Isaac Mwanzo

Insecticide-treated net (ITN) ownership, usage, and malaria transmission in the highlands of western Kenya

BackgroundInsecticide-treated bed nets (ITNs) are known to be highly effective in reducing malaria morbidity and mortality. However, usage varies among households, and such variations in actual usage may seriously limit the potential impact of nets and cause spatial heterogeneity on malaria transmission. This study examined ITN ownership and underlying factors for among-household variation in use, and malaria transmission in two highland regions of western Kenya.MethodsCross-sectional surveys were conducted on ITN ownership (possession), compliance (actual usage among those who own ITNs), and malaria infections in occupants of randomly sampled houses in the dry and the rainy seasons of 2009.ResultsDespite ITN ownership reaching more than 71%, compliance was low at 56.3%. The compliance rate was significantly higher during the rainy season compared with the dry season (62% vs. 49.6%). Both malaria parasite prevalence (11.8% vs. 5.1%) and vector densities (1.0 vs.0.4 female/house/night) were significantly higher during the rainy season than during the dry season. Other important factors affecting the use of ITNs include: a household education level of at least primary school level, significantly high numbers of nuisance mosquitoes, and low indoor temperatures. Malaria prevalence in the rainy season was about 30% lower in ITN users than in non-ITN users, but this percentage was not significantly different during the dry season.ConclusionIn malaria hypo-mesoendemic highland regions of western Kenya, the gap between ITNownership and usage is generally high with greater usage recorded during the high transmission season. Because of the low compliance among those who own ITNs, there is a need to sensitize households on sustained use of ITNs in order to optimize their role as a malaria control tool.

Physical condition and maintenance of mosquito bed nets in Kwale County, coastal Kenya

BackgroundDespite the extensive ownership and use of insecticide-treated nets (ITNs) over the last decade, the effective lifespan of these nets, especially their physical integrity, under true operational conditions is not well-understood. Usefulness of nets declines primarily due to physical damage or loss of insecticidal activity.MethodsA community based cross-sectional survey was used to determine the physical condition and to identify predictors of poor physical condition for bed nets owned by individuals from communities in Kwale County, coastal Kenya. A proportionate hole index (pHI) was used as a standard measure, and the cut-offs for an ‘effective net’ (offer substantial protection against mosquito bites) and ‘ineffective nets’ (offer little or no protection against mosquito bites) were determined (pHI ≤88 (about ≤500 cm2 of holes surface area) and pHI of >88 (≥500 cm2 of holes surface area), respectively).ResultsThe vast majority (78%) of the surveyed nets had some holes. The median pHI was 92 (range: 1–2,980). Overall, half of the nets were categorized as ‘effective nets’ or ‘serviceable nets’. Physical deterioration of nets was associated with higher use and washing frequency. Young children and older children were found to use ineffective bed nets significantly more often than infants, while the physical integrity of nets owned by pregnant women was similar to those owned by infants. Estuarine environment inhabitants owned nets with the worst physical condition, while nets owned by the coastal slope inhabitants were in fairly good physical condition. The results suggest that bed nets are optimally utilized when they are new and physically intact. Thereafter, bed net utilization decreases gradually with increasing physical deterioration, with most net owners withdrawing physically damaged nets from routine use.This withdrawal commonly happens following 1.5 years of use, making bed net use the most important predictor of physical integrity. On average, the nets were washed twice within six months prior to the survey. Washing frequency was significantly influenced by the bed net colour and bed net age. Lack of knowledge on reasons for net retreatment and the retreatment procedure was evident, while net repair was minimal and did not seem to improve the physical condition of the nets. The “catch-up” bed net distribution strategies are sufficient for ensuring adequate ownership and utilization of ‘effective nets’ in the targeted groups, but bi-annual mass distribution is necessary to provide similar ownership and utilization for the other groups not targeted by “catch-up” strategies.ConclusionsMonitoring and maintenance strategies that will deliver locally appropriate education messages on net washing and repair will enhance the effectiveness of malaria control programmes, and further research to assess ineffective nets need is needed.

Short-Term Mobility and the Risk of HIV Infection among Married Couples in the Fishing Communities along Lake Victoria, Kenya

Objective Mobility has long been associated with high HIV prevalence. We sought to assess sex differences in the relationship between mobility and risk for HIV infection among married couples in the fishing communities. Methods We conducted 1090 gender-matched interviews and rapid HIV testing with 545 couples proportionally representing all the different sizes of the fish-landing beaches in Kisumu County. We contacted a random sample of fishermen as our index participants and asked them to enrol in the study together with their spouses. The consenting couples were separated into different private rooms for concurrent interviews and thereafter reunited for couple rapid HIV counselling and testing. In addition to socio-economic and behavioural data, we collected information on overnight travels and divided couples in 4 groups as follows both partners not mobile, both partners mobile, only woman mobile, and only man mobile. Other than descriptive statistics, we used X2 and U tests to compare groups of variables and multivariate logistic regression to measure association between mobility and HIV infection. Results We found significant differences in the number of trips women travelled in the preceding month (mean 4.6, SD 7.1) compared to men (mean 3.3, SD 4.9; p<0.01) and when the women did travel, they were more likely to spend more days away from home than their male partners (mean 5.2 [SD 7.2] versus 3.4 SD 5.6; p = 0.01). With an HIV prevalence of 22.7% in women compared to 20.9% among men, mobile women who had non-mobile spouses had 2.1 times the likelihood of HIV infection compared to individuals in couples where both partners were non-mobile. Conclusion The mobility of fishermen’s spouses is associated with HIV infection that is not evident among fishermen themselves. Therefore, interventions in this community could be a combination of sex-specific programming that targets women and combined programming for couples.

Topography as a modifier of breeding habitats and concurrent vulnerability to malaria risk in the western Kenya highlands

BackgroundTopographic parameters such as elevation, slope, aspect, and ruggedness play an important role in malaria transmission in the highland areas. They affect biological systems, such as larval habitats presence and productivity for malaria mosquitoes. This study investigated whether the distribution of local spatial malaria vectors and risk of infection with malaria parasites in the highlands is related to topography.MethodsFour villages each measuring 9 Km2 lying between 1400-1700 m above sea level in the western Kenya highlands were categorized into a pair of broad and narrow valley shaped terrain sites. Larval, indoor resting adult malaria vectors and infection surveys were collected originating from the valley bottom and ending at the hilltop on both sides of the valley during the rainy and dry seasons. Data collected at a distance of ≤500 m from the main river/stream were categorized as valley bottom and those above as uphill. Larval surveys were categorized by habitat location while vectors and infections by house location.ResultsOverall, broad flat bottomed valleys had a significantly higher number of anopheles larvae/dip in their habitats than in narrow valleys during both the dry (1.89 versus 0.89 larvae/dip) and the rainy season (1.66 versus 0.89 larvae/dip). Similarly, vector adult densities/house in broad valley villages were higher than those within narrow valley houses during both the dry (0.64 versus 0.40) and the rainy season (0.96 versus 0.09). Asymptomatic malaria prevalence was significantly higher in participants residing within broad than those in narrow valley villages during the dry (14.55% vs. 7.48%) and rainy (17.15% vs. 1.20%) season. Malaria infections were wide spread in broad valley villages during both the dry and rainy season, whereas over 65% of infections were clustered at the valley bottom in narrow valley villages during both seasons.ConclusionDespite being in the highlands, local areas within low gradient topography characterized by broad valley bottoms have stable and significantly high malaria risk unlike those with steep gradient topography, which exhibit seasonal variations. Topographic parameters could therefore be considered in identification of high-risk malaria foci to help enhance surveillance or targeted control activities in regions where they are most needed.

Predictors of Extra-Marital Partnerships among Women Married to Fishermen along Lake Victoria in Kisumu County, Kenya

Background The vulnerability of women to HIV infection makes establishing predictors of womens involvement in extra-marital partnerships critical. We investigated the predictors of extra-marital partnerships among women married to fishermen. Methods The current analyses are part of a mixed methods cross-sectional survey of 1090 gender-matched interviews with 545 couples and 12 focus group discussions (FGDs) with 59 couples. Using a proportional to size simple random sample of fishermen as our index participants, we asked them to enrol in the study with their spouses. The consenting couples were interviewed simultaneously in separate private rooms. In addition to socio-economic and demographic data, we collected information on sexual behaviour including extra-marital sexual partnerships. We analysed these data using descriptive statistics and multivariate logistic regression. For FGDs, couples willing to participate were invited, consented and separated for simultaneous FGDs by gender-matched moderators. The resultant audiofiles were transcribed verbatim and translated into English for coding and thematic content analysis using NVivo 9. Results The prevalence of extra-marital partnerships among women was 6.2% within a reference time of six months. Factors that were independently associated with increased likelihood of extra-marital partnerships were domestic violence (aOR, 1.45; 95% CI 1.09–1.92), women reporting being denied a preferred sex position (aOR, 3.34; 95% CI 1.26–8.84) and spouse longer erect penis (aOR, 1.34; 95% CI 1.00–1.78). Conversely, womens age – more than 24years (aOR, 0.33; 95% CI 0.14–0.78) and womens increased sexual satisfaction (aOR, 0.92; 95% CI 0.87–0.96) were associated with reduced likelihood of extra-marital partnerships. Conclusion Domestic violence, denial of a preferred sex positions, longer erect penis, younger age and increased sexual satisfaction were the main predictors of womens involvement in extra-marital partnerships. Integration of sex education, counselling and life skills training in couple HIV prevention programs might help in risk reduction.

Across-sectional survey of prevalence and correlates of couple sexual concurrency among married couples in fishing communities along Lake Victoria in Kisumu, Kenya

Objective Sexual concurrency has been associated with HIV infection. Since HIV in sub-Saharan Africa is mostly spread within the context of heterosexual couples, it is necessary that intervention is focused on such couples. We sought to establish the correlates of couple sexual concurrency in Kisumu, Kenya. Methods We conducted 1090 gender-matched interviews in 545 couples in a cross-sectional survey. A random sample of fishermen and their spouses from 33 fish-landing beaches along the shores of Lake Victoria in Kisumu were asked to enrol in the study. Couples were separated into different private rooms for simultaneous interviews that documented socioeconomic and behavioural characteristics, and information on number of sexual partnerships in the preceding 6 months and their status. Based on reported concurrency status of the spouses, a couple was categorised as either concurrent when at least one spouse reported a concurrent sexual relationship or non-concurrent. Results Overall, 32.1% of the men and 6.2% of the women had concurrent sexual relationships in the 6 months preceding the study, resulting in 37.6% of the couples being sexually concurrent. Unmet sexual desire, intra-spousal suspicions of infidelity, male dominance scripts, domestic violence, couples’ children and womens age were the correlates of couple sexual concurrency. Conclusions Unmet sexual desires, inter-spousal infidelity suspicions, male dominance scripts and domestic violence were the main correlates of couple sexual concurrency in these fishing communities.

Should community health workers offer support healthcare services to survivors of sexual violence? a systematic review

BackgroundSexual violence is widespread, yet relatively few survivors receive healthcare or complete treatment. In low and middle-income countries, community health workers (CHWs) have the potential to provide support services to large numbers of survivors. The aim of this review was to document the role of CHWs in sexual violence services. We aimed to: 1) describe existing models of CHWs services including characteristics of CHWs, services delivered and populations served; 2) explore acceptability of CHWs’ services to survivors and feasibility of delivering such services; and 3) document the benefits and challenges of CHW-provided sexual violence services.MethodsQuantitative and qualitative studies reporting on CHWs and other community-level paraprofessional volunteer services for sexual violence were eligible for inclusion. CHWs and sexual violence were defined according to WHO criteria. The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Quality of included studies was assessed using two quality assessment tools for quantitative, and, the methodology checklist by the National Institute for Health and Clinical Excellence for qualitative studies. Data were extracted and analysed separately for quantitative and qualitative studies and results integrated using a framework approach.ResultsSeven studies conducted in six countries (Democratic Republic of Congo, Rwanda, Burma, United States of America, Scotland, Israel) met the inclusion criteria. Different models of care had diverse CHWs roles including awareness creation, identifying, educating and building relationships with survivors, psychosocial support and follow up. Although sociocultural factors may influence CHWs’ performance and willingness of survivors to use their services, studies often did not report on CHWs characteristics. Few studies assessed acceptability of CHWs’ to survivors or feasibility of delivery of services. However, participants mentioned a range of benefits including decreased incidence of violence, CHWs being trusted, approachable, non-judgmental and compassionate. Challenges identified were high workload, confidentiality issues and community norms influencing performance.ConclusionsThere is a dearth of research on CHWs services for sexual violence. Findings suggest that involving CHWs may be beneficial, but potential challenges and harms related to CHW-provided services exist. No different models of CHW-provided care have been robustly evaluated for effects on patient outcomes. Further research to establish survivors’ views on these services, and, their effectiveness is desperately needed.

P4.004 Actor and Partner Effects of Relationship and Sexual Satisfaction on Extra-Marital Partnerships Among Married Couples in Fishing Communities on Lake Victoria in Kisumu County, Kenya

Background Extra-marital partnerships have been associated with the spread of STIs including HIV among married couples. We sought to establish the actor and partner effects of relationship and sexual satisfactions on extra-marital partnerships among married couples. Methods We conducted a cross-sectional survey of 545 couples. We contacted a proportion to size simple random sample of fishermen on each beach as our index participants and asked them to enrol with their spouses. The consenting couples were separated into different private rooms for simultaneous gender-matched interviews. In addition to socio-economic and behavioural data, we collected information on extra-marital sex partners as well as the scores of participants on a 7-item relationship satisfaction scale and 25-item sexual satisfaction scale. We analysed data using multilevel modelling under the framework of actor-partner interdependent model (APIM). Results Men had a median score of 56 (IQR 52–61) and women 53 (IQR 47–59) on sexual satisfaction scale. Both men and women had same median score of 16 (IQR 14–18) on relationship satisfaction scale. We found a significant partner effect of men’s relationship satisfaction on their spouses number extra-marital partnerships such that the more men are satisfied in their relationship the fewer the number of extra-marital partners their spouses report (B = –0.10; p = < 0.01). Similarly, we found a negative effect of men’s sexual satisfaction on their own number of extra-marital partners (B = –0.46; p = < 0.01) and negative beta estimates for women (B = –0.15; p < 0.01) - meaning that if women are sexually satisfied, they report fewer number of extra-marital partnerships. Men’s sexual satisfaction had a negative interaction with women’s extra-marital partnerships (B = –0.17; p = < 0.01) such that the more sexually satisfied men are, the fewer the number of extra-marital partnerships their spouses report. Conclusion Inculcating and maintaining good relationship and sexual satisfaction within couples in this community reduces their own and their partners’ number of extra-marital partnerships.