Victims or perpetrators, agency, and politics of intimate partner violence in the social construction of health and wellbeing: a qualitative study from Kenya.

Deeply rooted cultural beliefs and norms relating to the position and the responsibilities assigned to men and women play a significant role in propagating intimate partner violence (IPV). It is yet to be understood in what ways experiences of IPV contribute to how people socially construct their health and wellbeing as they navigate the tensions created by the prevailing sociocultural systems. To address this knowledge gap, we employed a social constructionist perspective and the eco-social model to explore how Kenyans aged 25-49 years socially construct their health and wellbeing in relation to their experiences of IPV. We conducted nine in-depth interviews and ten focus group discussions in four counties in Kenya between January and April of 2017. Textual analysis of the narratives reveals that although men are usually framed as perpetrators of violence, they may also be victims of reciprocal aggression by women, as recently witnessed in cases where women retaliate through gang attacks, chopping of male genitalia, and scalding with water. However, women are still disproportionately affected by gender-based violence because of the deeply rooted gender imbalances in patriarchal societies. Women experience social stigma associated with such violence and when separated or divorced in situations of unsafe relationships, they are viewed as social misfits. As such, most women opt to stay in unhealthy relationships to avoid social isolation. These experiences are not only unhealthy for their psychological wellbeing but also for their physical health and socioeconomic status and that of their offspring.

Integrating digital solutions into national health data systems through public-private collaboration: An early experience of the SPICE platform in Kenya.

Public-private collaborative efforts to address healthcare challenges in low- and middle-income countries have been the focus of digital initiatives to improve both access and quality of health services. We report the early feasibility, experience, and learnings of migrating healthcare data generated from a proprietary, privately owned cloud-based environment into an on-premises National Health Data Center (NHDC) in compliance with Kenya's data management legislation. In 2018, Medtronic LABS entered into a partnership with the Kenya Ministry of Health and other stakeholders to improve access to quality services and data availability for non-communicable diseases (diabetes and hypertension), anchored on the SPICE digital health platform. Data migration from SPICE to the NHDC necessitated the establishment of multi-stakeholder coordination structures, alignment on system configuration requirements, provisioning of on-premises servers, data replication and monitoring. The data replication process showed consistency in format and content with no evidence of data loss. The monitoring of the server uptime and availability, however, exposed overall downtime of 15% of the total time tracked between April and December 2022 caused by Internet Protocol address configuration issues, power outages, firewall rule changes, and unscheduled system maintenance. Monthly tracked downtime however reduced from a high of 28% in April 2022 to 5% in December 2022. Our early experience shows that data migration from proprietary host environments to public "one-stop-shop" national data warehouses are feasible provided investments are made in the requisite infrastructure, software and human resource capacity to ensure long-term sustainability, maintenance, and scale to match cloud-based data hosting. Further, digital health solutions developed in collaboration with non-state actors can be integrated into national data systems, saving Governments the cost and efforts of building similar tools while leveraging private sector capacity.

Food Insecurity and Dietary Deprivation: Migrant Households in Nairobi, Kenya.

The current study focuses on food consumption and dietary diversity among internal migrant households in Kenya using data from a city-wide household survey of Nairobi conducted in 2018. The paper examined whether migrant households are more likely to experience inferior diets, low dietary diversity, and increased dietary deprivation than their local counterparts. Second, it assesses whether some migrant households experience greater dietary deprivation than others. Third, it analyses whether rural-urban links play a role in boosting dietary diversity among migrant households. Length of stay in the city, the strength of rural-urban links, and food transfers do not show a significant relationship with greater dietary diversity. Better predictors of whether a household is able to escape dietary deprivation include education, employment, and household income. Food price increases also decrease dietary diversity as migrant households adjust their purchasing and consumption patterns. The analysis shows that food security and dietary diversity have a strong relationship with one another: food insecure households also experience the lowest levels of dietary diversity, and food secure households the highest.

Identifying the necessary capacities for the adaptation of a diabetes phenotyping algorithm in countries of differing economic development status.

BACKGROUND: In 2019, the World Health Organization recognised diabetes as a clinically and pathophysiologically heterogeneous set of related diseases. Little is currently known about the diabetes phenotypes in the population of low- and middle-income countries (LMICs), yet identifying their different risks and aetiology has great potential to guide the development of more effective, tailored prevention and treatment. OBJECTIVES: This study reviewed the scope of diabetes datasets, health information ecosystems, and human resource capacity in four countries to assess whether a diabetes phenotyping algorithm (developed under a companion study) could be successfully applied. METHODS: The capacity assessment was undertaken with four countries: Trinidad, Malaysia, Kenya, and Rwanda. Diabetes programme staff completed a checklist of available diabetes data variables and then participated in semi-structured interviews about Health Information System (HIS) ecosystem conditions, diabetes programme context, and human resource needs. Descriptive analysis was undertaken. RESULTS: Only Malaysia collected the full set of the required diabetes data for the diabetes algorithm, although all countries did collect the required diabetes complication data. An HIS ecosystem existed in all settings, with variations in data hosting and sharing. All countries had access to HIS or ICT support, and epidemiologists or biostatisticians to support dataset preparation and algorithm application. CONCLUSIONS: Malaysia was found to be most ready to apply the phenotyping algorithm. A fundamental impediment in the other settings was the absence of several core diabetes data variables. Additionally, if countries digitise diabetes data collection and centralise diabetes data hosting, this will simplify dataset preparation for algorithm application. These issues reflect common LMIC health systems' weaknesses in relation to diabetes care, and specifically highlight the importance of investment in improving diabetes data, which can guide population-tailored prevention and management approaches.

Accuracy of computer-aided chest X-ray in community-based tuberculosis screening: Lessons from the 2016 Kenya National Tuberculosis Prevalence Survey.

Community-based screening for tuberculosis (TB) could improve detection but is resource intensive. We set out to evaluate the accuracy of computer-aided TB screening using digital chest X-ray (CXR) to determine if this approach met target product profiles (TPP) for community-based screening. CXR images from participants in the 2016 Kenya National TB Prevalence Survey were evaluated using CAD4TBv6 (Delft Imaging), giving a probabilistic score for pulmonary TB ranging from 0 (low probability) to 99 (high probability). We constructed a Bayesian latent class model to estimate the accuracy of CAD4TBv6 screening compared to bacteriologically-confirmed TB across CAD4TBv6 threshold cut-offs, incorporating data on Clinical Officer CXR interpretation, participant demographics (age, sex, TB symptoms, previous TB history), and sputum results. We compared model-estimated sensitivity and specificity of CAD4TBv6 to optimum and minimum TPPs. Of 63,050 prevalence survey participants, 61,848 (98%) had analysable CXR images, and 8,966 (14.5%) underwent sputum bacteriological testing; 298 had bacteriologically-confirmed pulmonary TB. Median CAD4TBv6 scores for participants with bacteriologically-confirmed TB were significantly higher (72, IQR: 58-82.75) compared to participants with bacteriologically-negative sputum results (49, IQR: 44-57, p<0.0001). CAD4TBv6 met the optimum TPP; with the threshold set to achieve a mean sensitivity of 95% (optimum TPP), specificity was 83.3%, (95% credible interval [CrI]: 83.0%-83.7%, CAD4TBv6 threshold: 55). There was considerable variation in accuracy by participant characteristics, with older individuals and those with previous TB having lowest specificity. CAD4TBv6 met the optimal TPP for TB community screening. To optimise screening accuracy and efficiency of confirmatory sputum testing, we recommend that an adaptive approach to threshold setting is adopted based on participant characteristics.

Preparing for COVID-19: Household food insecurity and vulnerability to shocks in Nairobi, Kenya.

An understanding of the types of shocks that disrupt and negatively impact urban household food security is of critical importance to develop relevant and targeted food security emergency preparedness policies and responses, a fact magnified by the current COVID-19 pandemic. This gap is addressed by the current study which draws from the Hungry Cities Partnership (HCP) city-wide household food insecurity survey of Nairobi city in Kenya. It uses both descriptive statistics and multilevel modelling using General Linear Mixed Models (GLMM) to examine the relationship between household food security and 16 different shocks experienced in the six months prior to the administration of the survey. The findings showed that only 29% of surveyed households were completely food secure. Of those experiencing some level of food insecurity, more experienced economic (55%) than sociopolitical (16%) and biophysical (10%) shocks. Economic shocks such as food price increases, loss of employment, and reduced income were all associated with increased food insecurity. Coupled with the lack of functioning social safety nets in Nairobi, households experiencing shocks and emergencies experience serious food insecurity and related health effects. In this context, the COVID-19 pandemic is likely to have a major negative economic impact on many vulnerable urban households. As such, there is need for new policies on urban food emergencies with a clear emergency preparedness plan for responding to major economic and other shocks that target the most vulnerable.

Assessing the Real-Time Impact of COVID-19 on TB and HIV Services: The Experience and Response from Selected Health Facilities in Nairobi, Kenya.

There was concern that the COVID-19 pandemic would adversely affect TB and HIV programme services in Kenya. We set up real-time monthly surveillance of TB and HIV activities in 18 health facilities in Nairobi so that interventions could be implemented to counteract anticipated declining trends. Aggregate data were collected and reported monthly to programme heads during the COVID-19 period (March 2020-February 2021) using EpiCollect5 and compared with monthly data collected during the pre-COVID period (March 2019-February 2020). During the COVID-19 period, there was an overall decrease in people with presumptive pulmonary TB (31.2%), diagnosed and registered with TB (28.0%) and in those tested for HIV (50.5%). Interventions to improve TB case detection and HIV testing were implemented from August 2020 and were associated with improvements in all parameters during the second six months of the COVID-19 period. During the COVID-19 period, there were small increases in TB treatment success (65.0% to 67.0%) and referral of HIV-positive persons to antiretroviral therapy (91.2% to 92.9%): this was more apparent in the second six months after interventions were implemented. Programmatic interventions were associated with improved case detection and treatment outcomes during the COVID-19 period, suggesting that monthly real-time surveillance is useful during unprecedented events.

Longitudinal-Survival Models for Case-Based Tuberculosis Progression.

Introduction: Tuberculosis (TB) disease continues to be responsible for a high global burden with an estimated 10 million people falling ill each year and an estimated 1.45 million deaths. Widely carried out analyses to utilize routine data coming from this disease, and well-established in literature, have paid attention to time-to-event with sputum smear results being considered only at baseline or even ignored. Also, logistic regression models have been used to demonstrate importance of sputum smear results in patient outcomes. A feature presented by this disease, however, is that each individual patient is usually followed over a period of time with sputum smear results being documented at different points of the treatment curve. This provides both repeated measures and survival times, which may require a joint modeling approach. This study aimed to investigate the association between sputum smear results and the risk of experiencing unfavorable outcome among TB patients and dynamically predict survival probabilities. Method: A joint model for longitudinal and time-to-event data was used to analyze longitudinally measured smear test results with time to experiencing unfavorable outcome for TB patients. A generalized linear mixed-effects model was specified for the longitudinal submodel and cox proportional hazards model for the time-to-event submodel with baseline hazard approximated using penalized B-splines. The two submodels were then assumed to be related via the current value association structure. Bayesian approach was used to approximate parameter estimates using Markov Chain Monte Carlo (MCMC) algorithm. The obtained joint model was used to predict the subject's future risk of survival based on sputum smear results trajectories. Data were sourced from routinely collected TB data stored at National TB Program database. Results: The average baseline age was 35 (SD: 15). Female TB patients constituted 36.42%. Patients with previous history of TB treatment constituted 6.38% (event: 15.25%; no event: 5.29%). TB/HIV co-infection was at 31.23% (event: 47.87%; no event: 29.20%). The association parameter 1.03 (CI[1.03,1.04]) was found to be positive and significantly different from zero, interpreted as follows: The estimate of the association parameter α = 1.033 denoted the log hazard ratio for a unit increase in the log odds of having smear positive results. HIV status (negative) 0.47 (CI [0.46,49]) and history of TB treatment (previously treated) (2.52 CI [2.41,2.63]), sex (female) (0.82 CI [0.78,0.84]), and body mass index (BMI) categories (severe malnutrition being reference) were shown to be statistically significant. Conclusion: Sputum smear result is important in estimating the risk to unfavorable outcome among TB patients. Men, previously treated, TB/HIV co-infected and severely malnourished TB patients are at higher risk of unfavorable outcomes.

Outcomes of isoniazid preventive therapy among people living with HIV in Kenya: A retrospective study of routine health care data.

INTRODUCTION: Isoniazid preventive therapy (IPT) taken by People Living with HIV (PLHIV) protects against active tuberculosis (TB). Despite its recommendation, data is scarce on the uptake of IPT among PLHIV and factors associated with treatment outcomes. We aimed at determining the proportion of PLHIV initiated on IPT, assessed TB screening practices during and after IPT and IPT treatment outcomes. METHODS: A retrospective cohort study of a representative sample of PLHIV initiated on IPT between July 2015 and June 2018 in Kenya. For PLHIV initiated on IPT during the study period, we abstracted patient IPT uptake data from the National data warehouse. In contrast, we obtained information on socio-demographic, TB screening practices, IPT initiation, follow up, and outcomes from health facilities' patient record cards, IPT cards, and IPT registers. Further, we assessed baseline characteristics as potential correlates of developing active TB during and after treatment and IPT completion using multivariable logistic regression. RESULTS: From the data warehouse, 138,442 PLHIV were enrolled into ART during the study period and initiated 95,431 (68.9%) into IPT. We abstracted 4708 patients' files initiated on IPT, out of which 3891(82.6%) had IPT treatment outcomes documented, 4356(92.5%) had ever screened for TB at every clinic visit, and 4,243(90.1%) had documentation of TB screening on the IPT tool before IPT initiation. 3712(95.4%) of patients with documented IPT treatment outcomes completed their treatment. 42(0.89%) of the abstracted patients developed active TB,16(38.1%) during, and 26(61.9%) after completing IPT. Follow up for active TB at 6-month post-IPT completion was done for 2729(73.5%) of patients with IPT treatment outcomes. Sex, Viral load suppression, and clinic type were associated with TB development (p<0.05). Levels 4, 5, FBO, and private facilities and IPT prescription practices were associated with IPT completion (p<0.05). CONCLUSION: IPT initiation stands at two-thirds of the PLHIV, with a high completion rate. TB screening practices were better during IPT than after completion. Development of active TB during and after IPT emphasizes the need for a keen follow up.

Bleeding Bodies, Untrustworthy Bodies: A Social Constructionist Approach to Health and Wellbeing of Young People in Kenya.

The Sustainable Development Goals provide a global development agenda that is meant to be inclusive of all people. However, the development needs for vulnerable populations such as youth are not reflected within the policy agenda of some developing countries. One of the reasons for this is that research that explores health and wellbeing concerns for young people are sparse in the region and where they exist, the focus has been on marginalized subgroups. To address this gap, this cross-sectional study explored the health and wellbeing of youth in Kenya. We conducted 10 focus group discussions and 14 in-depth interviews with youth ages 15 to 24 years. A thematic analysis of the data revealed that structural factors are important influencers of youth perceptions and their social constructions of health and wellbeing. Kenyan youth are concerned about the health status and healthcare services in their communities, as well as issues of community trust of youths and perceived risks of political misuse and emotional suffering. Our findings suggest that youth transitioning into adulthood in resource-constrained areas experience feelings of powerlessness and inability to take charge over their own life. This impacts how they perceive and socially construct health and wellbeing.

Assessing tuberculosis control priorities in high-burden settings: a modelling approach.

BACKGROUND: In the context of WHO's End TB strategy, there is a need to focus future control efforts on those interventions and innovations that would be most effective in accelerating declines in tuberculosis burden. Using a modelling approach to link the tuberculosis care cascade to transmission, we aimed to identify which improvements in the cascade would yield the greatest effect on incidence and mortality. METHODS: We engaged with national tuberculosis programmes in three country settings (India, Kenya, and Moldova) as illustrative examples of settings with a large private sector (India), a high HIV burden (Kenya), and a high burden of multidrug resistance (Moldova). We collated WHO country burden estimates, routine surveillance data, and tuberculosis prevalence surveys from 2011 (for India) and 2016 (for Kenya). Linking the tuberculosis care cascade to tuberculosis transmission using a mathematical model with Bayesian melding in each setting, we examined which cascade shortfalls would have the greatest effect on incidence and mortality, and how the cascade could be used to monitor future control efforts. FINDINGS: Modelling suggests that combined measures to strengthen the care cascade could reduce cumulative tuberculosis incidence by 38% (95% Bayesian credible intervals 27-43) in India, 31% (25-41) in Kenya, and 27% (17-41) in Moldova between 2018 and 2035. For both incidence and mortality, modelling suggests that the most important cascade losses are the proportion of patients visiting the private health-care sector in India, missed diagnosis in health-care settings in Kenya, and drug sensitivity testing in Moldova. In all settings, the most influential delay is the interval before a patient's first presentation for care. In future interventions, the proportion of individuals with tuberculosis who are on high-quality treatment could offer a more robust monitoring tool than routine notifications of tuberculosis. INTERPRETATION: Linked to transmission, the care cascade can be valuable, not only for improving patient outcomes but also in identifying and monitoring programmatic priorities to reduce tuberculosis incidence and mortality. FUNDING: US Agency for International Development, Stop TB Partnership, UK Medical Research Council, and Department for International Development.

Effectiveness of zinc-fortified water on zinc intake, status and morbidity in Kenyan pre-school children: a randomised controlled trial.

OBJECTIVE: Zn deficiency and diarrhoea are prevalent and may coexist in children living in low-resource settings. Recently, a novel approach for delivering Zn via microbiologically treated, Zn-fortified water was shown to be effective in improving Zn status in West African schoolchildren. We assessed the effectiveness of Zn-fortified, microbiologically purified water delivered as a household intervention on Zn intake, status and morbidity in children aged 2-6 years from rural western Kenya. DESIGN: Randomised controlled trial. Intervention included households assigned to water treatment device with (ZFW) or without (FW) Zn delivery capability SETTING: Rural households in Kisumu, western Kenya. SUBJECTS: Children aged 2-6 years. RESULTS: The ZFW group had higher dietary Zn intake compared with the FW group. ZFW contributed 36 and 31 % of daily requirements for absorbable Zn in children aged 2-3 and 4-6 years, respectively, in the ZFW group. Consumption of Zn-fortified water resulted in lower prevalence of reported illness (risk ratio; 95 % CI) in the ZFW group compared with the FW group: for cold with runny nose (0·91; 0·83, 0·99; P=0·034) and abdominal pain (0·70; 0·56, 0·89; P=0·003) in the intention-to-treat analysis and for diarrhoea (0·72; 0·53, 0·96; P=0·025) in the per-protocol analysis. We did not detect an effect of treatment on plasma Zn concentration. CONCLUSIONS: Daily consumption of Zn-fortified, microbiologically treated water results in increased intake of absorbable dietary Zn and may help in preventing childhood infections in pre-school children in rural Africa.

The next Sub Saharan African epidemic? A case study of the determinants of cervical cancer knowledge and screening in Kenya.

Early cervical cancer screening has been shown to be beneficial in reducing cervical cancer related deaths. Despite the benefits of early cervical cancer screening, uptake remains limited, with wide disparities in access and uptake in most developing countries. As part of a larger study, this paper uses a socio-ecological framework to explain the determinants of cervical cancer knowledge and screening among women of reproductive age (15-49 years) in Kenya. We conducted a multilevel analysis of cervical cancer knowledge (n = 11,138) and screening (n = 10,333) using the 2014 Kenya Demographic and Health Survey (KDHS). Results show regional disparities in cancer knowledge and the utilization of cervical cancer screening services; regions with high wealth inequality (OR = 0.70, 95% CI [0.56-0.87]) emerged as vulnerable regions where women were less likely to screen for cervical cancer. Gender equity, health insurance coverage and education level significantly predicted cervical cancer screening rates. Results further revealed regional as well as rural-urban wealth inequalities in cervical cancer screening. We argue that given that Kenyan women are highly exposed to human papilloma virus (HPV) due to the legacy of human immunodeficiency virus (HIV) in the country, cervical cancer may be the next epidemic if integrated measures are not adopted to increase cervical cancer knowledge and overcome the barriers to utilizing early screening services. The paper concludes with policy recommendations and directions for future research.

Combining food-based dietary recommendations using Optifood with zinc-fortified water potentially improves nutrient adequacy among 4- to 6-year-old children in Kisumu West district, Kenya.

Children in developing countries often face multiple micronutrient deficiencies. Introduction of zinc-fortified water can increase zinc intake, but additional recommendations are required to address overall diet nutrient adequacy. We developed and tested food-based recommendations (FBRs) that included zinc-fortified water for children aged between 4 and 6 years from rural Kenya to achieve the best possible nutrient adequacy. Dietary intakes of 60 children aged 4-6 years, from Kisumu West district, Kenya, were assessed using a quantitative multipass 24-hr recall. Linear programming model parameters were derived, including a list of foods consumed, median serving sizes, and distribution of frequency of consumption. By using the Optifood linear programming tool, we developed FBRs for diets including zinc-fortified water. FBRs with nutrient levels achieving ≥70% recommended nutrient intake (RNI) of the World Health Organization/Food and Agriculture Organization of the United Nations RNI for most of the 12 considered nutrients were selected as the final recommendations for the children. With no FBRs and no zinc-fortified water, percent RNI coverage range was between 40% and 76% for zinc, improving to 66-101% after introduction of zinc-fortified water. The final set of FBRs achieved nutrient adequacy for all nutrients except for vitamin A (25% RNI) and folate (68% RNI). Introduction of zinc-fortified water combined with FBRs will likely improve the nutrient adequacy of diets consumed by children in Kenya but needs to be complemented with alternative interventions to ensure dietary adequacy.

Factors in the management of feeding in nursery school children as perceived by their mothers in rural Bondo County, Kenya.

BACKGROUND: The effects of malnutrition on health status and survival of children has been the subject of extensive research for several decades. Malnutrition affects physical growth, cognitive development of children, morbidity and mortality. The current study was an exploratory survey that focused on factors affecting feeding of nursery school children as perceived by their mothers in a rural setting in Usigu Division of Bondo County, Kenya. METHODS: The sampling frame was mothers whose children were in Kanyibok, Sanda and Usenge nursery schools. Purposive sampling methods were used to draw a total of 108 respondents. In a logistic regression model, bad management of feeding was the dependent variable while factors perceived to affect management of feeding were the independent variables. RESULTS: Married mothers were more likely to manage good feeding practices (OR, 0.34, 95% CI, 0.21-0.76; P = 0.022) relative to those who were single or widowed. Additional analyses showed that low education levels (OR, 7.33, 95% CI, 3.37-12.91; P = 0.023), younger mothers (OR, 6.04, 95% CI, 3.22-9.68; P = 0.029) and mothers engaged in business (OR, 4.02, 95% CI, 2.11-7.85; P = 0.027) increased their likelihood of not feeding the pre-school children. Majority of the children who ate the main meals in other houses belonged to young mothers in the age category of 15-29 years. Further analyses demonstrated that if the order of serving food was to the children first, then they had high likelihood of having good feeding relative to when the father was served first (OR, 0.22, 95% CI, 0.14-0.61; P = 0.011). CONCLUSIONS: Based on these findings, there is an urgent need for sensitization of the mothers on the management of feeding of these pre-school children in Bondo County. It is hoped that relevant interventions would then be designed with the view of managing children feeding in such rural settings as in Bondo County in Kenya.

Factors associated with non-adherence to Artemisinin-based combination therapy (ACT) to malaria in a rural population from holoendemic region of western Kenya.

BACKGROUND: Over the years, reports implicate improper anti-malarial use as a major contributor of morbidity and mortality amongst millions of residents in malaria endemic areas, Kenya included. However, there are limited reports on improper use of Artemisinin-based Combination Therapy (ACT) which is a first-line drug in the treatment of malaria in Kenya. Knowing this is important for ensured sustainable cure rates and also protection against the emergence of resistant malarial parasites. We therefore investigated ACT adherence level, factors associated with non-adherence and accessibility in households (n = 297) in rural location of Southeast Alego location in Siaya County in western Kenya. METHODS: ACT Adherence level was assessed with reference to the duration of treatment and number of tablets taken. Using systematic random sampling technique, a questionnaire was administered to a particular household member who had the most recent malaria episode (<2 weeks) and used ACT for cure. Parents/caretakers provided information for children aged <13 years. Key Informant Interviews (KIIs) were also conducted with healthcare providers and private dispensing chemist operators. RESULTS: Adherence to ACT prescription remained low at 42.1% and 57.9% among individuals above 13 and less than 13 years, respectively. Stratification by demographic and socio-economic characteristics in relation to ACT adherence revealed that age (P = 0.011), education level (P < 0.01), ability to read (P < 0.01) and household (HH) monthly income (P = 0.002) significantly affected the level of ACT adherence. Consistently, logistic regression model demonstrated that low age (OR, 0.571, 95% CI, 0.360-0.905; P = 0.017), higher education level (OR, 0.074; 95% CI 0.017-0.322; P < 0.01), ability to read (OR, 0.285, 95% CI, 0.167-0.486; P < 0.01) and higher income (Ksh. > 9000; OR, 0.340; 95% CI, 0.167-0.694; P = 0.003) were associated with ACT adherence. In addition, about 52.9% of the respondents reported that ACT was not always available at the source and that drug availability (P = 0.020) and distance to drug source (P < 0.01) significantly affected accessibility. CONCLUSIONS: This study demonstrates that more than half of those who get ACT prescription do not take recommended dose and that accessibility is of concern. The findings of this study suggest a potential need to improve accessibility and also initiate programmatic interventions to encourage patient-centred care.