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Agriculture is the primary source of income and household food for >75% of rural Kenyans, including people living with HIV (PLHIV), making agricultural yields an important factor in food security and nutrition. Previous studies have shown the interconnectedness of food insecurity, malnutrition, and poor HIV health by elucidating that having one of these conditions increases the likelihood and severity of having another. However, few studies have explored the linkages between agricultural practices, food security and nutrition for PLHIV, or how agricultural livelihood interventions may affect these domains. This study aimed to examine the mechanisms through which an agricultural livelihood intervention can positively or negatively affect agricultural practices, food security, and nutrition for PLHIV. From July 2012-August 2013, we interviewed participants with HIV on antiretroviral therapy (ART) enrolled in a pilot randomized controlled trial (RCT) of an agricultural livelihood and finance intervention to understand the mechanisms through which the intervention may have affected HIV health outcomes. The intervention included agricultural and finance training and a microfinance loan to purchase the MoneyMaker hip pump, a human-powered water pump, seeds, and other farming implements. A purposive sample of 45 intervention and a random subset of 9 control participants were interviewed at 12-month endline visit with a subset of 31 intervention participants interviewed longitudinally at both the 3- and 12-month visits. Transcripts were double coded using an inductive-deductive approach and analyzed for impacts of the intervention on agricultural practices, food security, and nutrition using analytic reports for each key theme. All intervention participants described improvements in agricultural practices and yields attributed to the intervention while many also described improvements in income; these changes in turn contributed to improved HIV health, including suppressed viral loads, and a few people noted improved immunologic parameters. Key mechanisms included the knowledge gained from agricultural training which led to improved yields and access to new markets. The use of the irrigation pump was also identified as an additional, lesser important mechanism. All intervention participants reported sustained improvements in food security and nutrition through increased yields and income from the sale of excess crops used to purchase food, and diversification of fresh fruits and vegetables consumed through agricultural production. This led to self-reported weight gain which was a nutritional mechanism towards improved health. Agricultural and finance interventions that improve farming practices could lead to improved health outcomes through the pathways of improved food security, income, and diversified diet. The results from this study helped the team to enhance the intervention prior to implementation of the larger cluster RCT (cRCT). By understanding how agricultural livelihood interventions act upon pathways towards improved health, policy options can be developed and implemented to include components that are needed to achieve sustainable outcomes. ClinicalTrials.gov NCT01548599.

To determine if integration of family planning (FP) and HIV services led to increased use of more effective contraception (i.e. hormonal and permanent methods, and intrauterine devices) and decreased pregnancy rates. Cohort analysis following cluster randomized trial, when the Kenya Ministry of Health led integration of the remaining control (delayed integration) sites and oversaw integrated services at the original intervention (early integration) sites. Eighteen health facilities in Kenya. Women aged 18-45 receiving care: 5682 encounters at baseline, and 11628 encounters during the fourth quarter of year 2. \"One-stop shop\" approach to integrating FP and HIV services. Use of more effective contraceptive methods and incident pregnancy across two years of follow-up. Following integration of FP and HIV services at the six delayed integration clinics, use of more effective contraception increased from 31.7% to 44.2% of encounters (+12.5%; Prevalence ratio (PR) = 1.39 (1.19-1.63). Among the twelve early integration sites, the proportion of encounters at which women used more effective contraceptive methods was sustained from the end of the first to the second year of follow-up (37.5% vs. 37.0%). Pregnancy incidence including all 18 integrated sites in year two declined in comparison to the control arm in year one (rate ratio: 0.72; 95% CI 0.60-0.87). Integration of FP services into HIV clinics led to a sustained increase in the use of more effective contraceptives and decrease in pregnancy incidence 24 months following implementation of the integrated service model. ClinicalTrials.gov NCT01001507.

ObjectivesWe conducted an implementation science mental health treatment study in western Kenya, testing strategies for scale up of evidence-based mental health services for common adult disorders using a non-specialist workforce, integrated with existing primary care (Sequential Multiple, Assignment Randomized Trial of non-specialist-delivered psychotherapy (Interpersonal Psychotherapy) and/or medication (fluoxetine) for major depression and post-traumatic stress disorder (PTSD) (SMART DAPPER)). Because study launch coincided with the COVID-19 pandemic, participants were allowed to attend treatment visits via mHealth (audio-only mobile phone) or in-person. We conducted a secondary data analysis of the parent study to evaluate preference for mHealth or in-person treatment among our study participants, including rationale for choosing in-person or mHealth treatment modality, and comparison of baseline demographic and clinical characteristics.Design, setting, participants and interventionsParticipants were public sector primary care patients at Kisumu County Hospital in western Kenya with major depression and/or PTSD and were individually randomised to non-specialist delivery of evidence-based psychotherapy or medication (n=2162).OutcomesTreatment modality preference and rationale were ascertained before randomised assignment to treatment arm (psychotherapy or medication). The parent SMART DAPPER study baseline assessment included core demographic (age, gender, relationship status, income, clinic transport time and cost) and clinical data (eg, depression and PTSD symptoms, trauma exposures, medical comorbidities and history of mental healthcare). Given that this evaluation of mHealth treatment preference sought to identify the demographic and clinical characteristics of participants who chose in-person or mHealth treatment modality, we included most SMART DAPPER core measurement domains (not all subcategories).Results649 (30.3%) SMART DAPPER participants preferred treatment via mHealth, rather than in person. The most cited rationales for choosing mHealth were affordability (18.5%) (eg, no transportation cost) and convenience (12.9%). On multivariate analysis, compared with those who preferred in-person treatment, participants who chose mHealth were younger and had higher constraints on receiving in-person treatment, including transport time 1.004 (1.00, 1.007) and finances 0.757 (0.612, 0.936). Higher PTSD symptoms 0.527 (0.395, 0.702) and higher disability 0.741 (0.559, 0.982) were associated with preference for in-person treatment.ConclusionsTo our knowledge, this is the first study of public sector mental healthcare delivered by non-specialists via mHealth for major depression and/or PTSD in Sub-Saharan Africa. Our finding that mHealth treatment is preferred by approximately one-third of participants, particularly younger individuals with barriers to in-person care, may inform future mHealth research to (1) address knowledge gaps in mental health service implementation and (2) improve mental healthcare access to evidence-based treatment.Trial registration numberNCT03466346.

Few studies have explored land access, a structural driver of health, and women’s participation in livelihood interventions to improve food security and HIV outcomes. This qualitative study, embedded within Shamba Maisha (NCT02815579)—a randomized controlled trial (RCT) examining the impact of a multisectoral intervention among farmers living with HIV in western Kenya—sought to explore the influence of perceived access to and control of land on agricultural productivity, investments, and benefits. Thirty in-depth interviews (IDIs) were conducted with purposively sampled men and women, 3 to 6 months after receiving intervention inputs; data were deductively and inductively coded and analyzed. Farming practices and participation in Shamba Maisha were dependent on land tenure and participants’ perceived strength of claim over their land, with participants who perceived themselves to be land insecure less likely to make long-term agricultural investments. Land tenure was influenced by a number of factors and posed unique challenges for women which negatively impacted uptake and success in the intervention. Data underscore the importance of secure land tenure for the success of similar interventions, especially for women; future interventions should integrate land security programming for improved outcomes for all.

IntroductionDepression and post-traumatic stress disorder (PTSD) significantly contribute to the global disease burden, adversely affecting health, medical costs and economic productivity. The SMART-DAPPER project in western Kenya approached this challenge by deploying trained non-specialists to administer proven depression and PTSD treatments.MethodsParticipants were public sector primary care outpatients at Kiumu County Hospital with major depression and/or PTSD. They were randomised to first-line treatment with interpersonal psychotherapy (IPT) or fluoxetine. We evaluated three measures of economic productivity: income, absenteeism and presenteeism (lowered work efficiency). Change over baseline and comparisons between treatments were conducted using generalised estimating equations regression.ResultsThere were statistically significant gains in economic productivity from baseline to the end of first-line treatment. The percentage of participants earning a monthly income rose from 54.9% at baseline to 59.8% after treatment in the IPT group and from 54.5% to 61.5% in the Fluoxetine group. Improvement was significantly associated with illness remission. Average monthly income among earners increased by Kenya shillings (KES) 1920 (46 Intl$) with IPT and KES 1350 (31 Intl$) with fluoxetine. Absenteeism dropped in both treatment arms, by 1.5 days per month for IPT and 1.9 days per month for fluoxetine. Presenteeism decreased more with fluoxetine (4.8 days per month) than with IPT (3.3 days per month).ConclusionTreating common mental disorders with IPT and fluoxetine in public sector primary care settings was associated with economic productivity. Leveraging a non-specialist workforce for treatment delivery at scale may build individual and community economic well-being.FundingR01MH113722(NIMH), R01MH115512(NIMH-GACD).Trial registration numberClinicalTrials.gov Identifier: NCT03466346.

The objective of this study was to determine the association between the number of adolescents in a household and depressive symptoms among adult caregivers living with HIV. We examined cross-sectional baseline data among adults enrolled in the Shamba Maisha multisectoral agricultural intervention (n = 705) in the Nyanza region of Kenya (NCT02815579). Each additional adolescent 15–19 years in a household was associated with a 1.35 (95% CI 1.06–1.71) higher odds of depressive symptoms among women, but not men, adjusting for potential confounders. Interventions to support the mental health of adults living with HIV may target women caring for dependent adolescents 15–19 years.

Background The global shortage of trained mental health workers disproportionately impacts mental health care access in low- and middle-income countries. In Kenya, effective strategies are needed to scale-up the workforce to meet the demand for depression and post-traumatic stress disorder treatment. Task-shifting – delegating specific tasks to non-specialist workers – is one workforce expansion approach. However, non-specialist workers remain underutilized in Kenya due to a paucity of research on how to scale-up and sustain such service models. Methods Purposive sampling was used to recruit experts from policy, healthcare practice, research, and mental health advocacy roles in Kenya ( N  = 30). Participants completed concept mapping activities to explore factors likely to facilitate or hinder a collaborative Ministry of Health-researcher training of the mental health non-specialist workforce. Participants brainstormed 71 statements describing determinants and implementation strategies, sorted and rated the importance and changeability of each. Multidimensional scaling and hierarchical cluster analysis quantified relationships between statements. The Exploration, Preparation, Implementation, and Sustainment (EPIS) framework guided cluster interpretation activities. Results Twelve determinant clusters were identified: 1) Current workforce characteristics, 2) Exploration considerations, 3) Preparation considerations, 4) Sustainment considerations, 5) Inner context implementation processes and tools, 6) Local capacity and partnerships, 7) Financing for community health teams, 8) Outer context resource allocation/policy into action, 9) Workforce characteristics to enhance during implementation, 10) Workforce implementation strategies, 11) Cross-level workforce strategies, and 12) Training and education recommendations. Cluster 8 was rated the most important and changeable. Conclusion Concept mapping offers a rapid, community-engaged approach for identifying determinants and implementation strategies to address workforce shortages. Organizing results by EPIS phases can help prioritize strategy deployment to achieve implementation goals. Scale-up and sustainment of the non-specialist workforce in Kenya requires formal partnerships between the Ministry of Health and community health worker teams to distribute financial resources and collaboratively standardize training curriculum.

Little is known about the association of gender-based power imbalances and health and health behaviors among women with HIV (WWH). We examined cross-sectional baseline data among WWH in a cluster-randomized control trial (NCT02815579) in rural Kenya. We assessed associations between the Sexual Relationship Power Scale (SRPS) and ART adherence, physical and mental health, adjusting for sociodemographic and social factors. SRPS consists of two subscales: relationship control (RC) and decision-making dominance. Women in the highest and middle tertiles for RC had a 7.49 point and 8.88 point greater Medical Outcomes Study-HIV mental health score, and a 0.27 and 0.29 lower odds of depression, respectively, compared to women in the lowest tertile. We did not find associations between SPRS or its subscales and ART adherence. Low sexual relationship power, specifically low RC, may be associated with poor mental health among WWH. Intervention studies aimed to improve RC among WWH should be studied to determine their effect on improving mental health.

ObjectiveNon-adherence to antidepressants has been linked to increased symptom severity, relapse and hospitalisation from common mental disorders. However, there is limited knowledge of factors associated with antidepressant adherence in low-income and middle-income countries, especially in public sector, primary care settings.MethodsWe quantified fluoxetine adherence using the medication possession ratio. A limitation of this measure is that it does not always reflect the ingestion of medication. We constructed a generalised estimating equations linear regression with robust SEs, clustered by the participant, to identify independent predictors of fluoxetine adherence.ResultsParticipants randomised to fluoxetine were dispensed an average of 126 daily doses, or 70% of the 180 possible doses. Adherence was higher in the first half of the treatment period at 86.3%, 95% CI (83.5% to 89.2%) compared with 46.5% in the second half (44.3% to 48.8%) (p<0.001). Participants who opted for community-delivered fluoxetine demonstrated adherence at 79.7% (77.0% to 82.4%) compared with 58.6% (55.7% to 61.5%) of those who only picked up medication at the facility (p<0.001). Use of mHealth for at least one but less than half of the visits had the highest level of adherence at 84.6% (82.4% to 86.9%) compared with 49.6% (46.1% to 53.0%) among those who did not use mHealth and 67.2% (62.5% to 72.0%) for those who used mHealth at least half their visits (p<0.001).ConclusionsAdherence to fluoxetine was high relative to existing selective serotonin reuptake inhibitors adherence data, the majority of which is from high-income countries. Adherence was higher during the first half of treatment. People who were older, living with HIV and opted to use community delivery of medication and/or mHealth had higher adherence.Trial registration numberNCT03466346.