Profile: The Rusinga Health and Demographic Surveillance System, Western Kenya

Pregnancy Surveillance Methods within Health and Demographic Surveillance Systems

Background: Pregnancy identification and follow-up surveillance can enhance the reporting of pregnancy outcomes, including stillbirths and perinatal and early postnatal mortality. This paper reviews pregnancy surveillance methods used in Health and Demographic Surveillance Systems (HDSSs) in low- and middle-income countries. Methods: We searched articles containing information about pregnancy identification methods used in HDSSs published between January 2002 and October 2019 using PubMed and Google Scholar. A total of 37 articles were included through literature review and 22 additional articles were identified via manual search of references. We reviewed the gray literature, including websites, online reports, data collection instruments, and HDSS protocols from the Child Health and Mortality Prevention Study (CHAMPS) Network and the International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH). In total, we reviewed information from 52 HDSSs described in 67 sources. Results: Substantial variability exists in pregnancy surveillance approaches across the 52 HDSSs, and surveillance methods are not always clearly documented. 42% of HDSSs applied restrictions based on residency duration to identify who should be included in surveillance. Most commonly, eligible individuals resided in the demographic surveillance area (DSA) for at least three months. 44% of the HDSSs restricted eligibility for pregnancy surveillance based on a woman's age, with most only monitoring women 15-49 years. 10% had eligibility criteria based on marital status, while 11% explicitly included unmarried women in pregnancy surveillance. 38% allowed proxy respondents to answer questions about a woman's pregnancy status in her absence. 20% of HDSSs supplemented pregnancy surveillance with investigations by community health workers or key informants and by linking HDSS data with data from antenatal clinics. Conclusions: Methodological guidelines for conducting pregnancy surveillance should be clearly documented and meticulously implemented, as they can have implications for data quality and accurately informing maternal and child health programs.

A cross-sectional observational study investigating the association between sedges (swamp grasses, Cyperaceae) and the prevalence of immature malaria vectors in aquatic habitats along the shore of Lake Victoria, western Kenya

Background: Strategies that involve manipulations of the odour-orientation of gravid malaria vectors could lead to novel attract-and-kill interventions. Recent work has highlighted the potential involvement of graminoid plants in luring vectors to oviposition sites. This study aimed to analyse the association between water-indicating graminoid plants (Cyperaceae, sedges), other abiotic and biotic factors and the presence and abundance of early instar Anopheles larvae in aquatic habitats as a proxy indicator for oviposition.

Methods: A cross-sectional survey of 110 aquatic habitats along the shores of Lake Victoria was done during the rainy season. Habitats were sampled for mosquito larvae using the sweep-net method and habitat characteristics recorded.

Results: Anopheles arabiensis was the dominant species identified from aquatic habitats. Larvae of the secondary malaria vectors such as Anopheles coustani, An. rufipes and An. maculipalpis were found only in habitats covered with graminoids, whereas An. arabiensis, An. ziemanni and An. pharoensis were found in both habitats with and without graminoid plants. The hypothesis that sedges might be positively associated with the presence and abundance of early instar Anopheles larvae could not be confirmed. The dominant graminoid plants in the habitats were Panicum repens, Cynodon dactylon in the Poaceae family and Cyperus rotundus in the Cyperaceae family. All of these habitats supported abundant immature vector populations. The presence of early instar larvae was significantly and positively associated with swamp habitat types (OR=22, 95% CI=6-86, P<0.001) and abundance of late Anopheles larvae (OR=359, CI=33-3941, P<0.001), and negatively associated with the presence of tadpoles (OR=0.1, CI=0.0.01-0.5, P=0.008).

Conclusions: Early instar malaria vectors were abundant in habitats densely vegetated with graminoid plants in the study area but no specific preference could be detected for any species or family. In search for oviposition cues, it might be useful to screen for chemical volatiles released from all dominant plant species.

"We are called the et cetera": experiences of the poor with health financing reforms that target them in Kenya

BACKGROUND

Through a number of healthcare reforms, Kenya has demonstrated its intention to extend financial risk protection and service coverage for poor and vulnerable groups. These reforms include the provision of free maternity services, user-fee removal in public primary health facilities and a health insurance subsidy programme (HISP) for the poor. However, the available evidence points to inequity and the likelihood that the poor will still be left behind with regards to financial risk protection and service coverage. This study examined the experiences of the poor with health financing reforms that target them.

METHODS

We conducted a qualitative cross-sectional study in two purposively selected counties in Kenya. We collected data through focus group discussions (n = 8) and in-depth interviews (n = 30) with people in the lowest wealth quintile residing in the health and demographic surveillance systems, and HISP beneficiaries. We analyzed the data using a framework approach focusing on four healthcare access dimensions; geographical accessibility, affordability, availability, and acceptability.

RESULTS

Health financing reforms reduced financial barriers and improved access to health services for the poor in the study counties. However, various access barriers limited the extent to which they benefited from these reforms. Long distances, lack of public transport, poor condition of the roads and high transport costs especially in rural areas limited access to health facilities. Continued charging of user fees despite their abolition, delayed insurance reimbursements to health facilities that HISP beneficiaries were seeking care from, and informal fees exposed the poor to out of pocket payments. Stock-outs of medicine and other medical supplies, dysfunctional medical equipment, shortage of healthcare workers, and frequent strikes adversely affected the availability of health services. Acceptability of care was further limited by discrimination by healthcare workers and ineffective grievance redress mechanisms which led to a feeling of disempowerment among the poor.

CONCLUSIONS

Pro-poor health financing reforms improved access to care for the poor to some extent. However, to enhance the effectiveness of pro-poor reforms and to ensure that the poor in Kenya benefit fully from them, there is a need to address barriers to healthcare seeking across all access dimensions.

The effect of mass mosquito trapping on malaria transmission and disease burden (SolarMal): a stepped-wedge cluster-randomised trial

BACKGROUND

Odour baits can attract host-seeking Anopheles mosquitoes indoors and outdoors. We assessed the effects of mass deployment of odour-baited traps on malaria transmission and disease burden.

METHODS

We installed solar-powered odour-baited mosquito trapping systems (SMoTS) to households on Rusinga Island, Lake Victoria, western Kenya (mean population 24 879), in a stepped-wedge cluster-randomised trial. All residents in the completed health and demographic surveillance system were eligible to participate. We used the travelling salesman algorithm to assign all households to a cluster (50 or 51 geographically contiguous households); nine contiguous clusters formed a metacluster. Initially, no cluster had SMoTS (non-intervened). During the course of the intervention roll-out SMoTS were gradually installed cluster by cluster until all clusters had SMoTS installed (intervened). We generated 27 cluster randomisations, with the cluster as unit of randomisation, to establish the order to install the traps in the clusters until all had a SMoTS installed. Field workers and participants were not masked to group allocation. The primary outcome of clinical malaria was monitored through repeated household visits covering the entire population, once before roll-out (baseline) and five times throughout the 2-year roll-out. We measured clinical malaria as fever plus a positive result with a rapid diagnostic test. The SolarMal project was registered on the Dutch Trial Register (NTR 3496).

FINDINGS

We enrolled 34 041 participants between April 25, 2012, and March 23, 2015, to 81 clusters and nine metaclusters. 4358 households were provided with SMoTS during roll-out between June 3, 2013, and May 16, 2015. 23 clinical malaria episodes were recorded in intervened clusters and 33 episodes in non-intervened clusters (adjusted effectiveness 40·8% [95% CI -172·8 to 87·1], p=0·5) during the roll-out. Malaria prevalence measured by rapid diagnostic test was 29·8% (95% CI 20·9-38·0) lower in SMoTS clusters (prevalence 23·7%; 1552 of 6550 people) than in non-intervened clusters (prevalence 34·5%; 2002 of 5795 people).

INTERPRETATION

The unexpectedly low clinical incidence of malaria during roll-out led to an imprecise estimate of effectiveness from the clinical incidence data. The substantial effect on malaria prevalence is explained by reduction in densities of Anopheles funestus. Odour-baited traps might be an effective malaria intervention.

FUNDING

COmON Foundation.