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Abstract
Objectives The increasing burden of cardiovascular diseases (CVDs) in Kenya threatens its healthcare system. There is a need for innovative models that improve equitable access to CVD prevention services. Community markets are social establishments with untapped potential to promote public health. This is a multiphased feasibility study that explores the potential of Health Kiosks in Markets (HEKIMA) to improve access to CVD prevention services. In this formative phase, the aim was to assess the readiness of primary healthcare centres (HCs) and community markets to jointly deliver CVD prevention services.
Design Mixed methods using concept mapping and readiness surveys. Concept mapping with 35 stakeholders from different sectors (health and non-health) to identify feasible priorities for HEKIMA. The readiness questionnaire contained 193 items which were based on the guidance of the WHO Handbook for Monitoring the Building Blocks of Health Systems and adapted to suit the context of a single HC.
Setting Vihiga County is located in western Kenya and has a population of 590 013. A total of 18 HCs and 19 markets were assessed, with 10 HCs and 15 markets included in the evaluation.
Results 91 statements were generated from concept mapping and distilled into 8 clusters, namely equipment and supplies, access and referral, communication, manpower, networks and linkages, practice, service delivery and health promotion. Agreed actions for HEKIMA were provision of efficient quality services, health promotion and partnerships sensitive to the local context. HCs and markets had established governance systems and basic infrastructure. The majority of the HCs lacked essential CVD medications. No HC–market interface existed but there was willingness for a partnership.
Conclusion There was strong consensus that an HC–market interface via community health worker manned kiosks could have a positive impact on health systems, markets and CVD prevention in vulnerable communities. However, significant infrastructural, technical and resource gaps were observed that need to be addressed.
- Community-Based Participatory Research
- Health Services Accessibility
- Primary Health Care
- Primary Prevention
- PUBLIC HEALTH
- Cardiovascular Disease
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Community-Based Participatory Research
- Health Services Accessibility
- Primary Health Care
- Primary Prevention
- PUBLIC HEALTH
- Cardiovascular Disease
STRENGTHS AND LIMITATIONS OF THIS STUDY
A key strength of this study was the use of concept mapping: the participatory approach inherent in concept mapping identified priority actions that were agreed by stakeholders from different sectors which is critical for the successful implementation of a multisectoral programme such as Health Kiosks in Markets (HEKIMA).
The use of a readiness assessment tool tailored to a community setting such as markets was a novel methodological addition, which strengthened the understanding of the enablers and barriers to the implementation of HEKIMA.
By choosing community markets as the asset to use, there are possibilities of missing populations that may not frequent the markets; agreed on priority actions will inform targeted sensitisation strategies to maximise the reach of the health kiosks.
Introduction
Non-communicable diseases (NCDs) are a major challenge to the healthcare system that require at-scale, multilevel and multisectoral actions and cooperation.1 NCDs account for 50% of hospital admissions and 55% of hospital mortality in Kenya, with cardiovascular diseases (CVDs) leading the NCD mortality.2 Policy initiatives provide a platform for shifting emphasis from a disease-focused perspective to health systems strengthening. They propose integrating prevention and control policies; promoting healthy lifestyles and implementing interventions to reduce modifiable risk factors; promoting and strengthening advocacy, communication and social mobilisation; and sustainable local and international partnerships.3–6 There is global recognition of this needed transformation of health systems but there is sparse evidence on how to achieve it in complex sociocultural political contexts.7
Kenya has a population of approximately 50 million people who typically seek care at a local primary healthcare centre (HC).8 Due to the unequal distribution of HCs, people in rural areas travel long distances for face-to-face consultations. Health expenditure is heavily skewed towards disease management as a result of delays in seeking care,9 with those with chronic conditions exceptionally incurring high out-of-pocket expenditure.10 Workforce shortages, skill mix imbalances and poor working conditions add to the challenges faced by the Kenyan health system.3 Sustainable community-HC bridging initiatives may offer a unique route to address these challenges.11 Globally, there is a scarcity of these initiatives, particularly in low-income and middle-income countries (LMICs).
The Health Kiosks in Markets (HEKIMA) study is a theoretically driven multiphased systems-level intervention. It seeks to explore whether kiosks in community markets, run by community health workers (CHWs), who are supervised by HC nurses, can improve the reach of CVD preventive care to communities. It draws on social capital theory,12 which posits that resources available to individuals and groups through connections with a community, can facilitate behaviour change and adaptive coping. Markets are community assets with the potential to embed key health-promoting practices into everyday life in a culturally familiar and trusted context.13 In Kenya, markets are conveniently juxtaposed to allied services (eg, pharmacies) and used by all sections of the community. Emergent evidence on the effectiveness of health information kiosks signals the potential to enhance self-management of chronic diseases among low-income/literacy populations.14 Evidence on task shifting supports the cost-effectiveness of CHWs for the prevention and management of CVD in LMICs.15
HEKIMA was codesigned with stakeholders from the community, local health services and county government. In this paper, we report on phase 1 which, obtained stakeholders’ perspectives on important and feasible actions for developing HEKIMA as a system interface between HC and community markets, with trained CHWs delivering CVD services, mainly screening for CVD risk factors, lifestyle modification advice and referral to specialist care; and assessed the infrastructural capacity and capabilities of the HC and community markets for implementing HEKIMA.
Methods
Study site
Vihiga County located in western Kenya covers an area of 568.3 km2, has a population of 590 013 with 90% residing in rural areas, population density 1047 persons/km2 compared with the national average of 82 persons/km2, life expectancy of 56 years and overall poverty index of 38.6. The county has five subcounties, two in the upper and three in the lower midland agroecological zone16 . Health service delivery in Kenya is organised into six levels.1 Community health services form level 1, dispensaries, HCs, subcounty (primary) hospitals, county referral (secondary) hospitals and national referral (tertiary) hospitals form levels 2–6, respectively. Vihiga County has one secondary hospital, three primary hospitals, 18 HCs and 32 dispensaries, with a nurse:population ratio of 1:1947. The average distance to the nearest health facility is 5 km. It has 19 major markets with typical market days, 92% located in rural areas.
Design
A mixed-methods approach that uses concept mapping17 18 and readiness survey assessments of HCs and markets.
Stakeholder perspectives
Concept mapping was used to obtain stakeholders’ perspectives on actionable priorities for implementing HEKIMA. It is a participatory mixed method five-stage approach increasingly used in the planning of public health interventions.19
Purposive sampling was used to recruit multidisciplinary stakeholders (N=35), age range 25–74 years, who participated in a concept mapping workshop. They included HC practitioners—nurses, CHWs, medical officers, laboratory technologists, health promotion officers and public health officers (n=22), market and business community representatives (n=10), and non-governmental organization (NGO) and patient representatives (n=3).
Brainstorming: A focus prompt was agreed with a small group of stakeholders and was used for brainstorming with all stakeholders ‘Factors influencing the use of the health kiosks by market users are……’. The research team distilled the completed statements, deleted duplicates, clarified ambiguities and combined points.
Sorting and rating: Participants sorted the statements into conceptually similar piles and created a name for the piles. For each statement, participants were asked ‘How important do you think this will be for the prevention and control of CVDs in Vihiga County?’ and ‘How feasible is it to do this?’ They then rated each statement on its importance and feasibility using a 5-point scale (Importance rating: 1=relatively unimportant, 2=somewhat important, 3=moderately important, 4=very important, 5=extremely important; feasibility rating:1=not at all feasible, 2=somewhat feasible, 3=moderately feasible, 4=very feasible).
Multidimensional scaling (MDS): The Group Concept Mapping App20 was used to generate concept maps. First, the sorted data were analysed using MDS to create a two-dimensional ‘point map,’ or a visual representation of each statement and the distance between them based on the square symmetric similarity matrix. Each statement was represented as a numbered point, with points closest together more conceptually similar. The stress value of the point map is a measure of how well the MDS solution maps the original data, indicating a good fit. The stress value for the MDS analysis of the sort data was 0.3184 which falls within the average range of 0.10 and 0.35 for concept-mapping projects.21
Hierarchical cluster analysis was used to delineate clusters of statements (points) that are conceptually similar and create associated cluster maps using the grouping of statements from the point map. To determine the final cluster solution, the researchers consulted stakeholders on a series of maps and assessed the appropriateness and bridging values (BVs) of statements in each cluster, and the average BVs at cluster level. High coherence within a cluster (lowest BVs) meant that most participants agreed on the statements. Go-Zone graphs generated showed the most actionable (high importance, high feasibility) and least actionable (low importance and low feasibility) statements. Stakeholders were engaged throughout the process of analyses to ensure that the interpretation aligned with their expectations.
Preparedness of HCs and community markets
A readiness assessment of HCs and markets in Vihiga County was conducted in August 2021. The selection criterion for markets and HCs was the availability of two markets within 5 km of an HC, the agroecological zone, rural/urban status and market size based on average number of visitors on a typical market day. 10 out of 18 HCs and 15 out of 19 major markets in the county were assessed using semistructured questionnaires (online supplemental table 1). Readiness assessments used adapted questionnaires that were developed in the CONgregations Taking ACTion against NCDs11. The HC readiness questionnaire contained 193 items which were based on the guidance of the WHO Handbook for Monitoring the Building Blocks of Health Systems 22 and was adapted to suit the context of a single HC. The questionnaire was completed by the most senior staff member at each HC (usually the facility-in-charge), except for an observation section that was completed by trained research staff. The market readiness questionnaire contained 81 items, adapted for markets. The respondents were market committee chairpersons. We aggregated the responses in HC and market assessments into the following domains: client base, governance, resources, community health programmes, collaboration with other sectors and perspectives on having a health kiosk in the market. Descriptive statistics and thematic analyses23 were used to summarise the data.
Supplemental material
Patient and public involvement
The health system research question was arrived at on extensive consultations with local stakeholders on the disease burden and strategic focus of the county and country as a whole. Engagement of local stakeholders was ensured using participatory research approaches such as concept mapping in identifying contextually appropriate priority actions for HEKIMA, consensus building and intervention codevelopment.
Results
Stakeholder perspectives on important and feasible actions for developing HEKIMA
Online supplemental table 2 shows the 91 statements that were generated from the prompt, the 8 clusters that were coidentified, and the BV for each statement and cluster. The clusters were equipment and supplies (8 statements, 0.54), access and referral (12 statements, 0.45), communication (9 statements, 0.25), practice (10 statements, 0.24), manpower (14 statements, 0.34), networks and linkages (8 statements, 0.16), service delivery (8 statements, 0.05) and health promotion (22 statements, 0.17). The average BV among the clusters was 0.275. There was strong agreement on issues to do with the provision of efficient and quality services sensitive to the local context, partnerships and communication.
Supplemental material
Figure 1 is the Go-Zone with the thematic summary of statements (online supplemental figure 1 with all statements) showing stakeholders’ classification of actions by importance and feasibility. 45 of the 91 statements were rated as highly important and highly feasible (upper right quadrant), with most of the statements coming from a range of clusters. Issues to do with service delivery—competent workforce, functional equipment and drugs, cost-free services, privacy and confidentiality, flexibility in operating times, stakeholders’ engagement and support, availability of counselling and follow-up services, and accessibility of health kiosk; health promotion—health education, community sensitisation by the market leadership, information sharing, timely communication and use of local dialect; and partnerships—linkages with other community units, participatory dialogue days and public–private partnerships, were rated as highly important. Highly important and feasible action points included securing equipment and supplies, partnerships, accessibility, safe spaces, and training of personnel. Constraining factors such as availability of health facilities and seasonality were rated as the least important and less feasible action points.
Supplemental material
Go-Zone showing stakeholders’ classification of statements by importance and feasibility. CHV, Community health volunteer
Infrastructural capacity and capabilities of HCs and community markets for delivery of HEKIMA
Tables 1 and 2 highlight the context and general preparedness of the HCs and markets for the intervention, respectively.
Readiness of primary healthcare centres for the delivery of HEKIMA
Readiness of community markets for the delivery of HEKIMA
Client base
The median size of population served by an HC was 20 607. The markets served 80–5000 users/market day (average 2 days/week) and operated 8–17 hours depending on the market size.
Governance
The leadership and management of the HCs followed a hierarchical model. The HC governance was via committees which worked with the respective health facility management teams and reported to the executive. The county had designated NCD focal team, a CHWs supervisory framework and referral protocols. All markets had administrative structures (market management committees) established under the County Trade and Market Management Act 2018, responsible for decision-making, welfare and conflict resolution. They comprised county staff (market managers and revenue in-charge) and market community-based organisations (CBOs) officials (chairperson, secretary and treasurer) elected by peers and certified by the County Social Services Department.
Resources
The median number of nurses attached to an HC=8; CHWs/HC=22; 60% of HCs had a central database; 80% with a disease surveillance system; 40% with computerised data and 80% lacked essential drugs for hypertension (HT) and diabetes mellitus (DM), with stockout periods ranging from 2 to 24 weeks. The number of patients registered in the NCD clinics varied from 13 to 60 depending on the size of the population served. All HCs had basic equipment for blood pressure and blood sugar testing but lacked CVD risk assessment tools. There was partial implementation of protocols related to CVD and DM management; monitoring and audit remained weak. All HC had electricity but 80% lacked internet connectivity. The physical layouts of markets varied from enclosed to open air markets. All had access to electricity, the majority were constrained for space especially the larger markets, while some were in transition to new structures. Most traders were small scale. The CBOs collected revenues to run market affairs. Security varied by market size. 11 out of 15 market leaders lacked offices for record keeping.
Community health programmes
50% of the HCs offered HT and DM care services at least twice a week. 90% of HCs offered primary prevention and health promotion services. Health-related activities in the markets were evidenced by the presence of pharmacies, private clinics and traditional herbalists in all the markets, social health workers in four markets, and awareness of NCDs by market users. Barriers to CVD prevention included self-medication, lack of market-health sector collaboration regarding NCDs and market users’ wary of referrals to HCs due to frequent drug stock-outs.
Collaboration with other sectors
Nine out of 10 HCs had nearby non-public health facilities offering NCD screening and testing services. None reported homecare for persons with end-stage NCDs, or collaboration with markets targeting NCD prevention. Two HCs had local activities targeting NCD control and two reported a history of collaboration with markets in NCD educational campaigns. 90% were optimistic about the benefits of HC–market collaboration to the community. All HCs were open to working with CHWs.
Perspectives on HEKIMA
There was a recognised need for health education, involvement of CHWs, mutual respect and trust, regular communication using appropriate channels, construction and equipping the kiosks with drugs, and supervision of the kiosks by an HC–Market joint team. Sustainability of the intervention would depend on funding, adaptability and acceptance of the intervention, government support, leadership and frequent monitoring (details in online supplemental tables 3 and 4).
Supplemental material
Supplemental material
Discussion
With an emphasis on the participatory approach inherent in systems thinking,24 we sought to explore factors that may influence establishment of an HC–market system interface (health kiosk), delivery of and uptake of CVD prevention interventions by market users and community at large. Overall, concept mapping identified priority actions likely to influence the use of HEKIMA. Results from the readiness assessments highlighted areas of synergy, opportunities and barriers to be addressed.
Stakeholder priority actions to improve CVD prevention using HEKIMA
Concept mapping enabled synthesis of views across stakeholders with differing access to resources and the ability to implement change.25 Core elements of CVD prevention identified were efficient and quality service delivery, partnership and health promotion. Service delivery inputs encompassed functional aspects of the intervention such as provisioning of equipment and supplies, accessibility, cost-free services and competent personnel. They were complemented by relational priorities including good customer service, counselling and follow-up services, professionalism, privacy and confidentiality concerns. These priorities speak to the primacy of trust and mutual respect, key to building effective linking capital26 between the community and the kiosk service providers. The actions align with global recommendations on providing accessible, responsive and inclusive adequate and quality health services.1 27 The low BV for service delivery reflects strong correspondence and a shared vision of an acceptable standard of kiosk services. Provision of services sensitive to the local context was rated highly, implying that, to the extent possible, interventions should be sensitive to local culture and respect the cultural sensibilities of the communities in which they will be implemented.28 29
The stakeholders also identified health education, engagement of market stakeholders, social marketing, timely communication and use of local dialect as key enablers of health promotion. Engagement of market leadership in community mobilisation was highly rated, which, coupled with social capital of the trade sector, recruitment of local CHWs and social marketing, provides potential levers for mobilising support for the intervention. This points to the importance of interventions tapping from the wealth in cultural practices that promote public health.29 30 Also, empowering communities in the prevention and control of NCDs is of strategic importance to Kenya. Decisions involving social value judgements and participatory rights-based approaches are recommended when the potential for improved outcomes exists.1 Factors such as patients learning self-management skills rated as highly important but less feasible require appropriate dissemination strategies. The use of local dialects, posters and health education was identified as potential process outcomes.
Action points related to partnership-building included linking with other community networks, participatory dialogue days and private–public partnerships. These speak to the complex collaborations, pragmatism and adaptations necessary in aligning research undertakings to the local context. Integrating perspectives of stakeholders from diverse backgrounds helps capture promising strategies to inform a conceptual model of implementation that focuses on stakeholder priorities while fostering colearning.31 The least important and feasible actions such as the influence of private practice and the presence of other health facilities in the markets reflect structural factors inherent in market ecosystems, which needs to be factored in the design of complex interventions. Themes rated as highly important and feasible provide the basis to evaluate current research support. Future efforts should explore how to best support innovative targets, those rated highly important but less feasible.
Concept mapping is a time and resource-intensive consultative process. However, it revealed the complex interaction between the social, political, economic and environmental factors32 in delivering complex health interventions and unearthed a shared understanding of likely facilitators and barriers for action. Both divergent and convergent perspectives emerged, and collectively created signals for where to prioritise actions within a home-grown framework.
Infrastructural capacity and capabilities of HCs and community markets to implement HEKIMA
There is considerable variability in the burden of NCDs and in corresponding preparedness to deal with it.33 Existence of governance and coordination structures at HCs and markets showed strong policy support and demonstrated existing structural capital within the health and trade sectors and linking capital between the community and the local government, which provide opportunities for system strengthening.34 The basic HC infrastructure to support CVD prevention, potential reach of the health kiosks and demand for health education by market traders emerged as key enablers.
Community markets have the client base, reach and potentially bridging capital for the kiosks to access the population, and the distribution of HCs in the county makes linkage to care within the recommended 5 km radius from community markets feasible. The use of CHWs who form part of a vibrant community health services infrastructure provides another ready resource of bridging capital that can be leveraged to connect the market community to the health kiosks and address the risk of missing populations that may not frequent the markets. This capacity can be strengthened by incorporating community priority actions such as the provision of safe spaces that guarantee privacy and confidentiality.
The general goodwill for co-operation between health and trade sectors despite no previous formal interactions was another welcome finding. Existing networks could provide a platform for the intersectoral engagement needed to develop and implement the intervention, with the observed enthusiasm for partnership including willingness to form a joint oversight committee further presenting an opportunity to build the additional bridging capital needed to entrench and sustain the intervention. Another valuable insight that emerged was the need for mobilisation of sound support for service provision at HC level, and in particular a mitigation plan for drug stock outs to support linkage to care, and adequate training and provisioning for kiosk staff. The observed inadequacies in health systems inputs are corroborated by a recent study in Kenya which found similar gaps in the readiness of healthcare facilities to provide integrated care services for CVDs and DM.35 These and other long-standing health system challenges are potential confounders to the anticipated role of HEKIMA. Improved capacity of health information systems and capacity and quality of management within primary care facilities are necessary to improve the quality of care.36 Familiarity with data management and disease surveillance systems, although in a few HCs, signals the opportunity to strengthen the health system through digitisation.37 38 Consistent training of the healthcare workforce including CHWs, coupled with guidance and adequate logistical support, may hold promise in the creation of adaptable NCD service delivery models.39 40 The intervention design, which brings nurses and CHWs together in serving communities, may address the perceived lack of recognition of CHWs by formally trained health workers.
Importance of multisectoral partnerships in bridging community-primary healthcare systems
Kenya visions a nation free from the preventable burden of NCDs and advocates for the inclusion of health-in-all policies and whole of government approaches in public sector engagements. One of its strategic investments is reduction in exposure to modifiable risk factors through strengthening multisectoral and community-based interventions.1 Creation and promotion of HEKIMA will require cross-sectoral action and cooperation to address noted system gaps and the actions perceived to be important and feasible. Existing policy and governance structures (structural social capital) for HC and markets provide the basis for formation of new coalitions and a paradigm shift in collective governance for health. Stakeholders’ agreement on the action points reflects the commonality (roots of cognitive capital) and signals the possibility of linking activities and cooperation between different policy areas for joint outcomes.41 Our findings also signal that the boundaries (norms, practices, etc) within which people work have different levels of permeability for the local government, HC and community markets. This will influence how each partner contributes to the HC–market systems interface, possibly unique (eg, supply of essential drugs for CVD management) but also complementary (establishing how the kiosk is managed, and the role of traders, CHWs, etc).42 43
NCDs also reflect wider upstream social determinants that require policy response beyond the health sector. A multisectoral and systems approach to health enhances interaction and mutual support among the system components in addressing the social determinants of health.29 From our findings, strategies that incorporate local values and ideals in ensuring horizontal equity and social justice in health systems such as encouraging early and regular healthcare access through cost-free services and vertical equity through effective redistribution of information are essential. The current findings offer potential for understanding the mechanisms that contribute to the nonlinear behaviour of complex health and community systems, and the complementarity of partnering and boundary dynamics will be key to designing and operationalising HEKIMA.
Implications for policy and practice
Through concept mapping, primary care was being shaped with the community through codevelopment (bottom-up). The potential for this concept to be transferred under other conditions is tremendous (participatory approach). Use of community-based participatory approaches offers opportunities for sharing collective community experiences and knowledge generation for relevance and applicability. It offers planners a new frame for critically designing a social process that is responsive, and which fosters collaborative implementation of resulting plans.44 It strengthens research and practice outcomes by entrenching multisectoral collaboration, adaptation, mutual learning, sustainability and legitimacy30 and aligns with democratic rights to public participation (Kenya Constitution).
Primary healthcare is the cornerstone of strong and equitable healthcare in Kenya. Key enablers such as governance, NCD programmatic strategies, community mobilisation and partnerships can support multicomponent interventions for advancement of the universal health coverage, a central pillar of Kenya’s health reform agenda.28 32 However, attention to the critical barriers observed such as in financing, commodity supply and digitisation of health systems require high-level legislation and incentivisation to drive system change.45
Prevention efforts require investments in networking, communication, coordination and collaboration.46 The willingness to form a joint HC–market committee provides the opportunity for the shared vision in creating culturally relevant and acceptable health promotion programmes using a people-centred approach.47 Sustained advocacy and public education will be key to building and maintaining these relationships and trust.40
The identified priority actions, capacity and capabilities will inform implementation, process evaluation and intervention modelling in phase 2 of the study.
Strengths and limitations
Despite concept mapping requiring intense consultations with lots of statements to be pragmatically distilled and considerable investment of time and manpower, stakeholders from the different sectors improved comprehensiveness and gave breadth and depth in identifying priority actions of synergistic impact. Concept mapping by-passed power dynamics that usually stifle individual views thereby enabling diverse representation of views, customisation of the intervention and lends internal validity to the codevelopment process. By choosing the community market as the asset to use in this study, there are possibilities of missing populations that may not frequent the markets. The readiness assessments enabled rigorous assessment of the implementation context and gave a sense of who is likely to be missed, and for whom priorities identified in the concept mapping will help shape targeted sensitisation and mobilisation strategies. Combining readiness assessment and concept mapping provides in-depth understanding of an illustrative LMIC context within which CVD interventions can be implemented.
Conclusion
The concept mapping and readiness assessments highlighted a pressing need for community empowerment through accessible, readily comprehensible and trustworthy sources of health education on the prevention and control of CVDs. HEKIMA is premised on using existing resources in novel and innovative ways to build a closer community–HC interface. The social capital inherent in the markets and HC, and consensus built during the concept mapping process points to a favourable environment for building the intersectoral linkage needed to successfully deliver the intervention. Implementation and sustainability of HC–market systems will depend on community acceptability and cooperation and resourcing responsive culturally appropriate health promotion services. Notable adaptations for the next phase of HEKIMA will include careful evaluation of the interaction between complex political, economic, social cultural contexts and the social practices of implementing CVD preventive services in market kiosks.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Ethics approval
The study protocol was approved by the KEMRI Scientific and Ethics Review Committee (Ref. No. KEMRI/SERU/CPHR/3862) and the National Commission for Science, Technology and Innovation (Ref. No. NACOSTI/P/19/376). Written Informed consent was sought from participants prior to their participation in the study.
Acknowledgments
We are grateful to all the study participants from Vihiga County who took time to participate in this study. We thank the Director General KEMRI, the National Commission for Science, Technology and Innovation, the County Government of Vihiga and the Vihiga County Commission for granting permission and providing an enabling environment to undertake this study. Many thanks to our research collaborators, the HEKIMA global scientific steering group, and the HEKIMA local implementation team. We thank our research assistants Melvine Obuya, Miriam Bosire, Doreen Mitaru, Ester Andia, Priscilla Maiga, Brandy Mmboga, Sylvia Kagusha, Phydilia Mmbone and all the field assistants for their tireless efforts in bringing the study to fruition.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
X @bonnyoyugi_snr, @ProfOgola
Contributors LK, JO, JMutai, EM, EC, BO, CO, MO'K, HB, GK, JKC, EO and SH contributed to the conception and design of the study, data collection, analysis and interpretation. JMbuka and RO contributed to data collection, analysis and interpretation. JMurdoch and DP contributed to revising the draft for important intellectual content. LK is the guarantor.
Funding LK, JO, JM, CE, RO, BO, CO, HB, GK, EO, EM, SH were funded by MR/S009035/1. LK and SH were funded IOCRG\101801. SH was also funded by the Department of Health and Social Care, the Foreign, Commonwealth and Development Office (FCDO), the Global Challenges Research Fund (GCRF), the Medical Research Council (MRC) and Wellcome (MR/N015959/1) and by MR/R022739/1, MR/S003444/1, MR/Y009983/1, MR/X009777/1 and MR/X003078/1 and by NIFR7/1004. DP was funded by MR/Y009983/1. JM was funded by MR/Y009983/1 and MR/T040289/1
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.