BACKGROUND:Despite the socioeconomic consequences of an increasing burden of chronic respiratory diseases, there is little evidence on the incidence and determinants of catastrophic health expenditure (CHE) in people with chronic respiratory disease symptoms in Kenya. We aimed to generate this evidence by collecting data on medical and non-medical costs, lost income, social protection coverage, and financial coping strategies for such people in Kenya. METHODS:We conducted a cross-sectional survey of consecutively recruited adults seeking care for chronic respiratory disease symptoms at five public health-care facilities in Meru County, Kenya, between Sept 5, 2019, and Oct 1, 2020. Patient costs, National Health Insurance Fund (NHIF) coverage, financial coping strategies, and sociodemographic and clinical data were collected from surveys and medical records. The main study outcomes were the incidence of, and social and health factors associated with, CHE in this cohort. CHE incidence was calculated through the WHO threshold of direct out-of-pocket costs being greater than 10% of a household's monthly total expenditure. Multivariable logistic regression analyses generated adjusted odds ratios (aORs) with 95% CIs of health and social factors associated with CHE, including age, sex, education level, tobacco use, income, being accompanied, poverty level (with the first quintile being the richest to the fifth quintile being the poorest), NHIF usage, coping strategies, final diagnosis, and health system level at which they were seeking care. FINDINGS:Of 319 eligible people invited, 296 (93%) consented to participate and completed surveys. Mean total cost was 1062 Kenyan shillings (KES; 95% CI 896-1228; US$9·1), of which 40·0% was due to direct non-medical costs (KES 425, 95% CI 361-489; $3·7), 36·7% to direct out-of-pocket medical costs (KES 390, 324-456; $3·1), and 23·3% to lost income (KES 247, 153-341, $2·1). 212 (72%) of 296 participants did not have NHIF, 282 (95%) of 296 used coping strategies during care-seeking, and 59 (20%) of 296 were accompanied by a carer during health-care seeking. 76 (26%) of 296 participants had CHE. CHE was associated with being aged 30-44 years old (aOR 2·6, 95% CI 1·3-5·3, p=0·010), being female (1·8, 1·3-2·7, p=0·0021), having higher than secondary school education (1·6, 1·1-2·3, p=0·0083), being accompanied during health-care-seeking visits (3·2, 1·7-5·9, p<0·0001), belonging to the second poverty quintile (2·0, 1·9-2·1, p<0·0001), and seeking care from subcounty hospitals (9·7, 9·6-9·8, p<0·0001) and county hospitals (25·1, 15·7-40·2, p<0·0001). INTERPRETATION:These findings suggest a sizeable burden of CHE in people seeking care for chronic respiratory disease symptoms in Meru County in Kenya, driven by socioeconomic and sex inequalities and impaired access to health care and social protection. FUNDING:UK-Aid, UK National Institute for Health and Care Research, and UK Research and Innovation.

There is a pressing need for transitional water infrastructures in rapidly growing cities where conventional infrastructures lag behind human settlement expansion. In Kenya, sectoral innovations have addressed local socioeconomic challenges, but empirical evidence on their efficacy (combining quantitative indicators of safety and continuity) is lacking. We addressed this gap by comparing different water infrastructures in their ability to provide constant access to safe water in informal settlements in Nairobi, Kenya. We conducted a cross-sectional survey including 1,147 households in two informal settlements. Water infrastructures were categorized based on their distribution system: 1) piped to premises; 2) piped to a neighboring compound; 3) public tap/dispenser; and 4) street vendor. We tested associations between these systems with two outcomes: constant water availability and diarrhea (stratified by age group). We used adjusted odds ratios (AORs) to test associations between distribution systems and the selected outcomes, while accounting for confounders. Obtaining water from public taps/dispensers or street vendors was associated with service continuity (AOR = 1.45, 95% confidence interval [CI]: 1.06-1.99; AOR = 11.16, 95% CI: 2.45-50.82). Piped sources were associated with service disruption, especially when obtained from a neighboring compound (AOR = 0.45, 95% CI: 0.28-0.70). Public taps/dispensers were the only system consistently associated with lower odds of diarrhea, notably in children under the age of 5 years (AOR = 0.47, 95% CI: 0.29-0.79). Hence, in cities with a high prevalence of informal settlements and limited financial resources, public taps and dispensers hold promise as transitional water infrastructures.

Introduction Worldwide, 2.4 billion people rely on solid fuels such as wood or charcoal for cooking, leading to approximately 3.2 million deaths per year from illnesses attributable to household air pollution. Across Africa, household air pollution generated by solid fuel use accounts for nearly 700,000 deaths each year. Most studies to date have focused either household air pollution exposure, its impacts on particular health outcomes or on the efficacy of mitigation interventions. However, the economic, social, and cultural determinants of household air pollution in Africa are still poorly understood. The purpose of this study was to explore people’s experience of using solid fuels for cooking in two informal settlements, Ndirande in Malawi and Mukuru in Kenya, and the associated harms caused by household air pollution. Methods We adopted a community-based participatory method, photovoice, which was conducted with 9 participants in Ndirande and 10 participants in Mukuru. Participants took pictures reflecting their experiences and perceptions of household air pollution harms over a two-week period, and later discussed, sorted and analysed those in a series of meetings. Thematic analysis was used to analyse the data. Results With their pictures, participants described fuel stacking and switching behaviours in their communities. They described a mix of charcoal, firewood and other biomass fuels use. They also expressed their awareness and perceptions of the harms caused by smoke when cooking. Participants explained the simple behaviours used by residents to minimize the harms of household air pollution to themselves and within their own household. Other themes explored the roles and responsibilities for procuring fuels in the home, and the stated solutions required to address the issues and manage the transition to cleaner fuels in those informal settlements. Conclusion This study highlights not only the need to understand the daily life, priorities and concerns of those who use solid fuels on informal settlements, but also the urgency to place them and their experience at the heart of the solutions that will reduce the health harms of household air pollution.

Abstract Background Universal access to basic sanitation remains a global challenge, particularly in low- and middle-income countries. Efforts are underway to improve access to sanitation in informal settlements, often through shared facilities. However, access to these facilities and their potential health gains—notably, the prevention of diarrheal diseases—may be hampered by contextual aspects related to the physical environment. This study explored associations between the built environment and perceived safety to access toilets, and associations between the latter and diarrheal infections. Methods A cross-sectional study was carried out between July 2021 and February 2022, including 1714 households in two informal settlements in Abidjan (Côte d’Ivoire) and two in Nairobi (Kenya). We employed adjusted odds ratios (aORs) obtained from multiple logistic regressions (MLRs) to test whether the location of the most frequently used toilet was associated with a perceived lack of safety to use the facility at any time, and whether this perceived insecurity was associated with a higher risk of diarrhea. The MLRs included several exposure and control variables, being stratified by city and age groups. We employed bivariate logistic regressions to test whether the perceived insecurity was associated with settlement morphology indicators derived from the built environment. Results Using a toilet outside the premises was associated with a perceived insecurity both in Abidjan [aOR = 3.14, 95% confidence interval (CI): 1.13–8.70] and in Nairobi (aOR = 57.97, 95% CI: 35.93–93.53). Perceived insecurity to access toilets was associated with diarrheal infections in the general population (aOR = 1.90, 95% CI: 1.29–2.79 in Abidjan, aOR = 1.69, 95% CI: 1.22–2.34 in Nairobi), but not in children below the age of 5 years. Several settlement morphology features were associated with perceived insecurity, namely, buildings’ compactness, the proportion of occupied land, and angular deviation between neighboring structures. Conclusions Toilet location was a critical determinant of perceived security, and hence, must be adequately addressed when building new facilities. The sole availability of facilities may be insufficient to prevent diarrheal infections. People must also be safe to use them. Further attention should be directed toward how the built environment affects safety. Graphical Abstract

Background Although 1 billion people live in informal (slum) settlements, the consequences for respiratory health of living in these settlements remain largely unknown. This study investigated whether children living in an informal settlement in Nairobi, Kenya are at increased risk of asthma symptoms. Methods Children attending schools in Mukuru (an informal settlement in Nairobi) and a more affluent area (Buruburu) were compared. Questionnaires quantified respiratory symptoms and environmental exposures; spirometry was performed; personal exposure to particulate matter (PM 2.5 ) was estimated. Results 2373 children participated, 1277 in Mukuru (median age, IQR 11, 9–13 years, 53% girls), and 1096 in Buruburu (10, 8–12 years, 52% girls). Mukuru schoolchildren were from less affluent homes, had greater exposure to pollution sources and PM 2.5 . When compared with Buruburu schoolchildren, Mukuru schoolchildren had a greater prevalence of symptoms, ‘current wheeze’ (9.5% vs 6.4%, p=0.007) and ‘trouble breathing’ (16.3% vs 12.6%, p=0.01), and these symptoms were more severe and problematic. Diagnosed asthma was more common in Buruburu (2.8% vs 1.2%, p=0.004). Spirometry did not differ between Mukuru and Buruburu. Regardless of community, significant adverse associations were observed with self-reported exposure to ‘vapours, dusts, gases, fumes’, mosquito coil burning, adult smoker(s) in the home, refuse burning near homes and residential proximity to roads. Conclusion Children living in informal settlements are more likely to develop wheezing symptoms consistent with asthma that are more severe but less likely to be diagnosed as asthma. Self-reported but not objectively measured air pollution exposure was associated with increased risk of asthma symptoms.

Background Worldwide, 2.4 billion people rely on solid fuels for cooking. Approximately 3.2 million deaths from illnesses attributable to household air pollution are caused by cooking and heating on solid fuels (such as wood and charcoal). The Fuel to Pot study aimed to explore experiences and perceptions of solid fuel use for cooking in residents of informal settlements [slums] in Mukuru (Kenya) and Ndirande (Malawi) in order to understand their fuel choices. Methods This qualitative study used the participatory photovoice method for data collection. This entailed participants (10 in Kenya and 9 in Malawi) taking photos- using Android phones- and discussing and analysing those pictures in a group setting to identify and present the issues that matter most to them around solid fuels, smoke, health and cooking. The research was undertaken in Kenya and Malawi between July and September 2022. A focus group was also conducted with the participants at the end of the process to seek their views on taking part in a photovoice study. Results Although over the past decade the photovoice methodology has become increasingly used to explore health and social or cultural issues, there is very limited literature on the use of this method in African slums contexts and other resource-poor settings. Our results provide learning about the process of photovoice in this context, drawing on reflective fieldnotes and focus group discussion and practical tips on undertaking this participatory method in slums context. Overall, the participants enjoyed taking part in the photovoice and found it very informative and empowering in terms of understanding how and why members of their communities used solid fuels such as wood, charcoal, charcoal briquettes but also Kerosene, paraffin and other' non-clean' fuels for cooking. Methodological challenges in this context included the process around practicalities, confidentiality and anonymity in terms of taking pictures. For example, some participants reported others in the community demanding money to have their photo taken which required the team to develop a process for 3rd party consent to be administered by participants. Conclusion The photovoice method is increasingly used in health research and has been used recently to explore issues surrounding clean cooking. However, less is known about conducting it in informal settlements in low- and middle-income countries, which present particular challenges. This method offers an inclusive and unique chance to understand complex issues through the lens of those most affected, thus leading to better public health interventions.

Objectives: Acute breathlessness is a common and distressing symptom experienced by patients presenting to the emergency department (ED). Adoption of clinician-performed bedside ultrasound could promote accurate, early diagnosis and treatment to acutely breathless patients. This may be particularly pertinent in low resource settings with limited human resources and lack of access to advanced (gold standard) diagnostic testing. The aim of the study was to explore the experience of point-of-care ultrasound (PoCUS) users in the emergency department, and to understand the facilitators and constraints of PoCUS incorporation into patient investigation pathways. Materials and Methods: This was an exploratory qualitative study. Data collection entailed key informant interviews using a semi-structured interview guide between September 2019 and February 2020. Participants were purposively sampled according to role and responsibility in the acute care system at Kenyatta National Hospital, including front-line health practitioners and mid-level clinical hospital managers. Data collection proceeded until no new concepts emerged (thematic saturation). The analytical framework method was used for the thematic analysis of interview transcripts. Results: At individual level, the lack of training on the use of PoCUS, as well as fears and beliefs impacted on capability and motivation of the clinicians to perform PoCUS for clinical diagnosis. Hospital level influencers such as hospital norms, workloads, and staffing influenced the use of PoCUS by impacting on the clinician’s capability, motivation, and opportunity. General health system influencers such as relationships and power dynamics between clinical specialties and key stakeholders, and the lack of policy and practice guidelines challenged the uptake of the bedside ultrasound by the clinicians. Conclusion: Lack of PoCUS training for clinicians, limited resources and a fragmented health system structure impacted the clinician’s capability, motivation, and opportunity in performing PoCUS in diagnostics. PoCUS for diagnosis of acute breathlessness requires: (1) Well-maintained and accessible equipment; (2) highly trained individuals with time to perform the examination with access to ongoing support for the operators; and (3) finally, researchers must more accurately identify the optimal scope of ultrasound examination, the diagnostic benefits, and the opportunity costs. All three will be required to ensure patient’s benefit.

Background:Kenya has implemented a robust response to non-communicable diseases and injuries (NCDIs); however, key gaps in health services for NCDIs still exist in the attainment of Universal Health Coverage (UHC). The Kenya Non-Communicable Diseases and Injury (NCDI) Poverty Commission was established to estimate the burden of NCDIs, determine the availability and coverage of health services, prioritize an expanded set of NCDI conditions, and propose cost-effective and equity-promoting interventions to avert the health and economic consequences of NCDIs in Kenya. Methods:Burden of NCDIs in Kenya was determined using desk review of published literature, estimates from the Global Burden of Disease Study, and secondary analysis of local health surveillance data. Secondary analysis of nationally representative surveys was conducted to estimate current availability and coverage of services by socioeconomic status. The Commission then conducted a structured priority setting process to determine priority NCDI conditions and health sector interventions based on published evidence. Findings:There is a large and diverse burden of NCDIs in Kenya, with the majority of disability-adjusted life-years occurring before age of 40. The poorest wealth quintiles experience a substantially higher deaths rate from NCDIs, lower coverage of diagnosis and treatment for NCDIs, and lower availability of NCDI-related health services. The Commission prioritized 14 NCDIs and selected 34 accompanying interventions for recommendation to achieve UHC. These interventions were estimated to cost $11.76 USD per capita annually, which represents 15% of current total health expenditure. This investment could potentially avert 9,322 premature deaths per year by 2030. Conclusions and Recommendations:An expanded set of priority NCDI conditions and health sector interventions are required in Kenya to achieve UHC, particularly for disadvantaged socioeconomic groups. We provided recommendations for integration of services within existing health services platforms and financing mechanisms and coordination of whole-of-government approaches for the prevention and treatment of NCDIs.

Background: Chronic lung diseases are among the top four non communicable diseases (NCDs), associated with 80% of premature mortality worldwide, debilitating health, and poor quality of life for survivors. Common risk factors for lung diseases include exposure to biomass fuels, environmental pollution, tobacco smoke, hereditary factors, and lower respiratory tract infections. Low-and-middle-income countries bear the biggest burden of chronic lung diseases, due to increasing exposures to risk factors, and weak health systems.To manage this rising threat, countries need to orient their systems towards chronic disease management, strengthen their primary healthcare systems even as they pursue universal health coverage reforms. This paper draws on the views and experiences of health systems actors to explore the current challenges to improving high quality, accessible care for chronic lung diseases.Methods: We explored the perspectives of policy stakeholders on management of chronic lung diseases in five Sub-Saharan African countries, Kenya, Malawi, Sudan, Tanzania, and Uganda. Data were collected between May 2018 and March 2019 through key informant interviews and in-depth interviews with government officials, representatives of non-governmental organizations supporting various health system functions, and healthcare workers of 36 healthcare facilities. Data were analysed using the framework approach.Findings: We identified intersecting vicious cycles of neglect of chronic lung health at both the strategic policy level and the healthcare facility level. At strategic policy level, low diagnostic capacity, weak recording and reporting systems limit the availability of reliable data on the burden of disease, which negatively affects inclusion in policy, and in turn budgetary allocations for diagnostic equipment, training, and medicines. At the service level, lack of budgetary allocations for equipment and training of staff, constrains diagnostic capacity, which, along with limited availability of appropriate medicines reduces service delivery quality and collection of appropriate data within healthcare facilities. These vicious cycles leave health systems ill equipped to respond to the rising burden of chronic lung disease, an issue that has been brought into sharp focus as countries plan for dealing with post COVID lung disease. Interpretation: 1. There is increasing recognition among policymakers that NCDs, including CLD are rising in LMICs.2. CLDs are under-diagnosed, under-reported and underfunded leading to a vicious cycle of invisibility and neglect at all levels of the health system.3. Appropriate diagnosis and CLD management require strengthening of the health systems, particularly at the primary healthcare level.Funding Statement: This research was funded by the National Institute for Health Research (NIHR (IMPALA, grant reference 16/136/35) using UK aid from the UK Government to support global health research.Declaration of Interests: None declared.Ethics Approval Statement: The Liverpool School of Tropical Medicine Ethics Committee approved these studies separately (Kenya: protocol 18-054;Uganda: protocol 18-037;Malawi: protocol M1803;Tanzania and Sudan;protocol 18-043). Additionally, each approved was by in-country committees.

BACKGROUND:Sputum remains the most preferred specimen for detection of Mycobacterium tuberculosis due to its non-invasive method of production. Good quality sputum specimen is essential for accurate diagnosis of pulmonary tuberculosis (PTB). It is therefore imperative to assess factors that are related to the production of sputum that is of the best quality. OBJECTIVE:We assessed the intrinsic and extrinsic characteristics of presumed tuberculosis patients and the quality of sputum they produced. METHODS:This was a cross-sectional study in which consenting enrolled presumed tuberculosis patients were subjected to medical examination and a structured questionnaire administered to collect clinical history, demographic information, environmental and behavioral characteristics. The enrolled participants were instructed on how to collect spot and morning sputum specimens for macroscopic and microscopic assessment to determine any association. RESULTS:A total of 309 patients were enrolled into the study with an even distribution on gender (50.5% males). Of these, 202 (65.3%) submitted both a spot and a morning specimen for analysis. On macroscopic examination, 70% spot and 68% morning sputum were characterized as good quality (Purulent/mucoid). The factors associated (p<0.05) with quality specimen included both intrinsic and extrinsic factors. The intrinsic factors included: difficulty in breathing, presence of conjunctivitis and knowledge of the disease whereas the only extrinsic factor associated with production of good quality sputum for tuberculosis diagnosis was time taken by patient to seek tuberculosis treatment after occurrence of any of the TB symptoms. CONCLUSION:Both intrinsic and extrinsic factors affected the quality of sputum produced by presumed tuberculosis patients. Clinical and behavioral characteristics including conjunctivitis, difficulty in breathing and delay in seeking treatment were important factors that determined the production of good quality sputum specimens, while knowledge of tuberculosis disease did not compel presumed tuberculosis patients to produce good quality sputum for diagnosis of the disease.

To the Editor: Human immunodeficiency virus type 1 (HIV-1) infection is a major cause of mortality in young adults in Africa (1), and the number of new cases continues to increase (2). The clinical spectrum of HIV-1 disease has been well defined in Europe and the United States by numerous clinical and autopsy studies (3); however, the clinical spectrum of disease is less well defined in developing countries, and there are important differences in the type and frequency of opportunistic infections (4,5). A limited number of autopsy studies have been reported from Africa (5-7). To determine the major pathology in HIV-1-infected adults dying in hospital in Kenya, autopsy examinations were performed on consecutive HIV-1-infected adults who were subjects in an isoniazid preventive therapy study (8) and who died in hospital between January and October 1995. All subjects were confirmed to be HIV-1 infected antemortem on at least two immunoassays (Wellcozyme Recombinant VK 56/57 and Behring Enzygnost Anti-HIV-1/HIV-2, Germany). Lymphocyte subsets were determined antemortem using a FACScan flow cytometer (Becton Dickinson, Mountain View, CA, U.S.A.). Complete autopsies were performed within 3 days of death. Histopathology was performed on formalin-fixed tissue using hematoxylin and eosin stain and special stains as appropriate. Selected antemortem bacterial cultures and postmortem mycobacterial cultures were performed by standards techniques (9,10). Bacteremia was recorded as a cause of death in any patient found to have positive blood cultures for a pathological organism within 24 h of death. Nine autopsy examinations were performed on four male and five female subjects. The mean age was 36 years (range, 28-43). The median CD4 count taken within 6 months of death was 63 × 106/L (range, 10-370). Six subjects has received isoniazid 300 mg daily as prophylaxis for 6 months. A summary of the major pathology found is shown in Table 1. Tuberculosis was found in three of the nine patients (cases 1, 2, and 8), and in two patients it was disseminated. In one patient (case 1), tuberculosis was undiagnosed antemortem. The patient died of a paralytic ileus related to extensive infiltration of the mesentery and small bowel by tuberculosis. Mycobacterium tuberculosis was seen histologically and confirmed by culture in lung, liver, spleen, and mesenteric nodes postmortem. In the second patient (case 8), tuberculosis was suspected antemortem by the presence of fever and a pleural effusion; however, sputum was not available, and culture of pleural aspirate was negative. The third patient (case 2) had been treated for 11 months with a rifampicin-containing regimen for smear-positive, culture-positive pulmonary tuberculosis. Adherence to treatment was known to be poor, and disseminated tuberculosis was found in the liver, spleen, and mesenteric nodes at autopsy. Two patients (cases 6 and 9) diagnosed to have microbiologically proved tuberculosis antemortem and treated had no evidence of tuberculosis at autopsy. Gram-negative bacteremia was the cause of death in two patients (cases 5 and 8), one of whom also had disseminated tuberculosis. Pneumocystis carinii pneumonia (PCP) was seen in two patients (cases 1 and 4). Both patients died with clinical manifestations compatible with PCP; one patient had coexistent cytomegalovirus pneumonitis, the other coexistent tuberculosis. The CD4 counts in these two patients were 33 and 60 × 106/L. This small number of selected autopsies in HIV-infected patients has revealed a range of pathology similar to that seen in a large unselected autopsy series from West Africa (5). As in that study, most of our patients who died in hospital were severely immunosuppressed. Tuberculosis occurred in three of our nine patients. In all cases the histopathology was one of multibacillary tuberculosis with dissemination in two or more organs in two patients. In all patients it was difficult to diagnose antemortem. This finding emphasises the need to maintain a high index of suspicion for tuberculosis in the immunosuppressed patient with fever who is not responding to broadspectrum antibiotics. In Africans with HIV infection, PCP is reported to be uncommon (11). Prevalence ranging from 0% in Uganda to 33% in Zimbabwe in selected patients with pneumonia and from 0% in Uganda to 9% in Cote d'Ivoire in autopsy studies have been reported (11). In Kenya, PCP has not been previously reported in adults. Our cases demonstrate that PCP does exist in Kenya. Both patients were severely immunosuppressed (CD4 < 100 × 106/L), and it is likely that many HIV-infected patients die of more virulent pathogens before they reach this stage. Geographical and seasonal variations in the prevalence of P. carinii are also possible factors to account for the varying reported prevalence of PCP throughout Africa. Gram-negative sepsis was the cause of death in two patients. Previous papers have emphasised the importance, particularly in Africa, of this treatable disease entity in HIV infection (10). These findings highlight the need to carry out further nonselected autopsy studies that include antemortem blood cultures to confirm the range of pathology, cause of death, and any geographical differences that may exist within Africa. *Farzana Rana; †Mark P. Hawken; †Helen K. Meme; †Jeremiah M. Chakaya; †Willie A. Githui; †Joseph A. Odhiambo; ‡John D. H. Porter; ‡Keith P. W. J. McAdam; §Sebastian J. Lucas *Department of Human Pathology; Kenyatta National Hospital †Respiratory Diseases Research Unit; Clinical Research Centre; Kenya Medical Research Institute; Nairobi, Kenya ‡Department of Clinical Sciences; London School of Hygiene and Tropical Medicine §Department of Histopathology; University Medical and Dental School; St. Thomas' Hospital; London, England