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.

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.