"I'll take them another day": A qualitative study exploring the socio-behavioral complexities of childhood vaccination in urban poor settlements.

Despite improvement over recent decades, childhood vaccination uptake remains a concern across countries. The World Health Organization observed that over 25 million children missed out on one or more vaccines in 2021, with urban poor and other marginalized groups being the most affected. Given the higher risk of disease transmission and vaccine-preventable diseases (VPD) outbreaks across densely populated urban slums, identifying effective interventions to improve childhood vaccination in this vulnerable population is crucial. This study explored the behavioral and social factors influencing childhood vaccination uptake in urban informal settlements in Nairobi, Kenya. A grounded theory approach was employed to develop a theoretical account of the socio-behavioral determinants of childhood vaccination. Five focus group discussions (FGDs) were conducted with purposively sampled caregivers of children under five years of age residing in informal settlements. The Theory of Planned Behavior guided the structuring of the FGD questions. An iterative process was used to analyze and identify emerging themes. Thirty-nine caregivers (median age 29 years) participated in the FGDs. From the analysis, four main thematic categories were derived. These included attitude factors such as perceived vaccine benefits, cultural beliefs, and emotional factors including parental love. Additionally, subjective norms, like fear of social judgment, and perceived behavioral control factors, such as self-control and gender-based influences, were identified. Furthermore, a number of practical factors, including the cost of vaccines and healthcare providers attitude, also affected the uptake of vaccination. Various social, behavioral, cultural, and contextual factors influence caregiver vaccination decisions in urban poor settings. Community-derived and context-specific approaches that address the complex interaction between socio-behavioral and other contextual factors need to be tested and applied to improve the timely uptake of childhood vaccinations among marginalized populations.

Understanding the fine-scale heterogeneity and spatial drivers of malaria transmission in Kenya using model-based geostatistical methods.

Malaria remains a public health concern. Monitoring the fine-scale heterogeneity of the malaria burden enables more targeted control efforts. Although malaria indicator surveys (MIS) have been crucial in evaluating the progress of malaria control interventions, they are only designed to provide a cross-sectional national and regional malaria disease burden. Recent advances in geostatistical methods allow us to interpolate national survey data to describe subnational disease burden that is crucial in informing targeted control. A binomial geostatistical model employing Markov chain Monte Carlo (MCMC) parameter estimation methods is used to understand the spatial drivers of malaria risk in Kenya and to predict malaria risk at a fine-scale resolution, including identifying hotspots. A total of 11,549 children aged six months to 14 years from 207 clusters were sampled in this survey and used in the present analysis. The national malaria prevalence based on the data was 8.4%, with the highest in the lake endemic zone (18.1%) and the lowest in the low-risk zone (<1%). The analysis shows that elevation, proportion of insectcide treated net (ITN) distributed, rainfall, temperature and urbanization covariates are all significant predictors of malaria transmission. The 5x5 Km resolution maps show that malaria is heterogeneous in Kenya, with hotspot areas in the lake endemic area, the coastal areas, and some parts of the shores of Lake Turkana and Kajiado. The high-resolution malaria prevalence maps produced as part of the analysis have shown that Kenya has additional malaria hotspots, especially in areas least expected. These findings call for a rethinking of malaria burden classification in some regions for effective planning, implementation, resource mobilization, monitoring, and evaluation of malaria interventions in the country.

Malaria Burden Stratification in Malawi- A report of a consultative workshop to inform the 2023-2030 Malawi Malaria Strategic Plan.

Background: Malawi's National Malaria Control Programme (NMCP) is developing a new strategic plan for 2023-2030 to combat malaria and recognizes that a blanket approach to malaria interventions is no longer feasible. To inform this new strategy, the NMCP set up a task force comprising 18 members from various sectors, which convened a meeting to stratify the malaria burden in Malawi and recommend interventions for each stratum. Methods: The burden stratification workshop took place from November 29 to December 2, 2022, in Blantyre, Malawi, and collated essential data on malaria burden indicators, such as incidence, prevalence, and mortality. Workshop participants reviewed the malaria burden and intervention coverage data to describe the current status and identified the districts as a appropriate administrative level for stratification and action. Two scenarios were developed for the stratification, based on composites of three variables. Scenario 1 included incidence, prevalence, and under-five all-cause mortality, while Scenario 2 included total malaria cases, prevalence, and under-five all-cause mortality counts. The task force developed four burden strata (highest, high, moderate, and low) for each scenario, resulting in a final list of districts assigned to each stratum. Results: The task force concluded with 10 districts in the highest-burden stratum (Nkhotakota, Salima, Mchinji, Dowa, Ntchisi, Mwanza, Likoma, Lilongwe, Kasungu and Mangochi) 11 districts in the high burden stratum (Chitipa, Rumphi, Nkhata Bay, Dedza, Ntcheu, Neno, Thyolo, Nsanje, Zomba, Mzimba and Mulanje) and seven districts in the moderate burden stratum (Karonga, Chikwawa, Balaka, Machinga, Phalombe, Blantyre, and Chiradzulu). There were no districts in the low-burden stratum. Conclusion: The next steps for the NMCP are to review context-specific issues driving malaria transmission and recommend interventions for each stratum. Overall, this burden stratification workshop provides a critical foundation for developing a successful malaria strategic plan for Malawi.

Two decades of malaria control in Malawi: Geostatistical Analysis of the changing malaria prevalence from 2000-2022.

Background: Malaria remains a public health problem in Malawi and has a serious socio-economic impact on the population. In the past two decades, available malaria control measures have been substantially scaled up, such as insecticide-treated bed nets, artemisinin-based combination therapies, and, more recently, the introduction of the malaria vaccine, the RTS,S/AS01. In this paper, we describe the epidemiology of malaria for the last two decades to understand the past transmission and set the scene for the elimination agenda. Methods: A collation of parasite prevalence surveys conducted between the years 2000 and 2022 was done. A spatio-temporal geostatistical model was fitted to predict the yearly malaria risk for children aged 2-10 years (PfPR 2-10) at 1×1 km spatial resolutions. Parameter estimation was done using the Monte Carlo maximum likelihood method. District-level prevalence estimates adjusted for population are calculated for the years 2000 to 2022. Results: A total of 2,595 sampled unique locations from 2000 to 2022 were identified through the data collation exercise. This represents 70,565 individuals that were sampled in the period. In general, the PfPR2_10 declined over the 22 years. The mean modelled national PfPR2_10 in 2000 was 43.93 % (95% CI:17.9 to 73.8%) and declined to 19.2% (95%CI 7.49 to 37.0%) in 2022. The smoothened estimates of PfPR2_10 indicate that malaria prevalence is very heterogeneous with hotspot areas concentrated on the southern shores of Lake Malawi and the country's central region. Conclusions: The last two decades are associated with a decline in malaria prevalence, highly likely associated with the scale-up of control interventions. The country should move towards targeted malaria control approaches informed by surveillance data.

In Malawi, malaria continues to be a significant health issue, affecting people's well-being and the economy. Over the past twenty years, efforts to control malaria, such as using bed nets, specific medications, and introducing a malaria vaccine, have increased substantially. This paper explores malaria transmission patterns during this time to better understand the past situation and prepare for future efforts to eliminate the disease. We collected and analyzed data from various surveys conducted between 2000 and 2022, focusing on malaria risk for children aged 2­10 years. We used a detailed statistical model to predict yearly malaria risk. The results show a decline in malaria prevalence over the 22 years. The analysis also reveals variations in malaria prevalence, with hotspot areas particularly concentrated in the southern shores of Lake Malawi and the country's central region. This decline in malaria prevalence is likely linked to the increased implementation of control measures. The findings emphasize the importance of targeted approaches informed by ongoing surveillance data for continued progress in malaria control.

Characterisation of tuberculosis mortality in informal settlements in Nairobi, Kenya: analysis of data between 2002 and 2016.

BACKGROUND: Tuberculosis (TB) remains one of the key public health problems in Africa. Due to multifaceted challenges, its burden is poorly described in informal settlements. We describe tuberculosis mortality in two informal settlements in Nairobi, Kenya. METHODS: This is a secondary analysis of 2002-2016 verbal autopsy data from informal settlements in the Nairobi Urban Health Demographic Surveillance System (NUHDSS). A descriptive analysis of deaths assigned as caused by TB was done. Pearson chi-square tests were used to determine differences between socio-demographic factors. Logistic regression was carried out to examine the risk of death from TB within the characteristics. RESULTS: There were 6218 deaths in the NUHDSS within the period of analysis, of which 930 (14.96%) were deaths from TB. The average number of TB deaths per year was 62(SD 23.9). There was a reduction in TB deaths from 21.2% in 2005 to 1.7% in 2016. Males had 1.39 higher odds of dying from TB than females (AOR 1.39; 95% CI 1.18-1.64; p-value < 0.001). Compared to those aged 30-39 years, the ≥50-year-olds had a 42% lower chance of dying from TB (AOR 0.57; 95% CI 0.47-0.73; p-value < 0.001). Those dying at home had 1.39 odds of dying from TB as compared to those who died in a health facility(AOR 1.93; 95% CI 1.17-1.64; p value< 0.001). CONCLUSION: There was a reduction in TB deaths over the study period. Males had the highest risk of death. There is a need to strengthen TB surveillance and access to TB diagnosis and treatment within informal settlements to enhance early diagnosis and treatment.

Effect of bed net colour and shape preferences on bed net usage: a secondary data analysis of the 2017 Malawi Malaria Indicator Survey.

BACKGROUND: Malaria remains a significant cause of morbidity and mortality in the paediatric population in Malawi. Insecticide-treated bed nets are a key vector malaria control intervention, however, advancement towards universal access is progressing slowly. Malawi Malaria indicator surveys (MMIS) show diverse user preferences of bed net shape and colour. The objective of this work was to understand if bed net shape and colour preferences affect usage. METHODS: This is a secondary analysis of data from households that participated in the 2016-2017 MMIS. The main outcome variable was net usage defined, at net level, whether someone slept under a particular net on the night before the survey. The main exposure variables were preference attributes, whether a particular net is of a preferred colour or shape as defined by the household respondent. Both bivariate and multivariate logistic regression analyses were done to determine the association between the exposure and outcome variables. RESULTS: A total of 3729 households with 16,755 individuals were included in this analysis. There were a total 7710 bed nets in households that participated in the survey of which 5435 (70.5%) of these nets had someone sleep under them the previous night before the survey. Bed nets that are of a preferred shape have 3.55 times higher odds of being used than those not preferred [AOR 3.55 (95% CI 2.98, 4.23; p value < 0.001)]. Bed nets that are of a preferred colour have 1.61 times higher odds of being used than those that are not of a preferred colour [AOR 1.61 (95% CI 1.41, 1.84; p value < 0.001]. CONCLUSIONS: The results indicate that if a bed net is of a preferred colour or shape, it is more likely to be used. Bed net purchase by malaria stakeholders need to balance more factors on top of preferences such as price and efficacy.

Does recall time matter in verbal autopsies? Evidence from urban informal settlements in Nairobi, Kenya.

Background: To assign a cause of death to non-medically certified deaths, verbal autopsies (VAs) are widely used to determine the cause of death. The time difference between the death and the VA interview, also referred to as recall time, varies depending on social and operational factors surrounding the death. We investigated the effect of recall time on the assignment of causes of death by VA. Methods: This is a secondary analysis of 2002-2015 survey data of the Nairobi Urban Health Demographic Surveillance System (NUHDSS). The independent variable recall time was derived from the date of death and the date when the VA was conducted. Univariate and multivariate logistic regression methods were used to calculate odds ratios of assigning a cause of death in defined categories of recall time. Results: There were 6218 deaths followed up between 2002 and 2016, out of which 5495 (88.3%) had VAs done. Recall time varied from 1-3001 days (median  92 days, IQR 44-169 days). Majority of the VAs (45.7%) were conducted between 1-3 months after death. The effect of recall time varied for different diseases. Compared to VAs conducted between 1-3 months, there was a 24% higher likelihood of identifying HIV/AIDS as the cause of death for VAs conducted 4-6 months after death (AOR 1.24; 95% CI 1.01-1.54; p-value = 0.043) and a 40% increased chance of identifying other infectious diseases as the cause of death for VAs conducted <1 month after death (AOR 1.4; 95% CI 1.02-1.92, p-value = 0.024). Conclusions: Recall time affected the assignment of VA cause of death for HIV/AIDS, other infectious diseases,maternal/neonatal and indeterminate causes. Our analysis indicates that in the urban informal setting, VAs should be conducted from one month up to 6 months after the death to improve the probability of accurately assigning the cause of death.

Healthcare Providers' Level of Involvement in Provision of Smoking Cessation Interventions in Public Health Facilities in Kenya.

Healthcare providers can play a major role in tobacco control by providing smoking cessation interventions to smoking patients. The objective of this study was to establish healthcare providers' practices regarding smoking cessation interventions in selected health facilities in Kiambu County, Kenya. This was a descriptive cross-sectional study carried out among healthcare providers working in public health facilities in Kiambu County, Kenya. Self-administered questionnaires were distributed to 400 healthcare providers selected using a two-stage stratified sampling technique. Only 35% of the healthcare providers surveyed reported that they always asked patients about their smoking status. Less than half (44%) reported that they always advised smoking patients to quit. Respondents who had received training on smoking cessation interventions were 3.7 times more likely to have higher practice scores than those without training (OR = 3.66; 95%CI: 1.63-8.26; P = 0.003). Majority of the healthcare providers do not routinely provide smoking cessation interventions to their patients. Measures are needed to increase health worker's involvement in provision of smoking cessation care in Kenya.