This study examines the association between 3 dimensions of food insecurity (timing, intensity, and duration) and 3 domains of child development (gross motor, communication, and personal social). Longitudinal data from 303 households (n = 309 children) visited 9 times over 2 years were collected. Children in households experiencing severe food insecurity 3 months prior (timing) had significantly lower gross motor (β -0.14; 95% CI [0.27, -0.0033]; p = .045), communication (β -0.16; 95% CI [-0.30, -0.023]; p = .023), and personal social (β -0.20; 95% CI [-0.33, -0.073]; p = .002) Z-scores, using lagged longitudinal linear models controlling for current food insecurity; these results were attenuated in full models, which included maternal education, household asset index, and child anthropometry. Children in households that experienced greater aggregate food insecurity over the past 2 years (intensity) had significantly lower gross motor (β -0.047; 95% CI [-0.077, -0.018]; p = .002), communication (β -0.042; 95% CI [-0.076, -0.0073]; p = .018), and personal social (β -0.042; 95% CI [-0.074, -0.010]; p = .010) Z-scores; these results were also attenuated in full models. Children with more time exposed to food insecurity (duration) had significantly lower gross motor (β -0.050; 95% CI [-0.087, -0.012]; p = .010), communication (β -0.042; 95% CI [-0.086, 0.0013]; p = .057), and personal social (β -0.037; 95% CI [-0.077, 0.0039]; p = .076) Z-scores; these results were no longer significant in full models. Our findings suggest that acute and chronic food insecurity and child development are related, but that many associations are attenuated with the inclusion of relevant covariates.

Food-producing livelihoods have the potential to improve food security and nutrition through direct consumption or indirectly through income. To better understand these pathways, we examined if fishing households ate more fish and had higher food security than non-fishing households around Lake Victoria, Kenya. In 2010, we randomly sampled 111 households containing 583 individuals for a cross-sectional household survey in a rural fishing community. We modeled the associations between fish consumption and food security and fishing household status, as well as socio-economic variables (asset index, monthly income, household size) for all households and also for a subset of households with adult male household members (76% of households). Participating in fishing as a livelihood was not associated with household fish consumption or food security. Higher household fish consumption was associated with higher household income and food security, and was weakly associated with lower household morbidity. Household food security was associated with higher incomes and asset index scores. Our results suggest socioeconomic factors may be more important than participation in food-producing livelihoods for predicting household consumption of high quality foods.

Background: Pica, the craving and purposeful consumption of nonfoods, is poorly understood. We described the prevalence of pica among women on Mfangano Island, Kenya, and examined sociodemographic and health correlates. Methods: Our cross-sectional study included 299 pregnant or postpartum women in 2012. We used a 24-h recall to assess pica, defined as consumption of earth (geophagy), charcoal/ash, or raw starches (amylophagy) and built multivariable logistic regression models to examine sociodemographic and health correlates of pica. Results: Eighty-one women (27.1%) engaged in pica in the previous 24 h, with 59.3% reporting amylophagy and 56.8% reporting geophagy, charcoal, and/or ash consumption. The most common substances consumed were raw cassava (n = 30, 36.6%), odowa, a chalky, soft rock-like earth (n = 21, 25.6%), and soil (n = 17, 20.7%). Geophagy, charcoal, and/or ash consumption was negatively associated with breastfeeding (OR = 0.38, 95% CI: 0.18-0.81), and amylophagy was associated with pregnancy (OR = 4.31, 95% CI: 1.24-14.96). Pica was more common within one of six study regions (OR = 3.64, 95% CI: 1.39-9.51). We found no evidence of an association between food insecurity and pica. Conclusion: Pica was a common behavior among women, and the prevalence underscores the need to uncover its dietary, environmental, and cultural etiologies.

Understanding feedbacks between human and environmental health is critical for the millions who cope with recurrent illness and rely directly on natural resources for sustenance. Although studies have examined how environmental degradation exacerbates infectious disease, the effects of human health on our use of the environment remains unexplored. Human illness is often tacitly assumed to reduce human impacts on the environment. By this logic, ill people reduce the time and effort that they put into extractive livelihoods and, thereby, their impact on natural resources. We followed 303 households living on Lake Victoria, Kenya over four time points to examine how illness influenced fishing. Using fixed effect conditional logit models to control for individual-level and time-invariant factors, we analyzed the effect of illness on fishing effort and methods. Illness among individuals who listed fishing as their primary occupation affected their participation in fishing. However, among active fishers, we found limited evidence that illness reduced fishing effort. Instead, ill fishers shifted their fishing methods. When ill, fishers were more likely to use methods that were illegal, destructive, and concentrated in inshore areas but required less travel and energy. Ill fishers were also less likely to fish using legal methods that are physically demanding, require travel to deep waters, and are considered more sustainable. By altering the physical capacity and outlook of fishers, human illness shifted their effort, their engagement with natural resources, and the sustainability of their actions. These findings show a previously unexplored pathway through which poor human health may negatively impact the environment.

The objective of this study was to investigate the relationship among socioeconomic status, social support, and food insecurity in a rural Kenyan island community. A cross-sectional random sample of 111 female heads of households representing 583 household members were surveyed in Mfangano Island, Kenya from August to October 2010 using adaptations of the Household Food Insecurity Access Scale and the Medical Outcomes Study Social Support Survey. In multiple linear regression models, less instrumental social support, defined as concrete direct ways people help others (B = -0.81; 95% confidence interval [CI] -1.45 to -0.17), and decreased ownership scale based on owning material assets (B = -2.93; 95% CI -4.99 to -0.86) were significantly associated with increased food insecurity, controlling for age, education, marital status, and household size. Social support interventions geared at group capacity and resilience may be crucial adjuncts to improve and maintain the long term food security and health of persons living in low-resource regions.

Food insecurity and poor infant and young child feeding (IYCF) practices contribute to undernutrition. The Kanyakla Nutrition Program was developed in rural Kenya to provide knowledge alongside social support for recommended IYCF practices. Utilizing a social network approach, the Kanyakla Nutrition Program trained community health workers (CHWs) to engage mothers, fathers, and grandparents in nutrition education and discussions about strategies to provide instrumental, emotional, and information support within their community. The 12-week programme included six sessions and was implemented on Mfangano Island, Kenya, in 2014-2015. We analysed intervention effects on (a) nutrition knowledge among community members or CHWs and (2) IYCF practices among children 1-3 years. Nutrition knowledge was assessed using a postintervention comparison among intervention (community, n = 43; CHW, n = 22) and comparison groups (community, n = 149; CHW, n = 64). We used a quasi-experimental design and difference-in-difference to assess IYCF indicators using dietary recall data from an ongoing cohort study among intervention participants (n = 48) with individuals living on Mfangano Island where the intervention was not implemented (n = 178) before the intervention, within 1 month postintervention, and 6 months postintervention. Findings showed no effect of the intervention on IYCF indicators (e.g., dietary diversity and meal frequency), and less than 15% of children met minimum acceptable diet criteria at any time point. However, knowledge and confidence among community members and CHWs were significantly higher 2 years postintervention. Thus, a social network approach had an enduring effect on nutrition knowledge, but no effects on improved IYCF practices.

Antiretroviral hair levels objectively quantify drug exposure over time and predict virologic responses. We assessed the acceptability and feasibility of collecting small hair samples in a rural Kenyan cohort. Ninety-five percentage of participants (354/373) donated hair. Although median self-reported adherence was 100% (interquartile range, 96%-100%), a wide range of hair concentrations likely indicates overestimation of self-reported adherence and the advantages of a pharmacologic adherence measure. Higher nevirapine hair concentrations observed in women and older adults require further study to unravel behavioral versus pharmacokinetic contributors. In resource-limited settings, hair antiretroviral levels may serve as a low-cost quantitative biomarker of adherence.

HIV treatment is life-long, yet many patients travel or migrate for their livelihoods, risking treatment interruption. We examine timely reengagement in care among patients who transferred-out or were lost-to-follow-up (LTFU) from a rural HIV facility. We conducted a cohort study among 369 adult patients on antiretroviral therapy between November 2011 and November 2013 on Mfangano Island, Kenya. Patients who transferred or were LTFU (i.e., missed a scheduled appointment by ≥90 days) were traced to determine if they reengaged or accessed care at another clinic. We report cumulative incidence and time to reengagement using Cox proportional hazards models adjusted for patient demographic and clinical characteristics. Among 369 patients at the clinic, 23(6%) requested an official transfer and 78(21%) were LTFU. Among official transfers, cumulative incidence of linkage to their destination facility was 91% at three months (95%CI (confidence intervals) 69-98%). Among LTFU, cumulative incidence of reengagement in care at the original or a new clinic was 14% at three months (95%CI 7-23%) and 60% at six months (95%CI 48-69%). In the adjusted Cox model, patients who left with an official transfer reengaged in care six times faster than those who did not (adjusted hazard ratio 6.2, 95%CI 3.4-11.0). Patients who left an island-based HIV clinic in Kenya with an official transfer letter reengaged in care faster than those who were LTFU, although many in both groups had treatment gaps long enough to risk viral rebound. Better coordination of transfers between clinics, such as assisting patients with navigating the process or improving inter-clinic communication surrounding transfers, may reduce delays in treatment during transfer and improve overall clinical outcomes.

Background

Existing social relationships are a potential source of "social capital" that can enhance support for sustained retention in HIV care. A previous pilot study of a social network-based 'microclinic' intervention, including group health education and facilitated HIV status disclosure, reduced disengagement from HIV care. We conducted a pragmatic randomized trial to evaluate microclinic effectiveness.

Methods

In nine rural health facilities in western Kenya, we randomized HIV-positive adults with a recent missed clinic visit to either participation in a microclinic or usual care (NCT02474992). We collected visit data at all clinics where participants accessed care and evaluated intervention effect on disengagement from care (≥90-day absence from care after a missed visit) and the proportion of time patients were adherent to clinic visits ('time-in-care'). We also evaluated changes in social support, HIV status disclosure, and HIV-associated stigma.

Results

Of 350 eligible patients, 304 (87%) enrolled, with 154 randomized to intervention and 150 to control. Over one year of follow-up, disengagement from care was similar in intervention and control (18% vs 17%, hazard ratio 1.03, 95% CI 0.61-1.75), as was time-in-care (risk difference -2.8%, 95% CI -10.0% to +4.5%). The intervention improved social support for attending clinic appointments (+0.4 units on 5-point scale, 95% CI 0.08-0.63), HIV status disclosure to close social supports (+0.3 persons, 95% CI 0.2-0.5), and reduced stigma (-0.3 units on 5-point scale, 95% CI -0.40 to -0.17).

Conclusions

The data from our pragmatic randomized trial in rural western Kenya are compatible with the null hypothesis of no difference in HIV care engagement between those who participated in a microclinic intervention and those who did not, despite improvements in proposed intervention mechanisms of action. However, some benefit or harm cannot be ruled out because the confidence intervals were wide. Results differ from a prior quasi-experimental pilot study, highlighting important implementation considerations when evaluating complex social interventions for HIV care.

Trial registration

Clinical trial number: NCT02474992.

Background

Despite progress in the global scale-up of antiretroviral therapy, sustained engagement in HIV care remains challenging. Social capital is an important factor for sustained engagement, but interventions designed to harness this powerful social force are uncommon.

Methods

We conducted a quasiexperimental study evaluating the impact of the Microclinic Social Network intervention on engagement in HIV care and medication adherence on Mfangano Island, Kenya. The intervention was introduced into 1 of 4 similar communities served by this clinic; comparisons were made between communities using an intention-to-treat analysis. Microclinics, composed of patient-defined support networks, participated in 10 biweekly discussion sessions covering topics ranging from HIV biology to group support and group HIV status disclosure. Nevirapine concentrations in hair were measured before and after study.

Results

One hundred thirteen (74%) intervention community participants joined a microclinic group, 86% of whom participated in group HIV status disclosure. Over 22-month follow-up, intervention community participants experienced one-half the rate of ≥ 90-day clinic absence as those in control communities (adjusted hazard ratio: 0.48; 95% confidence interval: 0.25 to 0.92). Nevirapine hair levels declined in both study arms; in adjusted linear regression analysis, the decline was 6.7 ng/mg less severe in the intervention arm than control arm (95% confidence interval: -2.7 to 16.1).

Conclusions

The microclinic intervention is a promising and feasible community-based strategy to improve long-term engagement in HIV care and possibly medication adherence. Reducing treatment interruptions using a social network approach has important implications for individual patient virologic suppression, morbidity, and mortality and for broader community empowerment and engagement in healthcare.