Use of insecticide treated bed nets among pregnant women in Kilifi District, Kenya.

BACKGROUND: Malaria is one of the most serious public health problems in Kenya. Pregnant women are among the groups with the highest risk of malaria. Use of insecticide treated bed nets (ITNs) is a cost-effective method of controlling malaria. Despite this, there is low utilisation of ITNs among pregnant women in Kilifi district which is an endemic malaria zone. OBJECTIVE: To determine knowledge, attitude and practice on the use of ITNs in the prevention of malaria among pregnant women in Kilifi district. DESIGN: A descriptive cross-sectional study. SETTING: The district hospital and the five health centres in Kilifi district SUBJECTS: Two hundred and twenty pregnant women attending antenatal clinics (ANC) between October and December 2007. RESULTS: Knowledge on malaria illness and ITNs was high with majority of pregnant women having adequate level of knowledge (86.9%). There was significant association between level of education and adequate knowledge (P-value = 0.010). Good attitude on ITNs use was low. There was no association between good attitude and any of the socio-demographic variables. The majority of pregnant women attending ANC owned ITNs (75.4%). ITNs usage was high (70.5%). There was significant association between religion and good practice (p-value = 0.050). Although adequate level of knowledge on malaria and protective role of ITNs was high, there was no association between knowledge with practice and attitude. CONCLUSION: Before any malaria preventive intervention is implemented in an area, different socio-cultural factors must be considered when behavioural interventions for malaria control are designed and implemented. Targeted health education should be disseminated to the community to remove stigma and misconceptions associated with ITNs. Community concerns and fears should be addressed.

Gender, perceptions and behaviour towards health risks associated with urban dairy farming in Dagoretti Division, Nairobi, Kenya.

OBJECTIVES: To determine the socio-cultural, economic and environmental factors that encourage urban dairy production and the factors which may predispose the producer, consumer and other handlers to risks associated with dairy farming. To assess the knowledge, attitudes and behaviour of men and women towards health risks and benefits associated with urban dairy farming in smallholder dairy farming and their immediate non-dairy farming neighbour households. DESIGN: A cross sectional study and participatory urban appraisal (PUA. SETTING: Urban and peri-urban households in Dagoretti Division, Nairobi. SUBJECTS: Three hundred dairy farming households, and 150 non-dairy farming neighbour households and six participatory urban appraisals, 58 males and 45 females. RESULTS: There were more females than males dairy farmers. Both women and men had equal access to resources and benefits obtained from dairy farming but the men had the greater control over the resources. Low levels of knowledge on the specific health risks related to urban dairy farming were observed. Less than half of the respondents believed they were at risk of being exposed to the health hazards, while 63% sensed they could protect themselves from the health risks. There was an association between knowledge levels, perceptions and behaviour of men and women toward risks associated with dairy farming. CONCLUSIONS: Apart from giving treatment to animals most men did less dairy farming activities. Women rated men lower in all dairy activities but when the men did the scoring for the same activities they rated themselves higher, arguing that their participation was indirect such as providing cash to buy the feed supplements and veterinary services. There were gender differences in all important tasks associated with dairy keeping. Farmers stated that older children, when not in school sometimes assisted but in general children did not show much enthusiasm in dairy work.

Investigation on the prevalence of antimicrobial residues in milk obtained from urban smallholder dairy and non-dairy farming households in Dagoretti Division, Nairobi, Kenya.

OBJECTIVES: To assess the prevalence and the level of awareness of the risk posed by antibiotic residues among the urban dairy and non-dairy farming households using a household survey and laboratory analysis of milk samples. DESIGN: A cross sectional study. SETTING: Urban small holder dairy farming and non-farming households in Dagoretti division, Nairobi. RESULTS: The prevalence of antibiotic residues in dairy household milk samples was 4% (11/259) and in milk samples from non-dairy neighbouring households the prevalence was 0.07% (1/136). One sample was detected to belong to beta lactam and one to the tetracycline group of antibiotics. The remaining 10 were not categorised. Approximately 20% of dairy and non-dairy respondents were unsure of the risk that may be posed by the presence of antibiotic residues in milk. A high proportion of the respondents said they would be able to protect themselves from risk posed by antibiotic residues by following advice given by veterinary officers on the withdrawal periods after treatment of animals. CONCLUSION: Education of the farmers, continuous surveillance and understanding of the socio-economic incentives that would be traded off at farm level would help to reduce or eliminate the risk posed by the residues in marketed or consumed milk.

Investigation of the prevalence of bovine tuberculosis and risk factors for human infection with bovine tuberculosis among dairy and non-dairy farming neighbour households in Dagoretti Division, Nairobi, Kenya.

OBJECTIVE: To determine the prevalence of bovine tuberculosis in urban dairy cattle and examine possible risk factors for human infection with bovine tuberculosis (BTB). DESIGN: Cross sectional study. SETTING: Urban and peri-urban dairy and non-dairy farming neighbour households. SUBJECTS: One hundred forty three dairy cattle and 299 and 149 dairy and non-dairy neighbour households respectively. RESULTS: Ten percent of the animals (15/143) were found to be reactors to the tuberculin test. The majority of the respondents 57% (168/295) and 72% (106/147) in dairy farming and non-farming households respectively, had limited knowledge of the disease in cattle thus making them unable to adopt any precautionary measures to protect themselves from contracting bovine tuberculosis. Distance from the main house and cattle shed, the time spent attending to the cattle, (on average 4.8 hours), and making of traditionally fermented milk were considered to be the major risk factors. CONCLUSION: Due to the presumed high background prevalence of human tuberculosis, the specificity of the test employed was unknown. Therefore no definite estimate of the prevalence of BTB was made. It is therefore necessary for further investigation involving culture, isolation and molecular typing from reactors to establish the prevalence of M. bovis in this setting.

Investigations into the prevalence of bovine brucellosis and the risk factors that predispose humans to infection among urban dairy and non-dairy farming households in Dagoretti Division, Nairobi, Kenya.

OBJECTIVE: To explore the knowledge, attitudes and practices of dairy and non-dairy farming households in Dagoretti in regard to the risk posed by bovine brucellosis and determine the prevalence of the disease in urban dairy cattle. DESIGN: A cross sectional study. SETTING: Urban and Peri-urban dairy farming and non dairy farming households in Dagoretti division, Nairobi. SUBJECTS: Two hundred ninety nine dairy farming and 149 non dairy farming households. INTERVENTION: Segregated focus group discussions, administration of a household questionnaire and collection of unboiled milk from dairy and non dairy farming households were the instruments used to gather data on the practices, attitudes, perceptions and prevalence of bovine brucellosis. RESULTS: Three hundred and ninety three milk samples were collected and analysed for the presence of antibodies to Brucella abortus in an indirect ELISA. The apparent prevalence of bovine brucellosis from milk was estimated at 1% for the samples collected while in dairy farming households the prevalence was 1.1% [0.2, 3.4%] and 0.7% [0.4%] in non dairy farming households.. Thirty percent (90/296) of dairy respondents and 22% (32/147) of non-dairy respondents knew of the existence of brucellosis. Risk of contracting brucellosis was very low considering that milk is boiled together with other ingredients used in making tea and porridge. However, 31% (93/296) and 22% (31/143) of dairy and non dairy farming households respectively made traditionally fermented milk without first boiling the milk. This practice may predispose this group to brucellosis. CONCLUSION: The low prevalence of bovine brucellosis requires constant surveillance in case the prevalence rates do change. Education of dairy farming households who are more at risk of contracting brucellosis on the transmission pathways and risk factors is required in order to lower further the prevalence of bovine brucellosis in Dagoretti.

A transdisciplinary perspective on the links between malaria and agroecosystems in Kenya.

An ecosystem approach was applied to study the links between malaria and agriculture in Mwea Division, Kenya. The study was organized into five phases. Phase I had two components including a stakeholder workshop conducted with community representatives and other key stakeholders, and the collation of data on common diseases from outpatient service records at the local hospital. Phase I aimed at an a priori needs-assessment in order to focus the research agenda. Workshop participants directly contributed to the selection of two villages with rice irrigation and two non-irrigated villages for detailed health studies. In Phase II, various Participatory Rural Appraisal (PRA) tools were used to gather more detailed qualitative information from the study villages. The qualitative results indicated that Mwea residents considered malaria and lack of clean drinking water to be their most important health problems, and this was corroborated by local hospital records. Phase III consisted of a comprehensive household survey developed with inputs from Phases I and II. Phase IV involved a comparative evaluation of entomological and parasitological aspects of malaria in the villages with and without rice irrigation. The malaria parasitological survey found an average Plasmodium falciparum parasite rate of 23.5% among children up to 9 years of age. Results of the entomological evaluation showed a 30-300-fold increase in the number of the local malaria vector, Anopheles arabiensis, in villages with rice irrigation compared to those without irrigation yet malaria prevalence was significantly lower in these villages (0-9% versus 17-54%). The most likely explanation of this 'paddies paradox' in Mwea appeared to be the tendency for A. arabiensis in irrigated villages to feed overwhelmingly on cattle. The results suggested that zooprophylaxis was potentially a practical option for long-term malaria control in the rice irrigated areas, in spite of the large number of A. arabiensis. Phase V consisted of end-of-project workshops for the dissemination of research results and participatory decision-making regarding follow-up actions. Owing to the utilization of a transdisciplinary and participatory approach to research, it was possible to identify opportunities for maintaining zooprophylaxis for malaria in Mwea, through the integration of agroecosystem practices aimed at sustaining livestock systems within a broader strategy for rural development.

Decentralisation of tuberculosis treatment from the main hospitals to the peripheral health units and in the community within Machakos district, Kenya.

SETTING: A rural district, Machakos, in Kenya, facing decreasing national resources for health and an increasing tuberculosis (TB) caseload fuelled by the human immunodeficiency virus (HIV). OBJECTIVE: To evaluate the impact on district TB programme performance of decentralising TB treatment by providing ambulatory care in the hospital and peripheral health units and in the community. METHODS: A comparative study of district TB programme performance before and after the decentralisation of TB services at the end of 1997. To facilitate ambulatory care, ethambutol replaced streptomycin in the new treatment regimen. FINDINGS: The number of patients registered in the control period (1996) was 1141, of whom almost 100% were admitted during the intensive phase of TB treatment, and in the intervention period (1998 and 1999), it was 3244, of whom only 153 (4.7%) required admission in the intensive phase. Of 3244 TB patients (all forms) registered in the intervention period, the number (%) choosing the different options for directly observed treatment (DOT) supervision were: hospital clinic 1618 (49.9%), peripheral health unit 904 (27.9%), community volunteer 569 (17.5%) and hospitalisation 153 (4.7%). The options were found to be acceptable to patients, their families and health staff. The treatment outcomes among new sputum smear-positive pulmonary TB patients were similar in the intervention and control cohorts, with treatment success rates of 88% vs. 85% and death rates of 4% vs. 6%, respectively. Treatment completion was significantly higher among new sputum smear-negative and extra-pulmonary TB patients in the intervention than in the control cohort (79% vs. 48%, respectively). CONCLUSION: The decentralisation of the intensive phase of TB treatment resulted in maintenance of good TB programme performance, while Machakos hospital closed its TB wards. A separate paper describes the cost-effectiveness of this approach. The National Tuberculosis Control Programme plans to adopt this approach as national policy.

Household survey of injuries in a Kenyan district.

OBJECTIVE: To determine the pattern and burden of injuries, their causes and action taken in a rural and urban community in Kenya. DESIGN: Household interview survey and focus group discussions. SETTING: Four rural villages and five urban clusters in Kiambu District, Kenya. SUBJECTS: A total of 1,980 members of 200 rural and 230 urban households. RESULTS: The number of reported injuries was 495, corresponding to 300,000 injuries per 100,000 people per year. Most common were cut or piercing (38.4%), followed by fall (16.2%), burn or scald (14.3%), animal bite or kick (10.1%), hit by moving object (5.9%) and road traffic accident (3.6%). Poisoning, sub-mersion/drowning and explosion were uncommon, each below three per cent. Of all reported injuries, 149 (30.1%) sought care from traditional healers, 91 (18.4%) were subject to self-care, 76 (15.4%) obtained service from drug shops, 22 (4.4%) were brought to a health facility for attention and 17 (3.4%) took no action at all. Additional information was obtained through focus group discussions with students, teachers and members of women groups. These generated detailed information about cases of sexual assault within and outside households which had not been captured during the previous household interviews. CONCLUSION: Injuries are very common but most of them are mild, prompting only home care or no action at all. Only one out of 25 injuries were brought to a health facility for attention. Some types of injury, such as domestic violence and sexual assault, are more likely to be captured through focus group discussions than during household interviews. A combination of methods is likely to best reflect the pattern of injury at community level.

Abortion: behaviour of adolescents in two districts in Kenya.

BACKGROUND: In Kenya the reported high rates of unwanted pregnancies (more than 90%), among adolescents have subsequently resulted in unsafely induced abortions with the associated high morbidity and mortality rates. OBJECTIVE: To evaluate the adolescents' behaviour regarding induced abortion. DESIGN: A cross-sectional, prospective study done from July 1995 to June 1996. SETTING: Schools and health facilities in Kiambu and Nairobi districts in Kenya. PARTICIPANTS: Interviews were conducted among adolescents aged 10-19 years in schools at the two districts and selected using a multi-stage random sampling procedure, as well as adolescent girls at two hospitals and two clinics in the immediate post-abortion period. MAIN OUTCOME MEASURES: The number of adolescents health programmes, aimed at reducing the dangers of unsafely induced abortion, which are designed and subsequently implemented. DATA COLLECTION: Demographic and health data, as well as data on behaviour regarding induced abortion were collected using a self-administered questionnaire. RESULTS: The study sample comprised 1820 adolescents. These were 1048 school girls (SG), 580 school boys (SB) and 192 post-abortion (PA). Many adolescents were aware of abortion dangers, with the awareness being significantly lower among the SB whose girlfriends (GF) had aborted than those whose GF had not (p < 0.01). The practice of abortion was reported among 3.4% SG, 9.3% SBs' GF and 100% PA. Direct and indirect costs of abortion were heavy on the girls. Knowledge of the abortion dangers had no influence on the choice of the abortionist. Abortion encounter positively influenced approval by the adolescents, of abortion for pregnant school girls (p < 0.01). CONCLUSION: Despite the costs and awareness of abortion dangers by adolescents, they will take risks.

Abortion: knowledge and perceptions of adolescents in two districts in Kenya.

BACKGROUND: Pregnancy among adolescents is unplanned in many instances. Although some pregnant adolescents carry the pregnancy to term, abortion, in many instances unsafely induced, is a commonly sought solution in Kenya. OBJECTIVE: To determine adolescents' perceptions of induced abortion. DESIGN: A cross-sectional descriptive study carried out between July 1995 and June 1996. SETTING: An urban and a rural district in Kenya. PARTICIPANTS: Adolescents aged 10-19 years in schools in Nairobi and Kiambu districts, and a group of immediate post-abortion adolescent girls in some health facilities in Nairobi. MAIN OUTCOME MEASURES: The number of health programmes formulated and put into use, which are adolescent-friendly and providing information, education and communication on abortion issues. DATA COLLECTION: One thousand eight hundred and twenty adolescents were subjected to a self-administered questionnaire that collected demographic and health data as well as perceptions of induced abortion. Focus group discussions on perceptions of abortion were held with 12 groups of adolescents in schools and the information obtained recorded on paper and in a tape-recorder. RESULTS: One thousand nine hundred and fifty two adolescents, comprising of 1048 school girls (SG), 580 boys (SB), 192 post-abortion girls (PA) and 132 adolescents in the focus group discussions, formed the study sample. More than 90% were aware of induced abortion (IA). Knowledge of IA correlated positively with level of education (P < 0.01). Seventy one per cent of SG, 84% of PA and 40% of SB were aware of abortion-related complications, the most common being infections, death and infertility. Eighty three per cent of PA felt that complications were preventable by seeking care from a qualified doctor compared to one quarter each for the SB and SG. 56% PA, 69% SB and 72% SG felt that abortions were preventable. However, less than 40% proposed abstinence as a primary strategy. The most important source of information on abortion was the media followed by friends and teachers. CONCLUSION: Adolescents are aware of abortion and the related complications, but there is more variability in their knowledge and preventive measures.

Agrochemicals exposure and health implications in Githunguri location, Kenya.

A study conducted in a rural agricultural community (Githunguri location) in Kenya between 1987 and 1990 investigated the extent of use of agrochemicals, especially pesticides, by the farmers; their level of awareness of the dangers posed by these chemicals and their attitudes towards agricultural chemicals in general. The findings showed that more than 95% of the farmers used pesticides extensively. More women than men were found to be at risk of agrochemicals exposure, while babies and children were at more risk of agrochemicals exposure than the women. In this community, knowledge and awareness regarding safety in handling and storage of agrochemicals was to some extent limited. For instance, many had no knowledge of an antidote in case of accidental poisoning. Additionally, suicidal attempts by ingestion of agrochemicals was prevalent. Improper handling of the agrochemicals by the community members was implicated to have adverse health effects. These health effects were reported in form of complaints. They ranged from acute to chronic conditions. Consequently, an intervention programme was launched with the women as the key players. It is envisaged that community participation in the on going intervention programme is saving babies, children, women and the community at large from agrochemicals hazards.

The role of traditional medicine in ophthalmology in Kenya.

45 Kenyan traditional healers were interviewed with respect to the diagnosis and treatment of eye diseases. Traditional management of eye diseases is based on the healers' concept of the disease causation as well as their knowledge of the herbal, animal and chemical substances that possess (or are reported to possess) remedial effect on the disease. While many of the healers interviewed failed to give a clear distinction between the various eye conditions, diseases such as cataract, foreign bodies and injuries were recognized easily. In almost all cases the medicinal substances were first diluted in water before they were applied to the eyes. Human milk, blood and the white of the egg were the animal substances listed as medicinal to various eye conditions. A solution of sugar was one of the chemical substances used in the treatment of specific eye conditions. Given correct information, some of these healers could form a useful media through which the community can be reached regarding the health of their eyes.