Blessing Mberu

Background Solid Waste Management (SWM) in most developing countries, especially in Africa, faces several challenges that hinder proper management across the value chain. Kisumu City, the third-largest city in Kenya, faces numerous challenges in the waste collection and disposal sector. Kisumu generates an estimated 500 tons of waste daily, but only about 40% of it is collected and disposed of properly, leaving the rest to accumulate in open areas or water bodies. This poses significant health and environmental risks to residents and the ecosystem. Due to open dumping of waste, greenhouse gases (GHGs) are emitted into the air, causing air pollution and consequently contributing to climate change. Methodology We sought to identify the drivers of current solid waste management practices in five areas of Kisumu County (Nyalenda-A, Manyatta-B, Kaloleni, Manyatta - A, Migosi, and Nyalenda B). We used a cross-sectional study design and mixed-method approaches to conduct the research. About 400 household heads were interviewed, while 13 Key Informant Interviews and 10 Focus Group Discussions were conducted. Results About 8% of households practice proper SWM, and 35% of households receive waste collection services. Burning of waste is common at 77%. Level of education (P value = 0.11), income-generating activity (P value = 0.024), waste collection services P value = 0.001), and sex of the household (P value =0.09) had significant associations with proper solid waste management practices. Key challenges identified through the qualitative interviews include inadequate resources at the county level, a lack of awareness among the residents on the importance of proper waste management, poor policy implementation, and a poor attitude towards waste. Conclusion The county should have adequate budget allocation for SWM and the implementation of existing policies, for example, strict enforcement against illegal dumping, and littering by-laws, community sensitisation, as well as include women in decision-making in SWM.

Enteric infections, transmitted through exposure to animals and feces-contaminated hands and environmental fomites, cause substantial disease burden among children in low socioeconomic status (SES) settings. Modeling rates of both exposure and exposure mitigation behaviors is critical for accurately predicting the impact of disease control interventions. Yet, how often caregivers quickly implement hygiene behaviors following infant exposure to hazards is unknown. This study measured the frequency of infant exposure behaviors and the likelihood of immediate subsequent caregiver hygiene responses in Nairobi and Kisumu, Kenya. We collected 10 hours of behavioral observations for 275 infants aged under 12 months from low- and middle- income neighborhoods. We characterized the rate of 20 infant behaviors, accounting for variation in city, neighborhood SES, and infant age, using Poisson and negative binomial regression. We then estimated the odds that caregivers washed infant hands or face or moved an infant following zoonotic, feces, or environmental contact behaviors. Hands/face washing within 5 minutes of infant contact with animals, feces, or objects and removing infants from potentially hazardous settings within one minute was uncommon among caregivers. The likelihood of washing after contacting objects declined for infants over 4 months age. Neighborhood SES was associated with removing an infant from a high-risk surface/object and handwashing after touching feces. Handwashing after touching animals was higher with higher maternal education and access to a handwashing station. These estimates on the temporal relationships between infant exposure behaviors and subsequent intervention by caregivers will improve the accuracy of models of enteric pathogen exposure risk.

Introduction: Formal urban planning and infrastructure systems are failing to adapt to rapid population growth and shifting economic demands, leaving about 61% of the world’s workers to operate in the informal sector. These workers contribute significantly to urban life, yet their transformative potential for sustainable urban development remains invisible and untapped by mainstream planning. This research focuses on community capitals, a less documented but essential driver of informal operations. This study explored how informal workers utilize community capitals to transform urban spaces into sustainable communities in Kenya. We demonstrated how these community capitals catalyzed sustainable urban growth. Methods: This qualitative study explored the community capitals framework (CCF) in an urban context, addressing the limitations of quantitative data regarding the CCF, which often overlooks critical social factors. This research team conducted in-depth interviews with 36 informal service providers from the education, healthcare, water, sanitation, and solid waste management sectors. Additionally, four local leaders from two urban informal settlements in Nairobi, Kenya, were interviewed. The data from the transcripts were analyzed using thematic framework analysis, guided by the community capitals framework. Results: We identified seven forms of community capitals that benefit informal workers: natural, cultural, human, social, political, financial, and built. The study revealed that human capital, focusing on individual skills and qualities, was most often mentioned and valued, while social capital, which concerns connections and relationships, was the second most frequent. Despite being the least implemented, cultural capital was identified as valuable for representing community knowledge and traditions. Examples of these capitals in action included solid waste workers, manual pit emptiers, education providers, health workers, and water service providers, who all contributed to urban development and well-being through waste management, sanitation, education, healthcare, and access to clean water. Conclusion: Service providers use community capitals as a planning tool to understand dynamics, refine strategies, and build trust for urban development. Each form of community capital functions as a shared resource that provides both immediate support and future development opportunities for the community. Despite that cultural capital was identified as a priority by the few participants, it warrants further research to explore its drivers. Additional research is required to fully grasp the relationships among the various capitals and their impact on service delivery.

Public spaces in countries with limited societal development can be contaminated with feces containing pathogenic microbes from animals and people. Data on contamination levels, spatial distribution, and the diversity of enteric pathogens in the public settings of low- and middle-income neighborhoods are crucial for devising strategies that minimize the enteric infection burden. The objective of this study was to compare spatial–temporal differences in the detection rate and diversity of enteric pathogens in the public spaces of low- and middle-income neighborhoods of Nairobi, Kenya. TaqMan array card (TAC) molecular assays were employed to analyze soil samples for 19 enteropathogens, along with a selective bacterial culture for pathogenic Enterobacteriaceae. An observational assessment was conducted during every site visit to document the hygienic infrastructure and sanitation conditions at the sites. We detected at least one pathogen in 79% (127/160) and ≥2 pathogens in 67.5% (108/160) of the soil samples tested. The four most frequently detected pathogens were EAEC (67.5%), ETEC (59%), EPEC (57.5%), and STEC (31%). The detection rate (91% vs. 66%) and mean number of enteric pathogens (5 vs. 4.7) were higher in low-income Kibera than in middle-income Jericho. The more extensive spatial distribution of pathogens in Kibera resulted in increases in the detection of different enteric pathogens from within-site (area < 50 m²) and across-site (across-neighborhood) movements compared to Jericho. The pathogen detection rates fluctuated seasonally in Jericho but remained at sustained high levels in Kibera. While better neighborhood conditions were linked with lower pathogen detection rates, pathogenic E. coli remained prevalent in the public environment across both neighborhoods. Future studies should focus on identifying how the sources of pathogen contamination are modified by improved environmental sanitation and hygiene and the role of these contaminated public environments in enteric infections in children.

Objective Diarrhoea remains a leading cause of morbidity and death among under-5 children in Kenya, despite multipronged policy and programme initiatives to increase access to treatment. This study interrogates the comprehensiveness and adequacy of Kenya’s policies, frameworks and action plans for diarrheal management and prevention. The study seeks to identify policy and practice gaps that need to be filled to strengthen diarrhoea treatment and prevention among under-5 children in Kenya. Design Our study is a landscape analysis, which seeks to identify the gaps in the current Kenya diarrheal policy, frameworks and action plans. The critical questions included their comprehensiveness, the availability of elaborate treatment, management and prevention solutions, together with updatedness, building on evidence from extant literature on key pathways to infection relating to man-animal environmental interaction, which are critical in enteric infection prevention initiatives. Data sources We conducted an internet search of databases of Government of Kenya’s Ministry of Health; relevant websites/publications of international organisations and groups (Centre for Disease Control and Prevention, UNICEF and WHO) and published and grey literature (Google searches, Google Scholar and PubMed). Eligibility criteria Included are publicly available key national diarrheal policy frameworks, plans, strategies, laws, institutional frameworks and operational guidelines that inform pertinent questions on the adequacy of policy and practice and preventive policy updates and actions. Further, peer-reviewed and grey literature on diarrheal morbidity and mortality and diarrheal prevention and management are included. The analysis excluded any information that was not referenced on the internet nor obtained from the internet. Data extraction and synthesis The review team extracted the key provisions of the policy guidelines guided by a checklist and questions around the adequacy of existing national policies in addressing the determinants, prevention and treatment interventions of enteric infections and diarrhoea among under-5 children in the country. The checklist covered Kenyan background and diarrhoea situation analysis, policy objectives, policy strategies and policy implementation. Results The analysis identified a corpus of strategies for the management of diarrhoea at multiple levels: health facilities, communities and households. The policies highlighted advocacy, health communication and social mobilisation, as well as logistics management and prevention strategies. However, the triangulation of evidence from the policy provisions and extant literature identified critical policy gaps in diarrhoea prevention and management in Kenya, particularly the lack of focus on zoonotic pathways to enteric infection, environment-pathogen linkages and operationalisation of the roles of social determinants of health and related services. The policy documents had limited focus on rapid diagnosis, vaccine development and deployment, together with weak funding commitment towards implementation and unclear pathways to funding responsibilities. Conclusion Policies are central to guiding programmatic actions towards effective enteric and diarrhoea prevention and management measures in Kenya. This study shows the need for policy updates to reflect pathways to enteric infections not covered in the current policy guidelines. Further, there is a need to strengthen the treatment and management of infection through rapid diagnosis, vaccine development and deployment, and strong funding commitment towards implementation together with clear funding responsibilities. Together, these will be vital in strengthening the current policy provisions and addressing other pathways to the prevention of enteric infections relating to zoonotic, environment-pathogen linkages and social determinants of health in Kenya and other low-income and middle-income countries. Trial registration number NCT05322655.

Introduction Global morbidity from enteric infections and diarrhea remains high in children in low- and middle-income countries (LMICs), despite significant investment over recent decades in health systems and global water and sanitation infrastructure. Other types of societal changes may be required to reduce disease burden. Ecological research on the influence of household and neighborhood societal development on pathogen transmission dynamics between humans, animals, and the environment could identify more effective strategies for preventing enteric infections. Methods and analysis The “enteric pathome” - i.e., the communities of viral, bacterial, and parasitic pathogens transmitted from human and animal feces through the environment is taxonomically complex in high burden settings. This integrated cohort-exposure assessment study leverages natural socio-economic spectrums of development to study how pathome complexity is influenced by household and neighborhood development. We are enrolling under 12-month-old children in low- and middle-income neighborhoods of two Kenyan cities (Nairobi and Kisumu) into a “short-cohort” study involving repeat testing of child feces for enteric pathogens. A mid-study exposure assessment documenting infrastructural, behavioral, spatial, climate, environmental, and zoonotic factors characterizes pathogen exposure pathways in household and neighborhood settings. These data will be used to inform and validate statistical and agent-based models that identify individual or combined intervention strategies for reducing multi-pathogen transmission between humans, animals, and environment in urban Kenya. Ethics and dissemination The protocols for human subjects’ research were approved by Institutional Review Boards at the University of Iowa (ID - 202004606) and AMREF Health Africa (ID - ESRC P887/2020), and a national permit was obtained from the Kenya National Commission for Science Technology and Innovation (NACOSTI) (ID# P/21/8441). The study was registered on Clinicaltrials.gov (Identifier: NCT05322655). Protocols for research on animals were approved by the University of Iowa Animal Care and Use Committee (ID 0042302). STRENGTHS AND LIMITATIONS OF THE STUDY This cohort-exposure assessment study will provide new evidence on the nature of household and neighborhood developmental strategies that are most effective at preventing critical multi-pathogen transmission pathways among humans, animals, and environment in cities of low- and middle-income countries. We study middle class households and neighborhoods to test counterfactual theories about meeting basic developmental standards to reduce pathogen transmission. Our data collection uses objective methods to comprehensively document socioeconomic, weather, infrastructural, spatial, behavioral, environmental, zoonotic, and human data, including use of both selective culture and molecular methods to characterize pathogen community patterns. The observational study design is vulnerable to unmeasured confounders. The living conditions in middle-class households and neighborhoods may not offset hygiene conditions in the overall urban environment enough to alter enteric pathogen transmission patterns.

Background: The growing urban population imposes additional challenges for health systems in low- and middle-income countries (LMICs). We explored the economic burden and inequities in healthcare utilisation across slum, non-slum and levels of wealth among urban residents in LMICs.Methods: This scoping review presents a narrative synthesis and descriptive analysis of studies conducted in urban areas of LMICs. We categorised studies as conducted only in slums, city-wide studies with measures of wealth and conducted in both slums and non-slums settlements. We estimated the mean costs of accessing healthcare, the incidence of catastrophic health expenditures (CHE) and the progressiveness and equity of health expenditures. The definitions of slums used in the studies were mapped against the 2018 UN-Habitat definition. We developed an evidence map to identify research gaps on the economics of healthcare access in LMICs.Results: We identified 64 studies for inclusion, the majority of which were from South-East Asia (59%) and classified as city-wide (58%). We found severe economic burden across health conditions, wealth quintiles and study types. Compared with city-wide studies, slum studies reported higher direct costs of accessing health care for acute conditions and lower costs for chronic and unspecified health conditions. Healthcare expenditures for chronic conditions were highest amongst the richest wealth quintiles for slum studies and more equally distributed across all wealth quintiles for city-wide studies. The incidence of CHE was similar across all wealth quintiles in slum studies and concentrated among the poorest residents in city-wide studies. None of the definitions of slums used covered all characteristics proposed by UN-Habitat. The evidence map showed that city-wide studies, studies conducted in India and studies on unspecified health conditions dominated the current evidence on the economics of healthcare access. Most of the evidence was classified as poor quality.Conclusions: Our findings indicated that city-wide and slums residents have different expenditure patterns when accessing healthcare. Financial protection schemes must consider the complexity of healthcare provision in the urban context. Further research is needed to understand the causes of inequities in healthcare expenditure in rapidly expanding and evolving cities in LMICs.

Catalyzing change and promoting sustainable cities in informal settlements and their residents requires an understanding of unmet needs and resilience among marginalized and vulnerable groups (MVGs). This is because needs identified on behalf of MVGs as “unmet” are sometimes not perceived as unmet, or even “meetable”, and resilience strategies from above are often perceived as unsuitable by the MVGs. To the best of our knowledge, no study has used governance diaries to identify the unmet needs and resilience strategies of MVGs from their perspectives. As such, this study explored the unmet needs and resilience strategies of MVGs in informal settlements using governance diaries. This was a qualitative study using governance diaries with 24 participants from two informal settlements in Nairobi, Kenya. We used Maslow’s hierarchy of needs for the framework analysis. We identified unmet needs related to physiology, safety, love and belonging, and self-esteem, in the order of the hierarchy. MVGs did not need the full satisfaction of a lower need to yearn for a higher one, and continue living despite their unmet needs. However, there were no self-actualization needs as the participants could not satisfy the lower level needs. The urban paradox reminds us that cities are not always beneficial for all. There is a continued need for holistic approaches to uncover the often hidden resilience strategies for achieving unmet needs. Our study identified behavioural and cognitive resilience strategies. As such, actors need to embrace and build on local resilience strategies in efforts to address the unmet needs of MVGs in pursuit of inclusive urbanization in Africa. The identification of unmet needs and resilience strategies adds to the literature, policy and practice on how and why residents and MVGs continue working and living in informal settlements despite a lack of or inadequate basic amenities. Our study findings imply that actors in informal settlements need to build on and re-build local resilience strategies in pursuit of inclusive and liveable urbanization in Africa, as unmet needs tend to increase with worsened marginality and vulnerability status. Beyond the resilience strategies adopted by MVGs, governments, service providers and caregivers should take more useful actions to prevent or reduce unmet needs.

The increasing volume and complexity of municipal solid waste associated with the modern economy and rapid urbanisation are increasing concern worldwide. The management of MSW has become a severe problem for governments, especially in developing countries, partly due to the lack of efficient implementation and enforcement of solid waste management (SWM) policies and legislation. This study investigates the challenges associated with the enforcement of SWM policy and legislation and the available opportunities in urban Kenya. We employed qualitative approaches in the data collection, and a thematic analytical approach was used in analysing the data. The results showed that the bane of the Kenyan SWM sector is poor implementation and enforcement of SWM policies and regulations. The key obstacles included corruption, lack of political will, political interference, and cooperation from the citizenry. Besides, the existing policies and frameworks are not evident in content as expected to drive the future of SWM in the country’s cities. The study demonstrated that there is a poor SWM policy implementation and enforcement culture in urban Kenya. Efforts should be made to remove the possible barriers to the effective implementation and enforcement of SWM policies and regulations in the country.