to the respective health system building block. The weights were then aggregated to produce individual health system building block indices which were the independent variables in the multivariable linear regression model. Coefficients of the regression was used to assess marginal effects and p-value&lt;0.05 were considered statistics significant result Results: Service delivery (p&lt;0.0001), health financing (p&lt;0.0001), health workforce (p=0.005) and medical supplies and commodities (p&lt;0.0001) had significant effect on service provision. Health governance was not a significant factor influencing service provision. Conclusions: Among the health system building blocks that significantly influenced service provision were service delivery, health workforce, and health financing and medical supplies. This is the first study to the best of the knowledge of the researcher to apply principal component analysis, to analyze health system performance in a devolved system Kakamega. The method provides opportunity for future application in health systems analysis even in absence of comparative data Keywords: Principal Component Analysis, Health Systems DOI: 10.7176/JHMN/59-0

Pragmatic restaurant tipping in star-rated hotels in Kenya

Tipping can be traced to Tudor England in the sixteenth century. This act transformed into a custom, spreading to many countries. However, tipping is observed differently from one country to the other and thus is not homogeneous from a global perspective. The act of tipping is thought to be motivated by various predictors, which were studied and are thought to influence peoples’ tipping behaviour. They include gender, income level, religion, nationality, hospitality exposure, alcohol consumption and the weather conditions of the day. The study applied a cross-sectional survey design and was carried out in Kenya during from December 2019 to February 2020 in eight star-rated hotels. A questionnaire was applied in this study. The study has results showing that data is distributed close to the mean values. Further, the study results show that the independent variable explains 78.4% of the variability in the tipping practice. Thus the variable of “Patronage frequency” gave the strongest significant and unique contribution in explaining the dependent variable (B = 0.515, Sig. = 0.000, t = 15.363). However, religion gave the weakest unique and non-significant contribution (B = 0.013, Sig. = 0.770, t = 0.293). For hotel restaurants to achieve high levels of tipping, there is a need to adjust these predictors depending on the effect of each on the outcome variable. Thus, the study established a significant relationship between the determinants of tipping and the tipping practices in the sampled star-rated hotels in Kenya

Pattern and determinants of contraceptive use among the muslim women in Wajir and Lamu counties in Kenya: a cross-sectional study.

Background; Improving access to family planning (FP) is associated with positive health benefits that includes averting nearly a third of all maternal deaths and 10% of childhood deaths. Kenya has made great strides in improving access to family planning services. However, amid this considerable progress, regional variation has been noted which begs the need for a clearer understanding of the the patterns and determinants that drive these inconsistencies. Methods; We conducted a cross-sectional study that involved 663 Muslim women of reproductive age (15–49 years) from Wajir and Lamu counties in Kenya between March and October 2018.The objective of this study was to understand patterns and determinants of contraceptive use in two predominantly Muslim settings of Lamu and Wajir counties that have varying contraceptive uptake. Eligible women were interviewed using a semi-structured questionnaire containing socio-demographic information and history of family planning use. Simple and multiple logistic regression were used to identify determinants of family planning use. The results were presented as Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) ratios at 95% confidence interval. A p-value of 0.05 was considered statistically significant. Results; Of the 663 Muslim women of reproductive age consenting to participate in the study, 51.5%, n = 342 and 48.5%, n = 321 were from Lamu and Wajir County, respectively. The prevalence of women currently using contraceptive was 18.6% (n = 123). In Lamu, the prevalence was 32.8%, while in Wajir, it was 3.4%. The determinants of current contraceptive use in Lamu include; marital status, age at marriage, employment status, discussion with a partner on FP, acceptability of FP in culture, and willingness to obtain information on FP. While in Wajir, determinants of current contraceptive use were education, and the belief that family planning is allowed in Islam. Coclusions; Our study found moderately high use of contraceptives among Muslim women of reproductive age in Lamu county and very low contraceptive use among women in Wajir. Given the role of men in decision making, it is critical to design male involvement strategy particularly in Wajir where the male influence is very prominent. It is critical for the government to invest in women and girls’ education to enhance their ability to make informed decisions; particularly in Wajir where FP uptake is low with low education attainment. Further, our findings highlight the need for culturally appropriate messages and involvement of religious leaders to demystify the myths and misconception around family planning and Islam particularly in Wajir

Large-scale implementation of disease control programmes: a cost-effectiveness analysis of long-lasting insecticide-treated bed net distribution channels in a malaria-endemic area of western Kenya-a study protocol.

Introduction Historically, Kenya has used various distribution models for long-lasting insecticide-treated bed nets (LLINs) with variable results in population coverage. The models presently vary widely in scale, target population and strategy. There is limited information to determine the best combination of distribution models, which will lead to sustained high coverage and are operationally efficient and cost-effective. Standardised cost information is needed in combination with programme effectiveness estimates to judge the efficiency of LLIN distribution models and options for improvement in implementing malaria control programmes. The study aims to address the information gap, estimating distribution cost and the effectiveness of different LLIN distribution models, and comparing them in an economic evaluation. Methods and analysis Evaluation of cost and coverage will be determined for 5 different distribution models in Busia County, an area of perennial malaria transmission in western Kenya. Cost data will be collected retrospectively from health facilities, the Ministry of Health, donors and distributors. Programme-effectiveness data, defined as the number of people with access to an LLIN per 1000 population, will be collected through triangulation of data from a nationally representative, cross-sectional malaria survey, a cross-sectional survey administered to a subsample of beneficiaries in Busia County and LLIN distributors’ records. Descriptive statistics and regression analysis will be used for the evaluation. A cost-effectiveness analysis will be performed from a health-systems perspective, and cost-effectiveness ratios will be calculated using bootstrapping techniques. Ethics and dissemination The study has been evaluated and approved by Kenya Medical Research Institute, Scientific and Ethical Review Unit (SERU number 2997). All participants will provide written informed consent. The findings of this economic evaluation will be disseminated through peer-reviewed publications